Volume 378, Issue 9794, Pages 863 - 866, 3 September 2011
lraq's health system yet to heal from ravages of war
By Paul C Webster
Iraq's health system lies in a fragile state 8 years after the war. Thousands of doctors have left the country and the pace of health-care reconstruction remains slow.
Nabil Al-Khalisi had been practising medicine at Baghdad's Al-Kadhimiya Teaching Hospital for just 1 year when his job abruptly unravelled in April, 2010. He had been warned by colleagues that his criticisms of Iraq's war-ravaged medical system were attracting hostility. But when Al-Khalisi found an envelope containing a bullet on the windshield of his car in the hospital parking lot, he knew he was finished at Al-Kadhimiya. “I never went back”, he murmurs.
Al-Khalisi had little trouble tracing the cause of his problem. Weeks earlier, he had returned from an exchange programme in the UK, where he had given an interview to the BBC's Arabic service that strongly endorsed training for Iraqi physicians in western countries such as the USA and the UK. He had also mentioned that he had been awarded a Fulbright Scholarship to study in the USA in part because he had been an outspoken critic of corruption and incompetence within the Iraqi medical system since long before graduating from Baghdad Medical College in 2007. “Some people in the hospital administration were extremely offended by the broadcast”, Al-Khalisi recalls. “My visit to the UK made them think I was pro-western. And that's possibly why I was threatened.”
A car bomb blows up outside an Iraqi hospital in March (AFP/Getty Images)
The experience was all the more bitter for Al-Khalisi because he had actually come to the Al-Kadhimiya facility seeking sanctuary following an even more frightening experience at a different hospital. In April, 2009, while working an overnight shift at Baghdad's Medical City Complex, a child arrived with a severe case of methanol poisoning. Unable to save the child's life largely due to inadequate medical supplies, Al-Khalisi had been attacked on the ward by one of the child's relatives. The hospital's security team intervened before he was injured. But while he was on his way home, gunshots were fired at him, leaving two bullet holes in his car. “Patients can retaliate very badly. There is a tribal system of revenge and they will come after you”, Al-Khalisi explains. “I have lost many colleagues this way. So I immediately asked to be transferred.”
Having survived death threats at two of Baghdad's hospitals in his first couple of years in practice, Al-Khalisi transferred to a third one in April, 2010. His new job was at the Al-Furat General Hospital, a facility in a deeply impoverished zone on the city outskirts that was recently refurbished with US funds. To survive as a physician at Al-Furat, Al-Khalisi soon learned, it was advisable to stay as far away as possible from patients associated with militia or government military forces. But that did not diminish the hostility of hospital staff who believed he had been recruited to collaborate with foreign occupiers. “This is a hospital where many of the staff are strictly religious and many support the insurgency”, Al-Khalisi says bluntly. “It would be easy to get killed there. The doctors themselves tend to be benign, but the administrative layeror a fair section of itis politically or militia involved. I faced aggression from everyone but the doctors. It truly paralysed me.” Within weeks, Al-Khalisi began surrendering his shifts, and his pay cheques, to colleagues. Then he started packing his bags for the USA, where he is currently a Fulbright Scholar at the University of Georgia, Athens, GA, researching migration patterns among Iraqi health workers like himself.
8 years after the US-led occupation of Iraq triggered a wave of violence described by the International Committee of the Red Cross (ICRC) as catastrophic for health care in the country, conditions for health workers remain grim throughout southern and central Iraq. An estimated 18 000 physicians, about half the national total before the occupation, have fled Iraq, which now has about a fifth as many physicians and a third as many nurses per head as neighbouring Jordan. About 40% of the country's primary health-care clinics lack physicians. Although the Iraqi Government estimates that 628 physicians have been murdered in recent years, the Iraqi Medical Association has put the number closer to 2000. Managerial ranks within the Ministry of Health are similarly depopulated, explains Hayder Nasser, an Iraqi physician who serves as UNICEF's Child Survival and Development Specialist for the Middle East. “The current government lacks health management experience”, he notes, “largely because so many highly qualified people have left.”
Immunisation rates for children have decreased by nearly 20% in Iraq since 2000 (AFP/Getty Images)
Although episodes of violence against health workers and facilities continue, including the killing in March, 2010, of Mohammed Alwan, dean of the Al-Mustansiriya Medical School in Baghdad, and the bombing of a hospital in the city of Tikrit in June, 2010, the frequency of such atrocities has diminished in the past several years. Even so, few Iraqi physicians are returning from neighbouring countries such as Jordan and Syria, says Nasser. “There has been a gradual improvement in security, and perhaps some MDs are thinking of going back”, he notes. “But security remains the big problem.” Syed Jaffar Hussain, the WHO's country director for Iraq, agrees. At a time when Iraq's medical system is itself on life support, factional infighting within the government over the partisan division of ministerial spoils remains intense. The resulting confusion and conflict “puts the existing bureaucracy under tremendous pressure”, says Hussain. “There is a great deal of improvisation throughout the health-care system.”
