HEALTH AND HUMAN RIGHTS

Missing people and mass graves in

n estimated 300 000 international context.3,4 AIraqis have gone However, for the missing in the past ICRC, guarding its neu- 25 years1 in addition to the trality may be incom- unknown number who patible with the direct died in the Iran-Iraq war, provision of forensic the Gulf war, and the medical and scientific recent conflict. The services. Participation in 300 000 went missing processes related to against a background of obtaining justice is easily arbitrary arrest, imprison- Human remains exhumed by community of , Iraq, June, 2003 perceived as taking sides, The figure shows some of the 200 sets of human remains exhumed before the ment, and summary community halted work in order to seek advice. which in turn, could lead execution, and their to loss of access to the bodies are buried in mass graves across and examined for the tribunal’s people the ICRC is mandated to serve: Iraq (figure).1,2 purposes, but were not individually the victims of war or internal violence. Lancet readers will know of, but may identified because this was not legally This issue is important enough to not be able to comprehend, the necessary. Thus, unlike domestic allow the ICRC to withhold con- enormity of these crimes, and the scale forensic practice, a dichotomy exists in fidential information from the tribunal of the human catastrophe that has the international context between and the International Criminal Court, ensued. Together with most Iraqis, seeing justice done and identifying and is just one facet of the organisa- they may expect that some of the victims of violence. tion’s need to balance speaking out bodies will soon be exhumed and In addressing issues surrounding about what it sees with gaining access examined to bring perpetrators to missing people, the starting point for to victims. Therefore, the ICRC has justice. Both groups may also expect the International Committee of the aimed to elaborate standards of that the international community will Red Cross (ICRC) is the right practice in, rather than to provide, find all the graves, identify all the accorded to families in international forensic services. remains, and return them to their humanitarian law to know the fate of a None of the people involved in families. However, this expectation is missing relative. The experience of developing the ICRC framework unreasonable. dealing with devastated families in the expected that its integrity would be Experiences in Bosnia are Balkans, and the lack of consistent and challenged by the magnitude of the instructive. When peace came to coherent policies in this area, spurred findings in Iraq and the severity of the Bosnia in 1995, 30 000 people were the ICRC to research the problems constraints in working there. It is clear missing. By June, 2003, after 8 years’ associated with people missing as a that in Iraq the ideal of identifying all work by full-time forensic specialists, result of armed conflict or internal remains and returning them to their about 15 000 bodies had been violence.3 The project covered families is unobtainable. However, in exhumed and around 9000 (30%) traditional ICRC activities: dissemin- the face of severe constraints, lowering identified. DNA analysis has so far ation and strengthening of interna- standards of practice may be contributed to about 3000 of these tional humanitarian law; visits to compatible with ethical practice.3,4 identifications (http://www.ic-mp.org). detained people; general protection of What standard of practice can be These figures give some idea of the civilians affected by conflict; restoring recommended that is realistic but enormous resources involved in family links; and compilation and compatible with the ethical codes of excavating, exhuming, examining, and processing of tracing requests. practitioners? identifying the victims of mass killings. Also addressed, however, were This dilemma, which occurs in all Importantly, the International forensic and other issues relating to humanitarian aid situations, is Criminal Tribunal for the former managing human remains. Here, the worsened by one overriding Yugoslavia has been able to function main achievement of the project has constraint: lack of security. If the without the identification of all victims, been to create a widely accepted international community has made relying rather on demographic data framework (panel) within which plans to address the missing people in and causes of death information. forensic professionals can transplant Iraq, their remains, and, most Many human remains were exhumed domestic expertise and practice into an importantly, their families, these plans have surely been shelved in Topics covered in the framework light of the desperate security Roles and responsibilities, including ethical ones, of forensic specialists situation. Before the intentional The need to work in accordance with best practice guidelines killing of one of its fieldstaff and Forensic teams, the contracting agency, and the contracts the attacks on the UN, the The means to conclude identification recommendations of the ICRC were: Responsibility and accountability for examination and identification of human to support community-led excava- remains tions and exhumations for past events Working where the authorities may not be cooperative or competent while developing Iraqi forensic Use of DNA anthropology capacity; and to Standard formats for recording ante-mortem data and post-mortem findings rehabilitate Iraqi forensic services to When it is not possible to do an autopsy accommodate the existing workload, Management of human remains without forensic specialists much of which is related to the recent Involvement of communities and families in management, exhumation, and conflict and current security identification of human remains situation. Now, even these modest objectives may not be achievable.

