Championing For Mental Health Care In Somalia

 War has ghastly long term effects on a nation’s economy, not forgetting the even more dire ramifications on a nation’s people, their lives and livelihoods – specifically when the country in question is one of low income – meaning longer recovery periods, if at all, for both the economy and the people.

                          Dr. Habeeb attending to one of his patients in his clinic in Mogadishu/ Photo Credit: UNSOM

 For Somalia, the period between 1988 and 1991 was one of the darkest following the fall of President Siad Barre’s regime, a development that triggered a multifaceted decades’ long civil war.

The Backstory

 

Barre seized power in October 1969, emerging as the dominant one in a group of army generals who had staged a coup d’état. While showing early signs that his heart was in the right place as a potential stabilizing figure in Somalia, what followed was two decades of a dictatorship which included extreme brutality by the state on civilians, suppression of opposition groups and an increasing inter-clan conflict. By 1988, groups of dissatisfied and frustrated nationalists throughout the country attacked various government and military installations, setting off the First Somali Civil War.

 

What followed was massive bloodshed, extensive national division and a huge wave of displacement, causing masses of people to seek refuge in neighboring states, including Kenya. By the dawn of the 2000s, there were a raft of peacebuilding efforts; but even then, Somalia couldn’t fully recover in the years that followed.

 

Violence was still eminent, and swathes of Somalis who had been victims of war displayed symptoms of Post Traumatic Stress Disorder (PTSD) – a delicate mental illness that most caregivers and communities weren’t sure how to deal with.

 

How the problem was handled…

 

There is a widely held belief in Somali culture that hyenas can see everything. This perception eventually extended to mental illness, and so it became widely believed that hyenas had the ability to see the ‘thing’ that causes mental illnesses.

 

According to Somali Psychiatrist, Dr. Abdirahaman Ali Awale, two hyenas were transported from the bushes and taken to hospitals in Mogadishu as a way to treat the affected. Some psychiatry

patients admitted in these hospitals would pay up to Somali Sh700,000 (approx. KSH 133,000) to be locked in a room with one of the hyenas, hoping that whatever the root cause of the mental problem was, once it saw the hyena, it would drastically leave the patient, who would immediately be cured.

 

The story goes that for families on the move which could not afford this ‘treatment’, and who remained unsure of what to do with their kin suffering from mental illness, the easier way out was to tie the suspected patient to a tree when the families were migrating, leaving them for dead.

Moved by the unattended plight of his compatriots suffering from mental health and the attendant stigma, in 2005, Dr. Awale (then a psychiatric nurse in Somalia), pulled resources together to establish Somalia’s first psychiatric hospital.

 

Notably, Dr. Awale’s turning point came in November of that year when he witnessed a group of young girls being stigmatized for suffering from mental illness. Up until that moment, the good doctor hadn’t fully grasped the magnitude of the effects of mental health both on individuals and in communities. But the question that reverberated in Dr. Awale’s mind was… if such a brutal display of stigma had happened in public, what about the cases handled behind closed doors between caregivers and those suffering from mental illness?

 

The Habeeb Mental Hospital in Mogadishu thus opened its doors to those with mental illness and personality disorders, admitting approximately a total of 30 patients soon after. Of these, most were suffering from PTSD, and a number from depression. Dr. Awale had taken a small yet significant step towards resolving mental illness in his country, which had by then – according to a report by the General Assistance and Volunteers Organization (GAVO) – been thought to be the worst in Africa.

 

When Habeeb Hospital started treating psychiatric patients, there was awareness of the effectiveness of scientific methods in treating mental illness. In fact, it soon became apparent that it was the only way to treat this previously taboo medical condition.

 ...and is being handled

 

Dr. Awale’s efforts didn’t stop at the setting up of the Hospital. He put in the work, studying to become a psychiatrist, and worked tirelessly to improve and expand mental health care across Somalia. With time, he became an advocate for mental health awareness, slowly multiplying his psychiatric facilities, ensuring they included outpatient services.

