The World's Most Dangerous Place: Inside the Outlaw State of Somalia - James Fergusson (2013)


Chapter 3. The field hospital: What bombs and bullets do to people

AMISOM HQ, March 2011

There was almost no need, in the end, to leave the base to discover what the war had done to ordinary Somalis. AMISOM’s field hospital, barely a quarter of a mile along the edge of the runway from the Bancroft Hotel, turned out to be packed with wounded civilians.

The hospital had opened in 2007 as a tented triage station for wounded AMISOM personnel; the decision to treat civilians alongside the soldiers had come later on. At first, senior UN officials in Nairobi noisily disapproved. Allowing civilians in for treatment, they argued, risked compromising the base’s security, and breached the terms of neutrality under which, as ‘peacekeepers’, AMISOM technically operated. But the commanders in the field had taken the view that since their mission was to help the people of Somalia, it would be absurd to deny them medical assistance on grounds such as these. Enemy combatants were treated at the hospital too, after all. Winning over hearts and minds is a cornerstone of modern counter-insurgency theory – and what better way was there to achieve this when first-class trauma clinics were practically non-existent anywhere else?

Nairobi had grudgingly conceded this point, since when AMISOM had taken the principle further, and dug into their own budgets to open a civilians-only outpatients department near by. The OPD, as it was then known, was an instant success. On three mornings each week, about eight GPs treated as many as six hundred patients who came not just from Mogadishu but in some cases from as far away as the Ethiopian border, a dangerous 500-kilometre journey that could easily take several days to complete. This said much about the availability of medical treatment in this ruined country. The clinic was yet another bombed-out seaside villa. Although it did not open until nine, a long queue had always formed before dawn at the entrance in the camp perimeter, a narrow chicane of razor wire and Hesco barriers that AMISOM’s enthusiastic press officers had dubbed ‘the Gate of Hope’.

Medicine’s power to impress the locals was quickly demonstrated when al-Shabaab announced on the radio that anyone obtaining or even seeking treatment from the infidels would be considered ‘unclean’. When this admonition was ignored, an edict was passed warning that anyone found in possession of an AMISOM medical form risked having their tongue cut out. The militants also occasionally tried to mortar the OPD. And yet by ten o’clock on the morning I visited, the open-sided shed lined with crude wooden benches that served as a reception area was already full to bursting. Al-Shabaab’s threats, or the risk of a lucky mortar strike, were no deterrent at all.

The patients had segregated themselves, men to the right, women to the left where the shade was fullest. A hundred pairs of eyes swivelled in unison as this sweating mzungu advanced towards them, their teeth ethereally white against the darkened ovals of their shrouded faces. The atmosphere was very subdued, both here and in the clinic itself, where they queued for medicine with an almost bovine patience, dull-eyed and dazed. The patients exuded dejection, not hope, however the PR men tried to spin it.

At the head of the queue I found Sister Mary, a warm-hearted, big-bosomed Ugandan in combat fatigues, dispensing medicines from a table in the ruins of the villa’s kitchen. She offered me her wrist to shake – a frequent gesture in this infection-prone part of the world – and told me that the complaint she dealt with most often was diarrhoea; before adding that there was an even more common disorder, just as potentially serious, that the OPD was unable to treat.

‘The people here are very stressed,’ she explained. ‘They are traumatized. They do not know where to turn.’

This was literally true in the case of one elderly patient I watched being steered into the room by the shoulders, his eyes glazed and his jaw working from side to side: the effect, Sister Mary told me once he had stumbled out again, of too much qat.

‘You talk a lot in the West about PTSD – Post-Traumatic Stress Disorder,’ she said, shaking her head, ‘but for these people there is no “Post”. The trauma never ends. Psychologically, that is so much worse.’

Mogadishu was a city where violence was so endemic that it had become the norm. The sleep of its citizens was no longer disturbed by the sound of shooting at night; small boys thought nothing of playing football in their street while a firefight raged up and down their neighbourhood. In 2011, according to the World Health Organization, nearly half of Somali victims of weapons-related injuries were children under the age of five. An entire generation of Somalis had grown up knowing that they could be violently killed, at random, at any time. Fatalism of the deepest, darkest kind was inevitable in such a place – and who knew what long-term effect that might have on a person’s mental well-being?

