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FIMA (Federation of Islamic Medical Associations) Relief, IMANA (Islamic Medical Association of North America) Relief and Islamic Relief are working jointly in the worst famine and drought hit Somalia to provide much needed medical relief. The first group of Pakistani doctors from PIMA (Pakistan Islamic Medical Association) reached Mogadishu on 10 September 2011 and stayed for four weeks. Dr. Muhammad Asim is a paediatrician at Lahore General Hospital and is an expert in neonatology and a member of PIMA. Here are a few pages from his daily diary which he shared with his friends.

Shamo Hotel
Strategically located at the entrance of the Bab el Mandeb gateway to the Red Sea and the Suez Canal, Somalia occupies the tip of a region that, due to its resemblance on the map to a Rhinoceros' horn, is commonly referred to as the Horn of Africa. Somalia lies in the eastern-most part of Africa. It is bordered by Djibouti to the northwest, Kenya to the southwest, the Gulf of Aden with Yemen to the north, the Indian Ocean to the east, and Ethiopia to the west. It has the longest coastline on the continent, and its terrain consists mainly of plateaus, plains and highlands. Hot weather prevails year-round, along with periodic monsoon winds and irregular rainfall.

10 September 2011, when the team of Pakistani doctors were on our way to Somalia, we had many thoughts in our minds about our work there But when we landed at Mogadishu airport, we realized even before leaving the airport that we were very much “now in Somalia”, and this is the place for new ideas not the ones we had before. Somalia is truly the horn of Africa, hard to touch and difficult to change.

First thing we had to decide at the airport was, where to go! The problem was not about finding anyone to receive us rather there were many friendly faces with the hope of taking us with them and it was even difficult to disappoint anyone. All of them were friendly, sincere and dedicated towards helping humanity, especially in a land altogether strange to us. Having resolved this issue, and this was the first not the last one, we headed towards our resting place. On the way we got the idea of our workplace for the next weeks. Hard to see any places with no signs of firing and bullets and even mosques or houses were not spared. Armed persons moved freely all around and our hosts insisted that Mogadishu was now much safer area than before!

Shamo hotel is the hub of NGOs, being the only continental hotel in the city.Almost all the foreign guests stayed here and enjoyed the view of Mogadishu from the terraces, enjoying meals of their choice and taste. One quickly forgets that one is in Mogadishu, Somalia, a famine hit area where IDPs are more in numbers than permanent residents. We were advised to rest and prepare ourselves for work from tomorrow with brother Elmi.

Elmi is the health manager in the Islamic Relief Somalia. Management in health sector is not an easy job here in Somalia where every thing is transient: transient government, transient IDP camps and transient doctors’ stay. Having the opportunity of working with a person like Elmi is one of the good things one gets here. He is hardworking, cooperative, knows his job and ever ready to bring positive changes for the benefit of the people.

African Wazirastan
Since our arrival here all those who know Pakistan allayed our fears and worries by mentioning that the conditions here are not much different from the Tribal areas of Pakistan. And I have realized that it is true in many aspects.

One can see armed personnel with a ratio of 1:10 personseverywhere in the markets, street, IDP camps, and even hospitals. But most of them are so emaciated that it is difficult to say whether he is carrying a gun for defense or to support him in walking! After 20 yrs of civil war these people have more stock of ammunition than water in their houses. The Somali Government has advised them to provide security within their residential areas because the only thing they know is how to use a gun. Somali locals also informed us that since the famine and drought there has been a decrease in the intensity of civil war amongst them. Probably an unwritten treaty between rival groups that they will not affect the humanitarian efforts being undertaken here. So one may not have heard of any harm to any foreigner here. Notwithstanding, they usually remind each other that “they are not forgotten” and often this reminder is in the form of gun fires or explosions.

Another similarity with tribal areas is the lack of an organized infrastructure, system and government. Twenty years of civil warfare has virtually destroyed every form of infrastructure and democratic governance. This is the main problem which all NGOs have to contend with and security issues are paramount. And anyone working here has to do two things simultaneously. First to do the work assigned and secondly try to encourage, help and inform his local colleagues (according to the mind set of each one) about the benefits and output of working in a system. This notion and belief needs repetition because they, especially the youths, have only seen destruction. Now they need to know what the word construction means and undoubtedly construction takes much more time than destruction. Everyone in Somalai is very cooperative and want to do something for the IDPs. They are ever ready to support anyone who comes here.

