Professional Documents
Culture Documents
1
FALL 2011
SOMALIA:
AN UNNATURAL
DISASTER
Doctors Without Borders/
Médecins Sans Frontières USA HUMANITARIAN SPACE
Sophie Delaunay
Executive Director
Dear Friends,
Board of Directors
Matthew Spitzer, MD
President Doctors Without Borders/Médecins Sans Frontières (MSF) brings lifesaving
Deanne Marchbein, MD
Vice-President
medical care to people caught in emergencies around the world—war zones,
David Shevlin epidemic outbreaks, disasters, or less visible crises brought about by neglect. At
Secretary
the same time, we examine the causes of these situations as best we can, and
Bret Engelkemier
Treasurer speak out when we believe our perspective, based on our field experience,
Marie-Pierre Allie, MD can improve the situation for those caught in life-threatening circumstances
Nabil Al-Tikriti, MIA, PhD
Kelly S. Grimshaw, RN, MSN, APRN, CCRN beyond their control.
Suerie Moon
Aditya Nadimpalli, MD
Michael Newman, MD
In this issue of Alert, we share news and images of our response to the
André Heller Pérache ongoing crisis in Somalia, where MSF has spent the summer trying to expand
Amy Segal
its services to meet the latest emergency to befall the country’s people.
Board of Advisors Simultaneously, we have been conveying our perspective on the genesis of this
Daniel Goldring
Co-Chair of the Board crisis through press conferences, op-ed pieces, interviews, and meetings with
Susan Liautaud diplomatic officials and NGO colleagues. There is a drought afflicting the Horn
Co-Chair of the Board
Meena Ahamed
of Africa, to be sure, but the current emergency, which has driven hundreds
Elizabeth Beshel Robinson of thousands of Somalis from their homes in search of relief and threatens the
Goldman Sachs
Victoria Bjorklund, Esq, PhD
lives of hundreds of thousands more, is not solely the consequence of a natural
Simpson Thacher & Bartlett LLP disaster.
Robert Bookman
Creative Artists Agency
Charles Hirschler As our International President, Dr. Unni Karunakara, explained in an op-ed
Gary A. Isaac, Esq. originally published in The Guardian (UK) after he returned from Somalia,
Mayer Brown LLP
Laurie MacDonald there are many other factors behind the crisis, among them the decades of
Parkes MacDonald Productions bitter conflict, the wholesale destruction of the country’s infrastructure,
Larry Pantirer
Darin Portnoy, MD, MPH
rising food prices, and past failures to effectively mobilize and implement
Montefiore Medical Center international aid and assistance. Saying this is just about drought or just about
Richard Rockefeller, MD
Garrick Utley
famine both absolves many parties of responsibility for what is happening
Neil D. Levin Graduate School, SUNY now and encourages an approach akin to treating one symptom of a far more
Robert van Zwieten
complicated disease.
Asian Development Bank
US Headquarters
333 Seventh Avenue, 2nd Floor
We also look at projects in Libya, Ivory Coast, and Haiti, along with threats to
New York, NY 10001-5004 the manufacture of affordable generic medicines and the surprising resurgence
T 212-679-6800, F 212-679-7016
www.doctorswithoutborders.org
of measles, a disease once thought to be on the wane. Some of these situations
are more complicated than others, but none is simple. And it is MSF’s goal to use
Alert is a quarterly newsletter sent to friends and
supporters of Doctors Without Borders/Médecins Sans the resources you so generously provide us with to first understand the reasons
Frontières (MSF). As a private, international, nonprofit behind each crisis, and then to implement projects, communications campaigns,
organization, MSF delivers emergency medical relief to
victims of war and disaster, regardless of politics, race, and advocacy efforts to bring assistance to as many people as possible.
religion, or ethnicity.
