Special on healthcare in north

"Let me see what we had today," said one of Kirkuk province's leading general surgeons Mahmud Suleiman, in his small office at the Azadi hospital in northern Iraq. He counted his morning's work on his fingers: "A couple of nasty cases of bronchitis, a man with recurring nosebleeds, and half a dozen headaches." "Dealing with serious cases is made difficult enough by the ongoing shortage of equipment," he told IRIN in Kirkuk. "But it's made almost impossible by this continual barrage of minor complaints." A hundred metres down the hospital corridor, the lobby looks like the entrance to a football stadium 10 minutes before kick-off. The solitary receptionist is almost invisible behind a crowd of patients and their relatives. In the 1970s and 1980s, Iraq's public health system was the best and most generous in the Middle East. The skylines of Kirkuk, Mosul, Arbil and Dahuk still carry the evidence of Saddam Hussein's last round of improvements - huge identical district hospitals built by the Japanese in the early 1980s in district capitals around the country. A decade of sanctions changed all of that. Whereas in 1991, Iraq had 1,800 primary health centres, according to UNICEF, a decade later that number had fallen to 929, of which a third required serious rehabilitation. The country's fall on the UNDP's Human Development Index from 96 to 127 represented a rapid decline in human welfare in recent history. But on paper, and to a certain degree in practice, Kurdish-controlled northern Iraq weathered the sanctions storm better than the rest of the country. A joint UNICEF-Ministry of Health survey in 2001 concluded that Iraq's mortality rate for under fives had increased since 1991 by more than 150 percent to 56 per 1,000 live births. In the north, the figure was half that. And with 466 primary health centres (PHC) for a population of 3.5 million, according to the World Health Organisation (WHO), northern Iraq is better provided than the rest of Iraq - 1.3 PHC's per 10,000 inhabitants compared to 0.5 for the country as a whole. By comparison, Iran and Jordan in 2002 had 3.6 and 2.4 PHC units per 10,000 inhabitants respectively. Figures can be deceptive, however. In reality, experts say, while health facilities south of the Green Line, which divides the Kurdish north from the rest of the country, are fewer and more dilapidated, and escaped the massive looting that crippled hospitals and clinics in central and southern Iraq, overcrowding of central hospitals is just as serious a problem in the north. "Below the Green Line there is clearly more of a structured health system," Arbil-based Marinka Baumann, project manager for the Swedish NGO Qandil, told IRIN. "Health workers report to a district chief, who knows roughly what is going on in the district. Here a lot of district hospital chiefs are too overburdened to set time aside for clinical policies and guidelines." Abandoned to their fate by Baghdad after 1991, Kurdish areas found themselves obliged, unlike the rest of Iraq, to build up a health hierarchy from almost nothing. Four years' civil war, and the resulting division of the region into two separate authorities, made that job even more difficult. "Plenty of renovation has taken place, but the running of services at the district level does not function," Carole Pye, a health specialist working with HelpAge International, an NGO in Arbil, told IRIN. "There are lots of small centres, but little thought has been given to their value to the communities they are supposed to be serving." The nature of the problem, and the difficulty authorities will have in solving it, is clear in Hiran sub-district, nestled on the northern flanks of Safin mountain an hour north of Arbil. Of the 24 villages in the sub-district, locals say Dore is the only one not to have a clinic. "No wonder half the families forced out when Saddam destroyed this place [in 1988] have not come back," said one farmer. In northern Iraq, few complaints are more widespread than this. The irony is that when you visit a village with a health centre, you often find it almost empty. "We're supposed to be this sub-district's main clinic," Rizgar Qadir, the medical assistant in charge of Hiran's spacious Save the Children-funded medical centre, barely 10 minutes by car from Kore, told IRIN. "But we're lucky if we get a dozen people a day." He gestures sadly at one of the only pieces of equipment at his disposal, a primitive hand-powered centrifuge for blood tests. "People basically only come to us for medicine," he said. "Otherwise they prefer to go to a district hospital, and I suppose you can't blame them." "Too right," Ahmed Abdullah, who's been waiting for two hours in the crowded corridor of Shaqlawa's (in Arbil) small district hospital for his pregnant wife to see a doctor, told IRIN. "Up in Hiran, they're only medical assistants. They don't have good health information." More importantly, his wife prefers to be seen by a woman, and Hiran's female doctor left for Kirkuk two months ago. In a fully functioning health system, analysts say, up to 90 percent of the community's health problems can be solved at the primary health level. Quite apart from massive overcrowding at district hospital level, one effect of the bypassing of primary health in Iraq is that people suffering from chronic but treatable conditions like hypertension or heart trouble often end up as acute cases in casualty, costing the system far more. "The time has come for a major reassessment," Carole Pye said. "How far should people be expected to travel to primary health care facilities and, more importantly, what services should they expect to find there?" ISSUE OF REFERRALS For a rationalisation of primary health care facilities to work, however, attention needs to be paid to a raft of other issues, first and foremost the lack of a policy on referrals. It's not that referrals don't exist, either north or south of the Green Line. A large part of the success of the child physiotherapy networks set up in Sulaymaniyah and