Poor health indicators
Health-care data from WHO confirm that the Iraqi populationwhich in the 1980s was reported to have some of the best health indicators among the nations in the Middle Eastis paying a crippling price for the continuing violence, political infighting, and widely acknowledged rampant corruption within the health system. Life expectancy at birth in 2010 was 58 years, which is down from 65 years 30 years ago. The chance of an adult dying before the age of 60 years has increased almost 40% since 2000. At 84 deaths per 100 000 livebirths, Iraq's reported maternal mortality ratio is twice as high as Jordan's. Child immunisation rates are down nearly 20% since 2000, and mortality for children younger than 5 years now stands at 45 per 1000 livebirths, which is also twice as high as in Jordan and almost three times as high as in Syria. Tuberculosis rates are six times higher than in Syria and 30 times higher than in Jordan. And although WHO has no current data for HIV prevalence in Iraq, it says that only 3% of Iraqi females between 1524 years of age have comprehensive accurate knowledge of HIV/AIDS.
“Iraq is a rich country that was once on track to achieve the millennium development goals”, notes UNICEF's Nasser from his office in Jordan, where government health expenditure levels are currently 12 times higher than in Iraq. “There needs to be a complete reform of health care.” At WHO's Baghdad office, Hussain warns that even while Iraq's health-care system struggles with the existing disease burdenincluding high levels of communicable diseases and a constant flow of conflict-related cases that continually add to Iraq's huge population of permanently maimed victimsthe country also faces serious emerging health-care challenges. These principally come from substantial increases in diagnoses of non-communicable diseases. Iraq now has the highest hypertension prevalence in the Middle East, WHO reports, with almost all of it untreated. Diabetes and cancer rates are also believed to be escalating rapidly, although the full extent of such chronic diseases remains largely unknown. As the ICRC recently noted, very little epidemiological research has ever been done in Iraq.
Unmet mental health needs
Looming ever-larger against this background, WHO's Hussain warns, is a growing appreciation that war-ravaged Iraq is also wracked with various types of mental illnesses possibly affecting as much as half the population. This should come as no surprise: a household survey in three cities in southern Iraq published in 2004 found that, since 1991, about half of households reported one or more abuses including torture, killings, disappearance, forced conscription, beating, gunshot wounds, kidnappings, being held hostage, and bodily mutilation.
According to an integrated mental health survey funded by WHO and the Governments of Iraq and Kurdistan and published in 2009, the lifetime risk of mental disordersespecially acute anxiety and post-traumatic stress disorderhas substantially increased among young people in recent years, “possibly as a function of inter-generational increases in sectarian violence”. The survey, which was based on interviews with 4300 adults in 2006 and 2007, also found that only a minority of the patients who seek treatment for mental disorders in Iraq receive treatment that is even minimally adequate. “The integrated mental health survey identified a huge prevalence of mental health conditions among Iraqis”, WHO's Hussain explains. “This requires specialised care. But given the very small number of psychiatrists in Iraq, this task looks simply gigantic.”
Survey co-author Sabah Sadik, a psychiatrist who was until recently the Iraqi Ministry of Health's National Adviser for Mental Health, and is now the Ministry's Director of Training and Development, agrees that the prevalence of mental disordersespecially among children and adolescentsis rooted in “what the country has been through over the last three decades”. Much of the Iraqi public, Sadik says, have been exposed to several stress-inducing factors ranging from “the threat of violence and the constant fear of something happening when you go out or even when you are sitting at home” to more mundane pressures such as shortages of fuel, clean water, and food, and constant electricity outages. “From a population perspective”, he observes, “people are really very frustrated. And the health services have not responded to their needs.”
Seen from this perspective, recent efforts to deinstitutionalise mental health patientsfirst begun when US soldiers accidentally released patients from the Al-Rashad Psychiatric Hospital in 2003could be compounding the pressure. Community mental health resources are almost non-existent, Sadik notes. In a survey of popular attitudes towards mental health published in 2010, Sadik and colleagues at King's College London, UK, found that large proportions of the Iraqi population hold stigmatising attitudes towards people with mental illness in relation to treatment, work, marriage, and mental health recovery. Most respondents put the blame on the afflicted individual and avoided contact. Mental illness has been further stigmatised by associations with terrorism that are very firmly described by Sadik as unfounded. But such associationshowever misinformedwere reinforced when US and Iraqi forces raided the Al-Rashad facility in 2008 and detained its director for nearly 2 months on suspicion that he had supplied Al-Qaeda in Iraq with suicide bombers.
In this anguished setting, Iraq now faces a massive shortage of mental health expertise, Sadik worries. Mental health services and professionals have historically been sparse in Iraq, he notes, with only one psychiatrist per 300 000 people before 2003 falling to one per million until recently. “In the 1990s a large number of senior psychiatrists emigrated”, he explains. “The last straw was the violence in 2006 and 2007.” Whether many psychiatrists can be persuaded to now return remains highly doubtful, he acknowledges.
