QAYARRAH, Iraq — As she waits outside Qayarrah General Hospital, Haleema Yousef clutches two things to her chest. The first is her 2-month-old daughter Remas, who was born somewhere along her journey of displacement, as Yousef and her six other children fled fighting in Mosul. The baby smiles softly but quivers with cold despite being wrapped in layers of yellow and pink blankets.
With her other hand, Yousef grips a piece of paper from another health facility, referring the infant here. Of the dozen patients and families like her queueing outside, almost all have a similar document.
Medical referrals, written and stamped with diagnoses and case details, are usually an anomaly in the frontlines of ongoing conflict. But around the city of Mosul, which government security forces are still fiercely fighting to retake from the Islamic State militant group, they are increasingly becoming the norm — part of a uniquely defined chain of care.
Mosul has been the rare humanitarian emergency that everyone could see coming as the Iraqi government telegraphed its intent to retake the city. That has allowed an enormous amount of innovation to happen on the frontlines. One of the most unexpected players close to the battle has been the World Health Organization, a U.N. agency that usually prefers to coordinate from the sidelines.
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In Northern Iraq, WHO is essentially running a referral chain for trauma cases that sees patients from inside Mosul move through stabilization points, field hospitals, and eventually tertiary facilities within the “golden hour” — the crucial 60 minutes in which critical patients must get care to survive. Nearly 5,000 civilians have come out of Mosul with injuries from bullets, shrapnel, suicide bombings or shelling. So far, WHO have set up two field hospitals. One more will open imminently and a fourth is planned, effectively circling the entire city of Mosul with care.
WHO also helped rebuild and reopen Qayarrah General Hospital, where Yousef and her daughter wait, as well as Al-Shikhan Hospital to Mosul’s north. WHO is supporting labs to screen blood transfusion supplies, procuring ambulances to put in play and paying some doctors who the government can’t afford to.
All this is “generally something we don’t do,” said WHO country representative, Altaf Musani.
The story of how and why WHO stepped in offers a look at what the agency can do — and hopes to do more of here in Iraq — if and when circumstances call for a more activist role. The work comes at a transformative time for WHO itself, which is wrapped in an intense debate about how it should reform and what sort of role it could and should play across the globe, ahead of elections in May for a new director-general. The West Africa Ebola crisis of 2014 sparked difficult discussions about how and why the WHO fell short both in its coordinating and implementing role — and raised some questions about whether the organization should scale back its role in the field altogether.
The Iraqi work makes a case for a frontline role in emergencies. In interviews with Devex, aid groups, donors, doctors and patients told Devex the chain of referral is working well, considering that it is unfolding amid some of the most intense fighting Iraq has seen in several years.
To have a defined and operating trauma referral chain — “that kind of work is very rare in frontline emergencies,” Humanitarian Coordinator for the U.N. Mission in Iraq Lise Grande said, during a recent visit to the Qayarrah hospital. “And really it’s been exceptional leadership from WHO,” and its partners.
The initial trauma cases that came out of the military campaign to liberate East Mosul were referred to Erbil’s West Emergency Hospital, some three to four hours from the frontlines. Within days, WHO noticed a series of alarming trends. First, the Erbil hospital was complaining that its bed capacity was full, disproportionately occupied with patients from Mosul.
Looking at the types of wounds, WHO also realized that civilians were getting directly caught in the fighting. They were “stepping on landmines, fleeing front lines and being shot by snipers,” recalls Musani. The injured who made it out recounted stories of long delays at checkpoints and onerous journeys by road. Ambulances from Iraq cannot enter the Kurdish region and vice-versa, so patients would be forced to swap cars halfway along their journey.
“The typology of the data was telling us there was a major problem going on in East Mosul.”
At the same time, few emergency medical groups had established an effective enough presence as close as was needed to the battle, a major donor and several U.N. agencies told Devex. “We’ve struggled in getting partners to the frontlines,” Grande said a few days later at the Sulaimani Forum at the American University of Iraq in Sulaimaniya. The traditional actors haven’t been “as close to the fighting as possible to help people where they need it.”
