FEB-A-17
AN OVER-FILLED DAY OF MORNING AND
AFTERNOON
A VISITING PROFESSORSHIP AT HARGEISA
UNIVERSITY FACULTY OF MEDICINE, LECTURING THE NEW
MEDICAL STUDENTS OF A STILL-BEING BORN
AND A RETURN TO MEET WITH USAID GROUPS,
AND THE DIRECTOR GENERAL OF THE
MINISTRY OF HEALTH AND LABOR
February 9, 2004
I have
learned increasing numbers of details regarding
WHAT HAVE I LEARNED IN A WEEK
IN THIS UNIQUE SETTING OF
AN INITIAL ATTEMPT AT INSTITUTIONALIZING
A SURGICAL
IN
Much of
the remaining “elite,” if that term should be applied to the small group of
returned insiders who had been scattered during the immediate Civil War
Diaspora, had been educated in the Middle East.
As an example, Dr. Yasine had been in school and post graduate work in
Baghdad and Basra, and others in Russia or Egypt, whereas the former leadership
had been oriented to graduate work in the United Kingdom during the days of the
British post-colonial period, and the only other major European players seems
to have been the Italians, who had built and staffed the Berbera Hospital,
which had once been the center to which cases had been referred from Hargeisa
for specialist care. The run-down
hospital and its once well-functioning operating theatre had been the best in
what was then Greater Somalia, but in the post war degeneration, everything in
the country fell to as low as it could go and still be called a health care
facility. The officials here are proud
to point out that the sterilizer in
The
surgeon of note in Hargeisa is Doctor Suleiman and he had been sent by the
Ministry of Health to the Fistula Hospital in Addis to learn from Catherine
Hamlin how to improve care of women VVF and RVF (Vesico vaginal, and
rectovaginal fistulae—a complication of unattended obstetric care’s absence.) The regional center for US AID, for example,
is in NAMRU, in
Almost every one of the Somaliland “Boosters” points with pride to the area around us in what was once the outskirts of Hargeisa and was then bombed to oblivion by their own brethren under the Siyad Barre command. In a poignant irony, the air force based in Hargeisa airport, took off from the Hargeisa airport to bomb----Hargeisa! ---and return to land in the airport of its won city after each bombing run---a first in modern warfare! Nearby our region of the Hotel Mansoor (“Mansoor” means a “collection” since the incremental packets of devastated scrub land has been assembled and developed after cobbling together several tracts of trashed sand ravines for a total of US $300) are several of the twelve mass burial sites that followed that event in which 50,000 deaths are said to have resulted. Many of those who have returned have dug up the graves in search of relatives for re-burial. But, this Hargeisa of 12,000 inhabitants at the nadir after the bombing that all but escaped the notice of the rest of the world has now been re-built—it must be said in large part by squatters erecting hovels in the sand that look like patchwork quilts over geodesic domes—to a “city of 750,000 now, in a matter of a decade by returning destitute but proud people, who boast it is the “Safest City in Africa.” The many stab wounds on the general male ward and the eight gunshot wounds on the orthopedic ward might cause one to re-question the claim that this non-violent society is at peace. But at least the local militias are disarmed and there can be progress in communication and transportation, albeit over roads that wind through regions still heavily mined. And, they did it without outside help or foreign aid, or even international recognition! That means they stand in the unique position of being one of the only countries in Africa without massive foreign debt, because they are invisible to the IMF and World Bank, so that they cannot just access the cash register of international aid, such as Mozambique had done by pulling out of their civil war on the majority of the GDP of the nation being straight foreign aid from a world giving them money as fast as their debt burden could grow. The Somalilanders are proud to say that they have had an election, proving a democratic process of governance, and that entrepreneurs from the Diaspora are coming back with capital of their own making (such as that of Abdel in this Hotel Mansoor, making money in Kuwait to bring to Hargeisa to invest, and looking to use the connection with the sea water cement process I linked him up with to re-build Berbera into a commercial port center)—making money, as Charles Schwab would say, the old-fashioned way—they earn it. They have a very long way to go before they can even claim to be working up to some sort of acceptable standards, but in a nation hat can set its own rules as it goes along, there is a surge of entrepreneurial effort looking around for unofficial partners The odd part of this "poor but modern" scene is to see a barefoot fellow on a desert track littered with uncountable numbers of plastic trashed bags, shuffling along between domed hovels in the trash, heading to the open rack of meat on the market stalls with a cell phone at his ear, trying to make deals with a counterpart doing the same thing on the other side of the market, shouting in Somali into another cell phone those same international “Can you hear me now?”
