Nativity on a knife-edge: the struggle for survival in Somalia – in pictures

A young boy is measured to see if he is malnourished at a health centre near the Salama camp for displaced people, near Galkayo. Malnutrition is an underlying cause of a large percentage of deaths among children under the age of five in Somalia. Basic medical services are free to access here, but many cannot afford the transport to travel to them

For newborns in Somalia, many of whom are delivered in dusty, makeshift shelters without the assistance of a midwife or doctor, the risk of infection is high. With drought and conflict driving many women from their homes, one child in every 26 dies within 28 days of birth – many on the same day

All photographs: Kate Holt/Unicef

When Ubah Abdullahi went into labour she knew there was no chance of seeing a midwife or doctor. After a gruelling 12 hours her baby daughter arrived, delivered on to the floor of a makeshift shelter. Her family was among thousands driven from their homes by drought and conflict in central Somalia last year. Now living at the Najah camp for displaced people near Galkayo, Abdullahi did not have the money to travel to a health centre. ‘I couldn’t afford to take a taxi to the clinic but my mother-in-law was here to help,’ she said. Abdullahi is not alone. In Somalia seven out of 10 women give birth at home and babies born in basic shelters are at risk from infection and other complications

The sun sets over the Najah camp, where the majority of inhabitants are women and children. Babies born here are at grave risk due to infections and the lack of access to professional healthcare should complications occur. In Somalia the neonatal mortality rate – the death rate for babies under 28 days old – is the fourth highest in the world. One of every 26 babies dies within four weeks, many on the day they were born. Unicef’s health chief in Somalia, Samson Agbo, said many newborns could be saved if mothers could access proper medical care.

Women wait with their children outside a temporary community centre in the cooler evenings at the Najah camp. The effects of drought are still being felt throughout Somalia, which has forced thousands of people who were pastoralists to seek food and shelter around towns. A Unicef report found eight of the 10 most dangerous places to be born are in sub-Saharan Africa, where pregnant women are much less likely to receive assistance

Sahra Abdi holds a pan containing the rice she has to feed her five children. She arrived in the Najah camp at the start of February. Her four-year-old daughter died on the journey. Her husband has been suffering from mental health problems since all the family’s goats and sheep were wiped out by drought. He is being cared for by his mother in Galkayo town and Abdi is left at the camp to care for their children. Food shortages in such settlements mean many of the mothers are malnourished and commonly give birth to babies prematurely. In Somalia, where women have six or seven children on average, there is also a high adolescent fertility rate

Baby Farhia is cradled by an aunt in the maternity ward of Mudug teaching hospital in Galkayo. Her mother, Fadumo Abdullahi, had been forced to have a caesarean because she was suffering from pre-eclampsia. The condition was picked up on an antenatal visit, yet across Somalia many pregnant women do not have access to healthcare during their pregnancies, so complications are not identified early, leading to more serious health problems

Mariam Abdullahi comforts her newborn baby in the maternity ward of Mudug teaching hospital. Across Somalia, only 28% of babies were born in hospitals or clinics in 2017. Abdullahi said: ‘During a visit to the doctor before giving birth they told me the baby was large and I knew I would have care in a hospital’

A community elder prays next to the graves of two babies who died recently at the Najah camp. Local midwife Rahma Mohamed said that more support is needed for health services for expectant mothers. She works at the Salama mother and child health centre. ‘I think more women would come here if they realised it was free and if they had transport,’ she said. ‘We also need support to stay open 24 hours. And we have to do more to persuade women who still prefer to deliver under a tree or use traditional medicine’

By: Hannah Summers and Kate Holt

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'You Have Dark Skin And You Are Beautiful': The Long Fight Against Skin Bleaching

Amira Adawe has a radio show, Beauty-Wellness Talk, which is a platform where the Somali community can talk openly about skin lightening without fear of being outed or stigmatized.

Nancy Rosenbaum for NPR

Amira Adawe has just arrived at a Somali-American community radio station in Minneapolis where she hosts a weekly call-in show called Beauty-Wellness Talk. After peeling off her winter jacket, Adawe slides a pair of headphones over her crown of dark, short curls. "Hello? As-Salaam-Alaikum," she says into the foam mouth of her studio microphone. An anonymous stream of listeners starts calling in to confide about a subject that is deeply personal and also taboo — skin bleaching.

Adawe is a Minnesota-based public health researcher and educator who works as a manager in Gov. Mark Dayton's Children's Cabinet. In 2011, while a graduate student and health educator with St. Paul-Ramsey County Public Health, Adawe proposed a study to investigate how Somali women use skin bleaching creams in their daily lives. Growing up in Mogadishu and Minneapolis, Adawe knew that skin lightening was widespread in her community.

"A lot of it ties to colonization," Adawe says. "Certain skin colors were more accepted in the society. But through the years, it became so embedded in the culture to where it's become normal. If you're light-skinned, you're more accepted," she says.

