The midwife had nearly finished a difficult stillbirth delivery when she looked up from the bloody mess in the bucket and sadly asked, “Who would choose to be a woman?” Her question stuck in my head. For me, it has come to symbolize all the frustration and unfairness and inequality that are everyday facts of life for the women here. I’ve been planning to write about these issues almost since I arrived, but the more I learn the more difficult it is to convey my thoughts in a neat little essay on the internet.
It’s hard to know where to start. The issues are too far-reaching and pervasive to permit a simple explanation. I had hoped to write a piece that would explain the “how” and the “why” of the issues, but it’s simply too complex. So – here is the unvarnished “what” of these problems, in no particular order. Draw your own conclusions.
Women can’t make their own medical decisions. When a woman comes into the hospital here, she is treated the same way we would treat a child at home. If she needs induction, someone has to call the husband. If she needs a caesarean section, someone has to call the husband. If the husband isn’t available, the nearest male relative has to make the decision. Even in emergencies, the hospital isn’t legally permitted to perform procedures without a consent form signed by a man who has authority to make decisions for the woman. As might be expected, this policy sometimes kills women and often kills their babies. It also leads to some stunning contradictions – if the midwives here were to become pregnant and need a C-section, they would have to convince their husbands to sign the form, even though the midwives know far more about what the procedure is and why it is needed. Not to mention that, at the end of the day, it’s their body.
The C-section issue blends into the larger problem of family planning. Almost everyone here does family planning: they plan to have big, big family. We routinely see women who are coming in to have their tenth or even twelfth child; the highest number I have seen is fourteen. The desire for unlimited numbers of children leads to significant conflicts of interest when it comes to making medical decisions. A woman can only have a C-section three or at most four times, and typically once she’s had one C-section, the rest of her deliveries will also have to be C-sections. Clearly, having a C-section puts a severe limit on her ability to keep popping out kids, so husbands will often refuse consent and delay surgery as long as possible, sometimes until after the baby (or mother) is already dead.
It’s natural to wonder why everyone wants to have so many children. While the men’s motivation is somewhat ambiguous, ranging from ensuring some support in their old age to general concerns about masculinity to helping make Somaliland “a big country like America,” the women’s motivation is much simpler. If a woman doesn’t produce plenty of children, her husband will just go out and take a second wife (up to four are permitted under Islam) and she will be forgotten in a decaying house somewhere. If she keeps having children, she is more likely to remain in her husband’s favour and be better supported, along with her children – at least until menopause. Desperate middle-aged women sometimes show up saying they think they are pregnant, only to tell us that their last period was more than a year ago. Whether on not they can still have babies, the trip to the hospital for a maternity consult probably does good things for their status in the eyes of their husband.
Pregnancy (or lack thereof) is not the only reason for unnecessary trips to the hospital. At any given time, we usually have one or two women on the wards that are perfectly healthy, medically speaking. These usually get listed as something along the lines of “hysteria” or the more politically correct “conversion syndrome.” Their symptoms are usually mild, and change depending on who is asking them questions. Their history usually involves a fainting episode – the relatives bring them in if they don’t get back to normal fairly quickly – but a mysterious lack of any bruises, cuts or scrapes from the fall. Lab results, if any are taken, always come back normal.
Most of these women fall into two broad categories: teenagers who are psychosomaticizing the stresses of puberty and impending marriage, and older women who want some attention and a break from their families. Both of these groups of patients point to a larger problem: there is no psychological safety valve for most of the women in this society. The whole structure of their lives is dictated by others. There are no opportunities to go to the mall with friends, relax at the beach, take a vacation, or heaven forbid choose their own husband or get thoroughly drunk at the bar. The only thing they can do is adopt the sick role, bask in the attention of their family, snooze in a comfortable hospital bed for a few days, and try not to think about the future.
All of these problems are attributable to women’s lack of control over their own lives. Some of the other problems are even more aggressive. Essentially every single woman whose delivery I have been involved with has had some form of genital mutilation, including quite a few that obstructed the birth canal so much that the baby couldn’t get out until the midwife made some strategic snips with her scissors. While some people say that fewer young women have been having these procedures done to them in recent years, there are no solid statistics. We’ve had at least one teenager come in with abdominal pain resulting from an FGM that completely obstructed her opening to the point that her first periods couldn’t get out; the hospital’s OB/Gyv had to drain nearly a litre of stagnant blood. Brides-to-be, some as young as 15 or 16, sometimes come in to have their FGMs opened before their wedding night. It’s an ironic and extremely painful start to the marriage: the snipping procedures are done in the same room to which these women will return, year after year, for their deliveries. It’s hard to say whether they are marrying the husband or the hospital.
Even after her early years of marriage are over, women don’t have much of a chance. While husbands are supposed to support each of their wives equally, the majority of the men here are addicted to khat. Given the choice between feeding their families and feeding a khat addiction, many of them choose khat and head for a shady tree to chew away the afternoon. As a result, the women sometimes have to fend for themselves and their children or hide the money that families living in the UK or America send back as remittances.
