By ICHF guest blogger and medical volunteer, Sigurdur Stephensen
We are standing by the side of the road in the desert and staring into the distance. The sand is grayer than I had expected, somewhat grayish yellow and it stretches as far as the eye can see. No camels, no donkeys, no Beduin tents. Only this straight road like a pencil mark on a grey piece of paper. Outside it is 20 degrees Celcius and I wonder what I was thinking when I decided to travel here wearing a fleece jacket.
We are waiting for the police escort that was supposed to follow us from the airport in Basra to our destination in Nasiriyah. In Basra we had only been greeted by two bearded guys dressed in suits. I travelled together with Don, a perfusionist from Chicago, who is here for the second time. He recognized one of the men – Ahmed – from his previous trip. Ahmed walked straight up to Don, kissed him on both cheeks and said: “I love you.“ Don looked rather surprised by this warm welcome. I on the other hand received no kisses and no confessions of love. Then we headed in to the desert in an old van. After half an hours driving the police called and wondered where the hell we were.
We bend down and look at the small stones by our feet. Their surface is smooth as if it’s been polished, which is excactly what it has been. Sand polished for centuries. I throw a green stone into the sand. Now is the religious festival of Shia muslims in Iraq, when pilgrims march to the city of Karballah to remember the death of Hussein ibn Ali, who was a cousin of the prophet Mohammed. Because of recent bombings directed against the pilgrims, many of them walk all dressed in white, like a burial shroud, so they will be ready in case they die on their journey. I mention the bombings to Don. He had heard on his last mission that often the terrorists aren’t necessarily looking for a specific target. They just go out driving on the roads and wait until they find a target worth blowing up. “Like a couple of a whities” I think to myself. “Two representatives of the coalition of the willing, who stand sweating by the side of the road.” Despite the fleece jacket and the heat outside this new information gives me shivers down my spine. I just want to crawl back into the van. Maybe hide under the backseat.
International Children’s Heart Foundation and moral speculations
We have come to Iraq as part of a team from the International Children’s Heart Foundation (ICHF) (www.babyheart.org). This organization was founded by Dr. William Novick, a pediatric heart surgeon from Memphis, TN. The aim is to treat children with congenital heart defects in the developing countries and train the local staff so they can, in due time, acquire the knowledge and experience necessary to treat the children without external help. In the year 2011 thirty two missions were organized by ICHF to twelve countries where 450 heart operations were performed. In 2012 the number of operations doubled. I discovered the organizations, like ICHF online and went for my first medical mission to Honduras in October, 2010. Honduras is a poor country in central America that was hit by hurricane Mitch in 1998. Five thousand people lost their lives, 33000 houses and 70% of the roads were destroyed. In the beginning I couldn’t decide wether to join these highly specialized help organizations, or some other that focus on more common health problems. Diseases like congenital heart defects are highly specialized and the treatment is expensive. A heart operation done by ICHF costs on average $2500, which is much more than the treatment of other more common and serious diseases – such as pneumonia, diarrhea and malaria – although, in comparison to the Western world, these operations are relatively cheap.
Back to Iraq
We drive from the guarded guest house, a kind of “safe house”, to the hospital with police escort. Blue lights, sirens and loaded machine guns. I think the escort draws unneccessary attention and people stop in the streets to watch. I would have preferred walking to work. Or riding a donkey. Dressed in burqa. But I get used to the false sense of security and now it’s time to go to work. But it all starts pretty miserably. In the first operation an eleven year old boy dies. He came from the Kurdish region and was basically asymptomatic when he arrived for an operation for a ventricular septal defect and aortic stenosis. The following day a two and a half year old girl is operated for an atrioventricular septal defect. The operation goes well but during the night she develops pulmonary hypertension that does not respond to intensive treatment. Heart operations in the developing countries often pose increased risk in many senses. The children often have lived with their heart defect for a long time which has created additional problems such as pulmonary hypertension (PHT) and since they are often malnourished they are more vulnerable in the perioperative period. Secondly the knowledge and experience of the local staff is limited which increases the risk for mistakes. The general treatment customary in most pediatric intensive care units in the Western world can often not be provided. Medicines such as nitric oxide, used for PHT, and extra corporal membrane oxygenation is generally not available.
