TWN Info Service on Health Issues (January 07/07)

26 January 2007

Iraq: US cure for health sector worse than the disease

Iraq had one of the most advanced health care systems in the region prior to the 1991 Gulf War. Since then UN sanctions and the US invasion in 2003 has reduced it to shambles. The failure of the US occupation to revitalise the health sector is reported in the following article which is reproduced with the permission of South-North Development Monitor (SUNS) #6174, 23 January 2007.

Iraq’s long list of pricy failures

US attempts to rehabilitate Iraq’s health care system have produced dozens of incomplete clinics and unused hi-tech equipment. Meanwhile Iraqi doctors flee the country while others are murdered. The article below is reproduced with the permission of South-North Development Monitor (SUNS) #6175, 24 January 2007.

With best wishes
Evelyne Hong

Iraq: US "cure" for health sector worse than the disease?

By Pratap Chatterjee*, IPS, Washington, 19 January 2007

While some critics of the stumbling rehabilitation of Iraq's health care system focused on the failure to deliver basic infrastructure and supplies, others questioned the whole US approach.

Unlike other poorer countries, which focused on mass health care using primary care practitioners, in the 1970s, Iraq had developed a Westernised system of sophisticated hospitals with advanced medical procedures, provided by specialist physicians and financed by oil revenues.

A July 2003 report by UNICEF and the World Health Organisation noted that prior to 1990, 97% of the urban dwellers and 71% of the rural population had access to free primary health care; just 2% of hospital beds were privately managed.

Infant mortality rates fell from 80 per 1,000 live births in 1974, to 60 in 1982 and 40 in 1989, according to government statistics. A similar trend characterised under-five mortality rates which halved from 120 per 1,000 live births in 1974 to 60 in 1989. (Later studies have questioned these optimistic Iraqi government figures.)

With the 1991 Gulf War that followed Iraq's invasion of Kuwait, the situation changed dramatically. The war damaged hospitals, power generation, and water treatment facilities; foreign nurses left the country; and the health budget was slashed. Spending per capita fell from $86 to $17 in 1996.

In the eight months following the 1991 war, mortality rates for children under five shot back up to 120 per 1,000 live births, the highest recorded increase for any country in the world in the 1990s, according to the UNICEF/WHO report.

The war and the sanctions destroyed the capital-intensive model of free and sophisticated care. Water was often contaminated and the electricity supply erratic, making it difficult to operate the expensive medical equipment. Deaths from diarrhea rose fivefold and malnutrition-related diseases such as respiratory infections became widespread.

After the 2003 US invasion, sanctions were lifted, and the government finally started to earn cash on its oil income, allowing it to raise medical salaries. But the damage to the health care system was hard to reverse.

Today, Iraq needs either to initiate a major renovation programme to resurrect its old medical system or it needs to switch to a preventative health care model based on primary health care clinics. In the last three years, owing to lack of money and security, it has done neither.

The failure by the occupation forces to revitalise health care tracks back to immediately after the invasion, when the US Agency for International Development (USAID) dispatched Fred "Skip" Burkle to run the Ministry of Health. A doctor with four post-graduate degrees, Burkle had worked in Kosovo, Somalia and northern Iraq after the Gulf War.

He faced a health sector that - like the oil and electricity sectors - was devastated by post-war looting and had lost much of its infrastructure to theft and violence. Some 12% of hospitals were damaged and 7% looted. Central records were destroyed along with the country's two major communicable disease laboratories and four out of seven of its central warehouses.

"I spent my time planning a surveillance system and figuring out how to decentralise it, so that it was not Baghdad-centric," Burkle said in an interview.

"Remember, there were no communication systems between Baghdad and the provinces. I was also concerned about looting, as I had observed this first-hand after the first Gulf War, as the first civilian to enter the country."

Burkle's suggestions, which he had meticulously planned and researched, were never implemented. Two weeks after arriving in Iraq, the White House informed him, he says, that it wanted a "loyalist" in the job and recalled him to the US.

More than two months passed before the new Republican appointee arrived. Unlike his predecessor, Jim Haveman was not a doctor, had never lived outside the US and had never taken part in post-war or post-disaster reconstruction.

He had experience as director of community health in the state of Michigan, and was a former director for International Aid, a faith-based relief organisation that promotes Christianity in the developing world. He also previously headed up Bethany Christian Services, a large adoption agency that urges pregnant women not to have abortions.

Haveman said in an interview that he arrived to find that the ministry was still a mess. "I walked into a situation with two empty 11 storey towers, 120,000 employees, 240 hospitals and 1,200 clinics (but the) employees had not been paid for three months. The ministry had a $16 million budget."

He says he is proud that he got the administrative staff back into the building within 45 days, got the ministry up and running, drew up a budget, completed large-scale immunisations successfully, and responded to disease outbreaks.

