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Rethinking Medicine and Nation-building in Iraq

Ethnographic and Historical Perspectives

Vivek Neelakantan (vivekneelakantanster@gmail.com) is a historian specialising in South East Asian medical history.

Ungovernable Life: Mandatory Medicine and Statecraft in Iraq by Omar Dewachi; Stanford: Stanford University Press, 2017; pp xiii+239, price not indicated.

 

Ungovernable Life: Mandatory Medicine and Statecraft in Iraq is at once an ethnographic and historical account of medicine and nation-building in Iraq, from a Foucauldean perspective. As the author puts it in the preface, the research questions that drive the monograph are inspired by his personal experiences of growing up in Iraq and medical training in the aftermath of the Gulf War (1991). In his monograph, Omar Dewachi offers a compelling yet disturbing account of the genesis of Iraqi state medicine under the British mandate, and its dissolution following the end of the Gulf War.

Excluding the introduction and the conclusion, the book is organised into seven chapters. The chapters collectively trace the modernist agenda of Iraqi medicine. First, under the British administration between 1920 and 1932 (Mandatory Iraq), physicians were charged with moderni­sing the nation along Western lines. Second, the author explores the transition from British-backed monarchy to the socialist era (1958–1980). Third, between 1980 and 1988, during the war against Iran, the Iraqi state mobilised medicine as an instrument of nation-building. Finally—subsequent to the conclusion of the Gulf War—the author describes the dismemberment of state medicine, first under the United Nations (UN)-sponsored sanctions, and later in the aftermath of the United States (US) invasion (2003 to present).

In analysing state power and its breakdown under the US-led war in Iraq, he challenges conventional Western accounts of Iraq’s alleged unruliness and ungovernability (p 11). He contends that ungovernability is enmeshed in the disordered operations of power. The monograph—in examining the operation of power through biomedicine—seeks to eschew the conventional dichotomy in medical anthropology between modern medicine and traditional practices (p 12). In doing so, Dewachi traces the careers of three Iraqi physicians, particularly Kamal al-Samara’i, Saniha Amin Zaki, and Yousef ‘Aqrawi, as agents of state-building through a close reading of medical biographies.

Mandatory Medicine

Although the British did not directly colonise Iraq, as they did in the case of India, the discourse of Iraq as an “unruly place of sickness” dates back to the British military occupation of Iraq during World War I (1914). British cultivation of Iraq’s medical infrastructure was a product of imperial anxiety pertaining to neutralising the military fallout of the Mesopotamian occupation. The Kingdom of Iraq under British occupation, or Mandatory Iraq was created in 1920, following resistance against the proposed British Mandate of Mesopotamia, which was sanctioned by religious and tribal authorities. Mandatory medicine was central to the vitality of the new state. Under the banner of the nation-building logic of mandatory medicine, doctors were charged to bring Iraq into step with modern states through medical science and public health policy (p 19).

With the declaration of the mandate in 1920, rebellions ensued in different parts of the country, challenging British autho­rity. The newly founded Directorate of Health that the British engineered was intended to protect British interests in Iraq, diminish the threat of epidemics, and deliver a productive workforce. The introduction of the railways to the newly discovered oil-rich towns was congenial for the spread of the 1923 cholera epidemic. With the epidemic spreading in the predominantly Shia cities, especially Najaf and Karbala, the directorate introduced mandatory cholera vaccination. The management of the cholera epidemic through mass vaccinations silenced the demand for decentralisation of healthcare (p 63).

Iraqi Physicians

Efforts to cultivate Iraq’s state medicine during the early 1920s under the mandatory system had to confront the realities of the fraying Ottoman Empire, famine, epidemics, and the breakdown of medical infrastructure. Governing the health of the nation was contingent upon increasing the supply of physicians. The British proposal to establish an Iraqi school of medicine was a divisive issue among local physicians.

Whereas Amin Ma‘louf, King Faisal’s personal physician, welcomed the proposal to establish a new medical school, Fai’q Shakir, a Baghdad-based Ottoman-trained doctor, led the opposition camp (p 71). The latter contended that inaugurating a new medical school would incur a huge financial burden on the state and it would be difficult to staff with competent local faculty due to a shortage of Arabic-speaking educators in the country. Consequently, the proposal to establish a medical school was temporarily shelved until 1927, when Baghdad’s new Royal College of Medicine was established.

