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Development Director of BWHAFS, Shamis Dirir, visited the Togdheer region of Somaliland twice before the Barako project was fully established. This report follows the first visit, which focussed on the health care problems of the region, including the practice of FGM. The subsequent development of the Barako Family Health and Education Centre was intended to address some of the issues confronted in this report.

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2nd July - 21st July 1999

Introduction

For the last twenty years, Somalia has suffered greatly from natural disasters and civil war. The combined effect of these two calamities has left the whole country in ruins and inflicted heavy material and human losses.

Somalia is one of the few countries in the world where the practice of FGM is still on the increase. Although the work of BWHAFS in fighting FGM in Britain has been very successful, it is futile to deny that the problem needs to be eradicated in its country of origin, i.e. in Somalia/land for FGM to lose its powerful symbolic function for all Somalis in the diaspora. This was the primary reason behind this BWHAFS healthcare/ FGM assessment trip to Somaliland.

The objectives of the trip included;

- To assess the impact of the Somali civil war on the practice of FGM

- To gain an overall view of health care delivery in Somaliland, particularly in Togdheer Region

- To explore ways in which local activists can be supported in Togdheer, and to establish the future safety of the proposed Health Clinic

Currently the state of the healthcare in Somaliland is virtually non-existent. The need for healthcare services, including primary healthcare, in the Togdheer region of Somaliland seem to have been completely ignored.

Somaliland and its people have been through hell, and one of the tragic consequences of the long civil war is the number of people who have become mentally ill.

Care for those affected by mental illness is in severe need of professional assistance. The prevalence of mental disorders is said to be double that of those who suffer from hepatitis, which is a major killer in the region. Many people who have developed severe psychotic or neurotic symptoms wander around towns and villages without medical care or attention. Only the luckiest have relations with the means to buy them medicine, and rent a bed from a semi-private clinic.

There is no immunisation programme for children at all, in a place where diseases such as whooping cough, polio and TB are rampant.

The infant mortality rate is very high. Burco residents estimate that they bury around twenty children under five daily. The adult population also suffer a very high mortality rate with deaths resulting from TB, meningitis and sporadic outbreaks of cholera common.

There are a number of private clinics and chemists. However, the majority of Burco's population is made up of poverty-stricken people who cannot afford to buy modern medicine from drug stores or visit private clinics.

More often than not, they resort to traditional medicine as a cheaper alternative. Practitioners of this kind of healing often sell herbs that are not relevant to the illness in hand. For example, in one case, a patient who was suffering from gastritis was given a kind of herb and died later that day.

However, Western medicines are often unsafe as well: it was shocking to see that some of the drugs marketed in chemists have either expired or bear the wrong label. There is nobody to check on such fraudulent practices. Children have unrestricted access to all types of drugs and some reports alleged that children have been disabled by unlimited usage of drugs prescribed for adults.

Families with relations abroad often persuade them to send medicine that has neither been prescribed by a doctor nor recommended by other medical staff, but as a contingency measure should a family member fall ill. Some visiting relatives brought with them plastic bags full of drugs from Europe, the USA or the Gulf States.

Attitudes to drugs and medicine reflect the ignorance of the local people about healthcare and treatment. Many people assume that medicine makes you feel better, even if you are well. The question, 'have you brought any medicine with you?' is often asked to anyone visiting from abroad, without any regard for the type or efficacy of the treatment or illness.

It is worrying to find that all types of drugs are sold over the counter without questions. Most of the people who man the chemists are semi-literate and have only the vaguest idea about the products that they are selling, let alone how to administer it. Chemists are run like corner shops, with no regulation or controls, yet they are a mainstay of what passes for health services in Somaliland.

There are three government Health Care Centres in the Burco area, yet only one of these is functioning. However, even this centre is ill equipped to diagnose for a large of their patients, because they do not have the medical equipment to do so. The medical staff are either severely underpaid or not paid at all, forcing them to solicit money from their patients. The other two health centres are not functioning mainly because of lack of resources, and only a few demoralised unpaid staff remain, frustrated because they cannot offer the services they want to provide.

Aid agencies that bridge the service gaps in other towns, such as Hargeisa and Borama, have no presence in Burco. There are no ambulances to convey seriously ill people to the health centres.

There are no health education or awareness programmes in the area at all.

People who live on the outskirts of Burco get their drinking water from reservoirs that contain rainwater collected through channels that extend more than a quarter of a mile. The water is contaminated with, amongst other things, human faeces and animal dung. The reservoirs are breeding grounds for mosquitoes and people who live in the area often suffer from malaria including cerebral malaria. Water from the reservoirs has also been found to contain viruses that cause hepatitis and other killer diseases, which cause deaths in epidemic proportions. This constitutes a worrying development among the rural and semi-urban population, who live in newly established settlements. Urban centres are usually more fortunate because water is obtained from boreholes and some places are blessed with pipe-borne water.

Doctors in the area have come across several cases of HIV, but unprotected sex continues unabated, and the use of contraception is very low. There are no preventative measures in place to stop HIV/AIDS from spreading. Worryingly, the attitude towards discussing HIV/AIDS by the vast majority of the public is that discussing such matters in public encourages promiscuity. Neither the government or any international agencies have tried to overcome this potentially disastrous problem by adopting a strategy that is culturally sensitive. Unfortunately, health education is perceived as a luxury due to lack of resources for even the most basic health care, with doctors unable to treat common curable diseases.

