At the end of July 2020 in Baghdad something strange started happening. The doctors and nurses sweating in the Iraqi summer heat noticed that while their COVID intensive care units were ever fuller, the wards for less severe cases were emptying out. “The hospitals had been over-capacity in Baghdad and people were scared, so they were resorting to home care,” explains Omar Obeid, MSF’s project coordinator in Baghdad. “People stopped going to hospitals. They came only when it was so late that they were almost sure to die.”
The hospitals in Baghdad are used to seeing sudden flows of injured from the bombings that have followed the US invasion and the following long years of conflict. As COVID-19 began to spread through the city’s streets last summer, however, weaknesses in the overstretched health system quickly became apparent. “We tried to get her a test but we couldn’t,” says Hiba of her mother, Neamat, who fell sick in November. “We did a CT scan and saw that her lungs were all white, very damaged by corona. As I’m a pharmacist, I thought that we could manage it at home. The hospital was very last thing I thought of doing.” Eventually, however, Naemat’s condition deteriorated badly and Hiba was forced to bring her mother to a public hospital. “There was a different doctor every day and each doctor was writing a different prescription. There were only two or three nurses for about 20 patients, it was impossible for them.”
MSF’s teams were providing support in the respiratory care unit of al-Kindi hospital throughout the summer. They saw first-hand the increasing needs and how the hospital was unable to cope with the flood of COVID-19 patients that needed close and consistent follow-up. “It was understandable that we saw many staff scared of COVID-19 and hesitant to work,” says Gwenola Francois, MSF Head of Mission in Iraq. “What was more difficult was that often the senior doctors were often absent from the hospital, and junior doctors were often unwilling to make vital decisions without them.”
MSF therefore agreed with the health authorities to add its own COVID-19 treatment ward inside al-Kindi hospital, which opened in September with 24 beds, and later expanded to 36 beds in a purpose-built facility.
In the unit, doctors, nurses and other staff circulate in masks and blue gowns, taking vital signs, adjusting settings on ventilators, and explaining to family members what the situation of the sick person is and what treatments they are being given. “We previously saw that sometimes caretakers could be violent towards healthcare workers when a family member died,” explains Obeid, the project coordinator. “We tried to avoid such violent reactions by increasing our communication with the families, and luckily we have not had any issues with violent caretakers on our ward.”
This level of communication is especially important in a unit that has treated many very sick people, with the death toll reflecting the seriousness of the cases received: there were 168 people admitted between September 2020 and February 7, and the centre saw 86 deaths. “Medically, the situation here has been very difficult,” says Dr Aurelie Godard, MSF’s intensive care referent who worked in al-Kindi in September and October. “As patients have been hesitant to come to hospital they are arriving very late, with very low oxygen levels and lots of complications. When we started the mortality rate for critical patients was almost 100%, and although we’ve brought it down it’ still very high. But working with the Iraqi colleagues was amazing – we quickly developed new ways of working together and started to be able to discharge some patients that previously would have died.”
“In the first days of my work I was a little bit hesitant,” remembers Mahmoud Faraj, a nurse from near Mosul who is working with MSF in Baghdad. “I was thinking about driving for five or six hours to work with corona while other people were fleeing from this new dangerous disease. But when I eventually worked with the patients and saw how people’s conditions change and how happy they become when they improve I felt that I’m providing a great service.”
There is a jarring contrast between the world inside the ward -- where many sick people struggle to breathe, or are unconscious with machines breathing for them -- and the world outside where life seems to continue without much sign that COVID-19 has taken a painful toll on Iraq. Mask wearing is limited and businesses are open. With the country in the throes of an economic crisis, and no state support available, many Iraqis have had no choice but to keep on working as normal despite the pandemic. Unfortunately, many people are also not wearing masks in public, despite it being officially compulsory.
Despite a decrease in case numbers and admissions to the ward in December and at the beginning of January, the first few weeks of February have seen another worrying increase in the number of cases in the country, and a noticeable increase in admissions to the ward. “We are keeping a close eye on the situation because this increase is really concerning for us,” says Francois, the Head of Mission. “We are ready to keep supporting the Iraqi health authorities in case hospitals are overwhelmed again.”
Francois emphasises that mask wearing, hand washing and practising physical distancing all have a role to play in reducing the severity of a possible second wave. “These things could help keep people safe and help to avoid hospitals becoming overwhelmed again so quickly.”