GP/SURGEON

Based in JOWHAR

       Reference no. 1182

Médecins sans Frontières (MSF)Spainis an international humanitarian Non Governmental Organization, operating inSomalia.

We are currently recruiting for the position of Medical Doctor & Surgeon, based in Jowhar

General Purpose of the Job:

The Jowhar Medical Doctor & Surgeon will participate in the clinical & surgical aspect of the Jowhar maternity and give support to other aspect of the project e.g. OPD,MCH,ORand SC according to the necessities. Work in close collaboration with other medical supervisors, assist in organization and supervision of the medical team and contribute to setting-up of medical and surgical services in Jowhar and subsequent support to other MSF E projects or emergencies intervention when requested or needed.

Specific Responsibilities and Tasks:

1. 1.   General Knowledge of MSF and Safety at work

• Provide surgical and clinical services in Jowhar maternity.
• To give medical support to Jowhar OPD ,MCH,ORand SC.

• To work in close cooperation with the staff in the MSF health structures, following MSF medical protocols.
• To actively contribute to the MSF identity, values and principles.
• Attend to sick staff, those referred to him by Consultants or those in emergency or chronic situation.

• Is aware of activities of other departments and respect specific rules and procedures
• Comply with the health and safety rules / instructions of the supervisor for wearing protective gears (if/when applicable) related to the job for the sites.
• Ensure all staff supervised by him/her comply with the health and safety rules / instructions of the supervisor for wearing protective gears (if/where) related to the job for the sites.
• Respect medical ethics at all times

1. 2.   OPD

• Conduct 2nd line consultations on patients whose pathological status exceeds the knowledge and skills of the OPD consultants.
• Prescribe treatment according to MSF protocols
• Refers patients if necessary to other hospitals
• Participate in organisation of formal refresher courses and on the job training in diagnostics and treatment of the OPD consultants.
• To participate in  meetings.
• Improve in general the quality of the medical consultations done by the consultants in the OPDs.

1. 3.      Maternity/MCH
2. 4.      Management of  Surgical Department (OT)

• Supervision of diagnosis and treatment of both out and in patients in Jowhar maternity.

• To ensure that every patient under his/her care has the medical & obstetric history taken, received right prescriptions and daily observation and follow up written.

• Conduct daily ward round in the IPD (Maternity) to diagnose and treat mothers and their infants in every section of maternity, that is hospitalization, pre delivery, labor ward and post delivery.

• Conduct consultation of triage for obstetric & gynecological cases and for difficult cases referred from other section of the Jowhar project, e.g. MCH, OPD, etc.

• Collaborate with R.H supervisor and pharmacist on drug consumption, availability and it is rational use.

• Attend to obstetric and gynecological emergency in time, in collaboration with other concerned staff.

• Attend to other surgical emergencies and war-wounded victims, if necessary.

• Make proper documentation of all surgical and clinical activities in Maternity and OPD

• Arrange necessary referral for staff and patient to other actors if necessary.
• Prescribe treatment according to MSF guidelines and protocols
• Supervise the dressing procedures during medical rounds
• Supervise the admission and discharge of patients, prescription of medications and other routine procedures
• Check on severely ill patients daily
• Working together closely with the other MD in the management of patients.
• Identify training needs and perform trainings for staff when necessary

• Organisation of the OT on daily basis.
• In collaboration with the RH supervisor carry out daily and long-term management and provision of support to the staff in the department; including planning of leaves, back up planning, overtime, HR needs.
• To hold regular medical meetings with the OT staff
• Support staff in their execution of activities, and follow it up closely.
• Identify training needs and perform trainings for OT staff as necessary in collaboration with the other MD, RH supervisor and medical team inNairobi.

• Monitor use and care of O.T equipment and instrument.
• Contribute to the order of O.T items and drugs, that is both monthly and quarterly.

• Ensure aseptic and sterilization measures are in line with MSF standard in O.T.

