Javier Fernández has just returned from Somalia after a year and a half spent as a coordinator for MSF. During this time, insecurity has risen dramatically with extensive direct and indirect consequences on the civilian population. These include reduced access to healthcare due to a largely non-existent health system and the scarcity of NGOs who are unable to operate in the current security climate. MSF has also been forced to reduce activities and withdraw its international staff due to rising insecurity. One of MSF’s clinics in Mogadishu was forced to close recently due to increased fighting in the surrounding area which posed an unacceptable risk to patients and staff. Elsewhere in Mogadishu, MSF continues to provide essential healthcare and continues to seek new ways to deliver much needed medical aid, in spite of the rising insecurity. In this interview, Javier gives an overview of the current status of MSF’s projects in the country.
MSF treat a malnourished child in a feeding centre set up for IDPs and refugees in Bossaso, Puntland Region. Somalia, 2007.
Albert Viñas/MSF
What are the main problems affecting the Somali population?
Right now, one of our main concerns is the increasing number of people suffering from malnutrition. This is a problem affecting regions in several countries and not one that only affects Somalia. However, here the conflict exacerbates the problem as people find it more and more difficult to obtain food, leading to a rise in the levels of malnutrition.
Another serious problem the Somali population face is a lack of healthcare, again exacerbated by the conflict – the number of hospitals and health centres has decreased and even the ones that are still operational are increasingly difficult for people to get into. This is due to extremely high prices (most hospitals and health centres follow the cost recovery model or are private) and the difficulties of access caused by the conflict.
How has this malnutrition situation occurred?
Malnutrition is rife because the war has disrupted an already precarious economy. There is no regulation and chaos rules. Inflation is extremely high and the local currency has depreciated considerably. Prices have soared as the fighting has made land cultivation dangerous for farmers. There are also fewer people willing to work in the fields as the planting of crops is an investment, and therefore a risk. This lack of local production is compounded by unfavourable climatic conditions such as droughts and floods.
As people have fled their homes, often staying with friends and relatives in different areas, things have become even harder. A salary that previously had to feed five now has to go as far as to feed some fifteen people.
An IDP camp on the edge of Mogadishu.
© Jehad Nga
Are there still many Internally Displaced People?
Many people have fled Mogadishu since January 2007. Since then, some have returned and others left, some have travelled north heading for Bossaso in an attempt to cross over to Yemen and many have been confined to Mogadishu since the war broke out. There are patterns in people’s movements, but displacements are difficult to quantify in Somalia. In many places, displaced people have just arrived and are thus much more vulnerable.
Can you tell us how the project in Jowhar is going?
In the four clinics we have in the area of Middle Shabelle we conducted 59,025 consultations during the first half of 2008 in addition to 7,250 dressings and 10,910 antenatal care clinics. Almost 2,000 malnourished children have been admitted to the nutrition programme, both as outpatients and inpatients. At present, there are 700 children in the programme. At the maternity unit opened in February 2007, about 1,000 women were admitted between January and June this year and 743 babies were born.
Numbers of women attending the maternity unit had unfortunately decreased since the international staff left and no Somali surgeon was available - a very important position in a society where female genital mutilation is highly prevalent and c-sections necessary. However, we were able to reopen the operating theatre a month ago when a surgeon was recruited, so now we hope numbers will increase.
A MSF medical facility in Mogadishu, Somalia
© Oscar Sanchez-Rey
And what about Mogadishu?
In northern Mogadishu we have four clinics and a 50-bed hospital for children under 12 offering preventative and curative services, including mother and child healthcare and vaccinations. Between January and June 2008, 84,905 consultations were conducted at the four clinics, including 1,329 admissions at the clinic in Lido, 10,698 dressings and 698 war wound related consultations. Over 5,000 women have received antenatal care and 927 postnatal care. In order to address the high malnutrition levels, in July this year we extended our nutritional program to all three urban clinics in Mogadishu. Currently there are about 600 children in the programme. This month the MSF staff also started offering post surgical care to war wounded people.
What are the challenges for MSF in Somalia today?
There are three main challenges. Firstly, from a medical perspective, the challenge is to provide quality health services given that our projects are part-managed from Nairobi, due to insecurity. Secondly, finding representatives to promote acceptance of MSF’s projects to local groups and authorities is hard. In a country like Somalia, which is already complex, further complications arise as the groups involved become more and more fragmented: the different parties dividing into groups and subgroups. Finally, it is vital that we provide the best possible security for our Somali staff.
Can you explain what this way of working consists of?
Since the end of January, when we were forced to remove international staff from the project we have not been able to send them back on a permanent basis for security reasons. Our work has continued thanks to the dedication of Somali staff. They implement the projects on the ground with support from the international coordination team based in Nairobi. Here, we are also increasing the numbers of Somali staff and with their support, MSF is able to visit the country and supervise the projects. The level of operational and technical feedback with the Somali staff is much higher than before and of great importance.