May 2, 2003
Dr. Morten Rostrup Opening Statement:
Thank you all for coming.
Today I want to address very a very important issue as we see it in the current situation in Iraq, specifically in Baghdad.
I am the president of the International Council of Medecins Sans Frontieres, or Doctors Without Borders, but I also decided to volunteer as a field doctor in Baghdad, and left just before the war started as part of a medical surgical team, and I also stayed during the whole war and two weeks after the war. So in many ways I saw personally what happened in Baghdad, and specifically what happened to the health system.
What we have to realize is that, before the war started, most of the hospitals, 34 hospitals in Baghdad, were well functioning. They had staff, they were treating patients - they lacked some certain kind of medical supplies, but they did pretty well. And getting to know the Iraqi doctors, they were very skilled. They had advanced equipment for diagnosis and things were working pretty okay. What happened during the war was that the Minister of Health in Iraq, in fact, put together a kind of emergency plan to organize the hospitals in order to take care of casualties, and a few hospitals were designated to be first-line hospitals taking care of wounded. And some other hospitals were second-line hospitals.
Even during the war, at which time we were working as a surgical team in Al Kindi hospital on the eastern side of the Tigris River, which was one of these first-line hospitals. It was well functioning. A lot of medical staff, a lot of doctors on the shift system worked pretty well. There were even 8 surgeons at the same time in the hospital on 24-hour shifts. So things seemed to be pretty up and running and pretty well functioning.
Our surgical team worked together with our Iraqi colleagues until the April 2, this was also during the bombing phase, we kept on with our activities. Then two of our international volunteers were taken by the security police and detained. And then we had to suspend our activities for about ten days. This was in the last phase of the war, the last part of it in which our hospital Al Kindi turned out to be the major hospital receiving casualties. So of course we felt very bad about having to stop our work during this crucial period. However before we suspended our activities, we did have some kind of view of civilian casualties because we received in about two weeks time about 232 civilian casualties in our hospital. The major load of patients was in other hospitals, the other first line hospital, in that first phase of the war. There were about 20 deaths, a bit more, some people were dead on admission. Of course some patients died during treatment and in the in the emergency room.
I remember specifically one night we were working and there was an apparent missile attack on a civilian â€¦ three houses, and three families were severely injured, many children, and one of the children died before we were going to start our operation. And of course from a medical, human perspective, it is pretty tough some times to witness what is going on, and the consequences on the civilian population. So we kept on trying to work, but then we suspended activities and we were prepared as soon as we got our people back, which took another ten days, to start our activities again, also in this hospital.
But then on the 9th of April, of course as you all know, the American tanks rolled into Baghdad and took control of Baghdad. At the same time the insecurity in town increased tremendously. As you all know, there was a lot of looting and there was also a lot of shooting going on in different neighborhoods. This whole general insecurity led to the hospital staff not coming to work for that period, there was no public transport, no petrol and people were also afraid that their own homes would be looted so they preferred to stay there and protect their families. So it was pretty chaotic in those days and Al Kindi hospital, which had been working until the 8th of April had 120 patients and then suddenly due to this insecurity problem they had to close the hospital. And you can think just sending 120 patients, many who had been through major surgery, what to do with them. And many other hospitals, most of them, did not function because of the insecurity. There were a few, so some of the patients were discharged and transferred to these other hospitals, but many of the patients were discharged and sent home with out any real medical follow up of course. So it was pretty frustrating at them time also to witness that hospitals themselves were looted by people. And we saw that not only the general security was a huge problem, but also the specific security of the hospitals.
In my opinion it seems that the US forces present in Baghdad were not really prepared to deal with this problem, specifically the looting. I am a bit surprised about that because we all knew that this would be a phase immediately after the war and this lack of protection led to a total disarray later on in the hospital situation. And that I think is partly the cause of the very difficult situation we even see today.
Of course electricity was also a big problem at that point in time, as you know. We started our intervention in another hospital at that time because Al Kindi was more or less closed down, and we had a team in Al Zafarania hospital in a poor area of Baghdad and we managed to set up the operation theater in that hospital so that it could start working, and we also had our surgeon and anesthetist working there. So it was something we could do.
