The last 10 years of suffering

MSF has been working in Somalia since 1986. We saw the terrible build up of slaughter and famine that eventually produced the American led and UN backed military intervention on November 9 1992. The civil war that erupted after the fall of the long-term dictatorship of Siad Barre smashed central authority and stimulated a multiplication of clan factions struggling for local power. MSF started appealing for medical and food aid early in 1992. By the time UNOSOM troops arrived the famine had peaked.

The UN mission degenerated into a running battle with warlords. In October 1993, 18 US Rangers were killed in Mogadishu. The Americans withdrew from the country five months later and the UN mission in March 1995. Since then, a brutal competition for power has terrorised the civilian population and exposed them to injury, disease, displacement and hunger, while eroding the health services that might support them.

MSF has struggled to respond to the huge needs in the country. We have been regularly forced to evacuate and close clinics and projects. Other aid agencies have withdrawn completely. Most of the outside world has turned its back on what it thinks is an insoluble mess.

This cannot be the best we can do for Somalia. MSF appeals for a reversal in this neglect. The evidence we have gathered over the last ten years of suffering demands a response.

War casualties

In MSF's health centre in Xudur, wounds accounted for 46% of all pathologies in the dressing room between January and June 2002. In Galkaayo's hospital, trauma accounted for 48% of all morbidity in the hospital's emergency room (ER) in both 2000 and 2001, while 500 new wounded arrived in the ER every year

Consistently high casualty figures are seen again and again in areas still beset by conflict. After twelve years of war, Somalia's war-dead and wounded number tens of thousands.

MSF's medical-surgical facilities in Kismayo Hospital were open between 1992 and 2001. From the onset, the number of wounded arriving totalled 3-5 per day, with surgical teams working until 5 AM on most days. By April 2000, the team was seeing 4-5 wounded per day. Consistently high casualty figures are seen again and again in areas still beset by conflict. After twelve years of war, Somalia's war-dead and wounded number tens of thousands.

Since the vast majority of combatants are male (although there are reports of women warriors), men are far more likely to suffer combat-related trauma. MSF's out patient department (OPD) in Yaqshid, Mogadishu, saw 3,063 'trauma and burn' cases among men older than 15 in 2001. Among women, the figure was only 334.

However, there is also evidence of rape increasing since 1991. Somali women are targeted with sexual abuse when marauding clan-based militias - mooryan raiders - loot or forcibly occupy territories inhabited by members of rival clans. Looting and pillage is one of the main causes of violent death, displacement and loss of livelihood among civilians.

Landmines wound and kill civilians. One million were laid in Somaliland by Siad Barre in the late 1980s and early 1990s, often on agricultural land, around water resources and even in people's homes. Most were placed without corresponding records of their location. The target was clearly the civilian population and, since 1991, some 5,000 mine casualties have been reported in Somaliland alone (3,500 dead and 1,500 amputees).

MSF sees and treats these victims every day: from wounded militiamen to rape victims to children who lose limbs in mine accidents. NGOs meanwhile are often hindered in their work by the violence around them, with the victims of conflict deprived of access to care.

MSF estimates Somalia has less than 15 qualified doctors per million people.

Health Services

Lack of adequate health care is one of the biggest problems facing Somalis today. A staggering 78% of the population has no access to health services. MSF has estimated that the country has less than 15 qualified doctors per million people. Trained healthcare professionals fled the country to safety during the 1990s. The only nurse training facilities are in Bosasso and Hargeisa - and the few health workers that remain tend to be based in the more secure urban centres. The whole of eastern Sanag, for instance, had only one doctor in 2001.

Public health sector

The public health sector is in a lamentable state. A high proportion of staff providing services in the public health sector today are untrained or their qualifications are questionable. Recruitment is further limited by clan quotas - training or employing members of only one clan in an area occupied by several clans is, at best, inadvisable.

