The Horn of Africa

Monday, August 14, 2006

All Photos Uploaded

Click here for the gallery of all photos from this trip.

Friday, August 11, 2006

Slinking back into the West

On Friday I left Hargeisa without a hitch (although the USD$30 exit fee was a surprise).

For all the hype, the Daallo flight was quite normal. Very old plane, all the seats were broken so they bounced back and forth to full recline and back, service was dodgy, the air-nozzles didn't work, etc. Par for the course, I think.

The only thing that made the flight bad was the heat. We sat on the runway, with no air moving, and everyone started to sweat. As people became more and more hot, the din of chatter gave way to silence puntuated only be the sound of the paper flopping back and forth as it fanned people. After 20 minutes, I could see beads of sweat forming on my forearms. The Somali man next to me was periodically dripping sweat from his chin.

My plan was to sit, unmoving, like a lizard sunning itself on a rock, and just stop producing my own heat. This seemed to work, at least somewhat, and I sweated much less than the people fanning themselves around me.

Halfway through the flight, I felt water hit my arm and looked up to see that water was beading all along the ceiling, thick enough to drip large droplets. It's gross, to think of 60 peoples sweat pooling and then dripping onto you, but it was so hot that nobody cared.

The Djibouti airport had AC and was lovely, but once on to the next leg, from Djibouti to Dubai, the new plane was equally hot. We sat on the runway there for the better part of an hour. The heat was too much and I pulled out the plastic 'safety instructions' card and fanned myself vigorously until my forearms cramped.

The second plane was more modern and once we got into the air, they had a cooling system. The stewardesses apologized profusely, but I can't imagine it's ever any different. Djibouti is one of the hottest corners of the planet and if you don't have a cooling system that'll work while you're on the ground, you just don't. They played it off as if it was a one-time hiccup.

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I had a day stopover in Dubai and while I had some vague interest in going bead shopping, I really didn't want to be there. In the airport, I ate some chicken tikka masala and then went to the Emirates desk and asked to be placed on standby for an earlier flights to NYC. There was one leaving in three hours and I made my way over to the gate. I ended up boarding, almost twenty minutes after the flight was supposed to have left, because there ended up being a few "off-loads" despite it being a full flight.

Some mess of hours later, I touched down at JFK in New York. At customs, nobody was waiting to question me. That might be because they have no interest, though that seems odd since Somaliland is technically Somalia and there's been all this hullaballoo in the news over terror plots in the UK. Or maybe it's because I skipped the first leg of my tickets (from Addis to Dubai), ended up on an earlier flight from Dubai to NYC, because I boarded at the last possible moment, because my name was misspelled when it was entered into the computer for the Dubai to NYC flight, etc. In any case, no gabbing with the FBI this time.

Now I'm in NYC. While Emirates moved me to standby for an earlier flight for free, American Airlines said they wouldn't do it, despite four daily flights from NYC to SF, without me paying a $150 "change fee." That was, they said, because the flight I wanted a standby on was on the 11th and my ticket was for a flight on the 12th -- nevermind that they're within 24 hours of each other, etc.

San Francisco has my bed and New York City has new haunts to explore, but they're otherwise a wash. I'm as happy to stay overnight in NYC as I would be to fly to SF. I'm at NYPL now, googling up a place to stay tonight. I desperately need a shower after losing probably half a gallon of sweat on the flights from Hargeisa to Dubai. Shower, scrub, food, wander Manhattan all afternoon and into the evening.

Tomorrow afternoon, I'll be back in San Francisco -- "Baghdad by the Bay."

Wednesday, August 09, 2006

"But you can never leave..."

Well, I'm still in Hargeisa. My plans to go to Ethiopia have been scuttled.

I went to the airport bright and early this morning. I arrived at 7a for my 8:30a flight and the airport was mostly deserted. I walked right through customs and immigration and out onto the runway. I took pictures of the planes.

Half an hour later, a guard asked me where I was going and then promptly informed me that the flight was cancelled. We called the Daallo office on his mobile and they said the next flight was on Sunday. That's a bit of problem as my international tickets -- Orbitz, non-refundable, et al -- start Friday evening on Addis. Addis to Dubai to NYC to San Francisco.

I hopped a ride to the Daallo office, composing in my head the best method for getting the situation rectified and, secondarily, getting Daallo to foot any expense. I put my angry and exasperated face on and was quickly bumped to a manager. He and I explored options -- there're no other flights to Addis today -- and then decided that I could fly from Hargeisa to Dubai, bypassing Ethiopia entirely, and that Daallo had a flight tomorrow. Although I had plans in Addis -- dinner with Selam, bead market, the Fistula hospital for which I had a personal letter of introduction from Edna that I was going to hand-deliver -- Dubai seemed to be the only solution.

Of course, he wanted me to pay for the difference in ticket prices. Hargeisa to Dubai is much more expensive than Hargeisa to Addis Ababa. After 20 minutes of arguing, with me laying out clear, cogent explanations of where culpability lay, he conceeded and gave me the new ticket for free.

So, that's that. I'm back at the hospital today. Tomorrow I'll leave in the afternoon and fly to Dubai via Djibouti. ("And Djibouti, I still like Djibouti, doin' squats...") The airport is Hargeisa is too short to support jets, so my flight from here to Djibouti will still be on a puddlejumper. The flight from Djibouti to Dubai will be on a much larger, more modern craft.

As an aside, during the Communist days, the Soviets built a huge fuck-off runway on the coast near Berbera -- one of the longest in the world. It's sat mostly fallow, although in the 80s the NASA leased it for many millions per year as an alternate site for landing the space shuttle. Neato.

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This afternoon, I met two Somali sisters and their half-Arab friend, all on holiday from London. They've just started volunteering at the hospital, doing admin and filing and sorting the library. We had a four-hour discussion earlier today about Somaliland, the Somali people, culture clashes, Islam (and whether or not Islam is compatible with democracy, in particular). It was a great conversation. I'm going to have dinner with them at the Ambassador Hotel tonight. Which means... pizza! Awful, sloppy, Somali pizza, but pizza none the less. Or maybe a cheese burger. My "beef burger" last time was fairly bad, but I enjoyed feeding my dinner roll to the kittens slinking around the bushes. Skin and bones, whiney, awfully cute save for the obvious ringworm infections, little kittens. I took pictures.

I hardly took any trip pictures, despite having lots of flash memory and a battery charger with me. I don't know why, really. I think I see National Geographic photos and I desperately want to take similar photos as a testament to me being here... but then everything is boring. Hargeisa is a dusty, East African town, notable for nothing. Most men dress in quasi-Western style. Most women dress in beautiful bright colors and patterns but won't let me photograph them. Modesty, etc.

A few days ago, I set out to wander the neighborhood and just shoot photos until my battery died. I didn't get 100 meters before kids swarmed me, demanding I take their pictures. Correction, boys. There were a few girls around, demure, floating near the edge of the crowd, but they wouldn't let me photograph them. Eventually, a woman emerged from the masses and talked to me in English. She was sure, with my beard and my "Salaam Alaiykum" greeting, that I was Muslim. They want to know where I was from, etc. When I asked her about taking photos, I got a very interesting answer. "We don't want you to take our photo because we know you will show the photo to people and say, 'These are refugees.'" Refugees, of course, are largely Ethiopian, ergo infindels, ergo (and this is the most important part, I think) infected with HIV.

A few days ago, I had a taxi ride with two men who had an interesting viewpoint. "We are not black! We are like you. We are white. It is only because of the sun for so long that was look like this." He pinched his skin for emphasis. "We are not like Nigerian! We are white. If you stay here for one year, you will look the same as us." Nigerians, of course, are liars and thieves and have no honor and no pride, etc. It was disappointing to hear.

Later, talking to Ayan, one of the Londoners I mentioned earlier, she said she'd heard the same sorts of things here and has also heard much talk about "genuine Africans." "We are genuine Africans!" The rest of the people here in Africa are... not. They're Others, somehow less.

I want to jot down an interesting conversation I had with a British doctor, but I'm running late for dinner. He's old British -- interested in culture and empire and bettering the world with "civilization" and infrastructure. We talked for 45 minutes about nation-building and Iraq and Afghanistan and the NWFP of Pakistan, etc. More on this later.

Final Days in Hargeisa

Everyone here naps from 1p-4p, but I'm not really tired then. Or at least not usually. When we have an emergency in the middle of the night, the nap the next day is nice. I'm not "on call," really, because I'm not one of the physicians, but I've asked all the doctors to send someone to wake me up if there're emergencies during the night. At 1am, or whatever, someone pounds on my door, "David! David! There is a c-section... you come quick!"

So life here for the past few days has been more of the same. More D&Cs, more c-sections. We got two stroke patients in the medical ward. There's so little we can do for them without a CT scanner. We treat the symptoms and tell the family to keep trying to talk to them and keep trying to get them to move those arms and legs.

I was back at Hargeisa Group Hospital again on Tuesday for surgery. We did the urethra repair that was bumped on Sunday, removed a bladder stone from a one year old (no shit -- but there it was), placed a three-way catheter in an old man with a hypertrophic prostate (he's too weak to have survived a full prostatectomy), and then removed a bullet from the leg of a man who was shot in Ethiopia.

The last was the most interesting to me simply because of boyish fantasies surrounding removing bullets from people. I wanted to keep the bullet, but of course the patient wanted it to show his friends. "...and then! Bam! Right into my leg! This is the actual bullet!" Add appropriate embellishments until the story attains heroic proportions.

