In the international coverage of Iraq’s crumbling healthcare system, one faction has remained largely silent. Joanne Bladd learns what daily life is like for the dentists left behind.
The note was pinned to the door of the Baghdad dental clinic late last year. Scrawled and unsigned, it threatened the owner, warning the dentist to leave his practice within 24 hours.
Before the war we were under sanction, after the war we are under corruption. The effect on practice and patients is almost the same.
No one knows who sent the note, says Dr Rafi Aljobory, but it is far from an isolated incident. “You must expect a bullet,” he shrugs. “For five years this has continued, so we have learnt to have a sense of humour about it. One week in Iraq is like a lifetime elsewhere.”
Aljobory, the president of the Iraqi Dental Association (IDA), is one of a shrinking number of dentists still living and practising in Iraq. Since the US-led invasion, an estimated 50% of the country’s dentists have fled their practices, relocating to the North or joining the exodus of professionals driven abroad by the unrelenting violence.
Aljobory’s own house has been bombed and he has been forced to move several times. A vast majority of those exiled are the most senior dentists, and the dangers have increased for those who remain.
Professor Hussain Faisal Al-Huwaizi can’t remember the last time his clinic stayed open in the afternoon. A few years ago, when things were more normal, his practice would at times remain open well into the evening.
Not any more. Now Al-Huwaizi, vice dean of the College of Dentistry at the University Of Baghdad, shuts up shop by noon to ensure he and his staff are home before dark.
“When you are all living in the same situation, it becomes normal,” he says, tiredly. “We are all under pressure, but it is a generalised threat. You learn to live with it.”
He recalls how, before the invasion, dental practices jostled for business in Baghdad’s busy center. “In one street, there were previously 20 dentists. Now, you can see maybe six.”
The fall from the top
Iraq’s healthcare system was once a showcase for the rest of the Middle East. Its dentists often studied in Britain or the US, and the country’s dental schools boasted high standards.
But more than a decade of international sanctions, followed by years of war, have left healthcare in Iraq little better than that seen in developing countries.
“Like everything else here, the dental industry is struggling to stay alive,” is how Dr Mohammed, a government dentist, describes it. “When the war ended, we thought Iraq would be open to the world…but we were shocked by the isolation we live in.”
When war broke out Mohammed, like almost one million of his compatriots, fled to Jordan after his family received death threats from militias. He was unable to find work and so returned to Iraq a year ago.
He is now employed as an intern dentist in Iraq’s Ministry of Health where, he says, dental services are deteriorating daily.
“The majority of well-known and specialised dentists fled Iraq; they were either threatened, killed or were afraid to stay,” he says. Three dentistry college professors were jailed recently, he reveals, and are still being held without charge.
In the lawlessness, the usual rules of the consulting room have fallen away, turning doctor-patient frictions into aggressive confrontations.
Like physicians, dentists are tremendously vulnerable, because they are perceived as having more money than most Iraqis.
[Patients] are really committed to attend appointments, even in the most difficult of situations.
“When the anaesthesia is depleted, we are accused by patients that we are corrupt and stealing the materials,” Mohammed explains. He has taken to buying anaesthesia himself, to ensure he can always treat emergency cases.
Still, Mohammed counts himself lucky, when compared to dentists in the private sector.
“They face the same troubles as we do…added to the dangers of being targeted, threatened or kidnapped, and the daily trouble of providing clean water and electricity.”
Supplies and sanctions
The more mundane problems are no less serious. Decades of deficits have severed the supply chain, and clinics like Mohammed’s face chronic shortages in equipment, intensified by government corruption. And of course the dentists keep leaving.
He and other interns have learnt to make do with little. “We are forced to used expired materials because we have no other option,” he reports. “Every few months the anaesthesia disappears. Before the war we were under sanction, and after the war we are under corruption and the effect on our practice and patients is almost the same.”
One of the biggest complaints among dentists is that they are not paid enough. Mohammed brands his salary “a joke”. In the private sector, Aljobory believes the situation is slowly improving, with clinics seeing a gradual step-up in salaries. In a ripple effect, this is going hand-in-hand with a demand for better equipment.
