AT WHAT COST

Post-conflict Somalia was marked by total destruction of national institutions and social fabrics. The civil war affected the whole country politically, socially and economically. The health care system was not spared rather suffered the most severe form of destruction.  Somaliland has unilateral declared independence and started the rebuilding process.

Despite of tangible success in peace, reconciliation, rehabilitation and coordination of political institutions as well as democratization process, Somaliland has made little progress in health care delivery system. Apart from the inadequate funding of health care system, incompetent leaders at the ministry, lack of need-based well informed national health plan and insufficient trained health personnel; the Somaliland health system is ailing due to the burden of quack doctors, unregulated foreign health workers and the informal sector-traditional healers. The combined effect of these three factors is making Somaliland’s health care the most expensive one in Africa and is rendering young Somali doctors unemployed. This problem is stemming from the fact that there is no or little government oversight of the provision of medical services in the country. 

Due to the widespread privatization of health delivery, many private hospitals opted to bring expatriate doctors. This is because of the high illiteracy among the Somali masses that they think that every person with white skin is a good doctor. These doctors are not subjected to entrance examinations into the profession or at least not checked properly. On the other hand, many local quack doctors who have not attended medical school or are enrolled nurses are practicing in their private clinics as specialist. This people have adapted to the changing trends in the medical profession, though they have not attended medical school, they understood the dynamics of disease presentation. For instance if someone has a fever they will prescribe broad spectrum antibiotic, probably intravenous, an antivirus and an antifugal as well as strong pain killers and ant-inflammatories! A simple case of pneumonia may cost the patient an average of $100! This people are endangering the health and safety of the people and at the same time are competitively squeezing young newly trained doctors out of the market! No one is accountable to the negligence and medical abuse they do to our people. Their health service is very expensive due to their incompetence and ignorance!

The informal health sectors which is comprises the traditional healers, bone setter among others is also a major barrier to quality health services in the country. Though, they are more expensive than a medical practitioner, they still attract large number of clients. This is mainly because they dance to the tune of the masses. They give them meaningful cultural and religious explanation for their medical problems. For example if someone has presented with weakness of one side and deviated mouth due to stroke, these people tell the patient that an evil wind has struck them or a Jin has slapped them that is why they have a deviated mouth! For you as a doctor, it will be hard to convince the uneducated Somali patient that the cause of his deviated mouth is in the brain!

However, with the newly established NHPC (National Health Professional Council), there is some hope at the end of the tunnel. The NHPC have successfully started the registration and licensing process for all doctors and nurses in the country and this may alleviate some of the problem. It will be much better if the NHPC starts registering and licensing all health clinics so that no quack doctor runs a private clinic. This will create employment opportunities for young professionals who are the primary victims of this systemic deregulation. It will also be a great progress if the NHPC or the ministry controls the reliability and standards of the drugs brought into the country.  I also suggest that expatriate doctors should not come to work for us unless the skill they have is lacking in the country. What is the need of bringing physicians to work here?

Dr. Mohamed Bobe
Hingalool,  Sanaag.

#NomadicHealthCare #252healthcare

HIS FATHER'S ADDICTION IS MAKING HIS DISABILITY AN INABILITY.

Halimo, 36 years old woman, with six kids lives at Hingalool in Sanaag. I first met her in our OPD early September 2015. I heard a commotion outside my office and I tried to find out what it is about. I found this lady arguing with the lady at the reception. She was trying to see the doctor as her 12 months old son was sick. Upon seeing me, the lady at the reception desk gave in and allowed Halimo to see me. Halimo told me that she is from the Gabooye clan and she believes that she is closer to me than the other residents at Hingalool since Halim and I come from the same region, The North, (Ood Wadaag).

I don’t know but I had the same feeling about the matter although as a doctor I took the Hippocratic Oath not to discriminate my patients on the basis of their tribe, religion, race, political affiliation or social status. Halimo felt that she was a victim of the stigma associated with her clan, the Madhiban, but the truth was that apart from the stigma that people from this clan suffer, our receptionist wanted her to pay the little we charge for the consultation fee since our funding is very limited and for that matter we try to generate some income to run the hospital. It is like a cost sharing way to run the hospital.

Halimo’s son, Jama, is 12 months old; he failed to sit up let along to try to stand up. The mother noticed the obvious developmental delay in her son and her first complain was; why is he not sitting up at one year of age? As I embarked on taking more history and examining the child it was clear to me that the baby had what doctors call Down syndrome, a chromosomal disorder, characterized by intellectual disability and developmental delays.  While I was educating the mother on her son’s condition I dug her life story deeper as part of her social and family history.

Her husband is a Qat addict and despite the fact that he has multiple talents he only works for few days and uses the money to buy Qat/Mira and the following days he is suffering from the hang over!  He can find jobs easily. His Misfortune as Gabooye in Somalia becomes his strength when it comes to employment. Since the Gaboyes work on specific traditional professions-occupational Somali caste system, he can easily find jobs such as hairdressing, shoe mending and iron smelting.  However he provides little or nothing to his family and Halimo is living a miserable life under the poverty line with her kids.

