I WISH I COULD DO MORE!

Ubax is a 25 years old, she has two children and she is the third wife of her husband. Her story represents the typical life of a Somali woman in the nomadic pastoralist life. It is a very harsh life and the pain in her life story will prove me right! She is my patient and as I write this story she is lying on the bed in our hospital expecting me to solve everything for her not knowing that I feel small and helpless and angry at the same time!  She was in labour for about 10 days in her house. She lastly gave birth to a dead baby, a very big dead baby. She endured a very painful and long labour, a typical labour for young mothers in this part of the world.

But her suffering didn’t stop at there! She felt something is wrong with her genitalia and came to hospital. When I asked what prompted her to come to hospital after everything was over, the woman accompanying her says in full confidence “Way Isku Furatay”!

This explanation is not new to me, I hear it almost once in every week, and knowing the fact that Somalis exaggerate things, I decided to carefully examine her to rule out or in a perineal tear. What I found was very sad. The woman has a rectovaginal fistula-meaning that her vagina has opened up to the anus and the whole anatomy is distorted. It was at this point that I felt angry and at the same time betrayed, betrayed by my own skills and technical competence. I just wished I could repair it. But unfortunately I can’t help i am not a gynecologist!

To make matters worst, not only does she have a fistula, but a severe postpartum infection-puerperal sepsis and severe anemia. I later discovered that she bled a lot during and after delivering the baby. Her Hb was surprisingly 3 g/dl and the infection was severe.

At this point I decided to tackle the two major things that I can handle at my station; anemia and infection. We started her on two intravenous antibiotics the usual ones ceftriaxone and metro, and we transfused her with one unit of blood. This time we improved on our transfusion. We could screen for hepatitis B, C and syphilis but again we have to use a non blood giving set!
I am planning to contact anyone who can help her get a transport to and from Hargeisa or Borama or any other center where they can repair. I know the operations are free of charge at Adna Hospital and Borama Hospital so that won’t be a problem. I hope we can find a good Samaritan to help her get the transport!

I usually find cases of all types of perineal tear and I repair them but when fistulas occur it will be out of my scope to try. I welcome anyone who may help this mother.

In my short stay at Hingalool I came to realize that a lot of funding has been given to help the health delivery services in Sanaag and Sool regions but little or none reaches to serve the intended purpose. As far as I know Somaliland development fund has allocated 5 million us dollars to improve the health care in Sanaag and Sool, but that money was poorly allocated and is confined to Erigavo and Lasanod. I don’t know if it is out of ignorance or the leaders at the ministry were ill advised.

There are programs in Puntland such as the CARMMA program (Campaign for the Accelerated Reduction of Maternal Mortality in Africa) and EPHS (Essential Package of Health Services) but no signs of these efforts are seen in Sanaag and specifically at Hingalool district.

For God and My Country.

Dr. Mohamed Bobe, Hingalool, Sanaag.
#nomadichealthcare#252healthcare#Frontlinedoctor

NON OF THEM KNEW THEY WERE CARRYING TWINS!!

Today was a happy day at Hingalol hospital, as our first twins to be born safely by normal delivery were born. I won’t give you much detail about our hustle to convince the family that it can be delivered safely without the need to take her to Qardho, small town, 60km east of Hingalool but very expensive to transport the patient. After having assessed the mother, realizing that the first twin was cephalic (head was coming first) and the second one is a breach (the buttocks coming firs), cervix fully dilated and mother having adequate contractions on top of that this was her 6th pregnancy.

However, my fear was not much about the cost of transport, but I feared that those doctors at the other end may justify a caesarean section. C-section saves both the mother and the baby’s lives but you must be careful with its indication. Some
doctors may cut without a defendable indication,something my Cuban supervisor, proff Ivan Bonet emphasized. I decided the mother can deliver normally here in our hospital. Luckily within two hours of admission the mother delivered a bouncing baby girl and a baby boy. They were the seventh kid of their mother and made 13 kids for their father, others coming from his other wives!

At this point you may be wondering why I am telling you the story of normal twin delivery! This is why;before this case we had two previous cases of twin deliveries and this is what happened.

The first case happened early September 2015, it was immediately after my arrival at Hingalol district in Sanaag Region, local people heard that a doctor was posted here, so we had a call informing us that a mother had delivered a baby, who died upon delivery, and that the second one is stuck and refused to come out! We mobilized some fluids and drugs and fueled our ambulance and headed toward the bush. We drove for 4 hours and reached when the second twin already came out but died immediately. We found the mother bleeding, tired and dehydrated. She had post partum hemorrhage. We resuscitated the mother, gave her oxytocin in normal saline and some i.v antibiotics as stat dose. The mother felt better, bleeding stopped and we drove back for four more hours.