She had trouble finding women who were willing to be interviewed. Adawe says there's a stigma around admitting to skin bleaching. "Women don't want other women talking about them. They want to pretend that this is their natural color," she says.
Adawe suspected that the fast-acting creams contained toxic chemicals, and she was right to be suspicious. Out of 27 different creams tested by Minnesota researchers as part of Adawe's study, 11 contained mercury levels ranging from 4.08 up to 33,000 parts per million (ppm). (The U.S. Food and Drug Administration only allows mercury in amounts of less than one part per million in most cosmetics.)

The FDA classifies skin whitening creams as both a cosmetic and a drug. According to FDA spokesperson Peter Cassell, the "use of mercury in skin-bleaching preparations and other cosmetics, with few exceptions has been prohibited in the U.S." since 1973.
"The FDA has been aware of mercury as a potential allergen, skin irritant and neurotoxin for decades," Cassell says.

The seven Somali women Adawe interviewed for her study reported mixing several different creams into one concoction and storing it in the refrigerator. Some slathered the cream mixture over their bodies multiple times a day, even while pregnant or breastfeeding. These findings alarmed Adawe. The possibility that children or developing babies could potentially ingest mercury through breast milk or contaminated food or water was especially concerning. 

Skin bleaching products can also contain steroids, which thin the skin, as well as hydroquinone, a suspected carcinogen that is banned in some countries.

"That is a really huge public health issue. That mercury vapor alone can expose everybody in the home, even people who visit. That was really shocking to me," Adawe says.

Despite FDA regulations, toxic skin lightening creams are accessible in the United States. The products get smuggled past borders through personal luggage and can be found in ethnic markets and also online.

A global market
Globally, skin bleaching is a multibillion-dollar business. According to a 2017 market research study by Global Industry Analysts, the market for skin lightening products is anticipated to exceed $31 billion by 2024, with the Asia-Pacific region representing the fastest-growing market.
Adawe was surprised to learn that skin bleaching is such a global phenomenon. "I was so focused in the Somali community and other African communities that I didn't know this was happening in other places," she says.

Seventy-seven percent of women in Nigeria use skin lighteners, more than anywhere else in the world, the World Health Organization reported in 2011. In 2004, nearly 40 percent of women surveyed in China, Malaysia, the Philippines and South Korea reported using use skin lighteners, and in India, 61 percent of the dermatological market is comprised of skin lightening products, according to the same WHO report.

As Adawe continued to sound an alarm about skin bleaching, she realized that warning people about the health risks of toxic chemicals wasn't necessarily enough to change behaviors. So long as the belief that lighter skin is inherently preferable persisted, women would likely keep bleaching, she thought. So she decided to tackle the issue from another direction.

Radio outreach
Adawe launched her radio show, Beauty-Wellness Talk, in November 2017. It's a platform where the Somali community can talk openly about skin lightening without fear of being outed or stigmatized. From the beginning, Adawe made it clear that listeners could call in anonymously.

On a recent wintry Saturday afternoon, Adawe's in-studio radio guest is Hibat Sharif, an educator and outreach worker with St. Paul-Ramsey County Public Health. They're discussing how parents can build healthy self-esteem in their children, especially girls. 

"We're African, we're Somali, we have dark skin," says Sharif in a mix of Somali and English. "Our skin is melanated. It provides us with a lot of benefits. Why are we telling our girls: You'd look so much better if you were lighter? It's important not to put those toxic stereotypes in your child's head."
Sharif cautions listeners about words that reinforce harmful stereotypes, such as cadey, a Somali expression of endearment.

Questioning word choices
"That word is really heavy," explains Salma Ali, 19, a Somali-American college student who grew up in the Twin Cities area. Her friend, Yusra Abdi, also 19, agrees.
"It means whitey. Like white girl," Abdi says. "You will never hear anybody say madoowey, which is 'darky.' If anything, that would be an insult in the Somali language."

Colorism is personal for both Abdi and Ali, who describe themselves as dark-skinned. "Growing up, if somebody in my family was mad at me, they'd call me koor madow, which means, 'Hey darker-skinned,' " explains Ali. "And it was an insult," she adds.
Family members pressured Ali and Abdi to use lightening creams. When Abdi was in middle school, her mother gave her a lightening gel to help with acne scars. After about a month, she noticed her complexion had lightened and her acne marks had worsened. She decided to stop. 

"When women use these products, it comes from a very deeply ingrained place of insecurity," Ali says. "It's because of what society pushes on us to believe. Across all cultures, darker-skinned people have self-esteem issues."
Both Ali and Abdi say that they've seen Somali women obfuscate their use of skin lightening products by describing the practice as cleaning their skin or helping it to glow.

