Iraq: Can Arba’een Rise to a New Health Standard Amidst Terrorist Chaos?

Published on October 24, 2014
The medical community and local and central governments must work together to meet the growing demands of Arba’een, an annual Shia Muslim religious observance that attracts millions.

Each year, millions of Shia pilgrims travel by foot to the city of Karbala in Iraq to observe Abra’een. The event commemorates the martyrdom of Hussein bin Ali, the grandson of the Prophet Muhammad, and is one of the largest pilgrimage gatherings on earth. Undoubtedly, the gathering of some 18 million people in a hot desert climate presents numerous medical issues. Dr Shakir Katea, the President of the Iraqi Society for Emergency Medicine (ISEM), shares some of the problems he and his colleagues face when caring for the participants of Abra’een. These mass casualty lessons learned can be used to increase the efficiency of emergency medicine in Karbala specifically, and in Iraq as a whole.

EPI: What efforts were made to decrease the spread of infectious diseases during Arba’een?

Dr. Katea: We have a public health directorate which is the central directorate in the Ministry of Health. The directorate leads 15 public health departments in the 15 governorates of Iraq (the exception is Kurdistan, an autonomous government). Prior to the event, the public health directorate (PHD) distributed these instructions to other public health departments:

  1. Promote public awareness concerning the avoidance of infectious diseases through educational posters and media.

  2. Focus on food safety by monitoring food preparation throughout the event, and particularly that food supplied by volunteers.

  3. Encourage personal hygiene from those that prepare the food.

  4. Prepare medical teams to provide care to patients.

Pakistani Muslims perform religious flagellation rituals during an Ashura procession in Quetta. Blood loss from self-injury creates an even more complicated public health challenge for those managing Arba’een.

EPI: What kind of physical medical infrastructures were put in place during Arba’een? Were they successful?

Dr. Katea: Medical departments begin preparing for the event up to two weeks prior to its start. Some of the ways the infrastructure is bolstered are the following:

  1. The local hospitals of each governorate (there are 140 hospitals in total) prepare by increasing bed capacity, limiting the admission of non–urgent cases, preparing lists of medical staff on call, and providing an ample amount of medicines and appliances.

  2. There are three field hospitals: Kerbala, Najaf, and Basrah. Each consists of 13 medical units and facilities with surgical theater.

  3. Mobile medical tents provided by each PHD are distributed along the way of pedestrians (pilgrims).

  4. In selected areas more advanced mobile medical caravans are put in place.

  5. There are additional health services provided by Iraqi Red Crescent, military and civilian defense, and various others by volunteers.

  6. There are ambulance services provided by each governorate. There is at least one ambulance vehicle in each mobile team and additional others distributed in selected areas.

  7. The ministry of defense also provides additional ambulance services. The city of Karbala, home to the Imam Husayn shrine, has only three hospitals. One is a teaching hospital, one is for obstetrics and gynecology, and the third is a general hospital. Given that all three hospitals have low bed capacities, the additional measures taken to prepare for the event are absolutely vital.

EPI: Was there any data gathered on the kinds of patient populations seen during Arba’een? If so (or anecdotally) what were the main reasons that people fell ill or injured during the event?

Dr. Katea: There was some data gathered regarding the patient populations, but it is very limited. Details including age, gender, and even complaints are not included in the majority of patients seen by mobile medical units. We do have a study conducted by our colleagues about the pattern of morbidity of patients during the event. I visited many of the mobile medical units myself, and I have seen that common complaints include:

  1. Joint pain due to walking long distances from their home to Karabala, ranging from 80 to 400 km.

  2. Gastrointestinal issues due to the ingestion of variable and excessive foods provided by volunteers along the way. The common issues are diarrhea, epigastric pain, nausea, and acidity.

  3. Dermatological problems like skin rash and itching due to irritation during the long walk combined with ranges of 3-10 days without bathing.

  4. Disturbance of blood glucose regulation for diabetic patients.

  5. Ischemic attacks in those with ischemic diseases and cardiac issues.

  6. Headaches

  7. Common wounds of various causes: scrapes from falling during the walk, abrasions caused by shoes, dog bites, and many others.

  8. Sun burn and heat exhaustion

  9. Food poisoning due to the contamination of foods during its preparation.

  10. There are some severe wounds due to the ritual itself. Some pilgrims hit themselves with sharp instruments to commemorate the martyrdom of the Husayn ibn Ali.

  11. Asthma-like symptoms due to dusty conditions.

Arba’een is consistently among the largest peaceful gatherings in history. In 2008, approximately nine million religious observers converged on Karbala. In 2013, Arbaeen reached over 18 million.

EPI: Is there any kind of syndromic surveillance that takes place during events like Arba’een such that emergency health workers might prevent an infectious disease before it spreads?

Dr. Katea: Unfortunately, no. Syndromic surveillance is dependent upon symptoms and signs witnessed by medical staff in hospitals. The majority of cases during the event are seen by the mobile medical teams who are chiefly concerned with alleviating the problem in front of them. They are not focusing on symptoms or signs of public health threats. It is important to keep in mind the incredible number of pilgrims, a number that increases each year. The last event exceeded 18 million. That is enough to overwhelm any health system in the world.

EPI: Are there specific lessons learned at events like Arba’een that can applied to emergency medicine in Iraq?

Dr. Katea: There are many lessons presented by the event, but they are not always learned! As the prophet Mohammed said “A believer shouldn’t be bitten from the same hole twice.” Here is a list of the lessons, pitfalls, and issues particular to this event, and in all religious events in Iraq in general:

• The event is usually staged by the community, or volunteers. The central and local governments must develop rules, regulations, and measures to ensure the safety of the event and the health of its participants.

• There is a fundamental lack of communication and coordination among relevant agencies which leads to improper staging of emergency care during mass casualties. There is a vital necessity to work as a team.

• There should be better organization of the hosting tents of pilgrims. Currently, these are scattered in such a way that disturbs traffic flow, promotes crowds and road accidents, and creates difficulty for ambulances to respond.

• There is great difficulty in evacuating the pilgrims from Karbala after the event ends. There are low numbers of transport vehicles and those that are available (military vehicles) are very difficult for elderly and disabled persons to use. Overall, the transportation is unsafe and inefficient.

EPI: What do you think the medical community should do differently at the next Arba’een festival?

Dr. Katea: We believe that the medical community are most efficient when they are well prepared in terms of supplies and properly trained in terms of skills. We should work toward coordination, communication, and working together as a team to best serve the participants of the event.

Each year there are gaps and clear cases of what we need to improve. We need to document this and use it for the next year, when the number of participants always increases as will their demands.

This article originally appeared in Issue 14 of Emergency Physicians International.

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