In Iraq's disputed territories, a health services vacuum

KANDAL, 2 April 2013 (IRIN) - At 9am in the northern Iraqi village of Kandal, female residents are gathering in the leafy courtyard of the local mosque. But they have not come to pray; they are here to see the doctor - a rare opportunity in this part of the country.

Kandal sits on a busy main road connecting Erbil, capital of the northern autonomous Kurdish region of Iraq, to Kirkuk, one of several disputed territories. Located in Makhmour District, in Kirkuk Governorate, the land Kandal sits on is claimed by both the central government in Baghdad and the Kurdish Regional Government (KRG).

Although the status of the disputed territories was supposed to be resolved by a referendum before the end of 2007, the vote still has not taken place. Meanwhile, their residents have been caught in between, with neither side willing to provide basic services.

"This place is not a country," said Jwan Abdullah, an English teacher at the small village school. "We have no government; there is no doctor, no hospital. We don't have a [phone] number for emergencies, and we need this."

There is only one small clinic in the nearby town of Makhmour to service the area's nine villages, which have a total population of around 300 families. The clinic is a small general practice, ill-equipped to handle many cases.

"My son broke his arm playing football," said the local mukhtar, or village leader. "And they just gave him a pain killer and said we had to go to the emergency hospital in Erbil," some 100km away.

Falling between the cracks

KRG would like to build a permanent hospital in the area, says Raad Najmadeen, director of medical services at the Erbil Directorate of Health. But the political situation in the region means any attempt to do so would be seen as a land grab.

"The problem is, as I see it, if you build a health centre, this land will be allocated to the [KRG] Ministry of Health, so you will make this land permanently for the ministry. They may see that we are taking the land by this process. So it's sensitive."

Instead, these villages depend on visits from KRG's mobile hospital - which has an operating unit, a dental unit, a lab, an x-ray, and ultrasound and gynaecological support - and a mobile team with ambulances stocked with simple medication and equipment. But these visits occur only once or twice a year.

The Kurdish government has plans to set up an emergency unit halfway between Makhmour and Erbil that would service the district and give residents access to an emergency number and to ambulances.

But in the meantime, the lack of any emergency services means transportation is a problem, particularly for women in Kandal, none of whom knows how to drive.

One woman, Berivan, said the Makhmour clinic had diagnosed her with a kidney infection and told her to return for follow-up treatment, but she has been unable to make the 10km journey.

"My husband is a peshmerga [member of the Kurdish security forces] and he isn't here to take me. Without a car, you have to stand on the side of the road and wait for someone to pick you up."

The journey to the hospital in Erbil can take over an hour - sometimes the difference between life and death. Berivan's aunt's experience is a case in point.

"One morning she was very short of breath, so we took her to the clinic in Makhmour," Berivan said, "but they said she had to go to Erbil. In the car on the way, she just stopped breathing and died."

Mobile care for women

Because of the particular challenge women face in reaching healthcare, START, a women's empowerment organization, teamed up with the Kurdistan Ministry of Health to provide mobile health services in the area, focusing on women and children. With French embassy funding, the NGO will send a general practitioner to one of six villages in the area every week for the next three months to provide basic healthcare and respond to gynaecological needs.

"We follow [up with] the women about their family planning. Here they have many kids, so we examine and provide for them - condom, contraceptive tablet, intra-uterine device... Everything is portable. We have all types of medicines," said Afifa Sayid, a doctor with the visiting medical team.

This is the second such programme by START, and the Iraqi government has a similar programme in other disputed areas. But when funding for such programmes runs out, residents here will be back to square one.

The poor, high-sugar diet also takes a toll on local health, Sayid says, and the local pharmacists are an inadequate substitute for trained medical care.

"Here they have chronic disease: high blood pressure, diabetes. Their general condition is not good. It's very important to have a hospital in the same place to follow-up with them every day. I went to five villages before this village: No hospital. It should be that in every village you have a health centre or every day a portable centre. Every day, not every week."

By lunchtime, Sayid had seen 55 women.

One patient, who requested anonymity, suffered from conjunctivitis. "She was given the wrong medicine" by a local pharmacist, Sayid said, "and now her eye is bleeding."

The health programme also raises awareness about women's health issues, like breast cancer and female genital mutilation, which is practiced in Iraqi Kurdistan, and it trains girls on first aid and the use of medicine. "These girls will be the focal points of any health services and any awareness campaign," said START director Safin Ali.

The programme also aims to reveal the area's health needs.

"[A reason for] bringing the KRG staff members and their buses and their staff members is to draw their attention to the fact that this area needs a hospital. A mobile medical unit can help in the short term but in the long term, they need to build a hospital here."