"I've had my aunts come up to me telling me, 'Salma you're not ugly, it's just that your skin is just a little dirty. You need to clean it up. I got some products from China. I'mma hook you up.' I'm like, 'How is my skin dirty? I'm taking care of myself.' But because of the fact that I have darker skin, I'm seen as ugly. And that's just part of the way we've all been socialized."

Changing attitudes
Adawe wants to disrupt that socialization, but changing ingrained behaviors and perceptions takes time. She sees medical providers as key partners in actualizing systemic change. Over the past six and a half years, Adawe says she and her colleagues have trained more than 100 clinic systems, with a focus on pediatric care. 

She advises doctors and nurses not to ask patients about skin bleaching directly, but instead to probe slowly and with sensitivity about the different lotions women use. Nurses who conduct home visits with pregnant women can play an especially important role since they build a relationship with mothers over time and can see if skin lightening products are being kept in the home.

On a Thursday afternoon in mid-February, Sharif, the outreach worker, stands in front of a class of Somali, Hmong, Nepalese and Karen adult students and their translators. The students are all new arrivals to the United States. The class hums with a staccato melody of different languages.

"The No. 1 thing you can do is to stop using these products," Sharif tells the students in English and Somali. "The biggest takeaway from this presentation is that every shade is beautiful," she says.
A Somali man in the class says it's been ingrained in him to gravitate toward lighter-skinned women.

Sharif laughs and says, "The change needs to start with you. It really does."
She asks him if he has dark-skinned daughters, and the man says he does.
"What does that say to your daughter?" Sharif says when reflecting on the exchange after class. "Do you want a guy to treat your daughter that way where he tells her she's not beautiful because she's dark?"

"You have dark skin and you are beautiful"
Salma Ali says she had low self-esteem when she was younger. It's something she thinks a lot of darker-skinned young women experience. Things shifted in high school when she started reading books by black women writers and found inspiration in seeing black women actors play strong leading roles on television. 

Social media helped Ali and Abdi to find affirming messages about black beauty as well. Both of them are fans of black women beauty vloggers like Jackie Aina and Alyssa Forever whose YouTube channels attract millions of views. They credit Rihanna for leading the way with releasing a makeup line with many different shades for darker-skinned women.

"It can really change the way you think about yourself and the way you see the world," says Ali about social media. "I really do have hope for this next generation of darker-skinned women who want to be represented. Who want to be uplifted and celebrated for our skin. You have dark skin and you are beautiful. I really want that to be a cultural norm," she says.

Adawe says that after working on this issue for nearly seven years, she's starting to see hints of change. More people are talking, disagreeing and questioning colorism out in the open. "All of that didn't exist before," she says. "All of that helps."
Adawe is now writing a curriculum for teachers. Her next step is to take the conversation into the schools.

"This is going to need systemic change," says Ali, who is studying sociology with a focus in health care and a minor in public health and neuroscience at the University of Minnesota. "I feel like it's something that's so within us that it's going to take a while. It's going to take some work." 

Weekend Edition Sunday

Nancy Rosenbaum

 

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Qatar Charity gives ambulances to hospitals in Mogadishu

Doha: The Qatar Charity Office in Somalia delivered three ambulances to hospitals in the capital Mogadishu to support health services in a ceremony attended by local ministers and officials, members of the Qatari and other embassies.

Officials during the ambulance handing over ceremony.

 The ambulances have been provided at a time when many hospitals in Somalia were suffering from a severe shortage in the patient transport services, especially for urgent cases, as many vehicles were not designed to provide first aid, which had maximised the risk to the lives of many patients.

The Minister of Health of the Somali Federal Government Dr Fawzia Abikar Nour, the Minister of Planning and Investment of Somalia Jamal Mohammed Hassan, the Chargé d’Affaires of the Embassy of Qatar in Mogadishu Hassan bin Hamza, the Ambassador of Turkey in Somalia Olgen Becker, several members of the Somali Parliament, officials of the hospital benefiting from the project and the Director of the Qatar Charity Office in Somalia attended the ceremony.

Dr Fawzia Abikar Noor praised the role of Qatar in assisting Somalia, and highlighted Qatar Charity’s humanitarian efforts and contributions to alleviate the suffering of those affected by famine and disasters in all the regions of Somalia, expressing her gratitude for these humanitarian efforts and the effective initiative to revive the normal life in Somalia.

For his part, Hassan bin Hamza, hailed the continued Qatari support for the humanitarian cause and praised Qatar Charity’s humanitarian and developmental efforts in Somalia, pointing out that such a project will contribute to the rescue of many lives, and cover a part of the need of hospitals for ambulances.

Abdul Nour Haji, Director of the Qatar Charity Office in Somalia, thanked the people of Qatar for their continuous support to the people of Somalia to alleviate their suffering, by meeting their health and relief needs and implementing development projects to make a difference in the lives of the beneficiaries.

