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Waterborne Diseases and Wastewater Treatment in Iraq
Ewen C. D. Todd
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https://doi.org/10.1016/j.jfp.2023.100204
JFP 100204
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Journal of Food Protection
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28 September 2023
29 November 2023
1 December 2023
Please cite this article as: C. D. Todd, E., Waterborne Diseases and Wastewater Treatment in Iraq, Journal of
Food Protection (2023), doi: https://doi.org/10.1016/j.jfp.2023.100204
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Waterborne Diseases and Wastewater Treatment in Iraq
Ewen C. D. Todd
4183 Indian Glen Drive
Okemos, Michigan 48864
517 347-4270
todde@msu.edu
Abstract. Iraq is a desert country with access to large river resources and an extensive aquifer,
but these have already been overdrawn for domestic, industry and agriculture use. The
diminished flow of the Tigris and Euphrates rivers has allowed seawater intrusion from the
Persian Gulf 110 km up as far as Basra, the county’s third largest city. In addition, water
distribution systems are overloaded and wastewater treatment plants (WWTP) need upgrading,
and fresh water sources polluted by lack of sanitation, agricultural runoff, household and
industrial waste, and including the irrigation of vegetables with sewage water, have led to
episodes of bacterial, viral and parasitic diseases. Also, there have been increases in many types
of cancer since the early 1990s, and based on clinical and epidemiological data, these increases
could be attributable to exposure to depleted uranium in the environment arising from conflict in
Iraq and particularly during the Iraqi War started 20 years ago. The population affected would
like government action to reduce their health concerns, and policies that have been proposed for
improving water availability and quality, as well as but have not been followed up sufficiently to
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tackle these, including increasing the capacity and efficiency of WWTP; promoting the most
efficient irrigation techniques for the local growing conditions; reducing the use of chemical
fertilizers and pesticides that can decrease the water quality; reducing saline intrusion challenges;
building compact desalination units; constructing water storage facilities to address water
scarcity challenges; and establishing public education plans for consumers to reduce the water
demand during the hot season. Whether the government rises to the task remains to be seen.
Also, do those countries that used the DU have a responsibility to remove or otherwise dispose
of the fragments that remain?
Keywords: Iraq; wastewater treatment; waterborne diseases; depleted uranium; restoration;
recommendations; policies
Highlights
Much of the renewable water in Iraq is of poor quality for drinking or irrigation.
Wastewater treatment plants are often poorly maintained or overloaded.
Contaminated water has led to continuing population exposure to enteric diseases.
Depleted uranium ordinance fragments in the environment may be a health risk.
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Policies for wastewater treatment need input from appropriate institutions and farmers.
Introduction
This review is based on searches on relevant articles through Google Scholar, government, NGA
newspaper and blog sources, covering wastewater (WW) and its treatment; the presence of
bacterial, parasitic and viral pathogens and diseases related to polluted water and WW; and
studies on depleted uranium (DU) which is present in Iraq, through the years 2001 to 2023. The
population of Iraq is estimated at over 40 million, most of which is Arab (75-80%), or Kurdish
(15-20%). The largest cities are Baghdad (7.71 million), Mosul (1.8 million), Basra (1.5
million), Kirkuk (1.1 million), Najaf (960,000), and Erbil (897,000) (CIA, 2023). The
topography is mostly desert with mild to cool winters and dry, hot, cloudless summers. There are
reedy marshes along the Iranian border in the south with large, flooded areas. Water from the
Tigris and Euphrates rivers are shared with Turkey, Syria, and Iran; at the south they join to form
the Shatt al Arab before entering the Gulf. Turkey contributes about 90% of the total annual flow
of the Euphrates, and 38% of the Tigris, which means that country can partially control the flow
of the rivers. Land for agriculture is limited to only 18.1%, with 8.4% arable, 0.5% permanent
crops, and 9.2% permanent pasture. Iraq is rain dependent in the north and irrigation dependent
in the south. Wheat, barley, rice, vegetables, dates, cotton; cattle, sheep, poultry are produced
mainly concentrated in the south of Samara and in the east. However, the poor performance of
the agricultural sector and lack of employment prospects drive migration to the urban areas to
generate weight on service delivery and increase urban poverty (Cordesman, 2015). Population
growth combined with the need to produce more food from a limited and shrinking resource base
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of land and water have led to farming systems that tend to maximize short-term returns at the
expense of long-term sustainability. Government subsidy programs seriously distort markets and
demands for production efficiency. Some arable land is irrigated, much from the Euphrates and
Tigris River systems, but also from the Arabian Aquifer System shared with many Middle
Eastern countries, the most over-stressed aquifer system in the world. These river systems have
been reduced by upstream diversions and more of these are projected in the next 20 years,
reducing the water available to Iraq by up to 60% (Al-Ansari et al., 2014). The AQUASTAT
database (FAO, 2008) indicates that Iraq has access to approximately 100 BCM (billion cubic
meters) of renewable water resources per year, equivalent to 2,338 m³ per capita per year. This
includes around 96.5% surface water resources and only around 3.5% renewable groundwater
resources. Use of available water in different sectors in 2010 was: agriculture 46.000 BCM;
domestic 3.78 BCM; industrial 2.77 BMC; electric 0.40 BMC; groundwater 2.58 BMC; treated
wastewater; 0.58 BMC; agricultural drainage 7.00 BMC (Aziz and Aws, 2012). In Iraq, there is
about (580) million m3 of treated sewage waste. Most of non-treated wastewater is used by
farmers to irrigate some food crops like lettuce, cabbage, peppers, tomato, beans, and also the
raw sewage used for nonfood crop like alfalfa, clover. maize, cotton, sunflowers. WWTPs may
discharge treated wastewater without following national environmental regulations to increase
river pollution. Unfortunately, Iraq suffers from many problems in its infrastructure, such as
those related to water losses through its water distribution networks, water overuse in old
irrigation schemes, and pollution of fresh water sources by back water from irrigation and
sanitation. The efficiency of the distribution network is very poor (32%) and it is deteriorating
with time (Al-Ansari et al., 2014). Quality of drinking water often does not meet World Health
Organization (WHO) standards or Iraqi national water quality standards, and the high
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contaminated leaked sewage water threatens potable water networks. The estimated effluent that
discharged untreated directly to the rivers is over 0.5 MCM/day. Improper wastewater treatment
is acute in Iraq following decades of wars and sanctions combined with limited environmental
awareness by both public and governmental representatives, which have contributed greatly to
the destruction of Iraq’s national water system (Alyaseri, 2016). According to the United
Nations, six million people have no access to clean water, and more than 500,000 Iraqi children
access their water from a river or creek and that over 200,000 access their water from open wells.
In the first six months of 2010, there were over 360,000 diarrheal cases as a result of polluted
drinking water and a lack of hygiene awareness among local communities, particularly
vulnerable groups such as women and children. The report showed that every day at least
250,000 tonnes of raw sewage are pumped into the Tigris River threatening unprotected water
sources and the entire water distribution system.
