Pathology of War

I was born in Nineveh (Mosul), and raised in the mountainous Duhok Kurdistan region of Iraq. It’s the smallest province in Iraq, but you can find Kurds, Chaldeans, Assyrians, Arabs, Muslims, Christians and Yezidis all living and working there, so it’s an interesting place. And it’s full of history – there are caves and sculptures dating from the times of the Medes and Assyrians. I have a lot of beautiful memories from my childhood!

Unique specialty, unprecedented demands

I also remember that, as a child, I hated doctors, because of injections. As I grew up, however, I began to understand the important service physicians provide for the community. Eventually I came to admire them, and I ended up training as a doctor myself, and graduated from Duhok University Medical College in June 2000. During my studies, which included rotational internships in Azadi Teaching Hospital, I came to realize that pathologists are unique among specialists in that they help not just patients but also clinicians and surgeons, too. This decided the direction of my career, and after passing my pathology exams I joined the Duhok Specialized Laboratory Centre (DSLC).

Together with Duhok University, the DSLC is the main site for training of undergraduate and postgraduate molecular biologists, biochemists and laboratory biotechnology specialists in Iraq. Its major role, however, is to process samples from primary health centers and hospitals throughout Duhok. This is a significant task, as Duhok has been a safe haven for internationally displaced persons (IDPs) since 1991. The IDP population has been increased even further in recent times, though, as a consequence of the ISIS / Mosul and Syria situations, such that Duhok’s normal population of about 1.4 million now hosts an additional 0.74 million IDPs and 0.1 million Syrian refugees, including refugees from Sinjar Mountain. As a consequence, patient referrals have tripled compared with the original number of samples processed by the center (see Figure 1). This drain on resources has been exacerbated by the financial crisis suffered by the Kurdistan Regional Government since 2014.

It’s tough, but it’s personal

Unfortunately, it is the medical staff that bears the load in terms of dealing with war casualties, IDPs, and refugees – we keep our primary healthcare centers open 24/7, which is exhausting. However, we are highly motivated; some of my colleagues have family members in the Peshmerga at the front line, or relatives who have been kidnapped or killed by ISIS. So we do whatever we can to help. In addition, we are not entirely alone; international and non-governmental organizations have had an important role in providing training, consultation and financial support to our staff, and that has been very helpful.

Much of our work involves administration of vaccines and provision of medical consultations and diagnostic tests so as to prevent outbreaks of communicable diseases like TB, measles, cholera and polio (see Figure 2). However, in addition to screening IDPs and refugees, and maintaining surveillance of communicable diseases, we have to diagnose and manage patients with chronic diseases like cancer. These are referred to a specialized centre in Duhok city which also looks after the indigenous residents. So DOH-Duhok, in spite of severe resource constraints, has succeeded in responding to the mass IDP and refugee crisis that has persisted since 2014.

Challenges do not end with war

Nevertheless, we face tremendous difficulties in view of the sustained and growing crisis (see Sidebar “Public Health Challenges in Duhok”). On one level, we endure ongoing challenges in terms of routine pathology. For example, we may see interesting cases which need a diagnostic test that is unavailable in the lab due to resource constraints; sadly, we can’t always help these types of patient.

On another level, challenges arise from the increase in demand for health services due to a growing refugee / IDP population, and the increased numbers of war casualties we see as the Mosul operation proceeds. The burden on the host community is becoming increasingly difficult to bear: host public health facilities are overwhelmed with IDP and refugee patients, more than 70 percent of whom live outside camps. This is forcing host people to seek medical care at private health facilities, and has led to catastrophic levels of health expenditure for many families in the host community. Even if the war were to end tomorrow, it’s likely that up to 40 percent of IDPs would stay in Duhok governorate for decades, unless their homeland infrastructure were rebuilt. Another 20 percent or more will probably never return to their place of origin in any case, regardless of infrastructure investment. Furthermore, there remain many unsolved problems in this region, and we are concerned that these may trigger other conflicts.

International support is good, but not good enough

So the problems we face are not limited to the short-term. Against this background, it is clear that international and UN organizations are very important. They provide supplies of drugs and consumables, funds for construction of new primary health centres and purchase of ambulances, resources for vaccination campaigns, training for medical staff – for example, on how to deal with war injuries – and advice to help the Peshmerga prepare for possible chemical attacks by ISIS. This is all enormously helpful, and I would like to thank all of these organizations for their continued support of our institutes and staff during this critical period.

Even so, it has to be said that the support that we get does not fully meet the urgent needs of IDPs and refugees. Furthermore, INGOs and UN agencies don’t focus on host infrastructure, and in consequence we find it increasingly challenging to maintain existing health service provision in the host community. As mentioned, over 70 percent of IDPs live outside camps and seek medical care at host health facilities where infrastructure and equipment are sparse and staff are exhausted. Many anticipated capital-intensive projects have been suspended, including hospitals for emergency, cancer, and obstetrics and gynecology. We urgently need these projects to be funded so that we can sustain the existing health services at host facilities. Additional resources would be very helpful, but we should also consider doing more with what we have; for example, separating public and private health services would avoid duplication of practice and thereby reduce unnecessary expense.

Under these circumstances, we would urge continued international support not only for IDPs and refugees but also for the host community. This will help to maintain equity of access to health services for all residents in Duhok governorate. Support for regional and central government to maintain security and overcome the financial crisis is crucial to prevent future conflicts and disease outbreaks.

So it’s true to say that our circumstances are not easy; but even when faced with such large challenges, I take comfort in remembering that the small things remain important: the support of family and friends, and the satisfaction of helping each patient, one by one.