He believes that he helped the ministry to switch from a prescription-based health care system to prevention and primary health care, wrote up a mental health code, implemented new training systems, supported professional groups and worked closely with NGOs and international agencies.

Critics acknowledge that Haveman got the ministry building and payroll up and running but say that he focused on the wrong priorities such as rewriting the list of medicines that the state medical company should import. Asked what medicines they were able to buy, Dr. Nasser Jabar Sheyal, an assistant to the health minister, said in an interview in spring 2004: "We make recommendations but we don't decide anything. This is an occupied country, not a democracy, and the Americans make all the decisions."

Meanwhile, under orders from Paul Bremer, the US administrator of Iraq, senior doctors and health administrators with decades of experience were fired because they were members of the Ba'ath party. The ministry was handed over to the Da'wa party, a conservative Islamic group, with little experience in this field.

The party appointed Dr. Khudair Abbas, a respected breast cancer surgeon, to head the ministry. He started with a disadvantage: Abbas, who had studied in India and practiced in Britain, had not worked in the Iraqi health system since 1979. A year later, after Haveman left, Abbas also quit the ministry.

Some Da'wa officials struggled along bravely. Amar al-Saffar, the deputy minister in charge of finance for the health ministry, candidly confessed that he too, was out of his depth.

"I was not planning to be a part of the crew at the ministry. I came to serve my party [Da'wa] and I don't know how I found myself in this ocean, but I have to swim. Unfortunately, the current is very strong," he said. "My only experience is that for six years, I was the executive manager of an optical instruments business in Dubai."

While many top bureaucrats quit, he stayed on until he was kidnapped in November 2006 from his home in Adhamiya. His fate was unknown at the time of writing.

Meanwhile, doctors in Iraq began to resent the expatriates who were given control of the system in which they had laboured for so long. Dr. Koresh Al Qaseer, president of the Iraqi Surgeons Association, explained that he had a lot of respect for Dr. Abbas's medical expertise, but did not believe that his team knew Iraq's needs.

"Who are these people who left for 20 years and now think they can run our country? They don't know anything about it, and they don't care," he said angrily.

"Believe me, they did not leave because of Saddam, they left to pursue their careers and to make money. We have 35,000 doctors in Iraq, we don't need outsiders to come and run our hospitals, but we do need training."

Richard Garfield, a professor of nursing from Columbia University in New York who has visited Iraq almost every year since 1996 as an advisor to the UN, agreed that training was necessary, but he believed that that was just the first step - a fundamental overhaul of the system should have been conducted.

Some of the key mistakes of the Coalition Provisional Authority, he said, were investing in supplying medicines to a system where medicines were used poorly; holding short training courses with no supervision or follow-up to teach techniques that were not practiced in the country; catering to professional organisations that represented few people; and contracting US firms to build hospitals and clinics, few of which were built and fewer still well-utilised.

(* Pratap Chatterjee is the managing editor of CorpWatch. This article is the second in a three-part series on Iraq's struggling health care system.)

Iraq: A long list of pricy failures

By Pratap Chatterjee*, IPS, Washington, 19 January 2007

Today, almost four years after the toppling of Saddam Hussein, Iraq's healthcare system is still a shambles.

While most hospitals lack basic supplies, dozens of incomplete clinics and warehoused high-technology equipment remain as a testament to the US experiment in Iraq. Meanwhile, the hospitals are grappling with an unexpected health crisis - the daily toll of bombs and sectarian clashes, which leaves over a hundred dead each day and more seriously injured.

In mid-December, dozens of workers for the Iraqi Red Crescent, one of the few groups still operating in the country, were kidnapped in broad daylight from its Baghdad offices, forcing the group to shut down operations in the capital city.

The violence has also been directed at doctors, on the assumption that they were wealthy or a part of the strategy of civil war.

Since the invasion, 2,000 Iraqi doctors have been murdered and some 250 kidnapped, the Brookings Institution reported in December 2006. Altogether, more than half of Iraq's 34,000 doctors have fled the country, some leaving to drive taxis in Lebanon.

Even the repair and expansion of existing health care facilities in safe parts of the country was botched, leaving hospital administrators frustrated by the lack of basic supplies and simple training.

In Sulamanya, a relatively peaceful and prosperous town in northern Iraq where violence is practically unknown, the engineer in charge of construction at the health ministry said in an interview that the California-based engineering company Parsons Global promised $29 million to build five new primary health care centres, one new pediatric hospital, and to repair a maternity hospital. The ministry was allowed to select sites but the contractors and the US Agency for International Development (USAID) determined the design and budget.

Not one of the primary health centres in the province has been completed. Engineer Hewa, who was in charge of construction for the ministry, traveled to Baghdad in 2004 to review plans for the new hospital but that was the last time anybody talked about it. Nobody from the Army Corps or the company even visited the proposed site, according to Hewa.