Along the rutted sand road are several vehicles, most all of them white Land Cruisers with large radio masts on the font bumper guards and the big blue letters ‘UN” on the side. As I am riding in one, I am shooting illicit pictures from the hip as I am passing these market scenes, a surreal movie set through which I am passing, trying to record and report what it is that I am seeing to you who might not believe such a fanciful report without substantiating proof.
THE FULL DAY IN HARGEISA, TEACHING,
SEEING PATIENTS IN TWO OVERFLOWING CLINIC SESSIONS,
AND TRYING TO WITHDRAW FROM EACH “TAR
BABY”
OBLIGATRION TO BE WITHIN AN HOUR OF THE
SCHEDULED APPOINTMENTS TO WHICH WE ARE COMMITTED IN
MULTIPLE HARGEISA INSTITUTIONS
If this background scene is painted for you as the stark stage set, let me fill you in on the action in front of this set. We had staggered around at first to set up the surgical piece of the mission, which is always a complex process of inventing that wheel before riding it, and we worked at doing that while also developing several other missions so as not to come up empty handed if the surgical mission failed to materialize. It seems that it is now up and running to the pint that we cannot fulfill all the pending demand for surgery, but even more so for the now over-flowing medical outpatient screening clinics, for which publicity has brought overflowing crowds for a full day of a morning and afternoon clinic at Hargeisa Group Hospital. In the middle of this day and in the center of our mission, I am building an international medical education program, not only for the intensive learning experience for the accompanying GWU senior medial students, but also for the nascent institutions of Somaliland. So, with support from the director of the WHO in Somaliland, and in her presence as one of the attendees of my lectures, the middle of the day was spent in the new Hargeisa University, in a lecture an interchange with the still newer student body of the Faculty of Medicine, for which I appear to have been the first international visiting faculty.
Given the over-filled day, I would add that in just breakfasting and having dinner at the Mansoor Hotel had brought us into the center of all the international agencies coming and going through the Hargeisa area and so through this “holding court” in the Mansoor’s Lobby, we are getting to be a part of US AID, WHO, CARE and UNICEF projects, not to repeat the EOD (de-mining) operations and others previously described along with the international programs developed around the Edna Adan Maternity Hospital which we will now also be attending in an outpatient consultation session twice later this week. To end the day, the Director General of the Ministry of Health and Labor, who had previously met us at the airport on arrival, Dr. Ahmed Allah Jama came top meet with us here at the Mansoor Hotel and to outline how his ministry can help, despite their being out of the loop in the original planning and programming of our stay. A good deal about what we are doing here he actually learned from TV coverage! So, he was catching up on what we have actually been doing since our arrival a week ago when he met us on the airstrip and had his photo taken with us there, since when he has heard reports about us from the Faculty of Medicine, WHO office, Berbera (the Director of the Berbera Hospital and the chief medical officer were two who also came to my lecture in Hargeisa University) and the Group Hospital as well as Edna Adan who joined us later tonight her at the Hotel as well. Ironically BBC TV, of which we were only minimally aware of covering our visit, has made us into a bit of an international cause celebre. The BBC report in Somali was largely through the arrangements of Dr. Asea Osmania, WHO Director, who has also sent UN cars to carry us and others to attend my lectures.
THE MORNING
CLINIC IN HARGEISA GROUP HOSPITAL
A BARELY
CONTROLLED MOB SCENE,
FROM WHICH
WE MUST EXTRICATE OURSELVES TARDILY TO GET TO HARGEISA UNIVERSITY AND OUR
APPOINTMENTS FOR MEETINGS AND CONFERENCES,
BEFORE
PLUNGING BACK INTO THE OVERFLOW CLINIC
As we left the Mansoor after breakfast this morning, a young fellow whom I had seen before in the lobby came over to introduce himself, wearing a coat and tie since he was going to meet with the president this morning. He is Andrew Sisson, with the US AID mission in Nairobi covering the Horn of Africa. He is originally from Boston and was intrigued that I run through the hometown of Newton where his home is, and that I had been at the Peter Bent Brigham. He had told me that I should consider the Southern Sudan as a field and he will talk to me further about it, with the possibility that I might visit him on my next pass through Nairobi where he will be for the next two and a half years. He said that Senator Bill First had been there, and I told him I knew that story and another one that I had tried to arrange to Malawi. He told me about Paul Theroux’s new book on Malawi. We will probably see each other again and exchanged cards, bringing me down to about three cards left for Gondor Medical College in Ethiopia. He left with two Dutch colleagues and a CARE group through which USAID contracts here.
