Somali health care system and post-conflict hybridity
Healing has become a lucrative business which is difficult for the governments and local authorities to regulate and control.
Civil war destroyed the infrastructure of the Somali state, including health services. Rebuilding of the health sector is challenged by a shortage of professional staff, financial resources, and effective governance. Moreover, an overall privatization of the service sector, decentralization and deregulation following the war have greatly changed the health care scene.
At the same time as international donors focus on developing biomedically oriented (public) health services, the other side of the health sector, folk healers and their services, often remain unnoticed. However, folk healers are relied on in various problems and illnesses, and many prefer them to medical practitioners. They provide their patients personally and culturally meaningful illness explanations and their importance after the collapse of the state has even increased. In the context of Somalia and Somaliland the understanding of the overall health care system is incomplete without seeing the role of indigenous healers.
The aim of this article is to contribute to this understanding of the wider health care system in a post-conflict Somali context, in particular in Somaliland. The article is based on ethnographic fieldwork, in total 6 months, in 2005-2011 in Somaliland, mainly in Hargeisa and its surroundings. The fieldwork included participant observation and interviews of several local healers and their patients from the diaspora. Apart from one exception I will use pseudonyms of the healers, although the key informants have given their consent to be presented by their own names.
The exception is sheikh Aden, whose practice is so special and well-known in Hargeisa that it would be impossible to hide his identity. The last time I was in the field was in January 2011. So, some details such as prices at health care institutions may be already outdated.
Biomedical health services in Somaliland
Before the war, the state of Somalia maintained basic services with the help of foreign aid. Public health services were insufficient even at that time and mainly concentrated in towns, in particular Mogadishu. That time, in the whole of Somalia there were some 347 educated medical doctors and 1409 nurses. After the outbreak of the war, about a third of the educated health care personnel, many of them medical doctors and educators, left the country.
In Somalia, as well as in Somaliland, general health indicators such as mother and child mortality are among the weakest in the world. In addition to malnutrition and lack of clean water, diseases such as tuberculosis, malaria, diarrhea, cholera and polio are common.
During the reign of General Siad Barre, Northern Somalia used to be an underdeveloped area. Somaliland unilaterally declared its independence in 1991. Despite the lack of international recognition, Somaliland has gradually managed to rebuild governance and vital political institutions. The area has also remained relatively peaceful compared to many other parts of Somalia. Estimates regarding the population of Somaliland range from less than 2 million to 3.5 million, and people increasingly concentrate in urban centers.
Despite some economic development, Somaliland remains one of the poorest countries in the world. Local infrastructure is unreliable and there are urgent unmet needs for basic services such as health care, education, and access to clean water. According to Somaliland official statistics, in 2009 there were 86 medical doctors, 369 qualified nurses, 89 midwives, 24 laboratory technicians and 4 x-ray technicians working in the public health services. Furthermore, there were 24 hospitals, 1749 hospital beds, 85 mother and child health centres and 170 health posts.
Existing mental health services do not correspond to the services that are routinely available in industrialized Western countries. The public mental health institutions include the mental hospital in Berbera as well as psychiatric wards at the general hospitals of Hargeisa and Burco. To my knowledge there are no qualified psychiatrists regularly working in Somaliland – a couple of Somali psychiatrists from the diaspora, however, visit the country for some weeks per year and treat patients and well as train local medical staff.
The administration of Somaliland allocates less than 3 per cent of the annual budget to the health sector and services are largely dependent on international organizations (WHO, UNICEF, Islamic charity organizations), remittances sent by Somali diaspora, development co-operation funding and support provided by local businessmen. Public health services are not totally free but based on cost-sharing: the patient pays part of the cost. For example, in January 2011 a visit to a medical doctor at the Hargeisa Group Hospital cost 5,000 Somaliland shillings (about 1 USD).
In general, health services are weekly managed at all levels. Moreover, existing health services mainly concentrate in towns, and planning the services is difficult due to the lack of reliable health-related data and its analysis. Planning the health services as well as their regulation is also difficult due to privatization of the health sector and fragmentation of services. Lack of regulation is a severe problem: Health care staff is often unqualified; anyone may open a pharmacy or a health care facility; quality of medicines is unpredictable; and medicines such as antibiotics or psycho-pharmacies are freely available.