This is an area which might be expected to have some form of priority, but has unfortunately received no attention. There are no delivery wards or delivery facilities in the region at all. Many childbirth problems can be traced to FGM, which is almost universally practiced (see below). Consequently, the maternal and infant mortality rates are amongst the highest in the world. Although many in the local community are concerned about the issue, they feel they can do very little to effect change. This is an area that needs urgent attention.

There are a few small private clinics dotted around the region, run by doctors who have not received training of any sort for many years, and are unaware of new developments in medical practices. The same circumstances apply to midwives and nurses. Due to lack of funds, these private practices will not attend to mothers or babies if they cannot meet the fees charged, leaving the most disadvantaged sections of society with no assistance in childbirth whatsoever. Community-based charitable organisations, which are very few in number, have no funds and no training for staff, and above all they are cut off from the outside world which makes their work ineffective to say the least.

This is an outdated tradition that nevertheless is still being practised at the dawn of the new millennium. Visits made to fifteen rural villages revealed a disturbing scenario indicating how little life has changed in the rural areas as regards FGM, amongst other issues. The practice is centuries-old and is so embedded in the fabric of society that no one is even contemplating changing this tradition in the near future. Small girls are still being overpowered by groups of women and operated on forcefully without anaesthesia or painkillers of any kind. Their external genital organs are cut off and their flesh is pierced with thorns, which are left to remain in place for a week to ensure the vagina is almost totally closed up. Some girls bleed to death, others survive to suffer for the rest of their lives.

The way in which women in the villages visited discussed FGM showed that the practice is not viewed with any suspicion and great pressure is applied to those who delay the process of circumcising their daughters. Mothers, who are in charge of the process of circumcision, who have not circumcised their daughters before puberty - the most common age is around nine years old - are asked, 'have you done it for your daughter?', and, if the answer is no, are expected to justify their decision with a plausible answer. FGM is seen as a task which must be completed to prevent the family from being ostracised.

Families spend huge sums of money to pay for an operation, which, though unknowingly, has detrimental effects on the health of their daughters. Many families go out of their way to borrow money in order to fulfil what is perceived as an obligation for all parents with daughters.

When mothers were confronted with why they still pursued this harmful tradition, after all the pain and trauma they themselves must have been through, some confided that they do feel sorry for any girl who sheds her blood at a tender age in an operation which can ruin her future married life. Some went on to say that they have already forgiven their parents, because there is no doubt that their parents meant well, but they cannot forgive society as a whole for enslaving women and subjecting them to such misery.

Meetings with rural women to discuss FGM were both very depressing and enlightening. It does seem that many women have begun to realise that preserving this harmful tradition reflects on the dominance of men over women in Somali society, but women feel powerless to challenge this evil practice as it is sanctioned by long-standing tradition.

BWHAFS believes that the first step in eliminating FGM in Somaliland is to educate people about the dangers to health caused by the practice, and to facilitate open discussion of the issue at a grassroots level. The message about the benefits of eradicating FGM will need at least five to ten years to seep through. The sooner the campaign against FGM is started, the better.

There was no time to travel to other parts of Somalia/land, but other reports suggest that health care delivery is as bad, or even worse in some parts of the country and that FGM is even increasing, in the harshest of conditions. The social conditions that engendered the practice continue, and FGM is ingrained into Somali society as a necessary part of their lives. This society needs a lot of information about FGM, and its harmful effects on the individual, and an effective campaign would facilitate discussion of these outmoded values that are shrouded with myths in the name of tradition or culture.

This brief summary highlights some of the most important health issues that need addressing. However, it is important to stress that all is not doom and gloom. Ordinary people are trying hard to make ends meet by rebuilding their demolished houses and working very hard in order to earn enough to survive. Those with enough capital are establishing small businesses, and the country, after emerging from decades of civil war, is putting a lot of energy into trying to re-establish some sort of normality. However, there is a desperate need for external support in working alongside the local people to try and rebuild some sort of rudimentary health infrastructure and improve the critical morbidity and mortality situation.

1. Outside agencies are earnestly requested to assist the rebuilding of the healthcare infrastructure. Organisations working in all areas of health are needed to work in partnership with local health organisations that are in dire need of all sorts of support, especially of the technical and material variety. Immediate and effective intervention is required so that Togdheer's healthcare services can be resurrected.

2. It is critical that work is carried out with grassroots women's and community organisations in Somaliland to help build their capacity to initiate or strengthen existing services provision which would most appropriately meet the peoples' sexual, reproductive and primary healthcare needs.

3. An action plan that address FGM practice in Somalia is needed without delay. Urgent measures must be put in place until a comprehensive programme is negotiated and implemented.

4. International organisations and aid agencies with experience in the area, alongside local women's organisations, should devise this comprehensive programme and set of policies to eradicate this harmful practice which is having health implications on the lives of all Somali women. Donor countries can use their influence by asking FGM-practicing countries to comply with international regulations and treaties that apply to FGM, and link the supply of aid to the establishment of policies to counter the practice.

5. Organisations fighting against FGM should seek the support of religious organisations and solicit their assistance in demystifying the false myth surrounding FGM that it is sanctioned by Islam.

SHAMIS DIRIR
Development Director,
Black Women's Health and Family Support
In Burco and Hargeisa, 2nd - 21st July1999.

Link to:
Female Genital Mutilation
International Project - Barako Family Health Care Centre
Report on Shamis' Second Visit to Somaliland
Report on the Burao Region of Somaliland
Somali History
Somalia Facts & Figures