The health situation on the ground in Iraq has been grim since Gulf War I, with a combination of sanctions, the diversion of funds by the regime, and the collapse of infrastructure since the 2003 invasion by coalition forces. With medical supplies restricted, the health system in a state of total collapse, and most Iraqis unable to afford treatment, it should come as little surprise that Quackery in Iraq is booming, both local and foreign. But could some alternative medicine in Iraq be - at least temporarily - a force for good?

Welcome to the first of a series of posts on Quackery in the so-called "Axis of Evil". Why do this? Well partly because I want to try and show people something really random they maybe haven't seen before, and secondly because I think it helps put our own home-grown quackery into context. So without further ado, welcome to Part 1 - Quacks in Iraq.

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The World Health Organization's assessment of the current state of health in Iraq is stark: "Several wars and 13 years of economic sanctions left a heavy toll on the nutrition of the population, on the social structure, on the economy and on the health infrastructure and services. This is well depicted in the morbidity and mortality rates of the population of Iraq, particularly of infants, children and mothers. The majority of Iraqis completely depend on the food Public Distribution System for their nutritional requirements. The military conflict of March/April 2003 with the following looting and civil unrest led to a further disruption of water treatment and supply plants, of sanitation facilities and power production plants and to the destruction of the remaining medical equipment in health facilities. Continuing widespread insecurity and lawlessness constrain the access to health facilities with the exacerbation of fighting in different areas of the country causing a large number of casualties." [1]

I don't want to get into a debate on Iraq here. Forget spin, forget pro-war or anti-war opinions, nobody reading this right now would want to be a patient in what remains of the Iraqi health system, and that includes Iraqis. Even where treatment is available, it is often too expensive to afford. This is where alternative medicine steps in, and offers an easy way out.

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The first line of medical help for many in Iraq now is the Hijamma man, with practitioners such as "Shubbar" attracting huge queues in places such as Baghdad. The treatment costs just $1.50, far less than a visit to a medical doctor:

"Using small glass-like jars and a surgical knife, Shubbar makes small cuts in one of 123 areas of the body, depending on his patients' complaints: high blood pressure; blood sugar; migraines; back, hand or leg pain; and even some conditions of sterility. He can tell how to begin simply by looking at a person's back.

Shubbar's tools are simple: two glasses and a medical knife. When he chooses a spot, he burns a small piece of paper inside one of the glasses and puts it on the man's back (women are permitted to have Hijamma performed on them, but only by other women).

The burning uses up the oxygen in the glass and creates a small vacuum that pulls blood near the skin's surface. After several minutes, he takes off the glasses and uses the knife to slice six to eight small cuts in each spot. The blood, which he calls "spoiled," starts to ooze. [2]

Ben Goldacre over at Bad Science would have a field day with this after some of his recent posts on the placebo effect. The conditions being treated are telling - migraines, back pain, high blood pressure, these are conditions that are heavily linked to psychological influences and stress. The treatment - making physical cuts and incisions is liable to release endorphins and (at least temporarily) alleviate stress. It's the ultimate placebo treatment in the ultimate situation - a perfect alternative medicine storm. No wonder it's so popular.

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This is the old-fashioned and in-fashion local approach, but not all treatment is by locals. Increasingly, outside organizations have begun to move in.

"Frontline", describing itself as a homeopathic charity run by "The London International College of Homeopathy" [3], has given training in the U.K. to visiting Iraqis. This is pretty disturbing, given their shocking previous track record in Senegal.

"The group had just returned from Findhorn where they had been on a course about Non Violent Communication. They were interested in homeopathy as part of a package of tools they could use back home in Iraq to help bring some healing to their communities. The basic homeopathy training ourse they undertook covered basic principles, post-traumatic stress and the use of tissue salts. Each participant took away a detailed handout and arrangements were made for them to take remedies back home. We are hoping that this is the first of many workshops that Frontline can run in conjunction with the Iraqis to help them begin to work with the survivors of the conflict".

I think they'll manage without the tissue salts, but I'd be interested to know what PTS advice they gave to the students, and what they were actually qualified to give. It's not a welcome state of affairs if we have health workers in Iraq taking advice on PTS from a homeopathic clinic rather than mental health experts.

On a somewhat larger scale, India's Art of Living Foundation - a Bangalore-based foundation whose stated goal is to "eliminate stress, create a sense of belonging and restore human values" - moved into Iraq in 2004 [4,5]. Their volunteers found that people were taking pills indiscriminately:

"If they have a headache, they pop a valium. If they feel pain, they take steroids. There's a lot of reckless self-medication."

The reason for this? Stress and trauma:

"After the bombings, trauma and anxiety levels among people in Baghdad were very high. Though the war is over, we found many residents were unable to sleep or even eat. The residents go through mood swings and depression."

The Art of Living Foundation (I'll avoid referring to them as the ALF) prescribe herbal medicine, but also run hundreds of Iraqis through yoga, meditation and breathing exercises, activities which are likely to be of enormous benefit to stress victims. The Iraqis certainly seem to be happy with their methods, with a camp at al-Qadisiyah near Baghdad treating 200 people a day.

The Foundation have been in Iraq for for years in spite of "...risking hostile conditions such as threat to life, heavy army presence, language barriers" and in particular having to cope with the shocking "lack of fresh vegetarian food...".

We don't seem to see the same situation that we have in Africa, where quacks have invaded en masse (a lot more to come on this in the future on LayScience). This is probably largely because of the situation on the ground in Iraq - going there is dangerous, and only the serious, hardcore charities are operating there. I suspect that this is probably a good thing, but it would be churlish to deny organizations like the AoLF are helping Iraqis to cope with their shattered lives.

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In the west, when we scientists debate the dangers of "quack medicine", many of us are actually making several unconscious assumptions. We assume that alternative medicine is bad because it potentially interferes with the patient-doctor relationship and medical treatment, or because we feel that it is conning clients out of money for treatments that at best only offer a placebo effect. But what if there's no medicine? What if a placebo effect is the best treatment people can hope for?

There's an interesting debate here to be had, which is closely related to the recent debates on antidepressants and the placebo effect. In a country like Iraq, where civilians have to deal with stress and emotional trauma on a daily basis, and where often medical help simply isn't an option, is quack medicine actually doing good for now? Will we see a bigger, African-style influx as the situation on the ground becomes safer? And what will happen as mainstream medicine becomes re-established?

"Junk Science in the Axis of Evil" will return soon with "II - Science Journalism in North Korea"

[1]Health Action in Crises: Iraq (WHO).
[2]Alternative Medicine is Booming in Iraq (Assyrian International News Agency).
[3]Frontline - Iraq (LICH).
[4]Indian stress-busters target Iraq (BBC).
[5]AoLF - Iraq (AoLF).