Nursing in Iraq: Starting From Scratch

Peggy Dryden, RN, MSN, MBA, MLS

Disclosures

March 09, 2004

In This Article

Introduction

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This is the story of Marcos Mendez, a military officer and a nurse, originally from a small town in Puerto Rico, who is courageously helping to redevelop the field of nursing in Iraq. Working in a war-torn environment, where the medical conditions are difficult at best, Marcos has taken time out to write the Medscape Nurses readers about the state of nursing in Iraq. Marcos is an Operations Officer to the Public Health Team of the 352nd Civil Affairs Command. His work involves planning, organizing, and much more. Marcos shares his optimism for the future of nurses in Iraq; however, much needs to be done.



Question: Marcos, you are in a remarkable nursing position. Could you tell the readers about yourself?

Response: Before becoming a nurse, I spent almost 11 years in active duty as an infantry officer and a military intelligence officer. I left the Army in the mid-1990s to attend nursing school. I received a BS in nursing at Barry University in Miami, Florida.

I began working at the Miami VA Medical Center in 1998 and was assigned to the Spinal Cord Injury Unit. After 2 years, I moved to the Surgical Intensive Care Unit (SICU), where I was employed as the unit charge nurse before deployment to Iraq. I was also teaching classes part time at one of the Community Colleges in Miami. Currently, I am a Civil Affairs Officer in the US Army Reserves. I have never been a nurse in the military. I am assigned as the Operations Officer to the Public Health Team of the 352nd Civil Affairs Command.

Question: Tell us about your current experience stationed in Iraq.

Answer: My experience in Baghdad has been a very positive one. I never wanted to come to this region, but now that I have been here, I am thankful for the opportunity. People here are cordial, kind, and very friendly. It's nothing like the media portray in the news.

Question: How long have you been on duty in Iraq and where are you located?

Answer: I first came to Kuwait in March 2003. Our team entered Iraq on April 11, 2003. Initially, we stayed in different places, mostly in palaces. We are currently in a villa, which we have occupied since April.

Question: Can you describe your mission? Have you ever had an experience similar to this one?

Answer: No, I have never had an experience or a mission like this. I am not a nurse in the Army Reserves, but a Civil Affairs Officer who happens to be a nurse. There are other people in Civil Affairs who are nurses and who are trying to help as well. In this deployment, I am assigned to a public health team within the Civil Affairs Command. Our mission as a team is to support the soldiers of the command during the war around public health-related matters. A secondary mission is to support our military in the mission of nation building during and after combat operations. For example, the Ministry of Health in Iraq was looted, the building was burned down, and the employees dispersed. Our mission includes getting the Ministry of Health back to a functional level. This is only a temporary mission until US civilians as well as other Coalition partners come on board and take over the mission. Once these civilians are established, they have the option to say that they no longer need any military support. That's our ticket home.

Question: Can you describe where you have been, what the surroundings, facilities, and general "atmosphere" of your environment were like -- when you arrived and currently?

Answer: When we arrived there was a strange atmosphere. We were very alert to everything and constantly had a finger on the trigger of our weapons. Many of Iraqi civilians were waving at us and saying, "thank you," "Bush is good," and "Saddam is bad." However, we were uncomfortable when anyone came close to us. This discomfort was especially difficult when the children ran towards us and wanted to shake hands and touch us. The situation now is a bit different. People are not as eager to come and say hello.

On arrival in early April 2003, our team drove from Kuwait to Baghdad. I saw a lot of poverty, but I have seen this before in other countries where I've done missions. Generally, the roads in Iraq were not bad, although there were many burned out military vehicles when we arrived.

Question: How secure are you? How does ensuring security affect the daily activities of your team?

Answer: I have never felt secure. We carry our weapons everywhere we go. We are always in teams. Our public health team was ambushed in late April 2003. Three members were evacuated to the States. They have not returned. Although they survived the attack, their wounds were very serious. For some of them, the wounds ended their military careers.

The security concerns have kept many of us from working as we would like to. For example, I would like to go to the Ministry of Health every day. I would also like to visit hospitals, nursing schools, primary healthcare centers, and other facilities, but it is virtually impossible for anyone to go anywhere outside the military compound without a great deal of planning. We would need at least 2 military vehicles, and 6 armed soldiers with at least 2 "long-weapons." A trip must be coordinated days in advance and communication must be established before we depart.

Question: How would you describe your role as a civil affairs officer? What is the health system like? For example, what are the facilities and resources like?

Answer: The healthcare system in Iraq is unique. For instance, in most hospitals and clinics I visited, there are more physicians than nurses. Medical equipment and pharmaceutical supplies are in short supply. Many people, including healthcare workers, get their medicine and equipment on the black market.