The suffering up at the hospital was at least easier to discern. Most of the patients there had been injured by bombs or bullets. The wards were no more than large canvas tents, arranged either side of a dust and gravel roadway wide enough for the lumbering armoured ambulances to turn. The whole place bore a striking resemblance to the set of M*A*S*H. A new casualty, a TFG soldier, was being stretchered down from the back of an ambulance as I arrived. The bandages around his stomach were soaked in blood and his face was twisted with pain. A white-coated reception committee clustered around him, conferring rapidly, before reaching a decision and bearing him away. Among them I recognized Ed Parsons, a bearlike Canadian medic whom I had befriended back at the Bancroft camp, who held aloft a saline drip with a rubber-gloved hand, comically taller than any of them.

Demonic laughter came from above as the wounded man passed. I looked up and saw a monkey – very obviously a male monkey – reclining deckchair-style in the concavity of the hospital tent roof. He suddenly jumped up and, still cackling, swarmed down a guy-rope to join the cavalcade of medics, strutting along behind them on his hind legs with his chest puffed out. The medics paid no attention to this freakish apparition. I later learned that the monkey was the hospital mascot, a clever animal that had learned to lick the sugar coating from painkiller pills. The risk that it might bite and seriously injure someone had been removed by the surgeons, who had drawn its fangs under anaesthetic.

Ed came back a few minutes later, explaining that the soldier had been shot ‘through and through’, but that the wound had begun to bleed into his abdominal cavity, necessitating a rush into theatre. A veteran of military hospitals in both Iraq and Afghanistan, Ed knew a great deal about the lethality of gunshot wounds. A through-and-through wound, he said, was typical of a medium calibre round like an AK-47, and was the best kind to get. Smaller rounds such as a .22 could actually cause more damage because they tended to ‘tumble’ on impact, after which they could bounce around the body like a pinball, tearing through delicate organs and ending up almost anywhere.

‘Finding a tumbled bullet can be guesswork. A small one can even travel in the veins. People don’t fall dramatically backwards when they’re shot. That’s a Hollywood thing left over from the days of silent movies, when directors were always looking for drama. Getting shot for real is more like “bang – crump – down”. In fact, gunshot victims quite often just slump forwards. The real drama is all internal, invisible to the camera.’

The smell of stale sweat inside the ward tents was nostril-flaringly strong, as was the occasional cheesy whiff of suppurating wounds. The men in the TFG soldiers’ ward were thin and tough, and not all of them were welcoming. They were mostly locals from the same Hawiye Abgaal clan, one of the big players during the civil war and traditionally the major power in the Mogadishu region. I suspected it might not go well in here for a patient from a different clan. The new Somali national army that AMISOM were busily training up was supposed to be ethnically balanced, because favouring one clan over another during the recruitment process risked creating one more clan-based militia. But if this hospital ward was in any way representative of the new army’s make-up, AMISOM’s training programme risked ending up doing more harm than good.

I spoke to Mohammed, a 28-year-old shot laterally through the hips, a complicated wound that had also destroyed his bladder. He had been in various hospitals for over a year, but was now two days away from being discharged back to his family.

‘I bet you’re looking forward to that,’ I said. ‘Do you have children?’

‘Two,’ he replied, ‘but they are both dead.’

‘I’m sorry.’

‘No problem.’

‘So what will you do?’

‘I’ve always been a soldier. I want to go back in the army,’ he said.

I glanced down at the long metal rods that still protruded awkwardly from his sides, pinning his body together at the waist like one of those nail-through-finger tricks you get in joke shops. It was hard to imagine him ever returning to active service.

‘So many of my friends are dead,’ he went on. ‘All I want is peace.’

‘But if you want peace, why do you want to go back to fighting?’

‘It is my duty to fight the foreigners.’

By now, two or three other TFG men had gathered around Mohammed’s bed, nodding their agreement.

‘Al-Shabaab is led by people from Eritrea, from Afghanistan, from Pakistan, from India,’ Mohammed went on. ‘People with problems in their own countries who want to hide in ours.’

‘You don’t think al-Shabaab are fighting for Islam?’

The TFG men all shook their heads.

‘No,’ said Mohammed. ‘They are fighting for their own ends – for al-Qaida’s agenda against America. They only say they are fighting for religion. But Islam is based on peace and forgiveness. Al-Shabaab do not want peace.’