The second case was more horrible to remember, it was an 18 year old primigravida (first pregnancy or what Somalis call Ugub). We had a call at around afternoon informing us that a mother delivered one baby but the placenta and the second baby failed to come out, so we shall be ready for them.  We waited them throughout the remaining part of the day and the whole night but they did not turn up!
What they did was actually very astonishing.

They first went for the burial of the first dead twin and after completion they asked a car to come and pick the mother, so the car have to go pick them and come back. They reached us around noon next day.

I have to quickly examine the mother and ask few questions as we try to set up an i.v line. I found that the fist one that died was a breach and on examination the second twin was a cephalic. What the mother lacked was contractions only. She was fatigued.  We delivered the baby; to my surprise it was alive though it scored very poorly.  The baby was a premature at around 32 weeks of gestation; it only survived until next day, when it succumbed to respiratory distress syndrome.  We couldn’t do much, there is no specialist care, no incubators, no electricity and the only thing at our disposal was Kangaroo Mother Care and i.v antibiotics and fluids.  It was too expensive to run oxygen cylinder on the small hospital generator for long!

Somalia faces many challenges in giving quality maternal and child health services. There is a lack of trained professionals, services and resources to assist in deliveries and provide essential health services for women and girls. Maternal and child mortality in Somalia is exceptionally high, as we have heard, with a one in ten lifetime risk of a woman dying as a result of pregnancy or childbirth. One in three children is underweight, and malnutrition is a leading cause in high mortality rates in children under 5.

To make the matters worse, nomadic pastoralists are not accounted for in any of these findings, their health status is even worse, perhaps the worst in the world. Any high risk pregnancy in the nomadic people is a sure death for the mother.

The health of a nation is reflected in the health of its women and children. As they thrive, so too will Somalia.

Dr.Mohamed Bobe,

#nomadichealthcare #252healthcare #mypersonalEncounter

WARRIED MOTHERS, MENINGITIS, MALNOURISHED BABIES AND MISLEADING TRADITIONAL HEALERS

Up on returning from Uganda, after 7 years of intense training at Kampala international University (KIU) western campus, I started my work at Hingalool, a very remote village, around 700km east of Hargeisa. The news that a new doctor was posted here spread very fast partly due to the dire need for a trained doctor in the village.

 The first thing I did was a feasibility study on the district hospital which was closed for about 2 years and had nothing but just an empty building.

As I was doing my assessment on the list of what is needed urgently and what can wait, a 12 days old baby boy who was unconscious and was having seizures was brought to me. The mother told me the baby was okay until three days ago when he started having high grade fevers and later refused to breast feed. She also told me that the baby is making abnormal movements which she thinks there is problem in the head. What she was describing was generalized tonic clonic convulsions indeed. The baby was dehydrated and had no glucose in his blood as he did not breast feed for two days.

 To make the matters worse, the mother took the baby to a traditional healer who burned the whole of the baby’s head and some other parts of his body. I realized that the baby had what doctors call neonatal meningitis, but the main threat to his life was hypoglycemia-lack of glucose, fever, convulsions and dehydration. I needed to tackle this very urgently. 

Luckily the local drug shops had diclofenac injection, ceftriaxone, gentamicin, diazepam and cannulas as well as a nasogastric tube. It was hard to cannulate so I have to put an intraosseous line and a nasogastric tube so that the mother can milk herself and give expressed breast milk to the baby. After doing all I could do and using all the resources at my disposal, there was one thing I could not tackle! The baby was in severe respiratory distress. He could not breathe. He was breathing very fast. And it was very clear that without oxygen my efforts were in vain. Even the mother asked me what I was doing about his failure to breathe and grunting. I explained to the mother that he needs oxygen urgently. There is no single oxygen concentrator in the whole district despite the fact that there are so many clinics and very many so-called doctors!

 This baby was lucky because his mother was a very rich woman, her name is Hodan, she has over 1000 (one thousand) sheep and around 50 camels. For her, cost was not a problem. All she wanted was good medical care for her son, her 13th baby! This is not the case for the majority of nomadic pastoralists around here. After explaining everything to the mother, I referred the patient to Qardho, small town, around 70km east of our village for oxygen only.

 Transporting that baby from where we are to Qardho costed the mother $300 (three hundred us dollars), around 1.2 M Ugandan shillings. I made sure I document all my findings and the treatment I have given. Fortunately the doctors at the other end agreed with my diagnosis and continued my management plan.

 Mohamed, is now around 2 months old, and is one of my regular patients. He is doing well and recovered fully. Most children don’t recover fully from meningitis due to poor management, poor health attitude of the masses and so many delays in making a proper diagnosis. Most of them come to our OPD with all the complications of meningitis be it seizures, focal neurological deficit, developmental delays and loss of hearing. Children don’t get universal immunization programs and organisms which could have easily been prevented with immunization cause meningitis here. Heamophilus B influenza being one of them!

 The first thing I requested for was an oxygen concentrator. Now that we have one, the biggest challenge is getting the electricity to run it in case a patient needs oxygen for some good time!