But what it is even more frustrating, and I think leads to an unacceptable situation, is that more than three weeks after the fall of Baghdad we still see most of the hospitals in a total disarray. We still see that they are disorganized. We still see that emergency rooms are filled with patients. That operation theaters are not fully functioning. In fact there is not one hospital in Baghdad today fully operational. Even the big hospitals such as Al Yarmouk, a 1000-bed hospital, or Saddam Medical City Hospital complex, which had 3000 beds, they just have a few hundred in Saddam City, and Al Yarmouk is not really functioning well beyond a few wards being opened.
So it is interesting to see that during the war and before the war these hospitals were working and now when peace has come, at least a state of stability, after three weeks we see a very difficult situation. We also see a power struggle inside the hospitals, a lack of leadership which also makes it very difficult to intervene in the hospitals. Nobody seems to have the total overview of hospitals, supplies, and so on. But it seems pretty clear to me that there is enough staff in Baghdad today, enough doctors and nurses, also medical supplies seem to be okay for the time being, there are some specific needs in the early phase but still it is not very bad and what is lacking is really organization of the hospitals and the immediate care of the patients. And there is no doubt that the one responsible for this is, according to the Geneva Conventions, the occupying power, and that is the US led coalition. They are definitely responsible to see that basic services are put in place very rapidly so as to avoid suffering of people. And this has not taken place. After three weeks the hospitals are still in disarray and I find that unacceptable.
It seems that things are going on at a bit higher institutional level to put together a new Ministry of Health and to put together a new kind of administration. Of course this is needed, it takes time, there are meetings and negotiations with different groups and so on. In the meantime, the hospitals, the microcosms around are not functioning and people are suffering and dying due to this fact. I must be clear on that. I found it very surprising that there did not seem to be any kind of plan as to how to deal with this very precarious situation in Baghdad immediately after the war. I think it is important to point to these facts.
I think to sum up, that there was a failure to secure the hospitals in the first place. There was not really any proper assessment of the health needs immediately after the war. We knew there were huge amounts of patients not being taken care of. Not only the war wounded, who were prematurely discharged, but also people with chronic diseases who needed to refill their medicines; cardiovascular diseases, diabetes, epilepsy, a lot of these patients also are unattended. And I think the lack of leadership, the lack of intervening here, has cost an unacceptable amount of lives. And it is clearly the occupying power who has the responsibility to restore this and I think something must be done now pretty, pretty urgently in order to avoid further suffering among the civilian population in Iraq.
I will also say that as a humanitarian organization we are not only concerned about relief, but as humanitarians we are also concerned about the conduct of war. And I must say that I am a bit concerned specifically, and we have opposed previously and will continue to oppose the use of cluster bombs that it has been confirmed have been used, which lead to unexploded ordnance which may injure civilians. We found it unacceptable as a humanitarian organization to have these bombs being used in a war situation. We talked about it in Kosovo, we talked about it in Afghanistan. I think that incidents that happened in Falujah and Mosul in which civilians were killed may point to, or at least we are concerned that there is a kind of preemptive shooting practice still going on. I think that these incidents should be independently investigated, and I think we have to realize that hostilities are still going on and people are still sick, and that is why it is so desperate to have an up and running health system in Baghdad specifically.
We have also done assessments in nine other cities throughout Iraq, and the problems we face are a bit different. We have not yet seen any huge epidemics. We have not yet seen any mass displacement of people or famine, characteristic of a huge humanitarian catastrophe or disaster and we are happy that this has not yet taken place. But still there are very clearly specific needs in the health sector specifically, and I think the major point now is for the US-led coalition to really fulfill their responsibility to see that basic services in Baghdad specifically, and the hospitals are met very urgently. That is today. It should have been yesterday.
I will stop here and be happy to take some questions.
Q: What did you do when you were in Baghdad to complain about this to the Coalition forces and what kind of a response did you get from them?
