Iraq's once-envied health care system lost to war, corruption

Dr. Zinah Jawad leaned over her patient and peered into his glazed eyes. It doesn't look good, she said, shaking her head. The man had arrived at Baghdad Teaching Hospital's emergency department a few hours earlier with a high fever and dizziness. Now he lies shaking, sweat soaking his dirty clothes. The Teaching Hospital's emergency room is cleaner than most in Baghdad. 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. Jawad, a second-year medical resident, turns to the sick man's wife, who's 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 on Iraq's U.S.-backed government, which by many accounts is infested with corruption and incompetence. There's no doubt that years of economic sanctions, followed by years of war, have taken a heavy toll on all public services in Iraq. However, 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 at 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 with 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 more available, but anecdotal evidence suggests that the numbers are significant. Pediatrician Ali Alwan said the situation isn't so dire at Baghdad's Yarmouk Hospital, where he now works. But he said that 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 still 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. Progress beyond that has been minimal, however. 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," second-year resident 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. "We must be careful to only use the dependable labs," Jawad said. "There are many that give incorrect results, or they leave the samples to expire." At the Hospital of Radiotherapy and Nuclear Medicine, a dirty, rundown cancer treatment center in Iraq's capital, administrators said the hospital rarely runs out of chemotherapy drugs. Patients and low-level workers told a different story, however. They said the 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. Three are at the Hospital of Radiotherapy and Nuclear Medicine; the fourth is in Mosul, in northern Iraq. "If you need a new machine, there's no real process to get it," lamented a fourth-year resident, who didn't 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'll 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 that doctors told him they couldn't 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're 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 that 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're 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 that sometimes health ministry administrators skim off the top of ministry orders. Other times, he said, 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's 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 hasn't 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's no doubt that some problems aren't easily solved, foremost among them 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, moreover, 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 haven't 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, the parliamentarian, said 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 to use. Gaping holes pock the ceilings and big brown bugs scurry through the hallways. The elevators haven't worked in years. Relatives must carry the sickest patients up and down the stairs. Nuseyif said he's 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, and 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's widely considered weak and ineffective. Its officials have said that less than 3 percent of cases they investigate end with convictions, and they've complained of corruption even among the commission's own ranks. The health ministry's inspector general, who's charged with improving the department and rooting out corruption, acknowledged there are problems but downplayed their severity. Adel Mohsin Abdullah, who's held his position since 2003, said his office conducts audits on health ministry spending but that the findings aren't 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 isn't 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."