When we got to clinic at the Hargeisa Group Hospital, it was the same old story. It ha to be repeated on every new mission not only, but every day in the same place! First we must sit around and stagger start, talking about why we have no patients. Everyone should know that today we are promptly available even before eight o’clock, but at 9:30 AM without fail, we must leave no matter who is waiting, since the University of Hargeisa Faculty of Medicine lecture I am giving is scheduled for 10:00 AM and there are two UN cars being sent to carry the attendees from the Hargeisa Hospital who would like to hear the lectures as well as our team of four. Sure enough, patients start trickling in at 9:00, and then a flood appears at the time we were supposed to leave... Now a hundred vary anxious and angry patients are out there despite repeated explanations that we must be going away but would return here promptly at 1:00 PM. A few of the aggressive ones try to bang their way through the doors into the examining rooms, and several are looking at the accumulating crowds and the limited stock of free medicines, and jumping the queue. One older man begins shouting and swinging his walking stick. I have to shuttle between rooms both to see patients on each student team and also to get medicines from our bags, and a number of people begin snatching at the medicines. One woman had said she had come here for here medicine, since she has heard it was free, but when asked what her problem was, she waffled around saying she had just come here for medicine. Since she really had no real problem, she started confabulating and taking up more of our time. So, I double teamed patients and already had package some pills for the more common complaints and moved them through so that on one room we shuttled about fifty patients out before I had to go through the very pushy crowd to get to the cars. There, of course, was no one at the cars, so I had to go back to retrieve the students who would still be there tonight being pulled to pieces—meaning that I had to go back through the madding throng who immediately figured ”He is back!---and he has come back just to see me!” It is now 10:15 AM and the first ever visiting professor of the new Faculty of Medicine in Hargeisa University is functioning exactly on African time in his arrival;.
Not yet. First we have TWO UN cars to take us in one and all those who are going to be attending the lecture from the Hargeisa Hospital back and forth to the University. No one has shown up despite four announcements to this effect, and those who intend to go along will consider it my fault for not coming to get them. There is someone here however, and that is a fellow from the Institute of health Services who has come to find out when I am scheduled to give my lecture to their group—the first I have heard of that. We get to the University where about a hundred students are sitting in a classroom. I point to the two carrousels of slides that I told everyone about two days ago twice to say we needed a slide projector that could show slides. They have an overhead projector there, but no slide projector, so they will need to go somewhere in town and borrow a carrousel projector. This they do, but they will need almost an hour to do this. So, I give a little talk, and I introduce each of the team, and they each say what it is that brought them here and how they have appreciated the experience this far. I find out that there are fifty students in the most recent matriculating class, but there are seven upper classmen. These seven are only in their second year of what looks like a nine year program, so the group I am talking to are essentially high school students that will have to be doctors on a rush plan, to compact the last years of high school, all of college, and there six years of the British style University medical faculty together in the next few years. They keep asking how they can study without the implements, and the University Admin Officer asks me for my email address since the help they will need is that I send them all the 1990’s vintage laboratory equipment for them to use, listing microscopes and about two million dollars worth of equipment that would weigh about twelve tons and take a quarter million dollars to ship it through customs in about a year. But, that is not too much to ask, is it? What time will you be back at the Hotel? I will prepare a list for you so that you can take it back home to prepare it by the time of your next return trip. Yeah, right.
The audience included the two top people from Berbera who had come to meet me and to get the patients pre-arranged for Berbera Hospital under the naive assumption that they would select and pre-op patients who needed operations that we would simply drop-in and do. I do not think this is a good idea, but the team is still squeezing every chance to do a few more cases. We also have a close group of students—most seated in good Moslem isolation by gender, and one young woman in a black burka who must be six feet three tall. Zoura became very helpful. She had come forward during the “altar call” for those who wish to learn the skills that will help them to help their people, can accompany us in the clinics as we see and examine patients, and they could learn while assisting in translation. There were many others who said they would come to our next clinics.
