Imperial Life in the Emerald City

by Rajiv Chandrasekaran

  Once inside, however, there was no mistaking the three-story edifice for anything other than a modern American military hospital. It had five operating theaters, ten emergency room trauma stations, and seventy-six beds. There were respirators, computerized heart monitors, and a CT scanner. Neurosurgeons and burn specialists were at the ready to treat wounds from roadside bombs.

  The hospital was free of the fine desert sand that was everywhere in Iraq. The white tile floor was always scrubbed, as were the walls and windows. Only the military-issue boots worn by the emergency room doctors were dirty. Instead of light brown suede, they were black and crusty with blood.

  Iraqis called it the Ibn Sina Hospital, after a pioneering physician in the early Islamic world. The Americans called it the “Twenty-eighth Cash,” a reference to the army unit that ran the facility—the Twenty-eighth Combat Support Hospital—which deployed more than 350 physicians, nurses, and support staffers to the Green Zone.

  Before the war, the hospital had been a private clinic for Saddam’s relatives and Baath Party leaders. Once the Americans arrived, it remained a private facility, limited to soldiers, CPA personnel, and private contractors. The only Iraqis admitted were those accidentally shot by American troops.

  Despite its selective admission of Iraqis, Tommy Thompson, the secretary for health and human services, used the hospital as a backdrop to laud the CPA during a visit to Baghdad eleven months into the occupation. The facility, he announced under the portico, was an example of how the United States had begun to “reestablish Iraq as a center of excellence for medical protection and medical care.”

  None of that excellence was evident outside the Emerald City.

  Yarmouk Hospital, a campus of two-story concrete buildings erected around a concrete courtyard, was a five-minute drive from the Green Zone, just a few blocks off the road to the airport. It was one of Baghdad’s largest and busiest medical centers, but after visits to more than a dozen other hospitals across Iraq, I regarded Yarmouk as a fair representation of the country’s health-care system. It was, quite simply, a disaster.

  Nothing was clean. The bedsheets were soiled, the floors were streaked with blood, the toilets overflowed. The rooms lacked the most basic equipment to monitor a patient’s blood pressure or heart rate. Operating theaters were without modern surgical tools or sterile implements. The pharmacy’s shelves were bare. In the emergency room, a few bloodstained gurneys cast dim shadows on the floor. There was no defibrillator, no respirator, no blood transfusion equipment, and no syringes of epinephrine.

  I visited the hospital for the first time a few hours after a suicide car bomber leveled the Jordanian embassy. The ward echoed with the screams of men whose limbs had been blown off but who had not received anything to dull the pain. I smelled blood, shit, and corpses that had been stored without refrigeration. Despairing relatives huddled around loved ones who had been so burned and maimed that they wouldn’t survive the night. I touched the hand of a lanky young man, Abbas Ali, whose abdomen and legs were covered in what seemed to be third-degree burns. He winced but did not cry. Over and over, he repeated the words, “Bismillah ar rahman ar rahim. Bismillah ar rahman ar rahim.” (In the name of God, the beneficent, the merciful.) A doctor told my interpreter that Abbas wouldn’t live for more than a day or two. “There’s nothing I can do,” he said. “We don’t have the equipment to treat him.”

  The story of Yarmouk Hospital was the same as that of nearly every other public institution in Iraq. In the 1970s, it had been one of the best medical centers in the Arab world. Jordanians, Syrians, and Sudanese traveled to Baghdad for operations. That changed, of course, after the invasion of Kuwait and the imposition of sanctions. Although Saddam eventually won the right to sell his oil in exchange for food and humanitarian supplies, the hospital never had enough medicine. The government blamed the United Nations for screwing up the purchase orders. The United Nations blamed the government for ordering the wrong items and for steering contracts to cronies instead of to reputable suppliers. The Bush administration believed that Saddam’s government, which was trying to generate international support to overturn the sanctions, was deliberately depriving Yarmouk and other hospitals of needed supplies.

