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In Somalia, A Different Kind Of Medicine

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In Somalia, A Different Kind Of Medicine

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Balkanization & The Ghost Of Greater Somalia

In Somalia, a different kind of medicine Doctors tend patients ravaged by civil war, traditional healers and poverty


In Jowhar, Somalia, children wait to receive measles vaccinations from the Doctors Without Borders group. Chronicle photo by Michael Macor.

Galkayo, Somalia, April 09, 2006 – “Allah, Allah!" the woman moaned, writhing in pain on her cot in the tuberculosis clinic. One hand clutched the metal railing of the headboard; the other shielded her eyes against the blinding sunlight seeping through the open window.

Dr. Geraldine O'Hara, a British tuberculosis specialist at the clinic run by the French relief agency Doctors Without Borders, leaned over her. "Sweetheart, can I look at your tummy, please?" O'Hara asked. The woman let go of the railing, clasped the traditional Somali dress the doctor was wearing, and started to cry.

"Can you let go of my dress for a second, darling? What is it? Same place it always hurts?"

O'Hara has come here to help people ravaged by civil war being waged by rival clans. Each day, she and 10 other workers from the Nobel Peace Prize-winning medical aid group in this dusty town in west-central Somalia find their efforts thwarted by the lack of equipment to diagnose and treat patients; the archaic, often brutal remedies used by local traditional healers; and the abject poverty that perpetuates disease.

Somalia hasn't had a national government in 15 years, and thus there is no public health system. It has some of the worst health statistics in the world: Every fourth child dies, according to the World Health Organization, and only Afghanistan has a higher child-mortality rate. Out of every 1,000 women, 16 die in childbirth. The average life expectancy is 43 years for men, 45 for women. And the country is affected by the worst drought in decades to hit East Africa, which threatens about 1.5 million Somalis with even more hardship because aid is exceptionally difficult to deliver to those in the most need.

O'Hara ran her fingers over the woman's stomach. Five other patients, sweating in the 104-degree heat, watched from their flimsy beds along the ward's chipped, dark-blue walls. Swarming flies flew through the room, landing on the unpainted concrete floor, on bits of unfinished food, on patients' faces. O'Hara straightened up and turned to her translator, Aden Barkadle.

"It's not something I can deal with in the TB clinic," she said softly. To the woman on the cot, she said, "Safia, I'm so sorry. We're doing our best to help you."

"She has intestinal TB, possibly," O'Hara explained later, washing her hands in a clinic sink brown with grime and wiping them on a towel black from weeks of use. "We don't know for sure. We don't have the diagnostics."

Doctors Without Borders operates two general hospitals as well as a therapeutic feeding center for malnourished children and the tuberculosis clinic in Galkayo. There is no shortage of drugs, which are flown in from Kenya on a small Cessna passenger plane. But often the doctors simply don't know which medicine to prescribe because exact diagnosis is so difficult.

The tuberculosis clinic, which treats more than 200 patients daily, operates a primitive sputum laboratory. The 105-bed general hospital next to it has a lab that does the most basic blood tests -- for malaria, hepatitis B, HIV. There are no X-ray machines, no dialysis equipment for kidney patients. The only pieces of medical equipment in sight are rusted IV stands, on which some patients hang their belongings to thwart scorpions -- frequent night visitors. There is no air conditioning, not even fans to beat away the oppressive heat.

"It's a little different from San Francisco," said Ramesh Dahal, a cardiologist from Nepal.

Dahal, who trained in cardiovascular medicine at California Pacific Medical Center from 1999 until 2003 and lived in Daly City, was racing between the general hospital's outpatient and medical wards, across an unpaved yard strewn with used surgical gloves and syringe wrappings. "It's the cleanest we can get," Dahal said. "I've seen worse."

Some patients lay on straw mats in the dusty shade outside: a man half-paralyzed by a stroke, another man attached to a colostomy bag. The hospital was overflowing with patients, and cots lined dim hallways. In February, after two warring clans clashed over land outside Galkayo, the hospital admitted 100 men with gunshot wounds in one day, putting them in hallways and in the yard. Fourteen are still recovering in the surgical ward.

