In the neurology ward at the best hospital in Baghdad, patients lie on threadbare mattresses placed on flimsy iron beds. There are so few nurses that family members must tend to them, monitoring their condition and administering scarce medications.
“And these are the lucky ones,” said Iraqi-born Maha Alattar, MD, Assistant Professor of Neurology at the University of North Carolina in Chapel Hill. She returned from a visit a few months ago to the University of Baghdad Hospital as part of a delegation of US medical specialists who visited their Iraqi counterparts, a mission sponsored by the US Agency for International Development. In an interview with Neurology Today, Dr. Alattar shared her impressions on the state of neurology in Iraq.
“I walked into the neurology ward and it was just pathetic,” she said. “There were no nurses, just family members who they've taught to take blood pressure and give meds.” The purpose of the visit was to introduce Iraqi neurologists and residents to current medical standards of treatment and to reassure them that neurologists in the US are aware of their plight and are concerned.
“We want to help them catch up with new technology and medical advances after years of relative isolation. What really stood out was that all of the neurologists are hungry to learn, very eager, especially the residents. The chief of neurology is like a father and the residents are his children,” she said.
EFFECT OF SANCTIONS ON TRAINING
For more than a decade, Iraqi doctors have been denied expertise and technology because of UN sanctions following the first Persian Gulf War in 1982, Dr. Alattar said. “They are at least 12 years behind in technology due to the sanctions, and perhaps 20 years behind in treatment advances based on clinical findings in the West. Their equipment is 30 to 40 years old – and there is little in the way of diagnostic imaging equipment. They have had little if any contact with foreign neurologists or medical journals, and they are very aware how far behind they are right now.”
An acute shortage of medications, caused in part by the sanctions and the current fighting – which has had a severe dampening effect on delivery of medical supplies – only makes matters worse, she was told.
“Supplies are so low that doses of interferon and other medications have been cut in half, even though full doses are required to even be effective. Patients are suffering a great deal.”
MARGINAL POST-STROKE CARE
Post-stroke care and treatment is “marginal or non-existent,” she continued, and there is little if any preventive counseling or treatment for at-risk individuals. Dr. Alattar said she believes Iraq's population ranks high on the risk scale for stroke, at least as high as many western countries, but there is little in the way of basic health education and prevention.
“Routine screening and intervention measures that we provide at home on a daily basis simply don't exist in Iraq,” she said. “People don't know they are at risk until it is too late. Even a fundamental and inexpensive step like taking daily aspirin is unknown. We hope to change this.”
In addition to touring Baghdad's largest teaching hospital, Dr. Alattar met with the Vice President of the Iraq Neurological Medicine and Sciences Association and reviewed case reports with other Iraqi neurologists and residents, answering questions and discussing problems.
“For the first time since the sanctions, they are reconnecting with the outside medical community and catching up on what we've learned in those years,” said Dr. Alattar.
Iraqi doctors, she learned, have seen patients with symptoms they are not familiar with – especially among villagers from Kurdish areas where Sadam is known to have used nerve agents against civilians. “They also see a lot of Guillain-Barré, and many genetic disorders due to the accepted intermarriage of first cousins,” Dr. Alattar said. Although most Iraqi neurologists received their training in Great Britain, notably at Queen Square London, under Saddam Hussein's rule they were required to return home and serve their residencies in Iraq, Dr. Alattar learned. “All of them would like some training in the US, especially in ICU management of neurological conditions and neuroimaging.”
Access to current medical journals is another problem. Despite the availability of the Internet there are no funds for subscriptions to e-journals, Dr. Alattar said, although a new initiative by US organizations has established Medical Information Centers at 10 hospitals that will provide Internet journal access and other information for doctors (see box, “Internet Access in Iraq”).
Although US Army neurologists are stationed in Iraq, there is little exchange of information because of the need to treat wounded soldiers and civilians. Limited access to some state-of-the art imaging equipment is possible at the US Army medical facility, however, and more complicated neurological cases among Iraqis are referred to the Army hospital center, especially younger children, she said.
US MEDICAL FACILITIES: CAMP DOGWOOD
Medical City, a two-mile area in Baghdad that contains five hospitals and two teaching hospitals, including the University, was built in 1986 and has just 220 beds. Patients from all over Iraq travel to Medical City to be treated by the country's top medical specialists, but these doctors, too, are hampered by a shortage of medicine, equipment, and almost daily power outages.
“Camp Dogwood” is the “tongue-in-cheek” name given to the US Army's medical facility in the desert, about 15 miles west of Baghdad, home to the 207th Neurosurgical Team, nicknamed the “Skullcrackers.” The team of neurosurgeons from Walter Reed Army Medical Center is attached to the 28th Combat Support Hospital.
Dr. Alattar said she was impressed when she visited the hospital. “It was disorienting to see so much state-of-the-art equipment in the middle of nowhere and after seeing what the Iraqi doctors are using in Baghdad. The MRI facility was absolutely up to date; it looked like any US facility,” she said.
“The neurologists and residents at the University were happy to see us. The conference did a lot to raise the neurologists' morale. They felt that for the first time in years the international medical community is pulling together for them,” said Dr. Alattar.
