EHJ July 2003, pages 204-207 Now that post-conflict reconstruction is well underway, Ian Foulkes reports from Iraq on efforts to restore the infrastructure

APRIL 2003:

Now that the fighting phase of the second Gulf war is over, many commentators have been expressing their views on the environmental, health and humanitarian situation in Iraq, as mentioned in the editorial of the April issue of EHJ (EHJ, April, page 99). Many of these so-called experts offer their opinions from the comfort of a television studio in London, or nicely furnished office in Aylesbury, so, having just received a parcel containing the latest editions of EHJ and EHN (thanks to the Ed!) I thought I would let the readers know, in military parlance, the "ground truth".

OPERATION TELIC

Offensive combat operations began for British ground forces on 20-21 March 2003, alongside limited air operations. In planning the operation to cross from Kuwait into Iraq and secure the city of Al Basrah, much thought was given by the coalition on what action would be taken if people started to flee the fighting. Plans were put in place to address numerous needs, including how we would feed them and how we would provide water and medical aid etc.

Concurrently, an information campaign was mounted to let the ordinary Iraqi people know that the enemy of the coalition was Saddam Hussein and his regime, not the people, and that they should stay at home to remain safe. Fortunately, despite heavy bombing, the majority of civilians accepted this message and did indeed stay at home. Some did choose to try and leave Basrah by the southern bridge over the Shat-al-Basrah, only to be used as human shields by Saddam's regime, with several dozen being shot by the Iraqi militia.

COMBAT VS HUMANITARIAN AID

My own role with the British army is not as an environmental health practitioner. My job, although titles vary, is to work within the G5 branch which is concerned with the relationship between civil and military authorities and includes the military aid programme, liaison with international (IOs) and non-governmental organisations (NGOs) and post-conflict reconstruction. At the commencement of operations, I was working directly with combat troops as part of the 1st Battalion, the Black Watch Battle Group. Ensuring the commanding officer was fully briefed as to the G5 issues of his plan, I could directly influence the nature and extent of the help we were able to give to the civilian population as soon as the environment was permissive.

As the battle group advanced north, it first secured the town of Al Zubayr, with an estimated population of around 100,000. Within 12 hours of securing a base in the town, fighting troops of the Black Watch were handing out humanitarian aid, in the form of bottled water, food and baby milk, to the civilian population. Even this was not without risk and on two occasions shots were fired at soldiers engaged in this task. Thus, the stark and sudden contrast between combat missions and the delivery of humanitarian aid proved hard for some soldiers to comprehend. In the (edited) words of one 19-year-old soldier - a member of the Black Watch sniper team: "Sir, this is all screwed up. Twelve hours ago I was shooting these militia and now I'm feeding them."

I had no answer to this, as I too had been actively in combat just a few hours previously. I simply told him to shut up and get on with the job in hand. Later, I talked to him at length about why what he was doing as both a combat soldier and the deliverer of aid was vital to the long-term future of Iraq. And we did deliver aid, and a lot of it. At the same time we were assessing the existing infrastructure for water distribution, power distribution, health services, and food distribution etc with a view to restoring normal services as soon as possible.

POST CONFLICT RECONSTRUCTION

The reality of Iraq is that, after 20 years of Saddam's regime, a disastrous war with Iran, the first Gulf War, UN sanctions, and now the second Gulf War, it is a third world country with one of the highest infant mortality rates in the world. Yet the people are very resilient and are prepared to work hard to help themselves. The supply of drinking water is one of their prime concerns. Iraq is very fertile and has much natural water, but the infrastructure to deliver it to population centres has been badly degraded. Water from taps is only available to 70 per cent of the population in Basrah, and the water that emerges is not potable. Potable water is either purchased in bottles or delivered by bowser.

Much of the coalition's effort now the fighting is over is directed at delivering hundreds of thousands of litres of water by tanker every day, as well as devoting much of our engineer assets to working with the International Committee of the Red Cross to repair water treatment plants, water pumping stations and reverse osmosis plants. Power is critical to the water system, and further engineering effort is devoted to restoring the power network. Sanitation is becoming more of problem. Clearly with no running water there is no sewage problem. Now that the coalition has restored running water, we have a sewage problem.

THE ENVIRONMENTAL HEALTH ROLE

And what about the state of environmental health in Iraq? Military environmental health practitioners of the Royal Army Medical Corps (RAMC) have been busy testing water for both military and civilian purposes. The outbreak of rampant diahorrea and vomiting that affected a large number of British troops (yours truly included - two days in hospital with IV drips in both arms!) certainly tested the EHPs infectious disease investigative powers - needless to say when questioned I kept my occupation quiet!

Environmental health practitioners of the RAMC have also been assisting army engineers to assess sewage treatment plants with a view to using military assets to restore them to full operation. Medical and EHPs from the RAMC have been carrying out assessments of hospitals and clinics, and funding has been provided to purchase medical equipment to ensure that they can resume work. The disposal of domestic and commercial waste has clearly been neglected for many years, and in the short-term there is little that the coalition can do to clear every street of the piles of domestic waste, or deal with the many ponds of industrial liquid waste. But these issues have been assessed, reports written and the IOs and NGOs that eventually arrive here will be able to take the necessary action to tackle the problem.

