Nurse Midwife Bernadette Lawlor came to our hospital as a volunteer in 2014. During her three-month stay in Hargeisa, Bernadette threw herself whole soul into helping student nurses develop their skills. One year on, during a brief return visit, Bernadette had occasion to recall some of the highlights of her stay, and marvel at the progress made by her students, once timid young women, now confident and competent professionals who are a credit to all who have invested in their training.
I first came to Edna’s Hospital in Somaliland in 2014 as a volunteer Nurse Midwife from Australia. Not knowing what to expect and wondering how to be of use, I was nevertheless confident someone would teach someone a little, either way.
One year on, Bernadette reconnects with her student nurses
I was lucky to have timed my visit to coincide with the student nurses starting their first rotation to the ward where they had to actually work on real patients. I’m not sure who was more nervous, them or me. They were a wonderful group of young and enthusiastic students, so keen to learn, so scared of that first procedure or major critical event. We bonded well and made for a good team. They helped me with local knowledge and language, I helped them with all things nursing.
The first thing I needed to adapt to was ‘time’, it seems Somaliland time was a little more ‘relaxed’ than my Aussie time. We agreed to meet each day at 11am to talk, debrief, have an impromptu lesson on relevant issues on the ward etc. I was forever waiting for them to come, but one by one they came. Time seems to have a different meaning here; I eventually relaxed right into it.
I had a wonderful three months. The students progressed well, became more confident and skilled. They were happy with their progress, some amazed at what they had achieved.
While I was at the Hospital, Edna took me on a day trip to Gabiley, a nearby town where she was recruiting the next group of Community Midwives. It was a lesson for me on how tough it was to be accepted onto the course – the interview process, the exam, and the ‘Edna Lecture’ of what she expected, should they be accepted. It was an interesting day and Edna was patient with all my questions on the return trip. I was so impressed by the effort and commitment these girls were prepared to make. It was quite an amazing opportunity they were about to be given. I left Somaliland with a huge smile on my face and a sense of experiencing something wonderful.
I had no plans to return until a holiday in 2015 put me in the northern hemisphere again and I couldn’t help but ‘pop in’ to see how the students and everyone were going. Although a much shorter trip this time, it was great to see how the students were progressing, so much more confident and experienced.
Exam results announced
Over dinner one evening, Edna brought to my attention that the student Community Midwives currently on the ward were actually the young ladies we went to Gabiley to assess. They had made it through the first stage of study. It brought a wonderful sense of progress. They had developed from shy young girls to keen and eager student midwives. Great progress to witness.
Edna and all the staff who invest in the training of these young men and women should be so proud. Providing, as they do, hope and a future to these young adults of Somaliland. I felt privileged to have witnessed a snippet of Somaliland’s new future. Thank you to everyone at the Edna Adan Hospital for such a wonderful stay, both times. I look forward to seeing the graduation photos of both classes on the website.
Last month, the Edna Adan University Hospital hosted a special one-day medical conference on the subject of congenital and acquired disabilities among children in the Horn of Africa. The first of its kind in Somaliland, this was a landmark event for our hospital and the medical profession, drawing over 100 delegates from all corners of the country and beyond.
Since 2011, our hospital has been hosting surgical camps for infants and children suffering birth defects and acquired disabilities. Patients travel from a wide geographical area within the Horn of Africa to receive free treatment for conditions such as hydrocephalus, spina bifida, hypospadias, club foot, cleft lips and palates. Over the past four years the visiting surgeons involved in the camps observed a need for education among health professionals, both of the nature of the conditions and of the availability of treatment.
Dr Deeqa in action at a surgical camp hosted by the Edna Adan Hospital
Held at the Mansoor Hotel in Hargeisa, the conference offered all in attendance an opportunity to reflect on how children suffering physical disabilities in East Africa might best be served by the hospitals, medical schools and practitioners charged with their care. Opened by the Director General of the Ministry of Health, approximately 30 organisations were represented, including local and international NGOs, health and educational facilities. 13 representatives of the Ministry of Health attended from all regions of Somaliland.
