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News Conference on DoD Efforts to Help Rebuild the Iraqi Health System

Presenter: Assistant Secretary of Defense for Health Affairs Dr. William Winkenwerder
July 25, 2003

(News Conference on Defense Department Efforts to Help Rebuild the Iraqi Health System and to Advise the Iraqi Ministry of Health. Briefing slide used in this briefing are available at http://www.defenselink.mil/news/Jul2003/g030725-D-6570C.html. A photo of this briefing is available at http://www.defenselink.mil/photos/Jul2003/030725-D-9880W-037.html. Information requested in this briefing is available at http://www.defenselink.mil/news/Jul2003/d20030725nongovorgs.pdf and http://www.defenselink.mil/news/Jul2003/d20030725mohorgchart.pdf.)

Staff: Good afternoon. Today we have assistant secretary of Defense for Health Affairs, Dr. William Winkenwerder, to share with you the Defense Department's efforts to help rebuild the Iraqi health system and to advise the Iraqi Ministry of Health. Dr. Winkenwerder just returned from a week-long tour of the health care situation in Iraq and will bring you up to date.

Dr. Winkenwerder?

Winkenwerder: Good afternoon. Thank you for coming.

I just returned last week after visiting with the senior adviser for the Ministry of Health in Iraq, and after visiting with more than 250 medical leaders throughout Iraq in Baghdad and the surrounding communities. There are a number of very significant steps being made to improve the health situation and the lives of all Iraqi citizens -- Shi'a and Sunni, Arab and Kurd, men and women, and children of Iraq who make up almost 50 percent of the entire population. These steps are being accomplished through a broad effort involving agencies across the federal government and support from around the world.

I want to tell you about what I witnessed, what is happening, and what is planned.

There is a great deal of progress being made each day in Iraq led by an energized and educated Iraqi medical community who are ready and capable of reestablishing relationships with a worldwide medical community, from whom they've been isolated for many years now. And they want to reestablish their country as a regional health care leader, as it once was 30 or 35 years ago.

The United States and our allies are committed to assisting the Iraqi leadership in rebuilding its health care system, repairing its infrastructure, updating equipment and supplies, and establishing robust public and private sharing of medical expertise, training and materials.

First, however, some context is needed to understand the depths from which this Iraqi medical community is emerging after 30 years, literally, in the dark.

In effect, Saddam Hussein looted the health care system, and through the withholding of funds and corruption, used it to punish the people of Iraq. It's a very sad picture.

One of the pictures we have shows some of the children I saw in one of the children's hospitals who were obviously very malnourished, lacking for immunizations, obviously exposed to things that were totally preventable through just clean water or basic medical care.

There's been severe degradation of the entire system of the last 15 years. There's been little or no maintenance of basic infrastructure. Public and hospital lavatories are in poor shape. Hygiene conditions in many facilities need real attention.

The public health system has deteriorated, resulting in ever- declining clear water and other basic needs. Children are severely malnourished and they're dying because of contaminated water, vaccine- preventable diseases and the lack of proper nutritional diets.

In 2002, our investigation into what was being spent on Iraqi health system shows that less than $20 million was spent for health care for a population of 25 million people. That's less than $1 per person per year. Yet, Saddam and his sons continued to spend the money of Iraq and its resources in their palaces, and in their security apparatus and in their effort to pursue weapons of mass destruction. It is almost unbelievable. One has to be there to believe it and to see it.

Results were evident across the country. I want to quote a few health statistics for you.

Infant mortality rates. The current, or the most recent, data are that 83 deaths per 1,000 births is the infant mortality rate. Out of 17 countries in the Middle East, this was the worst infant mortality rate in the region.

Child mortality rate, which is for children under five: 125 deaths per 1,000. That means one in eight children does not reach the age of five.

Saddam Hussein squandered several decades of progress in reducing Iraq's child mortality rates -- or rather, increasing the rates and reducing survival.

Maternal mortality: 370 per 100,000 live births. Again, Iraq ranked at the bottom: 14th out of 15 countries in the Middle East.

