[NYTr] Iraq's Medical Meltdown

[All the News That Doesn't Fit]

sent by Tom Simonds (activ-l)

Discover Magazine - August, 2007 posted 7/17/07
http://discovermagazine.com/2007/aug/iraq2019s

Iraq's Medical Meltdown

The bombings are only the beginning of the story. What comes next for
Iraqs wounded is a frightening descent into a rapidly crumbling
health-care system.

by Michael Mason

He has no face. There is a mashed pulp where his nose should be, a
sticky, black suggestion of what may have been a mustache. A plastic
tube runs into a hole once lined with lips. His entire head is a
swollen, weeping burn. The blast disfigured him so badly that even
relatives would have a hard time identifying him. The man doesnt know
where he is, but I do.

He is in the intensive care unit for Iraqis at the Air Force Theater
Hospital at Balad Air Base (AFTH Balad), some 40 miles north of Baghdad.
When I look away from the man, I see there are more patients like him in
neighboring beds. The Black Hawk medevac team who brought him to AFTH
Balad said that the patient might be a member of the Iraqi Police
Service, a civil force maintained by the Republic of Iraq. They could
not be certain, and given his level of trauma, the man could
not cannot speak for himself. A ventilator breathes for him. He
occasionally twitches his hands.

They brought in another guy recently who we had heard rumors was a
police officer, explains Nicole A., a source who asks not to be further
identified. He lost both limbs and had burns on 30 percent of his body.
Ive been trying to figure out who he is, but the Iraqi police have no
system for keeping track of their own.

According to Iraqs interior minister, out of a force of about 190,000,
more than 12,000 Iraqi police have been killed since the United
States-led invasion.

Theres a lot of corruption inside the Iraqi police, says Nicole. Some
people we trained were setting up IEDs [improvised explosive devices].
They are police by day and insurgents by night.

Youre saying that we are inadvertently training the insurgents? I ask.

Correct, correct, she says.

With all those assumed to be insurgents, nurses bandage the patients
eyes for the entire time they are treated at AFTH Balad. At the first
opportunity, the insurgent will be questioned. In the case of the
patient before me, the man without a face, there was no need for that
measure. He no longer had eyes.

Every day is different, and there are constant challenges, explains Maj.
Charles Stresino, a patient liaison officer at AFTH Balad. The bulk of
the work is figuring out what we can do with the injured Iraqis. There
are just not many good options.

For a few precious days following an injury, all Iraqis at AFTH
Baladpolice, detainees, and ordinary civilianswill receive unparalleled
medical services, courtesy of the U.S. Department of Defense. A similar
level of care in the United States would run tens of thousands of
dollars per patient. In order to extend that level of care to Iraqis,
military doctors must keep beds open, and that means quickly
transferring them out of AFTH Balad and into an Iraqi facility. As a
result, the 200 Iraqis treated at AFTH Balad each month have an average
length of stay of less than a week before they are discharged.

There are a number of patients that we transfer into the Iraqi
health-care system who will not survive, says Maj. Jack Emps, a nurse on
the Iraqi intensive care unit. Unlike in the States where we have the
resources to take care of anything to any degree, they dont here.

I ask Emps what was the most common sentiment he heard expressed from
the Iraqi patients who could communicate.

Fear of being discharged, he says. They know what they are going to.
They know care is not as good. If they are missing limbs, or if a female
is disfigured, then theyre not of much value, and will pretty much be
scorned. Outcast. In the hospitals, theyll receive stabilization, and if
they are severely injured, it is not unusual for them to be put aside
and given comfort care.

Comfort care involves primarily pain management, hydration, and little
else. Patients are expected to die.

Working with a doomed population has battered Emps. His face is weary
from the long hours and the unpredictable surges of incoming injured.
In the past two days, over 35 wounded Iraqis have been brought to AFTH
Balad, and there are rumors that another, larger car bomb has just been
detonated in Baghdad. The pain the Iraqi patients endure is carved into
the heavy stress lines in Empss face.

