Somalia: A health system in crisis

UN Integrated Regional Information Network, 20 December 2000

No car, no bus, no heavily armed jeep can make its way through this Mogadishu roadblock: only goats and pedestrians attempt to climb the huge mound of rubbish—a solid mass tinted pink and blue with discarded plastic bags, empty tins, disintegrating packaging and debris.

Rubbish and sewage now constitute one of the main hurdles to freedom of movement in this city destroyed by civil war and absence of government. Dirt and disease—not bullets—pose the greatest threat to life here.

It is a wonder that we don’t have more serious outbreaks of disease, said Dr Muhubo Gure, who runs the UN clinic, treating local UN staff. Open sewers no longer flow, just stagnate. A fall of rain means stinking waste bubbles up onto the roads and pavements.

Dr Shaykhdon Salad Ilmi, director of Mogadishu’s Madina Hospital, is currently coping with another outbreak of cholera, which, he told IRIN, has unfortunately become endemic here. He said cholera outbreaks were largely due to poor sanitation conditions in the city.

A dangerous existence

Where Mogadishu residents used to have clean running water at the turn of a shiny brass tap, they must now depend on hand-dug wells. Dirty water, hauled up from about 30 metres underground, sells at Somali shillings 2,000 (US $0.20) per drum. People and animals use the same water supply. Among the devastated buildings, in the maze of broken streets, women with jerry cans join the goats and camels, and the queues of donkey carts. The wells are owned—but not maintained—by individuals. Aid agencies occasionally provided chlorine to treat the drinking water, but no-one really monitored its use or distribution, health workers said.

Once the water system had collapsed, many people dug their own wells. The wells that used to provide the city with running water are now in the hands of militia. One set of wells is on the Afgoi road between Mogadishu and Afgoi town; the other to the north of the city, between Mogadishu and Balad. The wells are in total disrepair.

So far, efforts by the new interim government to start tackling the 10 year-old waste dump—once a beautiful coastal capital—have barely touched the tip. Mogadishu has lacked government structures and services for almost a decade. You can’t clean up 10 years of piled-up rubbish without a complete campaign, with the right equipment, said one Mogadishu resident. Sanitation workers and equipment are available, but have yet to be mobilised, signed up and funded. Since establishing itself in October, the new government is struggling with other priorities: funding, peace and reliable personnel. And in a city where money, militia and warlord-run mafias have ruled since 1991, even rubbish is owned, explained the resident. Gangs expect nothing less than a cut from sanitation projects.

Hospitals and clinics

Before the civil war, Mogadishu had four major hospitals, all in the south of the city—the Chinese-built Benadir Hospital, for women and children; the European Union-built Digfer Teaching Hospital; the Russian-built Military Hospital; and the Madina Police Hospital. There were also numerous small clinics. All health facilities were government owned before 1990. Before the war, tuberculosis patients were treated and isolated in Lazareti in north Mogadishu and De Martini hospital in the south. A hospital and an SOS children’s village was established before the civil war, by the Austrian-based international organisation.

After fighting broke out in 1991, and sub-clan militia divided and laid waste the city, all the hospitals and clinics were either looted, destroyed or occupied by internally displaced people (IDPs). There was one exception: Madina Hospital was saved by its staff, and later rehabilitated by the International Committee of the Red Cross (ICRC). A lot of lives were lost defending that hospital, said a Mogadishu resident.

During the height of the civil war, when Mogadishu was divided by the so-called green line, the ICRC converted a former prison in the north of the city into a hospital. Keysaney hospital continues to serve north Mogadishu. Before the civil war Lazareti hospital in northern Mogadishu, and De Martini hospital in the south treated and isolated tuberculosis patients. There was also a hospital and children’s village established by the Austrian-based SOS organisation.

Madina is now the only public hospital serving the south. Over the last two years it has taken advantage of the gradual move away from all-out war in the city to establish a service. It has the feel of a sanctuary—clean, orderly and well managed, said one resident.

Once an abandoned, dirty structure with desperate patients sitting around unattended, Madina is now clean and functional with a beautifully kept garden full of trees. Some patients sit or lie in the shade in the heat of the day, carrying drips and watched over by attentive relatives, because the hospital has no air conditioning. There are 55 beds in the hospital, and a laboratory. Supplied and renovated by the ICRC, it runs on a cost-sharing basis. Patients pay about Somali shillings 400,000 (US $40) for major surgery and 15,000 (US $1.50) for a bed in a ward. Private hospitals in the city charge a lot more for the same services, the UN doctor told IRIN—about US $500 to $1,000 for surgery.