As with most of the social issues here, it’s hard to see a clear path forward to a brighter future. Most women are caught in a viscous cycle, and unless they are willing to forgo the marriage that their family expects and try to make a career for themselves, they don’t have any easy way to break the cycle. Education, empowerment, employability training would help, but in an economy that staggers along from day to day through the charity of the Somali diaspora, these can only do so much. Even now, our educational efforts with women are hampered by their continual need to go off and tend to the needs of their families. Typically, if a son and a daughter go to school together, the son studies in the evening and sleeps in the morning while the daughter is helping with the supper, cleaning the house, and ironing his clothes. As a result, girls typically fall further and further behind in school.
Even if a woman wants to have fewer children, the system here says it isn’t really her decision. Marriage is considered to be as much the family and the clan’s business as it is the bride’s. Clandestine birth control clinics would incur the unbridled wrath of an armed populace if they were discovered, and it’s hard to picture any of the NGOs here adding another item to their long list of security concerns. Working on the men, trying to inculcate attitudes that favour family planning and that value a woman for herself rather than her baby-making potential, is equally difficult. This is a place that is ripe for new ideas.
Somaliland takes the safety of foreigners seriously, at least on the surface. Westerners travelling outside the capital are required by law to arrange for an armed bodyguard, and most of the local NGOs arrange for guards in Hargeisa as well. Police checkpoints along the roads outside the city allow officers to check every car that goes by, although needless to say security is somewhat relaxed. Foreigners are only allowed past checkpoints if they have an accompanying guard, and with the exception of a memorable incident in which my driver smuggled me through two checkpoints under a pile of baguettes, I’ve generally played by the rules.
In practice, the system is imperfect and seems to provide a deterrent rather than real protection. All of the guards carry suitably large weapons, but I’m sceptical about how effective they would be if anything were to happen. Most of them carry stockless AK-47s, which are tremendously difficult to shoot with any accuracy. I’ve also seen at least one SKS rifle with the stock chopped off just behind the trigger, which seems like a recipe for broken fingers. Worse still, none of the guards bother to carry extra clips for their rifles; paired with their unwieldy weapons, this seems to guarantee that their participation in a fire-fight would be brief and ineffectual at best. Many of them also chew khat while on duty. While Edna has managed to hire her guards from the handful that don’t chew, most of the others throughout the country are likely to be high out of their minds by mid-afternoon.
As far as I can tell, the main advantages of the system are that it provides jobs for ex-combatants and allows the government to say they were doing their best to protect foreigners if anything bad happens. I sincerely doubt that it does much to improve our safety. The nature of the threats here is too unpredictable. Most of the incidents in the past few years have been perpetrated by radical Islamists using firearms or explosives, and I somehow doubt that the presence of a stoned guy with one clip of ammo would do much to change the outcome.
Most people who make the journey to Somaliland aren’t here to see the sights. Nonetheless, almost everyone eventually ends up visiting the cave paintings at Las Geel, one of the country’s only real tourist attractions.
Las Geel, which means “watering place of camels,” is an ancient cave complex in the desert outside Hargeisa. The cave paintings, which are somewhere between 3,000 and 9,000 years old, cover the walls and ceilings of numerous grottoes and overhangs along the side of a nondescript stone outcropping. It is believed that they were painted at a time when the desert here was green; they depict cows, dogs, people, an elephant, and a lone giraffe. The nature of the civilization that created them – and the story of its demise – are lost. Even the secret of the paint remains a mystery. When a French archaeological team attempted to create similar art using locally available materials, their creations flaked and disappeared in less than two years.
While the government has designated the site a protected area and requires permits and guides for access, the future of the site remains uncertain. Now that it is known, an increasing level of tourist traffic could damage the paintings if it is not managed appropriately. Even more concerning is the plight of numerous other sites around the country, many of them still undiscovered, which could hold additional clues to the pre-history of the region. Nonetheless, the art is a boon to the future of Somaliland, and well worth a visit for anyone that happens to find themselves in the region.
Many of today’s greatest political challenges revolve around finding a way to govern tribal societies. In Afghanistan, difficulty doing so has become a problem with global implications. Elsewhere, in places such as Burma, South Sudan, Papua New Guinea, and much of sub-Saharan Africa, conflicts resulting from interactions between tribal societies and state governments cause tremendous problems for local populations and regional security.
It is in the worst example of a tribal failed state –Somalia– that we find a controlled social experiment with remarkable implications. In an internally homogenous region, we can examine a home-grown multiparty democracy that sits side-by-side with a brutally violent land that has become synonymous with anarchy. The factors that let to the brilliant success of democratic governance in Somaliland and to its abject failure in Somalia provide tremendous insight into possible solutions to tribal conflicts elsewhere in the world.