Here she shares her expertise in the surgical treatment of hydrocephalus
The three keynote speakers and other invited specialists presented on the opportunities and challenges surrounding surgical treatment offered at our hospital for congenital and acquired disabilities. Each considered what might have been overlooked in the past and what needs to be addressed in the future. Several health presenters also discussed post-operative community rehabilitation for children. Some delegates were unaware of treatments available within Somaliland. It is hoped that the information presented will be shared with their colleagues, and within the communities they serve, in order that those affected will receive the treatment needed for an improved quality of life.
The conference represented the culmination of many years of dedicated service on the part of neuro-pediatric surgeon Dr Richard Bransford, as, for the first time, former trainees, Drs Shukri Dahir and Deeqa Omar, shared their expertise on the treatment of conditions such as hydrocephalus and spina bifida. The event closed with a number of awards: to Dr Bransford a certificate of appreciation, and to Drs Shukri and Deeqa, a certificate of achievement in recognition of their competence as surgeons, fully equipped to independently perform a range of procedures for children with physical disabilities.
The full conference report is available here
Dr Bransford receives a certificate of appreciation for his years of service
Conference speakers, hospital staff and board members gather
Dr Shukri reviews the list of patients awaiting surgery
By Sarah Winfield
Picture the scene: the stage is set with a mountain of bright orange boxes piled to the right, each bearing the words ‘Midwifery Kit’. In the centre stands a sign carved with ‘Hargeysa Cultural Center’, behind which hangs a poster proudly announcing the name ‘Edna Adan University’. A hush falls over the almost one hundred-strong audience, as members of staff, students, graduates and guests all wait expectantly for the event to begin.
This was the scene last week at the Hargeysa Cultural Center, where forty fully-fledged Community Midwives, the Edna Adan University Hospital’s third graduating class to date, were awarded midwifery kits courtesy of Direct Relief. This brings the total number of graduating Community Midwives trained through our hospital to 103 – a small army of women warriors who will help provide the knowledge, skills and health care so urgently needed in the far distant regions of Somaliland.
The ceremony was preceded by a presentation delivered by two exceptional students from the university’s Public Health department. The students reported findings from a survey concerning the socio-demographic characteristics, morbidity and vital statistics of the five major districts of Hargeisa. A thunderous round of applause completed the session, after which the ceremony for the distribution of medical equipment and supplies to our Community Midwives graduates took place. A delegation led by Dr Ali Sheikh, Director of Reproductive Health at the Ministry of Health, stood in line to award each midwife a much sought-after and complete midwifery kit. The contents of each box include delivery instruments, receivers, bowls, resuscitation equipment for mother and baby, catheters, sutures, scales, Sphygmomanometers, stethoscopes, headlights, etc.; in short, all the tools of the trade!
Edna with Community Midwife programme graduates
Showcasing the contents of the midwifery kits – all the tools of the trade!
Dr Ali Sheikh of the Ministry of Health presents the midwifery kits
One-by-one, the university Chancellor, hospital founder, and much loved mother of health care, Dr Edna Adan Ismail, called out their names. And up bounded the midwives, each in turn, to collect their kits. On, and on, the audience cheered them, these women standard bearers who will carry forward the life-saving skills they have been taught to the far-flung corners of Somaliland.
A special thank you to Direct Relief for their longstanding support in equipping this next generation of midwives to carry out their work. Many congratulations and best wishes to the 2015 graduating class of Community Midwives, and good luck to the group of 80 currently in training. We are so proud of you all!
Community Midwives stand tall. Edna beams with pride!
Lancet – May 30, 2015
by Sharmila Devi
Somaliland has made impressive gains in strengthening its health services, but substantial challenges remain for the unrecognised nation. Sharmila Devi reports from the capital Hargeisa.
