In the ER, in Baghdad

No one​ has a monopoly on violence in Iraq today. Competing Shia militias are as powerful as the army and police. They are seen as integral to the fight against Isis and officially sanctioned by the state, though they’re widely reported to commit war crimes, mostly against Sunnis. The Imam Ali Brigade, a Shia militia known for posing with severed heads and for its close ties to both the Iranian and Iraqi governments, also maintains a close relationship with the Baghdad Teaching Hospital. ‘I deal with the Imam Ali Brigade,’ Dr Rafid Al Waly, the hospital’s chief resident, said. ‘I ask them to protect my doctors and my patients. They co-operate with us and, in return, we provide services to their men.’ It was 2 p.m. and Rafid had been treating victims of an Isis bombing into the early hours of the morning. The day before, in the Shia neighbourhood of Sadr City, a pair of suicide bombers had ridden motorcycles into a mobile phone market. Isis claimed responsibility for the attack, one of the capital’s deadliest of the year so far, and more than seventy people had been killed with a hundred more wounded. Rafid estimated that his last patient – male, 58, perforated small intestine – hadn’t been stitched up until just before 3 a.m.

On a normal day Rafid would be overseeing the ward, operating on patients, monitoring his own cases and running the teaching programme. That day, he’d just welcomed their latest class of junior doctors (47 new medical school graduates), more than half of whom, Rafid said, were women. ‘The ministry sends women but I always say: “Send me men!” I can’t leave the women alone here at night, it’s not safe for them.’

In some ways the emergency room at the Baghdad Teaching Hospital is like any other ER – fluorescent light, the smell of antiseptic, nervous relatives. But just outside the door it’s common to hear the screams of women from a nearby lot, where corpses are refrigerated as they await shipment to their graves. Here the bereaved gather and wail. Most passers-by don’t even turn their heads. In the ER, all the beds were occupied and there were half a dozen injured men on their feet besides. Younger brothers and cousins in civilian clothes hovered everywhere. Nurses rushed about. Rafid walked in like a rooster and was greeted with an embrace by Major Salam, the Ministry of Defence’s liaison to the hospital. He was joking about rectal exams with a soldier who had suffered a minor shrapnel injury to his lower back. Rafid examined him briefly, then moved on to a group of soldiers and militiamen gathered around a stretcher. They were watching a young doctor in smudged glasses peer into the shattered back of a man’s head.

Rafid took a quick look as a janitor mopped away the young man’s blood from around his feet. He’d been standing beside a Humvee when it was struck by a rocket-propelled grenade in an area called Al Subaihat, east of Fallujah. He’d been fighting Isis with the 1st Division, 3rd Brigade of the Iraqi Army. ‘This man is past,’ Rafid quietly told the younger doctor, but he proceeded to intubate him anyway, handing the air pump to an enormous bearded militiaman in a tan jumpsuit.

Rafid shook his head and moved on. It’s a common complaint among Iraqi doctors that they have to pretend resuscitation, even when there’s no chance of survival, because relatives, often with militia connections, are liable to demand blood money if they’re dissatisfied with the doctor’s efforts. They are known to extract it via kidnap or extortion. In 2010, the Iraqi parliament increased sentences for anyone convicted of threatening or attacking a doctor but it doesn’t seem to have helped. In 2014, the Lancet reported that more than two thousand doctors had been killed in Iraq since 2003. One consequence has been a continuing exodus of doctors from the country. Dr Hilal Bahjat Al Saffar, a professor of cardiology at Baghdad University’s College of Medicine, told me that there are fewer than thirty cardiac surgeons left in a country of 37 million. Other consequences are harder to quantify. As one cardiologist put it, ‘after everything, if I see my neighbour in trouble, I will not help him. My country is my father, my mother, my wife and two children. It is enough.’

‘In this country,’ an old man waiting in the ER said, ‘we’re always paying a blood tax. We have the same hopes as cats: eat, shit, sleep.’ He pointed to his son, Karaar, splayed on a bed, a tube draining fluid from his torso. Karaar had also been at Al Subaihat when the grenade hit the Humvee. Shrapnel had entered between his ribs and some of it was stuck. ‘I called him this morning and he was fine,’ his father said. ‘He is a great furniture painter but there is no work, so he enlisted in the army.’

This is a common story in Iraq’s declining economy. The army and the militias are among the few reliable sources of income for the undereducated, under-employed, youthful population. These institutions also guarantee healthcare. Admission to a public hospital had cost less than five hundred dinars – about thirty pence – since the 1980s. Officially at least, this covered all treatments, for everyone, courtesy of the government. But in February, the Baghdad Teaching Hospital, like all public hospitals in Iraq, began to charge patients for individual services. In the face of a financial crisis precipitated by falling oil prices, the government is pursuing new revenue streams. Major Salam made a point of telling Karaar’s family that they wouldn’t have to pay anything for his treatment. ‘If anyone takes any money from you,’ he said, ‘I will destroy his luck.’

Two beds over from Karaar, the bearded militiaman was still pumping air into his dead comrade. The corpse’s chest rose and fell. Frustrated, the militiaman called for help, and several of his comrades joined him around the bed. Their uniforms were irregular but many wore the patch of the Hassan Brigades (probably named after Shia Islam’s second imam, one of the Prophet Mohammed’s grandsons).

