April 23, 2003
Challenges Facing the Health System in Iraq

We have an occupying power in Iraq and according to the Geneva Conventions it is the occupying power that has the responsibility to see that needs of the civilians are met and urgently so. As long as we have an occupying power, it is up to the Occupying power to find a solution to the problem. Whether they do it themselves or they bring in other parties, it is up to them to decide. – Morten Rostrup

© Copyright Bruno de Cock

April 23, 2003 -- Doctors Without Borders/Médecins Sans Frontières (MSF) has been working in Iraq for five weeks now, only interrupted by the imprisonment of two volunteers by the Iraqi authorities during the height of the fighting. Much of that work has been in hospitals, directly with patients and trying to identify the most critical needs of the health system, which was under strain during the war. MSF's International President, Dr. Morten Rostrup, was the medical coordinator in Baghdad for the past five weeks and has just returned to Europe. At a briefing for international journalists today in Brussels, he described what MSF sees as the challenges in Iraq. His remarks follow.

Thank you everyone for coming

I was the Medical Coordinator and was concentrating on the medical aspects of the mission - but I was also the International President and also saw a lot of what was happening and what was going on. I will give you first the background to the mission.

We started to approach Iraq and the Iraqi regime back in December of last year. We had several exploratory missions into Iraq before that in the time since 1991 when we left Iraq. We just had to realise it was not possible to create a humanitarian space under the regime that was in power. But we managed to get some kind of access and a Memorandum of Understanding (MOU) with some key players in Iraq just ahead of the war and we then decided to send a medical team to Iraq to stay there during the war and to support our Iraqi colleagues with medical supplies and also with manpower.

This was, for us, a very natural thing to do being a medical humanitarian organization and we thought there should absolutely be a presence of such organisations in Baghdad even though, of course, we had a lot of security constraints. And both from a personal perspective and from an institutional perspective, it is not an easy decision to take to put a team at risk in which the scenario was very, very unpredictable - as you all know.

So we did not know exactly what kind of challenges we would encounter in Baghdad.

The team of six, three doctors - a surgeon, anaesthesiologist and myself, an emergency intensive care doctor - and we had three logistical support personnel.

And on the second night of the bombing the team felt we had to find out what was happening to the civilian population because there was heavy bombing and we decided at around midnight to go to Yarmouk Hospital which was on the west side of Baghdad, in order to see what was happening. And there were a lot of civilian casualties coming in to the hospital at the time and we met with people in the hospital. We saw they were coping pretty well with the casualties and we also ran into, by coincidence, the Minister of Health of the Government of Iraq - he was also in the hospital in the middle of the night.

And so we were sitting there in the hospital during the bombing and discussing how to proceed further with the assistance to the Iraqi population. And there were certain needs not in the Yarmouk hospital but in the Al Kindi hospital and we then decided after an assessment the following day to put our surgical team in the Al Kindi hospital.

This was a first line hospital for war victims and it was supposed to play a major role in the second phase of the war in case the Americans were approaching from the south west side in which the Yarmouk hospital would be soon under American control.

So we started working in Al Kindi with our Iraqi colleagues. There were not many casualties in the first phase of the war in this hospital. Medical casualties came to other hospitals. But we were able to assess quite a lot of civilians being injured, some others having been killed and there was a wide range of casualties from minor casualties to more severe cases. But the majority were more minor cases.

We should be aware that it is still very uncertain how many civilian casualties there were in Iraq and nobody really knows the correct number - and maybe we shall never know the correct number. And also the classification of the casualties according to the severity of the injury has not been done at all. So it is difficult to get a total overview but of course with Baghdad we can talk about several hundred casualties, perhaps over a thousand. But the numbers are not very precise. And some of the registers are now lacking in the hospitals so it may be difficult even now to track down the exact number.

So we continued our presence in the hospitals for quite some time. We were staying there during the night time in case we were needed and all the time there was bombing. It was very irregular in many ways, both day and night, so we could not really take bombing into consideration when moving in town, we just had to move whenever in order to be able to do some medical action.

Then we experienced on April 2 a very severe event for the team. Two of our members were taken by the security police of the regime. They disappeared from the hotel without any sort of explanation or information. Or course, this was another factor that added to the stress we had at the time being in the middle of this war. It was a very difficult time for us and especially for them who were put in jail and spent ten days in three different jails, transported around during heavy fighting - especially in the areas where the jails were.

