Kenya 2011 © Brendan Bannon
Throughout the summer, waves of Somalis set out on desperate, arduous journeys, braving desert heat, hunger, and bandits to seek relief from a catastrophe remarkable even by the standards of this long-troubled country. The numbers of displaced reached into the millions. Some streamed into Mogadishu, the capital. Others crossed borders into Kenya or Ethiopia. Thousands died along the way. Even those who survived were not assured of respite.
MSF, which has worked in Somalia since 1991, has been trying to expand its programs in and around the country over the past several months. In some places, it’s been feasible to do so, but the severity of the crisis has been compounded by a host of obstacles particular to Somalia that prevent MSF and others from scaling up operations to the degree necessary. Given the sheer number of lives at risk, however, the efforts to reach as many people as possible continues.
An Unnatural Disaster
Somalia has existed in a near constant state of crisis for almost two decades, as warring parties and clans battled each other for control of territory and influence and foreign powers intervened for various reasons, albeit with little benefit for Somalis themselves. In the first half of 2011, the Islamist militia known as Al Shabaab held significant portions of territory, including much of the capital, and was holding off attempts by the Transitional Federal Government (TFG) and the African Union Mission in Somalia (AMISON) to dislodge it. Interwoven through this conflict were other disputes between clans, warlords, and other parties, and an international battle between Al Shabaab and western powers, most notably the United States, that further isolated the population and limited the ability of humanitarian organizations to access populations in need.
Somalia’s current crisis has been portrayed in many forums as a natural disaster, the result of a drought and subsequent crop failures. That is inaccurate—or, the very least, incomplete. There is indeed a drought in the Horn Africa. There is widespread malnutrition, too, much of it severe. But in many ways, this is an amplified version of the crisis that’s been affecting the country for two decades. The specific medical emergencies of the moment are symptoms of a larger disaster involving failures of governance, development, and policy that have left Somalis tragically vulnerable—which is why, when the drought did come, so many were convinced that their survival depended on getting themselves to a place where relief might be available.
Somalia 2011 © Yann Libessart/MSF
Thus began the exodus. There were indications of the drought in 2010, but, says Duncan Maclean, MSF’s director of operations for Somalia, “The signs of a major crisis were first seen at the Ethiopian and Kenyan borders, where thousands of Somalis started to leave the south of the country in June.” Quickly, the populations of the already overcrowded refugee camps in Dadaab, Kenya, swelled even further. The existing facilities could not accommodate all the new arrivals, and the United Nations, which ran the camps, was slow to find space for them. Some of the exhausted Somalis endured weeks or even months of living in ad hoc shelters on the outskirts of the camps, waiting to get registered as refugees and to receive the assistance they needed.
The UN did eventually establish new camps, but it was still a struggle to keep pace. In early October, an average of 6,000 Somalis were still arriving in Dadaab on a weekly basis. MSF was treating nearly 15,000 patients in its nutrition programs—inpatient, outpatient, and supplemental feeding—and had vaccinated more than 20,000 people for measles in the Dagahaley camp, where it had been running a hospital for the last few years. MSF was also providing primary health care and treatment for malnutrition to refugees who’d settled on the outskirts of Ifo, another camp, and was working at health posts in the more recently-opened Ifo 2 and Ifo 3 camps. Additional teams were working in the border town of Liboi, providing care to Somalis and local people in the area.
While the UN registered nearly 150,000 Somali refugees in Kenya through the first nine months of 2011, another 78,000 Somalis—including a frightening percentage of severely malnourished children—crossed into Ethiopia and found temporary refuge in camps there. MSF was performing health checks of new arrivals as they passed through a transit center and, as of late September, caring for nearly 10,000 malnourished children in the Kobe, Hiloweyn, and Malkadida camps. Teams were also vaccinating children for measles and providing primary care at health posts.
Somalia 2011 © Sven Torfinn
Trying to Expand
In Somalia itself, MSF expanded existing projects and is attempting to negotiate access to open new ones where needed. In the southern town of Marere, for instance, MSF is running nutrition programs and treating cholera and measles. In nearby Jilib, MSF has been distributing essential items to 1,600 displaced families and providing primary health care through mobile clinics. Teams in Galcayo manage feeding programs, care for malnourished children and adults on both an inpatient and outpatient basis, and tend to people wounded in fighting.
