Busy Days

It's been a busy couple of days here as I try to pack everything I can into my last few days.

I went with Edna to the installation of the new chairwoman of Somaliland's Human Rights Commission.  She's the first woman to chair the commission--a big step for Somaliland.  This is what I heard:  Somali Somali Somali Geneva Convention Somali Somali Somali Fact-Finding Mission Somali Somali Somali.  Though I didn't understand anything, it was still nice to be part of something like that.  The new chairwoman is on the right, with Edna.

Went grocery shopping with Edna on the way back from that, first at the market in central Hargeisa.

While we were waiting on the rice to be weighed at this shop, which is quite close to the hospital, a group of school girls came up wanting to look at me (um, I stand out a little in this country) and practice their English.  All the kids around here know Edna, and she had them get out their school notebooks and show her their English lessons.

This country has more lemons than I've ever seen in my life.

Which is convenient, since lemons are a critical ingredient in cheese-making, and I've thrown my cheese production into full-speed-ahead mode.  I made camel's milk cheese, which turned out perfectly:  creamy, mild-tasting, spreadable, delicious on bread.

And, due to popular demand, I also made a triple batch of goat cheese, which I then flavored with the Ethiopian spice berbere, which was a hit.

Spotted the long-rumored traffic light.  Or should I say, traffic lit.

Got stuck in traffic behind a khat truck, headed into town from Ethiopia.  There was another one behind us, equally loaded up.  This khat will be gone by the end of the day.  Might as well chew up $5 bills and spit them out.

Scrubed in on a supraumbilical hernia removal surgery.

Continued seeing the usual steady stream of eclamptic patients (as many as one or more a day) brought in by their families, usually after being unconcious or semi-concious for the better part of day.  It's a mystery to me (and many others) why eclampsia rates are so high here.  It's an even bigger mystery to me why families wait so long to bring in a woman who is so clearly unwell.  Perceived value of the woman?  Concern over potential hospital costs?  Failure to recognize it is a serious condition? I want to know.

Spent a lot of time with a woman who was brought in over the weekend, following the stillbirth of her twins at the public hospital in Hargeisa.  She presented with acute renal failure that had progressed to uremic encephalopathy (the toxins usually filtered out by the kidneys had accumulated and caused damage to the brain).  This is extremely rare in the US because dialysis is widely available to compensate for reduced kidney function, but there is no dialysis in Somaliland.  Her family was trying to decide whether to spend the money to take her to Djibouti, where she could probably get dialysis.  However, her prognosis was very, very poor and, at this point, unlikely to change even with dialysis given how far the disease had progressed.  With money as limited as it usually is here, a last-ditch treatment taken for granted in the US might or might not be worth it.  Last night, the family decided that they felt they needed to try, and left with the patient for Djibouti.  A minor frustration of being here is having no idea what ever comes of the patients who leave, though often you can make guesses.

Farmed at Edna's "small" farm (as compared to the "big" farm I went to a few weeks ago).

Ate sap from a thorn bush, regarded as quite a tasty treat here.  It was...sappy.

Needed rain.

Got rain.

Went to dinner at Hadhwanaag Restaurant on the river(bed) to celebrate Joanne's last night before she heads back to her daughters and job in Portland.  Delicious fish from Berbera and amazing coffee after dinner, only my second cup since leaving the US (hear that, Starbucks?). 

This cat took a liking to me at dinner.

Which turned out to be awesome, because it reminded Edna to tell us about her pet lynx, Pixie, and pet cheetah, Sanu, which she had when she was the first lady in the late sixties (1967-1969), living in Mogadishu.  When we got home, she got the pictures out.  She told us that the cheetah kept trying to lick her during this picture, that he was incredibly affectionate.  He was given to her as a sick cub by a Kenyan park ranger and she nursed him back to health with the help of the lynx, who appointed herself the cheetah cub's protector.

These other pictures from her days as first lady were in the album as well, and I love them, so I'm posting them too.

After Siad Barre's coup d'etat in 1969, which ended her husband's rule of Somalia, Edna was under house arrest for a period of time, her husband imprisoned and her passport revoked.  She spent three years working as a nurse in Mogadishu after the coup while awaiting a new passport and then left the country, living in Libya and Egypt working for the WHO.  She eventually returned, but was forced to leave again in the mid-1980s, this time leaving behind a half-completed hospital which the Siad Barre's troops quickly appropriated and subsequently destroyed.  She decided that she couldn't commit to building in Mogadishu again, but also saw how desperately Somaliland needed a hospital, and rallied herself and funders to start over again in Hargeisa, with this hospital I'm at as the result.  She's an amazing woman.