Life expectancy: For men, 59 years of age, and for women, just over 60, ranking 16th out of 17 Middle East countries. Only Iraq and Yemen have life expectancy below 60 years of age for men.

These outcomes, as poor as they are, would have been worse were it not for the heroic efforts of local health professionals and the indispensable assistance from outside agencies, particularly the World Health Organization, who I want to recognize, the Red Cross and the Red Crescent societies, and many nongovernmental organizations who have remained in Iraq despite difficult conditions over the past decade.

With the criminal activity and the grotesque human rights violations perpetrated by Saddam, his sons and their regime, doctors and health professionals were compromised and abused. Some -- we do not know how many -- were made to assist in torture and physical disfigurement of political prisoners and challengers to the regime. This is a particularly cruel and unimaginable stain for people who sought to serve in a healing profession. I spoke to some of these people while I was there.

Despite the poor state of the overall Iraq system, there is, I'm glad to say, an energized and educated medical community that's ready and capable of reestablishing this country as a regional leader. I met with them, I've seen their faces and I've heard their words. They never lost hope. They are ready to move ahead and they will, with our help and the help of other countries and interested parties around the world.

Let me say a word or two about the Iraq medical leadership. As I said earlier, the medical community is comprised of dedicated, well-trained and sophisticated leaders, and it has -- they have the opportunity to rebuild their system. There is a fundamentally sound medical infrastructure. There are enough hospitals; they need to be refurbished. There are enough physicians, but they need refresher training significantly, and they need contact with their peers in the outside world. They're dying for these relationships. There are too few nurses, but there are plans to train more.

We plan to invest our resources -- our staff, our money and our time -- in rebuilding this system, not in creating something new and altogether different. I have a great deal of confidence and optimism about this effort. Our most important short-term focus is to restore the Ministry of Health as the single accountable organization for the effective administration of health care in the country.

Let me take a few moments now to describe what we are doing.

There's a great deal of activity that's taken place. You've not heard about much of this, but I'm here to tell you about it today and to try to summarize it. There's a great deal of activity that's taken place in the past three months. More is happening every week. Mr. Jim Haveman -- that's H-A-V-E-M-A-N -- Jim is now currently our U.S. senior adviser to the Ministry of Health, working as part of Ambassador Bremer's Coalition Provisional Authority. He has been working closely with the Iraq medical community. They have established together a strategic plan for both the intermediate, near- term and long-term needs to reestablish the Iraq health care system. Let me share just some of the accomplishments and plans with you today.

First, money is flowing back into the health care system. We are paying health care workers salaries. They're getting paid and they're back at work.

Secondly, and very importantly, the system is now being funded at an appropriate level, certainly to get the system back on its feet. Ambassador Bremer has approved a budget of $210 million for the Ministry of Health for the next six months. That represents a 7,000 percent increase in budget authority for the health system. Decisions are being pushed, although still being made certainly in Baghdad, are being pushed to the regions and to the local levels.

This was a very tightly controlled, central-planned economy, classic Stalinist type of operation. We want to assist with getting decision- making pushed out closer to the people and their needs.

Secondly, hospitals and clinics are already seeing some renovation and facility improvements. First, with respect to facility repairs, minor things like minor construction, equipment replacement, cleaning, just some basic stuff, has occurred at a number of hospitals already throughout the country. And this has happened through the efforts of the Ministry of health, through the U.S. military and our military civil affairs units, through the efforts of USAID, which has awarded a contract for facility construction to the Bechtel Corporation, and through the World Health Organization and several other NGOs. And let me just highlight some of these things.

We recently installed a new sewage system, a $100,000 project, at the al-Mansur Pediatric Hospital in Baghdad. We opened a brand-new outpatient clinic just last week, fully outfitted, serving a population of approximately 50,000 citizens in a Baghdad suburb.

The Ministry of Health is completely overhauling the government- operated pharmacy and medical supply distribution system. This was known as Kimadia, K-i-m-a-d-i-a. More than 3,000 tons -- let me repeat that -- 3,000 tons; and one ton is 2,000 pounds -- 3,000 of those -- of medical supplies, pharmaceuticals and other perishable items, like syringes and IV packs and laboratory reagents, those kinds of essential things, have been sent to Iraq, are now in the hands of the health care community. That's all been done in the last 50 days.

