The Best and the Worst

I just got back from my going away dinner with all of my Somaliland "family." It's crazy to think the past two months have flown by so quickly. I will never forget the people I have met and the things I have learned while being here. Here are some of what I think are the worsts and bests about my time in Somaliland....


Worst:

1. Seeing people die who should not die.

It is one thing to see a person die who has come to the hospital in old age who has lived a good, long life and is ready to pass on. It is a very different thing to watch a 26 year old man die of abdominal TB, to see a 20 year old female die of congestive heart failure, or to see infants die in utero or immediately after birth. I knew I would see death before I even came, but it is still hard to watch people pass away when if they were living other places they would have so many other available treatments.

2. Oh, the frustrations of teaching.

Perhaps I just appreciate all my professors from home so much more after this summer. I definitely did love getting to work with the students and help many of them develop their English, but oh there were also those days where I did not want to speak to another student. Not doing homework, coming 30 minutes late to class or not showing up at all, missing exams, cheating during exams....

3. Poor quality care

Edna's hospital provides the best care in the entire country, and it has been amazing to work with the various staff members. However, even being the best in the country, some of the hospital standards can become a bit slack at times. I have a bit too frequently seen staff and students make poor decisions and provide less than quality care (i.e., not taking a fetal heart rate on pregnant women, going to dinner when a woman is hemorrhaging, not rotating or bathing stroke patients, failing to take vitals on patients, and on). While this hospital is amazing and the care here is better than the government hospital, there is still room for improvement.

4. Cultural frustrations

For all my thoughts of cultural competency and working within the current structure, there were definitely some times I simply wanted to hit my head against the wall in response to what I was seeing. As I have mentioned before, the issue of consent was huge during my time here. It was unbelievably frustrating to see women in need of a cesarean section waiting for hours as their husbands were found, convinced, and finally agreed for their wives. The gender issues in the society here, I feel are huge. It makes me sad to think of the many students who will get married in a few years and have stunted careers as future students/nurses/midwives as they are pushed into the role of housewife and child manufacturer.



Best:

1. Babies

As you might have picked up by my various blogs by now, I do love babies! I have loved getting to see, learn, and do so much with babies. Getting to learn and then help teach neonatal resuscitation skills to the nursing students, "catching" a baby from utero, helping mothers breast feed, and laughing at the over sized newborn outfits.

2. Passionate students

For all my teaching frustrations, and seeing some laziness in the students while working in the hospital, there is a great number of students who are truly passionate about their work and gaining further education. There is a smaller group of students I provided extra tutoring for because they were willing to take a bus back to the hospital many afternoons for extra help with their studies. I have absolutely loved working with and teaching these students.

3. Somaliland people

As a whole, the people of Somaliland have been absolutely wonderful and hospitable. From the students and staff at the hospital to random people we have met while riding the bus to the market, everyone is unbelievably kind. Getting to view the excitement around the elections and experiencing the spirit of Somaliland has been absolutely wonderful. As a whole, I have found the people here to be unbelievably welcoming and friendly.

4. Somaliland "family"

Edna always says that while we stay here, we are her daughters and sons. She also frequently calls her dinning table the UN dinning table because of the number of nationalities it holds. At dinner tonight alone, eight countries were being represented. These people who I live with upstairs have become my family over the past two months. The people are constantly shifting in and out (me included as I am not leaving) of Edna's hospital as various volunteers, visitors, and staff members come and go. I cannot imagine what my time would have been like here without having all of these friends to work with on teaching and figuring out various situations downstairs and debriefing at the end of the day. Seeing others with the same passions as myself and sitting each day with the most inspiring lady who is still working hard at 73 years of age has been amazing.

Some random photos:

Ice cream (or what they call ice cream here) with Randi-


Dr. Abdikani teaching the girls on rounds about eclampsia-


Asha!!! One of my tutoring students-



Post-teaching neonatal resuscitation. They wanted a photo shoot-


My favorite Canadians, Lauren and Harrison! I don't think I would have survived the summer without them. I will definitely miss them.


Well, that's all. Tomorrow morning I head home- Hargeisa, Berbera, Djibouti, Dubai, Frankfurt, DC, St. Louis, and then HOME!!

Beach...

In an effort to sort of get away from the hospital for a day, five of us volunteers decided to spend our weekend (Friday) in Berbera. Berbera is Somaliland's main seaport located on the Gulf of Aden and compared to Hargeisa is sweltering hot (note: despite being in an African climate, Hargeisa is very windy in the summer with mild evenings and mornings, and there has been a bizarre "cold"- this is relative- and rainy streak for the last few days). As our two hour drive from Hargeisa to Berbera progressed, we could gradually feel the increase in the temperature.

