BAGHDAD – Dr. Zinah Jawad leans over her patient and peers into his glazed eyes. It doesn't look good, she says, shaking her head.
The man had arrived at Baghdad Teaching Hospital’s emergency department a few hours earlier with a high fever and dizziness. Now he lies sweaty and shaking, soaking his dirty clothes.
This emergency room is cleaner than most here. In fact, it’s widely considered the best in Baghdad. But flies still buzz overhead and on busy days there aren’t enough beds or oxygen tanks to go around. Across the room a crude sign made with binder paper and tape marks the department’s two-bed cardiac unit, which lacks a reliable defibrillator.
Jawad, a second-year medical resident, turns to the sick man’s wife, who is perched anxiously on a ripped chair at his bedside. "We suspect meningitis," she says.
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If Jawad is correct, her patient will probably be dead long before she confirms her diagnosis. Even slimmer are her chances of getting the right antibiotics to treat him.
Her hospital can’t perform the lab test she needs. Its stock of drugs and basic supplies is so undependable that doctors routinely dispatch patients' relatives to fetch medicines, IV fluids and syringes from private merchants or on the precarious black market.
Jawad can't explain the shortages. Her department is always careful in placing its order with the national health ministry, which supplies all of Iraq's public hospitals. But the medicines often don't show up.
"No one can tell us why," Jawad says. "It is as if they just disappear somewhere."
Stories like this one – of missing drugs, of desperately ill-equipped doctors and of patients left to suffer the consequences – are everywhere in Iraq's public healthcare system. Some hospitals are filthy and infested with bugs. Others are practically falling down. More and more, blame is being placed squarely with Iraq's U.S.-backed government, which by many accounts is overrun with corruption and incompetence.
There is no doubt that years of economic sanctions followed by years of war have taken a heavy toll on all public services here. But with violence down and some sense of normalcy returning, improvements in health care should be coming far faster than they are, according to doctors, patients, aid organizations and some public officials.
They fault widespread problems that reach all levels of Iraq's government, and the examples they cite are troubling: Health ministry workers routinely siphon drugs from hospital orders to make extra cash on the black market. Bribery is rampant. Millions of dollars meant for clinics and equipment have instead gone missing. Millions more have been wasted on government contracts to buy expired medicines.
The health ministry’s inspector general openly admits the problems. Even so, the culprits are rarely punished.
In Iraq, corruption and ineptitude are hardly limited to health care; they are endemic in most public institutions here. But when it comes to the sick the repercussions are especially devastating, and they bring into sharp focus the failures that are threatening the country's American-financed effort to rebuild itself as a democracy at peace with itself and its neighbors.
"It costs lives every day," said a fourth-year resident at Baghdad Teaching Hospital who asked not to be named for fear of retaliation by his superiors. "The security situation is better now. The government has money. So you tell me why I can't get basic medicines at the best ER in Baghdad."
MORE COULD BE SAVED
No one keeps statistics on how many deaths might be avoided if not for the shortages of equipment and medicine, but anecdotal evidence suggests the numbers are significant.
Pediatrician Ali Alwan said the situation isn’t so dire at Baghdad’s Yarmouk Hospital, where he works now. But at the small hospital he left four months ago in Jalawla, northeast of Baghdad, he said children die daily from diarrhea and other highly treatable conditions.
“A lot more would survive if we had more medicines,” Alwan said. “I try not to think about how many.”
Families who blame poor government health care for the death of a loved one are easy to find here.
Ali Mohammad Abed, a student teacher from Baghdad’s Bayaa neighborhood, said he believes his 2-month-old nephew is dead because the public children’s hospital where he was taken last month didn’t have the tools to diagnose him.
“We noticed a strange color around his lips,” Abed said. “They couldn’t do the tests they needed to figure out what was wrong. He died the next day.”
Dhiya Francis, who works at a hotel in Baghdad’s Karrada neighborhood, thinks his brother would be alive if Iraq’s public healthcare system could have performed an operation he needed to clear a blood vessel in his heart.
Francis said his family found a private hospital to do the surgery, but they couldn’t afford it.
“The government hospital said they didn’t have the equipment,” he said, crying. “If the private hospitals can do it, why can’t the government?”
Before the 1990s, Iraq had perhaps the best healthcare system in the Middle East. Nearly two decades of international sanctions and war has changed that. For most of 2006 and 2007, when Iraq's sectarian violence was at its worst, the national health ministry was controlled almost completely by Shiite Muslim militias. In many neighborhoods Sunnis avoided hospitals altogether for fear of being murdered in them.
