EHJ January 2004, pages 14-15
Efforts to get the health sector back on its feet are well under way in Iraq. Colin Freeman reports

For Andrew Mathieson, the job of nursing Iraq's rundown health system back to fitness involves coping with everything from kidnappings and corruption through to murders of staff. Mr Mathieson, a major in the Territorial Army previously attached to an army field hospital, leads a team supervising a top-to-bottom revamp of the hospitals and clinics in southern Iraq. The challenges are formidable. Hospitals are operating with ancient 20-year-old equipment, doctors often lack even stethoscopes and children are dying for want drugs costing just 70p a time. But budgets, retraining and rebuilding programmes are not the only problems that land on Mr Mathieson's desk.

"Our main job is getting the health sector back on its feet, providing equipment where it is needed and co-ordinating things," he says. "But the Iraqi doctors who work here are facing frequent threats for the work they do from people who are trying to destabilise the country. Since I have been here, two have been murdered, another kidnapped, and many others have been scared off from working." However, he says that "as a military representative on the health side of things, these are things we are able to help deal with."

Mr Mathieson used to work as a lecturer in environmental health, and was originally deployed to Iraq with a medical unit. The public health experience of his civilian job saw him moved to a health team with the Coalition Provisional Authority (CPA), the main civil-military body co-ordinating reconstruction and government in Iraq.

Inside the CPA's heavily-guarded compound in Basra - where signs warn of mortar and rocket attacks - he works alongside an Italian doctor and four senior civil servants from the Department of Health. Using a strategy book borrowed from a London NHS Trust, they act as the improvised nerve centre for the redevelopment of the entire health system in southern Iraq, which has 8,000 workers.

"Health is better now than it was under Saddam Hussein, but it is still not as good as it should be by a long shot," he says. "The staff are highly capable, but there is just not the infrastructure to support them, and we are trying our best to co-ordinate supplies and train people."

Lack of equipment is a huge problem. "Some GPs for example, are sitting in surgeries that are literally bare, without even stethoscopes or basic equipment," he stresses, "so we give them kits that will allow them to treat 1,000 patients." He goes on, "the surgeons in the hospitals are pretty capable because they have seen so many injuries during the wars here, but they are about 10 or 20 years behind with their equipment. Many hospitals have no defibrillators, gas monitors or electronic equipment to speak of."

Across Iraq, malnutrition, tuberculosis, and cholera still occurs, as well as tropical diseases like malaria. Because of a lack of post-operative care and physiotherapy, wounds that are treated in hospital often end up being infected, and children still die from diarrhoea because of shortages of tablets. Shortages of medicines have been made worse by a thriving black market in pharmaceuticals, which the British Army is now trying to tackle.

"If US$1m of medicines are sent down to us from Baghdad for distribution, a tenth of that will disappear en route and then a lot more ends up being sold privately," he sighs. "The hospital pharmacists will sell packets of 30 tablets with only 20 inside and by the time people realise that, it is often too late to complain." There are streets around Basra full of people selling black market medicines, he explains and some of the pharmacists are making big profits through selling them illegally. "You can tell by the way they are well dressed that they are the only people making big money round here. We have warned them several times, and now we are planning a big crackdown on it which will involve arresting people - that will probably involve the British military."

In the current climate of violence, it can be hard enough persuading some workers simply to turn up to work. "One doctor I dealt with sent me a text message one night to say he was leaving work, and then twenty five minutes I got a phone call saying he had been shot dead. Other important staff have been threatened, and several surgeons have fled the area because of this. It is a job getting them to just stick it out."

Extortion and intimidation from powerful tribal sheikhs, who command private armies that will kill on their orders, is also a problem. "One doctor recently was asked to treat a sheikh who had bad kidney stones, and he was terrified that if the operation went wrong using invasive surgery then he would be blamed and people would get killed. In the end, we were able to supply an ultrasound device which crushes kidney stones without the need for invasive surgery. Sometimes these kind of political decisions have to be made. It is all about assessing priorities."

There is also a hectic financial and administration programme and recent grants bids include US$96,000 for oxygen, US$196,000 worth of medical equipment for 14 clinics and US$19,500 to take a group of Iraqi doctors for training scholarships in Britain, whose visas he has also had to sort out.

Another major project is putting together the area's first proper blood bank. "If you have an accident here, then hopefully you will be able to rely on your family to provide blood for you. But if you are knocked unconscious in that accident, and there is nobody who knows who your family are, then it is a big problem." Mr Mathieson came to Iraq in July and expects to return to the UK in February, by which time he will be expected to have put a long-term strategy in place that others can take over from. While it has been a long period of absence for his employers, he believes the skills he has learned have vastly increased his working experience.

"The job I do out here is everything from finance and governance through to pharmaceuticals, training, education, restructuring and public health. You are dealing with long-term strategies, management, and budgets of hundreds of thousands of dollars - sometimes stacked right up in front of you. It has been a fascinating time, and very worthwhile."

Andrew Mathieson is a former environmental health officer who worked as a senior lecturer in environmental health at the University of the West of England. He joined the TA in 1991, after deciding against a full-time career in the regular army, and was originally attached to 243 Wessex Field Hospital, based in Bristol. He came to Iraq attached to the medical branch of the divisional staff of the Multi-National Division South East (MND-SE), the multi-country force currently controlling southern Iraq.