Sunday, June 30, 2019

Dangerously Unregulated: The Dire Conditions at Hargeisa Group Hospital

If you need medical attention from one of the publicly run hospitals in Somaliland such as Hargeisa Group Hospital, make sure you bring with you latex gloves, syringes and most of the basic medical provision you will need. Should you be unfortunate not to have these basic medical supplies with you, the nurse of the doctor will simply move on to the next patient.
While government-run hospitals such as Hargeisa Group Hospital are much cheaper than their privately owned counterparts, every service you may need including the hospital stay is a service you will have to pay for separately and if you need white-glove service, obviously it’s an extra charge.
There are public hospitals in most major cities in Somaliland and Hargeisa Group Hospital is the largest in the country and was built in 1950 to serve 20 to 30 thousand people now serves more than half a million a year with no significant changes or upgrades.
We have visited Hargeisa Group Hospital and spoke to doctors and other medical professionals and patients to understand their experience of Somaliland’s public hospitals.
In the past, people lost their lives because basic medical services were inadequate in Hargeisa Group Hospital.
One person we spoke to told us stated that a relative passed away because the person in charge of the hospital oxygen supply was unavailable. Another patient died of her gunshot wounds because lifesaving surgery could not be performed without the anesthesiologist who went home for the night. 
It is important to note that these incidents particular incidents took place few years ago and we have confirmed that both departments are manned 24/7.
While many say the conditions at Hargeisa Group Hospital have substantially improved, others point to staff that are focused on ensuring they get paid a fee to place a patient in one of the payment based rooms than the wellbeing and care of patients.


Healthcare is the very expensive and consumes a large part of most nation’s GDP, but in Somaliland, the Ministry of Health Development has the 6th largest budget in 2019 at 73 billion Somaliland Shillings or roughly 8.6 million US dollars.
Only 1.3 million dollars is allocated for activities directly related to public hospitals. It is not clear how much the government has earmarked to individual hospitals and specially Hargeisa Group Hospital.
Many expansion and renovation projects are funded by aid agencies including EU, UNHCR, Danish Refugee Council, IOM, and MIDA FINNSOM.
Other agencies fund various departments of the hospital such as the maternity and neonatal, maternity and the dialysis departments.
The hospital itself generates significant revenue from various services it provides including hospital stay in the rooms. The prices are 8 US dollars for the older rooms and there are 34 of them and 15 US dollars for the24 newer rooms and according to current employees of the hospital, there are rarely any vacancies. The room occupancy alone could conservatively generate well over 200,000 US dollars a year.
24 $  15.00 $  360.00 $  131,400.00
34 $    8.00 $  272.00 $    99,280.00
Annual room Rental $  230,680.00
While there are no free services at Hargeisa Group Hospital, its fees are substantially cheaper than the privately owned medical facilities and there is also a waiver system for those that cannot pay.
According to a midlevel employee of Hargeisa Group Hospital who spoke on condition of anonymity, none of the revenue the hospital generates goes into government coffers where it can be properly accounted for and ensure that hospital running costs are actually paid and funds set aside to purchase or replace aging equipment.
In fact, according to the same employee, every Section Manager from the Ministry of Health was drawing a bonus of 700 US dollars a month from the hospital. Who approved these payments and how long this has been the case are unknown. The new Manager of Hargeisa Group Hospital Mr. Yassin Abdi suspended these payments.
Despite the many sources of funding and revenues to run and improve conditions at Hargeisa Group Hospital has significant debt to the tune of hundreds of thousands of dollars.
Only two weeks after the helm as the Director of the Hospital Dr. Yassin Abdi Arab told the Social Affairs Committee of Somaliland Senate that his predecessor Dr. Ahmed Omar Askar has left him with a debt of 423,000 US Dollars for unpaid electric bill and purchase of medicines for the hospital.
Sources with knowledge of the operation of the Hargeisa hospital who requested anonymity point to widespread corruption and mismanagement. When asked for proof of the corruption allegation, most have pointed to the lavish lifestyles of some employees of the hospital.
A medical professional working in Hargeisa Group Hospital said: We need a holistic review and a solid plan, I don’t think adding a new building every few years has worked for us.


