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Introduction
The world is experiencing a major demographic transformation
globally and the Middle East is not an exception. Today,
about two thirds of all older people are living in the
developing world; mainly Asia, and particularly China
and India. In the Arab countries the number of elderly
is increasing due to the improvement in health care
services as well as the eradication of most of the infectious
diseases that were causing early death (1).
Elderly people in Iraq in the
context of long term conflicts and repeated cycles of
violence are finding it increasingly difficult to cope
with daily life as the country's security conditions
worsen. Continuing violence and the consequent mass
displacement has had a debilitating effect on the health
and psychological conditions of the elderly, advise
the specialists. There are no reliable statistics available
for the number and conditions of elderly people in Iraq
but aid agencies say that it is the elderly who find
it most difficult to cope with displacement (2). As
a result, they have developed illnesses which, with
a lack of medical assistance, can lead to death.
Elderly are a fragile and vulnerable segment of population,
(like children and need especial care). "Without
a proper diet, medical assistance, pension and welfare
payments, aged people have been indirectly targeted
by increasingly violence in Iraq,(3)" according
to Iraq Aid Association (IAA). "With constant moving
to flee sectarian violence, elderly in Iraq are encountering
accelerated hardships of getting their pensions, their
monthly food rations and are even targeted by insurgents
or militants. Those unable or unwilling to flee their
homes become easy targets for fighters.
The vast majority of the elderly
group are encountering delayed or even not receiving
needed care because of cost. Although the most important
factor affecting the ability to use health services
in the non-elderly is lack of insurance, other factors
have also emerged. Factors highly correlated with lack
of insurance, including race, income, and other sociodemographic
characteristics, have been associated with lower health
care use in younger populations (4-6). Cost appears
to be one of the major factors associated with lack
of access to care. Even in high standard health care
system settings like the USA, between 1995 and 1997,
approximately 11% of Medicare beneficiaries reported
delaying care because of cost or because they had no
specific source of care (7). Because out-of-pocket expenses
are the greatest financial burden for Medicare recipients,
issues of cost in the elderly are primarily related
to insurance coverage supplemental to Medicare. Type
of insurance has been reported to be independently related
to both use of health services and medical outcomes
(8,9). In addition to lack of complementary health insurance,
evidence is accumulating that other sociodemographic
factors may affect the health care services received
by individuals aged 65 years and older, including race,
education, age, and gender.(10-14) It is also becoming
evident that satisfaction with provider services may
impact perceptions of access to health care (15,16)
and clinical outcomes (17,8). Socio-economic indicators
and nature of illness were the most pervasive determinants
of health care seeking behavior among the elderly, overriding
age and sex, and in terms of health-care expenditure,
the nature of illness and quality of service provided
ranked the major determinants (19).
Objectives
Elderly health profile in Iraq in the context of violence,
conflict and social exclusions. To assess response of
health care system health care services (to elderly
needs, problems and sickness).
Methodology
Systematic review research design was carried out by
using multiple search engines utilizing specific key
words relevant to elderly health profile, Iraq, conflicts
and so on with direct interview with experts, as well
as official reports of Governmental and NGOs. Multiple
Electronic databases were carefully investigated, through
a pre-defined search strategy. Additional references
from the bibliographies of retrieved articles and experts
in the area were approached.
Selection Criteria
Only original research articles seeking to identify
the (elderly health and conflicts, Iraq) were included.
By defining the review question and developing criteria
for including studies, we searched for studies, selected
studies and collected data, and assessed risk of bias
in included studies. The initial literature search identified
30 papers. Of these, 13 original articles met the selection
criteria, and directly related to human cost and health
relevance of conflict in Iraq. All were type II evidence
- population-based studies. The methodological qualities
of included studies were assessed using the Downs and
Black checklist.
Findings
Elderly related demographic data in Iraq showed that
the age group 55-64 years represents about 4.2% of the
total Iraqi population (male 652,973/female 713,662)
and for those of 65 years and over: 3.2% of total Iraqi
population (male 487,841/female 561,797) (2014 est.).
