One year after the World Health Organization (WHO) declared COVID-19 a pandemic, Iraq’s health sector remains unable to adequately respond to the crisis. Iraq has struggled to deal with the COVID-19 emergency since the first case appeared in the country in late February 2020. Weakened by more than three decades of conflict, international sanctions, corruption, and social and economic neglect, the country and its health system were ill-equipped to respond to a pandemic.
As of late March 2021, following another major surge in infections, more than 844,000 Iraqis have contracted the novel coronavirus, and more than 14,200 have died. The number of cases is about 22 per 1,000 people, a rate that places Iraq among the hardest-hit countries in the Middle East. The official figures, which are based on limited testing and poor data systems, are almost certainly lower than the actual number of cases and deaths.
A crisis waiting to unfold
In many respects, Iraq was a public health crisis waiting to unfold. Decades of conflicts, coupled with international sanctions and lack of attention to the health sector, have severely damaged Iraq’s health care system, shaping an environment that led many qualified doctors and other medical professionals to leave the country.
Iraq spends less than many of its neighbors on health. The country’s annual budget in 2019 was 133 trillion Iraqi dinar (ID); of that, only six trillion ID (4.5 percent of the annual budget) were spent on health and the environment. The World Health Organization notes that Iraq spent only $154 per person for health services in 2015, compared to neighboring Iran’s $366 and Jordan’s $257.
Iraq’s weak, under-resourced public health system has had a deep and widespread negative impact on public health. Non-communicable diseases, such as cancer, heart disease, diabetes, and chronic lung diseases, account for 55 percent of deaths in Iraq. More than 30 percent of the population suffers from hypertension, 14 percent from diabetes, and more than 30 percent is obese. In the last three decades, the Iraqi population has increased significantly, to more than 39 million in 2019 from 7.28 million in 1960. However, the health system has not kept pace. According to the World Bank, for every 1,000 Iraqis, there are 1.3 hospital beds, a drop from 1.9 in 1980, and 0.8 physicians, a significant drop from 1.0 in 2014. This is far fewer than other countries in the Middle East.
According to Dr. Abdulameer al-Shammary, the former head of the Iraqi Medical Association, which regulates, oversees, and advocates for the rights of doctors, these challenges are multifold. He notes, “The public health sector is suffering. The numbers of health professionals and centers are very low and do not match the increase in population. There is a lack of medical supplies and mismanagement of human resources. The waiting list in public hospitals is very long. Patients prefer to go to the private sector. There are no guidelines for treatment or proper sanitation or disposal of waste.” 
The long-term neglect of the health sector has also had a demonstrably negative impact on the country’s health infrastructure. Health centers suffer from chronic shortages of medical supplies and resources. For Iraqis, accessing public medical care is inexpensive. However, the quality of care is so substandard that many resort to private medical care if they have the financial means to do so. Because there is no private health insurance, the average Iraqi covers about 70 percent of their out-of-pocket health expenditures, making quality health care an expensive proposition for most people. Many Iraqis seek medical care in other countries, such as India, Iran, Jordan, Lebanon, and Turkey.
Thwarted efforts to control the pandemic
The Iraqi government has taken measures, including imposing curfews, shutting schools and other public buildings, and closing the borders, to respond to the COVID-19 pandemic. In some cases, this response has been inadequate and inefficient. In March 2020, the Iraqi government initiated a COVID-19 “Crisis Cell” task force to develop and implement preparedness measures that included universal curfews, the closure of schools and universities, the suspension of international air travel, and financial and security support for the Ministry of Health’s purchase of critical medical supplies. Despite these efforts, the number of COVID-19 cases rose exponentially around the country within months. That same month, the WHO warned about significant personal protective equipment (PPE) shortages in Iraq and indicated that this gap would further endanger frontline workers and become a key factor in driving the spread of COVID-19 in the country. Despite the rapid response by donors and UN agencies in contributing PPE and establishing new labs for COVID-19 testing, the virus’s spread continued unabated in Iraq. In addition, in the year since the pandemic began, the majority of the population has not followed COVID-19 guidance to wear masks in public and to maintain social distancing.
At the beginning of the pandemic, the Iraqi government’s efforts to isolate people who had been infected were seen as heavy-handed and helped to stigmatize those with the virus. The government initially sent security forces with medical professionals to apprehend infected people and hospitalize them – efforts that appeared to criminalize the infected. If people tested positive, they would be quarantined in medical facilities that, in many cases, lacked essential medical supplies. During these early days of the pandemic, men and women were quarantined together as they awaited the results of the COVID-19 test, a process that exacerbated the sense of stigma and shame that led many patients to avert quarantine and deny having the disease, hiding their symptoms to avoid apprehension. This response was particularly notable among Iraqi women, as many conservative families object to wives and daughters being taken out of the home.
