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The War Profiteers - War Crimes,
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May 30th,
2009 - Once Envied, Iraqi Health Care Is Lost to War, Graft |
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Once Envied,
Iraqi Health Care Is Lost to War, Graft By Corinne Reilly McClatchy Newspapers May 30, 2009 Baghdad - The Baghdad
Teaching Hospital's emergency room is cleaner than most in the capital city -
in fact, it's widely considered the best in the Iraqi capital. Still, flies
buzz overhead, and on busy days there aren't enough beds or oxygen tanks.
Across the room, a crude sign made with binder paper and tape marks the
department's two-bed cardiac unit, which lacks a reliable defibrillator. Dr. Zinah Jawad leans over
her patient and peers into his glazed eyes. It doesn't look good, she said,
shaking her head. The man had arrived a few hours earlier with a high fever
and dizziness. Now he lies shaking, sweat soaking his dirty clothes. Jawad, a second-year medical
resident, turns to the sick man's wife, who is perched anxiously on a ripped
chair at his bedside. "We suspect meningitis," she says. If Jawad is correct, the man
probably will die long before she can confirm her diagnosis. Her chances of
getting antibiotics to treat him are even slimmer. The hospital can't perform
the lab test she needs. Its stock of drugs and basic supplies is so
unreliable that doctors routinely dispatch patients' relatives to fetch
medicines, IV fluids and syringes from private merchants or the black market. Jawad can't explain the
shortages. Her department is always careful in placing its orders with the
national health ministry, which supplies all of Iraq's public hospitals.
Often, though, the medicines never show up. "No one can tell us
why," Jawad said. "It is as if they just disappear somewhere."
Stories of missing drugs, of desperately ill-equipped doctors and of patients
left to suffer the consequences are everywhere in Iraq's public health-care
system. Some hospitals are filthy and infested with bugs. Others are
practically falling down. More and more, the blame is being placed squarely
on Iraq's U.S.-backed government, which by many accounts is rife with
corruption and incompetence. There is no doubt that years
of economic sanctions, followed by years of war, have taken a heavy toll on
all public services in Iraq. But with violence down and some tentative sense
of normalcy returning, improvements in health care should be coming far
faster than they are, according to doctors, patients, aid organizations and
some public officials. They fault widespread
problems that reach all levels of Iraq's government, and the examples they
cite are troubling. Health ministry workers routinely siphon drugs from
hospital orders to make extra cash on the black market. Bribery is rampant.
Millions of dollars meant for clinics and equipment have gone missing.
Millions more have been wasted on government contracts to buy expired
medicines. The health ministry's
inspector general openly admits the problems. Even so, the culprits are
rarely punished. Corruption and ineptitude
aren't limited to health care, of course; they're endemic in most Iraqi
public institutions. When it comes to public health, however, the
repercussions are devastating, and they bring into sharp focus the failures
that are threatening Iraq's American-financed effort to rebuild itself as a
democracy at peace with itself and its neighbors. "It costs lives every
day," said a fourth-year resident at Baghdad Teaching Hospital who asked
not to be named for fear of retaliation by his superiors. "The security
situation is better now. The government has money. So you tell me why I can't
get basic medicines at the best ER in Baghdad." No one keeps statistics
on how many deaths might be avoided if equipment and medicine were available,
but anecdotal evidence suggests the numbers are significant. Pediatrician Ali Alwan said
the situation isn't so dire at Baghdad's Yarmouk Hospital, where he works
now. But he said children die of diarrhea and other highly treatable conditions
every day at the small hospital he left four months ago in Jalawla, northeast
of Baghdad. "A lot more would
survive if we had more medicines," Alwan said. "I try not to think
about how many." Ali Mohammad Abed, a student
teacher from Baghdad's Bayaa neighborhood, said he thinks his 2-month-old
nephew died because the public children's hospital where he was taken last
month didn't have the tools to diagnose him. "We noticed a strange
color around his lips," Abed said. "They couldn't do the tests they
needed to figure out what was wrong. He died the next day." Dhiya Francis, who works at
a hotel in Baghdad's Karrada neighborhood, thinks his brother would be alive
if doctors had been able to perform the operation he needed to clear a blood
vessel in his heart. Francis said his family
found a private hospital to do the surgery, but they couldn't afford it. "The government
hospital said they didn't have the equipment," he said, crying. "If
the private hospitals can do it, why can't the government?" Before the
1990s, Iraq had perhaps the best health-care system in the Middle East.