I have been here over four months now, he says. When you see this
suffering of war day in and day out, women and children, innocent
civilians, it is hard. You have a lot of emotional conflict and a lot of
sadness. I am still not used to dying children. It is all I can do to
get through a day.

As Emps and I sat talking in the Iraqi ICU tent, I again looked at the
various patients occupying the beds. Several children had missing limbs;
other patients had a number of lines running out of their necks and
torsos. At some point in our conversation, a graying Iraqi man entered
the room and glared at both Emps and me with an expression of contained
rage. His brothera mummy of bandageswas attached to a ventilator,
comatose. When the visitor sat down, he held his brothers hand gently,
and his face transformed into a mask of sorrow and acceptance. Barely
10 minutes later, the man stood up to leave the room, his shoulders
slumped in despair.

A lot of the time, they know the story before we do, Emps said.

The Iraqis brought to Balad are the lucky ones. Not all wounded Iraqis
are taken to a U.S. military hospital for treatment. If injuries happen
away from areas patrolled by the American military, the responsibility
of trauma care falls to local facilities.

Sixteen-year-old Zemen, a high school student in Baghdad, wore the same
school uniform to class each day: a white cotton shirt and a long navy
skirt. In October 2006, a mortar shell exploded in the schoolyard just
as Zemen was walking outside between classes. Shrapnel tore through the
cotton shirt into her skin and bones, ravaging Zemens neck and back.

At the emergency room of al-Numan Hospital in Baghdad, admitting doctors
did what they could to slow Zemens bleeding. It would be five days
before a surgeon would work on her.

Zemen survived, but spinal surgery left her with significant motor
control problems. Her fingers twisted when she tried moving them, and
her legs refused to obey the signals her brain sent. Nurses placed
Zemen in a hospital bed, not knowing whether she would live. Forty-five
days later, Zemen was finally discharged.

Zemen lives in her parents house in northern Baghdad. She passes the day
confined to a chair, with family conversation her only amusement. Even
electricity is in short supply. During the brief episodes when power is
available, Zemen is able to watch a precious few minutes of television.
Her father, a retired factory worker, sells cigarettes and vegetables
from a meager stand in front of their house. The family is dependent on
neighbors purchases to make ends meet.

Zemen might regain control of her legs and arms with physical
rehabilitation. But there isnt a place for her to get any care, and even
if there were, it would involve risking ones life to take her there. Her
only hope is to leave Iraq for Jordan, where she can find effective
health care. It can cost $400 for an Iraqi passport, and her family
needs three. A car rents for $600. With a monthly income of less than
$100, it isnt likely that Zemens family will be able to afford the
trip, much less the $5,000 in expenses once she arrives in Jordan.

Unlike the Iraqi man in AFTH Balad, Zemen has a face and a name. But the
identity does her little good. She is trapped.

America once had a blueprint for humanitarian efforts in an occupied
country. Before and during the Vietnam War, the United States had a
coordinated and efficient system in place to maintain and stabilize
health care for Vietnamese civilians, which was initially established
by the U.S. Agency for International Development (USAID). In a joint
effort by USAID and the U.S. Military Assistance Command, Vietnam, the
military implemented four civilian-oriented programs. The combined
effect of these four programs was an astounding level of health care.
Even in the midst of the Vietnam War, the U.S. military succeeded in
building three hospitals that provided 1,100 beds to civilians.

U.S. efforts to construct medical facilities in Iraq have been a
miserable failure. The most egregious example is that of Basra
Childrens Hospital, a stalled project supported by first lady Laura
Bush. In late 2003, Congress allocated an initial $50 million. Three
years later, construction had more or less ceased halfway through the
project, and completion costs were estimated at $120 million. (The
contract was recently transferred from a U.S. construction company to a
Jordanian firm.)

