Dr. Chris Salvino had been sleeping off another 18-hour day of surgery when the first explosion woke him.
"I rolled off the bed and onto the ground," Salvino recalls. "I thought it was either a grenade or a rocket, but it was hard to tell because I was still half groggy."
Two more blasts followed outside the sleeping quarters of the makeshift hospital in Kisimayo, Somalia. As it turned out, Salvino's first guess was right. Hand grenades. According to the doctor, a local warlord threw them after learning that a group of European diplomats had flown in and toured the hospital without his permission. Fortunately, no one was hurt.
This was the world into which Salvino temporarily stepped last spring: a country shredded by civil war and run by violent clansmen who express their hurt feelings in none too subtle ways.
"There's nothing over there," says Salvino, a 1983 graduate of Notre Dame who grew up and still resides in the southern suburbs of Chicago. "There's no infrastructure, no government, no simple things like plumbing. And they used to have all these things. There's no electricity, no telephone service."
Salvino, 35, is a surgeon who specializes in trauma cases, such as the victims of traffic accidents or gunshots. In March 1996, he left the relatively stable confines of his trauma unit in Downers Grove, Illinois, to ply his trade for five weeks in the northeast African country of Somalia.
"I wanted to do a give-back-to-the-community type of thing," says Salvino. "I didn't think doing it in the United States I would get enough bang for my buck. I figured a Third World country was worse off than the United States."
That certainly appears to be the case in Somalia. Most Americans were introduced to this arid, mostly flat country of about 8 million people in 1992. In December of that year, thousands of Marines, along with troops from numerous other countries, arrived to help deliver food to starving Somalis trapped in a civil war that had erupted in 1991. In March 1994, the last of those U.S. troops withdrew after a controversial mission in which the famine was halted but at least 30 Marines lost their lives.
When the United States — and much of the world's attention — left Somalia, the country's complex and multisided civil war raged on. Today, nearly no semblance of law or order exists there; numerous well-armed clans battle daily for territory and power. The years of civil strife have devastated Somalia's health care system. Warfare has destroyed hospitals and medical equipment, forced numerous doctors and nurses to flee the country and left millions of Somalis without access to the most basic medical care, much less vital surgical procedures.
Plenty of bang for a trauma surgeon's buck.
"There was a civil war going on, so I knew I'd get a combination of trauma surgery and regular good old-fashioned surgery," Salvino says, recalling why he chose Somalia over other destitute countries. "It's a place where you can actually do a lot of good in a short period of time for people."
Salvino traveled to Somalia through the medical relief organization Doctors Without Borders. Founded by a small group of French doctors in 1971, Doctors Without Borders acts basically as an emergency medical team to the world. The group recruits doctors and nurses and dispatches them — sometimes within a week's notice — around the globe to provide medical treatment to the victims of man-made and natural disasters. Each year, more than 2,000 doctors, nurses and other medical professionals from dozens of nations volunteer with the organization. They currently work in nearly 70 countries, battling cholera epidemics, operating on earthquake victims and patching up the victims of war.
Shortly after he heard about Doctors Without Borders, Salvino volunteered for duty. Before the group took him in, however, its administrators subjected him to a rigorous six months of interviews to determine if he was cut out to work in the world's hot spots.
"It was a tough interview process," remarks the thin, soft-spoken Salvino. "The rationale is a good one because they want to make sure someone's levelheaded and understands they're going to be in a Third World country with absolutely no comforts of life."
Salvino tasted what kind of life he was in for in Somalia before he even set foot in the country. As his airplane approached Kisimayo International Airport, the pilot repeatedly circled, refusing to land until the Doctors Without Borders vehicle arrived. Spending idle time at the abandoned, run-down airport, a vital plot of land over which the local clans continually fought, apparently was not a good idea. After the plane finally touched down, Salvino dashed into an awaiting car that was protected front and back by land rovers, each one filled with heavily armed guards.
"It was a pretty interesting welcome," Salvino says. "I've never been to Africa; you land there, you jump out . . . and all you see are these guys running around with machine guns all over the place."
