Twenty-three years later and a resident at Hennepin County Medical Center in Minneapolis, I found myself headed back to Somalia with the help of the American Refugee Committee to volunteer for a month. Excited and not knowing what to expect, I flew halfway around the world to see and treat the most vulnerable patients in a prestigious Mogadishu hospital called Banadir. A center of excellence in its early days, Banadir now carried the stains of war, and its corridors swelled with refugees from the famine-stricken regions of the south. Although lacking supplies and in disrepair, the hospital remains one of the few in the region, and people trek long distances to its doors. Arriving in the city, I felt a mix of emotions—an overwhelming sense of homecoming fused with sorrow at what had become of my childhood home.
The 40-bed internal medicine ward at Banadir was the newest addition to the facility, as well as the most neglected. The hospital was extremely short-handed, and because medical education was among the casualties of the war, the physician and nursing staff tended to be inexperienced. Our team consisted of one newly graduated intern, a nurse and several support staff. It didn’t take long before I realized I was the most senior member of the small team, rendering me solely responsible for my patients’ lives. As a resident who is used to supervision, I felt out of my element.
A typical ward in the hospital’s pediatric wing.
A typical ward in the hospital’s pediatric wing.
Moments after introductions, I was taken to the bedside of a patient, a cachetic-looking young man lying on a thin mattress surrounded by his worried family. He had a mass in his epigastrium and an intestinal obstruction. There were circular burn marks on his abdomen where a homeopathic healer had attempted to relieve his condition. Further history revealed that he had been coughing up blood-tinged sputum for months and his chest X-ray confirmed the apical cavities of TB. Because the surgeons would not explore his abdomen without a tissue diagnosis, we quickly put funds together and arranged for him to be taken the following morning to the only pathologist in the city for an FNA of his mass. Later that night, he began to cough terribly, his breathing becoming more strained. Our only oxygen machine was already in use, so we asked to use the one in the operating room. This was not a small request, as a needier patient could be brought in at any moment. The next morning, when I returned to work, I was informed that the man had coughed up a lot of blood and died. This news hit me hard, and I had to convince myself that there was nothing we could have done—that his TB was so advanced that even if we started treatment before testing his sputum, it would not have changed his fate.
The many patients at the hospital who were infected with TB illustrated what a terrible killer it is. The disease seemed to consume their bodies. More alarming was the emerging surveillance data showing a rapidly increasing number of cases of multidrug-resistant disease, no doubt a consequence of the dismantled health programs in the precarious region.
Urosepsis complicating obstructive kidney stones was another surprisingly common affliction. The water in Somalia is chock full of minerals, which quickly crystallize in the urinary tract. Patients frequently arrived in shock, some after several days of being unable to urinate. I recall the frustration I felt when I asked for antibiotics and fluids only to find them locked away in cabinets. One time, a nurse inadvertently left with the key, and after unsuccessful attempts to reach her, I broke open the locks. I learned that medicine was always kept guarded because of its potential to be sold on the black market, a common practice in the Third World and a concept I had never imagined.
The area outside the surgical ward. This area was always crowded with victims of war-related injuries.
The area outside the surgical ward. This area was always crowded with victims of war-related injuries.
Also surprising was the prevalence of peptic ulcer disease. The acid-loving H. pylori was not only ubiquitous, it also was deadly. Upper GI bleeding was common among young patients. The one whom I will never forget was a woman about my age who was also a new mother. She had had gnawing epigastric pain for months when she started vomiting blood. While taking her history, she suddenly jumped from her bed and had a bowel movement the color and consistency of cranberry juice. I felt a sudden dread; my heart began to race. She continued to rapidly lose blood and became unconscious within minutes. I desperately inserted an 18-gauge into her femoral vein for a makeshift central line. We pushed fluids and whatever blood we had. There were no intravenous PPIs anywhere in the hospital, so I gave her what I had: ranitidine, vitamin K and epinephrine. The hospital had no endoscope, and when the surgeons arrived, they quickly realized that she could not survive an emergency laparotomy. When she passed away, her family turned to me and thanked me for doing my best. I wept openly with them. I thought about the young woman often after that. I thought about how rarely patients died from bleeding ulcers back home.
On the plane back to the United States, I reflected on my father’s decision to leave Somalia all those years ago and how it changed the course of my life. I went back to Somalia to put my medical skills to use to help people escaping the famine and the consequences of war. I managed to save lives and provide comfort. But there, I learned to practice a different kind of medicine—to do what you can with what you have. In the end, it made me a better doctor, and for that I am grateful. MM
am immensely proud of my cousin
