Karbala

We spent only a day in Kuwait reporting what we’d learned and discussing options for proposals and programs. The only decision we made was that we needed to do more assessments and broaden our areas before we could submit our plans to USAID for approval. We showered and ate before heading out again, this time to Karbala and the surrounding rural areas in central Iraq. Neither the mass population displacement nor major public health disasters had yet occurred, but the fighting still raged, Iraq still faced enormous public health needs, and we knew that a catastrophe could yet develop.

We left the camping gear in Kuwait, certain that this time we were sure to find places to stay. Our food choices were better, too—raisins, bread sticks, carrots, crackers, and, as an ode to optimism, peanut butter again. We were headed to the two holiest cities in Iraq—Karbala and Najaf—and I would need to be thoroughly covered. Although I’d covered up in Nasiriyah, a baseball cap and elbow-length sleeves had sufficed. But for these cities, I’d be required, in the sweltering, soupy heat of central Iraq, to wear a veil or full scarf to cover my head, long sleeves to cover my arms to my wrists, and long, loose pants to cover every inch of my legs. I could already feel the sweat pooling on my neck.

The team for this trip would include me, Jason again for water and sanitation, and Jen, the emergency team coordinator, out from New York, who would help in Karbala with education and child protection assessments. We would also have a journalist embedded with us—Kevin, a freelancer writing a story for the New York Times Magazine. We groaned at the news. “A reporter?” I whined. But whining didn’t do any good. He was coming with us. No matter what.

We would travel in two rented SUVs (we still didn’t have our own), and none of us wanted to travel with the reporter. It wasn’t personal. He certainly seemed like a nice enough guy; we just didn’t want to be “on” the whole trip. Finally, we decided we would take turns riding with him, and to our surprise, and within only hours, he seemed like one of us. It was easy to forget that he was a journalist.

We stopped in Umm Qasr, a border town in Iraq, to pick up Akram, an interpreter who could drive one of the SUVs and provide directions. Akram was big—big bones, big belly, big presence—but he was also a gentle and quiet man, and he sank awkwardly into the driver’s seat. We soon learned that though he knew his country, his people, and surely the language, he didn’t know the way to Karbala. Every twenty or thirty minutes, we stopped to ask directions, and then we stopped again to check and then recheck those directions. Finally, late in the day we decided to spend the night in Nasiriyah. We checked into the hotel where we had stayed on our earlier visit, but now the hotel was cleaner, it was being repaired, and there were other aid workers and journalists there, too.

Kevin and I, already fast friends, decided to leave our backpacks in the lobby and check into our rooms later. We wanted to have a look at an orphanage we had heard about, one that War-Child, an Irish aid group, would be supporting. We drove around, Kevin at the wheel, and asked for directions, which didn’t seem to get us anywhere. Finally, an Iraqi man said that he would take us. He hopped into the back seat and directed us through a maze of alleys and streets until we finally arrived. The house, hidden behind a heavy steel fence, was located in a poor neighborhood. Garbage littered the streets, scraggly children poked through the debris, and hungry dogs roamed about, waiting for their turn. There seemed, at least to me, a feeling of hopelessness in the air.

We parked at the side of the road and the children instantly milled about, running their hands over the SUV’s fenders and doors. Our passenger scowled. “I will watch this for you,” he said, shooing the children away.

Kevin knocked at the imposing outer gate once, twice, and as he raised his hand to knock again, the door swung open. An older woman, dressed in the traditional long black dress and hijab, smiled and motioned us inside, where a crowd of shrieking, happy, healthy-appearing children greeted us. They guided us through the house and into their recreation room. Using a mixture of English, Arabic, and nods and smiles, we managed to communicate. The children were clean and neatly dressed, and they appeared to be well cared for and well loved. The staff here had had no reason to expect visitors, and it seemed to us that this must be how things always were here. Although they needed better access to health care and an upgrading of the house, the feel of this place was of a home where these children were nurtured and loved.

We said our good-byes and stepped outside the gate. Our passenger had disappeared, and the children, who’d been climbing all over the car, suddenly surrounded us. Their clothes were ragged, their skin grimy, their little arms and legs stick thin. They stood in stark contrast to the orphans we’d just left. The kids in the street tried to pick our pockets, pry off the hubcaps, and push their way into the car to grab whatever they could. When that didn’t succeed, they held out their little hands, wiggling their fingers, but neither of us had brought money. We had nothing to give them, and though we wanted to stay, to linger here with these children, hear their stories, learn their names, the sun was setting and we had to get back to the hotel before dark.

