Maroodi-Jeex: Somaliland Alternative Newsletter,
ISSN 1097-3850. Occasional papers, No. 3, September 2002.
Internet edition (1).

By Mohamed Bali, PhD.

Abstract: To remain healthy is an aspiration of all humankind; to be unhealthy is a universal risk. It is not surprising that human societies have universally developed ideas, technologies, social roles, and, more importantly, lifestyles related to health care. Modern medical care with its stress on the use of drugs and surgery sometimes helps us when we become sick, but it doesn't always keep us healthy. To a great extent, what makes us healthy or not is how we able to live our daily lives: the quality of the food we eat and the air we breathe; access to health care; how we exercise; and how we use tobacco and other drugs.

It is becoming increasingly clear that the promotion of public health and the prevention of disease is an interactive process involving the development of public policy and governmental action and the empowerment of individuals to take control of their well being. Self-empowerment leads to changes in public policy: For example, many governments in the developed countries have declared public places no smoking areas; food labeling is being revised with consumer input; and informed citizens are calling attention to a host of environmental issues. These policy changes, in turn, are propitious in facilitating changes in individual behavior (2).

Introduction

The present paper attempts to contribute to these discussions of major health-related issues surrounding the public health dialectic in Somaliland, a small and low-income Sub-Saharan Africa country, with particular reference to offering a number of concrete recommendations to the overall development in public health policy and practice. These comments are not from a petulant hypochondriac but from an observer who would like to contribute to the goal of betterment of the physical well-being of his countrymen, as well as those of other materially and developmentally-challenged countries.

Health protection, forming the heart of any safe lifestyle, can serve too as a universally and socially integrative force that is transcendent to the bitter social and political schisms that rule on the obstreperous ground. (Yet any reveria in evoking of ebullience that the incendiary socio-political particularisms, the region's Achilles' heel, in terms of development prospects, could be overcome on the crucible of health will only be feinted because such reality is not currently within reach).

The first section of the paper gives a truncated introduction of the national background, with an emphasis here given on the health information. The nation's material and political conditions mirror closely those of Somalia and other neighbors, Ethiopia and Djibouti. All three countries, all of them historical enemies, were arenas to bitterly fought out civil wars. These conflicts, while their causes and stories are different and their resolutions remain inchoate, they have had the similar effect of driving out the political titans who had helped shape their countries' destiny -- in the case of Somalia to a complete dissolution (3).

Somaliland, a relatively new nation that recently emerged out from the failed state of Somalia, is a product of that cataclysm and decades-long military repressions and the total depredations of an African civil war. Also, it is an example of a country grappling with many development challenges, in a period of intense transition, while lacking an international recognition.

The second section builds on the former by presenting the recommendations to confront some of these challenges. The recommendations should not interpreted simply as either palliatives or panaceas. In a narrow didactic sense, the aim of this discussion is mainly for its heuristic value. Only a starry-eyed charlatan would have the temerity to claim that any given menagerie of suggestions will fix our health crisis, even if we were under the control of a praetorian regime, which we aren't. On the other hand, under the more characteristic obscurantist influence, there will be those who will be unsparing in expressing their pooh-poohs.

Either way, since these discussions concern the mundane corporeal realms, there are no oracles here issuing euphony of hokey beatitudes (i.e. fatwas or Islamic religious edicts), as they will certainly be ersatz for our purposes of seeking practical and lasting solutions for our problems. Throughout, avoiding the employing of a scatter-shot approach, a unity is maintained by each recommendation building on the important nexus between health and sanitation, thus providing the keel that the pieces dovetail each other.

Background

The country, consisting of much of the northern littoral Horn of Africa, has 68,000 square miles or 109,000 square km. Its modest governmental structure is based on a constitution passed in a referendum in June 2002. The constitution establishes separation of powers among executive, legislative, and judicial branches; multiparty political system; and protection of human rights and freedom of speech. The constitution authorized the election of a president and a bicameral parliament composed of Senate and National Assembly in 2003. The Supreme Court has nine members and forms apex of other judicial bodies. Local government consists of six regions and twenty-eight districts.

The landscape consists of mostly barren undulating plateau, broken by few mountain ranges, that climbs from sea-level to 1600 meters. The varying combinations of climate, topography and livelihoods types give rise to three major zones: Northern (Guban) - hot coastal plain, low rainfall and low soil fertility; Central (Ogo) - high plateau, high rainfall and high soil fertility; Southern (hawd) - low plateau, adequate rainfall but low agricultural potential.

