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Cablegate: Prt Diwaniyah: H1n1 Update: A Lesson In

DE RUEHGB #0166/01 0221621
R 221621Z JAN 10



E.O. 12958: N/A

1. This is a PRT Diwaniyah reporting cable.

2. (SBU) SUMMARY: Diwaniyah officials responded
effectively to the H1N1 pandemic during Fall 2009,
strengthening both their governance and their healthcare
capacity. The initial response could be characterized as
disjointed as Provincial officials and health officials were
slow to identify and treat the early influenza cases. At the
same time, duplication of effort by Provincial officials,
healthcare workers, and civil organizations emerged and
hindered responses. As time progressed and numbers of cases
increased, Diwaniyah health officials turned to prevention
and treatment rather than dwelling on securing high-tech
equipment to identify cases. Efforts at educating the public
improved as officials, including the Governor, went on the
air waves to discuss what people should do. Provincial
officials, academic institutions and NGOs, with prodding from
the PRT, strengthened their abilities to work toward a common
goal by forming an H1N1 interagency working group and a
Diwaniyah H1N1 Operations Center. The H1N1 healthcare
experience had a beneficial political component as the public
judged provincial officials and agencies as responsive to
public needs, in contrast to the public,s usual view here
that provincial officials, including the Governor, are
unresponsive. END SUMMARY.

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3. (U) Of the Iraq nation-wide total of 2,328 cases and 42
deaths (among Iraqis, excluding multinational forces)
reported by the World Health Organization (WHO) as of 19
January 2010, 248 cases and five deaths occurred in Diwaniyah
Province. Diwaniyah, with about five percent of Iraq,s
population, had about 11% of the cases and about 10% of the
deaths. Among multinational forces in Iraq, none of the 628
confirmed H1N1 cases reported by WHO occurred in Diwaniyah.
(FYI: Iraq is a participating member of the WHO,s Eastern
Mediterranean Region Office ) EMRO ) providing daily case
counts to the WHO.)

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4. (SBU) Initially, it appeared that Diwaniyah Province
officials, health officials, and civil organizations devoted
a large amount of time and effort in what appeared to be an
orchestrated campaign to obtain high tech detection and
identification equipment from the PRT. Various agencies and
NGOs besieged the PRT, arguing that the local public health
laboratory urgently needed PCR (polymerase chain reaction)
diagnostic equipment to process samples for H1N1. The
officials saw this as shortening the time to six to eight
hours doing tests locally, rather than over a week, perhaps
two weeks, if samples were sent to the Baghdad Central
Laboratory. Local officials here viewed the Baghdad public
health bureaucracy as inefficient, slow and barely
responsive. When the PRT convinced officials that such
testing would only identify mutations, and that treating
symptoms was better, the pressure and requests for PCRs
finally slackened.

5. (SBU) Provincial officials used the media to advantage.
Preventive measures among the public took hold following
radio and TV reports and interviews with officials, including
the Governor. Hand washing was emphasized, though on a visit
to primary schools in one town, the PRT saw only unusable
hand washing facilities and no hand sanitizer, suggesting
that despite the words, little support trickled down to the
local level. School and health officials expressed pride
that they were spraying schoolrooms, desks, chairs and common
areas with disinfectant.

6. (SBU) The province,s Health and Education Departments
Q6. (SBU) The province,s Health and Education Departments
conducted special classes and train-the-trainers,
sessions, which instructed teachers on the basics of disease
surveillance. The trainees were expected to return to their
schools and instruct all teachers in surveillance, detection
and reporting. The PRT heard reports that some schools
received only five to ten forehead thermal strip thermometers
for schools with several hundred students, indicating poor
preparedness planning and unresponsive medical logistics
support from the national and provincial authorities.

7. (SBU) NGOs and government departments deluged the PRT
with requests to provide bottles of hand sanitizer, face and
surgical masks, thermometers, vaccines, and antivirals. PRT
Diwaniyah counseled officials that face and surgical masks
were inappropriate for general, daily, and full-time wear as
their effectiveness was limited, might cause undue panic
among a less-educated public, and were better used in family
or close-quarters situations if a family member was suspected
of having H1N1 (or seasonal flu). The PRT also counseled that
leaflets and posters showing people with face masks could add
to public worry. PRT Diwaniyah designed H1N1 leaflets, with

BAGHDAD 00000166 002 OF 002

simple instructions in Arabic, based on the Centers for
Disease Control (CDC) H1N1 website where simple instructions
in Arabic were posted.

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8. (SBU) Initially, multiple agencies and NGOs were all
involved and duplicating each other,s efforts, either
because each saw a role, was trying to outdo the other, had
genuine humanitarian concerns, or was acting out of
self-interest could not be determined. Those seeking our
assistance all urged that we work only with them, not with

9. (SBU) After several instances of this behavior, the PRT
met with Director General (DG) of Health Abdulameer Leelo and
Provincial Council Health Committee Chair Thamir Naji Skhale
to strongly recommend a collaborative inter-agency approach
to the H1N1 problem. We underscored that just as an
inter-agency response worked in the U.S., it would be a
useful approach in Diwaniyah. Those two competent officials
organized the first of several inter-agency meetings and
involved the Governor, several key DGs, academics from
Qadissiyah University, the medical and nursing schools, the
Diwaniyah Teaching Hospital, the Provincial Chief of Police,
and several NGOs. The PRT was asked to participate and offer

10. (SBU) The first inter-agency meeting focused on
understanding the H1N1 problem, hearing what each participant
could provide and accomplish, and assigning responsibilities.
That meeting was chaired by Deputy Governor Faisal Salman
and the PC Health Committee Chairman Thamir Naji. Most
attending saw it as a success. Officials stressed that
agencies should follow the established GOI and Provincial
plans for responding to pandemics, using the experience of
the earlier avian flu outbreak as guideposts. This strategy

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11. (SBU) The most important thing Diwaniyah officials did
was focus on detecting H1N1 in the schools. This area of a
concentrated and vulnerable population was a primary place
for spreading the disease by human contact and sneezing
children. Diwaniyah officials responded with a focus on
detecting and treating symptoms. Limited closures of
specific classrooms and schools occurred in the city most
affected, Ash Shamiyah, in accordance with policy and school
preparedness plans. (Note: Initially, Ash Shamiyah
officials stated that many cases in their city were
concentrated among persons who had attended the Hakim funeral
at the Imam Ali Mosque in Najaf ) just across the Euphrates

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12. (SBU) Diwaniyah,s response to H1N1 offers a case
study of mostly how to respond correctly and efficiently, and
a little of how not to respond to a pandemic. The governance,
preparedness and response lessons learned in Diwaniyah are
not new: have a plan, assign responsibilities, authorities
and funding, coordinate effectively across agencies and NGOs,
keep the public informed, teach and institute surveillance,
treat symptoms, and, limit large gatherings (such as school
populations). Provincial authorities made some initial
mistakes on both the health and governance fronts, but with
coaching from the PRT at key junctions, they adapted their
approaches. As best we can determine, the concerted effort
by political leaders to step out front and provide informed
advice to the public muted complaints about an unresponsive
provincial government ) whereas in other issue areas the
Qprovincial government ) whereas in other issue areas the
Diwaniyah Provincial government is seen as unresponsive.
Another governance problem exists at the Ministry of Health
level : though additional waves of H1N1 influenza are
anticipated, permission to begin vaccination of Iraqis has
not been given due to liability waiver issues with the drug
(vaccine) manufacturers.

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