A Trip to the Spice Shop

Several weeks ago I mentioned in casual conversation that I loved the staple Ethiopian spice mix berbere and had finished the supply I brought back from Ethiopia last year.  Edna asked around and discovered there was an Ethiopian spice shop in a poor but busy market area of the city known as Radio City, for its proximity to the Radio Hargeisa headquarters.

The shop, really an open-sided tin shack, is run by an Ethiopian man and filled with giant bags of spices imported from Ethiopia.

He's also got Ethiopian staple grains.

And roots...

And frankincense, which people throw in their fires for the scent.  Lots of this is packaged in tiny bags hanging from the rafters, amounts that people in the area can afford.

I somehow ended up with a kilo of berbere, which given that I usually don't use more than a pinch of it at a time, will probably last me between 7 and 10 years, unless of course my bags are searched at Dulles and I have to explain a kilo of random red powder. 

Back at the hospital, labor and delivery was empty, which was okay since I've been busy in postpartum.  The group of post-basic and community midwives that had been here more or less since I arrived went on vacation, and the group that had been on vacation started up again.  This means that I have been starting over with my teaching, which means I get to have this conversation over and over again, again.

Me (looking at chart):  This baby is 6 hours old.  Has he been breastfed?

Midwife:  No.

Me:  Why?  And why did he get sugar water?

Midwife:  (Giggles)  The mother, she is empty/tired/both.

Me: (Pulling out hair)  No, the mother is not empty!  No mother is empty!  She has colostrum!  They all have colostrum!  And NO BABY SHOULD EVER GET SUGAR WATER UNLESS THEIR BLOOD SUGAR IS LESS THAN 50.

After I've taken some deep breaths, we go see the mother, and usually with minimal effort she immediately produces some colostrum, and then probably 90% of the time the baby almost immediately latches pretty well. The babies who don't (often premature or c-section babies or ones who had difficult births), though, are often written off as unbreastfeed-able after that first encounter.

For a poor country without a reliably clean water supply, I cannot grasp the midwives attitude towards breastfeeding. All the mother has to say is that she doesn't have milk and the midwives will cheerfully let her feed the baby sugar water and formula.  This is a problem because that's generally pretty dirty water.  It's a bigger, and longer-term problem, because when the baby doesn't spend time at the breast, the mother's body doesn't start producing the same quantities of milk (a sort of self-fulfilling prophecy of not having enough milk).  Even when the mother does produce adequate milk after not breastfeeding the first few days, the baby has often been spoiled with the easy-flow nipples on the bottles here.  This is generally referred to as "nipple confusion" but the truth of it is, that baby isn't confused.  It knows exactly what's going on:  it was easy to suck from the bottle, it's hard to suck from the breast, I'll just refuse and I bet that easy flow nipple will come back!  And, without some pretty time-intensive teaching about how to get that baby back to the breast, that baby is usually right about the easy flow nipple coming back.

As a result, I've become a bit, well, aggressive, about teaching the midwives about breastfeeding, because promoting breastfeeding is an essentially free way to drastically improve neonatal, infant and child health (and increasingly it's understood, even adult health and intelligence).  I saw huge progress with the last group but it took awhile.  I only have a week with this group since I leave next Saturday (how did that happen so quickly?), so I'm a little bit on the warpath, hunting through charts for babies' feeding records and checking in on the moms and whenever I find problems taking as many of the midwives with me to learn how to fix the problem as I can. 

It's usually pretty straightforward:  explaining that there is colostrum now and milk will come in a couple of days, but the colostrum is very nutritious and enough for the baby, or help positioning the baby on the breast, or unwrapping the baby so it wakes up to eat.  For the babies who have serious trouble latching, it can be a time-consuming, intensive process to get the mom and baby on the same page and eating well, but it almost always ends up succeeding if the effort is put in.  Every now and then a stern lecture on the dangers of formula feeding, but usually it doesn't come to that:  these mothers WANT to breastfeed, they just need help figuring out exactly how to do it and reassurance that their baby won't go hungry (like mothers all the world over do). 

The midwives, especially the community midwives, are pretty willing learners, but it's a process because we literally have to start at the beginning.  I really like teaching them, and seeing them get it and start to use what they've learned, but it is also insanely frustrating to see things like "10 ml dextrose" written in the chart next to a blood sugar of 100, or a 8-hour old baby crazily sucking at its fist, alone in its bassinette, not having been breastfed yet. 