There is improvement that's being planned for the health professional educations program, how to restart and improve the training of health professionals. Last week, July 16th and 17th, a two-day national nursing conference was held, the first such conference in 35 years. It was very gratifying to see these 250 nurses come together, who had never been allowed to meet in 35 years, to plan what they believe the future of the nursing profession ought to be for Iraq.

I was fortunate to participate in the first national health care conference, in which 250 medical leaders from across the country gathered in Baghdad on July 17th. I might note that that was held on the anniversary of the revolution of the Ba'ath Party, possibly in a defiant decision to make clear that the people of Iraq, the medical community of Iraq wants to move forward. They worked that day and those two days establishing a plan for an integrated, country-wide health needs assessment and a plan to improve the laboratory and medical surveillance system in the country.

Let me touch on health care delivery and the needed primary care. It is back on its feet, and care is being delivered throughout the country. There has now been established monthly immunization days, that was restarted in June, on June 22nd. The next one will be July 22nd, which is -- it was the day before yesterday. We are going to support the Iraqi people in ensuring that the required immunizations are completed on more than 90 percent of Iraqi children by the end of 2004.

Finally, security of hospitals and medical warehouses has improved greatly, and it's getting better on a weekly basis. Nearly all 240 hospitals and 1,200 outpatient clinics are now open and accessible for care. The Iraqi citizens themselves, more than 300, have been trained and are already on the job serving as protective -- a protective service, a sort of police force to protect these health care facilities. More of these individuals are being trained. Another 300 graduates are expected soon.

More is coming in this overall effort. In the coming weeks, we will announce a program in which we will match U.S. and other international medical partners with specific medical centers in Iraq in which we will pledge -- or, those institutions will pledge specific support for training and materials for the local Iraqi medical community. And more to come on that program in the near future.

But I want to tell you about some of the efforts that have already happened along that same vein.

The United Arab Emirates -- and I met with representatives of the United Arab Emirates -- has already completely refurbished one hospital in Iraq and plans on working on additional facilities, and donors are being identified for that. They've done an absolutely terrific job, I thought, and we commended them for that.

The Italian Red Cross has also volunteered to renovate a pediatric hospital in Baghdad.

The government of Japan has entered discussions for assisting in the upgrade and equipping of a number of hospitals that they in fact had helped to build in Iraq in the 1980s, but had been disattached from for the last 15 or so years. And then, there are a number of other governments who have already come forward to offer short-term field hospitals and other offers of medical assistance. And we're trying to work with Mr. Haveman, Ambassador Bremer, others on the ground to coordinate that to make sure that this offer -- these offers of help get to where they're needed as soon as possible.

Goals are being set for the health care system, and these relate to things that they want to achieve in the next six months, in the next year, two years down the road in terms of restoring their system: Improving maternal and child health, mental health services -- and there's a great need for mental health services, given some of the -- literally, the trauma, the mental trauma, psychological trauma that people have gone through.

In fact, one physician who spoke with me about that described it as a new syndrome that the world needs to study -- he called it chronic fear syndrome; I think we've all heard about chronic fatigue syndrome, but he called it chronic fear syndrome -- and what impact that has on the health of people. I was persuaded after talking to many people that this fear factor is very hard to describe to Americans, but it is something that has just been overwhelming for the people there for so many years.

Just seeing the Iraqi medical community set longer-term goals, you can sense the optimism that they and we share in the future of Iraq. Upon Ambassador Bremer's final approval, we will introduce our program to link Iraq's medical community -- its hospitals, physicians, nurses, public health workers, et cetera -- with these other donor organizations. And we'll talk more about that in the near future.

Let me just close by saying it's difficult to express to you the energy and enthusiasm that exists within the medical community about the opportunity that they have to remake their country, and in this particular instance, the medical community and the health system. Neither the Iraqis nor we underestimate the challenge, the size of the challenge of this task. It is enormous. But, together with partners from around the world, I'm very confident that we and our Iraqi friends will be successful.

