Monday, July 11, 2005

The Books of Salah al Din

A Dispatch for Medical Professionals and others wishing to help Iraqi People

Salah al Din Province, Iraq
The imagination to see, the initiative to act, the energy to do; when a person has these essentials, a great journey can begin.

The successful bondage of man depends, at least in part, on equal measures of ignorance and intimidation. These are the twin towers of both tyranny and terrorism. Controlling access to information constrains the power of ideas, allowing a climate of confusion and fear to rise in the vacuum. In fields such as science and medicine, ongoing access to developing ideas and emerging technologies is essential to maintaining a capacity to deliver health care and to harness the power of unfolding developments.

In most instances, it would be oxymoronic to insert the name of Saddam Hussein in a sentence which also contained the phrase "the greater good." Under his regime, access to information vital to medicine was constricted to the point of atrophy. The danger grows over time; the quality of health care diminishes immediately, while the capacity to educate the next generation of doctors, nurses and allied health care professionals is seriously compromised.

Poverty is not the basic problem in Iraq. A helicopter flight over cities and villages reveals thousands of satellite dishes, thousands of automobiles driving about, and power lines crisscrossing the country. The people are starved, however, but the commodity for which they hunger is knowledge and information, particularly the kind that comes unfiltered. Yet many of the terrorists who make the misery they later feed on wish to cut ties to the outside world.

In the months immediately following the collapse of the Saddam regime, but before the tumor of insurgency invaded the body, medical officers attached to the 4th Infantry Division met with doctors and professors of the region's medical schools and hospitals, to assess needs and find ways to share resources to facilitate the rehabilitation of the health care system. Two of the key medical officers of the Division, LTC Kirk Eggleston, the Division Surgeon (and hence the principal medical staff officer ) and Major Alex Garza, the Division's Civil Affairs Medical Officer, visited the Medical College of the University of Tikrit.

During initial visits, they were taken aback by a discovery that Iraqi doctors and medical students were relying on photocopies of outdated medical texts for information. Initial inquiries revealed that what looked like an isolated case of an improvised library was actually the presenting symptom of a systemic deficiency--Iraq's scientific and technical resources were dangerously malnourished. All over Iraq, teachers and students were using photocopies of outdated textbooks and had been doing so for decades.

This was not about saving money; the cost of making the photocopies can be higher than purchasing books and journals. The issue was availability. Iraqi physicians and professors could not simply shop online and purchase a title for shipment to Iraq. Basic medical science textbooks as well as those relating to the medical specialties were only available as well-thumbed copies of out-of-date editions. Medical journals were similarly unavailable.

Not long after that first meeting, Eggleston and Garza shared their findings with then-Major Gifford who shared their consternation and alarm. Gifford shared his concerns about the condition of Iraqi medical education with his father, David Gifford, MD, a retired Army medical officer. To Dr. Gifford, the answer was obvious--he needed to find a way to fill those shelves. Collaborating with Army Major Alex Garza, MD, he launched a public health response in the form of an old-fashioned book drive.

The potential energy of knowledge is one of the most powerful, but most unpredictable forces on the planet. When these two men set out to equip the medical libraries near Bagdad, they had no idea what they were about to unleash. Their first moves were tentative–-requesting donations from textbook distributors and publishers--and lackluster in terms of results.

After fruitless weeks of efforts, they decided to modernize the book drive by taking it onto the internet. Dr. Gifford made contact with Susan Yox, RN, EdD, an editor at Medscape, an online clearinghouse for health professionals. This was the same Dr. Yox who, in 2002, publicized requests for assistance for physicians and hospitals in Afghanistan. Dr. Garza, in civilian life, is an assistant professor at the medical college of the University of Missouri, Kansas City. In this partnership with Dr. Yox, the right people combined with the right skills, and a passion for the mission.

Doctors Gifford and Garza began a small internet campaign where they sent emails and posted notices on websites for their alma maters, asking for donations of medical text books. Almost immediately, the response outraced their expectations. Although the donations began arriving through simple channels (mostly by mail or personal delivery), as groups of students and teachers in the US learned of the program and began to work collectively, the size of the deliveries began to be measured in tons.

Outside of formal military and governmental channels, and completely on a voluntary basis, a virtual organization consisting of both military and civilian members was born. A small but growing group of Americans, medical students and professors, ordinary doctors and nurses, medical librarians and eventually even medical publishers, created a way for colleges, hospitals, nursing schools and community clinics to fill Iraqi bookshelves with recently published texts and journals.

