Thursday, November 6, 2014

MUST READ: Ibrahim Samatar (1942-2011) By Carl Gershman

This article was posted to BlogATU by ATU President Dr. Ahmed H. Esa. It is a heartfelt article written about the late Ibrahim Megag Samatar for the Yale 50th Anniversary 1965 Class Book by Carl Gershman, President of the US National Endowment for Democracy


Ibrahim Samatar (1942-2011)

One of the most vivid memories I have from my senior year at Yale was the friendship I developed with Ibrahim Samatar, a Somali national who was studying economics.  We were both at Jonathan Edwards College and had dinner together regularly.  On the surface, we had very little in common.  He was a Muslim from Somalia and I a Jew from New York.  What brought us together, I think, was that each of was something of an outsider at Yale, and we were both deeply concerned with the social and political problems of our respective countries, which we would talk about endlessly.  I was focused on the civil-rights movement, which had led me to drive to Mississippi and then to Selma, Alabama, during our senior year to promote black voting rights.  Ibrahim’s focus, of course, was the future of his own country, which had become independent five years earlier.

Ibrahim was from the northwestern part of Somalia that had been the British protectorate of Somaliland during colonialism. At the time of independence in 1960, Somaliland merged with the former Italian Somali protectorate to form the Somali Republic.  Ibrahim had been an adherent of “the Dream of Greater Somalia,” the nationalist vision that rallied the Somali people against colonialism and looked toward the unification in a single sovereign state of all the Somali-speaking people – those living in the British and Italian protectorates that became Somalia, French Somaliland that became Djibouti, and Somalis living in Ethiopia and Kenya.  It was not to be, and even Somalia was a deeply divided country, with the central government in Mogadishu treating Somaliland as “a backyard province,” as Ibrahim described it, and not a country that had sacrificed its sovereignty for the sake of national unity. 

Still, Ibrahim was a patriot, and he returned to Somalia after graduation to become the country’s Director of the Budget in 1968, after which he held a number of cabinet posts, including Minister of Finance and Advisor to the President on Economic and Political Affairs.  In 1980 he was appointed Somalia’s Ambassador to Germany, but by then relations between the two parts of Somalia had badly deteriorated, with President Siad Barre becoming increasingly dictatorial and repressive.  Ibrahim defected in 1981 and sought asylum in the United States.   He also joined the Somali National Movement (SNM), a rebel group formed by dissidents tied to the Isaq clans of the North that sought the overthrow of Siad Barre and evolved into a movement for an independent Somaliland.

Ibrahim became the North American representative of the SNM and the Chairman of the organization’s Central Committee. It was that capacity that he re-connected with me in 1991.  The Siad Barre regime had just fallen, and the SNM had established the sovereign Republic of Somaliland, extricating itself from the civil war that was destroying the rest of Somalia.  (The abortive U.S. intervention in the civil war was the subject of the film “Black Hawk Down.”)  Ibrahim had discovered that I had become the President of the National Endowment for Democracy, and he thought that I could get NED involved in assisting the development of a democratic system in Somaliland, and also help him connect with the policy community in Washington so that he could make the case for the U.S. recognizing Somaliland as an independent country.  This was a step the U.S. was loathe to take (as was the U.N. and  the O.A.U.) for fear of encouraging the break-up of other African countries.

I arranged a meeting with Capitol Hill staff and others,  and I remember that Ibrahim gave an eloquent presentation, laying out the history of Somaliland, its struggle against a brutal dictatorship in Mogadishu which behaved like an alien colonial power toward the people of the North, and its pragmatic decision to separate itself from the chaos engulfing the rest of Somalia.  He also emphasized Somaliland’s democratic aspirations and character, saying that the NSM “was authoritative but not authoritarian” and intended to build a multi-party democracy with a free press.  Also, as he had hoped, NED did provide assistance in Somaliland, supporting more than a dozen NGOs working on civic education, human rights, free media, training youth and women activists, and strengthening Somaliland’s parliament and electoral processes.

Ibrahim was proud of what was being accomplished in Somaliland, and in a letter he sent to President Clinton in 1996, he declared that “One can hardly recall another example of a liberation movement which won power through the barrel of the gun and which was simultaneously so uninterested in ruling with its gun!  With stability assured through decentralization and consensus-reaching procedures, the formation of formal cross-sectional political organizations can, and will evolve, during the transitional stage.”

Ibrahim contemplated returning to Somaliland to participate in politics, and told me soon after the death of President Egal in 2002 that he might try to run for president.  But that didn’t happen.  He continued to teach at Josai International University in Japan, which is where he died in 2011. 