We did go to a private beach area, which is property of Edna's family. This was the nice part because we had the whole area to ourselves. The not so nice part was the fact that we went on a day when there was a sand storm. The second we stepped out of the car, all of our energy went into preventing ourselves from blowing away. The wind was picking up the sand and sweeping it across the beach, and smashing it against our arms and legs. My whole body was actually burning from the sting of sand against my skin. And within about a moment our eyes were filled with sand. Once we figured out we couldn't move without having our heads completely wrapped up in a scarf or towel to protect our faces, we slowly progressed down to the water.

The water itself was wonderful! Although it was very choppy, once into the water you were protected from the sand. All in all, it was great to see the beach but it would have been nicer to go when there was no sand storm (a bit unpredictable). It was nice to get away for a day from the hospital though. And I'll be back to Berbera on Friday...that's where I fly out from.


The beach all to ourselves:


Trying not to blow away:


Blain and Michelle trying to hide from the sand:


This is too far away to see...but our guard is walking and hiding his eyes from the sand:
(note about guards: We have to take a guard with us any time we leave Hargeisa. Somaliland has made this rule/law itself to protect foreigners, and as such the country's reputation. Along the road between Hargeisa and Berbera for instance there are 4 checkpoints where you are stopped and a police/military/guard guy peers in the window. If there are foreigners in the car, then there also must be a guard in the car for the car to continue along the road. Apparently if you do not have a guard, you will be stopped. So when we go places, we always have a guard chilling with us too.)

Babies, Babies, Babies!

I know, I've been bad about updating again. I just keep getting distracted by babies. Healthy babies and sick babies and preemies and chubsters and all those in between.

This past Wednesday was the busiest day I have seen in the hospital thus far. The North American group (Lauren, Harrison, Randi, Dawn, and myself) spent almost all day downstairs in the maternity ward. When we first went down in the morning, we found the hospital's lone incubator running at 200% capacity being shared by a preemie (28 weeks) that had arrived after being delivered at Group hospital and a Meconium Aspiration Syndrome baby born at Edna's in the middle of the night.


Most of Wednesday was spent monitoring this little guy and girl. Unfortunately, the little meconium boy had several seizures and needed one bought of resuscitation. The past days have seen improvements in both babies! The preemie slowly started to gain strength moving from NG tube feeding to sucking some from an NG tube. The mother's case is one of the saddest I have seen. This was her 7th and only living child. For every single pregnancy she has gone into labor around 6 or 7 months and her babies have all died shortly after birth. This little baby girl seems to be a fighter but she is still so tiny. Both mother and baby have been discharged. In the U.S., this baby would remain in the NICU for another month. Here, she is discharged because she is to a point where continued care in the hospital is expensive and the baby girl does not have to remain in the incubator with oxygen or an NG tube. Before she left, we found out her name is Ayaan. This is the first of her babies she has ever named.

The meconium baby boy has also seen improvement and was discharged yesterday. He slowly progressed from NG tube feeding to sucking from a syringe to breast feeding. There has been continuous discussion about his care and the possibility that he has brain damage. None of us much doubt that this baby does have brain damage, as he underwent a bit prolonged period of CPR and had some other hypoxic periods. The discussion has been whether doing resuscitation was beneficial to this baby. My immediate thought is that of course it was because it saved his life. However, the family of the baby told us that if Allah takes this baby that they would just try again and have another child. The perspective here is very different where some children and babies are expected to die. It can be hard to swallow this idea that it is okay to let one slip away because others will be born (undoubtedly with an average of 7 children per family) to replace those that were weak. He has been discharged home without any of us knowing what his mental capacities will be.

On Sunday, I meandered my way down to the maternity ward after teaching a morning English class to find the cutest little boy in the incubator. Normally, the incubator here means sickness or some problem. Turns out this adorable little baby (sorry I didn't get his picture before he left) had been born on the street. A multip who was at term had decided her labor pains might be starting and decided to walk to the hospital. About a block or two from Edna's, she realized the baby was coming NOW and delivered her own baby on the front steps of a random person's house. Another passerby ran on to the hospital to take a midwife back to help the woman. While the mother remained at the house of the woman's doorstep she delivered on (they didn't know each other prior to this encounter), they brought the baby back to be redressed and warmed. With not a single relative in the hospital with the baby (quite a rarity...as in I have never seen a patient without at least one relative in tow), the student midwives and staff kept claiming the baby. All morning was spent with random nurses and midwives coming in to see the cute little baby and claim him as her own. A relative finally did come a few hours later to take him home.

