- The Washington Times - Sunday, September 5, 2004

BAGHDAD - The patient is elderly, asthmatic and desperate for breath. Her family frantically wheels her into the emergency room, while a nurse prepares oxygen to ease her symptoms.

As the old woman settles into the gurney and her eyes close in relief above the plastic oxygen mask, her sons finally begin to calm down.

They probably shouldn’t.

“That oxygen tank over there, we used it two days ago for a patient with [tuberculosis],” said Dr. Elaf Mohammed, a resident in the emergency room at Yarmouk Hospital.

“I told [the staff] you cannot sterilize the mask, you should burn it, but we don’t have another one. So, we have to use it again and again,” Dr. Mohammed said.

The only hospital in southwest Baghdad, Yarmouk has seen a spike in tuberculosis, asthma and other health conditions that prey on a population ground down by constant stress and poor nutrition.

Cardiac problems, tranquilizer overdoses, premature babies, cancer and diabetes are also on the rise, according to exasperated doctors.

On the surgical side, even junior residents have a battle-hardened professionalism when confronting the horrific shrapnel, burns and fractures from now-daily attacks with car bombs, mortars and grenades.

They do their jobs with 20-year-old instruments and lack even clean plastic sheets for emergency-room beds.

Iraq’s health care system, once the finest in the Persian Gulf region, is in crisis.

Doctors are nearly ignorant of medical advances in the past decade. The number of hospital beds has remained constant even as Iraq’s population has doubled to its present 25 million.

Commonly prescribed pharmaceuticals, such as antibiotics and children’s cough syrup, are forever back-ordered, and primary care, the bedrock of prevention, is in free fall.

“The drug shortage is our No. 1 problem,” said Dr. Shakir Al-Ainachi, the Health Ministry’s director-general of medical operations and specialized health care services. “Primary health care in Iraq is very much a backwater.”

The ministry plans to build 150 primary health clinics in the county next year — one for every 165,000 Iraqis — a small step toward providing basic services to all Iraqis.

In some ways, Iraq’s health care is far worse now than it was under Saddam Hussein’s brutal neglect and a decade of U.N.-imposed sanctions.

Street crime, unimaginable here only two years ago, is now a terrifying reality. Common crimes such as carjackings and robberies, combined with injuries from attacks with rocket-propelled grenades and bombs, have strained emergency rooms to their brittle limits.

Foreign medical organizations and the United Nations, which would normally be counted upon to donate desperately needed equipment and expertise, are afraid to operate in an environment that requires more armed guards than nurses.

Doctors complain that the Iraq Ministry of Health, like most of Iraq’s ministries, is still being reorganized.

With budgets in flux and offices and administrators yet to be sorted out, they say, emergency decisions and long-range planning have been delayed or undertaken without full facts.

A campus of dilapidated two- and three-story beige buildings, Yarmouk Hospital is one of the top teaching hospitals in Iraq. Its residents, most of whom have graduated from Mustanseriya University College of Medicine, will be among the nation’s finest doctors.

But Yarmouk is also an “every hospital,” subject to the same shortages, demands and indignities that plague Iraq’s public health care system, from the Mother of All Battles Clinic in the southern port city of Umm Qasr to the Medical City Hospital Center in northern Iraq’s main city, Mosul.

In Yarmouk’s burn ward, the brother of a severely maimed Iraqi police officer sprays his own disinfectant on the floor, in an attempt to maintain a sterile environment.

In the urology unit, patients sleep swaddled in their own sheets and dine on home cooking. It’s more comfortable, they say, but also the hospital cannot provide for all 600 beds.

Relatives visit with their loved ones in shifts, day and night, in part to bribe the staff to change dressings or bring a doctor if necessary. Most have to buy and bring the medications because the hospital has run out.

Yarmouk’s warren of blood, urine, hormone and tissue laboratories is a patchwork of blocky Russian microscopes and vintage Egyptian electronics.

A broken sink pipe bubbles into a 2-liter water bottle, while an old man rinses disposable syringes and tubes with soap that will skew subsequent tests.

In the baby delivery room, the state of health care is made chillingly clear.

On an airless summer night, four women are lying on four narrow beds. Three of them are howling and hyperventilating with everything they’ve got. The fourth is lying under a bloody sheet, barely able to move, while a nurse hurriedly stitches her up.

Two more women in advanced labor crouch in agony, waiting for a doctor to find time and space.

Piles of bloody bandages lay in or near the wastebasket beneath each bed. The air is hot and strangely humid, with a salty, metallic taste that overpowers the weak air conditioner.

The doctors pass around a single pair of surgical scissors to snip umbilical cords.

With almost two dozen births every 24 hours, Yarmouk’s delivery room is a baby factory, a cluttered space with no privacy, few instruments and questionable cleanliness.

There is no anesthesia and no ventilators to help little lungs make the transition to fetid air.

Stress, malnutrition and pollutants mean lots of premature babies, according to Iraq’s tough neonatal specialists, who do what they can for premature newborns with barely formed lungs inside 3-pound bodies.

