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Fire and heavy smoke coming from the town of Qayyarah, which is located in the Mosul district in northern Iraq, after the offensive retake of Mosul in 2016. Photo by: Mstyslav Chernov/ CC BY-SA

ERBIL, Iraq Even as Iraqi government officials denythat chemical weapons have been used in Northern Iraq, local health authorities and partners, including the World Health Organizationand the International Committee of the Red Cross, are working to improve preparation for any future incidents.

Their strategy aims to improve referral pathways in the short term, boost regional capacity to handle cases going forward, and build readiness into the long-term reconstruction of local health facilities, including in the city of Mosul, where the most recent probable chemical cases came from.

Last week, Iraqi Prime Minister Haider al-Abadi said allegations of chemical weapons use in Mosul were mistaken. According to our information, [the Islamic State] doesnt have the ability to use [chemical weapons], and we understand [the incident reported was caused by] an explosion of smoke and gas, not chemical weapons, he told the audience at the American University of Iraq in Sulaymaniyah.

Devex previously spokewith the victims of one apparent chemical incident, as well as their doctors from the ICRC, who said they suspected mustard gas exposure. Lab tests are still in process to confirm the agent.

Mosul chemical attack exposes an ill-prepared health system

The first victims of an apparent chemical attack in the campaign to liberate Mosul from the Islamic State recount their story to Devex, revealing a public health system ill-prepared to receive and treat future cases. Government officials, NGOs and agencies are now urgently pivoting to reorganize protocol.

On the ground, however, organizations and local health authorities engaged in chemical weapons treatment and prevention are not waiting. They believe the symptomatic evidence from recent incidents, together with a regional history of chemical weapons use, is significant enough to warrant building improved capacity. These groups are working quickly throughout Iraq and particularly around Mosul, where a military campaign is ongoing to wrest Iraqs second-largest city from ISIS control.

WHO has a risk assessment and thats based on what we have seen in the region historically, more recently, and also on the basis of events that weve seen in the past 12 to 18 months, Catherine Smallwood, technical officer in the WHO Health Emergencies Program, told Devex from Erbil, where she is on mission. There has been authoritative confirmation of blister agent used in Northern Iraq by the [U.N.s Organization for the Prevention of the use of Chemical Weapons], so of course with that, events that have been reported, and the signs and symptoms that were seeing blister agents such as mustard gas are clearly one of the high-risk chemicals for us.

Immediately, that has meant re-examining how patients are delivered from the frontlines to the health facilities where they are eventually treated. The patients who spoke to Devex last week described a lengthy process of moving between health facilities and then check points to eventually arrive in Erbil, a city more than 50 miles away.

Distances traveled by the cases do increase complications, from secondary contamination risks all the way to delays in crossing between governorate boundaries and the complications that can come with it, Smallwood told Devex.

Future cases from Mosul will now be referred to Al-Shikhan General Hospital, a facility roughly 25 miles northeast of the city. The WHO has worked for the past 10 months to build capacity in the facility, as well as four others throughout Iraq.

The WHO also last week began training health workers even closer to the frontlines. The organization trained 10 health care workers (including medical doctors, nurses and ambulance drivers) from central Mosul, Altaf Musani, WHO representative and head of mission in Iraq, told Devex by email.

The training focused on how health care workers can decide whether a patient has been exposed to chemicals, how to protect themselves and others from secondary contamination, how to prepare for and conduct emergency decontamination, and how to triage cases and identify the class of exposure (ie. the type of chemical to which a patient has been exposed). They were provided materials to ensure they are both trained and equipped to respond safely and appropriately. WHO has now trained over 200 health care workers and first responders in this area across five governorates in Iraq.

In the longer term, the WHO and other partners hope to build chemical response preparedness into the reconstruction plan for local health facilities. The organization is working closely with local authorities to boost preparedness.

Weve had real engagement from the departments of health, Smallwood said. Its not WHO pushing the health authorities to do this, theyre taking action on their own.

Eastern Mosul, for example, is now largely under government control and clinics have begun to reopen for services. As the health facilities are becoming more accessible, as functionality is starting to come back to those facilities, well be able to increase capacity, Smallwood said.

Future training sessionswill vary depending on the capabilities the WHO and other partners find in local facilities, and initial assessments will ask exactly this question. Building capacity to respond to chemical weapons use is highly technical and varies widely based on what equipment and personnel are available.

Decontamination processes ideally take place with health care staff using personal protective equipment a set of sealed gear that protects health workers from secondary exposure. Putting the suits on and off is a complicated process that requires significant training and practice.

Public awareness is also vital to limiting the damage from chemical exposure. The WHO has crafted five key messages and plans to distribute them within Mosul and other high-risk areas.

Musani told Devex: WHO will continue to work with health facilities in and around Mosul over the coming days to provide further direct support to them as they increase their capacities to manage these types of events.

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Inside the mounting preparations for chemical attacks in Iraq | Devex - Devex