1. 5.      Surgery and related issues

• Consult and identify patients requiring surgery, emergency intervention and/or resuscitation
• Supervise the activities in recovery care room
• Prescribe the pain-management treatment according to the pain-level classification
• Prescribe pre-operative and post-operative treatment according to MSF guidelines and protocols
• Supervise all deliveries conducted in the hospital and identify those that need intervention
• Contact the other MD (surgeons), RH supervisor orNairobimedical team for any problem related to surgery.
• Identify training needs and perform trainings for staff when necessary

1. 6.                   Stabilisation Centre

• Monitor the nutritional and medical treatment in SC.
• Involvement of the staff in the planning, providing feedback of the past month achievements, and to regularly evaluate the achievements according to set indicators.
• Work closely with the nursing staff to improve general organisation, medical- and nursing procedures in the stabilisation center
• Do the medical round on a scheduled daily basis with nurses on duty, and ensure the ward round always contains a training element.
• Prescribe treatment according to MSF nutritional and other MSF guidelines and protocols.
• Responsible for the admission and discharge all patients, prescription of medications and other routine procedures.
• Identify training needs and perform trainings for staff when necessary.
• Ensure proper administration of the patient card, admission / discharge book

1. 7.      National staff Health
2. 8.      Management issues

• Responsible for the national staff health and follow the national staff health policy.

• To liase with Medical Supervisors and Medical activity manager incase of referral of national staff.

• To have regular meetings with RH supervisor and medical staff on demand
• To supervise the care and hygiene activities of the medical staff in the respective wards
• To actively participate in staff training activities

Additional Tasks:

• Be flexible and be able to give assistance with different activities not included in this primary job description.
• The MD position will collaborate in the overall coordination and analysis of data collection and Emergency Preparedness and Response in the project

Be able to assist other collaborating actors in case Management upon request from the Medical supervisors or Medical activity manager.

Requirements:

Nationality:

• Somali

Education:

• Official Bachelors degree of Medicine and Surgery from a recognized national/international institute.

Experience:

• Experience in an MSF facility or in any other organization with Medical background or knowledge.

Language:

• Fluent spoken & written English
• Fluent spoken & written Somali (a must)

Personal qualities:

• Good communication skills, Management skills,  Ability to listen
• Flexibility, Open-minded
• Ability to work with multi-disciplinary and multi-cultural people
• Capacity to work as part of a team is required.
• Honesty and motivation is required.
• Organization, initiative, tidiness and courtesy are mandatory.
• Willing to be based in Jowhar.

If you meet the above requirements, please send your filled-in Pre-interview questionnaire, CV detailing the above requirements, motivation letter, copy of certificates and any recommendation letter from previous employers to the MSF-Spain Somalia Admin department in Nairobi, email address: msfsrecruitment@gmail.com:. Please state clearly the job title and the reference number 1182 in the subject line of your application email.

Application must be received on or before the 31^st may 2013. Interested candidates are asked to avail themselves for interview and examinations shortly thereafter. Only short-listed candidates will be contacted.

MSF-E is an equal opportunity employer.

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Mone and Blanca

In October 2011, Montserrat Serra and Blanca Thiebaut were abducted from the Ifo 2 refugee camp in Dadaab, Kenya, where they had been working to help some of the most vulnerable members of the Somali population. They were then transferred to Somalia and they are still being held against their will.

While continuing to work for their release, MSF once again condemns this heinous and cruel act of violence perpetrated against humanitarian workers and reiterates its demand for their immediate release.

The Thiebaut and Serra families have expressed their concern and anguish over the kidnappings and remain committed to doing everything they can to gain the release of Blanca and Montserrat. Through MSF, they wish to thank the media and other local, national and international institutions for the caution and discretion they have shown with regard to the abduction, and MSF requests that all such discretion continue to be observed.

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Humanitarian organisation is unable to continue its work as minimum safety conditions for patients and staff are not guaranteed

Nairobi – March 11, 2013 – Medical activities have been halted at a clinic run by Médecins Sans Frontières/Doctors Without Borders (MSF) in Xadaar, a neighbourhood of the Somali capital Mogadishu, the international humanitarian organisation said today.