There has been one Cesarean section per day for the past three days. On Monday night, I stayed up (it didn't start until 11pm) to "catch the baby." One nurse or midwife always scrubs in and is responsible for taking the baby immediately after the doctor pulls him/her out of the mother's uterus and carrying the baby to the adjoining resuscitation room. In the next room over, Harrison and I did the immediate afterbirth care (suction, warming, chord ties, vitamin k, eyedrops, etc.). This little baby boy needed a little bit of positive-pressure ventilation to start breathing, but he pinked up pretty quick.

Today, a chubster was born. It was the woman's eight delivery and came out super fast. It is crazy to see these women who have had so many children who can progress in labor and deliver so rapidly. Her baby boy was 4.5kg (9 lb. 9 oz.). I always love the fat babies because I was such a chubster at birth myself. :)

Yep, so my week has been filled with babies and babies and more babies. Other things have been happening too (I just like the babies the most). The maternity ward has definitely been staying full the past week. We have a woman in congestive heart failure who is 35 weeks pregnant....not good. There is woman with eclampsia who arrived this evening semi-conscious. Dawn and Randi have now left, and several new volunteers have arrived (Blaine from Ethiopia, Fatima from Kuwait, and Michelle from Australia). And this Friday (Somaliland weekend), we are planning a trip to Berbera to see the beach! It will be nice to get away for a little bit. And a week from Friday I fly home...it is rapidly coming to an end. It is crazy how fast time can fly.

Las Geel

It has been a while since I updated, so I am going to try to recap the past week to week and a half as concisely as possible.

On July 3rd, we had a North American celebration. July 3rd was selected so we could include Canada Day (July 1st) as well for Harrison and Lauren. We actually had quite a crowd of North Americans- Harrison and Lauren- from Canada, Dawn and Randi- the nurses from Chicago, Jim and Becky- couple from Washington here for only 4 days, Robert and Jennifer- doctor and English teacher living in Hargeisa but from California, Scotty, Mark, and Charity- some other Chicago peeps who work with an NGO here. We feasted on American junk food (from a 50 lb. suitcase brought by Dawn and Randi), drank non-alcoholic malted apple beverage (there is no alcohol in Somaliland so they just sell malted non-alcoholic beverages everywhere), and sat on the roof of Edna's hospital.




Our celebration was prematurely aborted when a post-date cesarean section began downstairs. The woman had been induced earlier in the day but with little progress and fetal distress, a c-section began at around 9:45pm. From the appearance of the baby at birth, it had been sitting in meconium for quite a while with its orangeish-yellow stained umbilical cord and nails. Randi and I were the first two downstairs due to the number of people in the hospital and the celebration on the roof. The baby came out not crying, moving, or breathing. The next thirty minutes were spent attempting to resuscitate this little baby girl. For the first time, I bagged a baby. By this time we had most of the North American medical people in the room. This baby went through multiple rounds of CPR and ventilation. People ended up running around to collect the wall suction from another area in the hospital to clear out some of the fluid in the baby's lungs (there is a single deep suction instrument that is transportable for the whole hospital). There is no intubation here. She died.

The following day, July 4th, we had two more babies die (one placental abruption and another IUD with unknown causes). Needless to say, it was a bit of a bad few days.

But, Edna did surprise us with a 4th of July cake. We didn't even know cakes existed here...but apparently she special requested it from the Maan Soor Hotel (Edna has been there everyday because she is vice-president of the Presidential advisory committee which is helping select all the new roles/people/set-up of the new government).

I promise this cake does really say, "Happy 4th of July."

It was a delicious cake (sort of like pound-cake)...especially since desserts are pretty lacking here.

On the 5th, we managed to embarrass half the dinner table by asking about dating in Somaliland. Oops. Randi kept asking Dr. Bashir why he is not married (he is 26 and unmarried without children...not the norm for Somaliland). After prying, she found out that the family of the girl he wanted to marry refused because they were already planning for her to marry someone else. :( Poor Dr. Bashir. Dr. Bashir told us that you can date in Somaliland by going out to dinner. However, a female student informed us the next day that only "bad" girls would do such a thing. To be considered a "good" girl you are not to give your phone number or go on dates with any men. I think we won't ask them about dating anymore.

I don't remember what happened on the 6th??

On July 7th, we went to a small village to work in their monthly clinic. Harrison, Dawn, Randi, and myself went. This was much more of what you might think of when you think of "African-style health care clinics." We basically went through an NGO, arrived at a small cement building, and had a suitcase of medicines provided.