As very few Iraqi high school graduates completed the prerequisites for entrance to medical school, the main challenge thatthe Royal College of Medicine confronted was the selection of the cohort from a shallow pool of qualified candidates. The curriculum was loosely patterned along the lines extant at the Edinburgh Medical School. The deciding factor for admission into the medical school at Royal College of Medicine was applicants’ proficiency in English.

Dewachi follows the prosopographies of two Iraqi physicians, al-Samara’i and Zaki, during the formative years of the Royal College of Medicine. The prosopographical study illustrates that incoming medical students at the time were expected not only to absorb the scientific knowledge and practices of Western medicine, but also engage with moral and professional worlds that would enable them to become future doctors.

In 1941, the Directorate of Health underwent a major political reorganisation as it was placed under the newly established Ministry of Social Affairs. Administratively, the reorganisation signalled the transferring of physicians from Baghdad to the countryside. But, the ministerial measure faced resistance from doctors who were reluctant to work in the countryside due to poor amenities. Dewachi notes from ‘Aqrawi’s memoir the tensions arising from Iraqi doctors studying abroad and their reluctance to serve in rural areas, highlighting the dual roles of physicians as specialist doctors and general practitioners who would serve in the countryside (p 101).

Trope of Postcolonial Development

During the 1950s, Iraq’s statecraft was preoccupied with engineering economic growth and social change through develop­ment planning, while producing broader discussions about the incongruities between the rural and urban modes of life. Within the narrative of developmentalism, propounded by international agencies, and its appropriation by Iraqi leaders in the aftermath of World War II, agricultural workers (fellah) were cast as pathological specimens harbouring ancylostomiasis, ascariasis, bilharzia, trachoma, bejel, and tuberculosis.

Between 1941 and 1947, the second British occupation of Iraq took place. With its end came promises for wider socio-economic reforms (p 110). Nationwide development schemes proliferated after Premier Nuri al-Sa‘id negotiated a new treaty with the British government that dramatically increased royalties owed to Iraq by the British-run Iraqi Petroleum Company from less than 5% to 50% (p 111). With increased royalties from oil, Iraq constituted the Development and Reconstruction Board, charged with overseeing the modernisation of the country’s development projects. Apart from the infrastructure projects, the state invested in building expertise in different fields of science, engineering, and technology. The state turned to Britain to train its cadre of academics, engineers, professionals, and government employees through the Nidham al-Bi’that (Foreign Mission Program).

The July 1958 revolution led by Abd al-Karim Qasim ended 38 years of British-backed monarchy in Iraq and defined a socialist trajectory of development for the nation (p 121). It declared the country a republic. During Qasim’s reign, Iraq addressed the question of landless farmers in the capital through legislation. Subsequent to the 1958 revolution, the government initiated a new housing project—unofficially known as al-Thawra city—that offered plots of land to low-income families and those who lived in informal settlements in Baghdad. But, the state’s plan to remedy the problem of rural landlessness backfired as al-Thawra continued to receive rural migrants from the south of the country. The unfinished infrastructure at al-Thawra (now known as Sadr City) and accumulated waste generated public health problems and defined discourses about the backwardness of its inhabitants.

Of central importance to the revolutionary government was the mobilisation of medicine as an instrument of social and economic reform. With Iraq increasingly drawn towards the communist orbit, Qasim’s government benefited from technical expertise of the Soviet Union. The Iraqi and Soviet ministries of health signed a Memorandum of Collaboration to conduct a nationwide smallpox vaccination campaign in Iraq. With a view to ensure equitable distribution of physicians throughout the country, Qasim’s government introduced the Medical Service Law that aimed to enlist physicians in government service. Despite the popularity of Qasim’s reforms among the Iraqis, his reign ended in February 1963 due to a military coup led by the Ba‘th party and other political factions. The Ba‘th party continued the social reforms of the Qasim era.

In 1979—concomitant with the fears that Iran’s Islamic revolution might spill over to neighbouring Iraq—the then Vice President Saddam Hussein led an internal coup in the ruling Ba‘th party. In 1980, enmeshed in territorial skirmishes with Iran, Baghdad ordered air strikes against Iranian military establishments. The rise in military conscripts paralleled the swelling number of doctors (p 137). In 1987, the government inaugurated four medical schools in the governorates of Qadisiyyah, Najaf, Saladin, and Anbar. Iraq’s medical infrastructure played a vital role in ensuring readiness of conscripts for combat. Dewachi notes that the start of the Iran–Iraq war was a blow to primary healthcare with waning state funding. But, child survival, a component of selective primary healthcare—prioritisation of healthcare driven by market-driven considerations championed by Western states—tied well with the state’s focus on maintaining the productivity of the war economy. The wartime embrace of child survival transformed Iraq’s healthcare in two ways: (i) new stress on community-based birthing, and (ii) mobilising women’s organisations. The focus on maternal and child health during the Iran–Iraq war fostered policies to normalise a wartime politics of survival and productivity.

