Gorilla’s Guides

AMMAN, Jordan — On the third floor of the Amman Palace hotel, above a city block crowded with appliance dealers and video-game vendors, six Iraqi children formed a semicircle around their therapist and practiced how to breathe.

To the right of the therapist sat Abdullah, a 7-year-old boy missing his left foot and left eye. The afternoon sun slanted across his face, which once had been so erased his father failed to recognize it and now was a mottled mask of flesh grafted from his back. Two boys wore leg casts. A third had a burnt face. Three of the children sat in wheelchairs. Zaineb, an 11-year-old girl who could barely move her crippled legs, wore a black wool cap over her broken skull.

“The pain will be there,” the therapist said. “But if we focus on it, that will only make us feel worse.”

Five years of war have disfigured the people of Iraq, hobbling and maiming many thousands of them. There are no definitive counts. But Health Minister Salih al-Hasnawi said the number of wounded Iraqi civilians is “of course” higher than the estimated 151,000 who died from violence in the first three years of the war, the figure given in a recent survey by the World Health Organization and the Iraqi government.

“For any explosion, it is five to one, or seven to one, wounded to dead,” Hasnawi said.

About 50 of these wounded Iraqis have been living in the Amman Palace hotel, while half that number are in the Jordan Red Crescent hospital up the hill. Dozens more, limbless and broken, arrive in Amman each month asking to be remade. They stay an average of 53 days, sometimes more than a year, attended by a team of orthopedic, plastic and maxillofacial surgeons from the Geneva-based Doctors Without Borders organization.

“Fear is legitimate. It’s all right to be afraid, but we must not let it wear us out,” the therapist said.

The lives these people knew in Iraq changed in a moment, with no time for them to react. The young boy standing at his grandfather’s funeral when the suicide car bomb exploded. Neighborhood kids playing soccer when a mortar shell landed among them. A hotel clerk hailing a taxi when a bullet passed through his thigh.

Now they have nothing but time: for the melted gums and charred skin, the hair implants and the plastic legs, septicemia and osteomyelitis, antibiotic resistance and opiate addictions.

“Now, all together: One, two,” the therapist instructed. “Inhale from your nose. Hold your breath. Exhale from your mouth.”
‘His Face Was Totally Gone’

On Oct. 16, 2006, the day after his grandfather was shot to death, Abdullah, then 6, stood at his father’s side outside the funeral tent in Baghdad’s Shaab district. After a bomb exploded at a market down the street, neighbors began rushing toward the scene, but Abdullah’s father was nervous. As a captain in the Iraqi police, he knew to expect a second explosion when people crowded around the wreckage. Abdullah and his father stayed by the house. The second attack came to them.

The driver of the Volkswagen Passat blew up his vehicle in front of their home, killing Abdullah’s uncle, his great-uncle and three of his father’s cousins. Abdullah’s father, known as Abu Hiba, asked that his family members be identified only by their nicknames or first names, out of fear they might be further harmed. After the bombing, Abu Hiba was driven to a hospital with severe burns and a shattered right shin. Abdullah, a thin boy who was so excited about school that he arrived an hour early each day, was gone.

For three days, relatives canvassed Baghdad’s hospitals until they found him in the sprawling complex known as Medical City, where he had been driven by a neighbor in the chaos after the bombing. During that time, his father was recovering at another hospital, enduring daily antibacterial vinegar baths that made his wounds bubble, refusing amputation and begging his brothers for news of Abdullah.

“They would tell me: ‘Nothing’s wrong with him. He has some scratches on his face, and his big toe is hurting,’ ” Abu Hiba recalled. “I couldn’t stand to hear this. I told them, ‘By cane or by wheelchair, you have to take me to see Abdullah.’ ”

Abu Hiba, 33, a forthright man with a military bearing and a thick black mustache, was sitting on the single bed he shares with his son on the second floor of the Amman Palace. He asked Abdullah to leave the room so he could finish the story.

“When I entered the room, I saw he was attached to an IV,” he said. “Then I saw his face, and there was no face at all. His face was totally gone. I could not stand it. I stayed for a few minutes and I had to leave.”

Abdullah could not eat or speak, and the photos from those early days reveal not so much a face as flayed meat and tooth, the features blasted off or melted away.

“I didn’t imagine it could be so severe,” his father said.

A System in Crisis

Iraq’s medical system is all but incapable of caring for such patients. It was already beleaguered by the international sanctions imposed on the government of Saddam Hussein, but the problems have grown legion: Specialists have fled the country; necessities such as bandages, intravenous saline and electricity are in short supply; and hospitals are guarded by gunmen who intimidate and sometimes kill patients of rival sectarian backgrounds.

