US military struggles to help Iraq, despite US corporate America’s ambivalence

By the end of this year, I will have served 24 of the last 36 months in Iraq. I am the chief medical officer of a BCT (Brigade Combat Team) of the 101st Airborne Division. In military circles, my title is BCT Surgeon. By training, I am a Family Medicine Physician. My unit operates in North Baghdad. My part in the fight involves engaging with Iraqi medical authorities and caregivers and targeting coalition force assistance in order to improve the medical capability of the Iraqis in our sector. We as a military have been doing this for 5 years. I would like to think that we are better off now, but sadly I’d be lying if I said so.

I have visited many clinics and hospitals in Baghdad, many repeatedly. For the most part I see severe shortages of basic medications and broken equipment. I have had mothers present their children to me as I walked through a hospital desperate for American assistance because their doctors are not equipped to help. Some doctors admit that the supply problem has caused them to buy drugs on the black market because their own state run supply system is broken. Clinics also wrestle with the problem of essential services. Some have toilets that back up because the central sewer lines are inadequate. Most clinics in Baghdad operate on 2-3 hours of electricity per day. For those that do not have proper freezers which are able to maintain proper temperatures, this means that they cannot keep immunizations.

The MOH (Ministry of Health) reports that they have a 5 year plan, however when one actually studies it, it clearly is not reasonable. Listed are dozens of hospitals which the MOH states it will build in the next 5 years from the ground-up. Many of these are very specialized centers such as cancer centers and those specializing in blood disorders. What is missing is a plan to fix primary care clinics, to provide citizens with clean drinking water, a real public health focus, a plan to fix the medical supply system, a plan to attract doctors and nurses back to the country. Given the MOH's track record, it will be doubtful if even 10% of their projected facilties are complete in 5 years.

The root causes are vast and multifactorial. Public health issues started with the diversion of moneys away from preventive medicine initiatives and essential services and into Iraq's military machine. After the US invasion, there was a resultant fleecing of a great amount of talent. Shortly after the successful overthrow of the Hussein regime, those in positions of authority were systematically fired and members of the Shia religious sect were placed in power to counter the previously majority Sunnis. Because this population had not held power and was excluded from government jobs, most were very inexperienced. In addition to this, the great majority of the professional talent have fled the nation due to very real security concerns and poor living conditions. This has created a talent vacuum which has resulted in very little improvement. Those in power in the MOH are ill equipped to manage their posts.

What is the US solution? At my level, we are improving clinics and providing much needed equipment and structural refurbishments to clinics and hospitals. Although this is a step in the right direction, it still reminds me of the clichéd action of rearranging deck chairs on the Titanic. Despite all of our efforts, there is still the supply issue, a doctor shortage, an inability for the MOH to come to grips with the true scope of the problem and no realistic assessment or plan for the future. Until these are addressed at the national level, I fear that we are their only hope- which is difficult to swallow given the fact that our efforts should be aimed at Iraqi self-sufficiency.

A possible solution

The MOH has shown that in 5 years it is no closer to providing the leadership and expertise to formulate and execute a real plan to fix the many problems within the health structure of Iraq. At this point, the US and new Iraqi government continue to pour millions of dollars into a corrupt and unlead health system.

What is needed is a new direction. Corporate America and Europe are fat with the expertise and investment capital to easily develop an in-depth analysis and business plan to fix this broken health care system. Sure it may cost billions, but Iraq has plenty of oil revenue. All it takes is a little swallowing of thier pride to bring in outside help. I’m sure for the right price and guarantees, Humana Healthcare, or Health South, or any large health system will be happy to form an executive analysis team of people with seven figure salaries, spend a few months on the ground analyzing the problem, and provide a plan to completely restructure the healthcare delivery in this nation. All that stands in the way then is the Iraqi government’s willingness to write the check.

Actually it’s a little more complicated than that. For one thing, the US congress needs to provide companies willing to stake a claim in this market with some safety mechanisms. For most, investing here is probably a less secure bet than opening up a shop on the dark side of the moon, but Congress can certainly make the initial pill much less bitter. Consider terrorist and violent action insurance, for one thing. Another would be tax breaks for those who are willing to be the first in their respective service areas to set up shop in Iraq. Another suggestion is for the US to insist on its financial institutions such as Bank of America or Chase Manhattan to be allowed to bring Iraq’s commerce capability into the modern era with the advent of electronic funds transfer and other improvements to legitimize it as a true trading partner. Iraq can presently only spend a fraction of its capital because it lacks the talent to properly manage and execute national level fiscal policy and procedures. Once we set the conditions for trade, this nation, with its vast oil exports will begin to look less like a war zone and more like Dubai or Kuwait.

I've said my peace, lets hear your comments

Primary Care in Baghdad

Primary Care here is not like in the states. When one goes to their doctor, they usually see a family physician or internist. They may go to a small clinic office or a hospital if their doctor is affiliated with such. Statistically over 90% of primary care patients will be managed successfully without the need for specialist consultation. This illustrates how our system is centered around primary care.

Not so in Iraq. Small Public Health Clinics, or PHC's are usually staffed by 'family doctors' or 'community health' doctors, but in reality these physicians have recieved much less training than a specialist. Most of the time they are intern equivalents. Society has adjusted its practices to this and most people will bypass these PHC's if they feel their condition is serious. This is not a criticism of the Iraqi system of care, but it needs to be recognized. One mistake that outside entities make is that they try to change the Iraqi system into the US system (or that of other western nations). Problem is that the physicians nor the people understand this. It would be like someone telling a US hospital that ER physicians would need to start accompanying ambulance crews.

In light of this, one must understand that the primary role that Iraqi PHC's play is in the area of public health and preventive medicine. Unfortunately, they cannot perform this because most clinics are not entitled to the same 24hr essential power that hospitals, security stations, and other entities recieve. This makes it impossible to store immunizations. Lack of power also contributes to their overall lack of capability such as the inability to provide x-ray and laboratory services except for the 2-3 hours of public power that they may recieve.

Displaced Persons in Baghdad

The following provides insight into the problem of displaced persons. Due to many reasons, thousands in Baghdad have lost their homes and are forced to live is abject poverty in Displaced Persons Camps. These persons are forced to endure the elements with minimal shelter, no reliable or clean source of water, and very little money. No sewage system and inadequete trash pickup is causing conditions which will inevitably lead to a public health crisis as the summer months approach. Temperatures have already reached into the 100s.

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Dina Institute

One of the first places I'd like to highlight is the Dina Institute. Full name is the "Dina Habitation Institute for Caring and Mogolism." We ran into this facility while on a patrol to a local hospital. It is a sad and depressing place. It is really nothing more than a local home which contains about 800 sq feet of true living space and houses about 55-65 developmentally delayed persons, mostly children. The background to this is that the owner of the house who is a 40-ish female once had a child with a handicap who subsequently died, but in taking care of this child, others began to drop off thier handicapped and physically and mentally challenged children to her. On an upcoming blog, I'll cover how this society justifies this apparent abandonment of thier children. I have attached the video below of my first visit as words just don't do this place justice. There are some ongoing efforts on our part to assist, and I will keep posting any news.

Hello. My name is Amit Bhavsar. I'm a Family Medicine Physician presently in Iraq. My intent for this blog is to describe for others some of the medical issues that I encounter in this war torn society. I'll also from time-to-time discuss some of the idiosyncrasies of serving over here. I hope that this will be interesting reading for those interested in the state of Iraqi medicine.