2
HUMANITARIAN SPACE
Somali refugees in Kenya SOMALIA’S ONGOING EMERGENCY
carry their malnourished
children to an MSF feeding Throughout the summer, waves of Somalis set AN UNNATURAL DISASTER
center. Kenya 2011 © out on desperate, arduous journeys, braving Somalia has existed in a near constant state of
Brendan Bannon desert heat, hunger, and bandits to seek relief crisis for almost two decades, as warring parties
from a catastrophe remarkable even by the and clans battled each other for control of territory
standards of this long-troubled country. The and influence and foreign powers intervened
numbers of displaced reached into the millions. for various reasons, albeit with little benefit for
Some streamed into Mogadishu, the capital. Somalis themselves. In the first half of 2011,
Others crossed borders into Kenya or Ethiopia. the Islamist militia known as Al Shabaab held
Thousands died along the way. Even those who significant portions of territory, including much
survived were not assured of respite. of the capital, and was holding off attempts by
the Transitional Federal Government (TFG) and
MSF, which has worked in Somalia since 1991, the African Union Mission in Somalia (AMISON)
has been trying to expand its programs in and to dislodge it. Interwoven through this conflict
around the country over the past several months. were other disputes between clans, warlords, and
In some places, it’s been feasible to do so, but the other parties, and an international battle between
severity of the crisis has been compounded by a Al Shabaab and western powers, most notably the
host of obstacles particular to Somalia that pre- United States, that further isolated the population
vent MSF and others from scaling up operations and limited the ability of humanitarian organiza-
to the degree necessary. Given the sheer number tions to access populations in need.
of lives at risk, however, the efforts to reach as
many people as possible continues.
3
EMERGENCY DESK: SOMALIA
Somalia’s current crisis has been portrayed in Kenya, swelled even further. The existing facili- A camp for displaced
many forums as a natural disaster, the result of ties could not accommodate all the new arrivals, Somalis in Mogadishu.
a drought and subsequent crop failures. That is and the United Nations, which ran the camps, Somalia 2011 © Yann
inaccurate—or, the very least, incomplete. There was slow to find space for them. Some of the ex- Libessart / MSF
is indeed a drought in the Horn Africa. There is hausted Somalis endured weeks or even months
widespread malnutrition, too, much of it severe. of living in ad hoc shelters on the outskirts of
But in many ways, this is an amplified version the camps, waiting to get registered as refugees
of the crisis that’s been affecting the country for and to receive the assistance they needed.
two decades. The specific medical emergencies
of the moment are symptoms of a larger disaster The UN did eventually establish new camps,
involving failures of governance, development, but it was still a struggle to keep pace. In early
and policy that have left Somalis tragically October, an average of 6,000 Somalis were still
vulnerable [see page 9]—which is why, when the arriving in Dadaab on a weekly basis. MSF was
drought did come, so many were convinced that treating nearly 15,000 patients in its nutrition
their survival depended on getting themselves programs—inpatient, outpatient, and supple-
to a place where relief might be available. mental feeding—and had vaccinated more than
20,000 people for measles in the Dagahaley
SEEKING RELIEF camp, where it had been running a hospital
Thus began the exodus. There were indications for the last few years. MSF was also providing
of the drought in 2010, but, says Duncan Ma- primary health care and treatment for malnutri-
clean, MSF’s director of operations for Somalia, tion to refugees who’d settled on the outskirts
“The signs of a major crisis were first seen at the of Ifo, another camp, and was working at health
Ethiopian and Kenyan borders, where thousands posts in the more recently-opened Ifo 2 and Ifo
of Somalis started to leave the south of the 3 camps. Additional teams were working in the
country in June.” Quickly, the populations of the border town of Liboi, providing care to Somalis
already overcrowded refugee camps in Dadaab, and local people in the area.
not received any food since they arrived and of stopping the epidemic, we’d have to vaccinate at
are relying on help from those around them. least 10 times that number,” explains MSF medical
Several NGOs have set up dining halls with food manager, Dr. Andrias Karel Keiluhu. “Logistical
purchased on local markets, but this has led to and security constraints limit our goals.”
significant inflation. If prices continue to rise,
the entire population of the city will soon be MSF hopes that its teams will soon gain more
unable to feed itself without outside assistance.” access to deliver medical care in more regions.