Here is Harrison and Dawn examining a little boy:


It was an interesting experience. It was definitely frustrating in the sense that we made no long term impact. We were able to provide antibiotics for several people with gastroenteritis (bloody diarrhea and vomiting) from drinking unboiled water. However, we were providing no long-term help for the few patients we saw with arthritis, tachycardia, familial deafness, or hypertension. The most we could really do was see each patient and check their vitals and do a basic look-over. We did help a few people in the immediate by providing antibiotics, but really this community needs a long-term sanitation and water purification program to prevent most of the diseases we saw. Definitely a worthwhile experience to have, but makes me appreciate even more the importance of sustainability in global health care programs.

Later in the day, Dawn and I went with Edna to see her other farm. This one actually belongs to her brother. He is fixing up a little house on it and will retire here. We walked around and helped pick beets, onions, mandarins (we've been drinking mandarin juice ever since), and peppers.

Here we are in front of the mandarin tree!


On July 8th, I ate a hard-boiled egg. Eggs are not common here. That was the only important thing about the day.

On July 9th, we went out to lunch at the Ethiopian restaurant with Robert and Jennifer. Here are some baboons that were right outside.



Yesterday, we went to see Somaliland's one tourist attraction- Las Geel. Las Geel literally means "water camels." The site is where two rivers once merged making an ideal watering location for camel herders. These caves hold rock paintings. They think these caves have been around for thousands of years, and it is unknown what was used as the original "paint." It was a bit of a pain to climb around in full length skirts, flip-flops, and a scarf...but nobody fell down a rocky cliff. We actually had the whole place to ourselves...it turns out it was an Islamic holiday that nobody seemed to be celebrating except for the Ministry of Tourism, so we just sort of got free reign.

Las Geel from afar


One of the paintings:
View from the top:



Other than that...I've been helping out with English classes and tutoring individual students. I've also been proctoring exams...and yelling at students for cheating. All of them at the end of their exams write, "Good lucky teacher, Inshallah." I'm training Ibrahim to take over doing all the statistics once I leave...he is so organized compared to everyone else in the hospital, I'm excited he will be keeping the numbers! Still going on rounds most days and helping out around L&D. Dawn, Randi, and I have also been helping Lauren teach some of her neonatal courses. We spent one morning testing all the girls on neonatal resuscitation. Interestingly enough, they seem to have some difficulty determining an accurate heart rate on any baby using a stethoscope...which in turn makes neonatal resuscitation a bit interesting.

And tonight we watched the World Cup!! Viva Espana!

Kulmiye!

On Thursday evening around 7pm, every nurses' station in the hospital had a cluster of people...nurses and patients...as they sat awaiting the announcement of the election results on BBC radio. Across town at the Maan-Soor Hotel, Edna and others from the community awaited for the final announcement by the Somaliland Election Commissioner. By 8pm, a cry of celebration had gone up across the hospital and all of Hargeisa as people celebrated for the announcement of Ahmed Mahomoud Silanyo, of the Kulmiye opposition party, as having won the presidential election with 49.59% of the vote.

I cannot even begin to explain the contagious excitement over the election I have witnessed for the past two days. The decision was made to announce the results on Thursday evening, rather than the previously announced date of today (Saturday), so that Somalilanders would have an entire day of celebration since Friday is the weekend here. On Thursday night the streets filled with people. For the next 24 hours, there would be a continuous level of noise in the city as people yelled, clapped, sang, danced, drummed, and expressed their joy over the results. We watched from the roof of the hospital as masses of people gathered in the streets, vehicles passed by filled to the brim of Kulmiye supporters waving his flag, and we even saw three lone fireworks in the distance.

The saying in Africa normally goes that "the president always wins." Look at the elections being held in Ethiopia and Kenya in the past year or so and neither country was able to hold an election free from corruption. The trend has actually been away from successful Democratic elections in the past few years in Africa. In a country of civilians that strongly opposes the government, the incumbent Ethiopian government won 99% of the vote this past May due to intimidation (including the withholding of food aid to regions supporting the opposition) and an unfair election. Not even a recognized country, Somaliland, has been able to hold what is being hailed as a free and fair election.

I was a bit worried about what elections would mean and bring while I was here, but these past few days have shown the people of Somaliland as able to realize their hopes for a peaceful and fair election. On Friday, we spent the day celebrating with Edna! I do not believe anything in the world could have broken her jubilant spirit as she drove a group of us North Americans around town. We ended at the Maan-Soor Hotel, where Edna in her usual social butterfly fashion visited with other well known officials in Somaliland and international visitors in town for the election result announcement. Before we left the hotel, we also got to see the president-elect! He was in a room upstairs and came down and out through the lobby to be greeted by the Somali people. I do not think I ever again will stand as close to a president-elect as I did on Friday.