Dahuk governorate by the NGO Acorn stems from its training of local health staff to recognise the early signs of childhood disability and refer cases onto specialists. No less impressive, though on a far smaller scale, is the work done by dentist Muayyid Tariq and his colleagues, who set up a charitable health centre for Kirkuk's poor last year. Dependent for its money on donations, and with only two doctors, the health centre can only deal with the simplest of cases. "Patients with specific problems are sent on for treatment at the private clinic of one of the 30 doctors who provided money to set this place up," Dr Tariq told IRIN. "They pay only a nominal fee [US $0.30] for treatment here, and nothing for treatment there." Humanitarian aid co-ordinator for Kirkuk governorate Dr Burhan Rashid, told IRIN that local authorities were now making efforts to introduce a referral structure to the whole province. "It's a double-pronged initiative," he said. "Patients will only be allowed to visit district hospitals with a referral from a GP, and specialists will be obliged to give feedback on the patients to primary health centres." Director of health for Kirkuk province Dr Sabah Amin has his doubts. "It will not be easy persuading people who have not used local clinics for decades to use them now," he asserted. "Nor will it be easy to persuade medical staff to do any more than they absolutely have to." Salaries may have risen considerably since last year, when the average doctor earned US $20 a month, but the medical profession is still seriously demoralised. Ultimately, he thinks, success or failure depends on the political future of Iraq. "Restructuring is the job of the Health Ministry, and for the moment everything is in suspense." LACK OF MEDICINE Forty kilometres north of Arbil, the clinic in Kore is a victim of its own success. The narrow corridor outside the consulting room is packed with patients, most complaining of fever and bronchitis. "It's been particularly busy today," clinic doctor, Perwin Nouri, told IRIN. "Usually we have 50 to 60 patients in a morning. Today I've seen 80, because of the cold weather." She looks forward to the day when the Arbil-based NGO, HelpAge International begins work building extra rooms on the back of the health centre building. "There's going to be a second consulting room and a small surgery for vaccinations and sewing up cuts", she said. But she does have one problem which no NGO alone can be expected to solve. Partially because her clinic contains an ultra-sound machine, and partially because she is a woman, most of her patients are women too. "A lot of my patients come to me with easily treatable conditions like thrush, but I just don't have the drugs necessary to treat them," Dr Nouri complained. She scribbled a list of anti-bacterial and anti-fungal preparations down on a piece of paper. "Every month I ask the district hospital in Salahaddin to send me more of these," she said. "Every month the same tiny amount comes." But it is not just specific medicines that are in short supply. In health centres north and south of the Green Line, patients and medical staff say the same thing. Within two hours of clinics opening in the morning, the day's ration of medicines and medical supplies is used up. Patients have the choice either to come back early the next morning to beat the queues for free medication, or go to a pharmacy and buy what they need there. Many cannot afford to do that. It's not difficult to find those who blame such shortages on Iraqi medical practice itself. "Too many Iraqi doctors don't even bother to diagnose their patients," said one NGO worker. "They just hand them a prescription for antibiotics as soon as they walk into the consulting room." Not surprisingly, Iraqi doctors themselves react angrily to the accusation. "No doubt we do use antibiotics more liberally than our colleagues in the West," director of the paediatric teaching hospital in Suleimaniyah Dr Iklas Nimmat told IRIN. "We do so quite simply because we don't have the equipment necessary to make an exact diagnosis. We are forced to hand out prescriptions and hope." Like Nimmat, Dr Sabah Amin blames continuing medical shortages on what he sees as an excessively centralised distribution system. "It is not only Baghdad which allocates funds," he complained. "It is Baghdad which Decides how we are to use our share. Surely we know better than they do on how we should spend our money." His colleague Dr Burhan Rashid points out another complication – the existence of a two-tiered drug distribution system throughout the country. Up until three years ago, he says, distribution of medicines was the responsibility of local departments of health. Saddam Hussein then decided to hand the job over to the state-owned drug marketing company, Kemadia. "The health authorities have no control over Kemadia," he said. "That makes the drug distribution process more bureaucratic and increases the time gap between demand and reception. We have asked for a return to the old system." At a local level, steps are being taken to right the problem. Most NGO-run mobile medical teams working out of Kirkuk and elsewhere keep close tabs on the amount of medical supplies they are using. Other NGOs are training Local staff in health information management as part of their health centre rehabilitation work. "It's self-evident, but for NGOs and health authorities to be able to give you what you need, you need to be able to provide accurate information to them," health statistician Ilaria Donati told the staff of Kirkuk's dental and asthma centre, rehabilitated by her Italy-based NGO COSV, after it was looted last spring. Though he acknowledges that micro-projects like this will never be enough to resolve a country-full of problems, Dr Rashid thinks advice and expert help is what Iraqis need more than anything else. "We don't want to be coddled and we don't want to be patronised," he said. "What we want above all is help remembering all those things we forgot over the past 15 or 20 years."