Casualties of war: MSF surgeons treat wounded Iraqis

The car bomb sheered off nearly half of eight-year-old Ahmed’s face, stealing his left eye and amputating his left foot. Ahmed was so disfigured by the bombing last October that his father and uncle spent half an hour in the same Baghdad hospital room without recognizing him. The boy, in shock from the blast, was left speechless.

“He was there alone,” says Ahmed’s father through an interpreter. “He had an amputation without company from anyone in his family. No one knew him. He was just a child inside a hospital.” It would be three days before the father and son would be reunited.

After enduring several failed procedures to reconstruct his face, including multiple skin grafts, Ahmed and his father arrived in December 2006 at the Red Crescent Hospital in Amman, Jordan, where Doctors Without Borders/Médecins Sans Frontières (MSF) has run a reconstructive-surgery program for war-wounded Iraqis since August 2006. By April 2007, the young victim had already undergone two extensive microsurgeries and was scheduled for at least three more procedures aimed at reconstructing his nose and lips. Ahmed is just one of 210 patients admitted to the program since its inception.

MSF has begun providing essential medicines and medical supplies to a number of hospitals inside Iraq; yet, the Amman-based surgical program—staffed largely by Iraqi surgeons—is the organization’s most direct attempt at aiding Iraqis since the organization was forced to withdraw its staff from Iraq in November 2004 in the wake of the deteriorating security situation there.


Crippled Health System

The Iraqi health system is among the gravest casualties of Iraq’s violence. Hospitals, especially in Baghdad, do not have enough medicines, surgical supplies, or even electricity. Beyond the material needs, the Iraqi Medical Association estimates that, of the 34,000 Iraqi physicians registered prior to 2003, more than half have fled the country and at least 2,000 have been killed.

“It’s almost impossible right now to get operated on in Iraq,” says Dr. Bassam, an Iraqi orthopedic surgeon working for MSF. “All the more so since many doctors have gone farther north or left the country, looking for someplace safer. As a result, there are fewer and fewer specialists, and—on top of everything—they are being particularly targeted. Many of them were kidnapped after the war began in 2003. They are caught between a rock and a hard place.”

These factors have conspired with crippling effect to devastate Iraq’s health system. This scenario plays out almost daily: After a multiple-casualty attack, medical facilities are overwhelmed with wounded. Patients are often simply patched up, stabilized, and sent home, only later to face medical complications. Some people are afraid to go to hospitals that are operated by certain religious or political parties, or by armed groups.

“We have a very serious problem with the whole emergency medical system, from the time of the injury, to the evacuation, to the emergency rooms, until the final or elective surgeries,” says Dr. R., MSF’s medical coordinator in Amman and one of Iraq’s top orthopedic surgeons. “We see many cases of undiagnosed or mistreated injuries and many examples of complications of surgeries that should have been performed in a different way.”


Getting to Amman

Amman offers a secure environment in which MSF surgeons can work and in which patients, like Ahmed, can recover from surgery. A network of surgeons in Iraq refers patients to the program. Each patient’s medical history is reviewed carefully by the MSF team. Once the patient has been admitted into the program, MSF arranges all of the transportation and paperwork required to transfer him or her to Amman, a difficult and time-consuming process.


High-Tech Procedures for Devastating Injuries

The complexity and severity of the injuries endured by Iraqi war-wounded demand the most sophisticated and innovative surgical techniques practiced today. To repair Ahmed’s face, an MSF surgeon grafted skin and muscle from Ahmed’s back. MSF maxillofacial surgeons use three-dimensional computer models for preoperative planning and preparation.

“For plastics cases, we are dealing with difficult burns, scars, and contractures [lack of mobility],” says Dr. R. “We are not doing aesthetic surgeries; we are dealing mainly with functional surgeries. We have surgeries that last 11 or 12 hours. Some of the patients need six or seven surgeries, and they are admitted from four to six months.”


Drug-Resistant Infections

Nearly half of the patients needing orthopedic procedures arrive in Amman with severe bone and wound infections, which are often resistant to multiple antibiotics. Unhygienic conditions in Iraqi hospitals and significant delays in receiving treatment make patients susceptible to infection.

“We are receiving patients with very difficult infections from Iraq,” says Dr. R. “In Iraq, the mismanagement and misuse of antibiotics all lead to the appearance of resistant bacteria. These bacteria are resistant to almost all antibiotics except one or two. And these are the new generation of antibiotics that are very expensive.”


Just the Beginning

On average, 40 new patients arrive at the Amman program each month, and MSF aims to more than double the capacity of the program. Even then, however, MSF’s workload will represent a fraction of the number of Iraqi civilians in desperate need of proper surgical care. Other MSF teams are still assessing ways to provide direct assistance to Iraqis still caught in the conflict.