Somaliland has displayed many of the similar indices typical of Third World countries: Poverty (i.e. witness the GDP per capita = $176), rural primacy, dependence on primary products (chiefly livestock), dominant informal sector, dependence on overseas remittances and aid, militarism, and above all, poor health and low life expectancy. Life expectancy at birth in 1998 was estimated at 47 years (45 years for males and 49 years for females). The average infant mortality was estimated at 120.34 deaths/1,000 live births (female: 110.56 versus male: 129.84) (4).

Somaliland's population numbered 2.0 million in 1998 with an annual growth of 3.1 percent between 1991 to 1998. This startling growth has been due to consistently high fertility, along with declining mortality. The population is young; with 49 percent under fourteen and 18 percent under age five (5). Only 23 percent of the population has access to safe water (31 percent urban and 8 percent rural). Potable water is provided to approximately a third of the population in urban areas through private connections or through public stand-pipes. The remaining 77 percent get their water untreated from water wells and surface water of varying quality. About 48 percent of the population uses pit latrines. (6)

Under these conditions, it is not surprising that a range of diseases menace the populace in Somaliland. As is typical of a developing country, the main health problems are communicable diseases caused by poor sanitation and malnutrition and exacerbated by the dearth of skilled personnel and health clinics. Diseases such as measles, malaria, diarrheal diseases, tetanus, diphtheria, pertussis, poliomyelitis, and tuberculosis are preventable or curable given available technology; unfortunately, only 10 to 20 percent of the population has access to such basic technology and service. In addition, a majority of the population is infected with rabid intestines worms, including ascaris, hookworms and anklostomes; the noisome effects of these parasites is to further enervate a population already suffering from widespread malnutrition.

Health care in Somaliland is provided by an unruly congeries of public, semi-public, and private sources; all three subdivisions function simultaneously. There is the traditional system, which can be subdivided loosely into Cushitic and Islamic ecclesiastic. Commercial drugs and concoctions, used by both the largely peripatetic Somali (Cushitic) traditional healers and modern practitioners, constitute a transitional system. The British brought in the modern medicine in the period following the Second World War.

The extant health care system that is based on it can barely meet the challenge (i.e. doctors and nurses per 100,000 people are 0.4 and 2.0, respectively) (5). The government-run health clinics - located in all the more grotesque and decrepit structures and staffed by surly employees with cash-register smiles - are dysfunctional. Such spectacle would have been excused as a lame survivor of the recent national anomie if it wasn't for the jarring practice of the charging of exorbitant prices, as well as the hospitals being bereft of medications or in basic equipment and personnel.

For most of the population, poverty, transport problems, and geographic conditions stint effective access. What meager health care Somalis find they improvise it often from private sources. The elite, including the political mandarins, add to the embarrassment by continuing to seek quality care abroad. (The unabashed government ministers, having made a Faustian bargain, often describe to the credulous press that their frequent sojourns as being "official visits").

During the 1990s, the health care system had deteriorated further as a result of civil war effects and severe economic disruption, largely due to governmental corruption and mismanagement and the economic effects resulting from Saudi Arabia's ban on Somaliland's livestock exports.

Recommendations

I believe that the discussions of the following public health issues would serve as felicitous eye-opening introductions into laying foundations for the development of viable public health policies, on an even keel, in propounding these recommendations to the Somaliland public and authorities:

Safe water and sanitation

1. Making access to potable water supply and basic sanitation top national priorities. Most health problems are closely linked to problems of sanitation. The consumption of unclean water and un-pasteurized diary products are the main causes in the staggering incidence of tuberculosis, dysentery and hepatitis.
The health hazards as a result of poor sanitation are legion. Microorganisms (bacteria, virus, parasites) are major causes of waterborne illnesses. According to the World Health Organization, an estimated 25, 000 deaths per day were attributed to the consumption of unsafe water in the year 1990 worldwide, and 25 percent of hospital admissions were related to polluted water. Waterborne gastrointestinal infections accounted for 80 percent of all diseases. Even a little bit of celerity would pay big dividends in the lives saved: access to safe water and sanitation could cut by up to one-third the number of diarrhea cases (7).

