The MSF healthcare response in Somalia has responded to a diversity of needs, ranging from primary care and tuberculosis control programs to the provision of emergency trauma and obstetrical surgical services. Prior to 2008, local staff were supervised by permanent expatriates, but following the killing of three staff members in Kismayo by a targeted roadside bomb, expatriates were prohibited from working in the country for security reasons. Currently, MSF's projects in Somalia are run by local staff, with material and financial support provided by an international co-ordination team based in Nairobi, Kenya.
Istarlin Hospital, Gur-El, Galguduud
The Galguduud region is located in central Somalia and has a population of approximately 377,000. In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non-violent trauma. MSF based itself in a private facility, the 80-bed Istarlin Hospital, which received patients from the surrounding 250 km. The hospital operating room was in disrepair: sterilization was not properly done, and clean water and electricity were not readily available.
At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices. Specific guidelines concerning disinfection of surgical linen, sterilization of surgical instruments, essential medications, blood transfusions, the organization of the surgical and operating theatre departments, nursing care, and the layout of the health structures were developed. Protocols regarding antibiotic therapy and prophylaxis, post-operative pain management, indications for Cesarean section, anesthesia for pediatrics and obstetrics, and oxygen therapy were implemented. These guidelines and protocols were used to train the local staff to manage the surgical ward, sterilization, and the operating theatre. Technical training in surgical and anesthesia skills were also provided.
In January 2008, MSF's permanent expatriate presence ended due to increased insecurity. Since then, the surgical program has been run remotely from Nairobi, Kenya by a team consisting of a head of mission, a medical coordinator, an administrator, and a project coordinator. Visits are made to Istarlin at least twice a year in order to ensure that MSF standards, protocols, and guidelines are being followed in peri-operative care.
Surgical care is provided by a Somalian doctor with surgical skills who is extremely competent, especially in trauma surgery. He trained under MSF's expatriate surgeons for two years prior to the end of their presence. He also worked with two other non-governmental organizations, the International Committee for the Red Cross and the International Medical Corps, for several years and was mentored by expatriate surgeons. He has attended several training seminars including a WHO surgical training course in Mogadishu. This doctor with surgical skills must function independently. He does not perform elective surgery. Mogadishu has the closest referral hospital but is over 200 km away. MSF does not provide ambulance services due to security constraints, but cases are discussed with the surgeons there. MSF surgeons are also available by email consultation. A surgical nurse who has received informal on-the-job training, also performs procedures, mostly emergency obstetrics and minor operations. All anesthetics are given by anesthetic nurses.
This review describes surgical interventions done between October 2006 and December 2009; all procedures that required anesthesia and were performed in the operating room were considered as surgical interventions. Data was prospectively collected in an electronic database. Baseline characteristics on age, gender, military status, and American Society of Anesthesiology (ASA) physical status classification as well as data on surgical pathology, procedure type, and operative mortality were recorded in the database at the time of the procedure. Surgical pathology was grouped into the following categories: obstetric emergencies, infection, neoplasm, accidental injury, violence-related injury, and other.
Baseline characteristics were described using medians and interquartile ranges (IQRs) for continuous variables and counts and percentages for categorical data. Logistic regression was used to model associations with violence-related injury. Variables considered in the analysis included age, gender, military status, ASA classification, and blood transfusions. Factors with a p < 0.1 on univariate analysis were included in a multivariate model. All tests and confidence intervals were considered to be significant at a p ≤ 0.05. All analyses were performed using STATA 10 (College Station, TX, USA).