Skipping lunch and getting the UN vehicles and drivers who had been awaiting as an assignment from Dr. Osmania’s WHO office. We scrambled back to clinic to find----no one. Of course not. We sat and fiddled until a group of patients trickled in and swelled to a flood and then there were too many just at the time when we were already late for our four o’clock appointment and despite speeding up, there were still a group who were irate about not being seen for arriving an hour after we should have closed.
CIRCUS
HARGEISA
AND RINGSIDE
EXAMING ROOM
We were going with Omar to see the pride and joy of the project of HoVoYoCo---“Horn of Africa Volunteer Youth Council.” These are the street kids who would have been begging, stealing, or worse—fodder for Somali warlords’ bands of thugs-- after being found as orphans after the civil war. They have banded together to make a tumbling and performance act to earn money and to give them a skill and useful role in the society. They were good. They performed balancing acts and put on a dance program which included full flips in the air backward and forward. One six year old boy climbed a pole that was held by an older boy who then transferred it to his head to hold it without hands. The little six year old was doing what he had been told to do—holding on for dear life, looking terror stricken but intense. Life and its responsibilities start early here.
In the middle of this performance a family with concerns about ambiguous genitals of their daughter came by and we had to examine this little “girl?” with what looked like gonads in the labial folds. This is a big workup, and we were doing it as a sideshow between acts of the Circus Hargeisa. I suggested we see her in clinic tomorrow.
W went to the HoVoYoCo School, run by a Dutch NGO donor Nivib, and distributed gifts of toys and coloring books and Frisbees and bubble blowing bottles. While standing in the courtyard, I looked up in the sky as the chilling twilight was coming on, and there, soaring overhead, was the Lammergeyer, a rare raptor that is the emblematic bird of Somaliland. I had a chance to point it out to each of the team, and then Omar said, “Yes, there are many of them around here!”
COMPARING CAREERS
AT THE
COMPARABLE AGE AND STAGE
ONE GWU
SENIOR PROFESSOR,
AND THREE
GWU SENIOR MEDICAL STUDENTS,
AND THEIR
RELATIONSHIP TO AFRICA
The group I had mentioned as the US AID team here with their contracting team from CARE are moving on from Somaliland to Djibouti tomorrow, and asked us to report to them on our activities and suggested a meeting with the members of the team at various times in the next years in Nairobi. The EOD (Explosive Ordnance Disposal) team had also asked if they could relay messages back to Pretoria where the chairman of Anatomy would be interested in reaching me. I suggested that the Chairman of Anatomy at Wits University in Jo’burgh Phil Tobias and his colleague Raymond Dart, were world-renowned anthropologists whom I have met and spoken with in the period of my Senior Fulbright African Regional Research Fellowship in 1996, and passed along my regards to them through there colleague in Pretoria.
I am continuously conscious of the fact that all the groundwork for my international medical mission experience was formulate in my senior medical school experience in Nigeria on the foreign fellowship that made me start along the road as an Africanist. This is the same age and stage as the three senior students from GWU who are with me here on their eye-opening experience, and that for me this same experience was just thirty six years ago—longer by several years than any of my own senior medical students, and exactly twice the age of the median of the early medical students that I had lectured to today at Hargeisa University! While we are here, Jay Maguire submitted his ERAS (Electronic Residency Application Series) into the “Match” by way of his selections by email. Juan and Kevin had submitted theirs on departure for this experience. I had submitted mine by mail before taking off on my African Foreign Fellowship in Nigeria, and later that March of 1968, the NIRMP (“National Internship and Residency Matching Program”) had crunched the numbers in the choices made by the prestigious institutions to which applications had been made and aligned them with my own highest choices in what was then this new complex device known as “the computer.” Four weeks after the tumultuous celebration at which the envelopes were opened in Ann Arbor Michigan in a party at which I was not a participant, everyone back there knew I had got my first choice of a premier surgical residency at Harvard’s Peter Bent Brigham Hospital, a barefoot messenger wearing only shorts came through the dusty path at Takum Christian Hospital in Nigeria and delivered the envelope I opened there to learn that the next stage of my career would be launched in this renowned center when I returned to the US. The career parallels for my students in their excitement about both their immediate opportunities here in this exotic environment, and in their longer term futures in the Match are a source of interesting musings for me as I work here with them. They had a chance to share in that excitement of what I had done in Nigeria today at the lecture, designed around them and their experience here for which it was educating them in what they might see in “Tropical Surgery.” Just how “immediate this would be is seen the next day. How this stage of their life experience will prepare them of the next stage for which the computer---now in such common use that I have one in hand and the NIRMP is no longer so exotic, but the ERAS that has replaced it is now just an email away!