The Geneva conventions require that the sick and wounded be treated with
particular protection and respect. Article 56 of the fourth convention
states that the public Occupying Power has the duty of ensuring and
maintaining . . . medical and hospital establishments and services,
public health, and hygiene in the occupied territory. More than a dozen
articles in all govern necessary medical measures, from issues of
medical supplies to physician security.

Throughout the 1980s, Iraq was widely regarded as the premier
destination for medical care in the Middle East. The Gulf War, along
with the ensuing years of trade embargoes, weakened Iraqi health care,
but the policies of a despot nearly dismantled the national pride.

The Iraqi system was in bad shape before we got there, says Lt. Gen.
(Dr.) James Roudebush, the Surgeon General of the Air Force. Saddam
spent about 50 cents a year for health care for each Iraqi his last
year in power, while royal family members had entire hospitals devoted
to their health. Tommy Thompson, the former Secretary of Health and
Human Services, has publicly decried the decline of health care under
Saddams regime: Doctors were forced to watch their patients die because
they just didnt have the supplies or medications they needed. And
medical education was stifled for 25 years, which meant that new
practices and technologies couldnt be utilized, and in the end, people
suffered.

The ouster of Saddam has brought with it a new set of challenges. Last
March the Iraqi Minister of Health, Ali al-Shammari, a loyalist to
radical Shia cleric Moqtada al-Sadr, resigned his post amid allegations
of corruption and abuse of power.

Without so much as a phone call from a family member, it is likely that
the nameless Iraqi man will be sent to Medical City, a public hospital
in Baghdad that currently houses more than 2,000 Iraqis at any given
time. Typically, Iraqi patients must meet one important criterion in
order to be discharged to Medical City.

Iraqis at the Air Force hospital receive unparalleled medical
services, but usually for less than a week.

We will not send Sunnis to the two functioning Iraqi public hospitals
in Baghdad, explains Stresino. Tikrit Teaching Hospital was tried for
Sunnis, but it does not appear to be functioning at this time. We take
care to send only patients who meet a minimum standard of caretrach in
place if needed, wounds closed, PEG tube for nutritionas we are advised
that nursing care in the Iraqi health-care system is extremely limited,
so patients who require too much intense care are not given it. We
really try to encourage families to take patients whenever possible, as
the family will provide better nursing care according to what we have
been told.

Like hospitals throughout Iraq, Medical City is compromised by a number
of issues.

Many things were not enough, says Ameir Al-Mukhtar, who served as
director general and consultant surgeon of Medical City from February
2004 to August 2006. We had a CAT scanner where the wire was cut
deliberately by a medical terrorist, so that the machine became a
useless piece of steel. Our medical equipment would be sabotaged, and
the Ministry of Health does not help with repairing it. I could not buy
instruments or medicine even if I had the money. I could buy a TV or a
fridge, but I could not buy aspirin or antibiotics.?

Al-Mukhtar explained that bureaucratic hassles with the Ministry of
Health prevented him from accessing medical funds. While money issues
still plague the hospital, security concerns remain the greater
difficulty.

Dr. Gene Bolles, operating in Iraq, saw two very different levels of
care.

The U.S. military does not provide security for Iraqi hospitals; the
Facilities Protection Service (FPS), a security-officer force overseen
by the Iraqi Ministry of the Interior, manages that duty. It is fraught
with corruption. Units within the FPS are known to have ties with
Moq-tada al-Sadrs militia and have carried out murders and kidnappings
in the organizations they are supposed to protect. My bodyguard was
kidnapped and killed, says Al-Mukhtar. My cousin, who was employed at
Medical City for $60 a month, was killed. Six months before I left, I
ended up with a team of 15 bodyguards.

I wanted to work freely in my hospital, but I could not, says R. A.
(name withheld for security reasons), an Iraqi physician who recently
fled Iraq because of threats on his life. They [the Iraqi Ministry of
Health] made many limitations on us. We worked cautiously. Now it is
just like the Saddam regime. Just as we were afraid to say that Saddam
was wrong, we are afraid to say Sadr is wrong.

