Iraqi health care system rife with problems
By Kelly Kennedy - Staff writer
Posted : Tuesday Sep 11, 2007 18:39:04 EDT

ASAD, Iraq — At the 399th Combat Support Hospital in mid-July, a soldier carried an impossibly tiny, malnourished 5-year-old boy into the emergency room with a gunshot wound to the stomach.

Every doctor and nurse’s face registered a flash of sorrow, but they immediately converged to treat him. After the child had gone through surgery, the sorrow returned as doctors talked about the next stage of treatment: the Iraqi health care system.

“The Iraqi medical system was one of the best in the Middle East prior to the Persian Gulf War,” said Col. Paul Astphan, acting commander of the unit. “Now they look upon their care as God’s will. If someone lives, great. If not, it’s God’s will. That’s the Iraqi health care system.”

Statistics show 96 percent of Americans who make it to military hospitals in Iraq survive. But though the Iraqi soldiers, police officers and civilians who come into American hospitals with the same life-threatening wounds will receive the same care, the civilian follow-up care — or lack thereof — could kill them.

At a Pentagon news conference Sept. 6, Dr. Samir Abdullah Hassan, Iraq Joint Forces Surgeon General, said the Iraqi health care system continues to suffer a lack of doctors, people to teach new doctors and supplies, because the Ministry of Health’s warehouse is in a dangerous area. According to Hassan, Iraq has only 35 percent of the physicians it needs, though he said he couldn’t cite a total figure of needed doctors. The Iraqi army has 148 physicians and needs 600, he said.

“The health system is affected by the shortage of physicians, especially in unsecured areas,” he said. “It’s a countrywide problem. The government is thinking how to bring them back.”

Security and better pay — doctors average $300 a month in Iraq — are possible solutions, he said.

“We lost many lives because the medical care is not, you know ...” he said, pausing. “The medical care is not good.”

A report released this year by the International Committee of the Red Cross states the hospitals are overwhelmed, and people are afraid to go to them because doctors and nurses are “frequently targeted.” Security issues inhibit supplies, and health care workers often can’t get through checkpoints to work.

U.S. military doctors in Iraq agree. They say Iraqi medical personnel are scared to work in hospitals because they may be killed for not supporting the insurgents, or they take other jobs for more pay, or they can’t get jobs because many were part of Saddam’s Baath party.

Civilian hospitals lack supplies and often are unclean. Patients die from infection, or, one doctor said, through mercy killings, since people with amputations are often ignored and left to suffer because it’s assumed they will die anyway.

Possibly more disturbing for the Americans are claims that Iraqis sent to the wrong hospitals — a Sunni to a Shiite hospital — are being killed because of their sect.

But U.S. officials say Iraqis will not rebuild their health care system if they know they can go to U.S. facilities — a Catch-22 that forces American troops to watch helplessly as people suffer.

Officials defend the progress of the health care system, though even four and a half years into the war, the Iraqi army still does not have its own hospital.

Col. Mark McGuire, chief of staff for 3rd Medical Command, said Iraqi soldiers just trained their first flight surgeons, and the first class of combat lifesavers just graduated.

“It’s getting better and better,” he said. “Iraqis are growing every day in their confidence of what they’re able to do.”

And Maj. Gen. Ronald Silverman, who leads 3rd Medical Command, said it’s not the U.S. military’s responsibility to take care of the civilian population.

“I run the world’s largest trauma center,” he said. “I don’t run a full-service hospital. We’re not set up or designed to do that.”

He said the Iraqi health care system is “very good, minus the technologies we have in the States.”

“When we send a patient to a public health facility, I’m fully confident that they can provide the best health care system available,” he said. “When you see all the spectacular bombings, they don’t come to us. They’re taking care of their own people.”

But the stories about problems aren’t isolated. At each of several forward operating bases visited by Military Times this summer, service members, interpreters and patients told tales of woe.

The doctors say the situation is difficult because as health care professionals, they take an oath to treat those who need help — no matter what.

“Our mission is to treat anyone who walks through the door,” said Navy Lt. Wil Morales, commander of the TQ Surgical Detachment, 2nd Maintenance Battalion, 2nd Marine Logistics Group, at Forward Operating Base Taqaddum. “We don’t look at the face or affiliation.”

But in June, they had to look as they treated 50 Iraqi civilians — mostly for blast injuries — and moved them into the Iraqi system for long-term care, which they know the system can’t support.

“They don’t have chronic support systems,” said Navy Capt. Jefferey Jernigan, an anesthesiologist. “The standard of care is different.”

If a person is seriously injured, said a Navy doctor who asked not to be named, the cultural tendency is to let him fend for himself. Because the health care system is bad, families don’t expect those with serious injuries to live, so they don’t bother trying to help them. He told stories of sending people with amputations to a local hospital, then hearing the person was dead within a week. And forget basic follow-up care or prosthetic devices.

“The trust of the Iraqi system — that’s an evolving process,” Jernigan said. “It’s not like home.”

In the emergency room, a 7-year-old boy struggled against U.S. doctors trying to save him from a shrapnel wound to the head. The mood wasn’t good. His heart rate dropped. He bled from both ears. The doctors helping him said they knew they could save him, but the Iraqi system can’t handle a traumatic brain injury or a child left with mental deficiencies.

Navy Lt. Elizabeth Raphael, the company’s executive officer, said she worries about her staff’s mental health. It’s traumatizing to help a patient and grow attached, then send him off for care in a broken system.

“Especially the little kids — that bothers a lot of people,” she said. “We send the Iraqis off somewhere else. It’s against everything we’ve been taught.”