No one can guarantee absolute security, not even in our own homes. No where in this fallible world is there a perfect operational system. Allah has placed a a challenge on the Somali people and I think it is also a test for us, to see how much we care for our Somali brothers and sisters.Hopefully we will succeed in this test and trial.

Musteshfaa’
In Somalia the available health facilities for the population can be divided into 3 major categories. Primary health care centers, hospitals and private sector setups. Primary health care centers, mainly run by NGOs, are mostly located in or near IDP camps. They provide the treatment of minor ailments. Midwives are also present in most of them but there is a big gap in the provision of proper antenatal, postnatal and newborn delivery facilities for the population. Most of the births are handled at homes or in tents by traditional birth attendants (TBAs). Facilities for vaccination of pregnant ladies and children are not present in these centers. Availability of doctors is another issue which may vary for different setups and in the absence of doctors the senior most para medical staff manages the patients.

Benadir hospital is the only tertiary care facility available for the population of Mogadishu and its vicinity. It is a government hospital and it is affiliated with the Benadir medical college. PAC (Physicians Across Continents) has adopted this hospital for renovation and upgrading as decided in a health cluster meeting at OIC.Many NGOs are helping PAC in this regard. At present it has three functioning departments namely medicine, gynecology and pediatrics. Basic lab tests and radiology (X-ray, ultrasound) are also available. The hospital is in a dire need of an ICU setup, Neonatal ICU (neonates), operation theatre. oxygen cylinders have to be acquired from Nairobi, Kenya. Eventhough many organizations are supporting the hospital operations there is still a lack of various essential services and equipmens. Unfortunately, patients the poor included have to pay for investigations, radiology and medicines. This is a matter of concern because people here are mostly poor and are unable to afford the cost of treatment.

Fourlini hospital is situated in the periphery and was the second largest medical facility, after Benadir, before the civil war. It is now run by Gift of the Givers (a FIMA partner body from South Africa) and has secondary care facilities available. For surgical patients there are two separate setups here and both are facilitated by ICRC. All types of general surgical operations are done but there is lack of E.N.T, neurosurgery, gynae and orthopedic specialists. Al-Madina hospital is a renowned surgical setup having separate compound for emergency, OT, male and female wards and ICU. 8 doctors are working there currently.

There are only 2 or 3 major private setups in Mogadishu. Paramedics are running their own clinics everywhere in Somalia due to the lack of trained medical staff especially doctors. They serve as an alternative to bridge the paucity of healthcare professionals. There are 10 nutrition centers run by MSF and others under the supervision of UNICEF and they provide inpatient care for severely malnourished and outpatient management at IDP camps 2-3 days per week.

Sallo Haeya
When you interact with a patient in Somalia, you ask: Sallo Haeya? (What are you suffering from?) Diseases have different classifications and when in Somalia, you may need a new classification for the management. Patient with malnutrition and patient without malnutrition.

20 yrs of civil war, lack of permanent ways of livelihood, displacement, poverty and now famine has resulted in more than 60% children suffering from malnutrition and more than 75% women suffering from anemia. Malnutrition in children has various causes e.g. large families, limited or no resources, living in far off areas and present in variable severity according to contributing factors. Malnutrition in itself is a disease and also increases the incidence of many other diseases. Nutritional rehabilitation is undertaken by different NGOs but at a relatively small level relative compared to the magnitude of the problem.

Women are the second major sufferers of the disaster situation in Somalia. Every family comprises of at least 6 children and now women also have to look for added aid or financial support. This result in anemic, emaciated, tired women who are more worried about their children rather than their own lives.

Overcrowding due to movements of new families into IDP camps in Mogadishu and the lack of proper vaccination has resulted in recent outbreak of measles. The incidence of infectious disease including tuberculosis is also alarmingly high. IDP camps are pitched at most vacant areas without any planning about water, sanitation and other basic necessities needed for a hygienic life. Scattered and open toilets with children playing around, non-availability of continuous water supply and large sized families living in small tents has resulted in a surge of communicable diseases.

In August there was an outbreak of diarrhea and associated gastrointestinal diseases which has now decreased in intensity. But there is concern for the spread of malaria in the incoming season of rains from November onwards. Malaria is multi-drug resistant and often fatal. Scabies, dermatitis, acute respiratory infections, UTIs, dysentery and worm infestation are commonly encountered problem to any one working in health posts of IDP camps. Due to lack of proper, affordable, reliable and in many instances accessible medical, laboratory and radiological facilities it is difficult to know the true incidence of chronic illnesses in the community. The high birth rate has resulted in increased neonatal and infant mortality rate because of malnourished mothers and children but statistical data is not available.

