Wednesday, May 11, 2011

Iraqi Healthcare: Made in America

At Iraq’s Hospitals, a Man-made Emergency

By Stephanie McCrummen
The Washington Post
May 10 2011

BAGHDAD — Outside Baghdad Hospital, the gates are freshly painted white these days. Sidewalks are being cemented and marigolds planted, gestures of civility virtually impossible during the war, when Iraq’s marquee public hospital was overwhelmed with casualties and itself targeted by mortar shells and bombs.

Inside, Iraqis marvel at the dispensers of blue hand sanitizer mounted at each door and the faint soapy smell of clean hallways. Health Ministry officials tout new medical equipment and facilities — an entire wing stocked with $10,000 machines to treat bone spurs, a multimillion-dollar cancer treatment center — evoking a proud era when Iraq had perhaps the finest health-care sector in the Middle East.

But on a moderately busy day at the hospital’s emergency room, a newborn died because proper-size IV catheters, about $1 each, were not available. And as the first shift began on a slow Tuesday, Majid Abdullah lay unconscious on clean blue sheets, wrapped in white bandages covering blast wounds, in his 12th hour of waiting for a ventilator bed, as the ones promised to the ER were still words on paper.

“Maybe he will die,” doctor Layth Salim whispered. “Maybe we will find a bed.”

As security has improved and a semblance of calm has settled over Iraq, doctors say the biggest menace to patients these days is not so much a lack of money, basic training or even supplies. Rather, they say, it is the skewed priorities of a corrupt, often indifferent Health Ministry that has gone on spending sprees in certain realms while leaving basic health care to flounder.

The problems are emblematic of the wider dysfunction of the U.S.-backed Iraqi government as a whole, a bubble of elites for whom ministries are treated as spoils of bare-knuckled political battles, with key positions often going to the well connected rather than those with technical expertise. To some extent, such issues are common to developing nations, which is what Iraq essentially is, having been plunged backward by years of war.

But to a large extent, the dysfunction has been enabled and well modeled by the United States, whose $61 billion reconstruction effort included nearly $1 billion poured into the Iraqi health sector, spending followed by audits that documented huge cost overruns, delays, poor planning and waste.

In the U.S. campaign to win Iraqi hearts and minds, “the health sector was the worst,” said Stuart W. Bowen, the U.S. special inspector general for Iraq reconstruction. “It’s the sector that fell the farthest short of expectations.”

He noted that the United States spent about $150 million on advanced medical equipment that mostly sits idle because Iraqi doctors are not trained to use it, a pattern Iraq’s Health Ministry seems to be continuing.

At Baghdad Hospital’s ER, doctors feel the grim irony: They have a $40,000 Toshiba sonogram machine at their disposal, yet on any given day, patients die because antibiotics are not available.

“It’s an administrative problem of neglect,” doctor Nasrat Shakir said. “We call and say, ‘We need IVs!’ And they say, ‘You need IVs?’ And we say, ‘YES, YES, we need them!’ ”

Health Ministry officials declined several requests for interviews. But Baghdad Hospital spokesman Rady Sachit offered a question.

“Many accuse us of delaying progress,” he said. “But let me ask, if you’ve been through years of oppression, sanctions, insurgency, terrorist attacks, how much time would you need to rehabilitate everything? How much?”

Waiting and praying

Five years after Iraq’s government took office, down a long hallway and through doors strung with little lights shaped like stars, Majid Abdullah’s father was pacing. Then he was crying and rolling out a small red carpet in the corner of the emergency room, praying.

His son, an Iraqi soldier and a father of five, had been in an Iraqi army convoy hit by a roadside bomb, a kind of insurgent attack once aimed at U.S. troops, who are retreating to their bases as they prepare to withdraw by year’s end.

Abdullah’s brain was injured by shrapnel, and he was hooked to a small beige box, an old, temporary ventilator that is supposed to be used for two hours at most. It was going on 13.

