Research Article: Consequences of Ongoing Civil Conflict in Somalia: Evidence for Public Health Responses

Date Published: August 11, 2009

Publisher: Public Library of Science

Author(s): Debarati Guha-Sapir, Ruwan Ratnayake

Abstract: Debarati Guha-Sapir and Ruwan Ratnayake use field data to demonstrate the severe vulnerability faced by much of the Somalian population due to ongoing conflict, and call for concerted public health interventions and access to food aid especially in southern Somalia.

Partial Text: Recurrent civil conflict has blocked progress toward improving health in Somalia. Violent power struggles between political factions followed the breakdown of the government in 1991. Large numbers of civilians were displaced and warlords diverted food aid. In response, a United States-led military intervention attempted to facilitate access for humanitarian relief. While armed forces clashed in Mogadishu, food distribution was disrupted and famine continued in the south. United Nations (UN) peacekeepers followed but were unable to restore order. Of the ensuing period, Alex de Waal wrote that “centralized political authority has never reemerged” [1].

A little over a million people have been internally displaced since fighting resumed in 2006. The Food Security Analysis Unit of Somalia (FSAU) closely monitors livelihoods, and estimates 3.25 million in need of the most basic emergency food aid [5], a 77% increase since early 2008. The UN’s Consolidated Appeal Process is now seeking assistance for nearly half of the population [6]. While the world’s media has focused on the rampant piracy in the Gulf of Aden where oil tankers are seized, basic food aid is in danger of diversion every day. During August 2008 when sea escort for the World Food Program was unavailable, only 9,500 of the required 30,000 metric tons of food aid were delivered, causing major delays and impacting over one million persons [7]. Further threats of crop failure, drought, flooding, and escalating food prices are omnipresent.

The absence of central governance means that vital registration systems have ceased to exist. Nevertheless, the scale of the conflict’s impact on civilians must be monitored in order to identify where humanitarian needs are most pressing. UNICEF’s national survey of 2005 highlights the dangers already faced by children with a demographic mortality rate of 135 deaths per 1,000 children under the age of five years [8]. This is well above rates in neighboring Ethiopia and Kenya. With only 29% of Somali children under two years of age immunized against measles, this is no small wonder.

For mortality results with respect to time, we charted death rates among three regions (southern, central, and other regions) and noted the eruption of intense fighting in early 2006 (Figures 1 [CDR] and 2 [U5DR]). Comparisons of death rates over time from the conflict-affected south (defined as the region south of Galgadud and identified by the points in red) and comparatively stable center and north raise alarm (yellow and green points respectively). Since the onset of fighting, there has been a surge in mortality rates above the commonly used thresholds for a crisis situation of 1/10,000/day (CDR) and 2/10,000/day (U5DR), reflecting a critical health situation (encircled). In regions less affected by frequent conflict in the center and north, mortality rates have remained poor or acceptable but have come close to reaching emergency thresholds.

Survey respondents in the Shabelle and Gedo regions reported that killings or physical injuries were a leading cause of death for CDR estimates above the crisis threshold. Reports noted that this influx of violent deaths coincided with episodes of violence in Mogadishu and internal displacement to these southern regions. However, in other regions and time periods, malnutrition, preventable disease, and birth complications predominated as the main reported causes of child and adult deaths. These are well-known symptoms of poorly functioning health, public health, water, and sanitation systems; mass displacement; and ruptures in the food supply. Most of the population depends on food aid, health systems are localized with little central authority, and there is a vacuum of primary health care workers [12]. A widespread epidemic of clinically diagnosed acute watery diarrhea/cholera across the center and south throughout 2007 and 2008 is further proof of the need to reinforce basic systems [13].

Concise overviews of field survey data can be used as quantitative evidence to identify priorities for the humanitarian response and to monitor the impact of operations. The populations most in need of relief are clearly pooled around specific regions in the south. However, a key determinant of the magnitude of need has been the restrictions on humanitarian access in this region. While aid would be more effective if targeted toward these populations, safe and unhindered humanitarian access has been elusive.