Iraq’s Medical Meltdown

Thousands of Iraqis die needlessly in a crumbling health-care system.

By Michael Mason|Tuesday, July 17, 2007
RELATED TAGS: HEALTH POLICY
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The Air Force Theater Hospital at Balad emergency room.
Image courtesy of 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 doesn’t 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. I’ve been trying to figure out who he is, but the Iraqi police have no system for keeping track of their own.”

According to Iraq’s 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.

“There’s 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.”

“You’re 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.

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Image courtesy of Dr. Gene Bolles

“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 Balad—police, detainees, and ordinary civilians—will 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 don’t 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 they’re not of much value, and will pretty much be scorned. Outcast. In the hospitals, they’ll 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 Emps’s 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.”

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Zemen, a student from Baghdad, was injured when a mortar shell landed at her high school in 2006. Her surgery left her without control of her arms or legs and there is no system for providing her with physical therapy.
Image courtesy of Faiza Alaraji

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 brother—a mummy of bandages—was attached to a ventilator, comatose. When the visitor sat down, he held his brother’s 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 Zemen’s neck and back.

At the emergency room of al-Numan Hospital in Baghdad, admitting doctors did what they could to slow Zemen’s 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 isn’t a place for her to get any care, and even if there were, it would involve risking one’s 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 isn’t likely that Zemen’s 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 Children’s 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 Saddam’s regime: “Doctors were forced to watch their patients die because they just didn’t have the supplies or medications they needed. And medical education was stifled for 25 years, which meant that new practices and technologies couldn’t 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.

“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 care—trach in place if needed, wounds closed, PEG tube for nutrition—as 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.

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

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 Moq­tada al-Sadr’s 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 Iraq’s 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. “It’s 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 craniotomy—and he survived.”

Bolles soon learned that his patient happened to be the brother of Iraq’s 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 can’t 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 aren’t any lines going into the patients. No IVs, no oxygen, no catheters. There aren’t 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 didn’t have any automatic instrumentation. It’s back to the old days, and I was trained that way. A lot of young guys wouldn’t 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 Children’s 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 aren’t going to make it.”

“Are Iraqi hospitals unable to handle the level of severity we’re passing on to them?” I ask.

“I guess they aren’t,” he says. “They don’t 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 posthaze of an afternoon sandstorm, Burkle’s armored convoy sped through Baghdad streets as he snapped pictures and made rapid-fire observations. The mission was threatened repeatedly: Burkle’s 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 Burkle’s 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 Defense’s 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 Burkle’s death (and in fact, Burkle’s 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 1965–1970,” 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 don’t 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.

At the beginning of the Iraq occupation, the Department of Defense sent Burkle to run the country’s 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. It’s 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 refugees—if 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. Iraq’s 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 won’t die on our watch—we 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 won’t be any rehab, disability payments, or Medicare. For him, there is no promise of health or peace.

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