‘The family will kill you if the patient dies’: the doctors facing attack in Iraq’s hospitals | Global development

Maryam Ali had just walked into the neurosurgery on-call room when a man grabbed her, shoved her to the ground and put a knife in her back.

Hospital security guards shut the facility down and arrested the man. With unusual fortune, Ali says, the CCTV camera covering the ward was working.

“I remember saying I thought I was going to die,” she said. “I was in complete shock. I cursed the day I became a doctor.”

Ali, 27, was in the second year of her postgraduate medical residency at Baghdad’s Ghazi Al-Hariri hospital when the attack happened in January 2021. Her attacker was caught and jailed but Ali has since, like many Iraqi doctors, considered leaving the country.

A recent survey of Baghdad doctors found that 87% experienced violence in the preceding six months. The majority said violence had increased since the beginning of the pandemic, and three-quarters of the attacks were perpetrated by patients and their families.

The man who attacked Ali was a thief who frequently stole from the hospital, she says, and an example of the lack of security that sees Iraqi doctors suffer high levels of violence at work. She and female colleagues had complained about the on-call room’s broken lock on several occasions, but no one fixed it.

In Iraq, it is typical for a patient to be supported by friends and family, sometimes up to 15 people, when they come into hospitals. When a doctor can’t cure a dying patient or is perceived to have made an error, tensions can spill over into violence.

Riyadh Lafta, a professor of epidemiology at Mustansiriyah University in Baghdad, says: “When patients go to the hospital and are already tense and anxious, doctors face difficulty in dealing with them. The patients become furious, and they attack.”

Lax security means these attacks can involve guns, with around 20% of civilians in Iraq owning a firearm.

“People are anxious, they are armed, and there are problems with the healthcare system,” Lafta says. “All these factors contribute to the escalation of violence.”

Lafta personally recalls two incidents in which doctors were killed, and in 2005 a group of 10 doctors were murdered in the Karbala governorate to the south of Baghdad.

A 2020 CCTV image shows Tarik al-Sheibani, an Iraqi doctor and director of Al-Amal hospital, in Najaf, Iraq, being beaten by relatives of a patient who died of Covid.
A CCTV image shows Tarik al-Sheibani, an Iraqi doctor and director of Al-Amal hospital, in Najaf being beaten by relatives of a patient who died of Covid. Photograph: Al-Amal Hospital/Reuters

Lafta says clans operating under Iraq’s tribal system have developed a new method of extortion. They threaten doctors and their families for mistakes, real or fabricated, demanding a “tribal penalty”, which Lafta has seen reach 145m Iraqi dinars (£82,000). Other doctors claim to have seen penalties as high as 300m (£168,000).

“Unfortunately in Iraq, most of the people know that they can escape punishment,” Lafta says. “When there is no punishment, you may do anything you like.”

Cardiac surgeon Othman Qutaiba says such problems have driven doctors to indulge in “showbusiness” – performing useless medical acts on patients just to appease family members. “​​When you see a dead body and there are 10 people standing beside you, they will kill you if you say he is dead,” Qutaiba, 28, says. “So, you give him a DC shock [with a defibrillator]. Maybe two, three, four times. Maybe 10 times.

“You know it’s wrong, but what should you say?”

Qutaiba says colleagues do this daily. They also take precautionary measures, calling in security guards when they expect a patient to die.

The violence has led doctors to leave the country in droves. A 2017 study found 77% of junior doctors were thinking of emigrating. And in 2019, an Iraqi health ministry spokesperson said 20,000 had already done so, the violence being a principal cause.

Lafta says: “It’s not only the person who is subjected to the violence, but also his colleagues, family, friends or relatives. This is contagious.

“Previously, we had a problem with ‘brain drain’ – Some countries were taking our medical professionals. Now the phenomenon has changed to ‘brain push’. We are pushing our brains outside Iraq because of violence.”

Tribal penalties and threats also push doctors to avoid complex surgeries, and new medical graduates are avoiding high-risk career paths like neurosurgery and emergency medicine. “My specialty, cardiac surgery, has a high mortality rate,” Qutaiba says. “Nobody will do it. And if they do it and the patient dies, they will have problems.”

Graduates willing to pursue high-risk specialisms can now fast-track through the two-year postgraduate rotation as the government seeks to address the shortfall, he says.

After pursuing cardiac surgery, Qutaiba started paying higher monthly sums to his clan to support him should someone attack or attempt to extort money from him.

The Iraqi government attempted to combat the problem by introducing a doctor protection law in 2010, which allowed doctors to carry handguns to work. Lafta considers this ridiculous because he believes an escalation in firearm ownership is behind the violence in the first place.

“When the attackers go to the hospital, they have automatic guns and there are four or five,” he says. “The doctor cannot protect himself with a small firearm. He cannot be as fast as those gangs.”

Only all-round security will help, says Lafta. “When people respect the law and are afraid of it, then I think this violence will vanish by itself.”

Zahra Esudan, a medical student at Mustansiriyah, wants to change the status quo. “I want to help people. I want to change something in Iraq,” she says. “I want it from my heart.”

Ali, on the other hand, has lost faith in the system after her assailant’s clan visited her home at night to pressure her to withdraw her case. She has returned to work but is considering emigration. “I’m so close to my family, I don’t think it’s worth living alone without them,” she says. “That’s the only thing stopping me.”

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