Shortages, Armed Squatters Plague Hospital in Mogadishu : Somalia: Facility is a microcosm of the problems faced in rebuilding the country.

The anesthesiologist had no electronic gear to monitor the heartbeat of the patient splayed on the operating table, so he kept his index fingers tightly hooked under the man’s chin to feel his pulse.

The 35-year-old Somali’s colon had been shattered by a bullet. One hour into an operation to rebuild it, the surgeon, Dr. Omar Nur Abdi, complained that he had no proper thread to sew up the incision in the unconscious man’s left side.

“We need catgut, Dexon, vicryl--and in four different sizes,” Abdi said through his green mask.

In other rooms of Mogadishu’s biggest hospital, squatters with guns have holed up and now refuse to come out. More than 1,500 sick and dying people are crammed into the 700-bed facility that stands on a sunburned hillside in the city’s southern district.

In one postoperative ward Sunday afternoon, eight patients sprawled on padded pallets, their relatives trying to shoo away clouds of flies with flag-shaped whisks. Some of the ailing were connected by plastic tubes to intravenous fluid bottles. In a corner, a middle-age man coming out of anesthesia groggily intoned verses from the Koran.

A month and a half after the United States launched Operation Restore Hope, the plight of patients and personnel alike at Digfer Hospital, the former jewel of Somalia’s medical system, shows the daunting magnitude of humanitarian challenges still facing this East African country.

For two years, the staff received no salary at all. Now doctors are paid $450 a month by an international aid organization to stay. For many, it is not enough.

Badly shorthanded, Digfer is struggling to cope with the quickly changing health consequences of one of the greatest human tragedies of modern times, Somalia’s famine and civil war. The earth-toned hospital designed by two Italian architects is a microcosm of the problems the rest of the world must consider as it contemplates rebuilding Somalia.

Dr. Mohamed Ali, the hospital’s balding and diminutive director, is only mildly grateful for what the United States and other Western countries have done in Somalia on the health front so far. “There are a lot of resources available from international organizations, but what we get here is only a percentage,” he said.

Ali accused U.N. agencies and private charities of viewing all Somalis as either famine victims or armed thugs and of not consulting sufficiently with local health care professionals about the country’s needs. “If we are not invited to meetings, we cannot attend them,” Ali, who did postgraduate work at London’s School of Hygiene and Tropical Medicine, observed tartly.

But some of the scenes of suffering at Digfer seem linked more to a shift in Somalia’s health needs than to international conceit. From what Ali calls “war surgery”--wounds from grenade bursts, gunshots and artillery--the hospital is now being forced to retool rapidly to handle “all the other medical problems in the country that were neglected for two years.”

And despite the presence in the country of more than 38,000 foreign peacekeepers, a plethora of U.N. agencies and an alphabet soup of international organizations, even the country’s largest hospital is far from having regained normalcy. “If, today, a patient is admitted in a diabetic coma, he will die because I don’t have the insulin to treat him,” Ali said.

In refugee-clogged Mogadishu, where garbage festers in the streets under a hot sun and some quarters stink of human waste, diseases like hepatitis are increasing rapidly.

Malaria, borne by mosquitoes in low-lying areas near the Indian Ocean coast, is on the upswing too, as is tuberculosis.

Even with the gigantic airlift of medical supplies and other foreign aid into Mogadishu, Dr. Abid Omar Aways, another surgeon at Digfer, said he has had to donate blood at least three times for his patients.

Health needs are vast. More than 100 people now hospitalized at Digfer suffer from a bone infection called osteomyelitis. Recent tests by a U.S. Marine Corps medical unit showed that the disease responded to ciprofloxacine, an antibiotic Digfer doesn’t have. “We need donations,” Ali said.

Rising rates of contagious disease and the lack of some pharmaceutical supplies are only the beginning of Ali’s problems. By his count, a dozen gunmen have holed up in some hospital rooms and refuse to come out. Patients say that the number is at least 50 and that the men have stashed automatic rifles under their mattresses.

Ali throws his hands up in the air when asked about the problem, as if to say, “What can I do?” He said he has contacted U.N. officials to try to get the armed men evicted but that for the moment, despite Somalia’s critical health needs, some of Digfer’s rooms remain unavailable for the sick.

Not all problems in rebuilding the hospital, however, come from outsiders. Barbara Birchim, a nurse from San Diego working in Somalia for the Los Angeles-based International Medical Corps, soon developed a withering opinion of much of the hospital’s personnel.

“The nursing staff and the medical staff are prone to not showing up, even with the incentives that we (the IMC) are paying,” Birchim said. “It’s not uncommon to go back to the floor and find that the nurses have left, even when they know patients need injections or that there are IVs to hang. On Friday, the (Muslim Sabbath), the staff goes home.”

Ali calls such behavior understandable, given the travails his people, along with all Somalis, have been forced to undergo. “For two years, because there was no government in Somalia, the workers of this hospital were not paid. Now people are saying, ‘You know, I have to look to my future.’ ”

Patients, however, say the staff at Digfer demanded money from them when their government paychecks stopped.

Somalia’s brain drain, provoked by natural and man-made hardships, has also hit the hospital hard and shows how difficult it may be to refashion Somalia as a functioning nation. Two years ago, Digfer had 70 doctors and 400 nurses; what’s more, as a teaching institution it boasted some of the country’s best medical minds.

These days, only 25 doctors and 100 nurses are left, and they are often junior personnel. Ali, the director, is 40. One surgeon is 26.

During Somalia’s civil war, the hospital was looted of its laboratory equipment, X-ray machines and vehicles. “With all that we face, we don’t now have a single ambulance,” Ali said.

Neil Frame, procurement director for Los Angeles-based Operation USA, a private aid organization, said that “outright theft” of supplies donated to the hospital continues at Digfer.

Inside the hospital, reached by driving through a gate manned by a single armed guard, anarchy seems to reign. Dr. Rafael Lopez, an orthopedic surgeon from Bogota, Colombia, said there used to be such a parade of gawkers through the two operating theaters that some patients came down with infections during surgery.

Lopez said that keeping the operating rooms free of contamination is still a problem. Entire families of Somalis move in to be with the ailing, not trusting Digfer’s staff to feed and care for them, and their children roam the grimy corridors and stairwells in packs.

Digfer seems an apt metaphor for a country that as an organized state has ceased to exist. Nina Winquist, the spokeswoman for the Mogadishu office of the International Committee of the Red Cross, says Somalia’s entire medical system needs to be rebuilt, along with virtually every other national institution.