Biography

Iraq is rapidly losing its doctors and healthcare professionals; its public health sector is on life support. During her two years in the U.S., Hala Al-Saraf campaigned for sustainable improvements in Iraq’s public health sector, arguing that reconstruction dollars are best spent on investments in training programs and Iraqi medical schools, rather than building new health facilities that cannot be adequately staffed. We visited Hala in her New York City apartment and, over a cup of coffee, discussed the history of Iraq’s public health system, the challenges it faces today and what the U.S. and international community must do to help keep it alive.

Hala Al-Saraf received her undergraduate degree from Iraq’s Mustansiriya University in 1988. She worked in Baghdad with various UN agencies, including the World Health Organization (WHO), from 1996-2005, implementing training programs, managing health budgets, and collaborating with Iraq’s Ministry of Health. In late 2005, Hala was accepted to the Fulbright Program and came to the U.S. to study public health policy at Columbia University, where she recently earned her master’s degree. While in the U.S., Hala initiated Project THINK, an interactive, distance learning forum for Iraqi and U.S. medical students. In April 2007, she was honored by the Institute of International Education with the New Leaders Group Award for her efforts in building U.S.-Iraq understanding. The following month, she was recognized by the Embassy of the Republic of Iraq for her outstanding achievements in helping her people. Hala returned to Iraq in May 2007, where she joined her family, but she will be coming back to the U.S. this July for the University of Massachusetts conference Rebuilding Sustainable Communities in Iraq, which she helped plan.

Interview

Conducted in May 2007
Download PDF version

epic: What is the state of Iraq’s healthcare system right now? Do you think conditions will improve through reconstruction policies?

Hala: Immediately after the collapse of the regime in 2003, everyone was optimistic about the future of Iraq’s public health. The resources were there, the funds were there, and the people were there. What wasn’t there was the plan. Even with all the money in the world, if you lack an appropriate plan, you will not achieve sustainable results.

Authorities, especially those in the U.S. health administration, said nothing but the best would be established for Iraqis. But as time passed, achievements were minimal, and funds were redirected to more immediate security concerns.

Besides that, qualified, intelligent Iraqi doctors were never involved in the process. They are professionals, and they have learned to function in very primitive settings while still achieving solid results. But the opinions of even our best experts were not fully taken into consideration.

Why have these experienced doctors been excluded from the process of rebuilding Iraq’s healthcare system? It’s because experts in the U.S. are trying to use a model they’ve imported from their own country, one that meets predetermined requirements without considering the realities on the ground. Unfortunately, imported models just don’t work. Culturally, administratively, politically, Americans and Iraqis are so different.

So what did we end up with? Very nice buildings – well-painted, clean – but no trained professionals who could perform the tasks required. I don’t see how building highly sophisticated hospitals can improve the health of Iraqis if there is no legislation to administrate them, no health professionals to deliver services and no maintained system of supplies and equipment to ensure their functionality. Unless a policy is set for health, every effort in the reconstruction process may fail to bring about sustainable results.

A good example is the Basra Children’s Hospital. There is an argument that Basra didn’t need a new hospital, and the doctors and people there didn’t ask for one. They probably would have favored an investment in primary healthcare instead. But the hospital was imposed on them anyway, and as a result there is no sense of ownership for the hospital in that community.

Even if the community embraced it, who would staff it? Since there are no doctors to take over, no clear policy for financing it and no clear information system to support and maintain it, what will we achieve in terms of sustainability? If doctors, staff and resources are pulled from other hospitals, it will weaken the entire health system.

epic: Why aren’t there enough doctors and health professionals to staff the hospitals in Iraq?

Hala: Forced migration, which is often called “brain drain,” is perhaps the biggest problem facing the Iraqi health community. Iraq’s Ministry of Health reports that 102 doctors and 164 nurses were killed between April 2003 and May 2006, and some 250 Iraqi doctors have been kidnapped in the past two years. Because of this violence, Iraqi health professionals are fleeing in droves, as many as 12,000 since 2003. This is exactly what the militants want to see – professionals being pushed out to weaken the system.

Medical universities are cutting their departments since they have fewer and fewer professors. This leaves the medical graduates with no solid clinical training, while facing the daily hardships of continuous emergencies and other demands.

To make matters worse, these young doctors have to find creative methods to perform their tasks in the absence of required supplies and equipment, at a time when millions of dollars are allocated to healthcare services.

Can you imagine how that affects the healthcare system and the lives of the people? If we are unable to prepare a new generation of well-trained doctors, who will run the hospitals, treat patients, and help the Iraqi people live healthy lives? The exodus of so many professionals is really taking a toll on Iraq’s healthcare system, and could pose serious problems well into the future.

epic: Are there any programs that provide incentives for Iraqi professionals to return home?

Hala: The problem has recently received more attention in policy circles and the media, and I am very happy people are starting to talk about it. That’s the first step.

