Associate physician in the University of Pennsylvania Health System, Dr. Muhamed H. Almaliky is also director of the Iraqi American Institute, a non-profit organization based in Boston that conducts policy research regarding Iraq. In addition, as a member of the Weatherhead Center for International Affairs Associates, he has chaired study groups on the politics of disease, a subset of his primary research interests, which include postwar Iraq’s democratization and foreign policy, Iraq-U.S. relations, case studies on the water crisis in Iraq, and the intersection of medicine and international relations.
Harvard Political Review: With regard to access and quality of water, are those things affected by politics (racial, gender, or ethnic) within Iraq?
Dr. Muhamed Almaliky: I somewhat randomly chose water in Iraq as a case study because, to me, it is a dramatic linkage showing how a cheap resource that should be available to people becomes unavailable in the aspects of quantity and quality, thus affecting health in a dramatic way. This is not a way of asking for very expensive medical intervention. The whole idea is how politics, how things that affect health big time, can be influenced and affected by the government not paying attention to it—and it is essentially government work. For the water case, the idea is that a cheap resource that should be available to people has not been made available with very significant consequences on people’s health. And that is political in origin, not anything else.
HPR: What type of impact is that having on people in that region? And do you think that is just the government being caught up with other things or are there other reasons for it not paying attention?
MA: Well, Iraq is a unique case because I wrote this case study before ISIS, when Iraq started to recover from the war, and I was trying to bring attention to where government priorities are or should be. But then, ISIS kicked in and derailed the whole project, and now we’re back to square one with the security threats… However, if governments sit and discuss the country’s priorities, water should come at the top of the list of things to do. There’s sort of a global dimension to it, which has to do with Iraq’s relation with its neighbors, Syria and Turkey, who have been building dams on the rivers for decades now, diminishing the flow of water. When it finally gets to the city, the quality has been affected and the quantity as well.
What that means is that the government would have to work harder in order to purify water and make it available for public consumption. Now, most of the population really does use pipe water; they use bottled water or some RO (reverse osmosis) water, which is produced in high quantities and people buy it—if they can afford it. There’s still a larger portion of people who cannot afford it. What ends up happening with the climate—the city is very hot and water is not available—we have almost an epidemic of renal stones coupled with the unavailability of medical services in the city, so that people are dying of a disease they should not be dying from.
When we talk about health care, when we talk about medicine, we talk about hospitals, drugs, and procedures, and we talk about the medical community providing these services, but we ignore other determinants that are very heavily linked to health that are not managed by doctors, hospitals, or the medical community. They’re managed by the local, national, and sometimes international political system…. We’re not talking to each other. Health starts up in the political system and goes down through all levels of social systems, but at the end what is affected are people.
HPR: In regard to this specific problem in Iraq, how do you think we can best solve this problem? Do you think it needs to come from the government? Do you think there could be a third party source within the country that starts playing this role that the government should be taking on? Or should it become an international or at least a regional humanitarian effort?
MA: Well, what I teach students is that health and disease are the end-products of many processes, many actors, and state holders. So on the level of governments, almost all ministries are involved one way or another in the ultimate production of health and disease. If you say, well, it’s the Ministry of Health that should—no, it’s the Ministry of Finance because they allocate resources to things that affect health: housing, water, electricity, roads, infrastructure, city planning. The Ministry of Planning and how countries prioritize projects and services. The Ministry of Defense as well, because the resources dedicated to defense are taken from other things that could be dedicated to other beneficial services.
In Iraq, it has a regional dimension like you said. When Turkey began building dams on the Tigris and Euphrates Rivers—it’s called the GAP project—the government of Iraq was completely oblivious to it. It ignored the importance of negotiating with the Turkish government… The international dimension of it is maybe the U.N. could decide on all sort of water treaties, how countries that share water go about coordinating direction regarding this resource, and finding ways to oblige these countries to do the right thing of sharing water and not monopolizing it. So, that’s the point. Politics is not necessarily solely domestic….
The Ministry of Health has a few billions of dollars that they give to clinics and hospitals to treat kidney stones and do dialysis, but these are resources that are ill allocated and are not tackling the original problem efficiently. Thinking about it, in two decades, we could actually diminish this problem significantly by tackling it head on. Instead of focusing all your efforts in medical care, just look where else has the problem originated and try to solve it.
HPR: Do you think that the difference between the way health care and education are viewed as basic rights in other nations (like Germany, Britain, and Scandinavia) versus how the U.S. views it (more or less a luxury) is a matter of differences in political ideology?
MA: Yes. Political ideologies dictate the type of governments and political systems that nations have. The resulting systems, in turn, decide what type of services citizens are entitled to. The countries you mentioned are all social democracies where the “social” part of their free market system allows for these services to be provided or guaranteed to their tax-paying citizens. In the U.S., it has been decided that the burden falls onto the citizens themselves, where the system only guarantees freedom of economic activities in the hope that citizens would be able to fend for themselves––allowing only for the severely disadvantaged portion of the population to be protected under social welfare programs. The results, as we see it, in the U.S., are that millions of Americans are left unable to afford costly health care or higher education. These issues are being raised again in the ongoing presidential campaign.
HPR: Do you think it would be more beneficial for society, specifically government, to focus on providing preventative care or to focus on research and development of treatment of illnesses and diseases?
MA: A utilitarian argument can be invoked to answer this question. Personally, and I speak with the professional authority of a physician, societies can benefit tremendously from the provision of preventative and basic care services. What I mean by these services are: Pregnancy care, child birth care, well child visits, vaccination, nutritional support, cancer screening, mental illnesses screening, chronic disease screening, health education and control of chronic diseases. All of these are relatively cheap and if done well, they can avert more expensive services down the road.
Having said that, I am neither against more advanced care nor against dedicating resources to Research and Development. R and D are essential for producing the type of science and knowledge necessary for developing interventions along the entire continuum of health care, starting from prevention to organ transplants. However, nations with limited resources should first optimize preventive and primary services as the first line of a more adequate and worthwhile health system.
This interview has been edited and condensed.
Image source: Google images/Weatherhead Center for International Affairs