Groundwater recharge originates from three main sources: naturally from precipitation
and the infiltration of surface water, and artificially from irrigation in agriculture (Anonymous,
2022). Recharge occurs mainly in the northern, more rain-laden areas of Iraq, where recharge
rates can reach 100-300 mm/yr. Groundwater recharge in the south is negligible at less than 20
mm/yr. The annual recharge and sustainable groundwater yield is far from being enough to
replenish existing groundwater sources, which will be further impacted by the forecasted
removal by Iraq’s upstream riparian neighbors. This is partially offset by the Iraqi government’s
construction of the country’s first major desalination plant in Hartha, 20 km north of Basra in
2019. Construction was completed in 2019. Desalination is generally divided into thermal, which
includes Multi-Effect Desalination (MED) and Multi-Stage Flash (MSF) methods, temperature
controlled heat processes to avoid scaling, generally co-located with thermal power stations to
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use excess heat (Tollast, 2020). The other main type of desalination is membrane-based or
Reverse Osmosis (RO) which is now the most common type globally as membrane technology
has improved. The reverse-osmosis plant is designed to desalinate 199,000 m³ of brackish water
from the Shatt al-Arab per day, providing drinking water to 400,000 people in Basra. It is part of
a larger government project to improve water supply in the Basra governorate. Plans for another
large-scale desalination plant in Al Fao along the Gulf coast are currently being developed. This
may use MSF or RO plant, or it could be hybrid of these methods until better membrane
technology is developed. RO has several advantages in most regions. It typically uses half the
energy of thermal processes. However, membranes can be vulnerable to microbiological fouling
and for water with high sediment such as in the Shatt al Arab, much pre-treatment is required.
Rainwater harvesting schemes, usually in the form of dams along wadis, play an
important role in the management of Iraq’s water resources. They allow for the retention of
rainwater after high-intensity rainfall, which can then be used to replenish groundwater
resources. However, many of these dams have been affected by the build-up of sediment in their
reservoirs, reducing their storage capacity.
The current reuse of treated wastewater in Iraq is negligible, because there is limited
WWTP infrastructure capacity across the country, particularly in rural areas, and the knowledge
of the efficient reuse of wastewater is lacking (Anonymous, 2022). Recommended uses for
treated wastewater include municipal, such as street cleaning and watering of park spaces,
agricultural, such as irrigation of fodder crops, and industrial, such as cooling in industrial
processes and energy production. Due to the low overall irrigation efficiency in Iraq, most
drainage water is returned to rivers, with only a portion of it being collected and reused. The
Ministry of Water Resources plans to modernize its drainage water collection system in order to
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better reuse irrigation water, which is critical to meeting the country’s future water needs.
Among other things, the treated water can be used for oil well re-injection, creating green belts to
combat desertification and augmenting the water available for the Mesopotamian Marshes of
southern Iraq.
Wastewater treatment plants in Iraq
Al-Dewaniya is the capital city of Iraq's Al-Qādisiyyah Governorate (population, over 440,000),
and is situated 32 km west of a channel of the Euphrates River which is used for irrigating
farmland. This region is considered to be one on the most fertile parts of Iraq, and is heavily
farmed, with agriculture being the main occupation of residents cultivating palm trees, vineyards,
and orchards. Ghawi and Kriš (2010) reviewed the records of the Al- Dewaniya Wastewater
Plant (DWWTP) in Iraq. This plant showed that the influent quantity had reached the maximum
hydraulic designed loads. Thus, there is a concern that any water or biosolids from the effluent
could have public health concerns. Due to the natural increase in population of the city and the
connection of the non-sewered areas to the sewage network, the influent reached more than 2300
m3/hr. This negatively affected the treatment capacity of the system and as a result the quality of
the effluent deteriorated with biochemical oxygen demand (BOD) effluent of more than 60 mg/l.
The final discharge points of the treatment plant effluent are the Al-Dewanyia River which leads
into the Euphrates. The biological river water quality exceeds the WHO standard in most
locations of Al-Dewanyia River and health impact indications were observed on river users. In
addition, the water quality of agricultural nearby the effluent of DWWTP showed a large
increase in concentration of nitrates. The limited hydraulic capacity of plant has forced the
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Municipality of Dewanyia to divert the sewage flow from the pumping station directly to the
river, which increased the negative impacts on the river environmental quality and human
exposure downstream from the discharge points.
Sewage enters the primary treatment plant (mechanical) followed by aerated lagoons that
are designed to receive the separated domestic wastewater from the city, with the final effluent of
the plant planned for agricultural use. Suspended solids and turbidity are reduced by coagulation
and flocculation. Coagulation uses salts such as aluminum sulfate (alum) or ferrous or ferric
(iron) salts, which bond to the suspended particles, making them less stable in suspension. Alum
and ferrous sulfate showed better turbidity removal than that of lime and ferric chloride. A
mixture of alum and ferric chloride removed all the colloidal suspended solids at a dose of 200
ppm. Although the coagulation and precipitation improved the chemical oxygen demand (COD)
removal by about 40%, the relatively high cost for the coagulants may limit the application of the
process in the field.
Treatment inside factories was recommended rather than in mixed wastewater.
A sewage treatment plant was designed for the city of Al-Nasiriyah in Dhi Qar
governorate in southern Iraq near the junction of Tigris and Euphrates rivers serving 316,083
inhabitants (Ghawi, 2018). The resulting treated water was suitable for agricultural irrigation and
can be discharged to the Euphrates River after chemicals to the WWTP were added to remove
nitrogen and phosphorus compounds that would lead to eutrophication and algal growth. The
plant design was optimized by implementing modeling and simulation software, after the total
phosphorus flow was found to be higher than the desired limit of 2 mg / l, due to the excessive
release following anaerobic digestion. Phosphorus levels were controlled by adding aluminum
doses in the water line. This approach met the limits of the Iraqi standard of water used in
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irrigation; the effluent of TSS, COD, BOD, TN (total of nitrate-nitrogen (NO3-N), nitrite
nitrogen (NO2-N), TKN (total ammonia-nitrogen plus organically bound nitrogen), ammonium,
nitrate, and TP were approximately 11 mg/l, 87 mg/l, 2.1 mg /l, 8.6 mg /l, 1.8 mg/l, 0.4 mg/l, 6.8
mg/l, and 1.8 mg /l, respectively. This chemical addition allowed the effluent to conform to the
Protection of Rivers Law No. 25 of 1967, and also the System of National Determinants of the
Use of Treated Wastewater for Irrigation or to Discharge into Fresh Rivers, Law No. (3) of 2012.
Some predictive modeling on the health effect of improper WW treatment was done by
Alyasedri (2016) at the Alsamawah WWTP, located midway between Baghdad and Basra. The
author noted it would require a major effort to overcome its inefficiencies like many other
WWTPs in the country. The plant was not able to reduce contaminants such as COD, TSS, oil
and grease, or nutrients, and failed to comply with local regulations. Analysis of treatment
showed that most damages are related to climate change, depletion in resources, and human
toxicity, but also it encounters operating difficulties. In terms of annual negative consequences, if
the plant continues the existing treatment method, these will cause the city of Alsamawah 7.3
disability-adjusted life years (DALYs) and $1.1×107 more expense on future generations, as well
as loss of biodiversity. Treatment of one cubic meter wastewater in Alsamawah WWTP caused
an environmental burden equal to 44.9 mPt. To avoid these human and financial costs, the City
of Alsamawah should strive to achieve more efficient treatment in reducing the discharging
pathogens and chemical pollutants. If such efficiency could be achieved, the use solids as a
resource of energy would offset treatment costs.
