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Original Article ORIGINAL RESEARCH Health and Health Seeking in Mosul During ISIS Control and Liberation: Results From a 40-Cluster Household Survey Riyadh Lafta, MD, PhD; Valeria Cetorelli, PhD; Gilbert Burnham, MD, PhD ABSTRACT Objectives: ISIS seized Mosul in June 2014. This survey was conducted to assess health status, health needs, and health-seeking behavior during ISIS control and the subsequent Iraqi military campaign. Methods: Forty clusters were chosen: 25 from east Mosul and 15 from west Mosul. In each, 30 households were interviewed, representing 7559 persons. The start house for each cluster was selected using satellite maps. The survey in east Mosul was conducted from March 13–31, 2017, and in west Mosul from July 18–31, 2017. Results: In the preceding 2 weeks, 265 (5.4%) adults reported being ill. Some 67 (25.3%) complaints were for emotional or behavioral issues, and 59 (22.3%) for noncommunicable diseases. There were 349 (13.2%) children under age 15 reportedly ill during this time. Diarrhea, respiratory complaints, and emotional and behavioral problems were most common. Care seeking among both children and adults was low, especially in west Mosul. During ISIS occupation, 640 (39.0%) women of childbearing age reported deliveries. Of these, 431 (67.3%) had received some antenatal care, and 582 (90.9%) delivered in a hospital. Complications were reported by 417 (65.2%). Conclusions: Communicable and noncommunicable diseases were reported for both children and adults, with a high prevalence of emotional and behavioral problems, particularly in west Mosul. Care-seeking was low, treatment compliance for noncommunicable diseases was poor, and treatment options for patients were limited. (Disaster Med Public Health Preparedness. 2019;page 1 of 9) Key Words: health-seeking behavior, Iraq, ISIS, Mosul 10 ousehold surveys to determine needs and 2014. As ISIS consolidated its control of Mosul, it measure health-seeking behavior are common began restricting movements out of the city and Hamong displaced populations, particularly introducing strict control of nearly every aspect of life. when persons become settled in the post-emergency The omnipresent Hesba, or morality police, patrolled phase.1–4 Population surveys during or immediately the city streets, offices, schools, and hospitals issuing following a conflict and that attempt to understand citations to persons not observing the ISIS dress and behavior and events at a time when the access to a behavior codes. Female doctors were required to work population is limited are less common.5–7 In this paper, with a full body covering of thick black material, we report health-seeking behavior among resident gloves to cover all skin. They were allowed to lift the populations in Mosul during the period of ISIS control gauze covering eyes only while fixing an intravenous and during the time of the military campaign to drive line. Working after dark was forbidden for female ISIS from the city. health workers. Male health providers were not allowed to speak with female patients nor could 11 During December 2013, there were increasing clashes female providers speak with male patients. Mosul in Iraq’s Al Anbar governorate between ISIS forces health care workers speak of at least 2 health profes- entering from Syria and the Iraqi army. In January sionals being executed by ISIS for violating this rule. 2014, ISIS forces seized control of the cities of Ramadi Health workers were forbidden to speak with collea- 12 and Fallujah. From June 4–10, 2014, an estimated gues of the opposite sex. Doctors were also executed 1500 ISIS fighters overran Mosul, Iraq’s second city.8 for a perceived reluctance to prioritize treatment of 13 Initially, some 500,000 persons fled Mosul going ISIS fighters. Initially, ISIS authorities had promised elsewhere in the Nineveh governorate or into that high quality health services would be an ISIS Kurdistan.9 The population remaining in Mosul under priority. However, gradually, services deteriorated as ISIS control was thought to be about 1.5 million, access to supplies and services decreased, and woun- 14 compared with somewhere over 2 million before June ded ISIS fighters were given preference. People were Disaster Medicine and Public Health Preparedness 1 Downloaded from https://www.cambridge.org/core. Welch Medical Library, on 09 Apr 2019 at 16:22:55, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/termsCopyright © 2019. Society https://doi.org/10.1017/dmp.2019.11 for Disaster Medicine and Public Health, Inc. DOI: 10.1017/dmp.2019.11 Health Seeking in Mosul During ISIS Control hesitant to venture far from their houses to seek care lest they To document the impact of the ISIS occupation on the run afoul of the ever-present Hesba. health of Mosul’s population and to provide information to address the health needs of Mosul, this study was conducted. The first phase of the attack against ISIS in