Today, for the most part, Iraqis feel safe enough to go where they want, including to see doctors. Hospitals are no longer overwhelmed by victims of the violence. But progress beyond that has been minimal. Though government health care is free in Iraq, patients who can afford it usually seek private care because public facilities are so ill equipped. In rural areas and far-flung villages, the situation is dramatically worse.
MEDICAL SUPPLIES GO MISSING
Even at Baghdad Teaching Hospital, emergency department shelves often run dry of antibiotics, painkillers and life-saving drugs for heart attack victims.
"Much of the time we don't have IV fluid, so the family will go out to buy it and bring it to us," Jawad said. "The pharmacies know they are desperate, so they charge them three or four times the normal price."
At the Hospital of Radiotherapy and Nuclear Medicine, a dirty, badly rundown cancer treatment center in Iraq’s capital, administrators said the hospital rarely runs out of chemotherapy drugs. But patients and low-level workers told a different story. They said the sick often must bring their own medicines.
At Yarmouk Hospital, a 600-bed facility where entire wings are blocked off for fear they’ll fall down, nurses complained of constant shortages of materials. One said the hospital regularly uses water as a substitute for ultrasound gel.
"One day we will have a lot and the next day it will all be gone," she said.
Huda Fadhil, sitting at her ailing mother's bedside, said doctors at Yarmouk had sent her out several times to fetch supplies the hospital lacked.
"I just got back from buying this," she said, holding up a plastic syringe. "With all the fortunes this country has, the hospitals don't have syringes? It's crazy."
The shortages are so endemic that some hospitals won't treat noncritical patients if they come without a friend or relative to act as a runner on their behalf.
At Baghdad Teaching Hospital, an old man who’d come alone to have fluid drained from his abdomen said doctors told him they couldn’t perform the procedure until he brought a helper.
“I keep telling them I have no one,” he said, rubbing his bloated belly.
Doctors and pharmacists said it's widely known that drugs and other supplies are routinely stolen from the public healthcare system and sold to private merchants, who jack up prices.
All drugs that enter Iraq by way of government contracts are marked with health ministry stamps. They’re never meant to end up at private drug stores but they often do, said Husham Hussein, who works mornings stocking shelves at a public hospital and runs his own pharmacy in the afternoons.
He said the theft occurs at various points: Sometimes health ministry administrators skim off the top of ministry orders. Other times supplies are stolen by workers directly off hospital shelves. He described one common scheme in which clinic employees falsify paperwork for patients who don't exist, then walk off with drugs and other supplies.
"The leak of materials from the hospitals to the private pharmacies is well known," Hussein said. "But no one really tries to stop it. That’s why so many people do it."
By many accounts, buyers at the health ministry habitually take bribes from less-than-reputable manufacturers to purchase unnecessary equipment or medicines of such questionable quality that doctors refuse to use them.
Bassim Shareef Nuseyif, a member of the Iraqi parliament's health committee, said he’s aware of at least one case in which the health ministry bought millions of dollars worth of expired drugs.
"I can't tell you if this was corruption or negligence," Nuseyif said. "But either way it is very bad."
TOOLS THAT NEVER ARRIVE
Shortages of medical equipment also are a major problem across Iraq. At Baghdad Teaching Hospital, the emergency department lacks most basic diagnostic machines. Its lone defibrillator breaks regularly. Patient samples often must be sent out for testing because the department's lab is so ill equipped.
"We must be careful to only use the dependable labs," Jawad said. "There are many that give incorrect results, or they leave the samples to expire."
Excluding the semi-autonomous region of Kurdistan, Iraq has just four radiation machines for treating cancer patients, said Dr. Ahmed Abdulqadir, deputy director at the Hospital of Radiotherapy and Nuclear Medicine. Three are at Abdulqadir's hospital; the fourth is in Mosul, in northern Iraq.
"If you need a new machine, there's no real process to get it," lamented the fourth-year resident who didn't want his name published. "You're told to ask so many different administrators, and then none of them does anything about it. It's a mess."
Nuseyif told of an instance in 2007 in which provincial officials took roughly $9 million in central government funding to buy new equipment for hospitals and clinics in the southern province of Wasit. The equipment still hasn't shown up, Nuseyif said.
"We know this is happening other places," he added.
The same type of graft that’s at least partly to blame for drug and equipment shortages appears also to be delaying badly needed renovations at Iraqi healthcare facilities.