Sunday, August 06, 2006

Surgery, Diana's NGO, and Daallo Airlines

I went to Group Hospital this morning and, after two previous strike-outs there, spent the better part of four hours in the operating theatre with the Chief of Surgery, Dr. Sulaimon. (My favorite Neil Diamond song too. Double trouble!)

Our first case of the day was a thyroid adenomectomy. We used local anesthesia (lidocaine) and spent an hour digging our way down, easing the gland up out of the fascia, and then cauterizing off the vast majority of it. Zzt, zzt. I quite like the electro-cautery pen. As we closed things up, we put in a tiny tube for drainage. I've written "we" here, but I was only observing on this case.

Dr. Sulaimon invited me to assist on the second case. It was a prostate gland removal -- open prostatectomy. We cut into his abdomen first, then slowly cut our way down to his bladder. There we aspirated fluid with a needle to make sure we were in the bladder, not the intestine. Everything looked good, so we cut into the bladder and then had another assistant insert a finger into the patients rectum and push the prostate up toward our incision. Once we were certain of the positioning, we cut into the floor of the bladder and Dr. Sulaimon used his fingers to excise the prostate. After that, it was catheters in, suturing, a drainage tube, yadda yadda. Today's procedure was fairly simple really. It's the follow-up, recovery, complications, etc, that're potentially difficult.

Our last case was the removal of dead tissue surrounding an ulcer on the bottom of the foot. Our patient was young, strong, not diabetic, and had the ulcer for 12 years. When we removed the bandages from around it, the room was filled with an intense smell of BBQ. The ulcer itself was approximately an inch and a half in diameter, and necrotic, rotting tissue puffed out a good half inch for the inner 85% of that diameter. Dr. Sulaimon used the cauterizer to cut the tissue off, leaving a large hole.

As he worked, smoke curled up from the wound, filling the room with the smell of burning flesh. I was thankful for this. It smelled bad, sure, but it was expected bad -- the "cost of doing business" as it were. The BBQ smell was bringing back memories of cooking on the patio at work, the delicious BBQ restaurant in Oakland, etc. I was consciously trying to prevent myself from making the associations but as I smelled the meat cooked for dinner tonight, it seemed to smell exactly like that man's foot.

Punch "foot ulcer" into Google Images to get an idea of what it looked like, if you're curious.

The hole will be packed with betadine-soaked sterile gauze for months, I think, as they hope the tissue granulates and starts healing. It's possible that it could heal and fully close and he'd be able to walk normally for the first time in over a decade. Judging from some of the slides shown at the "Advanced Wound Healing" presentation at this years AAPA conference, I'm not especially optimistic. They don't use silver nitrate here and they certainly don't use advanced techniques like applying vacuum pressure to the surface of the wound.

We had two more surgeries scheduled but they were both cancelled. The first, a hernia repair patient, had a terrible cough. The other scheduled surgery was for a man who fell off a wall, catching his crotch on the way down, who had "urethra damage." For whatever reason he ended up eating breakfast that morning so we couldn't operate.

I'll be returning to Group Hospital on Tuesday morning for more surgeries with Dr. Sulaimon. For those of you keeping score: I wasn't even a smidge queasy during any of the stuff.

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After lunch, I hopped a taxi over to Diana's office today. She works for EDC, the Education Development Center, on a project called SIRIP: Somali Interactive Radio Instruction Program. They're writing scripts and producing radio shows to help educate the populace. Teachers, even in rural areas, will be able to tune in and listen to the program and guide students through exercises, stories, etc. Diana is a school teacher from Houston.

A few days ago, her husband, who's a concrete contractor with KBR in Iraq, came in to town and I joined them both for dinner two nights ago. Diana made Louisiana gumbo and it was delicious. Afterward, we played Monopoly. I thoroughly trounced them, taking early risks that paid off big-time later, trying not to snicker as I mercilessly drove them into the ground. The Monopoly set they had was Houston-themed. Boardwalk was NASA, one of the orange properties was the Astrodome, etc. My player token was an armadillo.

Afterward, we talked about education in the country, the dangers of travelling, etc, and I mentioned my upcoming Daallo flight. Diana mentioned that one of EDC's staff members was recently ambushed on a road outside Mogadishu. She was robbed and her driver nearly died from gunshot wounds to his legs. In the last few years, she's worked on contract, usually for a year at a time, as a teacher in China, Abu Dhabi (UAE), etc.

When I went and saw her today, she'd printed out a funny joke one of her staff had found. I've copied it below.

One of her co-workers is a Somali who grew up in the US from age 12 on. He's in his early 40s now, with a PhD, and has returned to Somaliland to coordinate this project. His name is Said. He and I spent a few hours talking, covering everything from George Bush to female genital mutilation to chewing khat to promiscuous Somali girls (!) to raising quadralingual (or pentalingual?) kids. I'd met him at the "ex-pat party" previously (it was at his house), but hadn't spoken about anything of consequence. This afternoon, I greatly enjoyed his company.

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Diana's gift was a sheet of paper. She handed it to me with a big grin.

It read, "Welcome to Daallo Airlines! Good morning, ladies and gentlemen. This is Captain Sharmaarke welcoming both seated and standing passengers on board Daallo Airlines.

- We apologize for the four day delay in taking off. It was due to bad weather and some overtime I had to put in at the bakery.

- This is flight 126 to Hargeisa. Landing there is not guaranteed, but we will end up somewhere in Somalia. If luck is in our favor, we may even be landing on your village!

- Daallo Airlines has an excellent safety record. In fact, our safety standards are so high that even terrorists are afraid to fly with us!

- It is with pleasure that I announce that starting this year over 30% of our passengers have reached their destination!

- If our engines are too noisy for you, we can, on passenger request, arrange to turn them off.

- To make your free fall to earth pleasant and memorable, we have complimentary tea and laxoox!

- For our not-so-religious passengers, we are the only airline who can help you find out if there really is a god!

- We regret to inform you that today's in-flight movie will not be shown as we forgot to record it from the television. But, for our movie buffs, we will be flying right next to British Airways and their movie will be visible from the right side of the cabin.

- There is no smoking allowed in this airplane. Any smoke you see in the cabin is simply the early warning system on the engines telling us to slow down!

- In order to catch important landmarks, we try to fly as close as possible for the best view. If, however, we get a little too close, do let us know. Our enthusiastic co-pilot sometimes flies right through the landmark!

- Kindly be seated, keep your seat in an upright position for take-off, and fast your seatbelt. For those of you who can't find a seatbelt, kindly fasten your own belt to the arm of your seat. For those of you who can't find a seat, do not hesitate to get in touch with a stewardess who will be happy to explain how to fasten yourself to a suitcase."

Saturday, August 05, 2006

War Stories, Cultural Oddities, and

Every night, I see outpatients with Dr. Deeq. It's almost exclusively antenatal stuff and I've taken over the ultrasound. The first day or two, the ultrasound seemed like pure divination, reading tea leaves. Looking at the screen was like looking for a dove in a blizzard. Since then, I've become more skilled with it. While I still can't find femurs or penises for the life of me, I can now nail the head (BPD), fetal heart rate, and placenta. It's fun.

In between patients, Deeq and I talk about anything under the sun. He's enlightened me on the khat economy, fat women, stained teeth, different styles of FGM -- female genital mutilation, social factors around pregnancy, STD infection rates in Somaliland, etc. A few nights ago, we were talking about the social stigma around seeing women. Husbands don't want you to see the face of their wife, even while she's giving birth, but if you leave her veil on you're welcome to examine the baby, etc. So peculiar. This is all contrary to the traditional nomadic Somali woman -- a strong, bossy, decision maker, deciding when to move to a new grazing area, which goats to sell at the market, etc. Edna thinks the current changes are a result of people wandering off into the nearby Arab world an picking up terrible ideas and habits.

Anyway, while we were talking about this, Deeq mentioned that he used to work as a doctor in Yemen and that they were far more conservative than anything he's seen here. He related a story about a husband and wife who came in, the woman having a horrendous pain in one of her teeth. The woman sat, hunched over, crying softly but saying nothing. Her husband stood next to her, explaining all of her symptoms, the history, how she was feeling now, etc. He was wearing a dagger on the front of his robes (the sheath is curved, but the daggers themselves are straight), had a pistol strapped to his hip, an AK-47 slung over his shoulder, and a grenade on his belt. When Deeq asked the woman to lift her veil so he could look in her mouth, the husband stepped forward and loudly objected. They argued and the man and his wife left, with Dr. Deeq saying that if he wasn't allowed to examine her mouth, he couldn't treat her.

An hour and a half later, the man returned to the clinic. He was smiling this time. "I have a solution," he said, and he proceeded to draw his knife and carefully cut a small mouth-hole into his wife's veil for the doctor to peer through.

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We have emergency cases come into the hospital now and then -- 8th month, severe bleeding, immediate c-section required to save the baby and the mother. Husbands, who decide if their wives live or die, balk at the prospect of surgery, refusing the sign the consent forms. Edna tells me that twice in the past, with women literally bleeding away on the operating table and husbands steadfastly refusing the c-section, she's gone to the nearby police station and told the commanding officer there that her and herself were going to sign the consent forms, laws be damned, and if the police chief wouldn't sign, the woman's death would be on his hands. "Let them sue us tomorrow! Tonight we're going to save that woman's life!" Both times, the chief has signed, over the protests of the husbands. (I swell with enormous admiration for her when she tells me this but I say nothing.)

