Talking about pharmaceuticals and medications in general is an interesting topic to discuss indeed but talking about them in Iraq takes us to a whole new level. The past, the present and the future events are not just a coincidence, they are a well connected chain of neglect and ignorance. Drugs can be a bless if are used properly and a curse if they ended up in the wrong hands. In this article I will discuss the Iraqi drug story which is somehow unfortunately a sad story to be told.

Misuse and Abuse
In a nice shiny day I went to Bab Al Sharqi (A place lies in the center of Baghdad’s economic heart where high tech electronics and other stuff are being offered for sale). I was amazed by a crowd of people gathered around a salesman who is offering a bunch of non-related drugs on the floor. NSAIDs, antibiotics, antihypertensive, multivitamins, anabolic steroids, herbal preparations, hallucinogens, weight losing medications, and Viagra are all being advertised in a bizarre way like they are not just medications but instead they are acts of magic! The salesman was doing a 3 in 1 job in the same time, a doctor, pharmacist and a salesman! People were listening to his speeches about his miraculous drugs one by one and they were totally taken by his charisma. When I saw what was really going on the first thing I said to myself In fact I was not that surprised by the scene because it is quite common these days in Iraq, yet I was surprised by the large number of crowd and the increasing success of illegal drug marketing in Iraq. Misuse is a very problematic here especially talking about certain drugs such as antibiotics, anabolic steroids, hallucinogens and Viagra. Antibiotic resistant strains are emerging in an incredible speed, no one can really tell the real size of this problem.

During my service in public hospitals I witnessed the multi-drug resistant strains that are killing hundreds each day. Anabolic steroids are given in gyms by incompetent ignorant persons, they are overdosed so much, the more you use them the bigger your muscle will be, and simply no one talks about any side effect or precautions. Hallucinogens are used in low socioeconomic areas especially by teenagers, they might be seeking stress relief or they just want to get high. Viagra in my opinion is used due to curiosity; sex is an overwhelming issue in Middle Eastern societies, people here want to try this blue pill just for a change! Many kinds of misuse are present but the real problem is not the misuse itself. No one can tell what is the scale of this thing; no one did a campaign to educate people about what is really going on; no media awareness of this crisis. Legislations here do not prohibit drug purchasing without a prescription. Anyone can buy whatever he likes with neither limitations nor exceptions! 

Storage and Transportation
Many drugs are sensitive to heat, light humidity…etc. In Iraq no body knows for sure whether his medications were stored properly. Transport is being done by low scale contractors and none of them seems to be specialized in drug transportation; the next day he might be transporting steel instead of drugs. Even the ministry of health can not make sure that its drugs are being stored in the right way!

A new dimension of the problem lies in energy sources. Fuel crisis is always a running news subtitle; this makes air conditioning very expensive to humans and drugs. The national power grid in Iraq is completely out of date. People can not afford to keep a vial of insulin in a refrigerator 24 hours a day; same thing happens in hospitals, pharmacies and major drug stores.

Quality vs. Cost
If anyone goes to a regular pharmacy; you can easily notice that 90% of drugs are manufactured in Indian, Jordanian, Syria or Iran. There are no brand names in here, not anymore. Drugs marketed are cheap and available to the public. No one is questioning their efficiency because simply if you want to market a world recognized brand name no one will buy it from you because no one in Iraq is willing to pay for good stuff as long as cheap substitutes are available. It is simply the market push; but it is pushing too hard as there is no one to stop it. Quality assurance agencies are crippled or corrupted; you can easily bribe a high class official to get whatever you want into Iraq.

One shocking example of bad drugs quality that I was terrified by is that patients undergoing general anesthesia are being tortured in the operating room because many of them will find himself awake in the middle of a procedure due to anesthetic underdose. Once I assisted two nurses in stabilizing a female patient undergoing mastectomy; she was awake and the surgeon was cutting her deeply; she begun to moan and then shout; we all worked as a team to finish this terrifying session as soon as possible!

New Drugs
Usage of newer therapeutic agents is quite common these days. Iraq had been deprived of vital access to international drug markets since 1991 due to the embargo. After 2003 things changed dramatically. Newer agents are being used in a wide scale and for a variety of clinical cases. The only limitation nowadays is the cost since the Iraqi economic status has not totally recovered yet and living standards are still low in comparison with America or Europe. Otherwise everything in regard to this aspect is just fine.

