Previously, I reported on some aspects of health care in Iraq
1, which were discussed also at the Nursing Conference in
Baghdad on 15 July 2003. I was in a clinical attachment at
the Department of Pathology, Teaching Laboratories (led by
Dr. Jassem T. Al-Khafaji), at the Baghdad Teaching Hospital
in the period May-July 2003, working simultaneously parttime
at a non-governmental organization (NGO) as a
project officer in the field of health care assistance. Late in
July 2003, I visited several hospitals in Basra, Mosul, Kirkuk
and Erbil. In Basra, I had an opportunity to observe the work
of the Department of Pathology of the Teaching Hospital
in some detail. Having returned to Russia, I remained in
contact with colleagues in Iraq, and met some of them at the
21st European Congress of Pathology held in Istanbul on
September 8-13, 2007. The main point that has driven me to write this and the previous
1 letters was understanding
by analogy of some problems of health care in Iraq because
of their similarity to those in the former Soviet Union and,
probably, in the whole former Eastern Bloc. To name but a
few common problems: relatively low social status of nurses
and medical technicians resulting in their shortage; limited
availability of modern, internationally used professional
literature; very limited number of methods available in
the everyday practice of pathology even at large university
hospitals; shortage of chemicals and modern equipment,
irregular technical servicing of the equipment
2. Some
social problems and those related to the management of
the public health are apparently also of a similar nature.
The vacuum remaining after the collapse of the Baath
regime was partly filled by criminal structures, who care for disorder, impeding restoration of the economy, which
would create working places and distract young people from
insurgency. It is known in Iraq that they are fused with the
governing spheres of the previous regime. Educational and
employment policy of the Baath regime resulted in shortage
of properly trained nurses and laboratory technicians
2.
Relatively low salaries and prestige resulted in the influx of
insufficiently trained persons. One of the impediments to
quality care is the fact that female personnel usually don't
work at night. Female nurses and doctors are engaged
during the daytime, which in Iraq means until around 1
p.m. The rest of the time predominantly male nurses are
working. Neglect of prescriptions by the nurses was often
reported by doctors. Responsible physicians make their
prescriptions, injections and others, themselves, not relying
upon the nurses. Management of hospitals tended to belittle
these problems. Furthermore, shortage of physicians was
discussed at the Nursing Conference. Having resided in
the “Doctor's House”, I observed in fact overabundance
of doctors in the Medical City of Baghdad. Many young
physicians came to the hospital irregularly and did not
participate on night duties; they prefer to stay in large
clinical centers sometimes almost without professional
engagement. Shortage of doctors in small towns and rural
areas is a consequence.
More details should be added with regard to the area of
pathology. First about advantages: English language is used
in the medical education and for clinical records in hospitals;
rather new literature is used both in histopathology and in
clinical departments, although, in general, there is a shortage
of modern books. Two editions were mainly used in the
Department of Pathology: Ackerman's Surgical Pathology
and the Lever's Histopathology of the Skin. Pathologists
have high level of knowledge, are responsible and attentive
while performing histopathological examinations. Some
of them had studied or practiced in Western countries.
There is modern equipment in the Department, but a part
of it, e.g. a freezing microtome and an automatic tissue
processor, were out of use because of insufficient servicing
and shortage of chemicals. Only hematoxylin and eosin
stain was applied in histopathology in Baghdad Teaching
Hospital; but special stains, immunohistochemistry,
and other modern methods were performed by some
private laboratories, thus being, in principle, available for
patients. Intra-departmental consultations were frequent
and efficient; in fact, difficult cases were examined by all
pathologists of the Department. External consultations
with participation of specialists from other institutions
were less frequent, but they were performed in case of indications, such as in an osteoblastoma case discussed
below. With regard to the continuing medical education,
it is difficult to give a comprehensive overview from a
position of a volunteer in a Department of Pathology, but
there were residents and rotators in the Department, who
were highly motivated and demonstrated a good level of
professional knowledge. With regard to the residents in
clinical departments, as mentioned above, their number
was rather high in the Medical City of Baghdad, while not
all of them were regularly engaged in professional activity.
Some drawbacks in the practice of pathology should
be mentioned, which obviously resulted from shortage
of adequately trained technical personnel, although
technicians are skilled and can produce high quality
specimens. Confusion of specimens sometimes occurred.
Sets of histological slides were sometimes given to the
pathologists incompletely, some blocks being left uncut.
Histological specimens were not always clearly marked.
The room for gross dissection had neither ventilation nor
air conditioning. Biopsies were often left “until tomorrow”,
sometimes because of lacking clinical data. Telephonic
contact with clinicians was relatively seldom. Pathologists
obtain clinical information mainly from patients or their
relatives, who bring specimens to the laboratory. This
practice has advantages: pathologists can examine a
patient or perform a fine-needle aspiration. If necessary, a
patient can be asked to bring X-ray, CT, or other additional
information; for example, a complicated diagnosis of a bone
tumor (osteoblastoma in a child) was successfully made in
this way and later confirmed by an external consultation.
On the other hand, specimens are often put aside “until the
patient comes”, and can be left for many days. There were no
special programs of quality control; although they would be
useful for ensuring of more reliable work of the laboratory,
preventing specimen confusion, guaranteeing cutting of
all blocks, clear marking of specimens and so forth. No
autopsies were performed in the Medical City of Baghdad.
No special regulations existed with regard to the waste
disposal, and the waste from the department of pathology
was disposed together with other waste from the hospital.
Used formalin and other solutions were purred out into
the sewerage. Another drawback was an often inadequate
formalin fixation of specimens in clinical departments,
both of small biopsies and of large surgical specimens,
which sometimes resulted in tissue autolysis (this problem
was prominent also at the Basra Teaching Hospital). The
problem was partly caused by lack of suitable containers
for fixation, and the specimens were placed into plastic
pockets. We discussed it with clinicians in the Medical City
of Baghdad, and a tendency of improvement was noticed.
To conclude optimistically, it must be said that health care in
Iraq has essential prerequisites for successful development.
Shortages and difficulties were partly caused by
mismanagement at the time of the previous regime and are
probably temporary in their nature. Unfortunately, health
care authorities and hospital managers sometimes belittle
and disregard some internally solvable problems, even if a
solution can be found. Possible suggestions for those who
will want to help out include different kinds of material
aid3, although supplies have been improving during last
years4. Considering shortage of modern professional
literature, donations to Iraqi medical institutions of books,
e.g. previous editions of handbooks and manuals becoming
unnecessary after acquisition of newer editions, would
help to improve diagnostics. Telepathology and online
consultations, exemplified by the program International
Consultants in Medicine5, are also helpful for the same purpose. Volunteering and clinical attachments of foreign
pathologists or other medical specialists are particularly
useful because they enable to see internal problems
from another viewpoint, which can be helpful in finding
solutions. This approach would be useful also in the former
Soviet Union2.
