Healing the Scars: Edna Adan Ismail’s Fight to Bring Women’s Health Care to Somaliland.

CONTENT WARNING: The following article discusses Female Genital Mutilation, a practice that was universal in Somaliland during Ismail’s youth, and is still widely practiced today throughout East Africa.

At the age of eight years old, Edna Adan Ismail was grabbed by her relatives and the elder women of her town, and held down as a healer cut away her clitoris and labia minora, and sewed the ragged edges over her vagina with thorns. The women had waited until her father was away to perform the mutilation, knowing he disapproved of the process, and when he came back home all he could do was hold his child in his arms and weep over what had been done to her, standing powerlessly by as she spent the next week, legs bound together, experiencing intense pain whenever she had to urinate as scar tissue formed that would radically increase her chance of dangerous infections for the rest of her life.

This traumatic experience was one shared by all women in Somaliland, though it was never talked about. The practice had originated in rituals practiced along the Nile to ensure the cooperation of the river gods, and was perpetuated by slave traders in the region as a means of ensuring the virginity of the women they bought and sold (the scar tissue that forms over the vagina makes the first sexual act both intensely painful and readily evident) until it became common practice for women in a wide swath fanning out from the Nile, who came to believe that it was a ritual demanded both by their religion and their traditions, that it would be shameful not to undergo.

In that moment, Edna’s life was shunted onto a new trajectory. She had been born in 1937 as the daughter of a dedicated and selfless doctor father and a mother from a Christian family who was determined to fit in with her new surroundings, and doubly determined that her daughter should avoid anything that might bring shame on the family in the eyes of the town’s elders. Before the age of eight, she ran wild, carousing with the neighborhood boys, disdaining the world of domestic responsibilities, and wanting nothing more than to follow her father to the hospital and be of use to him there. Her father, for his part, encouraged this independent streak in her and, to the exasperation of her mother, also encouraged her in her dreams of one day becoming a medical worker herself. She went on adventures in the forest, played street games with boys, and learned how to read by sitting in on classes that her father set up in his home to bring literacy to the boys of the neighborhood. 

Her carefree youth was ended when her own family betrayed her, permitting and even arranging for her mutilation, and then informing her that, if she moved too much and tore her scar tissue, the whole process would have to be repeated again. Cut off from the rambunctious capering that had filled her childhood with so much joy, she yet possessed her freedom of mind, and if her body had to be treated more gingerly than before, she now had a double motivation to explore a deeper knowledge of medicine and medical practice. 

To understand the next part of Edna’s journey, however, we first have to understand the political situation of her home country during the mid-20th century. The “Scramble for Africa” in the late 19th century saw European nations attempting to shore up the possessions they had already claimed on the continent by grabbing adjoining territories. On the horn of Africa, the British and Italians carved out two territories, known as British Somaliland (largely established by 1886 and growing out of the Isaaq Sultanate), and Italian Somaliland (which the Italians had begun claiming in the 1880s and had firm control of by 1926). The former had its capital at Hargeisa and corresponds to the modern unofficial state of Somaliland, and the latter at Mogadishu and corresponds to the modern state of Somalia. For some thirty years, from 1960 to 1991, the two countries were semi-unified in the Somali Republic, based in Mogadishu. In that union, the former British Somaliland was very much the junior partner, and with the rise of the dictator Siad Barre in 1969, Edna’s home country would be repeatedly the target of orchestrated state violence that reduced its capital city to rubble and scattered its people.

Meanwhile, a third state, known as French Somaliland, corresponding to modern Djibouti, was established in 1886, and mercifully managed to keep out of the swirling gnarl of the Somali Republic. French Somaliland had less rigid restrictions on girls’ education than British Somaliland, and it was here that Edna was sent for schooling for the six years after her involuntary infibulation, stretching from 1946 to 1952. She flourished here, becoming fluent in French and taking classes in a mixed gender setting that showed her the strict divisions between girls’ and boys’ worlds that she grew up with were not a universal fact of life. By the age of fourteen, she had completed her primary education, and was faced with the daunting prospect of what to do next. Nowhere nearby offered secondary education for girls, so her best option was to begin work in the field she felt drawn to - medical care. 