I'm absolutely incredulous at this. Is it that our head surgeon is male? Is is some part of Islam? It turns out that a big part of the reason husbands do this is because of the language. To describe slicing open a living being, we have the word "surgery." To describe slicing open a living being in the Somali language, there's only one word and it's not precise. "Slaughter." That's right -- the Somali word for "surgery" is the same word used for "and then we're going to the market and we're going to SLAUGHTER a goat." The nurses here have to devise clever, roundabout ways of describing the procedure to fretful husbands. "We're going to... open... your wife... and then we're going to lift the baby out..."

There're other reasons for refusing the surgery, but the language problem has gotta be a big one. You're a peasant from a rural area, living life as a nomad, absolutely zero education, almost no exposure to the modern world. Your wife is dying and you're in a huge metropolis, sights and sounds you've never seen, and someone in the hospital asks you to sign a consent form to slaughter your wife. Would you sign? :)

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A few days ago, at lunch, Edna described being a nurse here in Somaliland during the war with Ethiopia in 1977. "We were in Jijiga [present day Ethiopia, but ethnically Somali], loading up ambulances and driving back to Hargeisa. We could only drive at night and even then we had to keep the lights off, for fear the Ethiopia fighter planes would bomb us. We had patients loaded on top of patients; some were on the roof of the ambulance. The driver would go very slowly without lights and, when he couldn't see the path, he'd get out and walk ahead with a small flashlight, plotting our path for the next few hundred meters. Blood was leaking down the sides of the ambulance and I could hear hyenas howling in the darkness."

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I want to keep all three of my books for my personal library. They're that good. The plan was to give them away here, after I'd read them, gifting them out into the world. I could leave them in Edna's library, donate them to the absurdly expensive library in town, or give them to Diana -- the American NGO worker -- for dissemination into the NGO community. I'll probably do the latter, hoping for wide readership, and just buy more copies when I'm back in the States.

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My flight from Hargeisa to Addis on the 9th is on Daallo Airlines. The UN won't let their staff fly on Daallo because it's unsafe and now I keep hearing horror stories from expats. The gist of it seems to be this: Daallo planes are all small and old. Antonovs, I wonder? Some people have told me they're converted cargo puddlejumpers with benches against the walls. Everybody has said they have no seatbelts. This doesn't bother me since a seatbelt isn't much use when you're plummeting out of the sky in a metal tube. Still, the planes fly low and thus are buffeted by thermals. The turbulance can get so bad, I hear, that you can bounce off the benches/seats and slam your head into the ceiling. My flight is early in the morning, when it's still cool, so turbulance should be slightly reduced.

If I die in a plane crash in Somalia, I hope someone will gussy it up a bit and make the story more sexy. Not just a plane crash, but a traaaagic plane crash... not just in Africa, but a desolate corner of the Horn of Africa, a war zone maybe, where Westerners fear to tread!... not to be a volunteer doofus while on vacation from cushy San Francisco, but to comfort the weeping children! To "hold the line on AIDS!" A beacon of light in the heart of darkness!

That sounds pretty good. :)

In the afterlife, Edward Said will strangle me.

Friday, August 04, 2006

Somali Politics, Ex-Pat Party, and Books

I do my homework.

After I decide to visit a country, I start reading about the history, the culture, the political landscape. I delight in picking out small cultural cues, mentioned in passing. The customs, the mores, the folkways. Every day, I read the news -- BBC, CNN, a more local or regional source like Al Jazeera or, in the case of Somalia, Shabelle. Sometimes, I try to learn some of the local language.

I consider all of this to be pragmatic both for my own safety and for the depth of experience I'm able to have. In many of these places, I am the consummate outsider. It's unavoidable. As much as is possible, I want to get a real taste for a place. What do people want? What're they afraid of? What're simply "concerns" or causes of anxiety? What factors dominate the social or political landscape? I want to know and knowing requires talking.

In Afghanistan, I shied away from talking about politics, ostensibly for my own safety. Here, I haven't shied away at all. I've had long, meandering conversations with large handfuls of locals. We've discussed the history of Somaliland (Barre, et al), the "five zones" of the Somali people, the conflict between Ethiopia and Eritrea, the current situation in Somalia. Puntland, East Sool, Geddi's being forced out (which failed, but will probably succeed once there're no ministers left), the power of the government in Baidoa or lack there of (and why Ethiopian troops were the final nail in the coffin), the prior wars between Somalia and Ethiopia (Ogaden as a contested region, etc), how Mengitsu's mother was kidnapped and raped (no shit -- more on this later), the history between Abdullahi and Aweys, the real germinating force behind the nascent rise of the Islamic Courts Union (it's not who the Western media thinks), why the ICU will never fully control Somalia (they're purely Habr, among other things), which major African countries are supporting Somaliland (Ethiopia, Djibouti, South Africa), the tribulations of the Somaliland government as it has sorted itself out (15k population in Hargeisa in 1991 swelling to over a million today, ministries, pay raises for ministers, the "Al Qaeda-linked death squad" that was killing foreigners here for a few months), why Ethiopia will be ineffective in a cross-border war with southern Somalia (Somali rebels in Ogaden and opportunistic Oromo rebels -- and, counterpoint, why they'll be tremendously effective). The visits of US State Department officials to Somaliland (and how shitty the pizza is at the Ambassador Hotel compared to the local Italian restaurant -- Club Venizia?), why an American from a think tank linked to Project for the New American Century is poking around Hargeisa (and two reasons why he's not likely to come home with a complete picture), how and why a massive influx of aid money might fracture the Somaliland government, how and why international recognition might do the same.

It's all terribly interesting.

In the past three months, the situation in Somalia (not Somaliland, where I am) has changed almost daily.

Initially, I was watching it only with an eye to my safety in travelling to Mogadishu. The Islamic Courts Union, with popular support, wrested control of most of Mogadishu from the warlords who'd been controlling their little neighborhood fiefdoms. How does it bode for me? Good, in that things are now more stable, more uniform, etc, and bad in that things are now more ambiguous. It became unclear who could provide protection. What had appeared as utter chaos from the outside, with the warlords in power, was in fact very structured, albeit only on a "micro" level. The situation could be known, understood, and then gamed, with enough money, to provide relative safety and security. With the Islamic Courts Union having routed the warlords (or at least most of them -- at this point, there were still hold-outs in Mogadishu), a new issue comes up. The CIA was backing the warlords -- Americans with thick necks and briefcases had been wandering Mogadishu -- and an American male in Mogadishu will be assumed to be CIA -- very bad for me. A tentative peace deal was inked between the internationally backed government in Baidoa (the TFG -- Transitional Federal Government) and the ICU -- very good. Martin Adler, a Swedish cameraman with extensive experience in Africa, was gunned down at a rally in Mogadishu, seemingly simply because he was a foreigner -- very bad. The ICU condemns the killing and promises to provide protection to any journalist visiting Mogadishu -- good, if I can go in as a journalist. Sheikh Ahmed, a former school teacher who got into politics after a student of his was killed (aww!), is replaced as the head of the ICU by Sheikh Hassan Dahir Aweys and Aweys is on a US "known terrorist" list (linked to Al Qaeda, Africa embassy bombings, etc) -- potentially bad. Blah blah blah, on and on... Every day, BBC had an article or two. Al Jazeera had maybe five or six. Shabelle had more, but the commitment to quality in reporting might not've been there.

When I left San Francisco, Mogadishu appeared too dangerous to visit but I left it on the table as a possibility, figuring I'd be better able to sort things out on the ground. Things don't seem much (uh, any...) safer now, but it's a moot issue since I won't have time. I'm flying back to Addis on Wednesday the 9th before my flight(s) home on the 11th. I'm not sure what I'll do in Addis for a two days. I think I'll spend half a day visiting a hospital there that specializes in fistula repair and maybe visit the museum and see our great, great, great (ad infinitum) grandmother, Lucy.

And eat some food that is not goat meat. Every breakfast: Corn Flakes with powdered milk, french bread with peanut butter and chocolate sauce. Every lunch and dinner: oily rice, goat stew, and limp salad. Every few days, dinner will include goat liver and french fries, mixed. The liver is grey and clammy, like mutant elephant hide. Nothing is spiced or flavored. I've been drowning everything in hot sauce to make it more palatable. I'm used to eating Thai food on Monday, Indian on Tuesday, Mexican on Wednesday... I'm glad the food here hasn't made me sick, but damn, I'm desperate for variety.

Last night, I went to an "ex-pat party" full of out-of-shape UN and NGO workers drinking wine, smoking sheesha, and dancing to salsa music. I was happy to have a change of scenery, but I had a vague feeling that I was betraying my reasons for being here. The party seemed no different than any house party in the States except that you had to guess peoples nationalities. Italian, Armenian, Norwegian, the lone American resident. And then there was me. "Who're you with?" "Sorry?" "Who are you working for?" "Oh, I'm on vacation," I said. I got blank stares in return and then an, "Oh." I ended up spending half the night sitting outside, near the gate, talking politics with the guards and drivers. Redemption.

The most exciting part of the party, for me, was finding out that the Ambassador Hotel has "pizza" (of a sort) and that there's an Italian restaurant in town that's "really fabulous" -- no small compliment coming from an Italian.

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In other news, I finished "You Shall Know Our Velocity!" It was fantastic and had me laughing and giggling and reminded me so, so much of myself. The author, Dave Eggers, appears to be from San Francisco; he mentions 826 Valencia (my all-time favorite pirate supply store) in his acknowledgements section.

