Editore"s Note
Tilting at Windmills

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February 18, 2006
By: Jonathan Dworkin

IN THE PEDIATRICS HOSPITAL....Halabja has been at peace since American and Kurdish forces pushed a fundamentalist terrorist group out of the neighboring villages in 2003. People here tell me that some of the fundamentalists were Kurds, a thought that unsettles me, but they hasten to add that some were also Afghans and other foreigners fleeing the defeat of the Taliban. This recent history of the Shahrizur region, of which Halabja is a part, has been particularly contentious, because the Bush Administration claimed without much evidence that the terrorists received support from Baghdad. While they were no doubt convenient for the Baath Party, it's more likely that they received support from Iran, the country to which they eventually fled.

These arguments often create more smoke than fire, but the practical result is that many Kurds are still nervous about terrorism in the Shahrizur. The manager for Halabja Hospital, Dr. Ako, is concerned about being responsible for my secuirity. He mutters something about Guantanamo before stating that he wants me to commute back and forth to the town rather than staying overnight. I am not satisfied with this because I want to be on scene at all times to oversee the research. I begin to tell Dr. Ako that there's no chance he will end up in Guantanamo, but then I think of NSA taps, Abu Ghraib sex pyramids, and torture memos. We live in peculiar times, and I hold my tongue.

The new routine has me driving to Halabja a few times a week to solve problems while a group of deputized Kurdish nurses collect the data. To be honest this suits me well. In Sulaimania there are hot showers and clean drinking water. There is the bazaar with its endless alleys. And most of all there is the dar of the nchoshani minalan, or children's hospital. The dar is is my new home in Kurdistan, a communal living environment for all of the doctors working on the pediatric wards. I live with three men, all in their early 30s and equivalent in training to American residents. Some older doctors also live in the dar, though they tend to be transplants from more dangerous cities in Iraq. Housing is free; it comes with three meals a day and as many medical discussions as you want.

Rounding with the Kurdish doctors is an exotic experience for me. I am not headed towards a career in pediatrics, but it is obvious even to a neophyte that therapy here is a matter of improvisation, not protocol. One night a child comes in with diarrhea, dehydration, and rapid breathing. We give him IV fluids and base to slow his breathing, but three hours later his heart stops and he dies. We suspect he had a larger systemic infection, but without simple lab tests a leukocyte count, serum electrolytes the diagnosis is still unclear. Later I find out that some of these tests are available, but there is no lab technician working in the evening because the government has not approved the idea. This is a typical explanation for inertia in Kurdistan, and it never fails to make my jaw drop.

It is easy to look at the practice of medicine or any other sector in a developing country and point out the shortcomings. In fact this is a favorite pastime of some of the older, well-travelled physicians on the service. I find this has limited usefulness, and I make a point of staying beside the Kurdish residents even when a child dies of something unheard of in the United States. But some things are easier to correct than others, and as with many problems in Kurdistan, I sense that the centralization of authority is a part of the problem. Throughout the society young people are given little opportunity to pursue innovative ideas, and even simple reforms, like night staff, must be funneled through the political parties. Healthcare workers point every problem towards the Ministry of Health, a building occupied by pondorous people who are more slow and politically sensitive than outright corrupt.

A more decentralized system in Kurdistan would empower younger professionals to try new ideas, and it would end the political cover for bureaucrats that oppose them. In short, it would make everyone more accountable. Complex innovations like bone marrow transplant would take time, but simpler things like research, education reform, and diagnostic services would arrive quickly.

The Kurds are ready for this. Each year hundreds of doctors, engineers, and other professionals graduate from the growing universities, and they are more frustrated by the slow progress than any visitor possibly could be. The pediatric hospital in Sulaimania is an excellent place to see the new Kurdistan in all its strengths and flaws. And it's a good place to realize that the political parties, long the champions of the people, are becoming a barrier to their further development.


Jonathan Dworkin, a medical student in his final year at Mount Sinai School of Medicine in New York, is travelling in Iraqi Kurdistan from January to March of 2006. Other posts in this series:

February 18: In The Pediatrics Hospital
February 5: Halabja
January 25: Kurds and Jews
January 18: At Home in the New Kurdistan
January 14: City of Refugees
January 11: First Impressions

Jonathan Dworkin 3:25 PM Permalink | Trackbacks | Comments (18)

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Comments

the centralization of authority is a part of the problem

True just about everywhere, including the private sector.

Posted by: TomB on February 18, 2006 at 3:53 PM | PERMALINK

Breath taking post, Jonathan.

I think alot about how we could make healthcare in America better, but so many US health policy approaches (whether free market or government based) draw on institutions and rules of law that simply don't exist in other countries.

I look at the sickness and disease in foreign lands and want so badly to help, but what can you do today when the real prescription is to achieve another 100years worth of economic and institutional development which would simply bring you up to spead with an America that has so many healthcare problems of its own?

Hopefully good people like you are working on an answer. Let us know as soon as you find it.