Before examining the factors that affected political outcomes for each region in Somalia, it is essential to understand the process and the region into which they fit. Somaliain tres partes divisa est. To the south lies Somalia proper, a wide and until recently arable swath of land running along the Indian Ocean that includes the capital, Mogadishu. North of this, at the very tip of the Horn of Africa, lies the semi-autonomous state of Puntland. Finally, the independent but unrecognized Republic of Somaliland occupies the north-western corner of the country along the Gulf of Aden.
Somaliland, Puntland, and the South emerged from the same witches’ brew of tribal wars, guerrilla wars, civil wars, proxy wars, and famine two decades ago. However, their stories since then have been radically different. The South, which has been the focus of most Western aid and peacekeeping efforts, remains mired in interminable religious and tribal warfare. Puntland, which is not much better from a security perspective, is rumoured to accept international aid intended to improve its anti-piracy efforts while simultaneously providing a staging area for groups that hijack shipping just off its coast. Somaliland, however, has succeeded in setting up a multiparty democracy, reducing clan violence, and pushing back the twin spectres of piracy and militant Islam.
The great question, of course, is why Somaliland’s path has differed so much from that of the other two regions. All three are populated almost exclusively by ethnic Somalis who practice a variant of Sunni Islam and share a common language, culture, and worldview. All three regions consist of a variety of tribes and sub-tribes whose traditional economic focus is herding, and all three regions have small but vocal elites that were educated in the United States, Canada, and Europe. Up until the 1970s, most people in all three regions dreamed of a unified Greater Somalia that would include ethnically Somali portions of Djibouti, northern Kenya, and the Ogaden plateau in Ethiopia. Clearly, there was – and is – a great deal in common between the people of Somalia’s three regions.
It was random chance, colonial history, and a lone madman that ultimately broke the region apart. When Siad Barre came to power and declared a Marxist state, it was by chance that he came from a specific mid-southern tribe, many of whose members were to occupy high positions in his regime and contribute to the factionalization of Somalia. Later, political scheming led the Soviet government to redirect military assistance from Somalia to Ethiopia at the height of the Somali invasion, leading to a crushing defeat on the Ogaden plateau. In the aftermath, Siade Barre began to lose his grip on the country, providing an environment in which local and trans-border insurgencies could flourish.
Principal among these insurgent groups was the Somali National Movement or SNM, a pro-independence group of Somalilanders based in Londonand later Ethiopia. Many of its leaders had received their education abroad, and it had strong ties with expatriate Somalis in the U.K. Over time, it transformed into an Ethiopia-backed armed movement seeking independence from the totalitarian military dictatorship of Siad Barre.
After nearly a decade of low-intensity conflict, Siad Barre arranged a ceasefire with Ethiopia, and both parties agreed to withdraw support for the insurgent groups they had been using as proxies. Rather than wait to be eliminated, the SNM began an all-out offensive, capturing most of the northwest. Siad Barre’s crumbling regime responded with a military offensive, mass killings of men, women and children from the Isaaq tribe, and an aerial bombardment that left Somalia’s second largest city, Hargeisa, a smouldering pile of rubble. Soldiers used flares to mark the last buildings left standing so that they could be bombed more easily, and thousands of civilians disappeared into mass graves in the desert. Nonetheless, by May 18, 1991 the SNM had won a bloody victory, captured 15,000 soldiers from the Somali Army, and declared independence.
On Independence Day, the fate of Somaliland hung in the balance. The region was filled with thousands of young men – traumatized, armed, and angry. While the SNM had an international veneer, most of its members had never left the region. More importantly, tribal elders held tremendous power over their clans. It would have been easy – very, very easy – to shoot the prisoners and establish a military state. Throughout the history of post-colonial Africa, most successful revolutions have ended by replacing one strongman with another. However, this was not to be. A butterfly flapped it wings in the desert, the prisoners were given safe passage back to Somalia, and the winds blew in favour of democracy.
In the end, the tribes saved the country from the SNM and the SNM saved the country from the tribes. It is unlikely that either could have held the country together on its own. Flush with victory, SNM provided a sense of national unity and possibility, but faced the task of building an unrecognized government from the ground up while trying to control armed and historically independent-minded tribes. The tribes, for their part, were well equipped for controlling their members and their territories, but were too diverse and individualist to have any hope of running the country on their own. Nonetheless, it was their cooperation with the new government that ensured a smooth transition to multiparty democracy and the rule of law. Over the course of twelve years the politicians and the clan leaders arranged councils, policy changes, and new laws and institutions. During this period, the tribal leaders came out in favour of a unifying national government, and the government made every effort to respect and work with the tribal power structure.
The result was a tentative bicameral success shepherded to fulfilment by a combination of tribal elders from the clans ofSomalilandand internationally educated politicians working within the government. Somaliland has now seen three democratic elections, the most recent of which resulted in the peaceful transition of power from one political party to another – a rarity among fledgling African nations. Altogether, Somaliland’s experiment with democracy has been a resounding success, bringing stability and a better life for its people. Today Somaliland is calm, orderly, and functional. Non-profits are working with the government to improve conditions, educational systems are being set up and improved, healthcare is increasingly available, and businesses are busy rebuilding the capital city. The rest of Somalia has not been so lucky.
