Although a bitter, attritional conflict is still being waged in Chechnya, carpet bombing and pitched street battles are, thankfully, no longer a daily reality. But for many people living in the republic, physical scars and poorly healed wounds remain a painful reminder of the awful war that they have, and continue to, endure. In an attempt to help them rebuild their lives MSF has recently opened a reconstructive surgery project in the republic's main reference hospital, Hospital Number Nine.
"We realised that many people with long-standing injuries and chronic disabilities sustained in the war, or victims of road traffic accidents, are simply unable to access surgical services," says Dr Manana Anjaridze, the MSF Medical Co-ordinator in Russia. "Most people are only able to scrape together the money for an expensive operation when it is seen as life-saving. But there are many surgical procedures that can be done that dramatically improve quality of life."
Patients who present at the trauma and orthopaedic outpatient clinics are screened by hospital staff. Those who need surgery and who can be assisted by MSF's program are then admitted, and all care and drugs are provided for free. The MSF team includes a trauma specialist, plastic surgeons and anaesthetists. A physiotherapist is available for post-operative follow-up. The 20-bed trauma department shares a ward with vascular surgery, and so patients admitted for vascular operations are also supported by MSF.
Stories like that of Rustam, whose left leg and foot was injured in a mine explosion five years ago, are common.
"When he came to us, he had already endured several painful and unsuccessful surgeries. Now we have begun to reconstruct his limb, pinning and bracing his shin in an external metal frame, so the damaged bone can re-grow. The next step will be to realign his twisted foot. We are hopeful that in three months he'll be walking again," explains Chechen surgeon, Professor Yandarov.
To accommodate these reconstructive operations, the trauma department has been refurbished and re-equipped by MSF. An oxygen generator now provides patients with safe oxygen rather than the unstable industrial oxygen that they used to use, much of which had to be purchased by relatives. The "patient flow" through the sterile and non-sterile areas of the department has been reorganised to reduce the risk of infection.
MSF works with prominent Chechen surgeons, like Professor Yandarov. And Dr Khunarikov, a vascular specialist, coordinates the program. Both men worked in Chechnya during some of the heaviest phases of the war, living in basements and operating on patients in makeshift field-hospitals and administrative buildings. The MSF programme hopes to give them an opportunity to exchange ideas and surgical techniques with French surgeons. Three Chechen surgeons have already visited hospitals in Lyon and Fontainebleau, and more visits are planned.
Since the program began in July 2006, 52 patients have had operations. MSF doctors have catalogued the accidents, burns, bullets and mine explosions that caused their injuries. Some have had a number of failed or poor quality operations in Chechnya or neighbouring republics over the years, and many will now face a series of reconstructive surgeries to correct past trauma or operative error.
"One of my patients, Madina, was 18 in 2002, and living in Vedeno [a southern part of Chechnya where fighting was, and is, prevalent] when she was shot in both hips by a sniper with explosive bullets," recalls Professor Yandarov.
"Her hip bones shattered, riddling her legs with fragments, and she lost a lot of blood. It took two days to get her to hospital, on terrible roads and through numerous checkpoints. She was just alive when she reached us, and I managed to stabilise her and do a basic operation with the equipment I had available. However, I had to discharge her quickly as we were running out of space in the ward.
"Last August she came to see me again, and although one of the legs that I had hurriedly repaired was OK, the other had not healed well and was crooked, causing her to have a painful limp. This time I could do what I needed to do: we broke her leg again, straightened it, took a bone transplant and fixed a metal plate. Now she is able to walk normally on her leg."
Already the word is spreading about the program. "At the start, patients could not believe they were going to be able to access such operations for free, and they tried to press money upon us. But we refused, and now they have got used to it. We expect the numbers coming to the clinic to rise," says Dr Khunarikov. MSF plans to do between 25 and 30 operations of varying complexity each month.