As the coronavirus pandemic entered its second year, Iraq struggles to cope with an unending health crisis. While the peak of the epidemic is behind, a glimpse into the way it was managed in Thi Qar province will help shed some light on the high level of dysfunctionality within Iraq’s health services.

Ali Abdul Zahra had a hard time hiding his pain and sadness as he recalled the tragic events he went through during the Coronavirus pandemic last July. While being severely ill, this 27 year old activist was also struggling to save his family which had entered the main isolation center at Al-Hussein Teaching Hospital, one of the largest health facilities in al Nasiriyah, the governorate’s capital.

The young man did not rest as most would, despite being infected with the virus himself. Rather, he kept moving between the patient lobbies and the halls of the hospital, looking for oxygen bottles. Tragically, Ali had transmitted the virus to his family. He was now on a mission to save his relatives. But many challenges stood in his way, which ultimately led to a lethal outcome. 

Thi Qar Governorate has recorded 22,820 confirmed cases between March 2020 until November 15, while the number of total recovery cases reached 21,805, the number of deaths had reached 785. These relatively light numbers nonetheless hide the fact that the province has been the stage of a power struggle which saw local parties competing for dominion over health facilities, severely undermining the quality of the health treatment for patients.

No vacancy

Ali Abdul Zahra recalls how the hospital was short of everything at that time: “Transferring patients through crowded corridors was almost impossible. I transported my mother and grandmother myself with my bare hands, looking for a place to lay them down. [The] hospital was saturated with a crowd of infected people and other patients, screaming every minute, while nurses were constantly rushing through the emergency halls.There were no mobile beds, no wheelchairs, nor any other equipment available due to overcrowding.”

The only treatment that could alleviate the breathing issues caused by the COVID-19 infection was to provide oxygen to patients, which was usually administered by the patients themselves, as Ali reminisces: “I had to give my mother and grandmother oxygen while they were sitting on the floor. After a short time their condition stabilised, but the situation continued like this for three days on the hospital floor. Afterwards we managed to obtain a better place through an acquaintance working in the hospital.” But it was only the beginning of Ali’s ordeal.

Still sick, Ali had to go through the excruciating task of carrying oxygen bottles around to help his relatives breathe. At that time, there wasn’t oxygen scarcity yet, but already a lack of staff to administer oxygen. He had no choice but to transfer the bottles himself while waiting for beds for his close ones. Eventually, while trying to move his mother to the recovery hall, the hallway official came with bad news, informing him that the only bed was already reserved. It seemed like fate was playing against Ali’s family in wicked ways. Shortage was everywhere in sight. 

Apart from shortages, the management issues, which can be equated to corruption, have significantly worsened the treatment conditions within Iraqi hospitals. For example, instead of prioritizing the health of their patients, hospital staff resorted to prioritize their own health in many cases. An anonymous medical source told THE RED LINE that “as the Covid-19 crisis grew in al Hussein hospital, many doctors got infected while others were transferred through their contacts to quarantine health centers away from the pandemic treatment centers in order to evade catching the virus.”

Meanwhile, Abdul Zahra was still struggling to save his family and decided to use other types of leverage: “I decided to contact officials and colleagues in the media and in the health department to put pressure on the hospital in order to secure a bed in the intensive care section… to no avail. There was no vacancy”, he declared. Eventually, Ali managed to obtain an oxygen machine for his mother but she died several hours after receiving it and was transferred to the morgue.

Still, the race for oxygen was creating an endless ballet between the hospital corridor and the oxygen factories. It was a distressing scene to witness the queues of patients going back and forth, waiting for oxygen bottles to be brought from the private oxygen plants in the city. And soon, the hospital’s stock was depleted and the search for oxygen continued in front of private factories. Oxygen shortages led to the death of many patients.

