Iraq: a health system in crisis
Iraq is a dangerous place for many people to go right now. The ever present threat of war hangs over the country, and its people are still in desperate need of adequate health care, says Muhammed Akunjee
Iraq!? Why would you want to go there?" was said many a time with astonishment when our fellow medical students heard of our elective plans. Superficially, we probably did seem a bit crazy choosing such a destination; we weren't Middle Eastern and were from the United Kingdom, one of the countries active during the Gulf war. We had read numerous reports on the plight of Iraqi doctors and their patients after the war. In particular, we heard of the huge drug shortages, the lack of medical equipment, and the increasing childhood mortality facing the Iraqi nation. We wanted to visit the country and see how the health system was dealing with such a grave situation.
In Iraq, we were initially attached to the Al-Mansour paediatric teaching hospital in Baghdad. The hospital had 200 beds, 28 of which were devoted to paediatric oncology. We were attached to the oncology team at Al-Mansour, with a view to completing a short study comparing the management of acute lymphoblastic leukaemias in Iraq and the United Kingdom. Al-Mansour is only one of two specialist paediatric oncology centres in Iraq and sees the bulk of paediatric leukaemia cases in Iraqa total of around 600 since the Gulf war.
The oncology team consisted of 10 doctors and a single nurse. A specialist consultant with two associate registrars was leading the team. The day started at 8 am with a departmental meeting reviewing the previous night's admissions. Following this, there was a daily ward round at 9 am, lasting anything up to two and a half hours. On Tuesdays and Saturdays, we would attend outpatient clinics until 2 pm where around 70 patients would be seen. After a four hour lunch break, we would then attend the consultant's community based private clinic each day, except for Thursdays and Fridays.
From the exterior, the hospitals, including Al-Mansour, looked well kept, modern, and sophisticated. Inside, however, it was a different story. The wards and corridors were dim and poorly lit. In the oncology ward, all the beds were full. As we entered, a mother of one of the stricken children ran towards us inquiring as to whether we had any chemotherapy medication from the United Kingdom for her child. Agonisingly, we had to inform her that we did not, and we were then taken to see her child, who sat up in her bed looking at us in despair. The much needed chemotherapy, antibiotic, and antifungal medications were unavailable to treat her and the others that lay beside her. Tears filled the eyes of the doctors as we were told that there was nothing more that could be done for the children.
We were then taken to see another girl who was only 6. She was from the south of Iraq and from a poor family. Her mother and father had travelled to Baghdad in search of a cure for their child. They had presumed that, since Baghdad was a more affluent city, they would find the help they needed. But much to their dismay, the doctors at Al-Mansour were unable to provide the chemotherapy medication that was required to bring her disease into remission.
From this and the many others cases we saw daily we realised how perilous a situation Iraq's health system was in. Many fathers were forced to look abroad for help, and only the rich were able to afford the tremendous expenses incurred. In one incident, a father was forced to travel to neighbouring Jordan to obtain 12 vials of l-asparaginase, at a cost of 250 000 dinars (£56.50; a87.10), since they were unavailable in Iraq. Another child on the ward suddenly developed fungal septicaemia, and we were shocked to find that no antifungal medication was available to treat the infection. The child sadly died. We asked each doctor we met how such a shortfall in medication could occur. Each replied that this was solely a result of the sanctions against Iraq.
The sanctions of 1990 imposed by the United Nations severely restricted all imports and exports to and from Iraq.
Medicine and medical equipment were not exempted from this. In Iraq, we found that at least two thirds of chemotherapy medication required to treat acute lymphoblastic leukaemia based on the British protocols was unavailable. Doctors have seen disease free survival rates plummet from around 60% before the war to only 25% at present.
It was clear from our attachment that Iraqi doctors were facing a huge crisis. It was sad for us to see so many innocent children suffering from curable diseases; but the situation is far worse than what we had seen. Iraq's economy has collapsed. Medical education is in disarray since no medical journals or up to date medical texts have been allowed in. Doctors do not have the medication even to treat simple infections nor to manage common symptoms such as pain, nausea, and vomiting. We do not see much hope for the future in stemming the fall in disease free survival rates for childhood cancers or, for that matter, any childhood disease.
Please note that studentBMJ does not recommend travel to Iraq in the current international situation.
Muhammed Akunjee, fifth year medical student, Guy's, King's College, and St Thomas's Hospitals Schools of Medicine and Dentistry
Email: muhammed.akunjee@kcl.ac.uk
studentBMJ 2002;10:259-302 August ISSN 0966-6494
