"A person either is or is not insane” – in Somalia, there are no words for mental health care

With the support of FCA, psychotherapist Rowda Olad works in grassroots-level mental health care and participates in the reconciliation work in Somalia.

Rowda Olad spoke at the National Dialogue Conference in Helsinki. Photo Heli Pekkonen 

"In Somalia, people talk of invisible wounds, dhaawac yada qarsoon,” says psychotherapist Rowda Olad and describes how shocked she was to see the state of the entire nation’s mental health when she arrived in Somalia in 2016.

A young boy was driving the moped taxi, tuktuk, at breakneck speed through central Mogadishu. I asked him to slow down. ’You’re going to get us killed!’ I yelled from the back seat. ’What does it matter if we die,’ the boy replied.

”I was extremely shocked.”

Rowda says she immediately noticed that especially young men were not only fearless but also very angry. But in fact, almost everybody in Somalia seemed to be suffering from psychological traumas caused by the civil war and the violence, or from post-traumatic symptoms resulting from them.

There is a lot of crime, as well as disregard for other people’s possessions or lives. Whenever there was an explosion in Mogadishu, people rushed to see what had happened, whereas the natural reaction would be to run away.

"A person who is not afraid is not psychologically healthy,” says Rowda. “Seeing mutilated humans and bodies or victims of explosions is traumatising, especially to children.”

She witnessed and recorded all this during the first year after she and her family moved back to Somalia in 2016.

Psychological trauma changes a person’s world view and behaviour. In Somalia, aggressive behaviour can be seen often in everyday situations.

”Even during high-level political meetings, people may lose their temper at the drop of a hat.”

As a refugee in the United States

Rowda, who was born in Mogadishu, has her share of war trauma. The civil war began when she was seven years old.

Her siblings and other relatives scattered all over the world. With her uncle’s family, Rowda fled to the state of Ohio in the United States. She went to school and studied, but once she graduated from high school, she could not decide straight away what she wanted to do when she grew up. So, she volunteered to do social work with AmeriCorps. She helped Muslim immigrants, the Somali diaspora, young and old alike – and saw and experienced lots of things that could only be explained by the people’s backgrounds.

She started a volunteer group for young Somali women and became interested in studying to be a psychologist and psychotherapist. She also became fascinated with facets of Somali culture; what causes things? Why do we do this or think like this?

Rowda dreams of establishing a national mental health care system in Somalia. Photo: Kristiina Markkanen

Rowda studied, graduated, and worked as a psychotherapist. When the situation in Somalia began to settle down and the first post-war parliamentary election was held in 2016, even Rowda decided to move back to Somalia.

Rowda got involved in politics and initially worked in regional administration, but mental health care became more and more attractive. She dreams of founding a national mental health system in Somalia, entailing the entire structure, creating the foundations and the missing words for the work.

”For us, a person is either insane, waali, or not insane. There is no in-between, there are no other words. People who become seriously mentally ill are put in the hospital and forgotten there.”

”It is shocking,” she says.

Mental health care step by step

Rowda started her work in Somalia with small steps. She has been engaged in volunteer work and has spoken about mental health to representatives of the Ministry of Health.

First, my aim has been to open people’s eyes to the role of mental health in people’s behaviour and actions, and from there, I have slowly expanded the idea to the national level.

Rowda believes it is impossible for reconstruction and national reconciliation work to succeed without dealing with the trauma experienced by families, individuals and entire communities as well.

When people are traumatised, their capacity to function is impaired, which affects things such as their ability to work.

"The productivity of the entire nation, including entrepreneurs and civil servants as well as farmers, remains low.”

Rowda has started her own practice in Somalia, and with the support of FCA among others, has began a form of preliminary mental health care that she calls psychoeducation.

The purpose of the work is to talk about mental health and to provide different population groups with information. Topics include stress, depression, and how to overcome psychological trauma. What is considered ordinary grief and what kind of suffering is bad enough to require treatment.