Racing for oxygen

Mr Ghayeb Al-Amiri, a member of the Parliamentary Health Committee, described how the oxygen production and distribution in Iraq suffers many dysfunctionalities: “Liquid oxygen is being insufficiently imported and Iraqis suffer from shortages. Iraqi oxygen stations are only refilling plants; they do not produce oxygen”. Thi Qar governorate, whose population is about 2.5 million doesn’t produce any oxygen and has been importing the life-saving medical gas from the State of Kuwait to supply its health institutions since the fall of the Baath regime in 2003. The Al-Hussein Teaching Hospital has an oxygen system intended for distribution only, with a capacity of 25 tons per day, while Bint Al-Hoda Hospital, located on the opposite side of the city, has a dysfunctional system with a production capacity of only 2.7 tons per day.

Ghayeb Al-Amiri, explained that the oxygen crisis is not specific to Thi Qar; “[i]t occurs in most Iraqi provinces. In Iraq as a whole, oxygen demand was multiplied to the hundreds in only a few days”, he said. Following the surge in death rates related to the Coronavirus pandemic, and in order to cope with shortages, the administration of the Imam Hussain Shrine in Karbala provided funds to hastily build a small oxygen factory that eventually broke down and went out of service. The facility was built inside the Hussein Teaching Hospital and had a production capacity of 20 tons per day. This helped alleviate the crisis and relieve the increasing congestion of patients, but did not prevent the shortages.

But problems with transferring oxygen bottles and buying expensive medicines severely affected patients and their relatives. Still struggling to save his family, Ali Abdul Zahra described his distress when he realized the hospital could not provide oxygen anymore : “The public factory’s oxygen pressure dropped below 1000 bar, at which time we started searching for it in other districts and suburbs of Thi Qar”

He further added, “I bought 30 bottles of oxygen per day at a price of 3 dollars each, Eventually, I had to go to Basra Governorate to buy it where a bottle cost 7 dollars.” This quest for oxygen lasted for a month, until his grandmother died.

The dysfunctionality of the health system runs deep, with funding issues crippling any attempt to manage hospitals and facilities adequately. Second deputy governor of Thi Qar Abazar Al-Omar explained to the “Red Line” that he took over the governorate’s administration as Adel Al-Dakhili left his position in November 2019 to the current governor, Nazem Al-Waili who got appointed in May 2020 (later to be removed from his post in March 2021 due to unrest in the province) At that time, Dhi Qar had been given one billion dinars to combat Coronavirus. […] but the governorate’s health department received only 500 million dinars (roughly 380,000 USD at that time). In reality, a number of MPs sabotaged the money delivery process to the governorate’s health institutions for greedy purposes” .

An anonymous source within a medical facility in Thi Qar governorate confirmed to the “Red Line”, that “the main isolation center was due to obtain 400 million dinars (274,000 USD) at the beginning of the virus outbreak (not the billion that was initially announced), but that it was mysteriously disbursed without clear reasons. Furthermore, the hospital’s management was replaced no less than five times since the beginning of the outbreak of the pandemic. It also witnessed a change of general managers two times, which reflects the extent of the confusion at work.”

On top of these blatant dysfunctionalities and corruption issues, poor training and lack of adequate medicine led to further complications among patients. Another anonymous source recalled the events that followed the death of his relative: “the wife of my relative discovered that they were giving him wrong medicines. When she confronted one of the doctors, he apologized and told her that the intense pressure they endured disrupted their work to the point that they could not be efficient enough”. 

Political meddling

According to Mr al Omar, the disruption of oxygen plants was clearly intentional: “failures of the oxygen factory in Bint Al-Hoda Maternity Hospital was due to the intervention of some political parties who were benefiting from the private plants selling oxygen bottles to people and health institutions”, he admitted. Interference by political actors seems to run deep and have severely worsened the health crisis. Parties have split key responsibility positions between them to benefit from privileges and funds at the expense of the development of a reliable and efficient health system.

The overall chaos in hospitals was indeed severely exacerbated by political meddling. The phenomenon of political interference was described to THE RED LINE by a governmental source who spoke under the condition of anonymity: “Following the oxygen crisis in Thi Qar, two Saeron (Sadrist party and affiliates*) block members got the positions of Director General of the Thi Qar Health Department, as well as director of the Public Health Department, while the National Approach bloc (part of Al fadhila party affiliated to the Shiite cleric Muhammad al-Yaqoubi) was given the position of Director of the Hussein Teaching Hospital. In the meantime, the Assistant General Director of the Health Department was allocated to another member of the National Wisdom Movement (Tayar al-Hikma). The source added that the lion’s share went to the Saeron block.

