Approximately 5 billion people, or two-thirds of the world’s population, lack access to safe, affordable surgical and anesthesia care; and of the 313 million procedures that are performed globally each year, only 6 percent are done in the poorest countries.1 These staggering statistics speak volumes to the need for intensive capacity building in many parts of the world.
After decades of oppression, the people of Kurdistan, Republic of Iraq, have sought to build an independent nation—one with a self-sustaining health care system. This article describes how several Fellows of the American College of Surgeons (ACS) provided care to the victims of the malevolent regime led by Saddam Hussein and assisted in the establishment of a sustainable health care system.
Background on Kurdistan
The Republic of Iraq borders six countries in the Middle East—Jordan, Syria, Turkey, Iran, Kuwait, and Saudi Arabia. Iraq encompasses approximately 168,753 square miles (437,072 square kilometers), which is three-fifths the size of Texas. In 2015, the population was 36,575,000, making it the fourth-most populated country in the Middle East.2
Iraq’s current borders were drawn in 1920 under the Treaty of Sèvres, which allowed the League of Nations to partition the collapsed Ottoman Empire.3 For Iraq, the treaty had essentially amalgamated three different groups of people—the Arab Shi’ites and Sunnis and the non-Arab Kurds—into one nation. A plethora of other minority groups, such as the Assyrians, Turks, and Kurdish Yazidis, also inhabit the country. The Yazidi Kurds practice their ancient religion, Zoroastrianism, and have been persecuted by the Islamic State in Iraq and Syria (ISIS), also known as the Islamic State in Iraq and the Levant (ISIL), since June 2014.
The Kurds are descendants of the Indo-European tribes who resided in Iraq (Ararat Mountains of Mesopotamia) in the fourth century BC. An estimated 45 million Kurds live in Kurdistan, an area that is spread throughout the bordering states. Approximately 6.5 to 7 million Kurds reside in northern Iraq (Kurdistan of Iraq), comprising about 17 percent of the population of Iraq.4 The Kurds have their own culture and language; very few self-identify as Arabs. In fact, their history demonstrated fierce resistance against Arab expansion in the sixth century. The Kurds may be the largest ethnic group in the world that does not have its own nation.
In June 1992, Kurdistan formed its own parliament for the first time in its history. Members of parliament are freely elected, and the government has an appointed cabinet and functions under a ratified regional constitution. From our multiple trips to Kurdistan, we have found the Kurds to be extremely gracious people. They were quick to embrace and thank the U.S. for liberating them from Saddam Hussein’s regime.
Early trips to Kurdistan
Dr. Zibari, a co-author of this article, was one of the fortunate Kurds who survived Mr. Hussein’s atrocities; more than 50 percent of his high school classmates were murdered during the Iraq/Iran war and the Iraqi/Kurdish war. On May 1, 1976, Dr. Zibari immigrated to the U.S. after graduating from high school in an Iraqi Kurdish refugee camp in Kurdistan of Iran.
Like many other exiled Kurds, Dr. Zibari was forbidden from returning to Iraq, with a threat of immediate execution by Mr. Hussein. However, after 16 years in absentia and immediately after the first Gulf War, he returned to his native land in June 1992 after completing a solid abdominal organ transplant fellowship at the Johns Hopkins University School of Medicine, Baltimore, MD. His return was possible due to the no-fly zone over Kurdistan, which the North Atlantic Treaty Organization (NATO) established to protect the mass exodus of Kurdish refugees who had fled Mr. Hussein’s brutality following their uprising in northern Iraq, and the Shi’ite uprising in southern and central Iraq.
Dr. Zibari’s initial visit to Kurdistan in 1992 was a fact-finding mission. It was a historic time for the region, as 1992 represented the first year that the Kurds were allowed to vote freely and elect a Kurdish Parliament. The parliament met for the first time in June 1992 under NATO and United Nations (UN) protection. At that time, Dr. Zibari visited the only public hospital in Duhok, a city 50 miles from Mosul, which, at present, is under ISIL control. The hospital, Azadi Hospital of Duhok/Freedom Hospital, which had replaced Saddam Hussein Hospital, became the main center of Dr. Zibari’s humanitarian medical outreach program for nearly 25 years.
As would be expected following decades of war, Dr. Zibari discovered that the Kurdish medical community had a severe lack of resources and feeble system infrastructure. By his estimate, the Kurds’ medical system was at least two to three decades behind the American health care system. Examples of the multiple challenges that needed to be addressed included filling empty pharmacy shelves; updating antiquated ultrasound and X-ray machines; supplementing the shortage of allied health care personnel and physicians; establishing Internet service; replacing obsolete medical texts and journals; and compensating for a dearth of medical, dental, nursing, and allied health schools. Furthermore, the central government in Baghdad, which was still maintained by Mr. Hussein at that time, had refused to pay salaries to any employees who lived in the no-fly zone.
