The WHO & the 'Food for oil' deal

[Seb Wills <saw27@DELETETHIScam.ac.uk>]

---------- Forwarded message ----------
Date: Mon, 18 May 1998 04:21:59 -0700 (PDT)
From: Kathy Kelly <kkelly@igc.apc.org>

Dear Friends, I wanted to send you the he following transcript of a Feb
19, 1998 interview with the head of the WHO because I think it is useful
for clarifying that:  i--the World Health Organization readily states that
distribution of medicines purchased under the oil for food Resolution 986
(Memorandum of Understanding-- MOU) is 100% equitable according to UN
criteria and ii-- even if the amount of money allowed for purchasing meds
would be doubled, Iraqis would still suffer from inadequate access to
crucial equipment and medical infrastructure reparation. 

Mil Rai (lives in the UK, author of *Chomsky's Politics* ) interviewed Dr. 
Habib Rejeb while traveling with the February, 1998 VitW delegation.

All good wishes, Kathy Kelly, Voices in the Wilderness

INTERVIEW WITH DR HABIB REJEB,M.D. HEAD OF World Health Organization (WHO)
IN IRAQ
Interview by Milan Rai, Baghdad, (Voices in the Wilderness delegation) 19
February 1998

What I'm really here for is to ask a few questions related to 986 and the
supply of medicines to Iraq.  What is WHO's function in relation to health
situation in Iraq?  What is its remit?

Our main function at WHO is the development of human resources and
supporting the development of the health system to levels set by the World
Health Assembly and according to the priorities of the World Health
Assembly.  Our role in 986 is really circumstantial.  It is linked to the
duration and implementation of the resolution.  

What is your role in relation to 986?

In relation to 986 we have here in central and south Iraq the mission of
observing the equitable distribution of the supplies and at the same time
we have to make an assessment of the needs.  We have to see whether the
amount of money that comes to the health sector through 986 meets the
demand and needs or not, and how far it meets the needs.  
     To the north - the northern governorate is called the autonomous
regime - we have this function but at the same time we have the
responsiblity of taking the drugs from Baghdad to each of the governorates
and also have the responsibility for the distribution of those supplies to
the different health facilities.  There are more than 400 facilities.

More than 400?
Yes, there are 33 hospitals and more than 380 health centres.

So there are 2 roles.  There's monitoring and there's assessment of
adequacy.  If I can ask you about monitoring.  How confident are you that
drugs and medical supplies supplied under 986 are equitably distributed?

We are not monitoring.  We are visiting health facilities, we are visiting
warehouses, so we are doing direct physical observation of health
providers to see whether they concord with the documents.  At the same
time we are seeing how the drugs are distributed and there are criteria
for the distribution of drugs.  For example, you have some specialised
drugs, some specialised medical supplies, these go naturally to the
specialised centres and we see whether they reach the health centres.  If
yes, we say yes, if there is anything wrong we try to correct it.  Then we
have general drugs.  General drugs are distributed on the same criteria to
the different health centres.  In the same way they are distributed to
what are called the public clinics.  They take care of chronic diseases.
Certain drugs are distributed to private pharmacies, because you have
private hospitals and private clinics.  The objective is that the drugs
which arrive in the country are accessible to the people wherever they
are.  

What's the global figure for the medical supplies and drugs budget under
986?
Under 986, under phases one and two, $210m devoted to the health sector.
Medical supplies and drugs.  Very little goes to medical equipment because
the amount itself is not even enough for drugs.

You observe the distribution from the drugs coming in to the country?

>From the entry point, from customs, to the health centres. 

When they get to the health centre is there a posssibility that diversion
or hoarding could happen at that level?

We make our observations randomly so we could pick any items and we go to
the health centre and verify whether the quantity has actually been
received.  I would say they are received 100% of the time.
Yes, definitely.  Secondly we do random checking.  We see for example if
the item distributed - we go even to prescriptions - we see if there is
any discrepancy between what has been dispensed to the public and what has
remained on the shelves.  Most of the time very little if any remains on
the shelves.