Nearly two decades of international sanctions and war have changed that. For nearly two years in 2006
and 2007, when Iraq's sectarian violence was at its worst, the national
health ministry was controlled almost completely by Shiite Muslim militias.
In many neighborhoods, Sunnis avoided hospitals for fear of being killed in them. Today, for the most part,
Iraqis feel safe enough to go where they want, including to doctors.
Hospitals are no longer overwhelmed by victims of the violence. But progress beyond that has
been minimal. Government health care is free in Iraq, but patients who can
afford to do so usually seek private care, because the public facilities are
so ill-equipped. In rural areas and far-flung villages, the situation is
dramatically worse. The shortages of drugs,
equipment and basic supplies are among the biggest problems, doctors said. Even at Baghdad Teaching
Hospital, the emergency department's shelves often run dry of antibiotics,
painkillers and life-saving drugs for heart attack victims. "Much of the time we
don't have IV fluid, so the family will go out to buy it and bring it to
us," Jawad said. "The pharmacies know they are desperate, so they
charge them three or four times the normal price." The department also lacks
most basic diagnostic machines. Its lone defibrillator breaks regularly.
Patient samples often must be sent out for testing because the lab can't
handle them. At the Hospital of
Radiotherapy and Nuclear Medicine, a dirty, run-down cancer treatment center
in Iraq's capital, patients and low-level workers say cancer patients often
must bring their own medicines. Excluding the semi-autonomous northern region
of Kurdistan, Iraq has four radiation machines for treating cancer patients,
said Dr. Ahmed Abdulqadir, the hospital's deputy director. "If you need a new
machine, there's no real process to get it," lamented a fourth-year
resident, who did not want his name published so he could speak candidly.
"You're told to ask so many different administrators, and then none of
them does anything about it. It's a mess." At Yarmouk Hospital, a
600-bed facility where entire wings are blocked off for fear they will fall
down, nurses complain of constant shortages. One said the hospital regularly
uses water as a substitute for ultrasound gel. "One day we will have a
lot, and the next day it will all be gone," she said. Huda Fadhil, sitting at her
ailing mother's bedside, said doctors at Yarmouk had sent her out several
times to fetch supplies the hospital lacked. "I just got back from
buying this," she said, holding up a plastic syringe. "With all the
fortunes this country has, the hospitals don't have syringes? It's
crazy." The shortages are so endemic
that some hospitals refuse to treat noncritical patients if they come without
friends or relatives to act as runners on their behalf. At Baghdad Teaching
Hospital, an old man who came alone to have fluid drained from his abdomen
said doctors told him they could not perform the procedure until he brought a
helper. "I keep telling them I
have no one," he said, rubbing his bloated belly. Patients said bribery is so
widespread that the sick now accept it as part of the process of getting
treatment from hospital and clinic workers. Those who are able sometimes use
payoffs or personal connections at the health ministry to avoid long waits for
surgeries or hard-to-get tests such as MRIs. "My case is a simple
one, so I haven't paid any bribes," said Widad Jalal, who was admitted
to Yarmouk for a lung infection. "But many times you do. This is not
hidden. It's common." Doctors and pharmacists said drugs and other
supplies are routinely stolen from the public health-care system and sold to
private merchants who jack up the prices. All drugs that enter Iraq by
way of government contracts are marked with health ministry stamps. They are
never meant to end up at private drug stores, but they often do, said Husham
Hussein, who works mornings stocking shelves at a public hospital and runs
his own pharmacy in the afternoons. He said the theft occurs at
various points: Sometimes health ministry administrators skim off the top of
ministry orders. Other times, workers steal supplies off the hospital
shelves. Hussein described one common scheme, in which clinic employees
falsify paperwork for nonexistent patients, then walk off with drugs and
other supplies. "The leak of materials
from the hospitals to the private pharmacies is well-known," Hussein
said. "But no one really tries to stop it. That's why so many people do
it." By many accounts, health
ministry buyers routinely take bribes from manufacturers to purchase
unnecessary equipment or medicines of such low quality that doctors refuse to
use them. Bassim Shareef Nuseyif, a
member of the Iraqi parliament's health committee, said he is aware of at
least one case in which the health ministry bought millions of dollars' worth
of expired drugs. "I can't tell you if
this was corruption or negligence," Nuseyif said. "But either way,
it is very bad." Nuseyif told of an instance
in 2007 in which provincial officials took roughly $9 million in central
government funding to buy new equipment for hospitals and clinics in the
southern province of Wasit. The equipment still has not shown up, Nuseyif
said. "We know this is
happening other places," he said. Iraq's public health-care system has
seen some improvements in the past year or so, and there is no doubt that
some problems aren't easily solved - foremost, a shortage of doctors. As many
as 15,000 are estimated to have fled because of the war, and few of them have
come home. Foreign companies and
investors, which Iraq desperately needs, also have been hesitant to return.
