US War with Iran: A Narrowly Avoided Public Health Crisis and a Continuing Risk

The protracted conflict in Yemen-a civil war fought by proxies of Iran on one side and Saudi Arabia and the United States on the other-has ravaged the health care sector and facilitated the worst cholera outbreak on record, with more than 1 2 million people infected 2 Public health experts believe that destruction of infrastructure vital for health care delivery, such as the nation's largest seaport-an important gateway for the delivery of medical supplies and water, sanitation, and hygiene infrastructure-as well as security concerns related to ongoing violence, allowed this vaccinepreventable disease to rapidly propagate through the affected population The war, which started in 2011 as an outgrowth of the Arab Spring, marked a reversal of this trajectory 3 Perhaps most detrimental to public health in Syria are deliberate attacks on health care workers and facilities, which have been well documented since 2011 and are unprecedented in terms of scale 4 The United Nations and nongovernmental advocacy groups have documented and spoken out about the direct targeting of medical personnel, which amounts to war crimes under international law 4 Not only have these attacks limited the number of health care workers willing or able to address the health care needs ofthe besieged population, but they have created a powerful deterrent, preventing civilians from seeking care for fear of being caught in an assault- which is, perhaps, the intended goal The First Gulf War, along with crippling sanctions imposed by the United States, negatively affected Iraq's health care infrastructure, an effect that intensified during and after the 2003 US invasion 5 According to interviews with Iraqi refugee doctors, the war resulted in a substantial decline in health care services 5 In fact, four vaccinepreventable disease outbreaks- measles in 2009, mumps in 2004 and 2016, and rubella in 2004- occurred in the postinvasion period 6 Outbreaks such as these remind us that the lingering effects of conflict can last years or even decades after the declared war ends