Well we had several meetings while I was there with the US Marines who were in charge at the time. Later they were replaced by the US Army and we brought up the situation with them several times, especially in the early phase when general security was a major issue and also protection of hospitals. Things improved a bit after it was brought up to them, also by other organizations. Some hospitals were protected by them. Other hospitals were in fact protected by militia groups from the community and that prevented looting of some of the hospitals as well. And I think we started our intervention in one of the hospitals with our surgical team in order to get started some pure medical activities, at the same time we did some assessments in other hospitals and there were other organizations doing the same. And the lack of organization was really obvious, and the power struggle we saw in the early phase was brought to the attention of the people. I think the way they have been trying to deal with this has been on a more reconstruction thinking and building up the Ministry of Health, etc. And this takes time, this takes weeks, and they are still in the process of dealing with this. And, that is fine. We need this to get things up and running from a higher administrative point of view. But in the meanwhile, we cannot let patients die due to hospitals in disarray. So there need to be parallel efforts, to have intermediate measures taken, to have a kind of leadership on an intermediate basis there. And we can deal with the more organizational building up the ministries.
Q: Do you feel that, one of the reasons you are here, is that you did not get an audience with the American forces there and so you are coming here to reach out to other people here? Why here and not in Baghdad?
Well we have brought this up in Baghdad. We have a team there, a medical team in Baghdad, and they are bringing this up, of course, whenever it is possible. And we also tried to have a meeting with Garner to discuss the issues after he arrived. I have meetings here in Washington as well, that's why I am here, to try and really point to this precarious situation in the hospitals.
Q: As you say, building up a government does take time, what are some specific things, though, that they could do on the ground in the hospitals; specific examples that would make a difference while they are still working on administration?
I think it could have been possible in a microcosmic way to put up a kind of leadership, and just provide as simple a thing as salary to some key staff. They could even have concentrated on some key hospitals, at least have gotten a few hospitals up and running. It would have been possible to do that. As an occupying power, they have, in my opinion, the responsibility of doing that. But, it didn't seem that this was part of the plan. Part of the plan was building up a new administration, a new government, and so on, but if you see a health care system in disarray, you have to address that as well.
Q: We got the impression reading news reports that all of the hospitals were basically completely looted, completely bare, stripped bare, there was nothing left. Can you give an assessment to the extent of the looting based on your observation? And, secondly, are you doing specific fundraising to try to get people to contribute to charity to help your cause in Iraq? And what has been the public response?
For the first question, I think we have been visiting about 15 of the hospitals in Baghdad, there are 34. We don't have a total overview of all hospitals, but we have seen quite a few, and also the primary health care centers. And it is true that some of these hospitals have been severely looted, but not as many as we anticipated beforehand. Some hospitals have been protected and they have avoided looting. At Al Kamara hospital, for example, the doctors themselves protected the hospital with guns, and Al Kindi hospital was protected by a militia group. It was previously reported to have been looted. So the looting constituted a problem for some specific hospitals, but still hospitals did have quite a lot of medical supplies, some specific needs: yes, anesthetic drugs, yes, painkillers, and external fixators used for complicated fractures, yes, but they would have been able to work pretty immediately after the war if security had been there, and a kind of organization.
When it comes to fundraising, Medecins Sans Frontieres, we don't have any specific fundraising for this current crisis in Iraq.
Just to say on fundraising, we continuously ask for support of individuals for our emergency efforts around the world and have highlighted our work in Iraq as we do highlight our current work in Congo, in Liberia and in other places. The fact that we have a base of independent financing through the contribution and ongoing support of private individuals throughout the world is what helps us to respond independently to these crisis situations. And Iraq is no different.
Q: You mentioned that there were no epidemics, no famine, no displaced people yet. I had a question specifically about the children. Are basic immunizations and vaccine protocols, basic care for kids being looked after or are they being lost to the...?
I think definitely for kids, and I know that for vaccinations that there has been a problem due to lack of electricity and lack of refrigerators, and so on. And they need supplies for vaccination. We didn't specifically look into that in our assessments, but I have heard from other sources that this constitutes a problem. I've also heard that there has been some increase in the diarrhea cases. Nothing has been confirmed as of yet when it comes to, for instance, cholera. But it is, of course, very early to say what will happen. We do see, however, an increasing number of patients with specific diseases such as kala azar, which is a parasitic and deadly disease; we see that especially in southern areas. We know that in Basra, for example, there are a thousand TB patients without medication who had to discontinue their treatment, which is also pretty serious. So there are shortages there that must be met and have not been met so far, and that is a concern.