  However bad the place was before the Americans arrived, it got much, much worse when the U.S. Army rolled into the city. A tank shell struck the hospital the day Saddam’s government fell, knocking out the generator and sending doctors fleeing home. With nobody to watch over the building, looters carted away not just all the beds, medicines, and operating room equipment, but also the CT and ultrasound scanners. When doctors returned to work, they struggled to provide basic first aid with makeshift implements.

  Once the Americans arrived, the job of rehabilitating Iraq’s health-care system fell to Frederick M. Burkle, Jr., a physician with a master’s degree in public health and postgraduate degrees from Harvard, Yale, Dartmouth, and the University of California at Berkeley. Burkle was a naval reserve officer with two Bronze Stars and a deputy assistant administrator at the U.S. Agency for International Development. He taught at the Johns Hopkins School of Public Health, where he specialized in disaster-response issues. During the first Gulf War, he provided medical aid to Kurds in northern Iraq. He had worked in Kosovo and Somalia. And in the lead-up to the invasion of Iraq, he had been put in charge of organizing the American response to the expected public health crisis in Iraq. A USAID colleague called him the “single most talented and experienced post-conflict health specialist working for the United States government.”

  A week after Baghdad’s liberation, Burkle was informed that he was being replaced. A senior official at USAID told him that the White House wanted a “loyalist” in the job. Burkle had a wall of degrees, but he didn’t have a picture of himself with the president.

  Burkle’s job was handed to James K. Haveman, Jr., a sixty-year-old social worker who was largely unknown among international health experts. He had no medical degree, but he had connections. He had been the community health director for the former Republican governor of Michigan, John Engler, who recommended him to Wolfowitz. Haveman was well-traveled, but most of his overseas trips were in his capacity as a director of International Aid, a faith-based relief organization that provided health care while promoting Christianity in the developing world. Prior to his stint in government, Haveman ran a large Christian adoption agency in Michigan that urged pregnant women not to have abortions.

  A silver-haired man with a ruddy complexion and a modest paunch, Haveman wore glasses and a lapel pin depicting an American flag crossed with an Iraqi one. His voice had the twang of a Midwesterner and the courtesy of a man from small-town America.

  In the two months between Burkle’s dismissal and Haveman’s arrival, the Health Ministry was handed off to Steve Browning, the U.S. Army Corps of Engineers specialist who headed four ministries in the first weeks of the occupation and who would later get the job of increasing electricity production. Browning had no medical experience, but he knew enough, and he had talked to enough experts, to draw up a list of priorities. Preventing disease, providing clean drinking water, and improving care at hospitals were at the top. So, too, was obtaining drugs and medical supplies. Hospitals and clinics were out of antibiotics, painkillers, and other medicines. Determining if the government-owned company responsible for ordering and distributing drugs and supplies had the needed goods in stock, and finding a way to get those products shipped to hospitals, became top priorities.

  A few days after Jerry Bremer landed in Baghdad, he wanted to visit a hospital. His handlers assumed that his doing so would be a good photo opportunity. On the way to one, Browning rode with Bremer in his armored Suburban. Browning figured he could use the time to discuss his plans for the ministry and the need for a massive infusion of foreign aid, but Bremer talked at length about Operation Smile, an American charity that sends physicians overseas to provide reconstructive surgery to children with facial deformities. At first Browning nodded politely, bu
t when Bremer kept chatting about Operation Smile, Browning cut him off.

  “Look, you need to understand the situation on the ground,” he said. “We’re trying to prevent epidemic diseases. We’re trying to just provide some decent drinking water for people… . We’re trying to restore basic service in hospitals… and to push out the pharmaceuticals and medical equipment. It’s ludicrous to talk about something like Operation Smile.”

  If someone else had dismissed the viceroy in that way, it would have been a pack-your-bags moment, but Browning was something of a made man. He was regarded as one of the CPA’s most talented managers. And everyone seemed to know that, no matter what else Iraq’s hospitals lacked, they had generators because of Steve Browning.