In Guri-El, in the Galgaduud region, MSF works in the 80-bed Istarlin hospital, which has a pediatric ward, a women’s ward, and an operating theater—and which has been running over capacity as malnourished patients continue to arrive. MSF is also running six mobile feeding programs and two health posts in IDP camps in the area. “Before the droughts, less than 20 percent of our patients were malnourished, but now the number is closer to 50 percent,” said Dr. Faiza Adan Abdirahman, who runs Istarlin’s pediatric department, in late August. “With malnourishment, come all manner of other diseases. Many of these children are suffering from watery diarrhea and pneumonia. We’re also seeing other problems and complications such as measles and renal and heart problems.”
Teams in Belet-Weyne were admitting three times as many malnourished patients to their nutrition program as they were last year at this time. MSF staff was also carrying out nutritional screenings in IDP camps in Dinsoor, in the Bay region, and running four health centers, nutritional programs, and pre-existing maternity and tuberculosis treatment programs in Jowhar, north of the capital.
On the outskirts of Mogadishu, MSF remains active in the Daynille Hospital, where more than 1,250 war-wounded patients have been tended to in the first nine months of 2011, and approximately 75 people are being admitted to the surgical department each week.
In Mogadishu itself, teams are screening new arrivals for malnutrition and other health problems, carrying out stabilization efforts and supplemental feeding programs, admitting patients when necessary, and vaccinating for measles where possible. According to MSF Emergency Coordinator David Michalski, displaced people “are everywhere in Mogadishu, some with just a few families and some with hundreds of families. Most of the vacant land in Mogadishu has been taken over by these densely-crowded camps.”
Throughout the country, medical needs far exceed available health services. The displaced populations are living in precarious health conditions, their immune systems already weakened by poor nutrition. Many have never been vaccinated or exposed to infectious diseases such as cholera, pneumonia, dengue fever and malaria that are common in the city and especially potent in crowded camps with poor sanitation. The rainy season, which begins in October, could exacerbate their spread.
Deploying aid in this patchwork of shantytowns is particularly complicated. “Food distributions are still irregular and inadequate,” says MSF program coordinator Eymeric Laurent-Gascon. “Some of the displaced persons have not received any food since they arrived and are relying on help from those around them. Several NGOs have set up dining halls with food purchased on local markets, but this has led to significant inflation. If prices continue to rise, the entire population of the city will soon be unable to feed itself without outside assistance.” What’s more, due to security concerns, teams can often only work for a few hours per day.
The inability to vaccinate more widely for measles is another major concern. Though reliable numbers are hard to come by, it’s possible that more children are dying of measles at this point than malnutrition. As of early October, more than 54,000 people had been vaccinated. “That sounds like a lot, but if we are to have any hope of stopping the epidemic, we’d have to vaccinate at least 10 times that number,” explains MSF medical manager, Dr. Andrias Karel Keiluhu. “Logistical and security constraints limit our goals.”
MSF hopes that its teams will soon gain more access to deliver medical care in more regions. MSF also hopes to be able to resupply projects by air and send in much needed technical staff. To achieve these goals—and to ensure the security of our personnel in the country, to maintain the integrity and independence of medical facilities, and to communicate the nature and purpose of our actions—MSF remains in constant dialogue with Al Shabaab. This is a significant challenge because of Somalia’s recent history, the geopolitical aspects of the conflict, the ever-evolving nature of the context, and Al-Shabaab’s proclivity to view all humanitarian efforts as an extension of the military campaign against it.
“So in addition to the security constraints we face, some of which are inevitable when working in a conflict area, we are attempting to exchange with the appropriate interlocutors, and convince them of the pertinence of our medical activities,” says Mclean. “These initiatives have been periodically successful, although we are not satisfied with the scope of our intervention given the scale of needs. But for just this reason, we continue to persist.”