Public hospitals like those in Galkaayo or Baidoa are beset with insecurity. There is a lack of funding, equipment, qualified staff and drugs as well as having to serve an enormous area. Galkaayo Hospital serves a population of 650,000 while Baidoa is the only hospital for the whole of Bay Region.

Aid agencies have had to fill the gap in those areas where health services and structures have all but collapsed.

Private health sector

The Somali private health sector has grown considerably in the absence of an effective public sector. This means that the most vulnerable are completely excluded from the new services. Of the 20% of the population who get any care at all, about two thirds of them get it from the private health sector. The growth has thrown up a range of problems.

Over-the-counter drug prescriptions, the dispensing of expired drugs, and inadequately trained staff can lead to misdiagnosis and drug resistance (for example to anti-TB drugs, antimalarials or antibiotics). Moreover, private health care is characterised by high charges for services - pricing the poor out of health.

Aid agencies have had to fill the gap in those areas where health services and structures have all but collapsed. They struggle to provide health care in remote areas, where reaching the patients is a major problem. Insecurity is among the main reasons for this. The sparse distribution of NGOs means that the sheer distances which patients must travel are an obstacle to health.

Diseases

Somalia's health indicators are dizzying: Average life expectancy is around 46. Somali children are 26 times more likely to die before their fifth birthday than children in the developed world. Somali women are 22 times more likely to die in childbirth than European women. Less than a quarter of the population has safe drinking water. Under half the population have sanitary means of excreta disposal. Outbreaks of measles, cholera, dysentery and Kala Azar pose a major threat for the public health of Somalia. The country has one of the highest incidences of TB in the world.

Cholera outbreaks before the war had only been recorded in 1970 and 1985. But since 1994, Vibro cholerae has become an annual visitor, epidemics tending to be seasonal with peaks just before and just after the rainy season.

Mortality rates can be terrifyingly high. Tuberculosis and cholera are endemic. Somali children are 26 times more likely to die before their fifth birthday than children in the developed world.

The biggest reason for cholera outbreaks being endemic and recurrent now is the lack of safe drinking water and sanitation, with less than 25% of Somalis having access to potable water and 48.5% to sanitation (taking population groups and regions into account). The risk of acquiring water-borne diseases like dysentery, cholera, diarrhoea and Typhoid Fever are increasingly high as a result.

Mortality rates can be terrifyingly high. For instance, when cholera first reappeared in 1994, its arrival was as sudden as it was devastating. Starting in Bosasso, it quickly spread to Mogadishu, killing 400 people in just three days. MSF treated 3,200 cases in Kismayo and nearly 4,000 in Mogadishu. In many rural areas where NGO presence and information on how to treat cholera are lacking, an outbreak can quickly evolve into a latter-day plague.

Tuberculosis is endemic in Somalia and in 1999 MSF estimated Somalia to have the highest annual rate of infection in the world. At the end of 1990, levels had already reached a critical 60,000 - with a population of around 7 million, this meant that there were at least 14,000 new cases of sputum positive cases per year. Since the war broke out, however, it has been extremely difficult to measure global incidence levels, but it can be assumed that they have only risen, with a significant percentage going undetected and untreated. Constant movement, poor living conditions, lack of drinking water, malnutrition, closure of TB programmes and the off-the-shelf treatment from private dispensaries exacerbate the situation.

MSF's health clinic in Xudur, Bakool, includes a TB treatment centre. In just six months (January to June 2002), it found a TB incidence of 100 per 100,000, although the numbers that remain undetected can only be guessed at.

Malaria is considered to be a major contributing factor to mortality - both directly through its severe forms and indirectly by causing anaemia and low birth weight. Malaria incidence changes by geographical zone and those areas recording the highest numbers of malaria cases have the least developed health infrastructure. Unstable transmission, nomadic lifestyles and possible mass population movements of IDPs make Somalia a country that is especially vulnerable to malaria epidemics.

