Somalia: Doctors Without Borders pulls out after 22 years
Lack of trust in local authorities drives French medical charity away
by Simon Allison
Doctors Without Borders (known by its French initials MSF, for Médecins Sans Frontières) worked in Somalia for 22 years. It was a rough ride. During its time in this chronically unstable country, 16 staff members died in violent incidents, while others were abducted, threatened and intimidated. The organisation bent over backwards and had to negotiate its way through the byzantine and constantly shifting alliances of clans, armed groups and government and pseudo-government entities which make up this East African nation—a country which is infamously known as the archetypical failed state.
This is a tough place to work. Then again, this is what MSF does. It goes to the world’s war zones and disaster areas with a deceptively simple mission: provide basic, emergency health care to some of the planet’s most vulnerable people, in situations where no one else dares to tread. It is a job the organisation does so effectively that its calming presence can even allay tensions.
In 1999 MSF was honoured for its efforts with the Nobel Peace Prize. “In critical situations marked by violence and brutality, the humanitarian world of Doctors Without Borders enables the organisation to create openings for contacts between the opposed parties,” read the citation. “At the same time, each fearless and self-sacrificing helper shows each victim a human face, stands for respect for that person’s dignity, and is a source of hope for peace and reconciliation.”
In this context it is difficult to view its sudden departure from Somalia as anything other than a disaster. If MSF is a symbol of hope, then that hope just packed its bags and left Somalia.
Look at the numbers. Between January and July 2013, MSF helped 624,200 people across eight regions in Somalia (or 6.1% of the 10.2m population). Of these, 41,100 were admitted to hospital; 30,090 were treated for severe malnutrition; 58,260 were given vaccinations; and 2,750 had operations. The rest received basic medical care. With MSF now gone, and in the absence of a functional national health system, it is unlikely that any of these people will receive comparable medical attention.
Unni Karunakara, MSF’s international president, explained the decision in an emotional press conference in Nairobi on August 15th. “The closure of our activities is a direct result of extreme attacks on our staff, in an environment where armed groups and civilian leaders increasingly support, tolerate or condone the killing, assaulting and abducting of humanitarian aid workers,” he said, fighting back tears. “We have reached our limit.”
Several incidents in the last few years contributed to pushing the organisation over its danger threshold. A single group did not conduct these attacks, nor were they necessarily directed at MSF in particular. But taken cumulatively they have made working in Somalia extremely difficult for the organisation.
In December 2007, an MSF nurse and doctor were kidnapped in Bossaso, the main port in Puntland in Somalia’s north-east. They were released after one week. In January 2008 three staff members (two international and one local) were killed in a bomb blast in Kismayo on the southern Somali coast. In April 2009 an MSF medical coordinator and doctor were kidnapped in Radbhure in the south-western Bakol district.
They were released nine days later. In October 2011 Somali gunmen, alleged by Kenyan police to belong to Islamist militant group the Shabab, kidnapped two Spanish aid workers in Kenya’s Dadaab refugee camp, 80km east of the Somali border. The aid workers were held for 21 months before being released in July 2013. In December 2011 a local MSF staff member shot dead two foreign MSF aid workers after a quarrel with the foreign MSF medical coordinator. This last incident was the only one to produce any kind of legal proceedings. The shooter was tried and found guilty, but inexplicably released from prison several months later.
This roll call is tragic but it does not fully explain why MSF chose to withdraw. The year has been relatively peaceful as far as the organisation is concerned. Somalia itself is showing encouraging progress with a new government, a cowed (but not vanquished) Shabab and a flood of returning diaspora. International journalists and diplomats claim that Somalia has turned a corner—an image which just does not square with MSF’s description of it as a country in which it is too dangerous to operate.
Africa in Fact put this question to Arjan Hehenkamp, an MSF general director based in Geneva who has helped oversee MSF’s operations in Somalia and worked there himself during the organisation’s initial humanitarian intervention in the early 1990s. He was reluctant to comment on Somalia’s overall progress, but his assessment of the facts was damning nonetheless.
“MSF is not a political commentator, we are not The Economist and we don’t make a prognosis on the context and so forth,” Mr Hehenkamp said. “That’s not our job. But when we look at Somalia and when we look at our experience and our patient numbers in Somalia, it seems there is an ongoing humanitarian crisis and there continues to be violence and strife which affects the population significantly. There continues to be territorial disputes and armed altercations between various groups in Somalia that affects that population. And we see that we have tens of thousands of patients coming into our facilities every single month, without any reasonable alternative being present for most of these patients… If Somalia had turned a corner or was about to turn a corner, then anyway you could argue that MSF might have to consider leaving eventually. But we didn’t feel that to be the case.”
MSF’s withdrawal was not prompted by any specific incident or the result of the actions of any single armed group, Mr Hehenkamp said. Rather, it came after a long period of soul searching about MSF’s role in Somalia and a difficult, poignant review of its presence in the country.