“I wish more neurologists here at home would jump on the bandwagon and work toward helping the Iraqi neurologists and neurology students. They are interested having access to the US system and the information available here.”
She was surprised that the neurologists and students were unfamiliar with the concept of subspecialty fellowships.
“They don't have fellowships in Iraq. They are all general neurologists; there are no subspecialties – everyone does everything. In fact, they seemed surprised at the idea of specialists. In all, there are probably only 60 neurologists in the entire country for a population of more than 23 million, and all the neurologists fall under the umbrella of neurosciences and electrophysiology, which I suppose means technicians.”
SUPPORT FOR FELLOWSHIPS
Dr. Alattar said she hopes to generate the support of other neurologists at the AAN's meeting in San Francisco, especially those in the position to offer fellowships and training.
“Even two fellowships a year would mean these doctors could go back to Iraq and train others. In Iraq, most patients need primary care. Psychological and neurological treatment is pushed aside. The incidence of stroke is high in Iraq. Yet the concept of stroke teams doesn't exist there. I was amazed. I told them that stroke patients need an MRA (magnetic resonance angiogram) to determine the extent of the damage cause by an aneurysm and had to explain that it is not the same as angiography, that it shows any stenosis involved. They were not aware of the need to switch from aspirin to warfarin (Coumadin) for high-risk patients or to use stents to open stenoses. Preventive medicine simply does not exist. They don't even check homocysteine levels. There's no blood pressure education or management, even though we know now that monitoring needs to begin in schoolchildren. And there's very little treatment for Parkinson disease, MS, or even migraine.”
Dr. Alattar said she and the other American doctors will be communicating with their Iraqi colleagues by e-mail, offering assistance and answering questions while trying to generate support for education and training opportunities in the US.
ARTICLE IN BRIFE
✓ Dr. Maha Alattar, an Iraqi-born neurologist, returned to her native homeland in late February with a delegation of physicians. She observed that neurology was woefully behind the times in access to new medical advances, therapies, and equipment.
INTERNET ACCESS IN IRAQ
As part of an effort to provide medical schools and hospitals in Iraq with the latest medical information, WiRED International in mid-March outfitted six medical schools and teaching hospitals with its computer-based learning modules, or Medical Information Centers.
The six new facilities augment four centers put in place last year just after the war in Iraq was declared over. The first center opened last June at Baghdad University Hospital, Iraq's largest teaching hospital.
The 10 Centers located in Baghdad, Basra, and Kufae now serve more than 5,500 Iraqi physicians, students, and medical faculty with information they could not otherwise access, according to the organization.
Each facility now has four to 10 computers and a complete CD-Rom library designed to provide quick medical updates. As the Internet becomes more widely available throughout Iraq the centers will convert instantly to Internet-based facilities. WiRED will then provide access to on-line sources that supply the latest and most comprehensive array of medical information, the organization said in an announcement. WiRED International is a San Francisco-based organization, which often collaborates with San Francisco State University's Marian Wright Edelman Institute, the US State Department-sponsored Global Technology Corps and the US National Institutes of Health.
The 10-station computer network and e-library of medical topics provides more than 1,000 doctors and medical students with information about the latest advances in the diagnosis and treatment of illnesses, including neurological disorders.
WiRED also operates centers in the Balkans, Africa, and Latin America. The Medtronic Foundation, Pfizer Inc., Affinity Internet, the Christopher Reeve Paralysis Foundation, and smaller donors contributed to the new centers, while the original facilities were funded by the US Department of State's Bureau of International Information Programs and Education and Cultural Affairs.
IRAQ: RESPONSE FROM THE INTERNATIONAL NEUROLOGY COMMUNITY
The international neurology community has not been blind to the problems in Iraq, according to James F. Toole, MD, Past President of the World Federation of Neurology (WFN).
Dr. Toole, the Walter C. Teagle Professor of Neurology and Director of the Cerebrovascular Research Center at Wake Forest University Baptist Medical Center in Winston-Salem, NC, told Neurology Today that before 9–11, the WFN and the European Federation of Neurological Societies had been eliciting support for neurologists in Iraq. “But then the war began and everything stopped,” he said.
Even then the neurology community sought alternative and circuitous avenues to get material or training programs to neurologists there. Last year, Theodore Munsat, MD, a former AAN President who is now Chair of the WFN Education Committee and one of its trustees, met in Cairo with three neurologists from Iraq and a WFN representative from Jordan.
“The neurologists expressed interest in working with the WFN,” Dr. Munsat said. “We tried to get education materials into Iraq through our WFN representative in Jordan.” But, he added: “It is extremely difficult for obvious reasons [the war] to move ahead in an organized manner. We are waiting for things to calm down there.”
Dr. Munsat noted that the WFN sponsors CME programs in 28 developing countries, and the AAN donates 200 copies of the CME series Continuum annually to support the effort. “It is clear that there is a profound need for help in Iraq,” Dr. Munsat said, “but the needs there are so basic. Sending Continuum may not be enough.”
In an upcoming issue, Neurology Today will offer an update on the state of neurology in Iraq – as Dr. Maha Allatar returns from another visit there – as well as a broader look at how the WFN and other international neurology organizations are addressing the needs of developing countries.