U.S. Priorities Set Back Its Healthcare Goals in Iraq

Laura Bush’s gift to the people of Iraq is rising in a dirt lot across from a sheep market here, hidden behind high concrete walls and towers with armed guards.

Behind the walls, hundreds of Iraqi workers in blue jumpsuits scurry around a construction site filled with rebar, dirt and trailers. The project, funded by the U.S. government and donations raised with the first lady’s help, will someday be a hospital equipped to treat pediatric cancer patients.

But today, international health experts and Iraqi doctors say, it’s an emblem of the problems with U.S. efforts to rebuild Iraq’s shattered healthcare system.

Nobody denies that Iraq needs new hospitals, but the experts questioned the priorities of Washington’s $1-billion rebuilding plan, which has focused on construction instead of basic needs such as better training for doctors and public healthcare campaigns.

“We have more important priorities to solve our urgent health problems,” said Abdulamir Khafaji, the chief pediatrician at Basra’s largest hospital, citing the need for additional equipment in his emergency room.

Although reliable statistics are scarce, it does not appear that U.S. spending has markedly improved Iraq’s bleak healthcare landscape.

Easily treatable conditions such as diarrhea and respiratory illness account for 70% of deaths among children, according to a 2004 Iraqi Health Ministry study. A third of rural Iraqis skip treatment because it’s too costly. The Health Ministry estimates that as many as 25% of Iraq’s 18,000 physicians have fled the country since the U.S.-led invasion in March 2003.

A U.N. study this year found that a third of the children in southern and central Iraq are malnourished, the same as in 2003. And the American contractor in charge of revamping the healthcare system completed less than half its goals, according to a scathing U.S. audit.

Meanwhile, the number of clinics to be built has been reduced because of security costs and other problems. It is uncertain whether Iraqis will be able to staff and maintain the health centers that are being constructed. The U.S. spent funds on equipment that is now sitting in warehouses and on medications that later disappeared, presumably stolen, according to interviews and federal reports.

Iraqis and health experts said more attention should have been paid to refurbishing the country’s dilapidated network of 1,700 clinics and nearly 200 hospitals. A 2004 survey of 214 clinics found that only 10% had a regular water supply, only half had electric generators, and less than a third had “functional and relatively clean” toilets.

“I saw enormous incompetence which was more costly than even Iraqi corruption,” said Richard Garfield, a Columbia University health expert who worked with U.S. and international officials in Iraq last year. The U.S. “was pouring money down the drain.”

Officials with the U.S. Agency for International Development said U.S. efforts were beginning to show results. For instance, a United Nations campaign, to which the U.S. has contributed, has resulted in polio vaccinations for 98% of Iraqi children.

The U.S. also dramatically increased pay for doctors and nurses, raised the Health Ministry budget from $16 million under Saddam Hussein to $210 million in 2003 and recently implemented a training program for nurses and doctors.

The U.S. focus on buildings such as the Basra Children’s Hospital, which is projected to cost $50 million, will also pay off, the officials said.

“We’re building for the future,” said Heather Layman, a USAID spokeswoman. “Our belief is that planning for the future and setting ambitious goals ultimately helps the Iraqis achieve their goals.”

Other U.S. officials acknowledge early missteps. They say they regret that the U.S. did not do a better job of rapidly improving medical care in Iraq, especially for women and children, because it would have helped build goodwill.

“If the amount of child mortality under Saddam and since the conflict [had] happened in the States, things would be in an uproar,” said one U.S. official, who declined to be identified because he was not a designated spokesman. “You have to do more. We could be doing more than we are.”

After the invasion, U.S. officials hoped to rapidly improve Iraq’s healthcare system, which had collapsed under endemic corruption, a decade of U.N.-imposed sanctions and looting.

To improve things, the U.S. issued a $43-million contract in April 2003 to Abt Associates Inc., a Massachusetts-based consulting firm, to modernize the Iraqi Health Ministry and provide needed supplies.

But the company, which has worked on healthcare issues throughout the developing world, quickly ran into problems, according to an audit issued this year by the USAID inspector-general. Company officials were slow to mobilize. They bickered with Iraqis and officials with the Coalition Provisional Authority, the U.S.-led agency that administered Iraq until June 2004. One Abt manager “did not recognize” the CPA as a “legitimate authority,” the audit said.

Medical kits intended for 600 clinics contained damaged or useless equipment, the audit said.

USAID subcontractors questioned the quality of a device that Abt bought to sterilize medical tools, noting that it was manufactured by an Indian firm that hadn’t made such an appliance before.

