The details were horrific. Outside the besieged city of Mosul, 13,000 wounded civilians are today waiting for reconstructive surgery – from just this one seven-month battle. Another 5,000 Iraqi police militiamen are waiting for the same surgery from recent military offensives, in their case to be cared for by the Iraqi ministry of interior. But the health infrastructure that exists in the whole of Iraq cannot look after these wounded. As a result, some are turning up in Damascus – amid the frightfulness of the Syrian war – for the surgery they cannot obtain at home. A new graft in Damascus costs $200.
In the balmy early summer of Beirut this week came these detailed new horrors of Middle East war. For beside the state-of-the-art American University Medical Centre in the city, doctors from across the region, from Iraq, Syria, Yemen and Palestine – along with the International Red Cross and Medecins Sans Frontieres – came to discuss their fears for the wounded and the sick and their conviction that drug-resistant bacteria are growing in hospitals in the Middle East. Just how to deal with this may be within the knowledge of the military medical authorities – but not within the hands of civilian doctors.
Did this start in Bosnia, as one doctor suspects, where civilian and military casualties merged into each other – it was, after all, a war where a civilian turned into a soldier and then re-emerged as a civilian the moment he entered a hospital? Or do the clues lie much further back, in the vicious sanctions which the UN imposed on Saddam’s Iraq, at America’s urging, in the aftermath of the dictator’s invasion of Kuwait in 1990? The first Global Conflict Medicine Congress, arranged by Glasgow-trained Professor Ghassan Abu-Sittah, head of plastic and reconstructive surgery at the medical centre in Beirut, raised these questions in stark and painful ways.
Drug resistance, he said, did not exist in the 1980-88 Iran-Iraq war – when 150 Iraqi soldiers were wounded each day during the Fao peninsula battles alone – so what happened during the post-1990 sanctions period? “Iraqis were allowed to use only three antibiotics for 12 years,” he says. “These were the only ones allowed in by the UN. Heavy metals had been used in the 1991 [liberation of Kuwait] war. You found celinium [present in the smashed concrete of destroyed houses], tungsten and mercury in the casing of penetrating bombs. What are the long-term effects of these metals on the human body?”
A Medecins Sans Frontieres analysis – presented at the conference by Abu-Sitta and Dr Omar Dewachi who co-direct a newly created Conflict Medicine Programme at the AUB supported by Jonathan Whittall of Medecins sans Frontieres – said that multidrug resistant [MDR] bacteria now accounts for most war wound infections across the Middle East, yet most medical facilities in the region do not even have the laboratory capacity to diagnose MDR, leading to significant delays and clinical mismanagement of festering wounds. Beyond the physical damage caused by weaponry, Whittall added, “destroyed or degraded sanitation facilitates the microbiological seeding of wounds. The body, weakened by the wound, is reinjured when it interacts with the harsh, physically degraded environment.”
Iraqi-trained and Harvard-educated Dewachi, the Beirut American University’s assistant professor of medical anthropology, spoke at length of Iraq’s cavalry of war victims and quotes an Iraqi patient waiting for treatment in Beirut. “Most of the good doctors have left the country,” the man told Dewachi, “and those who remain have lost their humanity”. Dewachi’s forthcoming book, Ungovernable Life: Mandatory Medicine and Statecraft in Iraq, which traces Iraq’s medical history from the First World War to 2003, will reveal that successive post-2003 Iraqi governments have been sending civilians, military and security forces personnel, parliamentarians – and even militia and political party members – to hospitals in Beirut.
So dangerous is life for physicians in Iraq itself – where the families of wounded patients often want revenge for perceived poor treatment by doctors – that the Baghdad government recently allowed doctors to carry guns to their hospitals and surgeries. About half the medical force in Iraq has fled over the past 20 Saddam and post-Saddam years and the British National Health Service, where many Iraqis were trained, “hosts one of the largest populations of Iraqi medical doctors outside Iraq”, according to Dewachi. The post-World War One British mandate created UK medical training and standards in Iraq and this cooperation continued long after independence.
The MSF analysis not only raised questions about the long-term effects of the 1990 UN sanctions regime, but also the reversal of medical advances in the treatment of cancer and diabetes. “This is often due to the inability of healthcare systems and technology to provide the same level of care in harsh and complex war environments. Kidney failure patients can no longer access dialysis units and the delivery of chemotherapy to cancer patients is severely compromised…”
Dewachi is fearful of the way in which the nature of illness has changed in Middle East wars, where “the change in the base line of cancers has become very aggressive”. As he puts it, “when a young woman of 30, with no family history of cancer, has two different primary cancers – in the breast and in the oesophagus – you have to ask what is happening. You have to know what is happening.” Dewachi is overwhelmed by the sheer number of wounded patients in the Middle East. “There was a nine-year old girl with shrapnel wounds to the face. She was wounded in Baghdad in a 2007 car bombing. Her mother who was caring for her had a glass eye from a wound. Her father had a prosthetic arm after amputation surgery in the 1980-88 Iran-Iraq war. We found an Iraqi policeman injured in a car bombing who was being looked after by his brother who had lost three fingers in the Iran-Iraq war.”
In Iraq, patients wounded in Saddam’s wars were initially treated as heroes – they had fought for their country against non-Arab Iran. But after the US invasion of 2003, they became an embarrassment. “The value of their wounds’ ‘capital’ changes from hero to zero,” Abu-Sitta says. “And this means that their ability to access medical care also changes. We are now reading the history of the region through the wounds. War’s wounds carry with them the narrative of the wounding which becomes political capital.” Abu Sitta believes that the building – and deconstruction – of medical care goes hand-in-hand with state-building and state-destruction. “Today, it’s about dismembering nations rather than building them.”
For Abu-Sittah, “there is no such thing as wars that end – we call all this in medicine as ‘a chronic condition with acute flare-ups!’” In other words, war wounds continue to cause pain – and kill – long after wars have ended and restarted. “A wounded body ages differently,” he says. In Gaza, for example, a bullet wound effects a patient for decades after the wound is inflicted. “We have found that Israeli snipers fire at the back of the knee of the person they are shooting at – the back of the knee and the lower third of the thigh. This does not necessarily kill – but it almost always requires amputation. This is the junction of the sciatic nerve, the popliteal artery and the knee joint – with one bullet you manage to do all three. That’s why the IRA used to do knee-capping in Northern Ireland.”
An Italian professor of genetics says that tissue samples from the three-week 2008-2009 Israeli-Hamas Gaza war shows remnants of heavy metals in the wounds of Palestinians, both carcinogenic and teratogenic – which, she said, can lead to cancers and deformed children. Other physicians noted that Hezbollah’s medical corps had transformed the treatment of its wounded in the Syrian war. Speakers in Beirut included even those foreign doctors who witnessed the 1982 Sabra and Chatila Palestinian camps massacre at the hands of Israel’s Lebanese Christian militia allies.
All of the horrific developments in the medical history of the Middle East’s wars has prompted both the Beirut American University medical centre and MSF to create a research and training partnership in conflict medicine – Abu-Sitta, Dewachi and Whittall are on its steering committee – which means that no-one expects the five major wars in the region to end soon. All in all, I guess, a sobering reflection on all the wars on ‘terror’ which the West and Russia and its friendly dictators claim to be fighting in the Middle East – where the cancer of national and international power is just as fatal as the cancers which afflict the bodies of the victims.