I see Zamzam on the ward. Zamzam regularly helps us in our training in Somaliland. She has bipolar disorder but is well now and employed as a cleaner in the hospital. When unwell she has gone to battle front lines and put herself at great risk. She has a child as well, who she is sole parent for. She recognises me and even knows my name.  It is great to see her doing so well.

It is a Friday and day off but some of the staff have agreed to come in on their day off to have a case supervision session with me. It is effectively a CBD with a group. The nurses struggle to speak English but can understand.  We go through many cases and I think they have learnt some things. I tell them that I am not here to tell them what to do. However I can pass on what WHO tells them to do with their new mhGAP IG document which is a practical manual for treatment of mental illness in low resource environments.

I leave the hospital with sadness. I wish I could stay and be part of an exciting time of improvement. I always am left wondering whether I am more useful back in UK or in Somaliland where it can be so rewarding. It takes an immense amount of energy and commitment to change an inpatient unit in a place such as this. With Julie, I think they have someone who can do this if anyone can.

I make sure to have the goat kebab as my treat before leaving. This is one of Somaliland’s best attractions. I am about to leave. We have achieved our goals but there is much still to be done in this challenging environment. There is a drought but not to the extent of Somalia in the South. It is one of the most difficult environments for a foreigner but it is also one of the most rewarding experiences. The needs are immense, but you can make a difference.

What I get most from this, apart from direct experience and sense of accomplishment, is that for these few weeks I can totally forget my NHS work and stress!  It’s all about the clinical care and nothing more. Somaliland is my best vacation destination for that reason - and so many more. It is a country where I have grown to feel very much at home. 

I can genuinely say I want to come back - yet again.  

THET Somaliland Programme

I have the opportunity to go to the mental health ward. First I am diverted to do a home visit - or rather a mosque visit. We go to a mosque on the other side of town where they are having a convention of Islamic “missionaries”. Amongst them is a Somali man from Ethiopia who is saying he is Christian and shouting out repreatedly about being Christian.

I first think this could be a Christian missionary but as I arrive and speak to him I soon realise he is not mentally well. He wants to find a wife in Hargeisa. He has walked from Djigjiga in Ethiopia. He says he is a doctor of the spirits. He is clearly manic and my colleague with me organises a treatment plan but the real problem is the social one and getting him back to his home in Ethiopia.

I get back to the hospital just as a staff member is hit by a patient. The patient is mute and clearly paranoid. He has a twirling movement of his right hand. He has been hiding his medicine for the past few days. He gets a depot. The twirling is probably a stereotypy or a catatonic symptom. There is no real EPSE.

We have a wide range of medication from WHO and from MSF. We lack intramuscular lorazepam and anti-cholinergic but the supply is not bad. The hospital supplies medicines for free and there is good security around the medicine store. I note one of the nurses looks different from the last time. I hear that she suffered a serious assault from a patient with head injuries. This ward can be a dangerous place even now.

I spend a morning of supervision of the medical and nursing staff going through cases and discussing together means of treatment. There are some areas of improvement and I feel good that this exercise does show up areas of immediate improvement. I base my advice on the WHO mhGAP Implementation guide and “where there is no psychiatrist” by Vikram Patel. I note they have a few copies of this book in the hospital. An excellent resource.

Evening time I meet an old friend from Somaliland. She is due in Mogadishu for work shortly, and that is not something she is looking forward to. Security there is dreadful.  

I met Julie who I can describe as a tornado of dynamism and optimism sweeping through a severely necrotic ward. Julie is experienced in this type of work. She has a background in Darfur, arctic and other difficult areas. She covers this hospital and one in Bossasso in Somalia.

I can’t keep up with her enthusiasm and drive. She is an inspiration. We have tried over the years to change the ward. But maybe sometimes you need a tornado.

Day 11 - Mock OSCE exams

This is a trial run for the next year’s finals. The 5^th year students partake.

There are no psychiatry stations. However, I am examining in a station where the doctor has to break the bad news of a HIV diagnosis. There is work to do in improving the communications skills here. Students tend not to give time to listen and don’t allow the patient to express their sorrow and grief at the news. I heard people say – this is actually good news!  I don’t think so. The exams, after a delayed start, run like clockwork.

The president of Hargeisa University has sadly been killed in car crash so there is a sad atmosphere and the celebration for the new graduates is cancelled for that night.

Early travel to Hargeisa- the national Capital. It has been raining - I have never seen the area so green. We stop to take photograph of a resting camel. Preparations for exams at Hargeisa.

Day 8 - Review of exam site

Visited the psychiatric ward at Hargeisa Group Hospital. The ward has improved so much. I speak to the staff - Maryam and Mustapha know me as I have been coming here since 2008. I have done some training with them as well on a previous trip through an interpreter. They have only one patient chained currently. Last time I was here, many if not most male patients were chained. This is in great part due to the input of GRT- an Italian NGO, WHO and THET. This Italian NGO has worked on the ward to enable the patient numbers to be reduced. This leaves the staff able to offer a therapeutic environment.