A report last year by the Iraqi Red Crescent Society recommended leveling Yarmouk Hospital, one of Baghdad’s biggest. “It’s not fit for animal treatment,” said Said Hakki, the group’s director. “There is no medical system in Iraq to speak of. It doesn’t exist.”

An Iraqi physician who now works in Amman with Doctors Without Borders and who asked that his name not be used because he feared for his safety said that of the 100 resident doctors in his 2004 graduating class, only five remained in Iraq after a year.

“If patients are kept in a hospital there, they have a 90 percent chance of having a severe infection,” he said. “There are no blood cultures. No proper swabs. Labs are basically working on the routine biochemistry tests. Microbiology is almost nonexistent there. Elective surgeries did become nonexistent. It’s basically all trauma management.”

A surgeon in the northern city of Mosul, who also spoke on condition of anonymity, said hospitals have grown accustomed to handling a high volume of trauma cases, but not complex or lengthy procedures.

“Each patient gets no more than two hours maximum in surgery, because there is a long queue,” he said. “We end up with complications and infections. The patients might die two weeks after their operations.”

The experienced doctors who have left the country have been replaced by younger physicians. Concerned about contaminated instruments and unsanitary rooms, they often choose to pump patients full of antibiotics.

“The staff is not well trained, we don’t have the new techniques of sterilization, our operating theaters are dirty,” the Mosul surgeon said. “We can manage the quantity, but not with quality.”

Nearly four years have passed since Emad Mahmoud al-Sheikh fell to the pavement in Mosul with a gunshot wound through his thigh, but poor treatment in Iraq and chronic infection have impeded his recovery. On April 22, 2004, Sheikh was hailing a taxi, on his way to an evening English class at Mosul University, when gunshots rang out. To this day, he has no idea who shot him.

Doctors in Jordan, where he is now a patient, said Sheikh and many other Iraqis arrive with bone infections because of inadequate surgical procedures and a resistance to antibiotics. The nine pain pills he takes in Jordan each day can feel almost ineffectual, he said, because he developed a tolerance for much higher doses in Iraq.

“I wouldn’t be lying if I told you: Throughout the past four years, half of it I haven’t slept,” Sheikh said. “And if I sleep, it’s because of the painkillers I take. After four years, it is more or less the same pain. There has been no improvement at all.”

A New Doctor

Many of the Iraqi patients who arrive in Jordan are referred by physicians at home to Doctors Without Borders, one of the few organizations that help Iraqis wounded in the war and pay for their transportation and treatment. Since the group began treating Iraqis in Amman in August 2006, a dozen doctors have provided care to more than 340 wounded civilians in need of reconstructive surgeries. Another 140 people are on the waiting list.

“Sadly, we recognize that this is merely a drop in the sea of what is going on in Iraq,” said spokeswoman Val¿rie Babize.

In December 2006, Abdullah flew to Jordan, escorted by an uncle. His father soon followed, in part to seek treatment himself. Until they and other patients were moved to a new hotel this week, their home was Room 213 of the Amman Palace, more of an outpatient ward than a hotel, with about 50 of the 70 rooms occupied by Iraqi patients. The blown-up, bandaged and scarred hobbled or wheeled down brown-carpeted hallways under framed portraits of Jordan’s king. Amputees in wheelchairs sunned themselves along the sidewalk in front of the glass doors. Spare rooms were devoted to physiotherapy, counseling and tutoring sessions. Guests brewed sugared tea and boiled rice over hot plates in their rooms. When both elevators broke this week, as they often do, relatives carried the patients up the stairs.

The first procedure Abdullah underwent in Baghdad was a pedicle flap, affixing his face to his shoulder to regenerate the tissue. It failed because of infection and because Abdullah could not hold the awkward position for 21 days. So his doctors in Amman arranged for a German specialist in cranial maxillofacial surgery to fly to Jordan to take the case.

During the first of several painstaking operations in Amman, Andr¿ Eckardt took 12 hours to harvest skin and muscle from Abdullah’s back and transfer it to his face to repair what the surgeon called the “disastrous tissue loss.” Abdullah would also have his missing lower left eyelid remade, a temporary prosthetic eye inserted to prevent his eye socket from shrinking, and his scar tissue manipulated. The failed surgery in Iraq, the contamination of the blast wound and the quantity of scar tissue all made the work more challenging.

“To be honest, it is very difficult. He’s so severely injured, he will never look like a normal young boy with a normal face,” Eckardt said. “You can never completely remove all his scars.”

After his operation, Abdullah spent 24 hours anesthetized in the intensive care unit before he was revived. In the weeks that followed, he could barely mumble. He drank liquids and ate soft fruit. “He was like a newborn,” his father recalled.