The Iraqi government’s efforts to enforce its social distancing protocols also proved challenging. While it ordered curfews to maintain social distancing, the measure has not been easy to apply, particularly among those who have been most impacted by the financial and economic consequences of the curfews.
During the curfew and lockdown, unemployment within the non-government sector was much higher than in other sectors. Although the government kept paying the salaries of its employees, it did not offer any financial aid to the private sector. According to an internal medicine doctor practicing in Iraq, “people do not adhere to the lock-down due to economic challenges. Patients with COVID do not stick with the 14-day quarantine. This makes it difficult to control the infection.”
In very densely populated and low-income areas, the government attempted to prevent the movement and gathering of people who needed to work in order to feed their families. In Sadr City, a low-income neighborhood of Baghdad, authorities temporarily erected concrete blast walls at the main entrance in an attempt to control the movement of the nearly two million residents. These kinds of efforts to control the pandemic were largely ineffective and soon abandoned.
Religious leaders asked their followers to adhere to governmental directives related to social distancing; however, there were notable violations of this guidance during key religious events. For example, in March 2020, thousands of Shi’a pilgrims assembled at the shrine for Imam al-Kadhim in Baghdad without following basic public health guidelines. At the same time, some clerics claimed that collective worship has the ultimate power to protect and heal – a proclamation that encouraged some group gatherings amid a life-threatening pandemic.
A health sector staggers under COVID-19
Iraq’s health care system as a whole has struggled to respond to the pandemic. The system, already weakened by years of inadequate funding and corruption, became even more brittle when faced with the substantial medical supply shortages, lack of sufficient numbers of health workers, and surge in the number of patients brought on by COVID-19. A recent Iraqi Human Rights Commission report expressed its grave concern about the deteriorating health situation across the country due to a lack of infrastructure able to absorb the high volume of daily COVID-19 cases. The Commission also pointed to the government’s lack of adequate support to hospitals, which resulted in a severe shortage of oxygen, PCR COVID-19 tests, and preventive medications.
Similarly, Iraqi health care workers were overwhelmed by COVID-19. Dr. Nabeel Ibrahim, an internal medicine doctor in Baghdad, said that, during the height of the surge, he often had to examine more than 100 patients a day. He noted, “This makes the doctors so exhausted, and the patient frustrated because it is impossible to give enough time to each patient.”
Disturbing videos emerged on social media platforms showing the dismal treatment of patients in hospitals. One showed a COVID-19 patient displaying signs of distress while onlookers frantically knock on the ward’s door asking for medical help. Other videos show hospital bathrooms with no running water, or overworked staff unable to provide care for patients due to the lack of PPE, oxygen, and other medical equipment. Baghdad resident Abbas al-Fartosi, who stayed with his uncle – a patient with Covid-19 – in al-Kindi public hospital in Baghdad, told PHR:
“The service and the treatment were very bad. There was no central oxygen in the section when my uncle stayed. I had to change the oxygen tank for him every two hours, when the nurses failed to do it. The doctors checked on my uncle once a day for less than five minutes. No one remembered to replace my uncle’s IV fluids; I had to beg the nurses to do so. Later, I managed to move my uncle to the section (of the hospital) run by MSF. I had waited for a vacant bed in the MSF section when a patient died. Once there, I saw a significant difference. The nurses checked on my uncle every two hours.”
After 40 days of hospitalization, Abbas’ uncle died.
Public frustration fuels attacks against health professionals
The Iraqi government, many members of the public, and religious leaders have embraced health workers’ role in caring for COVID-19 patients, calling them the “White Army.” However, this is not how they are perceived by many patients and families receiving care for COVID-19 in the Iraqi health system.
Understaffed hospitals and overworked doctors have struggled to manage the high numbers of patients, leading to inadequate medical care. This, in turn, has increased patients’ and families’ frustration with the medical system. Some medical professionals have been attacked by patients’ families, who are angry with what they see as unsatisfactory care. For example, of the five COVID-19-related attacks mapped on Insecurity Insight – a data collection and analysis group that tracks incidents of violence and threats against health care around the world – two were a direct result of families objecting to hospitals or buildings being used to treat COVID-19 patients, and another two were a result of objections to medical health measures.