The health ministry budget is now roughly $3.5 billion, up from $16 million
in 2002, but health ministry officials said their share of the national
budget, about 3 percent, is far from adequate, and many lawmakers agree. Now, lower oil prices have
forced the government to cut spending by billions. Last year, the government
spent about $800 million buying medicines, officials said, but while health
spending has increased from $62 per capita in 2007 to $100 in 2008, doctors
said they have not seen improvements to match. Corruption may be a big
reason why. There are no approximations specific to the health ministry, but
the U.S. has estimated that 10 percent of the central government's money is lost
to corruption. One Iraqi official, Radhi
Hamza al-Radhi, told U.S. lawmakers in late 2007 that the Iraqi government's
Public Integrity Commission had uncovered losses of about $18 billion across
all ministries. Jobs often go to people with
the right connections, regardless of their qualifications. "This ensures that the
corruption can continue," said Saif Abdul Rahman, a senior adviser to
Iraqi Vice President Tariq Hashimi. "Until we institutionalize hiring, I
don't expect that to change." Nuseyif, parliament health
committee member, noted that problems such as Iraq's shortage of doctors
probably would be far less severe if not for the bribery and theft. "These things tend to
push out the honest and the efficient professionals," he said. Graft
also appears to be delaying badly needed renovations at Iraqi health-care
facilities. Roughly 40 percent of Iraq's
210 public hospitals are awaiting major repairs, according to the
government's own figures. At Yarmouk, entire wings are too decrepit for use.
Gaping holes pock the ceilings, and big brown bugs scurry through the
hallways. The elevators have not worked in years. Relatives must carry the
sickest patients up and down the stairs. Nuseyif said he has visited
hospitals where large sums supposedly were spent on renovations, but he could
see no evidence of improvements. "When you go to look at
these hospitals, it is clear the money didn't go where it was meant to,"
he said. "There is no accounting or monitoring, and the people stealing
the money know this." Mustafa al-Hiti, another
health committee member, said ministry administrators and provincial
officials sign contracts for renovations and equipment at costs far below
what was allocated, then pocket the difference. "Things end up breaking
down quickly, or they are useless," he said. "The contracts are not
made with reputable companies in Europe or the West." Last year, the health
ministry forwarded about 150 corruption cases to the Public Integrity
Commission, but authorities said such efforts rarely amount to much. The commission is supposed
to be the government's most powerful anti-corruption body, but it is widely
considered weak and ineffective. Its officials have said that fewer than 3
percent of cases they investigate end with convictions, and they have
complained of corruption even among the commission's own ranks. The health
ministry's inspector general, who is charged with improving the department
and rooting out corruption, acknowledged there are problems but downplayed
their severity. Adel Mohsin Abdullah, who
has held his position since 2003, said his office conducts audits on health
ministry spending but that the findings are not public. "We've uncovered
some problems, mostly with the contracts," he said. "We're working
to fix them." Abdullah named
"human-resources issues" among ministry administrators as the
biggest obstacle to better health care in Iraq. "The problem is half
corruption and half a lack of ability," Abdullah said. "When we
have a better department, you will see the improvements in our
hospitals." He declined to discuss
specific examples. "Please don't embarrass me with these kinds of
questions," he said, adding that the situation inside public hospitals
is not as bad as many doctors describe. Asked what the ministry has
done to get rid of unqualified employees, Abdullah said the health department
is still developing procedures to evaluate the performance of its 170,000
workers. "We are still in the
stage of determining who should be replaced," he said. "These
things take time." External link: http://www.timesdispatch.com/rtd/lifestyles/health_med_fit/article/I-IRAQ0514_20090528-203828/270485/ |