I also read Mark Bowden's "Black Hawk Down" a few days ago. Edna has it on her bookshelf. I'd seen the movie, of course, but had heard the book was much better. It had some good moments, with funny and insightful anecdotes about SFOD-D, but I didn't like the author's use of the soldiers own language in describing things. I imagine Bowden hoped readers would find it authentic, but I found it annoying. Chapters would talk about a soldier and describe his feelings, at whatever critical juncture, as (I'm embellishing here) "like two darn crawdads, fightin' in the Mississippi mud" -- it's got to be lifted from interviews, Bowden wouldn't write that -- or end a section with a line like, "It was fucking bad-ass."

Now I'm reading a medical terminology book and an embryology book. The library here is 99% medical but has a tiny "fiction" section that includes a collection of plays by Euripides and "A Prayer for Owen Meany." There's also a tiny library ("Gandi Public Library" -- not Gandhi) that's about a 25 minute walk from here. I skimmed their shelves and a book titled "The White Rabbit" looked interest, but when I asked about checking it out, they pointed me to their terms of service. Only members can check out books and the membership fee is USD$25 per year. Ha-fucking-ha. I'm not paying $25 to read a 180-page "wah wah torture" book about WWII. I'm leaving the country in five days. And I'm sure SFPL has it. And Euripides is probably better anyway.

Khat, Beauty, and the Public Hospital

The chat/khat (Amharic/Somali) economy is estimated at USD$700,000 per day. It primarily grown near Harar, so most of this money is flowing back into Ethiopia. Usage estimates among women in Somaliland are 10-20%. Usage estimates among men are 80-90%.

Khat can cause discoloration of the teeth, but it is NOT the cause of the dark brown staining that I keep seeing here. That, apparently, is from too much iodine in the water. It's a problem in the eastern regions of Somaliland in particular and may disproportionately affect women. (I'm not sure I buy that last part.) It's considered... sexy.

Also sexy: being fat. In the States, there's such a stigma for women around age and weight that they'll sometimes lie even to their healthcare providers. Here, women hem and haw and don't want to tell you their age, or they'll tell you a more optimistic age. But with weight, we always get the real answer (or a, forgive the pun, inflated answer?). Being fat means you're prosperous. Sexy.

Not surprisingly, the top two medical problems in this country are hypertension and diabetes. Infectious diseases are third.

It seems rather popular here to dip your finger tips in henna. You do this once this week, then again two weeks later, then again two weeks after that. Once the henna wears off your fingers, which're black to the first knuckle, you're left with a three-tone fingernail. The farthest portion, which has had three immersions, is very dark, followed by a band that's light, in the middle, and then a very light band near the cuticle. As the nail grows out, a "natural color" band is added. It's nailpolish, a French manicure, done henna-style.

When I gently pushed a Somali woman about it, she said pushed back. "In America, they put on the plastic and little drawings on them!" She's right. It's equally strange in America, except that at least this way you can still wash dishes and type.

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I spent this morning and yesterday morning at the Hargeisa Group Hospital near "downtown." It's a government run hospital and is wildly different than this one.

It's... big. It's a compound, with buildings spread all around. In between some buildings are barbed wire fences. Goats meander around, chewing grass between the maternity ward and the surgical ward. There're flies everywhere. The paint is peeling off the walls. Tile floors are in disrepair, stained by who knows what. Ceiling panels are falling apart.

In the operating theatre, there're things I can't even identify. I imagine one of the machines must be an ECG and one must be oxygen, but they look like they're from a 50s sci-fi thriller. Little metal switches everywhere; these are pre-button. There're boards lying around that look like spanking paddles for an over-the-top fraternity, but I figure they're probably old school traction splints. If you put rope in one end... yes, maybe. They have an x-ray. Non-portable, tiny, easily decades old. The nearest CT machines are in Addis Ababa, Ethiopia, and Nairobi, Kenya.

I want to take pictures but I'm worried it'd seem demeaning. They're doing the best they can. The wards are large. 25-30 beds each. Each is staffed, it seems, by a few nurses -- usually two. Doctors are "on call," not on site. I'm not sure what to make of this arrangement. I suppose it's fine if you have really crack, top-notch nurses. Nurses are the ones who really -run- a hospital, even when doctors are there.

Unfortunately, during my tour on the first day, it appeared that a lot of the patients weren't getting the attention they needed. In the middle of the tour, with me in my white lab coat from this hospital, a mother pushed her baby at me. Prolonged labor, became a c-section, infant is now about 5 hours old. It's wailing in a weird staccato in line with obviously (visually) labored breaths. Forearms are cold. I ask if there was meconium, if anyone has listened to breath sounds, etc. Nada. Where's the post-natal care?

Anyway, they do a lot more surgeries at Group Hospital than we do here, so I'm going to be going back on Sunday and on Tuesday, early in the morning, to observe surgeries all day. I met their head anesthetist and Edna has put me in contact with the chief of surgery there. It should be a good learning experience.

Tuesday, August 01, 2006

Craniotomy and Reflections on Reacting to Surgery

This morning, I went on maternity rounds with Dr. Qaws instead of the medical rounds I'd been doing with Dr. Derrick for the last week.

We examined a patient who was 8 months pregnant and had intrauterine death of the fetus four days ago. Since then, we tried to induce labor using an oxytocin analogue, Syntocinon, and had no success. Today, I put my fingers inside her and felt that the cervix was fully dilated, with the head of the fetus low, pressing against it, in something between a face and brow presentation. Dr. Qaws said that with this presentation, the space required in the birth canal is too great and the fetus cannot be delievered vaginally anyway. The presentation was missed on earlier examinations.

When I removed my fingers, a bit of the fetuses skin was stuck to my gloves. Four days was already really pushing it and the fetus had to be removed, pronto.

We were left with two choices. Either we perform a c-section and risk a likely infection, or we perform a craniotomy and risk rupture of the uterus. Since she's had no bleeding, and the risk of uterine rupture seems low, we opt for the latter.

A craniotomy is not a pretty procedure. The goal is vaginal removal of the fetus without labor. Labor would push the baby out; a craniotomy pulls it. The method is to cut into the skull of the fetus with very large, pointed scissors, remove some of the brain matter and fluid to reduce the size of the skull (for easier extrication), and then insert what amounts to a large pair of vise-grip pliers. The pliers grip a stable portion of the skull and then a tug-of-war ensues, doctor against uterus.

In our case, the whole procedure took almost half an hour. Dr. Qaws was trying to grip the back of the skull instead of the more readily available face -- a personal proclivity not medically indicated and one which lengthened the procedure.

With a strong heave, the fetus finally came out, skull split nearly in half, face badly misshapen, head like a deflated soccer ball forgotten under a porch. One eye bulged out of the socket. Brain matter littered the basin and table like so much pudding.

I started to imagine the psychological trauma that would result if a mother saw her baby in such a state. This patient was a calculating realist. When Dr. Qaws had explained the procedure to her before hand, she'd remarked, "My baby is already dead. If this (the destruction of the baby's body) is what you must do to save my body, so be it."

-----

Strangely, this procedure didn't phase me in the least. I found the first c-section and first D&C much more difficult to stomach.

I wonder, idly, if I'm over the hump in terms of having strong physical reactions to highly invasive procedures.

There's a big disconnect here between fantasy and reality. In my fantasy, it's a few years down the road and I'm alone in a war-torn country nobody could find on a map. I'm in a refugee camp, coldly calculating in triage, struggling to get a handle on an epidemic, performing surgery under abysmal conditions. I'm working 18+ hours per day and I'm positively masterful -- but it's still not enough. I'm stretched too thin despite giving my all. Every day is a struggle simply to keep my head above water, but I secretly love it. (To deal with the stress, I take up zazen instead of smoking, of course... haha!) I develop a "thousand yard stare" and later, in old age, I write a seminal book on philosophy informed by my experiences.

In reality, I'm sometimes a wet chick quaking in a cage, small in the world. (That overstates the case, but the idea is the same.) I've had two or three instances -- a bunch biopsy that became 15 minutes of digging with a scalpel, the elective c-section here in Somaliland -- that have left me woozy and flushed with sweat and needing to take a moment to breath and relax. Each time, it's struck me as painfully absurd, discordant with how I view myself. I've seen nasty traumas, gore, incredible messes, but these relatively minor, elective procedures have thrown me for a loop. I don't feel mentally or emotional distraught, but my body reacts: my temperature rises, I feel beads of sweat sliding down my legs, my forehead is wet.

I wonder if it's that they're elective? The punch biopsy was for a small, fatty nodule under the skin in the back. Invisible. He'd had one removed from the same place a few years previously and this time we used a scalpel to remove scar tissue. At first, I was fine, but the more my mind had a chance to wander... Perhaps an inability to turn empathy off completely? I can't make heads or tails of it.

In any case, I think, realistically, it's simply a matter of exposure. The first few times you compete in athletics, you're a mess of nerves and anxiety. Later, you realize that the "butterflies" are a positive sign, a symptom of excess energy raring to go, blood shunted away from the GI tract and into your biggest muscles, your body champing at the bit, ready for perform.

Perhaps surgery is the same. Either this stuff will simply stop happening or I'll learn to recognize the onset and channel it into something positive.

I also think I'm probably not alone in this. That it might be common for people coming into medicine. Besides, some people faint when they see, or even think about, blood, so getting woozy when liters of blood flood the floor and bodies are sliced upon is, at the very least, a step up from that. :)

Monday, July 31, 2006

Photos!

Here's a link to a couple of photos I've uploaded. They're small, untouched. When I return to the States, I'll redo the gallery.

