Cancer control in war-torn Iraq

Abstract

Before 1980, the Iraqi health system was described by the UN as the best health-care system in the Middle East with respect to its infrastructure, medical expertise and universal health coverage through its free of charge services. The repercussions of the war against Iran (1980–88), followed by the Gulf wars (1990–91 and 2003–11), and the civil war initiated by the Islamic State of Iraq and the Levant (2014–17), resulted in a severe decline in the availability of medical resources, funds, and medical personnel; factors that were exacerbated by an excess of bureaucracy, corruption, and turmoil at a time when the health sector was not considered a priority by the Iraqi Government. In 2017, the International Organization for Migration registered over 3 million internally displaced Iraqis, which added a further burden on the Iraqi Ministry of Health. Much of the focus from high-income countries centers on the aftermath of the second Gulf war in Iraq, but it is important to realise that this country has been in a continuous state of war for about 40 years, claiming the lives of hundreds of thousands of Iraqi citizens in which it is of little surprise that health-care service and provision of the country has suffered. During the Gulf war, Iraq and the surrounding regions were exposed to various weapons, including depleted uranium-tipped ammunitions, which raised a hitherto unresolved debate on the potential carcinogenicity of the weapons. The UN sanctions, undertaken to restrict Saddam Hussein's capacity to manufacture weapons of mass destruction, imposed an embargo on a range of cancer diagnostic and treatment equipment, including linear accelerators, some chemotherapy drugs, radioisotopes, and analgesics, which were blocked on the assumption that they might be converted into chemical weapons. The 2003 Gulf war saw the destruction of 12% of hospitals and public laboratories, while many others were either looted or destroyed. In 2004, David Kerr visited Basra to explore the residual robustness of the health service under the auspices of the British Army, and witnessed the extraordinary pressure that clinical colleagues and health-care professionals were under from sectarian, authoritarian, and criminal organisations to comply with living within dangerous and mysterious circumstances. Unsurprisingly, many senior clinicians had to put the safety of their families first and seek employment elsewhere, which substantially expanded the Iraqi medical diaspora. At such a time, individuals in high-level positions were specifically targeted—eg, Muhammed Alwan, Dean of Mustansiriya Medical College, was mysteriously killed by a car bomb in 2011. Why this hard working, universally acclaimed surgeon was targeted was much speculated on, but no clear motives have been discovered to date.