 

By 2016, Dr. Awale was running a total of six clinics across Somalia, where he provided free psychiatric treatment. And while PTSD was still a common diagnosis, Khat or miraa intake emerged as the other contributing factor in the high number of patients admitted into the clinics – affecting men between the ages of 18 and 30.

 

To date, more than 15,000 psychiatric patients have been treated in the six clinics.

 

The not so smooth sail

 

Yet in his 16 year tenure as a mental health advocate in Somalia, Dr. Awale has experienced expected difficulties that come with running a chain of medical institutions with limited monetary resources, this because it takes a long time to treat most patients.

 

Nonetheless, Dr. Awale has pulled through, going above and beyond the clinics. He has since organized an impressive number of mental illness awareness campaigns for the general public, including by running outreach programmes in schools to educate the youth and demystify misconceptions that mental illnesses are more severe than most illnesses, and debunk the myth that psychiatric illnesses cannot be cured.

 

In 2016, Dr. Awale took his advocacy a notch higher by initiating awareness efforts through broadcasts on three radio stations in Mogadishu. The information on psychiatric illnesses was broadcast three times a day, with the main takeaway message being an advisory to the public to take people displaying outlined symptoms of mental illnesses to Habeb Hospital, where they were guaranteed to receive proper treatment at no cost of their own.

 

While working in a mental hospital can be tiresome and often takes its toll on him, Dr. Awale hasn’t shown any signs of slowing down as a champion for better, accessible, and affordable mental health treatment for all in Somalia.

 

In his words, “mental illness is a disease which can be cured.”

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Quality emergency reproductive health services for communities affected by cyclone Gati

 Farhiya Abdi is an 18-year-old first-time mother living in Hurdiya village in Bari, Somalia. She gave birth to a baby boy in the only health facility in her village, Hurdiya Health Centre. This year, the facility, which just opened in February, has since provided free maternal and reproductive health services to more than 250 women. The services include focused antenatal care, deliveries, and postnatal care services.

Hurdiya Health Centre is part of the cyclone Gati response

project, integrated reproductive health, and Gender-Based Violence (GBV) project. The Somali Red Crescent Society (SRCS) is implementing the project with financial and technical support from UNFPA Somalia.

 

Cyclone Gati, the strongest tropical cyclone ever recorded in the East African country, made landfall on November 22, 2020. The cyclone left behind a trail of destruction; hundreds of houses were destroyed, several boats and fishing gears damaged, and many families lost large numbers of livestock. Women and girls continue to face the worst consequences, including rising cases of GBV.

 

Farhiya was among one of the first clients that gave birth in the facility. She first came to the facility for a checkup because she felt weak and had an irregular heartbeat, shortness of breath, and lightheadedness. After a couple of tests, Farhiya was diagnosed with anemia, a condition in which one lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues. She was given iron supplements for her anemia, among other supplements. Farhiya eventually gave birth to a healthy baby boy two weeks after she came to the facility for the checkup.

 

“I was very lucky that I went to the facility for the checkup. I received good quality care from qualified staff. If I didn’t get treated for anemia, the midwife told me I would have needed a blood transfusion, which I cannot get in Hurdiya. I would have traveled 10 hours to the nearest facility, and I wouldn’t have afforded to get the transfusion,” says Farhiya.

 

She says she is grateful to the organizations that made it possible to establish the health facility in her area; SRSC and UNFPA Somalia. “The facility offers free services. It is a real-life-saver. I can’t imagine what would happen to me if I had to travel for more than 10 hours in the poor condition that I was in,” Farhiya says.

 

 

Hurdiya is a small fishing village in the northeastern Bari province of Somalia, situated in Ras Hafun on the coast of the Guardafui Channel. It is the center of the Hafun district and the easternmost town in continental Africa. The nearest town to Hurdiya with a comprehensive emergency obstetric and newborn care facility is more than 400 kilometers away on very rough roads. Unfortunately, the condition of the roads was made worse by the cyclone.

 

The cyclone Gati response project is funded under the United Nations Central Emergency Response Fund (CERF) and implemented by SRCS in three districts affected by the cyclone, namely El-Dahir, Hafuun, and Hurdiya. In addition to the fixed health facilities, three mobile clinics are attached to each facility, which has a team of qualified health professionals that provide maternal and reproductive health care services to the nearby nomadic population, also affected by the cyclone Gati.