On the first aspect you said 100% of the times the quantities are
received.  On the second aspect of distribution from those facilities,
what would your estimate be?  Is there any discrepancy between what comes
out of the facilities and what's on the shelves, and what was received?

Very very seldom we find some discrepancy, which is usually related to bad
recording because most of the staff have not received any training in
dispensing of drugs.  Since these health centres do receive donated drugs
they sometimes mix between what we call MOU drugs, that means drugs
coming from 986, and donated drugs, so basically it is misrecording rather
than actual physical discrepancy.  And I don't know of any system where
the control of drugs is so tight.  There is very very tight control, even
on private pharmacies because control is exercised not only by the health
authorities but also by the syndicate.

What's the syndicate?
Syndicate pharmacists.  They collaborate with the Ministry of Health to
effect control.

Moving on to the adequacy of what is supplied, there's MOU medicine and
then there's some other medicine.
Very little.

Right.  What is the WHO view of the adequacy of those two streams?

Donated drugs can't be called streams because there is very little,
especially since 986 started - 90% of the donations have dried up.  In
terms of adequacy we pick up for example some very important drugs and at
the level of the health facility we see  how adequate this drug or another
is vis a vis the needs.  For example, we have a winter season.  We know
there is malnutrition because of the poverty of the majority of the
people.  The incidence of acute respiratory infection is quite high.  So
we take the medicine which is used for the treatment of acute respiratory
infections and we pick up items and go to the health facilities throughout
the country.  We have four teams going to the different governorates, and
the four teams assess the same items and see how far they meet the needs.
For example, we have one hundred children visiting the health facility and
maybe 25% or 30% of them came with respiratory problems, from pneumonia to
less acute respiratory infection.  Then we put this against the quantity
of antibiotics available that day for the clinic.  Only 10% to 20% maximum
of those children needing the drugs have access to them.  When I say
access I mean in terms of availability.  I mean you only have the right
drugs - the antibiotics for example - to treat a maximum of 10% to 20% of
children needing the drugs on that specific day.  Often the treatment
should last longer, for example to treat pneumonia you need a course of
eight or ten days of antibiotics, but usually they don't get more than two
to three days.  I would say that throughout the country, most of the
treatments prescribed are partial treatments.

It was put to me by a doctor that the prevalence of partial treatment
means that what is actually happening is that Iraq is breeding resistant
strains.

This is probably a timebomb in terms of public health.  For at least five
to six years, the needs in terms of drugs were met let's say 10% to 20% of
the time according to the health facilities.  Partial treatment has become
the practice.  When an infection is not well treated then bacterial
resistance develops.  This is a worldwide problem, even in places where
drugs are plentiful.  But in these circumstances you increase the chances
of drug resistance.  Unfortunately there are no studies here because the
laboratories are in very bad shape, and also you don't have the necessary
supplies and reagents to conduct the study.  For example to study
resistance you have to have the growth culture.  What we call antibiograms
have ceased to be performed so antibiotics are given randomly.

Doctors I've met say that they are giving children different antibiotics
virtually every day.

They give whatever is available and the attitude is that giving whatever
is on hand is better than giving nothing.  For example in circumstances
where strong antibiotics are not needed but only that antibiotic is
available, it is given.  Then you can't go back.  If resistance develops
to that antibiotic it's very difficult to go back to milder antibiotics.

This is a hypothetical question.  If the amount under 986 increases by,
let's say, $2bn, and if that $2bn was put entirely into the supply of
medicines and medical supplies, do you think it would be meeting the

