he C130 lurched precariously out of the low overcast in a maneuver designed to avoid ground fire and touched down at Baghdad International Airport, all but abandoned save for the incarceration of its former namesake, Saddam Hussein. It was Valentine’s Day 2004, two short months since Saddam had been unearthed from his rat hole and sent to a detention center at the airport and less than one year since U.S. forces landed in Iraq. Our group of 30 U.S. physicians nervously exited the aircraft, donned helmets and flack jackets and boarded a bus for the now infamous and dangerous journey from the airport into central Baghdad. Four soldiers from the 82nd Airborne, including one female, joined us on the bus attired in full “battle rattle” complete with an impressive array of firepower. If the bus was “disabled,” we were told, we were to stay onboard, and they would protect us. Little comfort given the destructive force of improvised explosive devices littering the highway into Baghdad.

Dr. Cromwell just after landing at Baghdad International Airport.

Thus began the Iraq Medical Specialty Forum (IMSF), a cooperative endeavor of 30 U.S. physicians representing nearly all medical specialties and 350 Iraqi physicians in the first international medical conference in Iraq since the fall of the Saddam regime. Conceived by the U.S. military and hosted by then American Ambassador Paul Bremer and the Iraqi Governing Council, the purpose was to re-establish medical specialty societies and resurrect their voice, now muzzled for more than 30 years, as the new government of Iraq evolved.

Although I did not represent ASA in an official capacity, ASA was extremely helpful in supplying education material to distribute to Iraqi anesthesiologists. Originally scheduled in Medical City, a teaching hospital affiliated with the University of Baghdad, the conference was hastily moved into the U.S.-protected “green zone” shortly before our arrival due to security concerns — concerns with an element of prophecy, as a bomb was discovered a few days later in the lecture hall of Medical City. With that move, we lost an additional 350 attendees who feared, with justification, becoming insurgent targets if they were seen associating with Americans. We were housed in the green zone on the banks of the Tigris River in the Republican Palace, a massive ornate structure and the largest of about 23 of Saddam’s palaces scattered throughout the country.

During the ensuing three-day forum, I met with some 15 anesthesiologists, the majority from Baghdad and a few from Kurdistan in the north, who had braved the treacherous drive through the “Sunni Triangle” to attend. Gradually a picture emerged of a once-proud medical system generally regarded as the most advanced in the Middle East. Older Iraqi physicians had been educated in Great Britain, and their medical education system was therefore patterned after the European model. Physicians enjoyed status in society, a comfortable living and a significant voice in the delivery of health care.

With the rise of Saddam Hussein to power some 35 years ago, everything changed in Iraq. Favoritism, greed and corruption became commonplace, and physicians were subject to the same terrors and intimidation inflicted upon other Iraqi citizens at the whim of Saddam Hussein. Some were incarcerated, some executed. The few who could left the country. The entire population was virtually cut off from the outside world. Physicians were rarely allowed to leave the country to attend medical conferences, outside educational materials were not permitted, and access to the Internet was considered a capital offense.
In his last year in power, Saddam allocated a total of $16 million to medical care in Iraq, a 94-percent reduction over a decade earlier and close to the lowest on earth on a per-capita basis. During the same year, the United States, with roughly 10 times the population, spent $1.6 trillion on health care. The results were predictable and devastating, condemning Iraqi medical care to that of a third-world country.
Due to security concerns, we were not allowed the luxury of leisurely tours through Baghdad hospitals, but we did manage a brief visit to one of Baghdad’s two teaching hospitals, Yarmouk, which appears periodically in the U.S. press as the receiving hospital for the majority of insurgent-inflicted trauma. The condition of the hospital was, quite frankly, deplorable. Dark, dirty, poorly equipped and teeming with patients. But the Iraqi physicians and medical students persevered with enthusiasm and optimism.

Anesthesiology
There are no accurate data on the number of anesthesiologists in the country, but as far as I could determine, there are four groups of anesthesia providers. The first and smallest consists of about seven older doctors trained in Great Britain and boarded as fellows of the Royal College of Anaesthetists. They control the anesthesia educational system, are responsible for the majority of lectures to trainees and determine which candidates will pursue a four-year residency program resulting in Iraqi board certification. A second group of between 50 and 70 younger anesthesiologists has thus been certified in a program, including six years of medical school, one year as a house officer (intern), one year of “permanency” (anesthesia) and four additional years of residency. A third and larger group of practitioners, roughly similar to our nurse anesthetists, has completed one year of training in addition to one year of permanency. The final and largest group has received only a single year of anesthesia training. There is general agreement that this category was a matter of expediency to provide sufficient numbers of providers.

The Iraq Society of Anesthesiologists, with Al Alousi Wajeeh, M.D., as president, is barely a society at all. There is no infrastructure, no office, no support, no funds and little interest and support from anesthesiologists who currently live in an environment in which mere survival is paramount. Many anesthesiologists are very frustrated by the system, which they feel holds the specialty of anesthesiology in low regard, a sentiment echoed by a number of surgeons with whom I talked. The younger anesthesiologists feel their training has been substandard and that things are not changing as rapidly as they should. The same criticism is voiced in regard to almost everything else in Iraq at the current time.

While the conditions in Iraq currently leave much to be desired, there is substantial room for hope, and such thoughts were repeatedly voiced throughout the forum. Anesthesiologists and other physicians present will be forever grateful to the United States for ending the previous regime and for sending a delegation of physicians to participate in the forum. They are quite positive in regard to the future. Given the fact that a modern health care delivery system and medical society structure existed before the Saddam regime came to power, I am confident it can once again exist.

To a certain degree, the expectations of the Iraqi physicians are unrealistic. We were told on a number of occasions that we were viewed as their saviors! At this point in time, it is difficult for them to understand why they cannot simply come to the United States for their education and training. Moreover, they seem to feel that the United States will be able to rebuild their antiquated hospitals overnight. In my discussions with them, however, I focused not on the largesse of the United States but on the need for them to develop their own vision, their own infrastructure and their own society such that they have a participatory democratic process that allows them to speak with one voice. I emphasized the importance of their voice being heard as the structure of their new health care system, indeed their new government, emerges. As the concept of democracy is new to most Iraqi citizens, progress will not be realized overnight, but it will come. I assured them that anesthesiologists in the United States will assist them in this process to the extent possible. To that end, ASA has graciously invited Dr. Wajeeh to the ASA Annual Meeting in New Orleans, Louisiana, in October. If he is successful in obtaining a visa, no easy task for an Iraqi at this time, he will be there and hopes to meet many of you.

Following the conclusion of the first IMSF 18 months ago, insurgent activity increased dramatically in Iraq as graphically chronicled on the front pages of virtually every western newspaper. As a result, a return visit has been impossible, and in lieu of that, the 30 American physicians met in Washington a few months ago. Included in the meeting were Senator Bill Frist, M.D. (R-TN); Surgeon General Richard H. Carmona, M.D.; John Howe, Director of Project Hope; representatives from the American Medical Association, the World Medical Association, the British Medical Association; and several members of the Department of State, all of whom are quite supportive of the effort. Private funding has recently become available to develop a medical teaching center in Kurdistan, well away from the continued chaos of Baghdad and its environs, and a second IMSF is now anticipated for later this fall.

If there are any adventurous anesthesiologists who would like to participate in such a teaching endeavor a year or two in the future, please feel free to contact me at <thc59@pacbell.net>.

Thomas H. Cromwell, M.D., is an anesthesiologist at California Pacific Medical Center, San Francisco, California.