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MSF in Somalia, 2005
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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.