What’s more, due to security concerns, teams MSF also hopes to be able to resupply projects by
can often only work for a few hours per day. air and send in much needed technical staff. To
achieve these goals—and to ensure the security
The inability to vaccinate more widely for mea- of our personnel in the country, to maintain the
sles is another major concern. Though reliable integrity and independence of medical facilities,
numbers are hard to come by, it’s possible that and to communicate the nature and purpose of
more children are dying of measles at this point our actions—MSF remains in constant dialogue
than malnutrition. As of early October, more with Al Shabaab. This is a significant challenge
than 54,000 people had been vaccinated. “That because of Somalia’s recent history, the geopo-
sounds like a lot, but if we are to have any hope litical aspects of the conflict, the ever-evolving
The current emergency unfolding in and around Somalia is Against the backdrop of conflict, where many agendas are
being portrayed by many aid organisations and the media at play, it is difficult for a medical humanitarian organ-
in one-dimensional terms, such as “famine in the Horn of isation like MSF to expand health services and have an
Africa” or “worst drought in 60 years.” But only blaming impact. MSF has been working in Somalia for two decades
natural causes ignores the complex geopolitical realities and has projects in nine locations on both sides of the
exacerbating the situation and suggests that the solution front lines – in areas under the control of the Transitional
lies in merely finding funds and shipping enough food to Federal Government and Al-Shabaab. We are doing every-
the Horn of Africa. Unfortunately, glossing over the man- thing we can to scale up our activities to meet the growing
made causes of hunger and starvation in the region and needs.
the difficulties in addressing them will not help resolve
the crisis. In refugee camps in Kenya and Ethiopia we have been able
to provide medical and nutritional care for tens of thou-
I just returned from Kenya and Somalia and what I and my sands people. But scaling up operations inside Somalia is
colleagues are seeing on the ground indicates a profoundly slow and difficult. MSF is constantly being forced to make
distressing situation. In Mogadishu, I met a young woman tough choices in deploying or expanding our activities.
from the southern region of Lower Shebelle who is now Without the ability to carry out independent assessments
living in one of the many makeshift camps appearing all and provide assistance in what we believe to be the hardest
over the city. She left home with her husband and seven hit areas, we will not be able to prevent the worst conse-
children because of a bad harvest and because they could quences of this emergency.
not afford food and water. Somewhere along her trek, she
had to leave her husband and three children behind, as Humanitarian aid has come to be seen by all sides in the
they were too weak to complete the five-day walk. Sadly, conflict as either an opportunity or a threat. In areas
her story echoes those of thousands of other families in considered to be the epicentre of this crisis, Al-Shabaab,
southern and central Somalia who have been ravaged by already suspicious of western agendas, has placed bans
conflict for years and tipped over the edge by drought. on foreign staff, on the supply of medicines and materials
by air, and on vaccination activities. Even the temporary
Malnutrition is chronic in many parts of the Horn of Africa lifting of US restrictions on the provision of aid in areas
and there needs to be a long-term international effort to controlled by Al-Shabaab is unlikely to improve access.
ensure that nutritious foods are reaching the people who Elsewhere, seemingly endless negotiations turn simple
need them. Today, however, the most urgent needs are procedures like hiring a nurse or renting a car into proj-
concentrated in southern and central Somalia. ects that take up precious time at the expense of the rapid
response that is needed.