The only thing completed was a new elevator that the Al Monel company installed in the pediatric hospital. During a site visit to the hospital in Sulamanya in April 2006, a security guard showed this reporter the new elevator large enough to fit a hospital bed. It hadn't worked for a couple of days, he said, because local mechanics didn't know how to fix it. The head technician promised to hire a new mechanic who could.

Elevators appear to be Parsons' Achilles heel. At the Najaf Maternity Hospital, a New York Times reporter found that only one of the hospital's four elevators functioned while the others awaited repairs.

The company was paid in full in June 2004 to install a new elevator bank at the Hilla General Hospital. When SIGIR auditors visited the hospital three months later, the administrator reported that just a couple days before, a renovated elevator crashed and killed three people.

Parsons did not return phone and email requests for comment.

Most prominent among the long list of failures is the Basra Children's Hospital, which was intended as the crown jewel of US aid to Iraq. Instead, it has become a showcase for everything that went wrong.

In August 2004, USAID awarded the $50 million contract to build the hospital to Bechtel, a San Francisco-based engineering company, one of the largest engineering companies in the world, which has become synonymous with the building of nuclear power plants, gold mines and large projects like the new Hong Kong airport.

The idea was to create a state-of-the-art facility to treat childhood cancer, a pressing need in a city where cancer rates have skyrocketed following the first Gulf War. (Contested data link the rise in cancer to extensive US use of depleted uranium weaponry in the region.)

The facility, championed by the US First Lady Laura Bush and Secretary of State Condoleezza Rice, looked suspiciously like a political propaganda effort. And as with much US aid, it was designed with little local consultation: the city lacked clean water and already has a leukemia ward where lack of funding means that each bed is shared by two or three children.

The hospital was planned by Project Hope, a charity headed by John P. Howe III, president of the University of Texas, San Antonio, and a family friend of George W. Bush. Project Hope had built similar hospitals in Poland and in China. Howe pushed the project after Rice and Bush invited him to visit Iraq to assess the country's health care system.

Before construction began in August 2005, the project attracted sceptics, who were concerned that it was a white elephant. Republican Congressman Jim Kolbe wondered: "Why build a hospital for kids, when the kids have no clean water?"

But it went ahead: No new technology would be spared in this showcase facility featuring 94 beds, private cancer suites, CAT scans, and a linear particle accelerator for radiation therapy.

But like so many US-initiated projects, the money to build this fancy facility would disappear when things went wrong. A year after the August 2005 groundbreaking, the project became a target for attacks, according to the company.

The price tag rose from $50 million to an estimated $169.5 million. Cliff Mumm, president of the Bechtel infrastructure division, predicted that the project would fail. "It is not a good use of the government's money" to try to finish the project," Mumm told the New York Times. "And we do not think it can be finished."

In July 2006, Bechtel was asked to withdraw from the project, which is now on hold. USAID spokesman David Snider's cheerful spin on the stall was that the contract did not actually require the company to complete the hospital. "They are under a 'term contract,' which means their job is over when their money ends... (so) they did complete the contract."

Deputy Minister Amar Al-Saffar charges that part of the failure traces back to Bechtel's decision to hire a Jordanian company to oversee work by local Iraqi construction companies, instead of working directly with the Iraqis. "Our counterparts should have full faith in the Iraqi companies," Saffar told the New York Times, in July, less than four months before his kidnapping.

Marshall agreed that a Jordanian team (Mid Contracting, Universal Hospital Services, and Hospital Design and Planning) had been awarded the sub-contract, but pointed out that the workers were mostly Iraqi.

"We could not find Iraqi firms of equal caliber for this job, although Iraqi sub-contractors were, of course, employed extensively," he said.

"Bechtel's record of hiring Iraqi firms was exemplary. We held major conferences in Baghdad and Basra to inform and recruit Iraqi partners. Over the life of the project, we hired Iraqi sub-contractors to perform about 75% of the work. At peak, our projects employed 40,000 Iraqi workers. Bechtel also trained and employed more than 600 Iraqi nationals on its professional staff."

Looking back at the last few years, Richard Garfield, a Columbia University professor who has visited Iraq almost every year since 1996 as an advisor to the UN, believes that Washington's reconstruction plans failed for very basic reasons.

"We designed beautiful systems, then we had workshops to train them (the Iraqis). Isn't that great?" he said sarcastically. "And now, we are out of there. That's not the same as making a system. It did not work because foreigners designed it and the locals didn't adopt it. And the foreigners weren't around long enough to help make it part of the regular system."

(* Pratap Chatterjee is the managing editor of CorpWatch. This article is the third in a three-part series on Iraq's struggling health care system.)