There is an increased trend of blood transfusion in anemic patients and multiple use of the same syringes is not uncommon. This may cause the transmission of Hepatitis B, C and AIDS, but due to many other major issues this potential threat is overlooked and not discussed at any forum.

Hypersensitivity
Hypersensitivity (also called hypersensitivity reaction) refers to undesirable reactions produced by the normal immune system. These reactions may be damaging, uncomfortable, or occasionally fatal. Hypersensitivity reactions require a pre-sensitized (immune) state of the host. In Somalia there are many kinds of hypersensitivity reactions prevailing.

One of my colleagues was in the health post of an IDP camp when there was an accidental car tyre burst on the road. All of a sudden every gunman on security opened firing in the air, every person rushed for his safety and it took them 15 minutes to realize that there is no real threat anywhere around. This indicates the fears of the people here though they are trying to return to a normal life. It also reveals the immature response of security personnel who know only 2 rules of having a gun, how to use and when to use it, but unaware of third and the most important one, when not to use it!

The same is true for peace keepers here. The African Union (AU) army is deployed here to keep peace and they remain peaceful until disturbed by someone. According to the local residents, these AU peace keepers, if at anytime they feel threatened, they would open fire blindly resulting in more and unnecessary casualities.

Doctors working here are also on high alert for cases of malaria, pneumonia and T.B. Due to the limited available diagnostic facilities and the lack of academic guidance and supervision, every case of fever malaria and/or pneumonia unless proven otherwise. If the fever persists despite treatment, then anti TB therapy is commenced. Even neonates and infants fall into this category.

Unfortunately, there is a lack of coordination in the humanitarian relief afforded to Somalia. Some areas are well served whilst others may be altogether neglected by many organizations. This inequity is more evident in the health sector where some times many doctors are available under one roof and 2 or 3 days later the same facility may face dire need for doctors.

The Somali government and its rivals are also at odds towards each other. Any foreigner entering an Al-Shabaab area for purely humanitarian work is often regarded as an American agent, so no one dares to enter these areas. Though local people can move freely across both territories but it is unrealistic to expect them to replacing foreigners in every field of work keeping in mind their capabilities and understanding of relief work. A breakdown and derangement of her health care services and its replacement by immature transient alternatives is not helpful. There is a clear need for some form of sanity and rationale in the construction of her health care infrastructure and operations.

Pieces
Pieces of window glass are scattered around in our guest house reminding us of the explosion that took more than 70 lives. This sad incident happened in the centre of Mogadishu city at a government compound. These broken pieces are also grim reminders of the broken peace and promises between rivals fighting in Somalia.

When this incident happened, I was at the President’s House with my friend to meet with the President and brief him about FIMA and its activities. But this blast resulted in the cancellation of all our appointments with the president. The site of the blast was on our route to the President’s House and I happened to pass there one hour before and after the incidenct.

Pieces of certificates and papers about future plans were seen flying in air. There were newly graduate students gathered at that place. They were the talent of Somalia who studied in a a country where getting a decent education is in itself a big challenge and in such circumstances they proved themselves as the crème dela crème of the nation. They were selected for foreign scholarships. It was difficult to identify the perpetrators of this horrific tragedy which has resulted in a huge loss of real and rare asset of Somalia i.e. talented, educated and visionary youths. Education and youth are part and parcel of a transformation package for any nation.

Parents were seen wandering around in search of remnants of their loved ones. They were present in numbers to encourage their children to achieve academically and to later shoulder the awesome responsibility fo nation building. No words or feelings can describe their pain and sorrow. People immediately rushed to the scene and tried their best to help the people despite the risk of any subsequent attack. Every one there was full of the love and spirit of humanity and brotherhood and hopefully this helps to decrease the grief of the families who lost their loved ones in the blast.

Somalia may be bursting at the seams. It is a stark example of natural disaster and human failure but it is also an opportunity for the genuine display of our humanity, our religiosity, mercy and brotherhood and for creativity and innovation. The resilience and dignity of those in the most precarious of positions - victims of drought, civil war and poor governance - offer an alternative to the often simplified images of desperation.

I met Somali people after this tragic incident and they seem to have moved on with life. Everyone was busy with his work and not afraid of anything to stop him from striving to live and dream of a peaceful Somalia for their families. I had only one question to ask to my humanitarian friends: If one cannot halt destruction then should one stop construction?

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