Photo © Pep Bonet |
Providing care amid chaos
Since 1991, Somalia has been a state without
a government on its own soil. Fourteen
years of lawlessness has left the country
with enormous unmet medical needs and a
high level of daily violence. The ongoing
civil war has brought about a virtual collapse
of public-health structures and services.
In most parts of the country, clinics
and hospitals have been looted or seriously
damaged. There are estimated to be only
four doctors and 28 nurses and midwives
for every 100,000 people in Somalia.
Unsurprisingly, Somalia has some of the
worst health indicators in the world. More
than one in ten children dies at birth and
of those who survive, a quarter will perish
before their fifth birthdays. Malnutrition is
one of the many scourges of Somalia. Mass
poverty and dry rainy seasons also contribute
to the problems. On a national level,
there is no authority to take up the challenge
of feeding Somalia's people, nor of
providing them with health care. The
effects are obvious: the average life expectancy
for a Somali is only 47 years.
Violence is so widespread and the country's
clan structure is so complex that few
aid agencies choose to work there. But
with no state and thus no state medical
services, Somalia is a country in desperate
need of this type of assistance. With significant
numbers of international and national
staff on the ground, MSF tries to fill some
of the huge gaps. Its projects involve primary
health care across the worst affected
areas in south and central Somalia, and
include treatment for those with tuberculosis
(TB) or kala azar, therapeutic feeding
of malnourished children, pediatric care
and even surgery.
In the Bakool region, which borders
Ethiopia, MSF operates a health center in
the regional capital of Xuddur and three
health posts in surrounding villages.
Through inpatient and outpatient facilities,
MSF offers vital services that would otherwise
be out of reach for the 200,000 impoverished
inhabitants of the region. The team
gives primary health care, and treats people
with TB and kala azar. Severely malnourished
children are also treated in the
health center.
The city of Galkayo in the northwestern
Mudug region is divided between two warring
factions. MSF supports two
hospitals in the city, in each of the areas
controlled by the two factions. The organization
provides inpatient and outpatient
care, therapeutic feeding, surgery, TB treatment,
maternal health care, and pediatric
and emergency services.
In Mogadishu, MSF runs a primary health
care clinic, providing outpatient services
and maternal and child health care. The
organization also does epidemiological
surveillance and intervenes when needed.
In the Middle Shabelle region in the west
of the country, MSF provides basic health
care and epidemiological surveillance in
the districts of Jowhar, Mahaday and Aden
Yabal. MSF's activities include running 10
outpatient dispensaries, 6 maternal and
child care health dispensaries, 1 emergency
room and 5 mobile immunization teams.
In the Lower Juba Valley in the Marere
region in northeastern Somalia, MSF provides
inpatient care for pediatric, medical
and maternity cases; therapeutic and
supplementary feeding; and outpatient
services for the rural population, including
the marginalized Bantu ethnic group.
MSF also runs a health center in Dinsor in
the Bay region in central Somalia. In addition
to providing outpatient health care
and immunizations, it runs an inpatient
department with 40 beds, provides emergency
surgery, gives antenatal health care,
and has opened a laboratory to support its
TB work. The staff also treats malnourished
children and patients with TB and kala azar.
In addition, MSF maintains an emergencyresponse
system in cases of epidemics or
clashes.
Where mercy is in short supply
Roda Musa lies on a bed, cradling her arm. Her f lowing, colorful clothes are a stark contrast
to the white plaster that covers her from hand to shoulder. She appears to be in her
early 20s, but her face is lined with anger when she explains why she has found herself in
the trauma ward of the MSF-run hospital in the town of Galkayo.
"A Somali man shot me in the arm," she says. "I have no idea why." She is not alone. The
same hospital has treated more than 300 patients for trauma injuries related to violence in
the first six months of 2005. Around 80 percent of these are bullet wounds.
Galkayo, situated in central Somalia, is an important trading town with a population of
80,000. It has all but literally been torn in two. Viewed from the air, Galkayo is a small
area of identical metal roofs in the midst of an unforgiving desert. But with no authority
other than warlords and no law other than the gun, a dispute between two clans has escalated
to the point where people from the southern part of Galkayo cannot venture north
and vice versa. A "green line" — which is more like a no man's land — is guarded by opposing
militia and splits the town into two halves. When MSF reopened the North Galkayo
Hospital in collaboration with local doctors in 1997, restarting a service that had collapsed
at the start of civil war in 1991, it became the first hospital accessible to all for hundreds
of kilometers in every direction. Except for those directly to the south, of course.
"We quickly realized that the green line prevented those in the south of Galkayo from
traveling the four or five kilometers north to get treatment," explains MSF head of mission
Colin McIlreavy. It would be six more years before MSF would finally deem it safe to
begin the process of opening a similar hospital on the southern side of the line.
For the majority of the people in Galkayo, to venture across the "green line" — even to
come near it — is to risk death at the hands of one militia or another. The latest f lare-up of
violence took place in April 2005 when a price dispute in the market that straddles the
green line escalated into a full-scale battle that left at least 18 dead and 37 wounded, many
of the victims caught in the crossfire. The MSF staff cared for the battle's victims.
The division between Galkayo's two factions may seem impassable, but in the hospitals,
the suffering is identical. "The needs are huge," explains McIlreavy. "We do over 40,000
consultations per year in the two hospitals but this barely scratches the surface. It is not
just for residents of Galkayo. People come from up to 700 kilometers away to get medical
care, because there is nothing else available to them. Across great swathes of the country
there is literally no possibility of access to medical treatment. This is why people come for
hundreds of kilometers to reach us in Galkayo. Worst of all, we know that for every person
we reach, there are many more who die for the want of sometimes basic care."
MSF has worked in Somalia since 1991.
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