The big struggle as always here is to mitigate the ever present risk of khat chewing or Qat. This is a “mild” stimulant leaf that is chewed. Its effect mirrors the effects of cannabis in many ways including those on mental health. It is a major problem for Somaliland and Somali people. One of the staff told me with great honesty the effect Qat-Khat has on him. He starts with confusion, then euphoria, then a hangover type effect the next day.

The staff showed me their newly refurbished areas of the hospital, their new uniforms and new toilets. It is remarkable and lovely to see a staff so rejuvenated in morale. Most importantly they are getting regular salaries. I will try and do some training during the week for the staff.

There is one area that still needs urgent refurbishment. This is an area of single rooms, or more appropriately, cells. The place stinks and is filthy. It is not suitable for humans. I hope we can get some practical support to improve this as soon as possible.

Day 8 - Exam preparationExam preparation in Psychiatry. For complex reasons there is only a small number taking psychiatry this time. We did Psychiatry exams for some of this cohort in December 2010. Most of the current examinees are resit students who have passed their psychiatry previously. 

Security: this has not been a problem for us. We go to and from the hospital to hotel and back in a taxi approved by THET. Our hotel is fortified against attack. Cars are searched for explosives and searches on entering the hotel. The situation in Somaliland can be volatile. The influence from the south of Somalia can be present in terms of occasional hostility to foreigners. My colleagues here for the longer term report an occasional sentiment of hostility to foreigners  from a few but nothing more than that.

My own experience has been Qat-khat induced hostility towards us foreigners in one trip to the market a few years ago. Somalilanders have been so welcoming to us in general. The country has had a general election in the past year and had a peaceful and successful succession to a new government.

Day 9 -  Psychiatry exams

We have a joint examining OSCE station with Dr Peter Hughes and a Somaliland counterpart. The expectation is for the Somalilanders to take over the examining role completely in time. The students are strong in picking up psychosis, violence, and depression but less skilled at anxiety. All pass comfortably.

Back at the hotel before evening curfew; the goat kebab is fantastic.

They have now built a new hospital here, which is funded by Somali diaspora and other donations. The hospital is modern, clean and equipped but still not open officially. There is a dedicated room for mental health clinics. Future plans include a small mental health unit for about 15 patients within the hospital grounds. It will provide short term care - around one week for acute stabilisation - and will essentially be for people who are tied-

up at home. The area is remote but probably Boroma town will expand to stretch this far.

Boroma has its British history, as the British were colonisers of Somaliland. The British laid a first stone in the University in 1952. However, they were not allowed to live in Boroma town or even be buried in the area.

My colleagues delight in the varied bird life around here.

Graduation celebration Friday eveningAll seven students, three resits and one nurse graduate. We listen to speeches from local elders, clan leaders, and many others. I estimate over 12 speeches. The new graduates are dressed up and with their proud families. There's a flood of cameras and photographs.

Edna Aden, one of Somaliland’s most famous residents, gives a speech. She has sponsored a few of the students through medical school here in Amoud University. Edna is head of the Edna Aden Maternity Hospital in Hargeisa. She gives a stirring, tear-filled speech. The emotion is clear and strong, even though I don’t understand Somali language.

Edna is one of the big figures in Somaliland who supports women’s rights and is against the female genital circumcision which is endemic in the region. She has done a huge amount for the people of Somaliland through her maternity hospital and other activities. It is always a pleasure to meet such an inspirational figure.

This is the big day for me here. But Dr Jibil has run the show and all goes like clockwork. We hope that Somalilanders can take over the whole exam process and mental health teaching in time. We run through our 6 OSCE stations first. A few minor adjustments. We have a varied subject matter. We brief actors on how to be psychotic, depressed, insomniac etc . There are a small group in final med this year - just seven. The examiners are briefed. The OSCEs have been rehearsed many times.

The OSCEs go brilliantly. All pass and do well. In my station the actor gave a fantastic rendition of psychosis. We had a sensitive sexual history OSCE which is always a highly sensitive area in Somaliland and all did really well in this. We had a Swedish Somaliland Psychiatrist visitor back from vacation to his native Boroma and became examiner as well.

I feel confident and happy that these seven are now ready to use their doctoring skills with a foundation of core psychiatric knowledge and skills.

Exam meeting in afternoon. We establish the scoring and passing of all the candidates with all external and internal examiners present. Some of examiners have been my students within the past few years bit have completed their internship. It is highly professional and of an international standard.

Visit to the Fistula Hospital in the afternoon. We go to the Fistula hospital as mentioned above. Having a fistula devastates a woman’s life in this region. It is usually a consequence of the dire obstetric services in the country. A girl is left incontinent. More often than not her family disown here and she is left destitute and abandoned by her husband. The fistula hospital runs as a charity subsidised by some other surgical work. Dr Gause works from about 4am every morning doing umpteen fistula repairs on women which come from as far afield as Mogadishu in Somalia. It changes the woman’s life. She is able to return to a normality which was not possible before. It is a surgical intervention that radically improves social and psychological well being for Somali women. It is always moving to see the work of Dr Gause in the Fistula Hospital and his devotion to this charity. When Dr Jibril was there, I know he paid particular attention to the psychological needs of the women there which are significant.

