Questionnaire

Terry Cline, PhD, has had many opportunities to observe resilience throughout his career, from his time delivering therapy to low-income Boston families to his recent tenure running the Substance Abuse and Mental Health Services Administration.

But Cline's newest post, Iraq health attaché for the U.S. Department of Health and Human Services at the U.S. Embassy in Baghdad, has given Cline a renewed appreciation for how people persevere in difficult and dangerous circumstances.

Just how different the challenge is was clear in a meeting he had last year with Iraqi health officials, held in a windowless room deep in the interior of a Baghdad hotel. In the midst of their discussions, the lights went out. While the Americans sat still and wondered what to do, he remembers, the Iraqis flipped open their cell phones or switched on keychain flashlights, ready to proceed.

"To me, that was so striking, that this is what life is like. You just adapt to that and continue on," Cline says.

Cline's been on the job since September, helping the Iraqi government recreate a health-care infrastructure of medical professionals and facilities that, decades ago, was one of the best in the Middle East. He coordinates assistance and training efforts offered by several U.S. agencies, including the Centers for Disease Control and Prevention and the National Institutes of Health.

Those efforts include periodically bringing Iraqi physicians to the United States for training, building 130 primary health-care facilities and hospitals and distributing equipment.

He meets regularly with Iraq's Health Minister, Salih al-Hasnawi, MD, and when not visiting a network of clinics and hospitals around the country, lives and works at the new U.S. Embassy in Baghdad's heavily-guarded Green Zone.

The system struggles with damage inflicted by neglect and politicization during Saddam Hussein's regime, an exodus of 12,000 physicians (half of the country's total) targeted with killings and kidnappings in the violence following the regime's end, a lack of modern equipment and technical skills, and an inadequate education and training pipeline, Cline says.

He recently talked with the Monitor about some of his experiences.

How would you describe the condition of the health-care infrastructure?

One of the biggest challenges is the inconsistent electricity supply and water supply, which has huge implications for the primary health-care centers because it takes electricity to run water up to the storage tanks and run water through filtration systems, and a lack of electricity presents challenges for running equipment, X-ray machines, lab equipment, refrigerators for vaccines.

What are some technical challenges you've seen?

I visited a primary health-care clinic, it was brand new, and it had a heating and air cooling system in the ceiling, and the system had gone out, and the people in the facility did not know how to repair it. So what they did—here in Iraq temperatures can reach 140 degrees—you need A.C., they went out and bought window units, and cut holes in the walls in all the rooms of this brand new building. This is where we need to learn about cultural competency. The Iraqi way is, you have all these small units, so if one goes out, you lose one room, you don't lose the whole system. And I think that as we've become more technologically sophisticated, it's made us much more technologically dependent.

What resilience have you seen among Iraqi health-care providers?

It reminds me of a book about the Dust Bowl in the United States. The book focused on people who stayed and survived instead of the people who left. In some ways, that's part of the miracle story here, too, that in all these circumstances, there's a huge number of people who did stay, who persevered, who continued to provide medical care. That, to me, is miraculous, given the challenges. When you go and visit one of the busy primary health-care centers, and there's no electricity or water, and you compare it to D.C. where a slight dusting of snow shuts the whole system down, you think, wow, it's a very different threshold here.

What are some signs of progress?

The Ministry of Health has significantly increased salaries for physicians, who at one point were earning $3 a day; that's now been increased to $1,600 a month. And last year, about 1,000 physicians returned to the country, up from 200 [who returned] in 2007. It'll take a while to get back that exodus of 12,000 or so, but it's trending in the right direction. And overall funding, which at the end of Saddam's era was estimated at $16 million for a population of 30 million people, is at around $4 billion today.

Given the eventual drawdown of U.S. troops, where is this effort going?

In the beginning, we were focused on doing: building health-care centers, building hospitals, conducting training. But now, there's an increased focus on developing capacity and infrastructure within the Iraqi Ministry of Health, to sustain all these activities.

How do you manage the stress of living in Baghdad?

I have access to a very nice pool, and at 4 in the morning, I'm in the water swimming about 2.5 miles, about four or five days a week. That's a strong relief for me, and I've always been a big believer in having that balance. It's a very small world here, just in terms of the embassy, it's like a small college campus. My next door neighbor is my boss, and your work colleagues know when you come and go, when you do your laundry, and when and what you eat. You lose that sense of privacy, but you also have a sense of community. Because of what you choose to do in your spare time, they say that as you leave here, you can be a hunk, because all you do is exercise, you can be a chunk, because all you do is eat, you can be a monk, because social interactions can be limited, or you can be a drunk. So, I'm trying to focus on all the positives in that equation.

What is it like outside the relative safety of the U.S. embassy?

If I go outside the Green Zone to visit primary health clinics or other sites, security is a top priority. It takes dozens of people to support a movement. I travel in convoys, wearing armor and a helmet, with one or two helicopters overhead, just scouting things out, to make sure there's no trouble waiting up ahead. There's a very professional group of people whose job it is to keep us safe.

What factors promote resiliency among Iraqi people?

There clearly is a very strong sense of family, and it's not uncommon to see intergenerational family units caring for their parents or sick relatives. And obviously, a huge component is faith and belief. Religious belief is very, very strong, and I think it provides people with the strength they need to face adversity.