And then there's always women like the one who delivered her 16th baby yesterday, about 12 minutes after going into labor and popped that baby on her breast like she'd done it a million times before, which she more or less had. 

SIDE NOTE:  I don't think formula is inherently bad, I just think it has to be used APPROPRIATELY.  There's always going to be babies that need formula for some reason and in a pre-formula era might have died of malnutrition.  It is the midwife's responsibility to identify these babies, and then do it right:  clean water, and no bottles (cup feeding or finger feeding) so that when the baby is able she can go back to the breast, and to have the mother pump so that her milk doesn't dry up. 

Swim in Gulf of Aden: Check.

Today Joanne and I headed off with the long-suffering Faisel:

...to Berbera, on the Gulf of Aden.  Berbera is about 2 hours north of Hargeisa and has a port that brings in significant revenue for Somaliland, partly because land-locked Ethiopia depends on it.  Here's a truck that was headed for Ethiopia, prior to a minor detour:

The drive is beautiful, if bumpy, especially the last hour.  It's across scrubby desert, with stark, rocky mountains along both sides of the road, and crisscrossed with dry riverbeds, some low, rocky canyons and others wide and sandy:

We arrived in Berbera and went straight to Edna's beach. 

 There was no one around except for lots of crabs.

I went for a swim in my Somaliland appropriate swimsuit:

There were some beautiful shells on the beach.

Unfortunately, they were already taken:

Cool to see camels kickin' it on the beach:

After a while at the beach, we went to see the town of Berbera.  This is what Lonely Planet said about Berbera:  "The name alone sounds impossibly exotic, conjuring images of tropical ports, spices and palm oil.  If the reality is a little more prosaic, it's a great place to chill a while nonetheless...soak up the atmosphere...dolphins frolicking in the bay." 

That's about as accurate, as well, let's put it this way:  About two years ago I found myself in a small town in Romania on what had been clearly marked as a main road on the Lonely Planet map but was in fact an alarmingly steep, pitch black, intermittently cobblestoned slightly glorified pathway, staring a growling feral dog down as I attempted to find my way back to town from a hotel Lonely Planet (2008 edition) had raved about but had been closed for more than 5 years.  I later told this story to someone who had lived in Romania, and she confirmed my suspicion that the author of this guidebook sat in his hostel for the entirety of his stay, collecting information only from others who had ventured past Bucharest.  I believe Lonely Planet Romania and the Lonely Planet Somaliland chapter may have been written by the same person.

It's not that it doesn't have possibility.  It has some lovely, if faded, Ottoman-era buildings down by the port.

There's the port--fishing is one of the bigger industries in town (and the fish I've had from Berbera have been excellent).  It's been a port for centuries, and scored a mention in Periplus of the Erythraean Sea, which was written by a Greek merchant in the first century AD.  He noted that "here the natives are more peaceable" and that Berbera exported "frankincense...myrrh...and slaves, but rarely." It got sacked by the Portuguese in 1518, then occupied by the Ottomans, then the British. 

In 1855, British explorer Richard Burton wrote, "Berberah is the true key of the Red Sea, the centre of East African traffic, and the only safe place for shipping upon the western Erythraean shore...this harbour has been coveted by many a foreign conqueror. Circumstances have thrown it as it were into our arms, and, if we refuse the chance, another and a rival nation will not be so blind."  I love that.

It has some shipwrecks.

But it also has a massive swath of uninhabited, barren, trash-strewn land between town and the ocean, which Edna tells me were pine forests until Siad Barre bombed them beyond all recognition.

There's a massive graveyard, also bombed to pieces.

There's the shell of the hospital.

And there's the other bombed out buildings, abandoned, scattered around town, with no evidence of having been touched:

And the former land-mine fields (the sign says, "The Government House Minefield was cleared by The Halo Trust with support of the Government of Ireland")

Throw in the fact that, for being a pretty big town there is almost no evidence of life in the streets...

 ...and it feels much more like a ghost town just days or weeks emerged from a long war, not one of the principal towns of Somaliland, 19 years out from war.  When I told Edna this, she told me people sometimes likened Berbera to the gullet--everything passes through, nothing stays and it never gets fat. 

I will say Berbera's got one thing going for it:  one of the longest runways in the world, built by the Soviet Union in the 1970s and used by NASA since the 1980s as an emergency landing strip for space shuttles. 

Who knows what Berbera's future holds?  There have been talks with Ethiopia to expand Berbera's port's operations, but there's no guarantee that money will impact Berbera itself.  Some people are pinning their hopes on beach tourism, but my casual assessment would be that they've got a ways to go. 

For now, it's one of the strangest places I've ever been.