FEB-A-11

REVIEWING PATIENTS AND CONSULTING AND

OPERATING IN HARGEISA GENERAL HOSPITAL

February 5, 2004

` We have finally got into some clinical action, but not enough or soon enough for the troops who are chomping at the bit to get into the “real deal” at higher volumes. It turns out that the timing is just wrong right now, since this Thursday afternoon is “Saturday night of their “weekend.” The holy day being Friday, we will come in for rounds in the morning, but later, at 9:00AM and there will be only a skeleton staff and no clinics scheduled. This is just like the kind of “Getting to Know YOU,” ceremonies characteristic of initial greetings by Africans who spend far more time on the formalities of inquiring after your health and that of everyone related to you than of getting directly to the business at hand—an American proclivity that is often offensive to those for whom the relationship building is more important than the cargo moved.

“GETTING TO KNOW YOU”:

AN AFRICAN RITUAL OF INTRODUCTORY RELATIONSHIP

BUILDING FOR MUTUAL TRUST

I remember Ivo Garrido expressing the exasperation of the international community when the negotiators from FRELIMO and RENOMO in the eleven year civil war in Mozambique were being supported at over a million dollars ad ay to keep their government running while the negotiators from either side spent over 90 days in just getting together without a single substantive issue ever coming up. “Don’t you understand? “ asked the Mozambican in charge in explaining the long and expensive delay; “No deal will ever be honored unless we can trust each other after over a decade of shooting at each other, and the only way to get to trust each other is to get to know one another, so it will have to be worth the wait to the international donor community for me to be enquiring whether the opponent’s daughter has had her baby and whether his wife has fully recovered from her operation or he will know that he can never trust me an no deal will hold between us! You Europeans, but especially you Americans area always in such a rush to get down to business that you never get to really know whom you must be doing business with!””

So, we will have a couple more days at half effort on “African time” which the team considers a painful and slow way to use efficiently the limited time and availability of a world-class experienced team for the maximum benefit of the people here and the saturation of the opportunity schedule. The Africans are so used to lack, delay and incomplete results that even their fondest hopes of a rapid and efficient team fulfilling most of their wishes is too much to hope for, and they are holding back so as not to overwork us.

TRYING TO AVOID THE ENERVATION OF AN AFRICAN

FATALISTIC HABIT:

SITTING BACK AND WAITING FOR SOMETHING GOOD TO HAPPEN TO YOU THROUGH THE GOOD OFFICES OF SOMEONE WHOSE DEPENDNET YOU MIGHT ASPIRE TO BE

So, I have used the “down time’ to write a few postcards (the only ones found in Somaliland are not very good and they show a bleak landscape that I would hardly consider the enticing scenes of a real world that would attract anyone here let alone tourism) and to set up the framework of this and future exchanges. We have sorted out the medial kits and brought over successive duffle bags of equipment and drugs, some of which we had apportioned out for the use in the later road trips to such places as Berbera on the Red Sea. But we are also concerned lest we go through the same down time and waiting period in anew spot, reinventing that wheel another time before we were ready to roll, so we are maximizing the opportunity here and pushing for an earlier schedule of events so that we do not leave a large waiting queue of disappointed hopefuls that are hoping for us to be helping them after a prolonged wait until after we are gone.

We got up early in our separate very comfortable Hotel Mansoor rooms and had breakfast awaiting the 7:30 AM pickup by the Hargeisa Hospital pickup truck driven by Essa (Arabic translation = “Jesus”) to begin our word rounds at 8:00 AM and our theatre operating schedule after that. We waited. At 8:00 AM, we still had not seen Essa, so we called the hospital and asked if he were delayed. One of the UN voluntary agency workers was here with a UN Toyota Land Cruiser (I would like to have that concession to furnish and service this fleet of white vehicles with the big blue UN stencils on them!) offered to carry us over to the hospital. We waited just long enough for me to sign on Kevin’s Yahoo server and “attach” the latest four chapters of this account and to send them under the quickly typed in title “Let’s Roll! Getting started in the Horn of Africa.” We then piled in the UN vehicle after loading the bags of surgical supplies and the boxes of precious antibiotics. We were ready to roll, when Essa pulled up without an explanation except a shrug “Sorry!” and we arrived at the Hospital, to find none of the doctors, but a couple of the “Admin Officers.” They were pleased and proud to take us around, unaware that we had made ward rounds yesterday on the patients, so they took us to all of the buildings in the pavilion style collection of British Colonial Buildings, built in 1954. Wheezing and gasping in one building was the pressure cooker steam sterilizer from the first and earliest equipment put in by the British—fifty year old original equipment—and, in this case, still puffing along in full function, even if inadequate to service 350 beds. Bravo!

