BMJ No 7070 Volume 313

Letter from Iraq: Effect of sanctions on surgical practice

Correspondence to:Professor H N Barnouti
PO Box 19172 Zayyona
Baghdad
Iraq.

The sanctions against Iraq have led health care to fall below minimally acceptable standards. Doctors must treat patients without adequate drugs, anaesthetics, or basic surgical supplies. The continuation of sanctions will lead to a further deterioration. No ethical, religious, or humane body should condone this. Sanctions and blockades are time honoured ways to punish people or exert pressure on them to change. The longer and more effective the blockade, the worse its effects on people. Sanctions have had deleterious effects on all aspects of Iraqi life, including medicine. Patients requiring surgery are a particularly vulnerable group, and this article reflects sanctions' effects on surgical practice.

Effects of sanctions on surgical practice
The six year blockade of Iraq has left surgery in a state that falls far below minimally acceptable standards of safety and efficacy. Shortages of drugs have created severe problems for patients and doctors. For example, without the right antibiotics, patients with peritonitis due to perforated bowel are at greater risk of death and complications such as intra-abdominal abscesses. They may require further operations conducted under the same circumstances, thereby further increasing the risk of complications.

Frequently, the right suture material is missing. Instead of using No 1 nylon suture, surgeons use finer nylon sutures, absorbable sutures, or even cat gut to repair a hernia or close a laparotomy--with higher rates of recurrence. Since the blockade I see many more cases of stitch bscesses and sinuses.

Anaesthetic shortages have resulted in substantial reductions in perating lists and increased anaesthetic complications due to the use of the available, sometimes expired anaesthetic agents, rather than the right ones. Postoperative fever, fluctuations in blood pressure, and chest infections are common under the sanctions. Deficiencies within the operating theatre have made surgery difficult and hazardous. Poor illumination of the operating field has increased both operative difficulties and a dependence on palpation rather than direct visualisation, with all the unfavourable consequences.

Bloody operations such as thyroidectomy become even more difficult because of non-existent spare parts for cauterising devices or no expert technicians to repair them. Repeatedly reusing resterilised surgical gloves means they have large numbers of holes. Without money to replace them, badly torn surgical gowns and towelsc ompromise aseptic technique and increase rates of wound infection. These have also increased because of shortages of antiseptic solutions for skin preparations.

Low morale among all staff--from consultant to porter--is the rule given the immense difficulties under which we work and the fact that we carry full responsibility for the outcome of treatment. Consider a patient admitted after a road traffic accident or a missile injury. As a consultant surgeon, you are fully responsible for the patient's outcome, but neither an intravenous cannula nor parenteral gentamicin and metronidazole are available. If colonic injury is present you do alaparotomy without appropriate antibiotic cover. Because of higher rates of septic complications, you may alter your surgical procedure and perform a colostomy instead of primary suturing or primary anastomosis under antibiotic cover. The poor illumination due to the absence of projectors means a higher rate of missed injuries. The use of the available rather than the ideal suture material to close the laparotomy wound means higher rates of burst abdomen, incisional hernias, and stitch abscesses and sinuses. Not only is morale low but medical ethics have also collapsed because of financial difficulties, with increased thefts from hospital by staff, patients, and visitors.

Conclusions

The sanctions against Iraq over the past six years have led to the disruption and collapse of the basic medical system, revealing the inhuman face of sanctions of such severity and length. Even in the eight year Iran-Iraq war, medical services remained efficient and up to date despite the vast demands made on them. There was war, but no sanctions or blockade; we could buy the medical supplies that we needed. Should sanctions continue, the already awful situation of medical services could become even worse. No ethical, religious, or humane body could condone this.

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