Apart from the scarce public health services, a significant number of private hospitals, clinics and pharmacies have been established since mid-1990s. For example, Edna Aden’s maternity hospital in Hargeisa is founded and maintained by funding collected from abroad. Aden’s maternity hospital is regarded as one of the best in the Horn of Africa and it also functions as a referral teaching hospital. Manhal hospital which is often regarded as the best in Hargeisa – and when it comes to eye treatment as the best in whole Somaliland – was originally funded by the Kuwaiti government. Non-Somali medical doctors, e.g. from Yemen, Egypt and Pakistan, occasionally come to work in specialized fields for 2‒4 weeks. At the Manhal hospital, one visit to a general practitioner costs somewhat more than in the general hospital: 15,000‒20,000 Somaliland shillings (some 2.7‒3.6 USD). An operation at the Manhal hospital may cost 200‒250 USD.
An ophthalmologist at work in the Manhal hospital.
Private hospitals and clinics attract educated staff with better equipment and, in particular, better salaries compared to public hospitals: For example, a medical doctor earns some 70 USD per month at the Hargeisa Group Hospital, compared to a minimum of 500 USD in the private sector. Low salaries decrease the commitment and motivation of the staff and hinder the development of public hospitals and health centres. For example, a nurse at the Hargeisa Group Hospital told that before she comes to the hospital in the morning, she works some hours at a private clinic. At the hospital her salary as a nurse was 40 USD per month whereas in the private clinic she earned 150 USD.
Hence, one of the problems of public health institutions such as the Hargeisa Group Hospital is that senior staff is often absent, and instead of coming to the hospital they prefer working privately. Some of the hospital staff actually refers patients from the hospital to their own private clinics. Even staffs, who in the mornings regularly work at public hospitals, work at private clinics in the afternoons and evenings.
Not only medical professionals, but also traditional healers offer their services in the private sector. Sheikh Ibrahim is one of the popular religious healers.
Folk medicine and intermedicality
A mother brings her ill child to the sheikh’s clinic and once her turn comes, she enters sheikh’s examination space. She sits down on a chair, and the sheikh sits by the desk on the opposite side. The sheikh asks: Who is sick? This boy. What is his name? How old is he? Six months. What is it with him, what kind of a disease does he have? The mother shows a pimple in his hand. Does he suck the breast? Yes, he does not drink other milk, he is afraid of something. Does he move a lot while he sleeps at night? And does he cry a lot? Yes. Is it so that he only sucks the breast and does not want any other drinks, for example water? Yes. When you in the evening tuck the child in, do you feel that he has difficulties in breathing and does he throw the quilt away? Yes. Does he feel warm and does he sweat a lot? Yes. Is he your first child? Yes. Are there any other people who take care of him together with you? Another child helps with taking care of the baby. The sheikh says that the child is beautiful, happy and laughing. Did you take him to the doctor or to a pharmacy when he started to get pimples? No, I did not. Sheikh says that the child’s illness is caused by evil eye. As a treatment he prescribes cashar – water on which he has recited Koran and mixed with certain ingredients from a tree. The child has to drink the medicine for 20 days and it heals the skin from inside out, the sheikh explains.
The discussion was conducted in August 2005 in the clinic of sheikh Ibrahim. The clinic consists of one big room, which has been divided by a wall to a waiting hall and an examination space. In addition, at the back of the clinic, there is a separate, closed room where the sheikh together with his assistant daily mixes secret medicinal concoctions. There is also a table of a receptionist, who delivers queuing numbers and takes care of the Koranic recitation cassette which is played out the whole day. On the wall of the waiting hall there are anatomical pictures of intestines, brains and the heart.
The waiting hall is usually full of patients. Most of them are women who suffer from gynecological problems. Beside the sheikh’s desk there is a bookcase which has in addition to Arabic religious literature also English medical books. The sheikh does not know much English, however, but he explains that he has learnt a lot about anatomy through pictures, internet and from other medical doctors. On the desk the sheikh has a stamp with his own name and a prescription book, where he writes down the medicine and the dose that he prescribes for a patient. Next summer the sheikh has also a laptop on his desk and he has started to keep a patient register electronically.
