In the Holy City of Karbala we stood close to two beautiful shrines with golden roofs. We saw an old man near the tombs gracefully putting his face in mud. He said that the mud is from the tomb of Imam Hussein, grandson of the prophet Muhammad. His belief was that the holy mud would bring the gift of health from Allah and ‘soak out’ disease. Many people with diseases as severe as this old man’s believe in God. Their belief helps them to fight their disease burden, the suffering and worries, bringing patience and a way to withstand their disease. They strongly believe that a higher power will protect and support them. Cancer patients with terminal illness strongly emphasize their belief in spirituality. Their religion and reading the Koran give strong assistance and support.

In the governorate of Holy Karbala five hospitals with around 1,000 beds serve a population of about 900,000 inhabitants [1]. The largest is Al-Husain University Hospital, built in the year 1970 and managed by the Ministry of Health [2]. It contains different departments: surgical theatres, internal medical facilities, technical and administrative departments, among others. The hospital has about 700 employees divided into more than ten professional groups. Fifty pharmacists work in the hospital, illustrating the important role the pharmacists play. Like many other Iraqi hospitals, the funding received is hardly sufficient to cover salaries and recurrent expenses. Due to the huge number of visitors and expatriates who either visit or settle in the city, there is an urgent need to build at least 17 hospitals and healthcare centres in order to meet the needs of the health sector [2]. According to the annual report of Karbala province council for the year 2007, the most common causes of death among the population of the province are those associated with heart diseases, stroke, cancer and respiratory diseases [3], as in many Western countries, although the death rate from cardiovascular diseases seems much higher.

Cancer treatment and care

What follows is an account of our recent observations at Al-Husain University Hospital.

Cancer patients typically stay in mixed medicine wards together with, for example, surgical patients, patients with severe cardiac disease, and others. There can be up to around 50 patients per ward, divided into individual rooms or bays each accommodating between two and eight patients. Each ward is served by 15 nurses, as well as cleaners, a pharmacist and visiting physicians.

We have observed, however, that there is nowhere for patients to meet their family or friends privately. This can cause considerable chaos, the large halls fill up with visitors. The hospital does not provide any active treatment for cancer, either radiotherapy or chemotherapy. Cytotoxic drugs are not available in any of the hospitals of Holy Karbala and patients have to go to Babylon for chemotherapy. Patients may get prescriptions for hormones which have to be bought at the patient’s own expense and brought to the hospital for administration by a nurse.

Cancer diseases are of major concern, where most diagnoses are made at an advanced stage and the treatment and care are obviously seriously deficient. Many patients arrive too late for cure. Their care is focused on palliative support with pain relief, prophylaxis for nausea and vomiting, dyspnoea and other disease symptoms. Eventually patients leave the hospital and go home for a peaceful death. There is a pressing need for specialist oncologists, palliative care nurses, as well as well-trained clinical pharmacists in the Holy City of Karbala.

Drugs from the hospital dispensary are administered free of charge to patients [3]. However, the dispensary only stocks essential drugs and not all the drugs needed by patients. Patients that can afford to buy medicines from private pharmacies but the costs can amount to more than a monthly salary. Remarkably, we have found that some physicians help to pay for the drugs from their own pockets. On the ward, a clinical pharmacist dispenses drugs to patients but is seldom in obvious contact with them but may be consulted over pharmaceutical problems. The clinical pharmacist checks and signs for prescribed drugs, as well as the appliances used in the hospital, and distributes medicine to the various departments based on need. Outpatients or their relatives can collect prescriptions from the dispensary.

The procedure for having a consultation with a physician is complicated. On arrival at the hospital patients must wait in line to get a pass, which allows a visit to a dedicated physician. They then have to wait in line again to see the doctor. Even patients from outside Holy Karbala may have to wait for up to four to six hours for clinical investigation. The queuing is so disorganized that many patients show up really early in the morning to be sure of getting examined. Physicians might arrive late, further delaying the consultation. Some physicians fail to appear altogether, which creates large problems for those who have travelled a distance, including from other governorates. Drugs are prescribed based on patient’s description of their symptoms rather than necessarily following tests. Follow-up appointments are sometimes put in a notebook but many patients are illiterate.

The hospital has a clear hierarchy in which the patient is the lowest. Consultations are often disturbed and the physician sometimes even leaves without any explanation. Without privacy, a patient is surrounded by other patients and ‘listeners’ while trying to give the physician his or her medical story and problems. Medical students may also be present. Even dying cancer patients can be present in the consultation room.

The hospital kitchen has a high standard of hygiene which may be due to an agreement with private restaurants to make food for the patients. There were guidelines as well but these are not followed.