A WELL-FUNCTIONING HIGH-VOLUME CLINCAL SERVICE

THAT WOEKS WEL IN A “NATION-STATE CANDIDATE”

THAT CAN CERTAINLY USE SUCH SERVICES:

THE HIGH “PREGNANCY WASTAGE”

OF A “LESSER DEVELOPED” HEALTH CARE SYSTEM

We saw the wards we had not visited the day before including a very impressive maternity suite for labor and delivery, which processes over 12 births per 24 hours, and a number of women in a post-partum ward adjacent to it. As we made rounds with the sister Noura, she presented each case with the group of post-partum women who are there for only six hours post-partum, and explained: this one had twins, one death in utero and the second delivered premature; that one had transverse lie and needed C-section but her husband refused, and only after the baby had died did he agree to the C-section to late; this one is pre-eclamptic at 34 weeks and is on hydralizine, with BP coming down to normal but had lost the previous two pregnancies in crises; that one had a prolonged trial of labor with traditional birth attendants, and has lost each prior pregnancy, and is being held near term to deliver here. All told, there were six dead babies accounted for in the first pass down one side of this very short term ward. It is now easier to see from this “pregnancy wastage” and infant mortality rate, that Somaliland holds the record after Afghanistan, but that the latter country is recognized and has international programs in place to reduce this rate. Unlike Malawi, where we explained that each woman was entitled to two previous C-sections, and at the third, she would have tubal ligation, so as not to go back to her hovel and labor on a scar for the next birth, there is no such policy here. In fact, when it was suggested for the one additional puffy edematous patient with a repeated pre-eclampsia that she have post-partum tubal ligation to save her life, the OBS sister said “Oh, no, her husband would immediately get another wife.”

An adjacent pavilion is being rehabilitated (with all the bricks and dust lying around big piles of construction materials—gift of a German benefactor—I quipped “It looks like my house in Derwood” to no one here present who would understand. But until that building is completed, according to the Admin Officer which is expected next month, maybe, there were several gynecology patents in the post-partum ward as well.

“WALKING BAREFOOT THROUGH THE UNBRIDLED ID”

A PSCHIATRIC EMERGENCY BEFORE OUR EYES

The real eye-opening story came with the clamor of a shrieking patient population that was reminiscent of Bedlam—the Psychiatry Ward. They had run out of the year’s budget for psychiatric drugs last month. There are 100 Psychiatry patients; there is no medicine, such as Haldol or Chlorpromazine. I remember well when I was a medical student a very graphic example of a public health psychiatric emergency at Ypsilanti State Hospital. The revolution in psychotropic drugs had occurred just before I was in medical school when Smith Kline French (as it was then know before multiple further mergers) had introduced Thorazine, the original chlorpromazine—and the “Insane Asylum” underwent an architectural modification immediately: they took the bars off the windows. When Michigan State Health Department ran into a budget shortfall and could not purchase the medications, the patients who had been docile and had been controlled from their self-mutilating outbursts, “ran amok” and they had emergency funds allocated to return the bars to the cells, when it was pointed out that for less money they could divert these funds to drug purchase. After a tour of the officials through the horror of the inmate population in full feces-throwing fervor, the moneys were quickly approved.

And here we now are. I heard the clanging of fists on bars and the shouted greetings and the wild-eyed stares and fascinated following of a large ragged inmate population which clung closely to this group of unusual white faced visitors as we walked through the 100 inpatients and as far as we could from the barred doors of the few causing most of the commotion. “Yes,” said the Admin Officer, “We will be meeting again with the officials, even though they have no resources to impress o them the emergency of the situation, and our Director Yasine is down at the commercial center trying to persuade business men to purchase the drugs on the market as a donation to keep us from being torn apart.” One of the male nurses came to see us and called out to see if we were part of the rescuing angels who might restore a drugged tranquility to this—literally-- Bedlam scene. The medicines we are packing to do not include the psychotropics for any long term care. As we were there, a UN vehicle pulled up in the midst of the din, and a white woman—as noticeable as we are in this setting—came out to look. She is from a UN agency that she said attempted psychosocial integration of the mentally ill back into their respective communities. She is from Bucharest Rumania. She realized from just the ruckus going around at the time of our visit that there would be no time for the little niceties of “psychosocial reintegration” and retreated to the security and quiet of the UN stenciled Land Cruiser. “Oh Little Town of Bethlehem (transliterated into London’s Briticism= ‘Bedlam’) Revisited!”