Even if the Kulmiye party won, many feared the government would not concede. The UDUB party (government) has already announced they will step down. This almost makes them as big of heroes as they are encouraging a smooth transition. Over the next month, the outgoing and incoming presidents and their various ministers will transition.

The people of Somaliland are looking ahead with new hope and excitement. More than anything else, they hope that these elections will bring international recognition and respect to their country. It truly is an exciting time to be in Somaliland!


A building in town decorated in support of Kulmiye!


Some cars showing off their support:



President-elect: (again, I don't think I will ever again go through such low security or stand so near a president-elect)

hophop

It's crazy to think I am just about at the half way point of my summer in Somaliland. In some sense, I feel very settled in and know the basic schedule for the hospital, classes, etc. On the other hand, each day seems to bring something different and slightly unexpected. I'm going to try and recap the highlights of this past week.

Sherri and I have been working on keeping some statistics for the hospital. The previous stats guy quit in March, and there seems to be no consistent recording of their patient diagnoses. However, Sherri and I quickly found that they do not have a very good system and so it has been a bit chaotic trying to keep them. They have the stats person read through all of the old charts to decipher what a given patient's diagnosis is and record this information. Unfortunately, they have discharge forms that clearly have a "Diagnosis:" blank....but nobody actually uses these. This has rather meant that Sherri and I try to decipher random doctors hand-writing and approximate the diagnosis into some broad, general categories.

Here is the lovely room of files:



Last Wednesday saw the arrival of two nurses from the United States. Dawn and Randi will be here until July 15th, and both are coming from the Chicago area and work at Children's Memorial Hospital in the PICU. It is always nice to have more people around to hang out with.

Sherri and I finally went to the market. It is a bit overwhelming with all of the booths of cloth. They have scarves hanging everywhere and then rows and rows of fabrics to be selected from to make dresses.


This man sits in the piles of cloth and then when you see one you like he will pull it out for you. Once you purchase the cloth you give it to a tailor to have the sides seamed together to form your dress. They are all one-size-fits-all dresses. You are supposed to stuff any excess cloth into your slip.


Last Thursday, there were about 15 people from the hospital (Edna, some staff and midwives, summer volunteers) invited to a patient's home for lunch. The patient was a Sudanese woman who delivered her first child, a boy, by cesarean section in the hospital about two weeks ago. There is a small Sudanese population living in Hargeisa, and it was interesting to have them all through the hospital during her few days here. In return for her care, her family invited all of us for a grand feast. I've never seen so much food at once!

This is a photo of most of the visitors at the lunch. Most of the Americans arrived at the house first, and none of us speak Arabic so we had to sit in awkward silence for sometime.



This is all the food sitting out! Everything is served community style, so you just take whatever you want. Goat liver, eggplant, peas, chicken, minced meat, Somali bread, orange soda, rice, noodles, hop hop, mango......


After lunch I was handed this cup....can you guess what it is??


At first, I thought it was just tea but the coloring is not right for Somali tea. Turns out it is "meat juice," or at least that is how Dr. Abdighani described it to me. It is a combination of the broth from cooking the various meats which is then simmered with vegetables. I was brave and took one sip....sort of salty and tasted like chicken broth.


Later, we did get real cups of tea and coffee. Real coffee is wonderful! At Edna's we only get Nescafe....

We also went out to eat at the Ambassador Hotel on Thursday evening as a farewell to Sherri and a welcome to Dawn and Randi. I had a chicken sandwich...not exactly like American chicken. Unfortunately, my camera battery was dead, so no photos. Sherri left first thing Friday morning.

Friday was very quiet at the hospital because all of the students had no classes from Thursday afternoon through today due to elections. The actual elections were held on Saturday. We thought it might turn out to be a busy day, but it was actually very quiet. The only bizarre part was a man came in covered in bees. They were locking the hospital doors behind him, and so at first everyone thought something really bad had happened outside. He was "stung by a bee" became he was "bitten by a bee" became he was "beaten." After about 20 minutes of this telephone-like game of interpreting what this patient had, it was determined he was indeed covered in hundreds of bee stings. Sounds awful but he did not have an anaphylactic reaction, and at least no one was beaten. The election results will not be announced until this coming Saturday. That is actually when there could be more problems if people are upset by the results. There is strong Kulmiye support within Hargeisa and they all seem pretty convinced he won....we will see.

Here is Ishmael proudly showing off that he voted! Voters had to register and arrive with their voter identification card at the polling locations, plus they also all dipped their pinkies as a double attempt to help prevent repeat voters.