Thank you very much for attending this. And I'll be happy to answer any questions you might have.

Yes?

Q: Sir, with the electrical systems not yet up to full power across Iraq, how are these newly improved hospitals affected?

Winkenwerder: The power situation has affected hospitals. And one of the steps that is being taken -- I want to just check my notes here to see if we mentioned this, or if in fact we stepped over it. One of the steps that is being taken -- in fact, I did, I stepped over this, skipped over it -- is that $40 million has been dedicated to purchase new generators so that there will be an uninterrupted source of power. That's already happened. Those generators are going to be delivered in the next six weeks. And I'm told that they will be installed within three days of delivery. These generators will be installed in 34 medical facilities and six out-patient clinics. And that will be a big, big help.

Yes?

Q: I've got several questions, actually, if I could. One, I wanted to ask you to clarify something. You said that the Hussein regime was spending $20 million a year on health care, and Ambassador Bremer's budget is $210 million for the next six months. At the Press Club the other day, he said that they were spending $13 million, or at least in 2002 --

Winkenwerder: I said less than 20 (million dollars).

Q: Is $13 million the right figure?

Winkenwerder: That's a figure that's been tossed around. I wanted to give, you know, the ballpark estimate.

Q: And he said $211 million was the budget. I just --

Winkenwerder: It may be $211 million.

Q: I'm picking -- (inaudible) -- but I want to make sure I get it right.

Winkenwerder: Yes. If that's what he said, that's what it is.

Q: And when you talk about the context, to what extent did the U.N. sanctions that Iraq was under contribute to the sorry state of the health care system?

Winkenwerder: The people I spoke with did not believe that that contributed to the problem. What they told me was that much of that money that was coming back into the country was diverted and never ended up for its intended purpose.

Q: In Europe there's been opinion for years that the U.N. sanctions were the reason there was so much suffering among the Iraqi people. Do you think that all of the blame lies with the regime, that the sanctions did not --

Winkenwerder: Absolutely. Saddam Hussein had choices; he chose to do what he did. We also know, without question, that the health care system was used to punish people -- the withholding of services from certain populations, certain groups, certain cities, certain regions.

One story I'll share with you is that in one southern city, what had been a clean water source was turned off and polluted water was placed into the water supply.

Q: Why?

Winkenwerder: To punish.

Q: Well, speaking of punishment, you talked about these doctors you met who had been forced to engage in torture or disfigurement of people. Are there a large number of doctors who were forced to do that?

Winkenwerder: We don't know how many. And let me be clear about the statement that I made. I spoke with physicians who described these things. They did not themselves say that they were involved in these activities.

Q: Wouldn't doctors who had done that be subject to trial?

Winkenwerder: It's possible that that would be something that would happen down the road. They're beyond my ability to describe it to you. There'll be, I'm sure, efforts to look at human rights abuses and --

Q: I'm just wondering if that came up in your conversations with members of the Iraqi medical community, if they feel that they should be put on trial.

Winkenwerder: Honestly, my sense if that there is a great unease, a great weight, a great burden that the community carries because of the obviously conflicted set of -- conflicted set of goals they were being asked to achieve -- that is, serve the people, be a noble health professional -- or at least that was their desire -- and then messages that came from the regime that obviously were in direct conflict with that. And that creates a very difficult situation psychologically for anybody.

Q: Well, at the risk of dominated here -- (laughs) -- I've got two more.

Winkenwerder: Okay.

Q: Are there any or many nongovernmental organizations at work in the health care system? Do you have a list? DR. WINKENWERDER: Absolutely. I don't have a list. We'll try to get that for you. I do know that WHO, the World Health Organization, is very active; the Red Cross; the Red Crescent; some of the ones I mentioned. There are others. I don't want to leave anyone out, so it's probably best for me not to try to list them. (List provided)

Q: Have any been dissuaded from coming because of the guerrilla attacks on the U.S. forces?

Winkenwerder: Not to my knowledge.

Q: You don't think that's interfering at all with reconstructing the health care system?

Winkenwerder: Sure. The activities that have taken place have interfered with everything.

Q: Could you give us some examples of how?

