BAGHDAD, Iraq - The letter came to this city's main cardiac hospital late last month. It was unsigned and handwritten, but its message was clear: It threatened the hospital's top doctors and warned them to leave their jobs immediately.
No one knows who sent the letter, but the relentless violence here is often baffling. Four of the hospital's top surgeons stopped going to work. So did six senior cardiologists. Some left the country.
It's the worst health care system Iraq has ever known.
Dr. Waleed George, chief surgeon at Al Sadoon Hospital in Baghdad
It was far from an isolated incident.
The director of another hospital, Dr. Abdula Sahab Eunice, was gunned down May 17 on his way to work, officials at the hospital said.
In the past year, about 10 percent of Baghdad's total force of 32,000 registered doctors - Sunnis, Shiites and Christians - have left or been driven from work, according to the Iraqi Medical Association, which licenses practitioners. The exodus has accelerated in recent months, said Akif Khalil al-Alousi, a pathologist at Kindi Teaching Hospital and a senior member of the association. A vast majority of those fleeing, he said, are the most senior doctors.
"It represents a very good chunk of the doctors," Dr. Alousi said. "These are the crème of the crème. They are the people who make the doctors, heads of departments."
But insurgent threats are not the only stress facing doctors in this once stellar system, one of the best in the Middle East. Iraq's lawlessness has reached inside the wards, turning doctor-patient frictions into armed conflicts. And doctors are easy targets for violent gangs that specialize in kidnapping because they move around the city to see patients and often cannot afford large numbers of guards.
They also must handle new hardships of their patients, who, if stricken at night, must choose between suffering at home or perhaps dying in the curfew-emptied streets. They also must deal with the continuing power failures that plague operating and emergency rooms, flooded with endless patients by the insurgency.
"It's the worst health care system Iraq has ever known," said Dr. Waleed George, chief surgeon at Al Sadoon Hospital in Baghdad.
"Imagine yourself trying to operate on a patient in a two-hour surgery and the power goes out," he said. "You pray to God, and you sweat."
In the early years of Saddam Hussein, the health care system in Iraq was a showcase, with most Iraqis receiving excellent, inexpensive care. Iraqi doctors often studied in England, and Iraq's medical schools, based at hospitals, had high standards. But Mr. Hussein let the economic penalties of the 1990's bite deeply into medical care and used the damage to the increasingly worn system to try to persuade the world to ease economic pressure on Iraq.
In the chaotic Iraq of today, rules have fallen away, and doctors say that after difficult or unsuccessful operations, they sometimes find themselves confronted by armed, angry relatives. Recently, a surgeon in Mahmudiya, a restive area south of Baghdad, faced with threats from a man who said his wife's abdominal tumor had grown back, closed her clinic.
One 32-year-old doctor at a medium-size Baghdad hospital said doctors now routinely exaggerated the risk of complications, hoping patients would opt against surgery.
"We try to avoid complicated operations," said the doctor, afraid enough for his own safety to insist on being identified only by his first name, Omar. "What if the patient dies? You're face to face with relatives with guns."
The Ministry of the Interior has already responded to the threats: it simplified gun license procedures for doctors, allowing them to get licensed weapons faster than other Iraqis.
Omar al-Kubaisy, one of the doctors who stopped going to work at the cardiac hospital, Ibn al-Betar, after he was threatened, kept working at his own clinic - watched over by his 23-year-old son, Ali, who stood guard with a large and always visible semi-automatic gun. But two weeks ago, Dr. Kubaisy, one of Iraq's top cardiologists, left for France.
The simple quest for money, which fuels the country's widespread kidnapping industry, appears to be the biggest motivation. Dr. Alousi estimated that 250 Iraqi doctors had been kidnapped in the past two years.
One 60-year-old gynecologist, who was kidnapped last December, said three cars, one of them a police cruiser, pulled her car over. Men banged on her window with guns, forced their way into her car and pushed her head to the floor. They took her and her driver to a house.
The men asked for $1 million, handed her a gun and told her to kill the driver. They said they would cut off her hand and send it, with the driver's body, to her son.
"I said, 'I cannot kill him,' " she said. "I can't even kill a bird. They started to beat me on the face."
The men released her after her family paid $250,000, most of it borrowed. Oddly, an American patrol stopped the car as the men were driving her and her driver home. Seeing her bruised face, they asked if she was all right. Terrified, she replied that she was on her way to the hospital. She made it home; a day later, she left for Jordan. Still terrorized by the incident, she asked that her name be withheld.
"I'm healed from outside, but I never heal on the inside," she said. A rarity, she has returned to Iraq - to work at repaying the friends who lent the ransom money.
The exodus of senior doctors has resulted in very unpredictable medical service, doctors and hospital officials said. Patients are not sure whether they will find their doctors. Junior doctors fresh out of medical school are performing complicated surgical operations that ordinarily would be done by more experienced doctors. At Ibn al-Betar, surgeries are still being performed and patients are still being treated. An official there declined to say how the losses had affected care. But the exodus of virtually every senior doctor and surgeon cannot bode well. "The sophisticated surgery, it will be in trouble," Dr. Kubaisy said.
At Omar's hospital, about half the doctors on the staff have left, the hospital director said in an interview. Junior doctors have taken their places, but some of the more complicated surgeries are no longer done.
"As junior doctors, we need to learn as much as possible," the doctor said. "Some cases, especially elective cases, cannot be managed sometime," Omar said.
The more prosaic problems are no less serious. The decade of deficits under the economic embargo left equipment in poor shape. The state no longer picks up the tab for medicine. And Iraqis in several clinics visited this month complained of not having access to basic heart and diabetes medications.
Dr. George, the surgeon at AlSadoon, said shortages of power and medicine had forced the hospital to reduce the number of operations by about half. It briefly solved its power problem by hooking up to the system of the Ministry of Agriculture nearby, but even that has chronic failures now, he said.
Emergencies are nonstop. Civilian deaths, the Ministry of Defense says, have more than quadrupled since the new government took power late last month. Omar, the young doctor, said he cut his teeth on emergency bullet-wound operations in the past year.
The workload increases for the doctors who remain. Dr. Hashem Zainy, a psychiatrist and the director of a psychiatric hospital, Ibn Rushud, said the doctors who have stayed must see almost double the daily caseload.
"It's ridiculous," he said. "They listen to the patient for a few minutes and write out a prescription and that's it."
Dr. Kubaisy saw his final patients at his clinic across town from the hospital this month. One patient, Halima Obeidi, a 75-year-old woman with kidney failure, lay on a hospital bed surrounded by worried relatives. They spoke in hushed tones, avoiding the topic of who would care for her once Dr. Kubaisy left. But for him, staying was simply not an option.
Perhaps Dr. Alousi, of the Iraqi Medical Association, put it best. "If you get a doctor and you need to be examined," he said, "and there's an AK-47 under the table, things are very bad."
Layla Isitfan and Zaineb Obeid contributed reporting for this article.
© 2005 New York Times