The tent reserved for injured civilians was just as hot and full as the TFG soldiers’ one, the wounds on display just as severe. I was met with more blank stares. A mood of sullen anger prevailed. A man with wild, crusty hair and a heavily bandaged arm lay on his back on a cot in one corner, quietly mouthing nonsense at the canvas ceiling, his ravings ignored by those around him. A portly Ugandan nurse explained that he was a mental case, a homeless beggar whose arm had been sliced open by a stray bullet. It was very common, he said, for non-combatants to be wounded or killed in this way. A lot of the gunfire in the city was speculative rather than deliberately aimed at anyone. Sometimes, in the case of weddings or birthdays, it was celebratory. Either way, the shooters apparently gave little thought to what their bullets might do when they came down.

On the way out I stopped by the bed of an elderly man, Abdulkarim, who had been brought in a week previously with a bullet-smashed thigh. His young grandson sat beside him, waving flies off his still blood-soaked bandages with a square-shaped, wickerwork fan. The bullet that hit the old man had dropped at random from the sky one morning as he sat on the porch of his home. He stared into the distance as he told me his story, his speech halting and barely audible. Perhaps understandably, he seemed terribly depressed. He was a retired agronomist who had learned a little English over the years, working alongside UNFAO, the United Nations Food and Agriculture Organization. He shook his head when he had finished and looked at me for the first time, his watering eyes filled with an immeasurable sadness.

‘I just don’t know what we’re going to do about our young men,’ he said.

‘Young men’ was a literal translation of the imported Arabic word, shabaab. But coming from the mouth of this blameless senior citizen, it somehow took on a deeper meaning. Abdulkarim was expressing the despair of a patriarchal society that had lost all control of its successor generation. With the traditional bonds broken, the young men were rudderless, and now, exploited by foreigners and misled by extremists, their mad and endless violence was slowly destroying Somalia, a country he loved and whose people he had served all his life. His words struck me, in that moment, as one of the most succinct analyses of the Somali tragedy that I had heard.

The violence between Somalia’s young men was hardly a new phenomenon. As a nation of nomadic camel-herders in one of the world’s hottest and driest regions, where access to water and grazing is often literally a matter of life or death, the competition between the clans has long been noted for its viciousness.

‘“Conscience”,’ wrote the famous explorer Richard Burton in First Footsteps in East Africa, published in 1856, ‘does not exist in Eastern Africa, and “Repentance” expresses regret for missed opportunities of mortal crime . . . Murder – the more atrocious the midnight crime the better – makes the hero. Honor consists in taking human life: hyena-like, the Bedouins cannot be trusted where blood may be shed: Glory is the having done all manner of harm.’

Somali society, though, had learned over the centuries to control the violence through the application of xeer, an ancient and highly developed system of customary law traditionally administered by the elders of the rival clans, who would sit down and negotiate a compromise in the event of major disputes. Somalia’s real troubles began in the late 1970s when Siad Barre began to exploit and exacerbate the old clan rivalries in order to maintain his grip on power – a classic instance of divide and rule – while simultaneously running down the xeer system in favour of scientific socialism. The old social contract was then further destroyed by years of terrible civil war.

Somalia’s tragedy is that the differences between the four major clan groups – the Hawiye, the Darod, the Dir and the Rahanweyn – are not as entrenched as the bloodshed between them since the early 1990s suggests. For instance, no Somali can tell a Hawiye from a Darod or a Dir merely by looking at them. They tend instead to identify their compatriots by listening for subtle regional differences of accent, to which they are acutely sensitive. Genetically speaking, the main tribes are all close cousins. For example, the Darod and the Isaaq (the dominant tribe of Somaliland, so closely connected to the Dir that they are sometimes described as ‘northern Dir’) both say their progenitors came over from Arabia in the tenth or eleventh century, and that both these men – Sheikh Abdirahman bin Isma’il al-Jabarti for the Darod, Sheikh Ishaq ibn Ahmad al-’Alawi for the Isaaq – were members of the Banu Hashim, the tribe of the Prophet Mohammed. The conflict between them was not like the dispute between, say, the racially distinct Hutus and Tutsis which led to the Rwanda genocide of 1994. Somalia’s long clan war, of which the battle against al-Shabaab was arguably just another manifestation, was more like a petty family feud that had run horribly out of control.

I had been warned that a visit to the AMISOM field hospital would require a strong stomach, and nowhere was this truer than in the women’s ward. Set slightly apart from the others, the nurses called it the ‘Fistula Clinic’, so often did they find themselves treating that serious obstetric disorder. A fistula is associated with the tearing of the perineum during childbirth, which frequently happens when the mother is a girl who has yet to reach physical maturity. Almost unheard of in the West, the condition is common in Somalia, where in some rural communities girls are still married off at the age of nine. In this war-ravaged country, furthermore, young girls are everywhere and forever being raped. Even al-Shabaab, the self-acclaimed defenders of Islamic probity, allowed its foot soldiers to force families to hand over their daughters for so-called ‘battlefield marriages’, a type of contract that tended not to last for more than a few weeks, and that really amounted to a form of sexual slavery. It was no coincidence that the patients in the fistula clinic were above averagely pretty as well as young.

