Baghdad in April 2003 was a difficult place to do effective humanitarian work, and things have become more awkward since. I was in the city as a surgeon with an international medical organisation. US forces had declared the Iraqi capital conquered, but buildings continued to burn and not an hour was free of gunfire.
The city's hospitals had treated many casualties during the bombing, emptying emergency stores of medical supplies. After the arrival of the Americans, much of the remainder was looted, with the pillage continuing even as staff tried to deal with arriving casualties. Operating rooms looked like charnel houses, caked underfoot with discarded surgeons' gloves, dressings and bloody clothes cut from the wounded. In the 1970s and 1980s, Iraq had boasted the most advanced healthcare in the middle east, but now limited electricity and water made cleaning difficult. Instruments could not be sterilised. Because of the risk of sepsis, Iraqi surgeons were operating only when it was unavoidable. There seemed little use for my surgical skills.
Doctors working in the emergency rooms made me welcome, but as the afternoons advanced, staff steadily deserted the treatment areas, until by nightfall the hospitals were abandoned to gangs of armed looters. Gun-wielding relatives of patients defended the wards, trying to stop the theft of the beds themselves. In the mornings, doctors would return, patching the casualties that had been dumped at the entrance in the night, while the local mosque saw to the bodies of those that had bled to death where they lay.
Instead of doing hospital surgery, I found myself working with my medical organisation at the opposite end of the clinical spectrum: primary healthcare - basic, low-tech intervention to try to prevent disease rather than the resource-intensive treatment of injuries in which I was experienced.
Every conflict area I have worked in has suffered its own particular horrors, but Baghdad was among the most complicated. Mozambique and Angola endured long-running wars of destabilisation; rebels rampaged in the countryside, attacking villages and sometimes mutilating captives - cutting off ears, lips and eyelids - before releasing them to wander like the ghouls of tribal folklore, spreading terror ahead of the rebel advance. In government-held towns, I treated people for wounds incurred in crossfire or by stepping on mines. In a mountain enclave in Burma, I operated on the boy soldiers of an opium warlord under siege by the Burmese army, and treated pneumonia and dysentery among hill-tribe refugees. In Eritrea in 2000, an Ethiopian offensive broke through the front line and I worked in hospitals in the threatened sector, helping treat waves of casualties. I made my first visit to Iraq, in April 1991, in response to the humanitarian crisis at the end of the first Gulf war when the Kurds in the northern mountains and the Shi'i in the south had obeyed George Bush senior's injunction to "take matters into their own hands, to force Saddam... to step aside," and had driven out the Iraqi army. Without allied support, the uprisings were crushed. I spent six weeks in northern Iraq operating on wounded Kurdish fighters, casualties of a desperate rearguard action in the mountains to cover the flight of 2m Kurds to areas along the Turkish and Iranian borders.
Occupied Iraq is governed by the coalition provisional authority (CPA). Its assistance and rehabilitation programme is integrated with the United States agency for international development (USAid), which hands out reconstruction contracts to private relief groups and corporations. At stake is a fundamental restructuring of Iraq's society and economy. "USAid," said Andrew S Natsios, the agency's administrator, in 2001, "is a key foreign policy instrument," in which "democracy programmes" are implemented alongside international humanitarian aid. "Foreign assistance is an important tool for the president and the secretary of state to further America's interests... Foreign assistance helps developing and transition nations move towards democratic systems and market economies; it helps nations prepare for participation in the global trading system and become better markets for US exports."
The assistance aspect of the medical operation appeared rather piecemeal in Iraq. Some of Baghdad's 32 hospitals - children's units, specialist centres, those with US-supplied security - were receiving aid and attention. But when I visited these places, I would find representatives from various relief groups waiting to be received by the hospital directors, who would courteously endure meeting after meeting, their days taken up with requests for data on bed numbers, or trying to find storage space for an imminent delivery of truckloads of donated therapeutic material. Sometimes this would turn out to be inappropriate or unusable, having been contributed by overseas drug companies and medical equipment manufacturers only too pleased to get low-demand products out of their warehouses, and to claim the tax write-off.
As well as the 140-plus big hospitals in major urban centres, the Iraqi government established over 30 years a network of primary healthcare centres in towns and villages across the country. During the mornings, the centres provided a free or nearly free service that treated coughs and colds, immunised babies and carried out antenatal assessments. In the afternoons they became public or "health insurance" clinics, where patients could, by paying a small fee, avoid the morning queues and get slightly better service. For the poorer half of Baghdad's 5m people, and for perhaps around 70 per cent of Iraqis across the country, the clinics were the only healthcare there was.
Through the bombing, most of the centres had kept running. It was often to the neighbourhood clinic that the injured would be brought. Drugs and dressings ran low. And, like the hospitals, many of the healthcare centres were looted.
One of the most overstretched of these clinics lay in Baghdad's eastern sprawl: the slum called al-Sadr. This grid of rough, low-slung buildings is home to almost 2m Shi'is. Off the main roads, the streets are dust, turned to swamp in places by the effluent from sewage pipes fractured in the bombing. I was taken around a clinic by its director. She had kept the place functioning throughout the airstrikes, turning its courtyard into a ward for the care of bombing victims. During the looting that followed, the centre had had its doors ripped off, its contents ransacked; she could only berate the thieves as they made off with examination couches, microscopes and dental instruments. The clinic continued to function, tending sick infants, dressing bullet wounds and treating the first of the season's typhoid cases.
