The questions that drive this book are inspired by my personal experiences of growing up in Iraq and training as a medical doctor in the aftermath of the 1991 Gulf War. On August 2, 1990, Iraqis woke up to the news of their government’s swift invasion and the annexation of Kuwait. Over the following weeks, a coalition of thirty-three countries, led by the United States, had mobilized to “liberate” Kuwait. For ninety days, the coalition pounded Iraq’s infrastructure, destroying the foundations of a modern state. Operation Desert Storm targeted government facilities and destroyed electricity grids, telephone lines, the water supply, and sanitation systems. For more than a decade afterward, Iraqis were subjected to one of the harshest experiments of war under UN economic sanctions (1990–2003). The sanctions prohibited oil sales—Iraq’s main export—and banned imports of goods, except for limited and selective supplies of medicine and basic food items. Furthermore, Iraq was prevented from importing material to fix its broken infrastructure.
Under the sanctions, Iraqis witnessed an acute deterioration in everyday life as the infrastructure of the state crumbled. Health and development indicators plummeted, and the country’s environment was severely scarred. In effect, the sanctions induced an ecology of “state failure,” where the besieged state became unable to restore its damaged infrastructure to prewar conditions. This was further complicated by the inability of the country’s advanced health-care system to respond to the swelling burdens of the general population’s afflictions. The far-reaching and detrimental effects of that war and sanctions—what Iraqis refer to as al-hisar (the siege)—were determinative in shaping Iraq’s precarious future for decades to come.
In the fall of 1991, I began my studies at the Baghdad Medical College, the country’s oldest medical school. I studied and practiced medicine under exceptional conditions and was one of thousands of Iraqi physicians who were witness to the sweeping assault on the physical, social, and political body under sanctions. From my vantage point, the war and the breakdown of state infrastructure were nowhere more obvious than in the collapse of the country’s medical establishment and the slipping away of lives in the hospital setting.
In the summer of 1997, I finished medical school and began my residency at al-Madina—Iraq’s largest teaching hospital. Like the majority of doctors in the country, I was a government employee charged with the responsibility of providing state-sponsored health care to the country’s population. Located in Bab-al-Muadham, al-Madina houses a complex of teaching hospitals and centers, as well as Baghdad’s Medical College. With a capacity of about one thousand beds, al-Madina has been Iraq’s epicenter for specialized medical care. Upon its inauguration in 1972, international medical experts celebrated the complex as one of the most advanced medical monuments in the Middle East. The large capacity of the complex and its outpatient department made it the main destination for patients from across the country, including referrals from the vast national networks of public hospitals and primary care clinics in Iraq. For decades, al-Madina had been a site for advancements in different fields of medicine and the training of Iraq’s reputable doctors—many of whom received their postgraduate training in the West. Al-Madina was in fact the epitome of a decades-long history that had shaped the inception and making of the state since the British Mandate (1920–1932).
When I started my residency at al-Madina, the main general hospital was in a state of remarkable disrepair. This monument of Iraq’s medical modernity was unrecognizable due to the lack of maintenance, the cannibalization of its physical structures, and the absence of spare parts for its outdated medical equipment. The hospital’s original white and green paint had dimmed to a dark grey. The paneled ceilings leaked from rusting water pipes, bathrooms were dysfunctional, and many hospital beds were broken. Once fitted with top-of-the-line medical gear, such as a built-in oxygen supply and mounted monitors, these became mere decoration. More than half of other hospital equipment had become scrap. Similar to other government-run places in Iraq during the 1990s, spare parts were scavenged from one machine to salvage another. Patients and their families brought their own bedding to spread over half-torn mattresses, and they were responsible for their own food, and often medicines and medical supplies as well.
My first months of clinical rotation were at the surgical ward. There was a severe shortage of professional medical personnel, and the daily duties of junior doctors, such as myself, compensated for the work of the scarce numbers of the nursing staff. My daily tasks entailed recording patients’ vital signs, following up with their medications, and changing dressings when needed. I followed up with lab results and reported the daily conditions of patients to the residents and senior physicians during their morning and evening rounds. For the most part, the main nursing station was abandoned, and only one or two nurses attended to each floor. During night shifts, I would sleep on a broken bed in a room located at the end of the ward, where I was the first to be notified if something happened on the floor during the night, usually by patients’ escorts. Such experiences were overwhelming and demoralizing.
