24 March 2014 - The sectarian violence that dramatically increased in much of Iraq in 2014 has displaced more than 2.5 million people. This, combined with the quarter of a million refugees fleeing to northern Iraq from the conflict in Syria, have put a great strain on a health system that had been making modest progress in its recovery from the prolonged crisis of the past decade. The frequent mobility and the cramped living conditions of those displaced are a particular challenge for the country’s tuberculosis (TB) programme.
Iraq is home to one of the highest TB rates in the region, with about 15,000 new cases annually. The Iraqi health system has been badly affected due to the long years of war and sanctions but thanks to a US$ 37 million TB grant from the Global Fund to Fight HIV/AIDS, TB and Malaria, the TB national response managed to control the disease. The grant is administered by UNDP in coordination with WHO-Iraq and three non-governmental organizations (NGOs).
As of early March, less than 10 percent of the displaced people were living in camps across the country, mainly in Kurdistan. Most of the displaced population, meanwhile, were settling in informal shelters, abandoned buildings, mosques and schools.
People who fled or remain in fighting areas have limited access to food, water, health care and power supplies and each day face a battle to survive. In these harsh conditions, infectious diseases are on the rise but the one posing the biggest long-term threat is tuberculosis (TB).
The current TB crisis threatens to wipe out the progress made since 2008. Patients who fled their homes have stopped their treatment, case detection is disrupted, and the deteriorating conditions in which displaced communities survive have fueled the rapid spread of the disease. Local health services are overburdened and cannot manage the increased number of infectious illnesses.
When patients stop their treatment, the consequences are severe both for the patients and for the national health response.
"Interruption of TB treatments, which normally require over six months of close monitoring, is now likely to lead to an increase in multi-drug resistant (MDR) strains of TB. It is much more difficult and longer to treat MDR patients and it implies a higher burden for the government. The cost of treating MDR-TB is about ten times the cost of regular TB. It is a regional issue as countries receiving refugees from Iraq are now exposed to the spread of TB," says Dr Mohammedsiddig Mudawi, UNDP Project Manager in Iraq.
Localizing the patients under treatment and matching them with the nearest clinic where they could keep receiving their drugs is the first priority. The Iraqi Ministry of Health set up an emergency cell phone unit to reach out to all TB patients with UNDP support.
"We have been phoning the patients one by one on their cell phones night and day and have accounted for 80 per cent of those displaced but close to 600 patients are still missing. We don’t know if they have died, if they’re on the road, if they are trapped in conflict areas. We need to ensure continuity of treatment in order to prevent illness, death and the emergence of resistance if we want to avoid a massive health crisis." explains Mudawi.
The logistics that enable patients to receive treatment is a complex task and in many cases required creativity to maintain patients under treatment.
"Internally displaced patients don’t have any resources. We have organized transportation in coordination with the International Organization for Migration that sends a car to take the patients to the clinic and to receive their medication. We also provide a small allowance to make sure patients make a weekly appointment".
The situation is even more complex in the large areas of the country where the conflict is still on-going. One-third of Iraq’s territory is not accessible and the security situation remains unpredictable, rendering access to these regions highly problematic. The remaining health structures are stretched beyond capacity and health workers have been displaced or have fled the area.
To supply TB treatment drugs, UNDP works with the Ministry of Health, the governorates adjacent to the conflict area, the Stop TB Partnership’s Global Drug Facility, UN agencies and local NGOs. UNDP uses alternative routes to bring the drugs to Kirkuk, where a local contact can pick up the shipment.
"These carriers have managed so far to get special permission from the local factions to travel to these points to pick up the TB drugs and other health commodities. But the stock is only valid for six months and to replenish we will have to work the same way or work with another humanitarian organization or find a local NGOs. Not so many people are willing to do such a job as it is extremely risky. Luckily we found some heroes who were willing to take this responsibility and provide the treatment to their communities," noted Mudawi.
Domestic spending on the health sector has decreased dramatically as funds are re-directed to deal with the conflict in large parts of the country. According to the Ministry of Health, currently 75-85 percent of the health budget pays for salaries and recurring costs. Resources for investments and programmes to fight TB and other diseases are very limited or non-existent for 2015 and is likely to be the same in 2016.
"I think it is everyone's duty to support the TB programme in Iraq. It will be absolutely mind blowing if we don’t find additional funding quickly," said Dr. Lucica Ditiu, Executive Director of the Stop TP Partnership. "The programme made huge strides with a lot of personal engagement and efforts. Any interruption to this support will lead to major risks in the escalation of the MDR-TB situation in the region."