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Fixing Iraqi Health Care Comes at Expense of U.S. Needs, Critics Say 

By Ceci Connolly
Washington Post Staff Writer
Friday, October 17, 2003; Page A25 

President Bush and first lady Laura Bush have a vision for health care
in Iraq in which all mothers-to-be receive prenatal care, childhood
mortality rates plummet and every person has access to virtually free
treatment and medicine through an extensive network of 1,400 renovated
hospitals and clinics. 

It is a vision that will cost U.S. taxpayers almost $2 billion in the
first 18 months -- an amount some lawmakers say is too steep,
especially when a growing number of Americans cannot afford medical
care. 

"I certainly understand the need for health care in Iraq," said Sen.
Debbie Stabenow (D-Mich.), who tried unsuccessfully Tuesday to shift
$5 billion from Iraqi assistance to domestic education, health and
construction projects.

"This administration has a sense of urgency in Iraq that I don't see
here at home. We see hospitals closing and the number of uninsured
going up, and yet we don't see any sense of urgency from this
administration."

The effort to revitalize Iraq's health care system is a source of
pride for the Bush administration in a postwar reconstruction program
that has often been hampered by violence, international squabbling and
logistical problems. Laura Bush has taken a personal interest,
lobbying for construction of a state-of-the-art children's hospital in
Basra that would one day draw patients and physicians from all over
the Middle East.

The Bush administration and many humanitarian relief groups say the
United States has a moral and legal obligation to rebuild Iraq.

"There is no doubt that the one responsible for this is, according to
the Geneva Conventions, the occupying power, and that is the U.S.-led
coalition," Morten Rostrup, international council president of the aid
group Doctors Without Borders, said recently.

Administration officials point to political and security imperatives
that make investment in Iraqi schools, hospitals, roads and housing
critical.

"If we are successful at rebuilding health care in Iraq, we can start
turning this terrible war against the terrorists," Health and Human
Services Secretary Tommy G. Thompson said in an interview. "We can do
that better, I think, by using a doctor and medical diplomacy than we
can by other means."

Winning the war on terrorism, Thompson suggested, requires doing
things that "show the Muslim world we really do care about women and
children." Medical intervention "is one way we can highlight our
compassion."

But as Congress conducts a fierce debate over the administration's
request for $87 billion to pay for operations in Iraq and Afghanistan,
the proposed medical program for Iraq illustrates the inherent
tensions in spending American dollars in a far-off land. At home, the
deficit is rising, unemployment hovers around 6 percent and many
voters complain to pollsters that Bush is not focused enough on their
economic plight.

"The same values that we hold for Iraq we must pledge for all
Americans," Rep. Rahm Emanuel (D-Ill.) said. "The same goals we
envision for Iraq's future, we must envision for America."

Emanuel and a contingent of liberal House members, in weekly floor
speeches dubbed "Iraq Watch," have contrasted unmet domestic needs
with the ambitious plans for Iraq. The group cites a long list of what
it calls neglected domestic programs, such as veterans' health care,
schools, police on the street, prescription drugs for seniors and an
aging electric grid. 

"Restoring the Iraqi health system is a key part of the overall
reconstruction effort," said Sen. Edward M. Kennedy (Mass.), the top
Democrat on the Senate's health committee. "But it is ironic that the
same administration that wants to improve health care in Iraq is so
indifferent to the exploding costs and declining coverage that are
undermining health care here at home."

William Winkenwerder, assistant secretary for health at the Pentagon,
said better health care in Iraq will enhance stability in the entire
region -- and improving health appears to be one goal around which a
diverse collection of nations and nonprofit groups can unite.

"The health care piece is working, and it's working pretty darn well,"
said Winkenwerder, who added that he believes the medical successes
have not gotten the attention they deserve. "This is one area where
the coalition has worked closely and effectively, and with a broad
international group."

In the past 12 years, Iraq's health care system deteriorated from
being the jewel of the Middle East to Third World-quality care. In
2002, Iraq spent $16 million on health care for 25 million people,
Winkenwerder said, or about 65 cents per person. 

Infant mortality rates more than doubled, from 50 deaths per 1,000
born in 1990 to 107 per 1,000 in 2000. More than half the pregnant
women in the country are anemic, and about one-third deliver
low-birth-weight babies.

Emergency intervention and repairs have restored much of the system to
pre-war levels, Winkenwerder and Thompson said. Now they hope to make
Iraq's health system a regional leader once again.

Of the $87 billion the administration is requesting, $850 million
would be spent on health care in Iraq -- about $300 million for buying
generators and medical equipment, and the remainder for major
infrastructure work, according to the Office of Management and Budget.

Bechtel Corp. is the lead contractor on construction projects at
hospitals and clinics; other organizations such as Abt Associates and
UNICEF have received smaller contracts.

That $850 million would be in addition to $211 million spent on health
care from July through the end of this year and $946 million targeted
for health in the U.S.-installed occupation authority's budget for
2004, said James Haveman, the senior U.S. adviser to the Iraqi
Ministry of Health. 

Another $100 million for administration and salaries at the hospitals
and clinics has been drawn from seized assets of Saddam Hussein.

Some international aid experts have voiced skepticism about the
selection of Haveman, whose international experience is limited to
work with International Aid, a Christian relief organization. Ron
Waldman of Columbia University said the administration is focused too
heavily on bricks and mortar, rather than on fundamental public health
approaches such as teaching mothers to breast-feed, immunizing
children and extolling the virtues of hand-washing.

He and many others were sharply critical of the administration request
for $150 million to start work on a new, high-tech hospital in Basra,
a project about which sources said Laura Bush is particularly
enthusiastic.

"A facility designed to handle top-level pediatric care, plastic
surgery, burn treatment -- those aren't things that contribute to
infant or childhood mortality," he said. "That's like building the
penthouse before the foundation."

U.S. leaders are under "tremendous pressure from the doctors and
public" in Iraq to "make symbolic improvements," said Richard
Garfield, a professor of clinical international nursing at Columbia
University, who spent the summer in Iraq advising the U.S. government
and international relief agencies. "Hospitals are a black hole; you
can pour all the money you have into them and still not get the bang
for your buck."

Thompson defended the project, saying, "It's something to leave as a
legacy" and could eventually draw patients from all over the Middle
East. House appropriators recently eliminated the Basra hospital and
shifted an extra $100 million to repairs of existing hospitals.

In a telephone interview from Baghdad, Haveman said 95 percent of the
$1.1 billion he controls is spent on direct medical services such as
nutrition counseling, vaccines, newborn screening, pharmaceuticals,
equipment, insect spraying, disease surveillance and training doctors
and nurses who have not heard about new Western techniques in more
than a decade.

Haveman nearly gushes over the level of U.S. support in Iraq. Yet he
realizes the United States cannot maintain those levels indefinitely.

Haveman and the Iraqis have done a needs assessment for health care.
Next week, at a donors conference in Madrid, he will ask the rest of
the world for $1.6 billion in aid through 2006. 

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