A woman wearing an abay is seated in a sinister hallway, rocking back and forth and sobbing: “She was in intensive care when the doctors warned me that they were running out of oxygen and that if I didn’t find some, she would die. We looked everywhere but could find none…” This video has gone viral on the social networks, and tells the story of a woman with children who came down with Covid-19, was put on life support at Nasiriyah Hospital and who had just died because of a scarcity of oxygen tanks. Her family was unable to find what she needed to keep her alive in time.
“Especially in Nassiriya, but elsewhere as well, the hospitals are faced more than ever before with governmental negligence. We saw patients’ families running around trying to find oxygen for their loved ones, Hardy Mede confirms. He is a PhD in political science and a research fellow at the Centre européen de sociologie et de science politique (CESSP, Paris University 1, Panthéon-Sorbonne).
A doctor in Dhi Qat told us that at the city’s Al-Hussein Hospital “31 patients died in the space of 4 hours for lack of oxygen.” At first the propagation of the virus was slower here than in other countries, but Iraq has caught up fast. During the month of June, contaminations increased by 600%, so that the public health system, already in a bad way, was soon unable to cope. On 19 August, the country numbered 184,709 cases and 6,036 mortalities. On that same day, there were 4,576 new cases in 24 hours, a record high since the epidemic began.
“We even run out of Paracetamol”
In 2015, health expenditures represented less than 1% of the national budget, as against 3.6% in Jordan, 3.8% in Lebanon and 4.1% in Iran. Often justified by the cost of the war against The Islamic State (ISIS), this glaring lack of investments was not remedied in 2019, a year of relative peace. Out of that year’s budget alone, amounting to 106.5 billion dollars (90 billion pounds), only 4.8 billion (3.6 billion pounds) were allotted to the Health Ministry, as against 19 billion (14.5 billion pounds) and 14 billion (10.7 billion pounds) for the security forces and the petroleum ministry respectively.
Besides this underfunding, the public hospitals are plagued by bribery on a huge scale. These corrupt practices already existed under Saddam Hussein but have increased tenfold since his fall in 2003. Sarkaout Shams, an MP belonging to the Coalition of the Future believe the phenomenon is due to the plethora of intermediaries, contracts and purchase orders which makes it harder to track the cash spent by the Health Ministry. “Already, it was one of the most corrupt in the country.”
Each year, the government chooses and imports the medicaments for the hospitals. Kinadia, the state-owned company in charge of these imports under the Saddam Hussein regime was severely weakened by the embargo, then by the war. Often indebted and underfunded, it now only covers 25% of the country’s need for medicaments. In 2018, more than 85% of the basic medicaments, essential for the country’s hospitals, were either absent or unavailable, despite the 800 million dollars (611 million pounds) pumped into Kimadia. These were quickly absorbed and even gave rise to a debt of 455 million dollars (347 million pounds). Kimadia’s bankruptcy incited the government to turn to other players for importing medicaments. These professionals had no special competence in the health business, and were not always honest or motivated by collective or national interests. “In Iraq there is an illegal traffic in medicaments. The people in charge of imports for the ministry often have links with political parties or the power elites. The medicaments purchased are often counterfeit or poor quality products at exorbitant prices.” is Hardy Mede’s analysis. Overcharging, theft of stocks and imports of counterfeits are the daily curse of a country where the average life expectancy is scarcely 70 years as against 72 for the world as a whole and 82 for a country like France.
In the opinion of Jaram Mahmoud, a pharmacist with eleven years experience “it would be easier to make a list of the medicaments we have than one of those we haven’t got. Sometimes we even run out of paracetamol.” Rouaa Al-Amin, a doctor in Nassiriya hospital, agrees with him. “The hospital personnel have set up a charitable network, associating doctors and pharmacists, to pay for medicaments unavailable in the hospital, or too expensive, so as not to let certain needy patients die.”
Public health is by a thread, that of civil solidarity: “We focus on one treatment and on the patient who needs it. Next we collect volunteer contributions from hospital workers and remit the money collected to a chemist’s shop. The patient’s family goes there with a special voucher we have given them and there is no charge for the prescription. We often do this for a chemotherapy. But in our hospitals, it is not only such specific treatments which are unavailable, Sometimes, families must buy and bring their own perfusion solutions and needles… It’s crazy, the population should not need to depend on such charity! Some patients, because they feel humiliated by what they see as begging, prefer to forgo medical care…”
Gucci medical slippers
Besides the scarcity of medicaments, the personnel have to work with outdated equipment and infrastructures dating from the Saddam Hussein years. Practically no new public hospital has been built since then.1 Again, the fault lies with the widespread corruption, according to Sarkaout Shams: “Dozens of projects have failed to materialise because of the corruption,” he insists. The average number of beds per capita, 1.2 for a thousand, is below standard for the region.