Photo Gallery

Sunday, July 30, 2006

Snapshots

Women here swim in the sea, but only on private beaches that are away from men. They swim in t-shirts and pants. Even if there're only women there: t-shirts and pants.

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It's my first D&C (see other post) and I'm standing behind the doctor, angling the lamp so that it shines through the speculum and illuminates the cervix. The doctor is below me, hunched over, curette scraping the inside of her uterus. The scene is very solemn; this is serious work. The nurse is frowning. The patient is biting her forearm to keep from crying out.

Suddenly: Deet-do diddle-da didi didi deet-da deet deet diddle-da!

Circus music. Under his surgical gown, the doctors cell phone is ringing. The caller is persistent and we sit through seven missed calls of Barnum & Bailey.

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Internet banner ads in the States say things like, "You've won a free iPod! Click here to claim your PRIZE!" Here, they say, "LIVE and WORK in the USA! Congratulations, you've got one FREE YEAR! Click here for your USA Green Card!"

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We're in the operating theatre for my second c-section. This one was not scheduled. The patient came in this morning complaining, as far as I can tell, of high blood pressure. She returned in the afternoon dripping blood from her vagina. She's 32 weeks pregnant. We have to operate immediately.

Nurses bustle about, making final preparations. The surgeon and her assistant and ready, waiting. I've been tasked to help the anesthesiologist and we're having trouble. The bag of blood is clotting.

From behind one of the steel tables -- skeletal, industrial, as you'd expect in an OR -- a nurse pulls out a three-foot-long, neon green, plastic flyswatter. WHACK! She kills one on the end of the operating table. WHACK! Another, against the far wall.

I suppose it's very pragmatic, but the very thought of it -- the idea of this kind of thing happening in an OR in the States... I can't help but laugh. Someone from OSHA would be apoplectic.

Dilation and Curettage

It's 9pm and dark outside. We're in a tiled exam room with bright yellow curtains. A row of gynecological tables are all empty. The nurse is assembling the tools we'll need. Two trays, sterile gloves, sterile gauze, a bowl of antiseptic solution, lidocaine for local anesthesia, a speculum, forceps, dilators of various sizes, curettes of various sizes, a large bowl at the foot of the table.

Our concerns are infection, Asherman's syndrome (intrauterine adhesions), perforation of the uterus (and perhaps subsequently the bowel, etc), lesions on the cervix, etc. But these are only the things that can go wrong.

What we're doing tonight is a D&C -- dilation and curettage. An incomplete miscarriage is the reason. Our patient miscarried and has had heavy vaginal bleeding for days. She's been receiving blood, but this will be a definitive fix. We used an ancient ultrasound machine to look at the uterus earlier and, sure enough, there is a small sac inside that needs cleared out. Once it's gone, the bleeding will stop.

The technique is this: Wipe the area clean with antiseptic solution, soak up the blood in the vagina. Insert the speculum and lock it on the open position, visualizing the cervix. Inject the cervix with lidocaine to provide local anesthesia. Use the dilators, starting with the smallest, to gradually dilate the cervix, giving access to the uterus. Insert a dilator into the uterus and note the depth, as if checking an oil dipstick. Insert a curette into the uterus and gently scrape the uterine wall, careful not go too deep (the dipstick), and then slide it out, along the speculum, until it drops into the basin at the foot of the bed, between your legs, below her legs.

As needed, use sterile gauze to sop up blood pooling in the vagina. As pieces of tissue are removed, give them a very cursory inspection. In the States, I think the tissue would be sent to a lab. Here, it is dropped into the basin. Be gentle with the patient but be diligent to get all of the tissue out of the uterus. Inevitably, the paper beneath the buttocks of the patient will become soaked with blood and bits of tissue, like a great crimson waterfall dripping down into the basin below.

-------

I observed my first D&C last night. I was uncomfortable and surprised and had to remind myself that any violence we were doing was in the patients best interest: without this procedure, she might eventually bleed out and die.

When the procedure was finished, I went to the library and read up on exactly what it was. The knowledge of what we'd been doing, why, what the salient considerations were, etc, was reassuring. As one might guess from the technique used, D&C used to be a rather common method of abortion. These days, there're much safer and easier medical abortions, but surgical abortions utilzing D&C, D&E (evacuation), etc, are still sometimes performed. The textbook here claims 2.6% in the US in 1996, down from 24.7% in 1970.

After a once-through with the gynecology textbook, I went and had dinner. Goat meat again, with rice. After dinner, Dr. Derrick and I went back down to the clinic.

I assisted in my first D&C last night. This one was messier, as the pregnancy had advanced further, but I felt immesurably more comfortable. This time, I helped prepare the tools needed and then put on sterile gloves to assist. I probed the cervix with a dilator, under the doctors guidance, noting and discussing the resistance felt in the uterus. This kind of experience is invaluable, I think. It will make the didactic portion of PA school immesurably more personal and visceral.

Saturday, July 29, 2006

Day-trip to Berbera

Edna owns property on the beach in Berbera, on the northern coast. Her niece and her niece's mother (which makes her... what?) are here and on Friday -- Friday is a holiday here, like our Sunday -- all of us piled into two Land Cruisers with armed guards and headed off to the beach. The only American living long-term in Hargeisa, a Texan woman named Diana, joined us.

It was a two hour drive and it became steadily hotter as we drew near the coast. Along the way, there were huge herds of camels, posses of thuggy-looking vultures, digdigs dead on the road, thousands of goats, baboons, and some warthogs. I took pictures of the camels and of a funny hotel along the road. (Speaking of, I'm going to try to upload a few pictures soon. This computer, at the hospital, has PhotoShop CS on it.)

The property, entirely undeveloped save for two grass huts that're falling apart, had a nice stretch of beach. Unfortunately, it was so windy that you had to walk with your head under a towel, shielding your eyes from the blowing sand. The water, normally crystal clear, was clouded by dirt and sand. It was great to get out of the heat, and I didn't get eaten by a shark, but standing up out of the water meant you'd get pelted by flying sand at such velocity that it caused sharp pain. We didn't stay long. Still, it was nice to get out of the city, even if it was in a coddled, hyper-privilidged sort of way. Edna is a gracious host and it was nice to talk with Diana about her travels, the security situation in Mogadishu, what her daily life is like here in Hargeisa, etc.

Hospital, Part One

At dinner on the night I arrived, I met one of the five or six doctors here. His name is Dr. Qaws and he is, I believe, the main surgeon for the hospital. Over dinner, he mentioned that there was a c-section planned for this evening and that I ought to join him and assist. I jumped at the chance, but had to point out that I'd never been in an operating room before so perhaps simply observing was best for this time.

After dinner, we went downstairs to the hospital and I scrubbed in on the c-section. Final preparations were underway as the nurses laid out the surgical tables, the pediatrician prepared himself to receive the baby in the next room over, etc. At this point, I was already feeling slightly hot and anxious. I'd never been in an operating theatre before and here I was, on a few hours of sleep, two days on busses, eating terrible food, and I was about to observe my first c-section.

The doctor soaked her belly and thighs in betadine while one of the nurses administered ketamine to put her out. Without any fanfare, it began. One quick stroke opened up the dark skin of her belly, exposing the white marshmellow beneath. Blood started to spot against the white and he cut deeper, teasing back the fascia, muscle, and scar tissue of two previous c-sections.

(Tense change!)

Within a few minutes, I can feel myself heating up sharply and sweating and I want to stave off feeling faint so I slip into the adjoining dressing room to take a breather. Back and forth and soon the baby is out, handed off to a nurse who rushes it into the next room to the waiting pediatrician. The baby is grey and completely limp.

The next minutes drag by as Dr. Amir, the pediatrician, tries to resuscitate the baby. Oxygen, manual stimulation, CPR compressions, a shot of epinephrine, suction, the heating pad. He's sweating and pushing the pace, trying to get some response. I'm thinking the baby is doomed and when I return to the operating theatre and see the amount of blood spilling out into the floor, the inadequate suction as Dr. Ouse stitches the uterus closed, I think we might lose the mother also.

Finally, after a good eight to ten minutes, the baby starts to poop and to cry. There's relief and smiles all around. Dr. Amir administers a shot of vitamin K to encourage clotting and begins to talk to me about determining the age of a baby. The cracks on the feet, the cracks on the scrotum, the descension of testicles, pinching the nipple, folding the ear. Each of these things gives you an indication, down to the week, of how old the baby is. "Mothers are not precise, you know? But these signs, they are accurate. I can tell."

In the other room, the mother is done being stitched up and seems stable. I go up to my room and collapse onto the bed. Even only as an observor, the event was stressful and emotional.

-----

The nursing team here is comprised exclusively of locals that have all been trained, in a three year program, by Edna and her staff. Edna herself is a nurse, trained in England. The head nurse, currently, is a Tanzanian woman named Paschazia (from the Swahili "Pasca" -- Easter, since that's when she was born) and the head nursing instructor is a Nepalese woman named Sitara. Sitara is here on behalf of the UN.

The physician team is equally international. Dr. Derrick is a Ugandan and his wife, Dr. Hawa, is also a physician here. (They have a beautiful 11 month old who's learned a few commands: "Clap your hands!" "Show your tongue!") Dr. Amir, the pediatrician, is an Egyptian, working at the hospital at the behest of the Arab League. Dr. Qaws and Dr. Dehk, I believe, are both Somali, though the latter also has Canadian citizenship. The head on-site doctor, Dr. Thereza, is Rwandan.

Thankfully, the common language is English, albeit spoken with varying degrees of skill.