Enteric diseases caused through inadequate wastewater treatment
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Waterborne diseases are widespread due to polluted drinking water supplies. Reports from the
Ministry of Environment for 2009 indicate that bacteriological contamination in the water supply
varies between governorates, ranging from 2.5% to 30%, with an average of 16%, exceeding
both Iraq’s National Drinking Water Standards and the World Health Organization’s Guidelines
for Drinking Water (Anonymous, 2022). Datasets regarding other pollutants, including organic
and inorganic substances, pathogens and bacteria, are limited in Iraq, which makes it difficult to
fully characterize the sources and extent of contamination or project changes that may occur in
the future. In addition to dissolved and suspended pollutants, waterways in Iraq suffer from high
levels of pollution from solid waste, including both household and industrial waste, as well as
rubble from damaged buildings in areas affected by recent conflicts. In Iraq, bacterial diarrhea,
hepatitis A, and typhoid fever are listed as major food or waterborne diseases, with water contact
diseases of leptospirosis and schistosomiasis. For instance, typhoid fever was common, with an
of 21 cases/100 000 patient-years in Sulaimania, Iraqi Kurdistan (Dworkin et al, 2014). The
second biggest city, Basra, has been suffering from contaminated water supply for almost a
decade, endangering the health of its residents as a result. Meanwhile, several other parts of the
country have been affected by poor water quality as well. The residents of Basra, home to some
1.2 million people, have suffered this contamination. The city gets it water from the Shatt AlArab River (SAR), which is a confluence of the Tigris and Euphrates Rivers, but which has
become inundated with industrial waste and sewage, as well as a high concentration of salt. The
collapse of appropriate sanitary facilities in Basra's schools is putting more than 277,000 children
at risk of waterborne disease with symptoms of diarrhea, vomiting, and rash (Aldroubi, 2018).
This situation has been caused by a number of different factors: few available WWTPs; lax
sewage and industrial waste standards; and a general ignorance around adequate waste disposal
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measures. During periods of low rainfall, reduced water flows contribute to a backflow of
saltwater from the Persian Gulf into the Shatt al-Arab with salinity levels 50 times the accepted
level for drinking water. This has affected not only people, but aquatic life and agricultural
yields. As well as water scarcity, oil-rich Basra province suffers from frequent power cuts, a
stagnant economy, poor health services, widespread corruption, unemployment and an
agriculture sector devastated by drought. This gave way to the rise of violent protests in 2018,
with more than half of the city's 800 schools in urgent need of emergency support. This began in
the summer, partly triggered by at least 118,000 admissions to hospitals by those claiming to
have been poisoned by contaminated water (Mason, 2022). No official report was released on the
sources of the contamination, but a scientific analysis of local water quality in 2018 revealed
critical levels of various pollutants and high salinity, which the authors attributed, respectively,
to insufficient raw water supplies and saltwater intrusion from the Persian Gulf (Almuktar et al.,
2020). That year, the water flowing to the SAR from rivers upstream decreased, resulting in
elevated levels of sewage, agricultural and industrial pollution, as well as high salinity due to the
intrusion of saline water from the Arabian Gulf. Water supply failures remained a major source
of public grievance in Basra (protests erupted again in 2019 and 2020). Water withdrawn from
the SAR supplies 60% of the water for treatment plants in the Basra governorate but requires
costly desalination and purification processes: it is often mixed with supplies from the Bada’a
Canal to improve water quality. Though the government claims to have a 20-year plan to
rehabilitate the water supplies, little had been done because of the war against ISIS (Islamic State
of Iraq and Syria). Since the 1990s the failure of the public water infrastructure to produce
sufficient potable water has compelled city residents to buy drinking water from private vendors.
Some families require water vendor supplies of 1-2m3 per day for both family and livestock
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(Tollast, 2020). Domestic tap water is used instead for cleaning homes and cars, watering and, if
not turbid, washing and cooking. Between 30 and 40% of the raw water is estimated to be lost to
leakages and illegal connections ‘illegal extraction’ where the piped public water is routinely
tapped into by, amongst other uses, ‘illegal housing’ (hawasim), factories, car washes and
horticultural businesses, supported by politically sanctioned corruption (Mason, 2022). The
effluents from eight WWTPs were tested and showed that all were inadequate to treat raw water
for drinking or irrigation purposes mainly due to the very bad raw water quality provided by the
SAR as well as the lack of maintenance for such plants, resulting in very low removal
efficiencies for various water contaminants (Almuktar et al., 2020). Water treatment in the Basra
governorate uses the conventional coagulation-filtration process, which is suited for most surface
waters, but will not lower total dissolved solids (TDS) levels. Hence, the population started to
use the water supplied from the WWTPs designed for purposes other than drinking and cooking.
Drinking water is usually purchased (reverse osmosis water) from private suppliers in containers
or delivered in bulk by tank truckers. Almost all WWTPs use aluminum sulphate (alum) as a
coagulant. However, this treatment method has rarely been fully effective because the dosing
equipment commonly malfunctions, as does that for chlorination (see section on Wastewater
treatment plants in Iraq). While the deterioration of Basra’s water sources has been a persistent
problem for decades, it became a full-blown crisis in the summer of 2018, when at least 118,000
people were hospitalized due to poor water quality. The protests were partly fueled by
government inaction as well as illnesses linked to the water supply. Iraq is rated the 170th most
corrupt nation out of the 175 countries rated by Transparency International, and it has an
extremely large and badly managed state sector, and the World Bank rates it as the 156th worst
of 185 Countries in its Global Ranking of Ease of Doing Business rankings (Cordesman, 2015).
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What was the evidence of pathogens causing waterborne diseases? Viruses play a large
role in transmission of food and waterborne diseases and WW is a major source of these. Human
astroviruses and human noroviruses are shed in high numbers by infected individuals and persist
for a long time in wastewater posing a serious threat to human health globally. Hamad et al.
(2022) found a high detection rates of these pathogens in WW samples collected from sewage
water plants and draining canals in Diyala province Iraq, using PCR sequencing and
phylogenetic analyses to genotype them. The study suggests that documenting sewage virome
using molecular methods provides information for molecular epidemiology and may be useful in
developing strategies to prevent further spread of viruses. Al Nasrawi et al. (2010) describe an
outbreak of hepatitis E virus (HEV) infection in Al-Sadr city, Baghdad. Blood samples obtained
from patients with jaundice attending 19 primary health care centers in Al-Sadr city during a 6month period in 2005 were tested for the virus, and HEV IgM antibodies were detected in 38.1%
of 268 patients. The association of HEV infection with unacceptable residual chlorine
concentrations and/or bacteriologically unsafe water samples was significant. High rates of HEV
infection, low chlorine concentrations and unsafe water were reported in June, 2005. It was
determined that gross disruption of sanitation and water supplies was the most likely contributing
factor in these illnesses.
In 2007, cholera spread across Iraq with more than 3,300 cases identified as positive for
Vibrio cholerae, and more than 30,000 people fell ill with acute watery diarrhea (UN, 2007).
Most laboratory-confirmed cases occurred in the north in Kirkuk and Sulaymaniah, but an
increasing number of cases of acute watery diarrhea were also recorded in the south. This is
typically a waterborne disease, and these cases were linked to the poor quality of water and
sanitation systems that greatly facilitates cholera contamination. WHO procured 5,000,000
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water-treatment tablets to decontaminate any drinking water for residents. Cholera continued
periodically over the years with little attention until a major outbreak started on June 19, 2022,
when Iraq’s health authorities announced at least 13 cases were confirmed across the country and
thousands of hospital admissions for acute diarrhea were reported (OCHA. 2022; WHO, 2022).
