Q&A: Dr. Adham Rashad Ismail, WHO head of mission in Iraq

The World Health Organization is still guardedly optimistic Iraq can avoid a coronavirus catastrophe, despite Iraq's poor mask compliance and perhaps premature end to its lockdown.
Dr. Adham Rashad Ismail, World Health Organization representative to Iraq, speaks to officials at the Iraqi Ministry of Health on May 31, 2020. (Source: WHO Iraq)

In early March, Iraq's COVID-19 pandemic data was cause for optimism: early adoption of restrictive lockdown measures kept cases, escalating around the world, at bay.

Three months later, Iraq has one of the lowest official case fatality rates in the world but an escalating caseload that forced the government to re-impose some lockdown measures, and has caused healthcare workers across the country to sound the alarm.

Part of the reason for the relapse is because some of the public didn't believe it needed to maintain precautionary measures like social distancing and mask-wearing, chalking the measures up to a government disinformation campaign.

Additionally, a change in government led to the disbanding of a technocratic cross-governmental committee that helped create and implement actions to support the beleaguered health care sector in fighting the pandemic. The committee’s replacement – a minister-level task force – has been less effective at convincing the public of the need to adhere to pandemic mitigation measures.

(Source: World Health Organization)

"The numbers won't come down," said Dr. Adham Rashad Ismail, the World Health Organization's (WHO) representative in Iraq. "It will continue."

Still, Iraq has a s low percentage of people severely or critically sick with COVID-19 and requiring ventilation compared to many harder hit countries, but most health professionals believe the situation in Iraq will get worse before it gets better.

"Right now I am not pessimistic but I am really worried when I see the people's behavior as I see we can really become the next epicenter in the next few weeks if they are not compliant. If the health system breaks it breaks and I doubt it can be brought back. In Italy it broke but the system was so powerful they brought it back. We have a weak system here and only way to do that is the fight the virus," said Dr. Ismail.

The full phone interview with Dr. Ismail is below.

Cathy Otten: The last time we spoke, the Iraqi government seemed to be managing the COVID-19 outbreak fairly well. What's your view now? And if your view has changed, then why?

Dr. Adham Rashad Ismail: Let me put it this way: I am still positive about the government handling of the crisis, although I have one disagreement which is that they dissolved committee 55. It had deputy ministers and under secretaries from different ministries and it was more appealing to the public and their decisions had a stronger impact. My proposal is to put that back even if it needs to be led by the PM and to have the deputy ministers and ports of entries representatives, etc. It had a better implementation on the ground.

So why has the scene changed? The international media didn't believe the numbers in Iraq, as we had much fewer cases due to the early announcement of the lockdown and to the very aggressive social mobilization and community awareness campaigns conducted. The same reporting mechanism was maintained, yet we are now reporting more cases, since the disease has spread at different scale than from before. We did well then. Because the numbers were low they thought it was a hoax. In the last few weeks and during Eid we saw funerals and celebrations of hundreds of people gathering – that wasn't something commendable by the public. This has forced the government to go back to lockdown.

People in hospitals have been trying to explain how terrible this COVID really is to people outside hospital. But still there has been non compliance. The markets have been crowded with people gathered. So I am not happy with the implementation. The implementation has been more security than health focused. If I am securing an area it doesn't just mean securing the entry and exit and then leaving the people in the middle to meet. No, the reason to lockdown an area is to stop people meeting except in necessary circumstances, like you have in the UK. They [should] wear masks and respect social distancing. Fines have not been imposed on people caught [not distancing] and people did not respect them. All these conditions have led to the escalations [in cases] during the last week of Ramadan and Eid.

Before Ramadan and in the early days the rate at which the cases doubled was 28 days and 30 days. This shows you how rapidly the curve is growing and how aggressively the infections are going up. That's why they brought back the lockdown until 13 June. The numbers won't come down. It will continue.

Economic pressure is not as important as health. Humans need to stay healthy and to deal with all the other problems. In other words, I am ok with what the government is doing but I demand stronger compliance and implementation.