The work also includes mental health care for prisoners and prison wardens. Inmates in the prisons of Somalia include both petty criminals and former terrorists, and it is important to get them too to commit to the development of Somalia.

A prison in Somalia. Photo: Jari Kivelä

"Even in prison, I provide mental health education for groups, during which we talk about how the human mind works. I also do clinical work, give diagnoses, and offer individual therapy to those who need it. Sometimes I have to refer an inmate exhibiting severe psychological symptoms to hospital treatment.”

Working with inmates, Rowda goes through their identity and the paths that led them to prison. Those who grew up surrounded by war and violence may not have the kind of identity that allows them to see themselves as citizens of an organised society.

For example, when I ask them who their role models are, they don’t say that as a child they wanted to be a doctor or a teacher, but might reply that they admire their father who was a war hero.

Rowda says that she will soon start working with the families of inmates as well. This is difficult because many families have moved. However, the Somali culture is very family-oriented, and Rowda believes it is possible for criminals to become rehabilitated into society if they receive strong support from their family and community.

Even therapy is a completely new concept in Somalia. There are only doctors and psychiatrists who work in hospitals and prescribe medication. If a doctor gives a person medicine, the person gets better.

”When I tell a patient I am offering them treatment, they expect medication, not discussion.”

She also hopes that mental health issues become part of reconciliation work. Rowda believes there will be no real peace in Somalia before recognising trauma and overcoming it is taken seriously on the national level.

Text: Kristiina Markkanen
Translation: Leena Vuolteenaho

Rowda Olad visited Finland in June for the National Dialogues Conference for peace work organised by the Ministry for Foreign Affairs, Felm, CMI, and Finn Church Aid.

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Turkey helps Somali youth to realize dreams

Turkey is becoming a favorite destination for many Somali youth, to pursue higher education in order to realize their dreams.

Young doctor Ahmed said Turkey had enticed him with its advanced education sector and strong economy

Somali Dr. Muhammed Ahmed ( Esra Hacioglu - Anadolu Agency )

Muhammed Ahmed, who graduated in medicine from Antalya University located in the Mediterranean resort city of Antalya, had fancied to study in Turkey since childhood.

Speaking to Anadolu Agency, young Somali doctor said his dreams became reality, when he qualified to seek admission at Antalya University in 2013.

Ahmed, who graduated in 2017 is now practicing at a private hospital.

He says Turkey had enticed him with its advancements in education, health and economy.

Looking forward to study further, Ahmed wants to become a cardiovascular surgeon specialist.

Turkey is a shining Muslim country. Normally, when we talk about Muslim countries, first thing that comes to mind is underdevelopment and a weak economy. But Turkey is a contrast, he said.

He said Turkey also had a well developed pharmaceutical industry.

Further, he said the hospitality of Turks was unmatched and they made Turkey a beautiful country for foreigners.

Highlighting historic ties between Turkey and Somalia, young doctor said his country was under the rule of the Ottoman Empire. He said people still remember the empire with love.

In my neighborhood in Somalia, people still drink water from a well dug by Ottoman rulers, hundreds years ago. The water in this well is coming from the nearby mountains. This is a marvelous engineering skill, he said.

After the Ottoman Empire, Somalia became a British colony [one part and Italian colony in other part].

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How Somaliland’s first midwife led the fight against FGM after traumatic childhood experience

As a child, Edna Adan Ismail’s doctor father, Adan Ismail, taught her to wash forceps and make bandages out of old bed sheets in the hospital he ran in Somaliland.

Edna Adan Ismail: ‘The hospital had never encountered a woman with nursing and midwifery certificates’

Edna Adan Ismail tells Pascale Hughes why she built a hospital to support Somaliland’s women and the importance of education

In 1950, when he went to work in a relief camp for people suffering from the drought known as the Year of Red Dust, he left notes for Ismail, then 13, telling her to ensure patients received medication and had sutures removed. 