There are four principal reasons for the tremendous present-day differences between Somalia and Somaliland. While Somalia has been a zero-sum game of every man or clan for themselves, Somaliland was forged in a cooperative spirit on the basis of strong unifying forces that went beyond clan loyalty. It was also relatively free of international meddling during its formative years, which gave the nation a self-directed character and removed the temptation of skimming aid money from the political calculus of its leaders. Finally, it benefitted from a cadre of highly educated nationals that returned from expatriate lifestyles in western countries to help build and lead the new country. Alone, none of these factors would have had much effect, but together they provided an ethos and an environment that allowed the government to integrate the dual values of tribal loyalty and democratic governance into a workable whole.
Throughout the process of insurgency, independence, and nation-building, the people of Somaliland have benefitted from the powerful unifying effects of a shared vision and a common enemy. The initial vision was simply independence, although that vision has expanded to include international recognition, trade, and development. The common enemies have changed over time as well. While Siad Barre provided a unifying symbol during the bloody civil war, new enemies have emerged to fill his shoes. Principle among these are whatever issues could result in bad press for the country and interfere with the process of recognition; these include terrorism, piracy, and the violent forces at play in Somalia. Somalilanders are fiercely proud of their democratic government and the peacefulness of their country, showing an emotional intensity that goes a long way toward explaining how the people of Somaliland have been able to unify and govern their country against tremendously long odds. While the specific issues have changed over time, they have forced people to cooperate in a way that they would not have had to otherwise. This cooperation has been essential to the establishment and endurance of Somaliland’s democracy, although cooperation alone would never have been enough.
A large proportion of the credit goes to the leadership of the SNM and eventually Somaliland. Thanks to their relatively low level of corruption and their firm commitment to improving the country, Somaliland has benefitted from a remarkably practical series of leaders who have been genuinely interested in solving the country’s problems. In addition, the dynamics of the Somali diaspora meant that most of these leaders received a high-quality education abroad but maintained strong ties with their home country. This impacted the dynamics of the new country in two important ways. First of all, it ensured that most of the leadership had firsthand knowledge of what they were working toward – a peaceful multiparty democracy – and understood the benefits and drawbacks of such a system. When it came time to draft a constitution, these people were able to make a powerful argument in favour of democratic ideals, while at the same time understanding, respecting, and integrating the tribes. Secondly, the availability of home-grown experts who could return to Somaliland meant that the SNM and later Somaliland’s government did not need to rely on foreign advisers and backers.
The self-directed nature of the Somali National Movement and the Republic of Somaliland had a profoundly beneficial effect. Unlike the puppet governments set up in Western nation-building attempts, Somaliland’s government had a profound legitimacy in the eyes of the local population – after all, they had struggled to help create it. The Westernized leaders were all ethno-culturally Somali, and while many had been out of the country for decades, their reintegration into local life was relatively seamless. In addition, the tribal elders working with the fledgling government were highly respected traditional leaders; their stamp of approval meant that the vast majority of the population was bound to support the new government on the basis of both national pride and tribal loyalty. Thanks to the completely local nature of the country’s leadership and the backing of the tribes, those opposed to the government could not claim that it represented outside meddling or was otherwise illegitimate. In addition, because the political and tribal leaders were Somali, they were able to reach a locally appropriate compromise position on the makeup of the government. The inclusion of an upper house of parliament composed of tribal elders helped ensure the lasting support of the tribal power structure, while the provision of a democratically elected president and lower house ensured that the majority of political power would lie with the people.
The integrative, compromise-based efforts of the early leadership were successful precisely because they were genuine. Local people had gone out and brought back ideas; hence, the ideas had certain legitimacy to those who had not left the country. The reverse dynamic would not have worked; had outsiders arrived bearing new concepts about democracy, it is very likely that the tribal leaders would have balked and the local population would have risen up against them, as has happened in Afghanistan. Thankfully, this is not what happened, perhaps because nobody outside the Horn of Africa knew or cared what was happening in a strip of semi-arid rangeland along the Gulf of Aden.
Being ignored can have its advantages. In many ways, Somalilandbenefitted from an almost complete lack of outside interference. In the political sphere, this ensured the local legitimacy of the new government. When the dust settled, the situation had stabilized and did not need foreign aid or peacekeepers to maintain its balance. In the economic sphere, the effects were even more profound. The total lack of outside aid money for the government has forced it to remain responsible in its handling of the limited funds it has. Much of the government’s revenue is based on taxes, and as a result Somalilanders feel a certain level of “buy-in” with respect to the government. This has helped create an environment in which the citizenry wants to hold the government accountable, and the government has to work toward the goals of its citizens if it hopes to remain in power. Some observers have gone so far as to argue that Somaliland’s experience demonstrates that aid money is a uniformly destructive force in developing African countries, and should be curtailed in the future. While this libertarian argument probably goes too far, ignoring the changing needs of a nation as it develops, there is a fascinating seed of truth at its core.