The medical kits, which were supposed to be purchased by October 2003, weren’t delivered to the warehouse until June 2004, eight months late, the audit said. By February 2005, some clinics still had not received the kits.

One subcontractor involved in delivering the equipment said he had “never witnessed such a debacle” in 20 years of working with USAID, the audit said. The audit also criticized USAID officials for constant turnover and failing to move quickly to address problems.

In the end, USAID officials cut Abt’s contract, paying it only $23 million. Abt officials refused to comment, referring all questions to USAID. A USAID official said the Iraq job was too big and dangerous for the company, which continues to work for the agency in other areas of the world.

“As we watched the work progress, it became clear that this job was more complicated than this one contractor could accomplish,” Layman said.

By the time the Abt contract expired in November 2004, the U.S. already had a new approach to improve healthcare: building and refurbishing hundreds of clinics and hospitals.

In March 2004, the Pentagon’s reconstruction agency, now known as the Project and Contracting Office, announced the award of a $500-million contract to Parsons Corp., based in Pasadena, to build 150 clinics and refurbish 20 hospitals and other facilities.

But violence flared in Iraq that month, causing security costs to soar. Parsons had to relocate its headquarters inside the heavily fortified Green Zone in Baghdad and limit trips around Iraq. The U.S. recently cut eight clinics from construction plans, citing security costs.

The refurbishment project also became mired in landownership disputes, problems with Iraqi officials demanding kickbacks and poor performance by Parsons’ Iraqi subcontractors, State Department officials said. The first of the new clinics is supposed to be complete by the end of this year. Parsons referred questions to the government.

Iraqi officials said that although they appreciated the U.S. effort, they had not seen enough concrete results.

The U.S. “can be blamed for being slow,” Health Minister Abdul Mottalib Ali said in an interview in the immaculate ministry building, which was refurbished by the U.S. “This makes obstacles and difficulties because it delays health services.”

At Imam Ali Hospital in Sadr City, one of only two serving the 2 million residents of the impoverished Shiite neighborhood in Baghdad, the third and fourth floors were recently closed for weeks because of problems with the contractor, a local Iraqi firm.

Patients in need of routine checkups, ophthalmological treatment or ear, nose and throat surgery had to forgo care or make long trips to other hospitals.

“I’m running behind schedule, and all other hospitals are also under construction,” Shakr Jasim Sadi, the hospital’s director, said as he sat in his cavernous office off the main corridor of the bustling medical center. “This will cause suffering for the patients.”

Other doctors said that the United States’ lack of progress had led to bad feelings among Iraqis.

“Two years have passed, and there is no serious change,” Abdali Qadhim, a physician at the hospital, said as he sat through the semi-darkness of a power outage. “In April 2003, people came to welcome an American convoy. Afterward, when people saw nothing, no services, no nothing, the opposite happened.”

In contrast to the delays that have beset other construction projects, Basra Children’s Hospital is on track to open its doors in September 2006 -- 3 1/2 years after the invasion.

That may be in part because of the intense interest shown by Laura Bush and Secretary of State Condoleezza Rice.

A White House official defended the first lady’s support for the project, saying it would help bring “modern-day standards” to Iraq. “If you’re going to build a hospital, it should be done right,” said the official, speaking on condition of anonymity.

The hospital is being built with U.S. funds, but equipment and doctor training are being paid for by Project Hope, a charity headed by John P. Howe III, a friend of the Bush family from Texas. Howe pushed the project after Rice and Bush invited him to visit Iraq to assess the country’s healthcare system.

As detailed in a previous Times article, congressional members initially balked at the state-of-the-art project, calling it unnecessary and a political favor to raise the profile of a charity run by a Bush family friend. Rep. Jim Kolbe (R-Ariz.), who chairs the House Appropriations subcommittee on foreign operations, dropped his opposition after the White House agreed to cut the hospital’s cost in half and expand its functions to include training and general pediatrics.

The first lady and Rice were the star attractions at a Project Hope fundraiser in a gilded ballroom in Washington this month. Bush told the audience members that their contributions -- an estimated $1 million of the $30 million the charity has pledged to raise -- were helping make a brighter future in Iraq.

“Every country’s success depends upon the health and wellbeing of its children,” Bush said. “By working together, we can help future generations of Iraqi children grow up strong and healthy.”

But Garfield, the Columbia University doctor, said it was too late for some Iraqi children.

“Many deaths would have been averted if this money had gone into setting up clinics for diarrhea and respiratory illness,” he said. “It was a stupid thing.”