Children’s Welfare Teaching Hospital, Iraq

The Medical City Complex, Baghdad.

In the last decade the health status of the Iraqi people has suffered serious setbacks. The unfortunate circumstances of wars and economic sanctions have damaged many aspects of life in Iraq, with adverse effects on physical health, nutritional status, psychological well-being and the rising incidence of communicable and non-communicable diseases including cancer - this after substantial progress had been made in improving survival rates for children with both acute and chronic diseases. The challenge of delivering effective health care has been made more difficult by limited investment in clinical facilities and the severe damage done to existing facilities in recent times.

Children’s cancer accounts for a higher percentage of cancer in developing countries than in high-income countries due to the greater proportion of children in poorer nations. Iraq is no exception in this regard. Unfortunately, given the complexities of diagnosis and treatment, children with cancer have greater needs, which often cannot be met. In this report, the situation at the Children’s Welfare Teaching Hospital (CWTH), part of a medical city complex in Baghdad, and in particular, the situation with childhood cancer, will be described in order to illustrate the problems faced.

CWTH is a tertiary care center established in 1984; maintenance was last carried out in 1989. The hospital is recognized by the Iraqi Commission for Medical Specialization for the training of post-graduate students for the National Board in Pediatrics. The clinical facilities of this 240-beds hospital include general pediatric wards and specialist units for hemato-oncology, neonatology, emergency medicine, pediatric surgery and respiratory care. The pediatric oncology ward was established in 1984; today it includes two medical oncologists, three fellows, two hemato-pathologists, four interns alternating every two months and fourteen nursing staff (versus five before 2003). We have an outpatient department and chemotherapy daycare (ten beds), but no bone marrow transplant unit.

Our infrastructure is damaged at the level of the most basic facilities. Electricity, sewage, water and communications systems, while improving, remain below the standard required for safe and effective health care. The support services, including the clinical chemistry laboratory, blood transfusion, radiology and pharmacy departments, are operating below capacity and to questionable safety standards, with a continued lack of maintenance. Information systems and warehousing facilities necessary for the distribution of medicines have progressively deteriorated. We do not have a radiotherapy department. While there is a national radiotherapy institute that provides services for the entire country, this facility has a long waiting list (which can be as long as six months or even more). Most radiotherapy is delivered by Cobalt60 machines from an earlier era; a single linear accelerator is out of order most of the time.

Chemotherapy is administered by resident doctors because we do not have dedicated oncology nurses. We are not equipped to insert and maintain indwelling intravenous catheters. The paucity of diagnostic capability, both quantitative and qualitative, imposes major limitations on diagnostic accuracy and jeopardizes appropriate therapy. Palliative care is nonexistent due to morphine being unavailable, while less effective analgesics are available only in small quantities. In addition, there are no social workers or cancer support groups. Infection is the most frequent cause of morbidity and mortality because of the children’s poor nutritional status, lack of an infection control policy and the high rate of parent illiteracy.

We see 260 new childhood cancer cases per year, excluding brain tumors, with a monthly average of 500 patients seen in the outpatient department and approximately 30 inpatients treated each day. Leukemia is the most common neoplasm, followed by lymphoma. Currently our unit is implementing western protocols modified to make them feasible in the context of the local situation. Our unit provides care to patients from various parts of the country. It is one of two centers for childhood cancer in Baghdad.

We do not have a functional data management system so that the data regarding cancer rates in Iraq are somewhat sketchy, although Iraq established a population-based cancer registry in 1976. The cancer unit registry is kept manually by the pediatric oncologists running the unit. We have a limited access to medical libraries and the latest research because of the intellectual embargo from the international medical community. Internet access is minimal. There is always a significant delay between the disease manifestation and referral to us because of delays in diagnosis, or the problems of transportation faced by families who live in distant provinces. We lose a relatively high fraction of patients to follow-up because of economic and security problems or military operations in their regions, causing difficulties in assessment of long-term survival in patients who have completed treatment.

Since 2003 the care of children with cancer has been supported by a number of organizations, including INCTR. INCTR, sponsored by the Office of International Affairs of the NCI, took primary responsibility for developing pediatric oncology workshops designed to identify problems faced by Iraqi pediatric oncologists and to provide relevant updates and continuing education with respect to the care of children with cancer. The strategy focuses on providing assistance to pediatric oncology teams currently practicing in Iraq, including educational updates offered through workshops. To date, three workshops have been held. The first workshop was held at the King Hussein Cancer Center (KHCC) in Amman, Jordan, in April 2004. Dr. Aziza Shad, Chairperson of INCTR’s subcommittee on pediatric oncology education, designed a program focused primarily on pediatric leukemia, lymphoma, and supportive and palliative care. A follow-up meeting was held in Cairo, Egypt, in October 2004 as part of INCTR’s annual meeting. We also participated in the First International Oncology and Nuclear Medicine Workshop and the First International Conference on Pediatric Oncology (a workshop focused on research methodology and management of common pediatric cancers), held on July 8-10, 2005 in Karachi, Pakistan, a meeting also conducted in collaboration with INCTR’s Pediatric Education Subcommittee. Our participation in these workshops and conferences, with exposure to internationally accepted current practices, encouraged us to implement improved patient management practices in our daily work. It has also provided us with access to expert consultants when we have difficulties in management, enhances our links with international institutions, and encourages a multidisciplinary approach to the management of childhood cancer. The value of this support is reflected in a decrease in overall mortality rate from 20.8% in the year 2000 to 10.9% in 2004.

Other international organizations are also providing aid. A recent collaboration with the hematology unit of La Sapienza University in Rome, supported by an Italian non-governmental organization known as INTERSOS, has been is a rewarding experience. One specific outcome has been the design of a modern treatment protocol for the management of Iraqi children with acute promyelocytic leukemia. The treatment protocol for this leukemia, which has a relatively high incidence and mortality in Iraq, includes the use of a retinoid drug (ATRA) provided by INTERSOS; professional consultation is provided via televideo linkage. We have seen survival rates improve from less than 10 percent to more than 80 percent in treated cases.

Dr. Salma Al-Hadad and staff.

International Medical Corporation (IMC) funded a partial reconstruction of the pediatric unit in 2004, providing a children’s playroom and internet connection. IMC also supported a six-week training program for five doctors and five nurses at KHCC. Japan-Iraq Medical Network (JIM-NET) is coordinating a program that provides chemotherapy medicines, infection control materials, a teaching microscope, infusion pumps, centrifuges, etc., as well as training at KHCC for a doctor, a nurse and a bacterial culture technician. At a workshop in Amman in September 2005, JIM-NET evaluated the support and medical situation in Iraq, and made recommendations for establishing a cord blood bank in Iraq.

Our requirements for improving patient care include improved infrastructure and human resources and more equipment and medicines, which should be made available through a government drug delivery system. We need to further develop our educational programs and research collaboration with other cancer centers in order to catch up with modern care and preferred treatment protocols after a long period of isolation from the outside world and, consequently, an inability to keep up with and implement medical advances.

Contributed by Salma Al-Hadad and Mazin Al-Jadiry, CWTH, Baghdad, Irak