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Medical care in Iraq after six years of sanctions

BMJ 1997; 315 doi: (Published 29 November 1997) Cite this as: BMJ 1997;315:1474
  1. Richard Garfield, Henrik H Bendixen professor of clinical international nursing,
  2. Sarah Zaidi, science director, Center for Economic and Social Rights,
  3. Jean Lennock, Health Development Information Project
  1. Columbia University
  2. New York
  3. Ramallah, West Bank

    In April 1996 we visited Iraq to assess medical care services six years after the United Nations imposed economic sanctions. We visited a range of hospitals and health centres, which included 20% of Iraq's civilian institutional beds, in all regions of the country, except the Kurdish Autonomous Region.

    We found nearly one third of hospital beds were closed, and the average length of stay had more than halved since before the Gulf war. More than half of the hospitals' diagnostic and therapeutic equipment was not working owing to a lack of spare parts or maintenance. All public hospitals experienced serious problems with lighting, cleaning, water supply, and sewage. We found that patients routinely brought their own blankets for warmth and used personal kerosene or electric heaters. By contrast, the second floor of Baghdad's Ibn El Baladi Hospital got so hot in summer that “any child who comes to the hospital without a fever ends up with one.”

    One hospital's cleaning budget was 1500 dinars a month (about £1.50 ($2) at black market rates), which provided only hand soap for operating theatres. Disinfectants and antiseptics were almost non-existent. Hospitals were cleaned only with water. At the Ibn Al Atheer Hospital pieces of sheets and blankets from beds had replaced brushes on electric floor polishing machines. The number of cleaning staff at this 200 bed hospital had fallen from 20 to two.

    Most hospitals' plumbing had been without repairs or maintenance for years. Every hospital we visited had leaking sewage pipes. Entire wards in some hospitals were without a working toilet, leaving toilets elsewhere overcrowded and unsanitary. Flies, insects, or vermin were seen at most hospitals. Unsurprisingly, private rooms in public hospitals, with their personal bathrooms, had become popular.

    Severe shortages of anaesthetics and surgical materials had curtailed surgery. In Mosul, surgeons who had performed up to 15 operations a week were now permitted two. Preference was given to cases taking less than an hour, as the anaesthetic required for a three hour oesophageal reconstruction could be used instead for several patients with appendicitis. There was a reluctance to begin an operation that might consume much suture material. Continuous suturing had replaced intermittent suturing wherever possible to save on suture thread. Internal closure was performed less often for the same reason. One surgeon described a modified procedure for a “clean” appendicectomy that used one suture thread instead of the usual three.

    Some institutions could provide no postoperative analgesia other than aspirin. On the postoperative ward in Al Kindi Hospital, each patient could have up to 50 mg of pethidine. The unit had only one ampoule on the premises; the empty ampoule had to be returned to the central pharmacy to receive another. We saw one patient with renal colic in an emergency department whose only treatment was a placebo injection. “Sometimes we can do nothing more than watch them writhe in pain,” said the duty physician.

    Shortages of surgical appliances abounded, leading to modifications in usual practice. Dr Mohammed Hawzi at Al Kindi Hospital described waiting to perform an internal fixation of the femur until the plate and screw had been removed from another patient. We saw a nasogastric tube attached to a surgical glove used in place of a urinary catheter and bag. Infant catheters and bags were more difficult to substitute. On the private market, the bag for a pint of blood cost 30 000 dinars, or 10 months' average salary. Plaster for casting was scarce.

    Several hospitals reported that the postoperative infection rate had risen from 5% to 25-30% among clean wounds. Shortages of dressings, burn ointment, and antibiotics, together with the inability in most hospitals to test for antibiotic sensitivity and to check electrolytes, greatly reduced the ability to treat burns patients. In Al Zahrawvi Hospital in Mosul, patients with burns covering 70% of their bodies used to survive; now only those with 40% or less survive. Samarra General Hospital used to do about 60 x ray examinations a day; now they are restricted to eight. The expiry date of the barium they were using was 1990.

    Between 1991 and 1994, patients with chronic diseases received a card guaranteeing them access to regular supplies of essential medicines through hospital outpatient departments. Since 1995 these supplies have dwindled so that the cards no longer assure supply. At Al Zahrawvi Teaching Hospital, those with chronic disease cards for asthma lined up at the emergency department for treatment. The hospital got 50 salbutamol inhalers each month and distributed two each day to those at the front of the queue. A clinic in southern Iraq also had 50 inhalers a month to distribute among its 1500 registered patients with asthma. Its supply always ran out within the first few days.

    Our ability to examine health conditions in Iraq was limited by time, problems in governmental administration, and a tense political environment. Only rarely could we verify what we were told. Without an open research environment and thorough data review, anecdotes and limited direct observations were all we had to go on.

    What we heard and saw suggest a remarkable decline in what was until recently a medically advanced country. Mustafa Harith, former army surgeon and director of Samarra General Hospital, characterised sanctions as more destructive than war. “In the war with Iran hundreds of bombs fell but perhaps no one was injured in a day. If there were injuries we had the supplies to treat them. With sanctions, people are dying every day, and we haven't the means to cure them,” he said.

    Health leaders face the overwhelming task of rationing a dwindling supply of medicines. Doctors must routinely make life and death decisions about who will receive them. The population has been burdened by a rapid rise in serious infectious diseases, nutritional deficiencies among pregnant women and young children, and other treatable conditions for which neither the right drugs nor operations are available.

    Iraq is a second world country, accustomed to a first world health system, which now has the epidemiological profile of a third world country. While the recent oil for food deal should alleviate some of the worst suffering, extensive support from the international medical community and greater funding will be needed to rebuild the Iraqi medical system.

    We acknowledge help from the John D and Catherine T MacArthur Foundation and the Iraqi ministry of health.

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