Trapier K. Michael
www.Marketplace.MD
www.blog.marketplace.md

Posted by: Trapier K. Michael on February 18, 2006 at 5:16 PM | PERMALINK

Decentralization of the health care systems in poorer countries can make sense, but it depends on what exactly is meant by the term. Decentralization of authority? policy? training? control of budgets? systems of financing?

The term has been tossed around the "developing world" for quite a few years now; WHO and UNICEF have felled plenty of trees turning out documents on decentralization of health care systems, but few people have any real sense of what it means in practice (it seems that way to me, anyway).

The key thing is to retain a strong government role in the health sector. Government doesn't have to be the actual provider of services (as in Iraq and zillions of other countries), but a strong government presence in the health sector, through, e.g., provision of universal insurance, is the only way that poor countries (and rich ones, for that matter) will be able to ensure that everyone has at least basic access to affordable and appropriate primary health care.

The private sector can't and won't ensure universal access. So, one hopes that Jonathan is not using "decentralization" in the context of "privatization."

Posted by: Wonderin on February 18, 2006 at 5:24 PM | PERMALINK

First, we need decentralization in America, and a privatized system (I argue that ours is very "centralized" with govt. being such a major purchaser of medicine, Medicare and Medicaid setting the tone for the "marketplace" with its coverage decisions and provider payment schemes, licensure laws, certificate of need programs, and the FDA regulating who can produce in the marketplace, etc...)

By why shouldn't Jonathan be suggesting healthcare privatization can help heal developing countries' health systems? Many great development economists (such as DeSoto in "Mystery of Capital") believe that a lack of private property rights is the major impediment to economic development around the world.

Trapier K. Michael
www.Marketplace.MD
www.blog.marketplace.md

Posted by: Trapier K. Michael on February 18, 2006 at 5:33 PM | PERMALINK

Why aren't lab techs housed on site as are the doctors? Are nurses? Can no doctors or nurses operate the lab?

Sounds like cross training and de-specialization would be more useful than anything else.

BTW, thanks for writing this series.

---

Posted by: Emma Zahn on February 18, 2006 at 5:55 PM | PERMALINK

There's a bit of a strawman argument going on here.
For years, the tendency to think there was a formula for the best way to do things has pervaded society. There is. Train people and get out of their way.
Sales trainers know that the way to find the best people is to give them freedom to excel. Measure the results and retain producers. Those with the ability to do this are not easily satisfied and chafe against restraints, real or imagined. They provide the impetus for change.
Excess regulation is something that grows over time. I wonder how much of the difficulty with excess restraint is due to less weeding out of heritage regulations by wars and regime change.
Legal systems grow unwieldy with time and need revision. The Queen's Bench grew out of a need for good sense to prevail over legalisms. That was centuties ago. Some problems are chronic and systemic.
Notice this has nothing to do with "right" or "left" but with "liberalism" ( i.e. freedom ) coupled with "conservatism" ( keep the good ) : a balance of action.

Posted by: opit on February 18, 2006 at 6:05 PM | PERMALINK

Just a good reminder that while our current government/private health care system has its problems, turning it over to a centralized authority can also have its problems.

Maybe the answer for the U.S. is moving closer to universal health care. Or the answer might be more market input. Or maybe the answer is something else.

People here rightly point out that centralized authority is not the same thing as centralizing the financial support. Unfortunately, it's hard to get the latter without the former coming into it eventually.

When, or if, we move toward more government control of health care we need to remember that there is a far end to that path that really needs to be avoided. The Kurds are not the only ones in this situation.

Posted by: tbrosz on February 18, 2006 at 6:24 PM | PERMALINK

I look at the sickness and disease in foreign lands and want so badly to help, but what can you do today when the real prescription is to achieve another 100years worth of economic and institutional development which would simply bring you up to spead with an America that has so many healthcare problems of its own?
Posted by: Trapier K. Michael

some simple hygiene measures and water and garbage sanitation would make a big difference. the pediatric killers in the developing world are largely infectious causes for which improved sanitation would greatly reduce mortality.

Posted by: Nads on February 18, 2006 at 9:25 PM | PERMALINK

I actually had someone say this week that only 150 were killed in the Halabja gassing. That's got to be miles beyond wrong, not even getting into the particular gas in question. It's a shame facts don't cross cultures very well. What's the body count by your reckoning and was it the Iranians?

Posted by: Mark A. York on February 18, 2006 at 10:37 PM | PERMALINK

Nads has a good point.

There are certain areas of health care in Third World countries where a surprisingly small investment in materials results in huge benefits. Vaccination is one. Simple oral rehydration fluids with ingredients that cost pennies have saved thousands of children and infants. DDT mosquito nets with most of the benefits of DDT and little of the environmental controversy.

Just shipping tons of food over there doesn't have the impact of giving a farmer a simple manually-operated irrigation pump.

Fortunately, there are many organizations doing these things, but more could be done. Do the simple things first.

Posted by: tbrosz on February 18, 2006 at 10:38 PM | PERMALINK

Welcome to the problem of developing markets and why anyone with half a bit of sense in them has to look forward to removing the dead hand of the State. More harm than good.