In reply to questions from Devex, the International Committee of the Red Cross disputed the account that it and colleagues at organizations such as Médecins Sans Frontières were not sufficiently close to the frontlines. “The coordination of WHO on trauma care is an important activity but it is the implementing actors of WHO who are on the frontlines,” Sara Alzawqari, media relations and spokesperson for the ICRC, said by email.
Still, WHO’s mandate includes two clauses that the country team thought merited — and even required — them to take a stronger lead: as a guarantor of accountable health aid, and as the provider of last resort.
WHO started prioritizing trauma care at weekly health cluster meetings, and then in November convened a specific working group that also met weekly. “The minute we stumbled upon [these issues], we convened a group of partners who have the expertise to manage this,” said Musani.
The group identified three key steps that needed to be built into the referral chain. Stabilization points no further than 10 minutes from the frontline would get patients stable enough to travel, and code them by critical level from red to green. Field hospitals a few more minutes away would do immediate surgical interventions; then prepare patients to move yet again. Finally, a set of tertiary facilities — ideally all in Ninewa province to avoid changing ambulances to Kurdistan — would provide necessary care.
These concentric circles of care would essentially put a ring around Mosul to “catch and release” patients: Catching all trauma patients and releasing them into capable facilities within an hour.
There was at least one field hospital on the ground. MSF opened a facility to treat red cases 18 miles north of Mosul in October. WHO focused on setting up an additional field hospital in Bartalla, a town to the east of Mosul on the way to Erbil — literally cutting patients’ journeys from stabilization to hospital care in half. The facility is staffed by Samaritan’s Purse, with two operating theaters. As soon as it opened in January, the caseload in Erbil fell.
Simultaneously, WHO worked to ensure that trauma stabilization points had vital medicines and equipment for paramedic aid. Among the groups that are or have run TSPs are MSF, ICRC, New York City Medics, and the International Medical Corps. Several different military forces also have TSPs that will treat civilians.
With Bartalla hospital in place, WHO then sought funding to set up similar facilities to Mosul’s north, south and west, effectively putting the second concentric ring around the fighting. A second field hospital in Athba opened on March 21, staffed by Iraqi health workers and Aspen Medical. A third in Hamam Al Ali is scheduled to be completed soon.
Meanwhile, WHO navigated between local health authorities, as well as other agencies and charities, to solidify the third ring of permanent tertiary facilities. Many of the hospitals in Ninewa had been occupied by ISIS or damaged in the fighting; they lacked facilities, equipment and sometimes staff.
Qayarrah General Hospital reopened its ground-level floor in early March with local Iraqi doctors, some of whose salaries are paid by the U.N. Population Fund. Al Shikhan Hospital in the north is also receiving patients, and has been equipped by WHO to treat any future cases of chemical weapons use.
Doctors here know the referral chain is working because they’re constantly very busy. “With the referral system now, we are receiving patients from locally in Qayarrah but also from the frontline in Mosul,” chief Doctor Ramadhan Mahjub said. “The majority we are receiving are the injured population who are trying to move from Mosul. ISIS put many explosions [in their path] or sometimes they are shooting them with guns. We see children, kids, females, the majority of them.”
WHO’s leadership gamble worked in part because they found donor support, most notably from the European Commission. WHO received a 4.35 million euro grant in late 2016 for their work around Mosul trauma care. Another grant from the U.N. Central Emergency Response Fund added $9 million to their efforts to stand up field hospitals.
But ECHO’s political support has proven perhaps even more vital. ECHO has been “really proactive on this,” Maud Bellon, Mosul field director for Handicap International, and a member of the trauma working group.
The donor backed and even encouraged WHO to lead the trauma chain, including in coordination meetings, allowing them to take on a larger role, despite not all parties working under WHO’s authority.
While ICRC coordinates with WHO, “independent organizations like MSF or ICRC are contributing to the government’s effort, however we are not coordinated or lead by WHO. We are coordinating with WHO but more so with the [Iraqi authorities],” said Alzawqari.
WHO and ECHO are also closely cooperating with authorities, both organizations told Devex. One key element of the WHO trauma coordination was orchestrating a “handshake” between Iraqi and Kurdish authorities, to make sure authorities and checkpoints on both sides knew to expedite patients, and how to direct them in the field.