A few years before his death, when he had retired from politics, Ibrahim issued a statement of fundamental principles called “Where I Stand” (http://arc.somaliland.org/2008/08/30/where-i-stand-by-mujaahid-ibrahim-meygaag-samatar/) that he hoped would help guide and inform the younger generation.  It’s a broad and comprehensive statement of his views on democracy, Somali unity, Islam and Islamic radicalism, and the economy.  It shows Ibrahim to have been a genuine democrat, searching for ways to integrate and reconcile modern political ideas with traditional culture and religion.  His vision continues to have profound relevance in today’s very violent and divided world.  These are his concluding words:

We know we are a poor nation. But, poverty need not be a curse. There are nations with meagre resources like us who overcame poverty. Human development and its mobilization can compensate for the lack of resources and perform miracles. In addition to investing in health and education human development also means instilling solidarity and a sense of belonging to one another, having a common future and destiny, among the citizenry and their various communities and clans. Competition in business, politics and among the communities can be both healthy and unhealthy. If the unhealthy aspect is not fought fiercely it can turn into ugly fratricide [look at the situation in Somalia]. One of the reasons motivating me to write this simple piece is that I noticed from afar that this competition is beginning to turn ugly. Simple matters that can be resolved through amicable discussion and dialogue between the concerned personalities and organs are sometimes turned into unnecessarily highly contested national controversies wasting, when they are finally resolved, a lot of energy and good will.
“Let us check that tendency in time. We still have not lost that capacity for good will and democratic dialogue, inherited from the struggle of SNM, which is the basis for the success of Somaliland so far. We need to revive moral values of integrity, cooperation, forgiveness and brotherhood in our people. And while this task is the duty of all of us, the primary burden falls on the leadership: political (whether in power or aspiring to it), religious, community elders, and the intelligentsia. We need to rise above minor squabbles and take the high moral ground. Some of you may say that I am too idealistic and out of touch. I do not think so. I believe what is written here is simple and practical. I am an optimist and have always been so even at dark moments when my life was in danger. Even if these words are idealistic, so be it. After all it is the image of the future that moves people and it is vision that enables a society to organize itself for the better. It has been said long ago that those who do not learn from history are condemned to repeat it. It is my hope and belief that we have learned enough and will continue to move forward.”

Ibrahim’s body was returned to Somaliland where he received a national burial.  It was said that Somaliland had lost “one of its illustrious sons.”  I feel honored to have known him and hope that he will be remembered by our class as one of its illustrious sons as well.  That he certainly was.

Saturday, October 25, 2014

The Ebola Emergency: Is Somaliland at Risk?