I did not know what these medicines were for but I was the boss’s daughter, so I would go to whoever was in charge and say, ‘By the way, dad wanted you to remove these.

She noticed the hospital never had enough instruments or supplies. 

I can’t remember the exact moment when I decided I would build a hospital, but I do know I had a very clear image of how it would be run.

Ismail went on to do more than that. Now 87, she is a former first lady of Somaliland, its first woman cabinet minister, foreign minister, and nurse-midwife, an anti-FGM campaigner and, today, the director of the maternity and teaching hospital she founded in the capital, Hargeisa. She is certain she is the only foreign minister in the world to have had to leave a meeting to deliver triplets.

As First Lady of Somaliland, Edna Adan Ismail met US President Lyndon B. Johnson (Photo: supplied)

Fight against FGM

Today, Edna Adan Ismail is the director of the maternity and teaching hospital she founded in Hargeisa

Education

Edna Adan Ismail with her pet leopard in 1968 (Photo: supplied)

Facing new challenges

As foreign minister of Somaliland, she met US president Bill Clinton (Photo: supplied)

With seventh Secretary-General of the United Nations, Kofi Annan (Photo: supplied)

Ismail’s life has been defined by her fight to improve maternal healthcare in Somaliland and the fight against FGM. Somalia, and the autonomous region of Somaliland, has the highest rate of FGM in the world, with the procedure carried out on up to 98 per cent of women. Ismail’s mother and grandmother arranged for her to be cut when she was eight and her father was away from home. It was a deeply traumatic experience she has spoken about around the world.

The problem is that the practice is “glorified” in some communities, she says. “The ones who haven’t had it say, ‘Why have we not been purified? Why am I being denied this?’ But we need to educate young people, young parents, and not glorify the procedure.”

Ismail says she only became a midwife because her father made sure she learned to read and write, which was almost unheard of at the time for girls in the region. When she was 17, Ismail moved to the UK to train as a nurse after winning a scholarship. She was accepted on a course at the West London Hospital in Hammersmith.Ismail never had children but tried for many years. She says FGM could be have been to blame because it can cause pelvic organ inflammation. As a midwife, Ismail has seen the many complications it can cause during childbirth.

The rotation she enjoyed most was in surgery. “I loved operating theatres,” she says. “They were so clean and efficient. The satisfying sense of accomplishment was like nothing I had experienced before.”

When she returned to Somaliland three years later, she was determined to become a surgical nurse. “I didn’t want to be a midwife,” she says. “But then my father asked, ‘What are you going to do for women? What will you do if there’s a woman in labour who needs you?’ My father gave me so many opportunities and never stopped me from doing anything. It felt like it was his way of asking me to do something.”

When she returned in 1961 to the new Somali Republic, formed of British Somaliland and Somalia, she met new challenges. She was assigned to work in a hospital, but was given no position, no salary and had to fight to be allowed to drive. “The administrators had never encountered a woman with nursing and midwifery certificates.” People reacted with hostility, saying she would never marry.Ismail returned to London and learned to be a midwife at Hammersmith and Lewisham hospitals. When she was delivering four or five babies in a day, she understood why her father had suggested she train as a midwife. “Somaliland has the highest maternal mortality rate in the world. There are still areas where they have never had a trained midwife. I have scars of a forceps birth, my sister died after just such a delivery and someone who wasn’t medically trained dropped and killed my baby brother. I would return to Somaliland with my midwife training where it was desperately needed.”

In fact, she married three times. Her first marriage was to Mohamed Haji Ibrahim Ega when he was head of government in British Somaliland five days prior to Italian Somalia’s independence. They met in London and he went on to become prime minister of Somalia (1967-69) and president of Somaliland in 1993. They divorced five years later. Ismail married twice more, but says midwifery and the hospital are her most important relationships. In 2002, after stints working for the World Health Organisation (WHO), Unicef and the Ministry of Health, Ismail opened the Edna Adan Maternity Hospital. It was built on a former rubbish dump donated by the government.

