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WHO cancer expert reviews cancer treatment in Iraq under sanctions

A letter in the British Medical Journal recently about cancer in Iraq:

   BMJ 1999;318:203 ( 16 January )
   Personal views
Cancer services are suffering in Iraq

   The Iraqi health minister, Dr Omeed Mubarak, recently asked the World
   Health Organisation to review the problem of cancer services in Iraq
   and suggest how things could be improved.
   It was immediately clear that there were staggering deficiencies in
   cancer treatment facilities because of the United Nations sanctions,
   which are intended to exclude food and medicines. A cancer centre
   without a single analgesic; a radiotherapy unit where each patient
   needs one hour under the machine because the radiation source is so
   old; and children dying of curable cancers because drugs run out are
   all accepted as normal.
   We as doctors cannot stand idly by and watch this slow, silent tragedy
   drag on
   Iraq has a population of 20 million. The cancer registry is good in
   some parts of the country and there are an estimated 50 000 new
   patients a year --- a relatively low but rising incidence as found in
   many Arab countries. Iraq is a wealthy, well educated country, but is
   now completely reliant on the administrators who enforce the
   politically inspired UN Security Council's oil for food agreement.
   There is plenty of oil, but Iraq can sell it only to buy food and
   medicines under this humanitarian aid programme.
   Somehow cancer care has become a Cinderella service. Requested
   radiotherapy equipment, chemotherapy drugs, and analgesics are
   consistently blocked by United States and British advisers. There
   seems to be a rather ludicrous notion that such agents could be
   converted into chemical or other weapons. Operating under the
   agreement is complex, slow, and frustrating. Dr Isam Al-Rawi, recently
   retired director of the Baghdad cancer centre, has endured eight years
   of frustration and witnessed much unnecessary human suffering. An
   internationally well respected oncologist, and first chairman of the
   Iraq Cancer Board, he has made the best of the deficiencies.
   Stopping cancer treatment will not topple a dictatorship
   Visiting the cancer centre in Iraq is a harrowing experience. The
   wards are busy, the clinics burgeoning, and the radiotherapy equipment
   primitive. There has been no investment for a decade. The medical
   staff are well trained and most of the consultants have spent a year
   or more in Britain, France, or the United States as part of their
   training. The younger physicians are now unable to train abroad.
   Clinical skills, the teaching, and enthusiasm are strong. Iraq follows
   the British system of undergraduate and postgraduate education. Now,
   because of hyperinflation, doctors earn about 3 a month.
   The radiotherapy equipment is becoming unusable. Lack of replacement
   isotopes for Baghdad's last two functional cobalt machines means that
   treatment times can take up to 45 minutes for each patient. One linear
   accelerator is working only intermittently. There are no planning or
   simulator facilities working.
   The department is open from 8 am until midnight each day to cope with
   the workload. The availability of chemotherapy is essentially a
   lottery. People with potentially curable cancers can receive only the
   drugs available at the time. Essential generic drugs such as
   cisplatinum, tamoxifen, and cyclophosphamide ran out during our visit.
   Symptom control is hopeless and analgesics are just not available.
   Patterns of cancer are changing. Iraq is one of the few countries
   where stomach cancer is increasing, probably due to reversion to
   poorer diets and the lack of good food storage facilities. Breast
   cancer is rising inexorably. A more sinister problem is the apparent
   threefold increase in leukaemia in the southern provinces --- the
   sites of the major battlefields of the Gulf war. A WHO investigation
   in 1995 suggested a possible link to products, now incorporated in the
   food chain, which were derived from depleted uranium used in piercing
   artillery shells. The trend has continued and a major epidemiological
   study is now proposed which will include a radiation survey.
   Whatever the political legitimacy of the embargo, the needless
   suffering of those with cancer is an unacceptable outcome. The WHO is
   making strong representations that drugs on its essential list,
   analgesics, and replacement radiotherapy equipment should be given
   priority. We as doctors cannot stand idly by and watch this slow,
   silent tragedy drag on. Stopping cancer treatment will not topple a
   dictatorship. It will serve only to consolidate a background of hatred
   in a new generation who will never forget the scars.
   Karol Sikora, chief.
   WHO Cancer Programme, and professor of international cancer medicine,
   Imperial College School of Medicine, London
   [14] British Medical Journal 1999

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