Three weeks without a major bombing constitutes relative calm in Iraq these days – a stretch that was broken February 19th when a suicide bomber killed as many as 20 and injured many more, and again February 23rd, with a string of car bombings claiming at least 50 lives. Iraq is still very much at war, entering a new, violent pattern in December. Some 500 more Iraqis were killed in January, according to UN statistics, in attacks timed to coincide with the exit of US forces, and marking the beginning of the real battle for Iraq’s future.
As heavy a burden as the deaths place on Iraqis’ daily lives, the large numbers of chronically injured are often overlooked, even as their suffering and disability constitutes an enduring strain on families in their efforts to get by.
Since 2006, when another major spike in violence gripped the country, Médecins Sans Frontières (MSF; Doctors Without Borders) has focused its efforts on the chronically wounded. The result, six years running, is a state-of-the-art reconstructive surgical facility based across the boarder in Amman, Jordan, that has treated more than 1,700 of Iraq’s most critically wounded. Originally intended to be a temporary project, the surgery center has taken on a more permanent feel. This stands as a testament to the Iraq conflict’s endurance, but on a more positive note, the surgery is emerging as a center of excellence in the region in terms of medical – and social – innovation as patients are transported from Iraq for treatment and prolonged recovery. Now, with the spread of violence regionally in the wake of the “Arab Spring,” the program is growing, expanding from 150 staff members to some 250 in 2012, with new patients being admitted on an expedited basis from several countries embroiled in violence and revolt.
“This is not the classic MSF program with the good, white doctors parachuting into a conflict zone,” says Antoine Foucher, head of MSF's mission to Jordan and Iraq. “Most of the senior staff here are Iraqi and Jordanian. We have all these nationalities coming in, staying in one hotel. Something strong is being built in this program – beyond the technology, beyond the humanitarian elements. There has been hostility, but also secret love stories. It’s an adventure. Every day, we are, like, ‘Wow, where are we?’”
Warscapes editor Michael Bronner spoke via video Skype with one of the program's Iraqi surgeons, deputy medical coordinator Dr. Assamarraie, who left his home and practice in Fallujah “for two months, three months, four months max” in 2006, but has been at the heart of the program in Amman ever since. He and Foucher were in Amman, Bronner in New York City. (Dr. Assamarraie asked that Warscapes refer to him with only one name out of security concerns for family still in Iraq.)
Michael Bronner: Thank you for doing this. I understand the surgery is particularly busy these days.
Dr. Assamarraie: Yes, it is. We are running work at full capacity, and a little bit extra even. We are renting extra beds now.
Bronner: Is this a reflection of a new phase in the war?
Dr. Assamarraie: The most important fact is that the level of violence in Iraq is increasing. In 2011, with the Arab Spring and the increase in need, we started to think of expanding the project, and we are now also receiving some patients from Syria, Yemen, Libya, Egypt and Gaza, so all this puts some burden on our shoulders.
Bronner: You saw this program grow from its inception…
Dr. Assamarraie: Yes, I was here from the very beginning.
Bronner: It’s unusual for MSF to have a project focused on a particular war, but existing outside the affected country’s boarders. What were some of the key objectives and criteria laid out in the discussions that went into the creation this project?
Dr. Assamarraie: The discussion started around the idea that the violence in Iraq at that time was extremely high, and at the same time a lot of people – while they were treated properly in terms of their acute emergency conditions – had real difficulty obtaining treatment for reconstruction after the initial emergency treatment. This represented a real burden on the health facilities in Iraq. For example, if you have a gush of [acutely wounded] patients, it’s not viable to spend ten hours doing reconstruction for one foot, or one hand, or one face, or whatever it is. But there is a significant need for reconstruction. The idea was to create a project not to replace the Iraqi health system but, as a principle, to support the Iraqi health system.
Bronner: So, describe the range of procedures you and your colleagues perform.
