ANTIMICROBIAL RESISTANCE: WHERE ARE WE?

Antimicrobial resistance, according to WHO definition, is a broad term encompassing resistance to drugs for treatment of infections caused by viruses, parasites, fungi and not merely resistance to antibiotics.

Resistant microorganisms are on a war path and have acquired an edge over our most important tool in the fight against disease causing microbes-antimicrobials.  It is one of the greatest threats to our health systems globally as it narrows down the therapeutic options for infections, prolongs hospital stay, increases cost of treatment and raises the rate of mortality/morbidity. It is real and it is happening now. It is not a thing for the future as many believed in the past. Some are saying we are at the door of the post antimicrobial era and expect by 2050 antibiotic resistance could lead to the death of 4.73 million people in Asia and 4.15 million in Africa.

While lack of doctor’s prescription, informal sector drug dispensers, poor infection control procedures in hospitals and antibiotic use in the farming industry are among the established factors fuelling antimicrobial resistance globally and in Africa, Somaliland together with the broader Somalia has her unique challenges when it comes to the matter in discussion! Sometimes I get panic attack when I look at the way people are doing reckless activities which are putting the public health at the greatest risk.
Human resource problem in the health sector in Somaliland/Somalia is in crisis proportions leading to poor, inadequate and wrong treatment for common infections by unqualified medical personnel.  The safety, quality, and efficacy of drugs in the market are not controlled paving the way for substandard and counterfeit drugs circulating in the country. These and the following are among the factors unique to Somaliland’s challenges when it comes to antibiotic resistance.

Moreover, after the collapse of the Somali republic in 1991, following the fall of Hargeisa and the subsequent declaration of independent Somaliland, there were no law enforcement bodies regarding health care service delivery and drug dispensing procedures. In Somaliland no laws were passed controlling the use, selling and prescription of drugs. In the south there was no central government until recently and health care institutions are merely in the rehabilitation phase. Therefore, absence of government bodies to put rules and regulations controlling pharmaceutical companies and drug prescriptions has been the biggest challenge in curbing the danger posed by antimicrobial resistance in the Somali health care.

Another public health problem concerning antimicrobial resistance, unique to Somali health care , is the presence of multidrug resistant TB. The type of MDRTB present in Somaliland is among the deadliest types seen in the world. This is partly due to the fact that anti TB drugs are not strictly regulated by the departments concerned with their distribution and control. It is unfortunate that private clinics order anti TB drugs from China and sell to patients on demand! Actually, it is the patients that order them like common items in the market. You will be surprised to find that a patient demands the anti TB drugs from the clinician on the basis that S/he is suffering from TB or was diagnosed TB 10 years ago and symptoms recurred! The clinician generously helps the patients with the antiTBs and cashes in his money.
Personally, the greatest of all the challenges, and the one single factor which can encampus all the others, is the lack of public health education among the Somali masses. Most of the Somali people are not formally schooled and therefore are ignorant of the dangers of taking drugs over the counter. There are no efforts to educate the people on how to seek medical attention if sick. Most of them revert to symptomatic treatment from over the counter drugs. For example if they have fever they go to the nearest drug shop and ask if they can have the medicines for fever and they conveniently buy whatever their money can purchase. There are no government campaigns to educate the people on public health. This is very dangerous and is at a level I have not seen in other developing countries facing the same Challenge. 

In conclusion, with ceftriaxone resistance (one of the most efficacious broad spectrum antibiotics)  being more than 21% in some regions in Somalia and the enormous work that needs to be done to tackle the crisis of antimicrobial resistance globally, in Somaliland it will be a good start to establish an efficient Food and Drug administration agency to enforce the rule of law, to have a well organized public health campaigns educating the masses on the risks of taking drugs without a doctor’s prescription. We also need to have our own national medical guide land, Somaliland Medical Guideline to establish a common ground for treating common infections in our country.
The rest, we may catch up with the rest of our fellow Sub Saharan Countries in the near future!

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

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.

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