Dr. Michael Pollanen is the Chief Forensic Pathologist at the Ontario Forensic Pathology Service
I have recently returned from a humanitarian forensic medicine mission in Iraq. The autopsies I performed gave me some insight into how people die in Baghdad die. My observations in the autopsy room are witness to the major cost of war and terrorism on a civilian population. I concentrate on the 6 most frequent types of preventable deaths that I encountered, many of which would not occur - or would not occur to the same extent- in Canada or other parts of the Western world.
Although my mission to Iraq was focused on the application of forensic pathology to the protection of Human Rights, during my time in Iraq I was struck by the observation that Iraq is a society embedded in conflict. It was once the major cultural and intellectual centre of the Middle East. Yet due to recent wars and internal armed conflict with terrorists, Iraq now faces problems with the safety and security of the population and a widening gap between people who have and do not have access to the essentials of daily life, justice and health care. Many of the autopsies I performed were cases related to internal armed conflict. But I will not discuss these deaths here. Most of the cases that I encountered were the non-violent deaths of citizens of Baghdad that underwent routine investigation by the Iraqi authorities. These deaths showed me how an armed conflict can contribute to preventable non-violent deaths.
Heart disease – uncontrolled modifiable risk factors
In Baghdad, sudden cardiac death from atherosclerotic and hypertensive heart disease is common. In a typical week, most of the natural deaths were due to heart disease as the cause of death. I performed autopsies on several men in their 30s who died of untreated essential hypertension. I frequently saw evidence of severe end-organ damage that indicated early onset. Fatal cases are often associated with obesity, type II diabetes, and smoking. There is also a widespread belief that the stress of living is a significant factor in the onset or progression of cardiovascular disease in Iraq. One of the most important factors that underlies lack of treatment of hypertension and diabetes is poor access to primary care.
Road traffic fatalities – no effective traffic rules
One of the most common accidental causes of death in Iraq, and many low- and middle-income countries, is injuries sustained from being hit by a car. This is often due to ineffective traffic rules, no enforcement of traffic rules, speeding, and poor road conditions. In addition, some of the injuries sustained would not ordinarily be fatal in other countries, but in Iraq there is a lack of access to tertiary trauma care. Furthermore, there appear to be more post-injury deaths in people who do receive surgical care, and some of those might be prevented by better post-operative rehabilitation and anti-coagulation.
Burns – no cadaveric skin allografting
Each day in Iraq, many children and woman are burned by kerosene-related fires or scalded by boiling water. Minor burns are treated medically on an outpatient basis. Essentially all patients with more than 70 per cent body surface burns are likely to die. However, many people with body surface burns around 50 per cent and even lower, especially in children, die from infection in Iraq. Most of these people would survive such injuries in Canada and other countries due to better access to medical and surgical care. The main factor that limits survival in Iraq is access to tertiary burn care. Specifically, for many patients with serious burns, there is no possibility of skin allografting as a preliminary surgical step prior to definitive therapy. In cases with serious burns, the family of the burn victim will often donate a skin allograft to cover the burned skin of their loved one. The family member must undergo a general anesthetic and an operation, so the family has another patient to care for. Unfortunately, sometimes the burns are so large that skin donation from a family member is not an option. On this basis, the only alternative is a cadaveric skin allograft – donation of the skin from the dead. This is commonplace in Canada and the Western world, but is not performed in Iraq or elsewhere in the Middle East. Developing this capacity in Iraq could save many lives each year.
A related type of accidental death, mostly in children, that I encountered was electrocution due to illegal splicing of wires to obtain electricity for household use. The main reason for these deaths was the need to gain access to electrical power. Sometimes, if death did not occur immediately, the electrical shock created a fire by igniting the child`s clothing or surroundings. On this basis, these children often suffered burns and would also have benefited from availability of skin allografting.
Child abuse – lack of awareness
The most difficult autopsies I performed were of children who were abused and unfortunately I performed many such autopsies. The cases of child abuse include child torture, chronic physical abuse and neglect. Many of the cases had the classical injury patterns observed in child abuse in all countries, such as multiple healing rib and long bone fractures that indicated protracted abuse, skull fractures, bruises and burns, and malnutrition. Some cases of extreme violence also occur, including traumatic rupture of the heart. There was little awareness of child abuse and neglect among the physicians I spoke with. There was no State-sponsored system to protect the live siblings of fatally abused infants and children. Therefore, there was no way to stop the cycle of abuse in families, which sometimes leads to recurrent preventable death and disability.
Self-immolation – suicide of women
In Toronto, the type of suicide cases that I encounter most frequently are men who kill themselves by hanging. In Baghdad, the most common suicide cases are young women who set themselves on fire. Kerosene is widely available because it is used as fuel for cooking. The self-immolation of young women is far too common in Iraq. The reasons and explanations for these suicidal deaths are complex, but there is sometimes an element of domestic maltreatment. Indeed, in some cases, it is not entirely clear if these death are suicidal or homicidal – sometimes other injuries are present, such as bruises and head injury.
Congenital and genetic disease – no newborn screening
There are many deaths of infants and children with undiagnosed and untreated congenital malformations and genetic diseases. In my experience, these included straightforward cases of congenital hydrocephaleus, porencephaly, cystic fibrosis, fatty acid oxidation disorders and trisomies. I also encountered many cases of children and young adults who died of malnutrition that I suspected had inborn errors of metabolism, including phenylketonuria. It appeared that male children were over represented in this group, perhaps hinting at X-linked genetic disorders. When I spoke with Iraqi physicians I learned that there was no newborn screening in Iraq and most children with congenital and metabolic diseases die at home without a diagnosis and without medical care. Public health system implementation of newborn screening programs would go a long way to limit the burden of disease and death in these families.
My observations underscore the toll that war, internal armed conflict, and the lack of resources takes on society and the families who are not directly involved in the conflict. Although all parts of civil society are at risk, women and children are the most vulnerable. Despite their best efforts, our medical colleagues in Iraqi face seemingly insurmountable odds against improving the lives of their patients. Clearly, in Iraq and similar contexts, political and economic stability is a key determinant of health and, it appeared to me, that is most acutely felt when the Rule of Law is weak, access to health care is limited, and infrastructure for the public health system is poorly developed or not well-sustained. The cost is felt by the civilian population as an increase in the burden of disease and injury, lack of human rights and premature death. Let us hope that the lessons in Iraq, and other parts of the world, can catalyze capacity development and international assistance, during these times of political and economic crisis. It is a global imperative.