And the rest of the team, the four of us, we also had a difficult time, having two people missing, our friends and colleagues and not knowing anything. And we decided to suspend our medical activities in Al Kindi hospital on April 2, which of course is already a difficult decision we had to make. We had to make it clear that is was totally unacceptable that volunteer humanitarian aid workers are arrested in this way. We could not accept this and we it was also a pity because at this phase this was the last week of the war and the battle for Baghdad that everybody had been waiting for was really approaching and we were not able, in the height of this conflict, to assist as much as we wanted to in the Al Kindi hospital.

I passed by and we gave some important medical supplies, so we did give some support despite the fact that two were missing.

On April 7, Yarmouk hospital was hit, according to the doctors there, and they had to close down the hospital. All the major casualties were transferred to the Al Kindi hospital. On April 9, due to insecurity - the Americans were entering Baghdad - the Al Kindi hospital closed down. There were 120 patients in the hospital. Some were referred to other hospitals but many patients were sent home for not any kind of follow-up medical treatment. And we saw at the same time a partial collapse of the hospital system in Baghdad and we started to wonder what were the reasons for this partial collapse. I think what we said at the time, and it was stated by other organisations being present - although there were very few international organisations present - that it was the security problem. The looting started as you all know. Hospitals were not protected and they were looted, many of them. And they were afraid of being looted themselves and so staff from the hospitals stayed home to protect their homes. There was a lack of public transport, a lack of petrol, people could not move so even though some of the hospital structures were there, even though they were not being looted, they were very short of staff and some of the Iraqi doctors who stayed in the hospitals did very good work. I think some of there Iraqi doctors were pretty heroic working for 24 hours for many days trying to treat their patients under very difficult circumstances. So I think we should also pay tribute to those doctors who stayed as many people left these facilities. And, in addition, there was looting of the hospitals and a lack of medical supplies. But we saw a staff shortage as a key problem in this stage - which could be described as a second stage of what happened to the health structures in Baghdad - in addition to electricity failure and a lack of generators in some hospitals, which made it pretty difficult to carry out appropriate medical work shortly after Baghdad came under the control of the Americans.

However it was also interesting to see things moving to another phase. The problems in hospitals in Baghdad are no longer related to lack of transport, security or so on as much as disorganization and a lack of administration. What we are seeing is a power vacuum in Iraq in general and very clearly in the hospitals. There is a lack of leadership, there are different groups that are trying to control the hospitals and I think we have to agree that hospitals may play a political role when it comes to the importance of service institutions and the control of hospitals may be looked at as a political issue. And it has been a bit frustrating to see that what has not been addressed that well is the problem of leadership in the hospitals. Many of the problems we see today in the hospitals are really due to this lack of leadership. That has to be addressed. The Ministry of Health (MoH) had a pretty clear hierarchical structure in Iraq and suddenly these people disappeared and the hospitals had nothing to relate to. And especially Baghdad this has been a big problem. Outside Baghdad and in the other cities some of the structures have been kept going, so they could work, more or less, in the same old fashion and you did not see the same crisis there. But In Baghdad still we have problems. There are problems with patients getting medical treatment even though it has improved quite a lot. But there is no big hospital that is functional in Baghdad today, two weeks more or less after the Americans took control of the city. So that is a great concern. As I stated earlier, when I was in Baghdad there were a lot of patients who were discharged and we have been pretty worried about the condition of these people because they have been without medical attention. Many of them may need secondary surgery so we still want to ask the question of whether there will be a kind of second wave with a lot of patients needing surgery coming again to the hospitals.

In addition to this, we also know there are many patients there with chronic diseases. Diabetes, epilepsy, cardio-vascular disease, kidney diseases that need regular follow up and also medication. Many of these patients have been without their regular medication and if you think of a diabetic who is insulin dependent, without insulin you will die of diabetes if you do not get care.

So what we still do not know is what has been going on in the many homes in the Baghdad, a city with millions of people, when the primary health system along with the hospitals broke down. But I hope we shall be able to do a proper assessment and the teams are trying to do this as well, even though it is a bit difficult under the current situation in Baghdad.