We said hurried good-byes and headed back to the hotel. Electricity, we were told, had been restored only the day before, and joyous Iraqis had fired their weapons into the air, a customary act of celebration. Unfortunately, the gunfire had knocked out a central transformer, and the city had been thrown into darkness again. That meant there would be only intermittent electricity and occasional running water, so only if we were lucky would any of us get a real shower. My room held only another bucket of murky water, so that evening, it was a not unfamiliar bucket bath for me.

My room was suffocatingly hot, and, without electricity, there was no cooling fan to move the air. I was too tired to care and fell into a welcome sleep on the bed. During the night, the power came back in spurts and the overhead fan screeched periodically into life. The rare moments of cool air lulled me into a deeper sleep. In the morning I woke to sunlight streaming in through my uncovered windows. I stretched, slipped from the bed, and saw that I was covered with a fine layer of dust. I looked down at the bed and saw the only clean area was the outline where my body had lain, a kind of dirt-smeared crime scene. I’d used up my water supply the night before; there’d be no wash for me that morning.

We headed out early and made it to Karbala by late morning. The Shi’a pilgrimage to that city had just ended, and there were still crowds swarming the city center. The cities of Karbala and Najaf and their surrounding areas were Shi’a strongholds, a branch of Islam whose public traditions were forbidden by Saddam. This was the first time in many years that the Shi’a had been allowed to openly celebrate their religion, and they did it now with a fervor and intensity that was powerful and a little frightening to see. The crowds chanted, men flagellated themselves, drawing blood; their passion was palpable.

The city center held a large, golden-domed mosque, the exterior elaborately decorated with exquisite pieces of tiny, hand-painted tiles set into the wall. The only rooming house we could find was just across the street from the mosque. Even when we were welcomed into an area like this, we were still considered nonbelievers and infidels and were not really welcome around the sacred mosque. It was imperative, we knew, to keep a low profile.

This rooming house had running water, intermittent electricity, and the hardest beds and pillows that any of us had ever laid our weary heads on. We rose early, breakfasted on a boiled egg and bread provided for us by the rooming house staff, and made our own instant coffee. We had two cars but three team members trying to get assessments done.

The desk clerk, overhearing our dilemma, offered to help. “I know a woman who speaks English. Her husband has a car. You want to meet her?” he asked. When I agreed, he made arrangements for her to come to the hotel. Aliya, newly married and about thirty years old, I’d been told, arrived at the hotel hidden under the full black abaya, only her eyes, a deep charcoal black, poking through. I led her to my room, where we could speak privately, and once I shut the door, she sighed loudly and pulled her abaya back. Long blonde hair with deep dark roots spilled out. She plopped down on a chair, smoothing her midlength skirt and white blouse. “So,” she said, “I need a job. Will we work together?”

“Well, let’s talk first,” I said.

She nodded and patted her hair down, her fingers untangling the ends, a fresh swipe of color on her lips. Crossing one knee over the other, she smiled. “Yes?”

I suddenly felt as though I was the one being interviewed. “I . . . well, this has nothing to do with the job, but your hair . . . I haven’t . . .”

“I did put color into it,” she said with a quick laugh. “But when I married, my husband told me he wanted my hair to be black again.” She shrugged. “I made my choice and gave up the color for my husband.”

I learned she’d graduated from college, spoke perfect English, and had worked for the World Food Programme until the war brought that food distribution program to a halt. “I know it will start again soon, and then I will go back to them. You agree?”

I nodded and told her what we were offering her for pay—an embarrassingly paltry sum of two dollars a day, which was in line, we were told, with average Iraqi salaries. She cleared her throat. “I know you cannot pay me what I earned with WFP, but—”

“What was your salary?” I asked, thinking maybe we could manage three or even four dollars a day, but I’d have to get permission before I made any promises.

She sat a little straighter. “Two thousand dollars a month,” she said, her smile revealing perfectly straight white teeth.

I slumped in my chair. I wasn’t even sure I was making that much. “I . . .”

“No worries,” she said. “I want to help my people. My husband can drive us. We will start tomorrow. Yes?”