The failed harvests exacerbated what was already a ca-
tastrophe. Somalia is the theatre for a brutal war between In spite of our constant negotiations with all parties to the
the Transitional Federal Government, strongly backed by conflict to gain access, we may have to live with the reality
Western nations and supported by African Union troops, that we may never be able to reach the communities most
and armed opposition groups, most notably Al-Shabaab. in need of help or that we will have to compromise some of
In a failed political landscape, it is this war, combined our independence when we do reach them. Unless all par-
with the internecine rivalries of the various Somali clans, ties remove the barriers that stand between organisations
that has kept independent international assistance away with the capacity to save lives and the people who rely on
from many communities. The Somali people are trapped them for their survival, thousands more may continue dy-
between various forces who are depriving them of assis- ing preventable deaths.
tance either for their own political reasons, or in an effort
to weaken their opponents. There is virtually no access to
healthcare in vast tracts of land across the country.
9 OP ED
Measles in Africa:
Portrait of a Resurgent Killer
Not long ago, it was tempting to think the battle against measles MEASLES IN AFRICA 2010: (SOURCE: WORLD HEALTH ORGANIZATION)
28 Countries
was being won. Stepped-up vaccination campaigns had driven af
the number of reported cases down to 32,000 in 2007, according In
to the World Health Organization, the lowest ever recorded. M
Experiencing
Over the past three years, however, there has been a resurgence. A
In 2009, more than 30 countries experienced widespread epidemics. in
In 2010, 28 countries declared epidemics, reporting 223,000
Outbreaks
cases and 1,200 deaths. In 2011, many African countries have co
experienced large-scale outbreaks, particularly the Democratic in
Republic of Congo (DRC). ur
d
ca
223,000
Chad as
Yemen
In
Somalia
Cases
Ethiopia
ou
DRC te
Burundi fa
Reported
Malawi
Fl
Zambia
Mozambique
no
Zimbabwe to
MEASLES DEATHS WORLDWIDE: 2000 - 2013 (SOURCE: WORLD HEALTH ORGANIZATION) DOCUMENTED PROJECTED M
800,000 5,
4,
600,000
3,
400,000
2,
1,
200,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
MEASLES IN AFRICA
10
MSF was a pioneer in the move to vaccinate widely for measles MSF’S RESPONSE: 2010 (SOURCE: MSF)
4.54 Million
after epidemics had already started, saving many lives in the process.
In 2010, MSF vaccinated more than 4.5 million children in Chad,
Malawi, South Africa, Yemen, Zimbabwe, and other countries. Through
People
August of this year, teams had vaccinated more than 3 million children
in DRC alone.
Measles is prominent in South Asia and present in many other
Vaccinated
countries—cases are rising in the US and Europe as well—but it’s
in Africa where the evidence is most striking. The data shows the
urgent need for action but most countries that experience epidemics
do not adequately mobilize resources and organize vaccination
campaigns. They pay a heavy price, and the costs may well rise
188,704
as case numbers continue to climb back towards previous levels.
In addition to its work in the field, MSF is calling for an effective
outbreak response mechanism, backed by secure financial and
Cases
technical resources, to be established immediately. "We know for a
fact that there will be additional epidemics in the near future," said
Treated
Florence Fermon, MSF's vaccination coordinator. "It would simply
not be right to wait for them to occur. We need an effective system
to anticipate and prepare for the coming outbreaks."
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
MEASLES IN AFRICA
11
FIELD NOTES
IVORY COAST: who’ve suffered gunshot or machete rata. These services included surgical
TREATING SURVIVORS OF wounds or been the victims of sexual care, maternal care, post-operative
ONGOING VIOLENCE violence. Teams have also seen evi- care, hospital support, and mental
Despite the ostensible cessation of dence of other violent killings, some health care.
the fighting that wracked Ivory Coast of which targeted children. The fear
earlier this year, violence against of harassment, extortion, or worse at MSF worked in Tripoli’s Central Hos-
civilians has continued in some rural armed checkpoints strewn throughout pital until patient numbers decreased
regions, particularly in the southwest. the area prevents many who need and local health staff returned to their
In mid-September, for instance, up to medical care from seeking it, however. posts. An MSF surgical team contin-
16 people were killed and 50 homes In September, MSF issued a press ued to work in Tripoli’s Ben Ashour
were burned in an attack on the release that called for all parties to clinic, handling orthopedic cases and
town of Zriglo. “Within a few hours the conflict to refrain from violence treating a backlog of patients waiting
of the attack being reported, one of against civilians and to ensure access for secondary surgical interventions.