The first patient I saw here was a beautiful young woman lying back on a cot and cradling a tiny newborn baby. She was smiling broadly, and I grinned my congratulations back, before noticing there was something not quite natural about her expression, a certain glassiness in her eye that hinted at heavy sedation. The sister in charge confirmed it. She had been brought in that afternoon, seven months pregnant and with a shell fragment lodged in her spine. She had just undergone an emergency Caesarean, and was still so full of drugs that she hardly knew where she was, nor why. This was perhaps just as well. The shell fragment, the sister explained in a kind, low voice, had gone too deep for the surgeons to remove safely. The patient was paralysed from the waist down, and it was unlikely that she would ever recover the use of her legs.

‘But what will happen to her?’ I said, aghast.

‘Who knows?’ shrugged the sister. ‘At least the baby is healthy.’

The baby’s mother gazed vacantly ahead, understanding none of this, her pearly smile as broad and beautiful as ever, a vilely tainted vision of the black Madonna and child. I could not bear to look any more, and hurried on down the ward. I mentioned what I had seen later to Richard, who remarked that it was nothing very unusual.

‘The worst thing I ever saw in there was a woman giving birth just after both her legs had been blown off,’ he said.

For the hospital staff, the catalogue of suffering never seemed to end. I was intrigued by the chief medical officer, Colonel James Kiyungo, a slight man with an intelligent, sensitive face, and a reputation for efficiency and calm, very popular with the internationals at the Bancroft Hotel. I was in moralistic mood after the fistula clinic, yet he refused to condemn the militiamen responsible for the carnage he dealt with every day.

‘You have to understand what motivates the violence,’ he said, collapsing into his office chair. As the hospital’s senior surgeon he was fresh back from theatre, where he had succeeded in stemming the abdominal bleeding of the TFG soldier I had seen earlier. ‘These people survive on the absence of government. The only hope they have is chaos.’

A few months previously, I had been told, the hospital had detailed a detachment of Ugandans to install a standpipe in a city district suffering from an outbreak of cholera. The standpipe went unused, however, because al-Shabaab had – allegedly – threatened to kill anyone caught using it. Was the story true?

‘I ordered the installation of that standpipe myself,’ Kiyungo said, swivelling in his seat and tapping a spot on the map of the city on the wall behind him. ‘Al-Shabaab want to prevent anything that might make people support AMISOM.’

‘But – don’t you think that action was wholly evil?’

‘I suppose you could characterize it that way,’ he replied after some thought, ‘but then: what is evil? Some people say eating meat is evil. For others, it is fornication. Or building a nuclear power station in the path of a tsunami – is that evil?’

He had seen more than his share of horror in the course of his military career, including during the campaign against the notorious Lord’s Resistance Army rebels in northern Uganda in the 1990s, yet his faith in humanity remained deep-seated, his compassion apparently unshakeable. It was hard not to be impressed. Even the previous summer’s devastating suicide bomb attack in his home city of Kampala, he said, was ‘part of the price you pay to redeem these people’. The root problem, he thought, was lack of education. ‘The fighters here learn to read the Koran, but they have no skills. There are no carpenters, no cooks, no plumbers – only the gun. I think it was Roosevelt who said that the security of a nation depends on ammunition in the short term, but that it is the economy that counts in the long run.’

I recounted something I had heard in a bar in Nairobi, how during Ramadan for the last two years, al-Shabaab had run a Koran-recital competition aimed at children, and broadcast the results on one of the radio stations they controlled. In 2009, the first prize was an RPG; runners-up received an AK-47 or a pair of hand grenades. Some of the competitors were as young as ten. (Al-Shabaab ran the competition again during Ramadan in 2011, when they handed out more weapons along with religious texts. ‘Youths should use one hand for education and the other for a gun to defend Islam,’ the adjudicator reportedly told the prize-giving ceremony in Elesha Biyaha, 20 kilometres from Mogadishu.1) The audience in Nairobi had reacted to this story with a breathless whistle, but Kiyungo simply laughed. To him, the competition was a sign not of evil but of misguided idiocy.

‘If people are hungry they will cling to almost any organization,’ he said.

