1. Introduction

In February 2018, a team from the Defenders for Medical Impartiality (DMI), with the European Centre for Democracy and Human Rights (ECDHR), undertook a field mission to the Kurdistan region of Iraq, also known as Iraqi Kurdistan. The team visited Erbil and Duhok provinces where they conducted in-person meetings with representatives of local and international non-governmental organizations (NGOs) and with Kurdistan Regional Government (KRG) officials. During the mission, the DMI team inquired about the obstruction of health services in disputed areas between the KRG and the federal Iraqi government following the Kurdish referendum held in September 2017.

  1. Background

On 25 September 2017, the Kurdish government led its first referendum on independence from Iraq.  An overwhelming majority voted to split from Iraq and form an independent country, though Kurdish leadership emphasized that the vote was non-binding. A day later, on 26 September, Iraq’s prime minister, Haider al-Abadi, gave the Kurdish region three days to surrender control of its international airports in Erbil and Sulaymaniya or face a shutdown of international flights. An Iraqi ban on international flights took effect on 29 September, at 6 p.m. local time. In early October, the federal government imposed sanctions on Kurdish banks, which included restrictions on foreign currency transfers to the Kurdish region. The Iraqi parliament lifted those sanctions on 29 January 2018, according to local media reports.

On 11 October, Kurdish leaders rejected a demand by the federal government in Baghdad to cancel the outcome of the referendum as a precondition for talks to resolve the dispute. The Iraqi federal army began moving into disputed areas that had been held by the KRG’s Peshmerga forces. These areas include Ninewa governorate, Kirkuk governorate, Salah ad Din governorate and Diyala governorate. By the end of October 2017, the Iraqi forces, with the support of the Popular Mobilizations Units (PMU), had pushed back the Peshmerga forces to the 2003 borders of the Kurdistan autonomous region in northern Iraq, consisting of the Duhok, Erbil and Sulaimaniya provinces.

On 15 October, the Iraqi military and the PMU began advancing into Kurdish-controlled parts of Kirkuk, and by 16 October the Iraqi federal army said it had seized control of the oil-rich city. Around 21 Peshmerga soldiers were killed in the Kirkuk battle and another 130 were injured, KRG officials told DMI. The federal army, with the support of the PMU, then asserted control of Tuz Khurmato to the southeast after clashing with Peshmerga forces. On 17 October, the federal army also took control of Gwer and Makhmour, south of Erbil; the Khanaqin area on the Iranian border; and the northwestern town of Sinjar. According to officials in the towns of Sinjar, Makhmur, Bashiqa, Rabia and in the Mosul dam area, Peshmerga forces withdrew from their posts as Iraqi forces approached. On 20 October, Iraqi forces announced that they had taken over Zummar, northwest of Mosul. The army and the PMU reached Sinjar Mountain on 23 October.

The conflict raised concerns of civilian displacement. The International Organization for Migration reported the displacement of 2,658 individuals on 27 September, two days after the referendum took place. The number of displaced individuals increasedfrom 5,364 on 15 October to 135,660 on 22 October, growing to 184,164 on 31 October. The total number of displaced people from the Kirkuk region alone reportedly reached 100,000. Approximately 11,000 people fled Tuz Khurmatu as Iraqi forces entered the town. As of 21 May 2018, a total of 105,534 individuals remained displaced following Iraqi military takeover of the disputed areas. Community leaders told DMI that people refuse to go back to their areas of origin for many reasons, primarily because of widespread destruction, lack of government services and the unstable security climate.

There were allegations that up to 150 houses in Tuz Khurmatu were set on fire by armed groups and another 11 were destroyed by explosives on 16 and 17 October. Further, at least 11 civilians were killed in indiscriminate attacks, Amnesty International said. Human Rights Watch reported that at least 51 civilians were injured in indiscriminate firing on 16 October. On 8 January 2018, the Iraqi parliament formed a committee to investigate human rights violations that occurred in the wake of the Iraqi military takeover.

  1. Violations of Medical Impartiality by Region
  • Erbil Governorate – Debaga area, Makhmur District

The federal army takeover of nearby Kirkuk rose security concerns in Debaga, leading to the closure of some health facilities that primarily serve internally displaced persons (IDPs).

A clinic run by Women and Health Alliance International, a non-governmental medical organization, was forced to open for just two hours on 17 and 18 October because of security concerns. Under normal circumstances, the clinic operates full-time. The clinic employs four doctors and eight nurses and specializes in reproductive health services. Around 30 to 50 patients seek treatment at the clinic on a daily basis. The clinic includes a delivery room with an average of 15 deliveries a month.

A clinic run by Jiyan Foundation for Human Rights, a non-profit organization providing psychological support to survivors of human rights violations, was forced to close between 16 October and 7 November. The clinic provides mental health services for mostly IDPs and is located inside the IDP camp in Debaga. There are two psychotherapists at the clinic, a doctor and a pharmacist. Under normal circumstances the clinic is open for patients two days a week from 9 a.m. until 1 p.m.

Zhian Health Organization, a non-governmental medical organization, runs four clinics located inside Debaga’s IDP camps. A doctor and two nurses at each clinic provide reproductive health services for mostly IDPs inside the camps. Medical workers also attend to urgent health cases. One of the clinics was closed for two days, on 19 and 20 October, for security concerns. The clinic normally serves between 50 and 80 individuals per day. The three remaining clinics, serving together an average of 225 IDPs per day, were closed on 20 October. Armed groups affiliated with the Peshmerga reportedly occupied some of the clinics. DMI, however, could not verify this allegation.