Most nurses or midwives had fled or been killed during the Somali Civil War, which destroyed Somaliland’s health infrastructure and 95 per cent of its cities between 1982 and 1991.

Ismail recruited more than 30 candidates and began training them while the hospital was still under construction.

There are now 200 staff members and 1,500 students, and almost three-quarters are female. “I just did what needed to be done,” she says about her decision in 1998 to sell her home and car, and donate her UN pension, to fund the hospital. Patients come from as far away as Mogadishu, more than 800km south, and neighbouring Ethiopia, to seek treatment in the best-equipped general hospital around. More than 14,000 babies have been delivered and more than 140,000 patients have been treated.

In 2002, Ismail became Somaliland’s first female cabinet minister. She became foreign minister the following year, but continued to work in the hospital. “I am a midwife first and foremost. One day when I was meeting with a European delegation, I knew that there was a woman in the hospital who was going to have triplets. When the hospital called I had to say, ‘I’m sorry, I know we have got important things to discuss but I really have to go. I’ll talk to you tomorrow.’”

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Somali regional state to vaccinate over half million under children against Polio

Addis Abeba, August 23/2019 – Five zones of Somali region of Ethiopia and, Somalia/Somaliland and Puntland from the WHO Africa and Eastern Mediterranean regions respectively jointly launched the synchronized cross border polio vaccination campaign where the Somali region alone targets to reach over half million (586, 511) children whose age are 0-59 months from the five high risk zones namely Fafan, Jarar, Dollo, Erar and Nogob.

The overall synchronized target areas involved in Somalia and Ethiopia are Puntland and all regions in Somaliland except one and five zones of Somali region respectively. This made the total target population 1.6 million (Somalia 1.1 M & Ethiopia 586,511).

mOPV2 vaccination in Fafan zone of Somali region

Mr Abdirazak Seid, Honorable Advisor for the Somali Regional President Office, Dr. Jahwar Yusuf, Deputy Head of Somali Regional Health Bureau, Mr. Abdihakim Sheik Hassen, Chief Administrator of Fafan Zone, Mukhtar Abib, Mayor of Togowajale City Administration, Sheik Ahmed Abi, the religious leader, and Garad Kulmiye, clan leader and Goodwill Ambassador of Immunization for Somali region and partners from WHO, UNICEF, CORE Group, Rotary and save the children were in attendance.

Speaking during the launching event, “Mr. Christopher Alexander, from WHO Regional Office and Coordinator for the GPEI Horn of Africa Office stated that: 

This synchronized effort is an important activity and really a milestone since it is the first time that the two regions of WHO (AFRO & EMRO) come together to fight the disease. We must make sure no child is unvaccinated.  We need to show the commitment that we showed here in the joint launching in the ground to make sure that every community of every child must be vaccinated. Remember the vaccine is a right for a child. We have no reason to let any child paralyzed because of the polio. Vaccine is available, we are committed, so let us reach every child where the child is.

Polio is a highly infectious, debilitating disease which affects children and causes permanent paralysis. Polio is not curable, and can only be prevented by vaccination. Families and communities must ensure their children are vaccinated both during polio campaigns and through routine immunization. The Horn of Africa is currently in emergency with imported poliovirus of circulating vaccine derived polioviruses placing polio eradication as unfinished business. Circulating vaccine Derived-Polio Virus (cVDPV) outbreak was reported recently from Somaliland and the first-round quick response has been conducted in July 2019. Since then four more cases have been reported in Puntland in Somalia, one in Bosaso district, one in Ufyan district, one on the border with Somali region in Ethiopia and one in Dollo Zone Bokh Wareda in Somali Region of Ethiopia.

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Leadership and Management in Health Course- University of Washington (USA)

Dates/Course Hours:

This course will begin in Sep 23, 2019 to Dec 15, 2019

12 weeks (3 Months), 6-9 hours study per week is required for your best utilization in absorbing learning resources given for your knowledge & success. 