Still, she said she understands the reasoning behind it.

“At first, the civilians could come here to get top-notch care,” she said. “But it’s supply and demand. If we do it, their system won’t grow. I’m convinced it’s the right thing …but it’s not easy.”

Medics at the smaller outposts face the same problems.

At FOB Apache in Adhamiya, U.S. Army medics working at the aid station there said they watched as Iraqi troops walked right past the station to bring their injured to the U.S. medics.

“They will never take their guys” to the Iraqi army aid station, said Sgt. Robbie Flowers of the 1-26. “They want their guys to live.”

He said the U.S. teams trying to train the Iraqi medics encourage Iraqi soldiers to go to their own doctors, but it seems pointless.

“I’ll see their medics sitting outside smoking cigarettes and playing cards while we’re working on two of their guys,” Flowers said. “We can’t turn them away.”

On the local civilian level, the problems seem even worse. People have no access to any care because there are no doctors and it’s too dangerous to travel to find one. If the U.S. military does not provide care, they won’t get any.
The gender gap

In Kabani, three female Navy corpsmen — medics — transform an Iraqi schoolroom into a women’s clinic. At first, no one comes. An edict emerges from the local Sunni mosque during morning prayers: Women will not be seen by American doctors. It is against Islam.

But soon, about 25 women and children appear anyway. They have no other options, and they said they remember a time when it was normal to go to the doctor.

Before, “They went to Fallujah, when there was a city there,” said Hospital Corpsman 2nd Class Janine Beaufort. “Or they went to Baghdad when it was safe, before the war.”

She smiled and hummed to calm the children as she treated a baby with scarlet fever and several children with diarrhea, but chose not to treat those with worms. They’ll only come back, she reasoned, because the water is still contaminated.

A little girl who had earlier been begging the soldiers providing security for the clinic for a toothbrush is diagnosed with a cavity in a tooth the corpsmen can’t treat — only pull.

Another woman comes in with cigarette burns — that’s how the locals tried to cure her stomach pains, she explained through an interpreter.

Worse, a 32-year-old woman came in with a burning sensation on her chest. Beaufort diagnosed obvious advanced breast cancer and tells the woman she must go see a specialist.

But will she?

During the press conference Sept. 6, Hassan explained water still hasn’t been cleaned, sewage still hasn’t been treated, and Iraqi citizens still have not been educated about sanitation — basics for keeping the population healthy. But he also said Anbar province, where Al Kabani is located, had been “completely secured” and doctors were working in those areas.

But the women won’t go to male doctors, and the Iraqi doctor attending men that day closed the pharmacy down before the corpsmen finished treating the women because he had already finished with the men. Women and children left without antibiotics because there was no way to get to them.

Army Lt. Col. Ricord Torgerson, health and education chief for the Ninewa Provincial Reconstruction Team in Mosul, said Americans have worked to coach, mentor and teach health care workers in Iraq.

“We’re with them as much as possible,” he said. “The primary health clinics are manned by very good people, but you have to be careful not to put U.S. standards on them.”

The U.S. doctors at the combat support hospitals are not allowed to leave the bases to help, he said, because they could be hurt and they’re in short supply. It’s not safe for the Iraqis, either.

“This area has a history of doctors being targeted when they talk to Americans,” he said.

Instead, Torgerson is working to have Iraqis teach each other, and to concentrate on basic first aid. Recently, 175 people went through a six-week course.

“What we really need is basic training — teach them how to react to an emergency,” he said. “They won’t seek care, but if you train the locals about how to seek help, that can make a difference.”

In the 399th Combat Support Hospital in Mosul, Lt. Col. Wayne Mosley works on a 6-year-old boy caught in the crossfire. His tibular nerve is exposed and he’ll need a skin graft, and he has a shrapnel wound in the stomach.

“We’ve had 57 pediatric cases in the last six months,” Mosley said. “We try to put everyone in the system where they can take care of them, but I don’t think they have access to medicines to prevent infections.”

Or the American doctors spend a lot of time carefully fixing a leg artery on an injured Iraqi, only to have the leg amputated when the Iraqi goes to a civilian hospital, said Maj. Michael Lake, working side-by-side with Mosley.

They must take care to ensure Sunnis go to Sunni hospitals, Kurds to Kurdish hospitals and Shia to Shiite hospitals.

“Our job here is to stabilize them and move on,” Lake said. “But there’s a concern if you’re the wrong religion and go to a civilian hospital in Mosul, you’ll be killed.”

Hassan said that in the past, 40 Iraqi soldiers were killed by doctors in a hospital in Kirkuk.

“But in the last year, there have been no more accidents with soldiers,” he said, adding that the hospitals are secured by Iraqi soldiers.

But an Iraqi army patient in a bed at the 399th thanked the doctors every day for treating him, though he lost his leg.

“He said, ‘If I went to the hospital, they would kill me,’ ” translated Kaniah Zangana, a Kurdish interpreter who has lived in San Diego since the 1970s.

But McGuire of 3rd Medical Command cited the good working relationship between the 28th Combat Support Hospital in Baghdad and Medical City, the Iraqi hospital — a relationship Hassan also praised. McGuire said Iraqi case management liaison officers are embedded in the hospitals to ensure everyone is properly cared for.

“Is it to our standard?” he said. “We can’t look at it that way.”

He talked about poor ward care and a lack of stabilization, but said the focus needs to be on Iraqis helping Iraqis and sustainable projects.

“We don’t want them to become dependent upon our assets. That’s the basis for counterinsurgency,” he said.