None of this is to say that Somaliland deserves a continuing place on the sidelines. The dynamics that helped it in its early years – enforced fiscal discipline, self-direction, and a tiny income – are not a sustainable plan for a developing nation. While they were beneficial during the formative decades after independence, these aspects of the country’s situation are quickly becoming more of a hindrance that a help. What Somaliland needs today are better roads, public health initiatives, and some sort of plan for curbing population growth and finding access to a reliable supply of fresh water. None of these things come cheap, and it is in the interests of Western governments seeking to prevent the rise of militant Islam to do what they can to support the continued development of Somaliland. That said, if Somaliland does eventually receive recognition, it will be interesting to see whether the political dynamics in the country change as aid money begins to pour into the government. Foreign donors might do well to direct the bulk of their efforts into the non-profit sector here, which has developed rapidly in the absence of significant outside funding for the government. Much of Somaliland’s present-day success depends on its diffuse but delicate power structure. With luck, it will survive the transition to full-blown statehood.
From an American perspective, the dual experiences of Somaliland and Somalia carry powerful lessons for our foreign policy and international aid efforts. Most profound is the simple fact that we cannot always expect to build a new nation in our own image. We have provided a tremendous amount of military, civilian, and monetary aid to the Somali government over the years with no discernable result, while Somaliland has set up a democratic, capitalist system in the northwest without any help at all.
Somaliland’s experience also indicates that governing a tribal society is a complex but feasible prospect. Thanks to unifying national issues, the leadership of foreign-educated locals, the organic nature of the movement, and lack of outside meddling, Somalilandhas forged a locally appropriate system of government that integrates democratic ideals with tribal power structures. In a different nation or culture, a different system of governance may be more appropriate. However, if a new government is to forge a unified nation from a tribal society, it is hard to imagine it doing so without the influence of these four factors. People need a reason to cooperate. They need leadership that understands what they are working toward. They need to come to their conclusions themselves, rather than have them handed down by a foreign power. Most of all, they need to build the country themselves. The resulting sense of ownership born through the cooperative act of creation goes a long way toward forging a durable sense of national identity.
As we hurtle into the second decade of the twenty-first century in an increasingly networked world, we should expect that issues of local governance will loom larger and larger in our view of the world around us. The asymmetric nature of today’s threats means that an increasingly large proportion of the balance of power rests in the hands of individuals and non-state actors. One of the most powerful ways to curb the destructive influences of these forces is to support strong local governments. Given that tribal areas also tend to be hotspots for groups following radicalized adgendas, it is essential that we absorb the lessons taught by the Somali experience. The course of our future may depend on it.
Today, I had the opportunity to see the other side of Hargeisa’s healthcare system. Dr Robert, an American physician who has spent the past twenty years in Africa, invited me to join him at the Group Hospital for the day and I gladly accepted. He donates his time three days every week to teach interns and act as an attending physician, although he often gets dragged into patient care because nobody else is available.
Group, as it is known here, has acquired something of a reputation among the staff at Edna’s. Thanks to its rock-bottom prices and rock-bottom standard of care, a fair number of women go to Group to deliver, don’t get proper medical attention, develop complications, and eventually head over to Edna’s hospital with a well developed haemorrhage, convulsions, or a dead fetus in obstructed labour. Edna’s staff often has to fix the mistakes made at Group, or deal with patients that should never have been allowed to progress to the conditions that finally force them to come through our doors. I was curious to see the place.
The Group Hospital consists of a rough assemblage of single-story buildings just west of downtown on the main road. From the outside, it hardly looks like a hospital; it is separated from the street by a sorry-looking stone wall and an open area covered in piles of windblown garbage. Inside, it is a government-run catastrophe.
We spent most of our time on the male and female medical wards. Each ward consists of a single long room with rows of beds along each wall. The rusting metal beds don’t have any sheets, so most of the patients bring their own bedding. Infection control consists of bright blue mosquito nets over the beds and a stained sink without any soap at one end of the ward. The infrastructure is basic. Partway though the morning, I heard mewing and looked up to find a confused kitten peering down at me through a gap in the ceiling tiles.
The patients don’t help the situation, though that could probably be said of any hospital. Most of them pay $2 for their chart and can stay indefinitely once they are admitted, so a certain proportion are perfectly healthy but don’t want to go home. One of the first people we examined was a muscular young man who said that he occasionally felt shortness of breath. He’d had a full workup that showed everything was normal and had been released two days earlier, but still hadn’t bothered to leave the hospital. His friends had decided to join him for the day – most of the young men in Hargeisa are unemployed – and his section of the ward had turned into the latest hangout spot.