HOTEL
MANSOOR DINNER
THEN MEETING
WITH US AID,
AND THE
DIRECTOR GENERAL OF THE MOH AND LABOR MINISTRIES WHO TAKES OWNERSHIP
OF OUR
“PROGRAMME”
Dr. Ahmed Alah Jama is the Director General of the Ministry of Health and Labor for Somaliland. We had met him at the airstrip upon our arrival, and had spoken with him at the time he was looking at us warily, wondering what was this delegation coming to descend upon Somaliland and for what purpose? He had been late in coming into the loop, and had said that he was surprised at our appearance here having received only a couple of days notice. This was the same case with Dr. Yasine, who also had met us at the airport, but at the Hargeisa Group Hospital where we would be working principally, he would be making an active part in our work here and came to see us only shortly after the King’s College London group had left, the only other international group with which they have an affiliation.
Dr. Ahmed came in Somali dress, and wanted to deliver to us in person some bad news. The assurances that we had been given by several representatives, that the President’s Office would be taking care of all our internal travel and accommodation expenses such as Hotel Mansoor, the food we have been eating and the transport from one center to another, had not come from him, and the other agencies have no money at all. Therefore, they would NOT be covering any of our expenses. That was the bad news. After he let that sink in, while each of us was totaling up the cost of al our expenditures, he told us several other longer stories about his overburdened office and his tenure in it, and the efforts that he had made in the rapid growth phase of the resurrecting Somaliland economy. He then launched into a much longer clinical story about his wife’s long history of hyperthyroidism, and her first recourse to traditional indigenous healing, which resulted in a large burn scar on her neck, with an inflammation that resulted in the sloughing of a wide area ok sin over a growing goiter. He pointed out that he had heard something about a goiter expert being here in Somaliland and wanted to further describe his wife’s condition for which he had sought treatment in Islamabad, Pakistan, in the institution in which I had lectured repeatedly. He wanted to know if he could present her chart and data to me, and also have me see her if I could arrange that. Of course, so it was set up for the next day.
At the end point of this long story in which each of us had said how happy we were to be in Somaliland, and how important it was for us to share this experience, and if there was no support for our expense that was to bad, particularly for the students, but if that was how it was to be, it in no way changed the high value of this experience for each of us. That is when he released the good news: His office would be covering the hotel bill, and from now on talk to no one else about it, since he would be talking with Said the owner’s son and Hotel Mansoor manager, to tell him all the bills should come directly to him. In this way, he had assumed personal ownership of the medical mission about which he had heard many things from the people and from BBC TV and from the University and the lecture, as well as from WHO and from Berbera and the representatives each had sent to the lecture. He wanted to outline our “programme” in advance and take advantage of our being here as well as a higher profile identification of the MOH in our volunteer project. We were delighted and relieved at his generous offer since I would not want to see the itemization of the supplies and food delivered to us without a thought as to economizing on any part of a successful mission. He also pointed out that he had seen the heavy duffel bags coming in with us through the airport, and would like to assure me that any future equipment and drugs would be welcome in through a container he would clear personally through his influential office,
As we were concluding our meeting with the Minister, Edna Adan came into the lobby, with a second group of people she had planned to meet here. We all got together and we posed for a photo of each of us in a portrait. When Dr. Ahmed put his hand on my shoulder, and Edna who had spoken familiarly with me came close on the urging of the photographer, I put my hand on her shoulder for the pose. She was wearing western dress, not a Somali gown, so I did not think of her at that point as a Somali, but as a westernized colleague. When the camera was just ready to click she said without any emphasis or smile, “You might take your hand away from my shoulder.” It is easy to forget where I am and with whom, when the appearances would have been quite different if the DG MOH were wearing a western suit and she were wearing a Somali gown, I would not have had to be reminded of the difference in colleagues as to gender status, since we are “closer to the Middle East than we are to Africa,” a statement that is now going to have to be made paradoxically in Egypt and the other parts of the Horn of Africa as American familiarity and Wahabi Sunni Islam are moving in opposite directions as all other aspects of the relationships are moving closer and very much quicker.
Ex Africa veni
semper aliquid novi.