In some cities, Iraqi patients have been murdered in their hospital beds
for being on the wrong side of the local insurgency. Former intelligence
officers in the Saddam regime are now allegedly in charge of security in
at least one of Iraqs public hospitals. I would see an average number of
75 patients a day, R. A. explains. But sometimes we received an
unbearable number, more than available beds. Many of the patients died
in front of my eyes due to the lack of life-saving drugs and
anti-ischemic drugs, and the lack of chest tubes.

The medical-care system in Iraq is in shambles, says Gene Bolles, former
chief of neurosurgery at Landstuhl Regional Medical Center (LRMC),
Germany, where American soldiers are taken after leaving Iraq. Its
almost minimally functioning. There have been over 2,000 doctors killed
and assassinated in Baghdad, with many more in Mosul. Iraq had 34,000
doctors prior to the invasion; 18,000 have since fled the country.

Bolles looks the military type: a stubbled head, a tough, stocky build,
and a firm grip. Looks can be deceiving, though. Bolles claims that his
tenure turned him into an advocate for peace.

While Bolles was serving at LRMC, he saw the horrors of war played out
on American bodies each day. On rare occasions, a different type of
patient arrived. Bolles remembers one in particular: a general in the
Kurdish army who was wounded by friendly fire.

He had a very bad intracerebral injury, a massive hemorrhage in the
brain, Bolles says. I took him to surgery, removed the blood clot, and
did a decompressive craniotomyand he survived.

Bolles soon learned that his patient happened to be the brother of Iraqs
president. As a token of gratitude, Bolles received an invitation to
tour the Iraqi health-care system. The trip, which took place in May
2006, left an indelible impression on him.

As I sit with him in his Denver, Colorado, hospital office, Bolles shows
me a collection of photos he took of wounded patients in Iraqi
hospitals. The majority of them are horribly disfigured by various
types of explosions. After viewing several photos, I begin to sense
something missing but cant quite put my finger on it. One picture shows
a boy with a missing arm, another a woman in severe distress over the
burns covering her body. Then it hits me. There arent any lines going
into the patients. No IVs, no oxygen, no catheters. There arent any of
the usual monitors in the background. The patients are lying in bed,
with little more than a bedsheet and pillow.

While visiting Iraq, Bolles was invited to participate in a
neurosurgery. It was like operating here [in America] 30 or 40 years
ago, Bolles says. In one hospital I was in, one CAT scan had been down
for six months, and they had an MRI that worked intermittently. In the
U.S., we use automatic saws and drills, but they didnt have any
automatic instrumentation. Its back to the old days, and I was trained
that way. A lot of young guys wouldnt know what to do.

In one of the most damning reports of American policy failures, Iraqi
Hospitals Ailing Under U.S. Occupation, journalist Dahr Jamail cites a
litany of horrors evident in Iraqi hospitals in and near Baghdad. At
Arabic Childrens Hospital, patients brought their own food because the
hospital lacked funds to provide meals. Chuwader Hospital operated with
only 15 percent of their necessary water -supply. The toilet on the
intensive care unit at Al-Karkh Hospital looked like a sewage nightmare
of the most noxious order.

I ask Bolles about the physical condition of Iraqi hospitals he visited
in the North. The hospitals that I went to are overburdened and
antiquated, he says. Their operating tables are pretty basic, and there
are a lot of people who are being seen who cannot be treated because
the hospitals do not have the appropriate equipment. If patients need a
vent [ventilator] for any long period of time, chances are they arent
going to make it.

Are Iraqi hospitals unable to handle the level of severity were passing
on to them? I ask.

I guess they arent, he says. They dont have the ability to give
patients care.

So the patients deteriorate?

Yes. Or they die.