This patient cost recovery programme was set up in September, and covers only about 7 percent of the total cost of the hospital. The ICRC pays the lion’s share with $20,000 towards the running costs of the hospital, and with a total contribution in cash and kind amounting to about 80 percent of the running costs. The business community in Mogadishu has contributed $17,000 in the past six months towards upgrading and supplying the hospital, said its director, Dr Ilmi.

In the aftermath of the civil war, the health system, like everything else, collapsed. In response to the collapse, private health facilities mushroomed. There are currently 62 such facilities in Mogadishu, with new ones appearing every day, said Dr Gure of the UN clinic. The quality of services varies from fair to very poor, she told IRIN. Of the existing 62 health facilities, 33 are run by qualified doctors and nurses, but the remaining 29 are run by people with little or no medical training, local doctors told IRIN. Clinics offer health services ranging from normal checkups to major surgery. The surgeries they performed tended to be of a war surgery type, said Dr Ilmi.

There are no controls in place to regulate these facilities. Personnel operating the clinics did what they liked whether their staff were qualified or not, said the doctor. Prior to the civil war, there were strict regulations and codes of practice for medicine, and all personnel had be certified and licensed by a board within the Ministry of Health. Today, former cleaners were performing surgery, local doctors told IRIN.

Dealing in drugs

Pharmacies are another area of the health sector that have proliferated since the outbreak of the civil war. Where stringent rules and licence requirements used to govern the running of pharmacies, today they are like kiosks, health workers warn. The problem is the same all over Somalia, but especially so in Mogadishu. IRIN counted 392 pharmacies on the main roads of Mogadishu alone. There are many more in the suburbs. Almost all are run by people with little or no training, who dispense all kinds of drugs on request, without doctors’ prescriptions. In many cases, the pharmacy owners are happy to both diagnose and prescribe.

Many of the drugs on the shelves are either improperly stored or have expired. A number of pharmacy operators told IRIN that they destroyed all expired drugs, but the evidence on the shelves suggested otherwise. According to local doctors, many of the drugs are sold from already expired batches, coming in from Italy, India, and Pakistan. Prior to the civil war, the Ministry of Health controlled the flow of drugs into the country, but today, no such controls are in place.

Prevalent diseases

The most common diseases treated by Madina Hospital’s out-patient department, according to Dr Ilmi, are tuberculosis (TB), malaria and gastrointestinal diseases such as cholera and dysentery. Dr Muhammad Mahmud Ali ’Fuje’, a consultant with the WHO, told IRIN that these three—he called them the big ones—were endemic in most of Somalia. According to Dr Fuje, the reasons for their prevalence are simple: the collapse of the health and other services, overcrowding, lack of national guidelines, the low level of nutrition of the population, and the poor quality of the available drugs.

An alarming new phenomenon in Mogadishu, said the doctor, was the incidence of infant TB. Normally adults are more likely to contract the disease than infants, but these days we are seeing infants of two months with TB, Dr Gure said. TB is most common in children under five, according to Dr Ilmi.

Dr Fuje, who runs his own clinic in Mogadishu, told IRIN that doctors were also coming to terms with the fact that HIV/AIDS was present in Somalia—although no real screening exists anywhere except at Madina Hospital.

Collapse of the health system

All the health workers IRIN interviewed agreed that the increased incidence of disease was linked to the collapse of the Somali state. Several factors were singled out.

The appalling sanitation conditions in the city are a breeding ground for all sorts of diseases, said the UN’s Dr Gure. With no running water, filthy water collects in the old drainage system, making it a perfect breeding ground for mosquitoes, according to Dr Gure. You don’t have to be a doctor to know that if you drink the water here you are going to get some sort of gastrointestinal sickness, she added.

She believes the increase in TB is related to the fact that most carriers remain untreated and mix with the general population—drinking and eating in the same places and using the same utensils. Before the civil war there was a TB hospital where patients were treated, fed, isolated, and cured, said Dr Gure.

Another serious problem is the low level of nutrition affecting most of the city’s population. Low levels of nutrition causes poor resistance to disease, said Dr Fuje, who sees the effects all the time in his private clinic.

And while medical workers struggle to treat, preventative health care has all but disappeared. Even where health services are functioning, they are typically understaffed and ill equipped. A once-effective primary health care (PHC) system completely collapsed in Mogadishu over the last decade. With sound primary health care you can reduce death from communicable diseases, and get the community involved in preventive measures, said Dr Fuje.