The Scholar Rescue Fund is one program aimed at helping Iraqi professionals. It places those under threat in temporary fellowships at institutions worldwide. Scholars work in safety at host institutions – teaching, lecturing, researching and publishing – and for young doctors in particular, it provides much-needed opportunities for training with experienced health professionals outside the country. The most important aspect of the Scholar Rescue Fund is its emphasis on ‘temporary.’ As conditions improve in a scholar’s native country, the fund facilitates a safe return home.

In terms of the Iraqi government, I’m not aware of any specific programs it’s running to help save and protect scholars or physicians. But I think this is an issue the government will need to take on, especially if we are serious about improving the healthcare system.

The biggest role the Iraqi government can play right now is to bring an end to the civil war; build security, and Iraqi professionals will come home. The good news is, for the most part, expatriate Iraqi doctors want to go back. Most are finding it difficult being the brains that left, and they are unsettled in their new homes around the world.

In the interim, we have to keep them invested in the future of Iraq’s healthcare system. I would say the best way is to create links between them and their institutions in Iraq. The institutions would need to understand that these doctors cannot be in touch directly because they are under threats. Before the doctors leave, they should come to an agreement on how to maintain a long-distance relationship, provide feedback, be in touch with residents and maintain communication with students. These types of links are crucial in rebuilding the base of professionals.

epic: How can the U.S. and the international community help young doctors in Iraq?

Hala: Our first priority should be compensating for the lack of training and residencies with experienced doctors. Iraqi medical students need books, guidelines, and manuals, and they need open communication with medical students outside the country. That’s why I am working on connecting American medical students with Iraqi medical students, to open up the lines of communication and to help Iraqis learn some of what they are unable to learn in their own classrooms.

For the past several months, I have worked through Columbia University as a facilitator for this kind of information-sharing. The students at Columbia are wonderful, and they’ve sent books, CDs, and manuals to many Iraqi students. My daughter, a medical student, raised $1,500 to buy fifty copies of Oxford’s guidelines for practitioners, which were sent to groups of fifth-year students to plan for their distribution. Those students then put the books in a free information system, so they can be used for a second year. It only required a $1,500 donation, but the books have made a difference.

In terms of how the U.S. can help, I would argue the involvement of the U.S. government should be minimal. One of the reasons my small information-sharing program at Columbia has been successful is because it is being carried out by American citizens, not the U.S. government. The key, I think, is that it’s a student-to-student, people-to-people effort.

epic: Tell us about Project THINK.

Hala: Project THINK is an information-sharing program I started working on as part of the Fulbright Program. It stands for Towards a Healthier Innovation and Networking Knowledge. This program is based on the belief that high-quality learning can still continue even when professors have fled to other countries. The project provides an online forum for exchanging information between Baghdad Medical College and some of America’s top universities.

The forum was designed by a medical student, who is a computer-whiz in Baghdad Medical College. It allows for uploaded documents and reference guides so students at Baghdad Medical College can use them in their own classrooms and on rotations. This is an ongoing project and what’s nice about it is that information technology is always changing, always improving, so there are really no limits on what we will be able to do.

Thanks to this effort, hundreds of Iraqi medical students now have access to important educational resources at universities such as Columbia, MIT, Johns Hopkins and Georgetown. Project THINK has built friendships and changed perceptions, and is helping to foster dialogue between America and Iraq.

epic: In addition to these people-to-people connections, are you aware of links being formed at the institutional level?

Hala: I’ve not yet seen it between institutions. It is actually my dream to help build connections between Iraqi and American institutions, and I plan to work on it as soon as I return to Baghdad.

When I worked on connections at the student level, I was contacted by one of the professors at Columbia to facilitate research work on health and human rights and Iraq mortality. I helped establish connections between U.S. students who are taking this course, and Iraqi students. They conducted the research together. I think it worked out well from all sides. The U.S. students were able to utilize resources here without taking the risk of traveling to Baghdad. At the same time, Iraqi students were able to conduct field research and receive training on how best to do it. The result was a solid joint research project.

The next step for me is going back to Iraq and meeting with the deans of Iraqi medical schools to help create official connections with U.S. and other foreign institutions. Having Baghdad University acknowledged by American medical schools would mean that our students could complete their clinical training electives in the U.S.

A 10-week internship would create a beneficial, short-term intervention that would introduce young Iraqi doctors to the wonderful U.S. community, as well as medical advisements in their areas of specialty. Such short visits can help them have the vision to determine their future direction.

With what is in place now, the U.S. student and visitor exchange programs have so far provided a number of opportunities for Iraqis to learn and excel in the best American academic institutions. Some of those students have completed their studies and others will soon be ready to go back home, with mixed feelings of hope and fear. If those students are granted job opportunities in positions where they can push the process towards stability and advancement, they will form the steering force in the process of change, and will surely provide their institutions with fresh thinking and updated knowledge – all of which is much needed and can be well invested toward a better, healthier Iraq.

epic: Can you walk us through the history of Iraq’s public health sector? What was it like prior to the 2003 U.S. invasion? Would you say that healthcare is better or worse today?