Saturday through Monday were mostly spent down in the hospital observing and helping out around labor and delivery. Below is a photo of everyone sitting around the nurses stations waiting for something to happen.


On Monday, we all got extremely frustrated when there was another sad case in the hospital. A woman was progressing in labor all morning, but around 11am the vaginal exam showed a prolapsed cord. In North America, this would mean an emergency cesarean section. In Somaliland, this means lets be delayed for three hours while we find the husband so he can consent to a cesarean section. By the time the husband was located, arrived at the hospital, refused to sign for an hour, and was finally convinced, the baby was dead. Instances like these are infuriating! This death was not the result of a lack of recognition of the problem or a lack of resources or a lack of trained personnel....it was a complete delay in anything happening because consent comes first. We have asked the doctors before about these consent issues and they say occasionally a procedure is done without husband consent, but we have yet to see this happen.

Today, Lauren (midwife from Canada) and I went to Group hospital to see their labor and delivery department for the morning. It made us feel a lot less frustrated about the labor and delivery department at Edna's.

This is the delivery room with three beds. While Edna's basic set up is similar, Group hospital lacks a lot of supplies. When we arrived, there were actually two midwifery students from Edna's doing one of their clinicals. They had with them a bag of supplies...gloves, soap, gauze, scissors, IV equipment, etc. This seemed a bit bizarre, but we found out that unless they bring some supplies with them from Edna's then they will not be provided with gloves or soap at Group hospital for seeing patients.


Here is the infant resuscitation table. At Edna's there is no capability to intubate any patients, adult or baby. However, they do have resuscitation bags and oxygen...both of which appear to be absent from Group hospital.


The craziest part about Group's L&D department is that they have no charting system whatsoever. Patients get a vaginal exam and get asked a few basic questions when they come in, but none of the information is recorded. We asked the nurses how often they get their vitals and fetal heart rate....the response is basically whenever a patient complains of a problem or the nurses/midwives decide they will check in on a patient. Any of these things: vitals, vaginal exam reports, patient history, fetal heart rates, etc. are never recorded. Unlike Edna's hospital, they have many more patients. Today we saw around 12 women in the ward laboring. How the staff manage to maintain care and know which patients are which is anyone's guess. Lauren described it later as a bit of a "free for all."

Still seeing and learning lots. And eating lots of hophop (watermelon)!

Four Wives

Sherri is leaving on Friday and so she has been saying goodbye to the various students and nurses. Today during an English class for the pharmacy students, the girls asked Sherri what she would tell her friends and family at home about Somaliland. Sherri responded that she would tell about all the nice Somalilanders she has met. But, then she also said that she would tell about the men with four wives and the pregnant women who must have their husband’s consent to have a procedure done. I decided I also want to share with my family and friends some of these cultural differences. So here goes on some of what I have observed so far.

I have never met a group of people quite so devoted in their daily actions. Whether this is true religious devotion or fear of societal backlash is probably dependent on the person, but either way these people have a daily ritual and they do not vary from it frequently. I have yet to meet a single Somali here who is not a Muslim. Living in an Islamic society means the entire day is structured around prayer times. Almost every mosque in town it seems has a loud speaker system to call to prayer the people of Somaliland. The first call begins around 4:30am. Not everyone wakes up at 4:30am (myself included) but the first thing people do in the morning is pray. The next call to prayer is not until 12:30pm, then 3:30pm, 6:15pm, and finally 7:30pm. Men are supposed to actually go to the mosque for prayer, but the women are allowed to pray from home (or in the nurses case…from within the hospital). The first day I taught English class, it was a 4pm class on a Sunday afternoon. Within the first five minutes, two girls asked me if they could leave class to go pray and come back. They had over slept their afternoon naps and missed the 3:30pm prayer. I was not about to tell them they couldn’t go pray to learn English, so they left.

The strong Islamic culture appears to affect the women most in comparison to the United States. All women wear full length dresses with a head covering. According to Islam, they should actually have everything covered except their hands and face. This means that some women wear socks with their sandals since their feet should technically be covered by this rule, but many women do not follow this. All women wear shamots or sheels (scarves/the two different hijab forms) and some also cover their entire faces except their eyes (burqa style). If they do not cover, they believe they will be going to hell.

To me it feels like women are oppressed in society, but who am I to say that about their culture. If you know no other way of life then how would your life feel oppressed? I have not met any women who seem to feel they are overtly oppressed by men, religion, or society. Coming from where I come from, I could not survive living truly within this culture without feeling suffocated.