As Iraq's senior health-care training official, Sadik says that he aims to help confront the mental health crisis in part by introducing mental health awareness into primary care and refashioning the role of physicians within a team-based approach of a sort still largely unknown in Iraq. “Until recently, the doctor was everything”, Sadik explains. “It was a dictatorial approach.” To bring nurses into the picture, he wants the government to implement a crash programme to retrain 1000 nurses in a 3-month intensive initiative including mental health components. “The minister”, he says, “is very keen on training nurses.”
Women wait to be seen at the mental trauma centre at Baghdad's Imam Ali Hospital (Karim Kadim/AP/Press Association Images)
With support from the US Government, staff at almost half the primary health clinics in Iraq have now undergone basic mental health awareness training, Sadik says. Other positive developments include tightened regulation of electroconvulsive therapy (which until recently was widely used without anaesthetics), the development of a national Mental Health Plan, and retraining of Iraqi psychiatrists with support from WHO, and the US and UK Governments.
Reform long overdue
The extent of disrepair and outright despair within the Iraqi health-care system, which has been under reconstruction with billions of dollars worth of new Iraqi and foreign investment since 2003, continues to confound most well placed observers within Iraq. In Baghdad, against the clatter of an electric generator firing to life after yet another power cut, Tariq Hassoon, a physician working with the International Medical Corps, a US-funded non-governmental organisation (NGO), says “the progress is slow. It's just not moving fast enough”. The Iraqi operations director for another major international NGO in Baghdad involved with health-care reform, speaking on condition of anonymity for fear of violent reprisals, said “the government is busy with other priorities”.
A leading adviser to the Iraqi Government on hospital reform, also speaking anonymously, complains about rampant corruption. “Hospital directors are appointed to get privileges”, he says. “The hospitals simply cannot progress as long as the Minister of Health operates in this fashion.” In Kurdistan, Ibrahim Said Gataa, a plastic surgeon, complains of a lack of basic competence in responding to long-commonplace events resulting in mass casualties. “We still follow a system from the 1960s and 1970s”, he says. Above all, Gataa laments, the continuing violence eclipses progress: “Security remains the most important barrier to practice. We have numerous researchers, teachers, and practitioners who cannot work for security purposes.”
Iraqi observers living abroad are equally blunt. Speaking from the USA, Nabil Al-Khalisi says that there are almost no guidelines for care in Iraqi hospitals, where “everything is a grey area”. Drugs including steroids, antibiotics, and narcotic painkillers are widely abused. “Everything is available for sale without regulation”, he says about the burgeoning, hugely profitable street market for prescription drugs in Baghdad. “The government is involved in this, one way or another”, he suggests. But critics of corruption are silenced with death threats, Al-Khalisi notes. He points to a video posted on YouTube in which a recently replaced health minister demands fasil, a tribal dispute resolution process involving financial compensation that carries an implicit threat of violence, from Iraq's Inspector General, who made corruption allegations against the former minister on Al-Iraqia TV, the national official television channel.
In London, Ali Kubba, an Iraqi-born gynaecologist who serves as chairman of the Intercollegiate Iraq Liaison Group, which helps arrange international training for Iraqi physicians, says Iraq lacks any sense of “a joined-up vision for health care”. User fees have become widespread, he notes, with many public doctors running busy private practices and the public system providing little more than emergency care. He describes “a rather toxic mixture of dynamics” including rampant fear, corruption, and incompetence. Iraqi physicians living abroad are highly unlikely to return, he thinks, in part because, if they do, they can face “animosity and antagonism”.
Iraqi doctors receiving training in Bosnia (MEL EMRIC/AP/Press Association Images)
At the Ministry of Health headquarters in Baghdad, Samir Sadik, whose task it is to revivify the national health workforce, does his best to put a brave face on the situation. “It's not as bleak as many try to put it”, he reasons. Regarding the violence against physicians, he disputes the Iraqi Medical Association's claim that almost 2000 have been murdered. “The admirable thing is the depth of Iraqi resilience”, he stresses. “In spite all of the difficulties there are quite a number of dedicated physicians who refuse to leave the country and who continue to supervise training of new physicians.” Foreign training programmes are also expanding and there is a national health strategy, Sadik insists, that is loosening the grip of central authorities and putting power in the hands of local experts who are being encouraged to initiate innovative approaches in health careespecially at the community level. “The concept of community health-care workers has not been easily established”, he notes. “But I think that could make a big difference in supporting communities.”
By the norms of the developed world, Iraq is “quite behind”, Sadik acknowledges. But compared with much of the underdeveloped world, he argues, the Iraqi health-care system still looks reasonably good. “It is very hard living and practising here, there is no doubt about it”, Sadik says. “But we have to strive toward achieving the conditions of the developed world”, he emphasises. And in Sadik's view, foreign aidat one point a major source of funding for health-care reconstruction that has now dwindled to a tricklecannot solve the problems. Instead, he wants Iraq to solve its own problems. “The time has come for Iraqis to put their act together and to unite and respect each other”, Sadik pleads. “Iraq has a lot of resources. If the politicians could be serious about reconciling and working together, I think Iraq could flourish very quickly.”