At the end of last year, the Qatar Charity Office handed over medicines and medical supplies to the Mogadishu City Hospital as part of the emergency relief project for the victims of the bombing to minimize the serious impact of the accident.

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IOM Partners with Americares to Provide Lifesaving Medical Supplies in Somalia

Somalia – IOM, the United Nations Migration Agency, has partnered with Americares to donate more than eight tonnes of medical supplies, for distribution across IOM project locations in Somaliland, Puntland, Lower Juba, Gedo and Banadir regions. The supplies will immediately be dispatched to IOM’s static and mobile clinics, to increase local access to life-saving primary healthcare services.

• In 2017, IOM Somalia provided emergency primary healthcare to over 470,000 beneficiaries. © IOM
• 

  This is Americares’ 7th major shipment to Somalia in response to the drought and acute watery diarrhoea/cholera outbreak. © IOM

Inadequate funding for healthcare continues to hinder the delivery of life-saving health services to populations in need across Somalia. The situation is further exacerbated by ongoing disease outbreaks including Acute Watery Diarrhoea (AWD)/cholera and measles.
In 2017, IOM provided emergency primary healthcare to over 470,000 beneficiaries. This is Americares’ seventh major shipment to Somalia to tackle the drought and AWD/cholera outbreak. The shipments include more than 190,000 litres of intravenous fluids, enough to treat 24,000 patients with AWD/cholera and other waterborne diseases.
Americares responds to an average of 30 natural disasters and humanitarian crises worldwide each year, establishing long-term recovery projects and bringing disaster preparedness programmes to vulnerable communities.
IOM Somalia Chief of Mission Dyane Epstein stated: “Improving access to medical supplies to ensure health facility stock outs are avoided is of the utmost urgency to alleviate the impact of the current crisis.”

“The crisis in East Africa is one of the worst humanitarian emergencies in decades,” said Americares Director of Emergency Response Kate Dischino. “IOM and Americares are partnering to ensure families have access to basic medicines and medical supplies, including lifesaving cholera treatments.”

More than five million people in Somalia have limited access to healthcare. The situation is worsened by a ravaging drought – the worst in decades. In 2017, more than 60,000 AWD/cholera cases and 800 deaths were reported in 52 districts across 16 regions of the country.

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Somali nationals benefit from KDF medical camp

More than 150 Somali nationals have benefited from medical treatment during an ongoing Kenya Defence Forces (KDF) clinic at Afmadhow in the lower Juba Region of Somalia.

In Summary

• More than 150 Somali nationals have in the past week benefited from medical treatment during a Kenya Defence Forces (KDF) camp in Afmadhow in the lower Juba Region.
• This is despite continued efforts by Al-Shabaab militants to block Somalis from getting aid from AMISOM troops.
• In January, the terrorist group destroyed a Hormuud communication mast in Elwak, Mandera.

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Babies born in poorest countries still face alarming risks: Unicef; Somalia has a one in 26 chance!

WASHINGTON (AFP) - Babies born in the world's poorest countries, most of them in Africa, still face "alarming" risks of death that can be 50 times as high as those in the richest countries, according to a Unicef report released on Tuesday (Feb 20).

A midwife cutting the umbilical cord of a newborn baby in a ward of the public hospital of Yambio, South Sudan.PHOTO: AFP

While the last quarter-century has seen broad improvements in older children's health, "we have not made similar progress in ending deaths among children less than one month old," said Henrietta Fore, Unicef's executive director.

"Given that the majority of these deaths are preventable, clearly we are failing the world's poorest babies."

The differences are stark. A baby born in Pakistan - the country with the worst newborn mortality rate - faced a one in 22 chance of death, while a newborn in Japan had only a one in 1,111 risk of dying, the report said.
Of the 10 highest-risk countries, eight are in sub-Saharan Africa, countries where "pregnant women are much less likely to receive assistance", due to poverty, conflict or weak institutions, according to the report.
Those eight countries are the Central African Republic (a one in 24 chance of death); Somalia, Lesotho, Guinea-Bissau and South Sudan (all with a one in 26 chance); Cote d'Ivoire (one in 27) and Mali and Chad (both with a one in 28 chance).

Each year, some 2.6 million babies do not survive through their first month.

PREVENTABLE DEATHS

The report was released in conjunction with the launch of a global campaign, called Every Child Alive, aimed at ensuring "affordable, quality health care solutions for every mother and newborn".
More than 80 per cent of newborn deaths can be prevented, the report says, "with access to well-trained midwives, along with proven solutions like clean water, disinfectants, breastfeeding within the first hour, skin-to-skin contact and good nutrition". But shortages of properly trained health workers and midwives are a major problem in poorer nations.
While a rich country like Norway has 18 doctors, nurses and midwives for every 10,000 people, impoverished Somalia has only one.
Every year, one million babies die the day they are born.

"We know we can save the vast majority of these babies with affordable, quality health care solutions," Fore said.