MSF's five OPDs in Jowhar, Middle Shabelle see around 85,000 malaria consultations per year

Kala azar (Visceral leishmaniasis) was only sporadically reported before the war, mainly in Middle and Lower Shabelle. Since the war broke out, however, its incidence has increased, with an outbreak along the Kenya-Somalia border reported in 2000 and prevalence on the increase near the Ethiopian border.

MSF's clinic in Xudur, Bakool, has seen between 10 and 30 new cases per month since August 2000. It must be assumed that, in those regions where NGO presence is negligible, kala azar - given its complex epidemiology and very high fatality rate when left untreated - is claiming lives.

What has probably worsened kala azar rates is the war's effect on susceptibility to the disease, with malnutrition and lack of immunity being significant risk factors. Displacement, poor living conditions and the collapse of health services have all contributed to a higher incidence of kala azar in Somalia than before 1991.

Poor living conditions, sanitation, water and healthcare - especially since 1991 - all contribute to the high mortality of children.

Maternal and Child Health

Somalia's maternal mortality rate is shocking: 1,600 per 100,000 live births, making it the third-highest in the world. Throughout Somalia, 45 women die every day during pregnancy or delivery. More than one in ten infants die before the age of one; nearly a quarter of all under-fives (22.4%) die before their fifth birthday. Only 21% of infants under four months are exclusively breastfed; and only 35 and 40% of children are immunised against DPT, Measles and Polio before the age of one.

MSF's findings over its 16 years in Somalia point to diarrhoea, acute respiratory infections, cholera, malaria, TB and measles being the biggest causes of child mortality. Poor living conditions, sanitation, water and healthcare - especially since 1991 - all contribute to the high mortality of children.

Food

Food shortages are a very real possibility in places like Bakool, where MSF has a clinic. One in every five harvests is a partial failure. One in ten a complete loss. While coping mechanisms are in place to bridge the gap between the rains and the harvest, the rains were poor in 2002. Not that hunger is caused exclusively by drought - far from it.

MSF's findings in 1991 and 1992 of consistently high global malnutrition rates among the war-displaced in Kismayo, Mogadishu, Kansardere and Baidoa - rates reaching highs of 75.6% - supports the thesis that conflict fuels hunger.

In 2001, the Enlarged Programmes of Immunisation (EPI) estimated that just over a quarter (25.8%) of Somalia's children are underweight for their age. The Food Security Assessment Unit (FSAU) stated that around 500,000 people are threatened by severe food shortages. Malnutrition is endemic in Somalia, and those worst affected are the displaced and farmers along the Juba and Shabelle river valleys. The global acute malnutrition rate for the whole country is 17%, but is markedly higher for these more vulnerable groups. In the north of Gedo Region, the FSAU estimates malnutrition rates to be as high as 30% due to the poor rains this year.

Meanwhile, with the exception of 1991-1993, food aid to Somalia is significantly lower than throughout the 1980s , placing the onus for providing social welfare on private households and their already straining coping mechanisms.

The cramped, unsanitary living conditions of the urban poor - often synonymous to IDPs - mean that the displaced make up one of the most disaffected sub-groups of the Somali population, with some of the country's worst health indicators.

Driven from their homes

When the war broke out in 1991 and famine followed in its wake, around 60% of the population was forced to move - either within Somalia or beyond its borders. Over the years, the cautious return home has reduced this percentage, but for the last two or three years it has levelled out and remained steady at around 10%.

Many internally displaced people (IDPs) and refugees still do not return home for fear of conflict or because they cannot afford to make the long journey back. The cramped, unsanitary living conditions of the urban poor - often synonymous to IDPs - mean that the displaced make up one of the most disaffected sub-groups of the Somali population, with some of the country's worst health indicators.

The majority of displaced are from the poorest rural families and live in the most deprived districts of urban centres. The 'Green Lines' in Mogadishu and Galkaayo, for instance, are the most dangerous - and therefore cheapest - areas of those cities.