One of the most bizarre things we have learned during our investigation of Hargeisa Group Hospital is that is the hospital has no incinerator or medical waste disposal facility.
There is no seperate stream to ensure hazardous waste does not end up in the hospital’s regular refuse. This could endanger the hospital’s custodial staff and the general public. 
What is more alarming is that the hospital chooses to bury placentas and other human tissues in the back of the hospital. Multiple employees from the Ministry of Health Development confirmed the unmistakable smell of decomposition coming from windows that face the back lot of the hospital where human tissues are allegedly buried.
In addition, the hospital has no process to dispose of an amputated body parts such as limbs they simply ask the patients family members to take it with them and bury it somewhere.
On the handover ceremony, the former Director of the hospital Dr. Ahmed Omar Askar stated that most of the wards that were build by the British have Asbestos and went to explain the dangerous health hazards associated with exposure to it including the fact that it causes lung cancer.


The lack of confidence in public hospitals has led to the creation to multiple privately owned hospitals throughout Somaliland where many are staffed by foreigners and the same doctors who work at the public hospitals such as Hargeisa Group Hospital.
The vast majority of patients who use the publicly run facilities such as Hargeisa Group Hospital are those who cannot afford the exorbitant price of the private facilities in Somaliland. 
When the former Minister of Health Dr. Hassan Ismail Yusuf fell ill in late January this year, he was taken to Haldoor private hospital and not Hargeisa Group Hospital.President Bihi accepted Dr. Hassan Ismail Yusuf resignation in April 2019 following his illness and replaced him with Mr. Omar Ali Abdillahi Bade as the Minister of Health.

President Bihi visits the former Minister of Health at Haldoor Hospital in Hargeisa
Private hospitals such as Haldoor, Hargeisa International Hospital, and Edna are not affordable to most patients but many believe that they offer the best chance of survival for acute medical conditions. 
Those with means avoid seeking medical care in Somaliland altogether and embark on arduous journeys to Ethiopia, Djibouti and as far away as Turkey and India to seek medical attention and potentially spending tens of thousands of dollars because they do not trust the healthcare system in Somaliland.
There is no data from the Ministry of Health to show trends and help compare private and public health facilities in terms of quality of care.
Other public hospitals throughout Somaliland fare even worse than Hargeisa Group Hospital and most lack even the most basic of services despite millions of public funding being spent on them and changing hands from multiple NGOs.
The new Direct of the Hargeisa Group Hospital Dr. Yassin Abdi has declined to comment for this story citing an ongoing review of hospital processes. 
Efforts to reach his predecessor Dr. Ahmed Omar Askar for comments were unsuccessful.

Source: Original version of this report published in Somaliland Chronicle  

Saturday, June 29, 2019

Humanitarian aid: over €110 million in the Horn of Africa

As the Horn of Africa region continues to be afflicted by severe and prolonged humanitarian crises, the EU announces a new aid package worth €110.5 million. Since 2018, the EU has provided humanitarian assistance in the Horn of Africa totalling €316.5 million.

The EU is committed to assist people in need in the Horn of Africa. I have visited the region several times and EU partners are making a real difference in helping those most in need. Our new funding will support those that have fled their homes, fragile host communities, and those suffering from natural disasters, especially drought. For aid to work, it is essential that across the region humanitarian organisations have full access to those in need, said Christos Stylianides, Commissioner for Humanitarian Aid and Crisis management.
The EU funding is allocated across the following countries: Somalia(€36.5 million), Ethiopia (€31 million), Uganda (€28.5 million), Kenya (€13.5 million) and Djibouti (€1 million).
EU-funded humanitarian efforts in the Horn of Africa support the most vulnerable people, including refugees, internally displaced people and host communities. providing them with food assistance, shelter, safe water, health and nutrition care, protection, and education for children caught up in humanitarian crises.

How EU aid helps
The EU is helping with life-saving food assistance and treatment for undernutrition in children under five years of age, while also protecting people's livelihoods. Where possible, multi-purpose cash transfers are used to allow households to feed and sustain their family.

