ENHANCE UNDERSTANDING

MITIGATING THE IMPACT OF COVID-19 IN IRAQ

PDFThe COVID-19 pandemic is hitting Iraq at a particularly bad time. The country has just begun to ramp up testing for the highly contagious virus, and the 1,031 confirmed cases and 64 deaths to date may only be the tip of an iceberg yet to reveal itself. These figures may also be far from accurate.  Several Iraqi health professionals believe that the number of cases could be as high as 9,000. The combined effect of a developing financial crisis, woefully inadequate health care infrastructure, lagging government response and poor information and community response place the country at huge risk from an outbreak that could kill many thousands in the coming weeks.

Healthcare crisis. Iraq’s health sector appears to be among the least prepared to deal with a pandemic that is challenging much more robust health care systems in the world’s developed countries. The sector suffers from decades of under investment, war damage, poor management, corruption, and emigration of doctors. As a result, Iraq faces a dire shortage of skilled health professionals, hospital beds, and reliable medications. Putting it mildly, the World Health Organization’s representative in Iraq warned that “preparations to confront the coronavirus were not proceeding optimally.” The following table includes quick facts that illustrate some of the sector’s key shortcomings:

 

Iraq has 0.8 doctors per 1,000 people (est. 20,000 out of 52,000 registered doctors left Iraq in the past three decades). Jordan has 2.3 doctors per 1,000 people
Iraq has 1.4 hospital beds per 1,000 people Lebanon has 2.9 hospital beds per 1,000 people
Iraq has 500 ventilators (~13 per 1 million people) U.S. > 62,000 (~187 per 1 million people, 2013 figures)
Iraqi government spends $152 per capita on health Kuwaiti government spends $1,068  per capita on health
85% of essential drugs are in short supply or unavailable

Data from the World Bank and recent reporting by Reuters, Aljazeera  and NPR.

Dr. Jafar Alaa, Head of Programs at the Iraq Health Access Organization (IHAO), told EPIC that when the outbreak of COVID-19 first hit Iraq, there was only one lab in the country prepared to carry out the polymerase chain reaction (PCR) test needed to detect COVID-19. It was at Baghdad’s Central Public Health Laboratory. The high death rate from COVID-19 in Iraq (presumed to be about 7%) is a further indication that the actual spread of the disease is wider than the 1,031 cases confirmed by limited selective testing of symptomatic individuals.

Lagging government response. The Iraqi government’s response, whether preventative or remedial, to COVID-19 has been lacking in timing, scope and implementation, placing Iraq at an elevated risk from the pandemic.

After the first deaths were reported in Iran in late February, the Iraqi government failed to secure its border against the spread of COVID-19 from its eastern neighbor; Iraq shares a long border, with more than a dozen crossings, and extensive trade and travel. Despite warnings from Iraq’s Human Rights Commission, early measures at the borders were vague and ad hoc. Authorities spoke of unspecified “stricter measures” that amounted to little more than sporadic temperature screenings of arriving airline passengers. The response remained weak even after the first case (an Iranian studying in Iraq) was identified on February 24. Iraqi Airways announced on February 25 that it would only operate flights meant to evacuate Iraqis stranded in Iran, but credible sources confirm that scheduled flights between the two countries continued well into March.

At Iraq’s land borders, conflicting reports of closures continued for two more weeks. On March 3, Iranian sources claimed that Iraq had closed borders to travelers only at two border crossings.

Iraq instructed its embassies and the Kurdistan Regional Government (KRG) instructed its airports to suspend all new visas to applicants from countries with high rates of coronavirus infections. The effectiveness of these travel bans cannot be taken for granted. In March, local politicians in Salah ad-Din Province claimed that the Peace Brigades militia of Moqtada al-Sadr was bringing in Iranian pilgrims to religious shrines in the provincial capital of Samarra, despite a government ban on the entry of foreign visitors.

In some areas, KRG authorities showed better judgment than their federal counterparts. The KRG closed borders with Iran right away and enforced a curfew more thoroughly. By March 10, local authorities in the KRG began to give the equivalent of “shelter at home” orders to citizens. At that point, similar but less stringent measures in the rest of Iraq were taken at the provincial rather than federal level.