On 28 January, two of the clinic’s security guards exchanged gunfire, apparently as the result of a personal dispute. Both security guards were wounded in the incident. Fortunately the shooting took place outside clinic opening hours and no one else was injured.

Immediately after the incident, MSF put its activities on hold while trying to restore the minimum safety conditions necessary for its work to continue. But today the organisation was forced to announce the closure of the clinic.

“We take what happened very seriously,” says Michel-Olivier Lacharité, MSF’s programme manager. “With hundreds of people attending the clinic every day, the consequences could have been disastrous. We can’t just wait for this kind of thing to happen again. The safety of patients and staff is an essential prerequisite for our medical work. That’s why today we have to stop our work in Xadaar, despite the medical needs that still exist for the population.”

Xadaar clinic was opened by MSF in April 2012 to provide free general healthcare, including care for expectant mothers and treatment for malnourished children, to local residents and people displaced from their homes elsewhere.

Since the clinic opened, more than 30,000 people have received medical consultations; 2,300 children have been vaccinated against measles and other common childhood diseases; and 556 children have been treated for severe  malnutrition.

In Mogadishu, MSF continues to run a 40-bed hospital and to provide outpatient care in the Jasiira neighbourhood of the city. MSF has also been working in Daynile general hospital, on the outskirts of the capital, since 2007. The organisation runs also medical activities in Hamar-Weyne, Hamar-Jabjab, Waberi, Yaqshid and Dharkenley neighbourhoods of Mogadishu, as well as in Afgooye town.

MSF has worked continuously in Somalia since 1991, and continues to provide lifesaving medical care to hundreds of thousands of Somalis in ten regions of the country, as well as in neighbouring Kenya and Ethiopia.

In 2012, MSF treated nearly 30,000 severely malnourished children and vaccinated 75,000 children against infectious diseases. MSF teams also assisted in over 7,300 deliveries and provided close to half a million medical consultations within its health facilities.

MSF relies solely on private donations for its work in Somalia and does not accept any government funding.

On 13 October 2011, two MSF workers, Montserrat Serra and Blanca Thiebaut, were abducted from Dadaab refugee camp in Kenya. MSF believes that its two colleagues are being held in Somalia and appeals for their unconditional release. Until the safe release of Montserrat and Blanca, MSF’s activities in Somalia are limited to lifesaving emergencies only.

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© MSF/Yahya A Somali woman with her two children in an MSF facility in Somalia

Integrating Aid into UN, AU Political and Military Strategy Will Threaten Humanitarian Efforts.

NEW YORK/PARIS/NAIROBI – February 28, 2013 – Efforts underway at the United Nations to integrate humanitarian assistance into the international military campaign against opponents of Somalia’s government will further threaten the safe delivery of independent and impartial aid to Somalis struggling to survive ongoing war, the international medical humanitarian organization Médecins Sans Frontières (MSF) warned today.

The United Nations Security Council is currently deliberating the future structure of the UN’s mission in Somalia. Under discussion is the possible inclusion of humanitarian assistance within the broader political and military agenda for Somalia. Such an approach, in a country where the ability to provide relief is already severely compromised, could generate distrust of aid groups.

“As many Somalis continue to struggle to obtain the basic necessities for survival, such as food, health care, and protection from violence, humanitarian assistance must remain a priority and it must remain completely independent of any political agenda,” said Jerome Oberreit, MSF Secretary General. “The humanitarian aid system must not be co-opted as an implementing partner of counter-insurgency or stabilization efforts in Somalia.”

Ensuring the safety of patients and medical staff remains a major challenge. Aid must therefore remain independent and impartial so that humanitarian organizations can try to negotiate access to populations in need with all parties to the conflict and mitigate security risks as much as possible. Attempts to further politicize humanitarian aid will put patients and aid workers in even greater danger, MSF said.

“As we’ve seen previously in Somalia, and in places like Afghanistan, Iraq, Sierra Leone, and Angola, when military stabilization or peacekeeping efforts integrate humanitarian aid as a tool to advance political and security objectives, aid actors, including health workers, are invariably delegitimized and prevented from reaching populations trapped in conflict,” said Oberreit. “In extreme cases, aid has even been denied to populations to serve political interests of stabilization efforts. Humanitarian assistance must be driven purely by the actual needs of a population, and not predicated upon any other agenda.”

