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)