Compounding these adverse conditions, the Kurds also had to endure a double embargo—one from the UN against Iraq and the other imposed by Mr. Hussein—which resulted in further isolating the Kurdish medical community. Despite these adversities, the Kurdistan/Duhok medical community approached the development of a revitalized health care system with dedication, energy, and optimism. With the assistance of U.S. volunteers, they were able to make great strides in rebuilding their medical infrastructures.
Building the foundation for future trips
Most of the earlier trips to Kurdistan were spent meeting and achieving buy-in from major stakeholders, such as the local health care leaders, the mayor of the town, the Kurdish political leadership, and the Kurdish Regional Government (KRG). Dr. Zibari sought advice from these parties, supported the founding committee for the creation of Duhok Medical School, and was instrumental in creating plans for the new medical school. The governor of Duhok and the prime minister of the Kurdish regional government donated a significant portion of land to the Azadi Hospital of Duhok to build the medical school and for future medical center expansion. Six years later, Dr. Zibari attended the first graduation ceremony for the medical school in June 1998. These successes led to the establishment of the University of Duhok, which now comprises 12 colleges.
Before each trip, we assembled a cadre of volunteers from different disciplines. This team included general surgeons, ophthalmologists, surgical oncologists, transplant surgeons, hepato-pancreato-biliary (HPB) surgeons, laparoscopic surgeons, traumatologists, otolaryngology–head and neck (ENT) surgeons, neurosurgeons, emergency physicians, medical oncologists, nephrologists, surgical residents and fellows, and nurses. On each trip, we also organized an academic surgical symposium where each volunteer gave a formal presentation on a specific topic lasting at least half an hour. We also invited local surgeons to speak on a topic of their choice. One such presentation was titled Review of Renal Transplantation at Azadi Hospital of Duhok and Abdominal Cocoon: A Cause of Intestinal Obstruction. The symposium was well attended and stimulated interesting discussion.
The total length of each trip to Kurdistan was a little more than a week. The first day began with the team arriving at the hospital and being greeted by hospital administration and heads of the different medical and surgical departments. A camera crew videotaped this event and broadcast it to the people in Kurdistan. After the introduction and discussion with the leaders of Duhok Hospital, the physicians split into three groups: neurosurgery; trauma/emergency care, otolaryngology, and ophthalmology; and general surgery, laparoscopy, HPB, and transplant. We treated a large number of cases that varied in complexity. Between cases, the teams saw patients and performed pre- and postoperative evaluations.
Like many regions of the developing world, patients would come to see us with folders containing their medical records and images. Unlike U.S. health care facilities, a centralized area dedicated to maintaining medical records does not exist in Kurdistan. Because on some missions we did not have a particular specialty surgeon with a certain area of expertise, we had to turn away some patients—specifically those with major orthopaedic and gynecologic disorders, as well as other patients whose medical diseases exceeded our level of expertise. Even then, the patients were grateful that we had taken the time to see them. Many patients had traveled on foot for days to come and see the “surgeons from the U.S.”
After each exhausting day, we would head back to our hotel to share a nice dinner with our Kurdish colleagues. This was probably one of our favorite times because we all had a chance to unwind, get to know each other better, and share war stories. On each trip, our Kurdish colleagues would reserve a day for us to go sightseeing and visit Dr. Zibari’s brother, General Babakir Zebari.
On our more recent trips in 2014 and 2015, we visited refugee camps to care for the people who had escaped ISIS’ atrocities. We employed the VSee system—a Health Insurance Portability and Accountability Act-compliant telehealth platform—to consult with our colleagues in the U.S.
For many years, Dr. Zibari has spent his vacation months traveling to Duhok to assist the medical community with capacity building. It was not until Mr. Hussein’s toppling that he felt comfortable enough traveling to the country to solicit help from medical colleagues who could provide the support needed to launch a capacity-building effort. For more than a decade, Dr. Zibari has consistently brought a dedicated and committed team of eight to 12 clinicians to assist with capacity building. These teams have been cosponsored by the Americas-Hepato-Pancreato-Biliary Association (AHPBA), the International Hepato-Pancreato-Biliary Association (IHPBA), Operation Hope, the World Surgical Foundation (WSF), the American Kurdish Medical Group, the Kurdish Regional Government, the Barzani Foundation, and other organizations. Through the years, the team has been able to achieve a number of notable accomplishments, including the following:
- Developed the resources, personnel, and facilities needed to offer basic and advanced laparoscopic operations. The first laparoscopic cholecystectomy was performed in Duhok in 2005. Laparoscopic cholecystectomies are performed more than 80 percent of the time over open cholecystectomies. Other advanced laparoscopic operations now include adrenalectomy, splenectomy, nephrectomy, Nissen fundoplication, gastric sleeve resection, and gynecologic procedures.
- Established a living-related renal transplantation program. More than 1,500 renal transplantations have been performed since Dr. Zibari established the program in June 2004. Today, an average of two renal transplants are done weekly in Duhok, and four are done in Erbil.
- Trained local surgeons to perform complex neurosurgical procedures such as craniotomy for temporal lobe tumor, resection of sphenoid wing meningioma, and spinal decompression/stabilization for traumatic fracture/dislocation.