I shared Jama’s photos and 5 other kids with chronic conditions; they are Cabdirahman, Jibril, Muna and Maryan. These children are suffering from some chronic conditions not common in Africa, mainly found in the western World. Two of them have Down syndrome, two of them have Cerebral Palsy-CP and one of them has phocomelia.

I can’t share the stories of all these children, but all of them have one thing in common, they all have chronic debilitating conditions that have no cure and they all come from very impoverished families. They all need frequent visits to the primary physician and once in a while to a pediatric specialist but their financial well being may not allow their parents to do that. What they need is free health services since they have frequent infections and other complications of their chronic illnesses. They need help and they need it now!

I am appealing first to Calmadow women organization whom I work with and I appreciate their generosity. However, anyone willing to support or give a helping hand to the families of these kids is highly welcome.

Personally, I believe that a doctor must not only treat patients but must act as a socioeconomic agent who helps to change the community for the betterment!

Dr. Mohamed Bobe, Hingalool, Sanaag.

#nomadichealthcare#252healthcare#Frontlinedoctor.

THE UNMET NEED FOR FAMILY PLANNING

Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy (WHO, 2014).

I was compelled to write about family planning in our series of nomadic health care because of the story of Khadija, a 30 years old young woman, with 6 kids and two spontaneous abortions within a span of 5 months! Scary huh! Welcome to Sanaag region of Somaliland. What inspired me is her willingness to have any form of family planning as she is fed up with unplanned pregnancy. Her husband, Awke, has also the same view about the issue and was excited when I told him that I can give them several options of contraception to choose from.

I was also frustrated by the fact that no one wanted to listen to me when it comes to family planning despite the fact that there was a tremendous unmet need for family planning among the nomadic pastoralists in Sanaag region. Actually I was kind of relieved to have finally found a couple that is ready to have a control of when to have a pregnancy!

I always find young mothers with very many kids with poor spacing of children. Most of them are not even aware if they are pregnant by the time they come to my office. Almost all of these young mothers would like to delay their next pregnancy by two or more years but are very skeptical of any contraceptive method. They believe it affects their fertility and may make them infertile forever! Others think that family planning methods may affect their health.

I am not in favour of contraception aimed at controlling the population growth in fear of limited resources on planet earth, but I am much inclined to have a solution to the unmet need for child spacing to have a healthy community. Lack of proper family planning is not only affecting the mother’s health but equally is detrimental to the child health status. It is a proven fact, that family planning directly reduces maternal mortality and infant mortality.

Family planning is also an essential component in achieving reduction of poverty, gender equality as well as allowing woman to attain their career goals. It also reduces both criminal and spontaneous abortions.

There are many forms of contraception which can be acceptable to the Somali community. One may face many challenges in implementing unnatural methods but in my experience I came to realize that most of the Somali couples are willing to try the natural family planning such as the coitus enteruptus  and rhythm methods. 
In the future, it will be very necessary to have a national plan based on national policy on reproductive health with special emphasis on family planning.

Dr. Mohamed Bobe,
Hingalool, Sanaag.
#NomadicHealthCare#252HealthCare.

The burden of brucellosis in Sanaag region

Brucellosis is a major public health concern worldwide. It is a zoonotic infection-meaning it primarily affects animals. It is caused by the bacteria called brucella. It is transmitted to humans by undercooked meat ingestion, direct contact with an infected animal or by inhalation.

I was annoyed by a review on brucellosis I read on the web that cited that brucellosis is of no public health importance in Somalia. I wonder if any properly formulated research was done on brucellosis in Somalia. Has that person ever come to Sanaag region? As a practitioner who treats the Somali pastoralists on a daily basis, brucellosis is a major public health problem among the Somali people especially in this region where people majorly keep sheep.

 The fact that our people are nomadic pastoralists and the disease is transmitted from the animals to the humans can even be used to object that statement.

Yes there are no microbiological isolation of the bacteria to make a diagnosis but in an extremely resource poor setting like Somalia we can depend on serological tests, though not reliable, and clinical presentation as well as response to the treatment.

There is no national program for brucella vaccination of our livestock, no public health education for the people on ways to stop the spread of the disease from their animals to them such pasteurization of milk, cooking the meat well  and drinking water from a separate well . When you combine all these one may come to the conclusion that brucella must be a major public health problem in this country. It was so surprising to me to find that these nomads drink from the same well with the animals. They believe that drinking the water with the camels and sheep has some healing advantage and is good for their health.

Whenever I am not busy at the hospital I visit the nearby well and try to educate them on the risk of brucellosis and how they can stop its spread to them. Most of them are too stubborn to convince!

The best way to control such a disease is to eliminate it from our animals. And on that note I think there is much work for our veterinary professionals.

Personaly I believe that Brucella is to Somalis, as Malaria is to Ugandans!

Dr. Mohamed Bobe, HIngalool,
#NomadicHealthCAre#252HealthCare#mypersonalencounter.