#nomadichealthcare  #252healthcare  #mypersonalexperience

COMING TO TERMS WITH THE UNEXPECTED REALITY

As a junior doctor, trained in Uganda, my lecturers emphasized the need to be trained and prepared to work in a resource limited setting which is the case for most African health workers. Indeed, they trained us well to serve such a purpose; at least I believed so until I recently came back to my country. What I found in the rural areas of Somalia is something I was not prepared for. I came to the conclusion that even the idea of health care in resource limited setting should not be an objective description rather a subjective one. Poor setting in Uganda means the best care in my country!

I would like to share with you a series of stories based on my own personal encounter as health care provider in the Sanaag Region of Somaliland to give you an insight into the reality of healthcare in Somalia. It is nothing but the reflection of a truly failed state!

Zaynab, 26 years old, shown in the photos below, was a G¬6P5+0(sixth pregnancy and has 5 children) unsure of her dates, brought to Hingalol District Hospital in a semiconscious state early this month (3 October 2015). Upon quick collateral history and examination, I found that she was in shock with an unrecordable Bp. We resuscitated as quickly as we could with intravenous fluids. We found that her Hb (Hemoglobin level) was 4.3 g/dl-extremely low hemoglobin level. Later, I made a diagnosis of decompensated heart failure secondary to severe anaemia in pregnancy. She also had septicemia. I made the decision to transfuse her with 2 units of whole blood but to do that I have to go about a series of obstacles.

To start with, there is no blood bank, no proper laboratory services and no one with technical know how on how to collect and store blood, no reliable electricity. Actually no one was transfused in the history of Hingalol District and local people have their doubts on the benefits of blood transfusion. It was very hard to convince them that blood transfusion is a life saving procedure if done properly and safely.

We only had a blood collection bag and our lab guy could do blood grouping but no screening for HIV or Hepatitis B or other infections, we didn’t have a blood giving set so at the end we have to use the giving set for other i.v fluids. I carefully explained to the husband of the wife, a nomadic camel rearer, what we found and what we are planning to do. Though he had no schooling, he was among the most intelligent and open-minded people I have ever seen. He told me since I am the doctor I should do whatever I think necessary to save her life but he requested he should be donating the blood as he only trusts his blood to be save and unspoiled. I told him it is ok if his blood matches her blood but we shall test both of them. Unfortunately, the patient was O+ while the generous caring husband was B+. Since I am 0+, I could not see any other option other than donating my own blood. I have to admit, it was not easy convincing the husband that a guy from a non-Wersangali clan could be of the same blood group to his wife while himself is not! I explained to him that even brothers and sisters could be of different blood group! Moreover, I am the only one, I guess, with enough Hb to donate blood; most people are anaemic and dehydrated because of the scorching heat and long march in search of pasture and water for their livestock. Remember cross-matching is not a luxury I have at this point in time and I will transfuse the blood as soon as I harvest my blood. I have to sit next to the patient and watch for any early transfusion reactions during the whole process. At the back of my mind, the basic hematologic fact that i am a universal donor reassured me.

The following day the patient could sit up and talk! However, the patient left before completion of treatment because the family and the livestock have moved to Sool region where it has been raining and she has to go because there is no other person to take care of her children, with a postransfusion Hb of 6.7g/dl-still seriously anaemic!

Anaemia in pregnancy coupled with the lack of antenatal care services and properly trained health workers and the fact that there is a severe drought in this region makes pregnancy a death sentence in this part of the world.

Mohamed Bobe, Hingalool.

‪#‎NomadicHealthCare #252HealthCare #Mypersonalexperience  #Servicetomycountry.

 

HELLO WORLD!!

Welcome to my blog, my name is Mohamed Bobe; I am a medical doctor, trained in Uganda, currently working in Hingalol, Sanaag region, Somalia. As a student I dreamed of working in a state of the art Hospital, having a well furnished office and going to work with my own car cooled by an AC. This was shattered by the reality at Home, the fact that our health care system and infrastructure is in a situation of despair and self pity! I decided not to run away from the reality but do what I can to change the status quo of our country in general and that of the health care in particular.

 I started my first job in a remote village in the most impoverished regions of Somaliland. What I experienced while working for the nomadic pastoralists in Sanaag was so shocking and I decided to be a blogger and share the world with the health crisis and the pitiable situation of the Somali nomads.

 I will be writing about the health care in the horn and my series is called Nomadic Health Care. You can follow the stories through either of these hash tags #252HealthCare, #NomadicHealthCare. Or you can follow me directly on twitter, my handle is @ bobe_dr. I will share with you my personal encounter as a firsthand experience in the form of narrative stories. I believe we can change the situation one diagnosis at a time. We must do what we can, with what we have, for what is needed in where we are! Nothing matters but the patient’s life. Once again welcome aboard and stay tuned for my series

 Mohamed Bobe, MD.