Out of Somalia

In June this year I arrived in Nairobi, to set up a new project in Marere, in the Lower
Juba region Southern Somalia. Primarily to start a small
outpatient department (OPD) and inpatient department (IPD),
I was employed as the midwife for the project to set-up the
services to cover maternal health. Although I had heard horror
stories before coming here, I was worried about how I would
be able to work with armed guards. Nonetheless, I had also
heard many positive stories about the character of the people
of the south of Somalia. It was going to be a challenge,
the unknown territory was the most important factor for me
to take on the mission. On the first day of briefing, MSF
was informed of high mortalities in Marere village of children
under five, this mortality increase was observed by locals
in the past week with 26
children reported dead in the village which has a population
of around 3,800 people. Information from the villagers was
that the children developed oedema and then died suddenly.
Other surrounding villages were reporting similar cases.
In various villages were heard rumours that there was an
outbreak of measles among the children that developed oedema.
The only thing that came to mind was that the children were
suffering from malnutrition disease called Kwashiorkor, classical
signs being oedema of extremities and in the face. Many reasons
can explain malnutrition (lack of food, disease, food availability,
etc). Among the population, the target group of children
range from above 6 months and under 5 years, as they are
more prone for sickness, and children are the last to receive
food. The cause of kwashiorkor is multi-factorial, although
dietary intake is dominant; infection and psychosocial factors
are also important. Based on the information we received
from the population in Marere, we organized a rapid assessment
team to visit the area.

When we arrived it was in the rainy season,
when most of the population depended on subsistence farming
growing mainly maize and simsim (which they make oil with).
Very few animals can survive in this area due to a killing
disease transmitted by the tsetse fly despite having a lot
of animal feed (grass) available. The crops were not ready
for harvesting maize, while the simsim was now flowering
and would take approximately two months before the harvesting.
The roads were in a bad condition during the rains making
travelling difficult to reach some villages. When we spoke
to the mothers in the villages, they had no food to give
to the children, they only were able to feed occasionally
on maize and most of the time they survived on boiling mangoes.
The purchasing power had eroded and they were not able to
buy milk or meat for the family. There were a lot of stories
of children dying from oedema, the skin is peeling off and
some wounds turning septic, all pointing to acute protein
energy malnutrition (PEM). A strong pattern was emerging
that in some villages a measles outbreak had occurred, and
the children were recovering when oedema of primarily the
feet, lower legs and hands progressed quickly within days.

MSF recommended to be able to address the
nutritional crisis in Marere. We would have to consider issues
surrounding the project like security, scarce human resources,
limited logistical and no medical material. When on the ground,
the security in Marere and the surrounding villages was acceptable,
with no incidents of banditry or clan fighting was reported.
We felt safe to move around in the villages.

With this in mind it was recommended to
start small and expand with time. To set up immediately a
day care centre, with a capacity for 50 children in the centre
of the three main villages. As many more of the children
were at risk of developing severe malnutrition from moderate
malnutrition. Lack of health facilities to deal with opportunistic
infections that could be handled would also accelerate the
magnitude of mortality. It was interesting to see that the
population was so obviously divided into 2 clans, the rich
and the poor, the Ogaden and Bantu. There were no mortality
reports from any of the Ogaden clan, but continually ongoing
stories of so many children from the Bantu clan dying.

After spending 3 days assessing the needs, on return to Nairobi
we began to get into action and start the preparation for
a medical feeding centre better known as a Therapeutic Feeding
Centre (TFC) intervention. The logistical co-ordinator was
running around to organise drug supplies, and most importantly
getting the therapeutic milk. Visa’s were obtained
and flights organised. A day before flying to start the response
a flight ban into Somalia was imposed by the Kenya government.
Letters were written to the office of the Kenyan President
and the US embassy to help get an exception for a humanitarian
flight to go in and attend to the dying children.

More distressing
news was to come after a few days of the flight-ban. An MSF
expat doctor working on the Kenyan border, was targeted and
seriously injured, when a grenade was thrown into a shop
killing two Kenyans. This was devastating news for all aid
workers in the region, as the flight ban continued and we
needed to be sure of our own security before heading back
into unknown territory.

Twenty two days later MSF expats were able
to travel into Marere. It was not easy to come back when
we knew that a lot of the children would have died in our
absence. My main worry was the recruitment process, which
can be a tricky busyness in Somalia. The recruitment process
started with announcing the positions required, doing public
examination tests and those short listed then undertook a
practical test and finally we were able to choose 2 nutritional
assistants and a cleaner assistant. Then we screened the
under five children in Marere, and admitted 14 children,
nearly all of which had a nutritional problem called odema.

On day 1 (15/7/03) the children that we
admitted first were in a bad state, the dermatological lesions
were raw and infected, the children looked as though they
had been burnt. It was difficult for the medical staff to
even touch the children to clean and cover the wounds, even
the mothers were afraid. In phase 1 (where all the new admissions
first arrive), the children were miserable and apathetic.
Trying to force the milk down their throats was the only
thing we could do to get the protein rich foods before they
went back to the boiled mango diet in the evening. During
the next weeks, we saw more and more cases, the admissions
rose steadily for the team to be able to manage. Staff recruitment
needed to take place on several occasions. We were fortunate
to find very committed and motivated staff. The first tent
structure we used for phase 1, then the building of the compound
commenced. For phase 2 we first used the logistical store-room
which was made out of mud and bricks, which made it nice
and cool to work in. Then as the numbers of the children
increased, the more in demand we were for space. Local structures
called tukels were built from local materials, and we even
used the temporary building that was meant for the outpatient
dept. It was finally decided that we should have a bigger
more permanent structure to work in. The third building was
erected and we moved in at the beginning of August. The mothers
then started to complain about the children getting fedup
of just drinking milk, they wanted rice or pasta. We had
already introduced the supplementary Bp5 biscuit. Now it
was time to prepare food for the mothers and also introduce
a local meal for the children. This action really made a
difference to the children’s gain of weight, there
commitment to the program rose.

Over a period of 2 months, 121 children
were admitted to TFC, 7 deaths (plus 4 defaulted who then
died at home), 15 defaulters and 95 children cured so far.
Although our outreach workers are busy trying to find malnourished
cases, at the moment it looks as though the crisis is over
for now. And as the TFC numbers are reducing to only a handful,
we have to decide whether to close, and focus on the original
intervention of setting up the OPD/IPD&#….which will
be for the next story to be told.

Written by Olivia Hill (16/9/03)
Nurse/Midwife, Marere, Lower Juba, Somalia