Dec 21, 2017
By Caroline Hopkins, ASCO Publishing
Prior to the 1980s, the Iraqi health care system had taken progressive steps to support the field of oncology. Iraq had procured three linear accelerators and established oncology institutes in Baghdad and Mosul, as well as a low dose–rate brachytherapy facility. All systems were go for the government to fully subsidize sophisticated hospitals and provide free health care to all patients with cancer.1
Had nearly 3 decades of war not transpired, Iraq might have one of the strongest cancer care systems in the Middle East today.1 But the sweeping effects of internal and external conflict hit pause on Iraq’s progress. Beginning with the Persian Gulf War in 1990 and spanning decades to the Islamic State of Iraq and Syria (ISIS) invasion of 2014, Iraq faced debilitating trade embargoes, on-the-ground violence, and subsequent economic instability that left a grave impact on cancer care.
As of 2012, there were 25,700 new cases of cancer annually in Iraq, a country with a population of almost 34 million.2
Only recently, and in select regions, has oncology begun to take steps toward improving care and accessibility for patients with cancer. In the past few years, parts of Iraq have seen a gradual rise in treatment centers, professional associations, and government-led efforts to establish infrastructure. But the momentum is difficult to maintain without resources and personnel—and is all the more difficult in the context of disputes over regional independence.
Jalil Ali, MBChB, is a radiation oncologist with the Zhianawa Cancer Center and a 2016 recipient of ASCO’s International Development and Education Award (IDEA). The award promotes professional development among early-career oncologists in low- to middle-income countries and facilitates knowledge sharing. Layth Mula-Hussain, MBChB, formerly with Zhianawa Cancer Center and the Mosul Medical City Hospital and now with Canada’s Cross Cancer Institute, is a 2005 IDEA recipient and a member of ASCO’s International Affairs Committee. Dr. Ali and Dr. Mula-Hussain are two of the oncologists determined to revive cancer care progress in Iraq.
As with any goal of progress on a scale this large, however, the first step is to acknowledge the barriers the nation will need to surmount.
War-related restrictions on international imports—most notably the United Nations trade and financial sanctions placed on Iraq from 1990 to 2003 in response to the country’s invasion of Kuwait—made it impossible for Iraq to obtain the equipment necessary to upkeep hospitals or meet medication demands.1
In a 2006 survey of 401 Iraqi doctors who had since left the country, 67% reported that essential drugs were available for patients less than half the time and 69% said essential equipment was available or functioning half the time or less.3
According to Dr. Ali, there are roughly 15 functioning linear accelerator (LINAC) machines today, which causes extraordinarily long waiting periods for patients in need of radiation therapy. At Dr. Ali’s center, the wait time averages 6 months. There is only one PET/CT scanner in the country, which relies on fluorodeoxyglucose (FDG) imports from Turkey. Without the necessary diagnostic equipment, oncologists struggle to detect cancers that may have been treatable at early stages.
“There is no efficient screening program,” Dr. Ali said. “This means many patients—especially those with breast cancer—aren’t diagnosed until late stages of the disease.” Today, 50% to 80% of cancers in Iraq are detected in advanced stages, making them nearly incurable, even with the best therapies.4
Essential medications go hand-in-hand with equipment when it comes to resource shortages in Iraq. Restrictions on drug imports render access to certain types of chemotherapy treatments challenging, if not impossible, and have kept Iraq from establishing a palliative care model. Across the country, it remains difficult for oncologists to obtain pain medications.
On-the-ground conflict and economic collapse in Iraq in the early 2000s caused a mass exodus of doctors (roughly 50%5) who began to travel abroad to practice.
From 1991 to 2003, national poverty rates in Iraq rose from 41% to 70%, and physicians’ salaries decreased drastically.5 In 2000, Dr. Mula-Hussain’s basic governmental monthly salary was a mere $2.
“When conflicts between different groups based on religion and politics expanded to central and southern Iraq, hundreds of doctors left for neighboring and Western countries,” Dr. Ali said.
