BMJ  2003;327:297 (2 August), doi:10.1136/bmj.327.7409.297

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PERSONAL VIEW

Poppies in Kosovo, gerbera daisies in Basra

This time the gerbera daisies will evoke memories for me. Last time it was poppies—deep blood red poppies ( BMJ 1999;318: 1707[Free Full Text]). Back then, in May 1999, the poppies lit the Macedonian fields outside the refugee camps—camps full of Kosovar Albanians fleeing ethnic cleansing. A splash of colour, incongruous amidst the misery of people who had lost everything. The daisies—pastel shades, covered in dust, struggling to survive without water—symbolise for me that there is hope amidst neglect.

I found them in a corner of the palace garden. The palace is magnificent: huge, high ceilinged rooms, miles of corridor, marble floors, and surrounded by a high wall and protected by acres of landscape that deny the outside. Opulence and gross extravagance on a scale you could not imagine, reflecting great wealth and self importance. Strange that the man for whom the palace was built liked the same flowers as I do.

An imposed health economy will not work

I am in Iraq, seconded to the Foreign and Commonwealth Office. Three of us from the Department of Health are here in Basra. We work in the southern office of the Coalition Protection Authority, which covers an area the size of Scotland. We are the regional government working within a multinational effort alongside Iraqi technocrats to regenerate a country. The politics of the conflict are not my concern. I see only a country systematically starved of resources, whose people were punished through purposeful withdrawal of the basic necessities for life, a people subjugated by fear and corruption. This is how they were repressed.

Basra itself suffered since the uprising of 1991. The policy of neglect was deliberate. The infrastructure has crumbled. The recent conflict cannot be blamed for the complete lack of essential services. Looting and deliberate sabotage in the aftermath of the conflict have contributed to the immediate and acute problems. Power is intermittent, the water supply is unreliable, rubbish lies in the streets, and salaries have not been paid for months. Gun battles regularly punctuate the dark hours. Society has almost broken down, and people look after themselves to survive or make money from the chaos.

And what of the health service? There are no drugs. Hospitals have run out of oxygen and have been looted of beds and equipment. There are no laboratory reagents. Elective and diagnostic procedures are impossible, with intermittent power and no essential clinical supplies. There is a public health crisis. The cold chain has broken down, and immunisation programmes have been suspended for more than six months. We have cholera, typhoid, and whooping cough. Water is contaminated with sewage. On street corners children take water from pipes that have been deliberately broken because pumps are not working and water is not reaching their homes. There is not enough fuel. Food, previously supplied on ration, is scarce and expensive.

Three of us. Where does one start? The British military here have done a wonderful job. Our medical colleagues—young regimental medical officers and senior medical command staff—have made huge strides in understanding the key structures and personalities and the immediate problems facing this region. Together we have a plan that covers immediate and longer term issues. Much of the plan rests on leadership emerging from the local profession—a tall order, given the political unrest and undercurrent of corruption. Self determination is the key; an imposed health economy will not work, nor is it for us to decide. We can only try to support, guide, and advise. But in the transition our leadership is essential.

In this chaos we must stay focused on the long term objective: an Iraq that gives its people choice and provides health, employment, shelter, adequate nutrition, and security—basic needs for all. That there is no service now must not distract us from the task. But this is difficult when we are faced with the inevitable personal tragedies. People come to our office hoping for help, for a gift that might transform their lives. One morning, a five year old boy and his loving, gentle father came to the gate. The boy has thalassaemia, common here, and needs a blood transfusion. Nothing is free; even blood comes at a price. The price is unaffordable for a man with no job. The blood transfusion service has been destroyed. The boy, yellow under his dark skin, will die without treatment. One day, sooner than later, I hope, we will have identified the way to replace this essential service, along with all the other life saving services that are lost. Other children may then live. This boy cannot wait that long. He needs a solution now. I cannot offer hope. His papers tell me his blood group is B+, the same as mine. But how many more children might need my blood? That is no way to solve the problem, even though it might make me feel better today. Later, in my office, I cry uncontrollably with impotent rage.

I will stay focused. Things will be better. There must be hope amidst neglect. Like the gerbera daisies, the will to survive is strong, and from the dust something good may grow. I may have helped. I hope so.

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East of England Regional Public Health Group celia.duff{at}dial.pipex.com

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Thank you all

Rihab F Tawfik
bmj.com, 1 Aug 2003 [Full text]