Somaliland—a self-declared republic that broke away from Somalia in 1991 and whose independence remains unrecognised by the world—has made great strides since civil war destroyed much of the region from where more than 500,000 people fled in the late 1980s.
Thanks to remittances from Somalilanders abroad and foreign aid, much of the capital Hargeisa has been rebuilt and the rubble removed while the trappings of statehood, including health services, are slowly emerging. But the challenges remain steep in a region that has some of Africa’s highest maternal and child mortality rates.
Multilateral agencies, including WHO, will not deal with Somaliland as an independent entity but as one of three regions of Somalia—the others are Puntland and Central-South Somalia, which includes Mogadishu (figure).
Healthy life expectancy is 45 years compared with a regional average of 58 years, according to 2012 WHO data for Somalia as a whole. Somaliland ranks as 161 out of 163 least developed countries in the world.
Edna Adan, a former foreign minister of Somaliland who founded a university hospital that bears her name in Hargeisa, is internationally credited with much of the energy behind the young state’s progress in health. But she is the first to acknowledge the many remaining obstacles. The challenges range from the quest for political recognition and the greater budgetary support that might accompany it, the urban–rural divide, the need for greater professionalisation, to combating mental illness, the use of khat, and female genital mutilation (FGM). “We now have security and stability with no warlords and the people in government have set up the physical structures of health and education”, she told The Lancet. “But we need help to train our health professionals, so we can acquire the knowledge to assist people.”
Adan returned to Hargeisa in June, 1991, soon after the declaration of independence. The city had suffered aerial bombardment by the Somalian dictator Mohamed Siad Barre. Mass graves continue to be discovered in Somaliland. “What I saw haunts me to this day. Hargeisa was a ghost town full of war debris and land mines”, said Adan, who has been spoken about as a possible Nobel prize nominee for her work in health and campaigning against FGM.
She was one of the first, and remains one of the few, Somaliland women to drive in this Muslim and socially conservative country where all women wear head scarves and long robes. Her local fame was palpable when she drove The Lancet’s correspondent through the slow traffic of Hargeisa as people shouted “auntie” in recognition.
“Somaliland has put in place a formidable health service since it separated from Somalia 24 years ago when the people and the government had the task of rebuilding the health service. Today, there is a public hospital in every region and there are mother and child centres throughout Somaliland. It’s a long way from ideal but there is continuing momentum”, said Adan.
Health cooperation among Somalia’s three “zones”, including Somaliland, according to UN terminology, was active and working, said Humayun Rizwan, the acting WHO representative for Somalia. A health advisory board with representatives from all three zones met regularly to set priorities and allocate resources according to need, he said. “I’ve been here for 6 years and I can say in the health sector, there have been improvements”, he said. “We used to have meetings when the representatives would sit in three separate rooms but now they all talk to each other.”
But political tensions meant, for example, that training for health workers could not be done in one of the three zones but had to be done in a neutral space, such as Kampala or Nairobi, he said.
WHO’s working population figure for Somaliland is about 3·4 million and some 70% are estimated to be under the age of 30 years. Barely 40% of the population have access to public health care, Rizwan said. Many people used traditional healers or consulted pharmacists, many of whom were not qualified to provide medical services or prescribe medicines.
The health ministries of the three zones are working closely together to increase the number of female community health workers (FCHWs), or marwo caafimaad in Somali. Several hundred women have been trained to work in rural areas where they register households, provide basic medicines and supplies, coordinate with traditional birth attendants, and undertake referrals.
“Human resources remain one of the biggest challenges and this significant intervention will help because the utilisation rate of public health facilities remains very low”, said Rizwan. “The FCHWs can interact directly in the community, deal with lack of awareness of many issues, address behaviours and attitudes, and provide some curative services.”
Somaliland’s public health sector remains only loosely regulated while a host of UN agencies and non-governmental organisations (NGOs)provide most health services. Much of their emphasis has been on primary care and maternal and child health.“Somaliland’s lack of recognition as an independent country means donors give to civil society although there is now a quasi-budget support system”, said Michael Walls, a Somaliland expert at University College London. “The Somaliland Government sets priorities but it doesn’t control the money [from donors] and is weaker than civil society.”
