Iraq Desperate To Rebuild Shattered Health System

A two-day conference on Iraqi health care at APA headquarters in late September drew more than 40 physicians from U.S. medical specialty societies including several Iraqi-American physicians and representatives of the Iraqi Society of Physicians, Iraqi Medical Sciences Association, AMA, British Medical Association, and World Medical Association.

APA member Col. E. Cameron Ritchie, M.C., the psychiatric consultant to the Army surgeon general, was a co-organizer of the conference at APA. “We wanted to show our support for our Iraqi colleagues and get an update on the health care situation there including government and nongovernment sponsored health care initiatives.”

Ritchie added, “I am pleased that APA leadership continues to support professional exchanges with Iraqi physicians. In addition to hosting this conference, the president's [Marcia Goin, M.D.] symposium in May was devoted to rebuilding health care systems emerging from conflict such as Iraq, and Marcia Goin, Jay Scully, Darrel Regier, and I participated in a July 2003 conference devoted to rehabilitating Iraq's psychiatric services sponsored by the World Health Organization and the World Psychiatric Association in Cairo.”

Michael Brennan, M.D., of the American Academy of Ophthalmology, moderated the September conference and coordinated the agenda with Ritchie and the organizing committee.

Brennan and Timothy Gibbons, M.D., of the American Academy of Orthopedic Surgeons and an Army reservist, spent two months last year developing the foundation for democratizing Iraqi medical societies based on mutual interest between Iraqi and U.S. representatives (Psychiatric News, April 2).

High-ranking U.S. government officials participated in the conference, including Senate Majority Leader Bill Frist (R-Tenn.), Surgeon General Richard Carmona, M.D., Joint Staff Surgeon Maj. Gen. Darrel Porr, M.D., and Department of State Under Secretary for Global Affairs Paula Dobriansky, Ph.D.

Abdul Hadi Al-Khalili, M.D., chair of the department of neurosurgery at the University of Baghdad, described grim public health conditions in Iraq and security conditions in Baghdad. Al-Khalili represented the Iraqi Society of Physicians.

Inadequate sanitation, purification of water, nutrition, and health care have taken their toll on the health of Iraqis. The rates of liver diseases, including hepatitis B and diphtheria, increased under Saddam Hussein, and the cancer rate tripled between 1984 and 2004, said Al-Khalili.

The mortality rate for infants and children more than doubled from 1990 to 1998. The United Nations (U.N.) had imposed sanctions on Iraq for its invasion of Kuwait in 1990, and the impact on Iraq's people and economy was devastating. Half a million children under age 5 were reported to have died between 1991 and 1998. To provide some humanitarian relief, in 1997 the U.N. established the Oil for Food program in Iraq. This allowed Hussein's government to sell some of its oil in exchange for U.N.-approved food and medical supplies. However, the benefits were limited because, experts claim, only a third of the oil revenue was used for the intended purpose. The sanctions were finally lifted after Hussein was ousted in May 2003.

Iraq's new minister of health, Ala'adin Alwan, M.D., faces enormous challenges. He has a budget of nearly $1 billion this year from Iraqi oil revenue; $578 million of it will go for pharmaceuticals and medical supplies, and the rest for operations and maintenance, said James Haveman, a former senior advisor to the interim Ministry of Health in Iraq. He also was the health advisor to former Ambassador Paul Bremer, the administrator of the Coalition Provisional Authority until the interim government was installed in May.

The United States contributed nearly $900 million for health care in 2004,“ including $498 million for the construction of new primary care centers and the renovation of 18 maternal and pediatric hospitals to reduce the number of infant and maternal deaths,” said Haveman. “About $17 million will be used for training health care staff, $300 million for new equipment, and $50 million for the new hospital in Basra,” added Haveman.

He observed that when he arrived in Iraq in 2002, “the ministry's budget was $16 million for 26 million people under Saddam Hussein. This was a 90 percent reduction from a decade earlier.”

A priority of the health minister is overcoming shortages of medical supplies and equipment allegedly stolen “under the corrupt U.N.-administered Oil for Food program, which was shut down,” said Haveman.

