WASHINGTON - If American forces topple Saddam Hussein and occupy Iraq, the United States and its allies will take on responsibility for a population severely weakened by two major wars, suppression of a post-Persian Gulf war uprising, 12 years of United Nations-imposed sanctions and Iraqi government mismanagement.
Over the past decade, Iraq's crippled economy, degraded water and sewer systems, erratic food supplies and poor health care have contributed to widespread poverty, disease and malnutrition, sharply increasing childhood death rates, lowering levels of education and devastating a once-large middle class.
In his speech to the nation Oct. 7, President Bush pledged that if war comes, "the United States and our allies will help the Iraqi people rebuild their economy and create the institutions of liberty in a unified Iraq at peace with its neighbors."
The form an occupation would take is uncertain and would depend on the amount of unrest in Iraq after a war, which other countries would participate and how strong a role Iraqis would be ready to play in running their country.
But the leading role played by the United States in maintaining harsh sanctions, drummed into the population of 23 million by Hussein's propaganda, probably will make ordinary Iraqis dubious about U.S. intentions.
Iraqis have seen that sanctions "didn't hurt the regime; it hurt the regular Iraqi," said Rahman al-Jebouri, spokesman for the Uprising Committee, an anti-Hussein Iraqi exile group. A U.S. pledge of liberation "is not going to fly on the Iraqi street," he said. "They want to see that it's practical."
The sanctions, on top of the U.S. refusal to back the popular anti-Hussein uprising in 1991, have fed anti-Americanism even among the many Iraqis who want to be rid of Hussein's cruel rule, said Phebe Marr, a historian of Iraq: "People are really unhappy with sanctions and want a return to normalcy."
By most available measures, conditions have improved in Iraq since the United Nations eased sanctions by introducing the oil-for-food program in early 1997, allowing Iraq to sell oil and use some of the proceeds for food, medicine and other humanitarian goods.
This year, the U.N. Security Council liberalized the sanctions further by allowing the import of all nonmilitary goods.
But U.N. agencies operating in the country still paint a bleak picture. In its latest report, the U.N.'s Office of the Iraq Program notes a "high incidence of waterborne diseases" caused by "the poor state of water and sanitation networks in the country."
Of a half-million children screened, 20 percent were found to be malnourished. Power blackouts continue, food rations remain short of recommended levels of calories and protein, and the country still faces shortages of medicines and vaccines.
Teachers earn $3 to $5 a month; doctors, $20 to $30 a month; and most of the population is dependent on food handouts, said Carel De Rooy, the Baghdad-based representative for UNICEF. Unable to get enough protein, more than half of Iraq's women suffer from iron deficiency, and the result is that one-fourth of babies are born underweight and vulnerable to disease, he said.
"We still are in a humanitarian crisis," De Rooy said.
While a small elite connected to the government lives in luxury, "for the overwhelming majority, life is extremely difficult in Iraq," Ryszard Krystosik, the Polish diplomat who represented U.S. interests in Baghdad until last year, said at a recent conference here.
With its immense oil wealth, Iraq enjoyed relatively high standards of prosperity, health care and education well into the 1980s, when the eight-year Iran-Iraq war began to take its toll on the population, causing rising malnutrition, medicine shortages and the destruction of some health and social facilities.
The Iraqi economy suffered after that war as a result of a sharp drop in oil prices and a cutoff of loans from other rich gulf Arab states that Hussein had used to help finance the war against Iran.
Iraq's invasion of Kuwait in August 1990 prompted the Security Council to impose a comprehensive economic embargo intended to block all trade with the Iraqi government, exempting only medicine and humanitarian food aid.
Many thought that the sanctions, by cutting off oil revenue, would prompt Hussein to withdraw from Kuwait or cause his government to crumble.
"It never seems to have occurred to anyone at the time that the regime would simply choose to allow its people to perish," Iraq specialist and former National Security Council official Kenneth M. Pollack wrote in a new book, The Threatening Storm: The Case for Invading Iraq.
Iraq was particularly vulnerable to a trade embargo because it had allowed its domestic agricultural sector to deteriorate and by 1990 was importing about 70 percent of its food. Food prices skyrocketed.
U.S. and allied bombs during the 1991 gulf war compounded the hardship, knocking out roads and bridges needed for internal trade and electrical power stations that kept water-treatment plants and sewer pumps operating. Rivers became both dumps for raw sewage and sources of water for drinking and bathing.
More destruction occurred during the government's suppression of the uprisings that occurred in the Kurdish north and the Shiite south immediately after the war.
