Maroodi-Jeex: Somaliland Alternative Newsletter,
ISSN 1097-3850.
Occasional papers, No. 3, September 2002.
Internet edition (1).
Promoting Safe Lifestyle in Somaliland
By Mohamed Bali, PhD.
Introduction:
To remain healthy is an aspiration of all humankind; to be unhealthy is a
universal risk. It is not surprising that human societies have universally
developed ideas, technologies, social roles, and, more importantly, lifestyles
related to health care. Modern medical care with its stress on the use of drugs
and surgery sometimes helps us when we become sick, but it doesn't always keep
us healthy. To a great extent, what makes us healthy or not is how we able to
live our daily lives: the quality of the food we eat and the air we breathe;
access to health care; how we exercise; and how we use tobacco and other drugs.
It is becoming increasingly clear that the promotion of public health and the
prevention of disease is an interactive process involving the development of
public policy and governmental action and the empowerment of individuals to take
control of their well being. Self-empowerment leads to changes in public policy:
For example, many governments in the developed countries have declared public
places no smoking areas; food labeling is being revised with consumer input; and
informed citizens are calling attention to a host of environmental issues. These
policy changes, in turn, are propitious in facilitating changes in individual
behavior (2).
The present paper attempts to contribute to these
discussions of major health-related issues surrounding the public health
discourse in Somaliland, a small and low-income sub-Saharan Africa country. The
emphasis here is with particular reference to offering a number of concrete
recommendations to the goal of overall development in public health policy and
practice. These comments, as they are placed here, are not from a petulant
hypochondriac but from an observer who would like to contribute to the goal of
betterment of the physical well-being of people, as well as those of
other materially and developmentally-challenged countries.
Health protection, forming the heart of any safe lifestyle, can serve, too,
as a universally and socially integrative force that is transcendent to the
bitter social and political schisms that rule on the ground. (Yet
any reverie in evoking of ebullience that the incendiary socio-political
particularisms, the region's Achilles' heel, in terms of development prospects,
could be overcome on the crucible of healthcare will only be feinted because such
reality is not currently within reach).
Anyhow, the first section of the paper gives a truncated introduction of the
national background, with an emphasis here given on the health information. The
nation's material and political conditions mirror closely those of Somalia and
other neighbors, Ethiopia and Djibouti. All three countries, all of them
historical enemies, were arenas to bitterly fought-out civil wars. These
conflicts, while their causes and stories are different and their resolutions
remain inchoate, they have had the similar effect of driving out the political
titans who had helped shape their countries' destiny -- in the case of Somalia
to a complete dissolution (3).
Somaliland, a relatively new nation that recently emerged out from the failed
state of Somalia, is a product of that cataclysm and the depredations of an
African civil war. Moreover, it is an example of a country grappling with many
monumental development challenges, in a period of intense transition, while
lacking an international recognition.
The second section builds on the former by presenting the recommendations to
confront some of these challenges. The recommendations should not interpreted
simply as either palliatives or panaceas. In a narrow didactic sense, the aim of
this discussion is mainly for its heuristic value. Only a starry-eyed charlatan
would have the temerity to claim that any given set of suggestions will
fix our healthcare crisis, even if we were under the control of a praetorian
regime, which we aren't. On the other hand, under the more characteristic
obscurantist influence, there will be those who will be unsparing in expressing
their pooh-poohs.
Either way, since these discussions concern the mundane corporeal realms,
there are no oracles here issuing euphony of beatitudes (i.e.
fatwas or Islamic religious edicts), as they will certainly be ersatz for
our purposes of seeking practical and lasting solutions for our problems.
Throughout, avoiding the employing of a scatter-shot approach, a unity is
maintained by each recommendation building on the important nexus between health
and sanitation, thus providing the keel that the pieces dovetail each other.
Background
The country, consisting of much of the northern littoral Horn
of Africa, has 68,000 square miles or 109,000 square km. Its modest governmental
structure is based on a constitution passed in a referendum in June 2002. The
constitution establishes separation of powers among executive, legislative, and
judicial branches; multiparty political system; and protection of human rights
and freedom of speech. The constitution authorized the election of a president
and a bicameral parliament composed of Senate and National Assembly in 2003. The
Supreme Court has seven members and forms apex of other judicial bodies. Local
government consists of six regions and twenty-eight districts.
The landscape consists of mostly barren undulating plateau, broken by few
mountain ranges, that climbs from sea-level to 1600 meters. The varying
combinations of climate, topography and livelihoods types give rise to three
major zones: Northern (Guban)- hot coastal plain, low rainfall and low
soil fertility; Central (Ogo) - high plateau, high rainfall and high soil
fertility and Southern (hawd) - low plateau, adequate rainfall but low
agricultural potential.