Corruption was widespread under Hussein's regime, and “medical supplies and equipment often disappeared out the back door,” said Haveman. To combat corruption, independent inspector generals have been installed in each of the ministries.

The Ministry of Health has been immunizing the country's 4.2 million children under age 5 against preventable diseases such as polio, diphtheria, and tuberculosis, according to the ministry's official Web site.

Al-Khalili complained that frequent power outages in Baghdad disrupt the hospitals' security and ability to refrigerate storage of vaccines.

Kidnapping Iraqi residents for ransom took place under Hussein, but the number of middle-class residents of Baghdad—including children—being kidnapped has risen sharply since Hussein was ousted, according to Al-Khalili.

“People are afraid to leave their homes and send their children to schools. A friend of mine hired three bodyguards, and he was still kidnapped,” he said at the conference.

Al-Khalili was kidnapped in August at gunpoint. The four-day ordeal ended when his family paid the ransom to his kidnappers.

Health minister Alwan has asked the Ministry of Interior for help in protecting medical staff at hospitals. Guards have been posted at hospitals, including outside operating rooms, Al-Khalili told Psychiatric News.

The kidnappings have exacerbated the already dangerous situation in Baghdad. Bomb explosions by insurgents are killing more Iraqi civilians than American soldiers. When American soldiers return fire, civilians have been killed in the crossfire, said Al-Khalili.

“Security is our most urgent problem. When the insurgents are fighting in the districts where guards live and it's unsafe for them to leave their homes, we have to postpone patient operations scheduled that day,” Al-Khalili said during the interview.

The health ministry allocated $3 million for mental health care this year, a fraction of the overall health care budget. “That was all we could afford, given so many primary health care needs,” Haveman told Psychiatric News

About $500,000 of the 2004 mental health budget is for Iraqi-run programs for victims of torture, said Haveman.

Scores of Iraqis including children were imprisoned and subjected to sadistic torture by Hussein's government.

In response to concerns about security in Baghdad, Frist said at the APA conference that about 15,000 more coalition troops would be deployed soon to Iraq to provide more security for the nation's January elections. He did not specify the date of deployment. The total U.S. troop count in Iraq on October 20 was approximately 130,000 soldiers.

Al-Khalili said he would prefer the U.S. military to train Iraqi troops and police in how to handle kidnappings and hostage-taking incidents.

Frist is a volunteer on apolitical, short-term medical missions in Africa. He said that such voluntary efforts to assist developing countries are“ the currency of peace.”

John Howe III, M.D., is the president and CEO of Project Hope, an international health foundation with offices and programs in 24 countries including Iraq. Howe described the program in Iraq as a public/private partnership between U.S. Agency for International Development (USAID), the U.S. National Cancer Institute, the King Hussein Cancer Center in Jordan, and Project Hope. The goal is to help Iraqi children with cancer obtain state-of-the art treatment and to train health professionals in Iraq to provide appropriate care for them. Howe mentioned that a new children's hospital will be built in Basra with a $50 million grant from USAID.

Baha Alak, Ph.D., an Iraqi-American board member of Life for Relief and Development, said the organization received a $12 million grant from USAID to build a small community hospital in Baghdad and a women's health center in Mosul,”which we ran for six months and left it with the local people,” Alak said. Life for Relief and Development is now a global organization dedicated to alleviating human suffering.

Life for Relief and Development also partnered with the Coalition Provisional Authority, Iraqi Ministry of Health, Elsevier Foundation, AMA, and the Noor Foundation to distribute more than 30,000 medical textbooks and reference materials to hospitals, clinics, and universities in Iraq, according to a news release.

Security concerns surfaced again when conference participants discussed meeting in Baghdad for the second international medical specialty forum for Iraq next year. When the discussion turned to meeting in neighboring countries such as Jordan, Iraqi physicians were concerned about the impact on participation of Iraqi colleagues. Other Iraqi locations were suggested, including Kurdistan in the north, which is relatively calm.

Information on the Iraqi Ministry of Health and its accomplishments are posted online at<www.mohiraq.org/overview.htm>. Information on Project Hope in Iraq is posted online at<www.projhope.org/where/iraq.html>. Information about Life Relief and Development is posted online at<www.lifeusa.org>.▪