NEWS UPDATE

For 14 years, the poverty-stricken population of Somalia has had no effective central authority to aid them in their battle against malnutrition and disease. Ever since the East African country was left without a functioning government in 1991, Doctors Without Borders/Médecins Sans Frontières (MSF) has been working to meet the enormous medical needs of its people.

It's like it's never going to end. Hundreds of women are walking single file into the huge compound, lining up at its remote end. They're all carrying children and they're all hoping for food.

MSF outreach nurse at monthly nutritional screening in the Bakool district. 800 children are checked for malnutrition in one day. Photo © Espen Rasmussen

It's a scene that repeats itself every month in the tiny village of Istorte in Somalia's Bakool region. The women and children are here for the nutritional screening, hoping that they will qualify for extra food rations. MSF is here to detect severely malnourished children, for whom extra food is not enough. When a child weighs less than 70 percent of what's normal for the child's height, he or she will need treatment in MSF's therapeutic feeding center (TFC) some 55 miles away.

Eventually, the compound gate closes behind the last of the children. "There must be 800 children here," MSF supervisor Ali Cuba says as he surveys the scene. He then embarks on the massive task of determining the level of malnutrition for each and every one of them.

Ali Cuba administers a simple and reliable test when checking the children. Using a color-coded bracelet, he quickly measures each child's middle upper arm circumference. If the bracelet shows green, the child is okay. Yellow is a sign that he child is at risk of malnutrition. Orange indicates moderate malnutrition, and the child will need supplementary feeding. If the middle upper arm circumference (MUAC) is in the red, the child is severely malnourished and will need treatment.

Every month, hundreds of mothers with children show up at the nutritional screening in the small village of Istorte. MSF checks children for malnutrition and refers the severe cases to MSF's therapeutic feeding centre in Huddur. Photo © Espen Rasmussen

The sun sets long before the last child has been screened. At the end of the day, MUAC testing and measurements of height and weight reveal that several of the children are severely malnourished. Luckily, Ali Cuba has caught them in time. Tomorrow, a truck rented by MSF will serve as a makeshift ambulance and take them to the feeding center.

No national authority

Malnutrition is one of the many scourges of Somalia. Mass poverty and drought of course contribute to the problem, but there's more. The country that makes up the edge of the Horn of Africa has been without a functioning central government since 1991. On a national level, there's no authority to take up the challenge of feeding Somalia's people, nor of providing them with health care. The effects are obvious; average life expectancy is only 47 years.

"All health care in Somalia is provided either by private pharmacies or by aid organizations like us," says MSF's field coordinator Göran Svedin.

Appropriate private health services are out of reach for all but the wealthiest of Somalis. Therefore, MSF is facing a staggering task. "You can stop anywhere in a country like this and the needs will be there," Göran says.

And meeting those needs is even more difficult without the framework provided by a government. "Without a central government, there's no Ministry of Health. Without a Ministry of Health, there's no national health policy. There's no coordination of the medical efforts made in Somalia," says Feisal Abdikadir, MSF's interim head of mission for the Bakool region.

"We're left to find our own way to provide health care to the population."

Violence

Since international attempts at peacekeeping failed some ten years ago, Somalis have largely been left to fend for themselves in a country torn apart by violent inter-clan rivalries. One testament to this is the structures that make up MSF's health center in Xuddur, the capital of the Bakool region. The facilities used to be a French military compound before the world gave up on Somalia. Now, all that's left of the peacekeeping efforts of the 90s is the rusted machine-gun shells and burned-out army vehicles that litter the environs of the health center.

In Xuddur, MSF provides vital services that would otherwise be out of reach for the 200,000 impoverished inhabitants of the Bakool region. But providing health care in Somalia is not limited to administering treatment. The need to understand the Somali culture is vital, all the more important as the vacuum left by the lack of a recognized and functioning national administration is filled by traditional and religious systems. Therefore, the MSF team also reaches out to community and religious leaders, as well as reinforcing the training of increasingly skilled local staff.