Despite its uniqueness, Somaliland has displayed many of the similar indices
typical of Third World countries: Poverty (i.e. witness the very low GDP per
capita = $176), rural primacy, dependence on primary products (chiefly
livestock), a dominant informal sector, dependence on overseas remittances and
aid, and above all, poor health and low life expectancy. Life
expectancy at birth in 1998 was estimated at 47 years (45 years for males and 49
years for females). The average infant mortality was estimated at 120.34
deaths/1,000 live births (female: 110.56 versus male:129.84) (4).
Somaliland's population numbered 2.0 million in 1998 with an annual growth of
3.1 percent between 1991 to 1998. This startling growth has been due to
consistently high fertility, along with declining mortality. The population is
young; with 49 percent under fourteen and 18 percent under age five (5). Only 23
percent of the population has access to safe water (31 percent urban and 8
percent rural). Potable water is provided to approximately a third of the
population in urban areas through private connections or through public
stand-pipes. The remaining 77 percent get their water untreated from water wells
and surface water of varying quality. About 48 percent of the population who reside in the cities uses
pit latrines. (6)
Under these conditions, it is not surprising that a range of diseases menace
the populace in Somaliland. As is typical of a developing country, the main
health problems are communicable diseases caused by poor sanitation and
malnutrition and exacerbated by the dearth of skilled personnel and health
clinics. Diseases such as measles, malaria, diarrheal diseases, tetanus,
diphtheria, pertussis, poliomyelitis, and tuberculosis are preventable or
curable given available technology; unfortunately, only 10 to 15 percent of the
population has access to such basic technology and service. In addition, a
majority of the population is infected with rabid intestines worms, including
ascaris, hookworms and anklostomes; the noisome effects of these parasites is to
further enervate a population already suffering from widespread malnutrition.
Health care in Somaliland that battles these crisis is provided by a mix of public,
semi-public, and private sources; all three subdivisions function
simultaneously. There is the traditional system, which can be subdivided loosely
into Cushitic and Islamic ecclesiastic. Commercial drugs and concoctions, used
by both the largely peripatetic Somali (Cushitic) traditional healers and modern
practitioners, constitute a transitional system. The British brought in the
modern medicine in the period following the Second World War.
The extant health care system that is based on it can barely meet the
challenge (i.e. doctors and nurses per 100,000 people are 0.4 and 2.0,
respectively) (5). The government-run health clinics -located in all the more
grotesque and decrepit structures and staffed by surly employees with
cash-register smiles - are dysfunctional. Such spectacle would have been excused
as a survivor of the recent national anomie if it wasn't for the jarring
practice of the charging of exorbitant prices, as well as the hospitals being
bereft of medications or in basic equipment and personnel.
For most of the population, poverty, transport problems, and geographic
conditions stint effective access. What meager health care Somalis find they
improvise it often from private sources. The elite, including the political
mandarins, add to the embarrassment by continuing to seek quality care abroad.
(For example, the unabashed government ministers, having made a Faustian
bargain, often describe to the credulous press that their frequent sojourns as
being "official visits").
During the 1990s, the health care system had deteriorated further as a result
of civil war effects and severe economic disruption, largely due to governmental
corruption and mismanagement and the economic effects resulting from Saudi
Arabia's ban on Somaliland's livestock exports.
Recommendations
I believe that the discussions of the following public
health issues would serve as felicitous eye-opening introductions into laying
foundations for the development of viable public health policies, on an even
keel, in proposing these recommendations to the Somaliland public and
authorities:
Safe water and sanitation
1. Making access to potable water supply and
basic sanitation top national priorities. Most health problems are closely
linked to problems of sanitation. The consumption of unclean water and
un-pasteurized diary products are the main causes in the staggering incidence of
tuberculosis, dysentery and hepatitis.
The health hazards as a result of poor sanitation are legion. Microorganisms
(bacteria, virus, parasites) are major causes of waterborne illnesses. According
to the World Health Organization, an estimated 25,000 deaths per day were
attributed to the consumption of unsafe water in the year 1990 worldwide, and 25
percent of hospital admissions were related to polluted water. Waterborne
gastrointestinal infections accounted for 80 percent of all diseases. Even a
little bit of celerity would pay big dividends in the lives saved: access to
safe water and sanitation could cut by up to one-third the number of diarrhea
cases (7).
