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Cover image: A full-body sca n from Siemens' new integrated PET-MR

SIMIDDLE EAST HEALTH

D Iraq Report

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Accessing good health care in Iraq is a challenge for many people, as it is in most developing
countries, however, women in particular face unique hardships when seeking healthcare in this
war-torn nation. Dr Nabil AI-Khalisi provides a first-hand account of his experience working
as a medical doctor in Baghdad and reveals the extreme difficulties many women face in
accessi ng proper hea Ith ca reo

Discussing health issues in Iraq is in itself a
distressing subj ect for health practitioners,
but when the subject turns to women's
health it pushes the discussion to a new
level of anguish. Although getting proper
health care is a challenge for most people
living in a developing country, such as
Iraq, women, in particular, face adversity
that is unique to them and can at times
render their efforts hopeless.
The Middle Eastern cultures tend to
objectify women and '6fhis is particularly
prevalent in Iraq. A s such, women are
treated as objects and w h en an object gets
sick then it is not a big deal. When a father
has a sick son the alarm bells ring, however
if his daughter is sick not much attention is
paid to her situation. This culture values
males more than females.
Women do not believe in themselves,
they lack self-esteem and this exacerbates
the gender inequality. They feel that they
are vulnerable without a male to protect
and support them. Thus, marriage is
viewed foremost as a place of safety and
security for most Iraqi women. This has
the effect of restricting the freedom of Iraqi
women - freedom of movement, for
example, which in turn limits their
freedom to easily access healthcare. In
most cases a woman usually needs to be
escorted to the primary healthcare centre
by her husband, father, or brother. This is