The young doctor, his smudged glasses wiped clear, returned and after some beseeching by the crowd began to examine the patient again. Rafid approached. ‘This man has been martyred,’ he shouted, raising a hand in aggressive benediction, ‘Take him away!’ For a moment the whole ER was still, save for the beeping of machines. Then the bearded militiaman began to wail.

A few minutes later, the young doctor caught up with Rafid at a nurses’ station. He was frightened of being held responsible for the death, and was pulling at his hair in panic. ‘If anything goes wrong,’ the young doctor pleaded, ‘if there is a problem, you will sell me!’ He was thinking of blood money. ‘I’m selling no one,’ Rafid said. Shouting interrupted them. The militiaman was now yelling at a grey-haired physician in green scrubs. The older man held his ground. ‘What is this?’ he demanded, his voice cold with disdain. ‘A tribal fight?’ Everyone turned to watch. The bearded militiaman looked as though he was going to strike the doctor. He stepped forward, chest out. But then several soldiers and Major Salam intervened, and pulled him out of the ER.

Time seemed to flow differently in that emergency room. Moments dragged, hours flew by. Still, it turned out to be passing at its normal pace, and 17 minutes after Rafid had proclaimed the martyr, one of his fellow doctors shouted for help. A middle-aged woman’s vital signs were fading, her monitors ringing in alarm. She lay in a corner bed, her black abaya pulled up against the blue hospital sheets. She’d been there for an hour, but the doctors had been occupied with the soldiers and militiamen. There was something wrong with her heart.

Though heart transplants aren’t performed in Iraq, cardiac care is very advanced. Eight floors above the ER, another female patient had just been discharged with a new pacemaker. The surgeon, Dr Ghassan Mohammed Mahmoud, had inserted the pacemaker’s battery under her left clavicle and wired its tiny leads into her right atrium via her subclavian vein. Ghassan did this kind of surgery regularly – he had performed three similar operations that day – but he expected to stop soon. Given the government’s new budget, he said, he would run out of stents and pacemakers in a matter of months. The office of the health minister, Dr Adeelah Humood, didn’t return my calls, and figures are not readily available, but a senior ministry official told me that the budget had been cut by around a quarter for 2016. Like Ghassan, he predicted a major reduction of equipment, drugs, salaries, personnel and then: ‘System failure. Like the 1990s, during the embargo, but worse.’

This is particularly troubling in the context of the new fees. Baghdadis tend to view healthcare as a right rather than a privilege, inadequate though it has always been. And dissatisfaction with the Abadi government is already widespread. ‘What is the citizen getting from the state,’ the relative of one patient asked, ‘now that he has to pay to keep the state going?’ The same question has animated the recent Sadrist protests, fifty thousand strong, which are driving a complete renegotiation of the cabinet.

In the ER, as the woman in the abaya went into cardiac arrest, Rafid and others rushed to help. In her final moments, they tried furiously to resuscitate her, but it was too late. Her screaming relatives were soon ushered away. The doctors returned to the militiamen.

The Baghdad Teaching Hospital has operated continuously since it opened in 1970 and has seen as much war as peace. Wathiq Al Jabiri, the hospital’s media director and informal historian, recalls that on 9 April 2003, when the statue of Saddam Hussein fell in Firdos Square, there were only five staff on duty. And that was a relatively easy day. But for all the difficult days, Jabiri speaks of the hospital with affection. In his office down the hall from the ER, thick with cigarette smoke and not much bigger than an upright piano, he recounted the occasions when patients had been moved to the facility’s bunker, when mortar shells landed on the grounds, when staff refused to wear lab coats in order to avoid being targeted by kidnappers. In the larger context, he said, the hospital was doing fine. It’s his job, of course, to present it in that light. A few days earlier, his boss, Jinan Fadhil Al Shaibani, the director of media for the whole Baghdad Medical City complex, had been lamenting their media coverage. The problem, she said, was that when ‘foreign journalists come by they only talk about the bad things. But they don’t write that these are exceptional circumstances, that even in war we are providing.’

This much is true. It’s also clear, and perhaps unsurprising, that sectarian militias are among this civilian hospital’s most important clients, and are deeply involved in its policymaking and resource distribution. Opposite Jabiri’s office a sign warns doctors not to send any civilians to the militia pharmacy, which has been separated from the hospital’s general supply of medication. ‘The doctor,’ it says, ‘will be held accountable.’ The increasing integration of security and public healthcare is troubling to many doctors. One, who didn’t want to be named, said: ‘I think one morning we will wake up and open our eyes and there will be no one in the street. No police. No army. There will be only militias. And then …’ He didn’t finish the thought. A pharmacist recounted an incident in which the militias had robbed him at gunpoint of all his codeine syrup and antidepressants. ‘Their loyalty isn’t even to Iraq,’ he said: ‘it’s like taking thugs and junkies, and making them prime minister.’

But the integration makes sense to the pragmatic Rafid. Ghassan the heart surgeon, who told me that two of his brothers, two nephews, and his father had all been killed by Sunnis in the third year of his postgraduate training, said he accepted it too. The militias are deadly to cross and they are fighting Isis. By working with them, the doctors, like the Iraqi government, believe they are saving lives.