About 10% of Baghdad's 32,000 physicians have left country, often forced out

BAGHDAD, Iraq - The letter came to this city's main cardiac hospital late last month. It was handwritten and unsigned, but its message was clear: It threatened the hospital's top doctors and warned them to leave their jobs immediately.

Four of the hospital's top surgeons stopped going to work. So did six senior cardiologists. Some left the country.

It was far from an isolated incident.

The director of another hospital, Dr. Abdula Sahab Eunice, was gunned down May 17 on his way to work, officials at the hospital said.

In the past year, about 10 percent of Baghdad's 32,000 registered doctors - Sunnis, Shiites and Christians - have left or been driven from work, according to the Iraqi Medical Association, which licenses practitioners. The exodus has accelerated in recent months, said Akif Khalil al-Alousi, a pathologist at Kindi Teaching Hospital and a senior member of the association. The vast majority of those fleeing, he said, are the most senior doctors.

"It represents a very good chunk of the doctors," Alousi said.

"These are the cream of the cream," he said. "They are the people who make the doctors, heads of departments."

But insurgents' threats are not the only pressure facing doctors in this health care system, once one of the best in the Middle East. Iraq's lawlessness has reached inside the wards, sometimes turning doctor-patient frictions into armed conflicts.

Doctors are easy targets for gangs that specialize in kidnapping because doctors move around the city to visit patients and often cannot afford large numbers of guards.

Health care providers must also deal with the continuing power failures that plague hospital operating and emergency rooms, coping with a seemingly constant stream of patients furnished by the insurgency.

"It's the worst health care system Iraq has ever known," said Dr. Waleed George, chief surgeon at al-Sadoon Hospital in Baghdad.

"Imagine yourself trying to operate on a patient in a two-hour surgery and the power goes out," he said. "You pray to God, and you sweat."

In the early years of Saddam Hussein, the health care system in Iraq was a showcase, with most Iraqis receiving excellent, inexpensive care. Iraqi doctors often studied in England, and Iraq's medical schools, based at hospitals, had high standards. But Saddam let the economic penalties of the 1990s bite deeply into medical care and used the damage to the increasingly worn system to try to persuade the world to ease economic pressure on Iraq.

In the chaotic Iraq of today, doctors say that after difficult or unsuccessful operations, they sometimes find themselves confronted by armed, angry relatives.

One 32-year-old doctor at a medium-sized Baghdad hospital said doctors now routinely exaggerate the risk of complications, hoping that patients will opt against surgery.

"We try to avoid complicated operations," said the doctor, who said he was afraid enough for his own safety to insist on being identified only by his first name, Omar. "What if the patient dies? You're face to face with relatives with guns."

The Ministry of Interior has responded to the situation: It simplified gun licensing procedures for doctors, allowing them to get licensed weapons faster than other Iraqis.

Guarded by son with gun

Omar al-Kubaisy, one of the doctors who stopped going to work at the cardiac hospital, Ibn al-Betar, after he was threatened, kept working at his own clinic - watched over by his 23-year-old son, Ali, who stood guard with a large and always visible semiautomatic gun. But two weeks ago, Kubaisy, one of Iraq's top cardiologists, left for France.

The simple quest for money, which fuels the country's widespread kidnapping industry, appears to be the biggest motivation. Alousi estimated that 250 Iraqi doctors were kidnapped in the past two years.

One 60-year-old gynecologist, who was kidnapped in December, said that three cars, one of them a police cruiser, pulled her car over. Men banged on her window with guns, forced their way into her car and pushed her head to the floor. They took her and her driver to a house.

The men asked for $1 million, handed her a gun and told her to kill the driver. They said they would cut off her hand and send it, with the driver's body, to her son.

"I said, 'I cannot kill him,'" she said. "I can't even kill a bird. They started to beat me on the face."

$250,000 ransom

The men released her after her family paid $250,000, most of it borrowed.

She made it home; a day later, she left for Jordan. Still terrorized by the incident, she asked that her name be withheld.

"I'm healed from outside, but I never heal on the inside," she said.

A rarity, she has returned to Iraq - to work at repaying the friends who lent the ransom.

The exodus of senior doctors has resulted in unpredictable medical service, doctors and hospital officials said. Patients are not sure whether they will find their doctors.

Junior doctors fresh out of medical school are performing complicated surgeries that ordinarily would be performed by more experienced doctors.

At Ibn al-Betar, surgeries are still being performed and patients are still being treated. An official there declined to say how the losses had affected care. But the exodus of virtually every senior doctor and surgeon cannot bode well.

At the hospital of the young doctor who identified himself only as Omar, about half of the doctors on the staff have left, according to the hospital director. Junior doctors have taken their places, but some of the more complicated surgeries are no longer performed.

The more prosaic problems are no less serious. A decade of economic embargo left equipment in poor shape.

The state no longer pays for medicine: Iraqis in several clinics visited this month complained of not having access to basic heart and diabetes medications.

"As junior doctors, we need to learn as much as possible," Omar said. "Some cases, especially elective cases, cannot be managed sometime," he said.

George, the surgeon at Al-Sadoon, said shortages of power and medicine had forced the hospital to reduce the number of operations by about half. It briefly solved its power problem by hooking up to the electricity system of the Ministry of Agriculture nearby, but even that has chronic failures now, he said.

Emergencies are nonstop. Civilian deaths, the Ministry of Defense says, have more than quadrupled since the new government took power late last month.

The young doctor who identified himself only as Omar said he cut his teeth on emergency bullet wound operations in the past year.

Workload doubles

The workload increases for the doctors who remain. Dr. Hashem Zainy, a psychiatrist and the director of a psychiatric hospital, Ibn Rushud, said the doctors who have stayed must see almost double the daily caseload.

"It's ridiculous," he said. "They listen to the patient for a few minutes and write out a prescription and that's it."

Kubaisy said he saw his final patients at his clinic across town from the hospital this month. One patient, Halima Obeidi, a 75-year-old woman with kidney failure, lay on a hospital bed surrounded by worried relatives. They spoke in hushed tones, avoiding the topic of who would care for her once Kubaisy left. But for him, staying was simply not an option.

Perhaps Alousi, of the Iraqi Medical Association, put it best.

"If you get a doctor and you need to be examined and there's an AK-47 under the table, things are very bad."