DUCKING INTO THE PEDIATRIC AND OTHER WARDS,

BEFORE FINALLY GETTING INTO OUR SURGICAL WARD ROUNDS WITH DOCOTR SULEMAIN

We looked into the colorful pediatric ward with the mothers all sitting around comparing notes on the status of their sick babies. This is not peak malaria season, so the top killers are the usual “DAMMM Shame.” Diarrhea, Acute Respiratory (Pneumonia, including TB), Measles, Malaria and Malnutrition. There is a strong resemblance to the peds ward at Embangweni, with the mothers taking the children outside to sit under the trees awaiting the nurse or doctor to come to review the patients and their status and to count up the ones who did not survive the night, mainly casualties in the nutritional rehab program who were too late. When there might be rains, malaria will replace the universal third world leading killer---diarrhea from water born contamination—as the number one, for at least a brief season.

Doctor Asea Osmania had described a borderland village where there was a crisis since ten out of twenty eight people who drank from one well died. She explained it with what I believe is a euphemism. She said that there had been a drought there for many years and the water level was such that the cattle could not be saved since there was no available water for them to drink even of the contaminated residual of the poor ground water that was difficult to reach. A donkey, she said, had tried to get at the receded water level and had slipped into the well and had died and putrefied there but there was no other place for the people to find any water to drink, so they used this water anyway. My own view is that this is a story to avoid discouragement of the visitors unused to the cruelty of civil war, as I had seen it in the horrors of Mozambique and the Congo. The village well is always the favored repository for disposal of assassinated victims: the disposal of bodies into wells accomplishes not only that death, but the following deaths of the community who are terrorized through the savagery of being killed by their own.

She had added, as others had in reassuring us, that the personal crime rate is very low, and that thievery is minimal, and non-political killing is quite exceptional. When asked the murder rate by Kevin who prefaced his question by saying that he came from Washington DC where there was at least a murder every night, she said only one every six months. This means there are no vital statistics of any reliability—after all there is not birth or death certification in the “lawless non-state”, but that murder rate seems rather miniscule in view of my counting up six stab wounds with lethal intent found resident on the wards at this moment, one of which—the man with the Brown Sequard Syndrome and the seizures no doubt due t meningitis---will yet eventuate in the murder that was intended by the assault. That being said, this society has far less of the random violence than ours, but when they get going in real civil unrest, there is a fervor of the Islamic “run amok” and the promise of the true believer going straight to paradise in death in the cause of the faith. On the latter score, there is peace right now here, at all but the southern border with their “Somali brothers” and in the fundamentalist Wahabi crusade for “Puntland” by al-Yussef in the region of Sool. We will not be going there.

RENDEZVOUS, FINALLY, WITH THE DOCTORS FOR

SURGICAL WARD ROUNDS AND CLINIC CONSULTATION:

THE STORY OF TWO LITTLE BROTHERS AND A HYENA!

We made a very rapid round of the male and female surgical wards, seeing some of the patients we had seen yesterday, and noting that they had been very attentive to our suggestions on the treatment changes we might recommend on our first cursory review of their limited information. People who looked anemic had been sent to the lab, where the very dedicated director of the lab which we saw for the first time today had checked their hemoglobins, most of which were alarmingly low. There were several new patients for evaluation, one an older man who had an acquired left inguinal hernia. It was not incarcerated, nor suspicious in itself, but it was attributable to a correctable cause. The three questions asked of an adult who acquires a direct inguinal hernia not obviously a congenital defect are: 1) Chronic severe coughing (Tb, COPD, asthma) 2) Prostatism (BPH vs. cancer) or 3) Constipation (Bowel obstruction from malignancy). If the hernia is fixed, which is just a harbinger of the obstruction that causes the straining and increased intra-abdominal pressures, but the underlying more serious cause goes unresolved, the fixed hernia will, inevitably, recur. Sure enough, this fellow has been straining to pass urine and has a big obstructing prostate, and has a bladder catheter now, with an ultrasound scan and digital exam revealing BPH (benign prostatic hypertrophy). Both may be fixed simultaneously, as we plan to do, but the prostate takes precedence over the hernia. The second BPH is ready for transvesical resection, along with my pre-op nursing care lecture on the importance of maintaining a patent catheter by continuous irrigation to prevent plugging of blood clots---my oft-repeated and less often heeded Embangweni lecture on each occasion of my operating there.

