Mosul chemical attack exposes an ill-prepared health system

A view of a street in Mosul, Iraq. Photo by: Ashley West

ERBIL, Iraq — Eleven-year old Yasir Hamid squinted as his uncle used gauze to clean the hair around his wound. “I’m ok, I’m ok,” he said, trying to force a smile from beneath the gray woolen blankets on his hospital bed. Five other members of his family lay and sat nearby, each bearing their own signs of what public health experts believe was the first chemical weapons attack during the campaign to retake Mosul from the Islamic State.

Doctors treating Yasir and his family in the northern Iraqi city of Erbil now believe that mustard gas was the chemical that filled their family room just under two weeks ago, burning the children’s skin so much it blistered and burst. The lesions go so deep that 10 days later, Yasir’s doctors still put him under full anesthesia to re-dress the wounds.

“The clinical signs indicated that this is most probably mustard gas,” said Dr. Johannes Schad, a German physician with the International Committee for the Red Cross who is now overseeing their care. “We don’t have lab results now back, and in that case we could finally confirm. But most probably it was mustard gas,” he told Devex.

Recounting the events of the past few days, the Hamids’ story reveals an individual family’s tragedy, but also how ill-prepared the broader health system here is to respond to any similar attacks moving forward.

Health facilities in most of Mosul, including areas already liberated from the Islamic State, have only basic primary care facilities. The clinics where the Hamid family initially sought treatment failed to undertake even the most basic decontamination procedures, prolonging their exposure to the chemical agent and possibly jeopardizing other persons nearby.

Aid groups and NGOs are now reconsidering protocol and contemplating the possibility that such an attack could happen again, or even at a grander scale.

A blistering attack

More than 10 days later, Yasir and his family could still smell something foul lingering in their hair and on their skin. The signature of a chemical agent, an unpleasant odor hung heavy in their throats, searing their lungs. Three year-old Dima shouted out for water, then curled her elbow over her eyes.

In some ways, this family has been remarkably lucky; they made it through layers of checkpoints out of eastern Mosul with relative ease. Soldiers examining the children’s burned faces let them pass and even expedited their travel to the regional capital of Erbil.

Aid groups brace for Mosul humanitarian crisis

Aid groups and diplomats in northern Iraq expect ongoing military operations dislodging the Islamic State group from Mosul to produce a potentially catastrophic humanitarian crisis. Professionals on the ground told Devex they are ready to meet the immediate needs of the up to 1 million who could be displaced by the fighting. But the medium- and long-term future is less clear.

Yasir’s wounds are the most dramatic, because he was the one in the living room when a mortar pierced through the family compound and landed in front of him. His mother, brother, and two young sisters were home too, and their wounds correlate to their geography in the house when the weapon hit. The least affected among them, Sidra, age 6, was in the bathroom at the time of the attack.

“It was like a black smoke,” Yasir’s father Nazim Hamid now says. Mostly, they remember the smell.

The family’s home in the neighborhood of Garag Al Shamal is in an area controlled by the Iraqi army, but the frontline with ISIS was just a few kilometer away. Neighbors who heard the mortar helped rush them to the hospital, the boys to one facility and the girls to another.

The first priority for chemical attack victims should be to shower or douse in clean water, however possible, said Dr. Schad. Affected persons should try to avoid touching — and thereby contaminating — other body parts, particularly their eyes and mouth. The longer a patient is exposed to a chemical on their skin, the deeper it sinks internally. In severe cases, mustard gas exposure can mean liver failure or severe upper-respiratory difficulties.

Eliminating the gas from the skin can limit the damage and also prevent the chemical from spreading into the lungs of bystanders. If a victim enters a hospital ward with other patients, for example, the gas on his or her body can trigger an allergic reaction in anyone nearby. A victim who has not gone through decontamination might spread the agent for a week, Dr. Schad said.

Yet neither of the clinics that received the family undertook that basic procedure. The facility treating the girls sent Dima and her sisters home that evening to bathe on their own — in a home still thick with the chemical.

“There was no hospital, not a real hospital,” said Hamid, the father. “It was like a small clinic, where some patients were seated on the floor and there was no medical care to help.”

