Under the rule of Saddam Hussein, Iraqi doctors made about $20 per month in the 1990s, says James Haveman, the Coalition Provisional Authority senior adviser to the Iraqi Health Ministry.
Hussein slashed health spending 90% during the decade, Haveman says; in 2002, the oil-rich nation's health budget was $16 million, or about 68 cents per person.
"It's really sad. I sit down with these physicians and have them tell me their skill practice stopped 10 or 15 years ago," Haveman says, noting most had no Internet access and only outdated carbon copies of medical journals.
To help nourish this starved health system, the recently approved $87 billion U.S. package to fund military and reconstruction efforts in Iraq and Afghanistan devotes $793 million to rebuilding healthcare infrastructure that is struggling to meet the needs of more than 25 million people.
Haveman's boss, a physician executive who has ultimate responsibility for assembling the team that will direct those funds, is Assistant Secretary of Defense for Health Affairs William Winkenwerder Jr., M.D. Winkenwerder oversees providing healthcare to U.S. service members deployed worldwide, including 130,000 in Iraq, and administering the 130,000-employee Military Health System that supplies benefits to 8.7 million people.
"It is an incredibly multifaceted, diverse set of responsibilities unlike any other of which I'm aware. I am drawing on all prior experience to do my current job," says Winkenwerder, who came to the Department of Defense in 2001 following 13 years of executive leadership in private-sector healthcare.
Top doc's toolbox
Among the relevant skills Winkenwerder draws on are the abilities to function within a large organization, to make people accountable for results and to set clear objectives, he says.
"We have a good relationship with each of the armed services divisions," Winkenwerder says. "Instead of just one service, we work on it jointly. It is an important goal for the Secretary (of Defense Donald Rumsfeld) and for Chairman (of the Joint Chiefs of Staff Gen. Richard) Myers."
As for the work in Iraq, which he says consumes about 10% of his time, Winkenwerder emphatically insists the rebuilding is going on there, not here.
"The effort is there on the ground and involves Iraqi people and members of the Iraqi medical community who feel liberated from a horrible past," he says. "The medical community there has been terribly isolated for more than 20 years. Yet they themselves have done a lot, with the assistance of the United States and other countries."
The Iraqi Governing Council selected Khudair Abbas, M.D., a surgeon in the United Kingdom, as interim director of the Ministry of Health, which is staffed by 120,000 employees. Iraq's healthcare work force consists of about 22,000 physicians, most of whom are specialists, and 39,000 nurses, although just 600 nurses have the equivalent of four years of college, according to Haveman. About 1,200 primary health clinics and 240 hospitals currently offer services, including 70 private hospitals.
Haveman, former director of the Michigan Department of Community Health and a man Winkenwerder calls a "real American hero," is the key liaison between the Pentagon and Abbas.
Other members of the coalition health team include active-duty and reserve military personnel, civilians from the DoD, HHS, State and other federal departments, and Iraqi expatriate physicians. Ten doctors, three pharmacists and one registered nurse advise the CPA-MOH team, in addition to engineers and medical facility planners.
"We had to be sure (Haveman) had proper support to get this large job done," Winkenwerder says. "I thought Jim would be a good choice because of his experience as the administrator of a large state dealing with public health and healthcare. He had to be adept at dealing with politics and different constituency groups."
Esteemed Iraqi colleagues
There is a deep history of professionalism in Iraq, Haveman says.
"Physicians are held in high esteem," Haveman says. "During the war, pediatricians altered their practice and treated adults, many hospitals stayed open, and doctors stood by the door when people were trying to loot."
An initiative to establish a medical association, with a conference and elections to be held in February, will help provide a more formal and accountable structure for the medical profession, he says. Iraqi physicians also have asked for some type of licensure program to ensure doctors meet standards.
Since the war, doctors have been making $500 to $600 a month, and salaries for all the health professions are improving, Haveman says. A 2004 operating budget of $942 million for the Ministry of Health will pay for salaries, pharmaceuticals, hospital and clinic operations, and public health and forensic centers, he says. The funds come in part from recovered Iraqi money, oil money and the CPA.
Over and above that is the $793 million in supplemental money. About a half-billion dollars will be spent on hospital remodeling and the remaining $300 million on equipment purchases, says Haveman, who estimates more than 50% of the equipment in Iraq's hospitals is either broken, in need of repair or should be replaced. The international donor community, the World Bank and the United Nations have pledged additional support.
Other priorities include addressing problems such as maternal and child health, the shortage of qualified nursing staff, poor administration, a lack of supplies and security. Physicians in two areas of the country have been assassinated, Haveman says, albeit off hospital grounds.
Some 6,000 Iraqis are being trained as part of force protection, and security is improving, he says. Most hospitals will have trained guards within a year.
Winkenwerder says recent media reports that Iraq has a national healthcare system seem to criticize a U.S. system that doesn't do as much for its own.
"I don't think that's quite right," Winkenwerder says. "At best, it was a dramatically broken healthcare system, spending less than one dollar per person per year, the lowest of any country in the Middle East except Yemen. We're working with Dr. Abbas and the Governing Council to rebuild, and obviously we want to rebuild the parts that work and are in place today. Any transition to a new system will take planning and the involvement of many people."
Although 95% of Iraq's health services are provided by the state, there is a role for the private sector that will involve American and Iraqi physicians and their organizations, Winkenwerder says.
"It is, we believe, an important part of the future healthcare system for Iraq," he says.
Haveman says that in the past, under the Oil for Food program that ceased operations on Nov. 21, all equipment and pharmaceuticals came from Jordan, Syria, Turkey, India, Russia, Sudan, Germany and France, and almost none from the United States or the United Kingdom.
"In the future, I've said to pharmaceutical and equipment manufacturers all over world, we are going with a drug formulary that will be bid out on value, quality and price efficacy, and the same for equipment and supplies," Haveman says. "It will open up a worldwide market to Iraq."
An intellectual capital exchange program will help the Iraqi health ministry and the Pentagon coordinate institutions to share concepts of healthcare management and education, Winkenwerder says. His experience meeting Iraqi physicians in July was that "they are desperate for these kinds of relationships," he says.
Another plan is to bridge U.S. and Iraqi physicians for training and skill development. The team also is working with medical associations to gather journals and textbooks and to raise money to ship them to Iraq.
Ali Al-Attar, M.D., a U.S. citizen who was born in Iraq, confirms that the Iraqi health system suffocated under Hussein.
"He concentrated the modern health facilities that he built in Baghdad to serve him first and his immediate circle, and he neglected the rest of Iraq," says Al-Attar, who practices internal medicine in Falls Church, Va., and serves as president of the Washington, D.C., chapter of the National Arab American Medical Association.
While individual physicians and medical organizations are helping, "the burden is going to be mainly on the big health institutions in the United States," he says.
The transition to a private system will take time, Al-Attar says, and may have to go through models more akin to those of Great Britain and Canada first.
But he contends that Iraq has the ingredients to build an advanced health system that could influence the entire region.