By Sheila Mulrooney Eldred, Sahan Journal
Minnesota doctors Abdirahman Madar and Max Fraden of Hennepin Healthcare have gotten portable ultrasound devices into the hands of Somaliland doctors and opened a clinic in Somaliland for non-communicable diseases. Next, they want to tackle Hepatitis C.
Dr. Abdirahman Madar uses the same type of hand-held ultrasound when he sees patients in Minneapolis as when he’s training doctors at Hargeisa Group Hospital in Somaliland.
In Minnesota, the device is just one of many available diagnostic imaging tools, a convenient alternative to costlier and more time-consuming options at Hennepin County Medical Center.
In Somaliland, it complements a single CT scanner as the hospital’s only diagnostic imaging tool. For the poorest people, it can be a lifesaver. There may be no other affordable option to accurately detect conditions such as blood clots, cancer progression, and newly onset heart or liver failure.
Partnerships with Western doctors and medical organizations are essential in providing basic health care to the poorest citizens of developing nations. In Somalia, doctors from Minnesota provide that connection. The hand-held ultrasound devices at Hargeisa Group Hospital come courtesy of two Minnesota doctors’ fundraising and education efforts. Drs. Madar and Max Fraden have coordinated funding and training for pilot projects at public hospitals that introduced ultrasound devices and established a non-communicable disease clinic that has served about 1,100 patients so far. The doctors hope that the government of the semi-autonomous Somaliland region will eventually replicate the models at other public hospitals.
From Somaliland to Minnesota
In Somaliland, the quality of health care is directly related to whether you can pay for it, said Madar, a hospitalist at Hennepin Healthcare. Private hospitals in Somaliland operate on an out-of-pocket system. People often sacrifice food to spend $30 for an ultrasound or $120 for a CT scan, said Fraden, also a hospitalist at Hennepin Healthcare. Public hospitals, which serve roughly one-third of the population that cannot afford to pay anything, are extremely underfunded, Madar said. In all of Somaliland, there are two or three MRI machines, all in private hospitals. Hospitals in Hennepin County have at least 28 MRI machines; some NFL teams have even installed them in their stadiums.
The lack of resources in his home country became clear to Madar in high school after his father suffered a stroke. Later, he realized that the root cause of the stroke, hypertension, was never addressed. He resolved to go to medical school and improve healthcare. He earned a placement at a branch of an Italian university in Mogadishu, got his degree, and did some basic surgical training through the International Committee of the Red Cross.
For five and a half years, Madar worked as a surgeon in Berbera, a coastal city in Somaliland, primarily taking care of people hurt in civil wars. It was the only well-equipped, well-functioning hospital doing surgeries in Somaliland at the time.
In 1999, he entered the United States Diversity Visa lottery, intending to learn as much as he could from Western medicine and return home. When he won a spot, he and his family moved to North Carolina to take advantage of the three major research universities in Raleigh, Durham, and Chapel Hill. His wife had no interest in returning to Somaliland, but after one and a half years, she suggested they relocate to Minnesota to find a bigger Somali community.
With most of his family still in Somalia, however, Madar stood by his goal of improving health care in his homeland. After settling in Minneapolis in March 2000, he started sharing best practices for quality control with his former colleagues overseas.
When the COVID-19 pandemic struck, Madar founded a charitable organization called the Somalilander American Health Association to send supplies and do COVID-19 education in Somaliland.
Fraden, meanwhile, had helped train doctors and nurses in Rwanda on portable ultrasound devices and non-communicable disease clinics, and the results were promising.* The imaging changed treatment in 43 percent of cases, according to a 2023 study of their use in low- and middle-income countries published in Nature. And 96 percent of doctors agreed that ultrasound improved care and outcomes.
So when the primary COVID-19 threat passed, the two traveled to Somaliland together, where Madar’s former colleagues greeted their projects with enthusiasm.
The doctors raised about $100,000, including donations of equipment or funds from the Global Ultrasound Institute and the Butterfly Network, the government of Taiwan, the relief organization Amoud Foundation, and private sources in the Minnesota Somali community. They delivered the first eight ultrasound devices in April 2022 and opened the non-communicable disease clinic that November. The two doctors currently pay for their own flights and trip expenses and are hoping to land a much bigger grant for future projects.
Sharing knowledge and devices
Madar and Fraden conducted a four-week basic training on how to use the devices for 20 general practitioners at Hargeisa Group Hospital, a 250-bed facility for a city of 1.2 million. Some physicians traveled from rural areas to attend.
“We’re not teaching them to be radiologists,” Fraden clarified. “I teach residents here at Hennepin, and it’s the same curriculum—the basics. Is there fluid in the lungs or not? Are the kidneys dilated or not? These are not subtle findings.”