By mid-1991, humanitarian groups were witnessing a surge in diseases such as cholera, typhoid, dysentery and infectious hepatitis, as well as malnutrition among many Iraqi children.
The next five years saw a bitter standoff between the Security Council and Hussein's government, with each blaming the other for the miseries inflicted on the Iraqi population.
Led by the United States, the council refused to lift sanctions as long as Hussein failed to come clean on his weapons of mass destruction. It pressured Iraq to cooperate with humanitarian agencies in distributing food and medicines and to let the United Nations control sales of oil, with much of the proceeds going to meet basic needs of the populace. Iraq balked at this infringement on its sovereignty, while making sure to display evidence of the population's suffering before the Western media.
Through the 1990s, sanctions became a source of controversy. Critics reported staggering death tolls that, on close scrutiny, seemed to draw heavily on statistics supplied by the Iraqi government or data obtained with its help. Independent information-gathering is extremely difficult in Iraq.
Supporters of sanctions denied that they were the cause of Iraqi hardships. "Iraqis are indeed suffering, but not because of sanctions. The role of Iraqi President Saddam Hussein is the problem," Patrick Clawson of the Washington Institute for Near East Policy wrote in February 2000.
While the debate raged, more accurate measures of the human toll in Iraq emerged. Two that are widely accepted as the best available are an extensive UNICEF survey of deaths among children and mothers, and an analysis drawing on the UNICEF data by Richard Garfield, a public-health expert at Columbia University.
Surveying 24,000 families across Iraq in 1999 and comparing the results with those of earlier surveys, UNICEF reported that the infant death rate had more than doubled since the late 1980s and that the death rate among children younger than 5 had gone up nearly 2 1/2 times, from 56 per 1,000 to 131 per 1,000.
Iraq's government cooperated with the UNICEF survey, but the agency said it oversaw every aspect, using female Iraqi medical doctors to conduct face-to-face interviews, and subjected the results to a careful review by experts from major academic institutions outside Iraq.
Garfield, using the UNICEF data and what he calls conservative estimates of population trends, concludes that at least 343,900 "excess deaths" have occurred among children younger than 5 over the past 12 years. "Excess deaths" means the number of deaths above the pre-1990 rate.
State Department spokesman Richard Boucher said he could not comment on Garfield's findings because he was not familiar with them and was not aware of any official studies seeking to arrive at a figure on Iraqi deaths.
However, he said that as part of the sanctions, the United States had ensured that money was put aside for health care, medicine and welfare - money that Iraq has not spent - and that "nutrition and health levels in the north, where Saddam is not in control, are much higher."
"We've made efforts to revise the U.N. administration so civilian products are not constrained," Boucher said. "We've consistently shown that we're trying to make sure that the people of Iraq did not suffer on our account."
UNICEF spokesman Alfred Ironside attributes the decline in health to sanctions, poor government use of resources and the long-term impact of two wars.
Garfield said, "My feeling is that in the first years of sanctions, the majority of responsibility for the damage was on the U.N. for cutting off money and making it difficult for the government of Iraq to do the right thing." But over the past four years, "most of what should and isn't being done is a result of errors of omission and commission by the Iraqi government."
"Within the government of Iraq, you don't get brownie points by saying, 'It isn't sanctions; it's us,'" he said.
Experts and Iraqi exiles have faulted the Iraqi government for, among other things, poor management and favoritism in the distribution of aid supplies, using money from oil sales for sophisticated medical equipment instead of basic health care and supplying infant formula, which is often mixed with contaminated water, instead of encouraging breast-feeding.
David Mack, a senior State Department official responsible for the Middle East from 1990 to 1993, said, "I don't think there is any doubt that the combined effects of sanctions and Iraqi government policies" from 1991 to 1998 led to "serious and probably permanent damage to vulnerable groups such as children at a development age."
One of the shortages resulting from the sanctions was chlorine, which can be used in chemical weapons but is also needed to purify water. In the late 1990s, UNICEF convinced the Security Council that imports of chlorine could be closely monitored. Imports resumed.
That the Iraqi government compounded the deprivation caused by sanctions is evident in the better condition of people in northern Iraq, where Kurds mostly govern themselves under protection of U.S. and British warplanes. In that region, the United Nations controls the way relief is managed.
But the difference between the two regions in terms of human well-being is "not very big," De Rooy said.
While maintaining the sanctions, the United Nations turned a blind eye to Iraq's smuggling of oil through Kurdistan and Turkey, an arrangement that benefited Turks, Kurds and the Iraqi government.