One of my first "inspections" was of the former public health laboratory. As I exited the rear door of a Warrior Armoured Infantry Fighting Vehicle, wearing helmet, combat body armour festooned with grenades, carrying an automatic rifle and accompanied by six of the finest special forces soldiers the USA has to offer, I thought how na•ve I had been to carry out inspections in the "old" days armed with nothing more than a warrant card. With absolutely no chance of being "obstructed" on entering the premises, I went in to interview the director and view his heavily looted facility. The public health laboratory used to provide services to the hospitals as well as fulfiling the tasks of the public analyst. Regrettably, it will take many months to restore the lab to operation but with help of coalition forces, the work of clearing the building has at least begun.

JUNE 2003:

OPERATION STEPTOE

Since the beginning of April, much has happened in Iraq as a whole, and in Basrah particularly. Security problems, while still present, have diminished significantly in the British area of operations (AO) and the work of an increasing number of IOs and NGOs is helping to restart the local infrastructure. A major project for the coalition forces, together with UNICEF and the Coalition Provisional Authority (CPA) has been to lead a city-wide clean up of Basrah. A project that is known as OP STEPTOE.

During the years of the Hussein regime, refuse collection was undertaken in only some districts of Basrah and final disposal left much to be desired, with thousands of tonnes of refuse dumped on the outskirts of the city, typically close to the Shi'ite slum areas. In order to remove this significant public health hazard, and to provide an immediate visible improvement in the environment for the citizens, 7th Armoured Brigade (The Desert Rats), together with the Municipality of Basrah, UNICEF and CPA have funded a street cleaning and refuse disposal operation. The project budget is currently in the order of US$250,000.

A suitable landfill area was identified some 30km from Basrah, and labourers and plant were hired to provide the workforce to collect the mounds of rubbish scattered around the city. Coalition forces ensured that the workforce was provided with suitable and sufficient personal protective equipment in the form of face masks, overalls, gloves and boots. Due to the extreme temperatures now being in experienced in Southern Iraq (average daily temp is 50oC), work commences at 05.30 and is conducted on a task and finish basis with the last work completed at around midday.

Lorry loads of waste are supervised at the point of collection and at the final disposal point, thereby providing a simple, but effective, "duty of care" system. The operation will be further developed to provide night-time security to allow the clean-up of areas such as markets that are simply too busy during the day to be cleaned. There is nothing new about cleaning streets at night, after all it is the norm in the UK, however, in downtown Basrah, to ensure the safety of the workers and their equipment, they will be escorted by Warrior Armoured Infantry Fighting Vehicles and troops from the 1st Battalion, the Black Watch and the 1st Battalion Royal Regiment of Fusiliers. Although only in its early stages, OP STEPTOE is already making significant improvements to the environment of Basrah.

FUTURE PRIORITIES

Housing standards, food safety, air pollution, contaminated land, sustainable development and health and safety are not immediate coalition priorities. However, with the involvement of the Iraqi people, they will be addressed in the near future. There will clearly be a need for experienced environmental health practitioners to assist the Iraqi Ministry of Health, and the UK Government will play a part in this work via the Department for International Development (DFID).

The CIEH and its members are uniquely placed to assist DFID in providing some of that support. I hope that the CIEH grasps the nettle and for those of you that wish to escape the constraints of Food Standards Agency targets, Health and Safety Executive initiatives and Defra league tables etc, I suggest you put your personal affairs in order, buy a mosquito net and some sun tan lotion and be prepared to practise environmental health at the very, very sharp end.

Ian Foulkes, CIEH director of technical policy, is still serving with the British Army in Iraq as part of 7th Armoured Brigade HQ in Basrah. He is expected to return to the UK in the autumn after completing his tour.

A number of other CIEH members have been, and are still, serving with the British Army in Iraq, as full-time RAMC environmental health technicians and members of the TA. Further coverage of the environmental health aspects of the war in Iraq and of individual CIEH members' experiences will be published in future issues of EHJ.

KEEPING THE TROOPS HEALTHY

Other environmental health staff in Iraq are tasked with the job of keeping the troops healthy. Alastair Witt, a CIEH member, heads the 3 Commando Brigade RM team and has three Royal Army Medical Corps (RAMC) environmental health technicians working under him to ensure that all military personnel are fit to undertake their duties.

Full-time environmental health technicians within the British Army are primarily involved with the promotion of and the maintenance of health and the prevention of disease. This includes advising on all aspects of environmental health, occupational hygiene and environmental protection, both in barracks and under field conditions, working within a small team that advises headquarters, or as part of a medical field unit. Some of the issues these technicians are involved in includes the setting up of basic sanitation, control of infectious disease, water quality, pest control and toxic chemical hazards.

Basic military training includes all aspects of field training (foot drill, field craft, physical fitness, map reading, weapon handling and firing skills) while the second phase of "specialist" training is undertaken at the Defence Medical Services Training Centre at Keogh Barracks in Aldershot. After completion of training, recruits will have passed the Environmental Health Technician HND Higher Course.

Entry requirements: Four GCSEs (grades C or above) including English language, maths and two science subjects. If applicants are already trained, then the army would look at an individual's experience and discuss what training would be required, as army environmental health technicians take on a much wider role than their civilian counterpart.

Minimum age: 16 years 6 months
Maximum age: 26 years 11 months
Minimum service: 4 years (after training)

For further information visit: www.army.mod.uk/careers/healthcare/jd_env_health_tech.html

PROFESSIONAL SUPPORT

The Territorial Army (TA) is a fully integrated and integral part of the British Army. The TA accounts for one quarter of the British Army's total capability and has a vital role to play in its military operations. Environmental health practitioners have professional skills that are highly sought after by the TA, and more volunteers are required.

For further information on the Territorial Army, how to join, training requirements and general information on pay and conditions visit: www.ta.mod.uk or visit your local TA unit and talk to an expert.