On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.102 n.8 Cape Town Aug. 2012
Zeyn Mahomed; Muhammad Moolla; Feroza Motara; Abdullah Laher
The authors are specialist emergency physicians attached to the Emergency Department, Charlotte Maxeke Johannesburg Academic Hospital, and lecture at the Department of Emergency Medicine, University of the Witwatersrand, Johannesburg
Reports about The Horn of Africa Famine Crisis in 2011 flooded our news bulletins and newspapers. Yet the nations of the world failed to respond and alleviate the unfolding disaster. In August 2011, the Gift of the Givers Foundation mobilised what was to become the largest humanitarian mission ever conducted by an African organisation. Almost a year later, the effort continues, changing the face of disaster medicine as we know it.
Somalia is the epicentre of a hunger crisis in the Horn of Africa, affecting over 13 million people. Ravaged by war and famine, the country has been without a national government since the overthrow in January 19911 of President Mohamed Siad Barre who, in a coup in 1969, ushered in an authoritarian socialist rule with persecution, jailing and torture of political opponents and dissidents. Following the regime's collapse, Somalia descended into turmoil, factional fighting and anarchy. The northern clans declared an independent Republic of Somaliland which, although not recognised by any government, has remained stable and continues efforts to establish a constitutional democracy.1
Somalia is tremendously impoverished, ranking in the bottom 10 countries internationally. Changing weather patterns have made droughts more common in the region, and food shortages have been exacerbated by the lack of humanitarian access to many areas, and sharp increases in food prices. By UN estimates, over 10 million people are starving in the horn of Africa.2
To contain the humanitarian disaster, aid agencies desperately need access to areas where insecurity is rife and where the militant group, Al-Shabab, is in control. The World Food Programme withdrew from the Al-Shabab-controlled areas of southern Somalia in 2010 because of threats to the lives of UN staff.3 Uncharacteristically, Somalis have streamed into camps set up in war-ravaged Mogadishu. Traditionally, city residents take refuge in the countryside when fighting in the capital has intensified.
The death rate among Somalis arriving at refugee camps was several times above the levels normally seen in emergency situations. The mortality rate in June 2011 reached 7.4 deaths/ 10 000/day, which is sharply above the sub-Saharan baseline rate of 0.5 and the emergency situation of above 1/10 000/day.3 A famine is generally declared when the mortality rate exceeds 2/10 000/day and when wasting >30% occurs across an entire region. The UN also estimated that 3.2 million Somalis required immediate life-saving humanitarian assistance.2 Tens of thousands were fleeing drought areas, often walking 600 - 800 km to escape the disaster zone. Many never made it; the path is littered with bodies and the bones of the dead.
Gift of the Givers
Heeding the call for help, the Gift of the Givers Foundation (GOTG) mobilised what was to become the largest humanitarian effort by an African organisation. Over a few months beginning on 1 August 2011, the following was achieved:4 11 flights carrying 175 tons of emergency aid delivered direct to Mogadishu; 5 ships carrying over 2 080 tons of supplies; 4 feeding centres set up in refugee camps feeding 47 000 people 2 meals daily; 4 more feeding centres being planned; 1 000 new families given dry rations daily; establishment of an orphanage that feeds 3 000 orphans daily; 10 700 patients treated, 80 operations performed; each child given nutritional supplements worth R1 300; Forlanini Hospital was taken over, with funding and personnel trained by GOTG; the foundation took on 94 personnel including 57 medical specialists, over 2 missions; and installation of a borehole at 22 m costing $US15 000, providing water for drinking, washing and cooking to 30 000 people in 11 camps. All this was made possible with support and donations from the South African government and national and international businesses, individuals and institutions. All races, faiths and nations responded with donations to help the Somali people.
The first medical mission departed on 1 August 2011. The second comprised 3 paediatricians, 6 dieticians, 2 nurses, 7 general practitioners, 3 orthopaedic surgeons, 3 anaesthetists, 1 emergency physician, 2 paramedics, 2 obstetricians, 1 pharmacist and a general surgeon - 30 in total. To increase global awareness of the plight of the Somali people, both missions were accompanied by large media teams.
The second mission
We were privileged to be part of the second mission, and now share my experience and lessons over those unforgettable 2 weeks. We reached Mogadishu on 6 September, landing on a runway bordered by pristine coast. We thought, 'Hey, this is not so bad at all, looks pretty good.' - only to be met by the sight of a recently shot-down cargo plane at the end of the runway, which immediately dampened the mood. The reality of where we were and the associated risks began to hit home when we met our heavily armed escort at the arrival hall. GOTG must be given credit for taking no chances regarding security. As we know well in medicine, safety first. The heroes always die first.