History evinces that without a continued and forceful governmental
intervention, it is hard to be sanguine that positive change will occur on its
own. Leaving things on their own would certainly yield nothing better than
Ludites in a distopian. Therefore, I present the following recommendations to
the Somaliland public and the health authorities in helping promote safe
lifestyles:
(a) Educate the public with the health risks incident in the consumption of
unsafe water and foods through the media and the schools.
(b) Spur the private sector to become a vehicle for protecting public health
by banning the sale of unsafe water, un-pasteurized dairy products and
un-protected meats.
Waging an onslaught on the problem of sanitation requires a tremendous effort.
Before the society reaps the immense social and economic benefits from it, the
public should create, in a form of treacherous shoals, a strong demand for safe
products. The private sector, facing such a demand plus a governmental pressure,
will eventually supply the desired goods.
It is by now apparent that the existence of the lax regulatory milieu is
no longer a credible excuse for brooking a shirking of public health
responsibility. Also, a specious quixoticness on this matter - even in a land
dominated by the tyranny of illiteracy and superstition - does not in itself
sully the principal fact that the fundamental responsibility of any government
is to provide for the welfare of its citizens. If there is a realization of this responsibity and this is
utilized right, it could be envisaged to become a public policy vortex for many other difficult public policy issues.
(c) Enforce a safe, hermitic toilet for each household. Ban the practice of
locating of pit latrines inside the buildings. Each building, instead, should
have an internal PVC plumbing designed to remove, through gravity, wastes into
either a sealed septic tank or a sewage pipe both buried outside. To slog
through an effective ban in the face of the perversity and monstrosity of the
corruption morass would be truly hailed as a veritable indication of a
measure of genuine public service and prudence.
Safe foods
(a) Regulate the public food service through the adoption of safe food
service techniques.
The food-borne illnesses are illnesses caused by the food we consume. For instance, even
though America's food chain is the safest in the world, millions of people are
still affected by food-borne illnesses. Food-borne illnesses cause about 76
million cases of illnesses, 325,000 hospitalizations, and 5,000 deaths in the
United States each year (8).
But there is a solution: "Food-borne illness can be prevented by following
five simple rules: Store cold foods at 34 degrees to 40 degrees Fahrenheit; cook
food to a temperature of 140 to 165 degrees F; keep the kitchen clean;
refrigerate leftovers quickly; and toss out any food if its safety is in
question."(9).
(b) At the point of production: Require that all diary products and meats
should be produced under sanitary conditions in only licensed and regularly
inspected abattoirs and creameries.
(c) At the point of sale: Require that all retailers should store and sell
only chilled diary products and meats that meet the universally accepted
sanitary requirements, including refrigeration needs. (For example, these
perishable products should be produced, transported and stored at temperatures
not higher than 35 degrees F).
Healthful foods: Low fat, high fiber
2. Promoting the substitution of
low saturated fat vegetable-based cooking oils (i.e. corn, sesame seed,
sunflower, etc.) in the place of the ubiquitous ghee, the locally-produced high
saturated fat rarefied butter, which is made from un-pasteurized milk under
unsanitary conditions.
3. Promoting the cutting back of the consumption of high-fat red meats: Lamb,
mutton and beef cuts. Along with whole milk, these are the main sources of the
artery-clogging cholesterol, a fatty substance that builds up on the inner wall
of an artery and hardens into a substance called plaque (10).
4. Instead, promoting the increased consumption of lean low-fat meats:
Skin-less chicken, turkey and seafood. Aside from their prophylactic qualities,
it is not futile economics in a land afflicted with 'full unemployment' to
suggest that the increased consumption of these products would have the added
economic benefits of creating jobs through-out the economy.
5. Similarly, promoting the increased consumption of vegetables, fruits,
grains and legumes, such as dried peas, beans and lentils. In contemporary
zeitgeist, buttressed by the much-accumulated knowledge of the last 50 years,
scientists are of universal agreement on the salubrious benefits of plant fiber
in our diets.
Due to the challenge and its health benefits galore, it is
imperative for the schools and the media and the governments to promote first
the supply-side production of these products through farming and gardening,
especially, among young students.
Exercise
6. Disseminating widely the health benefits of regular exercise
regimens for all ages. Benefits of regular exercise include the improving of the
cardiovascular fitness and muscular endurance and the reduction of the risk of
coronary artery disease (11).
To promote fitness, in addition to conducting the educational campaigns, the
governments should do their part by endowing city parks in all neighborhoods,
complete with trails for walking jogging and bicycling and courts for playing
basketball, volleyball, and other athletics. Schools, too, should offer
calisthenics in physical education classes to every child.