These limited resources increase the pressure on hospitals. Getting a date for an operation or merely a consultation with a specialist can take an enormous amount of time.
This congestion of the public system encourages bribery. For many years and still today (even though the phenomenon is declining with the development of a private sector) bribing a hospital director enables you to have your operation sooner, reserve a cleaner private room or receive more frequent visits from nurses in your room. Like many doctors interviewed, Rouaa Al-Amin bore witness to these little arrangements. A part of the personnel goes along with them, motivated by their low wages (a doctor’s monthly salary is between 630 and 720 pounds — 830 and 950 dollars).
“There is a joke often heard between colleagues”, Rouaa Al-Amin told us. “When one of them complains, he is told with tongue in cheek: ’Don’t speak ill of our minister: he supplies us with Gucci medical slippers’”. This bitter joke has its origin in a scandal dating from 2017, when the health minister of the time signed a contract for hundreds of thousands of dollars with a company that made throwaway medical slippers for the daily use of healthcare staff. “We are short on cancer treatments and sometimes on the most basic supplies, but our minister signed a lucrative contract for medical slippers. We weren’t fooled, we knew that was a barely disguised instance of fraudulent over-invoicing,” a woman doctor of 25, already fed up with a health system where cash is blatantly misappropriated.
Corruption in the canteens
Tannaz (her first name has been changed) is a doctor in Bagdad’s Al-Kindi hospital. When she signed her first contract with the Health Ministry, she read carefully her wage details and saw that 333,000 dinars ($277, £210) were to be deducted from her monthly paycheck. This amounted to 30% of her monthly salary and was meant to cover the meals served in the hospital canteen. She didn’t let it faze her and signed the contract. Since that day, like all her fellow workers, she has received a monthly giro transfer, never accompanied with a detailed breakdown. “The meals we are served during working hours are not fit to feed a pet,” she says when asked when it was the first time in her career she came up against corruption.
Many doctors confirm the existence of these food expenses which many regard as tantamount to overbilling or to theft.
Some have been so angered at losing such a large slice of their salary that they have tried to have the provision removed, have suggested that the hospital personnel should be at liberty to take their meals outside the hospital canteens. “Each time, the holdouts received death threats if they didn’t let the matter drop”, Tammaz told us.
It was for this reason that Ali Alilali, 38, fled the country. In 2016, he was elected staff representative by the 345 doctors at Al-Yarmouk hospital. Very soon, he visited the kitchens.
“There were dozens of kilos of meat and other food missing. What the Ministry had paid for had vanished. I demanded that what was missing be recovered so the personnel could be properly fed. In the end, the manager told me that if I didn’t keep my mouth shut, someone would kill me. I asked him who would do that, but he wouldn’t say. The sums at stake for that mafia are enormous.” He was frightened, he resigned, left Iraq and went to practise in Denmark.
Young people going into exile worsens the shortages
In these conditions, Iraq has a hard time keeping young people with medical degrees. “Last month the health minister came to visit the hospital where I work and suddenly, on that very day, all the ’vital medicaments’ that are never available to us appeared in the hospital,” Tannaz tells us. Rouaa Al-Amin also remembers the ambulances ordered by the hospital. “They were brand new but they arrived totally stripped. Even the cushions had disappeared.”
These absurd tales of fraud, Iraqi doctors experience them every day. Young graduates are coveted by Jordan, Egypt, or Lebanon. Iraq’s per capita ratio of doctors and nurses is very low: in 2018, it had only 2,1 nurses and midwives for 1,000 inhabitants. Far less than Jordan (3,2) and Lebanon (3,7). Worse than that, Iraq has only 0.83 doctors for 1,000 inhabitants, a ratio far smaller than the rest of the Middle East. “After 2003 and the US invasion, many Iraqi physicians, well known at home and abroad, fled the country. Most of them were Sunni, because under Saddam Hussein, people of Sunni persuasion, had a privileged access to higher education scholarships for foreign studies” is Hardy Mede’s analysis.
Clientelist hiring
The quality of the health system has also declined due especially to the clientelist policies of the administration.
“If our medical system is so corrupt, it is largely because since 2003 it has been suffering from a quota policy. This affects all administrative levels, even the departmental heads.” Such is the analysis of Raid Fahmi, former minister of science and technology and a member of the Iraqi Communist Party. To get into medical school and even to earn their degree, some people have no qualms about using their membership in the ruling party as an argument in their favour. " Iraqi parties all want to get hold of the egregious ’ministerial services’ and especially the Health Ministry in order to satisfy their card-carrying activists. Not at all to serve the population as a whole.”
During the current pandemic, the party that holds the Ministry gives preference to its activists, Sarkaout Shams assures us. And Hardy Mede bears him out: “Access to medical care is highly personalised and very political. I can get an appointment with such and such a doctor more easily, or a hospital bed for my wife or some hard-to-find medicaments if I am a party member. Joining the party that controls the Health Ministry enables a citizen to have better medical care.”