The director and I were talking near the compound gate when a tearing burst of gunfire came from the street. While I was still registering the sound, she yanked me down into cover. The clinic guard flattened himself against the gatepost, his weapon raised. There were scattered shots, then silence. The director stood, a pale smile on her face. "Sorry, doctor." She pressed a hand to her chest and laughed nervously. "Please excuse me..." Back in her office she told me about her fears of an epidemic caused by bomb-damaged sewers contaminating ruptured water mains and the collapse of vaccination programmes. The public health laboratory, which would normally respond to any outbreak, had been torched, its centrifuges and microscopes ruined by the heat. Drugs to combat contagious illness were in short supply. The ministry of health was a 12-floor shell, its interior partitions stitched with bullet holes, and Baghdad had already seen the start of serious outbreaks of measles and gastroenteritis.
A priority for the CPA is the restructuring of Iraq's health system. There is an interim minister of health - Khudayer Abbas, an American-appointed Iraqi exile who was a doctor in the US for many years - and a plan: to privatise Iraqi healthcare. A new pay scale for doctors is already being implemented. One proposal that has been discussed is to reduce salaries for government employees working in public health and primary healthcare centres; salaries which, under the Ba'athist administration, were designed to encourage a lifetime career in public service. Instead they would be invited to supplement their incomes through private practice.
USAid has awarded a $43.8m contract to the American healthcare corporation ABT Associates - which describes itself as "one of the largest for-profit government and business research and consulting firms in the world" - as consultants on the reshaping of Iraq's medical services. Under new investment regulations decreed by US administrator L Paul Bremer, health provision, like all other areas of the country's economy (except oil), is to be opened up to foreign companies which will be allowed to own sectors in their entirety and to repatriate their profits.
Described by the CPA as "setting the most far-sighted investment climate in the middle east," these reforms were announced by the US delegation to IMF meetings in Dubai in September. Notwithstanding the dangers of operating in Iraq, the new regulations make the country highly attractive to the predominantly US-owned global healthcare industry. Shareholder pressure will require companies that invest in Iraq to concentrate on lucrative "curative" medicine, with unprofitable areas like primary healthcare expected to be subject to the principle of "cost recovery," where services are required to generate the revenue they need rather than being subsidised by the state.
Iraqi doctors might like more private practice, but many I spoke to objected strongly to the idea that foreign companies would cherry-pick prime areas of the Iraqi economy and repatriate the profits. Some expressed to me their suspicions that this second Gulf war was the first war of globalisation, aimed at forcing open Iraq's markets - and later, perhaps, those of Syria, Iran and the rest of the middle east - with an ease that no number of WTO forums could ever achieve. The resulting privatisation will suit affluent Iraqis, but the benefits for the - mainly Shi'i - poorer two thirds of the population are less tangible. For their health needs they may be forced to turn more and more to the mosque.
In early summer, the primary healthcare clinics in parts of Baghdad where Shi'i Muslims predominate were, increasingly, no longer under the control of the ministry of health. They had been taken over by islamic groups whose affiliation would be flagged up at the entrance: black and green banners and portraits of Shi'i clerics. Men with beards and AK-47s controlled the clinic gates. My arrival was often greeted with anger or the thrust of a gun barrel against my chest. My origins would be challenged: "Amrika? Britania?" I would explain that I was from South Africa: "Jinub Afriqye," I would say. "Nelson Mandela." The South African ex-president's public opposition to the war was known throughout Iraq, and the hard faces would relax. But mention of the ministry of health or foreign aid could bring renewed rage - "They must stay away from here! We are providing for our people" - and I would be shown the pharmacy, restocked with cartons of drugs donated by the mosque.
The growth of Islamic influence in healthcare in Baghdad is potentially divisive - clinics run by Shi'i mosques may start to refuse treatment to non-Shi'i patients. I have seen a staff doctor beaten, and been struck myself, by young zealots who had taken over a hospital and were trying to dictate who should work there and to prevent male doctors attending to female patients. Women health workers are forced to wear headscarves and some told me that local clerics were against women working at all. The female doctors who ran one clinic had been evicted, with medical care now being provided by an appropriately devout medical student. In some areas clinics have been closed down and replaced by health centres operating in mosques or madrassahs (Islamic religious schools). Access to westerners is denied.
The economic changes now being introduced in Iraq may, at least in the short term, strengthen the militant Shi'i movements that provide social support - healthcare, shelter, aid to the poor - in place of the state institutions that previously saw to these requirements. (The Shi'i Islamic group Hizbullah did not exist in Lebanon until the 1982 Israeli invasion. During the void in civil order under the Israeli occupation, Hizbullah collected taxes, supplied social services and healthcare. Its resultant popularity and political strength built the organisation into a powerful military force that drove Israel from southern Lebanon.)
Until recently, the greatest risk for those of us carrying out humanitarian work in Baghdad or Ar Ramadi or Falluja was being fired upon by a nervous soldier or being near a US convoy caught in an ambush. Frightening although these possibilities are, they remain the known dangers of working in a war zone. The death rate, even among medical volunteers treating front-line casualties has, up until now, been surprisingly low in the world's conflict areas. Aid workers could expect to be respected and protected by the people among whom they worked, and not sought out as targets. Now, it appears, these rules of engagement have changed; the attacks on UN headquarters in Baghdad are an indication that distinctions between humanitarian aid and foreign invasion are disappearing.
Baghdad was dangerous when I arrived in April. When I left at the end of May, it was even more so. Since then, the International Committee of the Red Cross, the World Bank and the UN itself have withdrawn most of their personnel. So too have a significant number of the independent aid groups, including some involved in primary healthcare. There is a danger that the principle of accessible healthcare, and the independent humanitarian workers attempting to help maintain it, may become casualties in this collision of fundamentally opposed worldviews.