Q: When you talk about lack of disorganization, you mean the lack of administrators, or senior doctors? I mean what is going on, I mean if there is a doctor you assume they know how to treat a patient, what is the problem with disorganization?
Well what happened was, of course, you know Iraq was very centrally controlled, and the Ministry of Health did have a lot of influence on the hospitals, and had their own representatives in the hospitals. So it was a very top-down organization, and this layer disappeared after the regime fell. Then the doctors were coming back and trying to organize themselves without any proper leadership. They have made some councils, some of them. Then you may have other groups coming into the hospitals. Religious groups, for example, who may want to have a say in making sure that the hospital in their community is working, and so you have a lot of discussion going on there. And what we have been witnessing, I myself when I went to hospitals; I could meet one so-called director one day and discuss the needs and our intervention, and then the next day I met another one who was also the so-called director, who said something else. It was very difficult for any of them to really make a kind of decision, or to know who was responsible. Of course, you have to organize the shift system, you have to organize the hygienic system, which is pretty terrible, also the waste care which is a big problem now, so it really needs a kind of organization. As you can also understand, the patient flow of the hospital is also something that must be organized. So all of this was in a kind of disarray and not really addressed by the US-led coalition.
Can I just add to that? It is also in response to your question about what the US could have done there. As Morten is saying, this gridlock and limbo is, in a way, what characterized the system, and they were waiting for a sense of leadership, and that is what the US-led coalition failed to provide. A sense of political leadership and administration to allow the hospitals to get organized and start running properly. Waiting for the signal from the top, since the top had been removed, is what failed to occur and has failed to occur for the past three weeks, and that is what is impeding and paralyzing the functioning of the hospitals which leads to the fact, as Morten has said, that even today there is still no fully functioning hospital in Baghdad, still no ambulance system, patients are still not being admitted correctly and that is having a direct consequence on treating patients. That is what we are very much concerned about.
Q: Did you have a chance to do an assessment of conditions in any of the psychiatric institutions? And assess conditions for adults and children with mental illness or mental disability?
No, we did not look into mental institutions. I know there was one in Baghdad that was looted and it was the big problem. That was not very long ago, actually. We were mostly looking at hospitals with a surgical unit because we had a surgical team, and because we were very concerned about the war wounded that had been sent home and needed secondary surgery, and also in case of new casualties. But there have been other people, other organizations, looking into these hospitals.
Q: How much of the problems stem from lack of physicians going in due to lack of security? I was over there and a lot of the hospitals didn't have staff because they were afraid, but that was two weeks ago and I am wondering if that has changed?
That has changed, as you see more normalization now in Baghdad, the petrol started a couple of weeks ago, you could buy petrol, the public transport, the traffic took up, and electricity was coming back in a major part of the city. So things started to normalize, and also staff could come back, the worst phase of the looting was over. So at this point in time, it is not lack of staff, or lack of doctors. There are plenty of doctors in Baghdad, skilled doctors, and also nurses. We do have also quite a lot of medical supplies, some specific needs, yes. This is not the problem now. It should have been up and running, there should not be any reason why now it is not running, but still it is not. That is, in our opinion, due to a lack of leadership, in which the US-led coalition has responsibility.
Q: I visited one hospital in Saddam City and the hospital director there said it was running fine.
That is interesting, it was in Saddam City? Yes, I have also been to that hospital, and when I was there it was not what I would say "running fine." I know that when you talk to certain people in hospitals that they will say that things are fine and they are running fine, but if you look into the hospital from a medical perspective, and as I am a doctor and saw what was happening, I found it totally unacceptable in many, many places. You turn the lobby into a triage center and people are screaming because they don't have painkillers, and the responsibility of some doctors to follow up on patients is also diluted to some extent because of the disorganization in place. And people are also reluctant to go to hospitals, because they know the conditions are not that good. So, I think from my point of view, and I just talked to my team in Baghdad that has done assessments these past days as well, the situation is not very much improved.