  • Kirkuk Governorate

On 16 November, in an official document issued by the Kirkuk Health Directorate, the acting health director in Kirkuk, Hussein Ibrahim, requested all medical centers and hospitals provide the names of employees who partook in the independence vote. The directorate also requested the names of the employees who were on leave or absent on the day of the referendum. DMI was unable to determine if any action was taken in response to this measure, but raised concerns that medical personnel might face intimidation or reprisal on the basis of their political views.

A clinic run by Jiyan Foundation for Human Rights in Kirkuk was forced to close between 16 and 22 October 2017. Under normal circumstances, the clinic opens between Sunday and Thursday from 8:30 a.m. until 4:30 p.m. The clinic provides rehabilitation services for survivors of torture. Some personnel were unable able to reach the clinic until the end of October due to the heavy presence of security checkpoints. Between October 16 and mid-December, staff noted a decrease in the number of patients seeking health attention at the clinic.

  • Ninewa Governorate – Sinjar, Shingal District

Approximately 400,000 people, mainly Yazidis, reside in Sinjar, which is located in Shingal district of Ninewa governorate. In 2014, more than 3,000 were killed by Islamic State (also known as ISIS) militants in a crime described by the United Nations (UN) as genocidal. Between 20,000 and 25,000 Yazidis returned to Sinjar after liberation from ISIS in 2015. An estimated 250,000 Yazidis are scattered across refugee camps in Iraqi Kurdistan, Syria and Turkey.

In November 2015, Ninewa’s Department of Health visited Sinjar General Hospital, which, prior to the ISIS takeover, was the primary hospital in Shingal district. In their assessment report that DMI reviewed, the Department of Health concluded that 80 percent of the hospital’s skeleton and infrastructure were destroyed due to the fighting. The hospital’s medical equipment, water and electric grids were fully destroyed. Ninewa’s Health Department recommended tearing down what remains of the hospital and rebuilding the facility. This has not yet been done.

Sinjar General Hospital – December 2015

Currently, only the hospital’s emergency department is operating. The rest of the hospital remains destroyed. The emergency department consists of two emergency rooms with four beds each, and includes a pharmacy and a medicine storage unit. Doctors treat between 100 and 150 patients daily. The hospital’s main medicine storage unit remains in Duhok. However, due to security checkpoints and other obstacles to access, Ninewa’s Department of Health began sending medication directly to the hospital to avoid unnecessary delays.

In August 2017, the Christian Aid Program Northern Iraq, a relief organization, began to provide health and logistical support for the hospital. However, the organization withdrew from the area on 15 October for security concerns. Then, DORCAS Aid International, a relief organization, took over in mid-November. DORCAS provides support for the emergency room and employs two part-time doctors. Between 16 October and 12 November, only one nurse and a pharmacist from the area were at the hospital. Between October 2017 and March 2018, at least 11 people died because of lack of medication, ambulances, medical equipment and resources, hospital staff said.

In October, Kurdish forces handed over Sinjar to the PMU. Road connections between Sinjar and Kurdistan were then closed for two months. In December, the road between Mosul and Kurdistan was re-opened. However, a road connecting Sinjar directly to Duhok remains closed. Health workers explained that patients are hesitant to seek treatment in Mosul, which was an ISIS stronghold for more than three years. Instead, they seek treatment in Duhok or in the city of Qamishli in Syria, both located about 170 km away by road.

Hospital staff work in a climate of instability. On 4 May, hospital workers informed DMI about the presence of an unexploded bomb that they claim was left by ISIS. The bomb is planted around 15 meters away from the hospital. Health workers informed concerned authorities and are currently following up with the Mine Action sub-cluster to ensure the safe removal of the bomb.

Prior to 16 October, the Duhok Health Department equipped the hospital with two ambulances. The ambulances were retrieved when the area fell under the control of the Peshmerga forces. Patients who require transfer are asked to use their personal cars. In some cases, health workers request to use military ambulances belonging to the PMU to transfer patients. These ambulances operate only in territories under the control of the federal army and cannot transfer patients to hospitals located in Iraqi Kurdistan. A health worker at the hospital explained that PMU ambulances are not always available to transfer patients.

An NGO official told DMI that PMU forces looted two health facilities in Zummar and Rabia in the Ninewa Governorate in October of 2017. DMI was not able to verify this information.

  1. Conclusion

During its field mission, DMI documented the interference with the delivery of health care at seven clinics. Six of them are located in Debaga area in Erbil, while the other is in Kirkuk. Further, the team noted the concerning situation at Sinjar General Hospital, which is largely destroyed. The hospital lacks ambulances and continues to operate in an insecure environment.  DMI could not travel to every clinic that was potentially impacted by the conflict or verify every report received; it is likely that even more facilities faced interference in the delivery of health services.

State and non-state actors must take every precaution to avoid interfering with the delivery of health services. The Iraqi government, now in control of the disputed areas, must take measures to ensure the delivery of quality health services. Hospitals should be equipped with the medical supplies and transport they need to properly attend to the needs of local communities. Further, the Iraqi army should ensure that hospitals and their surroundings are safe and free from unexploded mines or other bombs. Further, the Iraqi federal government must take immediate steps to begin reconstruction of health facilities affected by the conflict. All connections linking Kurdistan to the rest of the country, especially the Sihila road linking Sinjar directly to Dohuk, should be re-opened. Lastly, DMI calls on Kurdish officials to coordinate with the Iraqi government in order to ensure the smooth and uninterrupted transfer of patients.

  1. Acknowledgements

DMI wishes to thank Rwanga Foundation, Zhian Health Organization, Jiyan Foundation for Human Rights, Women and Health Alliance International, the NGO Coordination Committee for Iraq and Alind Organization for providing research and logistical support for the DMI team throughout the completion of the research project.