The ultrasound devices replace less precise, more time-consuming methods for a variety of ailments: Tapping a patient’s chest, for example, to determine if there is fluid in the lungs
Recently, a pregnant mother with diabetes came to the hospital complaining of sudden shortness of breath, pain in her chest, a fast heart rate, and a swollen right leg, Dr. Ahmed Hirsi, who works at the hospital in Hargeisa, said via WhatsApp. Doctors used the handheld ultrasound device to confirm the woman had deep vein thrombosis with a pulmonary embolism, which can be life-threatening: A third of patients with the condition who aren’t diagnosed or treated die, according to the Mayo Clinic. In this case, without the new devices, the doctors would have referred the woman to a private clinic. If she wasn’t able to pay $30 for an ultrasound, the condition could have been missed.
Madar and Fraden have returned to Minnesota, but the doctors aren’t totally on their own: The devices are connected to software that allows users to add comments to images via WhatsApp. So before the Minnesota doctors clock in at HCMC, they review images and diagnoses from their colleagues at Hargeisa Group Hospital.
“It’s a really nice way for people to learn,” Fraden said.
Once the devices are in hand, costs are extremely low, Madar said. Hopefully, that will allow the project to be scaled up by the government, Fraden added.
When he goes back to visit, doctors tell Madar how the ultrasounds have improved their practices.
“They are seeing patients on a daily basis, making decisions that are sometimes life and death,” he said.
Tackling non-communicable diseases
After successfully supplying the ultrasound devices, the doctors returned to Somaliland to open the first non-communicable disease clinic there, which helps treat people with conditions such as diabetes, high blood pressure, chronic kidney disease, cardiovascular disease, and lung diseases.
Non-communicable diseases that people successfully manage in the U.S. often go untreated in Somaliland until emergency care is required. Amputations and death due to diabetes are common due to both a lack of education about the disease and an inability to afford regular health care. A one-month supply of insulin costs about $5, which is prohibitive for most public hospital patients, Fraden said. “That would be a big cut of a paycheck,” he said. The mean age of heart failure in sub-Saharan Africa is 52 years, 20 years earlier than in Western countries. Almost half of heart failure cases are attributed to hypertension.
Fraden said he often sees patients in a diabetic coma or with a stroke or heart failure, most of which could be prevented if they could afford routine care.
About 30 percent of mortality in Somalia is attributed to non-communicable diseases, he said, even though historically, such diseases have been associated with more affluent countries. Doctors see severe consequences of chronic diseases early in life, such as patients in their 30s and 40s who need dialysis, he said. In the U.S., dialysis patients are usually in their 60s or older.
At the new clinic, patients get insulin and other medications for free, and they are taught how to manage their conditions.
“If someone has diabetes in the U.S., you can live with it,” Madar said. “But in Somalia, you don’t live with it.”
A 10-year review of similar clinics in Rwanda shows that people enrolled in these types of clinics fare significantly better, experiencing fewer heart attacks and deaths than the average in Africa.
If someone has diabetes in the U.S., you can live with it. But in Somalia, you don’t live with it.
Dr. ABDIRAHMAN MADAR
Another of Ahmed Hirsi’s patients in Hargeisa, a 23-year-old man with Type 1 diabetes from a poor family who couldn’t afford insulin or glucose strips, used to be hospitalized frequently for diabetic ketoacidosis, a life-threatening complication of the disease. Since the clinic opened, he’s been getting free medical support and hasn’t had a single such episode or been hospitalized, Ahmed said.
“[The clinic] helps the patients a lot,” said Dr. Yasin Obsiye, a general practitioner at the Hargeisa clinic, via WhatsApp, explaining that many patients do not read and previously knew nothing about diabetes. “We provide continuous appropriate care, including counseling, follow-up, and free medications, as well as glucose monitoring machines and strips.”
For many, their glucose and blood pressure are, for the first time, under control.
One early indicator of the success of the Minnesota doctors’ projects: The clinic is outgrowing its physical space, Ahmed said. “We need a new building to expand our capacity,” he said.
Fraden is eager to start another project to focus on Hepatitis C, which affects about 5 percent of the population in Somalia. In the U.S., new medication can eliminate the disease within 8–12 weeks. In Somaliland, you cannot get treated for it, he said.
If it’s up to him and Madar, that won’t be the case for long; if they raise enough funds, Fraden plans to go back in November to start work on it.
About Sheila Mulrooney Eldred
Sheila Mulrooney Eldred writes stories about health equity for the Sahan Journal. As a freelance journalist, she has written for The New York Times, the Washington Post, FiveThirtyEight, NPR, STAT News, and many other publications. She is a graduate of the Columbia School of Journalism. She lives in Minneapolis.
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