52 I MID D LEE A S THE A L T H

D Iraq Report
particularly prevalent in rural areas.
A combination of this cultural objec-
tification of women and their restricted
movement, in many cases, results in
women accessing healthcare only when
the symptoms are severe and in some
cases not at all. Unfortunately, seeking
treatment at so late a stage, results in
death in the worst cases or a long,
drawn-out recovery in the more fortu-
nate cases.
For example, women with breast cancer
tend to only visit the doctor for the first
time when the cancer is at an advanced
stage. At this point medicine can do very
little to help them. Visiting the doctor
when the symptoms were first noticed
would have provided a greater opportunity
for successful treatment.
o (OUn r
The improved political representation of
women in Iraq is in sharp contrast to
their broader disempowerment, as high-
lighted by the persistence of domestic
violence and early marriage, according to
a new report by the UN Inter-Agency
Information and Analysis Unit.
Women may hold 25% of seats in the
Iraqi parliament, but one in five in the
15-49 age group has suffered physical
violence at the hands of her husband.
Anecdotal evidence alleges that "many
women are being kidnapped and sold
into prostitution", and female genital
mutilation is still common in the north,
the report notes.
"The situation many Iraqi women and
girls face is beyond words," journalist
Eman Khammas told IRIN in a telephone
interview. "Before, I was a journalist, a
professional; now, I am nothing."
Khammas noted an underlying polit-
ical climate of intolerance that has
become increasingly poisonous for
women. She was forced to flee Iraq after
receiving death threats that effectively
stopped her - like thousands of other
Iraqi women - from working. She now
lives in Spain.
Stay home
Women's participation in the labour
54 I MID D L E EAST HEALTH
Financial issues
Economically, men are generally the
breadwinners in Middle Eastern societies.
This means women are generally submis-
sive to men as most are totally financially
dependent on them. This can cast a dark
shadow on women seeking healthcare.
The financial burden of healthcare for a
women in some cases results in the male
relative refusing to provide money for
visiting a doctor. Thus, a man can simply
determine the course of a woman's health
care based on his perception of her value,
by asking the question: Is she worth the
financial cost of health care?
However, it is not always the case that a
woman is unemployed or dependant on
her husband or male relative. I know tens
of working women on whose salaries entire
or women
force has fallen sharply since 2003. Before
the invasion, 40% of public sector workers
were women, according to a report by the
Brussels Tribunal, an anti-war organisa-
tion. Some sectors, such as the teaching
profeSSion, were almost entirely staffed by
women, Khammas said.
She cited the "new, fundamentalist
thinking", which emerged after the 2003
invasion of Iraq that has been aggressively
imposed by the militias, armed private
groups purporting to uphold religious law.
The collapse of public social services has
also limited access to education, health
and jobs, while a high level of insecurity
has pushed women out of public life and
into the seclusion of their homes, and an
ineffective judicial system has created an
atmosphere of impunity, Khammas said.
The conservative attitudes of public
sector officials has been reinforced by a
government that supports keeping women
at home, according'~ a 2007 report by the
international women's resource network,
MADRE.
"In 2006, the Iraqi Interior Ministry
issued a series of notices warning women
not to leave their homes alone and
echoing the directives of religious leaders
who urge men to prevent women family
members from holding jobs," the report
noted.
The most shocking
image of the pain and
suffering Iraqi women
endure due to the
insecurity is apparent
in the hardships they
suffer when they are
pregnant.
,
"Thus, the violence carried out by
militias in the streets is backed up by
more respectable political leaders, who
support the call for a women-free public
sphere."
Escalating poverty has pushed Iraqi
families into prioritizing schooling for
boys, stifling future opportunities for
women.
"For every 100 boys entolled in primary
schools in Iraq, there are just under 89
girls," the UN Children's Fund (UNICEF),
said in a report released in September
2010. School enrolment figures for girls
have been progressively declining, while
drop-out rates have gone up in every
academic year.
Getting out
Factors pushing girls out of schooling
included "security risks, attitudes to girls
and education, the state of the nation's
schools, what is taught and how it is
taught, the skills and attitudes of teachers,
family poverty," UNICEF said.
Like Khammas, many other women
have chosen to leave Iraq, but asylum
does not necessarily end their difficulties.
Neighbouring Syria is home to the
majority of what the UN Refugee Agency
(UNHCR) considers as Iraqi "persons of
concern" - people who have left their
families depend; yet, their husbands
control the cash flow. Traditions, religion
and cultural heritage tell women to be
submissive; entire generations are raised
this way and the vicious cycle continues.
Violence
The terrorism and violence which swept
Iraq in the past decade added a completely
new dimension to the problems in Iraq in
general and to women's health in partic-
ular. Transportation became very costly,
making it inaccessible to many. People
were (and many still are) afraid to go
outdoors on a regular basis.
Generally Iraqis in Bagdad try to stay
indoors as long as possible for fear of being
trapped in armed conflicts or blasts.
Therefore, a sick person will wait at home
home country out of fear for their safety
but do not conform to the legal defini-
tion of "refugee".
Of the 139,000 registered Iraqi
persons of concern in Syria, 28% fall
under female-headed households, the
UNHCR Protection Officer in Syria,
Aseer Al-Madaien, told IRIN in an
email interview.
Many do not have work permits,
which compounds the difficulties female-
headed households face in neighbouring
countries, where they struggle to make a
living, "especially paying the rent", while
still "coping with family, social and
community pressure", Al-Madaien
commented.
Their vulnerability can lead to
exploitation. "There is trafficking
happening among the Iraqi refugees,
[bur] the scope and modality is not
known to us," said Al-Madaien.
According to the UN Inter-Agency
Information and Analysis Unit report,
"Victims are trafficked internally and to
neighbouring countries, including Syria
and the Gulf states". -IRIN
on the
WEB IAU - End Violence Against
Women Campaign
imp ://www.iauiraq .org/end-violence-
againsH(lomen-cam/)ain. asp
as long as possibl~ until the symptoms like
pain, discomfort and disfigurement
become unbearg.'ble and he or she is forced
to seek medical treatment.
The most shocking image of the pain
and suffering Iraqi women endure due to
the insecurity is apparent in the hardships
they suffer when they are pregnant.
Crucial antenatal check-ups are, in many
cases, omitted during early pregnancy,
because the obstacles of getting to a
primary healthcare centre are too great.
What's even more shocking is the number
of cases of women who go into labour and
are unable to get to the nearest hospital in
time to give birth. Police and military
check points cause delays by inspecting
everyone, including ambulances. No one
dares venture out after midnight because of
the curfew (midnight to 4am) in Baghdad
and some other parts of the country.
During my medical practice, I received
many cases like this. In one such case I had
to deliver the baby of a 20-year-old woman
in an ambulance because we could not
make it to the hospital in time.
Distressing incidents
Another incident I experienced - one of
many such incidents - highlights the plight
of women seeking healthcare in Iraq.
One evening, while doing an ER shift at
a hospital in a poor part of Baghdad, an 18-
year-old woman admitted herself, escorted
by her sister. She was in a hurry and asked
me to treat her quickly. I asked her what
had happened and she told me that her
husband had stabbed her with a screw-
driver. She showed me four deep, heavily
infected wounds in her left thigh. I asked
her why she had not visited a doctor
earlier. She replied, saying that her
husband locked her in the house for a week
as an additional punishment following the
physical abuse.
I treated her and told her that she should
let me report her husband to the police,
but she told me to mind my own business,
adding that she did not want to get into
even more trouble and quickly left with
her sister.
Another distressing incident happened
during a visit to Al-Najaf in southern
Iraq. There are two types of hospitals in
the city, one that is strictly for women
and managed by women, and another
MIDDLE
They refuse to be
examined and treated by a
male doctor. And in some
cases where the woman
accepts the idea of being
treated by a male doctor,
their male relatives refuse
to allow it.
that mainly receives men, although it
can receive women as well. The women's
hospital has an all-female staff and men
are not allowed to enter, even if they are
doctors. Due to the huge shortage of
physicians in Iraq, the women's hospital,
in particular, lacks many specialists, such
as anaesthesiologists. Despite this,
women continue to visit this hospital in
the knowledge that the care may not be
that good because of the shortage of staff.
They refuse to be examined and treated
by a male doctor. And in some cases
where the woman accepts the idea of
being treated by a male doctor, their male
relatives refuse to allow it.
The future
Although more healthcare resources
would help the plight of women in Iraq,
this is not entirely the solution to the
inequitable health care for women. What
is required is a change in the way the
people of Iraq view women in the society.
Gender equality, women's rights and access
to proper healthcare are issues that are
fundamentally intertwined and interde-
pendent. Enabling unencumbered access
to health care for women involves a funda-
mental shift in the mindset of the people
of the country, to improve gender equality
and ensure that basic, universal human
rights are applicable to all women in Iraq.
Education is the key to implementing this
change.
Dr Nabil AI-Khalisi, MD, worked at
the Iraq Medical City in Baghdad. He is
currently doing Public Health Research at
the University of Georgia. Dr AI-Khalisi
has written several articles about his
medical experiences in Iraq which have
been published in several publications
including the British Medical Journal.
Email: nabeelraad@gmail.com
E A S THE A L T H I 55