Q: Can you be a little more specific about what you would like to see happen? Would you like the US government to send money over for ambulances and to pay salaries of doctors and nurses? And also, you talk about a top-down bureaucracy, should the US come in and say: "You are the hospital administrator, you are the chief of staff?" I mean, how do you work with people when you are trying to bring in democracy?
You need to have, in my opinion, a kind of emergency approach here, which will not be the final solution or the final setup for the hospital. But I think if you focus on some key hospitals, you can try to institute a kind of leadership and salary system, organize the staff, and say that this is a temporary system just to save lives and alleviate suffering at this point in time. And of course when we get a Ministry of Health and a government up and running, we will look into other ways of organizing. In my opinion as an emergency doctor, you really need to have a kind of emergency approach to this, which will be on an intermediate basis. It really should be possible to do that. I am not a hospital administrator, I am just a clinician, but I have seen a lot of hospitals around the world, and it should be possible to put up a kind of interim leadership there, to pay salaries, and to get the staff organized, at least in some of these hospitals.
Q: Before and during the war, your organization and a lot of others said that it is going to be very hard to work for a military occupying power, and that the division humanitarian organizations normally prefer, to be neutral, was going to be sacrificed. How did that play out? Or did it play out while you were in Baghdad after the war and the US coalition set up?
For us in MSF, we kept our totally independent status all the time. Of course we have always to relate to occupying powers or military groups or whatsoever, that's for sure. But our assessments, we could do freely in Baghdad and other places in Iraq. We could move around, we could monitor, we could give aid according to the needs that we defined and saw. So we didn't have any specific problems regarding that. But, MSF is well-known to be very independent, and we have stated on many previous occasions the same, and immediately after the war I felt that we didn't face any problem with the US-led coalition when it came to access to patients.
Q: If this gets changed, this assistance gets in place, if organization begins to happen, what is the big picture for health in Iraq, since it was a relatively stable system? Do you see long-term health challenges?
As I said, there are skilled people in Iraq. There was a good health system, to some extent. What I think is a concern, and which is very important to see to is, the new health system, which I think will be very good when it is up and running. Our colleagues were just waiting for a peace situation to start to build up a new good health system. But what we need to address very clearly is creating a system that will also offer health care to the most vulnerable, the poorest part of the population. I am a bit concerned about tendencies to privatize much of the health system in Iraq, and I think we should be very cautious not to allow this to happen on a large scale, so that poor people will not have proper access. This will be a challenge, to build up a good health system with access to health care for also the poorest the most vulnerable.
All that is true, contingent obviously upon the establishment of a political framework that is stable, that respects rights and insures security. The health system is, I think Morten is saying, technically there and should be no problem, but politically it is another issue we still need to be watchful of.
Q: But there are no diseases like we have in Afghanistan, certain problems that really needed to be tackled. I mean do you expect it to be stable if we can get these other problems worked out? Is mental illness going to be a big problem?
I think it is for sure that many people are traumatized after this war. I saw some children who had been through the '91 Gulf War and were traumatized during the bombing, and it was a reactivation of some of these symptoms, when they were now older and the bombing started again, they were reminded of what had happened in their childhood. So, of course, it has been a very, very tough period for the Iraqi population. We have yet to see the lot of new needs that may be uncovered in the time to come, and the health system should also be prepared to deal with that. So, there will be challenges but it should be possible absolutely, if the political situation allows it, and if there is a peaceful final solution.
Q: If I heard you correctly earlier, you said lives were lost due to the failure of the health system, and of the US occupiers to make sure it was working well. Do you have any figures to show this?
No, it is very difficult to get figures, because the registration of patients in hospitals is also now, to some extent, in disarray. We know some of the people we see in hospitals should have been better taken care of, and we know also that a lot of patients who should have been in the hospital are not, and the capacity in many of these wards is totally overloaded. So for sure, but a set of figures is really impossible to say. We also don't know how many people with insulin-dependent diabetes are dying at home because they don't have insulin, there are a lot of things we don't know. In the immediate aftermath of the war, I was very concerned about what was happening to all of these people. This is a city of 4.5 million, and what is happening to all of these patients with chronic diseases? They are staying at home, and they have nowhere to go. I think we will perhaps get to know stories, after some time, of what actually happened to them. But it is a kind of silent emergency that could be going on in Baghdad without anyone registering it.