After the difficulties of the first days things start getting better. We suffer no major incidents even though two children have to be reoperated. My job is to examine the children pre- and postoperatively, do echocardiography and take part in deciding which child will need an operation this time and which one can wait. It is evident that we are only going to be able to treat a fraction of the long waiting list. We operate on 15-20 children in two weeks, but each year 30,000 children are born in Iraq with a heart defect that will need an operation.
Teaching and training of the local staff is a big part of our job. The doctors usually speak good english but the nurses and other staff usually do not. The nursing staff are almost exclusively men and often they have not chosen their profession themselves. Therefore not everyone is in the profession because of interest or vision which can be reflected in how receptive they are to our teaching. I try to share my knowledge but I also learn a great deal myself. In Western countries congenital heart defects are usually detected in the first months of life and the patients that require surgery are operated within a few months of birth, or before they develop a lot of symptoms. Therefore, we seldom see the longtime effects of an untreated heart defect. For instance, when I was in Honduras I saw a 7 month old child with transposition of the great arteries, which generally is repaired within a few days of birth in the West.
Iraq was never hit by a natural catastrophe like Honduras. Perhaps more like a man-made catastrophy. But the prize was much higher. The tornado Saddam Hussein created didn’t just blow over the country in a few days – he had 24 years to go about obliterating his own people. The only pediatric cardiologist in Nasiriyah – and one of only ten pediatric cardiologist in the whole country of 30 million people – put it rather mildly the other day. He said: “The main problem of this country is that it has never had a decent leader!“ As long as I can remember Iraq has been at war. I remember recurrent news of casualties in the Iran-Iraq war, that led to nothing in a nine years period (1980-1988), than one million fallen soldiers. Next on the program was the invasion of Kuwait in 1990 and ongoing use of chemical weapons against the Kurds in northern Iraq. And then came the invasion of the West in Iraq in 2003 with the unprecedented participation of Iceland as one of the parties in the so called “coalition of the willing”. The last soldiers from that miserable mission left the country about a month before our arrival. I had expected to meet people suffering from post traumatic stress disorder after decades of fighting and fear of suicide bombing, that have escalated after the evacuation of the American soldiers. On the contrary I met positive, smiling and brave people who didn’t look as if they had endured fear, suppression and war for decades. After repeatedly asking a local pediatrician about the effect of the fighting and the insecurity on daily life, he admitted that war had probably become a part of daily life for the Iraqi people. A help organisation member from America, Preemptive Love Coalition, who originally brought ICHF to Iraq, stated that the first months after the invasion in 2003, foreigners were greeted as friends and invited into peoples’ homes, even if they were total strangers. But as the occupation dragged on and there were no major improvements the hospitality of the locals declined. Now they are more careful and avoid associating with foreigners.
But Saddam Hussein can’t proclaim all the honour of Iraq’s miserable health system. In that matter the United Nations (UN) have a heavy cross to bear. Before the year 1990, 93% of the Iraqi people had access to a health system that was among the best in the Middle-East. After the invasion of Kuwait the UN put sanctions on Iraq and as a result the economic status, as well as the health system, plummeted. Saddam Hussein restricted expenses to health system by 90%. Hospitals and outpatient clinics were closed, there was a shortage of medicine and medical equipment and health personnel fled abroad. The incidence of congenital defects escalated as did malignancy amongst children and adults. This is believed to be the effect of the use of chemical weapons against the Kurds in Northern Iraq, where the incidence of congenital heart defects has multiplied. But the sanctions of the UN also directly affected the people’s health status. Child mortality, under five years of age, doubled from the year 1989 to 1999. Many died of hunger. Maternal malnutrition and failing maternal care also increased the incidence of congenital defects. When the willing nations invaded the country in 2003, the weapons were used against the main pillars of society such as roads, power stations, water supplies, sewers and health institutions. So-called depleted uranium was used in the warheads. This is a radioactive metal with a prolonged halftime. The dust from the explosion, which is thought to be carcinogenic, becomes dispersed in the atmosphere and settles in the soil. Thus the incidence of many malignant diseases has increased at the same time that the means for diagnoses and treatment has diminished. Actions, such as the sanctions used by the UN, reflect the deficiency of the organizations, their naive view of the world and the indifference for the real consequences caused by these actions.