Even if you assume that there are enough funds to buy medicines, and I
think the assessment for needs of medicines and medical supplies would be
$400m each six months, or $800m a year, this will give a figure of around
$30 per capita.  The WHO range is between $10 to $50 per capita.  Say $30
because the country does not have a stock.  If you build a stock that
means you have about $10 to $20 per capita available.  If you have this
quantity available it's likely you'd meet the needs in terms of drugs and
medical supplies.  But you would be providing this in a vacuum because you
don't have the equipment.  If you buy laboratory materials and you don't
have the equipment it's useless.  As it happens there have been
circumstances where the material was distributed but the equipment was not
there, for it had broken meanwhile.  You buy X-ray films and half of your
machines are out of order, so you can't really improve the quality of
care.  You give antibiotics but because of the poor hygiene in hospitals
it's unlikely that you can prevent cross-infections.  If you don't provide
the proper food in hospitals then you can't enhance recovery.  You can't
really work without electricity, you can't really work without water, and
you can't step on sewage which comes out often.  To improve the health
situation you don't only need drugs because this is the tip of the
iceberg.  You have pneumonia, you don't have antibiotics, you need
antibiotics immediately.  You forget about sewage, you forget about
electricity and so on.  But if you want to provide the proper care to the
population then you have to rehabilitate the infrastructure, otherwise you
can't get the best from your investment, you'll waste resources.  I must
also add that during these past seven years you've had several generations
of doctors coming out of schools of medicine.  They've been left without
any continuing education, their knowledge is not updated, they have no
access to medical literature, so you cannot think that proper care is
given to people in those circumstances.

Doctors have expressed anger about 986 to myself and the group as we've
been going around as they say it perpetuates the conditions we've been
discussing and particularly in Faluja general hospital they felt that
because the level of medicines wasn't adequate under 986 the issue of
resistance....

Resistance is another issue which is due to the history and reality of the
past years.  But the main problem with 986 is that donations have almost
ceased.  We used to have money from donors to buy drugs, for example.

What was the scale of donations that's gone?
Very small.  For example the donations coming in through WHO could meet
only a minor fraction of needs.
Before.  Now we don't have any donations.  Since 1996, since the start,
the funds have dried up.  But the problem of 986 remains. If we had
started to receive shipments in the normal way, in a sensible manner, the
situation would have improved.  But the problem is that one year after the
implementation of 986 we have received only 70% of phase one.

Phase one was the first six months?

Yes.  So far we have received something like 2% of phase two, which ended
in December 97.  I must say that we expected that in the second six months
the drugs and supplies would arrive at a better speed.  So the doctors
were feeling frustrated because the drugs were arriving at a very slow
pace and as soon as they were distributed they dried up.  From our
observations we have noticed that the quantity delivered to health
facilities, particularly health centres, was enough probably for one to
three weeks depending on the items.

How long is it meant to last for?

We don't have the same items coming every time so it is very difficult to
tell you, for example if you provide penicillin I can't tell you exactly
how long it lasts.  You have a shipment of penicillin today, the second
shipment may come after a month or after three months.  The main thing is
that there is no regular flow of supplies, that applies to all essential
items.

So there's no predictability?

For phase one predictability was very small.  But predictability was much
better in the second six months because the procedures of contracting,
approval etc have improved.

What are the reasons for the delays?

The reason was the slow approval of contracts, also the suppliers did not
have a deadline for shipping the goods, and finally, they don't have the
supplies available in stock so they have to manufacture them.  So usually
between the date the contract is approved and actual delivery takes at
least three months, from three to four months is normal, because they
cannot start manufacturing before approval.

So there's a period up to approval and then there's a period from approval
to delivery?
That's right.

So if for phase two there's only been 2% received and it's now two months
after the phase ended and the delays are three months to four months in
terms of the suppliers, the main delay seems to come from the approval?

After the recommendation of the Secretary General, we have the feeling now
that the procedures of approval are much speedier, otherwise I think we
would not have seen this 2%.  Also I think the contractual arrangements
now are precise so this is why we can predict when the goods will arrive.
For example now we know once a contract is approved the delivery will be
done in three months.  That's why we are confident that the delivery of
the second phase will be much speedier.  I think everybody is learning in
this process and I am confident that things will keep improving.

I've visited leukaemia wards where doctors have said to me there are no
cytotoxic drugs available.  In your view would that be because the costs
of getting them is so high?

It has nothing to do with cost.  The cancer drugs have been ordered but
the delays are due to the contracting and approval procedures for phase
one.  As I mentioned for phase two, things will be much better.  This is
part of the slowness of the arrangements of phase one because in phase one
there was no control over the duration of delivery.

Thank you for your time.  





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