The staff members are not much better. While Dr Robert took the time to do things like take histories, perform physical exams, and talk to families about their needs, it was evident from the notes that many of the patients had received nothing but symptomatic treatment, and that little effort had been made to diagnose their actual problems. We had to go fetch one of the nurses who had wandered off to drink tea under a tree with her friends when it came time to see her patients, and we played an endless game of find-the-chart on both wards throughout the day. My personal favourite was a file folder that had inexplicably been stuffed underneath a patient while they were sleeping.
As might be imagined, many of the patients were seriously ill. We saw a diabetic coma, liver cirrhosis, an array of gastric bleeds in need of repeated blood transfusions, and a teenage girl who had mysteriously lost motor control in her arms and legs but was alert enough to be terrified. For most of these people, definitive care is not available in Somaliland. Many conditions that would be treated surgically in the United States are treated medically because the surgeries cannot even be attempted here.
Despite the chaos and inadequacies, there were some happy moments. I left the hospital with a smile on my face after meeting the gentleman in the following photograph. While he still has tuberculosis in both lungs, his condition is improving, and he was chatty and friendly throughout our visit. Afterward, we talked about his family and he invited me to sit with him for a picture. All is not lost at Group Hospital, and while it may be true that everything moveable has been stolen, for at least one man the crumbling buildings still provide some hope.
“Watch out for land mines,” Edna said, gesturing toward the side of the road with her cane. “The area near the ruined tank is OK, but the blue stones… you should not go beyond them.”
We were standing at a high point on the road with low hills to either side. Looking out at the desert, it was easy to imagine a rebel unit settling into position on the hills overlooking the road, knowing that sooner or later Somali troops from Siad Barre’s army would have to pass through their field of fire. They got their tank, eventually, a rusty monster donated to Somalia by the Soviets before they decided that Ethiopia was a better recipient for their military hardware. At some point – maybe before, maybe afterward – somebody planted mines in the powdery red soil of the pass.
It is safe to say that nobody still feels the need to defend a nameless pass on the road between Berbera and Hargeisa. The mines, however, remain. Edna remembers treating land mine victims in the early days of the hospital, though their numbers have thankfully fallen close to zero. International mine-clearing teams and better signage have been a major help, though it must be said that a portion of the credit also goes to Somaliland’s unfortunate, unwitting hoofed minesweepers.
Land mines and rusting military hardware aside, the scars of civil war are a fact of life in Somaliland. The chaos of the early nineties is slowly being erased from the landscape under a wave of new construction, but it is not so easily erased from the memories of my friends. Some lost families; others lost homes that now exist only in their memories. One of the fellows I drink tea with in the mornings usually struggles to convey his ideas in English, yet can give a piercingly clear description of the U.N. flight that carried him out of Mogadishu eighteen years ago.
The war has given birth to what some consider a “lost generation” here, a cohort akin to the shell-shocked servicemen who returned from World War I to drown their sorrows and their dreams. Many of the college-age students in Somaliland got most of their early education in refugee camps, or simply did without while their families – if they still had them – struggled to stay alive. As a result, many students still have great difficulty understanding lectures given in English, or are unaware of basic facts that they would usually have learned in high school. For many, motivation is also a challenge, and most of the teachers here give some leeway to students who seem to be dealing with the lasting effects of psychological trauma.
Nonetheless, these are the lucky ones. Most people in Hargeisa are unemployed, uneducated, and unlikely to do much to change their situation. According to those who are old enough to remember, khat chewing is much more prevalent – and destructive – than it was before the war. For many, it seems, what was once a social drug has become an addiction and an escape. These latest casualties lie where they were hit, slowly chewing and staring at a horizon that has long since been blocked by the tents and houses of the city.
This, then, is the aftermath. The factories and businesses and houses are being rebuilt, but broken minds are harder to repair. Gaping holes that will not close are ever-present in families, educations, hearts and dreams. I have no reason to think that this truth is unique to this place, or to this war. Long after this country has donned the garments of peace, landmines buried in dusty shards of memory will continue to claim their victims.
The media has done a great disservice to the Horn of Africa. If you ask most Americans what they know about Somalia, they will probably mention pirates, jihad, and Black Hawk Down. Those with a slightly longer memory might mention war, drought, and famine. The popular image of this region has become a dark mirror into which we look to congratulate ourselves on the success of our civilization.
This is tremendously unfair, both to the Somalis and to anyone seeking to understand what is really going on here. The news stories and sensationalism are true as far as they go, but in reporting only the violence they miss the more important story: this is one of the most unusual places on the planet. There are lessons to be learned here that could provide valuable guidance elsewhere in the world.
If we are to learn these lessons, we must put aside our prejudices and examine this story from the beginning. The Horn of Africa has been inhabited since before the first brick was laid in the cities of Mesopotamia; some of the paintings on rocks in the desert may be as much as 10,000 years old. Throughout this lengthy history, most of the people living here have been herders. In the early years, they herded the cows pictured in the region’s cave art; later, as the climate dried up, they switched to goats, sheep, and camels. The social patterns associated with herding have had a significant impact on the history of the region, an impact that will be examined in subsequent posts.
