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!