While 2.8 percent of the total Iraqi people were 65
years old and older in 2005. Population projections
reveal that the total number of women 55 years and above
in Iraq is estimated to about one million women; which
comprises around 6.8 percent of total women in Iraq,
and about 53 percent of total elderly population aged
55 years and above. The results of I-WISH survey also
showed that 43.3 percent of these women are widowed,
3.3 percent are unmarried and 23.1 percent are heads
of households. The results also showed that elderly
women live in households with an average of 6.5 members,
amongst 13.4 percent who live in households with average
household size totaled to less than 3 persons. About
76.2 percent of these women live in urban areas and
23.8 percent live in rural areas. The results of the
survey reveal also that 72.4 percent of elderly women
are illiterate and only 5.4 percent of them have a diploma
degree or higher. About 35 percent of these women reported
that their physical conditions are either bad or very
bad and there are no differences in women's situation
in Kurdistan and other governorates of Iraq. About 11
percent of these women reported that they are unhappy
with their life in general of whom 6.4 percent live
in Kurdistan and 11. 4 percent in other governorates.
Furthermore, 12.9 percent take care of disabled, sick
or weak members of the household, amongst 46.5 percent
who needed help in this task but couldn't find it. 31.1
percent of these women needed help in eating, drinking,
wearing clothes, moving around and using the bathroom
in the year that preceded the survey. The main source
of this help came from family members (88.8%), while
0.5 percent received help from government health care
workers. Family forms the main safety net for elderly
women in Iraq; about 83.6 percent of women 55+ reported
that family members such as sons, daughters, grandsons
and others provided them with help regularly when needed.
Furthermore, about 66.9 percent provided financial and
material assistance, versus about 71.2 percent provided
health care, and 68.4 percent provided company when
needed.
Health Care Services for
the Elderly
About 52.1 percent of women
55+ needed health care during the month preceding the
survey. About 60.5 percent of these women got it from
government health facilities, of which 30 percent reported
that quality of service was good, while 18.7 percent
reported that quality of the service was bad. About
58.6 percent found it hard trying to get government
health care. This difficulty of finding government health
care increases in other governorates (60.9%) compared
with Kurdistan region (48.0%). Those who faced difficulties
reported different reasons for that; due to inability
to reach the service (40.6%), or due to lack of enough
money to get help (47.7%), and 8.8 percent could not
find anyone to take them to the health facility. There
is a general belief that health care is improving in
Iraq although there are differences by environment and
region.
Covering the cost of health
care
About 40.3 percent of women
55+ faced difficulties to cover the cost of health care.
It is worth noting that this percentage is higher in
Kurdistan region (44.2%) compared with other Iraqi governorates
(39.4%). Only 14.3 percent of women 55+ suffer from
a health situation that requires medical treatment or
medication that government or NGOs cover all/part of
the required cost. Concerns about future: 64.5 percent
of elderly women 55+ were concerned about the future
for different reasons. About 40.6 percent reported to
be concerned due to the likelihood of leaving her usual
residence due to health reasons. Around 53.5 percent
were worried not to have enough money for long term
health care, 49.3 percent were concerned to have to
become a burden on her family, 53 percent were concerned
of the increasing cost of health care and not having
enough money to cover it, and 29.9 percent were afraid
to go to elderly houses.
Violence:
About 11.3 percent of women
55 years and above in Iraq have experienced some kind
of verbal violence by family members during the year
preceded the survey. About 12.2 percent were not allowed
to move freely, 12.9 percent have been told that they
cause burden on the family, and 17.1 percent were left
alone. Women who had income were less exposed to violence,
8.4 percent of them were exposed to verbal violence
and 11.2 percent were not allowed to move freely, 11.7
percent were told they are a burden on the family, and
16.9 percent were left alone.
Elderly women:
Population projections according
to CSO reveal that the total number of women 55 years
and above in Iraq is estimated to be about one million
women; which comprise around 6.8 percent of total women
in Iraq, and about 53 percent of total elderly population
aged 55 years and above. The results of I-WISH survey
also showed that 43.3 percent of these women are widowed,
3.3 percent are unmarried and 23.1 percent are heads
of households. The results also showed that elderly
women live in households with an average of 6.5 members,
amongst 13.4 percent who live in households with average
household size totaled to less than 3 persons. About
76.2 percent of these women live in urban areas and
23.8 percent live in rural areas. The results of the
survey reveal also that 72.4 percent of elderly women
are illiterate and only 5.4 percent of them have a diploma
degree or higher. Elderly women in Iraq have gone through
two fold pressure; on one hand the need to be more dependent
due to their increasing needs for health and social
care; but on the other hand they are requested to take
care of other members especially disabled, sick and
weak family members. About 51.35 percent of these women
reported that their physical conditions are either bad
or very bad, and there are no differences in women's
situation in Kurdistan and other governorates of Iraq.
