The authorities' failure to react strongly to serious violence against MSF staff was a key factor in the agency's decision to quit Somalia, where its medical work was a lifeline for tens of thousands of Somalis
MOGADISHU/LONDON (Thomson Reuters Foundation) – Abdurahman Ali, a specialist nurse, walks through the only hospital in Mogadishu's Daynile district, home to the Somali capital's biggest camps for people uprooted by conflict and hunger.
The hospital receives up to 200 patients every day. At least 10 babies a day are born in its maternity ward.
The hospital has been a lifeline, offering patients treatment free of charge and employing dozens of local staff. Ali doesn't know what will happen now that Medecins Sans Frontieres (MSF), the medical charity that runs the hospital, has decided to pull out of Somalia.
"Neither the government nor another party has pledged to take over the responsibility of running the hospital," Ali said.
MSF announced its decision to leave Somalia and the semi-autonomous regions of Puntland and Somaliland last week, dealing a severe blow to hundreds of thousands of Somalis who depend on it for free health care. MSF teams have been treating 50,000 patients a month. In 2012 alone, they held 624,000 medical consultations, treated more than 40,000 people in hospital, and delivered 7,300 babies.
It is only the second time MSF has voluntarily left a country in the middle of a humanitarian crisis and where there are no obvious alternative sources of healthcare.
“This is what makes (the decision to withdraw) so hard and harsh … we are specialised in bringing medical assistance to people in crisis situations, not … leaving them behind,” Arjan Hehenkamp, MSF Holland general director, who was involved in making the decision, said by phone from Amsterdam.
“WE’RE NOT AN ARMY”
The agency has worked in Somalia for 22 years, the only provider of healthcare in some areas.
But MSF workers have experienced “unparalleled” levels of violence in Somalia, even for an agency used to working in extremely dangerous conditions. Sixteen MSF staff have been killed, most of them Somali, and many have been abducted or threatened.
Those incidents alone were not enough to persuade MSF to pull out. “It’s an impossible discussion for a humanitarian organisation – how many dead staff can you tolerate. We don’t want to make a decision on that basis, we are not an army,” Hehenkamp said.
The extent to which Somali authorities were responsible “by omission or commission” for the violence against MSF staff was a major factor. The authorities include clan leaders, government authorities, and leaders of armed groups including al Shabaab.
“That becomes a real problem in terms of creating and agreeing conditions of work with those very same authorities that eventually do not stand by the agreements that they have made,” Hehenkamp said.
Many hope MSF’s decision will push Somalia’s authorities to improve the safety of aid workers.
DIFFERENCE “BETWEEN LIFE AND DEATH”
Somalis have a life expectancy of just 50 years, and the country has one of the highest child death rates in the world – one in five children die before the age of five. It also has some of the worst mortality rates for women in pregnancy and childbirth.
“I’m primarily concerned about the women and children who benefited from MSF’s services … in the most difficult and inaccessible areas,” Philippe Lazzarini, U.N. Resident and Humanitarian Coordinator, said by phone from Mogadishu. “I’m less concerned about cases where we have a more important presence of healthcare partners or international NGOs because there we will find ways to fill the gap or scale up,” he added.
He said the full impact will be felt in the next two to three months, when medicines supplied by MSF run out.
MSF “made a real difference between life and death” in Somalia, Ewan Watson, spokesman for the International Committee of the Red Cross (ICRC), another major healthcare provider, said by phone from Geneva. Replacing it will be “very challenging”, especially in rural parts of southern and central Somalia where MSF has had a constant presence for many years.
Replacing MSF isn’t just a question of finding the resources and staff, Watson said. “It’s a very complex security situation and the organisation needs to … build the trust of the different communities in order to be able to set up in these areas and work safely.”
The ICRC supports two surgical hospitals in Mogadishu and Somali Red Crescent Society primary healthcare clinics and mobile health teams in southern and central Somalia, treating more than 600,000 people a year. The organisation already planned to scale up its operations before MSF announced its withdrawal.
“We’re going to be reflecting upon and monitoring the implications of MSF’s decision, however we are definitely not in a position to take over MSF’s projects at the moment,” Watson said.
The impact of MSF’s pullout is also being felt in relatively stable Puntland, a semi-autonomous region in the north. Speaking last week on local Radio Garowe, Puntland Health Minister Ali Abdullahi Warsame said the agency played an “immense role” in improving the region’s health services, and plans to expand health programmes there may be hampered by MSF’s withdrawal.
Several Somali politicians have called on the government and the international community to stop MSF from leaving, and hundreds of Somalis have lost their jobs.
Back in Mogadishu, Asha Yarow, a female cleaner in Daynile hospital, said: “I am the only breadwinner for four children and I have no other job now.”
Mohamur Nur, a young nutrition officer in nearby Hamarweyne district, has also lost his job, which enabled him to pay college fees. "Now I am unable to continue my study at the university," he said.
(Editing by Katie Nguyen and Timothy Pearce)
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