Somalia: Small signs of government in a fractured country

  • International staff: 12
  • National staff: 30 Somalia has been mired in civil war since the Siad Barre regime collapsed in 1991. While the central and southern regions of Somalia are still seen as lawless and chaotic by the West, the northern regions of Puntland and Somaliland have succeeded in establishing a halting peace and, more importantly, a system of governance - without international help or intervention. MSF insists on impartiality The country's clan system, the social hierarchy of elders, businessmen and warlords and the fallout from the conflict between Ethiopia and Eritrea make working in Somalia extremely difficult. Yet MSF has maintained its presence throughout the country for a decade now, always insisting on impartiality. The organization works in many areas of Somalia and deals with all contexts: from the relative stability of Galkaayo in Puntland to the besieged and troubled Kismaayo in the south. In Galkaayo, MSF is working together with the local community to refurbish, equip and help out at Mudug Regional Hospital, where teams also train staff and do emergency preparedness work. Further southeast, in Middle Shabelle, MSF runs primary health programs with outpatient dispensaries, mother and child health clinics, mobile vaccination teams and emergency monitoring and response. In Mogadishu, MSF has set up an early warning system for epidemics and has been responsible for a cholera treatment center in North Mogadishu since 1994. "The incidence of diarrhea [a key symptom of cholera] tends to rise every November, with confirmed outbreaks starting around January," says André LeSage, MSF Head of Mission until April 2000. "Part of the problem is that, while oral rehydration salts are effective in treating early-stage cholera, Somali common sense dictates that the only effective treatment is ringer lactate (isotonic solution administered intravenously), which is only used when there are no other alternatives. Having an IV plugged into your arm is more impressive than drinking the rehydration salts, so they think it must be more effective. But it also means a delay in treatment." The realities of working in a conflict In the southern city of Kismaayo, the realities of working as an NGO in a conflict area are brought home. MSF works in the hospital, providing in- and outpatient care, health care for tuberculosis (TB) patients and surgical care for the war-wounded. However, the mission had to be temporarily evacuated several times due to insecurity. MSF left Kismaayo in June 1999 and returned for several monitoring and assessment visits in the fall and winter of that year. After an unexpectedly strong appeal from Somalis in the area (women's groups, the Regional Health Board Committee, and some of the warlords themselves) and renewed guarantees of security, the team was finally able to go back in February 2000. The war has also led to problems accessing populations in other areas notorious for their insecurity. The drought which plagued the entire Horn also led to problems in the western regions of Somalia bordering Ethiopia: Gedo, Bay, Bakool, and Hiran. Despite the security risks, MSF sent an exploratory mission to the Bay and Bakool regions to assess the nutritional and medical needs there. Because the people of this area are nomadic, it was even more difficult to reach the populations in distress. The exploration led to an outpatient dispensary with 20 hospital beds and a mother and child health care center in Hudur, near the Ethiopian border, with vaccination campaigns planned for the surrounding villages. MSF has been working in Somalia since 1991.