Providing Institution: 

University of Washington, Department of Global Health E-learning 
Faculty/Course Professors:

Prof. Ann Downer, EdD, MPH

Prof. Britt Yamamoto, PhD 

Overview

Learn how to lead organizations and manage people in this course on leadership and management. The course focuses on the practical leadership and management skills required for working in complex local, regional, national and global health environments. By the end of this course, you will develop a clear sense of the issues and challenges associated with leading organizations and managing people. 

Personal leadership development and practical management skills are both emphasized. Format This online course has video lectures, readings, discussion forums, quizzes, and three assignments. You can participate in this course as an independent participant or as part of a site with five or more people. 

We encourage participation as a group because it provides a forum for discussing course concepts and applying them to the local setting and customs. If you can’t join a group, the discussion boards can provide that forum. The course is taught in English. Participants should be comfortable with written and spoken English. 

Eligibility

The course is most useful for health care professionals and public health specialists who have some experience in management and who wish to enhance their skills working with people and other organizational resources. 

Most case studies, readings, and assignments assume an existing knowledge of the health care system, labor law, and funding landscape in your country. Participants will get the most out of this course if they can apply the concepts and strategies immediately to a work setting, including being in a position to lead meetings, facilitating team development, communicating on behalf of the organization, managing conflicts, analyzing and monitoring management data, supervising and delegating work, and managing some aspects of complex project implementation. The course is less well suited to individuals in entry-level positions in the workforce.

Syllabus

Learning Objectives

Participants completing the course at the highest level of achievement should be able to:

✔ Approach management challenges in primary health care settings with core knowledge and skills in economic, organizational, and management theory as a guide;

✔ Pose meaningful questions about what constitutes effective management and leadership in different cultural and organizational contexts;

✔ Make decisions that weigh practical needs and conditions with ethical, legal, and

compliance considerations;

✔ Use core principles and tools from human resources and finance to address challenges and solve problems;

✔ Translate insights from self-assessment into personal plans for improving leadership and management skills;

✔ Identify and consult appropriate sources of data for making sound management decisions;

✔ Align and motivate individuals, systems, and resources toward a common purpose;

✔ Design and manage systems that are responsive to donor and Ministry of Health requirements and assure financial and ethical accountability;

✔ Identify monitoring and evaluation methods that answer key questions about programmatic efficiency and effectiveness; and

Use active participation in class discussion, activities, and assignments to form a personal and professional value system for management and leadership in global health.

Topics

Module 1- Leading and Managing Frameworks

What is the difference between leadership and management? What are the skills associated with each? How can we measure the impact of effective leadership and management on health care systems?

Module 2- Accountability

What is the accountability cycle? How can you increase individual and team accountability for quality work in your organization?

Module 3- The 7 Habits of Highly Effective People (Covey)

How can you apply the 7 habits to increase your proactive thinking patterns, clarify your values, plan your work more effectively, improve time management, listen, negotiate and mediate more

skillfully, create cooperation, and grow professionally?

Module 4- Team-Building

What are the key characteristics of highly functioning teams? What threatens the effectiveness of a team? How can you be more effective in leading meetings, building teams, and managing

conflict?

Module 5- Supervision and Delegation

What are the important principles of delegating and coaching? How can you prepare for different conversations? What questions should a performance review answer? What tools can you use to analyze performance problems?

Module 6- Conflict Management

How does conflict impact team dynamics and teamwork? How comfortable are you with conflict? What are some cultural differences in how people express and respond to conflict?

What actions can you take to resolve conflict within a team?

Module 7- Influence without Authority

What is the difference between positional and personal power? How can you use reciprocity and currency exchange to increase influence?

Module 8- Systems Thinking

What is the difference between event-oriented and systems thinking? How do you model a system of concern? How can you exert influence from your position?

Module 9- Financial Management

What are the principles of financial management? What are financial controls? What are the roles and obligations of the leader and manager in relation to financial management?

