November 19th, 2007 by tiranah

There are more people arriving from Mogadishu. The first woman we met is 70 years old, the same age as my father, it is hard to believe how different their two worlds are. Whilst her face tells a story of life full of challenges and struggle, she still has an energy that just resonates and despite the displacement and the tragedy of her experience, she tells her story and even laughs and jokes.

She invites us into a small one room house, where she is staying with her three grandchildren. She took them here after her son was killed during the fighting in Mogadishu. She rolls out a small plastic mat, which she explains is the only thing she left Mogadishu with, besides the clothes that they were wearing.

As I am sitting on this mat, I realise how numb one can become to the language of 170,000 people are ‘fleeing’ Mogadishu …You read and listen to the reports and think of it in a non emotional way when you see…the people are ‘displaced’, ‘fleeing’, ‘leaving’…But, as Mariam is talking it hits me, what this REALLY means. For Mariam, it was running, it was looking around and grabbing her three grandchildren children 8, 5 and 3 years old and running, and as she was running out the door, she saw her son being killed. There was no time to stop, to think, to plan, not even to grab a few thing, she just ran and has never been back. That is what displacement is like. As we end she asks me if I have her name spelt correctly, she is not sad, she does not want pity, she just tells us, she only has this mat, what more does she have to lose, she wants us to tell her story to people outside, to someone who cares, to someone who will do something.

Impossible choices.

November 18th, 2007 by tiranah

In MSF we are always constantly aware of the impossible choices that the people in places like Somalia face on a daily basis. For instance, we were wondering why children are dying from diarrhoea or malnutrition only 3km from our hospital which is free. Free drugs, free therapeutic feeding, free medical care. The reality is that these children are sick during the day when they are at home being cared for by their 9,10, 11 year old sibling. Their parents are working, the mother is in the market or in someones house washing clothes to try and make enough money to take care of the family, it is day by day survival. Of course there is no sick leave, if she misses a day at work to bring the sick child to the clinic where will the money come from to feed the other 5 children? If she does come and the medical staff need to admit the child into the therapeutic feeding centre (that is the place you have probably seen on television, rooms with malnourished children being fed with big orange cups by their mothers), she sometimes can’t stay in the hospital and care for the child as she has to get back and feed the other children who are alone in the camp where they live. Nor can she stay for several days in the hospital or the families she washes clothes for will find someone else, and then she will go from little income to no income. These are real dilemmas these people face every day.

November 15th, 2007 by tiranah

We went to a camp on the other side of town today. I was not expecting to find such large numbers of Mogadishu displaced in the camps. The chairperson said they had received between 600-700 people displaced from Mogadishu. We speak with numerous people today. They are some of the most recent arrivals from Mogadishu, they are young mothers many of them, with children and they have absolutely nothing, they have come to Galcayo to flee the fighting in Mogadishu. There are consistent stories of people witnessing horrific things as they were fleeing. Many have left and are lucky to have their lives. 3 separate people tell us the house next to them as destroyed when artilleries fell on them, they could all tell us how many people were in each of the houses when it was destroyed, all of which died.

People tell of running and not looking back, being separated from children, husbands and family members on the way, and still not knowing where they are. Even when they have made away from the fighting, the journey out of Mogadishu is perilous. The roads are scattered with thieves and bandits who set up road blocks, where they demand money to pass. If you run out of money then they begin to take your personal belongings. By the time most of them arrive here, they have absolutely nothing, just the clothes on their backs. We have been told there are approximately 150 checkpoint between Mogadishu and here, that is only 750 km, it should only take a couple of days but with the roadblocks and the searches the journey takes anywhere between 7 to 12 days now, depending on if you have problems at some of the checkpoints.

Sometimes it is hard to put into words what you see and hear. If I tell you the stories verbatim, you may feel a sense of hopelessness and these are incredibly tragic stories in incredibly brutal circumstances. But when you talk to these people you are mostly struck by the resilience. These people are focused on survival, there is no time to sit around and be sad they are focused on finding work and building a life for their families.

I ask one woman where she is living in the camp, I assumed she had family. She tells me she knows no one here and her daughter was 6 months pregnant when they arrived and miscarried on arrival. She told me that someone in the camp moved out of their small shelter and stayed with another family to let her and her children have somewhere to stay. I am not sure if I could say the same thing would in my community. Amongst all of this chaos there are incredible acts of compassion which are quite humbling.

Dusty and hot

November 14th, 2007 by tiranah

Galcayo is dusty and hot, when you look around this is the type of picture that someone who has never been here probably has of Somalia. But amongst this harsh backdrop today is a great day at the hospital, they are doing measles vaccinations and ambulatory therapeutic feeding, it is crowded with mothers and children, more than 150 children, the place is a buzz. The children really are very sweet, you just want to pick them up and play with them although as soon as they see our funny coloured fair skin (which most of them have never seen before) they usually burst into tears, so I let go of that idea.