The number of diarrheal cases kept increasing well beyond the normal ranges witnessed in
previous years. By November 2, 2022, there was a total of 3,063 confirmed cholera cases and 19
deaths across the country, spread from Kirkuk and the north to other governorates due to the
persistent movement of the people across the country. The irrigation of vegetables with sewage
water, an increasingly common practice due to water shortages in both the Euphrates and Tigris
rivers, was the reason given for the continuing outbreak. The situation was further exacerbated
by the COVID-19 pandemic, along with the already-weak state of the overly stretched national
health infrastructure. Unfortunately, the people have some hesitation in drinking water treated
with Aqua tabs (releases hypochlorous acid) with the complaint that the natural taste is lost.
Communication on the derived benefits from disinfected water would help change the perception
of water treated with chlorine or Aqua tabs. During the Persian Gulf War of 2005 to 2011, there
were 36 208 cases of typhoid documented (Zolnikov, 2013). This was when 20% of the general
Iraqi population and 40% of rural citizens did not have access to safe drinking water; and 17% of
the Iraqi population did not have access to adequate sanitation services. In fact, violence
continued well past that War, in this case over scarce water resources which has persisted in
various forms for thousands of years, driven by complex ideological, religious, economic, and
strategic factors (Gleick, 2019). The Tigris and Euphrates basin is shared by Turkey, Syria, Iraq,
and Iran, all of which build dams to divert the river flow. These dams, along with the water
14
delivery systems associated with the rivers were significant targets and weapons of armed
conflict in the region during the ISIS occupancy (2013-2018).
Based on 33 Salmonella enterica cases from 320 diarrheal hospitalized young children
living in south-eastern Iraq, multivariable logistic regression analysis indicated that the odds of
Salmonella infection in children from households supplied by pipe water was 4.7 times higher
compared with those supplied with RO-treated water (Harb et al., 2017). Salmonella infection
was also three times lower in children belonging to caregivers who reported always washing
hands after cleaning children following defecation, versus those belonging to caregivers who did
not wash their hands. These data indicate that contaminated water sources could have infected
the children and the infection spread through lack of personal cleanliness. Most of the
Salmonella isolates were classified as multi-drug resistant (84·9%). That Salmonella could arise
from treated water was shown by Hassan and Mahmood (2018) who found Salmonella in
drinking water from one of two Baghdad’s treatment plants in the spring and summer (5.5 - 6.3
CFU 100/ml). Other parameters of microbial contamination (APC, TC, and fecal coliform) also
exceeded the allowable limit for drinking water in summer in both plants. The highest counts of
enteric bacteria in summer can be attributed to suitable environmental conditions for growth, also
to the domestic WW and random defecation events on the riverbanks by both humans and the
animals that graze along these banks. Furthermore, the intermittent detection of Salmonella in
aquatic environments may be due to the period of the irregular adding of chlorine due to the
malfunction of the chlorination pumps.
A review of the extent of waterborne parasites in Iraq showed that many intestinal
parasites are transmitted by sewage water that can lead to cause diseases in both human and
animals including protozoans Cryptosporidium sp., E. histolytica and Giardia lamblia in fresh
15
and tap water in some provinces of Iraq (Hind et al., 2020). In one study, the total contamination
rate in sewage water in Baghdad Province was 60% with Ascaris lumbericoides, Entamoeba
histolytica, Fasciola sp. and Strongyloides stercoralis, and 17.2% in tap water. Drinking raw or
municipal water and living with four or more children at home were significantly associated with
G. lamblia giardiasis infection, exacerbated in hot weather. Cryptosporidium oocysts and other
parasites are resistant to environmental conditions and WW disinfectant treatment, and can
penetrate the physical barriers to water treatment because of their small sizes. Moreover, they are
resistant to many disinfectants used in water purification.
Saheb (2018) showed that the highest levels of visceral and cutaneous leishmaniasis
infection (21.91%, 13.85%), toxoplasmosis (20.0%), giardiasis and amoebiasis (20.21%,
12.72%) respectively, were in different governates. Because of the absence of new projects for
WWTPs since 1986 in most of Kirkuk province, led many regions in Kirkuk city to illegally
combine their domestic sewer drainage with the rainwater network of their districts, resulting in
an increased burden of infections and diseases among small children and infants. A cohort study
found that the most probable explanation of disease incidence increase was due to the emission
of sewer gas from the rainwater duct slot containing pathogenic microorganisms (Tawfeeq and
Taher, 2018). The significant decrease in rainfall and the accumulation of solid wastes in the
streams all together had possibly increased the presence of pathogenic bacteria because many
enteric bacteria were isolated, particularly Escherichia coli and Pseudomonas aeruginosa.
The estimated prevalence rate of parasitic diarrhea in Al Sadr city was 22% (ALKubaisy
et al., 2014); the major diarrhea determinants were large household size, residential location,
water source, low socioeconomic status, and low parent education. Giardia lamblia was found to
be the most prevalent parasite with an infection rate of 45.5% followed by Entamoeba histolytica
16
23.4%, Enterobius vermicularis 12.7%, Hymenolepis nana 9.8%, Trichuris trichiura 5.4%, and
Ascaris lumbricoides 2.2%. This study demonstrated that poor sanitation, inadequate
environmental conditions, and low socioeconomic status were the main determining factors that
predispose children to parasitic diarrhea. Mass deworming programs was recommended for
school children, as this population is easily accessible.
Research on contamination and treatment of wastewater
In Iraq, most of the WW used by farmers to irrigate food crops like lettuce, cabbage, peppers,
tomato, beans are not treated; and also, raw sewage is used to fertilize nonfood crops like alfalfa,
clover. maize, cotton, sunflower (Aziz and Aws, 2012). For instance, in Baghdad, treated
effluent directed to the Diyala River from Rustumiyah and Karkh treatment plants goes to Tigris
River through additional natural flow purification processes before it is abstracted for irrigation
downstream, but if the treatment does not follow national environmental standards, river
pollution will increase, and crops will be contaminated by heavy metals like lead and cadmium.
Aziz and Aws (2012) tested different stages in the output from the Rustumiyah WWTP: dried
sewage sludge, non-treated sewage, treated sewage, and tap water. The results showed that
sewage sludge and untreated influent with its positive value as a crop nutrient source and soil
improvement properties, however, causes potential hazards with microbiological and heavy
metal accumulation. A repeated study by Rasheed (2016) showed that problems continued, with
the most important factor being at the first stage (settlement of heavy solids), which failed to
withdraw TSS (total suspended solids) and TDS (total dissolved solids), which negatively
affected the next treatment stages. Also, the amount of water entering the plant was more than
17
the capacity was designed for, leading to discharge of untreated water directly into the river
without treatment, as has been shown elsewhere in Iraq. The issues, summarized below, are
probably typical of many Iraqi WWTPs.
1. The amount of water entering the plant is more than the designed capacity, leading to
discharge of untreated water directly into the river without treatment.
2. The repeated interruptions in the power supply lead to a lack of plant efficiency.
3. The water is discharged to the station treated with physical and biological methods only, and
there is no other treatment that result in high concentrations of the chemicals such as
phosphates and sulphates affecting the effluent.
4. The lack of specialized technical staff in sufficient numbers for the operation and maintenance
of WWTPs in all its stages.
5. The discharge of effluents from the industrial and service activities directly through the sewer
system in addition to human waste negatively affects the terminal units and hampering the
liquidation process.