CO: But you're OK with the policies?

Dr. Ismail: Yes of course. We have nothing else but the preventative measures. All we have is the lockdown, closure of areas, social distancing and masks. There is nothing else! This is the only measure.

CO: Have you noticed a change in response between the two governments for better or worse?

Dr. Ismail: The previous government was temporary and the new one has the confidence of parliament. It has some serious challenges ahead, yet we are optimistic. One of the challenges is to change the current relaxed approach by many toward COVID. It was unfortunate to listen to some people stating to there is nothing called COVID. Also, the government is facing many political challenges, which has forced attention to shift [away from COVID] and to the political process. These factors together led to this situation. They had bad luck and bad timing.

CO: How are Iraqi and KRG hospitals dealing with the uptick in terms of ICU and ventilator capacity?

Dr. Ismail: Let me start by telling you there is a bright thing in all of this: the number of people lying in ICU all over Iraq is less than 100. Compare that to the total number of infections, which is close to 15,000, so that means that less than 1 percent of cases require ventilations and that less than 1 percent of cases are severe or critical. This is good news! The severe or critical will likely not make it – among them fatalities are very high. We are using almost 100 ventilators and we have 450 and another batch coming.

CO: How many ventilators are coming?

Dr. Ismail: There is an extra 850 coming our way in the coming months.

CO: When?

Dr. Ismail: Typically, they said within months. We can't have a definite date when the suppliers are over stretched. What we can say is that we are so far away from occupying respiratory units and ventilators. The normal bed capacity is the problem now.

CO: Why?

Dr. Ismail: If you look at the people lying in bed now we are speaking about almost 8,800, around 9,000 patients who are active cases. Half of them are in Baghdad. That is my problem. The rest are distributed among the others with 600 each in Sulaimaniya and Basra, which are the next highest governorates in terms of cases after Baghdad. I said to the minister of health that we need around 4,000 beds in Baghdad and we are reaching maximum capacity. He assigned new bed space and has taken over the Baghdad convention center and we have another 3,000 beds there.

CO: Is the convention center accepting patients?

Dr. Ismail: Right now, no, we have not reached the stage to fill them but they are there as a reserve measure, on standby. If the numbers keep escalating in the next few days in the same way, adding thousand plus then we will start using them.

In Baghdad since the start all the cases were hospitalized: mild, severe, and moderate. In other countries mild cases require home rest and they become OK. In our case, even those cases were staying in hospitals. [If things get worse] we will not be able to deal with [these mild cases] in hospitals [and they will need] to be sent home and managed at home with government supervision to see that they progress to negative. So two things are good: ICU respiratory beds are not yet filled and we are way below the current 450 ventilators, and then the second thing: the beds are in shortage but we still have extra beds and the flexibility of being able to send some mild cases home, which they are doing everywhere except Iraq.

The new minister is working extremely hard on this issue. The tide is high but he is doing the best he can. It hasn't paid dividends yet, but hopefully it will. He came from a small institution: Baghdad Medical City to a big institution at the Health Ministry and therefore it is hard. I'm sure he will pick it up very quickly. He knows the scene well.

CO: Are funds meant for COVID relief from international bodies going where they should go? Are you satisfied with the procurement procedures or are you concerned about money potentially going where it shouldn't such as to fighting groups?

Dr. Ismail: I can speak about WHO. We don't discuss this with the government on a larger scale. For us as WHO and other UN agencies we have shortage of funds and this shortage has been widened by the American administration's decision to sever ties with WHO including the decision to stop funding. This has put some stress on WHO, as we were in the process of negotiating a big grant with the OFDA [U.S. Office of Foreign Disaster Assistance] in support of COVID-19 response, however this was put on hold at the final stages. This has put some stress on us to find other sources but many others coming forward. We are stressed. Maybe Iraq is in a different position. The World Bank funds have not materialized for us and the government. With all this we may get by if they all materialize, but If not then Iraq will need funds.