Almost all women are housewives, doing all the cleaning, cooking, laundry, etc. A student told me recently during class that husbands will not even take their dishes to the sink after dinner because this is considered shameful. I told her my future husband would have to not only take the dishes to the sink but wash the dishes too. J I certainly cannot imagine this life on a daily basis forever.

The most disturbing part to me is the effects on women within the health care setting. Within the hospital setting is becomes interesting to observe the husband-wife relationships. The labor and delivery department is most definitely a place for women without their husbands. A laboring women will arrive at the hospital with about two to five relatives in tow (sisters, mothers, mother-in-laws, friends, whoever). This is actually funny because you will look into the laboring room and think there are about 10 women in labor when it is actually only two plus all the relatives. The husbands will randomly stop by, gaze into the labor room, and then promptly leave without speaking to his wife. I mentally give a grand celebration when a husband stays for more than a few minutes and actually talks to his wife. Sometimes a woman will come to the hospital, deliver a baby, be transferred to maternity, and leave the following day with the husband stopping by perhaps for a total of 10 minutes. However, anytime a woman has a variation from a straight-forward vaginal delivery (i.e., induction, c-section, D&C for IUDs), the husband must sign his consent for any procedure to be done. This becomes very frustrating when the husband is not at the hospital. If the doctor determines a c-section should be done, there will be a chain of cell phone conversations or a relative going to hunt down the husband. Once the husband arrives, which could be anywhere from 20 minutes to several hours later, there will then be debate as to whether he is willing to consent or not. Some husbands request that they try for another hour or two before he will consent while others are more willing to agree when everything is explained to them by one of the midwives or doctors. Recently Fadiyha, one of the midwives, sat down a husband and told him that unless he wanted his wife and first child to die he needed to sign the papers…so sometimes they will play hardball and it works (people call her the boss woman). While this consent issue does really bother me, it is also something that is the cultural standard. The hospital could not decide to abolish it without upsetting the traditional societal set-up. It could be argues this is for the worst and the hospital should try to change things, but if they were to remove the consent forms it would also mean that many men might not allow their wives to go to the hospital to begin with. It seems to be one of those cultural-competency issues; you have to work within the current system to try to improve health outcomes as best as possible.

As you might expect, everyone also has tons of kids! Family planning is pretty rare as families leave the number of children up to Allah’s discretion. So far it seems that 7-9 is pretty average. The most I have seen so far is a woman having her eighteenth child. Eek. Having a male child is also very important within the culture here. If a woman does not have a son, then there is some pressure on her to have one. The husbands also seem to show up around the hospital more frequently after delivery if there is a boy. Some men also have multiple wives. A husband will only marry additional wives if he has enough money to afford maintaining multiple households. Many men will marry again especially if their first wife has not had a son. The female students are funny to talk to because they all so they want to marry a man who will not marry other women. From what they say, some men will marry a woman and promise to only marry her. But, then later in their marriage, he will decide to take another wife. The wives live in different homes, sometimes even in different towns. This may be for the best considering multiple wives hate one another. Apparently the husband will often refurbish the home of his first wife after taking a second wife in an attempt to appease her anger about the second wife.

There are other things too…but that’s all for now.

Samboosas and Somali Tea

I haven't updated my blog in about a week....the internet has been a bit spotty here. I do not even know where to begin with telling about the last week. It has been wonderful, sad, frustrating, and everywhere in between. This is a compilation of various things....there is not really any order to it.

Last Thursday, Edna took Sherri, Lee Cassanelli, and I on a driving tour of some different areas in Hargeisa. We visited two different “shanty-towns” where many of the patients of the hospital live. There is a clear division in society here between the families that live in these “shanty-town” areas and those who do not. Families that have migrated into Hargeisa from surrounding Somalia regions often live in these rundown neighborhoods that have no electricity, running water, or good sources of employment. The other portion of the population lives in a more centralized area of Hargeisa with electricity and water. The living conditions and economic levels are definitely variable across the city.

This is what a house looks like in one of the poorer neighborhoods. They recycle milk containers and other recycled paper or tin products and roll them out into sheets which become the siding, and then on top they layer cloth.

There were little kids everywhere trying to occupy their time. These kids made a makeshift scooter.

Edna also took us to her farm. Apparently her family owns some random land outside of Hargeisa, and she is trying to get a farm started their so she can provide some additional food to the hospital. The drive out was wonderful as we got to see all sorts of Somaliland wildlife….baboons, camels, goats, dek deks (these tiny little antelopes), tortoises, and sheep. The environment is completely different traveling from downtown Hargeisa to about 30 minutes outside of Hargeisa. The land is actually green and the climate much cooler than where we are in central Hargeisa.