The EU supports basic health care and the strengthening of disease outbreak prevention and response measures. For example, the EU has contributed €2.5 million in humanitarian aid this year to the Ebola rapid detection and reaction efforts in Uganda.
Humanitarian situation overview
Taken together, Somalia, Ethiopia, Uganda, Kenya and Djibouti host more than 2.7 million refugees, mainly from South Sudan, Somalia, the Democratic Republic of Congo and Burundi. Moreover, conflicts and weather-related disasters have forced over 6 million people into internal displacement in Somalia, Ethiopia and Kenya.

The Horn of Africa region is prone to epidemic outbreaks due to low vaccination coverage, high undernutrition rates and mass population movements.
Repeated spells of drought and floods continue to exacerbate the vulnerability of people in the region. An estimated 11 million people in the region are in need of food assistance as a direct consequence of extreme weather events or displacement, and as many as 4 million children under five years of age suffer from undernutrition.

When immigration detention makes healthy people sick

We’re two doctors who work as part of a growing network of volunteer medical providers advocating for adequate medical care for people in immigration detention.
A troubling case demonstrates that increased Immigration and Customs Enforcement (ICE) detention of immigrants is causing the people they detain avoidable medical harm.
Suheila, 2 1/2, daughter of Abdikadir Mohamed holds a sign during a rally in support of her father, who has been detained by immigration authorities for 18 months. June 11, 2019 (Photo: Monsy Alvarado/
Abdikadir Abdulahi Mohamed (“Abdi”), a man in his 30’s from Somalia, was athletic and healthy 18 months ago, before ICE placed him in a New Jersey for-profit immigration detention center in Elizabeth.
During his medical intake, Abdi was found to have latent tuberculosis (TB). Latent TB doesn’t cause symptoms and isn’t infectious to others. But people with latent TB are at risk for developing active TB disease when exposed to malnutrition, stress, and conditions that weaken the immune system.
ICE did not treat Abdi’s latent TB, as recommended by the Center for Disease Control’s guidelines for treatment. This matters in crowded and poorly ventilated immigration jails because if TB becomes active, it could spread. And active TB can be fatal.
Abdi complained of worsening health for months. He began to lose weight and became too weak to exercise. He complained of rib pain and was given over the counter analgesics. Even when he developed a cough, pain with breathing, and fevers, his lungs were not examined.
In November 2018, six months into these symptoms, Abdi worsened suddenly. For 10 days he asked to see a physician. He stopped eating, he had fevers, and was too weak to get out of bed. The pain was excruciating. He was told he needed a chest x-ray, which he got five days later.
That chest x-ray showed Abdi had fluid in his lungs. Only then was he was taken to the hospital. It turned out that he had developed pleural TB, an infection in the lining of the lungs.

Abdi was shackled to the hospital bed throughout his 10-day stay. He understood few details of his illness, because at no point in all of this time, was he offered an interpreter.
After this avoidable delay in diagnosis, Abdi suffered further inadequacies in care. One physician told him he only needed one month of TB treatment, instead of the standard six months, leading to a dangerous interruption in his care. He was not provided with consistent transport to follow-up appointments with the TB specialists. He did not get the recommended blood work to monitor his liver function, because TB medications can rarely cause liver failure. 
Luckily, he has survived. But Abdi still has pain and may have permanent scarring in his lungs. It is not clear if his untreated latent TB became active in the setting of toxic stress and poor nutrition, or if he contracted a new infection. It is clear that he did not get the medical care he deserved.
TB control efforts in the community have kept the spread of TB in check for decades, even with ongoing immigration. Outbreaks of mumps, chicken pox, and flu have led to quarantines at over 50 ICE detention centers across the country.
Currently, individuals in ICE detention at Bergen County Jail in New Jersey are being quarantined for mumps, leading to interruptions in their court hearings and visitations. Given that detention centers are located in our communities and staffed by community members, these outbreaks threaten the health of everyone.
In a patchwork regulatory system, it is unclear whether ICE, or the county and state health departments, are responsible for ensuring public health oversight. Adequate latent TB treatment takes months, but since people may be in ICE custody for only days to several years, treatment is often not initiated. This means peoples’ lives are in danger of falling through the cracks.
The exponential increase in detained individuals is overwhelming the capabilities of immigration jails and prisons to attend to peoples’ basic health needs and prevent the spread of disease. If Abdi’s case and the mumps outbreak at the Bergen County Jail are any indication, we can expect more outbreaks in the future. Meanwhile, his health will continue to be at risk until he is released.
Chanelle Diaz and Elizabeth Chuang are doctors and part of the medical providers network organized by New York Lawyers for the Public Interest.