Large segments of the Somali population throughout the country require basic assistance, many in active conflict areas and in zones controlled by armed groups, such as in south-central Somalia, underscoring the need for independent and impartial humanitarian aid. Access to food and adequate medical care is severely limited.  More than 730,000 Somalis have sought refuge in camps in Kenya and Ethiopia. Overall levels of assistance in Dadaab, Kenya, home to hundreds of thousands of Somali refugees, itself remain insufficient.  Calls by Kenya for the return of refugees are premature as long as the security situation remains perilous in Somalia.

More than one hundred Somalis cross each day into Ethiopia to escape the deprivation, stating food shortages and insecurity as the main drivers for fleeing. In a recent survey of MSF patients, more than half (424 out of 820) reported being displaced within Somalia or to Liben, Ethiopia. More than 187,000 Somali refugees are living in Liben, according to the UN High Commission for Refugees. Direct or feared violence were the main reasons for displacement (46%) followed by food shortages due to drought and limited access to assistance (32%).

“I have been displaced more than 10 times in my life,” a 25-year-old woman from Lower Juba region told MSF. “My husband died in an attack, and two of my children died because I was not able to give them food. I try to stay strong but this situation that our county has been facing for too long is killing us.”

MSF has already had to curtail its activities in Somalia due to security risks.  In October 2011, two MSF aid workers, Montserrat Serra and Blanca Thiebaut, were abducted in the Dadaab refugee camp and taken to Somalia, where MSF believes they are still being held.  Following the abduction and until the safe release of the two aid workers, MSF has limited its operations in Somalia to strictly life-saving emergency work.

MSF has worked continuously in Somalia since 1991, and continues to provide lifesaving medical care to hundreds of thousands of Somalis in ten regions of the country, as well as in neighboring Kenya and Ethiopia. Over 1,400 staff, supported by approximately 100 people in Nairobi, provide a range of services, including free primary healthcare, malnutrition treatment, maternal health, surgery, response to epidemics like cholera or measles, immunization campaigns, water and relief supplies. During the first half of 2012, MSF treated nearly 30,000 severely malnourished children and vaccinated 75,000 against infectious diseases. MSF teams also assisted in over 7,300 deliveries and provided close to half a million medical consultations within its health facilities. MSF relies solely on private donations for its work in Somalia and does not accept any government funding. 

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Patients describe persistent violence, displacement and hunger in new MSF Report

February 13, 2013

Nairobi/Amsterdam. In a report released today, Médecins Sans Frontières (MSF) highlights violence, displacement and food shortages as salient features of Somalia’s humanitarian landscape. The report, entitled “Hear My Voice,” draws on the testimonies of more than 800 Somali patients attending MSF medical facilities in Somalia and in the Ethiopian border area. Patients describe a consistent pattern of high vulnerability and needs related to basic survival such as food, health care and protection from violence.

“As the Somalia government and the international community look to a brighter future in Somalia with a focus on stability and development, we cannot forget that many thousands of people are still exposed to extreme levels of violence and in need of emergency life-saving assistance,” says Operations Manager, Joe Belliveau.

Over half of the persons interviewed report being displaced from their homes with approximately half of them stating violence and fear of attack, and another third stating food shortage, as the main reasons for displacement.

“Lack of security, lack of food, lack of humanity, lack of freedom and family separation are the hardest things in life. I have been displaced more than 10 times in my life. My husband died in an attack, and two of my children died because I was not able to give them food.” Woman, 25, from Lower Juba

The report emphasizes that humanitarian assistance must remain a priority in large parts of south central Somalia and that it must remain independent of any political agenda.