An expert in postcrisis stabilization in areas like Kosovo and Serbia,
Frederick Skip Burkle was the first nonmilitary American sent by the
Department of Defense into Baghdad following the initial coalition
invasion in March 2003. His primary objective was to shore up the
collapsed Iraqi health-care system, starting by setting up a
surveillance system to figure out who was getting sick from what. In
the surreal post haze of an afternoon sandstorm, Burkles armored convoy
sped through Baghdad streets as he snapped pictures and made rapid-fire
observations. The mission was threatened repeatedly: Burkles
five-Humvee convoy was ambushed three separate times within an hour.

Our convoy was hit by small arms gunfire, Burkle says. Our shooters
claimed they saw a 50-cal [machine gun] up in a nearby apartment house.
I also heard an RPG [rocket-propelled grenade] go whizzing between our
vehicles, but it did not detonate.

Prior to entering the city, Burkle had predicted that Baghdad would be
ravaged by looting, but he was surprised by the ingenuity of the actual
strategy. It centered on health care. The looters were able to destroy
morale very quickly by looting the health-care system. It was highly
organized, focused on hospitals, the public health-care system,
pharmacies, and pharmaceutical warehouses, and it was unrelenting.
Doctors and nurses had their homes looted if they left for work.

During Burkles April 2003 visit to Yarmouk Hospital, a teaching hospital
in Baghdad, he was shocked by what he saw.

There was nothing in Yarmouk left after the looting. The only beds and
stretchers were in the emergency department. They had only a handful of
bed sheets. Everything had been torn off the walls: The cardiac monitors
were gone, dialysis units were trashed, and the motherboard was stolen
from the CAT scan. Patients were lying on the floors because their beds
had been stolen.

Burkle had gone to Yarmouk Hospital to convince the administrators to
allow the head of the Department of Defenses Office of Reconstruction
and Humanitarian Assistance entry into the hospital for an inspection.
Yarmouk officials balked, claiming that it would draw attacks from
insurgents. During the meeting, a young bearded Shiite cleric entered
the room and glared angrily at Burkle. The cleric left without saying a
word. Soon after, Burkle learned that the cleric was Moqtada al-Sadr
and that a fatwa had been issued calling for Burkles death (and in
fact, Burkles successor was shot). Yarmouk Hospital has since received
new desks and chairs, but patients reportedly continue to die as a
result of medication shortages.

Burkle looks back at the radically different American attitude toward
local medical support during the Vietnam war. Vietnam was a time when
the world respected the U.S. for that kind of commitment, he says. I
think we knew about cultures back then, and the State Department had a
much bigger role. According to the report Medical Support of the U.S.
Army in Vietnam 19651970, U.S. military clinicians treated some 220,000
Vietnamese civilians a month through the Medical Civic Action Program
(MEDCAP) in 1970. As a result of the Military Provincial Health
Assistance Program, teams of 16 Americans augmented the clinical staff
in each of 30 civilian hospitals.

I dont think there are many MEDCAP missions at all now, says Burkle.
There is no presence of U.S. military in Iraqi hospitals. Our troops get
space-age medicine, but 70 percent of the Iraqis who get injured in the
same blast die.

In his book Military Medicine to Win Hearts and Minds: Aid to Civilians
in the Vietnam War, Robert J. Wilensky points out that from 1963 to
1971, American medics engaged in nearly 40 million civilian encounters
in Vietnam. AFTH Balad treats about 2,000 Iraqis a year. The quality of
care that the military gives to Iraqis in field hospitals is
indisputably superb, but the scope of treatment (which falls outside of
military responsibility) is cause for serious concern. Although the
Iraqi Ministry of Health has refused to report the number of injured
civilians, the medical journal The Lancet estimates the number of
seriously wounded Iraqis at nearly a million. According to the World
Health Organization, there were a total of about 35,000 hospital beds
in Iraq in 2005. The numbers suggest that the majority of injured
Iraqis are treated in an overburdened Iraqi health-care system, if at
all. +++

Traditionally, the lead responsibility for humanitarian efforts has
fallen to USAID, as it did in Vietnam. But in a move that Burkle calls
unprecedented, President Bush transferred that authority to the
Department of Defense in 2003, leaving a single agency in charge of both
engaging the enemy and patching up the people they blow apart.

