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September 2009

Clinical Update: International
Iraqi Ophthalmologists: Tending to the Vision of Their Country
By Denny Smith, Senior Editor

(PDF 466 KB)

Risking their own lives to mend eyes besieged by war, Iraqi physicians have quietly been winning hearts around the world. “These doctors are not dispirited people. They are courageous in doing everything they can to give the best care possible, even as they face amazing challenges,” said George G. Ulrich, MD. Dr. Ulrich, who is in private practice in Coronado, Calif., met with fellow ophthalmologists in Baghdad last winter in a medical delegation sponsored by the International Medical Corps (IMC). “Iraqi eye surgeons are optimistic and energetic about addressing ophthalmic disease in Iraq. In the face of serious obstacles, the doctors we met were eager to provide the standard of care to their patients.”

Healers Among the Ruins

One of those doctors is Hamza H. Al-Majedi, MD, president of the Iraqi Ophthalmological Society. Although many things stand to improve with time, Dr. Al-Majedi said that Iraqi physicians still face security threats, infrequent communication with colleagues in developed countries, and, most frustratingly, a simple lack of ophthalmic supplies. “There are medications and technologies that physicians in Iraq do not have, so many Iraqi people are not getting the medical care they need, such as timely cataract removal, prenatal care and diabetes management. There are daily waiting lines for these patients.”

In fact, Zeena A. Khuzaali, MD, an ophthalmology resident at Al-Nahrain University in Baghdad, thinks circumstances have not really improved since the U.S.-led invasion began. “As a whole it’s not a bright picture, and many things that should have been fulfilled by now are out of reach.”

An American weighs in. These remarks parallel the impressions gathered by Dr. Ulrich. In the matter of cataract surgery, for example, “Iraqi doctors are well-trained and experienced in ECCE, but they have been hampered in acquiring skills in small-incision techniques. This is because they have been largely unable to obtain visas for travel abroad,” Dr. Ulrich said. “And the disruption caused by many years of armed conflict and an import embargo has limited their access to upgrades in materials and skills. This includes obtaining phaco equipment, going through the phaco learning curve and maintaining a cadre of trained technicians.”

Same problems for general medicine. Rafid Al-Taweel, MD, is an internal medicine specialist at Al-Nahrain and Al-Kadhumiya Teaching Hospital, and he described similar inadequacies in the rest of the health care system. “In remote and rural areas, especially, many Iraqi people are not getting the attention they should. Even in urban areas, there is limited access to modern technologies like PET and SPECT scans and cardiac imaging techniques. Appointments for a simple MRI can be two to three months away.”

Exile from Babylon. Perhaps the most important components of care now missing in Iraq, said Bashar Alwash, MD, are physicians themselves, many of whom have been exiled by the profound disruption of the last seven years. “Iraq lost many highly specialized doctors who were killed or who left with tears and broken hearts for their country.” Dr. Alwash is completing a residency at the Ibn Al Haitham Teaching Eye Hospital in Baghdad. One of his own brothers, also a physician, was kidnapped and tortured several years ago. Upon his release he fled the country with his family. That story is tragically familiar to many Iraqis.

Dr. Al-Taweel knew many doctors who emigrated immediately after the U.S.-led occupation began, in anticipation of increased violence. “Right after the fall of Saddam, many physicians felt threatened and left the country.”


The Human Cost of War

The physicians who remain have shouldered terrible armed violence, and Dr. Alwash said that patients with serious eye trauma are a near-daily presentation for ophthalmologists.

Dr. Al-Taweel said the mortality and morbidity come primarily from suicide bombers and car bomb explosions in crowded places. “These result in limb amputations, severe face and eye lacerations, abdominal and thoracic injuries, skull fractures and brain injuries.”

A cumulative reckoning of Iraqis injured in the war is almost impossible to pin down. Even the number of violence-related deaths is elusive, ranging as high as 1 million by some estimates. Every reputable estimate, including one endorsed by the World Health Organization, agrees that at least 100,000 Iraqi civilians, and probably more, have been killed.1 The number of violence-related injuries is likely to be far higher than that, if the death/injury ratio reported for U.S. soldiers is used even conservatively as a projection.

Unfortunately, said Dr. Al-Taweel, rehabilitation or long-term care services are rare for patients who have lost an eye or a limb.


The Seeds of Solutions

Through all those developments, said Dr. Ulrich, Iraqi physicians have remained utterly competent and professional. “Because of access to information through online sources, their fund of knowledge is quite contemporary. They express frustration at the difficulty of moving ahead technologically, but these ophthalmologists are aware of the present state of technology.”

Dr. Alwash proposed some steps he believes could propel ophthalmic medicine forward:

•  “First of all, the problem of security should be solved.

•  Then we must make available all tools and technology needed for ophthalmologists to diagnose and treat our patients correctly.

•  I think care must be given in the selection of students for residencies, and to developing standards for teaching programs.

•  I believe attention must be given to the income of doctors, because without this they will definitely find other sources of income to secure their physical needs.

•  Finally, we must prepare opportunities for Iraqi ophthalmologists to pursue specialized studies in developed countries, and the selection of those who get those opportunities must be based on qualification and not on a political bias.”

The eyes of hope and experience. Heading up the IMC ophthalmology delegation was Robert W. Butner, MD, assistant professor of ophthalmology at the University of Texas in Houston, who saw hope on the near horizon. “I think Iraqi ophthalmologists are faring better and better as security in the country increases, as travel within Iraq becomes easier and as more Iraqi expatriate physicians return.” Dr. Butner would like to return to Iraq. “I think there is definitely value in further collaboration, especially if we’re able to include ophthalmologists from the United Kingdom, given that the Iraqi medical system is structurally similar to the British one.”

Three steps toward one answer. A new approach to glaucoma, considered a major problem in Iraq, may serve as a paradigm for other ophthalmic care, said Dr. Ulrich. “Our Iraqi friends are quite concerned that the current infrastructure, distribution of resources and lack of public education leave many cases of glaucoma unattended. The impracticality of providing eyedrops at regular intervals, for example, means that treating glaucoma with topical medications is almost futile.”

Dr. Ulrich brainstormed with Iraqi colleagues for novel answers to this problem, and together they drafted a template of sorts for tackling the bureaucracy that neglects glaucoma and other ocular pathology:

1.  Given the impracticality of using topical medications, the health ministers should obtain a number of diode lasers. These are relatively inexpensive, portable and durable, and can be used to lower pressure by trabeculoplasty or by transscleral cyclophotocoagulation.

2.  Diode lasers could have an immediate impact on a widespread disease, thus casting the government as fostering health and well-being, and overcoming objections to a large public expenditure.

3.  The Ministry of Health could use mass media, like television, both to increase public awareness of glaucoma and to publicize the government’s commitment by providing the lasers.


Vision in the Cradle of Civilization

Every generation of Iraqis now alive has known war and tremendous deprivation, as well as miracles of hope and resilience. “I don’t think the level of eye care is ideal in Iraq, just as I don’t think the level is ideal for undocumented immigrants in Houston. I think it will improve with increased funding and increased training and increased cross-fertilization of ophthalmic information inside of Iraq and internationally,” said Dr. Butner.

Dr. Ulrich added, “These doctors face everyday challenges, even in simply moving around and doing their clinical work. But they know their standards of care. The ophthalmologists of Iraq deserve our greatest respect and collegial support—they are living up to the trust placed in them.”

1 Iraq Family Health Survey Study Group N Engl J Med 2008;358(5):484–493.