Trained in the science and art of modern medicine, textbook therapeutics were becoming obsolete in the face of the lack of medical supplies and the rapid corrosion of the health-care establishment. At the same time, diseases were becoming increasingly unruly. Bacterial wound infections spread with vicious speed and were the primary causes of post-operative deaths. Treating such infections was becoming a menace for the doctors, who had to improvise to deal with the fallout of the limited availability of medications and the mounting septic conditions in this debilitated hospital setting. Many crucial antibiotics were put on the UN sanctions list of banned imports due to their “dual use” for military and civilian purposes. Available options were limited. Regardless of the magnitude of the surgical procedure, it became a common practice to routinely prescribe the only three available antibiotics at government pharmacies to cover the broad spectrum of possible bacterial and fungal infections. Still, the hospital supply of a certain antibiotic would be available one day and not another—disrupting treatment regimens and predisposing the hospital population to further complications. The hospital also lacked regular supplies of intravenous fluids and cannula tubes, urine catheters, sterile gloves, and surgical stitches—essential supplies used in everyday medicine and surgical management. Doctors reused cannulas to economize, replaced urine catheters with nasal tubes to empty bladders, and sterilized disposable gloves and the remains of surgical sutures so they could be used on the next patient. In this mélange of care and toxicity, such improvised practices became essential to saving lives at the hospital ward.
Death was a common sight in al-Madina. Empty coffins went into the hospital’s morgue to come out full, accompanied with shrieking screams of mourning. Such screams, unsettling as they were, became familiar. Outside the hospital, clusters of impoverished men and women sat awaiting news about their sick relatives, as they shared their experiences with others. Many of the patients and their families had come from different parts of the country—many were from Iraq’s poor provinces and rural peripheries. They had traveled hundreds of kilometers by buses, taxicabs, and private cars to seek essential treatment for their sick family members in the country’s largest health-care facility, where the state machinery of maintaining the lifeline of the population had been undermined. Such state failures often manifested in outbursts of violence against doctors led by patients’ disenchanted family members.
The breakdown in health care further refracted in the intensifying state control over doctors. Physicians were banned from travel without government approval. At the same time, government bureaucrats and informants monitored physicians closely at the workplace. Hospital administrators would harass doctors in cases of disobedience through bureaucratic and political threats. If caught trying to leave, a doctor would be charged with treason and subjected to six years in prison. Despite the tightening of control, hundreds of Iraq’s senior and junior doctors were escaping the country every year. This entailed taking high risks in defiance of the state’s travel ban and paying off smugglers to escape the country. Passports were forged and state officers were paid off, as doctors crossing the borders undermined the state’s dysfunctional control apparatus. The exodus of Iraq’s doctors during the decade of the 1990s, and later after the US occupation of Iraq in 2003, would become a decisive blow to the country’s health care.
I escaped Iraq in 1998. I followed the footsteps of hundreds of my colleagues who were leaving the country secretly. I paid off smugglers to renew my passport at the border and left the country unquestioned. Exiting Iraq marked the beginning of a tortuous journey. Many of my colleagues continued their life trajectory to the West. They entered European states both legally and illegally, and applied for asylum as they prepared and sought careers in alternative health-care systems. Unlike them, my trajectory in exile led me to the study of anthropology in the United States—where I lived and experienced the immediate aftermath of the 2003 invasion and occupation of Iraq. Because the 2003 war and occupation became the central event that defined public discourse in the West about Iraq, the impact of the First Gulf War and the sanctions experiment became somewhat obscured. More troubling was the obliteration of a history of a modern nation under ill-informed explanatory models of religion, sectarianism, and authoritarianism.
My aim here and throughout the book is to give readers an insight into Iraq’s complex and often obscured history of state building. I have chosen to focus in this preamble on the sanctions as illustrative of a larger theme in this study—that is, of the making and unmaking of Iraq’s health-care system. Seeing the sanctions era as a critical event enables us to contextualize the breakdown of this system in relation to a hundred years of medicine and state making in Iraq. Beyond analyzing breakdown and loss within Iraq, this study is a critical intervention in the history and anthropology of medicine, biopower, and governance: an exercise in unraveling the complex histories, topologies, and trajectories of medicine, statecraft, and empire that have shaped life in a region subjected to decades of war, displacement, and destruction.