My schedule has become somewhat routine over the last few days. In the morning, I'm up at 5:30a or 6:00a, after the first call to prayer at the mosque across the street. Breakfast is at 7:00a and then Dr. Derrick and I do rounds starting at 8:00a. This continues until lunch, at 1:00p, which is followed by a three hour siesta. People retire to their quarters and nap. Things start rolling again at 4:00p and starting at 5:00p, I go to to the outpatient clinic with Dr. Dekh and we see whatever comes through the door for a few hours.

This hospital is private, albeit not-for-profit. While the name includes "maternity," and that remains a big part of the mission here, we see cases of all sorts, excluding trauma. (I'm hoping, while I'm here, to spend a few days at the main government hospital where all the trauma cases go.) Typhoid is common. Malaria less so. The UN claims HIV levels at 15%, the local lab technician claims less than 5%. In the few days I've been here, we've discovered a number of HIV+ individuals.

Two days ago, we visited a patient with severe oral thrush. It was exciting to see, in person, what looks like a textbook case. My first thought was, "HIV. Thrush, Kaposi's Sarcoma, pneumocystis -- always point to the possibility of HIV." Outside the clinic, afterward, Dr. Derrick turned to me and said, "In Uganda, there are certain things that always point to HIV... oral thrush, Kaposi's Sarcoma, cerebral toxoplasmosis, pneumocystis..." He was thinking the same thing I was. The nurses drew blood and had him tested and sure enough...

Today we went and talked with him privately, approaching the topic obliquely, encouraging him to get tested, asking him what he would do if he was positive, what he would do if he was negative, etc. HIV/AIDS has a huge stigma here. Nobody wants to talk about it, nobody wants to get tested. They're aware of the problem, of course, and the symptoms, etc, but everyone thinks it won't happen to them. In that regard, it's an awful lot like the US. Half the HIV+ population doesn't know it because they've "always been careful" and "feel totally fine," etc.

Medicine here lacks a measure of precision due to the lack of tools available. Everyone is trying their best, but things are tough. A headache that doesn't change for four days can't get a head CT because there isn't one in Hargeisa. The baby the first night I was here needed intubated, but there're no infant-size ET tubes available. Some antibiotics are given out willy-nilly because we've received a large donation of them and they're all about to expire anyway. Others simply aren't available. We turn to the medical library here and try to sort out what the fourth or fifth choice antibiotic is for a given disease because the first, second, and third choices simply don't exist here.

I'm learning a lot. There's a well-stocked medical library here and I spend much of my "down time" reading up on things we saw in the clinic earlier in the morning, etc. The doctors are all happy to discuss things with me, though language can sometimes be a problem. While this is no substitute for formal education, I think it'll help me "get hooks in," making the same topics more familiar and engaging when they come up during PA school. I'm also hoping I'll see some things here that you simply don't see in Europe and the States.

Speaking of that, I've received a few email acknowledgements of receipt of my PA application and, for Duke, a request for a supplemental application to be filled out by August 15th. I'll do that as soon as I get back in the states as internet access here is too dodgy. I'm more excited than ever about PA school... I can't wait to learn all of this stuff. I'm just scratching the surface here.

Friday, July 28, 2006

Crossing into Somaliland

In the morning, it took an hour to fill the bus and it was too dark to read. I had forty or fifty pages to go in "Ravelstein" and was eager to get to it. Once the bus was full, the bus driver turned the key and -- nothing. I won't go into the details, but we sat for two hours, as people fiddled with things, before I gave up on them and found another bus heading east.

On the new bus, I met an ethnically Somali Djiboutian man who was a French teacher in Hargeisa. His English was very poor, and my French doesn't extend far beyond asking someone to sleep with me, but we made do and chatted off and on as the bus made its way toward Jijiga.

Once in Jijiga, it became apparent that we'd have an hour to kill before a bus left for the border. We had pasta for lunch and I convinced him to ask the waiter if he'd seen American soldiers. He said yes, but not for the last two weeks. A little more poking around town after lunch pointed us toward a nearby hotel.

At the hotel, it turned out that the Americans who'd been staying there had now left for a nearby town, but that they'd given the hotel two placards as "thanks." I looked and, sure enough, it was two Civil Affairs groups, from the 412th and the 96th. The hotel owner showed me pictures of them and explained that while they'd been here, they'd worked in Jijiga and the surrounding areas to build twenty schools, dig six wells, and start a medical clinic. It wasn't the exciting counterterrorism scoop I thought it might be, but this was good: hearts and minds. Everyone at the hotel was gushy over how good it was of the Americans to help out.

We boarded the bus for the border, at Togowahale (sp?), and arrived a few hours later. On the Ethiopian side of the border, my new friend was detained and sent back for now having his papers in order. Apparently, he had no passport but had citizenship identity papers for Djibouti, Ethiopia, and Somaliland. Somali people extend into all three countries, true, but apparently people are only allowed to pick one country to be a citizen of. If I understood correctly, they were going to force him to pick one and then tear of the other two sets of papers. The guards shooed me toward Somaliland and marched him into a back office.

The border between Ethiopia and Somaliland is almost exactly nothing. There're dumpy shacks on one side, an open expanse of a hundred meters or so, and then some more dumpy shacks on the other side. In the middle is a metal pole, the sort you see at a parking garage exit. I walked across it alone, baking in the hot sun, past bushes completely plastered with plastic bags and other trash. On the other side, one of the shacks looked more official than the others and I stopped in to have my passport stamped.

The man inside looked mildly surprised to see anyone, but he was quick to ask for my passport and visa, writing my information into the log book. Full log books from earlier years lined a shelf and I smiled at the idea that a single leaky roof or fire could wipe out every record of who has come and gone from a country in the last decade.

And that was that. Somaliland. I was officially in Somaliand, technically in Somalia, standing on the ground of a country claiming to exist while the world denies it.

Now on the Somaliland side, I found a shack that looked to sell cigarettes and change money. I wanted to change USD$100 into Somaliland money, but I wasn't exactly prepared for the man to start pulling out stacks of bills, rubbed-banded together, and piling them up on the counter. My USD$100 bought me $640,000 in Somali shillings. The largest note is 500 shillings. Sixteen thick bricks of cash went into a plastic bag and I walked away from the counter feeling like a mob boss.

I wasn't fifty feet down the road, eyes darting side to side as it was blatantly obvious that the sagging bag in my left hand was filled with cash, when a man approached me and asked if I would like a ride to Hargeisa for free. He came to the border to drink, he said, with his friend and girlfriend, and they were leaving back to Hargeisa right now. I found his motives highly suspect, though the smell of alcohol on his breath lent credence to at least part of his story. I kept walking toward the taxi area as we talked, me trying to feel him out, him trying to get me to turn around and get in his car.

Taxi drivers started to approach and a sort of bidding war broke out, except that this guy was offering to drive me for free. After a minute of confused bickering, the police showed up. Police here, mind you, are slouchy guys in khaki who carry machine guns. The argument escalated and one of the police shoved the guy who was offering me the ride. I didn't immediately realize he was police and I stepped in between them, without thinking, and pushed the two of them apart, one hand against each mans chest. Immediately, I realized it was a mistake. The policeman didn't even look at me, but I thought, "What the fuck am I doing? I need to defuse this, get out of here, not get involved." Another shove and then a second policeman was there, pushing the man backward out of the crowd.

I got in the nearest taxi, one with an English-speaking passenger who'd been beckoning to me, and we immediately pulled away from the crowd, parking a few hundred feet away. In the ten minutes before we really got underway, two interesting things happened. One, a policeman showed up and asked, through the English speaker, if I knew the man who'd been offering the free ride. I gave a short account of meeting him and the policeman said they'd already arrested him: alcohol is illegal in Somaliland and they too had noticed the smell of alcohol on his breath. Second, the French-speaking teacher appeared, looking badly shaken. He told me that they had let him across the border but that they'd taken all of his ID papers and robbed him of all of his money. The taxi I was in was full, but I gave him what was left of my Ethiopian birr and hoped that would be enough for him to get a ride to Hargeisa. I felt bad, in that I may have drawn attention to him because I was a foreigner, but I wasn't sure how to make the situation right beyond giving him some money.

The road to the border from Jijiga is a road, albeit a very poor one. A single lane, dirt, but still a road. The "road" from the border to Hargeisa starts off being not a road at all. It's a dirt track, or rather a series of dirt tracks crisscrossing each other across the desert. After heavy rains, the whole route might be wiped out. Thankfully, after 45 minutes of this, you end up in asphalt.

We cruised into Hargeisa and I caught another taxi straight to the hospital here that I'm volunteering at. I was completely knackered from three days of little sleep and two days of the physical pain associated with cramming 34 people into a minibus -- the size of an American minivan but three or four feet longer. 34! Edna was here when I arrived and dinner was about to be served. I put my bag in the room I'll be staying in here and went downstairs to have dinner.

Wednesday, July 26, 2006

East Across Ethiopia, Part Two

In Coptic Christian Ethiopia, Harar stands apart as a Muslim city. The "Old Town" portion of it, I hear, is 65% Muslim and has twenty mosques. The houses are angular and low, with white walls.

My bus ticket is for Jijiga and I will join the bus again in the morning at 5:00a. After finding a hotel, I debate the danger of wandering around after dark against the disappointment of sitting in a hotel room when there's a new town to explore.

Curiousity gets the better of me and I strike off into the night.

After twenty minutes of walking, a young man approaches me and strikes up a conversation. His name is Addis ("new" -- Addis Ababa, the capital of Ethiopia, means "new flower") and he's 16. His english is quite good and we're soon joking and laughing. He tells me that he loves reggae music and mentions Burning Spear and Bob Marley. I ask him what other kinds of music he likes and we turn to rap. "50 Cent. You know 50 Cent? Eminem. Tupac."