The ER was quiet at 11 a.m. Only a few patients were behind the long rows of pink curtains, mostly ordinary Iraqis who finally feel comfortable enough to leave their homes and seek care for long-neglected conditions.

Behind Curtain No. 11: a young man with kidney pain. “We’ll send him for a sonogram,” Salim said, noting the man’s good fortune. Several sonogram machines were available.

A few beds down, an elderly man had pain on his left side, possibly a tumor. Salim ordered a CT scan, and the patient was in luck. The Health Ministry had recently purchased six of the sophisticated X-ray machines, and the wait, once a potentially lethal six months, was only a few days.

Salim walked to the semicircular desk in the middle of the ER.

“Did we call for the RCU?” he asked a nurse, referring to the hospital’s respiratory care unit upstairs, which had 13 beds, all full.

The doctor walked to a small office outside the ER, the operations center, a recent Health Ministry innovation intended to help manage such situations — in this case, by checking for ventilator beds at other hospitals.

Inside, an employee lay on a cot. A second tapped at a computer. A red phone was on its hook. “I’m calling,” said the employee on the cot, getting up. “If a bed becomes available, I will inform the ER.”

‘It’s not available’

It is difficult to overstate how far Baghdad Hospital has come since the worst days of the war, when supplies were so scarce that doctors sometimes performed open heart surgery without gloves. Crucial drugs ran out because drivers would die fetching them from depots around Baghdad. Arriving at work was a small miracle: The hospital has lost at least 40 doctors to assassins since 2004 — they are still occasionally targeted — and their photos stare down from walls.

But with security significantly improved, doctor Musab Amer wondered why the emergency room’s lifesaving crash cart was almost empty during a slow day.

He looked down at its metal trays.

“We need adrenaline,” he said, noting the missing drugs. “We should have dopamine — it’s not been available for five months. We should have Valium for seizures.”

On a lower shelf were three rubber breathing pumps and a broken pediatric one. “Maybe it’s enough,” he said, shrugging. “But what if we have a mass casualty?”

Behind Curtain No. 3, he examined a man with chronic diabetes and a gangrened foot.

“We’ll give him IV fluid and antibiotics,” Amer said, then corrected himself. “Only today we don’t have broad-spectrum antibiotics — just penicillins.”

Fortunately, the patient was not allergic to penicillin.

As Amer checked another chart, a man approached him waving a little scrap of paper, frantic. A doctor had sent him across the hospital to hunt for a central veinous line, a type of IV critical for people with collapsed circulatory systems. Amer shook his head.

“I’m sorry, it’s not available,” he said. “Some days, we have piles of them. Some days, we don’t.”

‘My son, my son!’

By afternoon, Majid Abdullah was still waiting, the little beige box beside him slowly beeping. His father was in the corner again, praying. Abdullah’s cousins gathered around him. An uncle, Thamir Abdullah, paced with all the urgency that Iraq’s bureaucracy seemed to lack.

“Nobody has tried to explain this situation,” he said. “We don’t understand.”

In the little operations room, the red phone was quiet. A different employee was there, who said he had not been instructed to make calls. Frustrated, a doctor behind the half-moon desk picked up a receiver.

“Hello!” the doctor said. “Do you have any ventilator beds?”

“Wait, let me check,” the voice on the other end said. A long pause, during which a doctor explained that the ventilator beds for the ER are part of a long-range plan and that, no, the United States never invested much of its health-care reconstruction dollars here.

Abdullah’s father touched his son’s shoulder.

“There are no beds,” came the reply. The doctor began dialing again.

And then Abdullah’s father began beating his own chest and crying, “My son, my son!”

Three doctors crowded around Abdullah, who survived eight years of U.S. bombs, insurgent bombs, bullets and the chaos of life during war. They called for a defibrillator — available — and a certain cardiac drug, which was also available.

Then they closed the pink curtain. Security guards ushered Abdullah’s family into the lobby while a doctor pronounced his death, the only one of the shift.

No comments:

Post a Comment