I work with a dedicated public health team of the 352nd Civil Affairs Command, which includes doctors, a psychologist, a psychiatrist, a microbiologist, and others. In the first months, about half of the team was wounded in combat and sent back to the States. These members have not been replaced. As a matter of fact, one of the team physicians was in an ambush. Amazingly, he saved himself from being killed. After he was in the hospital for 2 days, he refused to go back to the States and decided to stay in Iraq to finish his job.

Question: What obstacles are the most difficult to overcome? Have you been able to manage these obstacles?

Answer: In June, the US civilians arrived to take charge of our duties as planned. Unfortunately, although we share the same vision, their methods and ours are different. This affected our performance and has made working together difficult.

There have been several obstacles. Some of these obstacles are similar to what you would see in the United States. Others are unique to this part of the world. There are, for example, social, physical, and cultural obstacles for women seeking employment. Iraqi women are expected to be at home by 2 PM each day. No Iraqi woman touches a man who is not her husband or son. These are significant barriers for healthcare workers that will take a long time to change.

Lack of telephones and a mail system make communication difficult. Religious and geographic differences contribute as well, causing nurses to constantly bicker among themselves. I believe that the main reason for these conflicts among the Iraqi nurses has to do with the long history of intimidation and fear imposed on these women by the previous regime.

Funding is another problem; we only have so much money from the military unit. USAID was offering money to assist in public health, including nursing, but it has been very difficult to get grants approved.

Question: What are some of the accomplishments?

Answer: The progress we have made is only superficial. However, we have managed to bring all of the interested parties to the table and discuss the future of the nursing profession. We developed a nursing vision for Iraq in the form of a 10-year Nursing Reform Plan. This plan was the product of many of the most experienced and highly educated nurses in the country. In July of 2003, we held a National Nursing Conference. The senior leadership for nursing in Iraq (more than 300 nurses) attended the conference where the plan was presented (see Related Links). One hundred of the nurses attending volunteered to create subcommittees for the purpose of coming up with specific tasks to accomplish the objectives of the plan.

Some of the notable accomplishments are the:

 

  • Publication of the first Iraqi nurses newsletter;

  • Development of a National Library for Nursing;

  • Creation of a national nurses database (previously, there was no way to tell how many Iraqi nurses there are);

  • Provision of equipment to the largest Iraqi hospital complex and the Department of Nursing, including computers, printers, copiers, air conditioners, and other equipment;

  • Development of computer classes for the nurses through a contract with an Internet Café specifically set up for the nurses;

  • Rebuilding of the Iraqi Nurses Association through the provision of office furniture and equipment, as well as providing financial assistance;

  • Provision of citywide transportation to nurses; and, finally

  • Distribution of books and other professional supplies.

We also have provided assistance to many of the various hospitals' nursing stations in the form of furniture, funds, and/or stationery.

Question: What has it been like working with the Iraqi nursing community? What is your role?

Answer: Working for the nursing community in Iraq is interesting. The nurses tell us how much they want more respect and more pay. However, it is difficult to justify an increase in their pay and benefits because their responsibilities are limited. The Iraqi medical community tells you how important nursing is for the healthcare of the country. However, the medical community also seems to undermine, undercut, and disenfranchise the nursing profession by belittling the nurses and showing little respect toward them. Both the nursing and the medical community are working toward the same goals, but both are having difficulties finding solutions. Nurses in Iraq need more than help; they need empowerment, encouragement, and genuine support.

My role is primarily to guide and support nurses so that nursing will be seen as an asset and become relevant in the future healthcare system. I hope to empower the nurses here. I spend most of my time coordinating resources and organizations that are available in order to accomplish our objectives. The objectives have been broken down into various projects. Most of my time is spent working these projects or finding someone who is willing to take ownership of them. This is time consuming as I still have military officer responsibilities. Fortunately, there are other organizations and individuals also working on the nursing issues. We are all trying hard to avoid redundancy.

Our goal is mainly to set the stage for the healthcare system to improve. We like to call it "capacity building." The US civilians have their plans, and once they are in place, the military will go home.

Question: How much progress has made so far? What are the next steps needed for nurses in Iraq?

Answer: The next steps include the continued efforts of the nursing subcommittees to follow the recommendations in the 10-Year Reform Plan -- this is essential because it is the only way to channel resources and effort in a centralized manner. One of the first things that must happen is to legalize the nursing profession. Currently, anyone can claim that he or she is a nurse. I am not sure what steps are needed, but we have a team working on this issue at the moment. The Iraqi Nurses Association needs to become a strong organization. At the moment, they have no influence. The organization needs to learn about politics, policy development, and how to self-finance the association.

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