Over the course of time, trade, agriculture, and settled life have come and gone throughout greater Somalia. Arab traders and Somali fishermen built settlements and market towns along the coast almost as soon as they had boats. Turkey later established a presence along the Red Sea, leaving elegant examples of Ottoman architecture standing in the coastal desert. More recently, Somalia was carved up and colonized by Europeans during the scramble for Africa in the late nineteenth century. The French acquired Djibouti, the British claimed British Somaliland and a portion of what is now north-eastern Kenya, and the Italians established a colony along the Indian Ocean with its capital at Mogadishu.
Appearances aside, this was not a simple land grab. Just as it is today, the Horn was a region of high strategic value. Djibouti provided the French with a deepwater harbour and coaling station on the Red Sea – prime territory with the opening of the Suez Canal. Similarly, the herds of Somaliland provided food security for the British garrison in Aden and the Italians obtained a major port city on the Indian Ocean. For each of the colonial powers, it was an arrangement that furthered their imperial goals. However, in setting up their desert fiefdoms, they drew a set of neat, geometric lines across the brush-land and desert that would come to have profound consequences for the peoples that lived astride them.
The days begin with prayer call at four-thirty in the morning. The local mosque is directly across the street, and its crackling loudspeaker can be heard even in the deepest corners of the hospital. In my room, I lie on my back in the pre-dawn darkness and listen to the night wind whistling past my window while the faithful trudge to their first set of prayers.
Afterward, if I’m tired enough – and I usually am – I drift back into sleep until the disembodied voice of my local cell phone cackles into my ear, repeating a single, disjointed phase: “It’s time… to get up. It’s time… to get up.” There doesn’t seem to be a way to switch my alarm clock to something more pleasant, and I’m beginning to feel a certain special loathing for the canned lady in my phone. At least it’s in English.
Breakfast is usually at about eight. There are corn flakes, powdered milk, tea, porridge, and my personal favourite – Somali pancakes. They remind me a bit of Ethiopian injera bread, with their soft, spongy texture and not-quite-sweet taste. I smother them in peanut butter and Nutella, stuff my cheeks like squirrel, and head downstairs for rounds.
Dr Said leads the medical rounds, which can last anywhere from twenty minutes to an hour and a half, depending on the number of patients and how many questions he decides to ask the gaggle of medical students that trail after him like baby geese. We see a variety of patients spanning a wide range of medical problems, though not the ones I was anticipating when I arrived. For some reason – probably something to do with the words “Africa” and “Somalia” – I was expecting to see trauma, malnutrition, and infectious disease. All three of these are present, as are a large number of GI cases. However, I’ve been surprised at the preponderance of diseases that we traditionally think of as affecting developed nations: diabetes, high blood pressure, and their complications. I think this may be partly to do with the diet, which is high in carbohydrates and fat, and partly due to the lack of health education and primary care for the general population. Whatever the reason, it is a twist of fact that has challenged some of the assumptions I brought with me on the plane fromDubai.
After rounds, I usually have a couple of hours of free time. On some days, I help with wound cleaning and bandaging for the burn and skin graft patients. On other days I shadow Dr Tanmay while he does his antenatal consults; he has begun teaching me the basics of ultrasound, and I’m fascinated by the planning that goes into successfully managing pregnancy. On some days, however, I’m too busy working on lectures and handouts for the students to spend any time downstairs.
Lunch usually appears at about 12:30, though people come and go as their schedule allows. Before lunch, I usually manage to sneak in a half hour of situps, pushups, chinups, and rather humorous cardio on an exercise bike that was donated to the hospital. It isn’t much, but unless I go on one of my rare walks in the surrounding neighbourhood, it’s the only exercise option available. Such is life on the compound.
The afternoons are sleepy and uneventful. If I’m tired, I nap or read on the roof. If not, I walk the wards and help the nursing students improve their patient presentation skills. At Edna’s suggestion, I’ve been spending at least an hour doing this almost every day since I arrived, and some of the students are getting much better at conveying vital information about their patients. Many, however, seem a bit confused by the whole exercise, and never seem to know how many patients are on their wards or what is wrong with them. They are still in their first few months of training, which begins after high school, and are still learning the basics of what they should be doing in the hospital. Nonetheless, Edna very appropriately wants to set high standards, and I have been doing my best to help the students learn how to meet them.
In the late afternoon, life creeps back into the streets and the wards and the courtyard. As the day cools toward evening, I usually find a quiet place on the roof to read. When dusk takes away the light, I spend time practicing English with local friends or working on pronunciation and grammar with medical students who are anxious about class presentations they have to give the next day.