My journey from Amoud university to the National Health Service, UK.

  I am now a Doctor in the national health service NHS. I am serving the community that I live in and work is just a short walking distance from home. However, the journey to get to this point has been very long and rather challenging.

  I graduated from Amoud University in 2014. I completed my one year internship straight afterwards. My intern year provided me with a broad exposure to a variety of surgical and non-surgical specialties, with a focus on the care and management of patients.
I undertook teaching roles at Amoud and Eelo Universities. I was also Medicine Africa Co-Ordinator for the King’s Somaliland Partnership.

I came to the UK in November 2016 to join my wife. Shortly after arriving; I enrolled into an International English Language Testing System (IELTS) course to prepare for my academic IELTS. This course was structured and enabled me to successfully pass this exam. To register as a Doctor I am required to demonstrate that I possess the necessary knowledge of English to practise safely in the UK. Therefore, a score of at least 7.0 in each testing area; reading, writing, speaking as well as listening and an overall score of 7.5 are required.

  The Professional and Linguistic Assessments Board (PLAB) test provides the main route for International Medical Graduates to establish that they have the necessary skills and knowledge to practise medicine in the United Kingdom. I independently prepared for PLAB 1. This is a written exam made up of 180 multiple choice questions which must be answered within three hours. The exam tested my ability to apply my knowledge for the care of patients and questions related to current best practice in the UK, and equipment routinely available in UK hospitals.
Dr. Aidrous Elmi Yousuf
 PLAB 2 is an objective structured clinical exam (OSCE). It's made up of 18 scenarios, each lasting eight minutes and aims to reflect real life settings including a mock consultation or an acute ward. I went to Manchester to sit this exam. Prior to this, I undertook a two months preparation course to enable to successfully grasp standard criteria and competencies.

  I completed a one day Immediate Life support course at King’s College NHS Foundation Trust in November 2018. This course has enabled me to refresh my skills as a first responder and treat patients in cardiac arrest until the arrival of a cardiac arrest team.
Currently, I work Royal london hospital in London, renal medicine and transplant centre which is the 3rd largest transplant centre in the whole UK. What I was taught inAmoud university enabled me to work in the UK in the same way as the UK trained doctors. Which means if you are trained in Amoud university, you are allowed to work and practise in the UK provided you pass the licensing exams.

 I am so grateful for my wife and family for their support and particularly for prof Said Ahmed Walhad and Dr Ismail Aye for their relentless assistance.
Moreover, I am also indebt for Ahmed I. Nour
Nuradin Adam
In netshel, no matter where you learn hardworking is the key to success.

Friday, June 28, 2019

Omobari Omotwe: the highly skilled traditional ‘head surgeon’ of the Kisii tribe in Kenya

The Kisii tribe of Kenya is among one of the earliest Bantu settlers in modern-day Kenya. They are the dwellers of the highlands east of Lake Victoria. Accounts concerning their points of origin before situating themselves in their present locality are of varied nature; some scholars claim they came to their present settlement from ancient Egypt whilst others claim they settled from Uganda.