MSF's OPD/MCH in North Mogadishu is in the Yaqshid area, near the Green Line. Many of the patients here are Internally Displaced Persons (IDPs) from elsewhere in the country. It sees an astonishing 250-300 consultations per day, around 95,000 consultations per year - a reflection of the absence of other, affordable health services in the area. Immunisation of under-fives, pregnant women and women of child-bearing age (16-45), plus monitoring the nutritional status of under-5s, are automatically part of any treatment given to women and infants.

The OPD/MCH also offers post- and ante-natal care, while the consultation room is crammed with patients - ailments from scabies to heart murmurs to conjunctivitis all wait to be treated.

IDPs today constitute over 60% of those Somalis considered to be 'food insecure' and over the last two years, malnutrition rates as high as 25% have been noted among IDPs (the global malnutrition rate for the whole of Somalia is 17%).

In April and May 2002, with fierce fighting in Bulo Hawa, Gedo Region, over 10,000 Somalis sought refuge in Mandera, just across the border in Kenya. Just 500 metres from the border, the temporary camp was still too close to the fighting - four refugees were killed in May 2002 by stray rounds from the battles just across the border.

Exodus

Before 1991, Somalia played host to one of the largest refugee populations in Africa. Mostly from Ethiopia's Ogaden region, one in six persons residing in Somalia was a registered refugee. The war reversed this population stream.

In 1991 an estimated one million fled the war and looming famine to countries both in and outside of Africa. Many returned in 1993 and after 1995, but - as with IDPs - the slow and cautious return home levelled out. The number of (visible and invisible) refugees who remain in neighbouring countries is still estimated to be around half a million.

While Somaliland alone has absorbed over 50% of repatriations between 1992 and 2001, the Somalis continue to flee from conflict in Lower Juba, Middle Juba, Gedo and Bay. In April and May 2002, fierce fighting in Bulo Hawa, Gedo Region, forced over 10,000 Somalis to seek refuge in Mandera, just across the border in Kenya. At just 500 metres from the border, the temporary camp in which the refugees sought shelter was still too close to the fighting - four refugees were killed in May 2002 by stray rounds from the battles just across the border.

The international NGOs working in Mandera appealed to the Kenyan government to move the refugees to a safer place further removed from the fighting. Instead, the Kenyan government forced many of the refugees back to the fighting in Somalia at gunpoint.

Deserted and ignored

The disengagement of the international community has been slow but steady over the last ten years. In 1992 there were over 200 international aid organisations working in Somalia. In 2002, according to the NGO Consortium, there are 61, only a handful of which work in the most insecure and/or remote areas where their aid is needed most.

The most needy and vulnerable populations are those living in the most insecure areas - the very areas beyond the reach of humanitarian organisations.

The experiences during the UNOSOM intervention led some agencies, understandably perhaps, to reach the conclusion that their presence in Somalia was more trouble than it was worth. Unfortunately, the most needy and vulnerable populations are those living in the most insecure areas - the very areas beyond the reach of humanitarian organisations. When a nutritional crisis was identified in Gedo region in 2002, for instance, the population could not be adequately assisted due to insecurity.

The level of funding available has also dropped dramatically. Since 1995, international aid has fallen to below pre-war levels. The annual aid programme dropped from $1.6 billion for UNOSOM II alone, to roughly $115 million in 2001 for both UN and NGOs - the majority spent in the more secure north of the country.

The imposition of conditions on the provision of aid has added to the problem. The latest example could be seen at the national reconciliation conference in Eldoret, Kenya, in October 2002. Mohamed Sahnoun, representative of UN Secretary General Kofi Annan, said that if Somalia's leaders could create a peaceful environment, the UN would "provide increased development and humanitarian assistance."

It is not clear whether this trade-off includes emergency, life-saving aid (although the words "humanitarian assistance" would seem to indicate that it does). If so, MSF fears that, in areas where the creation of a "peaceful environment" is unlikely in the immediate future, the Somali population will suffer as a result.

The needs themselves continue unabated, far exceeding the operational capacity of MSF - indeed, of all aid agencies currently working in Somalia put together.