In Somalia, there are some days when the sky suddenly darkens as hundreds of millions of hungry desert locusts descend over the country's crops.
This year's locust outbreak is Somalia's worst in 25 years, threatening the food supply, and prompting the government to declare a national emergency in February. The infestation was exacerbated by heavy floods that have displaced half a million people and created an ideal breeding ground for the locusts.
To that nightmare scenario, add a pandemic. A pandemic in a country already fighting many serious threats, such as terrorist groups who control large parts of rural areas, or the widespread corruption in the country.
Despite these challenges, WHO's country representative is resolute.
"We can only end this pandemic if we can end it in settings like Somalia," said Dr. Mamunur Rahman Malik.
A fragile health system
Somalia ranks 194th out of 195 on the Global Health Security Index (behind North Korea and in front of Equatorial Guinea), its health systems decimated by decades of civil war. While the global standard for health care workers is 25 per 100 000 people, Somalia only has 2 health care workers per 100 000 people. With only 15 ICU beds for a population of more than 15 million, it is listed among the least prepared countries in the world to detect and report epidemics, or to execute a rapid response that might mitigate further spread of disease.
In January, WHO began pre-positioning enough PPE to treat 500 patients and organizing trainings for health care workers. The local team quickly took nasopharyngeal swabs from four Somali students returning from China, and sent them off to the Kenya Medical Research Institute to be tested. One of the results --- from a 26-year-old male --- came back positive, indicating the country's first official case of the virus on 16 March 2020.
150 more samples from around the country were sent to Kenya to be tested, while the WHO team began building local testing capacity. Two virologists were brought in from Ethiopia on UN special flights to provide expertise and help set up the facilities. The UN Humanitarian Air Services (operated by the UN World Food Programme) flew in molecular testing machines, procured by WHO, from Nairobi to the new testing locations. The UN Population Fund provided a biosafety cabinet and extraction kit machine --- which is used to examine viral genetic material from the swabs.
In an unprecedented feat, WHO Somalia managed to set up three molecular testing labs across the country by 30 April 2020: one each in Mogadishu, Garowe, and Hargeisa.
Stepping in for the Health Ministry
Another challenge unfolded in the Somali capital, Mogadishu. Only days after the first cases of COVID-19 were announced, ten senior officials and staff from the Ministry of Health were arrested on corruption charges, and the office of the prime minister assumed control of the government-led response. With the health ministry under scrutiny, the WHO Somalia team assumed an even larger role, leading the charge against COVID-19.
Communicating the threat to the Somali population was critical.The WHO Somalia office drafted and translated COVID-19 awareness materials into Somali, distributed messages to radio programs, and published on billboards. In March, 25 trainings were conducted, preparing more than 800 health care workers in screening, infection prevention and control, and surveillance.
"Every week, we are challenging ourselves," said Dr. Malik, WHO's country representative.
"If we want to be sure that this outbreak is contained, there is no alternative than to emphasize containment and mitigation measures."
Dr. Malik says the operational challenges are severe. Contact tracing, an essential tool in tracking the possible spread of disease, is difficult in remote areas. Health care workers must travel through unforgiving terrain, braving heavy rainfall and the threat of violence. In late May, following a spate of clashes between state security and Al-Shabaab insurgents, seven health workers from a local aid organization were kidnapped and killed in a Somali village.
Some Somalis avoid testing, fearing they'll be stigmatized by the community. Others do not self-isolate --- either because they are living in crowded conditions and are not able to, or they simply do not follow directives --- and continue to affect family and community members. Patients often do not go to the hospital until it is too late.
"What we are seeing in Somalia is cases remain undiagnosed, undetected, the self-isolation and quarantine measures are not working as efficiently as we expect them to work," said Dr. Malik.
It is the older people who are suffering the most from community transmission. The country has had 2 416 cases of COVID-19 and 85 deaths, with the majority of these deaths falling between the ages of 60 to 70. Many of these patients are not recovering because of a lack of oxygen in the country's health facilities. WHO Somalia purchased three oxygen machines to fill the gap.
Investing in future resilience
The country team is working with local and state authorities in Somalia to help them understand the extent and impact of infections. They're advising on when to ease lockdown restrictions, and sharing modelling techniques and data-driven thinking needed to take informed decisions. This also includes making sure that other life-saving services such as polio surveillance continue.
"With polio vaccination campaigns temporarily paused, the teams must be able to track any resulting spread of poliovirus and get ready to respond as soon as it is safe to do so," said Dr. Malik.
Without this help, Somalia will remain captive to the virus --- and that is a risk the international community should not be willing to take. As UN Secretary-General António Guterres continues to remind us, an increasingly interconnected world means that, "we are only as strong as the weakest health system."
So far, WHO has helped train more than 4 000 community health care workers in proper handwashing techniques and hygiene, identifying suspected cases, and effective contact tracing. Last month alone, community health workers visited more than 300 000 households; more than 6 500 samples were tested in the three laboratories; and more than 10 000 sample collection kits were distributed to federal member states in Somalia.
"We will continue to work as One UN and keep the country safe, showing our solidarity, unity, and partnership with the government," said Dr. Malik.
How can you help?
Heavy rainfall is expected throughout June, and locusts continue to threaten crops and food supplies. Somalia needs continued support. WHO not only leads Somalia's COVID-19 response, but works to prevent infectious diseases like cholera and measles. WHO is indispensable to promoting health in fragile countries around the world.
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