MSF has worked continuously in Somalia since 1991, and does not receive any government or institutional funding for its Somalia programs. Despite a reduction in activities over the past two years related to insecurity and attacks on MSF staff, MSF continues to provide lifesaving medical care to hundreds of thousands of Somalis in ten regions of the country, as well as in neighboring Kenya and Ethiopia. On October 13, 2011 two MSF workers, Montserrat Serra and Blanca Thiebaut, were abducted in Dadaab refugee camp in Kenya. MSF believes that its two colleagues are being held in Somalia and appeal for their unconditional release. 

The full report can be found here: Hear my voice, Somalis on Living in a Humanitarian Crisis

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MSF teams are treating pregnant women providing ante-and postnatal care and working to ensure women have safe deliveries.  On average twenty babies a month are born in the hospital.  Women are often admitted to the hospital with pregnancy related complications, many women arriving at the hospital are underweight, weak and dehydrated not only due to the hard conditions of life but also due to multiple pregnancies with too little time in between each pregnancy.

In this isolated border area according to official government figures only 3.8 per cent of women receive antenatal care compared to 42.1 per cent nationally and only 2.6 per cent of deliveries are attended by a health professional compared to 12.4 per cent nationally. Most women deliver their babies at home or in the bush with the assistance of traditional birth attendants.

In the past women would only come to the Wardher hospital where MSF is working if they had experienced complications in labour. MSF’s team of midwives and nurses say this slowly is beginning to change as more women are coming to the hospital for antenatal examinations and check-ups.

I returned from Wardher a month ago where I spent time meeting MSF midwives, health workers and pregnant women. During the five days I spent in Wardher two babies died after delivery due to complications in pregnancy. One baby died because she was a breech birth. A breech birth occurs when a baby is positioned feet or bottom first, making delivery much more complicated.

Here are some of the stories of women I met:

The midwife:  Iman

“In Somali culture women get married young and have many children. Sometimes babies do not survive to adulthood and so women have as many as ten babies in a short space of time. Women are then becoming weak; their bodies are unable to cope with being pregnant so soon after they have given birth and so many of the women who come to the hospital are anaemic and weak. Women and girls often do not have enough food to eat.

When women find out they are pregnant, they are of course very happy but also scared because they know giving birth is hard here.  Pregnant women suffer from many health complications. Most of the women I meet suffer from urinary tract infections. Often their husbands have more than one wife and this also increases the chances of them picking up infections and becoming unwell.  Most of the patients I see have low blood pressure and don’t practice family planning. They have many babies in a short space of time.

I enjoy working as a midwife, for me it’s important that I’m doing something to help my community. I meet women who walk sometimes for two hours to reach the Wardher hospital despite being heavily pregnant. Women travel from long distances to arrive at the hospital. Often they have suffered a miscarriage and come to see us for treatment.

I’ve noticed that more women are now coming to the hospital to deliver their babies. Before they would have their babies in the bush but now they feel confident of getting good medical care in the hospital. It takes years to change the behavior of people but I feel these changes are good and that women are relieved that they can come to deliver the babies here. MSF is part of our community now and as a midwife I feel proud to be part of the MSF.”’

The patients:

Badoo,  40, from  Dolo Zone

“I gave birth seven days ago to a baby girl. I delivered my baby in the bush where I live as I have done with all my previous babies, I have ten children. A traditional birth attendant delivered my baby but soon after I became very sick. I had a very high fever and was shaking uncontrollably. I felt like all the energy was leaving my body. I had been cut very badly and became infected after the birth; I found it painful to pass urine and the pain made me want to be sick and I almost fainted. I told my family that I felt very unwell and I needed help.

My family put me on a donkey cart and it took two hours to get here. The road isn’t good but its sandy and so I was able to cope with the journey even though it was very hot and exhausting. I have been in the hospital two days and the staff check my blood pressure. They have given me medicine and have put me on an oxygen machine. The doctor says I look better now and I feel like I’m getting a little more energy in my body.

This is the first time I’ve become sick after delivering a baby. I don’t want more children. I am tired now. I feel like now I am here in the hospital I will be ok. I was in a lot of pain but every day that I’m here I feel a little bit better. I have to breathe with an oxygen mask on because I’m still weak. If I had stayed in the bush and not come to hospital I don’t know what would have happened to me.”

