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Iraqi medical education under the intellectual embargo
THE LANCET, Volume 355, Number 9209 25 March 2000 Viewpoint
Leila J Richards, Stephen N Wall
Lancet 2000; 355: 1093-94
Brooklyn, New York (L J Richards MD MPH), and Department of Pediatrics, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA (S N Wall MD SM)
Iraq's health services have declined substantially since the Gulf War and the imposition of United Nations sanctions.1-7 However, the impact of sanctions on the flow of medical and scientific information has received little attention. Iraq was essentially cut off from all outside medical information in 1990 when United Nations Security Council Resolution 661 froze Iraqi assets abroad and banned all trade with Iraq after the invasion of Kuwait. Unlike previous sanctions imposed by the United Nations against member states, Resolution 661 provided no exemption for the transmission of medical and scientific literature. The resulting intellectual embargo has isolated Iraq from the international medical community for the past decade. In the USA, this intellectual embargo has been enforced through postal-service regulations, licensing requirements for goods sent to Iraq, visa restrictions, and a ban on travel to Iraq by Americans.
We were members of a public-health delegation to Iraq in May, 1999, to examine the impact of the intellectual embargo on medical education. Our trip was sponsored by the American Friends Service Committee, with assistance from the Iraqi Red Crescent Society, the Middle East Council of Churches, and the Mennonite Central Committee. In Baghdad we met with officials from the Iraq Ministry of Health, who granted us unrestricted access to all sites we requested to visit. We were also briefed by senior members of WHO, UNICEF, and the Office of the United Nations Coordinator of Humanitarian Affairs in Iraq.
We visited six of Iraq's ten medical colleges, meeting with more than 30 physicians and academicians. At each medical college we talked to deans and senior faculty staff, visited hospitals, and toured medical libraries. During hospital tours, we held impromptu meetings with clinical faculty members and house-staff physicians. Unfortunately, medical students were not available to meet with us because of examinations. We asked the physicians we met how their working and teaching environment compared with the pre-sanctions period, and how they were coping with 9 years of scientific isolation.
Iraqi medical education
Iraqi medical education is based on the 6-year British curriculum and is carried out in English. Medical education is free, and before sanctions were imposed all required textbooks were provided free to students. Postgraduate residency training is required for both Iraqi and Arab board certification in each specialty. Before the Gulf War, the government funded subspecialty training abroad, and most members of the senior faculty we met had been trained in British or American hospitals. Academic physicians in Iraq, most of whom are specialists, are expected to publish their research in peer-reviewed journals to be eligible for promotion to the highest levels. After United Nations sanctions were imposed in 1990, the delivery of European and American medical journals to Iraq abruptly stopped. US government regulations enacted since 1990 have explicitly prohibited the export of such printed matter to Iraq. The US Postal Service stipulates in its International Mail Manual that mail sent to Iraq must weigh less than 340 g and contain only "personal communications".8 All other categories of mail, including regular printed matter, books, periodicals, and sheet music have been "suspended until further notice".8 US Treasury Department regulations explicitly state, "except as otherwise authorized, no goods, technology (including technical data or other information) or services may be exported from the United States . . . to any entity owned or controlled by the Government of Iraq, . . . or operated from Iraq". The only exceptions are "donated foodstuffs in humanitarian circumstances, and donated supplies intended strictly for humanitarian purposes".9 Our conversations with Iraqi doctors and librarians indicate that European nations have issued similar regulations.
Since the imposition of sanctions, Iraqi medical students have no longer received British and American textbooks, which had been the basic texts used in all classes. WHO is now the major supplier of Iraq's medical literature, and has provided a limited number of medical textbooks, journals, and CD-ROMs to Iraqi medical college libraries, but must receive approval from the United Nations Sanctions Committee for each item sent.
Iraq's other major supply of medical literature is from visiting delegations that hand-carry medical textbooks and journals into the country. Isolated editions of these medical journals, or photocopied versions, are prominently displayed on the shelves in medical libraries, often bearing the original address label of the donating physician. Donated medical textbooks are reproduced as bound photocopied versions by the Ministry of Health or by medical school libraries. These were often the only recent textbooks available in the libraries we visited. Although the quality of the copied text was often good, the illustrations were undecipherable.
Some medical schools now provide photocopied textbooks for free to their senior medical students. Most of the recent medical literature we saw, both original and photocopied versions, were in the libraries of Baghdad's three medical colleges. Few medical libraries in north or south Iraq had new textbooks or journals, even photocopied versions. There was no cataloguing system to help physicians find journals in the random assortment of donated medical literature in Iraq's medical libraries. Such a system would be difficult to implement in any case since Iraq's medical colleges are not linked by computer, and the telephone service between regions of the country is erratic because of bombing damage to the telecommunications
Travel, infrastructure, and research
The intellectual embargo also restricts travel to and from Iraq. Travel to Iraq from the USA is punishable by a fine and a prison term.10 WHO has sought the United Nations' permission to bring consultants to conduct training conferences in Iraq, and to arrange for Iraqi physicians to take courses abroad, but to date without success. Iraqi physicians who wish to attend international conferences also face travel restrictions. Several physicians spoke of being denied visas to European countries or the USA to attend medical conferences, even when invited as guest speakers by conference organisers.