- Trained local surgeons to perform complex HPB and oncologic operations such as the Whipple procedure, major liver resections (central hepatectomy, formal lobectomy), radical cholecystectomy, esophagectomy, and gastrectomy with lymphadenectomy; and the team introduced them to modern technology and surgical devices such as the Ligasure, staplers, and modern laparoscopic instruments.
- Supported the first medical journal in Duhok, Duhok Medical Journal.
- Engaged surgeons in the global surgical community by assisting them with obtaining membership to professional organization such as the ACS and AHPBA.
- Established an annual Joint Operation Hope, AHPBA, and World Surgical Foundation Surgical Symposium to update the medical community on innovations and technologies.
- Established a trauma team—composed of trauma surgeons, critical care clinicians, a neurosurgeon, and an emergency medicine clinician—who taught the local surgeons prehospital patient care, mass casualty triage, and management of patients exposed to chemical weapons.
At present, efforts are under way to establish telemedicine and tele-fellowship programs. The purpose of this endeavor is to train clinicians to use telemedicine as a means to remotely evaluate patients. A memorandum of understanding was signed between the Duhok University president, the director of the health system of Duhok, and the surgical team.
Lessons learned through the decades
In the course of our efforts in Kurdistan, we have learned several lessons that may be of value to other health care professionals interested in providing surgical care to patients in underdeveloped countries, including the following:
- Plan far in advance (at least nine months to a year).
- Start with a fact-finding mission to assess patient needs to determine the specialties that are in greatest demand.
- Have a reliable contact person at the host institution.
- Travel with the support of a recognized health care outreach organization, such as the ACS Operation Giving Back Program, AHPBA, Operation Hope, or World Surgical Operation.
- Do your homework, and contact the state department and the embassy. Make sure to inform the U.S. embassy once you arrive at your destination.
- Obtain adequate vaccinations and go to the state department Web page to learn more about the host country.
- Obtain medical/airlift insurance in case of an emergency medical evacuation.
- Learn as much as possible about the culture and customs of the country where you will be providing care. The last thing you want to do is to offend the patients whom you are trying to help.
- Ship supplies ahead of your scheduled arrival, and make sure a contact person in the host country can verify that necessary equipment clears customs and is available for use. Carry any must-have devices (such as reuseable instruments, Bovie devices, and retractors) and keep a list of supplies/equipment to bring on subsequent trips.
- Know the host institution’s infrastructure and resource capacity before tackling big cases.
- Start with straightforward, low-risk cases initially to build confidence and trust among your hosts.
- Seek help and advice from local government, as well as from the health care system leadership.
- Empower the local medical team, and get its members involved from the start. This effort will ensure the establishment of great relations with your counterpart health care community.
- Prepare to revisit the same destination multiple times to have a meaningful impact on capacity building.
- Be ready to improvise. The host country may not have all of the equipment and support to which you have grown accustomed in the U.S.
- If possible, arrange for a host surgeon to visit your medical center, so he or she can see how surgery is practiced in the U.S.
- Help host surgeons become members of U.S. surgical societies.
- Plan at least a day for an academic symposium during your visit.
- Encourage host physicians to publish clinical papers and assist them in establishing their own surgical journal if one is not available, so they can better share their research and best practices.
With proper help, time, dedication, and, most importantly, good intentions and perseverance, health care providers can help build advanced surgical programs, such as renal transplantation, advanced laparoscopy, HPB surgery, and esophageal surgery, in a developing nation. It is important to keep in mind that the care of the patients of the host country should be no different than that in the U.S. It is advisable to provide care only for those cases with which the surgeon is comfortable, and it is also important to ensure that patients can be cared for by the local clinicians when a surgical team, like the one described in this article, has departed the country. The work that we have accomplished in Kurdistan is a testament of the effective and meaningful effect that can be achieved through collaboration with major stakeholders.
The authors would like to acknowledge the AHPBA and its Foundation, IHPBA, Operation Hope, the World Surgical Foundation, the Kurdish Regional Government, Willis-Knighton Medical Center, Louisiana State University Health Sciences Center-Shreveport, Vsee, Eye Consultants of Texas, and our countless host colleagues. We also want to acknowledge the assistance and support of the following individuals: the late U.S. Army Lieutenant Colonel Mark Weber; Roger Lindley, cinematographer and director; and Nicolas Thompson; Thai LaGraff; Monirul Islam, MD; Yvette Sanchez; Beverly Wright; and Shelly Humphrey, who provided technical assistance.
- Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2016;386(9993):569-624.
- Wikipedia. List of Middle East countries by population. Available at: en.wikipedia.org/wiki/List_of_Middle_East_countries_by_population. Accessed April 5, 2016.
- Lawrence Q. Invisible Nation. How the Kurds’ Quest for Statehood Is Shaping Iraq and the Middle East. New York, NY: Walker & Company, 2008.
- Izady MR. The Kurds: A Concise History and Fact Book. New York, NY: Taylor & Francis; 1992.