Amoon, 35,  from Wardher

Amoon gave birth to a baby girl in Wardher hospital on December  3^rd.2012.

“I have five children, two died shortly after birth and two are still alive. This is the first time I delivered my baby in hospital. I came here two days ago for the delivery. I found the birth difficult and painful but what was more painful was when the midwife had to pull the placenta out (manual removal of placenta). That was the worst pain. My babies, two of them have died shortly after birth. I know this baby is sick because I can see the midwife spending a lot of time with my baby. I hope she survives and I can take her home. If it is Allah’s will for her to survive she will and if not then I accept it.”

Amoon’s baby girl died in the hospital on December 4^th 2012.

Asle , 39, ten children, visiting the hospital to see a patient

‘’Most women I know come to the hospital for deliveries as they feel more comfortable coming here. I had my children in the bush with the help of a traditional birthing attendant. They are good but they do not have the same information the midwives have and if the delivery isn’t easy and there are problems they are unable to do much to help keep the baby alive. I have lots of children; my husband likes a big family. I am happy that I won’t have more children now because I am tired of being pregnant and delivering babies.’’

“Many men here take four wives and keep on having children but are unable to provide for their wives or children. There isn’t a lot of work here and not much to do. It’s very hard for women. They suffer a lot and are not able to make decisions about who they want to marry and how many children they want. I see cases every day of very exhausted women; they are weak women, anaemic and come to the hospital for checkups when they are pregnant. They will never say they are unhappy about being pregnant but they look very tired and exhausted.’’

Rape and sexual violence

MSF’s midwives are also sometimes confronted with women who have been raped. At times this results in an unwanted pregnancy.

Between Jan 2009 and December 2012 fifteen women and young girls came forward seeking treatment for injuries sustained during rape.

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Médecins Sans Frontières calls for rapid registration in countries with high drug-resistant tuberculosis burden

NEW YORK/GENEVA – Embargo TBC – Médecins Sans Frontières (MSF) welcomed the approval by the US Food and Drug Administration of bedaquiline, the first new drug active against tuberculosis (TB) to be registered since 1963.

“The first new drug to treat TB in 50 years is an immense milestone,” said Dr Manica Balasegaram, Executive Director of the MSF Access Campaign. “The fact that the drug is active against drug-resistant forms of the disease makes it a potential game changer.”

Today’s treatment for multidrug-resistant TB (MDR-TB) is a two-year course of up to 20 different pills per day and around eight months of daily injections. Patients are subjected to excruciating side effects, ranging from permanent deafness and persistent nausea to psychosis. Globally, only 48% of people who start treatment for DR-TB are cured.   In MSF programmes, the cure rate is slightly better – 53% – but still unacceptably low.

“Ministries of health and drug regulators need to work together to make sure people with MDR-TB benefit from this important medical advance as soon as possible. The onus is on all of us to use bedaquiline to devise new treatment regimens for drug-resistant TB that are shorter, more tolerable for patients, and are more effective,” said Dr. Balasegaram. “With better treatment on the way, there should be all the more incentive to scale up our efforts to treat MDR-TB today.”

The scale of the DR-TB epidemic is huge, with 310,000 new cases notified in 2011. But globally, only 19% of people thought to be infected are receiving treatment.

“Scale-up of global DR-TB treatment has remained shockingly low, to a large degree because the current treatment regimen is so complex and costly for health programmes and difficult to tolerate for patients,” said Dr Francis Varaine, leader of MSF’s TB Working Group. “With simpler, shorter and more effective treatment regimens, we will be able to scale-up treatment and cure more people with DR-TB.”

In addition to bedaquiline, developed by Janssen, a second new drug that is active against MDR-TB called delamanid, developed by Otsuka, is undergoing registration by the European Medicines Agency and is expected to be approved for use in 2013. Together, the two new drugs represent an unprecedented opportunity to improve treatment for MDR-TB, and ensuring the drugs are combined and introduced in the most effective manner is extremely urgent.