The majority of oncologists who left Iraq have not returned. As of 2012, there were only 30 clinical and radiation oncologists practicing in Iraq,6 and the numbers have yet to significantly improve.
Despite the high income Iraq now receives from selling oil, most of that money goes to repairing war devastation—consequentially, the Iraqi government cannot provide an adequate budget for health systems. This means that in addition to the slashed salaries, new research efforts have been pushed to the back burner.
“There’s little focus on research because of time and mentorship shortages,” Dr. Mula-Hussain said.
Funding aside, those oncologists who would have liked to go into research are fully occupied treating as many patients as possible.
“As oncologists, our top priority must always be treating our patients,” Dr. Ali said. “So while we are struggling and fighting for the health system to establish comprehensive cancer centers in every province, we are also fighting for the budgets to support training and salaries for our oncologists and nurses.”
Iraqi Kurdistan and the Influx of War-Displaced Patients
Throughout decades of conflict in Iraq, the country’s northernmost region, Iraqi Kurdistan, maintained stability relative to the rest of the country,7 and the effects have been significant in respect to oncology.
This stability—and, in turn, safety—is an outgrowth of the region’s semi-autonomy. While still a part of Iraq as of October 2017, Iraqi Kurdistan has its own semi-autonomous government in place, the Kurdistan Regional Government (KRG). The KRG controls a portion of its own spending, which, in combination with its economically lucrative position atop many of Iraq’s oil fields, has given it the means to invest more heavily in health resources than some of the more conflict-ridden provinces in central and southern Iraq.7,8
One of the upshots of Iraqi Kurdistan’s stability has been the KRG oncology system, a part of the regional government’s ministry of health. The KRG oncology system is still early in its devleopment,1 but Dr. Ali said he has seen it lead to tremendous improvements in Iraqi cancer care over the course of his career.
The KRG oncology system offers residency programs for both radiation and medical oncologists, and has placed a focus on collaborating and learning from oncologists globally, including the United States. The city of Erbil in the Kurdistan Region has hosted two Best of ASCO® (BOA) conferences to share practice-changing research presented at the ASCO Annual Meeting; in September 2017, Erbil’s Rizgary Oncology Center held the BOA in collaboration with the Hiwa Cancer Center and several other nearby centers. Although BOA conferences took place in Baghdad in 2012 and 2013, conflict-related challenges have limited the conference to the Kurdistan Region since.
Dr. Ali says the hospitals in Iraqi Kurdistan, which includes his own Zhianawa Cancer Center, provide treatment superior to that of most Iraqi provinces. All treatment services are government-funded and free of charge. Despite recent improvements and relative prosperity, however, Iraqi Kurdistan’s cancer care is still limited compared with that of much of the world. For instance, Dr. Ali pointed out that there is no surgical oncology department, meaning most patients with cancer who need surgery are treated by general surgeons.
Nonetheless, the stability of its cancer care reflects the region’s reputation as a safe haven in Iraq and the surrounding areas—making it a destination for refugees fleeing regions occupied by ISIS. As of April 2017, Iraqi Kurdistan was home to 1.8 million war-displaced persons entering from Syria and less stable Iraqi provinces.1
Patients with cancer make up a significant portion of those displaced persons; as of 2017, 35% of patients at the Hiwa Cancer Hospital were from outside Iraqi Kurdistan.1 The influx of patients presents a heightened challenge for the KRG oncology system in terms of resources and personnel. For the oncologists in the region who strive to uphold care equity at all costs, the challenge is also an ethical one.
In 2016, when Kurdish officials recommended that providers restrict their limited medical resources to Kurdish patients alone, for instance, Dr. Mula-Hussain said he could not allow himself or those in his practice to comply.
“I must treat those patients who have no access to radiotherapy services elsewhere due to their poverty and insecurity in exactly the same way as I treat those born in Kurdistan,” Dr. Mula-Hussain wrote in an email sent to the Zhianawa Cancer Center’s supervisor and to his residents—who at the time included Dr. Ali. “Unless the official Kurdish authorities clearly define the meaning of ‘refugees’ and officially write an order to prevent them from receiving treatment, we shall care for these innocent people as medical professionals.”