Q: There are people you know of or have heard of who have died because they could not get to a functioning hospital to get medical care?
Yeah, we know of infections in war wounded, for instance, leading to septicemia, which is a complication, and we have seen some of the cases coming in with deteriorating medical condition due to delay in medical treatment. So, of course, those are patients we see and there are also a lot of patients that we don't see, and that is also of great concern.
Q: Can I ask you a little bit about cluster bombs? Do you have any sense of how widespread of how the injuries, the civilian injuries and deaths were from them? And, secondly, is your group doing anything to try and push for them to be banned?
Well we have addressed the cluster bombs several times in each conflict we have encountered them. Specifically in Iraq we have just seen reports, and also confirmed reports from the US and the UK that they have used cluster bombs. We have not, as far as I am aware, our teams, we have not actually treated patients with cluster bomb injuries. But we know from previous experience, in Afghanistan specifically and also Kosovo, how harmful these devices are. So that is why I want to address it on a kind of principle level here.
And just to make it even clearer. What is really the problem with these types of bombs, cluster bombs and cluster munitions, is there indiscriminate nature. The fact that the way they are constructed and used, they cannot distinguish between military and civilian. Discrimination and targeting is a key principle in international humanitarian law, to preserve civilians, and these devices cannot do that and therefore they should not be used as a matter of principle.
Q: They should not be used at all? Or just in civilian areas?
They should not be used.
Q: The United States has said that they will make no attempt to find out the civilian deaths because of the war. Is there any group in Iraq, any foreigners, and Iraqis, anyone trying to find out what the death toll will be for the civilian population of Iraq?
Not that I know of, but I think it could be possible if one looks into all the hospital registers during the war to see at least how many people were admitted to the different hospitals. I am not aware of anyone doing that. But I think it is very important that there is an investigation into the consequences of this war, and how this war was conducted should also be looked into.
Q: Can you briefly describe the health system under Hussein? Were there hospitals and doctors for the rich and others that catered to the poor?
There was a pretty advanced health system in which you had the public hospitals and you also had a lot of private clinics, private hospitals. The doctors usually worked from 8 am to 2 pm in the public hospital. They were obliged to do that. But after this they could go to their own private clinic. The salary system was not that good, so most of the doctors seemed to get most of their salary from the private clinics. Patients had to pay when coming to the hospital. It was 350 dinars, which is not more than 10 cents today, but it was another kind of exchange rate at that point in time. And they also had to pay a bit for the drugs. Since we were not actually working very actively during the Saddam Hussein regime, I cannot really tell in detail to what extent the poorest had access to the health system, but I think this is an important point for the future to address. And then you had health centers around, several primary health care centers, which also dealt with the patients on an out-patient basis, but as we know the maternal death rate was pretty high, infant death rate very high, so of course there were shortcomings in the health care system previously.
Q: Was there any difficulty or limitations to take care of the female patients?
The wards and emergency wards are very gender specific, but as far as I experienced it, it did not constitute any major problem in the hospitals I was seeing.
Q: You mentioned that the coalition forces had a lack of organization hampered an efficient delivery of care. Were there any instances that you are aware of where the coalition forces essentially prevented care from being delivered either directly or indirectly? Or was that not the case?
I did not experience anything of that. Nope, not that I know of.
Q: Did you hear of any reports or confirming reports that coalition force tanks, accidentally supposedly, actually broke open gates around some hospitals?
No, I am not aware of that. I didn't hear any such reports.
Q: And who are you meeting with here?
We are meeting with people at the Pentagon, people on the Hill, and the State Department.
Q: Have you encountered any concern regarding Christian missionary groups or groups that may have religious conviction. Is this any kind of thing that the doctors are dealing with regarding any kind of tension between Muslims or Christians or any other groups? I know there have been reports that there are Southern Baptists and Franklin Graham's Samaritan's Purse groups ready to go in to help as well. Do you have any interaction with these organizations and is this anything you are dealing with at all?
I haven't been dealing with that so it is a bit new to me as well. So I can't comment on that.
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