  A month after Baghdad’s liberation, an angry crowd had converged upon the Health Ministry. As Browning waded into the mob to ascertain their grievances, a tall, thin man who looked like an Iraqi Abraham Lincoln began beating his own chest. When Browning approached him, the man held up a photograph of a tiny infant. It took some minutes for Browning’s interpreter to explain: The infant was the man’s daughter. There had been a power outage, and the hospital in which his daughter was born didn’t have a working generator. She had died in her incubator.

  Browning drew up a proposal that night to buy new generators for every major hospital in Iraq. He took the document to Jay Garner, who approved it on the spot.

  To address the problem of getting medicines from government warehouses to hospitals, Browning deputized Chuck Fisher—the Special Forces physician who would later rescue Elias Nimmer from the al-Rasheed—with czarlike powers to pull cartons of drugs off the shelves and send them to hospitals by military convoy. Forget the paperwork or the pretense that Iraqis had to be the frontmen, Browning said. People needed medicine, and the Americans had to deliver.

  When Browning heard that Haveman had been tapped to take over the CPA’s health team, he tried repeatedly to get in touch with him while he was still in the United States. He wanted to give Haveman a briefing so he’d have a head start. Haveman never called back.

  Haveman arrived in Baghdad with his own military aide, his own chief of staff, and his own priorities. He emphasized to the press the number of hospitals that had reopened since the war and the pay raises that had been given to doctors instead of the still-decrepit conditions inside the hospitals or the fact that many physicians were leaving for safer, better-paying jobs outside Iraq. He approached problems the way a health-care administrator in America would: He focused on preventive measures to reduce the need for hospital treatment. He urged the Health Ministry to mount an antismoking campaign, and he assigned an American from the CPA team, who turned out to be a closet smoker, to lead the public-education effort. Several members of Haveman’s team noted wryly that Iraqis faced far greater dangers in their daily life than a little tobacco. The CPA’s limited resources, they argued, would be better used raising awareness about how to prevent childhood diarrhea and other fatal maladies. I was reminded of a comment made by my Information Ministry minder before the war, when I asked him why a pack of cigarettes cost only about thirty cents.

  “Ali, your government keeps complaining that it doesn’t have enough money,” I said. “Why don’t they tax the cigarettes like they do in America?”

  “In our country,” Ali said, “it would not be wise to tax a tranquilizer.”

  Medical care in Iraq had long been free. In Saddam’s welfare state, the government picked up the tab. That was anathema to Haveman, who insisted that Iraqis should pay a small fee every time they saw a doctor. He also decided to allocate almost all of the Health Ministry’s $793 million share of the Supplemental to renovating maternity hospitals and building 150 new community medical clinics. His intention was “to shift the mind-set of the Iraqis that you don’t get health care unless you go to a hospital.” A noble goal, no doubt, but there was no money from the Supplemental set aside to rehabilitate the emergency room and operating theaters at Yarmouk and other hospitals, even though injuries from insurgent attacks were the country’s single largest public health challenge.

  A massive cog in Iraq’s health-care wheel was Kimadia, the state-owned firm that imported and distributed drugs and medical supplies to hospitals. It would have made a Soviet central planner proud. It had thirty-two thousand employees, an annual budget of $600 million, and unparalleled influence over the health-care system. Kimadia selected which medicines to import, chose which countries and companies would get Iraq’s business, warehoused the products, and distributed them to hospitals and clinics. Everything was paid for with government funds. In Saddam’s Iraq, medicine was supposed to be free, but it rarely was. More often than not, government hospitals and clinics lacked vital drugs. Those who could afford it bought medicine from private pharmacies, which often sold items that had been imported by Kimadia and then fenced on the black market by warehouse employees.

  Bureaucrats at Kimadia, not doctors or hospital administrators, decided which medicines, and how much, to send to hospitals and clinics. Dispensary shelves would be overflowing with one antibiotic but empty of another. Sometimes this was due to incompetence; the other drug would be sitting in the warehouse. Other times it was because Kimadia hadn’t purchased enough. It would buy a five-year supply of one drug while failing to order dozens of others. Contracts were given to firms in countries supportive of Saddam instead of to suppliers who provided the best price or quality.