The health center has inpatient and outpatient departments, and in addition to the TFC, it houses a tuberculosis ward and a ward for children who suffer from kala azar, or leishmaniasis–a fatal, but relatively unknown disease.

Black fever

A day ago we visited five-year-old Faduma Ahmed Macadir on her mattress in the health center. Today, she's dead. Her body is in the health center's morgue, waiting to be buried in the cemetery only a few yards away from where she died. Faduma fell prey to kala azar. Sadly, had Faduma's mother managed to bring her to the health centre sooner, the young girl probably would have survived.

MSF doctor examining a 2 year-old in the kala azar ward of MSF's health centre in Huddur. The baby has kala azar and is very weak and dehydrated. Photo © Espen Rasmussen

Kala azar is Hindi for "black fever." The disease is transmitted through the bite of the sand fly. Symptoms include fever, anemia, weight loss, and an enlarged spleen. Kala azar is fatal within months if left untreated.

Needles

It's 11 o'clock in the kala azar ward of MSF's health center. The first sobs of the young patients grow into full-fledged screams as clinical officer Abdullai pulls on his surgical gloves and prepares to give the children their daily injection to fight off the black fever. It's a long and painful treatment for the children, but it's their only chance of survival.

The drug in Abdullai's syringes is called sodium stibogluconate (SSG). It's an old treatment, developed in the 1930s. Each child must be given its injections daily for a period of a month. After two to three weeks of treatment, the fever normally abates and the child's strength returns. After another 14 days, the child is cured, and can return home.

Eight-year-old Nurow Mahamed Ahmed was seriously ill when his grandmother Amino walked with him the 15 miles to the health center.

"He was very weak and in a lot of pain when we came here," says Amino. Nurow has endured the SSG treatment every day for 28 days. He's the only child who takes his shots without crying. And the 28 painful intramuscular injections have paid off. Nurow has won his battle against kala azar.

"I'm feeling very much better now," the boy says. Now, only two more injections stand between Nurow and his discharge from the health centre.

Reaching out

"Regina! Regina! Regina!"

The children's exhilarated shouting is the first sound we hear when we step out of the car. The woman they are so excited to see is MSF's outreach nurse Regina Dehnke. The children know her well; Regina has spent two years with MSF in Somalia. Her job is to supervise three health posts, one of which is here in the village of El Garas, 30 miles away from the Xuddur health center. Regina also does nutritional screenings in the more remote areas of the Bakool region as well as training the local staff at the health posts.

"Giving the health staff proper training is extremely important in Somalia. You don't find many qualified or experienced people here," Regina says.

The health posts make medical services far more accessible for people who live far away from Xuddur town. For diseases like kala azar and tuberculosis, patients must be referred to the health center in the regional capital. But now they actually have the chance to be diagnosed and transferred before it's too late.

We're here in El Garas with Regina to inspect a newly rehabilitated structure, which will soon house the village health post. The old site–a small, dark room in a house on El Garas' main road–will be abandoned in favor of the new building. A dressing room, a consultation room, and a waiting area sheltered from wind, rain, and scorching sun make up the new health post, which is very welcome among the villagers.

"Up to 10,000 people from El Garas and the surrounding areas will benefit from this new health post," says the District Commissioner, the highest local authority of the village. "Life will be a lot easier for those of us who are sick."

One of the diseases affecting a great number of Somalis is tuberculosis (TB). Somalia has one of the world's highest rates of the disease.

"Luckily, the situation in Xuddur is stable enough for the moment for us to offer TB treatment in the health center," says MSF doctor Ingrid Herder.

Curing TB takes at best six months of treatment. If the treatment is interrupted, drug-resistant strains of the disease can develop. "And it's heartening to see the results of the treatment," says Ingrid.

"A ten-year-old boy called Schuheeb came to the health center carried on a wheelbarrow a few months ago. His deformed back was covered by a pus-filled boil, and he was unable to walk. Now, after a few months of treatment, he's running around with the other children. This kind of thing is a daily reminder that our work actually pays off."

© 2005 Doctors Without Borders/Médecins Sans Frontières (MSF)