Friday will be graduation ceremony where the candidates will be there with the proud parents. And most of all I can get up late Friday as a rest day. Looking forward to that.  

Day 4 - final year exams, Boroma The exams for final year medical students have started. This is the first year of an OSCE type format supported with technical advice from THET. Professor John Rees is leading our group of examiners. There is a surgeon, GP, physician and of course a psychiatrist - me.  Mental health is seen as a priority area so we have been able to support all exams since 2008.

I'm an observer for the day in the medical OSCE exams. Fortunately I’m not needed as an examiner. The examiners are mainly local specialists and us externals.

There are mental health type issues raised with loss of a baby and HIV diagnosis being given as an example of tests of communication skills and psychological awareness. Exams are held to international standards.  

Arrive in Boroma after a long “road” journey of several hours. We swerved past a giant tortoise leisurely crossing the road. Also there are baboons and camels loiter in the distance.  Other drivers pass with people hanging from all grabable parts.  It’s surprisingly green as this is the rainy season. Usually this area is a yellow barren wilderness. Arrived escorted by an SPU security vehicle in convoy with two soldiers for our protection.

Boroma is a small town about one mile from Ethiopia. I have never walked around it in my many visits here so don’t know exactly what it is like, but it does look a bit like Haiti after the earthquake in terms of rubble strewn across the “roads”. There’s hardly a car in sight, but goats wander the main streets with no fear. 

I orientate myself to Ray’s hotel - the place to be in Boroma - if not the only place in Boroma. We are a short walk to the Fistula Hospital, but we can never walk there without our armed guards. This is a heartbreaking place where women whose lives are ruined by obstetric misadventure have their lives returned to them by a relatively simple surgery.

We can however cross the road.  It's about five metres to the venue for the final medical exams. Nine students wait anxiously for their obs and gynae exams. This morning they had surgery.

This is OSCE format. There are many amazingly and disconcerting anatomical specifications to do a removal of a placenta, deliver a baby and other tasks all in eight minutes. The exam is now over so I can reveal one of the OSCEs was a discussion with a woman (actor) whose baby had died. The actor gave a wonderful performance. Most candidates were sensitive and empathic to the plight. Maybe in some way our mental health training last December helped this group. If I wasn’t a psychiatrist I would want to be in obs and gynae after seeing what happens here to women and the dreadful problems of giving birth in this country.

I met Dr Jibriil who is doing fantastic things for mental health in Boroma. I taught him some years ago as a medical student and now he is developing psychiatry out-patients in Boroma, a maternal mental health programme and community services along with the support of the wonderful Faduma. Faduma is a Somalilander who lived in Canada then came back to her homeland. She devotes herself to developing maternity health in the region but also is a strong supporter of mental health work. I always come away enriched after speaking to Faduma who in her quiet way has improved the lives of so many people in direct clinical training contact, and by her selfless devotion to others around her. 

Looking around at the medical students and nurses, I acknowledge that I have taught mental health to just about everyone. I am unsure if I feel a sense of accomplishment or just old!  Abdel Ghani is another keen nurse who now works in mental health and helped me during nursing teaching last December. Everywhere, I see my old students who are now working, teaching and giving life to the principle of sustainability.

It is now raining with thunder and lightning. So much for the tropical weather and break from the UK. However this is not a place to go for a walk. We are allowed to walk around the hotel and that is it. There isn’t a feeling of poor security as we follow the rules and 8pm curfew, and never walk around outside of the hotel complex unescorted.

It has been reported that there is a risk of attacks on foreigners since the death of Osama Bin Laden.  Al Shabab in Somalia have taken to using women as their preferred method of weapon. Yet Boroma has been a peaceful place relatively for some years. We are about one mile from Ethiopia.

Day 2 - Somaliland

Uneventful night in Nairobi. Flight to Hargeisa is from Jomo Kenyatta airport, Nairobi. It’s a non-commercial flight so after much struggling, I find that it is piggy-backing on a gate for another flight. I am last to board the tiny propeller plane which will take four hours to Hargeisa. The women in the plane put on their veils to be ready for Somaliland life and customs. Men, however, don’t have to do anything!

Somaliland is one of the five Somali regions which include Somalia, Ogadon and Djibouti. It is a self-proclaimed republic recognised by itself, Djibouti, Ethiopia and that’s about it. It was formally a British colony. The war that ripped apart the region and continues today in the South started on this corner. 

Kings College London and Tropical Health Education Trust have invested in this deeply impoverished and serviceless country for about a decade. The first mental health programme was set up in 2008.  I am proud to have been part of that first group and have made many trips since then.

Two universities have been created since relative peace was established in the region. Kings THET provides the mental health component by an intensive two-week course led by external lecturers and local co- lecturers. There are follow-up teachings during the year, and in the past year internet distance learning. The people we trained since 2008 are now the pioneers and leaders in mental health in Somaliland. We have a few champions who we heavily rely on to develop the mental health strategy in Somaliland. Again I am proud to have been part of their education and development.

We help the Hargeisa Group Hospital mental health ward where standards are in urgent need of improvement. I am glad to say that slowly things are a bit better.