Events in April and May

I got confirmation from my contact at the hospital that the latest shipment of drugs from India reached the hospital last week. Again, the shipment contained 50 vials of doxorubicin and 10 vials of carboplatin as before.

When I spoke to my contact, he indicated that oncologists at the hospital have become dubious of the quality of the drugs in recent shipments based on apparent response of patients to treatment. Because of the poor phone connection I was unable to understand all the details and I have asked him for clarification.

The chemotherapy drugs in recent shipments have been produced in India and shipped from there. I was very careful to investigate the competency and quality control program of the supplier in India before deciding to work with them, and I have good reason to believe they are competent and well equipped to properly test and verify the quality of their products. I have asked them to provide analytical reports for the drugs delivered in recent shipments. Hopefully, such data will enable the specialists at the hospital in Mosul to make a well informed assessment of the drugs and decide whether to continue using them.

I am not sure but I suspect there may be a general suspicion of all imported drugs among Iraqi doctors. I think perhaps I need to caution the people at the hospital that there is strong reason to believe that the drugs from the Indian supplier are full strength and exactly as labeled, and that it could be unsafe to assume otherwise when administering them.

On another subject, in April there was an event dubbed a "Global Activism Expo" in Chicago sponsored by Chicago Public Radio. Here is a Link. Mr. Robert Braam attended to represent the Mosul Chemotherapy Project, and several hundred people had an opportunity to look at flyers about the project. There has so far been little that has come of it in email or comments on this blog, but perhaps someone who took home a flyer will pass it along. If you'd like to look at a PDF version of the flyer, you can find a copy by following this Link.

Update - Crediting Kimadia with SOME Improvement

I spoke to my contact at the hospital today about the continuing supply problems, and he indicated that although the shortage of chemotherapy drugs from Kimadia is still critical and near-total, there have in fact been some improvements over the last year in deliveries of other supplies. One example he mentioned was a recent rather large delivery of ostomy supplies. Another was improvement in delivery of surgical supplies including such things as dressings, anesthetics and antibiotics, to the extent that the number of surgeries per week per surgeon which is possible with the available supplies has approximately doubled in the last year.

I asked whether the supply problems seem attributable to corruption or to shortage of funds or some other cause. His feeling seemed to be that it is the general chaos that afflicts Iraq that is the most important problem. He seemed doubtful that highly placed people in the Ministry of Health were diverting supplies to the black market but considered it possible that lower echelon personnel might do so if the opportunity presented itself.

I have never ceased to be impressed by the dedication and courage of Iraq's doctors, and to the extent that the Ministry of Health is staffed by physicians I have no doubt that the welfare of the patients of Iraq is their primary concern.

March Shipment

I got confirmation from the hospital that the latest shipment arrived there OK on March 23, 2008.

The shipment included:

1. Doxorubicin 50 mg vials : 50 vials
2. Carboplatin 450 mg vials : 10 vials

USA Today Article Blames Sadr

A recent USA Today article titled "Sadrists' grip on Iraqis' health care takes toll" indicates that Sadr and his cronies control the Ministry of Health and it's Kimadia agency and use them as a tool to exercise power. The presence of a large portrait of Sadr's relatives outside the Ministry offices is offered as confirming evidence.

In part, the article says:
Al-Sadr's control over Kimadia, the state-run company that is responsible for importing and distributing drugs and supplies to Iraq's hospitals, also poses problems, Ferrati said.

"Kimadia has a stranglehold on the whole medical sector, and that is a source of power through which Sadr can control the health sector and threaten the country," Ferrati said. "If they decide to stop working, then you cut off all the drugs into Iraq."

This is interesting because it suggests a face or group identity to blame for the supply woes afflicting Iraq's hospitals, but I suspect it might be erroneous or oversimplified. If I had to guess I would say not all of the Health Ministry is corrupt although serious corruption would be consistent with the poor job Kimadia seems to be doing; Kimadia's personnel in Mosul seem to have the respect of my contacts there although they are far from satisfied with the job Kimadia is doing. I suspect many Ministry and Kimadia people are honest enough and if there are miscreants they are probably a minority, possibly in management positions if they are in fact Sadr's politically appointed agents. Also, I have seen no indication that the medical supply situation is better in any particular place in Iraq than others, suggesting that rather than withholding medical supplies from some parts of Iraq that don't toe Sadr's line and providing them to other areas that do, necessary supplies are being denied to (or stolen from) all without prejudice. This would be more consistent with diverting medical supplies for profit and using the proceeds to finance criminal/sectarian activities than bartering the supplies for favors. That would match reported profiteering on diverted oil in southern Iraq where militis are reportedly heavily involved it that corrupt trading problem. If medical supplies and drugs are being diverted for profit, it's presumably happening in Baghdad and involves collaboration of militias.

Of course I'm half a world away and have no direct knowledge of any of this, but something pretty outrageous is causing serious problems for Iraq's hospitals.