The Bush Administration violated every single tenet that has been known
in humanitarian circles for decades, says Dr. Frederick Burkle.

At the beginning of the Iraq occupation, the Department of Defense sent
Burkle to run the countrys Ministry of Health; he had previously headed
up a trauma center during the first Gulf War and for more than 20 years
has led recovery efforts in war-torn areas from Somalia to northern
Iraq. Burkle proposed a plan that included establishing a
health-surveillance system, decentralizing health care, and ensuring
medical services for the large number of demobilized Iraqi
soldiers since, as many previous wars have shown, neglected soldiers
will keep on fighting. The Bush Administration replaced him after two
weeks, claiming it wanted a loyalist in the position, Burkle says. He
was recently invited back to Baghdad to offer consultation but declined
the opportunity. He sees it as an exercise in futility.

The Bush Administration violated every single tenet that has been known
in humanitarian circles for decades, Burkle says. Whatever plans were
implemented were ad hoc, and the military was given very little help
from the CPA [the Coalition Provisional Authority, a temporary
government in Iraq that was established by the United States]. What can
be done?

Knowing his experience in rebuilding other health-care systems, I ask
Burkle how long it would take to restore Iraqi health care to its
revered pre-Gulf War days, assuming the effort would be conducted
perfectly and without setbacks. Oh, my God, he says. I can tell you
that in Africa the recovery rate of its countries takes about a decade.
It is going to take a long time for Iraq to come back. Even if there is
a will, there are no doctors or nurses. Its going to take a long time,
just for medical and nursing education alone.

Burkle explained that neighboring countries like Jordan and Syria are
providing the most medical care to refugeesif the Iraqis can actually
make it out of the country.

They will never see the country they had before, Burkle explains.
People have split and divided along ethnic, tribal, and religious lines.
I think the legacy is that we have given them a license to divide Iraq,
and it will never be the same, for good or bad.

Before the CPA dissolved in June 2004, it issued a summary of its
accomplishments, stating that the entire country is at prewar
capabilities for providing health care. Every indication points to the
contrary. Iraqs infant mortality rate increased 37 percent after the
2003 invasion. It is now among the very worst countries, along with
Sierra Leone, Liberia, and Afghanistan, says Burkle, whereas it used to
be one of the best in the Middle East. One in eight Iraqi children
perish before their fifth birthday, according to a report by Save the
Children.

Hospitals operate without enough X-ray machines, ventilators, or
ambulances to meet patient demand. The International Committee of the
Red Cross issued a recent report stating, The humanitarian situation is
steadily worsening, and it is affecting, directly or indirectly, all
Iraqis. . . . The plight of Iraqi civilians is a daily reminder of the
fact that there has long been a failure to respect their lives and
dignity.

Standing next to the faceless Iraqi man, I feel undone by paradox. As an
American, I take a certain amount of pride in the fact that our country
is providing him with the greatest trauma care ever afforded a civilian
war casualty. He wont die on our watchwe will spend any amount of money
to make it so. But our best intentions unravel the moment he leaves AFTH
Balad. If he goes to Medical City, he may not survive the week. If he
regains some ability to communicate, if he can write a note or speak
some words, the pieces of his identity may begin to float together.
Then he may be returned home. Like Zemen, the Iraqi without a face will
require the efforts of his entire family to sustain him each day. He
will battle infections, prescription drug shortages, and blindness.
Shiite or Sunni, there wont be any rehab, disability payments, or
Medicare. For him, there is no promise of health or peace.