A small army always accompanied our extensive convoy, including at least 2 armoured vehicles with guns that appeared to have antiaircraft capabilities. We were even escorted to every area of any health facility by personal guards. There was no deviation from this safety-first rule. Any potential security threat was taken seriously and thoroughly investigated.
A month earlier, the first mission was met with alarming pictures of the starving internally displaced persons arriving at refugee camps throughout Mogadishu. Since then, the GOTG had established feeding centres. When we visited those camps, those who had been on the first mission were pleasantly surprised. Although still in desperate need, the children and parents were better nourished and mortality rates had begun to decline. The feeding programmes were working, and it was heart-warming to see their impact. That's when I began to realise the purpose of our mission. Disaster medicine and relief efforts go beyond dropping food parcels, treating patients for 2 weeks and then returning home. We must all share a broader vision when responding to a disaster. The aim is to rebuild a nation by passing on skills to the Somali people, implementing sustainable practices, outfitting and starting clinics, drilling boreholes, and instilling hope.
During our first few days, our base was the largest hospital in Mogadishu - a dilapidated building staffed by a few medical trainees with only basic knowledge. Somalis have been without access to medical care for over 20 years; at Banadir Hospital, the staff lack the education, equipment and manpower to help them.
The theatre and wards were in a horrible state. An ancient, non-functional anaesthetic machine stood testament to the fact that surgical procedures were conducted without anaesthesia. The wards were filled with victims of botched surgical attempts, indicating lack of medical training. There is no medical oxygen in Somalia. We had to fly in everything of our own. In true South African style, within 7 hours of arrival we had made the theatre fully functional, with orthopaedic, general surgical and obstetric lists.
Next, the team that I was assigned to established a makeshift emergency department and a high-care area, and we began to see and treat patients who had been lying in the wards, some for months. The paediatric team set out to do the same in the paediatric wards while the general practitioners established outpatient clinics. All the while, we tried to pass on knowledge and skills to the existing staff.
Life in Mogadishu is difficult. Only a fortunate few have running water and electricity. Our team was very fortunate as GOTG housed us in a well-protected compound. Yet most found it difficult to fall asleep to the continual drone of mosquitoes, sporadic gunfire and frequent mortar shelling.
After a week, Dr Sooliman identified a new site in the west of Mogadishu, where the need for medical help was even greater. Forlanini Hospital was an abandoned clinic, but was fortunately structurally sound, considering that every other building within a 20 km radius was a ruin. Again, we set up a theatre and obstetric, paediatric and general practitioner consulting rooms, feeding clinic, high-care area and a paediatric in-patient facility. These are all still open, functional and manned by some of the 80 GOTG employees stationed in Somalia.
Despite seeing heart-rending images of suffering and turmoil, I learnt some awe-inspiring lessons. Firstly, South Africans across the board responded generously and without hesitation to their neighbours in need. When GOTG handed out food parcels to our own impoverished in the informal settlements in South Africa, many were returned. The poorest among us asked that their food be donated to the people of Somalia, as they believed that the Somalis needed it more. What a marvellous country we live in!
Secondly, I learnt about an amazing organisation with inspirational leadership, that aspires to instil a nation with hope and that taught me that disaster medicine is far more than just the initial response. Many relief organisations that mobilise teams at great cost to the afflicted area and often return without accomplishing much, have been criticised worldwide. However, much is accomplished beyond the obvious saving of lives and rescuing of trapped people. The morale boost of a visiting team is priceless; that another nation is there to support one in one's time of need provides a stricken nation with hope. The GOTG provided far more than a temporary morale boost. It is now more than 10 months since their first response to the Somali crisis in August 2011 and they are still the largest NGO operating in Mogadishu. The feeding centres, orphanage, borehole and Forlanini Clinic remain open and will remain open and operated by GOTG staff for as long as is needed.
Lastly, I learnt about the resilient Somali people. The first team arrived with abundant food and medication in Ramadhaan, the holy month when Muslims fast. No Somalis would break their fast, not even for medication, despite probably having had their last proper meal weeks ago and that in Islam one is not obliged to fast in such dire circumstances. They waited patiently in the sun for hours to be seen; first children, then the old, then women, and lastly the men; all of their own accord. Would we show such patience and faith if faced with such adversity?
In a country where no medical oxygen is available, skilled medical personnel are a luxury; there has been no orthopaedic surgeon for 21 years. It takes little effort to imagine what South African intervention has done to boost Somali morale, give hope and restore faith in humanity and especially in Africa, as they are emphatic that Africa came to the rescue of people whom the world had forgotten for 21 years. The campaign continues.
1. Central Intelligence Agency. The World Factbook. https://www.cia.gov/library/publications/the-worldfactbook/geos/so.html (accessed 4 May 2012). [ Links ]
Accepted 18 May 2012.