Roughly 40 percent of the country's 210 public hospitals are awaiting major repairs, according to the government’s own figures. At Yarmouk, entire wings are too decrepit for use. Gaping holes pock the ceiling and big brown bugs scurry in the hallways. The elevators haven't worked in years. Relatives must carry the sickest patients up and down stairs.
Nuseyif said he's visited hospitals where large sums supposedly were spent on renovations, though he could see no evidence of improvements.
"When you go to look at these hospitals, it is clear the money didn't go where it was meant to," he said. "There is no accounting or monitoring, and the people stealing the money know this."
Mustafa al Hiti, another health committee member, said ministry administrators and provincial officials sometimes sign contracts for renovations and equipment at costs far below what was allocated, and then pocket the difference.
"Things end up breaking down quickly, or they are useless," he said. "The contracts are not made with reputable companies in Europe or the West."
Patients said bribery has become so widespread that the sick now accept it as part of the process of getting treatment from hospital and clinic workers. Those who are able sometimes use payoffs or personal connections at the health ministry to avoid long waits for surgeries or hard-to-get tests such as MRIs.
"My case is a simple one, so I haven't paid any bribes," said Widad Jalal, who was admitted to Yarmouk for a lung infection. "But many times you do. This is not hidden. It's common."
To be sure, Iraq’s public healthcare system has seen some improvements in the past year or so. And there is no doubt that many problems at play aren’t ones the government can easily control, foremost an overwhelming shortage of doctors. As many as 15,000 are estimated to have fled because of the war and few have come home.
Foreign companies and investors, which Iraq desperately needs, also have been hesitant to return.
To a degree, money is also a problem. Falling oil prices recently forced the central government to cut its expenses by billions, and health ministry officials said their share of the national budget, about 3 percent, is far from adequate. Many lawmakers agreed.
But even as health spending has increased – from $62 per capita in 2007 to $100 in 2008 – doctors said they haven't seen improvements on the ground to match.
The health ministry’s total budget now stands at roughly $3.5 billion, up from up from $16 million in 2002. Last year the government spent about $800 million buying medicines, officials said.
FEW ARE PUNISHED
There are no approximations specific to the health ministry, but the U.S. has estimated that 10 percent of the central government’s money is lost to corruption.
One Iraqi official, Radhi Hamza al Radhi, told U.S. lawmakers in late 2007 that the Iraqi government’s Public Integrity Commission had uncovered losses of about $18 billion across all ministries.
Last year the health ministry forwarded about 150 cases to the commission, but authorities said such efforts rarely amount to much. Though the Public Integrity Commission is supposed to be the government’s most powerful anti-corruption body, it is widely considered ineffective and weak. Its officials have said less than three percent of cases they investigate end with convictions, and they have complained of corruption even among the commission’s own ranks.
Poor hiring practices appear to be a big part of the problem. Across government departments, jobs often go to people with the right connections, regardless of their qualifications.
“This ensures that the corruption can continue,” said Saif Abdul Rahman, a senior advisor to Iraqi Vice President Tariq Hashimi. "Until we institutionalize hiring, I don't expect that to change.”
Nuseyif, the parliamentarian, noted that setbacks like Iraq's doctor shortage probably would be less severe if not for all the bribery and theft.
"These things tend to push out the honest and the efficient professionals," he said.
The health ministry's inspector general, who is charged with improving the department and rooting out corruption, acknowledged there are problems but downplayed their severity.
Besides the doctor shortage, Adel Mohsin Abdullah named "human resources issues" among ministry administrators as the biggest obstacle to better health care in Iraq.
"The problem is half corruption and half a lack of ability," Abdullah allowed. "When we have a better department, you will see the improvements in our hospitals."
He declined to discuss specific examples. "Please don't embarrass me with these kinds of questions," he said, adding that the situation inside public hospitals isn't as bad as many doctors describe.
Abdullah said his office conducts audits on health ministry spending but that the findings aren’t public. “We’ve uncovered some problems, mostly with the contracts,” he admitted. “We’re working to fix them.”
Asked what the ministry has done to get rid of unqualified employees, Abdullah, who has held his position since 2003, said the department is still developing procedures to evaluate performance among its 170,000 workers.
"We are still in the stage of determining who should be replaced," he said. "These things take time."
Reilly reports for the Merced Sun-Star. McClatchy special correspondents Jenan Hussein, Sahar Issa and Hussein Kadhim contributed to this story.