John Drysdale: Lifelong Friend to Somaliland

John Drysdale: Lifelong Friend to Somaliland

We wish to extend our heartfelt condolences to the family and friends of John Drysdale, who passed away yesterday. John was a British citizen who first came to British Somaliland Protectorate in 1943 as a young Lieutenant during the Second World War, and who lived in Somaliland for most of the intervening years.

John was a friend of Somaliland and a friend of my late parents as well as my late first husband, President Mohamed Ibrahim Egal. When the Edna Adan Hospital was opened in 2002, John was a member of the first Board of Trustees of my hospital. John had many books published about Somaliland and was among the few foreigners who spoke our Somali language fluently. He will be greatly missed. – Edna Adan Ismail

International Day to End Obstetric Fistula

International Day to End Obstetric Fistula

On International Day to End Obstetric Fistula, Kate Grant, CEO of the Fistula Foundation asks why a million women worldwide still suffer the preventable and treatable condition of fistula. Answer: lack of healthcare infrastructure, especially proper obstetric care and safe and affordable surgery.

Kate Grant of the Fistula Foundation writing in The Guardian

An obstetric fistula is a hole between the vagina and rectum or bladder that is caused by prolonged obstructed labour, leaving a woman incontinent of urine or faeces or both.

One of the toughest aspects of fistula is the stigma. The leaking of faeces and urine results in hygiene issues and a smell that are difficult to cope with. This condition used to be common in the west until the early part of the 20th century. In fact, a fistula hospital once stood on the site of today’s Waldorf Astoria Hotel in New York City. But thanks to the widespread availability of emergency obstetric care and interventions such as C-sections, fistula is now rare in developed nations.

Why do a million women still suffer the treatable condition of fistula? (full article)

Fistula Foundation + Direct Relief

Fistula Foundation and Direct Relief have helped us to provide surgery to many women.

Thanks to your support together with partners like Fistula Foundation, Edna Hospital is working tirelessly to address these issues and bring about a fistula-free world for the women we serve in Somaliland and throughout the Horn of Africa.

Somaliland in Drought on World Water Day

Generosity means sharing the last drops of water with your baby sister during the ongoing drought in Somaliland…

Only about one-third of the Somaliland population has access to safe drinking water. In recent months, devastating drought exacerbated by El Nino weather patterns has left over 240,000 of our people without enough food and killed 35% to 40% of our country’s precious livestock.

For this little girl, her sister, and all of us, ?water gives life. Health and hope depend on it. ?

United Nations World Water Day

Slowly and Steadily, Somaliland Builds its Health System

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.

Edna Adan Liba Taylor/Corbis

Edna Adan
Liba Taylor/Corbis

“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.”

Mental scars

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.”

Edna Adan at first Girl Summit in London

Edna was invited by Somaliland First Lady Amina Weris to serve on the country’s delegation for the first Girl Summit in London on July 22, 2014.

The event, co-hosted by the UK Government and UNICEF, was aimed at mobilizing domestic and international efforts to end Female Genital Mutilation (FGM) and child, early, and forced marriage (CEFM) within a generation.


First Lady Weris stated that the government of Somaliland, one of the leading 30 countries in the practice of FGM, is fully committed to achieving the end of FGM and forced marriages through concerted effort.

As a mother, midwife, and former student of Edna’s, First Lady Weris is a valuable ally in the fight against FGM.

As of today, over 11,000 people have pledged to join in the Girl Summit movement to end FGM and Forced marriages and nearly 1 Billion people have been reached via Social Media.  Will you join us?

Take the Pledge

Read more about Somaliland’s delegation in the Somaliland Sun newspaper: Government Committed to Ending FGM and Early Forced Marriage in this Generation


Community Midwife Training Program Expands

Community Midwife Training Program Expands

Everyone who’s familiar with Edna and her work knows about Edna’s dream of training 1,000 Community Midwives to be deployed throughout Somaliland. This past week, we took a big step toward making that dream a reality.

Community Midwives are healthcare workers who receive two years of training in basic midwifery and nursing skills. They are recruited from all over the country with the hope and expectation that they will return to their home region and serve that community after graduation. In Somaliland, where there is an acute shortage of doctors, and hospitals are few and far between, the Community Midwife is the only trained healthcare professional accessible to large segments of the population. She is able to provide prenatal care, assist with deliveries, immunize infants and children and dispense basic medicines.

The program has been embraced not only by the Somaliland Ministry of Health and Ministry of Education, but also by the towns and villages where the Community Midwives serve after completion of their training. However, a limiting factor in the training has been that Edna Hospital is the only facility where Community Midwives have been tutored under Edna’s watchful eye. Since the Hospital can only accommodate one class of approximately 40 students at a time, young women cannot be trained fast enough to meet the increasing demand.

For some time, Edna has been looking to establish training centers in other areas. An opportunity presented itself recently as funding became available to begin classes in the towns of Berbera and Gabilay.

In order to maintain the high quality of the program, the first step was to identify lead tutors for each facility, and to give them a two-month “teacher training” course at Edna Hospital. Simultaneously, Edna was busy obtaining support from the Ministries of Health and Education, and then getting approval from the governors and mayors where the new courses would be held, as well as from Berbera Hospital and Gabilay Hospital. Fortunately, thanks to the program’s strong reputation, backing for the proposed expansion was unanimous.

Next, candidates were recruited in each town. Applications were open to women at least 18 years old who had completed secondary school; 53 young women in Berbera and 37 in Gabilay applied for 20 openings in each town. The prospective students gathered last week – April 15 in Berbera and April 17 in Gabilay – for the selection process which was overseen by Edna along with representatives of the Ministries of Health and Education and local officials. The ladies first underwent a face-to-face interview to assess their English language ability as well as general deportment. Those who passed the screening sat for a written examination that covered English, mathematics and science.

The 20 top performers at each location were invited to join the program, which begins immediately. Each student had to appear with a parent or guardian who cosigned a student contract that sets forth the high expectations for the young women who are privileged to take the first step on the path to becoming Community Midwives.

Congratulations to the ladies who were selected and to Edna for this remarkable achievement!

Berbera Photos

Gabilay Photos

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