Winkenwerder: Well, it's obvious that if you've got the kinds of activities that have gone on sporadically and in certain places, that it gives concern for everyone involved for their safety.

And you must remember that the people that have been killed have not just been U.S. soldiers or U.S. citizens; there have been Iraqi citizens that have been killed and maimed and injured in some of these attacks. So, has it had some effect? I'm sure it has had some effect, but I would just say it --

Q: (Off mike) -- things like that.

Winkenwerder: But what I'd like to leave with you is my sense, in meeting with the people, that they are determined to press forward. They are not going to let what has happened deter them from achieving their goal. They're energized. One young medical resident described it as being -- having been holed up in a bottle and they were released. And they have a tremendous amount of energy. They're anxious to get things done quickly. They want our help. They desperately want to relate to the medical community in the United States and other countries. They just want to connect with what's going on in the outside world.

Yes?

Q: You said your short-term -- one of your short-term focuses is restoring the Ministry of Health. How long do you think it will take for Iraq to govern its own -- its own ministry of health? How long do you think until they can sort out these things for themselves?

Winkenwerder: Well, the first step was identifying those who were loyal to the previous regime, de-Ba'athification. And that is a process that has been going on, and individuals who were thought to be sympathetic to the regime were identified, have been identified. Others have come forward and said, "Please don't allow this person to continue to lead."

Q: And among those are doctors who performed such atrocities?

Winkenwerder: There well may be, yes. Of course, not everyone who is in a leadership position, to my knowledge, would have participated in some atrocious act, but certainly were part and parcel of a regime that had the effects that I've just described. So --

Q: Any timeline till this ministry is formed?

Winkenwerder: It is formed. People are -- Q Already formed.

Winkenwerder: The ministry is reopened. A $2 million -- the ministry building in Baghdad is reopened. I visited it. That's where the meeting was held on July 17th. A contract was let for almost $2 million to actually repair the building. It had been significantly looted. It is being repaired. It's habitable to work in at this point. And a significant proportion of what had been its total staff is back at work in their jobs.

Yes?

Q: What do you see as the greatest obstacle now? Would you say it's the continuing violence, or would you say that perhaps you're not getting as many nations stepping forward as you would like?

You mentioned Italy and Japan and UAE. But there's a number of nations that haven't stepped forward because they keep saying they want to have a U.N. umbrella here. What do you see as the greatest obstacle -- violence, more nations? What?

Winkenwerder: I don't see the issue of the lack of offer of help from either within this country or other nations as being a problem at all. In fact, my sense at this point is that we're going to have a heck of a time trying to coordinate all the offers of assistance to make sure that they get there. There have been numerous offers of support. I don't believe in any way the issue that you referred to serves as a barrier.

Your second point of your question related to --

Q: Well, let me must follow up on that for just a moment. What other countries have offered help besides UAE and Italy and Japan? Those are the ones that I know about.

Winkenwerder: I'd rather not go into the whole list because I know there are several more who have done a number of things. That's being compiled as we speak. It's best for me not to make any country who's been offering support -- if I fail to mention them, to --

Q: But you haven't seen any people -- any nations holding back?

Winkenwerder: No, absolutely not. None that I'm aware of. And everything I hear from the CPA -- the Coalition Provisional Authority -- team on the ground is they've had all kinds of support offered. It's just a matter at this point, I think, of coordinating all of that offer of support; standing up the Ministry of Health, a new Ministry of Health, transferring the leadership and decision- making to leaders within the Ministry of Health, and also out in the governorates, the regions. And all of that is happening literally as we speak. So our goal is to transition that leadership just like the rest of the Iraqi society to the leadership of the medical community. It's their system, and they're trying to rebuild it, and we're trying to help them.

Q: And really, the overall question was what do you see as the main obstacle at this point? Would it be the continued violence? Or what do you see as the main obstacle for you?

Winkenwerder: The most difficult obstacle is -- it's hard to put one's finger on one single issue or item. I think that there are lots of -- I won't call them "little," but there's lots of different types of challenges. The power generation that I mentioned is certainly one of them. A new sewage treatment facility or facilities throughout the country -- that's going to cost a lot of money, as I understand it-- that's important. So there's these basic infrastructure issues that affect the health care system.