CO: Is COVID in Iraq now being driven by community transmission or is travel from Iran still an issue in the spread of cases?

Dr. Ismail: No, I mean before the opening up of the lockdown – the partial lockdown – all transmission was local community transmission. After the easing of measures, especially in the Kurdistan Region of Iraq and Sulaimaniya specifically, there are cases coming from travelers smuggled through the borders in the southern governorates and in Sulaimaniya. Iraq is also repatriating citizens from the EU and the US and many are COVID positive, and the 14-day quarantine measure has not been respected and this has led to an appearance of COVID in some governorates. Some people have escaped the quarantine as tribes have taken them, etc.

This has occurred because of people coming legally via government mandated planes, the 14-day quarantine not being properly implemented and also from illegal smuggling and from people going back and forth through unofficial entry points.

Because of this, the government issued a statement as part of the 1 June – 6 June lockdown. One of their decisions was to put a hold on repatriation until stronger measures are in place. From [this week] repatriation will resume because they have stricter measures and have places they can be watched properly.

CO: Has Iran got to grips on their pandemic?

Dr. Ismail: The only thing I can say is that Iran is currently suffering from a second wave as big as the first wave. I'm just following the curve because of the close relationship between the two countries.

CO: How do you grade Iraq relative to other regional states in terms of response?

Dr. Ismail: Right now we are – let me speak about the Eastern Mediterranean region of 22 countries, North Africa and the Middle East with the inclusion of Iran and Pakistan – this is the Eastern Mediterranean Region for WHO and if we rank it, then Iraq is in the middle. It is number 10 in infections out of 22 but it is number 5 or 6 in the fatalities, which is very good and which means the percentage of fatalities is 2.7 percent which is among the lowest in the region. Less than that of the U.S., less than Spain and England! This is the second brightest thing. The first brightest thing was the numbers in the ICUs being very low. The US is 5.7 percent! Brazil 5.1 percent! The U.K. is 14 percent! Spain 9 percent! India 2.7 percent! Italy is 14 percent! Germany 4.7 percent. The same with Iran, 4.7 percent! Iraq at 2.7 percent – this is excellent!

It means we have dug deep and caught all the cases and it means our case management is good and it means we are avoiding death. Out of 9,000 lying in the hospitals, 90 percent of them are less than 60 years old. With COVID, being older than 60 means a higher risk of death. This means that most of the people in hospitals in Iraq are a younger age, which means we have high hopes of them recovering.

CO: Why are there not more elderly Iraqis in hospitals with COVID?

Dr. Ismail: Because people live in multi-generational houses and most Iraqis decided to keep their parents in the house and not going out. They have respect and protection for their parents. This is something to be seen.

The UK in my own assessment – the UK prime minister has said that, first they went with herd immunity and neglected COVID and wasted February and March waiting for herd immunity to show effects and it didn't so then they went into lockdown too little too late when the thing had started to spread. They started on the wrong foot and the numbers kept rising.

If you look at one country that applied herd immunity like Sweden and then Norway that didn't and everything else is the same – they are both rich and have highly educated people. Norway took the same measures as Iraq. Norway has 8,500 with only 239 people dead so that's a 3 percent fatality rate. Sweden said we will leave it all open and let it flow and here you go Sweden is unbelievable – 10.5 percent case fatality rate.

That explains how at first the policy was good in Iraq and the implementation of the people was good; they were still frightened but now we have a second wave and some say it is the same as the first wave. We have the same measures, but people are not respecting them at all because they haven't seen cases and they care about their daily salaries.

Everyone was doubting what we did and said on the first wave, they said we were lying and hiding cases, we had the New York Times and Reuters on our backs, but despite everything I was confident because I knew what was happening. Right now I am not pessimistic but I am really worried when I see the people's behavior as I see we can really become the next epicenter in the next few weeks if they are not compliant. If the health system breaks it breaks and I doubt it can be brought back. In Italy it broke but the system was so powerful they brought it back. We have a weak system here and only way to do that is the fight the virus.

Cathy Otten reported from the United Kingdom.

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