The physical breakdown of educational and health facilities also contributes to the declining quality of medical education. Frequent power blackouts shut off lights and audiovisual equipment in classrooms and laboratories. Broken or obsolete equipment needed for teaching cannot be replaced; the United Nations' oil-for-food programme does not include funds for training and teaching supplies. Educational facilities have few computers, and no access to the internet. Hospitals are filled with aging and broken medical equipment (eg, cardiorespiratory monitors, ventilators, and radiography machines) and wards still lack basic items such as soap and bed linens. To make the best use of remaining resources, some medical colleges have cut their class sizes by as much as 30%.
The academic physicians we spoke to had been forced to curtail all basic and most clinical research. Those who still carried out clinical research had to contend with a dearth of recent specialty journals, limited access to computers, and medical records lacking basic diagnostic studies and therapeutics. Iraqi academic physicians frequently expressed doubt that any international journals would be willing to consider their papers written under these conditions. As one Iraqi physician stated, "If I sent my work outside for evaluation I would never get an answer." Nevertheless, Iraqi medical colleges have continued to publish their own national specialty journals in English, and some doctors told us of getting their work published in Arab language journals.
Faced with poor working conditions and dwindling salaries, thousands of experienced Iraqi doctors have left the country in recent years. The dean of one medical college told us that he was the only remaining faculty member in his department who was a member of the Royal Society of Physicians, whereas before the Gulf War there had been 12. Even recent graduates have left medicine to pursue more lucrative jobs in the local cash economy, such as driving taxis or taking menial jobs with United Nations agencies. At a prestigious Baghdad medical college, the dean described his students as depressed, demoralised, and anxious about their future.
Iraqi doctors we talked to offered the following suggestions for international physicians and organisations who desire to assist medical education in Iraq: provision of current textbooks (in English) for students, recent journal abstracts on CD-ROM, and teaching materials (eg, undergraduate and continuing medical education) on videocassette or CD-ROM; organisation of conferences on medical updates in each specialty, to be held in Amman, Jordan, should travel bans preclude lawful entry into Iraq; and advocacy to end the intellectual embargo of medical information by the United Nations and member states.
Infrastructure damage, a failing economy, and a 10-year intellectual embargo have affected every level of medical education in Iraq, leaving the country's next generation of doctors ill-equipped to inherit the country's health crisis. We believe that there is no justification for this intellectual embargo against Iraqi physicians. Restricting the flow of scientific information to Iraq ultimately serves to undermine the care of patients, and denies Iraqi doctors the right "to share in scientific advancement and its benefits", as stated in the Universal Declaration of Human Rights.11 We hope that international physician groups will organise efforts to support Iraqi colleagues, and to advocate an end to the intellectual embargo.
1 United Nations. Report of the second panel established pursuant to the note by the President of the Security Council of 30/12/99, concerning the current humanitarian situation in Iraq. S/1999/356, 30 March 1999. New York: United Nations, 1999.
2 Richards L, Dugbatey K, Garfield R, Hansen C, Sunderwirth R, Wall S. Living under sanctions: the intellectual embargo and the oil-for-food program. Philadelphia: American Friends Service Committee, 1999.
3 United Nations Security Council. Report of the secretary-general pursuant to paragraph 6 of Security Council resolution 1242. S/1999/896, 19 August 1999. New York: United Nations, 1999.
4 UN Coordinator of Humanitarian Assistance. Special topics on social conditions in Iraq: An overview submitted by the UN system to the Security Council Panel on Humanitarian Issues. Baghdad: UNOCHI, March, 1999 (also available online at www.cam.ac.uk/ societies/casi/info/spec-top.html).
5 UNICEF. Situation analysis of children and women in Iraq. Baghdad: UNICEF, April, 1998.
6 Richards L, Cunningham N, Dale N, Sunderwirth R, Wray J. Child and maternal health, nutrition and welfare in Iraq under the sanctions. Philadelphia: American Friends Service Committee, 1999.
7 Hoskins E. Public health and the Persian Gulf War. In: Levy B, Sidel V, eds. War and public health. New York: Oxford University Press, 1997: 254-78.
8 Postal restrictions governing mail sent to Iraq. In: US Post Office international mail manual. Washington, DC: Corporate Publishing and Information Management, 2000: 581.
9 Prohibited exportation and reexportation of goods, technology, or services to Iraq. Title 31, vol 2 (revised July 1, 1998), section 575.205. In: Code of federal regulations. Washington, DC: US Government Printing Office, 1998: 665 (also available online at www.access.gpo.gov/nara/cfr/waisidx_99/31cfr575_99.html).
10 Prohibited transactions relating to travel to Iraq or to activities within Iraq. Title 32, sections 575.207 and 575.701. In: Code of federal regulations. Washington, DC: US Government Printing Office, 1998.
11 Universal Declaration of Human Rights, article 27. In: Universality of science. Handbook of ICSU's standing committee on the free circulation of scientists. Stockholm: International Council of Scientific Unions, 1990-91:10.
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