Sometimes you hear the funniest things in the field. Today as I was stepping out to meet some women who had arrived from Mogadishu I was stopped in my tracks by the midwife Sarah, with her hands in the air, crying ‘thank god we found a fistula’!! Not quite as strange as it may sound. It’s actually more of a statement that they found someone eligible for the surgery, someone they can actually help.

You see this is not purely a medical issue the social consequences of fistula are incomprehensible. First of all you dribble urine down your leg, all day every day. Of course you wash and wash and wash but you can not get rid of the smell and often your husband rejects you, maybe you are lucky enough to have your family take you in, but the stench sometimes means that even they drive you out, out of the house, to sleep under a tree or sometimes out of the family. Some of these women are with out any support, living in isolation and humiliation; it is incredibly tragic, especially when you think it is preventable. The team here have been trying to identify women for weeks that may be eligible for the surgery. There is a sense of nervous excitement amongst the midwife and the surgeons who will be involved. If they are successful it could change these women’s lives.

Fistulas and Fighting

November 13th, 2007 by tiranah

Today I am en route to Galcayo, that is a town on the cusp of a region of Somalia they call Puntland. MSF runs quite a big hospital here. It does surgery, in patient and out patient care, an emergency ward, a TB programme as well as paediatrics and therapeutic feeding. It is busy and the team is energetic and fun to work with. They are all very switched on to MSF’s witnessing and advocacy work so it is bound to be a busy time.

I am travelling in with a Danish surgeon, Peter who is going to be conducting 4 weeks of very technical surgeries to correct fistulas. It is a little tricky to explain to those of us who are non medical, but the easiest way to describe it is as a physical hole that is created either between the vaginal wall and the bladder, or sometimes between the vaginal wall and the rectum which means she has urine constantly running down her leg. It is caused by prolonged labour, when the babies head is thrust against the pelvic wall for a long period of time. In Somalia some of the women who have come to have their fistulas repaired were in labour for 3 days. During the prolonged labour the babies head damages the tissue around the vagina, which eventually causes a hole to form. One of the main reasons this happens here is because girls are marrying and having babies in their early and mid teens and their bodies are still too small to deliver naturally. It has massive social consequences for a woman, not to mention that most of the babies die during child birth.

Whilst I came originally to document this fistula problem, Mogadishu also remains plagued with troubles. The situation has degenerated. The area that MSF had the children’s clinic is now deserted. The fighting was so intense in the area that pretty much everyone fled in the 1-hour window of calm at 5am on Thursday morning. The team described it as ‘empty’, ‘deserted’; they were virtually the last people to leave as they struggled to find a window of opportunity to move out of the area. Now they have moved to another area and the Mogadishu staff, besides all of their own personal worry and the fact that majority of them are displaced themselves or housing members of their families who have been displaced have said they will work and they want to work so they are sending out mobile clinics to the camps.

We see the press releases and news reports and calls by various bodies who are focusing on the displacement from Mogadishu. It is dire, no doubt about it but what we are worried about is the people who are stuck in Mogadishu still. The market closed 3 days ago and that means no income for many of these people so how do they buy food? It is too unsafe to pop your head out your front gate let alone ‘take a quick trip to the market’. Getting enough for bus fare to leave is totally out of the question for the IDP’s who relied on the now closed Bakara market for their daily income. A woman in Mogadishu described it to me once as “if there is no market there is no work, if there is no work there is no money and if there is no money there is no food.” Now with the road blocks in the city even walking out is also becoming less of an option. Between poverty and insecurity they are trapped.

“No safe place in Mogadishu”

November 5th, 2007 by MSF Field Blog

Read MSF’s latest Press Release :

“No safe place in Mogadishu” – 05 November 2007

Plastic and sticks

October 27th, 2007 by tiranah

We are flying out today. It is two days earlier than our original plan, but we have managed to get everything we need to get done, and the political situation is getting increasingly tense with a split brewing between the President and the Prime Minister which increases the risk of political violence which would be in addition to the existing insecurity. Basically this would mean the Mogadishu becomes an even more difficult place to live in for the average person. But even when the international staff leave the clinic will continue, it is fully staffed by a skilled set of professionals, experienced doctors nurses and medical staff which keep the clinic open six days a week. The international team will be back soon, this in and out method is how MSF has to operate for now, not a preferred option but sadly the only option. But the team is managing more in than out, which makes MSFs approach to the delivery of humanitarian aid quite unique in Somalia. It is hard to work in Somalia, I think that is clear, but should not be considered impossible. You just have to look around, speak to people to see there is a desperate need for more direct assistance (not just medical) to people in Mogadishu.