Dismemberment of State Medicine

The dismemberment of the state’s medical infrastructure subsequent to the Gulf War, the exodus of physicians abroad, and the increasing vulnerability of the figure of the physician to accusations that they have lost their moral compass have radically transformed the biopolitical state in Iraq. The US occupation (2003) and its aftermath are the historical inversion of the state-building experiment that began with the British Mandate.

Dewachi notes that the legacies of the biopolitical experiment initiated by UN sanctions and US invasion have come to be inscribed in the travelling wounds of Iraqis seeking treatment in neighbouring states, especially Lebanon (p 177). Younger Iraqi patients seeking healthcare in Lebanon present a clinical challenge as many suffer from aggressive types of cancers which are uncommon. Lebanese doctors also encounter Iraqi patients with high rates of multidrug resistant bacteria that defy antibiotics. On a rather disturbing note, Dewachi concludes to the effect that the Iraq experiment seems to have conditioned an ecology of state collapse that seems to have spread like a pathogen to neighbouring states in West Asia and elsewhere under the guise of the global War on Terror (p 181).

Challenges in Writing History

Ungovernable Life is a welcome addition to the relatively uncharted field of West Asian medical history. Chronicling the rise and dismemberment of state medicine under various regimes in Iraq poses various methodological challenges to the researcher, particularly the unavailability of local archival materials. Eclectic in the use of primary sources from various Iraqi research centres, autobiographical accountsof Iraqi physicians, and interviews with various generations of Iraqi doctors and civil servants in exile, the monograph offers a compelling interpretation to analyse nation-building in Iraq through a focus on state medicine. Dewachi is one of the few scholars apart from South Asian historian Sunil Amrith (2006), who transcends the colonial/postcolonial divide in medical history by drawing parallels between colonial anxieties regarding Iraq’s “tropical” ecology and the pathologisation of the Iraqi peasant in the post–World War II period. For these reasons, the book should be recommended reading for any graduate course focusing on global health history or medical anthropology.

A number of minor points escape the attention of the author. The narrative is at times tedious to follow and does not always conform to chronological sequence. A few issues merit further investigation. For example, the author does not examine the high rate of attrition in the Royal College of Medicine, prior to 1945 (p 99). What was the niche occupied by traditional healers in Iraqi society vis-à-vis physicians trained at the Royal College of Medicine? How did Iraqi physicians mobilise and transform Western medicine for the cause of nation-building during the British Mandate? Any discussion examining the appropriation and transformation of Western medicine by Iraqi physicians would benefit by situating Iraq within broader developments in West Asia. In this context, it would be useful to examine Hormoz Ebrahimnejad’s Medicine in Iran: Profession, Practice, and Politics (2014).

Chapter 5 of the monograph misses out the larger context of the Cold War in West Asia and the way in which disease eradication campaigns were used by the US to purchase the allegiances of leaders of Asia and Africa in its bid to subvert the spread of communist ideology. Also, what were the motivations for Soviet support for the nationwide smallpox vaccination campaign in Iraq (1959)? The narrative alludes to but does not elaborate the ways in which the dynamics of the Cold War shaped the professionalisation of the Iraqi physicians during the 1950s.

One unsubstantiated statement merits further investigation. For example, Dewachi contends that different geo­political interests intersected in defining the scale and longevity of the Iran–Iraq war and contributed to the re-engineering of state population policies during the war. The success of Iraq’s child survival campaign illustrates the interconnectedness of different geopolitical interests (p 140). The author does not elaborate on what the different geopolitical interests operating in Iraq during the 1980s were. However, these minor points should not detract a serious reader from a nuanced understanding of healthcare as a modality of governance, and the entanglements between medicine and state-building during various epochs of Iraqi history.

References

Amrith, Sunil (2006): Decolonizing International Health: India and Southeast Asia, 1930–1965, Basingstoke: Palgrave MacMillan.

Ebrahimnejad, Hormoz (2014): Medicine in Iran: Profession, Practice and Politics, 1800–1925, Basingstoke: Palgrave Macmillan.

Updated On : 7th Dec, 2018

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