Dr. Assamarraie: We are doing reconstructive surgery in orthopedic, plastic, and maxillofacial [jaw and face]. Our target is functional recovery, not aesthetic. In the spectrum of orthopedic surgery for example, we are dealing with all cases of nonunions [broken bones that will not heal], osteomyelitis [acute and chronic bone infections], other difficult infections, cases of combined bone and soft tissue loss and difficult hand surgeries. For plastic surgeries, we are doing all types of flaps for soft tissue defects, including the most complicated type of flaps, which are free vascularized flaps. We are doing complex brachial plexus injuries [affecting the network of nerves that originate near the neck and shoulder]. We are treating all types of nerve injuries, tendon transfers, tendon grafts, nerve grafts, as well as difficult hand surgeries. And in the maxillofacial, again, it’s nonunions, infection and bone defects. We complete everything for maxillofacial, starting from bone grafts and ending with dental implants and providing prostheses to achieve full function of the mouth, as best we can.
Bronner: How many days a week are operations going?
Dr. Assamarraie: Five days a week. Orthopedic is three days a week.
Bronner: I imagine that the need in Iraq is probably far greater than the number of patients that come to the clinic. How are they selected?
Dr. Assamarraie: We have a network of doctors inside Iraq, as well as some contacts in the Ministry of Health and the hospitals to recommend cases. Whether a patient is accepted depends completely on medical criteria. The files we review don’t mention anything but the date of the injury and medical details about the injury. Can we say that we are reaching all the patients in need in Iraq? No, definitely we cannot say that, but again, we are trying our best.
Bronner: I understand that video is an important part of assessing potential patients’ injuries?
Dr. Assamarraie: Yes, specifically for nerve injuries and tendon injuries, because these are difficult to assess just from written files. You have to see the patient walk. You have to see him moving the foot, moving the hand. So, specifically for hand and foot and joints, video clips are essential.
Bronner: Were there any more key parameters for the project that were important, particularly from your perspective as an Iraqi physician?
Dr. Assamarraie: The most important requirement was for the project to be neutral, and to show at every opportunity that we are neutral, because at that time it was a period of big, big sectorial violence. We insisted on having all varieties of Iraqis as patients, and when a particular patient was approved for treatment, we as doctors weren’t told where the patient was from or from which sectarian group. What was important for us is only that he’s an injured Iraqi patient. Fortunately, from the early beginning, if you see our data, it’s clear that all of Iraq has been represented in this project. It was actually quite amazing in these early days, when there was terrible sectarian fighting: Here in our project, the patient from Ramadi was sitting with the person from Mosul and the person from Karbala and Najaf, everyone eating together, joking together. And that was surprising to all the ex-pats here. They were asking me, “What’s the story?” I told them, “This is the story of Iraq.” The violence was imported with the occupation. It’s not really an Iraqi thing.
Bronner: Tell me a little bit about your background, and how you came to be part of this. You did your training in Iraq?
Dr. Assamarraie: Yes, all my training was in Iraq – my initial studies at the college of medicine, as well as my internship and specialization. I completed my Iraqi Board Certificate in Orthopedic Surgery in 2001, two years before the occupation.
Bronner: So, what was the state, or condition, of the Iraqi health system before the invasion?
Dr. Assamarraie: I remember when I was at the college of medicine at the end of the 80’s, the system was much better. The embargo [following the 1991 Gulf War] affected the health system a lot. When I was in my residency, it was very difficult for us to treat patients properly because you had to split, for example, one vial of a particular medicine between three kids, even though the proper dosage would have been one vial for each kid. The embargo had a very bad effect on the health system, but there was still a system. There were a lot of professionals – a lot of skilled people at all levels.
After occupation in 2003, even immediately after the occupation, the system was still surviving, but after the security situation deteriorated, and after the first sectarian attacks occurred and the violence increased, a lot of professional doctors had to leave Iraq. At the same time, the system started to break down in all aspects.
There has been a big effort more recently, beginning in 2009 – I know because I have still have a lot of contacts and friends in Iraq – to reclaim and rebuild the health system, and these efforts continue. They are succeeding, but very slowly.