Mosul by Iraqi The extent of deaths and injuries during control by ISIS and forces, known as the liberation, began on October 17, 2016. during the liberation had been reported by us elsewhere.15 It The initial targets were the villages to the east of Mosul. This received approval from the Scientific and Technical Com- displaced populations to the east and southeast of the city. The mittee of Al-Mustansiriya University, and the Institutional army reached the east edge of the city at the end of October. Review Board at Johns Hopkins Bloomberg School of Public Phase 2 of the military operation began on November 1, when Health declared that analysis of data without personal iden- Iraqi forces reached Kokjali, an urban suburb of east Mosul tifiers as exempt. (also called left Mosul), and moved into more densely popu- lated urban areas. On January 24, 2017, Prime Minister Haider Al-Abadi declared the east side of Mosul liberated. Phase 3 of METHODS the military campaign for the liberation of the portion of This survey was carried out as soon as entry to Mosul was Mosul lying to the west of the Tigris river began on February permitted by security forces and before further substantial 19. Some residents of west Mosul had moved to east Mosul population movement began. Even then, the situation was (before its liberation) anticipating the fighting; the few who unsettled with precarious security. Forty clusters were ran- could fled the city starting in December 2016, but many others domly selected from a listing of the residential administrative remained. West Mosul, particularly the old city, was densely units or neighborhoods of Mosul. Before ISIS control, these populated. When fighting began, military progress was slow, residential administrative units would commonly contain with widescale damage, obliterating whole neighborhoods. around 400 households. From this listing, 25 neighborhoods ISIS fighters retreating from east Mosul had fortified the area. were randomly selected on the east side of the Tigris river and Civilian populations were used as human shields by ISIS 15 on the west side, representing the population distribution fighters, and those trying to flee were often picked off by sni- of pre-ISIS Mosul (Figure 1). The neighborhoods where pers. Persons seeking safety in the basements of houses were clusters were located are found in Supplemental Table 1. No systematically killed. The flight from west Mosul dramatically information on population shifts under ISIS was available for increased the number of displaced persons in Nineveh gover- Mosul. For each cluster, 30 houses were visited. The “start norate to over 800,000. On June 29, Prime Minister Haider house” for each cluster was selected at random using a 10-m Al-Abadi declared West Mosul liberated, marking the end of grid overlay of an aerial map of Mosul. Reserve clusters with military activities in Mosul. start houses were identified in case the selected cluster was inaccessible. A questionnaire addressing multiple aspects of the population health and experiences was developed, based FIGURE 1 on previous survey work in Iraq. The health section is found in the supplemental materials to this paper. Location of Sampled Clusters in Residential Areas of West and East Mosul. Four interviewers worked in teams of 2. Interviewers were physicians with a doctoral degree in community medicine. Three interviewers were female, and all were natives of Mosul but had left as ISIS seized Mosul. Training prior to the survey was provided, and field testing was carried out in an area not to be included in the survey. Security measures for the interviewers were developed and included safe houses and regular communications among the interviewers with cell phones during the field work. For this survey, a household was defined as a group of people living together, eating from a common kitchen, and living in a structure with a separate entrance from the street. After interviewing the start house, interviewers moved to the next house to the right. At intersections, they turned to the right. Where a house had been destroyed or was unoccupied, the interviewers continued in the same direction to the next occupied house. The interview teams used caution moving between houses to avoid attracting attention. The only dwellings included were those where the household had been present during the entire period from June 2014. At each 2 Disaster Medicine and Public Health Preparedness Downloaded from https://www.cambridge.org/core. Welch Medical Library, on 09 Apr 2019 at 16:22:55, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/dmp.2019.11 Health Seeking in Mosul During ISIS Control house, verbal informed consent was secured from the head of During the previous 2 weeks, 265 (5.4%) out of 4924 adults the household. The head of the household or the senior reported an illness, 125 (4.0%) out of 3164 in east Mosul, and female was interviewed.
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