On the way to the airport we manage to stop by the mobile clinic, this is a rarity that you are able to move somewhere beyond our accommodation and the clinic. By mobile clinic we are referring to a small minivan, with an MSF sticker stuck on the side filled with the relevant materials (it may not be pretty but it works) and then the team sets up a temporary facility to see children in the IDP camp. Today it is in an empty abandoned house in the camp compound. The camp is a typical Mogadishu IDP camp. It is crowded, and chaotic, small round tent like structures made of sticks and covered with layers of bed sheets, fabric, I think I even see a goat skin. These layers are patch worked across the rough wooden frame and most (but not all) have a piece of plastic sheeting which falls over the top, and that will hopefully make it waterproof to some degree. The ground is dirt and rubbish is scattered throughout. Some of the shelters have a small barrier of sticks around them (a kind of yard) where mothers sit on the ground with their babies, washing hangs all around.

There is a rather chaotic line of mothers with armfuls of children. Actually as you look around we notice you pretty much only see women, there are a few men, but certainly majority women. During our discussions some of the women say that majority of the women here are alone with children, the numbers vary but they say most of the women are either divorced, their husbands have left to find work outside of Mogadishu or some their husbands left because of the desperate situation, and they don’t know where they are. The social impact of years of violence is something we have not touched on, and is a longer discussion than there is time for today.

Lady, where do you think we can go?

October 26th, 2007 by tiranah

I was speaking to some of the women today and some of the staff about the In-Patient Department (IPD). They were telling us about their experience when the shelling occurs. A number of them look at me blankly when I ask if they left Mogadishu when the fighting was at it worst a few months ago. I am beginning to understand this look, it is something like… “lady where do you think we can go? It is not like we have spare change to just take the bus and go”… ok, so it is not their words, but sometimes I wonder if they think these questions are ridiculous. The answer is no, they didn’t move, they just moved into a building with a concrete roof that was in their camp as they knew the mortars would rip through their makeshift shelters. One of the staff who was working last Tuesday when there was fighting close to the clinic tells us of how all the women with their children in the In Patient Department scrambled across the compound to the Out Patient Department which is a larger more solid structure. I look up in the IPD, and see the tin roof, and can only imagine it would provide little protection from heavy artillery. At least the OPD has a concrete roof. It actually puts it into perspective. Even where MSF can try and assist, and offer some level of protection not even the clinic is safe from the level of violence that exists here right now.

Waking up with a boom!

October 25th, 2007 by tiranah

Woke up at 1am with a boom, but there were no sounds of firing so I went back to sleep. When we arrived at security meeting today there was only about half of the team present. I was told it was because there are checkpoints around town so it takes a little longer to get to work.

We have another meeting with Internally Displaced People (IDP) women this morning. They brought their children, who were really sweet, all malnourished to varying degrees, so after our discussion they were all able to go down in a consultation. It is a different conversation today, to what we heard the other day. That is why we met with two different communities, and it would be better if we could even meet with some more, but we have to strike a balance.

What is so encouraging today is that the head of the IDP camp who came to see the clinic on Thursday has hired a bus and sent a large group of women and children to the clinic today. There are 20 children from the camp in the Out-Patient Department (OPD) and the midwives just said there are dozens of women from the camp in the Ante-Natal Clinic (ANC), they have run out of room and women are sitting on the floor and waiting outside. This reinforces an important point. One on one contact is key to being able to get information to the most vulnerable and that if people have a positive experience in our clinic then they will encourage others to come and word will spread. Somalia has a very oral culture and we can see it in motion here.

One of the other things that come out of today is that we don’t have a full picture of how small the world is for the really poor. There are different types of displaced people in Mogadishu; actually the violence over the years has displaced nearly everyone at some point. It is those in the camps that are the most vulnerable of the most vulnerable. If you are an IDP living in one of these camps in Mogadishu, then you spend your days wondering and worrying not only about the security but also about how you are going to feed yourself and your children. The harder that is the smaller your world becomes. The more children you have to feed, the smaller your world becomes, it is near impossible for some of these people to lift there heads for a moment and think about finding out where there is a health care facility, or trying to keep your ear to the ground to work out when a new one opens. It reinforces the importance of a proactive approach to the work MSF does, and mobile clinics, which the teams are planning to visit the IDP camps are an excellent first step.

Tentative stability

October 23rd, 2007 by tiranah

Today is a slightly different day; it is Friday, which is the day off in Somalia. We head to the office but there are some skirmishes on the streets and we are advised to head back to our accommodation. So I am spending the day writing up a week of notes from the various interviews we have had. Today’s skirmishes are nothing like the other night, but serious enough to indicate that things are still not stable.

We have heard people have left Mogadishu or moved to the outskirts of central Mogadishu. It is reflecting in the numbers of people coming to the clinic, Fuad has said they have dropped slightly in the past weeks; it would make sense with the consistent exit of people from the surrounding neighbourhood. There was a large area, that people described to me as a slum, close to the clinic that was shelled quite badly a few weeks ago. As a result most of the people have fled the area and we have gone from seeing 88 patients from that area last month to only seeing 17 this month and we already at the 19th of the month. The people just could not stay anymore, it does not mean they still don’t need the assistance; it is just too unsafe for them to get to us. This is the reality of access to healthcare here.