"Everybody likes Tupac," I say.

"No, not true. East... in the East... of America." He flashes a "W" gang sign with his hand. "West siiiiide..."

We talk about the history of Harar and things to be done in the city. He mentions that there's a man on the edge of town, outside the city walls, who feeds hyenas every night. I'm game. We walk across town in a downpour, Addis leading me through narrow alleyways of cobblestone.

In twenty minutes, we arrive. The hyena feeder is a man named Yusuf. He's not the original hyena feeder; that was his uncle. I don't ask where the uncle is now. Yusuf brings out buckets of meat and with clucking and whistling, draws the hyenas near. He puts scraps of meat on the end of a stick and the hyenas slink forward, slowly, and then pounce and jump, tearing the meat off the stick.

After a few minutes, he invites me to give it a try and I don't hesitate. When's the next chance I'll have to feed hyenas? It's fun and funny. I'm thinking about how the pictures will come out, but I'm afraid, as they lunge for the meat, that one of them will lunge straight AT the stick, get stabbed in the gums or eye, and flip out. A hyena fight in Ethiopia is an even better story than feeding them -- and the scars are sure to be wicked -- but the stakes are awfully high. Besides, the odds are stacked against me: I'm a soft-bellied, clawless human and hyenas are... well, they're hyenas. They killed Mufasa.

Addis and I have dinner together afterward -- my treat -- and he tells me that he's seen American soldiers in Harar. They're living in Jijiga, he says, and were in Harar to buy shoes and swords. I ask him if they have beards and when he says some do, I wonder if they're Special Forces, Civil Affairs, or a mix of both. I decide that if I get stuck in Jijiga for some reason, I'll go track them down and see what's happening. If they're CA from Djibouti, that's rather boring. If they're SF, and they're in Jijiga, which is Ethiopia despite being almost completely Somali (ethnically), and Jijiga is a smuggling town, and... I get excited thinking about it as my mind swirls with possibilities.

Later that night, I wander back to the hotel. I'm completely drenched. Before bed, I lay my passport and plane tickets under books so they'll dry flat. I get a few hours of sleep before waking at 4:45a to make my way to the bus stop.

Tuesday, July 25, 2006

East Across Ethiopia, Part One

With my visa in hand on Monday, I made arrangements to leave for Jijiga on Tuesday morning. Unfortunately, the bus wouldn't leave, I was told, until 11:30a. Not exactly the early start I had imagined. When I frowned and tried to ask if there was an earlier bus, someone interjected that it was leaving at 11:30a "Ethiopian time" -- 5:30a "European time." Apparently Ethiopia is six hours ahead of what it's "proper" time zone ought to be. That's strange, but it's maybe even more strange that it's 1998 here. "Gregorian calendar," I'm told, but that just adds to the confusion.

That night, I made friends with the girl in the hotel internet cafe and took her to dinner across town. Her name is Selam ("salaam" - peace). Owing to her excellent english, we were able to happily range across topics from what it means to be Orthodox/Catholic or to simply be a "good person," to local problems with sex tourism. At the end of the night, we exchanged email addresses and I'll hopefully see her again when I'm back in Addis for my flights home.

In the pre-dawn darkness the next morning -- 4:30a, European time -- I made my way to the bus stop. The scene was complete chaos. There were a hundred or more busses and thousands of people bustling about, shouting, pushing, selling wares. I had a ticket from the day before indicating that I ought to find bus 2123, but most of the busses seemed unmarked and those with numbers might have it any variety of places: on the front, the right side, written on a placard in a rear window.

With local help, I soon found the bus. Then the real waiting began. We spent an hour and a half, idling, waiting for more people to arrive. I read "Freakonomics." Once we were ready to go, it took almost an hour simply to leave the bus lot and get onto the road. Wading through the sea of people, around the other busses that're still parked, knocking heads with other drivers also trying to leave. Young men and women would jump onto the bus, selling tissues, gum, bread sticks, mangos. Occaisionally, a begger would spot me and lunge forward, hand outstretched, "Faranji! Money! Faranji! Money!"

I am a faranji here -- a foreigner. No amount of tanning or local clothing would hide that. Everyone seems pleasant and unsurprised to see me even though I haven't seen another white person since arriving. They all want to know where I'm from and I tell them I'm American though it's not my first impulse -- a habit, I think, from Afghanistan, though it's one that was unwarranted even there.

Most people spend the morning sleeping. When we stop for lunch after a few hours, people return to the bus with bunches of green leaves on sticks and the rest of the afternoon, and on into the evening, is spent chewing "chat." Chat is a local plant -- a bush -- growing small stalks with leaves twice a year after heavy rains. It's purchased in bunches of sticks and the leaves -- the younger the better -- are plucked off each stalk and chewed to release a mild stimulant. It's bitter and stains the teeth, but gives feelings of energy and greater focus. People, addicts really, complain that without it they cannot think. Psychiatric wards here are mostly populated by chat addicts.

As afternoon recreation, it seems incredibly common. At least half of the bus chews it and every town and village marketplace is lined with people selling it. The police stop the bus at multiple checkpoints seemingly exclusively to check to see how much chat is on the bus. Each person is allowed one large bundle. People with more pass bundles around the bus until it's evenly distributed, appearing as though we each only have one. After the checkpoint, they're passed back to whoever they really belong to. In the country side, goat and camel herders appear out of nowhere and run toward the bus, throwing money in the windows in exchange for bundles of chat. Chat is its own economy.

The eleven hours passes mostly uneventfully. I finish "Freakonomics" and nearly finish "Ravelstein." Both are delightful. The former is a fast, playful read. The latter is filled with little bits of wisdom and demands more careful consideration. That night, we stop in Harar.

Monday, July 24, 2006

Addis Ababa and the Somaliland Visa

Addis is a breath of fresh air after Dubai. The land is green and hilly. It's 19 degrees and overcast. Earlier, it was pouring rain.

Before I left, I found a note on the internet describing how to get to the Somaliland Liaison Office here in Addis. The process involved finding the Awraris Hotel, which is across from the St. Gabriel Hospital, and then walking 200 meters down the dirt road that adjoins the hotel, turn right, walk another 200 meters. You'd come to an unmarked house, notable only because it has doormen. That's the spot.

As it turns out, this is no longer true. The new Somaliland Liaison Office is an unmarked compound in an entirely different part of town. I called one of the mobile numbers that Edna -- the founder and director of the hospital I'll be interning at -- gave me before leaving and seven stops for directions later, my taxi driver and I managed to find it.

As we arrived, there was a man standing at the gate, waiting to be let in. He and I started talking and he asked where I was from. When I told him I was American, he said, "You people need to not confuse Somalia and Somaliland." I told him I knew the difference and, as we walked into the compound, he gave a short run down of the history of Somaliland and how they deserve independence because they've held many elections, have laws and social structure, etc. It's all history I've been reading prior to this trip, so when he paused for a moment, I interjected that Somaliland has been stable for 15 years. He smiled at my knowledge of the history and shook my hand as we parted, me into the visa office and him into another building.

Inside, I was given a visa request form to fill out and told to return at 10a tomorrow because the consul was in an all-day meeting and he was the only one who could issue visas. I was a bit disappointed, having hoped to secure the visa and started heading east today.

As I walked out of the compound, I ran into the man from the gate again and he asked me what happened. When I explained the situation, he frowned and walked back to the visa office with me and spoke with the woman there. As it turned out, he was the Minister of Agriculture for Somaliland and got on his cell phone and called the consul on my behalf. Ten minutes later, the consul showed up with an entourage of business men, signed a visa for me, and then shook my hand and said, "Welcome to Somaliland!" as he left.

The first rule of travel is: be nice. The person sitting next to you on the bus might be a warlord. And the person standing outside the unmarked gate might be one of the countries ministers and have a lot of pull.

With my visa in the bag, I hopped a local bus for 40 cents and started heading across town toward the bus station. It was too late in the day to catch a bus, as it turned out, but I bought a ticket all the way to Jijiga for 66.55 birr.

The basic size and shape of getting to Hargeisa overland is: Addis to Nazret to Dire Dawa to Harar to Jijiga and then cross the border at _______ (I'm not sure) and then on to Hargeisa. When I mentioned to Edna that I was going to go overland, she said that people did it, but she wasn't sure how it would work for foreigners. I guess I'll find out in a day or two.

In the mean time, I think I'm going to go track down some delicious Ethiopian food before it gets dark. Oh, and it's true what they say about Ethiopian women: they're beautiful. Smiles, butts, boobs, sass, fashion of every sort in a rainbow of colors. They work, waitressing, cleaning, handling money, moving, shopping, arguing, bumping into and pushing past men. They're present in a way that stands in contrast to women in, say, Afghanistan or Dubai. In the former, they're invisible, like ghosts. In the latter, they're veiled child-minders, wholly ignored, set apart from "normal" society.

Sunday, July 23, 2006

Heading East and a Day in Dubai

I'd wanted to have breakfast with Eva in New York City but the plans fell through and the layover was a bust. Too bad, since I spent much of the flight reading "Ravelstein," Saul Bellow's pseudo-biography of Alan Bloom, and wanted to discuss it with her. A late departure from SFO meant that my already short layover was whittled down to the point where it was moot to try to go into the city. Instead, I wandered out of the terminal and walked around for a while. It was hot and sticky. (That's a Hemingway line.)