Kiyungo’s generosity of spirit was exemplary, but I still found the idea of arming ten-year-olds hard to forgive. There is no ignoring or escaping the damage that Somalis have inflicted on one another over the last twenty years. No one knows for certain how many people have been killed since 1991, whether by bombs or bullets or by the effects of the famine that the fighting exacerbated, although the figure usually given is 500,000. The AMISOM field hospital proved an old observation – almost an East African adage – that the introduction of modern weaponry by gaalo, foreigners, in the nineteenth century was a particular disaster for Somalia.

Somalis resisted the new-fangled weaponry to begin with. In the 1850s, firearms were still considered ‘cowardly weapons with which the poltroon can slay the bravest’.2 In the 1900s, however, firearms began to leak into Somalia from Abyssinia – modern Ethiopia – where the tribesmen had been armed by the French during negotiations to build the Addis Ababa–Djibouti railway in the 1890s. In 1903 a British political officer, Major Harald Swayne, wrote: ‘The result of their contact with civilisation, to one who has watched the Somalis for nearly twenty years . . . has known them at their camp fires, and had their interest at heart, gives rise to melancholy reflections.’3

Swayne’s foreboding was soon justified. Somali society could accommodate killing in the name of honour in an era when men were armed with arrows and spears, but technology soon turned the old rituals on their heads. Somalia’s addiction to the gun first flourished during World War One when the ‘Mad Mullah’, Sayyid Mohammed Hassan, led a rebellion against the British in their northern Somali protectorate, Somaliland. Armed with rifles provided by the Ottoman Turks – the ‘main cause’ of the uprising, according to Swayne – the Sayyid’s campaign took inter-clan killing to a new level. Then, at the beginning of World War Two, Italy and Britain fought back and forth across the region, bringing mechanized warfare to Somalia for the first time. In 1941 when Mussolini withdrew from Mogadishu, the capital of Somalia italiana, his troops abandoned their ammunition dumps and turned their locally levied recruits loose with their guns, creating a whole new class of bandit shifta and ushering in another era of lawlessness.

Somalia’s independence in 1960, which came after ten years of administration by the UN and the unification of the former British protectorate and Italian colony, was at least a relatively bloodless affair. But a military coup in 1969 brought General Siad Barre to power, along with a flood of Russian weaponry from his Communist sponsors. Henry Kissinger accused Somalia of hiding missiles in its minarets.4

In 1977, Barre invaded Ethiopia, hoping to annex its Somali-inhabited eastern region, the Ogaden. Moscow, however, sided with Ethiopia’s Communist Derg regime – as did Fidel Castro, who agreed to send 5,000 of his troops to stiffen the resistance. When Siad Barre’s troops were repulsed, he switched his allegiance from Moscow to Washington, turning his country into one of the hottest fronts of the Cold War. Between 1979 and 1980, the US spent $35m upgrading the former Soviet naval facility and airstrip at the Somaliland port of Berbera. With Washington’s help, Siad Barre set about expanding and modernizing his army until it was the largest in Africa, a force he didn’t hesitate to unleash on Somaliland when the former protectorate rebelled against his regime a decade later. Two-thirds of the Somaliland capital, Hargeisa, were flattened in an aerial bombardment that killed tens of thousands of its inhabitants.

Siad Barre was ousted in 1991 by clan-based opposition groups backed, once again, by foreigners: Ethiopia and even, this time, Libya’s Muammar Gaddafi. By then Somalia was super-saturated with weaponry. When the clans fell out with each other (as the clans always did), the stage was already set for one of the longest and cruellest civil wars of modern times – and it was all made possible by the machinations of foreigners over the preceding century.

The gaalo, furthermore, are still supplying the country with weapons. Al-Shabaab and their allies obtained at least some of their guns from jihadist sympathizers in Yemen and the Gulf states, or from rogue states like Eritrea which was intent on destabilizing their arch-enemy, Ethiopia. AMISOM’s weapons were also paid for by foreigners. In 2011, the US granted Uganda and Burundi $45m in military aid. In December of that year even Beijing joined in, when the Chinese defence minister, General Liang Guanglie, pledged $2.3m to the Ugandan military. It is small wonder that so many Somalis blame outsiders for their country’s ills. If Afghanistan is the ‘Cockpit of Asia’, as the Viceroy of India Lord Curzon once said, then Somalia is Africa’s unfortunate equivalent, a nation strategically located at the crossroads of competing powers and ideologies, whose fate it is to be endlessly fought over by foreigners.