End of the road
In our trip to Iraq seventeen children underwent heart operations on defects such as ventricular septal defect, transposition of the great arteries, tetralogy of Fallot, atrioventricular septal defect, aortic stenosis, double outlet right ventricle, subvalvular aortic stenosis, single ventricle and persistent arterial duct. Two children needed reoperation and two children died. A few children that had waited in the hospital for two weeks for surgery could not be operated this time. Hopefully they will be first on the list when the next mission arrives in three months.
Three days before our departure reporters from several TV stations arrived at the hospital. They were informed about the purpose of the mission and interviewed some of the staff. To keep a low profile this was not supposed to take place until the last day. When one of the chief physicians was asked why they had changed the schedule, and if this wouldn’t jeopardize our safety, he replied: “Don’t worry. You are low value targets.”
Early one morning in late January we are two low value targets – one from Iceland and the other from Belarus – sitting in the back of an old van driving along the same pencil mark as before. We are on our way to the airport. It’s still pitch dark and we are freezing in the back. This time I am glad that I brought the fleece jacket with me. The driver is drowsy and it looks to me that he is about to fall asleep at the wheel under a full moon. I keep an eye on him in the rear view mirror. We lag behind the police escort and when we finally catch up with them the drivers get into a heated argument. That’s all good because our man is suddenly wide awake. Gradually the day awakens and the desert sand gets a reddish hue in the morning sun. The Iraqi nation is at a crossroads. In some aspects it is like a man waiting by the side of the road in the desert. The invaders are gone, at least for the time being and the people have their own government and president. However, down under is disagreement and hatred between groups of Shia muslims, Sunni muslims and the Kurds, that has been boiling for centuries. I certainly hope that the people will make the right decisions and choose to have peaceful communications with their fellow countrymen and neighbours. And also that the nations that represented the coalition of the willing, now live up to their expectations and prove that the reason for the invasion in 2003 was really concern for the Iraqi people and not something completely different. That can be done by supporting help organizations like the International Children‘s Heart Foundation in this war-torn country.
By conservative estimates, the war in Iraq cost the American taxpayer some two billion dollars a week for nearly ten years: first by wrecking the place and then, because it was a modern war, rebuilding it. Exactly what was rebuilt is hard to say, but according to the Congressional Budget Office, we certainly paid to remodel the country. Still, some places in Nasiriyah look like the Marines rolled through sometime in the early spring. There are big dusty piles of rubble where buildings once stood as well as power and water outages several times a day.
Nasiriyah was the site of the famous battle on the drive to Baghdad where army supply clerk Private Jessica Lynch was captured and then famously rescued by Army Rangers. Both Private Lynch and Nasiriyah both reluctantly captured America’s attention, and both faded quickly. Not much has happed here since.
Politics, at the very best, are muddled. They lead to wars and wars lead to more politics which leads to…you get the picture. Wars serve the abstract: economics, self-determination, nationalism, and conquest. Democracy is a sneaky concept; there are plenty of repressive democratic ‘people’s’ republics in business. Freedom is sneakier still. Freedom to do what? Whatever you want? To be a free society you have to accept that the guy down the street with the loud stereo and the crab grass in his yard. Freedom to do the right thing? Who decides what that is? If it isn’t you, are you still free?
These are hard questions, and to look at the bill, expensive ones. They may be worth asking but the fact is that people’s lives are tripped up on much smaller matters – like the death of a child. The International Children’s Heart Foundation, as a non-profit, can’t afford to ask questions at two billion a week, so it doesn’t. Its job is more visceral. For an average $22,000 a week, the ICHF serves a very different, and arguably more affective mission: twelve lives saved. You could argue that those numbers are but a drop of water in the ocean, but you’re chasing the wrong metaphor. It is a bead of brightly colored ink on a piece of paper that spreads among the families and friends of the young that have been given a second chance to be alive. You don’t have to soak the paper to change it completely, just keep applying drops. They spread.
The US Military dubbed the war in Iraq “Operation Iraqi Freedom”; the Iraqis called it an invasion. The same call the extended ICHF program in Nasiriyah “The Remedy Partnership.”
“The goal of our [the ICHF] being here is not to do surgery on children.” Says Dr. Novick, “It is to establish a regional pediatric heart center for southern Iraq at the Nasiriyah Heart Center, to establish a system that works. The goal is to work with local teams to bring the level of competence in simple to medium complexity to acceptable levels by the end of the year.”