6. Untreated fats resulting from processing plants are landfilled at the site.
Reed beds are an alternative technology WWT system that mimic the biogeochemical
processes inherent in natural wetlands (Begg et al., 2001), and sludge drying reed beds appear as
a new and alternative technology which has low energy requirements, reduced operating and
maintenance costs, and causes little environmental impact. Sludge drying reed beds consist of
shallow tanks filled with a gravel layer and planted with emergent rooted wetland plants such as
Phragmites australis (common reed); they have been used in Europe and Palestine. In these
systems, waste sludge is pumped and spread on the reed bed surface, where most of its water
18
content is lost by evapotranspiration from the plants and by water draining through the gravel
filter layer, leaving a concentrated sludge residue on the surface. The roots of the plants
contribute to the oxygen transfer through sludge layers creating aerobic microsites that promote
sludge mineralization and stabilization. Furthermore, the complex root system maintain pores
and small channels within sludge layer that preserve the drainage efficiency through the bed.
When the sludge is dry, the movement of plant stems by the wind causes cracking of the surface
of the beds and subsequently improves the aeration of the sludge layer. The resulting final
product is suitable for land application, and might be further treated to improve sludge
hygienisation, promoting in either case sludge reuse as opposite to sludge disposal in landfill or
sludge incineration. Begg et al. (2001) found that the removal efficiencies for sludge dewatering,
TSS and BOD were all over 90%. Nitrate and total phosphorus removal rates were 90% and
80%, respectively. Overall metals removal efficiency was 87%. The highest metal concentrations
mostly tended to be in the lower tier of the sludge profile. Uggetti et al. (2009) found there was a
systematic increase in the TS concentration from 1-3% in the influent to 20-30% in the beds,
which fits in the range obtained with conventional dewatering technologies. Progressive organic
matter removal and sludge stabilization in the beds was also observed (Volatile solid
concentration decreased from 52-67% TS in the influent to 3149% TS in the beds). The
concentration of nutrients of the sludge accumulated in the beds was quite low (TKN 2-7% TS
and TP 0.04-0.7% TS), and heavy metals remained below law threshold concentrations.
Salmonella spp. was not detected in any of the samples, while E. coli concentration was
generally lower than 460 MPN/g in the sludge accumulated in the beds. Small remote WWTPs
could well use reed beds because they have a good efficiency for sludge dewatering.
19
Depleted uranium as a unique long-lasting health concern for Iraq
Iraq is unique among MENA (Middle East North African) countries in having a risk of exposure
to uranium compounds originating from ordinance used in the Gulf and Iraqi (Second Persian
Gulf) Wars. The weapons were first used in 1991 during Desert Storm, when the U.S. military
fired guided bombs and missiles containing depleted uranium (DU), a waste product from
nuclear reactors. The Department of Defense particularly prized them because, with dramatic
density, speed, and heat, they blasted through tanks and bunkers (Koeppel, 2016). It is thought
that between 17 and 20 countries have weapons incorporating DU in their arsenals, but only the
US and the UK have acknowledged using DU weapons in Iraq and elsewhere. Concerns have
been raised particularly for peacekeeping forces, humanitarian workers and local populations
living and working in areas contaminated by DU following conflict (WHO, 2001). Potentially
DU has both chemical and radiological toxicity with the two important target organs being the
kidneys and the lungs. DU aerosols created by the impact of penetrators against an armored
target settle within minutes of the impact and near the target site. Then, DU particles combine
with other material and increase in size, becoming less of an inhalation hazard, but remain on or
in the ground. Because much of DU ammunition fired will miss the intended targets, they are
buried at various depths under the surface of the ground. With time, chemical weathering will
cause the metallic DU to corrode and be oxidized to soluble chemical forms and migrate to
surface and groundwater from where it will eventually be incorporated into the food chain,
which then can be consumed (IAEA, no date). This would take several years before enhanced
levels of DU could be measured in water and food, but the time lapsed from both wars (1990–
20
1991 and 2003-2011) is ample time for oxidation to take place until today (2023), marked with
the 20-year anniversary of the start of invasion of Iraq.
Like any radioactive material, there is a risk of developing cancer from exposure to
radiation emitted by natural and DU. This risk is assumed to be proportional to the dose
received.
Limits for radiation exposure are recommended by the International Commission on
Radiological Protection (ICRP) and have been adopted in the International Atomic Energy
Agency (IAEA)'s Basic Safety Standards (IAEA, no date). The annual dose limit for a member
of the public is 1 mSv, while the corresponding limit for a radiation worker is 20 mSv. The
additional risk of fatal cancer associated with a dose of 1 mSv is assumed to be about 1 in
20,000. However, any cancer may not become apparent until many years after exposure to
radioactive material. In the long term, the exposure pathways that become more important are
ingestion of DU incorporated in drinking water and the food chain through migration from the
soil or direct deposition on vegetation. The risk from ingestion of food and water is generally
low, because uranium is not effectively transported in the food chain, but research shows it can
happen from mine-tailing wastewaters. The uranium transferred to livestock through ingestion of
grass and soil is eliminated quickly through urine and feces.
Consumption of water and food is a potential long-term route of intake of DU. Given this,
monitoring of water sources may be a useful means to assess the potential for intake via
ingestion. If the levels are considered unacceptable, some form of filtration/ion exchange system
could be implemented to reduce levels of DU. Ingestion can occur in a large section of a
community or population if drinking water or food supplies become contaminated with DU. In
addition, ingestion of soil by children is considered a potentially significant pathway (WHO,
21
2001). The ingestion exposure pathway currently has several established risk levels and
standards for chemical toxicity (Littleton, 2006). The Agency for Toxic Substances and Disease
Registry of the U.S. Department of Health and Human Services has a "minimal risk" level for
intermediate-duration ingestion set at an oral uptake of 2 µg of uranium per kg of body weight
per day (ATSDR, 2013), though the WHO has established a tolerable daily intake (TDI) for
uranium of 0.6 µg-1kg body weight per day (Khalaf, 2005). The WHO has a provisional
guideline for drinking water quality of 15 µg/l, a value considered to be protective for subclinical renal effects reported in epidemiological studies. The US Environmental Protection
Agency (EPA)’s Rule on Radionuclides in Drinking Water sets a maximum contaminant level
for naturally occurring uranium at 30 µg/l, and its preliminary remediation goal (PRG) for
Superfund is 2.2 2 µg/l for 238U in tap water. The Nuclear Regulatory Commission’s
occupational annual limit on intake for oral ingestion is 14.8 mg. Data on long-term exposure is
lacking and important information could come from studies of populations exposed to naturally
elevated concentrations of uranium in drinking water.
The International Atomic Energy Agency (IAEA, 2008) generally concluded that the
radiological risk was not significant to Iraqis and could be controlled with simple
countermeasures conducted by national authorities. However, Zucchetti (2009) and Al-Azzawi
(2013) disagreed that earlier studies did not have complete information on health reports from
Basra and other parts of Iraq. Between 300 and 365 contaminated sites were identified by 2006,
with most of them in the Basra region of southern Iraq. These reports claimed that published
epidemiological studies in Basra introduced a clear correlation between DU related exposure and
the multifold increase of malignancies, congenital malformations, and multiple malformations
among the population in DU contaminated areas. There have been increases in many types of
22
cancer since the early 1990s and based on clinical and epidemiological data, these increases
could be attributable to exposure to DU in the environment. But more sophisticated studies to
prove cause and effect relationship are suggested.
