Medical treatment in Iraq involves not just costs that most of its people can ill afford but also difficulties created by a shortage of doctors and and medicines and poor facilities in government-run hospitals.
Health care in a critical state
AZIZIYAH, IRAQ // Outside a tiny, run-down shop with a cracked front window and a sad-looking display of dusty shampoo bottles, a disorderly group of men stand waiting in the early afternoon sunshine. All of them need medical treatment, but rather than going to the main city hospital or one of its many private doctors they had instead come to see Salah Mehdi Mohammed. The 25-year-old runs a clinic that is hugely popular among Aziziyah's poorer residents. It is also unlicensed and the city's health authorities want it permanently shut down.
Mr Mohammed has medical training - he was a doctor's assistant working an X-ray machine - but is neither a qualified physician nor a pharmacist. Yet he diagnoses patients' illnesses and dispenses drugs. In the two years since opening his practice, he has won the trust of hundreds of patients who consider him to be more honest and effective than the state-run health system. "I came here because I have faith in him, he always gets it right and makes me better," said Abu Mohammed, 52, one of the clinic's regular patients. "If I have a problem I come straight here, I'd never go to a doctor. Salah is good for the poor, he's not interested in taking our money."
The price and quality of medical treatment across Iraq is a controversial subject. Government hospitals often charge more for low-quality drugs than private pharmacies charge for better western medicines. And despite investment plans, poor facilities and shortages of equipment and trained staff have undermined public confidence in official medical services. "If I go to a doctor they'll want 20,000 dinar [Dh64] just to see me, whereas Salah will take 2,000 or 3,000 dinar, or nothing if I have no money to give him," said Abu Mohammed. "All of my family come here, he's the only man I will bring my daughter to."
Aziziyah General Hospital, 60km south-east of Baghdad, has just 100 beds serving a local population of 150,000. The buildings, a low-rise cinderblock complex, used to house a primary health care centre. It was reclassified as a general hospital in 2001 but underwent only a limited upgrade in facilities. Waheed Kamal Hussein, head of its accident and emergency department, said the hospital was hit by problems that have affected its ability to serve patients. "There was an accident on the highway recently and we couldn't cope," he said. "People lost their lives because of that, because we didn't have the ability to properly treat them. When there are accidents we have real difficulty coping."
Aziziyah lies on one of the main roads between southern Iraq and Baghdad and its ambulances are frequently asked to pick up the pieces after car crashes. Mr Hussein, who has worked in Aziziyah's accident and emergency department for six years, also said the hospital was failing to provide care for hundreds of women patients because it had only one female doctor. Much of the local population is made up of conservative Shiite Muslims who will only accept limited treatment for women from male medical staff.
"There is a single woman doctor and she is overwhelmed," he said in an interview. "She works during the day in the hospital and then holds extra private clinics after that. She has no time to see everyone. She is exhausted." The hospital's management - appointees of the ministry of health, which often gives out jobs to political party loyalists - have known about the matter for two months, according to Mr Hussein. "They have promised us a new female doctor but so far we've seen nothing. We just heard the words. Promises mean nothing here.
"It makes problems for me because I have to use our ambulances to take women to other hospitals. It takes more than an hour to get to Kut. It's an added pressure." The private clinic for women, on Aziziyah's main Khaleej Street, opens in the afternoon and is a constant chaos of activity, dozens of black abaya-wearing women struggling to get appointments. Haider Shammrai deals with prescriptions and gives injections to some of the clinic's patients. He also works on the night shift in Aziziyah General Hospital, where most staff hold down two jobs.
"The hospital cannot cope," he said. "We have one surgery, there are no beds. You'll often see children needing care sleeping on the floor. Can you imagine, you have children sleeping that way in a hospital in a country as rich as Iraq? "Twenty years ago, we had excellent medical facilities, we had everything. Now, this." During the 1990s, after the first Gulf War that followed Saddam Hussein's invasion of Kuwait, sanctions on Iraq crippled the country economically and had a devastating impact on a health service that had once rivalled that of many western states. The US-led invasion of 2003 dealt another blow to the healthcare system, as doctors found themselves targeted by militants as Iraq plunged into civil war. Many doctors were killed, many more fled the country.
In the pharmacy attached to the women's clinic, Dr Said Mohammed Abbas said critical drugs were not available at the city hospital. "We sell imported medicines here that people cannot get from the state," he said. "Some courses of treatment may cost $1,500 [Dh5,500] a time and people have to come in and buy them independently. Obviously if you are poor you cannot hope to afford that. The poor pay with their lives."
Dr Mohammed al Bahadi, Aziziyah hospital's administrative director, refused to discuss staffing levels or answer questions about drug supplies, and would not allow any photos to be taken of the wards. There was a shortage of beds, he admitted, but he insisted the hospital never turned patients away and that people's reliance on unlicensed backstreet clinics or private care was unnecessary "We need more facilities, we plan to build a new hospital this year," he said in an interview. "We already give medical treatment to every patient who comes here. Those who go to unlicensed clinics do so out of ignorance. Such clinics should be shut down and we are expecting a new law from the government soon to make them illegal."
Dr al Bahadi denied the A&E department was unable to handle the demands placed upon it. "The emergency room can cope with the patients we get. We do not have a neurosurgeon so those cases are referred to Kut hospital." The ministry of health's claims that construction on a new hospital is due to begin this year are viewed with a weary cynicism by medical staff and city residents alike. "They say we will get a new hospital," Mr Shammrai said. "But until the building is finished - not started, it must be finished - I will not believe it."
Even if new facilities are built, the problem of cost remains. Patients can pay 2,000 dinar for a single injection at the hospital but can get two injections for half that price at a private clinic. "Outside of the hospital you get a better quality of drug for less money," Mr Shammrai said. "And the fact is that not all drugs are available at the hospital. Ninety per cent of medicines are imported by the private sector, not the government."
Patients getting treatment at the hospital often have to supply doctors with the medicine they need, rushing outside to buy drugs that the hospital either does not stock or has run out of. According to local pharmacists, significant amounts of drugs intended for the hospital end up being sold on the black market. In the backstreets of Aziziyah, in his absurdly cramped and unlicensed consulting room, Salah Mehdi Mohammed said inadequate facilities, high prices and bad doctors were forcing patients - sometimes as many as 100 a day - to come to him.
"Most of the time from experience I know what is wrong with people," he said. "I get some coming in who have been to doctors and spent their money but were misdiagnosed. To be honest most of the doctors are not good, their standards are not high. I would say there are two or three good doctors in Aziziyah, not more." Mr Mohammed insisted he was providing an important service, and did so responsibly, often at cost or free of charge. "Most matters are minor ailments, gripes and so on," he said. "I always refer serious cases or things I don't understand to one of the good doctors."
He shrugged off the criticisms made by the Aziziyah health authorities and the prospects of being banned from his work. "Some of the doctors are angry with me, and they're rude if I pass them in the street," he said. "I just ignore them. If they were doing their job properly, if they charged less, no one would come to see me. "People need treatment, and the poor especially need help they can afford. Until they get that care, I will keep doing my work even if it's illegal. Someone has to do it."