Because of British influences in the region after World War I, Iraq's six-year medical program is patterned after Great Britain's model, and the training is in English. Of course, just because there's no detour for translations doesn't make the road clear of all obstacles, and this journey would have more than a few.

The Books of Salah al Din

As word spread on the internet, the chatter triggered an avalanche of donations. A retiring plastic surgeon in Texas donated his professional library of texts and specialty journals. Students at Mt. Sinai School of Medicine in New York City donated over 2,000 texts. A senior medical student at the University of Tennessee School of Medicine took the idea and advanced it another step among his peers and faculty by using flyers and email. His group accumulated nearly 4,000 texts and journals. Elsevier, an international medical and scientific publisher, donated packaging and postal costs. Evidence of the growing momentum was seen in the donation of 1,000 copies each of Scientific American Medicine and ACS Surgery from Medscape Publishers. This one collection of new texts weighed 17,600 pounds and had a retail value of $429,000. The magnitude of this donation was leveraged to ratchet up the credibility and visibility of the project, culminating when Merck Canada donated five pallets of medical and scientific journals.

Swerving to Avoid Obstacles

When Doctors Gifford, Yox and Garza began the internet campaign, using the services of the Medscape electronic bulletin board, they hadn't really planned for success. Because their earlier efforts failed to gather any momentum after several months, they weren't predicting success on either the scale or speed that reality was about to demand. But the response was overwhelming and instantaneous.

Donations directed to Dr. Garza began to arrive in Iraq through mail channels, while many other donations were delivered directly to Dr. Gifford's office at the hospital at Fort Hood, TX. The first major obstacle was a regulation prohibiting soldiers from requesting donations. Cognizant of this, Garza had been careful in how the first internet messages were worded, but apparently, not careful enough to avoid an admonishment, with hints of court martial.

Things might have derailed then and there, since at the time, Dr. Garza was the sole point of contact in Iraq for the campaign. Rather than quit, he passed the load to the American Red Cross representative attached to the Army, who assumed responsibility for receiving the books.

To make the transition official, the team again turned to internet-savvy military support and medical education communities. They asked for help putting the word out that future donations should be sent to the American Red Cross and packages should have the phrase "Humanitarian Medical Aid" clearly written on the outside. Since there is not a rule against accepting this type of mail, they interpreted the rules to allow the packages to pass through the military postal system.

Cartons and pallets arrived in ever larger quantities, while other shipments were too costly to send, creating a log jam. The daunting logistics could have spelled the end, and just as quickly as the initial internet solicitations had gone out, the organizers could have pled "NO MORE BOOKS PLEASE."

But this was not to be. Indeed, this is an instance where the bureaucracy of the U.S. Military paid dividends for the greater good. No organization in the world moves heavy loads about the Earth—-into combat and disaster areas-—as efficiently as the U.S. Military. Working with the Army, the Air Force cleared these large donations to be included as Space A cargo (space available) on military flights.

As the donor base grew, so did the list of persons willing to distribute texts, journals and related items in other parts of Iraq. When the donations to Tikrit began to saturate the capacity, other medical officers stepped up and began distributing materials across wider areas of Iraq.

The donors continue to come from different corners of the U.S. "The Muslim Medical Students Organization in the Chicago area is participating," explained Dr. Gifford, "and a sidelight of this is that the predominantly Jewish medical school at Mt. Sinai, the Roman Catholic Loyola University School of Medicine in Chicago, as well as the secular schools have been equally involved. Students at Rush Medical College and UCLA are organizing book drives."

Everyone who gets involved in this effort, from medical students to publishers to the soldiers loading the books, all seem to get distracted by the desire to make a difference, and energized by the fact that they are. It's doubtful that most could even imagine the impact of their contributions in Iraq.

Since the campaign was launched, there have been four separate iterations of medical personnel to maintain it, at considerable expense to their non-duty time, and risking considerable exposure to danger. From this vantage in Iraq, seeing so many Americans, Europeans, and others pulling together to help Iraqis whom they have never met is fulfilling, heartening, and provides a welcome respite from writing and thinking about war.

Anyone, anywhere in the world who has English-language medical, dental, veterinary or nursing texts or journals and would like to send them to Iraq, please contact David Gifford, MD:, for suggestions about how to do so.