Her linguistic skills served her well in this transition, landing her a job as an interpreter for a doctor at the Ruth Fisher Clinic in Hargeisa. That position led in turn to another post as a pupil teacher at a newly founded boarding school for girls in Burao (Somaliland’s second largest city) where she used her developing English skills to facilitate communication between the Somali-speaking students and the English speaking teachers, in exchange for which she would get some pay and special private tutorial sessions from the teachers after the end of the school day. Her conscientiousness and drive to learn impressed her teachers to such an extent that, for the first time ever, they put the name of a girl down on the roll of those being considered for a Colonial Office scholarship to study in England, a scholarship she won her second year trying. 

She had no doubt about the area she wanted to study while in London - nursing. Her dream was to return to Somaliland and be of help to her father, who labored under constant limitations to deliver quality medical care for his people, and who stood most in need of reliable help trained in the practice of modern medicine. Edna’s mother was predictably aghast at the idea of her daughter, the daughter of a respectable family, taking on such shameful work, but she was not to be deterred, and in October of 1954 made her way to England, where she would remain, with small breaks here and there, until 1961. 

Here she was tempted for a time by the excitement of becoming a surgical nurse, but ultimately, on her father’s advice, opted for maternity nursing, as her country stood in such singular need of qualified women employing modern antiseptic practices, and as a trained maternity nurse she could not only personally aid in the delivering of babies, but serve as a node for both the training of an entire generation of qualified maternity nurses, and for the retraining of the nation’s midwives. While in London, she had a passing encounter with a young man of wealthy family from Somaliland by the name of Mohamed Egal, who disappeared suddenly only to, through her father, ask for her hand in marriage upon his return to Somaliland. She refused, but it would not be the last time their stories would cross paths.

Ismail completed her nursing program, and stayed on to take extra courses in medical administration, knowing that, as the daughter of her nation’s most eminent doctor, she would not just be helping him in his hospital, but would have to take a large share in the running of it as well. That extended the course of her stay in England, and it was not until 1961, after the dizzying days of independence and then quasi-union with Italian Somaliland, that she would return home to a nation that wasn’t entirely sure what to do with her. With the departure of the British, the medical infrastructure of Somaliland was left in something of a shambles, and with the dominance of the Mogadishu faction in government, the proper funding of Somaliland’s health system was never going to be a priority. In fact, though she started working for Hargeisa Hospital right away, setting its somewhat ramshackle administration in the best order she could as a single individual, it would be well over a year until she received any pay for her work, being supported in the meantime by a stipend from her father, who, with all his other obligations providing financial support for those in need during those lean years, was stretching his finances perilously thin, as the family would come to discover upon his passing.

Meanwhile, the government was doing all it could not to pay her a salary, arguing that as a woman she couldn’t possibly need it, and besides couldn’t possibly be worth it. Meanwhile, she was facing pressure from her mother and the women of her town saying that having a profession, and especially a profession that brought her in contact with such unseemly things, was a shame on the family. But her father’s support and admiration for what she was accomplishing sustained her, and after a few dramatic cases where she managed to save women that other traditional midwives had given up as lost, her reputation in the community grew, and she was soon able to begin recruiting more women to train as maternal nurses, while opening up exchanges of information with rural midwives to gently nudge them towards a higher standard of cleanliness, and to not tug on the placenta to hurry its dislodgement, which was a common source of hemorrhaging and maternal mortality at the time.  

These were years of trials and triumphs. Most significantly, Ismail had to weather the passing of her father, who had since childhood been her constant source of support in a community that largely did not understand her or why she felt compelled to risk her reputation to do the things she did. Some compensation came in 1963 when, after nearly two years of bickering, the government finally gave her a position as a senior civil servant, with a salary to match that distinction. A few months after that, Mohamed Egal, who had served as prime minister of the Somali Republic briefly in 1960 and was devoted to a political life in support of Somaliland’s political identity, proposed to her again, and this time she accepted, on the understanding that she would not be giving up her work to become his spouse. 

This was the first of Ismail’s three marriages, and set the pattern for those to come. In all three cases, the men involved had said that they completely understood that she had a separate career, only to devolve into bitter recriminations that they had married a woman who cared about her job first and her home life a distant second. She was her father’s daughter - in the face of a choice between saving a patient and staying home, she would always rush out the door to do her medical duty, a devotion that brought each marriage in turn to divorce. Before that happened with Egal, however, Ismail was ushered into the whirl of international politics as her husband was appointed Prime Minister in 1967 by president Shermarke. Traveling the world with him, attending receptions by world leaders, had its charms certainly, but also took her away from her hospital, where she felt most at home. 