In a recent study, a validated instrument to measure Quality of Life EORTC-QLQ-C30 in cancer patients gave a low score for overall functioning and a high score for symptomatology in those with advanced disease in the Holy City of Karbala [4]. The patients’ scores for emotional, social, physical and role functions but not cognitive function were generally low, indicating poor overall quality of life. The frequency of treatable side effects from the disease and the treatment, such as pain, constipation, nausea and vomiting, indicated that there was only limited knowledge and resources available for patients. Fatigue, which seems to be one of the most reported symptoms among advanced cancer patients, showed a high association with other symptoms and functions. Qualitative studies have also revealed that the highest amount of social support came from a patient’s spouse, physicians and from his or her spirituality. Many of the advanced cancer patients focused on specific problems as a way to cope with their disease [4].

Our observations, together with these published studies, suggest an overall lack of sufficient relief of symptoms for cancer patients and lack of palliative care in Iraqi hospitals. Just one good relationship from a single source may provide an important level of support for patients. Spiritual coping and religious support, praying and reading the Koran, is of great importance as an additional coping element.

Perspectives

In the last decades, Iraq has been destroyed by war, sectarian conflicts, sanctions, and rigidly centralized and authoritarian rule. These conditions have increased the Iraqi grievance and economic crisis and led to a huge loss of human life [5].

Despite the country’s rich natural resources, Iraq’s human deve lopment indicators are now among the lowest in the region, and imply suffering from a double burden of diseases. There are major communicable diseases, along with cardiovascular diseases, diabetes and cancer which are all of major concern. Critical weaknesses characterize the management of the health sector in the country. A rational process of strategic planning, evidence-based decision making and a formal health policy is not available in Iraq. There exists no national insurance system or a system based on sickness funds [5, 6].

It is clear that Iraq currently faces enormous health challenges. Obviously, few other countries have experienced such deterioration in health status during the last two decades [5]. We have found the problems to be obvious for the cancer care in Holy Karbala. There is an urgent need to build and develop health centres and hospitals, and to train professionals to provide support. It is also important to educate palliative care physicians and nurses in order to respond to the patient’s needs [3].

The provision of psycho-social care, nursing, symptom relief, rehabilitation and palliation in cancer patients should be based on the individual patient’s needs including their own preferences and situation. Academically based, continuous and systematic screening may be the best way to help individual patients, taking into account their physical, mental, social and existential needs. A comprehensive picture of the patient’s entire problems is needed in order to provide a comprehensive plan of action involving the appropriate specialists. Clinical pharmacists can play an important role in these procedures as well. This whole process is crucial for raising the quality of life for Iraqi patients [7].

In summary, Iraq has a dire need for studies to assess the needs of cancer patients so as to develop palliative cancer care units and the Iraqi health system in general [8].

Authors

Ayat Mohamad-Ali Majid

Professor Per Hartvig-Honoré, PharmD, PhD
Professor in Pharmacokinetics

Department Pharmacology and Pharmacotherapy
Farma, University of Copenhagen
2 Universitetsparken
DK-2100 Copenhagen, Denmark

Riyadh Toma, MD
Department of Urology
College of Medicine
University of Karbala
Karbala, Iraq

References

1. IACCI-Iraqi American Chamber of Commerce and Industry [homepage on the Internet]. Karbala Governorate. 2012 [cited 2012 October 12]. Available from: www.i-acci.org/News/karbala.htm
2. Imam Al-Hujjah Hospital [homepage on the Internet]. Karbala; c2012 [updated 2012; cited 2012 Dec 20]. Available from: www.karbalahos-pital.com/karbala.html
3. Alwan A. Health in Iraq: challenges facing reconstruction of the health sector, and our vision for the immediate future. Baghdad, Iraq: Ministry of Health; 2004.
4. Mohamad-Ali Majid A, Toma R, Hartvig-Honoré P. Quality of life of patients with advanced cancer disease in Iraq; 2012 [Unpublished].
5. Iraq. Ministry of Health, Directorate of Public Health and Primary Health Care; Ministry of Planning and Development Cooperation, Central Organization for Statistics & Information, Iraq; World Health Organization. Chronic non-communicable diseases risk factors survey in Iraq. Baghdad: Ministry of Health of Iraq; 2006. Available from: www.who.int/chp/steps/IraqSTEPSReport2006.pdf
6. Iraq. Ministry of Health, Central Organization for Statistics & Information Technology, Iraq; World Health Organization. Iraq Family Health Survey 2006/7. Baghdad: Ministry of Health of Iraq; 2008. Available from: www.who.int/mediacentre/news/releases/2008/pr02/ 2008_iraq_family_health_survey_report.pdf
7. Nielsen MM. Report on the organization of palliative care in North Jutland. Region North Jutland. 2008;J.nr.:1-31-72-0001-07. Danish. Available from: www.rn.dk/NR/rdonlyres/56E3B348–102C-467C-86 A8-EF6D68802F4C/0/Rapportvedr%c3%b8rendeorganiseringafden palliativeindsatsiRegionNordjyllandDOC.pdf
8. Alwan A. Health in Iraq: the current situation, our vision for the future, and areas of work. 2nd ed. Iraq: Ministry of Health of Iraq; 2004.