 

The project aims to provide quality maternal and reproductive health services to the affected communities. This is so that each birth is attended by skilled birth attendants. Furthermore, each complication is managed or referred from the Basic emergency obstetric and newborn care (BEmONC) facilities and mobile clinics to the nearest facility that can provide comprehensive emergency obstetric care services. This is also so that all mobile clinics and BEmONC facilities can respond to the COVID-19 pandemic appropriately.

---Samira Mohamoud

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African Covid-19 patients 'dying from lack of oxygen'

 Many African countries are facing a "growing crisis" of severe oxygen shortages which is leading to preventable deaths, international health agencies have warned.

A doctor in Somalia's semi-autonomous region of Puntland told the BBC that between five and 10 of his Covid patients were dying because of a lack of oxygen almost every day.

These would all be preventable deaths if we had adequate oxygen, said Dr Jama Abdi Mahamud at the government-run Gardo General Hospital.

There are no official figures available showing a rise in preventable deaths, but many low-income countries are struggling to access oxygen supplies amid surging coronavirus cases, and limited or no access to coronavirus vaccines.

Every Breath Counts, a coalition of global health campaigners, say 18 low-income countries are currently dealing with oxygen shortages or are at risk of facing the crisis, with most of those being in Africa.

"The G20 Global Health Summit leaders didn't mention oxygen at their meeting in May, but the G7 has now signalled there will be financial support for oxygen," said Leith Greenslade, co-ordinator of the coalition.

Jessica Winn, head of pneumonia support hub for Save the Children, said the need for oxygen in these countries was high and urgent.

"Now that a third wave of the pandemic has arrived in Africa, populations are again at risk. Since 1 June 2021, the oxygen needed to treat Covid-19 patients in Zambia has increased five-fold to 50,000 cubic meters, and three-fold to 12,000 cubic meters in the Democratic Republic of Congo.

"Demand for oxygen to treat Covid-19 patients is steeply rising in Zimbabwe."

A study published in the Lancet last month suggested more than half of the Covid patients that died in 64 hospitals in 10 African countries were not given oxygen.

'No oxygen plants'

Dr Mahamud said that during the second wave in Somalia up to 25 people were dying each day in his hospital because of a lack of oxygen: "It is really stressful to work in this condition."

According to World Health Organization (WHO), of the 14,823 confirmed coronavirus cases in Somalia as of 16 June, 775 people have died.

Health professionals say the real figure could be many times higher because there is no proper reporting mechanism, and many deaths occur in villages.

"There are around 750 hospitals and primary health centres across Somalia which urgently need more than 1,400 oxygen concentrators, but they have received less than 300," said Dr Joseph Serike, senior health technical specialist with the Save the Children in the capital, Mogadishu.

Government officials admit it is a growing challenge.

"No government-run hospitals have oxygen plants. Only three private hospitals in the capital, Mogadishu, have them," said Dr Ubah Farah Ahmed, director of family health department at Somalia's health ministry.

In neighbouring Ethiopia, health officials said some government hospitals had oxygen plants but they are overwhelmed because they now need to supply to other hospitals too.

"And because of the high production pressure, the plants break down worsening the shortage," said Dr Menbeu Sultan, chair of Ethiopian Society of Emergency Medicine Professionals.

"The shortage is severe in remote and very poor places because they have no production of their own.

"And lorries carrying oxygen cylinder have to travel hundreds of kilometres to reach such places and in some cases it is too late for patients who urgently need the gas."

As of 16 June, Ethiopia has seen 274,346 confirmed Covid cases and 4,250 deaths.

During the last major wave between April and May, Ethiopia needed around 15,000 cylinders of oxygen in a day, according to an oxygen-need tracker updated by Path, an international non-government organisation working in health sector.

It shows the need is now down to 1,200 cylinders per day but experts with the tracker said their calculation is based on reported Covid cases and most of the cases in the country go unreported.