Bronner: Why did the system deteriorate so badly after the invasion and over the course of the occupation.
Dr. Assamarraie: Well, first of all, there was mismanagement from the beginning. This was coupled with the introduction of the wider violence, in which doctors were targeted specifically. A lot of my colleagues were killed – from all sectors of Iraq and in all cities. These were targeted attacks against doctors, especially specialized doctors.
Bronner: Why target doctors, let alone specialized doctors?
Dr. Assamarraie: Whoever was responsible clearly didn’t want Iraq to move forward or to retain any of its skilled people. All the surgeons were at risk. All the highly trained and highly experienced physicians – even junior doctors – were attacked. Many of them were killed. The number was very, very high. I think it is a fair estimate to say that a thousand Iraqi scientists were attacked and killed. We think it was coordinated by outside forces. I don’t believe there is an Iraqi who would want to kill a doctor or a specialist, because the next day he will need him to treat his child, his wife, his mother.
Bronner: When did you decide to leave Iraq?
Dr. Assamarraie: Well, it’s difficult a question. There were cumulative factors. First of all, I felt insecure. Second, my round-trip commute every day was very, very risky because I had to pass through difficult, contested areas. At the same time, some members of my family, close relatives, were killed for sectarian reasons. The most important factor was that I reached a point where I could not offer proper treatment for my patients. That’s when I got the offer from MSF to treat Iraqis in Jordan, and that’s ultimately why I decided to leave. Maybe if I didn’t get this offer from MSF, I wouldn’t have left. I would have tolerated all these stresses.
Bronner: What month was it? Do you remember?
Dr. Assamarraie: Exactly, it was the 22nd of May.
Dr. Assamarraie: If you want it exactly. At that time I came by airplane.
Bronner: Were you considering leaving before that?
Dr. Assamarraie: The idea was there always, in the back of my mind, but I’m not the kind of person who’s generally prone to taking risks. I’m sure that without this offer from MSF, I would not have done it.
Bronner: Did you imagine you’d be gone for so long?
Dr. Assamarraie: No. I thought I was leaving for just two months, three months, four months max. My family was not with me in the beginning. I didn’t prepare myself for a long stay. But that’s it. We started, and the violence in Iraq increased and increased and increased, and we continued the project and I stayed. We [Iraqi doctors] believe we are doing something worthwhile for Iraq even though we are working in Jordan.
Bronner: And how has the project grown, from the first day you arrived to its present state?
Dr. Assamarraie: Definitely, this is a highly technical project. The surgeries are constantly demanding, and there are a lot of evolving challenges. Fortunately, the Jordanian people and the government are welcoming to Iraqis, and we haven’t felt as if we are foreigners, but rather as if we are working in our own country, feeling secure, treating Iraqis in a good hospital with good standards of care. We’ve definitely had our success, and we’ve had our failures, as any surgeon has, but still we do believe that we are doing something good for ourselves and more importantly, for our patients.
Bronner: When there is an attack that happens – for example, on December 22nd there was a huge attack immediately after the U.S. pulled out, with 63 killed and almost 200 injured – can you describe the sort of course that patients from an attack like that might travel before getting to you? Where specifically would they run up against limitations in the Iraqi system, and how long would it be before they end up in Amman?
Dr. Assamarraie: Up to this point, we have not been dealing with acute cases – patients in the immediate aftermath of an attack. So in terms of your example, we will not receive those patients at the time of the injury. They will receive acute care inside Iraq in emergency conditions. We are trying to make some modifications to the project so that we can receive more fresh cases here, but the center is mainly designed to deal with semi-fresh and chronic cases – patients who are suffering a lot and are finding it difficult to get complete treatment in Iraq. So for this bombing incident, for example, I don’t expect that we will receive patients for at least twenty days, and maybe as long as two or three months. Then we will start to receive some of the most complicated cases – those who, let’s say, survived the major incident and are suffering from nonunion or major infection, or other serious orthopedic problems.
