“In the beginning, I had a lot of pain in my breast, back and arm. I ignored the pain because I thought it could be muscle spasms or an infection,” she said.

The only option for her to seek treatment was the camp’s health centre, where services were limited. She could not leave the camp due to a COVID-19 lockdown, and private clinics were too expensive for a jobless refugee.

It was only in the summer of 2020, when she was finally able to visit a doctor in one of Erbil’s biggest hospitals, that she was diagnosed with breast cancer.

“My nipple was bleeding, and I had to get a biopsy immediately,” she said. She later underwent surgery and started chemotherapy, which, although completed, she continues to feel pain from.

Shireen is not alone. Nine other women in her block at Kawergosk have been diagnosed with cancer.

Doctors operating in the Kurdish region of northern Iraq and residents believe that flaring – the process of burning off petroleum gas by setting alight any excess in a jet of fire – by a nearby oil refinery may be contributing to a rise in cancer rates. The refinery is operated by KAR Group, Iraq’s largest private-sector energy company. The KAR Group did not respond to a request for comment.

A study published last year in the Asian Pacific Journal of Cancer Prevention (APJCP) found that the number of patients with cancer doubled between 2013 and 2019 in Erbil and Duhok, also in northern Iraq, correlating with a resumption in production at oil facilities in the region following the end of the conflict with ISIL (ISIS).

Several residents shared their health records, with diagnoses ranging from respiratory disorders to cancer.

Shireen’s life has changed in the last decade. “We were happier in the village because everything we ate was organic, and our life and mental health were better when we lived there,” she said, referring to the village of Sheir in Qahtaniyah, Syria where she had been living.

ISIL attacked the area in 2013, forcing villagers such as Shireen to flee, leaving their livestock and farmland, to the Iraqi side of the border.

Exposure to chemicals

About 1,200 tonnes of ammunition were dropped on Iraq during the Gulf Wars of 1991 and 2003, making it difficult to distinguish between cancer cases caused by flaring and those originating from the depleted uranium left by the bombing.

But experts were still very concerned that the 8,000 refugees living at Kawergosk were exposed to dangerous chemicals such as benzene because of the flaring.

“[Benzene] is a potent carcinogen that causes leukaemia,” said Laura Cushing, presidential chair in Health Equity at the Fielding School of Public Health at the University of California, Los Angeles (UCLA). “I do think it is concerning that people are being exposed nearby.”

Pregnant women living near natural gas and oil wells that burned off excess gas through flaring were 50 percent more at risk of premature birth than women with no exposure, a 2020 UCLA study headed by Cushing found.

“We were able to say that people exposed to 10 or more flares during their pregnancy had a 50 percent increased odds of preterm birth, when a baby is born too early – fewer than 37 completed weeks,” said Cushing. “The earlier you are born can result in severe health impacts.”

Long-term exposure harms the bone marrow. Those exposed feel increasingly weak and tired as their red blood cell count decreases. Bruising and bleeding become more common, with healing taking longer.

According to research by the University of Southern California’s Keck School of Medicine, in partnership with University of California Los Angeles scientists and in which Cushing was involved, women living near natural oil and gas wells that burn off excess gas through flaring had a 50 percent higher risk of giving birth prematurely.

Cancer and premature births are not the only concern. A study by Global Paediatric Health found respiratory viruses to be almost twice as prevalent among children under the age of 15 in areas administered by the Kurdistan Regional Government (KRG) compared with neighbouring Iran. With residents suffering deteriorating health, the KRG issued oil and gas companies a directive to phase out all flaring by 2023, giving them 18 months to comply.

Flaring levels, however, appear to have remained largely the same based on satellite data from 2018 to November 2022, which was analysed as part of a collaborative investigation funded by the Environmental Reporting Collective (ERC).

The investigation also identified Erbil and its surrounding villages, including fringe communities living in Kawergosk and Lalish, as having the highest incidence of flaring.

Winter months normally show a drop-off in flaring, as most of the gas produced at processing plants is sent directly to houses, as opposed to the summer, when gas use slumps. However, historical data revealed that flaring levels have not decreased compared with 2018 and 2019. Flaring levels began to creep back up again during the summer – with less gas consumed during the hot months.

Unable to meet flaring deadline

A KRG official, speaking under condition of anonymity, said “headaches” with the Iraqi government made meeting the flaring deadline difficult.

Iraq has been planning to set up a new state oil company to negotiate the KRG’s oil contracts, a deal reached after a political standoff between Erbil and Baghdad.

The Iraqi Federal Supreme Court ruled in February 2022 that the KRG negotiating its own oil and gas contracts was “unconstitutional”, a claim strongly rejected by the KRG.

Early proposals seen by local Kurdish media suggested that Iraq was willing to re-form the State Organisation for Marketing of Oil (SOMO) company that oversees the country’s oil contracts to include a Kurdish veto, smoothing over the regional dispute.