In DR Congo, the demand has gone up to nearly 2,000 cylinders per day from less than 500 earlier this month, according to the tracker.

'Blind spot'

Experts say many of the lowest-income countries in Africa, like very poor countries elsewhere, lack commercial oxygen production facilities, which could then potentially divert supplies to hospitals to help during emergencies.

As a result, very few hospitals can supply high-flow oxygen that critical Covid patients need, health experts say.

"In our whole country, only one hospital has the capacity to treat at a time more than 10 patients needing high-flow oxygen and their Covid unit is usually full," said Dr Sarah Wandia, who works in Maua Methodist hospital in Kenya.

"We lost two patients from our hospital waiting for the space in that unit.

"Our hospital's current oxygen plant has the capacity of producing 45 litres of oxygen while one Covid patient can use 15 litres of oxygen leaving a precarious amount to care for premature babies, intubated patients in the operation theatre and in the accident and emergency department."

Health experts say it took a year for oxygen supply to be recognised as an essential medicine in the global strategy to treat Covid patients.

"The impending crisis was a blind spot for the global health community for a year," said Ms Greenslade of Every Breath Counts.

International financing agencies like the Global Fund say they have now made fast-track funding for oxygen available to some lowest income countries including The Gambia, Kenya, Malawi and Tanzania in Africa.

"With the help of donor agencies, we will soon install 10 oxygen plants in some government hospitals," said Somalia's Dr Ahmed.

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Women Leading Somalia’s Health System

 Somalia is one of the most complex regions of the world, with threats and political instability, extreme weather conditions, movement of internally displaced people (IDPs), decades of conflict, poverty-related deprivation, poor health and communicable diseases that are killing people. There is a constant risk of gender violence making women, children and members of minority groups particularly vulnerable, and more so during displacement or while seeking work. Three decades of civil war and instability have weakened Somalia’s health system and contributed to it having some of the lowest health indicators in the world. The COVID-19 pandemic has added yet another strain on its tremendously fragile infrastructure presenting unexpected challenges and dilemmas.

This report by Oxfam states that, “the multitude of crises and rates of inflation have left the majority of families food insecure and without income, halted education and health services, and exacerbated existing vulnerabilities and the incidence of violence. Needs far exceeds the current available resources and capacity.”

One of the doctors leading healthcare and currently involved in the fight against COVID-19 in Somalia is Dr. Deqo Aden Mohamed, an obstetrician-gynecologist, founder of ‘The Hagarla Institute’ and co-founder of ‘The Somali Cancer Society’.

Dr. Deqo has been working full time on the ground in Somalia, and leads multiple projects on maternal health and the National Call Center for COVID-19, and is part of the Somali National Taskforce for COVID-19, 2020. In an interview given to me, Dr. Deqo says, “the pandemic has been exhaustive, we created a national call centre last year, which helped reduce the effect of COVID-19 to some extent. We have a very young population in Somalia who are all below 40 and they were able to recover from COVID-19 with very mild symptoms. A few elderly with comorbidity needed beds, but we were not ready when COVID-19 hit last year. We barely had 19 beds, and we didn’t even have ventilators.

The good thing in Somalia is that because we have been through several famine and natural disasters, people or the government or the non-profit organizations/ international ones, are set in their mechanisms, where they are able to quickly react in emergency situations. They were able to set up one hospital last year very quickly, which also was just not enough. Dr. Deqo said.

Last year amongst many, Somalia also lost one of its fearless and most compassionate humanitarian whose life’s work gave hope to tens of thousands in her native Somalia, while inspiring countless others worldwide. Also known as “Mama Hawa” and “the Mother Teresa of Somalia”, Dr Hawa Abdi, gave refuge to 90,000 displaced Somali’s in a refugee camp close to the Adbi hospital, which was dubbed as Hawa Village. It is estimated that two million were served by her foundation over a period of 35 years. It was in these camps, Dr. Deqo grew up feeding the refugees her mother was harboring and shaping her destiny of becoming a doctor herself.