From there, Salvino spent his days and nights working with seven European doctors and nurses from Doctors Without Borders, as well as with dozens of Somalis at Kisimayo Hospital, an abandoned canning factory that the locals had transformed into a small fortress. The hospital grounds consisted of several dreary, one-story white stone buildings with bare walls and bare supply shelves. The buildings had few windows, and inside the medical staff and patients baked in temperatures that often climbed to more than 100 degrees. Surrounding the entire compound was a 20-foot-high, thick concrete wall (which is why the hand grenades, while unsettling, did little damage) topped by sandbags and barbed wire. The compound provided a relatively safe haven from the constant battles.
"There was so much fighting, even in town, that we were told not to leave the hospital complex the whole time we were there," Salvino says.
Not that the doctors and nurses at Kisimayo Hospital had much time for sightseeing anyway. Each morning, a large and steady stream of patients began filling the hospital's waiting room. Salvino says roughly 20 percent of the hospital's patients were direct victims of the civil war. They usually suffered from either gunshot wounds or blunt trauma. However, the war seemed to touch nearly everyone who visited Kisimayo Hospital. While the rest of the hospital's patients suffered from a variety of afflictions — such as hernias or tuberculosis — they shared one thing: In a country where it was easier to find bullets than penicillin, their maladies had reached an advanced and acute stage. "Everything was related to the war," Salvino says.
As the only surgeon on staff, Salvino handled the more serious cases. Performing 10 to 15 surgeries a day, he did everything from set broken bones to repair hearts. All this on about five hours of sleep a night. "It wasn't too bad," he says, sounding more like a first-year resident than a slightly balding trauma surgeon.
Because he was the only surgeon on the team, Salvino had to perform all operations -- even the ones he did not know how to do. The doctor says the most valuable items he brought with him were two large surgical instruction books. "I was reading all the time," he says, recalling the case of a Somali man who needed his prostate removed as an example of his learn-on-the-go technique. "I've never taken out a prostate. I'm reading how to do it the night before and then going in and doing it and there's no one there to instruct you."
Unfamiliarity with some of the surgeries he performed was just one of the obstacles Salvino faced in Somalia. Medical supplies and equipment were scarce and what tools the hospital did have were outdated. "I had it in my mind before I went over there that I'd be dealing with limited supplies and limited resources, and that there is only so much you could do," Salvino says. He found himself faced with his limitations almost immediately. A half-hour after he arrived at Kisimayo Hospital, a car struck a boy, who suffered massive brain injury. With no equipment to stabilize the child, the doctors and nurses could do little but watch him die.
"You didn't have the supplies, so you just had to accept more people dying," Salvino recalls stoically.
Less easy for the doctor to accept were several Somali customs that often impeded his work. Particularly frustrating was the general population's strong aversion to Caesarean sections. Many Somalis have little knowledge of the procedure and view it with suspicion, says Salvino. He recalls that several pregnant women needed Caesarean sections so their babies would survive. Each time, the woman's family forbade the operation, and the baby died. "You had to take your own personal thoughts on mortality and almost throw them away and adopt their customs and practices," he says. "Since they wouldn't allow C-sections, I was watching two or three babies eventually die who could've been saved, and it was pretty hard to accept that."
Overall, however, Salvino says he found the Somali people to be warm and gracious. Salvino, who plans another medical tour of duty in the near future, says he gladly would return to Somalia. Right now, though, he's busy helping to run a trauma unit and trying to promote Doctors Without Borders in the United States.
Since returning from Kisimayo, Salvino has worked to drum up financial support and volunteers for Doctors Without Borders. He talks with fellow doctors and nurses about the organization and disseminates his own video about his experiences in Somalia to various fund-raising groups. In addition, he is working to open a Doctors Without Borders office in Chicago to help strengthen recruitment efforts in the Midwest.
"As long as there's a major discrepancy about medical care in the world, hopefully there'll be more and more people who will consider going over to help out in the Third World countries," Salvino says, "because unless individuals do it, health care there is not going to improve."
The doctor already has signed up at least one volunteer. His wife, Sue, a registered nurse, says she plans to offer her services to the organization. Chris and Sue Salvino have discussed working together in such places as Sri Lanka or Central America.
But not Somalia. Salvino stresses that were he to return to the African nation, it would be without the company of a loved one. "It's too dangerous," he says.
Several weeks after returning from Somalia, Salvino heard that Kisimayo Hospital again had come under fire. This time, a rocket destroyed part of the hospital. The hospital closed down and the Doctors Without Borders volunteers fled to safety in a neighboring country.
Not to worry, though, Salvino adds with a hint of pride in his voice. The hospital did reopen and the volunteers all returned.