EU Commissioner for Humanitarian Aid and Crisis Management Christos Stylianides also told Devex that he saw building the trauma chain of care as an opportunity to build long-term development into the immediate crisis response. Each of the field hospitals and tertiary facilities that WHO has either built or rehabilitated will be turned over to the government when the relief operation ends. “It’s impossible for humanitarian actors to establish hospitals with real infrastructure,” Stylianides said.
That long-term impact has strengthened the case for WHO’s work, both inside and outside the organization. Iraqi authorities and doctors have largely welcomed the chance to build their capacity and rehabilitate damaged infrastructure.
Internally, a key mandate of the agency is to build national capacity — something that is literally being done in Ninewa. “It’s an entire health system we have created, from stabilization to op and post-op care,” said Musani. “We feel very comfortable that [what we are doing] is not outside the health system, but rather, we’re expanding and promoting it.”
Just as the trauma chain was crystallizing, the Iraqi military opened up the second half of its campaign to liberate Mosul, pushing into the western part of the city, where the streets are narrower and the buildings are older. The population is densely packed into neighborhoods, many of which are less affluent than on the east side. Analysts expect more hand-to-hand and block-to-block fighting, as ISIS militants have no exit from the city.
That combination could make for an even higher civilian toll. As of March 11, 57,000 people had been displaced from West Mosul, pushing the total of internally displaced people from the city up to 225,000.
Ambulances may be the biggest current gap in bringing casualties across the frontline for care, according to one frontline medical group that declined to be named because of security concerns. On March 20, WHO airlifted 15 of a new procurement of 30 ambulances to Ninewa Province, on top of 32 they have donated already. The medical group said this number would still likely leave gaps.
Despite the new beds and operating theaters opening, demand is also outpacing capacity at times. Typically, patients arriving to field hospitals and tertiary facilities cannot stay longer than 48 hours before they are cycled out, so that more cases can be treated. Doctors would ideally like to keep many of those patients far longer, for initial recovery but also for the rehabilitative care that nearly all casualties will require.
That next phase — post-operative care — is now one of the trauma working group’s key focuses. “Today there is a good referral from the trauma stabilization points to the hospital,” said Fanny Mraz, head of mission at Handicap International. “What is missing is after, at the discharge.”
Handicap International is among the NGOs here that are considering leading this post-op care chain. Many patients are on the move, making it difficult to track them, and ensuring they come back for care. Others struggle to pay the transportation fees to the hospital, or to sacrifice the day of work or childcare it would require. A first step here will be to make sure hospitals record patients’ and caregivers’ contact information and probable location.
Then there is the medical capacity. Iraq has a severe lack of physiotherapists, compared with the demand, said Mraz. Although her organization and others are providing training, the deficit is far more severe than shortages of doctors or nurses, for example.
Basic health care is another growing concern. During ISIS’s control of Mosul, some health facilities were operational, but civilians fleeing the areas say ISIS charged for care, and clinics lacked vital medicines such as vaccines. Now as the population comes out from two years of siege, they are “seeking health care at an astronomical rate,” said Musani. He recently visited two clinics in East Mosul that have reopened. Typically, they would expect 100 to 200 patients per day, but were receiving 700 to 1,000. “People want to make sure their children are vaccinated, that they got prenatal and antenatal care.”
Several aid groups also stressed to Devex that coordination remains a process, changing as the frontlines shift. For example the medical organizations operating near the frontlines said they often receive less-severe cases, when their facilities should be reserved for the most critical cases, a result of TSPs or military forces not understanding where or how to refer cases.
ICRC echoed the need for ongoing vigilance. “Coordination with all actors, which we focus on, such as Humanitarian, Governments and Military remains high for operational reasons, avoiding duplication and for security reasons,” said Alzawqari.
Here and across Iraq, Musani hopes the example of Mosul can make the case of WHO’s stronger hand.
“I’ve worked for WHO for 18 years and I’m trying to take all [that I have learned in] the last 15 and cram it into Iraq,” he said. Across the country, as well as in Syria, WHO is “doing some really unique stuff. When we look inside the institution, a lot of [the operations] are seeing how far we are pushing the envelope.”
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