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Somalia: Fascioliasis is suspected on goat deaths in Middle Shabelle

Fasciolosis is a well known worldwide and an important helminthic disease of silvatic ruminants caused by liver fluke species of the genus Fasciola, which is one of the most neglected diseases that can lead to human infection.

Copyright of this photo belongs to OMICS International

 In a recent Radio Ergo report, goat herders in Mahaday district of southern Somalia’s Middle Shabelle region say they are losing many of their goats due to the liver flukes. The report notes that some 4,000 goats have died from the parasite during the past three months. It is extremely difficult to verify such numbers, although experts say that Fascioliasis alone would most likely not cause such high fatalities, the report notes.

The livestock disease is reported in areas where the water has been contaminated after seasonal flooding of the river Shabelle.
Fasciolosis infections in livestock can result in significant economic losses,  from decreased productivity to mortality.

Fasciola hepatica, the common liver fluke (also called the sheep liver fluke) is a flatworm belonging to the Trematodes. Its final hosts are sheep, goats, cattle and other domestic and wild mammals, including horses, dogs, cats and humans.

The common liver fluke occurs worldwide but is particularly abundant in humid regions with temperate climate where it can be endemic.

It is one of the most abundant and damaging helminth parasites of grazing ruminants (sheep, goats, cattle). In endemic regions 100% of the animals can be infected. It is particularly harmful, even fatal for sheep. Prevalence and incidence in a particular region depends strongly on ecologic and climatic conditions (e.g. habitats for intermediate hosts and wild mammals, overwintering of the parasites in the environment, etc.) and on livestock management practices (stock density, grazing patterns, etc.).

Adult Fasciola hepatica Photo/Adam Cuerden via Wikimedia Commons

 

 

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Somalia to Probe Evictions of Thousands of Displaced Families

Photo file - Newly displaced Somali women queue with their malnourished children as they try to receive medical treatment on outskirts of Mogadishu on April 11, 2017.

The Somali government responded to widespread criticism by aid agencies on Wednesday, promising to investigate reports that thousands of families fleeing drought and conflict were forcefully evicted from more than 20 informal camps.

The United Nations and groups such as the Somalia NGO Consortium say more than 4,000 families, or about 20,000 people, had their homes bulldozed last month inside settlements on the outskirts of the capital of Mogadishu.
The demolitions on private land were unannounced, they said, and pleas by the community largely women and children for time to collect their belongings and go safely were not granted.

  Some aid workers who witnessed the evictions said uniformed government soldiers were involved in the demolitions.

“Regarding the forced evictions, we are really deeply concerned. We are investigating the number of evictions,” Gamal Hassan, Somalia’s minister for planning, investment and economic development, told participants at a U.N. event.

“We have to make sure we investigate and have to make sure we know exactly what happened. And then we will issue a report and you can take a look at it and see what happened and how it happened,” he said by video conference from Mogadishu.

The impoverished east African nation of more than 12 million people has been witnessing an unprecedented drought, with poor rains for four consecutive seasons.
It has also been mired in conflict since 1991 and its Western-backed government is struggling to assert control over poor, rural areas under the Islamist militant group al Shabab.
The U.N. says drought and violence have forced more than 2 million people to seek refuge elsewhere in the country, often in informal settlements located around small towns and cities.

The U.N. Office for the Coordination of Humanitarian Affairs (OCHA) on Wednesday condemned the demolitions, and said the fate of those evicted did not fit with the progress Somalia has made.

“Not only did these people lose their homes, but the basic infrastructure that was provided by humanitarian partners and donors, such as latrines, schools, community centers — has been destroyed,” said Peter De Clercq, head of OCHA in Somalia, at the same event.

“I reiterate my condemnation of this very serious protection violation and call on the national and regional authorities to take necessary steps to protect and assist these people who have suffered so much.”

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Villagers in remote part of northern Somalia relying on traditional remedies in measles outbreak

Sawir/Kaydka/Ergo

Fifty one measles patients have been on their sick beds in their homes in Yadagta area, 120 km north of Burao, Togdher region, where there are no health centres.
The patients, including children and elderly receive traditional medication in their homes as the area has no health centres.
Mr. Muse Abokar Suudi, District Health Officer of (now called Saraar region), told Radio Ergo they sent a team of medical staff to Yadagta, after the local administration reported an outbreak of measles to the ministry.

The team found that 34 of the sick are children, who were not vaccinated during the last vaccination round that was carried out two years ago. The vaccinators did not reach out to the people in the rural areas.
Some of the sick include adults and children from families that were recently displaced in the last six months, after the prolonged drought was unbearable in their previous locations.

Mohamed Warsame Abdi’s children aged three and seven were infected with measles. This drought-hit father told Radio Ergo by phone that he could not afford the $30 he needed to take his children on the long journey to a hospital in Burao.
He suspected measles when he noticed symptoms including rashes and fever. He said he had been taking the children out into the sun and covering them with blankets in the hope that they would get better, but it had not helped. However, they are now recovering after the ministry doctors attended to them.