Foucher: We are perceived as a reconstructive surgery program, but 20 percent of the cost of treating each patient is dedicated to the fight against infection. The determinant of infection is the condition of the first operation in the first instance of care – that’s the first thing. People are not necessarily cured from their initial infections. The second is that there is a lot of [drug-] resistance creation. We have a lot a lot a lot a lot of people who have multi-resistance infection. We are gradually becoming a center of excellence for that. There are some patients who are referred to us only for that.
Bronner: So you said that the emergency care is very good in Iraq. Where does it fall off? Is it in the recovery stage? Where are the gaps now in the system?
Dr. Assamarraie: As a surgeon, I do believe that emergency care is relatively good in Iraq. People are surviving, but then reconstruction is a problem. It’s not because of the lack of technical ability, because there are still a lot of technical people there, but I think the number of patients and the availability of the facilities is simply not comparable to the need. By treating some of the more complex, difficult cases, we are supporting the health system. I believe those cases may someday be treated properly in Iraq, but it will take time.
Foucher: The ability of emergency rooms to cope with such levels of mass casualties is deteriorating over time, even though it’s still functional. Mass casualties is a matter of organization, not just a matter of skilled people…We think that we can make a difference in terms of future mobility of patients by taking in more fresh cases of nerve injuries, for example...We are in the process of negotiating a fast-track [with the Iraqi government] in order to take in more fresh cases. As mentioned by Dr. Assamarraie, there is a health system in place in Iraq at the moment. It’s clear the doctors are good, and there is money available, but definitely the management and the institutional disarray constitute a real obstacle to proper health care. It’s a very strange situation. There is money. There are qualified people. There is a huge amount of money, actually, but you don’t know where it’s going. Nothing is working. A lot of qualified people are going abroad, whether internally in Kurdistan [where it is relatively safer] or actually abroad because of the security situation.
Dr. Assamarraie: Really, Iraqis are struggling for services much more than for political issues. They are more concerned about the availability of electricity, availability of fuel, availability of security, rather than stories of who’s doing what in politics. And services are deteriorating. The government says so itself.
Bronner: When the people come to Amman for treatment, what are they told about the program? How are they prepared for this kind of a transition, from what really remains something of a war zone. You mentioned that MSF doesn’t discriminate between one sect and another…
Dr. Assamarraie: If you go to my neighborhood in Iraq right now, it is a mixed neighborhood. I am Sunni, my neighbor is Shi’a – who cares? And the patients here are also living together. Definitely, there have been extremists. In the early days of a patient’s entry into the project, we have a complete session run by a psychosocial team to brief them about the MSF rules regarding the project. The first rule is that there be no sectarian discussion at all. This is a red line for us and we will not accept it. That is the message. As I told you, there were some extremists, but those patients have been managed and those behaviors stopped.
Bronner: You’re getting patients that have severe physical injuries, but I imagine also fairly severe psychological trauma in some cases.
Dr. Assamarraie: Post-traumatic stress is one of the major complications. All of our psych experts are ex-pats – we have Austrian, German, Australian, and many others. They have reported a wide spectrum of anxieties and related conditions, but real [chronic] psychiatric and psychological problems have not proven significant. Iraqis, it seems, are used to a lot of these situations. A lot of them find support in their religion. We have encountered depression with tendencies toward suicide in only a couple of cases. The majority of the psychosocial activity is social activity to help them through long stays away from home, staying in the hotel and receiving treatment here.
Bronner: Treatment in the program really does mean a long exile in many cases, doesn’t it? What is the average stay?
Dr. Assamarraie: The average stay is three months, but we have patients who stay nine months, one year, 18 months…
Bronner: What is the ratio of male patients to female?
Dr. Assamarraie: It is 85- to 90 percent adult male. The remaining ten percent are children and women. Usually the latter are protected in their homes. The males are more active – they are in the markets and streets, trying to work and conduct business – so the rates of injuries are much higher in men.
Bronner: Do patients come with their families, or do they come alone?