Hala: Prior to the sanctions period, the World Health Organization said Iraq had one of the best primary healthcare systems among the Middle Eastern region. So why did we drop from 1st to a level of the least developed countries? I don’t think we can point to conflict or poor decision-making, because those factors have always been present in Iraq. I think our healthcare system declined because our base of expertise disappeared.

The hardest work was done before the British left in 1932. Because of World War I and Iraq’s positioning, the country’s leaders thought it was important to have healthy troops. So Iraq began pouring time, money and resources into improving the healthcare system throughout the country. Baghdad Medical College was established, and when the British pulled out they recruited doctors from Lebanon and other Arab countries to serve as professors until local people were trained to properly maintain the system. This was the beginning of a prosperous time in Iraq.

However, after the Baath party takeover in 1963, some of the professors sensed a threat to their personal freedom. This led to the first of three waves of “brain drain” emptying the system. The first people left in the late 1960s and early 70s, and are now well established all over the world. Those who stayed or returned did well, however, as the 1970s proved very prosperous. Huge amounts of scholarship funds were available, thanks to the nationalization of oil. The expatriates who returned were honored, and Iraqi doctors during that time maintained a very good standard of living.

Then came the early 1980s, the peak of the healthcare system. By that time, we had a regional center for communicable diseases, where people from all over the Middle East came to study and learn.

But the war with Iran drained the system from 1980 to ‘88, as the national budget was shifted toward military industrialization. Traveling was restricted, so immediately afterwards, when the Gulf War ensued in 1991, many doctors left the country. That was the second wave of “brain drain.”

It’s hard to say with textbook accuracy how the sanctions period, from 1990 until the 2003 invasion, affected public health because you can’t get precise data from that era. The regime reported a lot of propaganda, so it’s hard to sort through what’s true and what’s not.

We do know many children died, evidenced by the waves of collective funerals during that time. It was devastating. Even under the sanctions, Saddam could have brought in whatever food or medicine we needed to save the children. But he didn’t, and the regime blamed the sanctions for all the deaths.

When the U.S. invaded in 2003, people hoped things would get better, and health professionals dreamed of returning to the prosperity of the 1970s and 80s. But today, we are seeing the worst period of flight. How can we even begin to rebuild? It seems we have nobody to start with because everyone has left. That’s why we need to replenish the base, starting with improving training for medical students.

epic: Tell us a about yourself and your background. What drew you to the field of public health?

Hala: I am a proud mother of three; I think that is my greatest achievement. I have a wonderful husband who supported me in pursuing a Master’s degree. He believes knowledge is the best thing we can give to our children, and I agree. The greatest legacy I can leave is an enlightened generation with a fresh attitude toward life.

I am from Baghdad, and I’m looking forward to returning home. I just completed my time as a Fulbright Scholar at Columbia University’s School of Health Policy and Management. My dedication to health came through my eight years of work with the World Health Organization, collaborating on programs with the Ministry of Health in Iraq.

The Fulbright program has been truly fantastic, and getting to know the people here is an incredible asset for me. For years, Iraqis were denied admittance to the Fulbright Program due to strained U.S.-Iraq relations. When the program was re-activated and I was accepted, I couldn’t turn it down, even though I knew it would be difficult to be away from my country at this critical time. The Fulbright Program has been a wonderful experience.

epic: Why did you decide to study health policy?

Hala: When I chose health policy as my specialty in early 2004, I was strongly motivated by the fact that my country was witnessing a new era, and I was glad to take part in its foundation. Following the 2003 invasion, Iraq had a lot of resources at its disposal, and I dreamed of helping return my country to being a leader in healthcare, as it was in the early 1980s.

However, in the war’s aftermath, I have witnessed inadequate health planning and policy setting, a major bottleneck that has hampered much advancement in my country’s health system. Three years after the collapse of the previous regime, Iraq still does not have a clear policy regarding a number of vital issues related to health, such as health financing schemes, human resource redevelopment and information management systems. And now that I have a policy degree, there are no resources with which to make policy.

epic: Tell us about the award you received from the UN General Assembly.

Hala: Yes, it is the New Leaders Group for Mutual Understanding Award, for my work with THINK. This is a very special thing I am taking home with me. It’s actually a call for peace. If you bring people into dialogue, and if they can see the benefit of exchanging views, then nobody would want to fight. This is my means of peace, it represents how I feel we should try to see similarities and make the best of the current situation rather than digging into differences.

epic: What draws you back to Iraq?

Hala: It’s my country. It will always be my home, and I want to do what I can to help improve the public health of my people.