10- Data for Management Decision-Making

Which data sources are important for purposes of accountability vs. program effectiveness? How do different donor agencies approach the issue of performance management? How can health leaders and managers create an organizational culture of information generation and use?

11- Project Management

What are the steps in the project management cycle? How can you apply project management skills to your current work in order to improve quality and productivity?

12- Effective Communication

What are your strengths and weaknesses in verbal, written, and virtual communication? How can you improve your ability to speak spontaneously? What are the elements of persuasive

communication? How can you use storytelling to strengthen your impact?

Certification

For those who successfully completed the course will receive a formal printed Certificate of Completion on vellum paper with University of Washington seal mailed to them. 

We will ship them all together to your Site Coordinator for distribution.

Sample- Certificate of completion

Further Information

Any additional enquiry and questions about this program you should contact Dr. Mohamed Y. Dualeh, MD via his email: mydualeh@gmail.com and if possible discourse with his on

phone:(+252 63 4417945 by texting him in WattsApp) regarding how to register, getting an assistance in application process while he is exercising as an official local resource for our participants acting as Site Coordinator for Somalia, UW Global Health Department

Official website of the University of Washington Department of Global Health E-learning: https://edgh.washington.edu  

PS: We are currently running Economic Evaluation in Global Health course and will be also be offering another course in these Global Health series named Fundamentals in Implementation Science in Global Health concurrently. It is advised to enroll just only one course at a time to not overwhelming participants as these are graduate academic activities which need sufficient time and attention. 
 

Volunteer Somali midwife of 30 years earns gratitude of Hingalol town

(ERGO) – Saynab Abdi Warsame, a midwife, has devoted almost 30 years of her life to providing lifesaving care to women and children in the northern Somali town of Hingalol. 
Saynab, who graduated from a nursing school in Buran, Sanag region, in 1988, has never earned a salary for her work, which she sees as a vocation. 

Midwife and hero, Saynab Abdi Warsame, who is loved by a whole town/Mohamed Salah/Ergo

My aim was always to target poor people, IDPs, and minorities. Their happiness was my happiness because my ambition was to save their lives, Saynab told Radio Ergo. 

Saynab’s career began when she saw that the only health post in Hingalol was serving hundreds of people from the town and surrounding villages but was not able to offer care for pregnant women or children and had no trained midwives.  
She used to visit the homes of patients who could not get treatment at the centre, especially expectant mothers and sick children. 
“I started work at my house without a salary and with no support from anywhere,” she told Radio Ergo. 

Saynab started working at the only hospital in Hingalol in 2004. It was getting some support from local NGOs at that time, but funding soon ended, meaning there was no money to pay staff salaries. 
Saynab, a mother of three, is now the head of the hospital, where she manages 11 other volunteer staff. 
“I work here for six hours but afterwards I go around the suburbs to visit the families to see if there are sick people who need my help,” she explained. 

Saynab and her team have to refer complicated cases to larger hospitals in Erigavo. 
“The world has changed. Phones and cars have helped us very much. Serious cases like pregnancy complications and very sick people are referred to big hospitals for further treatment,” Saynab noted. 

Saynab has trained many women from different parts of Hingalol on creating awareness of the importance of delivering their babies at the hospital. 
She has been the only midwife helping mothers in the IDP camp in Hingalol for the last two decades.  
Now there are mothers and their daughters, two generations, who were midwifed by Saynab and cherish her for her commitment.  
“I am now helping the next generation whose mothers I had helped. I met their mothers delivering and today they come to deliver here,” said Saynab. 

Among the children born with the help of Saynab is Amina Ahmed Abdullahi, 20, who is now a mother herself. 

I have to thank her for what she did for me and my mother. I respect her like my mum, people of this town owe her a lot,” said Amina. 

Amina, who is studying medicine, sees Saynab as a role model and wants to follow in her footsteps: 
“People work for money but she decided to sacrifice her time and service to the people of this town. Nobody can compare to her in what she has done for this town.” 

Source