What we have been able to do over the past two weeks is to send MSF teams from Iran, Syria, Jordan, and Kuwait into different areas of Iraq. And we have now done quite a few assessments of medical needs in Iraq in general by visiting about ten cities now and we are getting, more and more, a kind of overview of the health situation. Of course it takes time. These are rapid assessments and to do a thorough assessment we need more time to look into the morbidity, mortality, epidemiological studies and so on so that could take some time.

But I think it is telling that, after two weeks, and after being in ten cities, MSF has not found any reason to justify a major humanitarian medical program in Iraq. I think it is pretty interesting and for me what we have been doing so far contrasts what has been portrayed, especially in Europe I think, about this huge humanitarian crisis or catastrophe in Iraq. This perception does not correspond with what we have been so far able to see ourselves in Iraq and I think we also have to ask a question whether it is really justified to use the whole notion of a major humanitarian catastrophe from a medical perspective at this point in time.

Things are working pretty OK in many places. Of course there are needs, definite needs, there are specific needs in the medical community. There is a shortage of oxygen and anaesthetic drugs. There is kala azar, a special disease that is pretty abundant in Iraq. So for sure there are needs and there is a kind of crisis in the health care system. But I would really ask the question of if it justifies this notion of a huge humanitarian crisis or catastrophe.

For MSF it is still to early to draw any final conclusions on the situation. We shall still be carrying out assessments for some weeks to come. But it is a bit provoking to see how attention has been brought to this humanitarian situation in Iraq while, at the same time, we are struggling with tremendous humanitarian problems and crisis in the DRC at this time, in the Cote d'Ivoire, Liberia and we have alarming data from south Sudan with increased levels of malnutrition. We have not seen any signs of famine or epidemics in Iraq nor any mass displacement of people. We have not seen any of the general characteristics of a huge humanitarian crisis. I think we have to be a bit critical in order to be honest and precise as possible in describing what is going on today.

The people responsible today for Iraq have to address the current problems. The lack of leadership and administration has to be addressed very, very urgently. I think it is a shame that such issues mean that people are not getting adequate treatment. It should be easy to put in place a system very quickly that will take on the responsibility to get the Iraqi health care system working. It is more needed now than huge amounts of medical supplies.

There are challenges in Iraq. There are needs of reconstruction and development. And there are many challenges still to come and MSF shall continue to be present.

QUESTIONS

Who is responsible for improving the hospital administration?
We have an occupying power in Iraq and according to the Geneva Conventions it is the occupying power that has the responsibility to see that needs of the civilians are met and urgently so. As long as we have an occupying power it is up to the Occupying power to find a solution to the problem. Whether they do it themselves or they bring in other parties, it is up to them to decide.

Are the British and Americans doing enough?
What we are seeing after two weeks is that some of these needs are not being addressed in a pertinent way it should have been dealt with . It has clear consequences for the civilian population and I would have thought this would have been addressed. Two weeks, I would have hoped we would not have seen this administrative chaos.

What about the French proposal for an air bridge for patients?
I think the Iraqi doctors I have met are skilled people and the level of the health care system in Iraq has been pretty advanced. I think they are able to deal with most of the cases that they see.

When we think about airlifts to Liberia or Cote d'Ivoire it is not even a question. It is not raised at all.

What is wrong with the reporting?
We are here in a very politicised crisis as well and the media attention has been tremendous in this crisis. Take a step back and look at what is really happening and what kind of crisis is this and what is an adequate way of dealing with this and also keep a perspective on other crises in the world today.

There was a media report that in one week about 1,000 people were massacred in Congo. At the same time, Iraqi authorities felt that 1,200 civilians had been killed so far in the war and 5,000 injured. It gives a perspective on what is happening and how we all get drawn into this crisis in a way that is not all the time appropriate.

Have you shared your analysis with other agencies?
There are very few really big international organizations inside Iraq. Lots of them have been outside Iraq and still many of them have not had access to Iraq properly but they are starting to come now. We have shared our thoughts with the International Committee of the Red Cross (ICRC) who was also present in Baghdad. But of the big international organisations, it was only the ICRC and MSF who were present during the war.

And remember, we are only talking about the medical situation. We are not looking into the water or food situation in Iraq. We have not found a huge amount of malnutrition. We are speaking specifically of the medical humanitarian situation. Even there, we have a lot of practical issues to be resolved. Salaries, for example, who is going to pay the salaries for the people who work in the hospitals.