A young fellow who is said to have bleeding hemorrhoids had so sever blood loss, that his Hemoglobin was 3.5 g (Normal= 15 g) and he had 1500 ml blood transfusion which brought it only to 8.5 g. That is three units of blood which did not catch him up fully, so that is an unusually severe bleeding from hemorrhoids. But he is to be brought to theater, and I had assigned Juan to lead off with this case. When seen in theatre, he did NOT have hemorrhoids, but a torn anal sphincter. I asked what might be the cause of that and I was told he had constipation with hard stools. I accept all such reports as information, not necessarily as fact.

In clinic, a woman was seen with an eight centimeter mass in the subcutaneous thigh with depigmentation over it. It was not expecially tender but firmer than a lipoma, and was said to have shrunken on a course of penicillin. I suggested that it might be the filarial problem of Onchocerciasis. This is the filarial worm of Oncocerca volvuli or OV, the same filaria that causes river blindness. We brought her to theatre and took it out, and Jay, who had previously needled it without any yield of pus, shoed it to be a hemorrhagic OV nodule.

The team was puzzled by a 39 year old male nurse who had an episode of hemoglobinuria and hypertension and had been worked up even going to Addis Ababa for study. His urinalysis showed some kind of crystals which they were working on a presumption of gout, and on an ultrasound scan it showed a small cystic area in one kidney. They were still puzzled, as they would not be if they considered the geographic medicine of the area. Since hemoglobinuria is nearly uniformly Bilharzias—or Schistosoma hematobium. He need s a single course of Praziquantel, an essential drug that the hospital, of course, ode snot have, but is available in the market, and this fellow being a nurse can have access to it, so we will have to track him down since he was presented to me at lunch after he had been discharged.

A veiled Somali woman was brought in—who, incidentally, looked far more intriguing with the veil than after she had it removed by the nurse—with a complaint of obstipation and a tender sigmoid. She might have had intermittent sigmoid volvulus, and she will return for the Konsyl psyllium powder I just happened to be carrying and will give to Jay to treat here with when he sees her on Saturday, the day after the hospital is closed down for the holy day.

In the small pediatric surgery word we saw one of the more fascinating young patients, who had a problem interesting in its original cause, but now complicated by something still more interesting. This young fellow and his brother were playing outside their village hovel when they were attacked by a hyena. (This, I pointed out to Juan, considerably increases his experience in the management of hyena bites over that which he had acquired in Washington DC!) The younger brother had his skull crushed by the powerful snapping jaws, but remarkably recovered and had the wounds granulate in primarily. This boy has been in the hospital since October when this happened. The area of the skull was completely “degloved” (although a more appropriate term here would be “de-stocking capped.”) With the loss of the scalp, down to skull with the galea aponeurotica stripped away—the only meat the hyena managed to eat from these two boys, who were very lucky to have survived an attack by a very efficient and vicious killer, not just a scavenger. So, this scalp area had granulated in. But, now, he had a puffy swollen face with an orbital edema that has closed off the eye, which still had vision. He does not have fever and there is no tenderness or “pointing” of the area which is not fluctuant as with an abscess. I believe he has developed a cavernous sinus thrombosis; a major problem often discussed an infrequently seen. He is the first patient I took pictures of, with the permission of the nursing staff and the attentive Somali mother. This will go into my less than extensive collection of African hyena bites of young boys.