Health Poverty Action (HPA), a UK-based NGO, has been implementing projects in Somaliland since 1994. “A lot of progress has been made and more people are getting free health services”, said Rohit Odari, HPA’s country director. “There have been vaccination programmes and in the past 2 years no major outbreaks of measles have been reported. But the people remain very poor and rural areas still have no roads or services.”
Although Somaliland has achieved a level of security and stability unseen in Mogadishu, for example, the scars of conflict remain, with two out of five people estimated to have a mental health disorder. Mental health care remains sparse not least because international donors will only fund “emergency” care. Local stigma against mental illness is still entrenched. “No one is advocating for mental health care at a high level and there is a lot of shame surrounding the issue, so it’s still very difficult to get treatment”, said Susannah Whitwell, clinical lead for the King’s College Hospital and Tropical Health & Education Trust Somaliland Partnership (KTSP), which focuses on medical training and academic support.
“Mental illness affects one in five families in Hargeisa and 70% of sufferers have been chained”, said Whitwell, who is a consultant psychiatrist.
The high rate of mental illness is compounded by the use of khat, a plant that is chewed for its amphetamine-like stimulus by most Somaliland men. A highly efficient distribution network exists in Somaliland, whereby the fresh leaves are delivered several times a day by air and road from neighbouring Ethiopia and other regions. “It’s the most efficient logistics system in the country and even where there’s conflict, the planes arrive whatever the situation”, said WHO’s Rizwan.
One of the KTSP’s projects has been to help with the curriculum of medical schools that many campaigners hope will lead to greater treatment of mental illness and to combat social attitudes around it and other issues such as FGM.
“There’s a lack of human resources; there are no special mental health nurses, psychologists, or psychiatrists”, said Whitwell. “The medical community is still very young. The next step is to ensure homegrown post-graduate professionals coupled with better regulation of health-care services.”
At present, Somalilanders have to go abroad for specialised and postgraduate medical qualifications and the first cohort should be returning in the next few years, she said. Many people are crossing their fingers that they do not become part of a brain drain.
Attitudes are slowly turning against FGM but the practice remains widespread. A 2009 study by the Edna Adan University Hospital, which has been at the forefront of the campaign, found 97% of women receiving antenatal care had undergone FGM. Some 99% underwent the most severe mutilation, known as pharaonic, in which all external genitalia are excised. On average, the girls were aged 8 years when the procedure was done.
“I started public campaigning against FGM in 1976 and since that time, the fact that the whole world now knows about it gives me hope”, said Adan. “But we are nowhere near the end of this and still too many little girls are being mutilated and cut.”
Her hospital initially started as a maternity hospital but was broadened to offer a wide range of treatments as well as different types of medical education. “There’s no room for complacency. Too many women die in Somaliland of post-partum haemorrhage because there’s no well-distributed blood bank system or facilities for caesarean section”, she said.
“There are no epidemics but a lack of education and literacy means too many people die of preventable health conditions that can be addressed.”
Report May 16: Day 8
By Sarah Winfield
We witnessed a spectacular skyscape over Edna Hospital this evening as the sun set on another surgical camp. Plastic surgeon Dr Rhodes and Laura, his wife and surgical assistant, emerged from Operating Theatre Two after an intensive week catering to the needs of twenty-six patients who travelled from all parts of the Horn of Africa seeking treatment.
Among the most dramatic transformations were the seventeen patients, mostly children, who received reconstructive surgery for cleft lips. A further seven patients also suffered cleft palates, a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. These surgeries, Laura says, take two to three times longer than the cleft lip cases. In both cases, however, the recovery is rapid. After three days patients are free to go home, and after one week they return to the clinic for a final check up.
Meet Mohamed, one of seventeen cleft lip patients who received free surgery at this week’s camp
Resident doctor and surgeon in training, Dr Naima, describes the condition of another patient who sought treatment this week.