We shook hands and I walked her to the entrance, where she pointed out her dilapidated old car. The cars in Iraq were all old and barely able to sputter to life. Twelve years of UN sanctions had kept new cars, as well as the necessary parts to repair old ones, out of Iraq. Only the ingenious and lucky were driving now. They had somehow worked on and tinkered with their rusted-out, old hulks of cars. They’d jerry-rigged engines and found pieces of scrap, somehow combining it all together to make these dying cars go. This was a nation of resourceful and skilled mechanics. The only new cars on the roads were those belonging to the NGOs, the UN, or the coalition, but in that decaying old rust heap, I would surely blend right in.

The center of Karbala was like any European city—paved streets, cars with honking horns, ornate buildings, open-air shops, carts selling their wares, and crowds of people at every turn. But these days, it was a city that screamed to be cleaned, to be rid of the rotting garbage in the streets, the debris that fluttered on the slightest breeze. The invasion had halted all basic city services, and Karbala, like so many other cities, was decaying from within.

As soon as we pulled away from the city center, there was no mistaking that we were in a rural land. Bicycles were everywhere, and the bray of a donkey and the bleat of a goat replaced the cacophony of rusty engines and tooting horns. Cows and sheep were herded by children, and camel caravans made their way peacefully through village roads. Some of the camels were wild, living and hunting in packs, while many others were domesticated and were pulled along by children who tugged on the camels’ ropes as they strained under their weight. The towering date palm trees for which Iraq had been famous were plentiful here and covered the roadsides and dusty earth. For many, they provided the only source of shade during the hottest time of the day, and children and others clamored to sit underneath and fan themselves with the loose branches. The scene was idyllic, almost biblical, but it hid the disease and malnutrition and dirty water that flourished here.

We were the first NGO to arrive in Karbala, the first to undertake assessments, and the first to establish a presence there. Just as in Nasiriyah, the people were excited to have us there and eager to cooperate with the assessments. On our first full day, I headed out of the city with Aliya to evaluate the rural and semi-rural clinics. The very first clinic we saw, the Al-Hur, was literally falling down. It was housed in one part of a decaying old school; even before the war, this had been a neglected area. Still, they had a generator and intermittent running water from their own water tank, though the water hadn’t been treated with chlorine since the invasion and so required boiling before use, a time-consuming procedure in a busy clinic.

The surrounding area was without electricity and running water, and most people drew water from the canals. Not many villagers had the resources or the fuel to boil water, so diarrhea, particularly bloody diarrhea, was increasing, especially in children, for whom it was most dangerous. Just as in Nasiriyah and everywhere else in this country, the medicines necessary to treat diarrhea and other problems were in short supply, and no one could be sure when the central drug warehouses would be resupplying the clinics. To make it all last, the clinic staff were handing out lesser amounts of the drugs they prescribed. This meant that patients were treated inadequately, if at all, and the diarrhea or other issues would likely recur, at a more virulent level. It was a terrible dilemma for the Iraqi doctors and staff, who had been working without pay since before the war; they were dedicated but helpless without medicines.

I felt energized. I knew that IRC could help here. We could provide medicines, rehabilitate the clinic buildings, repair and upgrade water and sanitation services, work on the cold chain to restart the immunization programs, send community health workers out to teach hygiene and nutrition and general health. We saw several other clinics that first day, and they all had much in common—decaying, neglected buildings, usually without electricity, little or no medicines and supplies, and poor staff morale. As in most of Iraq, many clinics here had been looted, although many had been saved by the courageous actions of the staff.

At a time when concerns for public health disasters and dangerous epidemics loomed on the horizon and were discussed at every meeting with the UN, the ability to recognize, diagnose, and treat these epidemics was virtually nonexistent. There may not have been a public health emergency yet, but we certainly faced a crisis, and without immediate help, a disaster could result. As I evaluated the clinics and hospitals, and assessed the health of the villagers, I was already making plans for programs. These were the areas where IRC could have a real and lasting impact.

We were also learning that many women in these rural areas gave birth at home. There were no reliable statistics available on the number of home births, on maternal mortality, or complications in childbirth, and no one was even sure of the level of training of the midwives or traditional birth attendants (TBA) who helped with the births. It seemed clear to us that there was a need for midwife and TBA training. No one was even sure if these rural TBAs and midwives had supplies, or, if they did, whether the supplies were even clean.

The children, too, suffered from an inadequate system. There were no reliable statistics on malnutrition among children; our only source for that information had been anecdotal, health staff essentially guessing at the numbers based on their own observations. These children needed comprehensive screening to determine their need for nutritional supplements, vaccines, and to better understand their overall health. And then they would need the nutritional supplements, vaccines, and primary care interventions to bring them to optimal health.