At home that night with her daughters, Ikhlas saw blisters forming on their skin. She returned to another facility, which this time referred the cases on to yet another clinic. It still lacked care but had something else vital: the ability to refer patients directly to hospital in Erbil.

The family arrived in the regional capital not long thereafter, still not fully decontaminated.

Fallout

Countless agencies and organizations have issued statements in the wake of the incident condemning it as a horrific precedent. “This is horrible,” U.N. Humanitarian Coordinator in Iraq Lise Grande said in a statement. “There is never justification — none whatsoever — for the use of chemical weapons.”

Yet the more lasting impact may be how the local government, health NGOs and international organizations are considering the vulnerabilities that this attack has exposed in the response structure.

Without better local care, the most severe cases in any future chemical attack around Mosul “probably will die on the spot,” Dr. Schad said. “We are here about 60 to 70 kilometers from Mosul and there are several checkpoints, so most people will not make it directly through,” requiring at least a day to travel.

Even here, there is only so much that the health care system can do. “Basically you cannot treat the cause but you can treat the symptoms,” he said. Yasir and his siblings are now tied to meandering IV pipes with painkillers; pills wouldn’t be strong enough to help. They’ve been given steroids to suppress their bodies’ inflammatory responses and antibiotics to prevent the infections that could result from a demobilized immune system.

The cases have spurred the hospital here to reorganize its emergency protocol. Rather than receiving possible chemical patients directly to the emergency room, for example, they will be decontaminated outside. The ICRC is building out a team to both respond to attacks as well as prepare local staff to do the same.

4 things to know as Mosul relief unfolds

Aid groups are facing a unique set of technical and logistical challenges as they work to assist the nearly 60,000 who have so far been displaced from a military campaign to retake Mosul from the Islamic State group.

The World Health Organization has also been working to help prepare local clinics for the worst.

“Since 2016, WHO and partners including MSF have trained health facilities in the field to conduct patient stabilization and decontamination prior to referring patients for further treatment at designated hospitals,” WHO spokesperson Fadéla Chaib told Devex.

“Guidance has gone out to field facilities and the capacity is also being increased through training. WHO has also been training clinical staff from health cluster partners providing services in the field to increase level of capacity of relief partners, and to familiarize them with the referral pathway for possible chemically contaminated patients.”

A future of need

Back in the hospital room where the Hamid family lurches between doctor visits, nurse check-ins, tests and procedures, something even more grinding captures Ikhlas’s attention. Her five children, aged between two months and 11 years, will require long-term physical therapy and possibly a lifetime of follow-up care.

Dr. Schad is hopeful that the Hamid family is recovering well, but he can’t predict what the years ahead will bring. Mustard gas exposure has been linked in U.S. war veterans to conditions as wide ranging as cancer to depression.

“Now we have nothing,” Ikhlas said, thinking about the future ahead. Local authorities in their neighborhood said they would need to burn their house to eliminate the contamination; now they will have nowhere to live. Mosul is many miles of daunting checkpoints away. Physical therapists are a luxury few back there can even consider for now.

Amid the medical scrambling, Yasir hands an ICRC doctor a note of thanks as he passes by with his team, looking at x-rays and checking his and his siblings’ breathing rates. Yasir has written a few sentences on a spare piece of paper, marking each letter with small movements of his aching limbs.

There was a time not long ago when Yasir used those hands more nimbly to tap away at a PlayStation. His sister Sidra would invent stories with her dolls, grooming them with the care of a child who knows a mother’s touch. Young Dima and baby Rami filled the house with smiles and coos.

“These are our children, and they need a lot of things going forward,” Ikhlas said. “I don’t know how we will provide.”

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About the author

  • Dickenson beth full

    Elizabeth Dickinson

    Elizabeth Dickinson is associate editor at Devex. Based in the Middle East, she has previously served as Gulf correspondent for The National, assistant managing editor at Foreign Policy, and Nigeria correspondent at The Economist. Her writing also appeared in The New Yorker, Wall Street Journal, New York Times, Politico Magazine, and Newsweek, among others.