Even before the pandemic, doctors and nurses were fearful of being harmed while doing their jobs. “Some doctors avoid undertaking higher-risk treatments on patients, fearing potential negative reactions by the patient’s families if their loved ones don’t survive the care,” said Dr. Ibrahim, the internal medicine doctor. “This impacts the quality of medical care and what’s best for the patient.”
Since the spread of COVID-19 in Iraq, physical and verbal assaults on health care workers have escalated, and incidents of beating have been heavily reported on social media platforms. Tariq al-Shaibani, director of al-Amal Hospital in the city of Najaf, southern Iraq, was reportedly beaten until he lost consciousness by 10 relatives of a patient who died as a result of COVID-19.
The lack of the security and stability in Iraq has likely made medical professionals more vulnerable to these kinds of attacks. Dr. al-Shammary said that many doctors relied on “tribal customs” and not the local police to seek protection.
Furthermore, in some social media and TV shows, doctors have been accused of greed, with allegations that they are prioritizing their financial interests over their patients’ health. This narrative has put doctors at further risk of violence, which, in turn, has led to requests to reinforce existing legal measures to protect health care workers. In September, dozens of Iraqi doctors participated in a protest in Baghdad to demand better protections for medical professionals. Much of this has focused on the enforcement of the “Iraq Physicians Protection Law” that was enacted in 2013, and on Article I within the law, which states that “Doctors are protected from assaults, tribal demands, and extortion from the results of their medical work.”
In Iraq, this vicious cycle – which starts with weak infrastructure and inadequate resources and is exacerbated by too much demand on overburdened health professionals, which in turn fuels distrust and hostility towards the medical establishment – can only result in a health care system unable to face the relentless challenges of a global pandemic.
Despite the daunting challenges to Iraq’s health care system, the country can improve its ability to provide adequate medical care in response to COVID-19. These opportunities exist in four key areas: increased investment in the Iraq’s health sector; strengthened legal protections; better medical professional training and support; and better public health communication strategies to combat misinformation and decrease the public’s alienation from the health system.
The Iraqi government should increase its investment in the health sector through appropriation of domestic funding and by soliciting international aid, as follows:
- Support hospitals through the modernization of key medical equipment to better support patient demand and increase capacity in the context of COVID-19 and other public health needs and emergencies;
- Increase staffing of medical professionals in public facilities to meet the needs of Iraq’s population; where there are insufficient medical professionals to meet staffing demands, the government should make immediate investments in additional medical training and education, while meeting the urgent, temporary need through partnerships with other countries, international governmental organizations, and international aid nongovernmental organizations;
- Review and evaluate existing public health awareness campaigns and address the gaps that are hindering these campaigns from effectively helping to change behaviors to better combat the spread of the COVID-19 virus;
- Conduct an assessment to determine where gaps exist in the supply of quality PPE, and provide hospitals and health care centers across the country with sufficient PPE; and
- Ensure equitable compensation of health care professionals working in public hospitals.
In addition, Iraq should take steps to improve accountability mechanisms for both medical professionals and patients, as follows:
- Fully implement and enforce the “Iraq Physicians Protection Law;” and
- Ensure transparency, accountability, and compensation for patients and their families if they receive inadequate or improper care that results in serious injury or death.
The government of Iraq should improve professional training and support for health care workers, as follows:
- Establish a requirement for comprehensive medical ethics trainings for all health care workers and professions and provide sufficient resources to implement such trainings through professional associations; and
- Prioritize training and resources for health care management and systems design to allow health care workers to better manage increased workloads.
This paper benefitted from assistance from Mona Rezvani, Arabic-speaking research and investigations intern.
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 Phone interview with internal medicine doctor, December 17, 2020.
 Interview with al-Sadr City resident, January 5, 2021.
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 Phone interview with Dr. Nabeel Ibrahim, on December 5, 2020.
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 Phone interview with the author, Abdulrazzaq Al-Saiedi, December 21, 2020, Baghdad, Iraq.
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 Attacked and Threatened: Health care targeted in conflict and COVID-19, http://mapbox.insecurityinsight.org/.
 Phone interview with Dr. Nabeel Ibrahim, on December 5, 2020.
 Ahbab al-Mosul, “#الموصل الفديو يظهر اعتداء اهل ذوو مصاب بفايروس كورونا على احد الاطباء في مستشفى الشفاء” Facebook, 2:16, July 6, 2020. https://www.facebook.com/watch/?v=574092756879511; see also, Irfa’a Sawtak, “لماذا تتكرر الاعتداءت على الأطباء في العراق؟,” Facebook, June 11, 2020, https://www.facebook.com/irfaasawtakonline/videos/281912932854715.
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