Modeling pollution transport from hundreds of destroyed munitions to surrounding areas
showed the extents of DU contamination in the area from 1991–1996: 1718 km2 of soil
contaminated with DU oxides and particles, 140,000 m2 of channel sediments, 845, 100 tons of
vegetation cover (Al-Azzawi, 2013). Fathi et al. (2013) stated that because of the 1200 tonnes of
ammunition that were dropped on Iraq during the wars of 1991 and 2003, DU contamination
occurred in more than 350 sites in Iraq. Currently, Iraqis are facing about 140,000 cases of
cancer, with 7000 to 8000 new ones registered each year. In Baghdad cancer incidences per
100,000 population have increased, just as they have also in Basra. They claim that overall
incidence of breast and lung cancer, leukemia and lymphoma, has doubled, even tripled. The
situation in Mosul city is similar to other regions. Before the Gulf Wars Mosul had a higher rate
of cancer, but the rate of cancer has further increased since the Gulf War (Fathi et al., 2013).
Fallujah (pop. 300,000) is Iraq’s most contaminated city after the U.S. military attacked it twice
in 2004, and in the November siege, troops fired thermobaric weapons (Koeppel, 2016). Busby
et al. (2010) visited Fallujah, and obtained responses to a questionnaire on cancer, birth defects
and infant mortality. The total population in the resulting sample was 4,843 persons with an
overall response rate better than 60%. Highest risks were found in female breast cancer, allleukemia, all-lymphoma, and brain tumors of all ages. Infant mortality was 80 deaths per 1,000
births, compared with 9.7-19.8 in three other MENA countries. There was also genetic damage
to the 0–4 age group. Whilst the results seem to qualitatively support the existence of serious
mutation-related health effects in Fallujah, the authors stated that care should be exercised in
23
interpreting the findings quantitatively. Hindin et al. (2005) reviewed literature on toxicological
data on both natural and depleted uranium on birth malformations due to natural and DU. They
found that animal studies firmly support the possibility that DU is a teratogen. While the detailed
pathways by which environmental DU can be internalized and reach reproductive cells are not
yet fully elucidated, again, the evidence supports plausibility. In aggregate the human
epidemiological evidence is consistent with increased risk of birth defects in offspring of persons
exposed to DU.
Ratnikov et al (2020) established that the accumulation of 238U by crops is closely related
to the content of humus, mobile calcium and physical clay in the soils. The uptake of 238U from
sod-podzolic soils to barley was 1.4–3.4 times higher than that of chernozem-type soils with a
high content of humus and mobile calcium. Shroder et al. (2016) found that fungi and some
bacteria thrive in high-uranium environments, and uranium contamination selects for the types of
microorganisms that can survive. Some plants can accumulate uranium, but most can only
tolerate it if the pH of the soil is high enough to keep the uranium insoluble and not bioavailable.
Remediation techniques include natural attenuation, ex situ processing, and bioremediation, but
none of these is perfect and the correct approach depends on each site. The negative human
health effects associated with uranium contamination make further research and remediation
work vitally important.
Research of uranium mining waste tailings gives ideas what contaminated DU sites might
be like. Anke et al. (2009) reported that compared to control plants, wild and cultivated plants
from the immediate vicinity of waste dumps of naturally-occurring uranium in Thuringia,
Germany, were found to store normal to eightfold higher uranium contents. Leafy plants species
accumulated more uranium, compared with thick stalks, fruits and grains. With the increasing
24
age of the vegetation, its uranium content decreased significantly. The uranium content of 116
foodstuffs and beverages varied. The authors examined several foods, with vegetable products
accumulating between 0.8 μg U/kg dry matter (DM) in margarine, bee honey and pearl barley, 50
μg U/kg DM in asparagus, and >100 μg U/kg DM in mixed mushrooms. As a rule, sugar-, starchand fat-rich foodstuffs proved to be uranium-poor (fruits, seeds, flour), whereas leafy vegetables,
tea and herbs can be uranium-rich. Animal foodstuffs accumulated lower uranium contents, with
0.7 μg U/kg DM in butter and 1.1–1.9 μg U/kg DM in condensed and normal cow milk, 1.5–3.1
μg U/kg DM in pork, beef, chicken and mutton, 3–10 μg U/kg DM in fish, and 16 μg U/kg DM
in hen eggs. Prepared food for babies and young children proved to be uranium-poor. Water is
also an issue since the high uranium contents are delivered to the mineral waters and the food
chain by the granite in the subsoil of these areas. Of the uranium ingested by adults, 41% are
delivered through beverages, 33% through vegetable and 26% through animal foodstuffs. In a
Bulgarian study, the highest soil to plant transfer coefficients were for leafy greens, lower in
cereals, and the lowest in maize (Lazarova et al., 2020). However, the type of leafy plant or
barley made a difference; the transfer factors for arugula and chard were up to three times higher
than those for sorrel. and up to 50% lower accumulation in barley F173 than in other varieties
tested. They concluded that despite relatively high uranium activity concentrations of 234U, 238U
and 235U measured in soil, transfer of uranium isotopes to those plants was relatively low and
they recommended that corn, barley and triticale were preferable to leafy greens for growing on
uranium-contaminated soils.
The content of radionuclide uranium in the water, soil and rice around a decommissioned
uranium mine in China was analyzed, and the radioactive pollution, distribution characteristics,
migration pattern and health risks were evaluated (Shi et al., 2021). The authors found that
25
radionuclide 238U, 235U around the tailings dam of this mine made their way into water, soil and
rice at 500 m and 1000 m from the dam. The average content of 238U in groundwater of the
tailing area was nearly three orders of magnitude higher than the national average. The 238U in
tailing sand was transported to paddy field soil through percolation, and rendered it polluted, as
was any rice grown in the fields. The authors reviewed the health impacts of long-term exposure
and found that even though most uranium is excreted rapidly from the body, some is deposited
on bone surfaces together with calcium and can remain on the surface of the bone for many
years. Uranium crosses the blood–brain barrier and accumulates preferentially in specific areas
of the brain: the olfactory bulb, hippocampus, cortex and cerebellum. Studies have found that the
risk of leukemia and lymphoma is highest in the 0–34 age group; the risk of breast cancer is
highest in the 0–44 age group; the risk of brain tumor is highest in all age groups, and female
exposure to uranium during pregnancy can cause fetal malformations. Male excessive exposure
to uranium can also affect the genome, increasing the risk of cancer. All this is consistent with
the public health findings in DU contaminated regions of Iraq. The authors recommended that
uranium content of drinking and mineral waters needs to be publicly controlled, and they would
agree with Tang et al. (2023) that the rapid and efficient removal of uranium from WW,
particularly mining tailings, remains a major challenge for environmental protection and
ecological security. These researchers claimed to have good reduction of uranium through
phosphate-modified biochar supporting nano zero-valent iron (PBC/nZVI). The introduction of
polyphosphate can greatly increase the specific surface area of biochar pores, and then the zerovalent iron can be evenly distributed on the surface of material, thus leading to excellent removal
performance of the PBC/nZVI for uranium. This work shows that there are ways to reduce
uranium during WWT.