Most of those who took over the administration of Al-Hussein Teaching Hospital were approved by partisan sponsorship. Sairoun managed to take over the administration of several departments within the hospital after the inauguration of the current pro Sairoun director Saadi Al-Majed. 

Examining the Iraqi health issue more closely thus reveals that the dire situation in the country is not the result of a lack of equipment or manpower. Rather, it can be said that the inclusion of politics in the management process severely inhibited the capacity of hospitals to handle the pandemic. According to the MP, from Thi Qar Governorate, Abd al-Hadi al-Saadawi, “there is no oxygen crisis in the governorate, [only] a political struggle over positions as well as over gains; […] Thi Qar’s health department suffers from huge problems that need to be addressed”, he added.

“[T]he conflict between Sairoun and Al-Fatah over the presidency of Thi Qar Health Department became more visible during the oxygen crisis as people suffocated and died amid the political struggle.” explained the human rights defender and civil activist Hussein Al-Gharabi.

Legal situation

Legal expert Ali Hussein Jaber stated that “the most important goal of the public utilities is to provide government services to the people. Highly dependent on government income, the Health ministry significantly suffered from the drop of oil prices and the overall disruption of the economy. Deep structural defects due to the dependence on the rentier economy resulted in the deterioration of people’s social and economic standards as well as government income. 

Jaber continued stating that “what happened in Thi Qar governorate last summer led to an administrative crisis, with the cumulative effect of mismanagement and the partisanship interference within public institutions. Political meddling turned institutional administrations in endless political arenas where parties compete for funds. 

The most important factor encouraging “unscrupulous people” into corruption is the lack of transparency and legal oversight in administrative procedures around spending. This makes the public funds easily embezzled. The most worrying part, al Jaber added, is that the lack of oxygen for covid patients or poor treatment treatments provided was never investigated. On top of this, people’s lives are at risk due to conflicts and political bargaining. 

According to the legal expert, these criminal acts are comparable to cases of abuse of power that carry a minimum penalty of seven years imprisonment according to the text of articles (353 / second), (368) and (369) sanctions”.

Additionally, there is another constitutional gap since the dissolution of the Governorate Council that could supervise these practices. The overall weakness of monitoring tools led to bad behaviour within executive institutions where corrupt individuals never received sanctions for their abuse of power.

The spokesman of the Crisis Response Committee ‘which was established by the government to confront the pandemic) and former director of the public health department in Thi Qar, Haidar Hantoush, explains that “ the province was allocated one billion dinars ‘ by the Ministry of Health, additionally, Thi Qarr’s Health department received a million dinars (695 000 USD) worth of medical supplies from the Thi Qar oil company.” The funds received by the Health Department were not enough at the time because the demands were high and price rose tremendously at the peak of the pandemic since there were no stock of supplies and commercial lines were insufficient to curtail the scarcity. Hantoush claims that the governorate was not prepared to deal with the pandemic. The entire Al-Hussein Hospital turned into an intensive care hall. It did not happen in Iraq’s health history that a 400-bed hospital transformed into an intensive care hall like this.

Today, the new coronavirus variant is stepping in Iraq and posing a new threat to Dhi Qar and Iraq’s population in general. Since the last outbreak, nothing has been achieved to overcome the structural deficiencies within the health care system. More deadly than his predecessor, the British variant of the coronavirus could have even more devastating effects  than his predecessor.

*The Saeron Alliance, led by the head of the Sadrist movement, Muqtada al-Sadr, is an Iraqi electoral coalition that was formed to run in the general elections in 2018. The coalition won 54 seats in the Iraqi parliament, which qualified it to form the largest parliamentary bloc in parliament from which the government of Adel Abdul Mahdi emerged, who resigned following angry popular protests in The central and southern governorates of Iraq in 2019).

VIAAli Al-Ameer