Later that first day, I joined Jen and Kevin at one of the clinics, and en route to our rooming house, we three and Akram stopped at a Bedouin camp outside the city. The Bedouins are nomads who live in tents and move on or stay in a particular place according to the changing seasons or simple vagaries of life. These Bedouins had been in this spot for a long while, well over six months already, Akram told us. Their tents, tattered and worn, were clustered together for safety. On this day, only the women were “at home.” Painfully thin, their black abayas covered with dust, they crowded around us, thrilled to have foreign visitors. They touched us, took our hands, and led us into the main tent, where they fluffed up old pillows and invited us to sit.

We tried to communicate through Akram, but the women, excited to have foreign visitors, spoke too quickly, and much was likely lost in translation. They were able to communicate how frightened they had been in the recent war and how they had cowered in their flimsy tents when the bombing started. One old woman, toothless and bent, described the closeness of the planes and helicopters as they swooped in to drop their weapons. She and the others reenacted what had happened during the bombing campaign by cowering together and looking fearfully skyward. The Bedouins were alarmingly close to an Iraqi army training center that had been heavily bombed, and they had been desperately afraid that they would be targeted as well. Though their physical lives and flimsy tents had been spared, they were clearly deeply affected by the war and were still alarmed and fearful when they saw soldiers.

We shared tea, sweet and sticky, and finally we had to leave. We said long good-byes and they kissed Jen and me and grasped our hands, asking us to return.

As we drove past the now crumbling Iraqi army training center, there seemed to be people living inside, so we pulled over to have a closer look. The building, a three-story cement block structure, had been heavily targeted and was now literally falling down, yet here living among the debris were about five families, each with children who were playing outside among unexploded ordnance (UXOs). We walked through the now collapsing outer walls and stepped carefully around the shattered glass, pieces of cement, and UXOs, trying to convince these children how unsafe those old bombs were. They wanted us all to get a closer look as they kicked at them and swung them about, but we declined. We would later report the UXOs to the US military here so that they could destroy them.

In the meantime, we wondered if these people were displaced from their homes, or if they’d been, like the Bedouins, always on the move. With Akram carefully translating, they told us that they were displaced, but not in the traditional sense.

“We lost our jobs,” one man with a fresh growth of beard said. “Once the war started, there was no money to pay us and no work. Without money, we couldn’t pay our rent and had to leave our homes. We have no place else to go.”

“You were evicted?” I asked, incredulous that a landlord would behave so callously in times like these. The man nodded. I shook my head. Sometimes, the worst of times brings out the worst in people. These families planned to stay here only a short time.

Still, we were concerned for them. We reminded them to keep away from the UXOs and to boil water, and told them that they were very close to a clinic, where they could at least be seen by a doctor. Here, as in so many other destitute places in the world, people were well used to living with danger, whether unexploded rockets or surviving in crumbling buildings. It’s likely they didn’t heed our advice.

We arrived back at the rooming house, and there, sitting in the lobby, was an older woman with heavy makeup on and bright red lips, the color extended shakily beyond her lip line. She had a bright scarf wrapped fashionably around her head, not draped, as was the custom here, and she was smoking, all of which made her either very brave or very crazy. She noticed me looking at her, and in a clipped and proper British accent, she said, “Hello, hello.”

I was drawn to her. “Oh,” I said, “you speak English?”

She looked around the room and then at me and said, “Fifty-fifty.”

I was dying to hear more. She was such a wonderful diversion here. “Where did you learn to speak English?” I asked.

“Oh, Paris, London,” she replied as she waved her cigarette about.

She must have some fascinating tales, I thought as I sat down beside her. “When did you learn? Do you live here?” I asked.

She smiled, blew a long plume of smoke into the air, and looked me in the eye. “Hello, hello. Fifty-fifty,” she said, pausing to take another drag on her cigarette. “Paris, London,” she added in that clipped accent, but it was all she could say, and she repeated it over and over until the desk clerk shooed her out. Although she had been a welcome distraction, she worried me. We had no plans to care for people like her, the most vulnerable, who might not recognize danger and who could be so easily targeted.

