GROZNY, Russia -- The international aid agencies at work in Chechnya cut their teeth on African disasters but are learning that a war against civilians in a country like Russia presents a different set of problems.
They are trying to set up relief operations in a country that has a highly structured -- if not always sophisticated -- medical system.
"You have to fit in with a system that has been running for many, many years, which is very tight and very fixed," said Dr. Michael Schubert, a physician with Merlin. "This is a new situation for us -- totally new."
You might not always agree with what a Russian doctor is doing, Dr. Schubert said, but you can't tell him to do it differently.
The most acute problem is warding off threatened epidemics of cholera and dysentery. That doesn't require medical expertise, but simply a commitment to sanitation and to the delivery of medicine. "Cholera is not a medical problem, it's a logistical problem," Dr. Schubert said.
But along with the threat of epidemics comes a problem that rarely arises in Third World countries -- the need to restore medicines to people who have been living, sometimes for years, with chronic illnesses.
The thousands of emergency medical kits being brought to Chechnya by foreign relief agencies are geared toward trauma and tropical diseases rather than diabetes or high blood pressure. The Red Cross is scrambling to try to find the kinds of medicine needed here.
Grozny is a city that has been reduced to rubble with vengeance and thoroughness, and yet it once provided a reasonably comfortable standard of living for citizens of a world power.
The average age of Grozny residents already was higher than that usually found in an African relief camp. And when the war came, it was the elderly who stayed behind in the largest numbers. Among them are people who relied on medicines to stay alive. Their chronic symptoms now are becoming acute ones.
One recent, bright afternoon, Dr. Schubert stopped at an apartment shared by an elderly brother and sister who remain despite the lack of water, electricity and window glass, and the bullet holes that lacerate their kitchen wall.
The couple had approached him on the street looking for help, and now he was dropping off medicine for high blood pressure and a urinary infection.
No one knows how many people citywide are similarly in need of help, nor how many have died from diseases such as diabetes or heart failure since the Russian army assaulted Grozny in January.
As Col. Gen. Anatoly Kulikov, the Russian commander, put it: "It's difficult to estimate the numbers in the civilian population, because no one has counted them."
The new Chechen government estimates that 130,000 people live in Grozny, compared with more than 400,000 before the war began, and says that 3,000 to 4,000 are returning every day from surrounding villages.
But Marianne Coradazzi, head of the Red Cross office in Nazran, where relief convoys are organized, said that many have come simply to look around and check out their former homes, and that they leave again within days.
Hospital No. 4 is one of three functioning hospitals, compared with 20 at the start of the war. It depends on electrical generators provided by the Russian Ministry for Emergency Situations. Before the war it had 510 beds; aerial bombing has reduced that number to 109. One entire building, housing a children's unit and an eye unit, has been closed because it was mined.
But the hospital isn't crowded. Dr. Magomed Sulumov, the chief physician, believes that people don't know it is open, or that they can't reach it. He said 60 to 70 people walk in every day, most seeking treatment for infections.
The hospital had about 100 doctors; all but 20 have disappeared.
"Did they leave? Are they dead?" asked Dr. Sulumov. "Who knows?"
The workload isn't overwhelming, he said, but the 20 Chechen doctors and 40 nurses are under a great deal of stress.
Hospital No. 4 is being managed, in a sense, by Merlin and by the Red Cross -- but they are acting more as suppliers and consultants than as providers of direct health care.
"They have doctors. They have nurses," said Ms. Coradazzi. "It's the medicine they need."
But Medecins sans Frontieres is considering bringing in a specialized team of foreign doctors -- psychiatric specialists. Russian and Western doctors agree that the level of mental health problems in Grozny is potentially staggering.
More so than in Rwanda, Lebanon or Yugoslavia, they say, the level of destruction in Grozny was so vast that mental breakdown has become frighteningly common -- and it's not a problem that will likely be solved in six months or a year, when the aid agencies will be packing up and moving on to the next emergency.