Superficially the sheikh’s clinic looks like any other modern medical clinic, but through observation one clear difference can be noted: his diagnoses and the medicine which he prescribes. The most common diagnoses that sheikh Ibrahim makes, are jinn spirits, evil eye and witchcraft, and the medicine is always a mixture of cashar and herbs that has been prepared by him. In addition to cashar, he may also recommend and prescribe other medication.
Sheikh Ibrahim at work.
Health care in Somaliland (as well as in all Somalia) is a good example of so called medical pluralism, which refers to the existence and use of self-care and folk medicine in addition to medical treatments. The important role of traditional healers and parallel use of different types of treatments has been reported in many African countries. In general, health care sectors comprising medical care, self-care and folk medicine can be regarded as a universal phenomenon.
In Somaliland, a variety of traditional and religious healers provide health services. Folk healing can roughly be divided into treatments that focus on ‘natural’ illnesses and pragmatic problems and treatments that focus on illnesses caused either by supernatural agents such as spirits or by problems in social relationships (e.g. evil eye). The first category includes treatments such as cupping, burning and bone-setting, and the second treatments such as recitation of the Koran and spirit possession rituals, for example. Indigenous healers comprise, for example, leaders of spirit-possession cults, sheikhs who heal with the help of the Koran, diviners, herbalists, cuppers, and bone-setters. Problems related to mental health are primarily treated by reciting the Koran, spirit-possession rituals, or herbal medication, depending on the condition of the patient and the preferences of the family.
I find the word ‘traditional’ impropriate to describe today’s Somali healers. ‘Traditional’ healing practices have not frozen in the distant past, but they change and develop in the same way as culture in general changes and develops. Shane Greene, who has studied shamans in Peru, suggests the concept of intermedicality to describe how traditional healing practices mix with modern biomedical practices. Also Somali healers absorb influences from modern medical practices and techniques, but at the same time the religious and cultural foundations of the treatments have remained strong.
A new phenomenon following the war is religious healing clinics, which in general are referred to as ‘cilaaj’. Cilaaj derives from Arabic language and means healing. In Jamuary 2011, I observed a clear increase in the number of cilaaj that had taken place in four years. Most of the cilaaj are like hospitals that have inpatients who pay on monthly basis, but the patients are not allowed to leave according to their own will. Indeed, some patients believed that they were in a prison. The treatment mainly consists of listening to the recitation of the Koran and herbal medicine, and sometimes also ‘ordinary’ medication.
In addition to clinical settings and encounters that remind from encounters between a medical doctor and a patient, Somali healers have adopted new diagnostic and treatment equipment. For example, I have observed some of the healers take urine and blood samples or measure blood pressure. Moreover, a common electronic device is a neuro/muscle stimulator which is also used in Western physiotherapy: in a healer’s clinic, however, it is used to diagnose if a person has a jinni, and moreover, to expel it. Jinn spirits are afraid of electricity, I was explained, and hence, an electric ‘shock’ is very efficient. In 2011 the latest innovation was sandals which give electrical vibration and are therefore also efficient in exorcising the spirits.
Electric sandals to exorcise jinn.
One of the healers showed how he emptied medicine capsules from the original medicine and thereafter filled them with his own herbal mixture. According to him, it was easier to take the right dose that way. According to my analysis, this practice also helped him to create a more medicine-like image and power in front of his patient. I have also been told that some sheikhs may put a patient on a drip with cashar. One of the well-known healers in Hargeisa, sheikh Aden who used to be an ordinary bonesetter, has by years developed his skills and nowadays makes complicated surgical operations, including anesthesia. Aden and also other healers may also send their patients to a laboratory or x-ray. Mobile phones are commonly used and through them even patients from the diaspora may easily contact healers, and jinn spirits may be expelled by recitation of the Koran through a mobile phone. In addition, like in the example of sheikh Ibrahim, the use of laptop and internet are becoming part of healers’ equipment, at least among the younger generation of healers. One of the religious healers whom I observed regularly is currently my facebook friend!