The communal dinner comes later in the evening, between 7:30 and 8:00, and is generally a pleasant affair. We have a fine melting pot of nationalities, with nearly a dozen countries represented: Somaliland, Somalia, Ethiopia, Yemen, Oman, Sudan, India, Nepal, Australia, the U.K., and America. The evening meal is at time for jokes and stories, including interesting titbits from Edna’s life.
After dinner, I usually work on my lectures and grade the week’s quizzes. I’m teaching a course on the basics of research to all three sections of the Pharmacy students, which totals about six hours of lectures every week. However, I spend at least twice as much time writing and photocopying lectures, handouts, and quizzes. I’m also spending two hours twice a week with a class of B.Sc. students, trying to help them understand their research projects, so the teaching hours add up fast.
My days end with a half hour of TV on the couch outside my room. The television gets a package from Dubai, which means that other than Al-Jazeera, the BBC, and a channel that plays action movies, there isn’t a great deal to watch. The wind usually picks up as my bedtime approaches, so I fall asleep the way I wake up, listening to the wind pouring past the high white walls of the hospital.
I’ve been lucky enough to spot a few interesting birds while I’ve been here. These are some of the ones I saw when I went with Edna to her farm on Thursday.
This is a Superb Starling, Lamprotornis superbus.
The one in the image above is a Somali Fiskal, Lanius somalicus.
That’s a camel in the background. Don’t know about the bird… possibly some type of starling.
These guys are White-Headed Buffalo Weavers, Dinemillia dinemelli.
This is a bulbul, one of the common locals.
This is a rather blurry picture of a White-bellied Go-Away Bird, Corythaixoides leucogaster, so named because of its call. Note the feathered crest on its head.
Edna’s hospital is a gleaming, gritty miracle. It provides the highest level of maternity care available in Somaliland, and handles plenty of unrelated medical cases ranging from car accidents to diabetes and meningitis. It is a place of great contrasts, both technological and cultural; sterile, modern operating theatres sit at the ends of hallways whose floors are cleaned by women in headscarves using buckets and pieces of wet cloth.
The hospital consists of a large central building surrounded by smaller buildings in a walled compound. The south wall runs along the main road and contains a tea shop, a mosque, the main gate, a supermarket, and a pharmacy. On the east side are the outpatient buildings and laboratory, while on the west there is an open area filled with construction materials. The north side of the compound has a lush garden, water tanks, and dormitory space for some of the local staff. In the centre of this archipelago looms the main building, rising to a platform four stories above the rooftops of the town. The effect is not unlike that of a medieval castle, with its surrounding town, outer wall, gate, and central keep. Inside, however, the hospital is anything but medieval.
The ground floor of the hospital is divided into three wards that radiate away from a central reception desk and staircase. To the right is the Medical ward, which consists of a mixture of shared and single rooms. Patients are generally divided into rooms by gender and disease type, and the nurses make an effort to isolate infectious cases such as measles and meningitis.
On the left side of the building is the Maternity ward. Like the medical ward, is has several large shared rooms and some smaller private rooms. Most of the patients here have recently delivered, either normally, with assistance, or via C-section, and are simply waiting until they are ready to go home. The maternity ward is in many ways the most pleasant part of the hospital, replete with happy families and brand new babies.
The third ward, Delivery, is at the end of a hallway that radiates directly away from the entrance. It includes a labour room, a delivery room, an operating theatre complete with scrub and sterilization rooms, a minor operating theatre, and some private patient rooms off the hallway. This part of the hospital changes like a sultry summer day; one moment it will be silent and empty, and the next there will be an emergency C-section going on in the theatre while the midwives deliver babies next door.
The upper floors of the hospital are dedicated to teaching, living, and administration. The second floor includes Edna’s office, some living space, the kitchen, the dining room, a library, computer rooms, a classroom, and the hospital’s administrative office. On the third floor, there are two more classrooms, a conference hall, living quarters for the staff, and more offices. My room is in a separate area on the third floor of a building behind the hospital, right above delivery, which is connected to the main building via a fifteen-foot bridge.
Beyond the third floor lies the roof, which is easily accessible and probably one of the nicest places in the whole neighbourhood. Wide, flat, and ringed by a railing of whitewashed masonry, the roof is perennially breezy. In the centre, above the stairwell, is a raised section that holds three large water tanks and can only be reached by climbing a steel ladder. From this eyrie, the whole city of Hargeisaspreads out in strokes of green, white and brown until it fades into the surrounding desert hills.
Closer to the hospital, the roof gives an excellent view of the neighbourhood. The main street just south of the hospital runs east-west, and is lined with stalls and carts and shelters that contain restaurants, money changers, tea shops, and the ubiquitous bundles of fresh green khat imported from Ethiopia. Behind the hospital lies a neighbourhood of single story houses with tin roofs. Goats and children gambol along the uneven, sandy lanes and the occasional car picks its way between trash-hung patches of cactus and tumbledown, bullet-pocked foundations left over from the civil war twenty years ago. The neighbourhood and the hospital stand together as an inspiration, an affirmation of the will to move past violence and build something better than what came before.
