Somaliland! Report From the Field
Somaliland! Report From the Field
By Philip R. Fischer, MD, DTM&H
Dr. Fischer is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
Dr. Fischer reports no financial relationships relevant to this field of study.
Synopsis: Despite lingering security concerns in Somalia, there are areas of the country where medical education and health services are improving.
Source: Noor AM, Rage IA, Moonen B, et al. Health service providers in Somalia: Their readiness to provide malaria case-management. Malaria J 2009;8:100.
Somalia, ravaged by civil unrest for most of the past two decades, is striving to upgrade its health care. Since 2005, national policy has been that rural health posts should use sulfadoxine-pyrimethamine (SP) for presumptive first-line treatment of malaria; established health centers should use either a rapid diagnostic test or microscopy for diagnosis, and then the combination of artesunate and SP to treat confirmed cases of malaria. A survey of three districts revealed a total of about one physician for every 55,000 people; 11,000 people per public health facility; and 3,000 people per pharmacy. Sixty-two percent of facilities reportedly used the recommended first-line malaria treatment, but only 33% had that treatment in stock on the day of the survey. In the private sector, 53% still were using chloroquine as first-line anti-malarial therapy. Improvements in medical care policies will need to be combined with further educational efforts and pharmaceutical supply systems to ensure that the population benefits from recommended malarial therapy.
Commentary
Practitioners of travel medicine need to guide travelers on how best to deal with medical problems in parts of the world where appropriate staff and supplies are not always readily accessible. Similarly, health professionals all should be concerned about the sub-optimal levels of care available to local residents in many parts of the world. Combining travel and medicine affords some of us with the great opportunity and privilege to impact health and health care in underserved corners of the world.
"Somalia? Are you crazy?" Some greeted news of my recent travel plans with incredulity and questions of insanity. Others, remembering helicopter crashes in Black Hawk Down, asked if it would be safe. A few friends, aware of recent headline media reports, wondered if I was planning to go on a cruise in the Gulf of Aden. For many of us, our understanding is tainted more by entertaining, but incompletely relevant, movies and media than by facts.
True, there has been civil unrest in Somalia for a long time. Trading posts were established along the coasts of present-day Somalia by Muslim Arabs and Persians during the 7th through 10th centuries. Nomadic Somali groups and pastoral Oromo peoples occupied inland areas. During the 1800s, British and Italian exploration influence was strong, and various colonial divisions followed this multi-national involvement. The Republic of Somalia became independent in 1960, but decades of strife followed. While many Somali people find loyalty more with a clan than with a nation or region, two specific areas (Somaliland to the northwest, Puntland in the northeast) declared their independence in 1991 from what remains as Somalia to the south. That independence, however, has not been widely recognized by international organizations, even though governments function independently in each of the three semi-autonomous areas. Most current fighting is in the south, and the pirates of recent news reports reportedly have been based along the coast of Puntland.
So, I went to Somaliland. Innocently, I planned to provide some general pediatric education to Somali medical students while physician friends from the United States and Kenya did surgery and provided general medical instruction. Relatively calm and isolated from events hitting current news media, Somaliland still desires and attempts to make sure that its foreign visitors are protected from violence (presumably the sorts of violence that would be triggered by outside terrorists who would infiltrate to tarnish the reputation of this calm part of the region). Thus, I was constantly accompanied by armed guards. These friendly soldiers stayed at the gates and doors of the hotel and lecture hall but were otherwise at my side. Jogging beyond the hotel compound was prohibited, and I gradually became accustomed to bedside teaching in the 20-bed pediatric ward with an AK-47-toting guard as part of our "team" with medical students and nurses.
One afternoon, though, I did get to walk beyond the confines of the hotel, hospital, and armed convoy between those two sites. I joined the medical students (and the soldiers with AK-47s) on their weekly "community health" excursion. As noted by Noor and colleagues, Somaliland does have health infrastructures, but not everyone in the population has access to regular medical care.
We left the bus at the end of a rocky road and headed by foot past grazing camels and over a dry riverbed to the site of a former refugee camp that now serves as home to about 400 families. Under cloudy skies graced at the end of the day by a rainbow, I saw a high desert with its rocky hills colored by the early green hints of a coming rainy season. From one made-from-scrap hut to the next we trekked as the students checked up on their community. With such weekly contact, this community had achieved excellent immunization coverage, received good prenatal care, and was screened for a variety of health problems. Students compassionately stooped in the shade to check on their patients — improving nutrition in a child, lessening a cough in a man with presumed pulmonary fibrosis, and improving blood pressure control in a hypertensive mother. In one home, a skin examination revealed no pressure sores in an elderly stroke victim. Laughing, joking, and teasing, the students enjoyed close bonds with this community, learned about true primary care, and provided needed services.
Over a delicious goat meat dinner the evening before our chartered Cessna Caravan headed south to a commercial airport in Kenya, I chatted with the founder and president of the university. Trained in the United States, he had returned home to Somaliland despite the challenges of working in a country torn by war. Caring about education, he surveyed young people a bit over a decade ago to learn about their hopes and dreams. It became clear that a major goal of young Somalis in that area was to "study abroad." These survey results provided the impetus to launch a new university to help the next generation of Somaliland youth study and eventually serve without having to leave home. Now, the top 20% of students completing the first year of university studies are invited to enter a six-year medical school program. I focused my week's activity on the eight final-year students who are soon to be the third graduating class of this university program.
Of course, I am not the first foreigner to offer help at this university. As reported in Lancet three years ago1 by an impressive group of co-authors that included two of my hosts, this university has linked with King's College Hospital in London as well as Britain's Tropical Health and Education Trust to make great strides toward the development of improved health infrastructure. And I was impressed! The students were very knowledgeable and provide compassionately personal care to their patients. They expertly obtained historical information and performed physical exams; they tried to think through differential diagnoses; they explained details of pathophysiology and potential treatments. And they did this after getting most of their teaching from books and Internet sources. One student estimated that only about 10% of their time was spent with or under the direct supervision of a faculty member. We shifted our four hours of daily lectures from PowerPoint expositions to personalized interactions, and we worked through differential diagnoses and management plans during our hours each day of bedside case discussions. Without my own books and lacking quick Internet access myself, I was stretched beyond the comfortable limits of my own pediatric knowledge by the stream of complicated patients the students presented.
Travel medicine practitioners often want to contribute to health care needs overseas. Earlier this decade, a physician visited Somaliland and gave advice that is still pertinent to medical professionals wanting to help in many areas of the world: Visitors and NGOs want to contribute, and the easy way is to contribute a piece of equipment, or a month's supply of an expensive medication. This is definitely not the way to go. Sharing knowledge, teaching skills, and upgrading health care professionals is an investment that will last much longer and improve the well-being of the population.2
References
- Leather A, Ismail EA, Ali R, et al. Working together to rebuild health care in post-conflict Somaliland. Lancet 2006;368:1119-1125.
- Alkan ML, Ali AA. Report of a medical mission to Somaliland, 2001. Rural Remote Health 2001;1:87.
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