IRAQ HEALTH SYSTEM COLLAPSED UNDER U.S. OCCUPATION

by Pratap Chatterjee

(IPS) WASHINGTON -- While some critics of the stumbling rehabilitation of Iraq's health care system focused on the failure to deliver basic infrastructure and supplies, others questioned the whole U.S. approach.

Unlike other poorer countries, which focused on mass health care using primary care practitioners, in the 1970s, Iraq had developed a Westernized system of sophisticated hospitals with advanced medical procedures, provided by specialist physicians and financed by oil revenues.

A July 2003 report by UNICEF and the World Health Organization noted that prior to 1990, 97 percent of the urban dwellers and 71 percent of the rural population had access to free primary health care; just 2 percent of hospital beds were privately managed.

Infant mortality rates fell from 80 per 1,000 live births in 1974, to 60 in 1982 and 40 in 1989, according to government statistics. A similar trend characterized under-five mortality rates which halved from 120 per 1,000 live births in 1974 to 60 in 1989. (Later studies have questioned these optimistic Iraqi government figures.)

With the 1991 Gulf War that followed Iraq's invasion of Kuwait, the situation changed dramatically. The war damaged hospitals, power generation, and water treatment facilities; foreign nurses left the country; and the health budget was slashed. Spending per capita fell from $86 to $17 in 1996.

In the eight months following the 1991 war, mortality rates for children under five shot back up to 120 per 1,000 live births, the highest recorded increase for any country in the world in the 1990s, according to the UNICEF/WHO report.

The war and the sanctions destroyed the capital-intensive model of free and sophisticated care. Water was often contaminated and the electricity supply erratic, making it difficult to operate the expensive medical equipment. Deaths from diarrhea rose fivefold and malnutrition-related diseases such as respiratory infections became widespread.

After the 2003 U.S. invasion, sanctions were lifted, and the government finally started to earn cash on its oil income, allowing it to raise medical salaries. But the damage to the health care system was hard to reverse.

Today Iraq needs either to initiate a major renovation program to resurrect its old medical system or it needs to switch to a preventative health care model based on primary health care clinics. In the last three years, owing to lack of money and security, it has done neither.

The failure by the occupation forces to revitalize healthcare tracks back to immediately after the invasion, when the U.S. Agency for International Development (USAID) dispatched Fred "Skip" Burkle to run the Ministry of Health. A doctor with four post-graduate degrees, Burkle had worked in Kosovo, Somalia and northern Iraq after the Gulf War.

He faced a health sector that -- like the oil and electricity sectors -- was devastated by post-war looting and had lost much of its infrastructure to theft and violence. Some 12 percent of hospitals were damaged and 7 percent looted. Central records were destroyed along with the country's two major communicable disease laboratories and four out of seven of its central warehouses.

"I spent my time planning a surveillance system and figuring out how to decentralize it, so that it was not Baghdad-centric," Burkle said in an interview. "Remember, there were no communication systems between Baghdad and the provinces. I was also concerned about looting, as I had observed this first-hand after the first Gulf War, as the first civilian to enter the country."

Burkle's suggestions, which he had meticulously planned and researched, were never implemented. Two weeks after arriving in Iraq, the White House informed him, he says, that it wanted a "loyalist" in the job and recalled him to the U.S.

More than two months passed before the new Republican appointee arrived. Unlike his predecessor, Jim Haveman was not a doctor, had never lived outside the U.S. and had never taken part in post-war or post-disaster reconstruction. He had experience as director of community health in the state of Michigan, and was a former director for International Aid, a faith-based relief organization that promotes Christianity in the developing world. He also previously headed up Bethany Christian Services, a large adoption agency that urges pregnant women not to have abortions.

Haveman said in an interview that he arrived to find that the ministry was still a mess. "I walked into a situation with two empty 11 story towers, 120,000 employees, 240 hospitals and 1,200 clinics (but the) employees had not been paid for three months. The ministry had a 16-million-dollar budget."

He says he is proud that he got the administrative staff back into the building within 45 days, got the ministry up and running, drew up a budget, completed large-scale immunizations successfully, and responded to disease outbreaks. He believes that he helped the ministry to switch from a prescription-based healthcare system to prevention and primary health care, wrote up a mental health code, implemented new training systems, supported professional groups and worked closely with NGOs and international agencies.

Critics acknowledge that Haveman got the ministry building and payroll up and running but say that he focused on the wrong priorities such as rewriting the list of medicines that the state medical company should import. Asked what medicines they were able to buy, Dr. Nasser Jabar Sheyal, an assistant to the health minister, said in an interview in spring 2004: "We make recommendations but we don't decide anything. This is an occupied country, not a democracy, and the Americans make all the decisions."

Meanwhile, under orders from Paul Bremer, the U.S. administrator of Iraq, senior doctors and health administrators with decades of experience were fired because they were members of the Ba'ath party. The ministry was handed over to the Da'wa party, a conservative Islamic group, with little experience in this field.

The party appointed Dr. Khudair Abbas, a respected breast cancer surgeon, to head the ministry. He started with a disadvantage: Abbas, who had studied in India and practiced in Britain, had not worked in the Iraqi health system since 1979. A year later, after Haveman left, Abbas also quit the ministry.

Some Da'wa officials struggled along bravely. Amar al-Saffar, the deputy minister in charge of finance for the health ministry, candidly confessed that he too, was out of his depth. "I was not planning to be a part of the crew at the ministry. I came to serve my party [Da'wa] and I don't know how I found myself in this ocean, but I have to swim. Unfortunately the current is very strong," he said. "My only experience is that for six years, I was the executive manager of an optical instruments business in Dubai."

While many top bureaucrats quit, he stayed on until he was kidnapped in November 2006 from his home in Adhamiya. His fate was unknown at the time of writing.

Meanwhile doctors in Iraq began to resent the expatriates who were given control of the system in which they had labored for so long. Dr. Koresh Al Qaseer, president of the Iraqi Surgeons Association, explained that he had a lot of respect for Dr. Abbas's medical expertise, but did not believe that his team knew Iraq's needs.

"Who are these people who left for 20 years and now think they can run our country? They don't know anything about it, and they don't care," he said angrily. "Believe me they did not leave because of Saddam, they left to pursue their careers and to make money. We have 35,000 doctors in Iraq, we don't need outsiders to come and run our hospitals, but we do need training." Richard Garfield, a professor of nursing from Columbia University in New York who has visited Iraq almost every year since 1996 as an advisor to the UN, agreed that training was necessary, but he believed that that was just the first step -- a fundamental overhaul of the system should have been conducted.

Some of the key mistakes of the Coalition Provisional Authority, he said, were investing in supplying medicines to a system where medicines were used poorly; holding short training courses with no supervision or follow-up to teach techniques that were not practiced in the country; catering to professional organizations that represented few people; and contracting U.S. firms to build hospitals and clinics, few of which were built and fewer still well-utilized.