Doubters Welcome!—Clarifying Our Numbers For The Backlog

Since August 2011, we’ve publicly speculated about a backlog of 30,000 Iraqi children in need of lifesaving heart surgery. After decades of war and sanctions, in a country that lacks a national registry for heart defects, have you ever wondered where The Backlog numbers come from? Here’s a peek behind the curtain…

UNICEF states the approximate number of children born in Iraq in 2010 was 1,125,000i. Numerous studiesii estimate the normal rate of children born with congenital heart defects (CHD) to be somewhere between 6-10 out of every 1,000 children. As a percentage, that is somewhere between 0.6% and 1% “incidence.”

That means that every year in Iraq, between 6,750 and 11,250 children are born with congenital heart defects.

However, there are other factors that potentially raise the incidence of CHD in Iraq beyond 1%. Some of these factors include increased rates of diabetes, vitamin deficienciesiii, intrafamily marriageiv, and environmental exposuresv. It’s difficult to know exactly how much all of this combined would raise the incidence of CHD in Iraq. But we can confidently assume that at least 11,000 children are born with heart defects every year in Iraq, based on the incidence and amount of children born.

Thankfully, not every child born with CHD will have severe enough defects to require surgery. But somewhere between 25-50% of those 11,000 children will need surgery or else they will dievi. Sadly, the healthcare infrastructure in Iraq was decimated by sanctions, war, and internal strife and no longer has the ability to reduce its backlog or operate on new children born with CHD. Every year, 90% of the children in Iraq fail to receive the surgeries they require to survive.vii

Each new year, up to 5,500 new children will need surgery. This is what we call The Backlog. Unfortunately, some 31% of all children born with CHD will die in the first year without surgery; they would not make it to the next year’s backlog. Similarly, many infants die from other causes, so that would also lower the amount of children on the backlog. Amazingly, some children heal on their own.

When children come off the backlog from these, or any other, causes it’s called attrition. While it’s hard to measure the rate of attrition, it’s almost insignificant if we assume an incidence rate higher than 1%. If we simply began (albeit arbitrarily) with the beginning of the Iraq War in 2003, our estimates above would place The Backlog between 22,000 and 44,000 kids. That averages to around 33,000 children who need surgeries to survive.viii

This is why we work so hard each day to train Iraqi doctors and nurses across the country—it is only by establishing local heart care centers that these children will be served as they are born and the future buildup of The Backlog will be avoided!

iIraq: Statistics. UNICEF. Accessed on 4 June 2012
 iiHoffman, J. I., & Kaplan, S. (2002). The incidence of congenital heart disease. Journal of the American College of Cardiology, 39(12), 1890-1900. 
iiiILDP, The Status of Women in Iraq: Update to the Assessment of Iraq’s De Jure and De Facto Compliance with International Standards, December 2006, pg. 45 
iv“Al-Ani ZR. Association of consanguinity with congenital heart diseases in a teaching hospital in western iraq. Saudi Med J. 2010 Sep;31(9):1021-7.
 vJenkins KJ, Correa A, Feinstein JA, Botto L, Britt AE, Daniels SR, et al. Noninherited risk factors and congenital cardiovascular defects: Current knowledge. Circulation. 2007 June 12;115(23):2995-3014. 
vi“Mitchell, S.C, Korones, S.B., & Berendes, H.W. Congenital Heart Disease in 56,109 Births Incidence and Natural History. Circulation, 1971; 43:323-332
 vii Based on PLC surveys conducted with government officials, cardiologists and surgeons across Iraq.
 viii The actual number may be less due to our inability to calculate real attrition and our inability (as yet) to estimate the actual increased incidence due to extraordinary factors in Iraq. We do not want to engage in hyperbole or sensationalism. But we choose the higher side of the spectrum because our mandate requires us to help the Ministry of Health establish a sufficient number of surgery centers across the country. Choosing the high number will not cause us to develop too many centers, but choosing the lower end of the spectrum might very well cause us to develop too few.