Payment at a healer’s clinic may be done through a mobile service.
Fees at healers’ clinics differ depending on the treatment. For example, at the sheikh Ibrahim’s clinic a patient’s first visit costs 10,000 Somaliland shillings (some 1.8 USD) and the second visit half the price. Hence, the first visit to sheikh Ibrahim is more expensive than a visit to the Hargeisa Group Hospital. The price of his medicine varies, but according to the sheikh the most expensive cashar costs 10 USD (the dose is for five days) and the cheapest some 3.6 USD. Moreover, he sells imported medicine such as ‘Honey for headache’ which is the most expensive of his medicines and costs 20 USD; ‘Happiness Mixture’ which increases sexual drive; and ‘Moraren – the womb herbs’ which women may use, for example, after pregnancy.
Sheikh Aden’s hospital is located in a partly ruined building, which was formerly a Hargeisa museum. He is famous for his surgical skills and operations, where he, for example, implants animal bones to a human body in order to heal severe fractures, or removes bullets even from the brain. He charges between 100‒200 USD per operation, depending on the operation and economic situation of the patient. In fact, all healers as well as general practitioners mentioned that if a patient is poor and can not afford to pay, they may treat even for free. Some of the healers have emphasized that a patient may pay what she or he can. Those healers who heal illnesses caused by spirits, however, emphasize that it is crucial that a patient pays before the treatment. As they say, paying money is a key to the healing process, it ‘opens the gate’ for spirits. A spirit-possession ritual may cost from 100 USD to several hundreds of dollars, even to 1500 USD depending on the length and needed arrangements for the ritual.
Sheikh Aden sterilizes the instruments.
Medical and Somali treatment combined
Most of the medical doctors with whom I discussed in Somaliland, seemed to have negative views on indigenous and religious treatments. However, some of the medical doctors said that they might accept and understand in particular religious treatments such as reciting the Koran if a patient and/or his family regarded it necessary for the healing process. I was also mentioned names of some of the well-known healers with whom some co-operation had occurred. Moreover, some healers mentioned that in case they could not treat a patient or found that the reason behind his/her problems required medical treatment, they would send him/her to a medical doctor.
During the last field visit it was easy to notice the ‘cilaaj boom’. Several new places had been opened in Hargeisa where in particular patients who suffer from jinn, evil eye and/or sixir (witchcraft); mental health related problems; or drug abuse, were treated. The patients typically stay in cilaaj or ‘psycho-social centres’ as some of them are called for several months. The treatment costs around 100‒150 USD/month.
One of the cilaaj that I visited in January 2011 was founded in 2007 and it consist of three different houses that seat in total 120 inpatients. In addition, there are 20 out-patients per month. All the patients are men, because the staff finds it difficult to organize the treatment of women; according to Islam, also the caretakers should be women, but in that case they should also be physically strong enough. The most common diagnoses are schizophrenia, psychoses, bi-polar disorder, khat abuse, and PTSD. According to the medical doctor in charge, unemployment is one of the biggest problems in Somaliland and also causes mental health problems.
The monthly fee includes also clothes, cleaning, guards, medicines and laboratory exams. The doctor complained that the situation at the mental ward in the Hargeisa Group Hospital was problematic: Patients paid only 10 USD as first time admission when they entered the hospital. The number of male patients was 70, and females 30. However, there was neither food nor proper medication available for the patients, and also the sanitation and cleaning were bad. Therefore, he maintained, his cilaaj was a better place for the patients. In the cilaaj they combined medical and religious treatment. The doctor explained that he himself believed only in the medical part, but families sometimes requested also religious/traditional treatment which consists of, for example, reciting the Koran and herbal medication.
Another cilaaj was led by a person who also worked for the Hargeisa Group Hospital. Also this cilaaj had three different buildings, including one for women. The total number of patients was 136. One of the buildings that I visited was presented by a qualified nurse, as he introduced himself. He was convinced that a combination of medical and religious treatment was very efficient: if medical treatment did not work well, they would take the patient to the sheikh who also works in the cilaaj. According to him, the cilaaj had ‘full co-operation with the mental hospital’ and also the government had provided them training and workshops.