“Look, I am a human ventilator,” said Dr. Mohammed Ahmad, a pediatrician, who is gently squeezing an oxygen bag and trying to coax a fragile preemie to breath on her own.

An hour later the baby is dead, never having heard her father whisper verses from the Koran in her ear, an Islamic custom to ensure a blessed and righteous life.

Despite the conditions, obstetricians say they are delivering more babies these days than every before.

“I think we are trying to replace what is lost,” said Dr. Nadia Sulaiman, an obstetrician-gynecologist with a cream-colored head scarf firmly clipped beneath her chin. “After three wars and Saddam, we want to live again.”

Iraq’s infant-mortality rate in 2003 was 83 deaths per 1,000 live births, according to the Ministry of Health, compared with fewer than seven in the United States and nearly double the 43 in neighboring Iran.

It wasn’t always like this.

By the mid-1970s, as Arab nationalism was taking hold, the monied and powerful came to Baghdad for their medical treatment, rather than jetting off to Europe or the United States.

Iraq led the Arab world in health care and its hospitals were the pride of the region, as well as the Iraqi people.

Fluent in English, Iraqi doctors routinely trained in hospitals in Europe and the United States, and the government invested oil revenues in cutting-edge diagnostic equipment and newly available drugs.

Older physicians speak with pride of discovering that tests and treatments available in Baghdad had not yet come to Saudi Arabia or even Egypt.

“Cairo had everything else,” said respiratory specialist Dr. Bassim Safi al-Mgoter with a wistful smile. “But in the 1970s, you came to Baghdad for medicine.”

But the Ba’ath Party did not maintain its initial investment in health care.

Thirteen public hospitals, all of them named for Saddam Hussein, were built in 1984. Since then none has been built.

It is easy to blame Saddam, but U.N. sanctions set new hobbles on the health care industry, which by 1990 still maintained some of its international luster.

The sanctions, imposed less than a week after the Iraqi army invaded Kuwait, followed by the U.N. oil-for-food program that began in 1996, were manipulated by Baghdad to prevent necessary equipment and drugs from reaching public hospitals.

But Washington and other capitals contributed to the collapse.

Led by the United States, the Security Council frequently blocked contracts for medicines and equipment, including X-ray machines and chemotherapy drugs, saying that much of it was of “dual use” for suspected weapons programs.

The former regime, say angry doctors, withheld medicines to maximize the humanitarian impact of the embargo.

“We are more than a decade behind our profession,” said Dr. Adil Eidan, a surgeon who chain-smokes Iraqi cigarettes in the emergency room.

“We have great experience in trauma and bombs, but we have deficits in our diagnostic equipment, our education. We don’t know the latest medical reasoning.”

In an effort to make up lost ground, many doctors are devouring Arabic or English textbooks, however dated, and trying to do research on the Internet.

Yarmouk has set up an Internet center, with eight slow computers, to allow doctors to research cases or interests.

But even then it is not easy. Some of the best medical sites require membership and registration fees. But Iraq has no credit cards or electronic banking, yet another obstacle for young doctors.

Doctors in Iraq’s public health system earn from $200 to $300 a month — a 10-fold increase from only two years ago. But they still complain it is not enough.

Alongside a decaying public health care system, the private market for health care flourished, with for-profit hospitals and specialized clinics springing up in urban areas to take care of the rich and well-connected.

They are evident all over Baghdad, although on a national level they account for just 7 percent of all hospital beds. Even Yarmouk has a private, if not very luxurious, wing.

Dr. Al-Ainachi, an orthopedic surgeon who sees patients in a private clinic most afternoons, says the for-profit sector does not redirect resources from public health care.

But in the competition for qualified doctors and medication, the cumbersome and underfunded public hospitals usually lose.

The most acute shortage is for commonly prescribed medications, such as children’s cough syrup, antibiotics, psoriasis ointment and blood-pressure pills.

A prescription costs no more than 30 cents if it is in stock. But three patients out of four walk away from the marble-topped pharmacy counter at Yarmouk without getting what they need.

“I cannot afford these vitamins, but the doctor says I need them,” says Najma Abid, a frail 56-year-old mother of seven who has been returning to the pharmacy here weekly for several months. “This is a pharmacy, but they have no drugs.”

The pharmacists are accustomed to desperation and frustration.

“We always order these things, but the state company for drugs simply does not supply them any longer,” says Sahar Mohamad, Yarmouk’s chief pharmacist, as she supervises the staff counting 10 tablets into handmade paper cones.

She scans her hand across empty shelves that are supposed to hold medications.

The Ministry of Health estimates that more than 400 of the 900 drugs classified as “essential” are still not readily available inside Iraq.

In the meantime, Baghdad and other Iraqi cities are dotted with tiny pharmacies that sell every imaginable pharmaceutical from Viagra and steroids to birth-control pills and Prozac, over the counter and for a fraction of their cost in the West.

“My staff can do miracles,” says Yarmouk’s newly appointed administrator, Dr. Haqqi Razzouki, of his 150 specialists and 300 residents.

“But they are without the new drugs, new equipment, the new ideas.”

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