Medicine beyond frontiers
We quickly become immune to the images of poverty and
violence that bombard us throught he media every day. Noor Kadhim asks us to
think a little deeper about the plight of medical students in Iraq
These days,
news of a suicide bomb going off in Iraq and killing innocent people is
nothing new. It is predictable, almost expected. Harsh, but true. But how
many of us stop to consider just what day to day life is like for the
living—the daily survivors—who must endure the ongoing fear,
pain, and terror? What of the patients who have been deprived of proper
treatment and drugs since sanctions were imposed after the Gulf war back in
the 1990s? What about the doctors and other healthcare professionals forced
to flee the country, only to return to a city liberated yet devastated of
resources. And le's not forget the students, their initial ambitious
dreams left tattered now by a succession of sanctions, the crippling
effects of a brutal regime, and the chaos of foreign occupation and
terrorist activity in the aftermath of war.
To discover just how different the perspective is from
a student on the other side of the war on terror, I spoke to medical
students studying in London and in Baghdad. Ahmed Saffa, a final year
medical student at Baghdad University, told me that "it is indeed
hard to concentrate on studies." Only now is he beginning to
reconcile himself to the fact that last December, the acting dean of the
medical faculty of Baghdad University, Dr Hassan Al-Rubaiee, was
assassinated. There seems no apparent reason—he was not even linked
to the government. What did that make students such as Ahmed feel?
"Anger. This wasn't just anyone—a prominent physiologist,
an influential figure, and one of the most respected of professors in the
faculty." Unsurprisingly, lectures, tutorials, and hospital sessions
are cancelled all the time because of growing instability and tension in
the city. "Many weeks," said Ahmed, "professors
don't even turn up to lectures for fear of being killed." The
fear was so real that only last year, the course director packed his bags
and fled to neighbouring Jordan in the middle of term without notice. Life
has been like this for some time in Iraq. The murders and constant
bombs—first those falling from the air and then those exploding from
out of nowhere—have numbed people's senses. Fear is
automatically instilled. But it is different now. The new wave of terrorism
to hit the country has evolved with a darker side than before: it is now
targeting senior govermment members, well known academics, and prominent
professionals, and eliminating them one by one.
MOHAMMED URAIBI/EMPICS
Two thousand miles away in London, Jonathan Behar, a
fifth year medic, tells a different tale. I ask him to recount his daily
routine. The day I speak to him, for instance, there is a guest lecture,
delivered by Professor Albert Singer, one of the leading specialists in
gynaecological cancer. Not that University College London is any stranger
to such names. It counts among its alumni Nobel prize winners—Huxley,
Hill, and Katz—and numerous fellows of the Royal Society and the
Academy of Medical Sciences. "I was running late yesterday. The
lecturer was on the dot, though," he mused. Picture the scene: it is
only too familiar. Still feeling the effects of the night before, many
heads nod off to the sharp clicks of the slideshow. Someone's mobile
phone goes off in the front row. A general stir ensues, during which a
hundred other mobile phones are discreetly switched off. Exactly five
minutes before the lecture is due to end, there is a loud shuffle of papers
and fits of coughing. "I had to rush off right after," Jonathan
said. Every day, there are a million different tasks, activities to do,
patients to see, and sessions to attend. Next stop the library, to get that
book for Jonathan's own PowerPoint presentation.
Back in Baghdad, however, the library is a ghost of its
former self. It has been looted and ransacked several times now, and yet
every day Iraqi students hope and pray that the situation will improve. It
must improve, surely? Or that someone will arrive and cure the medical
department of its ailing lack of resources. Indeed, with other matters on
their agenda, US troops failed adequately to safeguard educational
institutions after the war, unfortunately a fact that one tends to overlook
amid the confusion of bomb blasts and political assassinations.
For some students in Baghdad however, the much needed
saviour may for the time being be a man called Dr Ameir Al-Mukhtar,
consultant surgeon and director general of Medical City, Baghdad. I caught
him while he was on sabbatical in Scotland, and quizzed him about the state
of Baghdad's medical teaching facilities. "Well, we only
established internet access for the students a few months ago," he
tells me. "There are 140 computer links, most of which I paid for
from my own pocket. As for medical supplies? We are still waiting, and
always waiting, for more to come." Dr Al-Mukhtar, who graduated from
Baghdad University in 1974, remarked bitterly that in fact, on his return
in 2004, he was astonished to see that the medical college was in "a
worse state than [he] had ever seen it before, from a facilities point of
view." This was despite the natural global evolution of medical
equipment, teaching, and methods of treatment. "Of course, this is
due mainly to Saddam's rule," he added. "But I'm
not trying to make it political. Can you imagine, however, a medical
college being left in such a state? Sanctions have stripped the hospitals
of the most basic resources. One day, I had the dean of the faculty asking
me if I could lend him a microscope." And the nightmare continues.
"There was, and still is, a dire lack of blood pressure monitors and
[electrocardiography] machines… even stethoscopes. The looters are
crazy."