Dubai is 12 hours off San Francisco and Addis is similar. I decided it was easier to stay up "later" than to go to sleep "earlier" and spent much of the flight struggling to keep my eyes open, or at least not nap for too long. I watched "The Matador," "V for Vendetta," "16 Blocks," and "Walk the Line." After that, I tried to play a word descrambling video game, but with no sleep in 35 hours, I was so out of it that I couldn't unscramble things with more than four or five letters. After some particularly frustrating stare downs with some of the longer scrambles, full of Y's and Z's, I began began to suspect some of the words were in Arabic rather than English.

We touched down in Dubai early in the morning. I didn't particularly feel like staying, knowing that it would cost a small fortune for even a day. Never mind the fact that at 8 o'clock in the morning it was already 35 degrees. I immediately tried to switch my ticket -- scheduled to leave for Addis 24 hours later -- for one leaving sooner to Addis, Hargeisa, or Djibouti. With no luck, I hopped a taxi and headed off to find a hotel for the night. I ended up in the Deira neighborhood, where many of the famous "souks" (marketplaces) are. The hotel I ended up at was a block away from the entry to Dubai's famous "Gold Souk."

By mid-afternoon, it was 46 degrees and too hot to do much walking around. I went to the Emirates Mall, on the other side of town, and ate a delicious lamb curry while watching people play in the snow at <a href=" http://www.skidxb.com/">Ski Dubai</a>, an indoor ski resort in the mall. It was good fun watching young Arabic men hike up their dishdashas with one hand and sprint forward, diving onto the inner tubes and flying down the slope.

Afterward, I walked down the length of the mall and back. The directory listing for this mall is about eight feet long and every shop imaginable is there. I stopped into the Diesel store and was unsurprised to see that the high-end jeans here cost as much as they do in London or San Francisco. There's perhaps more sticker shock here since the tag says "AED 950." Dubai, or at least the fancy "city center" area of Dubai, caters to a jet-set clientele. Many of the shops are custom tailors selling USD$5000 suits, USD$10000 dresses, et cetera. In addition to a ski resort, there's a cinema, a bowling alley, an arcade, an amusement park with 100' ceilings for the rides, etc. In the center of the mall, there was a queue of hundreds of kids, mothers standing by in black robes and full veils, waiting to have their picture taken with Mickey Mouse while the MC hyped the crowd, "Do you love Diiiiisney?!"

Eventually, I ended up at the cinema and bought a ticket for "The Road to Guantanamo," momentarily forgetting that I was in a mall in Dubai, not a mall in the states. The English portions of the documentary were subtitled in Arabic and French, but the the Arabic portions were -- "duh" -- without subtitles. To make matters worse, I'd forgotten how tired I was and in the comfy seats and darkness, I kept nodding off only to be awakened periodically by a dramatic re-enactment of an American soldier booming at one of the characters, "You fucking PUSSY! Why are you in AFGHANISTAN, you aren't worth SHIT!" After one of my wake-ups, I glanced at my watch and had a moment of delirious, sleep-deprived panic where, owing to an "AM/PM" mix-up, I thought I'd accidentally stayed in the theatre all night and was about to miss my flight to Ethiopia. I decided I'd better just leave.

In the early evening, I spent a few hours walking around Deira, even more abysmally tired and with sweat stinging my eyes. The older parts of Dubai have winding alleyways that remind me of Peshawar. Everything imaginable is available here and shops tend to cluster by what they sell. One area is almost exclusively fabric and clothing, another electronics, and another building supplies or household appliances. In my travel clothes, I felt under-dressed and dirty at Emirates Mall, but in the back alleys of Deira, I felt conspicuously over-dressed. Eager men with moustaches would follow me and offer me "ladies, pretty ladies" over and over and I'd turn them down in Arabic, "la(g), shokrun."

My whole time here, I've delighted in using my miniscule Arabic to talk to people. The airport visa desk, my taxi drivers, hotel managers -- nobody has been safe. Pimsleur claims "good day" ("sabeh el kheir") and its response ("sabeh en noor") are common, but I'm not so sure. The former means, "fine morning" and the reply means "light (of the?) morning." (Noor, nur, like Nuristan. The people of light.) I've had people respond to me with "sabeh en noor" and a delighted smile, but I've heard nobody else say it. The closest I've heard is a quick, casual "sabeh." Mornin'. I think that me using the full phrase is a bit highfalutin, like saying, "Top of the morning, sir!" would be in English.

I'm back at the airport now. Since I'm already almost done "Ravelstein," and the only other book I brought is "And You Shall Know Our Velocity," I picked up a paperback copy of "Freakonomics" at the duty-free store here. My flight leaves for Addis soon. I'm eager to get to Hargeisa and start volunteering (and to off-load the small mountain of thermometers from my backpack). My first order of business in Addis will be to find the Somaliland Liaison Office and get a visa. After that, I think I'll strike out for the border, maybe even getting as far as Dire Dawa or Harar today if I'm lucky.

Sunday, July 16, 2006

Packing List

BASIC: My same Nike sneakers, my small Victorinox backpack. A money belt, although I wonder if I should bother putting my (paper) plane tickets in it again or not. They're bulky and can probably be replaced (with some effort) if they're lost/destroyed. Because of the exchange rate to local bills, even small amounts of USD are going to be big piles of local currency, so I think I'll end up taking a lot of small USD and changing it frequently.

BACKPACK CLOTHING: Two pairs of travel pants. Two long-sleeve ultra-lightweight cotton shirts. Maybe a wicking, synthetic t-shirt. Buy one or two sets of local clothes once there. Six pairs of underwear, six pairs of moisture wicking socks.

BACKPACK DOCUMENTS: A copy of my passport information page, a copy of all relevant visas, and a copy of my flight itinerary and tickets. List of phone numbers/relevant contact information, extra passport photos (2x), and my drivers license.

BACKPACK KNICK KNACKS: Two large, heavy gauge trash bags. Four large zip-lock freezer bags. A watch (waterproof). A bottle of 35%+ DEET spray, because malaria is uh-scary-uh. Small roll of duct tape, 12' or so of paracord, some Katadyn water purification tablets. A few novels (???) and a map of Somalia and eastern Ethiopia.

MONEY BELT: Passport, plane tickets (or not?), backup cash, credit and debit cards. Tiny phone number list, 2x passport photos, 4x analgesics.

GADGETS: Sony Psyc MP3 player (AAA), Pentax Optio W10 (waterproof, proprietary D-L18 battery). Spare AAA or two, spare D-L18, D-L18 AC charger, spare microSD card.

TOILETRY KIT: Two rolls of camp toilet paper. Nail clippers, small safety pins, deoderant, biodegradable camp soap, toothbrush, toothpaste (small), earplugs, some q-tips.

MED KIT: Scissors (TSA?), immodium, eletrolyte replacement powder (at least 12 packets), superglue, coban (?), band-aids, Malarone treatment dose, Cipro, Aleve (analgesic + anti-inflam), moleskin. Wrap the god damned superglue seperately.

Consider: Sunscreen, a camp towel? Why am I still bothering with any paracord at all? Why the coban? Is the ability to wrap a wrist or an ankle really worth the size? Nevermind the superglue.

Friday, July 14, 2006

The Horn of Africa

Another trip, another blog. This time it's the Horn of Africa. I don't know why, exactly, except that there's been an interesting undercurrent of news about the HoA for months, even years, now and it's piqued my interest. It's like that old Beatles lyric, "...but I just had to look, having read the book."

I'm flying into and out of Addis Ababa. For those of you who never had chickenpox while in grade school, and thus no opportunity to memorize all the countries and capitals in Africa, that's the capital of Ethiopia.

I'd like to visit the churches at Lalibela in northern Ethiopia and I feel strangely drawn to Mogadishu, the "capital" (sort of) of Somalia proper. I'd love to poke around the Mog for a few days and get a real feel for what it's like on the ground, but it may be too dangerous to do so.

The only thing concrete is that, at some point in the trip, I'll spend two weeks as an intern at a hospital in Hargeisa, the capital of Somaliland. Somaliland is a breakaway republic in the north of Somalia which declared its independence from the rest of Somalia in 1991 after a decade-long civil war. Today, there isn't a single country in the world that formally recognizes its independence.

If you had chickenpox before 1991, you're off the hook for that one.

The Horn of Africa

Monday, August 14, 2006

All Photos Uploaded

Friday, August 11, 2006

Slinking back into the West

Wednesday, August 09, 2006

"But you can never leave..."

Final Days in Hargeisa

Sunday, August 06, 2006

Surgery, Diana's NGO, and Daallo Airlines

Saturday, August 05, 2006

War Stories, Cultural Oddities, and

Friday, August 04, 2006

Somali Politics, Ex-Pat Party, and Books

Khat, Beauty, and the Public Hospital

Tuesday, August 01, 2006

Craniotomy and Reflections on Reacting to Surgery

Monday, July 31, 2006

Photos!

Sunday, July 30, 2006

Snapshots

Dilation and Curettage

Saturday, July 29, 2006

Day-trip to Berbera

Hospital, Part One

Friday, July 28, 2006

Crossing into Somaliland

Wednesday, July 26, 2006

East Across Ethiopia, Part Two

Tuesday, July 25, 2006

East Across Ethiopia, Part One

Monday, July 24, 2006

Addis Ababa and the Somaliland Visa

Sunday, July 23, 2006

Heading East and a Day in Dubai

Sunday, July 16, 2006

Packing List

Friday, July 14, 2006

The Horn of Africa

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