Ultimately, three factors contributed to the decision: first, the various violent incidents affecting MSF staff mentioned previously. MSF might not specifically have been the target of these attacks, but it certainly suffered the consequences.
Second, MSF compromised its standard operating procedures to work in Somalia by employing armed guards, a security measure it has not adopted in any other country. Another major concession was to operate in some locations without any international staff, relying only on local employees. Usually, in a conflict zone, international staff are deemed necessary to safeguard the perception of MSF’s independence and impartiality: it is easier for local staff to be drawn into the conflict, or perceived to be on one side or the other.
Third, and perhaps most importantly, MSF could not rely on the various authorities in different parts of the country. Somalia is a fragmented country. Operating in it safely requires cooperation not just from the central government, but from various armed groups (including the Shabab), assorted local authorities and traditional clan leadership structures.
Mr Hehenkamp decried the “persistent and structural inability and unwillingness of the authorities, leaders [and] government in Somalia to either prevent or to address these attacks when they occurred”. Without that cooperation and basic level of trust, it was nearly impossible to guarantee a reasonable level of safety for staff.
“We make agreements with them, whether it be locally or regionally or nationally, or whether it’s an armed group or government and so forth, and if these same people show that they are unable, unwilling, or sometimes downright implicated in some of these incidents then that affects us as an organisation,” Mr Hehenkamp said.
“We can anticipate in the future that we will face these same incidents.”
It is this last point that clearly pushed MSF over the edge. It can live with insecurity and danger as demonstrated by its work in the world’s most dangerous countries: Afghanistan, Central African Republic, the Democratic Republic of Congo, Iraq, the Sudans, Syria, to name just a few. Compromises too are part of the job. No two conflict zones are the same. Each requires its own rules and operating procedures; each presents unique challenges. But this work is only possible in an environment where there is a basic level of trust between MSF and the local authorities; a respect for MSF’s work; and an understanding that medical facilities and personnel are not legitimate targets. This is absent in Somalia. Africa in Fact contacted several Somali government spokespeople for comment, but received no response.
The Shabab is not the only guilty party, although it has been particularly outspoken in its criticism of Western humanitarian intervention. (Hours after MSF announced its departure, the group raided one MSF hospital in southern Somalia, looted equipment and evicted patients.) Mr Hehenkamp was at pains to emphasise that MSF had lost faith in all the various Somali authorities it had relied on to operate safely.
The decision to leave and the actual departure were two different endeavours. It took MSF a few weeks to wrap up its operations, with priority given to finishing treatments for existing patients. After the announcement, no new patients were treated or admitted. The organisation made a point, however, of leaving behind its stockpiles of medication and supplies in the hope that someone would use them. Where possible, it struck deals with local authorities to employ some of MSF’s Somali staff to keep at least a skeleton medical programme in place. This, however, was the exception rather than the rule.
The 1,500-odd local staff, some of whom have been with MSF for many years, are now unemployed. “We’re talking about hundreds of staff that have worked incredibly hard and were incredibly loyal to MSF…quite apart from the impact on patients, there is a major impact on people who have been the backbone of our operations in Somalia for the last 22 years,” Mr Hehenkamp said.
Despite its influence, MSF was not the only international NGO offering health services in Somalia. The International Committee of the Red Cross (ICRC) is still present. It has been working in the country since 1978, offering emergency and long-term planning on health, water, food and shelter needs. In comments to Africa in Fact, ICRC spokeswoman Sitara Jabeen expressed the organisation’s sympathy to MSF for “the human cost that it has paid recently in Somalia”, and said it was “very sorry to see its departure”.
Like MSF, the ICRC also relies on a large network of Somali staff to mitigate security risks, the spokeswoman explained. The key difference, which was not specified by Ms Jabeen, is the ICRC’s cooperation with the Somali Red Crescent Society, a local NGO that is part of the International Red Cross and Crescent Movement. This long- standing working relationship gives the ICRC more local legitimacy, which is very useful in negotiating Somalia’s labyrinthine power structures and makes staff less of a target.
MSF is in ongoing talks with the Somali government about returning to the country, but this does not look likely anytime soon. The situation would have to change enough to meet MSF’s three-pronged cri- teria for assessing whether to engage in any dangerous area.
“First we look at the level of insecurity,” Mr Hehenkamp said. “Then the target or focus of that insecurity; and finally the effective relationships with the armed groups. Of course, in all that we need to take into account the needs of the population, and our ability to impact on the needs of the population. If we can make…very little impact with a very massive security risk, then this is not balanced.”
Ultimately, MSF’s engagement in Somalia was out of kilter. It made a huge, positive impact on Somalia’s healthcare. The ICRC said its services were vital, the difference between life and death for large numbers of people.
Despite this valiant effort, the danger was too great. Blame the people who rule Somalia, from the national government to the armed groups to the local community structures. Unable to provide healthcare themselves, their infighting and power games hounded out one of the few organisations that could provide these life-giving services, and at no cost. As usual, it is the Somali people who will pay and suffer.