About 11 percent of these women reported that they are
unhappy with their life in general of whom 6.4 percent
are in Kurdistan and 11.4 percent in other governorates.
Furthermore, 12.9 percent take care of disabled, sick
or weak members of the household, amongst 46.5 percent
who needed help in this task but couldn't find it. As
for the need for help in daily activities, the results
of the survey showed that 31.1 percent of these women
needed help in eating, drinking, wearing clothes, moving
around and using the bathroom in the year that preceded
the survey. The main source of this help came from family
members (88.8%), while 0.5 percent received help from
government health care workers. Family forms the main
safety net for elderly women in Iraq; about 83.6 percent
of women 55+ reported that family members such as sons,
daughters, grandsons and others provided them with help
regularly when needed. Furthermore, about 66.9 percent
provided financial and material assistance, versus about
71.2 percent who provided health care, and 68.4 percent
provided company when needed. In regard to health care,
about 52.1 percent of women 55+ needed health care during
the month preceding the survey. About 60.5 percent of
these women got it from government health facilities,
of whom 30 percent reported that quality of service
was good, while 18.7 percent reported that quality of
the service was bad. About 58.6 percent faced a hard
time trying to get government health care. This difficulty
of 52 finding government health care increases in other
governorates (60.9%) compared with Kurdistan region
(48.0%). Those who faced difficulties reported different
reasons for that; due to inability to reach the service
(40.6%), or due to lack of enough money to get help
(47.7%), and 8.8 percent could not find anyone to take
them to the health facility. There is a general belief
that health care is improving in Iraq although there
are differences by environment and region. About 40.3
percent of women 55+ faced difficulties to cover the
cost of health care. It is worth noting that this percentage
is higher in Kurdistan region (44.2%) compared with
other Iraqi governorates (39.4%). About 12.2percent
were not allowed to move freely, 12.9 percent have been
told that they cause burden on the family, and 17.1
percent were left alone. Women who had income were less
exposed to violence, 8.4 percent of them were exposed
to verbal violence and 11.2 percent were not allowed
to move freely, 11.7 percent were told they are a burden
on the family, and 16.9 percent were left alone have
no income.
Regarding mortality rates of NCD among elderly in Basra
governorate south of Iraq , the study revealed that
most of NCDs mortalities increased on 2007 comparing
with 1978.
Table 1: shows frequency
distribution of health care services (access and cost
) provided to elderly as per their perception all over
Iraq 
Health Survey- (I-WISH) Iraq Elderly Women)(25)
Click here for Figure
1: Trend of quality of Governmental health services
provided to elderly population in Iraq. (http://www.irinnews.org/report)
Figure 2: Distribution of elderly population in Iraq
based on income and Future concerns
Health Survey- (I-WISH)
Iraq Elderly Women)(25)
Figure 3: Distribution
of elderly population in Iraq by Urban- Rural and Future
concerns
(Health Survey- (I-WISH) Iraq Elderly Women)
Figure 4: Death
Rate of selected cause of Death among elderly people
above 65 age in Basra governorate (1978 and 2007).(26)
(Age-standardized mortality rates by cause in Basra,
Iraq: 1978 and 2007)
Discussions
The study revealed that the elderly percentage in Iraq
is considerably higher than UAE (20) , but much less
than 12.6 percent of the U.S. population and 17 percent
in Japan are 65 or older (21). Elderly in Iraq kept
suffering multiple burdens, as they are a truly vulnerable
and fragile segment, and due to the lagging of response
of health care system in Iraq to needs and problems,
the violence and the conflicts added major burden to
their suffering leaving them victims to shortage of
care, illnesses, helplessness, and pushing them to facing
their hard fate lonely. Some of the elderly were even
left as direct victims to the conflicts and violence
widely spread in the country(22).