My mother, (Dr Abdi) started the Hawa Abdi Foundation, it was started with the goal to help mothers have access to maternal healthcare. But once the civil war began, it transitioned from rural healthcare to an organization that did everything. It was very inspiring to watch her, the way she stood up as a woman, the way she negotiated with the elderly, the way she taught that your femininity should not hold you back, because in a society as a woman you are undermined. She was a strong woman, Dr. Deqo added.

What began as a one-room clinic, changed the course of healthcare in Somalia, and helped in alleviating poverty and suffering in the country. However, the health care system in Somalia still remains one of the weakest, poorly resourced and inequitably distributed in the world and in the absence of functioning public sector facilities, the country’s healthcare system has been “vertically privatised.”

While private health services and the pharmaceutical sectors largely remain unregulated, they are the backbone of healthcare in the country. Most funding for the health sector comes from international donors and is ‘off-budget’.

“The government runs only three hospitals here, so imagine in Mogadishu we have 4 million people and just three hospitals. The second wave of COVID-19 was much harder than last year. What we lost in one years time, we lost in one month in 2021,” says Dr. Deqo.

Currently the country is grappling with the triple threat of drought, COVID-19 and insecurity in Mogadishu which is driving severe humanitarian needs in Somalia. Somalia has already seen a 48% increase in deaths from COVID-19, doubling of cases from 6687 to 13,812 cases in just 59 days. The recent conflict in Mogadishu, is adding to the difficulties in deliveries of humanitarian services in several parts of the country.

In a statement issued by International Rescue Committee, (IRC) Richard Crothers, IRC Somalia Country Director said, “Over 80% of the country is suffering from drought conditions, cattle and crops are dying as the frequency of climate-related hazards increase. We’ve seen a spike in COVID-19 cases and deaths over the last month, with many cases going undetected and untested. In a country already suffering from severe humanitarian crises, with almost 6 million people in need, the drought will drive even more displacement and food insecurity. Now more than ever we need an increase in support and funding in order to meet the rising humanitarian need.”

In this report, co-authored by Dr. Deqo, lack of access to screening services and important information about COVID-19, could put millions of internally displaced people in Somali settlement camps at risk.

Three million internally displaced people (IDP) live in more than 2,000 settlement camps in Somalia. The large-scale camps are a tinderbox for potential outbreaks of infectious disease. Overcrowded conditions restrict opportunities for physical distancing and the camps often lack reliable access to basic amenities such as running water, soap, and medical treatment. The humanitarian crisis is already acute in Somalia, the report states.

“The government wants to help, they communicate everyday, but the capacity is very limited, they don’t have funding, allocation of funding to government healthcare is very limited, basically they cannot run their own hospital, so that’s the situation.

“…If we have people in place – those with the right skills, knowledge and moral compass, things will be fine. Right now, as a doctor I am putting my energy and resources to have the best people in place. The country was brain drained, it lost two generations due to civil war and I think that’s what we are missing. I cannot solve all the issues from the ground, but I think we have the best opportunities in Somalia right now, and if we can learn from the mistakes, we can have a good healthcare system in the country,” says Dr. Deqo.

Somalia is among the first African countries to receive doses of COVID-19 vaccine delivered through the COVAX Facility. According to UNICEF, 300,000 doses of COVID-19 vaccines arrived in Somalia, but health officials say less than half the doses have been used. One of the major reasons according to this report is “the Islamist militant group Al-Shabaab’s warning in Somalia that people are used as “guinea pigs” for AstraZeneca, large sections of Africans are steering clear of vaccines.”

Despite mechanisms in place to react quickly, as mentioned earlier by Dr. Deqo, the broader challenge for Somalia to battle through is the combination of a weak healthcare system, raging political and humanitarian crisis and adding to this, vaccine hesitancy must be a priority for the Somali government to overcome. If not, then COVID-19 will not only remain a regional threat, but possibly a global one as well, given the aggressive and uncontrollable mutation of the virus, which Somalia cannot afford to risk.

The author is a journalist and filmmaker based out of New Delhi. She hosts a weekly online show called The Sania Farooqui Show where Muslim women from around the world are invited to share their views.

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