But access to the new drugs will depend to a large degree on the manufacturers. MSF calls on the manufacturers to make the drugs available for research in order to develop shorter, more effective regimens, to register them in high-burden countries as quickly as possible once they have been approved, and to ensure they are affordable in countries where they are needed most.

MSF treated 26,600 TB patients in 36 countries in 2011 – 1,300 of whom had drug-resistant forms of the disease.

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© Yahya/MSF Philippe and Kace

29th December 2012  It is with great sadness that the medical humanitarian organisation Medecins Sans Frontieres (MSF) marks one year since its two colleagues, Philippe and Kace, were brutally murdered in Mogadishu.

Philippe Havet, a 53-year-old emergency coordinator from Belgium, and Andrias Karel Keiluhu (Kace), a 44-year-old medical doctor from Indonesia, were working with MSF teams to provide emergency medical assistance to displaced and resident populations.

“Philippe and Kace are greatly missed and today we extend our heartfelt sympathy and condolences to their families and friends”, says MSF General Director Christopher Stokes.

Following the tragic killing of our colleagues, MSF decided to close two large medical centres in the Somali capital city. However, MSF continues to run  10 projects throughout the country and provides medical and humanitarian aid to thousands of Somali refugees in camps across the border inEthiopia and Kenya.

Today, two other MSF employees, Blanca Thiebaut and Montserrat Serra, remain held against their will in Somalia after they were abducted from Dadaab refugee camp, Kenya, on 13th October 2011. MSF once again condemns this act of violence and demands their immediate release.

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In the Dadaab refugee camps, in northernKenya, the rainy season is increasing the risk of disease and epidemics among an already extremely vulnerable population.

“The assistance provided here in Dadaab is already completely overstretched and is not meeting the current needs,” says Dr. Elena Velilla, MSF’s Head of Mission in Kenya.“Furthermore, due to the ongoing insecurity in the camps, MSF would not be able to scale up or respond to a new emergency situation if there is an influx of new arrivals in the camps.”

Over the last month, the number of children admitted to the MSF hospital for severe acute malnutrition has doubled and around 300 children have been hospitalised. Most of them are also suffering from acute watery diarrhoea or severe respiratory tract infections which reflect the poor living conditions in the camp.

“Since the beginning of December and the heavy rains which have caused floods, the shelter and sanitation situation that was already precarious in the camps, has become even more deplorable,” continued Velilla. “This has had dramatic consequences on the population’s health.”.

With a 200 bed hospital that serves as a referral facility for several camps in Dadaab, MSF is one of the main health providers, but it has been struggling to cope with the considerable and growing medical and humanitarian needs.

Since the camps were established 20 years ago, emergencies have consistently plagued Dadaab, with floods, nutritional crises and disease outbreaks commonplace. According to the UNHCR, eleven epidemic outbreaks were reported in 2012. Today, sporadic cases of cholera and hepatitis E continue to be reported throughout the camps.

With conditions continuing to deteriorate, MSF therefore fears the impact of the Kenyan government’s decision on the already disastrous medical and humanitarian situation of the refugees living in Dadaab.

MSF activities in Dadaab

MSF runs a hospital in Dagahaley, one of the five refugee camps in Dadaab. MSF teams carry out an average of 14,000 outpatient medical consultations each month and admit 1,000 patients from the refugee and host communities to the hospital. There are currently more than 300 severely malnourished children enrolled in the nutrition programme, 63 of whom were admitted to the intensive care unit this week as complicated cases.

More than one year ago, in October 2011, two MSF aid workers, Montserrat Serra and Blanca Thiebaut, were abducted in Dadaab refugee camp while carrying out emergency assistance for the Somali population. They remain in captivity, and MSF, while continuing to respond to acute crises, has put on hold the opening of any non-emergency projects in Somalia until their release.

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As a result of fighting and a lack of access to water and food, 60,000 people have fled Somaliasince the beginning of 2012. They join one million Somali refugees in neighbouring countries – mainly Kenya, Ethiopiaand Yemen– and a further million displaced within Somalia.