DELIVERING DRUGS AND SURGICAL SUPPLIES,

RETURN FOR LUNCH AND A TWILIGHT RUN UP

THE ADJACENT “WOMEN’S BREASTS” MOUNTAINS,

GATHERING KIDS LIKE THE PIED PIPER RUNNER,

AND A HIGH LEVEL MEETING WITH THE OWNERS,

SHAKERS AND DOERS OF SOMALILAND

After dropping the bags with the medical supplies we had delivered, we returned and went for a run from the Hotel Mansoor. It was just at the twilight time of the tangential sun’s rays, and we ran up the rock-strewn hillsides called in the Somali language “women’s breasts” because of their conical smooth appearances from a distance, but I can testify from closer observations that they are not “user friendly“ surfaces. We gathered up a whole crew of fellow runners who were ranging in age from about eight to sixteen including some little girls with littler girls on their hips, and even some boys who were pulled away from their obsession with “futbol” (=soccer) to ask each of us our names, and why we were “wearing short trousers.”

It was good run, and is made an even harder work out by the soft desert sand interspersed with roller bearing rocks. It was much harder when I had done the run after dark and had to guess where my feet would be landing. Upon return we were met in the lobby upon our coming down for dinner by the owner of the Hotel Monsoor, Abdul Rahid whose son Said manages it for him. When I asked how many children he had, he said he had six sons, and "one daughter, who outweighs all the rest." He means by this that she is the apple of his eye, of course, but a wealthy Somali woman is likely to achieve a weighty presence for other good and sufficient reasons, I have noticed. She is an engineer, having returned from Toronto to Somaliland now, so that he is bringing back each of his children from their own Diaspora to help build the new nation. He said to me, from his Kuwait based real estate business and Berbera shipping interests "I am interested in making and saving money out there, but back here there is no profit, only an investment in building up the people from the very poor state they are in now." I said to him "This is your own form of Zakat here in Hargeisa?" He replied, "Ahah! You know!" He is a tycoon with principle offices in Kuwait and has businesses all over but especially keen on repatriating the educated members of the Diaspora of Somalis who have stayed abroad since the civil war in1988 on. His brother Muhammad came in wearing traditional Somali dress to greet his brother who had arrived her from Kuwait by way of Dubai. Muhammad is a deceptive looking sleepy eyed fellow whose bilateral ptosis obscures his lightning quick mind and careful analysis. He is Commerce minister of Somaliland and ticked off in a moment the six priorities for exploitation of their natural resources and gemology. Muhammad had been the chairperson the hospital committee in Hargeisa, and because of his presence with us the head of the Red Crescent Society in Somaliland came over to greet us and to pay his respects. With him was the head of BBC Somaliland. They are delighted with our presence here and told us we were at their collective disposal to call upon them for any aid they can offer. A group of people came in and each came to pay homage in the ‘holding court' (= “majlis" in Arabic) around us, including the BBC Middle East correspondent, the sub-minister for agriculture and a number of other officials and family members that came along too quickly for me to pick up each name in turn.

We learned that Ethiopia and Somaliland are key elements that are in the headwaters of the waters that flow on to form the Nile, and the Egyptians are dead set against the international community recognition of Somaliland since the added leverage could get them to pay tribute to the water resources that fall outside their control as rain in the highlands along the Ethiopia Somaliland border. All of Egypt’s civilization depends on the water that even Herodotus already knew---“Egypt is but a gift of the Nile,” whose origins were then unknown, but are now entirely understood with strategic advantage to those who can dam, or contaminate them. Since the US has considered the Egyptian ally a crucial one in its relations to the Arabic World as the kingpin of the Arab league and that their balance will be needed in managing the struggle between the Palestinians and Israel, the USA will not override Egypt’s concerns. All of the Middle East policies forever have been based in the “enemy of my enemy is my friend” foreign policy, and we as an international community have had to fit into that modus operandi. It is like South Africa building the Nkomati dam a kilometer from the Mozambican border, or Brazil building the Itaipu Dam as a strategic defense imitative against archrival Argentina perceived as a threat by the then military governments that initiated such policies.

From this geopolitical strategy, and speaking with and listening to the insiders of Somaliland’s small elite in this democracy, we are getting a better picture of the potential prospects and complex present realities of the current impasse in their development. On the other hand each African state that is recognized is immediately a debtor nation to the World Bank and IMF and the Somaliland advantage is that they have had to go it alone and are indebted to no one since they, legally, do not exist! Not a bad way to start a slow growth from a zero base start up of a company or country, or a health care assistance project!

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