In July 2009, I traveled to Mogadishu, Somalia (of “Black Hawk Down” fame) to replace Dr. Joseph Williams, a gregarious Irish fellow who was completing a 6-month stint as North Galcayo Hospital's de facto Chief of Staff and only anesthesiologist. Our stays were to overlap by 2 weeks, in order to help orient me to a radically different clinical environment.
The facility was a small former Christian mission hospital now run by the Physicians International charity. Residing about 90 km outside Mogadishu, in the middle of farmland, stray chickens and goats attracted by food scraps were regular visitors. The hospital was equipped with a single operating room containing a still serviceable operating table and an old Boyle anesthesia machine supplied by oxygen and nitrous oxide cylinders, subject to availability. An associated EMO draw-over vaporizer often sat unused, as halothane was frequently unavailable. As a result, local anesthesia with or without ketamine had become the technique used for a great many procedures.
Williams reminded me of the special hazards of working in Somalia. Since the outbreak of the 1991 Somali Civil War no central government control over most of the country's territory existed; the internationally recognized Transitional Federal Government in reality governed only a limited region of the country. The result was that about 15 warlords controlled various other regions of the failed nation. Somalia was one of the poorest and most violent nations in the world, Williams warned.
The hospital was located in a region governed by “General” Gabriel Mugabe, a vicious warlord given to pathologic rages. His reputation for sadism was legendary, and even included unverified accounts of ritual cannibalism. Williams told of numerous patients he had cared for who had been the victim of Mugabe's wrath, including hand, ear and breast amputations carried out on his orders using a large machete. One patient ended up with a suprapubic catheter when Mugabe inserted a crochet needle deep into a man's urethra to teach him a special lesson. More commonly, however, Mugabe simply shot his victims through the head.
On one occasion before my arrival, Mugabe and his entourage of thugs had been to the medical compound to steal supplies and food for his troops. Fortunately Williams was somehow able to satisfy them with a combination of Irish charm and fine whisky, and the loss of supplies ended up being minimal. No blood was shed. Evidently Williams was a shrewd negotiator.
Three days before Williams returned to Dublin, Mugabe visited again, looking for tribute. His self-assured, arrogant swagger disgusted me. I wisely let Williams do the talking. To my bewilderment, Williams extended Mugabe the utmost hospitality. He offered the General his best single malt scotch, although he himself only drank orange juice at the time, having patients to see later that day. While I had a hard time disguising my contempt for Mugabe, Williams was instead the epitome of graciousness. Obviously Williams was trying avoid the loss of life that other places had so frequently seen when Mugabe came to visit. Still, the respect and cordiality he bestowed on the General appalled me. What a strange man, I thought. Williams would have even presented a cordial bedside manner while treating Hitler. In any event, Mugabe and his three well-armed bodyguards soon left, arms fully laden with food and supplies, including a bottle of Johnnie Walker Black Label Williams had thoughtfully provided as a parting gift.
Mugabe returned to us 9 weeks later. Williams had long since gone, and I feared I would not be able to deal with the situation as skillfully as had Williams. For one thing, I had no whiskey to offer the General. But this time Mugabe had arrived seeking medical advice, and his mood was completely different. Could I try, he politely asked, to see what was causing his complaints? The last 10 days or so he was suffering from tingling in his legs and arms. He felt weak and tired easily. And there was more: headaches bothered him, his speech had become slurred and his vision “was not so good anymore.” Weak, and with his peripheral vision badly impaired, he could no longer drive.
As an anesthesiologist my exposure to undiagnosed neurologic diseases was limited, but a number of possibilities still quickly came to mind. Syphilis was foremost in my thoughts, given what I knew about the General. Other remote possibilities I considered included multiple sclerosis, Alzheimer's disease and Parkinson's disease, although none even loosely fit the clinical presentation.
In due course, it dawned on me that Mugabe's complaints suggested that he had been poisoned. But poisoned with what? And who would want to poison him? The second question was certainly easy to answer – just about everyone. Even members of his own inner circle might be poisoning him, either as part of a power struggle or simply as revenge for his many acts of humiliation and cruelty.
But what poison? Toxicology studies were out of the question in rural Somalia; any diagnosis would have to made on purely clinical grounds. I drew a VDRL and other studies to send off to Mogadishu to rule out syphilis, and told the General that he would have to go to Mogadishu for special testing if syphilis was not the cause. He indicated that it was not safe for him to travel there. The VDRL eventually came back negative.
Seven weeks later, the General visited a final time. He had deteriorated greatly. He was now barely able to walk and exhibited severe arm and leg tremor. It was then that I remembered about Minamata disease, an affliction first discovered in Minamata, Japan in 1956, where the cause turned out to be mercury contamination from a local chemical factory.
But if mercury were the poison, where did it come from? One alarming possibility soon occurred to me. A few weeks earlier I noticed that one of the wall sphygmomanometers had been drained of all its mercury. At the time I assumed that the mercury had been stolen for its resale value; now I suspected a more sinister explanation. But still, a second question remained: even if that was the source of the mercury, how had the General ingested it?
I then remembered back to Mugabe's visit where Williams had provided him with a bottle of Johnnie Walker Black Label as a parting gift. I wondered whether Williams might somehow have been involved, but I told no one of my suspicions.
The General died a few weeks later, leaving a power vacuum quickly grabbed by General Aidid, a warlord with a far more benign reputation. I e-mailed Williams to update him. His terse reply: “Some people just can't handle fine liquor.”