Without proper equipment, Dahal often half-guesses the diagnosis. Fatha, 22 -- who, like many Somalis, goes by only one name -- has frequent seizures and paralysis on her right side since she endured a head trauma years ago. "She has epilepsy -- well, we don't know that it's epilepsy," Dahal said. "All we can do is look after this patient, give her medicine (to prevent seizures) and hope for the best."

Around the corner, in a hallway lit by a single bulb, Maxed Xarsi, 50, was slowly recovering from what Dahal thought was a stroke with left-side paralysis.

"We don't have equipment to do further testing," the doctor said.

"Let me show you the magnitude of what we're dealing with here," he said, sprinting into a room where the blue walls were streaked with something brown and yellow. Aden Chama Yusuf, 30, lay on a bed, his skeletal wrists twisted in a spasm, his face half-concealed by a soiled scarf. The hospital had admitted him two years ago. "No one knows what to do with him. He has some sort of neurological disorder. It's like a hospice for him," the doctor said.

On an average day, after her morning rounds to check on patients staying at the tuberculosis clinic, O'Hara sees between 10 and 20 patients at the clinic's outpatient consultation room. "Sometimes the things you can't treat are the really awful things," she said.

Tuberculosis is one of the main killers in Somalia, international relief workers say, but no one has researched the scope of the disease. For researchers, travel is too dangerous in a country that rival warlords have split into dozens of fiefdoms since the last national government collapsed in 1991.

Another obstacle is poverty. The standard TB treatment period is six months, but many Somalis -- who may travel hundreds of miles on foot or riding buses or donkeys along perilous roads to the only clinic in this third of the 1,000-mile long country -- cannot commit to the regimen. They are too poor to stay in Galkayo, where they get treated for free, but also too poor to buy the full course of medicine, which is available at Somali markets.

Often, feeling their health improve after a month or two, patients leave, creating a strain of drug-resistant tuberculosis that is much harder to treat, said Colin McIlreavy, head of the Doctors Without Borders' mission in Somalia. No one knows how widespread drug-resistant TB is here.

Similarly, no one knows the number of malnourished children, said Hamza Atim, a doctor from Uganda who runs Galkayo's only therapeutic feeding center. His 150-bed center admits between one and 10 new patients daily, brought by worried mothers. Most of the malnutrition cases Atim sees are caused by diseases with symptoms including diarrhea and vomiting, which prevent nutrients from staying in children's bodies.

"Because of security constraints, we are unable to physically look for these patients," Atim said, stepping through a crowd of squatting mothers holding quiet, skeletal babies. "I feel that we don't know the real problem."

Many children in Atim's center are covered with scars from the most widespread form of traditional treatment in this part of Africa -- healers burning patients' skin with coals or making tiny cuts to release blood. Burns and cuts usually heal quickly, leaving ugly marks, but sometimes they cause inflammations and abscesses.

"Sometimes the mothers claim they didn't know where to go (for treatment), so they go to traditional healers" instead of the hospital, Atim said. "We have really horrible traditional healers here."

Some patients arrive too late. One day last week, when Canadian nurse Naomi Fecteau returned to the hospital after lunch break, she came upon a man carrying a tiny body wrapped in cloth across the hospital yard.

"That would be a little one who just died," Fecteau said quietly, and kept walking.

Some cases have happy outcomes. Last week, a mother of one of Atim's recovered patients gave birth to a healthy girl. She named the child Hamza, after the male doctor.

At the end of a long workday, the doctors and nurses sit in the yard of their heavily guarded compound, reflecting on their successes and failures. Slumping in a canvas chair one day last week, O'Hara dragged on a cigarette and thought about all the patients she had helped -- and all the patients she couldn't.

"The day that it doesn't upset me, the day I go to bed without thinking about it -- that'll be the day I need to give it a rest," she said.

Source: San Francisco Chronicle


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