Since he migrated to Yadagta area six months ago, Mohamed said he had not seen any health teams coming to conduct vaccinations.  His family used to own 90 goats, which all died in the drought.
Mr. Muse said the ministry was working to contain the outbreak of measles, which spreads easily through coughing and sneezing. They are also conducting awareness campaigns among people in the rural areas, where aid agencies do not reach.

Amina Osman Harbi, a mother in Yadagta, said her two children caught measles around five days ago. She saw rashes, inflamed eyes, running nose and constant fever. Her neighbours lost two children aged three and four and she believes they could have died of measles.
Amina explained that she was applying cooking oil and black seed oil to reduce the symptoms but their recovery was still slow. This mother of four said none of her children had been vaccinated against measles. She had never seen vaccination teams in the area.

By: Mohamed Yamani 

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Shamsa Abdullahi Bybook: A champion for Somali women’s reproductive health rights

Mogadishu – Shamsa Abdullahi Bybook was a young nurse in her twenties when she fled the mounting chaos and tensions of Mogadishu in 1989 to start a new life in the United Kingdom. She became an experienced midwife at a North London hospital with a master’s degree from Middlesex University and raised a family.
But she never forgot Somalia. On her periodic visits to her homeland, the mother of six was appalled by the poor medical facilities available to young pregnant women and the numbers who died during childbirth.

“We saw the suffering the mothers were going through,” the 59-year-old native of Kismaayo recalls. “The babies were also dying unnecessarily for (the lack) of a simple procedure called resuscitation and oxygen.”

In 2016, she decided to do something about it. Shamsa and her husband packed their bags and moved back to Mogadishu to found a maternity hospital offering quality reproductive services to Somali women – the Bybook Maternity Hospital.
Shamsa fully realized the risks her homecoming entailed. She was working in London as a part-time newsreader for the British Broadcasting Corporation’s Somali language service when she was sent to Kismaayo on assignment in 1997 and was briefly abducted by armed militia.

Within months of her return to Mogadishu, the maternity hospital opened its doors in the Hodan district of the Somali capital in October 2017. It offers a wide range of inpatient and outpatient services that include safe birthing, pediatric and childcare, female genital mutilation counselling, diagnostic sonography, postpartum care and infertility care.

“We decided to be different by focusing more on quality care. For example, we ensured that no newborn baby dies for lack of oxygen or resuscitation equipment or even incubators. This is important for the country,” she observes, adding that she has also launched a campaign touting the benefits of giving birth in a tub of warm water to reduce maternal mortality rates.

The importance of high-quality medical facilities for Somalis cannot be overstated. According to the United Nations Children’s Fund (UNICEF), mortality rates among Somali children are amongst the highest in the world. One out of every seven Somali children dies before their fifth birthday, which translates into a death rate of 137 out of every 1,000 live births. Mortality rates for mothers are also high, with UNICEF flagging that one out of every 12 women dies due to pregnancy-related causes – a death rate of 732 out of every 100,000 live births.

The 45-bed Bybook Maternity Hospital records an average of 50 safe deliveries each month and also treats newborns with breathing complications. Word of mouth has spread the reputation of the hospital far and wide, with pregnant women coming from towns as distant as Afgooye and Jowhar.

“Due to our positive effort, many people now know about our services,” notes Shamsa. “Even less educated mothers tell me they have been told that we have special equipment that help mothers and their newborn babies survive.”

However, the lack of effective regulation in Somalia’s health care sector remains a source of constant concern for Shamsa. She blames poor training and inadequate equipment for causing bodily harm and unnecessary loss of life on a regular basis.

UNICEF notes that Somalia is plagued by inconsistent health care delivery structures, with medical services provided by a mix of health authorities, private entities and international and national non-governmental organizations. The former nurse urges Somalis wishing to improve the state of health care in their country to consider medicine as a career option and expand the number of hospitals that can save lives.

“My husband and I have left our children and our grandchildren to have this (maternity hospital) and help the people who are in need of our services,” she says.

“I would advise everyone who has that ambition to go ahead with it because we have been through it. Do not stop, do not become discouraged.”

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Three Humanitarian Challenges for Africa in 2018

When a cholera epidemic threatened to overwhelm Somalia's heath-care system last year, a coordinated response by local, regional, and international organizations contained the crisis and saved countless lives. Somalia and other African states facing natural or manmade disasters this year should seek to build on that success.
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Somalis with mental health concerns are benefiting from St. Scholastica initiative which brings social work students to medical settings

Chris Roemhildt, a student at the College of St. Scholastica, asks a question during a class at Essentia Heath-St. Mary's about accessing medical records. Roemhildt and fellow students are working on their Master's in Social Work degrees, which includes an internship at Essentia in the ROBUST program. Bob King / rking@duluthnews.com

 As a social work intern in the Twin Cities, Najma Mohamed hears traumatic stories from her fellow Somali immigrants every day.