A sign of healer where he advertizes his treatments that derive from religion and herbal medicine. He promises to treat e.g. different kinds of pains with modern equipment.
Some other cilaaj clinics were not always happy with these new ‘psycho-social centres’. For example, a well-known and respected sheikh in Hargeisa explained:
"I founded the first cilaaj where I had inpatients in 2006. After that also others learnt. There are two types of places where people are treated: first, cilaaj, where treatment is religious, and second, mental hospital and psycho-social centres. These later ones are just like NGOs, they just keep people. But we [in cilaaj], we treat people."
In January 2011 I also had a chance to discuss the issue of folk medicine with both the Minister of Health and the Minister of Religious Issues. In the Ministry of Health the general opinion was that they need to visit different cilaaj and check, what kind of treatments are given. In particular, they condemned the use of cashar as infusions and also herbal medications that are not well examined. Moreover, they wanted to better control the quality of imported medicine. However, the Minister of Health emphasized that Somali healers often have a good contact with the community, and hence, co-operation with them was worthwhile. Also, some of the healers were very skillful and made useful things, even if some of their practices might not be acceptable.
The Minister for Religious Issues related that he wanted to promote the right process of Islamic healing and create guidelines on how medicine and Islam could exist hand in hand. In addition, he saw the need to develop a referral system from medical doctors to Islamic healers and vice versa. Moreover, he mentioned a few sheikhs as examples of qualified healers. He also mentioned that the practice of spirit possession rituals or Sufi healing practices were incorrect practices that should be abandoned.
Extreme poverty and unmet needs of the Somali people have resulted in a booming private health sector, where private medical practitioners and folk healers fill in the gaps in public health services. In Somaliland, Hargeisa is a huge health market, where services are commercialized and compete over customers. Healing has become a way to earn income, and unregulated conditions have created a jungle-like healthcare space. Patients and their families circulate between different healers and health institutions, ranging from biomedical to religious treatments. Sometimes a healer may be the only available option for an ill person, or a healer is consulted because a patient may not afford to visit a medical doctor.
My data shows, however, that services provided by a Somali healer may be even more expensive than services provided by a medical doctor. Hence, patients rely on healers because they are trusted: healers provide patients with meaningful cultural and religious illness explanations. Moreover, a healer may be part of the kinship network of a patient and/or live nearby, which entails easy access.
Part of the reason why Somali healers continue to be relied on, is their ability to renew and hybridize their practice as part of modernization and globalization. Local healers adapt new techniques and tools, which medicalize their practice and enhance their symbolic power in front of the patients. International donors and other actors involved with developing health services in Somalia and Somaliland would gain from seeing the whole picture and understanding the different, interlinked layers of the health care system.
As Enrico Pavignani has critically noted, the Somali health care arena is far from being barren or idle, but it is filled by a variety of actors with multiple interests. The main challenges regard organization, collaboration and regulation of services. Also the powerful role of the private sector and commercialization of the health care provision, as well as the blurred boundaries between the private and public health care sectors have not been properly understood.
At the moment, Somaliland government does not have real opportunities to manage or control the quality of medical staff, not to mention the variety of folk healers and their practices. However, in the government of Somaliland there seems to be willingness to some extent acknowledge the work done by some of the Somali healers, in particular a few religious healers. In the Somaliland Constitution (article 5) it is mentioned that the religion of Somaliland is Islam. This notion can be seen to give a kind of constitutive foundation for the practice of Islamic healers. Another question is what kind of Islam and Islamic healing is regarded as ‘correct’ in a given period and from whose point of view. This is a highly political question, which is linked with the larger political-religious scene of Somaliland and the Horn of Africa at large.
Text and photos: Marja Tiilikainen
The author works as Academy Research Fellow at the Department of Social Research, University of Helsinki. This article is mainly based on her post-doctoral research project (2008-2010) on transnational healing practices among the Somali migrants, funded by the Academy of Finland.
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