The Kisii tribesmen are predominantly farmers and craftsmen; economically viable activities that put food on their table and accord them media of exchange for those goods and services they are unable to produce and provide for themselves. Kisii tribesmen follow a tradition of fathering a lot of children, partly to aid the agro-culture on which they subsist and partly to carry on the tribe’s legacy and cultural heritage. They are a well-educated and highly skilled cohort whose endeavours are characterized by order, structure and precision; functional features of one of their most revered practitioners…
‘Omobari Omotwe’ is the Kisii word for a head surgeon. These highly knowledgeable men in the medical art of ‘craniotomy’ and highly skilled in those medical practices that bring to bear the practical application of their knowledge are recorded to have practised their craft with astonishing success long before ‘official’ means of documentation were made feasible.
Omobari understudies a more advanced practitioner who is usually a relative, by years of study and apprenticeship ordered along the lines of increasing difficulty given each assignment, a young Kisii can rise with dedication, determination and hard work to become Omobari over the years. And this spells out wealth, prestige and recognition for the said individual and his family.
Omobari’s craft is tailored towards the resolution of; acute cranial trauma and post-traumatic headaches. The cases brought to Omobari tend to have causes rooted in accidents and violence. Accidents can range from hitting one’s head against the low lintel of a Kisii hut to being struck in the head with a hoe on the farm unintentionally. Violent actions leading to seeking out the services of Omobari can also range from a severe blow to the head using a blunt object on the field of war and the use of head trauma inducing ‘weapons’ such as wooden clubs in severe cases of sibling rivalry or disputes among wives.
When a patient is brought before Omobari, he foremost says a prayer for guidance and then palpates the head of the patient to pinpoint the spot on the head where the incision will be made. Patients are given herbal concoctions before, during and after the operation to; minimize pain, boost immunity, sterilize the open flesh on the head and to stop bleeding and the patient from smelling the scent of blood during the procedure, because it can have a nauseating effect on the patient in question. The use of herbs thus improves the efficiency and overall effectiveness of the entire procedure.
In the case of acute cranial trauma, this is usually caused by a direct blow to the head by the use of blunt objects as mentioned earlier. The destructive effect of such deathly encounters is easily noticeable by the experienced and highly skilled Omobari who quickly but adeptly cuts his way into the skull of the affected area. This is to help remove all fractured bones and smoothen out the fractured edges to allow for the affected area to heal. All these are done with an astonishing success rate as all those modern medical practices that guarantee success in any surgical procedure are duly and methodically observed by Omobari and his apprentice(s), except within the parlance of his cultural traditional practice which is equally valid nonetheless.
Cases arising from post-traumatic headaches tend to tow the lines of examining the head critically by Omobari to help him identify which point on the head to open in order to resolve the case in question. Once Omobari is satisfied with the site located, he employs his homemade tools in digging into the area beneath the skull in his bid to drain out what has been named; ‘bad blood’. This is most probably non-circulating blood collected in an area beneath the skull that has gone bad. A critical examination of the site is also carried out to make sure there are no fractured bone fragments in the region, as these can puncture delicate blood vessels and lead to the same or more complicated medical conditions.
There is little to no known case of infection over operated areas given Omobari’s art. Furnas et al (1985) reported Omobari and his apprentice(s) as neat and orderly when engaged in their line of duty.
The craniotomy undertaken by Omobari and his team of medical specialists is very effective in the treatment of acute cranial trauma and post-traumatic headaches. Their Maasai neighbours are known to visit the Kisii Omobari for treatment on occasions. The procedure is again reported by Furnas et al (1985) to have a strong placebo effect. Thus the Omobari and his team of medical specialists do not only resolve the physiological anomaly associated with reported cases but its psychological dimension as well.
The Afrikan in view of these must make highly conscious efforts to foremost safeguard his continent within which can be found highly advanced practices, and also learn to safeguard him/herself by whom these advanced practices are made manifest.
Furnas et al. (1985). Traditional craniotomies of the Kisii Tribe of Kenya. Annals of Plastic Surgery. Vol 15 (6).

Thursday, June 27, 2019

Inside Somalia’s mental health emergency

Despite high rates of mental illness in Somalia, the country is unable to provide the most basic of care to those in need – many of whom are isolated, chained to hospital beds, or even jailed.
One in three Somalis are affected by some form of mental illness, a far higher rate than the one in five expected among communities living in war zones, according to the World Health Organisation(WHO).
Somalia has been at war for close to 40 years. It has suffered three famines, waves of displacement, and currently 5.4 million people – more than one third of the population –  rely on aid to survive.
Despite these trauma-inducing conditions, Somalia has only five WHO-recognised mental health centres – basic at best – and just three psychiatrists for the entire country.
“All this violence and killing could be the manifestation of a wider problem.”
Abdurahman Ali Awale is one of them, working out of the hospital in the capital, Mogadishu, serving a population of 2.8 million.
Awale worries that the scale of unaddressed mental health problems is so vast it may be contributing to Somalia’s instability. “All this violence and killing could be the manifestation of a wider problem,” he told The New Humanitarian, referring to the country’s political instability and insecurity.
In the self-declared independent republic of Somaliland, psychiatrist Djibril Ibrahim somehow manages to see anywhere between 20 to 50 patients a day. There is only one other psychiatrist working in a region of four million people.