“My salary, previously, was US$3 per week in a private clinic. Now it is about $400, monthly,” he says. “We are seeking better supplies – not the best, because we can’t afford the best, but better.”
Dental firms, however, remain wary about resuming business with Baghdad. In talks with US and German brands Al-Huwaizi, who is chairman of the IDA’s scientific committee, reports they have no plans to pick up ties with Iraq.
Pragmatically, he confides that most of them are too highly priced anyway. “Chinese firms are better suited for Iraqi dentists…or bargains at exhibitions.”
Surprisingly, the lack of supplies has done little to drive down enthusiasm among patients. Those practices still operating boast an attendance level that would be the envy of most western practices.
Mohammed trades stories of patients braving bombings and checkpoints to keep appointments. “They are really committed to attend appointments, even in the most difficult situations.”
Al-Huwaizi optimistically maintains that this is reflective of an improvement in the security situation. “A year ago, we would hear 12 car bombs a day – now we only hear one every two or three days. Every day there is something. Patients are coming back, asking about bleaching or ceramic treatments.”
Dentists struggle to keep their doors open in unpredictable circumstances, conscious of the hardships their patients face in getting to appointments.
“[They] struggle to give their best to the people…to face the everyday difficulties to reach the clinic and quickly remove the impact, to be able to welcome patients with a smile,” Mohammed reveals.
Many dentists have become used to operating against a backdrop of gunfire, Al-Huwaizi suggests. He tells of a huge explosion, occurring less than 1km away from his clinic and rocking the building’s foundations.
“We were very startled for half an hour, and then we went back to work,” he says simply. “That was it.”
Running its course
It is our country – if everyone goes, who will stay? We are Iraqis. Life goes on.
While hundreds of exiled Iraqi dentists adjust into new lives, those left behind report signs of hope. Travel access is gradually opening up, allowing the Iraqi Dental Association to marshal more than 1,200 of its members abroad for conferences, a step towards plugging the educational gap left by sanctions.
Iraq is still off limits for continuing education companies, but the association is doing its best to keep its dentists updated. “We manage,” says Al-Huwaizi.
At the recent AEEDC dental show, held in Dubai, the IDA collaborated with the FDI to run a hands-on course for its members. Brandishing a newly-purchased bleaching kit, Al-Huwaizi said delegates would recreate the course back in Iraq for other dentists. “I think this is a good solution for the time being,” he adds.
Despite the conflict, dentistry has remained an attractive career prospect for Iraqi students. Throughout the war, Baghdad University’s College of Dentistry has continued to house students, with more than 50 currently pursuing their degree.
The college has retained close ties with the UK’s General Dental Council, and the panel recently evaluated the quality of the Bachelor of Dental Surgery. For a once proud institute, it’s a mark of achievement that many of its graduates still make the grade.
“We have 40 to 50 PhD students, we offer diplomas and these are still going on,” Al-Huwaizi reports. He carefully documents each achievement in the pages of the college magazine. “Student numbers have receded but, with these circumstances, I think it is still an achievement.”
Post-sanctions, several international dental associations have reached out to offer support and educational tools to Iraqi dentists. The IDA relies heavily on these props, and Al-Huwaizi is hopeful it will continue.
“In the previous 15 years, no Iraqi was introduced to any international committee.” Gesturing to Iraqi AEEDC delegates, he says: “More than 150 members have participated in this conference. We are honoured.”
Looking to the future
When the US invaded Iraq five years ago, millions of nationals fled. The obvious question is; Why did these dentists not go with them? For Mohammed and others his age, a lack of experience means it is almost impossible to find a job outside Iraq.
Other dentists like him face a long haul and numerous licensing exams to secure work outside of their home country, and for many it is too much. Of his government post, Mohammed shrugs; “It is true that the payment is a joke, but at least it is a job and it’s paid.”
For Aljobory, the reason to stay is more prosaic. “It is our country – if everyone goes, who will stay?” he asks. “We are Iraqis. Life goes on.”
Al-Huwaizi retains the optimism that has kept him at his teaching post, and in his clinic. Unlike many Iraqis, he believes the security situation is improving. “It doesn’t happen overnight, but I hope the gloomy times are over,” he confides. “I see change. Previously, there was only a tunnel. Now there is light.”
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