Letter from Iraq: Ethical Dilemmas in an Iraqi Burn Centre

Guest Post by Mustafa AL-Shamsi

Health requires a multidisciplinary approach.  In the absence of proper support, facilities and literate people, there is little that a physician can do to cure his patient regardless his proficiency.  The following is not a story; it comes from what I experienced when I was an intern at the burn unit.  I faced a lot of ethical rather than medical challenges.  Some I could cope with; others were not so easy.

I was an intern in Basra city, according to the internship curriculum.  My internship in the burn unit changed my outlook and made me aware of how fragile the health care system is in Iraq.  Being a doctor in the Iraqi health care system is tough; there are many challenges to stand against, but you have little to do because of a limited resources, poor training and supervision.  The most disturbing thing is you have little to do for your patient!  (Others have noted similar problems.)

I learned a lot of good-sounding terms like mercy and empathy during medical school, but is any of them is applicable in the burn unit?  There was too much sorrow and pain to deal with.  Human lives were placed on the shelf without care from authorities.  On my first few days I was upset by every burn patient; however, this made me feel sick and frustrated, and I began to project my emotion on my family, friends and patients.  I realised that I would not able to manage patients properly if I continued dealing with this situation from this position, so I developed a new strategy: apathy.

In the past, I always considered apathy to be a malaise; but in the burn unit it became my salvation.

I learned how to manage the burn patients without emotions because I have little to do for them.  For example, I could cure an infected burn with antibiotics (although some of them are missing), but I could not manage severe pain as I did not have proper analgesics.  Meanwhile, the patients took things from a narrow perspective and complained: they did not see the breaches in the system and the burden on the doctors.

Most of the burn patients are not victims of accidental burns; they are victims of suicide attempts.  Young women constitute the majority of burns victims.  They are trying to commit suicide, because they face social and psychological pressure such as domestic violence, illegal relationships, depression, and forced marriages.  (See here, for example.)  One from many cases that shocked me and left a deep impact on my psyche was a sixteen-year old patient from the countryside who had burned herself because her father forced her to leave school and marry a man who was twenty years older.  These cases are difficult for interns deal with alone as it requires a multidisciplinary approach, including social and psychological support, that is not available.

I felt guilty for my inertia, but sadly, it is hard to make a change when you are alone in the field.  Training in an environment where support is weak makes it difficult to take action, such as investigating the factors that lead them to attempt suicide in order to provide better understanding of the situation; action to prevent these incidents in the future is vital.  During the month that I attended, there were 9 cases admitted due to suicide attempts – and this was the lowest number for three years.

The smell of the ward makes me feel sick most of the times.  It is miserable, dismal, cheerless and dark and not even an optimist can encourage or give hope to the poor patients.  There is too much sorrow for one person to deal with.  The constant screaming from patients caused by their pain and suffering can be heard, the smell of the death in the air can be sensed.  The suffering is endless.

And yet good things sometimes happened.  I feel proud when I am thanked by a patient whom, despite everything, I can treat.  Being left alone, without a support from a supervisor and staff, to handle hard situations taught me skills and gave me a confidence to make a decision.  Sometimes it is better to start your career in hard way, depending on yourself, so that the next steps will become easier as time passes.