The tension between the life of a medical official (in the mid 1960s she occupied an important position as a medical official for WHO working in Libya) and a politician’s wife was resolved in 1969 with Barre’s military overthrow of the Somali government. For the next twenty-two years, political repression was the order of the day, visited with special violence upon Somaliland, where the clans opposing Barre’s usurpation of power were based. Hundreds of thousands were murdered and displaced in the ensuing decades. Ismail was placed under house arrest for her association with Egal, and likely only avoided being murdered by Barre’s troops because of her popularity at home and international ties. The nation’s desperate need for trained health workers eventually secured her release, even as Barre’s police regularly invaded and ransacked her home to keep her rattled and aware that any action publicly taken against his regime would result in violence upon herself and her family. She had to submit to anti-capitalist retraining regimes and attend long ceremonies giving honor to Barre and his magnificence, but she was able to swallow her pride and get on with the work of healing people, a job which grew in urgency as Barre threw his country into a ruinous and unnecessary war with Ethiopia (the Ogaden War of 1977) that produced a steady and gruesome stream of broken male bodies to be cared for as best as could be managed by the nation’s woefully underfunded medical system.

The one good thing to come out of these years was that the regime’s avowed belief in scientific socialism (a term coined to clothe atheistic Communism in a term that wouldn’t be instantly offensive to the Muslim population) meant that it had a theoretical interest in promoting forward-thinking policies that raised the population out of the mire of traditional, superstition-laden practices. In 1976, Ismail attended a WHO conference in Khartoum that openly discussed the myriad of health problems faced by women who underwent Female Genital Mutilation. That conference was a revelation to her - not only were these individuals openly talking about this subject, which in Somaliland was considered under an absolute taboo, but they were doing so from the perspective of its medical, rather than its social or moral, standing. She was fired with the desire to bring a similar talk to the Somali Republic, and on her return proposed it to the government. 

Barre supported this proposal, not because of his great belief in feminism, but because he thought the topic was so outrageous that it would cause her downfall in the community, which would rid him of her once and for all as a popular thorn in his side. When the day came, however, and Ismail began talking about the medical problems created by infibulation to a large gathering of women, what she found wasn’t condemnation, but a slow but steadily gathering enthusiasm as different women rushed forward to share their own stories of the pain they had experienced, and their relief that somebody was FINALLY talking about it. The conference was a triumph, for which the government duly claimed credit. With that, Ismail’s career as an advocate for the complete outlawing of FGM as a practice was launched, a campaign she would take to the highest levels of the international health community. 

In 1991, the Barre government fell, and in the aftermath Somaliland reclaimed its independence, though to this day its existence as a separate country is not recognized internationally in spite of a 2001 referendum in which 97.1% of the population voted for independence and a new constitution. Ismail had largely spent the last years of the regime in a state of exile, knowing from her international sources that Barre was targeting her. When she returned to the country, she found her beloved hospital in shambles, complete with the rest of the city, as burned out buildings and lonely acres populated only by desperate squatters were the order of the day after decades of intensive governmental persecution. Nevertheless, she resolved to stay in Somaliland and rebuild, putting every penny she owned into the creation of a new hospital, built on the grounds of Barre’s most notorious public killing fields. By dint of superhuman efforts by herself and her dedicated group of volunteers that hospital, the Edna Adan Maternity Hospital, opened its doors in 2002, an important first step to re-establishing regular medical care in the heart of Somaliland’s capital. 

That hospital is coming up on its first quarter century of operation now, and its success spawned the creation of a new institution in 2010, the Edna Adan University, which focuses on the training of healthcare professionals. Today, eight decades lie between that horrifying moment when a young girl was betrayed by all the women she had ever trusted, and the dignified woman who has weathered a stream of personal tragedies as well as the larger scale tragedies of her people, and yet continues to give her time and wisdom to the cause of improving the health of her nation, and using education to protect the girls just being born from having to face the horrors of what had been done to her. It can often seem, in this world of fast-paced micro-challenges, that the age of national-level heroes has passed, but there are some who still walk this Earth, pointing us to a path of larger-than-personal effort, and of those one would be hard pressed to find a greater example of professional devotion married to a fundamental sense of empathy and the dignity of mankind, than Edna Adan Ismail.

FURTHER READING: 

Ismail’s memoir, A Woman of Firsts (2019) is an utterly engaging book that, once begun, cannot be put down. If you want to support the Edna Adan Maternity Hospital and the program against FGM, or just learn more about what they are doing now, you can find their website here.