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Cancer services are suffering in Iraq

BMJ 1999; 318 doi: (Published 16 January 1999) Cite this as: BMJ 1999;318:203
  1. Karol Sikora, chief
  1. WHO Cancer Programme, and professor of international cancer medicine, Imperial College School of Medicine, London

    The Iraqi health minister, Dr Omeed Mubarak, recently asked the World Health Organisation to review the problem of cancer services in Iraq and suggest how things could be improved.

    It was immediately clear that there were staggering deficiencies in cancer treatment facilities because of the United Nations sanctions, which are intended to exclude food and medicines. A cancer centre without a single analgesic; a radiotherapy unit where each patient needs one hour under the machine because the radiation source is so old; and children dying of curable cancers because drugs run out are all accepted as normal.

    We as doctors cannot stand idly by and watch this slow, silent tragedy drag on

    Iraq has a population of 20million. The cancer registry is good in some parts of the country and there are an estimated 50 000 new patients a year—a relatively low but rising incidence as found in many Arab countries. Iraq is a wealthy, well educated country, but is now completely reliant on the administrators who enforce the politically inspired UN Security Council's oil for food agreement. There is plenty of oil, but Iraq can sell it only to buy food and medicines under this humanitarian aid programme.

    Somehow cancer care has become a Cinderella service. Requested radiotherapy equipment, chemotherapy drugs, and analgesics are consistently blocked by United States and British advisers. There seems to be a rather ludicrous notion that such agents could be converted into chemical or other weapons. Operating under the agreement is complex, slow, and frustrating. Dr Isam Al-Rawi, recently retired director of the Baghdad cancer centre, has endured eight years of frustration and witnessed much unnecessary human suffering. An internationally well respected oncologist, and first chairman of the Iraq Cancer Board, he has made the best of the deficiencies.

    Stopping cancer treatment will not topple a dictatorship

    Visiting the cancer centre in Iraq is a harrowing experience. The wards are busy, the clinics burgeoning, and the radiotherapy equipment primitive. There has been no investment for a decade. The medical staff are well trained and most of the consultants have spent a year or more in Britain, France, or the United States as part of their training. The younger physicians are now unable to train abroad. Clinical skills, the teaching, and enthusiasm are strong. Iraq follows the British system of undergraduate and postgraduate education. Now, because of hyperinflation, doctors earn about £3 a month.

    The radiotherapy equipment is becoming unusable. Lack of replacement isotopes for Baghdad's last two functional cobalt machines means that treatment times can take up to 45minutes for each patient. One linear accelerator is working only intermittently. There are no planning or simulator facilities working.

    The department is open from 8am until midnight each day to cope with the workload. The availability of chemotherapy is essentially a lottery. People with potentially curable cancers can receive only the drugs available at the time. Essential generic drugs such as cisplatinum, tamoxifen, and cyclophosphamide ran out during our visit. Symptom control is hopeless and analgesics are just not available.

    Patterns of cancer are changing. Iraq is one of the few countries where stomach cancer is increasing, probably due to reversion to poorer diets and the lack of good food storage facilities. Breast cancer is rising inexorably. A more sinister problem is the apparent threefold increase in leukaemia in the southern provinces—the sites of the major battlefields of the Gulf war. A WHO investigation in 1995suggested a possible link to products, now incorporated in the food chain, which were derived from depleted uranium used in piercing artillery shells. The trend has continued and a major epidemiological study is now proposed which will include a radiation survey.

    Whatever the political legitimacy of the embargo, the needless suffering of those with cancer is an unacceptable outcome. The WHO is making strong representations that drugs on its essential list, analgesics, and replacement radiotherapy equipment should be given priority. We as doctors cannot stand idly by and watch this slow, silent tragedy drag on. Stopping cancer treatment will not topple a dictatorship. It will serve only to consolidate a background of hatred in a new generation who will never forget the scars.

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