Another Delivery

I got confirmation February 26th that the most recent shipment was received at the hospital OK. The shipment included the following:

1. Doxorubicin 50 mg vials : 51 vials
2. Carboplatin 450 mg vials : 10 vials

An intensive effort by the supplier to upgrade packaging procedures was effective, based on photos of the shipment and it's preparation, and all the vials arrived intact.

In addition to the chemotherapy drugs, the supplier also sent a separate shipment containing some samples of broad spectrum antibiotics intended to combat infections in patients with immune systems compromised by chemotherapy. They have indicated a willingness to provide additional supplies if the hospital finds the samples effective. The antibiotics arrived at Mosul Airport without advance notice a few days after the chemo drugs, and it was not possible to transfer them to the hospital at the same time as the chemo drugs.

Another shipment of chemo drugs has been ordered and will hopefully reach the hospital in March.

This project has been delivering chemotherapy drugs to Mosul Oncology and Nuclear Medicine Hospital on a more or less regular basis since August 2005. Regrettably, I have never managed to attract major funding or support for the project. The shipments are funded mainly out of my own pocket, and my resources are not sufficient to do more than demonstrate that delivery of shipments is possible.

I can never hope to provide enough supplies to resolve the severe shortages afflicting the hospital. Little evidence has materialized to indicate that the Iraqi Ministry of Health and it's purchasing arm, "Kimadia", can be soon expected to properly provide adequate supplies to Mosul's hospitals or to any of Iraq's hospitals.

The inevitable result is that people are dying who would not die if the Ministry of Health and Kimadia did their job and supplied Iraq's hospitals properly and effectively. The shortages of necessary supplies at Iraq's hospitals are lethal to the patients who depend of the Ministry of Health system for care, despite the best efforts of Iraq's doctors to deliver care in the face of continuous desperate shortages. I have no idea how many lost lives can be attributed to the failure of the Ministry of Health and Kimadia to properly supply Iraq's hospitals, but I believe the numbers must inevitably be huge, comparable to the number of lives lost to violence if not larger.

The outrageous supply shortages in Iraq's hospitals are not frequently mentioned in the news, but they exist with total certainty and they are nationwide. Every news report, however brief and however un-noticed, attests to their severity. Nothing is heard to indicate that the nationwide tragedy of neglect afflicting Iraq's hospitals is some mere figment. The plight of Iraq's hospitals is clear to anyone who has the interest to open their eyes and investigate.

I have tried to avoid speaking ill of Kimadia and the Ministry of Health, because I am a half a world away and I have no way of knowing with certainty exactly what is causing the shortages afflicting Iraq's hospitals. However, whatever the cause, and whoever is responsible, the shortages are real, and they are lethal to the patients of Iraq, and those responsible for supplying Iraq's hospitals have failed to do so. To keep silent about the problem is no longer reasonable.

Recent Deliveries

I have been remiss in logging recent deliveries.

A shipment reached the hospital on 11/22/07 or thereabouts - I got confirmation by telephone sometime on 11/21, I think, and sent an email that phone call on 11/22. Unlike the FedEx tracking info that documents shipment locations and times enroute to the airport, transport to the to the hospital is accopmplished by busy people by methods and on schedules which can not be reported or discussed for security reasons - nobody takes notes, they just get the lifesaving drugs where they need to go and send me an email that they did so.

This shipment included 50 vials Doxorubicin (50 mg/25 ml) and 8 intact vials Carboplatin (450 mg/45ml) (2 were lost by breakage in transit from India)

A shipment reached Mosul Airport January 9th and is safely stored under refrigeration there pending arrangements to transport it to the hospital.

This shipment in progress includes 49 intact vials Doxorubicin(50mg/25ml) (1 was broken in transit from India) and 12 vials Carboplatin(45mg/45ml).

The breakage of vials in transit in the last two shipments is being energetically investigated and an effective correction of the problem is hoped for soon. No breakage has occurred in the many shipments which preceded these. These drugs are potent and potentially hazardous if spilled, and standard procedure in the event of a spill is to wear protective gloves and safety glasses, wipe up all spilled liquid, and wash the area. All cleaning materials and waste including the gloves need to be bagged up and either buried or burned. The vials come each in it's own individual carton, and any contaminated cartons have to be discarded with the other cleanup materials.

I have checked with FedEx representatives and there is no obvious cause for the recent breakage in transit other than problems in how the shipments are packaged for shipment. I made it clear to the supplier after the first incident that the shipments needed to be packaged better, and we agreed that they would be. Now that there has been a second incident, my understanding is that high level management will be watching and taking photos as the next shipment is packed to ensure that everything possible is being done to prevent further breakage in transit.

Stalled

Although it was my hope to get two shipments to Mosul during December it has so far been impossible to get the drugs shipped from India. I am not completely sure what the cause is. A phone call today brought news that the goods are now available and may hopefully be shipped this week.