January 17, 2007
On January 17, 2007, David Michalski, Doctors Without Borders/Médecins Sans Frontières' (MSF) head of mission in Somalia, delivered the following speech at the "Securing Somalia's Future: Options for Diplomacy, Assistance, and Security Engagement," conference on Somalia hosted by the Center for Strategic International Studies, the Council on Foreign Relations, and the Woodrow Wilson Center in Washington, DC.
Ladies and gentlemen,
On behalf of Doctors Without Borders/Médecins Sans Frontières (MSF), please accept our thanks at the invitation to address this forum today.
I have just returned from Somalia, having been in Galgaduud region on Saturday. I was leading our international team back into Galgaduud, an area that has been Level 5, or off limits in the UN security jargon, for years now. We evacuated on December 23rd, one day before major hostilities broke out in Somalia. During the absence of international staff, our national team continued to work, carrying out some 60 surgical operations on war-wounded patients. On January 10th, the international team returned to help run the hospital and clinics in outlying areas.
It is at this point that you might expect some breathless report on how the things are getting worse by the minute and an emergency is unfolding before our eyes. Are things getting worse or better? — it's hard to tell. What is sad to tell is that I could have rushed here just as breathless 5 years ago or 10 years ago and given you the same type of update on the humanitarian situation. It is an ugly disaster that has raged for years to the general indifference of the outside world. This indifference has literally left thousands of Somalis breathless.
While news about floods or droughts have grabbed the headlines in the past year, and stories about the Ethiopian intervention and Rift Valley Fever dominate coverage the last month, the situation for the population over the last 16 years has been a disaster.
Headlines seldom deal with the hard truth that the floods, wars, droughts only exacerbate the suffering where approximately 1 in 4 die before their fifth birthday. Malnutrition is chronic and in many places above the threshold that would cause an emergency intervention in other countries. Tuberculosis infection is rampant. Rare but fatal diseases like kala azar are endemic in certain areas. Many children die from easily curable disease every day including malaria and respiratory infections. A vast majority of Somalis have no access to health care.
Of course, my description of the humanitarian condition is slanted towards the medical field. However, the situation with regards to education, water and sanitation, and other fields are equally precarious.
While indifference and neglect have been the hallmark of the past years, currently there is significant attention to Somalia given recent political and military developments there. And on the humanitarian front, following the overthrow of the Islamic Courts, the US Government, the EU, and the UN have announced increases in assistance, citing the need to improve living conditions for Somalis and bolster the Transitional Federal Government (TFG).
Against this background, I'd like to divide my talk into two main parts: first to describe some of the lessons we have learned from providing humanitarian aid in southern and central Somalia in recent years; and second to outline some of the concerns we have about the current situation.
Providing Humanitarian Aid in Somalia — Some Observations
The conventional wisdom is that it is almost impossible to work in Somalia, and that foreigners risk their lives at every turn. It is true that there are some very distinct features about running humanitarian programs in Somalia. An almost unique characteristic for MSF operations is that armed protection is required because we are particularly vulnerable as foreigners, given our resources and our lack of standing in the clan system that remains the fabric of Somali social and political order.
But it is possible to provide assistance — MSF has continuously worked in southern and central Somalia for over 17 years. Today we have some 40 international staff and over 700 national staff working in our 12 locations in south and central Somalia. Each location is unique in the clan makeup, the people in charge, the security arrangements necessary, and in some cases, the prevalence of diseases. All locations share huge needs and a war economy that has not allowed a governmental structure to provide any social services for over a generation.
In 2006, we performed more than 300,000 outpatient consultations, and 10,000 inpatients were admitted in our hospitals. In general, the quality of the work is verified by high cure rates, low defaulter and death rates. To our regret, we do not have programs in the main urban centers, namely Mogadishu and Kismayo. This has not meant that our projects are small. In the tiny town of Huddur (approximately 20,000 population), we have the largest inpatient department in southern Somalia with 250 beds full almost every night. Many come from long distances, some traveling for over a hundred miles away to receive care.
So you may ask, how do we do stay on the ground in what is admittedly a difficult security context? A few operating principles have proved to be critical:
First, MSF is one of the few NGOs that has kept operating in Somalia with internationally staffed teams on the ground. It is our opinion that this continued international presence allows for a better understanding of the local security situation, greater medical quality in the services delivered, and solidarity with a population in an acute state of need.
Second, we have worked to build up our independence from all political and military actors, both local and international. Our independence comes from a number of sources. For instance, logistically, we hire our own planes and do not fly with UN air services or ECHO. Security is intertwined with availability of air transport when we need to evacuate our teams on short notice.
This logistical independence leads to operational independence because it means that we were not forced to follow ECHO or UN security interpretations. This has huge ramifications on our ability to maintain humanitarian projects on the ground. Concretely, it meant that we were able to open a large project in Galgaduud that provided a hospital and referral outpatient facilities for an estimated population of over 300,000 for the past year. ECHO and the UN do not fly there.
In the past two years in Huddur, we have been evacuated approximately 7 weeks in total. Were we to rely on the UN flights and their security interpretations, Huddur operations would have been suspended for over 16 months? Therefore, the perception of the population is that MSF will only pull out when there is a security threat. Of course, then the population considers why others have chosen not to remain operational.
Third, we have focused on providing quality services. In our projects, patients come from further and further away, and the availability of decent medical care is giving MSF a reputation for being serious about its work— one of the greatest assets we can have to ensure our safety.
