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Infection control poses challenges for Iraqi hospitals
Volunteering in Iraq gave James H. Brien, DO, a new perspective on Iraqi hospitals and a glimpse into practicing medicine under severe funding limits.
Infection control is challenging for the wealthiest hospitals, but physicians in resource-limited, war-torn and politically tumultuous areas face even greater obstacles. In Iraq, basic medical supplies such as surgical gloves and gowns are lacking, but medical dedication is steadfast, according to a volunteer physician who recently traveled there.
“Most people would be surprised by the capability in Iraq because people here [in the United States] only see the violent parts of it, but the doctors there are dedicated and smart,” said James H. Brien, DO, a pediatric and infectious diseases specialist from Scott and White Children’s Health Center in Temple, Texas. “The doctors are great; they are doing the best they can.”
Brien, who is also a member of the Infectious Disease News editorial advisory board, volunteered to teach a course to doctors in Iraq through the IDSA Fellows Infection Control program. Brien said he learned about the opportunity after colleague John Podgore, DO, MPH, a professor at the University of North Texas Health Science Center’s Texas College of Osteopathic Medicine, told him about the philanthropic effort for infection control. Brien, Podgore and Barbara Atkinson, DO, associate professor of internal medicine and chief of the infectious disease division at the University of North Texas State Health Science Center taught the course at Hawler Medical University in Erbil, Iraq, in June.
Erbil is the historic capital of the Kurdistan region and touts itself as the oldest continuously populated city in the world. In 2005, the estimated population of Erbil was 990,000. It is located about 300 km north of Baghdad.
“The city of Erbil dates back 6,000 years, and some parts look that way,” Brien said. “The whole country is a war zone, but the Kurdish region is relatively peaceful.”
About two weeks before Brien and colleagues arrived, a suicide truck bomb went off where 14 people were killed and 84 people were wounded. Because of the bombing, Brien and his colleagues’ accommodations were switched from a standard international hotel for Western travelers to an Iraqi hotel.
“I had a feeling I was safer because that’s where local Iraqi people go,” Brien said. Guards with machine guns were everywhere, which was not surprising to Brien.
Iraqi physicians, hospitals
In the middle of a shaky political region, medicine is still being practiced, and patients are being treated as best as possible with substandard facilities and limited resources.
“We toured a pediatric hospital there and we encountered smart and motivated doctors, but their facilities were fairly primitive and run down,” Brien said. “A second floor was being added to the hospital, which was a good sign.”
Brien and his colleagues also toured a maternity hospital, which was a completely different, modern and well-equipped facility. Like the majority of Iraqi doctors, the physicians at the hospital all spoke English well. The course was taught in English, as are all classes at the medical university, and the library was full of the same medical textbooks – also in English – found in American medical school libraries.
“It’s not as archaic as some people may think. In the pre-Saddam Hussein era, Iraq was an example of progress, with decent facilities and good care as compared to other nearby nations,” Brien said.
Public health fell in priority when Hussein’s rule began, according to many people Brien met. “Everyone that we talked with was strongly against Hussein,” Brien said. “They are affected by the politics of Iraq just as we are affected by the politics of Washington, and sometimes it’s good and sometimes it’s not so good.”
Infection control course
About 60 people, some traveling from Baghdad and other regions of Iraq, took the infection control course taught by Brien, Podgore and Atkinson. The majority were physicians, but class members also included microbiologists, the dean of the nursing school and the head of microbiology at the medical school.
Brien said he was overwhelmed by how appreciative these health care professionals were for the course. “They are hungry for continuing medical education. Any one of them would give anything to come to the United States for additional medical training,” Brien said.
Contrary to popular belief, Brien noted that women in Iraq hold many of the top positions in medicine, including an obstetrician and member of the Kurdish Parliament, who they met during the course.
“Medical education is not a problem for women, and they are not second-class citizens there,” Brien said.
Improvised hospitals
Brien said health care professionals in Iraq have to deal with a health care system that is, in many ways, quite different from the American system. Basic infection control necessities, such as surgical gloves, are not readily available in many of the hospitals in Iraq.
“At the Children’s Hospital at Scott and White, I have three sizes of gloves to choose from in each patient room while I do my rounds, but in Iraq, I never saw gloves,” Brien said.
Physicians improvise by washing their hands frequently. Gowns and masks are also used minimally because of limited funding. “For the most part, Iraqi doctors know what they need to do for infection control, and they do the best with what they’ve got,” Brien said.
Culture also plays a role in the hospital environment. In a pediatric hospital Brien toured, a typical room housed eight patients. As is the cultural norm, each patient has one or two female relatives, usually including the mother, at the bedside continually, which adds to the crowding.
Rooms were not big, with barely 3 feet between each bed.
“From an infection control standpoint, this is not a bad start, but it is clearly not adequate for airborne illnesses,” Brien said.
In the same room as children with gastroenteritis was a baby with an enlarged heart and heart failure. In most U.S. hospitals, the workup for the baby would be a cardiology consult and an echocardiogram. For the baby in the Iraq hospital, both the consult and the echocardiogram could be two to three days away. The equipment and the specialists are on a circuit, and patients get services as they are available. If the baby had to be seen, doctors may attempt a transfer, but transfers are rare, according to Brien.
“They do the best with what they have. You can stop a lot of transmission with strict adherence to hand washing,” Brien said.
Team members encouraged Iraqi physicians to use alcohol-based hand cleaning products for more effective hand washing. “But that costs money. We can give them the information so when they do have the resources, they can use it,” Brien said.
Volunteers wanted
Organizational skills to start infection control committees were the most important aspect of the course, according to Brien. At present, the hospitals Brien toured did not keep track of nosocomial infections.
“Once they can establish committees, the dialogue can begin to discuss problems at specific committees,” Brien said.
The International Medical Corps, a nonprofit organization, covered all expenses. The physicians had to volunteer their time. Opportunities are numerous for medical professionals who want to volunteer in hospitals and universities worldwide.
“The experience was worthwhile, and I’d do it again,” Brien said. “Whether we like it or not, we’re in it. Rather than sitting around complaining about how the war is going, if you have a chance to take an active role, it’s a good way to participate in the process.” – by Kirsten H. Ellis
For more information:
- For more information on The International Medical Corps, visit www.imcworldwide.org.