  “Kimadia was filled with thieves and incompetents,” said Scott Svabek, an army procurement officer on the CPA’s health team. “It was corrupt and dysfunctional.”

  To Haveman, the answer was to privatize it. But before he sold off Kimadia, he wanted to attempt something he had done in Michigan. When he was the state’s director of community health, he sought to slash the huge amount of money Michigan spent on prescription drugs for the poor by limiting the medicines doctors could prescribe for Medicaid patients. Unless they received an exemption, physicians could order only drugs that were on an approved list, known as a formulary.

  Haveman figured the same strategy could bring down the cost of medicine in Iraq. The country had 4,500 items on its drug formulary, meaning that Kimadia was supposed to stock 4,500 different products. If private firms were going to bid for the job of supplying drugs to government hospitals, they needed a smaller formulary. A new formulary would also outline new requirements about where approved drugs could be manufactured. It would be a way to get Iraq to stop buying medicines from Syria, Iran, and Russia, and to start buying from the United States.

  He asked the people who had drawn up the formulary in Michigan if they wanted to come to Baghdad. They declined. So he beseeched the Pentagon for help. His request made its way to the Defense Department’s Pharmacoeconomic Center in San Antonio. A few weeks later, three formulary experts were on their way to Iraq. They arrived eleven days before the November 15 Agreement.

  The group was led by Ted Briski, a balding, middle-aged pharmacist who held the rank of lieutenant commander in the navy. Haveman’s order, as Briski remembered it, was: “Build us a formulary in two weeks and then go home.” By his second day in Iraq, Briski had come to three conclusions: First, the existing formulary “really wasn’t that bad.” Second, his mission was really about “redesigning the entire Iraqi pharmaceutical procurement and delivery system, and that was a complete change of scope—on a grand scale.” Third, Haveman and his advisers “really didn’t know what they were doing.”

  Haveman “viewed Iraq as Michigan after a huge attack,” said George Guszcza, an army captain who worked on the CPA’s health team. “Somehow if you went into the ghettos and projects of Michigan and just extended it out for the entire state—that’s what he was coming to save.”

  Briski and the two other experts nevertheless set about designing a modern formulary. They took the 4,500-item list and slimmed it down to about 1,600 entries. But simply creating a new list wasn’t sufficient for Briski. The Iraqis, he decided, needed a way
to manage the formulary, so he drew up plans to form a committee of pharmacists that would update the list every few months. By choosing which drugs should be purchased, the committee would wrest a little power from Kimadia. Briski viewed his work as part of a larger plan to improve drug distribution. For the new formulary to succeed, Kimadia would have to be privatized or it would need a complete overhaul.

  Haveman told him not to worry. He had big plans for Kimadia. He was going to create an efficient, market-based system to distribute drugs. It was part of his strategy to refashion Iraq’s socialist health-care system into one that looked more American, with co-payments and primary-care clinics. Making it happen would require a fundamental redesign of health policy in Iraq, but it was the CPA’s mission, as he saw it, to tear down the old and build anew.

  Then came November 15, and the announcement that the United States would hand over sovereignty to the Iraqis by the following June. Everyone in the palace would be going home by then, if not sooner.

  Bremer held an all-hands meeting of CPA staffers on November 16. He didn’t mention that, in the name of political expediency, he had torpedoed his grand plans to have the Iraqis write a constitution and hold elections before a transfer of power, but everyone knew what had happened. CPA staffers, Bremer said, now needed to focus on “building capacity” among Iraqis to run their government. It was time to scale back plans and expectations. Put Iraqis in charge, he said, and pursue only those projects you can accomplish by June.

  Haveman stopped talking about privatizing Kimadia. There was no way the CPA could pull it off by June. With an outright sale off the table, Haveman and his loyalists decided not to pursue other ways to restructure Kimadia. Haveman wanted his ministry to be the first one handed back to the Iraqis.