And, you know, if there's one frustration, I guess, as a health care person, it would be that, you know, normally you don't have to worry about those issues to improve a health care system. And in this case, those issues need work.

Yes, sir?

Q: You said that there were enough hospitals, but many need to be refurbished. Is that work that's needed a result of looting, or is it underfunding from the regime?

Winkenwerder: Both. Both.

Q: Okay. I mean, is it mostly looting, or a combination of all of it?

Winkenwerder: It's far more related to the former, the neglect of the Saddam regime. There is no question about that. The war did not damage large numbers of hospitals in significant ways. I think others have said that. That's what I was told, and where I did visit and saw, that's what I saw. I didn't see, you know -- I'm sure I didn't -- was not at enough locations to make a personal testimony to that fact, but I think that's unquestioned. So, it was more of the fact that there had been very little investment for 10 to 15 years, and the money was being diverted to palaces and the military and to, you know, other uses. It just wasn't being spent on a health care system.

Yes, sir?

Q: I'd like to ask you about Mr. Haveman, if I could, because he had a reputation in Michigan for basically having wrecked the mental health system in Michigan by closing about two-thirds of the psychiatric hospitals. So, I'm wondering what qualifications -- what qualifies him for this task in Iraq, and what kind of advice is he giving the Iraqis?

Winkenwerder: First of all, your assertion is a pretty broad statement and supposition.

Q: Well, there were state legislators who said that as a result of what he did to the psychiatric system, that large numbers of the inmates who ended up in the state prison system were identified as having mental health problems.

DR. WINKENWERDER: I'm sure there were and are many others who would tell you a very different story.

Let me talk about the job that Jim is doing right now. He's doing an outstanding job, an excellent job. He is a very able administrator. He was the state health director for the state of Michigan, serving for several years under Governor Engler. He volunteered for this effort. You've got to understand, to volunteer to leave your spouse and your family and to take on a job like this is a very admirable act in and of itself. He brings a lot to the job and to the position. All the feedback I received in talking to numerous -- and my own observations of him at work with the Iraqi community is that he has quickly established credibility and strong ties with the medical leadership and has the full support of everybody involved. He's doing a great job.

Q: Can you clarify one more thing for me? There were reports that another man was originally appointed to that task, Dr. Frederick Burkle. Can you clarify what happened with him?

Winkenwerder: I can't give you all the details. I know that Dr. Burkle was there as part of the original ORHA, Office of Reconstruction and Humanitarian Assistance. The job that is there to be done, obviously, by the description I've just given you, is not humanitarian assistance or crisis medical relief, it is rebuilding a health care system. And obviously, Mr. Haveman brings the right set of skills to that task.

Q: Is he a political appointee? Is he a Republican?

Winkenwerder: A political appointee to this position?

Q: Yes.

Winkenwerder: No.

Q: Or did politics play any role in it?

Winkenwerder: No. No. We were asked to review people who would be suitable for the job. And we have people as part of his team from DOD, from Health and Human Services, from the State Department. This is a joint federal U.S. government effort. And we obviously are interested in getting the best team on the ground, getting the best people. And we think we've got a great team there, and they're doing a terrific job.

Q: How large is it?

Winkenwerder: It's about 20 people.

Q: All government employees, no --

Winkenwerder: No, there are some Iraq expatriates as part of that team, some real leaders in the American medical community, who are serving as part of the team. And if you'd like their names, we'll try to get the list to you.

Q: Yeah, okay.

Winkenwerder: Yeah. Okay.

Q: Do you know off the top of your head or do you have handy the -- how do the mortality rates that you cited in Iraq compare with the United States or with other –

Winkenwerder: The infant -- I don't have -- it's not on the tip of my tongue, but the infant mortality rate in the U.S. is in the low single digits, as I recall, and so you're talking something that would be an order of magnitude of nine or 10 times as high.

Staff: Thank you. Thank you, Dr. Winkenwerder.

Winkenwerder: Great. Thank you very much.

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