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Zakira Arajiy is head of the plastic surgery unit at Baghdad’s Medical City Hospital, a complex of surgical specialty hospitals built beside the river Tigris. It overlooks one of the many palaces built for Saddam Hussein on the river’s banks. But since March, Arajiy has had no time to enjoy the view.

Since the outbreak of the war Arajiy has taken only 3 days off–to be with his family during the bombings in the first days of the conflict–and has worked every day since, arriving at the hospital as the sun is rising, returning home late in the evening.He has the pallor of a man who rarely sees daylight, the body of man who eats little, and eyes that sadly reflect the horrors he has seen. This is his third war. “I have worked though the Iran–Iraq war and the Gulf war but have seen nothing like this”, he says in an interview in his tiny cramped office outside one of the operating theatres. “The injuries are the result of different weapons that appear to be used, like cluster bombs.

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People arrive here torn to pieces, and we are seeing soft tissue injuries never seen before. We are normally a referral hospital, but during the war Al-Yarmouk General Hospital was bombed so we took over.At one time we had 60 beds in the ground floor reception area and were dealing with 100 to 140 casualties a day, often operating on more than one patient at a time.

” “Now we are getting at least three to four patients a day injured by cluster bombs, most of them children. 60% of our work after the war is dealing with gunshot wounds and soft tissue loss. Last week we lost a child. He had very severe injuries and had lost both his eyes. His brain was coming out of his left eye. We had to work many hours on him, and he was unconscious for 10 days but then developed more complications, which we didn’t have the drugs to treat.His family is devastated. ” There is a tense pause as the lights flicker and the hospital generator takes over after yet another power cut.

“Under the conditions we operate in you have to make compromises. We give primary treatment and then defer secondary treatment. A burns patient or amputee needing a graft, for example, is likely to wait for a long time. Some go home and don’t bother to come back. ” As well as working long hours, medical staff throughout Iraq have had to deal with their own personal tragedies.

Arajiy’s nephew was blown to pieces by a cluster bomb outside his home while playing with three friends.”It’s difficult to suppress your own feelings of anxiety and depression. We are human beings too”, Arajiy says in his perfect English. “I am not happy at all.

The tragedies I have seen are too high a price to pay for this so-called freedom of Iraq. ” Out-of-date practices The Iraqi health system is in “chaos”, says Bushra al-Rubeyi, who recently completed a 5-week fact-finding tour for the UK Royal College of Paediatricians and Child Health. The tour, which included visits to 10 hospitals, took the Iraqi-born paediatrician who now practises at Queen Elizabeth Hospital, London, to all 18 provinces of the country.

“I saw a lot of congenital heart disease which should have been treated years ago. One child aged about 4 years had hydrocephalus and had not been operated on after her birth. Consequently her head was huge. Drugs that have been superseded here are still being used. For example, asthmatics are still being treated with outdated medicines. As a doctor I felt helpless, and as an Iraqi I feel angry. ” Before UN sanctions were implemented in 1990, Iraq had one of the most sophisticated and efficient health systems in the Middle East with a national budget of US$450 million.

By 2002 spending had fallen to $22 million, due to both the sanctions and the previous regime’s slashing of the health-care budget. In 1998, according to WHO figures, there were 55 doctors per 100 000 people–far fewer than in neighbouring countries such as Iran, Turkey, and Syria, which have 85, 121, and 141 doctors per 100 000, respectively. Many of the older doctors and consultants were trained in the UK, but, isolated from the international medical community, many have been unable to update their expertise and rely on outdated practices and equipment.

“The most important need now is updating of medical practice, not more doctors”, says Rubeyi. Iraq’s new interim Minister of Health, Khudair Abbas, a surgeon, was appointed in September. Originally from Basra, Abbas studied medicine in Baghdad and went to Dublin and the UK for further training, receiving a fellowship as a staff grade general surgeon at King George Hospital. He practised at various UK hospitals before returning to Iraq. Abbas now works from the 11-storey Ministry of Health building in Baghdad. It was completely looted after the war, and telephones have only recently been reinstalled.His Ministry has a $210 million budget for this year.

In 2004 his budget is expected to be between $600 and $800 million. Abbas’s main concern is for the infrastructure of the health service and the security of staff. “Progress depends on repairing the basic infrastructure, such as buildings and electricity”, Abbas says. “At present, doctors can do little more than admit patients to emergency rooms, where they receive basic medical treatment at best.

” Over $40 million of the Ministry of Health budget has already been allocated to providing stable generators in Baghdad and $8 million towards water and sewage repairs.The lack of security affects patients as well as staff: many people who need regular medication or hospital treatment, such as insulin-dependent diabetics and patients with kidney failure, are going without adequate treatment because, nearly 5 months after the war, they remain too frightened to visit clinics or hospitals. Abbas will be working with James Haveman, who has been the Coalition Provisional Authority’s senior adviser to the Ministry of Health since June.

Haveman, a former head of the department of health of the state of Michigan, says Iraq’s health-care system has great potential.”I had dinner not that long ago with some surgeons who in 1964 were doing kidney transplants–over 100 a year in Baghdad. And so some of the old physicians have a reference point to what it used to be, and they share this with young physicians and the young physicians keep thinking about what it can be and how they can build on that. ” But Iraq won’t be a “quick-fix”, says Havemen.

“You don’t repair hospitals overnight, that haven’t been repaired in 16 years. ” The infrastructure needs, for example, are great. Equipment is out of date and often in disrepair.

“When I toured our equipment warehouse the other day, the staff were telling me that upwards to 50-70% of the equipment in the hospitals, which had been purchased over the past 10 years, either wasn’t working or was inadequate. When I go to most of the hospitals, most of the regulators for intensive care units are all from about 1980. You do not find defibrillators in hospitals. I mean, none of that type of equipment was purchased.

Throughout this, though, the physician community–there’s about 23 000 physicians and 39 000 nurses–provided basic services.” Bringing doctors to the UK for retraining The Royal College of Paediatrics and Child Health has invited seven doctors from Iraq to the UK for retraining. The doctors will stay for a month as guests of hospitals in Birmingham, Northern Ireland, and London. “It’s the least we can do”, said Len Tyler, secretary of the college. “Because of the problems with security we can’t send people over, so this is the next best thing. We can’t compete with a big organisation like WHO, which has an enormous overseas infrastructure.

But we have a lot to offer in terms of experience and have already had discussions with a couple of non-governmental agencies. The intention is that our doctors will work with them in Iraq in the future. ” al-Rubeyi thinks the UK should do a lot more than it is doing. During the war, colleagues in Iraq contacted her to find out whether child victims of cluster bombs could be treated in the UK.

“They just did not have the facilities. It was very frustrating. I rang health trust after health trust and all people could say was, ‘Where do we get the money from?’ I was so angry. I thought, these cluster bombs that are killing and maiming Iraqi children are known to be made in the UK and the Ministry of Defence admitted during the war to using them. Each bomb dropped contains up to 200 bomblets, some of which don’t go off and lie on the ground looking like toys and are picked up by children. It shouldn’t be left to charities to bring victims over and pay for their treatment. So when I was asked who should pay for the treatment, I replied, ‘Whoever paid for the bomb. ‘”

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