Oncologists in the region will continue to uphold their ethics as they endeavor to address the strain on resources appropriately and equitably.
The strain on resources is not a temporary phenomenon expected to disappear if and when conflict subsides in neighboring regions—the KRG oncology system will need to treat a large displaced population for years to come,1 and therefore will need to continuously develop strategies for improving care access. Iraqi Kurdistan must collaborate across regional and national borders to do so, despite growing political tensions with neighboring countries—and with Iraq itself.
On September 25, 2017, the people of Iraqi Kurdistan issued a referendum declaring their intention to become a fully independent state, and, in effect, secede from Iraq. The vote in favor of full independence immediately resulted in threats of economic and military retaliation from the central Iraqi government, which does not support the region’s secession. The remainder of Iraq is not alone in this response; neighboring countries such as Turkey and Iran, with which Iraqi Kurdistan depends heavily on trade given its land-locked location, also oppose the region’s independence.
The reality of the situation in Iraqi Kurdistan is such that an actual pursuit of independence could mean major setbacks in the KRG oncology system’s progress to date.
“I am not a politician, so it is hard to predict what would happen if the region were to become an independent country,” Dr. Ali said. “But because neither the Iraqi government, the neighboring countries, nor the United Nations support its vote for independence, I think the result would negatively affect Iraqi Kurdistan’s oncology services. [The region] gets some cancer medicines from the Iraqi central government, and resources from neighboring countries.”
Dr. Mula-Hussain added that this portion of the medication supply is upwards of 75%—and it comes from the Ministry of Health of Iraq in Baghdad. “Without such regular support, I expect a shutdown of the care facilities in Iraqi Kurdistan,” Dr. Mula-Hussain said.
As of October 2017, the Kurdish referendum for independence had not led to any immediate actions to secede, but the threat of consequences was clear: Central Iraq’s swift occupation of the oil-rich northern city of Kirkuk in the wake of the referendum was a bold warning of what could be to come.
“This is a complicated issue,” Dr. Mula-Hussain said. Even if conflict and sanctions do not ensue, he predicted that tensions might endanger the welcome status of the internally displaced people from other provinces in Iraq who enter the Kurdish region.
For oncologists and health care administers in Iraqi Kurdistan who have invested tirelessly in establishing a secure system of cancer care, what happens next is a definite concern. But oncologists like Dr. Mula-Hussain and Dr. Ali cannot spend time holding their breath in anticipation for what Kurdish independence might mean. The top priority remains to provide the best available treatment and care to as many patients as possible, regardless of where they’re coming from.
- Skelton M, Mula-Hussain LYI, Namiq KF. J Glob Oncol. DOI: 10.1200/JGO.2016.008193. Epub 2017 Apr 27.
- World Health Organization. GLOBOCAN 2012: Iraq. globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed Oct 19, 2017.
- Burnham G, Malik S, Al-Shibli AS, et al. Int J Health Plann Manage. 2012;27:e51-64.
- Diaz J, Garfield R. Iraq: Social Sector Watching Briefs, Health and Nutrition. apps.who.int/disasters/repo/11224.pdf. July 2003. Accessed Oct 19, 2017.
- Schweitzer M. Iraq’s Public Healthcare System in Crisis. epic-usa.org/healthcare-in-crisis. March 7, 2017. Accessed Oct 19, 2017.
- Mula-Hussain L. Cancer Care in Iraq: A Descriptive Study. Saarbrücken, Germany: LAP LABERT Academic Publishing, 2012;45.
- Kurdistan Regional Government. The Kurdistan Region in Brief. cabinet.gov.krd/p/page.aspx?l=12&p=210. Updated October 15, 2017. Accessed Oct 19, 2017.
- Kurdistan Regional Government. About Kurdistan. krg.us/aboutkurdistan. Accessed Oct 19, 2017.