Embarrassed by his appearance, Abdullah wore a surgical mask and refused to let anyone touch him. His father decorated their hotel room with cut-out photographs of tigers, monkeys and bears to approximate home and bought him so many toys — soccer balls, stuffed animals and remote-control cars — that some of them remain unopened, stacked on a cabinet.

“Sometimes people look at him on the street, and he says, ‘Papa, why are people staring at me?’ ” his father said. “I say, ‘Don’t worry about them.’ “

A Family Traumatized

About three months ago, Abdullah took off his cap and is now growing accustomed to his appearance, his father said. He is still shy around strangers, although he is not in pain. More than anything, Abdullah said, he misses his mother and his two younger siblings.

“I’d like to go back to school,” he said. “I like it here, but Baghdad is better.”

To pass the time, Abdullah sometimes removes his prosthetic foot and kicks a soccer ball in the hallway with his stump. He also likes a wrestling video game and has found a new friend, a 9-year-old named Omar.

On the last day he could run, Omar was playing soccer. He and five friends were resting outside his home on the southern outskirts of Baghdad on Sept. 20, 2007, when the mortar shell fell. The explosion killed one of his playmates and shattered both of Omar’s legs.

The local hospital had been closed earlier in the year, and because no ambulances were available, he was driven in a police car to Baghdad’s Kindi Hospital. It is a dingy, crowded facility where, after bombings, bloodied patients wander the halls amid wailing relatives.

He stayed for 15 days and didn’t realize until two days before he left that they had amputated his left leg below the knee. “I started to cry,” he said. When he arrived home, he had no wheelchair, so his parents carried him if he needed to move. The youngest of five children, Omar was distraught, his father recalled. He lost weight, threw fits and would ask his father to carry him to the window in the mornings so he could watch the children walk to school.

“He was in a very bad condition. Sometimes when we told him he must eat, he would get angry and start pulling out his hair,” said his father, a grave, deep-voiced government official who massaged some worry beads as he spoke. “He paralyzed the whole family.”

In early January, Omar and his father arrived in Amman, where Omar is being treated for an infection in the stump of his left leg, multiple fractures in his right leg and shrapnel embedded in both. They live in a single room with two beds, a television and a table where Omar reads. His father, who declined to be named, carries Omar to the bathroom, bathes him and washes his clothes and hangs them to dry on the shower rod.

Omar was in fourth grade when he was injured and now takes classes with tutors who follow the Iraqi curriculum. His days are a routine of doctor appointments, physiotherapy, wheelchair rides down the hallways and many hours alone with his father. Omar is frustrated with his wheelchair, his father said, and often stays in his room rather than fall behind as other children run around. But Omar insists that being in Jordan has given him hope he can someday walk again and has also settled one important question. He has decided to become a doctor.

“I learned how to be a doctor because I know how to bandage now, and how tests are done, and how many tests you have to do,” Omar said. “I’m familiar with all that now.”

In their time alone, recovering together, Abdullah and his father have developed an intimacy they might not have found in Baghdad. Each morning they follow the same routine. After Abdullah wakes, his father helps him wash his eye socket and the rest of his face. Together they put on his prosthetic foot, which his father has had to replace twice as Abdullah has grown.

The two of them are cut off from the rest of their family. When Abdullah’s father returned to Baghdad last fall, he chose not to take his other children new clothes from Jordan because he did not know what size they had become.

‘Only to Walk’

Sheikh worked in hotel administration in Mosul, but his company terminated his contract when it became clear he would not be able to return quickly. He once played tennis, soccer and volleyball and even used to whip through his office paperwork standing up. Now he lies in traction in Amman, with a 14-pound bag of water attached to his leg to stretch the muscles. Since he was shot, he has been bedridden, forced to rely on his wife and five brothers to take care of his four children and every mundane errand.

“I can overcome all the pain, all can be endured, only to walk, even with a cane, just to walk,” he said.

Sheikh could not help crying.

“I don’t feel sorry for myself,” he said, apologizing for his tears. “I feel sorry for the thousands and thousands of Iraqis who are in the same position as I am. We’re tired. We’re exhausted. The first time I ever left my country was to come for treatment. We haven’t seen anything from this world. All war and devastation and tragedy. How long can I rely on my brothers? I’m hopeless. I’m devastated. I just want to walk. Thousands of Iraqis — and many are worse off than I am. What wrong have we committed?”

He lay back on his pillow.

“I thought I would have a better life than this.”

Special correspondent Yasmin Mousa in Amman contributed to this report.

For Broken Iraqis, A Haven of Healing - washingtonpost.com