Weathering the storm: humanitarian work amid the Somali maelstrom

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What started as a disagreement over prices in the market degenerated into a deadly battle because the two men involved were from rival clans. Some 18 people were killed and over 37 injured in the resulting gun fight. Most of them were civilians caught in the cross-fire. This incident occurred only a few months back in Galkayo, a key town with a population of about 80,000 in Central Somalia.

"This was just a normal day," explains Medecins Sans Frontieres (MSF) head of mission, Colin Mcllreavy. "There was no build up, no escalation of tension, it just happened out of the blue. One of our teams had been in the market not long before, they could have easily been caught in the middle."

Violence, often unpredictable, is a fact of daily life in Somalia. It is the main reason that, despite the huge needs, outside the relatively stable Somaliland situated in the north of the country, Somalia boasts less than 50 expatriate aid workers. Focusing on south and central Somalia, around half of these are from MSF.

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MSF is not immune to the violence. Since beginning work in Somalia, the toll on its staff has been high. Eight members of its national staff and one expatriate have been killed in violent incidents in the past nine years, the highest in any mission worldwide. The majority of the killings have been unrelated to the work of MSF, the reasons are as diverse as a family feuding and stray bullets. But they all reflect the banality of violence in Somalia. Many other incidents occur that do not involve deaths, but nonetheless are of a serious nature.

The question of aid in Somalia

"The question of our presence in Somalia is a matter of constant debate within MSF," explains Mcllreavy. "There is no question about the need for humanitarian aid because Somalia has some of the worst health indicators in the world. Additionally, significant numbers of people face discrimination, violence and exclusion from health services. But the needs have to be weighed up against the risk to our staff. We are not willing to be martyrs, but MSF is a frontline organisation and, at the moment, we believe our work in Somalia is worth the risks incurred."

Security needs to be evaluated constantly as, in the lawless anarchy of Somalia, problems can occur seemingly out of the blue and clashes break out with almost mundane regularity.

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While MSF has been working in Somalia since 1991, teams are regularly forced to temporarily - and sometimes permanently - evacuate areas due to insecurity or threats, leaving the projects to be closed or run by teams of national staff. Today, two of the seven project regions in which MSF works have been evacuated because of worries about safety.

A complex society

To the outsider, the structure of Somali society is opaque. There are five main clans in the country, each divided, sub-divided, then sub-divided again and again endlessly. Alliances are formed then broken on a daily basis and due to clan links, events in one part of the country can have consequences elsewhere. Understanding the context is vital.

"MSF has a strong information network, with key members of the national staff following events around the country to predict the possible impact on MSF operations," said Mcllreavy. "Every morning, the staff discuss the previous days events to gauge for signs of danger."

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As with every mission, the proximity of MSF to the people we aid serves as an important line of defence. In Huddur in the southern Bakool province of Somalia where MSF has been running a primary healthcare project since 2000, MSF runs information exchange seminars with local leaders and elders to discuss the organisation and its work as well as the needs of the community.

"Information is vital, but Somalia is too unpredictable to be risk-free," Mcllreavy said. "The Somali people have been living under an incredible strain for the past 15 years and this has had a serious effect on the mental health of the population. Sometimes, a person will look for a scapegoat, somebody to blame for his predicament. As we stand out, we may be also a target."

Somalia is also an extremely rare example of a country in which MSF employs armed guards - a difficult contradiction for a humanitarian organisation.

"It is not an easy situation, but it is something that we have to accept," said Mcllreavy. "It is the nature of the country, today, most people have a gun and society lacks the means to prevent them from using it. So many people have themselves been touched by the violence over such a long period of time that they have become accustomed to threats, intimidation, injuries and killing."

Clan rivalry permeates every aspect of life in Somalia and can render tasks as seemingly straightforward as recruitment a nightmare.

"Somalia is short on resources," explained Mcllreavy, "and organisations such as MSF represent one of the few that exist. For a Somali clan, MSF is a rare source of jobs, as well as bringing in income from the rental of houses, cars, equipment and so forth. Such income is worth fighting over."

Galkayo hospitals

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MSF began working in the hospital of North Galkayo in 1997. With conflict dividing the town into two, MSF became aware that only half of the city's population had access to the northern hospital and were travelling hundreds of miles to get medical care in the capital, Mogadishu. Even so, opening a hospital in the south was fraught with difficulties.

"We began negotiations with the authorities in South Galkayo at the beginning of 2002. They were very keen for us to open a hospital. The only hitch was that each sub-clan - and there are many of them - demanded that they should receive preferential treatment in terms of recruitment and other financial benefits from MSF's presence," said Mcllreavy.

"It took us eight months of tough negotiation, including MSF insisting that we could only proceed with hospital activities if the community would agree that negotiations be handled by a representative body and that the decisions of this body and of MSF would be respected. Otherwise we would be compelled to cancel the project."

Eventually, the agreement was struck and MSF began more substantial work in the hospital from mid 2004.

At other times the result has not been so positive. In 2001 for example, insecurity, in large part due to staff issues, forced MSF to withdraw from a hospital in the port of Kismayo after years of work. Numerous other projects have been closed for the similar reasons.

"In Somalia, discussions over pay and other administrative matters can easily become a matter of life or death," explained Mcllreavy. "Threats are not uncommon, and in a place like this, they are taken seriously."

As with every MSF mission, it is necessary to balance the range of risks against the needs of the population. In one health centre alone in Mogadishu, MSF is carrying out around 120 000 medical consultations per year. With careful management, room for MSF to work has been created amid the maelstrom in a number of locations across the country. Through steady and often painstaking work with the clans, projects such as the two hospitals in Galkayo are accepted by the community and provide care for people coming from up to 700km away.

"It can be a dangerous and unpredictable place to work," concluded Mcllreavy. "But Somalia is at the heart of why MSF exists; to work on the front-line of humanitarian action aiding those people who are most in need."