THE LANCET • Vol 362 • October 18, 2003 • www.thelancet.com 1325 For personal use. Only reproduce with permission from The Lancet publishing Group. HEALTH AND HUMAN RIGHTS

The victims in Iraq are not just the *Stephen Cordner, Robin Coupland 2 Stover E, Haglund WD, Samuels M. dead or injured, but also the hundreds Exhumation of mass graves in Iraq: *Consultant in Forensic Pathology, of thousands of people awaiting an considerations for forensic investigations, Assistance Division ICRC, 19 Avenue de la humanitarian needs, and the demands of end to uncertainty about the fate of Paix, 1202 Geneva, Switzerland (SC); Legal justice. JAMA 2003; 5: 663–66. their relatives. If the missing dead Division, ICRC, Geneva (RC) 3 ICRC. The missing. http://www.icrc.org/ cannot be identified, a pessimistic (e-mail: [email protected]) web/eng/siteeng0.nsf/iwpList2/Focus:Missing conclusion is that a substantial part of _persons (accessed October, 2003). 1 Bouckaert P. The mass graves of Al-Mahawil: 4 Coupland R, Cordner S. People missing as a Iraq’s population will be unable to the truth uncovered. New York: Human result of armed conflict. BMJ 2003; 326: come to terms with the past. Rights Watch, 2003. 943–44.

Medical education and training in Iraq

ith the inauguration of the first facilities, and funding than other schemes to provide health insurance Wpost- cabinet of teaching or district general hospitals. and improve living conditions in the ministers in Iraq, the country’s health Medical graduates spent 2 years, as rural areas to encourage newly qualified professionals are looking forward to resident training doctors, in the main doctors to pursue careers in the less radical improvement in medical branches of medicine and surgery, popular regions and specialties. education and training, and to re- before being recruited to national In the Kurdish region, doctors and establishing international comm- military service for an uncertain length health workers are involved in planning unication channels. In the past two of time—normally 2 years, but up to the future of the health-care system via decades, wars, corruption, and lack of 10 years during wars. After national democratically elected unions and strategic planning have damaged Iraq’s service, doctors would spend a syndicates; similar organisations would system of medical education. Further- compulsory period of at least 1 year benefit the rest of Iraq. Additionally, a more, persecution of doctors and in rural areas without support, free press would guarantee that the abuses of human rights caused many to supervision, or modern facilities. ideas of intellectuals in the community leave the country. Throughout the Doctors could then apply to specialise, would be heard. Finally, priorities must 1990s, Iraq’s medical schools and which entailed spending up to 4 years be identified for the best use of the health-care professionals became in secondary and tertiary hospitals in current scarce resources, but not at the isolated, and a generation of doctors major Iraqi cities. neglect of necessary long-term graduated with inadequate training and planning. poor motivation. “As in most autocratic Since the establishment of the Iraqi Except in Kurdish-controlled systems, Iraqi graduates had Governing Council and the inaug- northern Iraq, which was removed very little say in the time, uration of the cabinet, communication from Saddam’s control by the creation and collaboration has begun between of the safe haven in 1991, Iraqis were place, and subject of their Iraqi health professionals, academics, almost cut off from the outside world. further training” and their professional organisations Internet access was restricted and and their counterparts abroad. Hope- heavily censored, travel was not We think that training in rural areas fully, a new democratic Iraq will bring affordable, and education was not a top under appropriate supervision must be back many intellectuals who left during priority for the regime. The Kurdish included in the curriculum of medical Saddam’s rule. But Iraqi health pro- region, home for more than 5 million schools, but once qualified, working in fessionals and authorities will require people, was neglected by successive the army and in rural areas must be all the help they can get from the Iraqi governments. Until 1992, it had voluntary and based on incentives. outside world. Assistance could be in only one university and a small medical Whereas it used to be the rule for the form of establishing an active pro- college, but now has three universities doctors to travel abroad, mostly to the cess of dialogue, exchanges of visits, and three medical schools. Despite the UK on state scholarships, this became and accommodating Iraqi health-care UN and Iraqi regime’s double extremely rare in the past two decades. professionals in western countries for sanctions imposed on the Kurdish Instead, doctors underwent a training brief periods to help them catch up Regional Government, health scheme characterised by harsh, authori- with the latest developments in medi- professionals remained in touch with tarian discipline. During sanctions, cine. The US-led Coalition Provisional the outside world via the internet training became grossly inadequate and Authority has expressed keen interest in (widespread in our region), access to out of date. As in most autocratic supporting such efforts during the next satellites, travel, and exchange visits systems, Iraqi graduates had very little couple of years while the Governing with international colleagues. The say in the time, place, and subject of Council is focused on preparing for fair Kurdish government and health profes- their further training, which was poorly elections and a solid democratic sionals are now actively supporting the planned and centrally managed by the constitution. It will be up to the Iraqis, development of health care and ministry of health; there was little room supported by willing partners abroad, educational institutions in the newly for competition between candidates to establish a modern, democratic, and liberated parts of Iraq. and no transparency about the ethical system of modern medical Under Saddam’s government, ministry’s decisions. Invariably, the education and training in Iraq. medical education and training was not main determining factor of the quality *Nazar M Mohammad Amin, well integrated with, and evolved of specialist training was the Mohammad Qadir Khoshnaw independently of, the health-care candidate’s connection to the ruling *Vice President, The University of Sulaimani, system. Furthermore, the standard of elite, and in parallel, there were few Sulaimani, Region, Iraq (NMMA); undergraduate and postgraduate train- incentives for candidates to choose Minister of Health, Kurdistan Regional ing varied greatly across Iraq: the major disciplines such as primary health care. Government, Sulaimani (MQK) hospitals in had far more staff, The new cabinet should consider (e-mail: [email protected])

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