Following the KRG’s declaration, the Iraqi government announced in December that it set 2024 as a target for the elimination of gas flaring. It was unclear if the KRG will fall under the 2024 deadline once the new state oil company is set up.

The ERC has reached out to Iraqi government officials for clarification, but they have not yet responded to a request for comment.

According to World Bank data, Russia burns the most amount of natural gas globally, flaring off 24.88 billion cubic meters per year as of 2020, with Iraq following closely with 17.37 billion cubic meters.

But an analysis by the ERC showed that Iraq’s population, on average, lives much closer to flaring sites than Russia’s.

Since October 2018, we found that 1.19 million people in Iraq had lived within a one-kilometre radius of more than 10 flaring events. In Russia, only 275,000 experienced the same level of exposure across the same period.

Russia’s oil refineries are often in remote locations and spread across the arctic tundra, unlike in Iraq where major cities and towns are more commonly situated close to the flares.

Companies serious about phasing out flaring would need to implement infrastructure to capture or sell the gas, reducing the amount they burn. In certain countries, companies use filters to stop the smoke from reaching towns or villages. In Iraq, there is no pressure to do the same, making operational costs cheaper than in other parts of the world.

“In most places, we try to capture the natural gas and use it, burn it for heat, in this case, it is just being burned off as a waste product,’ said Cushing. ‘The [energy] boom happened so fast that [the Iraqi regions] don’t have the infrastructure to bring this to market or the resources on site to capture the gas.”

‘Cancer rates fears’

It was not until COVID-19 hit the region that its residents realised how bad asthma rates had become, said Iraqi environmentalist Rebin Mohammed*.

Doctors in rural areas of the Kurdish region of northern Iraq, such as those working in the Kawergosk refugee camp, almost always referred residents to a hospital in Erbil, the nearest city with basic health facilities, but many cannot afford the transport due to rising fuel prices.

The Enabling Peace in Iraq Centre reported that Iraq’s public health sector has fallen into steep decline after cycles of war, sanctions, funding shortfalls, and neglect for 30 years.

“The government is not forcing them [the oil companies] to start giving back to the environment and the community,” said Mohammed.

Environmental activist Salah Saed Goran said that the situation could be worse in a decade. “All the damage it’s doing now is going to be five times more in 10-11 years after they surround us with oil fields.”

“[We are concerned that] cancer rates are going to increase in the future because of the flaring spots surrounding here,” Mohammed added.

Almost every oil field in KRG-administered territory in northern Iraq has a 20 percent stake held by the KRG, which negotiates its own oil contracts, overseen by sitting Prime Minister Masrour Barzani.

Officials were evasive when asked about the issue.

Local municipality official Rebaz Qasim Mirani, who represents the Khabat district in Erbil, blamed the pollution on traffic from the nearby road, dismissing flaring as the leading cause.

On the Global Paediatric Health study, a senior KRG official, who asked not to be named, said that the government remained committed to the policy to end gas flaring by the start of 2023 and that Barzani was personally encouraging the policy, but could not say what consequences companies who continue flaring into the new year might face.

Meanwhile, the government has applied strict procedures for hospitals to issue public health data in the region. Several health officials and doctors who had agreed to speak about respiratory problems from gas flaring dropped out at the last minute. Many would be putting themselves at personal risk, they said. “People are scared,” said Mohammed, with refugees fearful they would be removed from the camps if they speak publicly about the flaring, and medical officials worried about their job security.

Companies such as the KAR Group, whose processing plants were photographed flaring gas earlier this year, do not disclose how much gas they lose due to flaring and do not publicly provide updates on their efforts to phase out the practice.

The KRG has said that it stands by its commitment to phasing out flaring by 2023, but so far oil and gas companies in the region it governs – none of which responded to requests for comment – are projected to have a similar output as the last two years, based on an ERC analysis.

On July 13, 2021, the KRG’s Minister of Natural Resources Kamal Atroshi issued a decree giving energy companies in KRG-administered territory 18 months to put a complete end to flaring, with the deadline falling in January 2023.

That deadline has now passed, but Lawk Ghafuri, the KRG’s head of foreign media affairs, said that the directive was “still in effect”, but that some “minor extensions” had been provided to some companies who had “proper justifications”.

“This project is a costly one and needs proper design and planning, which, in turn, takes time,” Ghafuri said.

In May, however, the minister who issued the order, Kamal Atroshi, resigned from his role as minister of natural resources, a role covered in the interim by the KRG’s Minister of Electricity Kamal Muhammad Salih.

A flare gas-to-power project recently completed in the southeast of KRG territory could provide a path forward. The plant, built by energy firm Aggreko, has cut flaring by a third.

Locals hoped the government establishes healthier and safer camps for refugees, but regardless of whether the situation improves, many have no choice but to remain in the area.

“Our ancestors lived here, and we love this land so we have to stay here. We are sadly used to it,” said Goran.

*Real name not used