Two major sectors of patients were benefited greatly from newer agents; cancer patients and rheumatologic patients. Biological agents and cytotoxic drugs can offer the main hope for a cure in cases intractable to traditional treatments. Despite the high prices, these drugs are offered for free in public hospitals but not that often. On the other hand you can purchase them easily from private pharmacies if you are in a desperate need for them; you do not have to go fetch a drug from Jordan anymore!

Major Crisis
As far as I am concerned there are two major drug crises that are worth mentioning; one of them happened in the eighties and the other happened at 2005. I will mention the events briefly and explain the significance of each event in details.

During the eighties of the past century the ministry of health imported potassium vials; they had different concentration than the old vial that Iraq used to import for 30 years. What happened is that hundreds of patient died of cardiac arrest due to overdose! The nursing staff used to handle doses in terms of volume not in concentration since the concentration of the vial has been constant for the past 30 years. Saddam Hussein executed the Minister of heath by shooting him in the head; blaming him for what had happened! This crisis refers to two major aspects that are really distressing; ignorance and poor education. The nursing staff in Iraq barely can understand English alphabet and can almost never ever understand a written sentence; most of them could not notice the change in concentration and were unable to calculate a proper dose.

What’s next?
To be realistic, the future neither lies in more resources nor newer drugs; in fact it lies in professional management. Health administration must evolve in order to coupe with this country’s health needs. Better planning, better resource utilization and smarter targeting is the key. A new way of thinking must be adopted; we should all work together to make use of modern techniques and technologies. Fortunately funding is always there in Iraq; more and more oil is being extracted each day; this should be more than enough if used wisely.

The coming generations are eager to be treated as humans. We all suffered bad circumstances; all shared the same dreams of prosperity and safety. National health should be one of our top list priorities right now. Iraqis endured war, poverty, intellectual deprivation and many other bad things. Now is a time where a change is really needed and should be contemplated as soon as possible.

Nabil Al-Khalisi,
Junior House Officer,
Medical City Complex,
Baghdad, Iraq.
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Commentaar

Rezan  - What about Europe and the west in general?   |Administrator |2010-03-09 02:25:21 Even here in Europe, just about everybody can buy drugs without consulting a doctor or a recipe. Any one can get Anabolic steroids, not to mention professional sporters (Tour de france, athletics etc.) who suppose to be a role model to the youth. Getting Viagra is as easy as opening an e-mail message and clicking a button, with all the spam about it we get every day, that would'nt be problem. And i'm talking about Europe, which can be conciderd as a the most controlled environment i ever heard about at the moment. With it's efficient healthcare policies, high quality healthcare insurance, wich is available to every person and all the campaigns that we see here every day about illegal drugs. All that does'nt help to stop buying or selling these kinds of drugs, so i'm not surpriced at all that a man in bab el-sharqi is able to sell these drugs in country with much greater problems than illegal drugs. This is a Middle East problem Nevertheless, there must be more focus on these kinds of issues in Iraq, but not Iraq only, the entire Middle-East is Suffering from this problem. Iraq will never succeed solving this problem if the other countries in the region don't help. But, unfortunately all the countries have there own problems. But if we can't solve a problem at the moment, we can diagnose it, think about solutions and talk about it as long as necessary. Nabil, thank you for sharing these information about Iraq with us. This way you are creating an opportunity for us to help our country. Hopefully you'll stay update our information about Iraq.

Catharsis  - Political affiliation versus Technocracy   |Registered |2010-03-23 14:30:23 That was a very great and informative read! Thanks! To add my personel views, I have always believed that the health ministry should be run by technocrats. Scientists, and other health or technical experts should in control of the decision making proces. The reason for this is because professional management has nothing to do with religiousity or political affiliation, but rather with knowledge and experience in the field and a high rate of succes in project management. And also, we don't want to have basterds like Ali al-shemari and Hakim al-zamili from the Sadr group running the ministry of health, to give you an example. To go even further, the same reason is also valid for many other ministry's like the ministry of education, of industry, of electricty, and of water resources. And probably aswel for the ministry of trade/economic afairs, of finance, of oil and many more.

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