Over the next days, I visited the remaining hospitals and most clinics—nearly nineteen—in the province of Karbala. Many clinics and even hospitals here were run by women. It seemed, too, that about 50 percent of the physicians here were women, and though many were still confined to traditional Muslim roles, many others had been encouraged, under Saddam Hussein, to go to school, become professionals, and work. At home, they were still subservient—they still cooked and cleaned and reared the children—but once they stepped beyond their walls, they worked alongside and often managed the men here. To balance the dichotomy of those roles required a degree of grace and intellect that I shall never have.

I completed assessments as I had in Nasiriyah, filled out the Rapid Health Assessment forms, and filed my trip reports. The assessments here revealed a population and medical system in desperate condition. The needs here were enormous, and I knew we could have an impact and really make a lasting difference. I met with the director of health, who was easy to find. Though gruff and excitable, he was pleased to work with us and see his health systems, which had been isolated for so long, back at capacity.

Jen and I had both been wearing scarves and long shirts, but under those shirts, we both wore jeans. On our third afternoon, we ventured out with Kevin for a walk around Karbala’s center. A group of men, all wearing turbans, began to follow us.

“What are you doing here?” one shouted, a sneer curling his lips.

We three turned, and, our mouths agape, watched as another piped in.

“Look at you!” he sneered as he looked us up and down.

Despite the heat of the day, a shiver ran along my spine. Another man’s eyes, almost hidden under a heavy brow, flashed angrily as we backed away. We had surely tried our best to dress and behave appropriately within the strict confines, but it wasn’t enough. We learned that Coalition soldiers here were not even allowed to patrol this area around the mosque. As nonbelievers, their presence, and now ours, would defile the mosque. We headed back to the hotel and decided it was best just to leave Karbala and head to Najaf, another holy city just to the south, after some final assessments the next morning. We had been joined in Karbala by Tom, a New York Times photographer working on the story with Kevin, and he would accompany us for the rest of this trip.

On that last evening in Karbala, I was called to the lobby, where a young family had gathered. “They are here to ask for your help,” the desk clerk said apologetically. “They heard that your group was here and insisted I call you.”

“Please,” a voice implored. I turned as a man, his beard freshly trimmed, his hair sleek with oil, nudged a little girl toward me. Tiny and almost lost in the ruffles of a lacy yellow dress, she stumbled forward. I knelt down quickly to catch her, the flat of my hand resting on her bone-thin chest, her heart fluttering there, a fragile butterfly beat.

“Hello,” I said, smiling. She stepped back, her large brown eyes filled with fear. Her hair was gathered with a shiny yellow ribbon. The man reached down and lifted her into his arms. “She is very sick,” he said, his voice hoarse. She looked like a little princess, but just a glance at her thin frame and pale skin told me she was indeed very sick. His forehead dotted with beads of sweat, his hand trembling, he handed me a manila envelope. “Please,” he said, “see for yourself.”

I sat down and patted the seat next to me. The girl clung more tightly to her father, but the woman, clad in the now familiar abaya, who’d stayed almost hidden in the background, sat down next to me. I opened the envelope and read the records inside. Isra, the tiny girl, was three years old. She’d been born prematurely and had been diagnosed with a heart defect that would require surgery; without surgery, breathing would be difficult for her and grow more so until her weary little heart would finally stop. I felt my own heart sink as I read. The records also indicated that Isra had a bony deformity—one of the bones of her left forearm was missing. It was then I noticed that indeed her left arm hung limply at her side.

“Yes?” the man said. “You see?”

I paused before explaining that I could not help, that we did not provide cardiac or orthopedic surgery. “You must take her to Baghdad,” I said. I wrote out a referral asking for help on their behalf. I knew that before the war and the resulting chaos, specialty surgery was limited but available. These days, the military was stepping in, along with the international community, to fill that void, and I hoped that they might be able to help. Without surgery, she wouldn’t survive another year.

Her family was one of many that sought us out for medical and other help. People here believed that once the invasion and war were over, America would take care of them, make their children healthy, fill their hungry bellies with food, and turn on the lights and let the water run. Although none of that had happened yet, they still had faith; they still believed that everything would be better soon.

Our three days in Karbala had been more fruitful than any of us had expected. I was sorry to say good-bye to Aliya, my interpreter, but the World Food Programme had contacted her and she was ready to go back to work. I hadn’t had much of an opportunity to speak with her once her husband joined us, for then she became a good, quiet Muslim wife. She refused our offer of pay that last day, and once again, I was humbled. She and her husband had been so helpful and kind, and they wouldn’t even let us pay them. “It is for our country that we helped,” she said.

Amidst the devastation of war and loss, there is such generosity of spirit.