Fourth, it is critical to engage with all relevant political and military actors. In Somalia, few in power are without allegations about their backgrounds and their past. Yet the humanitarian actors need to engage with the power brokers in an area in order to provide services to the population. When we assessed and then opened a project in 2005 and early 2006, it was in one of the few Islamic Court- controlled areas (before the battles in Mogadishu and their subsequent expansion). Throughout our time working there with the Courts, we received support to run our medical operations independently. Now that they are not active in the region, we are engaging with the new authorities. If the warlords or traditional elders or Islamic Courts can give credible assurances of support and security along with the independence to run humanitarian operations, many, many areas of Somalia are open for work.
Our experience has shown that when we remain on the ground with international staff, it is far easier to adhere to the humanitarian principle of impartiality and face the operational challenges. It allows us the opportunity to witness the situation. With our own eyes, we can corroborate or disprove information reported by various organizations, including the UN, in our locations. Many times information is distorted while published and cannot be validated by the actors themselves as they are not in the field. Occasionally, we have to evacuate for a short period but it is always with the goal of reinserting the international teams quickly and not being on "remote control" or with prolonged lack of continuous international supervision. Many programs by most agencies in Somalia are set up in this "remote control" or "hit'n'run" as an operational starting point with no planned supervision other than occasional visits every few months.
It is not for want of good national staff. National staff clearly make up the backbone of our projects and the vast majority of our staffing. However, the environment in Somalia puts such pressure from the employee's clan to favor their own kin that it is almost impossible and frequently dangerous for people to resist. An international staff presence can take considerable community pressure off a key national staff.
MSF has witnessed in our own projects that are forced to run on "remote control," a loss of fiscal and operational accountability and a likely diversion of aid. In a worst case scenario, diversion of aid and loss of financial accountability can be siphoned off to enrich the war economy.
In Somalia, loss of accountability can lead to a vicious circle: aid being diverted to a certain clan leads to a breakdown in trust of the humanitarian principles we should be upholding. Consequently, the community at large will be naturally suspicious of the next project and therefore the chance that it too will be diverted is large. This breakdown of trust in the humanitarian principles leads to a general suspicion of humanitarian motives and thus creates the climate that is ripe for at best, suspicion and at worst, abuse and corruption.
Many blame the security situation and the scramble for resources in Somalia as the principle cause of diversion; however at times, donors, international agencies, and various political actors are knowingly supporting policies and programs that feed into this vicious cycle.
Some Areas of Concern about the Current Situation:
Now that I have described some of the operational realities of working in Somalia, I would like to turn to some of our concerns about the current situation.
The lessons learned over the past 17 years of MSF action in Somalia were hard-gained. The advances we have made remain fragile.
Currently, there seems to be a greater interest in the humanitarian situation in Somalia and Somalis clearly need an increase in assistance. However all actors must ensure the fundamental principles of humanitarian aid are not left in an office in Nairobi, a conference room in Washington but followed all the way to the recipients in the field. Given the difficulties of providing aid in Somalia, failure to do so could have serious negative consequences.
Skepticism of the motivations of humanitarian actors is high in Somalia. With a significant Diaspora community and excellent communication links, Somalis are well aware of the apparent paradox between the large infrastructure and aid coordination for Somalia present in Nairobi and the amount of actual aid currently delivered to the recipients in country.
Consequently, there will be suspicion and questions about the sudden interest in Somalia's humanitarian predicament following a major military operation undertaken by at least 2 foreign countries. A sudden deluge of politically motivated aid could well add to the general suspicion and consequently lessen the ability of actors like MSF to operate in an independent and impartial fashion.
Maintaining the perception among all parties of our independence and neutrality is always difficult in Somalia, and we are concerned that it may become even more so in the coming months. A much-publicized US military airlift of relief supplies to flood-affected populations on the Kenya-Somali border just weeks before the US military operation in Somalia underscores the risk that humanitarian efforts will be perceived as an extension of the broader politico-military agenda. This could add to the difficulty of gaining acceptance for humanitarian efforts.
For aid to be effective and relevant to the needs of the Somali people, fundamental rules and principles of international humanitarian law must also be respected by local and international political actors, as well as by donors and aid organizations. Humanitarian access must remain open for the transport of goods, services, and aid workers. Governments have often used "national security" arguments to justify actions that have resulted in limitations on assistance. Three flight bans have been issued in the past 16 months alone on Somalia's airspace. All of these initially cited security concerns but none of them allowed exemptions for humanitarian flights. Humanitarian aid was hampered for days, even weeks. Recently, security concerns were also cited when refugees were halted at the border of Kenya and turned back. Serious incidents have occurred at the Buale hospital and the MSF hospital in Dinsor in the past weeks that endangered medical activity, as well as staff and patient safety. Hospitals must be places where all wounded can safely receive treatment and where staff is free from coercion and intimidation by warring parties.
Simply put, the will to help the situation is not enough. There needs to be a commitment and substantial efforts at developing the infrastructure, security conditions and delivery mechanisms that will ensure that humanitarian principles are upheld and that aid effectively reaches the intended beneficiaries.
As far as it is possible, MSF will continue to work on the ground in Somalia because the needs are staggering and we have shown that, with adaptation and independence, the results can be substantial in a difficult environment for humanitarian work. Over the last two years, MSF staff have represented more than 60 percent, and at times the entirety, of the international aid worker presence in south and central Somalia. This is not a point of pride for MSF: we should and will look to expand our operations. It is our hope that the rest of the international humanitarian community has similar plans.
What Somalia needs now is a transparent willingness to help the population facing a 16-year-old crisis, exacerbated by recurrent episodes of acute vulnerability. The Somali people need a renewed commitment to leave the various agendas behind, to get on the ground and to ensure that aid is responsibly delivered.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)