By Mohamoud Ahmed Farah, ATU Master of Science candidate[1]
The current epidemic of Ebola in several West African countries has been characterized by the World Health Organization (WHO) as the most serious medical emergency in the modern era.  Ebola is a multi-systemic acute febrile viral infection which is characterized by flu like symptoms such as fever, headache, myalgia (muscle pain), and abdominal pain, and later vomiting and bleeding. Ebola, previously known as Ebola Hemorrhagic Fever, is also known as Ebola Virus Disease or EVD. It is often fatal. The current outbreak of Ebola is caused by the Ebola virus, the single member of the species Zaire ebolvirus.  There are five species in the genus Ebolavirus: Zaire ebolavirus, Sudan ebolavirus, Täi Forest ebolavirus, Bundibugyo ebolavirus and Reston ebolavirus.  The first four species are known to cause Ebola in humans.  The fifth, Reston ebolavirus, named for the town of Reston, Virginia in the US infects primates, but does not cause Ebola in humans. It may have originated from the Philippines. Ebola was first discovered in 1976 in an area in Zaire near the Ebola River. It has since caused outbreaks in the Sudan, Gabon, Democratic Republic of the Congo (DRC), Uganda and Ivory Coast.  The current epidemic is centered on the three countries of Liberia, Sierra Leone and Guinea, but cases have also been seen in Nigeria, Senegal, the United States, and Spain, and most recently in Mali.  There is also a lesser known and unrelated outbreak of Ebola in Boende, Equateur in the DRC, but this outbreak appears to have been stopped.
Ebolviruses belong to the virus family Filoviridae which is part of the order Mononegovirales. Other members of the Filoviridae are the Marburg virus and the Cuevavirus.  Marburg virus, which also causes hemorrhagic fever, was first described in central Europe in 1967 and has also been seen in central and southern Africa.  Cuevavirus, a more recent discovery, found in the Lioviu cave in Spain, is not known to cause human disease.  It is endemic in Spain, France and Portugal.
Ebola is highly contagious and lethal.  WHO considers it a Select Agent Risk Group 4, which requires the highest level of biosafety (Biosafety Level 4 or BL-4); some countries consider it a bioterrorism agent.
Transmission of Ebola
The primary animal host of Ebola virus has not been definitively proven, but fruit bats are thought to be the natural host. Humans can be infected by contact with body secretions, blood or organs of infected animals such as bats, monkeys, chimpanzees, antelope or gorillas.  Once Ebola jumps to humans, it can spread via direct contact with blood or bodily secretions of an infected and symptomatic person through skin cuts or wounds and via contact with the mucous membrane.  Bedding and clothing contaminated by fluids of infected individuals are also a source of transmission.
Health care workers and close relatives of the infected who are most likely to come in contact with infected material are at the highest risk for infection.  People who work at burial sites and funeral homes are also at an enhanced risk.
The incubation period of Ebola virus is between 2 and 21 days.  Infected people can transmit the virus once symptoms of the illness appear.  They remain infectious as long as their body fluids including breast milk and semen contain the virus.  Men who recover from the virus may have the virus in their semen for up to 7 weeks after they recover from the illness.
Outbreaks of Ebola start with a single patient or a patient zero.  According to a report in the New England Journal of Medicine, patient zero in the current epidemic may have been a 2-year old who died on December 6, 2013 just 4 days after showing Ebola symptoms in a village in Guinea near the border with Sierra Leone.  Soon after, several members of his family including his mother, sister and grandmother became ill and died.  Ebola then broke out of the village via people who may have attended the funerals for the deceased. 
Fatality Rate of Ebola and the Current Epidemic
Ebola has a high mortality rate.  In some past outbreaks, 90% of infected individuals succumbed to the illness, but a 25% case fatality has also been seen.  The current epidemic is the most extensive and so far approximately 50% of the nearly 10,000 people infected (almost all in West Africa) have died.
Extent of the Current Epidemic
According to WHO, as of October 23, 2014, 9966 people have been infected and 4881 have died of Ebola. Almost all the cases are in Liberia, Sierra Leone and Guinea.  All three countries have been through recent wars and have poor health care infrastructure.  One acutely ill person who flew to Nigeria from Liberia led to the infection of 20 people in Nigeria.  Upon confirmation of the infection, Nigerian heath authorities quickly activated an Ebola Incident Management Center.  The center identified 894 contacts of the index patient.  Twenty patients were confirmed to have been infected as the result of this incident, eight of whom later died of Ebola. In Senegal an infected person travelled over land from Guinea. The patient was successfully treated.  Both Nigeria and Senegal appear to have stopped further spread following rigorous case detection control measures and both countries have now been declared free of Ebola by WHO. 
On 24 October 2014, Mali announced that a young girl whose mother died of Ebola in neighboring Guinea and who was brought to Mali by relatives is suffering from Ebola.  Health authorities in Mali indicate that the child was quickly diagnosed and immediately place in hospital isolation and that people who have had contact with the infected child are either in isolation or being closely monitored.  The child succumbed to the illness on 25 October.  Later reports indicate that the child was brought to Mali in a bus and had travelled for more than 1000 km while symptomatic.  Once in Bamako, the child was first treated for typhoid and only later tested for Ebola.  Forty-three people have so far been identified for the possibility of high risk exposure.  Mali lies next to Guinea, one of the countries at the epicenter of the epidemic.  Mali, which is going through a rebel insurgency, has very few health care workers for a population of more than 12 million.  According to the Malian Ministry of Health, Mali has allocated 672,000 US dollars to combat the spread of the disease and has created 10 hospital isolation wards for treatment. 
Cases in Europe
Two Spanish missionaries in West Africa became infected and were evacuated to Spain.  An assistant nurse who took care of both patients (who later died) became infected and is currently hospitalized.  Some of her contacts are quarantined and others are being closely monitored, but so far none of them have shown symptoms of Ebola. 
Cases in the United States
Three American health care workers were infected in West Africa and were medically evacuated to US hospitals.  All three survived and are now virus free. 
A Liberian man who travelled from Liberia by air was diagnosed with Ebola soon upon his arrival in the state of Texas and later died of Ebola.  Two nurses who assisted in his treatment became infected and are being treated in specialist hospitals in the US.  None of the other contacts of the patient have been infected and 44 of them have been declared virus free and are no longer monitored, but health care workers who treated the patient or people who have been in contact with the infected two nurses are being monitored.  Monitored individuals include some passengers of two airlines one of the nurses travelled in prior to her showing clear symptoms of the infection.  On October 24, one of the nurses who contracted Ebola after treating the Liberian patient, was declared virus free and has been released without movement restrictions.  Few hours after being released from the hospital, the President of the United States Baraka Obama met her at the White House ostensibly to calm public fear and remove the stigma that could be attached to this infection.
A cameraman working in Liberia for the US TV news outlet NBC became infected and was evacuated to a US hospital.  His co-workers who also returned to the US have been quarantined.  In addition, on 23 October, a hospital in New York City announced that there has been a positive diagnosis of Ebola in a doctor who worked in West Africa for the NGO Medicines sans frontiers.  The doctor is being treated and health authorities indicate that the risk posed by this patient is minimal since he was admitted to the hospital as soon as he developed initial symptoms.  Three of his contacts are under voluntary quarantine.