In Tannaz’s view, the Covid-19 crisis has only exacerbated this clentelist and party-based logic. “Right now, I am working in a unit devoted exclusively to the virus. The patients need Actemra, a medicament that costs a fortune on the black market, several hundred dollars a phial. We had several stock shortages and our ministry replenished us several times, but when we asked our administration for more, they told us they were all out of it. The Sadrist movement which is in charge of the Health Ministry steals rare drugs. I have also seen beds for intensive respiratory care reserved for VIPs, members of militias, MPs’ cousins, etc. Several of my patients died because those people had taken their place,” the young doctor tells us.
Cancers treated in India
Covid-19 is not the only health disaster that has laid bare the terrible corruption of the Iraqi medical system. Another significant marker is cancer, which is treated quite inadequately. In 2018, the Health Ministry imported only 4 of the 59 treatments that the WHO considers essential in the fight against cancer. “If you don’t have enough money to be treated abroad or to buy your own treatment, you are very unlikely to survive,” Touaa Al-Amin explains. In India, in Lebanon or even in Iran, Iraqi families who can afford it spend hundreds of thousands of dollars to save a sick relative. In July 2017, the Iranian ministry of health revealed that an average of 374,000 Iraqis came to Iran each year for purposes of medical tourism. In 2018, the Indian government provided Iraqis with 50,000 medical visas and they spent 500 million dollars (380 million pounds) on medical treatments in that country.
“For the last 17 years, public hospitals have mostly served to make the rich richer through bribes and juicy contracts. The corruption in that ministry has amounted to over ten billion dollars [7.5 billion pounds] since 2003”, Sarkaout Shams maintains. We got in touch with several former health ministers, who all refused to let us interview them. Only Alaa Alwan, a minister who resigned in 2019 because of “insuperable corruption”, did agree to answer our questions in the following interview.
“The stepping up of corruption aggravated the decline of the health system” Alaa Abdessaheb Al-Alwan was health minister from October 2018 to September 2019. He is a physician who had also worked for the WHO and made serious efforts to fight the rampant corruption before he resigned. Interview.
Quentin Müller. —Why is the Health Ministry one of the most corrupt in Iraq?
Alaa Abdessaheb Al-Alwan.—Practically every government institution in Iraq is affected by corruption. Most officials in key positions were chosen on the basis of their political affiliation or political interests rather than their qualifications. A large share of the health budget goes to the purchase of medicaments and medical equipment. Now, for want of rational management and strict controls, public funds are often misused, with irrational decisions and unsuitable purchases. Bad management and corruption also affect infrastructural projects, construction contracts and the management of medical personnel careers. There are also major lacunae in our educational system. For example, we have a shortage of doctors and nurses, but a plethora of dentists and pharmacists.
Q. M.—Why is there a shortage of medicaments in public hospitals?
A. A.—The health sector in Iraq is under-financed. Public health expenditures are lower than in neighbouring countries, including those which have fewer resources than Iraq. Our health budget, which is already limited, is further eaten up by corruption and poor management.
The result is this shortage of essential medicaments. Such was the situation when I was appointed health minister at the end of 2018. With the changes I brought about in the administration and its managerial staff, there was an increased availability of these treatments between 2019 and 2020. Without those changes, Iraq would have been incapable of caring for the tens of thousands of people injured during the 2019 street protests and other emergencies of that period.
Q.M.—How did one of the best health systems in the Arab world become one of the worst?
A.A.—The thirteen years of U.S. sanctions had devastating effects on the health system. Afterwards, the bad management of the ministry by most of the governments since 2003, and the stepping-up of corruption have aggravated the decline.
For the past four decades, hospitals have not received any serious maintenance or renovation. Contracts for new hospitals were signed in 2008, but their construction was delayed by irregularities in Baghdad and in the governorates, prompting several judicial investigations. As a consequence, the construction of these hospital came to a halt in 2014. When I took office at the end of 2018, all the building sites had been closed down for the past four years. We finally succeeded in solving some of the problems and one of the hospitals (in Kerbala) is now finished and at least four others should be completed in a few months.
Q.M.—So why did you resign?
A.A.—In my letter of resignation, I explained that it was due to the constant resistance which my reforms encountered from the political groups and the aggressive efforts to obstruct actions of prevention and control of corruption. It was clear that the reconstruction of the country and its rational and transparent management are not in the interests of the men who hold the reins of power in Iraq.
1TRANSLATOR’S NOTE: The Saddam Hussein regime ended with the invasion of Iraq by the United States, Great Britain and their allies in 2003. The US remodelling of the country’s power structures is largely responsible for the tragic situation described here.