Even now, almost two years after Saddam's hated
statue was torn down by triumphant US soldiers, the main university
library, with its rubble filled rooms and cracked walls, resembles the land
that time forgot. Ahmed Saffa, who has come to recognise this as the
backdrop of his studies recalls what his father often said of his own days
as a medical student. Back in the days before the Gulf war, Iraq was
praised for possessing one of the strongest education systems in the Middle
East. Medical teaching, spread over six years, reflected that of the most
advanced European systems, and this due largely to Western influence, and
out of the Arab countries, Baghdad University came perhaps second only to
Cairo in reputation. Since then, under the tyranny of Saddam Hussein, 12
years of sanctions have, as Dr Mukhtar laments, largely isolated the Iraqi
community from medical advancements in the rest of the world. Not only
that, the university was suddenly struck out of vital programs of academic
cooperation with US, European, Russian, and other major international
educational institutions. Furthermore, the systematic persecution of
doctors and ongoing human rights violations led to a severe brain drain
from Iraq. Indeed, the standard of training in the 14 medical schools in
Iraq dropped to such poor standard in the 1990s that generations of doctors
graduated with desperately inadequate experience. Few books remain here of
any use to students or practitioners—many texts are more than 10
years old. Indeed, Ahmed recalls a first year class in which they were
handed outdated 1984 editions of one textbook whose new edition had just
come out—in 1994. Hospital libraries are skeletal, too. A recent US
army report said that on average they do not possess more than 12 books
each.
Another glance at Jonathan Behar's typical day in
London continues this study of contrasts. Leaving the auditorium, Jonathan
walks briskly across the road towards the main library—a stunning
state of the art building. Of the three libraries—Cruciform, Science,
and Boldero—that house texts and journals for medical students, the
Cruciform is the largest, with lots of new books available to all year
groups. Sixty journals, with backdated copies, are kept there. There are
often as many as six copies of the book he was looking for. He looks at his
watch and suddenly remembers his patient case consultation at Middlesex
Hospital… scheduled for 20 minutes from now. Perhaps his best bet is
the Boldero, the small library based in the hospital that specialises in
clinical texts. After all, it's easier than rushing back to Gower
Street for one book, even if it did only take a quarter of an hour. In any
event, he could always go online. Most of the information anyone ever
needed was invariably online anyway.
In Baghdad there is another shudder, but this time it
isn't the sound of US tanks or a suicide bomb explosion. The
electricity supply in the city cuts out. All of a sudden, everything grinds
to a standstill. Ahmed is in an internet cafe—one of many that have
recently sprung up across the city. For years Saddam had deprived Iraqis of
access to the internet, but now cafes are scattered everywhere—such
is the country's thirst for knowledge. But disaster has struck in a
different way today. The flickering lights go out, and in an instant it is
plunged into darkness. Ahmed dived to the ground, covering his head with
his hands, a reflex reaction. Others do not even flinch, such events are
part of the fabric of their lives by now. But for most, the constant fear
is ingrained.
HADI MIZBAN/AP/EMPICS
Dr M H Ali, another academic member of staff (this time
in the engineering department) in Baghdad University summed it up,
"We are in fear from the moment we leave our homes to head to the
university: fear of explosions, fear of what may happen while we are stuck
in a traffic jam, fear of the military police checkpoint, and fear of the
students who now belong to so many religious and non-religious parties. The
electricity shutdowns make it impossible to do laboratory work. Most
faculty members do nothing at all except teach basic subjects. We
communicate by phone, from home. There is no mail from outside countries,
and no communication with Arab or foreign universities. There is no
personal initiative to do research. There are no conferences; there is no
consultation work."
And while most of us in the West are safe in the
knowledge that if even we have a bad day by our standards, we can take
refuge at the end of the night in our comfortable beds, safe in our homes.
Many Iraqis do not have such a luxury. "Quite apart from the spate of
kidnappings of teaching staff we have been having," says Al-Mukhtar,
"there is also the increasing problem of those who have been deprived
of an adequate place to live, or who are too scared to go back to find out
what has become of their homes. Just the other day, a woman—an
accountant by profession, no less—approached me, asking if there was
anywhere she could stay. She lived in one room only, the size of a
garage." And as if there were not enough internal difficulties,
hospitals now have to concern themselves with "moving all the
squatters from the hospital grounds." The joke circulating in Britain
is that under the NHS, no sooner do you fight for and get a bed than you
are ejected unceremoniously from it. In Baghdad, nobody laughs because it
is a reality. "In all honesty," Al-Mukhtar admits, "I
can't see how it can get any worse; the coming few weeks are
critical."
So where, in all this, lies the optimism so
characteristic of ambition and youthful aspiration? "The difference
I've noticed between Iraqi students and Scottish students, for
example," says Dr Al-Mukhtar, "is that students here are full
of hope and look to the future, whereas Iraqi students are disillusioned
and cannot see the light at the end of the tunnel." Despite the mood
of despair, however, Al-Mukhtar is mindful to stress that the attitude of
doctors and students is one of resilience. Students are tougher than those
who have it easier than they, for sheer need to survive in such an
environment. "I remember a situation not long ago which will always
stick out in my mind", he says. "A doctor came to the hospital
after a missile explosion on the surgical level. Everyone else at the scene
was fleeing, including the so called guards at the gates. Why did this
doctor stand out? He was desperately fighting his way to get in, to save
any victims. That, in any language, is what medicine is all about."
Noor Kadhim, freelance journalist, Oxford
Email: nkadhim@veryspeedy.net
studentBMJ 2005;13:265-308 July ISSN 0966-6494