Stopping the Epidemic
The current epidemic is the most wide spread.  Past outbreaks have occurred in remote rural areas, but this epidemic has spread to heavily-populated urban centers.  Few cases have been identified in Europe and the United States, but these regions have the resources and the health care infrastructure to limit the spread of the virus.  The biggest concern is that the virus may breakout of the three stricken West African countries to the neighboring region.  Many countries in the region have the same ecosystem and health care infrastructure inadequacies as the three affected countries. However, the fact that Nigeria and Senegal have been able to deal with the first cases of Ebola to reach them is an encouraging sign.
There is no cure for Ebola.  Two vaccines are currently being fast-tracked through human trials. If these vaccines prove effective, they will first be giving to health care workers in West Africa. There are no known effective antiviral drugs for Ebola.  ZMapp, an antiviral drug in clinical investigation trials, has been rushed to treat several patients, but supplies of ZMapp quickly ran out as only enough had been made for investigations and not for treatment.  Another drug brincidofovir has also been used in a patient in Texas who did not survive the infection.
With respect to treatment, there are some encouraging signs.  US hospitals have been able to successfully treat 5 patients.  Spanish doctors have also been able to treat the first person infected in Spain. The recovery from the infection of these patients is currently attributed to the supportive care available at the medical facilities in the US and Spain. While not definitive, there are indications that patients who have recovered from an Ebola infection have transferable antibodies that may be used to help in treatment.  Whether some people recovering from the infection develop long lasting immunity awaits more research and data.
International health authorities indicate that it may take 4 to 6 months to bring the current epidemic under control.  At the present time, the spread of the infection is exponential with some predictive models suggesting that as many as 1 million people may become infected in West Africa by early next year if the epidemic is not quickly brought under control.
What Steps Should Somaliland Take to Protect its Citizens from the Spread of Ebola?
Somaliland should be considered a low risk country.  Somaliland has no trade or other links with the affected countries of West Africa and the chance of direct transmission is minimal.  So far no cases have appeared in the Horn of Africa region countries with which Somaliland has a contiguous border.  In the Horn of Africa, the two countries of Kenya and Ethiopia are major travel and tourist destinations.  Many international organizations have substantial presence in both Kenya and Ethiopia.  Kenya and Ethiopia are also major commercial centers and receive large numbers of travelers from all over the world.  Both countries have stopped direct airline travel to the stricken countries in West Africa.  So far no cases have been seen in these two countries.
Somalia has large number of African peacekeeping soldiers some of whom come from West Africa. The African Mission in Somalia (AMISOM) has indicated that it will no longer bring new soldiers from the Ebola-affected countries.
The probability of someone travelling from the stricken countries bringing Ebola to Somaliland is low. However, at the present time, Somaliland does not have adequate health care infrastructure for detection and case control.  Somaliland authorities and local WHO officials have indicated that they are working hard to put control measures in place as soon as possible and that an epidemic control unit has been created.
A key in stopping transmission of Ebola is the quick diagnosis of infected people and effective isolation. Health care workers treating patients are at heightened risk and must be provided with proper protective equipment and clothing.  Somaliland authorities should create an Ebola Incident Emergency Unit with trained personal and hospital isolation wards.  All health care workers must receive Ebola specific infection control information.  Health care staff at ambulatory care centers, including private clinics, must be trained to recognize Ebola symptoms and instructed on how to deal with suspicious cases.
Identification of all contacts or contact tracing is essential for an effective control of infectious diseases outbreaks. Contact tracing requires full community participation and health authorities must provide the public with complete and correct information in a manner that does not create panic.  Public health authorities must begin a proper education campaign to make sure that people have the right information and confidence in the system. It is important for the public to avoid superstitions and the pursuit of unproven remedies outside of the health care setting.  Health authorities and the media must work hard to remove any stigma associated with the infection to ward off against patients going underground and spreading the infection further in untraceable manner.  The steps Senegal and Nigeria took are good examples of what Somaliland should do to protect its citizens from Ebola. These examples indicate that it is possible to counter this epidemic effectively when the public health system is vigilant, ready and well-prepared with the right tools.





[1] Mohamoud Ahmed Farah is a Master’s Degree candidate at ATU’s Biomedical Science Department.  He is currently preparing a chronicle of parasitic diseases common in Somaliland.  He works under the supervision of Dr. Ahmed Hussein Esa.