26
Surdyk et al. (2021) summarizes some of the issues in a systematic review of the health
risks associated with DU. DU, used as weapons in Iraq, is a chemotoxic and radiotoxic heavy
metal and is classified by the International Agency for Research on Cancer (IARC) as a Group I
carcinogen. Many studies have investigated the association between DU exposure in Iraq and
adverse health outcomes, but the data are either limited or controversial. Most reports published
in 2010 or later (after US Gulf War sanctions had been lifted) showed a positive association
between uranium exposure and adverse health outcomes among the Iraqi population. A risk of
bias assessment rated all the included reports as high or probably high in the domain of
confounding. As United States’ sanctions on Iraq may have played a role in limiting research and
publication on the health impacts of weaponized uranium on the Iraqi population, they conclude
that more primary research on this topic is needed, with adequate assessment and control of
important confounders.
Policies for Regulating Wastewater in Iraq
The Ministry of Water Resources (MWR) is the premier water supplier for the country and
responsible for the whole national water planning, operating 25 major dams, hydropower stations
and barrages and 275 irrigation pumping stations serving almost the entire irrigated area (2008
data). The MWR comprises five commissions and eleven companies, employing 12 000 staff.
Making the MWR functional again in the aftermath of the wars and collapse of the previous
regime is a top priority and measures to achieve this are under way. Other key institutions related
to water in Iraq include the Ministry of Agriculture, the Ministry of Energy, the Ministry of
Municipalities and Public Works, the Ministry of Environment and other ministries and local
27
governorates concerned with economic and human resources. The Iraqi government has issued
Regulation No. 25 of 1967 concerning protection of stream and reservoirs from pollution. This
law prohibits wastewater discharge into the water bodies without a special permit issued by the
health administration. The law regulates quality and quantity of wastewater that is allowed to be
discharged into natural waters. In addition to Regulation no.25, the Baghdad sewerage board
issued further instruction regulating different chemicals in industrial wastewater to be discharged
into municipal sewerage system. A Law on Irrigation (No. 12 of 1995) and another on
Environment (No. 3 of 1997) have been enacted. Iraq was considered rich in its water resources
till 1970s, but not since then. The supply and demand are predicted to be 17.1 billion cubic
meters (BCM) and 77 BCM, respectively in 2025. In addition, future predictions suggest that
Tigris and Euphrates Rivers will be completely dry in 2040. The Iraqi government tried to reduce
the salinity in the two rivers by constructing what is referred to as “the third river”. This river,
565 km long flowing from Baghdad to the Gulf via the KhorZubair Canal, was completed in
1992 after 30 years of work (Al-Ansari et al., 2014). It collects drainage water from more than
1.5 million ha of land between the Euphrates and Tigris Rivers. It was to resolve the chronic
salinity problem affecting farmland between the two rivers, by collecting saline drainage water
and preventing it from flowing into the Euphrates. About 17 million tons of salt reportedly
flowed into the Gulf through the Third River in 1995. Long term expectations of the decrease of
rainfall and temperature increase due to global climate change will inevitably reduce the quantity
of the internal water resources and increase the desertification in Iraq which already reached
75%. Turkish water projects will control 80% of the Euphrates water and 47% of Tigris River
flow to Iraq. At least, 696,000 ha of agricultural land will be abandoned influenced by these
projects. The diversion of the water of Karun and Karkha tributaries inside the Iranian borders
28
caused very high increase of the salinity in Shatt Al-Arab. To overcome this problem, a Strategic
Water Management Vision plan was to focus on development of irrigation techniques, reduce
water losses, use non-conventional water resources, and initiate research and development
planning (Al-Ansari et al., 2014). In 2022, the Food and Agriculture organization (FAO) in Iraq
and the MWR launched the start of a Monitoring Water Productivity using Remote Sensing
program, funded by the Ministry of Foreign Affairs of the Netherlands (Marzouk, 2022). This is
to monitor and improve water and land productivity in agriculture, both rainfed and irrigated,
responding to the challenges that are posed by the dwindling of freshwater resources and the
need to sustain agricultural production to ensure food security in the face of a changing climate.
This will identify water productivity gaps, suggest solutions to reduce these issues, contribute to
a sustainable increase of agricultural production, lessen water stress while taking into account
ecosystems, and recommend the equitable use of water resources.
Recommendations
General recommendations are needed for increasing the supply of good quality and safe drinking
water, and for agriculture use from WW and other sources. Infrastructure damage from conflict
and neglect, along with lack of knowledge of the long-term effects of use TWW for agriculture
and also the availability of other sources of water in Iraq have prevented large-scale WW
applications. TWW for portable and domestic purposes is not recommended unless it is treated
close to the standards required for drinking water. Public demonstrations and recommendations
from the MWR and academics have repeatedly urged the Iraqi government along with the FAO
and foreign aid to do more to alleviate the shortage of quality water in the country to enhance
29
population health and have more productive agriculture. Aziz and Aws (2012) wrote a report for
MWR on wastewater production, treatment and use in Iraq which include recommendations.
Almuktar et al. (2020) in a multi-university collaboration from Iraq, Sweden, UK, and South
Africa recommend measures for improving the water quantity and quality situation for Basra and
other regions facing similar challenges according to three lists of priority. The highest priorities
for them are to: 1) develop sustainable and alternative water supply sources such as constructed
wetlands for raw water and wastewater treatment as well as lakes/ponds and reservoirs for
rainwater harvesting; 2) continuously monitor the water supply network conveying treated water
to the consumers, avoiding any uncontrolled water contamination; and 3) establish public
education plans for consumers to reduce the water demand during the hot season. The combined
recommendations of the MWR and universities reports for improving WW supplies are listed
below excluding the highest priorities already noted.
1) Establish a clear policy for WW reuse prior to any development activity in this field, and
create an integrated long-term National Water Master Plan
2) Recommend TWW for the following purposes: municipal uses for street cleaning, gardens,
watering of roadsides; agricultural uses for irrigation of forests, fodder crops; industrial uses
such as cooling pipes.
3) Increase the capacity and efficiency of WWTPs across the country.
4) Improve the technical management capacity, budget, and skill development for WWTP
operators.
5) Recommend research and training at different levels of work on WW reuse should be
directed towards finding ways to reduce hazards on human health.
30
6) Improve and control water resource management strategies to achieve adequate water supply
and reduce saline intrusion challenges.
7) Control point source pollution negatively affecting raw water quality such as domestic and
industrial WW as well as drainage waters due to agricultural activities.
8) Construct activated carbon units to improve water color, taste and smell.
9) Increase knowledge of health risks from WW for all users.
10) Construct water storage facilities to address water scarcity challenges.
11) Specifically build water holding facilities in high flood risk areas to store access water and
control flooding linked to snow melts during spring.
12) Build compact desalination units such as reverse osmosis at the site of the conventional water
treatment plant to reduce salinity.
Al-Ansari (2013) and Al-Ansari et al., (2015) in Management of water resources in Iraq:
perspectives and prognoses recommend that an integrated long term National Water Master Plan
should be designed and put in practice immediately. “Such a plan should be the outcome of
Water Resources staff at universities, private sector, NGO’s and representatives of regional and
international organizations concerned. It should include improving the efficiency of distribution
networks specially diversion and supply down to the point of use which is most cost effective
and irrigation modernization using suitable techniques.” Specific recommendations for irrigation
and other agricultural uses are listed below.
1. Consider the most efficient irrigation techniques that are suitable for the local conditions of
soil, water availability and quality, crops, etc.
2. Promote efficient water harvesting methods.
31
3. Discourage traditional WW irrigation methods; consider drip irrigation for orchards using
salty water, and sprinkler irrigation for grains.