Ahmed, is in his mid-thirties and suffers from epilepsy. Some years ago, during a seizure, he fell into a fire and sustained third and fourth degree burns across his entire head, penetrating into the bones and tendons of the skull. With his eyes burned out and all other sensory awareness lost, Ahmed’s life is a living nightmare. To meet him is to count one’s blessings.
This week Ahmed underwent first phase surgery, which involved a skin graft inserted across the bone flap of his skull. In subsequent surgeries his nose, mouth, and other features will be reconstructed so that, in time, his face will be restored, and with it, a degree of long lost dignity returned.
Our dedicated nursing staff provide round-the-clock care
For Ahmed and the other fifty-nine patients receiving life-changing surgery at this week’s camps, the Edna Adan Hospital represents a place of refuge. The selfless dedication of the medical teams attending their needs is matched only by the excellent post-operative care provided by our wonderful nurses.
Our heartfelt thanks go to Dr William and Laura Rhodes for their longstanding zeal and commitment to serving our community and imparting the knowledge and skills needed by our doctors to make this vital work sustainable. Much appreciation also to Smile Train and Humanity Direct for their unwavering support in ensuring that many of the poorest and most needy of our patients receive treatment free of charge. Please consider making a gift today to ensure that other patients who are without the means also continue to receive free surgery.
On the eve of 18 May, a red, white and green striped flag flies proudly from the roof of the Edna Adan Hospital. Wherever they may be, we wish Somalilanders a very happy Independence Day. A new dawn is on the horizon.
Sunset over Hargeisa
On the eve of 18 May, the Somaliland flag flies proudly from the Edna Adan Hospital
Happy Somaliland Independence Day!
Report May 15: Day 7
By Sarah Winfield
Day 7 of this month’s surgical camp, also the day of Dr. Bransford’s departure, got off to an even earlier start than usual. After providing life-changing surgery to thirty-three people from all corners of the Horn of Africa, there remained one young girl with hydrocephalus whose delicate condition necessitated two operations, back-to-back.
Having supervised Drs. Shukri and Deeqa performing these surgeries, Dr. Bransford was content that his work was done. As he left, he described his service to the hospital, and the countries it serves, as a ‘privilege’. Witnessing his trainees grow in knowledge, skill and confidence is a source of great pride, he says, and he leaves comforted in the thought of these ones providing the medical expertise and care so urgently needed in Somaliland. Truly a giant in the field of healthcare, a teacher, mentor and friend to so many in the Edna Hospital community, Dr Bransford’s selfless dedication to serving the needs of others is valued more than words can say.
Suhayb with his mother and baby sister before surgery
As activities came to a close in Operating Theatre One, the line of patients awaiting surgery from Dr. Rhodes in Operating Theatre Two continued to grow. Children with cleft lips and palates, adults with severe burn contractures and other disfiguring conditions crowd the hallways outside. Nervously, but patiently, they wait. Meanwhile, in the main hospital building, the wards are filled with infants, young ones, and older ones, recovering from surgery. Mothers sit anxiously by bedsides, nurses diligently monitor patients’ progress, and, all the while, visitors come and go, wishing their loved ones a speedy recovery.
Outside, young Suhayb is seated in a wheelchair under the shade of a tree. Six days ago he received surgery for a torn anterior talofibular ligament (ATL) in his right ankle, a condition which severely impairs his mobility. Now all bandaged up, his ankle will slowly heal and return to normality.
Like most of our patients, Suhayb comes from a desperately poor family and has travelled hundreds of miles from Ethiopia with his parents, mostly by foot, to receive free surgery at this week’s camp. Like so many, he has nowhere else to go for treatment. If Suhayb’s story, and that of other patients featured in this week’s campaign, touches your heart, please donate today to support their surgery. By making a gift you are ensuring that camps like this will continue in the future.
Suhayb relaxes in the grounds of the hospital after surgery