History evinces that without a continued and forceful governmental intervention, it is hard to be sanguine that positive change will occur on its own. Leaving things on their own would certainly yield nothing better than Ludites in a distopian. Therefore, I present the following recommendations to the Somaliland public and the health authorities in helping promote safe lifestyles:

(a) Educate the public with the health risks incident in the consumption of unsafe water and foods through the media and the schools.

(b) Spur the private sector to become a vehicle for protecting public health by banning the sale of unsafe water, un-pasteurized dairy products and un-protected meats.

To do an onslaught on the problem of sanitation requires a tremendous moxie. Before the society reaps the social and economic benefits from it, the public should create, in a form of treacherous shoals, a strong demand for safe products. The private sector, facing such a demand and a governmental pressure, will eventually supply the desired goods.

It should be palpable that the existence of a scabrous regulatory milieu is no longer a credible excuse for brooking a dilatory shirking of public health responsibility. Also a specious quixoticness in this matter, even in a land dominated by the tyranny of illiteracy and superstition, does not in itself sully the principal fact that the fundamental responsibility of any government is to provide for the welfare of its citizens. If this is utilized right, it could be envisaged to become a public policy vortex for many other refractory public policy issues.

(c) Enforce a safe, hermitic toilet for each household. Ban the practice of locating of pit latrines inside the buildings. Each building, instead, should have an internal PVC plumbing designed to remove, through gravity, wastes into either a sealed septic tank or a sewage pipe both buried outside. To slog through an effective ban in the face of the perversity and monstrosity of the corruption morass would be truly hailed as a veritable indication of an exceptional measure of genuine public service and prudence.

Safe foods
(a) At the point of production: Require that all diary products and meats should be produced under sanitary conditions in only licensed and regularly inspected abattoirs and creameries.

(b) At the point of sale: Require that all retailers should store and sell only chilled diary products and meats that meet the universally accepted sanitary requirements, including refrigeration requirements. (For example, these perishable products should be produced, transported and stored at temperatures not higher than 35 degrees F).

(c) Regulate the public food service through the adoption of safe food service techniques.

The food-borne illnesses are illnesses caused by the food we consume. Even though America's food chain is the safest in the world, millions of people are still affected by food-borne illnesses. Food-borne illnesses cause about 76 million cases of illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States each year (8).

But there is a solution: "Food-borne illness can be prevented by following five simple rules: Store cold foods at 34 degrees to 40 degrees Fahrenheit; cook food to a temperature of 140 to 165 degrees F; keep the kitchen clean; refrigerate leftovers quickly; and toss out any food if its safety is in question."(9).

Healthful foods: Low fat, high fiber
2. Promoting the substitution of low saturated fat vegetable-based cooking oils (i.e. corn, sesame seed, sunflower, etc.) in the place of the ubiquitous ghee, the locally-produced high saturated fat rarefied butter, which is made from un-pasteurized milk under unsanitary conditions.
3. Promoting the cutting back of the consumption of high-fat red meats: Lamb, mutton and beef cuts. Along with whole milk, these are the main sources of the artery-clogging cholesterol, a fatty substance that builds up on the inner wall of an artery and hardens into a substance called plaque (10).

4. Instead, promoting the increased consumption of lean low-fat meats: Skin-less chicken, turkey and seafood. Aside from their prophylactic qualities, it is not futile economics in a land that is afflicted with 'full unemployment' to suggest that the increased consumption of these products have the added economic benefits of creating jobs throughout the economy.

5. Promoting the increased consumption of vegetables, fruits, grains and legumes, such as dried peas, beans and lentils. In contemporary zeitgeist, buttressed by the much-accumulated knowledge of the last 50 years, scientists are of universal agreement on the salubrious effects of plant fiber in our diets.

Due to the stupendous challenge and its health benefits galore, it is imperative for the schools and the media and the governments to promote first the supply-side production of these products through farming and gardening, especially, among young students. It takes decades for the best edifying experiences in even the best educational systems to ossify into promising mythos that assist in molding of a well-informed, healthy and genteel society.

Exercise
6. Disseminating widely the health benefits of regular exercise regimens for all ages. Benefits of regular exercise include the improving of the cardiovascular fitness and muscular endurance and the reduction of the risk of coronary artery disease (11).
To promote fitness, in addition to the educational campaigns, the governments should do their part by endowing city parks in all neighborhoods, complete with trails for walking, jogging and bicycling and courts for playing basketball, volleyball, and other athletics. Schools too should offer calisthenics in physical education classes to every child.