4. Develop and maintain closed water conveying systems to reduce evaporative losses.
5. Improve the drainage systems of cultivated lands to prevent soil leaching and reduce soil
salinity (consider perforated pipe drainage system).
6. Avoid return of drainage water to the rivers and drainage projects to be implemented.
7. Reduce the use of chemical fertilizers and pesticides that can decrease the water quality when
used irrigation water discharges to the rivers.
8. Adopt policies and plans to involve appropriate institutions and farmers and decentralize
where appropriate.
9. Enhance private investment in the agricultural sector.
10. Promote public awareness program for farmers to use more suitable techniques in irrigation
(drip irrigation and sprinkler irrigation).
11. Complete partially built dams to increase the storage capacity of dams.
To both these sets of recommendations, we can add: research to confirm or refute a positive
association between uranium exposure and adverse health outcomes among the Iraqi population
(Surdyk et al., 2021). All these recommendations make sense, but it takes commitment by the
Iraqi government and international organizations to promote and fund these, and as can be seen
in the Conclusions, improving the WW systems may not be as high a priority as addressing other
health and infrastructure needs. There should be agreement on what proposals can realistically be
accomplished first based on human expertise, funding and impact.
32
Conclusions
Iraq’s water supply is in urgent need of attention because of lack of sufficient water for potable
as well as agricultural and industry use which has led to unemployment and political unrest.
Contaminated water has also led to continuing population exposure to enteric diseases and many
Iraqis believe that the government should be doing more to protect water security. The irony of
this information is that the volume of renewable water per capita in the MENA region was the
highest in Iraq at more than 2.2 thousand cubic meters of renewable water per capita in 2020
(Statistica, 2023). In comparison, the Gulf Cooperation Council (GCC) countries had the lowest
volume of water from renewable resources per capita among the region. Recommendations for
Iraq already stated above need to be implemented and this will require international cooperation
(Linder, 2019). The water policies of Turkey and Iran building dams have reduced Iraq’s water
supply, affecting agriculture and increasing water pollution in most areas of the country. By 2050
it is estimated that precipitation will decrease by 25%, that will intensify desertification with Iraq
losing around 25,000 hectares of arable land annually. In addition, Iraq’s rising population,
government mismanagement of water, and climate change also affect Iraqis’ access to water
(Miri, 2022). Despite, dam building, in 2019, Turkey agreed to assist Iraq by allowing more
water to flow into Iraq from the Tigris and the Euphrates, financial aid to help rebuild
infrastructure, and training Iraqis on wastewater treatment and hydrology. The United Nations
Educational, Scientific and Cultural Organization (UNESCO) has aided access to water by
modernizing irrigation systems in the northern and southern regions of the country, the two parts
most affected by the water crisis (Cooney, 2019). UNESCO is partnering with the Iraqi
government to reform the water management sector and improve irrigation systems. It is
33
assisting the Ministry of Water Resources’ efforts to expand the capabilities of water
management experts, strengthen the institutions which impact water resource management and
create a national policy for water sustainability. Specifically, UNESCO has worked to restore
the Kahrez system, an ancient method of providing water for drinking and agricultural irrigation;
through this system, water is collected at the base of hills and transported to fields by a network
of wells. The agency is also collaborating with officials in the Kurdistan Regional Government
to train workers in the water management field and has provided hydrological testing equipment.
And what about the continuing presence of DU in the environment? If most studies believe that
there is a positive association between uranium exposure and adverse health outcomes among the
Iraqi population, do the occupying forces 20 year or more years ago have an obligation to
remove most of the DU ordinance fragments? There are between 300 and 365 sites, mostly in the
Basra region, where DU contamination was identified by Iraqi authorities following the 2003 US
invasion, with an estimated cleanup cost of at least $30 million, according to a Dutch peace
group report based on three investigatory trips to Iraq in 2011 and 2012 (Edwards, 2013). The
report warns that the contamination is being spread by poorly regulated scrap metal dealers,
including children.
Yet, despite some aid and promises, most of the needed improvements are not being met,
and as Miri (2022) states, seven million people in Iraq are at risk of their health and livelihood
because of a lack of water and the crisis is only intensifying. Political divisions and corruption
within successive Iraqi governments as well as social divisions in Iraq have contributed to the
neglect of important issues such as water. To reverse or at least halt the current negative trends,
the Iraqi government will need not only to come to an agreement with its much stronger
neighbors over water rights, but also to commit to a long process of major domestic political,
34
economic, and social reforms, including water use and pricing. If action is not taken soon, it may
mean the drying up of the Tigris and Euphrates in our lifetimes.
It is interesting that the WHO (2022) Iraq Annual Report 2021 does not mention the main
health issues raised in this review (waterborne diseases, infectious diseases in general, or
increased rates for cancers including those related to DU). Instead, the Foreword to the Report
states that the “WHO and Ministry of Health collaboration focused on increasing diagnostic
capacities and building the capacity of hospitals and health centers to prepare for and respond to
moderate and severe cases of COVID-19 in Iraq. ….While WHO has focused its efforts in recent
decades on preparedness and responding to the humanitarian situation and displacement in the
northern provinces, we decided together with the Ministry of Health to shift our focus to building
resilience in the health system.” The latest Ministry of Health and Environment statistics show
that communicable diseases account for 17% of all deaths in Iraq and are the second largest
cause of mortality and morbidity in the country (WHO, 2023), but none of the diseases covered
in this review are mentioned; the stated diseases of most concern are: tuberculosis, AIDS,
hepatitis B, malaria, and unspecified neglected tropical diseases, none of which originate from
ingestion. The WHO has had no recent reports on DU. So, I must assume that although there is
an awareness of many health problems related to water and the environment, these are not high
enough priorities to be addressed compared with other health issues in the country.
This review focuses on Iraq but many of the same lack of good quality WW concerns
apply to other MENA countries, including over usage of aquifers, desertification, and
inappropriate irrigation practices. What is unique about Iraq is that it has historically had a steady
source of water year-round to allow civilizations to flourish since before the Bronze Age, and it
has been heavily devastated by recent warfare causing considerable infrastructure damage.
35
Unfortunately, the Euphrates and Tigris River system is now much reduced in flow and polluted,
and there are too few WWTPs to meet the demand for household, industrial and agricultural
water needs. And those that are still operating are inadequate to produce pathogen-free water.
Therefore, for improved WWTPs and better-quality water in Iraq it will require a champion to
call for international attention to address this pressing need.
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Highlights

Although the volume of renewable water per capita in the Middle East and North Africa
region is the highest in Iraq, much of it is of poor quality for drinking or irrigation.

Wastewater treatment plants are often poorly maintained or overloaded.

Most non-treated wastewater is used by farmers to irrigate a variety of food crops.

Contaminated water has led to continuing population exposure to enteric diseases, and
many Iraqis believe that the government should be doing more to protect water security.

The presence of depleted uranium (DU) ordinance fragments in the ground is an
additional risk to the health of the inhabitants.
44

Developing policies and plans for wastewater treatment should involve appropriate
institutions and farmers and options to consider decentralization strategies.
Declaration of Interests
I have no financial or non-financial assistance provided by a third party for writing this review.
Nor do I have any other support or conflict such as advisory positions, consulting fees, or stock
ownership. I have no patents or copyrights that are relevant to the work in the manuscript.
Ewen Todd
Ewen Todd Consulting LLC
Okemos, Michigan
.
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