"These are clients that are coming from war-torn countries," said Mohamed, 26, who came to the U.S. when she was in her early teens. "They witnessed a lot of violence, a lot of robbery, a lot of burning houses. ... I had one client, she said she was raped by 10 men."

Her desire to help people with such horrific backstories led Mohamed to obtain a bachelor's degree in social work at The College of St. Scholastica's St. Paul campus. Now, as she works toward her master's degree from St. Scholastica, Mohamed is getting support from a program for which the school received a federal grant of $1.3 million over four years.
The program goes by the acronym ROBUST, for Rural Optimization of Behavioral Health for Underserved Settings, and it's being used to support six-month internships for 20 St. Scholastica graduate students in social work.

The buzzword for the program is "integrated." It means placing social workers alongside other professionals in helping clients with multiple needs.

"I really hope to see this become a way of our practice where we have physicians and nurses and social workers working cooperatively on a singular treatment plan versus a handful of individualized treatment plans," said Julie Seitz, clinical director at the Center for Alcohol and Drug Treatment in Duluth.

Seitz already was working on her master's at St. Scholastica when faculty member Paula Tracey encouraged her to apply for a ROBUST internship. She did, she got it, and she's using it particularly to look at ways to reach people outside of Duluth who are seeking to overcome opioid addictions.
That can include working to help more rural physicians obtain the waivers needed for them to prescribe medication to assist in recovery and providing counseling via telehealth, said Seitz, who has worked at the Center for Alcohol and Drug Treatment for almost 20 years.

Different perspectives

For Colleen Wheeler of Chisholm, the internship has her working alongside other health professionals at Fairview Range in Hibbing. Wheeler, 40, has been assigned to several different departments since beginning her internship shortly after the grant was awarded in October. The doctors and nurses she works with are open to her views, Wheeler said.

"It's really an environment of, 'I respect you, but this is my perspective,'" she related. "'I see where you're coming from, but look at it this way as well.'"

The biggest participant in the program is Essentia Health, which has just begun training the 12 interns who will serve in Duluth, Superior and Virginia, said Diane Holliday-Welsh, operations administrator for emergency medicine and behavioral health.
Essentia's participation is driven by the emotional and behavioral baggage many patients bring with them when they come to the hospital, Holliday-Welsh said.

"Thirteen percent of our patients who present to our St. Mary's Duluth emergency department are presenting with a mental health concern," she said.

'The best thing'

A ROBUST internship comes with a stipend of at least $10,000 plus allowances for gas money and books, said Lee Gustafson, who chairs the Department of Social Work at St. Scholastica.
The money made a big difference to Mohamed, who worked hard to pay off the loans that helped her get a bachelor's degree.

"I was able to pay off some of my tuition, and then as soon as I was supposed to apply for loans, this was offered to me," she said. "It was just like, out of nowhere, it was the best thing."

With a population largely clustered in the Twin Cities, a student focused on Somalis might seem an odd fit for a grant that begins with the word "rural." But Gustafson said it does fit the program's emphasis on disadvantaged groups. Also, he pointed out, their native Somalia is largely rural.
Most of the clients Mohamed sees have post-traumatic stress disorder, depression, anxiety, or a combination of the three, she said.

About 150,000 Somalis live in the U.S., according to a 2015 United Nations estimate, and more live in Minnesota than in any other state. "They all come here," Mohamed said. "Even if people come to other states, they end up moving here to Minnesota just because they need the help from the community."

Extreme challenges

While many of her peers chose to seek nursing careers, Mohamed opted for social work because it deals with all aspects of a person's life, she said. She feels especially called to her own community because it's a population that's underserved and has experienced so much trauma.
The woman who was gang raped 25 years ago still experiences physical effects as well as nightmares and flashbacks, Mohamed said. A man told her he was restrained and beaten while being forced to watch other men rape his wife. "Another client said, 'My two sons were shot right in front of me.'"
She's still learning how to help people who have been through such extreme circumstances, Mohamed said. But she has learned to keep her emotions under control as she listens.

"I have to remain strong, because that's the only way I can help them through it," she said.

Whether in the state's Somali community, on the Iron Range or in a drug treatment program in Duluth, participants in the ROBUST program say they hope to be better-equipped to meet the broad needs of underserved populations.
"This grant goes far beyond the walls of any of our health care organizations," Essentia's Holliday-Welsh said. "It's really going to pay dividends for our community."

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Warning Alarm on Public Health: Resistance to anti-tuberculosis drugs growing in Somalia

Gene specialist Samira Alrahman Abrahim investigates samples in the laboratory of the Hargeisa tuberculosis hospital. Photo: Joonas Lehtipuu.