Substance abuse
7. Smoking and Khat chewing cessation campaigns. The
social and economic benefits for the ex-users and the society are incalculable.
Access to healthcare as a right
8. Finally, adopting of the following
basic statements as sine qua non of any health care organization:
- (a) Health is a basic human right of every individual and an important
responsibility of any government.
- (b) Health care services ought to be accessible to the entire population,
geographically, economically and socially.
- (c) Health care service should function to integrate the physical and
social dimensions of health and to address the conditions of work and
residence as they affect health.
These remarks are consistent with the
current interest in reordering health care from the conventional clinic-based
service and towards an individual and community-based participatory approach
that grew strongly in the 1970s following the Declaration of Alta Ata, which
supports these statements and are educed from:
" Primary health care is essential health care based on appropriate means and
accessible to individuals and families in the community through their full
participation and at a cost that the community and the country can afford to
maintain in the spirit of self-reliance ". (12)
Concluding remarks
1. These recommendations take as their genesis the
principle that, although their country is poor and they are exposed to all the
evils of underdevelopment, Somalis have the same fundamental rights, including
the right to have access to healthcare and basic sanitaion, as all other
citizens throughout the world. There is no reason why their lives should not be
precious and well protected as the lives of citizens of the Netherlands, for
example.
2. It is a truism, though, that the ultimate success of efficacious
preventive and curative regimens is usually dependent upon individuals'
willingness to undertake and maintain the required behaviors.
3. Regardless, the upshot is that our hubris comes with a heavy price. This paper is not
meant to be just a paean for healthful living. As much as irreverent it may
sound, it is proffered, too, to bring about a bathetic reawakening. In a public
policy milieu lolling around in a smug levity, it is not being captious to
recall that 'amorphousness' is the preferred term in describing it. So speaking
of protecting public health engenders an uneasy bathetic development. But to
accept the prevailing public health situation is to continue to wallow in
treating it either as a crapshoot affair or simply, even, something subject only
to the vagaries of fluke. Such attitude, however, bodes ill for being inauspicious for us
taking charge over our own healthcare. In a mutable world, allowing the
disconcerting specter of the traditional prudishness in forming a reified and
seemingly permanent barrier that is impervious to accommodating change should be cast of
as both a zany and scurrilous belief.
4. It is exigent, therefore, to heed the incessant calls by the World Health
Organization that emphasized that access to safe water and food and basic
sanitation - as part of a national comprehensive public health policy - were a
fundamental human right and were components of any effective poverty-reduction
strategy.
References cited
1. The article first appeared on The Iowa Muslim
Reader, Sep-Oct 2002 (Cedar Rapids, IA)
2. U.S. Department of Health and Human Services. "Healthy People 2000:
National Health Promotion and Disease Prevention Objectives". (Washington) 2000.
(http://odphp.osophs.dhhs.gov/). Web
site
3. U.S. Department of Army. Country Studies/Area Handbook, Somalia. Edited by
Helen Chapin Metz, May 1992. (Washington)
(http://lcweb2.loc.gov/frd/cs/sotoc.html) Web site.
4. UNICEF. Multiple Indicator Cluster Survey, Somalia 2001 - (MICS) . January
2001. (http://www.unsomalia.net/infocenter/reports/Final.pdf). Web site.
5. CIA World Factbook, Somalia, 2002.
(http://www.odci.gov/cia/publications/factbook/geos/so.html). Web site.
6. Ibid.
7. World Health Organization, "Guidelines for Drinking Water Quality", 2nd
edition, Health Criteria and other Supporting Information, Geneva, 1993.
(http://www.who.int/water_sanitation_health/dwq/guidelines/en/). Web
site; and World Health Organization, Water, Sanitation and Health WWW Portal.
(http://www.who.int/water_sanitation_health/en/).
8. Mead P, and et al. "Food-Related Illness and Death in the United
States". Emerging Infectious Diseases 1999; v5 (5):
607-625. The Centers for Disease Control (CDC),
(http://www.cdc.gov/ncidod/eid/vol5no5/mead.htm). Web site
9. Prevention, Aug 1997, V49 (8) Pg 86.
(http://www.prevention.com/cda/cda2002/1,4811,s1-999,00.html). Web site.
10. Healthy People 2000: see #2
11. Ibid
12. WHO-UNICEF. "Report of the International Conference on Primary Health
Care", WHO, Geneva (1978)
(http://www.who.int/entity/chronic_conditions/primary_health_care/
en/resolution_wha566_eng.pdf). Web
site.
July 05, 2002