Members of the Iraqi security forces enforcing the curfew meant to contain the COVID-19 spread in Iraq. (Photo by @Kirkuknow_DT)

The nationwide curfew, since being ordered on March 17, has been only partially enforced. In places such as the 2-million-resident Sadr City section of Baghdad, people have continued to move around; Iraqi security forces have no power there and the district’s de facto chieftain, Moqtada al-Sadr, hasn’t been inclined to put restrictions on residents, many of whom are his followers. As of March 28, Baghdad’s police chief was talking about “large unnecessary crowds” at several large marketplaces in Sadr City. Meanwhile, there have been reports of arbitrary and confused enforcement of travel restrictions that sometimes impacted the wrong people, like doctors commuting between remote work stations and their home districts.

Perhaps the most glaring failure of the curfew’s enforcement was allowing the annual Shia Muslim pilgrimage to the Kadhim shrine in Baghdad to continue virtually unimpeded, despite warnings from authorities, pleas from  doctors, and a message from the country’s top cleric telling people to avoid crowds.

Taking cues from Moqtada al-Sadr, thousands from Baghdad and other provinces proceeded with the pilgrimage, creating heightened risk for a spike in infections. The fact that between three and four hundred thousand worshippers gathered in Kadhimiya without much protection against disease means Iraq may be about to witness the kind of exponential growth in COVID-19 cases that other hotspots have seen in recent weeks, except that Iraq would be the least prepared of all.

Although more testing is happening today compared to a month ago (there are half a dozen labs carrying out PCR tests compared to just one), testing appears to be primarily targeting symptomatic cases and “high risk” persons who have traveled or attended the pilgrimage ceremony, according to IHAO Director Hala al-Sarraf. These cases may only be the tip of the COVID-19 iceberg. So far, test results require 1-3 days to arrive because most samples have to travel to centers in Baghdad, the KRG or Basra. Most of Iraq’s remaining provinces are just beginning to establish the capacity to run tests locally, according to Ms. Sarraf. Since the actual test only requires 3-4 hours for results, speeding up the turnaround to deliver results to health workers and patients remains a critical area for improvement.

Social aspects. The COVID-19 crisis has been tough on the people of Iraq in ways other than its direct toll on public health. Although government numbers regarding cases and deaths remain comparatively low — around 1,031 cases as of April 6 with 60-80 new cases detected each day — there are reasons to expect actual numbers to be higher, possibly as high as 9,000 in tested cases alone. Putting aside suspected government manipulation of testing numbers, there are likely many more cases that have not yet been identified for a variety of reasons. In Iraq, disease often carries a stigma that impacts whole families, not just the carrying individual. There is also fear of being isolated in dreadful conditions at ill-equipped hospitals, which Iraqi doctors think may be preventing many patients from seeking medical attention.

Quarantine policies have also been of questionable effectiveness. Our IHAO colleagues mention, for example, that when the head of a family tests positive for COVID-19, only that individual has been placed in isolation.

Iraqi health workers hold signs that read “I stayed at the hospital for you, stay at home for me.” (Photo by @Kirkuknow_DT)

The COVID-19 threat is also raising new barriers between communities, Ms. Sarraf tells us. Fear of the disease is isolating people, and reopening divisions that were until recently disappearing under the unifying effects of the pro-reform movement. Shia worshipers who participated in the recent pilgrimage are being blamed for spreading the disease. Authorities and towns are placing barriers to prevent them from returning home from Baghdad. And travelers from districts with significant Shia communities, like Tal Afar, are being screened before entering Mosul city, the provincial capital.

Perhaps one of the most painful expressions of misinformation and social stigma of this disease is the fact that some towns won’t allow people who died from COVID-19 to be buried in their cemeteries.

Another issue that has contributed to an attitude of complacency or carelessness about the seriousness of the COVID-19 crisis is the deeply rooted feeling among many Iraqis that they have seen worse. After resisting for a while, protesters finally evacuated protest sites they have occupied in Baghdad and other provinces, although frustration with government incompetence and corruption is only likely to grow.

To date, there has been no government plan for providing financial support for people laid off due to the pandemic. Unlike government employees who can rely on steady paychecks, day laborers have been particularly hit hard as they rely on what they make day to day and often have no cushion of savings.  In a country where the government admits at least 22.5% are below the poverty line, a prolonged disruption to economic activity can be catastrophic for millions across the society.

The crisis has highlighted some social bright spots. Society has shown notable signs of solidarity and volunteerism. Groups of volunteers have begun organizing to distribute food to families that need assistance and provide other forms of aid, such as helping with rent and utility bills.