Finland participated in the fight against the spread of tuberculosis (TB) in Somalia already before the Somali Civil War in the 1980s. The war complicated efforts to handle the tuberculosis situation, but efforts to eradicate the disease is now continuing.

Idris Muser Walays, aged 55, is sitting on a hospital bed. He has been hospitalised for 40 days.

"I was very sick before I came to hospital. I couldn't walk and had breathing difficulties."

Idris Muser Walays (aged 55) is treated for a serious tuberculosis in the Hargeisa Hospital in Somaliland. Photo: Joonas Lehtipuu.

This is the first time that Walays has been admitted to the Hargeisa Tuberculosis Hospital in Somaliland. He has contracted a serious form a tuberculosis, which has spread not only to lungs but also to all internal organs. Difficult cases like the one Walays has can be treated in only few hospitals in Somalia.
Somalia is one of the high TB burden countries (high burden country, HCB) in Africa. In 2016, more than 14,000 people were diagnosed with the disease but many cases continue to remain undetected.  The Hargeisa Hospital treats over 2,000 patients a year.
"Poor population groups are at increased risk of TB infection, which is why the disease is common in Somalia.  Undernourishment, poor general health and poor living conditions make people vulnerable to the disease and its spread."
In many countries, the most vulnerable people, including the elderly, children and HIV-positive, contract the disease.

"In Somalia, the disease is often diagnosed among the adult population, which is exceptional," Abdullahi says.

Tuberculosis is a droplet infection. One person with the bacteria may infect as many as 15 others around him or her and these then pass on the disease to others. In the end, all villagers may be affected. Abdi Yusuf Ahmed, aged 85, came to the hospital to have treatment for tuberculosis for the first time in his life. Ahmed tells that tuberculosis is endemic in the village.
"We saw many patients with tuberculosis who were coughing but as we were not aware of how the infection is contracted we didn't know to avoid them."
During the Civil War, hardly any health care was available in rural areas for decades. Misconceptions about the disease were also common.

"In my childhood, parents told that people could contract the disease by drinking camel milk. We are wiser than that now."

Hargeisa Tuberculosis Hospital in Somaliland. Photo: Joonas Lehtipuu.

Increasing resistance to drugs is a cause for concern

Dr. Adam Abdullahi says that the biggest concern in Somaliland is the increase of drug-resistant tuberculosis.

"Our hospital is the only one beside hospitals in the capital city of Mogadishu and in Puntman state where drug-resistant tuberculosis can be treated."

The World Health Organization (WHO) estimates that the incidence of multidrug-resistant tuberculosis in Africa is one of the highest in Somalia. Over eight per cent of the new cases are drug-resistant. Moreover, as many as 47 per cent of patients coming to be treated for a second time carry a drug-resistant strain of the disease. The main reason for the increase of the drug-resistance is treatment with wrong medication and patients' failure to complete the course of medication because of lack of knowledge or money. Tuberculosis requires a long course of treatment, even for as long as over six months. In a poor country, few patients can afford long treatments.

"We treat approximately 300 patients with a multidrug-resistant form of tuberculosis every year and manage to cure about 83 per cent of them," Abdullahi estimates.

The laboratory determines which strains are drug-resistant

Patients must leave their shoes at the door and wear rubber shoes provided by the laboratory. They must cover their hair under a cap and wear a respiratory equipment and  a disposable protective gown. No one is allowed to walk into the TB laboratory located in the hospital area without permission. A laboratory funded by the Finnish Physicians for Social Responsibility (PSR) organisation functions as a national reference laboratory.  The laboratory staff diagnoses TB samples sent from all parts of the country and determines which ones are drug-resistant.

"Earlier laboratories' incapacity to determine which cases are drug-resistant constituted the bottleneck for treating patients. In the course of the past couple of years, treatment has become much more effective because we know which drug suits the patient," says Farhan Mohammed Osman, Assistant Manager of the laboratory.

According to Osman, the laboratory has managed to step up its procedures thanks to new, effective microscopes provided by Finland.

Minttu-Maaria Partanen
The author of the article is a freelance journalist

FACTS:
Results of Finland's anti-tuberculosis work

• Finland supported Somalia before the eruption of the Civil War in the 1980s. At that time, there was a National TB programmes (NTP), which led to a marked drop in the incidence rate. Finland's work to fight tuberculosis was then considered to be among the most advanced in the entire African continent.
• Finland supports work to fight tuberculosis in Somalia for example through the Physicians for Social Responsibility (PSR) organisation.
• The PSR diagnoses and treats TB patients in the biggest tuberculosis clinics in Mogadishu and Hargeisa. In Somaliland, the PSR maintains a national tuberculosis laboratory.
• In 2016, the PSR was engaged in approximately 8 per cent of all TB cases that were diagnosed. 83 per cent of them were cured.

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