our teams managed to reach Zriglo,” to basic services, including health care. MSF also provided care to approxi-
said Tara Newell, head of mission for mately 1,200 migrants and refugees
MSF in Ivory Coast. “But they only LIBYA: AIDING THE DIS- in Tripoli who sought refuge from
could count the dead and the burned PLACED, THE WOUNDED, attacks by armed men in two make-
houses. The population, including the AND MIGRANTS shift camps that lacked water, food,
wounded, had already fled.” Heading into the fall, MSF was provid- security, and sanitation.
ing a range of medical services in
MSF clinics in the region continue Libya’s capital, Tripoli, as well as in Additionally, after many attempts, MSF
to see a steady stream of civilians Zintan, Yefren, Benghazi, and Mis- was able to send medical supplies into
FIELD NOTES 12
ing serious complications, along with
antenatal and postnatal care, family
planning, treatment of sexually trans-
mitted diseases, and counseling and
testing for HIV.
13 FIELD NOTES
“STARVED FOR ATTENTION” Clockwise from top left: Debbi Li/MSF (2); Suanne Schaal, Code
TRAVELING EXHIBITION
NY (2); Michael Goldfarb/MSF (2)
This fall, MSF-USA traveled to New York, Philadelphia, Bal- malnutrition, but that they will join us in the fight against
timore, and Washington, DC, to stage “Starved for Atten- it,” said Sophie Delaunay, MSF-USA’s executive director.
tion,” a free interactive exhibit designed to raise awareness
about the global crisis of childhood malnutrition. This is Malnutrition is not merely the result of too little food. The
a preventable, treatable condition that continues to affect first two years of life are a critical window when children
195 million children worldwide and contributes to at least need access to a diet of high-quality protein, essential fats,
one-third of the eight million deaths of children under five carbohydrates, vitamins, and minerals, in order to avoid
every year. impaired growth and development and increased risk
of death from common illnesses. Yet most food aid does
Initiated two years ago, "Starved for Attention" is an not include these essential ingredients. “Foods we would
advocacy campaign that seeks to achieve key reforms of never give our own children here in the U.S. are being sent
the international food aid system, to ensure that children overseas as food aid to the most vulnerable children,” said
receive the quality foods they need. The exhibit recreated Delaunay. “This double standard must stop.”
an MSF field hospital just like those used to treat tens of
thousands of malnourished children in countries such as As of October 10, more than 130,000 people—including
Somalia, Kenya, Niger, Burkina Faso, and India. MSF medi- many who attended the exhibition—had signed a petition
cal staff and aid workers, veterans of malnutrition efforts demanding that policymakers improve the nutritional
in the field, guided visitors through a simulated clinic that quality of food aid.
featured photographs taken by the award-winning photo-
journalists of VII Photo and highlighted methods that have For more information, and to see the photos and films,
been proven effective in the battle against malnutrition— please visit starvedforattention.org
tools that must be scaled up worldwide. “Our hope is that
visitors will not only learn about the underlying causes of
SNAPSHOT
A girl selling food along the Congo River in Mbandaka, in Democratic DRC’s summer cholera epidemic killed hundreds of people and
Republic of Congo, listened this summer as an MSF health promoter spread to the capital, Kinshasa. MSF emergency medical teams
explained that a cholera epidemic had been spreading along the established a cholera treatment center in Mbandaka that was
river and had caused outbreaks in many of the towns on its banks. receiving around 20 new patients every day. DRC is also dealing with
He explained how to avoid getting cholera, the symptoms to watch a massive and deadly outbreak of measles, for which MSF sought
for, and what to do if one contracts it. and recently received permission to launch a widespread vaccination
campaign in Katanga.