Economic peril. The economic crisis that had already begun to hit Iraq’s oil-dependent economy is the easiest to quantify. It may also be the most difficult for the Iraqi government and people to address with emergency measures. Oil prices collapsed in March under dual pressures from both slowing demand due to the COVID-19 impact on global economies and a supply glut resulting from competition for market share between major producers Russia and Saudi Arabia — an issue that won’t necessarily go away with the virus. By the end of March, the nosedive decline had dragged oil prices below $20 per barrel, threatening to turn a moderate downward trend in Iraq’s oil revenue visible since January into a full blown meltdown.

Even at $30 per barrel, the head of the International Energy Agency warned that Iraqi government revenue could drop to as little as $2.5 billion a month, compared with $6.2 billion in January. If this global economic slowdown continues for even two quarters, Iraq’s 2020 revenue would suffer some $30 billion in losses, compounding its difficulty of balancing its books. The following chart illustrates the potential impact of lower oil prices on Iraq’s deficit in the yet to be approved 2020 budget, expected to be $135 billion.

In the immediate term, this financial crisis threatens to make an already under-funded health sector more vulnerable to being overwhelmed by the demands of a pandemic. Earlier in March, Iraq’s Health Minister pleaded on television for $5 million to finance emergency response to the COVID-19 crisis, after requests for funds went unanswered by the Finance Ministry. The Health Minister, Jafar Allawi, assessed that Iraq has the highest mortality rate from COVID-19 in the world, at 10% of cases, arguing that his ministry needs $150 million a month to manage a proper response. Ms. Sarraf of IHAO told EPIC that the Ministry of Health is asking NGOs to help mitigate the shortage in personal protection gear by supplying face masks, gloves, protection and other sanitation needs.

The oil revenue drop also has grave medium and long term implications for the viability of Iraq’s economy and post-2003 political order, already rocked by deep popular discontent with inequality, nepotism, foreign interference and corruption.

Less oil money will expedite the inevitable.  If oil prices do not recover quickly, the Iraqi government will fail to sustain the bloated, unproductive and expensive public sector that has enabled the political establishment to keep a large enough segment of the population sated, while expanding their patronage networks and prolonging their grip on power. The timeframe for default may be only months, with little to slow it down other than tapping the country’s limited financial reserves of $62 billion.

What’s next? The COVID-19 crisis is evolving rapidly in Iraq. The case increase curve below, based on publicly available information, may suggest that Iraq is about to enter the exponential increase phase that other affected countries encountered in March.

More thorough modeling by Dr. Ghassan Aziz, an Iraqi epidemiologist, presents three COVID-19 progression trajectories by examining three management scenarios. While the models are based on variables that could change at any moment in the following days, they are very useful in highlighting the dramatic difference preventative measures can play.

In the worst case scenario, 3.9 million patients would become infectious and close to 140,000 would die by June 1. In the scenario where aggressive counter measures successfully reduce transmission by 50%, fewer than 18,000 would become infectious and 1,070 would die during the same time period.

Scenario People exposed by June 1 Patients become infectious by June 1 Deaths by June 1
No preventative measures or treatments <7.5 million 3.9 million 139,969
Preventative measures reduce transmission by 25% <0.7 million <0.33 million 14,148
Preventative measures reduce transmission by 50% 17,856 10,086 1,070

Based on our observation and analysis of conditions in Iraq and conversations with leading epidemiologists and public health experts, EPIC has developed the following recommendations for Iraqi and KRG authorities on measures to mitigate the next phase of the COVID-19 crisis:

  • Continue to step up efforts to educate the public on how to prevent the spread of COVID-19 including staying at home, frequent hand washing, social distancing, and avoiding contact with those who are sick and helping loved ones who are sick avoid contact with others. Public education is also needed to de-stigmatize testing and humanize the victims of COVID-19. Right now, messages like “we’re all in this together” and media coverage of community members, religious leaders, and health professionals providing care and attention to COVID-19 patients can go a long way.
  • Iraq’s Ministry of Health urgently needs emergency funding from the Iraqi government and the international community to better respond to the pandemic. Strong leadership and management are required to secure and direct necessary funds, preferably with appropriate consultations and oversight by WHO and international donors, before the country is overwhelmed with COVID-19 cases.
  • Stronger infection prevention control (IPC) measures are urgently needed to protect health workers and prevent secondary transmissions. This includes: establishing stronger IPC protocols at hospitals and healthcare centers; making personal protective equipment (PPE) available to doctors, health workers, and first responders, as well as families caring for family members with COVID-19; and providing trainings on the proper use of PPE and how to prevent secondary transmissions.
  • The Iraqi government and KRG should establish hotlines staffed by health professionals to field queries, and should make use of telemedicine and mobile health teams to reach symptomatic patient in their homes, especially for routine consultations. WHO has established a protocol for home care that should be widely encouraged and put into use, especially given the risk of secondary infections at health facilities.
  • Given Iraq’s limited resources and ongoing deficiencies in its health sector’s capacity to effectively carry out PCR (polymerase chain reaction) testing to detect COVID-19 cases, Iraqi health authorities and WHO should consider changing the case definition for COVID-19 to allow for clinical diagnosis (as was done in China). In the absence of test results, such a change is critical to more accurately count, track, and treat COVID-19 cases. Iraqi physicians will need to be quickly educated on the combination of symptoms associated with COVID-19, to ensure that those clinical diagnoses are done with a reasonably high degree of certainty.
  • In areas where widespread community transmission may already be occurring, such as Baghdad and Najaf, testing will no longer serve to identify and isolate cases to reduce transmission. However, testing in those locations will remain useful, to rule out cases, so that non-COVID patients can receive more appropriate care and COVID patient can be safely discharged without risk of further transmission.
  • Work with WHO and the UN Health Cluster to make more hospital beds, ventilators, labs, and other resources available. This will require mobilizing more skilled health workers and preparing more hospitals and other buildings (including schools, mosques and churches) for an expected surge in cases. At the same time, given that Iraq’s population of over 40 million may only have access to some 500 ventilators, averting deaths will be less about hospitals and more about home care.
  • Extreme efforts must be taken to protect the elderly; people with serious underlying medical conditions such as heart disease, lung disease, hypertension, and diabetes, lifetime smokers, and others who are especially vulnerable to death by COVID-19.
  • In areas where the virus is not widespread, contact tracing of confirmed cases can help to better target resources and predict where new transmissions of the virus will occur, while at the same time educating the public to avoid stigmatizing victims of COVID-19.
  • Enforce and extend the closure of borders and travel bans from countries experiencing an outbreak of COVID-19 and/or quarantine new arrivals for 14 days. Border closures must include Iran. If the quarantine option is chosen, given growing evidence of person-to-person transmission by asymptomatic individuals, all travelers must be quarantined, and comfortable quarantine options should be made available.
  • Develop and execute a nationwide COVID-19 surveillance and prevention plan to determine the location, coverage, timing, and duration of lock-downs – and make every effort to educate the public and win support for such lock-downs. It is unrealistic to expect that a country like Iraq can undertake a lock-down of sufficient intensity and duration (14 weeks or longer) to effectively “kill the virus.” As the epidemiologist Dr. Ghassan Aziz explains, “Lock-downs can help slow the spread of the disease and buy time to treat existing patients. If done well and timed right, instead of one overwhelming peak, you can spread out smaller peaks over time. This helps prevent your health sector from being swamped with cases.”
  • While fighting COVID-19, far more will be needed to offset the harm done to day laborers and other vulnerable groups who depend on their work to feed their families. This should include the delivery of food baskets and hygiene kits to under-resourced families with COVID-19 who have self-quarantined themselves to protect their communities, and mobilizing resources for those most impacted by the economic downturn, lock downs, and higher prices. In addition, during a lock-down, reliable case-by-case exceptions should be made for essential workers and day laborers, provided that they are screened and cleared for work, and provided that they work outside or in ventilated areas, and use proper social distancing and take other preventive measures.
  • Iraq and the international community must do more to support interventions to counter the pandemic’s social impact. The pandemic is stressful. It causes fear and anxiety, and counter measures can lead to feelings of isolation and serious related problems. In countries affected by the pandemic, there are already reports of an increase in mental health needs, domestic violence, and gender-based violence (GBV). In Iraq, some of the victims of COVID-19 and their families have been ostracized by their communities. Therefore, it is important to provide resources to those who are helping to heal the social fabric of Iraq during this time of pandemic. Volunteers who are giving their time and businesses who are donating goods and services should be recognized to inspire more such efforts.
  • Finally, the response to COVID-19 should not put at greater risk patients who require medical attention for other conditions. It is therefore important to prevent Iraq’s health sector from becoming flooded by COVID-19 cases. Iraqis with treatable medical needs must continue to receive the care they need.

The Government of Iraq and the Kurdistan Regional Government are facing an extraordinary test of leadership in responding to the pandemic. Every effort made today can help buy time and save lives. However, even with the best leadership and under the best of circumstances, these governments will need help from the U.S. and international community. Iraq and other developing countries with currently inadequate healthcare systems should not be left to face the pandemic alone. We are all in this together.

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