Doctors Without Borders pullout: What will become of Somalia’s children?

Doctors Without Borders' decision to pull out of Somalia this week after 22 years of medical humanitarian work is sobering news for hundreds of thousands of Somalis who relied on the NGO for healthcare, but it could be particularly troubling for children.

The international group, also known as Médecins Sans Frontières (MSF), is withdrawing from the country in response to repeated violent attacks on staff members. It’s too soon to predict exactly how the move will affect children in Somalia, but the sheer volume of child-centered programs that MSF is shutting down leaves little doubt that they will suffer.

MSF runs the capital city’s only pediatric hospital, where — until this week — doctors operated a general ward, an inpatient feeding program and isolation units for measles and acute watery diarrhea. In addition to providing mobile healthcare, the NGO supported a maternity hospital in Jowhar and offered mother and child heath care, including nutrition and vaccinations, in a number of clinics across the country.

In 2012 alone, MSF cared for 31,000 children, administered 60,000 vaccines and delivered 10,300 babies.

“We are certain that our withdrawal will lead to huge gaps in the places were we were working until today,” said Dr. Unni Karunakara, MSF’s international president, during a press conference this week.

Research also suggests children bear the brunt of the burden when humanitarian aid providers flee.

Eighteen percent of the humanitarian aid workers in Darfur withdrew between 2006 and 2007, for example. When researchers at MICROCON analyzed the country’s death rates, they found that while violent deaths decreased during that time period, more children under 5 died of disease.

Already, Somalia has the second highest child mortality rate in the world. Nearly 20 percent of children die before they reach the age of 5. While many of its neighbors have dramatically improved child health in recent years, Somalia’s child death rate has not budged since 1990.

Somalia struggles to improve child health, in part, for the same reason MSF is leaving the country: conflict. Research shows children who live in war-torn areas are more likely to be malnourished and catch infectious diseases. 

Aid workers on the ground in Somalia, who asked not to be identified for security reasons, said 20 years of widespread instability has resulted in a “gaping lack of basic services” that is “eroding the health and wellbeing of Somalia’s children.”

The country leans heavily on international NGOs to provide healthcare, but at the same time, foreign health workers often find themselves caught in the middle of the fight. Since 1991, MSF reported, 16 staff members have been killed. In 2011, the Islamic extremist group al-Shabaab accused 16 aid agencies, including the UN Children’s Fund and the World Health Organization, of “illicit activities and misconduct” and banned them from the country.

"The state of child health in Somalia is one of the worst in the whole world,” Somalian health minister Maryan Oasim Ahmed told Associated Press earlier this year, after accusing al-Shabaab of creating a hostile environment for aid workers. “The children of Somalia are dying from diseases that don't exist in the rest of the world."

International NGOs work together to fill in the service gaps in the country’s crippled public health system. For example, the Somali Red Crescent Society has health clinics and mobile health teams that can treat children suffering from simple cases of severe acute malnutrition, said Ewan Watson, a spokesman for the International Committee of the Red Cross (ICRC), Somali Red Crescent Society’s parent organization. But, if there were any complications, they asked MSF doctors to take over.

“Complicated cases were referred to MSF until now, so clearly there will be an impact on child health arising from that,” Watson said. The ICRC — along with a number of other NGOs that similarly relied on MSF — is now scrambling to find another way to care for the sickest children.

Things have improved since the 2011 famine, but more than one million people are still living in a state of crisis. An estimated 215,000 Somali children are acutely malnourished. The problem is no longer a shortage of food, aid workers said. The problem is access. Because of security issues, it’s difficult — if not impossible — for NGOs to reach the children most in need of services.

Somalia is also in the midst of a polio outbreak that the UN Office for the Coordination of Humanitarian Affairs (OCHA) has labled "the worst in the world in a non-endemic country." Although the nation was declared polio-free six years ago, OCHA reported Friday that at least 105 cases have been confirmed since April.

The country has the second worst polio vaccination rate in the world, according to the World Health Organization. Getting drugs to the more than 600,000 children in south and central Somalia, which are partly controlled by al-Shabaab, is "extremely challenging," according to OCHA, and the inability to access the area constitute a "major threat to the control of the outbreak." Even in areas where al-Shabaab has been pushed out, some parents are still heeding the rebel groups’ warnings that vaccines caused AIDS or infertility and refused to get their children inoculated.

MSF’s Dr. Karunakara declined to discuss how the NGO's withdrawal might affect the campaign to fight polio in Somalia. But he said MSF planned to do “whatever it takes” to withdraw responsibly.

“The sad fact is that in many places people will be left with no care at all,” he said. “No access to healthcare at all. And that is a sad reality in Somalia today.”