Dr. Assamarraie: A male patient who can manage himself will come alone, while female patients and kids have to come with caretakers. Male patients who are unable to manage alone must also come with a caretaker.
Bronner: Given the violence in Iraq and some of the psychological trauma, is it difficult to prepare a patient to return to Iraq?
Dr. Assamarraie: The majority has gone back smoothly. A lot of them ask repeatedly to go back; their families and their commitments are there. In other cases, patients have gone to the UNHCR [United Nations Human Rights Commission] and asked for asylum, and they have been transferred to other countries.
Bronner: How do you see the future of the country through the lens of your work?
Dr. Assamarraie: The future is a struggle. I believe Iraq needs, and is going to need, a lot of effort. Personally, I believe the occupation itself was the most significant factor in destroying Iraq – occupation by itself. We hope for the best in future in Iraq, Insha’allah. If the politicians can communicate with one another, I think Iraq can witness a leap in development, but if the current political struggle continues, we’ll continue to have real problems.
Bronner: What have been the most frustrating moments for you?
Dr. Assamarraie: The most frustrating is to see how severely injured the people are. We’ve had a lot of emotional moments. Just to see a child… I remember one girl, she was the same age as my daughter, and she came here from Iraq completely blind, her face completely amok from scars and incisions. She was in a very difficult situation – she was struggling with very serious infection in her scalp and her head. For me, it was really emotional. It was depressing – to see such injuries in a child who’s just one year old. What’s her crime? We see such severe injuries just because of fights between politicians – nothing more than that. Who cares about these things? I lived in Iraq until I was 36 and no one cared who was Kurdish and who was Shi’a and who was Sunni. We were all living together, then all of a sudden we find people killed in the streets or seriously injured for nothing.
Bronner: Have the injuries gotten worse, or have they been consistent over the course of the conflict?
Dr. Assamarraie: The patterns are different. When the violence is high, we see more cases of nerve and tendon injuries. When the violence decreases – for example, in the period of 2008 and 2009 – most of the cases are difficult, complex cases in which there is infection and chronic, neglected injuries. So, technically, 2006 and 2007 was a period of maximum violence. In 2008 and 2009, it was more of a transitional period. 2010 was a year of chronic cases and difficult cases. And 2011 to the present we have returned to a pattern of violence that resembles that of the end of 2007. Now that violence is again on the rise, we are seeing a fresh instance of nerve and tendon injuries. It all depends on the level of violence.
Bronner: How was the decision made to expand to include other countries?
Dr. Assamarraie: Well, really, we are responding to the need. We found that there is a currently great need in these countries.
Foucher: It’s very different from one country to another. In Iraq, you have a system, but it’s degrading. If you take Yemen, there is hardly any credible capacity. In Syria, of course, we have a big increase in need and incoming patients, simply because of the situation. It’s not a matter of Syria’s capacity – it’s a matter of whether you’re going to be shot in the hospital.
Bronner: What are some of the moments that you’ve found to be the most uplifting – moments when you’ve felt this project is really working as it should?
Dr. Assamarraie: Well, there are a lot of moments like this! We’ve had a lot of visits from experts from all over the world. For example, there was one from the Orthopedic Trauma Association in the US. They were very enthusiastic about the project, and they documented that in their journal. These moments are high points professionally. But the most important thing is when you see a child or an adult patient who came on a crutch or in a wheel chair return to Iraq moving and walking, and blessing you and blessing the project – this is the most beautiful thing for any doctor.
Bronner: Do you foresee a day when you can create a center of expertise like the one you’ve helped build in Jordan back in Iraq?
Dr. Assamarraie: We hope to do that as soon as possible, whenever it is feasible, Insha’allah. This has been our objective from the beginning.
Bronner: And you will personally return and work again as a surgeon in Iraq?
Dr. Assamarraie: My house in Iraq has been empty for six years now. It is waiting for me. I’ve never given a thought to leaving Iraq permanently. The point is to treat patients properly – that is the objective of any doctor. We are doing it properly here for now, and I will continue.