The hard circumstances that
the country faced - the fighting and killings, the displacement
- all of these factors have left senior citizens homeless.
Aging Iraqis traditionally lived with relatives, but
as conditions in the nation have worsened, a new phenomenon
has popped up: the old folks' home (23). The elderly
in Iraq have been dealt a very bad hand and short of
a miracle very little can be done to help them,"
according to Iraqi Medical Association. "Sometimes
they just close the door of the house and wait to die
slowly." The most vulnerable senior citizens are
in frail health with little or no income and cannot
live independently. Many have no children to support
them or have never married. Adding to their misery,
Iraq's devastated health care system makes it nearly
impossible for Baghdad's elderly residents to receive
adequate medical treatment. The lack of potable water
and electricity here further threatens their welfare
during the sweltering summer months. For Iraqis like
87-year-old Mariam Ansari, who have beaten the odds
and endured, self-preservation these days is a daily
struggle. Mrs. Ansari lives in a single room with cement
walls.
Elderly women in Iraq are gone through twofold pressure;
on one hand threatened to be more dependent due to their
increasing needs for health and social care; but on
the other hand they are requested to take care of other
members especially disabled, sick and weak family members.
About 35 percent of these women reported that theirre
physical conditions are either bad or very bad and there
are no differences in women situation in Kurdistan and
other governorates of Iraq. About 11 percent of these
women reported that they are unhappy with their life
in general of whom 6.4 percent in Kurdistan and 11.
4 percent in other governorates. Furthermore, 12.9 percent
take care of disabled, sick or weak members of the household,
amongst 46.5 percent needed help in this task but couldn't
find it. The results of the survey showed that 31.1
percent of these women needed help in eating, drinking,
wearing clothes, moving around and using the bathroom
in the year that preceded the survey. The main source
of this help came from family members (88.8%), while
0.5 percent received help from government health care
workers. Family forms the main safety net for elderly
women in Iraq; about 83.6 percent of women 55+ reported
that family members such as sons, daughters, grandsons
and others provided them with help regularly when needed.
Furthermore, about 66.9 percent provided financial and
material assistance, versus about 71.2 percent provided
health care, and 68.4 percent provided company when
needed.
Some elderly Iraqis have lost
all their relatives over the past few years and now
have to fend for themselves. Being unable to work because
of age or health conditions, some of them have turned
to begging in the streets while others are supported
by their neighbors. According to local NGOs and doctors,
the general health of elderly people has been fast worsening
in the past three years. "Limited healthcare access,
deteriorating services and deteriorating social support
networks are making elderly people more vulnerable to
diseases and worsening their current illnesses,".
Many elderly people in Iraq were suffering various heart
diseases which were under control before the US-led
invasion of 2003 but now, with a dire lack of medicines
and equipment in the country, were going untreated.
"For those living in displaced camps or improvised
tents, the situation is critical as they cannot reach
hospitals on time and so might die for lack of medical
assistance (24).
Conclusion
The elderly population in Iraq continue to be victims
of a non-responding health care system in terms of high
numbers of elderly "bed blockers" at the main
acute hospitals. (Cost); Lack of Elderly Rehabilitation
Centers. (Transitional care); and Lack of Local Geriatricians
or physicians trained in geriatrics. There are slowly
developing geriatric services but lack of Geriatric
teaching in medical school's curriculum. There is an
under developed community services model. (Not ideal)
The UN needs to provide equal service delivery among
the needy sector. There are geographic variations, in
accessibility to and quality of services. There is lack
of emergency hotlines for older persons, lack of trained
geriatric nursing services, and the elderly are directly
and indirectly victimised by long term conflicts and
never ending violence cycles.
Recommendation
There is a need to formulate a National Strategy for
the elderly that will include the following
1. Setting up sustainable
national elderly protection
2. Setting up national care program
3. Involving multisectors of the society in the
care
4. Developing elderly care policies to address
care access, care cost, care quality& other gaps.
5. Recognizing elderly population as fragile,
vulnerable victims for the conflict and violence context.
6. Establishing national committee for the care
of the elderly.
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