Substance abuse
7. Smoking and Khat chewing cessation campaigns. The social and economic benefits for the ex-users and the society are incalculable.
Access to healthcare as a right
8. Finally, adopting of the following basic statements as sine qua non of any health care organization:
(a) Health is a basic human right of every individual and an important responsibility of any government.
(b) Health care services ought to be accessible to the entire population, geographically, economically and socially.
(c) Health care service should function to integrate the physical and social dimensions of health and to address the conditions of work and residence as they affect health.
These remarks are consistent with the current interest in reordering health care from the conventional clinic-based service and towards an individual and community-based participatory approach that grew strongly in the 1970s following the Declaration of Alta Ata, which supports these statements and are educed from:
"Primary health care is essential health care based on appropriate means and accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain in the spirit of self-reliance". (12)

Concluding remarks
1. These recommendations take as their genesis the principle that, although their country is poor and they are exposed to all the evils of underdevelopment, Somalis have the same fundamental rights, including the right to have access to health care and basic sanitaion, as all other citizens throughout the world. There is no reason why their lives should not be precious and well protected as the lives of citizens of the Netherlands, for example.
2. It is a truism that the ultimate success of efficacious preventive and curative regimens is usually dependent upon individuals' willingness to undertake and maintain the required behaviors.

3. The upshot is that our hubris comes with a heavy price. This paper is not meant to be just a paean for healthful living. As much as irreverent it may sound, it is proffered, too, to bring about a bathetic reawakening. In a public policy milieu lolling around in a smug levity, it is not being captious to recall that 'amorphousness' is the preferred term in describing it. So speaking of protecting public health engenders an uneasy bathetic development. But, to accept the prevailing public health situation is to continue to wallow in treating it either as crapshoot affair or simply, even, something subject only to the vagaries of fluke.

Such improvident attitude, however, bodes ill in being inauspicious for us taking charge over our own health. In a mutable world, allowing the disconcerting specter of the traditional prudishness in forming a reified and seemingly permanent barrier in accommodating change should be cast of as both a zany and scurrilous belief.

4. It is exigent, therefore, to heed the incessant calls by the World Health Organization that emphasized that access to safe water and food and basic sanitation - as part of a national comprehensive public health policy - were a fundamental human right and were components of any effective poverty-reduction strategy.

References cited
The article first appeared on The Iowa Muslim Reader, Sep-Oct 2002 (Cedar Rapids, IA)
U.S. Department of Health and Human Services. "Healthy People 2000: National Health Promotion and Disease Prevention Objectives". (Washington) 2000. (http://odphp.osophs.dhhs.gov/). Web site
U.S. Department of Army. Country Studies/Area Handbook, Somalia. Edited by Helen Chapin Metz, May 1992. (Washington) (http://lcweb2.loc.gov/frd/cs/sotoc.html) Web site.
Multiple Indicator Cluster Survey, Somalia 2001 - (MICS) UNICEF. January 2001. (http://www.unsomalia.net/infocenter/reports/Final.pdf). Web site.
CIA Factbook, Somalia, 2002. (http://www.odci.gov/cia/publications/factbook/geos/so.html). Web site.
Ibid.
World Health Organization, "Guidelines for Drinking Water Quality", 2nd edition, Health Criteria and other Supporting Information, Geneva, 1993. (http://www.who.int/water_sanitation_health/dwq/guidelines/en/). Web site; and World Health Organization, Water, Sanitation and Health WWW Portal. (http://www.who.int/water_sanitation_health/en/).
Mead P, and et al. "Food-Related Illness and Death in the United States". Emerging Infectious Diseases 1999; v5 (5): 607-625. The Centers for Disease Control (CDC), (http://www.cdc.gov/ncidod/eid/vol5no5/mead.htm). Web site
Prevention, Aug 1997, V49 (8) Pg 86. (http://www.prevention.com/cda/cda2002/1 ,4811,s1-999,00.html). Web site.
Healthy People 2000: see #2
Ibid, pp 14.
WHO-UNICEF. "Report of the International Conference on Primary Health Care", WHO, Geneva (1978) (http://www.who.int/entity/chronic_conditions/primary_health_care/ en/resolution_wha566_eng.pdf). Web site.

 

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