Cluster of causes

Traditional male gender roles are under pressure in the Somali context of endless war. The exacting expectations for men is that they be “courageous, generous, [good] orators, patient, humane and capable,” according to a Rift Valley Institute study. But men are not only the overwhelming perpetrators of violence but also its victims – and they additionally tend to lose out in the aid agency gender pecking order over who receives assistance, said the study.
Joblessness makes matters worse. An unemployment rate of 80 percent in Somaliland is not only a source of distress, but many people resort to chewing the mild stimulant khat to pass the time – which can be detrimental when taken in excess.
“The bulk of the literature about khat abuse and psychosis indicates they have a direct relationship,” said Ibrahim. “In the 70s and 80s people [in Somaliland] used it in the afternoon. Now we are seeing khat used from sunrise to sunset due to unemployment and depression.”
GRT (“Gruppo per le Relazioni Transculturali”), an Italian NGO based in the northeastern port city of Bosaso – in the autonomous region of Puntland – has linked nearly a quarter of its mental health cases to khat use.
Migrants returning to Somalia, often traumatised during their journey or time abroad, are adding to the mental health caseload. Deportees [including from the United States and Europe] are among my patients,” said Awale. “Cases I have seen include drug addiction but also traumatised persons.
Ismail Mohamed, now 40, migrated from Mogadishu to Yemen five years ago. During a boat crossing from Bosaso, he said he witnessed women and children drown and was himself beaten by the smugglers on the boat.
“Men are not only the overwhelming perpetrators of violence but also its victims.”
He reached Saudi Arabia, where he hoped to find work but was deported eight months later after spending two months in jail as an undocumented migrant. In December 2016 he was back in Mogadishu, struggling to reintegrate.
“It was like that something bad was going on in my mind,” Mohamed explained. “I could not talk. I would fight my mother and family members. I did not know what I was doing. Sometimes I would sleep for two days and two nights.”
His family contacted Awale.
“When I first met Ismail he was suffering from a very bad post-traumatic stress disorder [PTSD], which is a mental health condition triggered by the terrifying events he has witnessed,” said Awale. “Daily, about five to 10 [people] with PTSD arrive at the hospital.”
Awale and other mental health professionals say its difficult to keep up with the need for mental healthcare. Government support is minimal and public hospitals rely almost entirely on private charity. “We survive [through] donations provided by members of the diaspora,” said Awale. 
Awale has routinely called for a more robust government policy to protect and treat mental health patients – to no avail.

Chains and cruelty

In Somalia, as in many countries of the world, the problem is not only the lack of care but the quality of treatment. Chaining patients is a widespread practice both in hospitals and in private homes which is “socially and medically accepted,” according to a WHO report. For some families, forced to look after sick relatives, this may be “an act of desperation” rather than cruelty.
“The stigma and discrimination towards people [with mental illnesses] is beyond imagination in this country.”
“You see patients who are sometimes traumatised and need some sort of support are being chased and insulted on the streets of Mogadishu by a mob,” said Awale. “It’s painful to see the cruel treatment meted out to these patients by some parts of society.”
It’s a similar case in Somaliland. “The stigma and discrimination towards people [with mental illnesses] is beyond imagination in this country,” said Ibrahim. “People are denied treatment or even prevented from receiving treatment.”
This extends to some drug rehabilitation facilities. “There was a rehabilitation centre I was called [to] for a patient. I was shocked to see the mentally ill patient who had a high fever kept in chains and shackles,” Awale recalled.
In some cases in Somaliland, relatives take their kin suffering from mental health issues to prison, Ibrahim told TNH.
“You can’t believe it, but I did a study in 2014 at Borama Prison where 143 of the 200 inmates were mental health patients with no criminal record,” said Ibrahim. “We had to advocate for them, talking to lawyers and police, to ensure they were released.”
Last year Awale and other volunteers took part in WHO’s Chain Free Initiative, a campaign that aims to achieve dignity for the mentally ill. The goals include chain-free hospitals, chain-free homes, and a chain-free environment that can offer an improved quality of life for patients.
“Mental illness should be seen as a normal illness,” said Awale. “Sometimes patients may need only a short counselling period.”