• empowerment
• humanitarian
• independence
• Iraq

Between my missions in Iraq in 1994/95 and the latest in May 2003, the health of the Iraqi population has dramatically deteriorated¹ and what little remained of the healthcare system no longer exists. Total chaos reigns, healthcare centres have been looted,² and patients are not receiving treatment. Twenty million dollars per month would be needed to revive the system.³ But for it to operate effectively, it is necessary to first reconstruct it. The purpose of this paper is to stimulate a debate on the possible effects of the current process of humanitarian assistance in Iraq, in which non-governmental organisations (NGOs) are involved, because it is necessary to meet the needs of the Iraqi people in an appropriate way.⁴

For some time now, humanitarian actors have been alarmed at the confusion that results from military implementation of humanitarian projects. When American forces bombarded Afghanistan in 2001, with grenades accompanied by daily food rations and medicines, NGOs drew attention to this possible confusion.⁵ On the other hand, the humanitarian agencies are not exempt from reproaches (for example, their links with the war⁶ or the harmful effects of their interventions⁷). In Iraq, the English-American occupying power* granted itself the right to run the country. Hence, they have taken on the major responsibility for providing security and covering the basics needs of the Iraqi population.

NGOs and United Nations agencies working in Iraq have to deal with these new actors today. The challenges of doing so are immense, because of the great confusion surrounding the role of the occupying power: “US-led reconstruction is starting out in something of a historical vacuum”. (page 2)⁸ As a result, the armed forces have established the Office of Reconstruction and Humanitarian Assistance (ORHA). Yet NGOs know nothing about this organisation. After insisting for a long time, as of the end of May, the new coordination body of NGOs (NCCI) had still not managed to obtain an information meeting about the ORHA’s role and mandate. The occupying power maintains confusion by continuing to create new authorities, bodies, and daily meetings. Some NGOs have decided to work in total collaboration with the US military. They are considered “embedded” by other NGOs. In our view, we feel that such collaboration undermines the independence of NGOs and their various codes of ethics.^8,9 The meaning of accepting financing grants from the American government (USAID) is different when one collaborates with an occupying army, when the money is given to one by someone in combat uniform† and when one acts as a contractor according to the modalities defined by the latter.

In our view, the current reconstruction process is not adequate. In a post-conflict situation, it is necessary to coordinate assistance¹⁰ but also to favour the appropriation of change and the empowerment of individuals, communities, and organisations.^11,12 It is particularly true for Iraq where the regime in power has always controlled all structures and systems and forbidden any personal initiative. The problem of nursing is a good illustration of this inappropriate process. The healthcare system is still based primarily in hospitals. There is an insufficient number of nurses, the quality of care they provide is inferior, and this profession is depreciated. To tackle these problems, two American military (nurses) were mandated (ordered?) to help the ministry to reorganise nursing care and training programmes. The interested NGOs are invited to participate. When military personnel arrive for meetings, they are adorned with their bullet proof jackets and M16s. They have downloaded training programmes on the internet and distributed them. After some days in Iraq, a member of an embedded NGO wrote to the ministry staff the Iraqi Plan for Nursing Development.

Not only is it necessary to be careful when promoting the training projects but especially important to act in a different way. At first, we believe that reflection concerning the reorientation of nursing has to be part of a more global discussion of the reform of the health system (that is, directed to primary health care). Then, it is necessary for NGOs to keep their critical role in the face of the reconstruction of a country by occupying forces and in the face of the importation of the Western biomedical model. Finally, the process of rehabilitation must be participatory and bottom up; considering capacities, values, and faiths of the population. To organise a consultative national forum of nursing is not enough, it is necessary that all actions reflect a will to empower professionals, population, and organisations more. It is necessary to plan reconstruction with the aim of social change¹³ and not simply for technical reasons. Individuals and organisations in Iraq have to become aware that they have a window of opportunity to decide on their fate. To be able to act so is certainly not the culture conveyed in military academies.