Here is the farm...mostly watermelon and then any type of bean they can grow.

The sad part of the week has been that I have seen three infants die, and also seen an intrauterine death (IUD). It is definitely not enjoyable to see newborns die. The first was the meconium aspiration baby I mentioned in my last blog. He did not make it. Then there was a bizarre 24 hours where there were three different sets of twins in the hospital. The first set of twins was a delivery of a 7 month pregnant woman at Group hospital (the government hospital across town). Both infants weighed 1.7kg (very little), and one died directly after birth. The second infant the family brought to Edna’s hospital where he was in the incubator for about 12 hours before dying. The second set of twins also began at Group hospital. The first baby was born vaginally at Group, but the second was a face presentation and they could not deliver her. The family brought the woman and the first of the newborn to the Edna’s hospital. The second baby was delivered by cesarean, but she had a lot of facial bruising and a cleft pallet. She ended up dying later in the day. The third set of twins was born at Edna’s hospital, and I got to see her deliver!! She had beautiful identical girls, both 2.5kg. The IUD was another sad case though….one that also started at Group hospital. The woman arrived at Edna’s around 9pm with all the supplies for a cesarean section. Apparently Group hospital had not surgeon, and so sent the family to Edna’s. There is no real communication between hospitals though, so everything is based on what the patient and/or the patient’s family says has occurred. They could not find the fetal heart rate, and it turns out she had been in labor for five days. The baby was delivered by cesarean and found to have the umbilical cord tightly wrapped around her neck.

These are sad stories, but they are not all sad. I have gotten to see a lot of healthy deliveries. Last night I helped out with the delivery of a woman having her ninth child, but she didn’t want to push. She kept grabbing my hand putting it at the top of her belly and saying “rei, rei, rei” (“push, push, push”). So I would remove my hand and tell her “rei, rei, rei.” I turned away for a minute and she grabbed hold of my skin and would not let go! Ouch…but I am definitely thinking she was in more pain delivering than I was with her pinching me.

Sherri and I got to go to an Ethiopian restaurant on Friday with Dr. Robert and Jennifer Thiel. It was wonderful to get out of the hospital complex for a little bit and have something different to eat. Overall, the food here is good but it is exactly the same everyday…so a little Ethiopian variety was much appreciated! I got my fill of injera and goat meat.

This is my little lizard friend living in my bathroom. I haven’t seen him for a few days, so maybe he left.

In the afternoon, there is a window where you can get snacks. I've heard it called the cafeteria and also the magic window.....

They have samboosas. The nurses here have introduced us to them. Most people have an afternoon snack and tea around 4pm after their afternoon naps. So if we are down in the hospital in the afternoon, we sit with the nurses and enjoy samboosas and tea.

Here I am enjoying some Somali tea....basically sugar and milk with a little tea.

World Cup craze is here in full force! The games are on at 2:30, 5:30, and 9:30pm, and someone at the hospital is always watching. Edna’s brother has watched almost every single one. After dinner, a group of us (doctors and volunteers) have been watching in Edna’s living room. The England v. USA match was a fun one since we had two Americans and two Brits at the hospital at the time. Most people here seem to be supporting England since they know most of their players.

As I mentioned before…you never quite know who will show up at Edna’s. She does not really tell us in advance who is coming, and so a Canadian couple has just arrived. They are recently married and decided to spend the summer in Somaliland. Harrison is a medical student and Lauren is a midwifery student. So far it has been really nice to have them around the hospital, and after Sherri leaves in a week it will be nice to have some other younger people still around.

Sherri and I are still teaching classes, which is a bit frustrating. The students are very sweet and appear motivated, but give them an assignment and it sort of goes downhill. We are now teaching two English classes a week for the Community Midwives group, helping out Thiel at her various English classes throughout the week, and continuing with two classes working on miniature research projects. It is frustrating when they say they want to be involved and learn English or research, but then they do not have the follow through to actually study or do assignments to help them improve. There are definitely some dedicated ones, but there are also some who seem to have no clue what is going on. Tonight we will be working with one of the research groups....we'll see how it goes.

There is also a British obstetrician/gynecologist visiting for a week, Peter Jackson. He was the first doctor to do a cesarean section at Edna's hospital back in 2002. He has since visited periodically to do various trainings and help write protocols for the hospital. He took an evening to give several of us a presentation on maternal health in the developing world. It was amazing!!! It has been wonderful to meet and talk to other people interested in global health, many of who have been working in the field for some time now.

Still haven't gotten to visit the market....hopefully on Saturday. Hope that wasn't too much randomness. That's all for now!