If we want to win the minds, let’s save the hearts. Let’s save the hearts across a world where one in a hundred children are born with congenital heart disease. You don’t have to save them all, you only have to save one.
According to Muhammad, a 25 year-old cardiac surgical resident – and part of the newly launched ICHF mission – Nasiriyah is a small town, with only around two million residents. It is not the center of things. Not yet at least.
His dream growing, up in Baghdad (a city of about 6 million), was always to be a doctor. He kept his grades up through primary school to ensure he’d qualify for medical school. It was a goal he held onto throughout the troubles of the last decade. Recalling his time as a medical student in Baghdad, he says, “It bad, horrible, colleagues were killed and kidnapped right before our eyes. What do you do? You must live. You must go to work, go to school, go have fun.”
If he was raised in a center of violence in Iraq, he now works at the center of the solution. As a surgical resident at the Narsiriyah Heart Center, he is part of the “Remedy Partnership”, the ICHF one-year mission at the hospital.
The program, launched this week, is off to a successful start with four successful procedures in two days. This mission is not about just stepping in and saving lives, though. Those blue babies who are given a second chance at childhood are a means to an end. A major component to this mission is the establishment of protocols and systems that will create an efficient and effective program over the course of the next year that will last long into the future.
By establishing as a regional pediatric cardiac center in Nasiriyah to serve southern Iraq, the ICHF helping change the center of things from violence to healing.
The 4:10 flight from Istanbul came in a little early. Even though many of us had been up all night traveling, the ICHF team was excited to get to work. Nabwa Qaragholi, the determined Executive Director of Living Light International, met the team at the Basra Airport. With a lethal combination of kindness and pushiness, Ms. Qaragholi handles the backstage logistics in Iraq to make sure the extended program launching this week will run smoothly.
After loading our kit for the drive, we met our army escorts and rolled out into the desert. There is a certain stark beauty to Iraq that grabs romantic figures like T.E. Lawrence and Captain Sir Richard Burton. The sand has a barely pinkish hue and is very fine, so when it kicks up it stays there. The affect is that, without any real point of reference, you can’t tell where the land and sky meet at the horizon. It blurs like a finger dragged across a line of chalk.
In the light traffic the drive through the desert is featureless but quick. As we approached Nasiriyah, the landscape got greener, sort of. In these brutal summer months the only thing growing is sparse scrub. The dry brush gives way to the tall, thick reeds of the marshes fed by the ancient Euphrates River, and when you cross it you are in the Fertile Crescent where civilization started. In fact, we are only about an hour away from Ur, the biblical city considered the oldest settlement in the world.
Nasiriyah is hard to conceive. There is still rubble that hasn’t been cleaned up from the war, but there is new construction going forward as well. Large walled homes abound, painted gloriously in a riot of color. Older buildings are the color of the khakis my wife won’t let me wear out of the house.
At the Ministry of Health guesthouse, Dr. Novick and the ICHF team are greeted warmly as old friends embrace and have a laugh. This is the first trip of an extended yearlong program, but friendships have been cemented over several shorter ICHF Mission trips over the last two years. The famed Arab hospitality is lavish and an Iraqi friend is a friend for life. It is one of those scenes that makes the troubles of the last decade seem far off – where they should stay.
We were fed an enormous traditional meal of chicken and rice with peppers. Set out on platters around the tables was a blackened fish called silva, a creature about 14 inches long. Eat it with our fingers, and once you learn the trick of taking some without a getting a mouthful of bones, it is excellent. Being Ramadan, our hosts were fasting and didn’t join us.
And while this was a happy occasion, both the ICHF team and our hosts know that it is time to get to work: the year ahead will be trying but triumphant as well, for the volunteers, Iraq and mostly its children.
ICHF was in Sulimaniyah, Iraq in August performing heart surgeries on children — part of the Remedy Mission in conjunction with the Preemptive Love Coalition. While Dr William Novick was operating, photographer Jon Vidar captured this image of surgery as reflected in a heart monitor machine. The photo received the People’s Choice Award at FotoWeekDC 2010!
Congratulations to Jon Vidar (http://www.jonvidarphotography.com) for capturing some of what our medical teams do in the field!
ICHF will be traveling back to Iraq December 4-18 to operate on more children. It is estimated that there are more than 4,000 children in Iraq waiting for life-saving surgery. Worldwide, more than 1,000,000 children are born each year with a heart defect — making this the number one birth defect globally.