For relief organisations such as Médecins Sans Frontières/Doctors Without Borders (MSF), providing assistance to people in distress in Somalia remains a challenge. In the centre and south of the country, it is possible to identify at least three types of contexts, each posing significant constraints for humanitarian workers.

As a result of a massive military deployment,Mogadishu is currently experiencing a period of relative stability, not seen since 2006, when the Union of Islamic Courts took control. Restaurants have reopened, foreign traders are in business again, and scaffolding testifies to economic investment by the Somali diaspora.

But the city is still not secure. Bombings and targeted assassinations are frequent, clashes between militias continue in some areas, and Al Shabaab fighters have intensified attacks against pro-government forces. In addition, living conditions for the majority are atrocious – in particular for the 300,000 to 400,000 people displaced, most of them as a result of the 2011 nutrition crisis. Many displaced still live amongst the rubble in makeshift shelters of plastic sheeting supported by pieces of wood. As land comes up for development, those living in these makeshift camps have to relocate; some have moved several times. Access to drinking water is insufficient and irregular – it is not uncommon for taps in the camps to remain dry for several weeks at a time – while the few hospitals in the capital struggle to cope with large numbers of patients from all over the country. Following the evacuation of its staff due to heavy fighting in April 2012, Daynile hospital – supported by MSF – reopened in September.

The second context is in the main Somali cities, which have been ‘liberated’ from Al Shabaab administration over the past year by the joint military mission of the African Union in Somalia (AMISOM), Ethiopia and the Somali Transitional Federal Government. Yet today the security of these urban populations is probably more fragile than it was a year ago. Assassinations, attacks, robberies, extortion and intimidation are commonplace. Access to health facilities remains a problem, and few people brave the journey to hospital after dark.

Finally, in many south and central rural areas, Islamist fighters still hold sway. Most are opposed to the presence of foreign aid organisations and, after successive waves of bans and expulsions, only a few humanitarian organisations – including MSF – are just about able to continue working in these areas.

Working inSomalia means, first of all, accepting to work in dangerous conditions. For our staff, it means assessing the risks linked to their mission, on an individual basis. Incidents can happen for a number of reasons – related to the drugs trade and to the fight for jobs, among others – plus the risks of being in the wrong place at the wrong time.

At the time of writing, two MSF staff are still being held in Somalia, more than one year after they were kidnapped from Dadaab, Kenya. And in December 2011, two members of the MSF team in Mogadishu– Philippe Havet and Dr Andrias Karel Keiluhu – died from their wounds after being shot by a Somali employee of the organisation.

The situation leads us to reduce the activities we would normally want to do given the needs, for two reasons.

The first is a choice we have made to just prioritise medical emergencies and nutrition, until the release of our kidnapped colleagues who are being held in the country.

The second is the practical reaction to the risks our staff face; we have to limit the scope of our projects and the number of international staff, who are particularly vulnerable to abductions. This can mean accepting that we have less control over our activities than we would wish, or having less assurance of the medical quality of our programmes. The choice to provide support mainly to hospitals and surgical centres, also reduces the movement of our teams, and therefore their exposure to risk.

In addition, and very unusually for MSF, we use armed guards inSomaliato deter attempted kidnapping or attacks. This is itself not without risks, notably the possibility of human lives being lost in crossfire.

Insecurity is not the only constraint for aid organisations working in Somalia. It is difficult to identify reliable partners with whom to create alliances and negotiate the access we need to work, while weak and disorganised medical facilities, a lack of trained health workers, and an incomplete understanding of the medical needs all represent obstacles for aid organisations.

Finally, while it is essential that MSF’s resources are for the benefit of patients, we must be aware that humanitarian aid can be a source of power for local stakeholders, and that taxes, diversions of aid and attempted extortion are all common practices in Somalia.

Away from generalisations and clichés, these are the issues that define the limits to MSF’s work in Somalia, which we believe is still possible and still useful. This is the price we have to pay to do our work. Rather than deploring these limits, we need to accept the fact that they exist and to learn how to deal with them.

Michel-Olivier Lacharité, MSF programme manager
Michaël Neuman, director of studies at CRASH / MSF Foundation

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