I sense that the centralization of authority is a part of the problem. Throughout the society young people are given little opportunity to pursue innovative ideas, and even simple reforms, like night staff, must be funneled through the political parties. Healthcare workers point every problem towards the Ministry of Health, a building occupied by pondorous people who are more slow and politically sensitive than outright corrupt.

A more decentralized system in Kurdistan would empower younger professionals to try new ideas, and it would end the political cover for bureaucrats that oppose them. In short, it would make everyone more accountable.

I emphasized the key observation - what drives frustration, why many young people of all kinds of backgrounds join radical groups, and why I chose to make my career in finance in the MENA region.

There is no shortage of wasted talent due to political corruption and vampiric governmental regulation. (and for the knee jerking Lefties, no, not all governmental regulation is bad nor all the time. But in emerging markets regulation is usually a means of petty extortion)

However, a decentralised system is not going to happen in Kurdistan.

Behind the fine agitprop about Kurdism, about 'self determination' and all those things the ignorant Westerner laps up, the real focus of the Kurdish leadership is carving out their own fiefdoms. Decentralisation threatens fiefdoms. Threatens the patronage networks that lie at the heart of the Barzani clan power, etc.

Forget about the fine discourse constructed for liberal Western consumption, look at real practice and structure.

Drum et al think I am jerk for opposing Kurdish statelets, and what was I accused of, racism last time? Brown not as valuable as white? I'm married into the region, I know better than to lap up the spin the cynical clan leaders give to the innocent foreigner. The Kurdish statelet merely means a fiefdom of a narrow, corrupt leadership and yet more fractured power structures living vampirically off of the productive sectors.

Posted by: collounsbury on February 19, 2006 at 12:36 AM | PERMALINK

And re this:
but what can you do today when the real prescription is to achieve another 100years worth of economic and institutional development which would simply bring you up to spead with an America that has so many healthcare problems of its own?

Invest in basic infrastructure and when working on emerging markets problems stop comparing with an idealised Western market/world - go for the incremental improvements.

A hospital or a factory or generally any activity need not be "best practice" - it need only be better, more efficient and sustainable by local institutions and resources. The phrase, don't let the perfect be the enemy of the good is something I live by.

Stepping back and looking for incremental increases in capacity, step-wise achievements that local staff can sustain gets real value unlocked.

And I would say investing in local capacity - capital to local doctors to take the medical sector to invest in sustainable project, rather than pure aid programs is the best way to go. Perhaps subsidised capital not expecting a pure market return, but capital to the locals. Support the innovators that are not part of the old-boys network, that is useful.

Posted by: collounsbury on February 19, 2006 at 12:43 AM | PERMALINK

Kudos to all involved w/making this available

Outstanding use of the medium !

"The bond of our common humanity is stronger than the divisiveness of our fears and prejudices." - James Carter

Posted by: daCascadian on February 19, 2006 at 1:36 AM | PERMALINK

Wow, this comments thread was actually worth reading.


As for the post; Jonathan is providing some of the most interesting on the ground coverage I've read on Iraq. He should be (almost) as proud of his writing as he is of his current work.

Posted by: preslove on February 19, 2006 at 4:27 AM | PERMALINK

This well written and profound article clearly demonstrates the huge challenges that still lie ahead, not only in Iraq but much of the middle east and the rest of the third world. Bringing the health care situation in Iraq into the 21st century will take years, if not decades and because of that I agree with Nads in that a short term solution will be preventive health care. Prenatal care, vaccinations, sanitized water, better food preparation, cleaner environments, etc. The bodies natural immune system is an amazingly effective disease control system, although it needs to develop; and that begins at birth, with proper care and nurturing.

Posted by: Jay on February 19, 2006 at 9:29 AM | PERMALINK

Jonathan: Would you please comment on the congenital malformation controversy?

Posted by: [[WP:User]] on February 19, 2006 at 1:14 PM | PERMALINK

Well, isn't a centralized system associated with government healthcare?

So how come you criticize it in Iraq but all of you liberals want it in the US?

Liberals, always whining, never effective in government.

Posted by: McA on February 19, 2006 at 10:47 PM | PERMALINK

Well, stupidity.
Well, isn't a centralized system associated with government healthcare?

Indeed, it is. No other way for it to work, but there are all kinds of ways to centralise.

What is realistic in a situation like Iraq, well, that is open to question.

So how come you criticize it in Iraq but all of you liberals want it in the US?

Liberals meaning US Left, they don't deserve this incoherent criticism.

The capacity of a country in the midst of a low-grade civil war, and an administration in a region based on clans with a thin veneer of modern administration, democratic politics stretched over it, well it doesn't reflect on the capacity and utility of a centralised one-payer system in a middle or higher income country.

The criticism is irrational and ignorent. There are criticisms to be made of the US Left's positions in this matter, but the fact that commentators here are not "one size fits all" is a positive.

Liberals, always whining, never effective in government.

Ideologues, always making stupid statements. Right, Left. All the same.

Posted by: collounsbury on February 20, 2006 at 12:39 AM | PERMALINK




 

 

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