Interview with doctor back from Liben In early 2011, there were some 40,000 Somali refugees in Ethiopia. By the end of 2011, that number had more than tripled, to 142,000. This mass exodus has been triggered by a drought that is killing crops and herds in a country already dealing with a 20-year violent conflict, a conflict that seems far from receding. The massive number of refugees on its own does not reveal much about the days, even weeks, many Somalis spend walking to reach and cross the border into Ethiopia, with barely any food or water. It does not tell about the dire malnutrition affecting the children in the refugee camps, it doesn’t express the effort made by humanitarian agencies to reduce hunger and exclusion. In this interview, José Luis Dvorzak, a physician who has worked with Médecins Sans Frontières (MSF) in Liben, explains there is still a long way to go to help a population hit by chronic malnutrition, people whose options to return to war-torn Somalia are limited. You have worked as a doctor at different times in the past two years in the Liben camps. Can you tell us a bit about the camps? I first arrived in June of 2010. There were three international workers and 35 Ethiopian employees. We carried out nutritional activities in the two camps, in Bokolmayo and Malkadida (where 40,000 refugees live) and in the Dolo Ado Health Centre. The second time I arrived in September 2011, I saw an enormous change: we had 50 international workers and more than 800 Ethiopian employees. By then, new camps had been opened, Kobe and Hiloweyn – sheltering 25,000 new refugees each. People had arrived from Somalia in the worst shape, resulting in very high mortality rates. At one point there were up to 13,000 people admitted in our feeding programs. In September, after months conducting a nutritional intervention, we managed to reduce mortality to levels below the emergency threshold.

Ethiopia © Samuel Hauenstein Swan
At the MSF health centre in Hiloweyn camp in Liben, a staff member teaches the mother of a severe acutely malnourished child how to supplement her breast milk by inserting a tube into the baby’s mouth while breast feeding.

How would you describe the medical situation endured by people in the camps at present? We still have children admitted in our stabilization centres suffering from severe malnutrition complicated with other diseases such as pneumonia or diarrhea. We see some 45 kids weekly in the centre (during the emergency peak this figure was consistently more than 150). The most common health issues for people in general are respiratory infections, diarrhea, intestinal parasites and skin diseases. Currently, we are also implementing mental health and epidemiological surveillance programs using community health workers. What are the challenges of working in Liben? People’s health is precarious. After a 20-year civil conflict in Somalia, where public health structures in the country are scarce or have been destroyed, people are not used to using medical services. What is the impact of this on the overall health condition of the population? We have gone from an emergency nutritional crisis situation to a chronic one. The situation in the camps does not make it easy for the people to cook their own food: women need to go to the bush for firewood, running the risk of being attacked on the way. In other cases, the standardized food they receive, with the nutritional intake they need, is rejected and sold in the markets to buy food stuffs closer to what they traditionally eat but lacking the most essential nutrients. Changing these habits is not easy and it requires much discussion, explaining and understanding. Global malnutrition levels were already high before the emergency context and they skyrocketed with the enormous flow of new arrivals from May to October. How did you manage to improve people’s health and reduce mortality rates to below the emergency threshold? Once the new camps were full and no new arrivals were being admitted, the tasks were to provide food, monitor severe malnutrition in children and conduct epidemiological surveillance activities to respond to eventual outbreaks. In Kobe, which was housing 25,000 refugees and registering mortality rates far exceeding the emergency threshold of one death per 10,000 people a day, we had to fight a measles epidemic (a disease that combined with malnutrition can be fatal) and organize a mass vaccination campaign targeting children under 15 years of age. What is the situation like now in Liben? We are undergoing a stabilization phase. The authorities have handed over part of our activities to other actors while MSF is still managing stabilization centres for children in critical condition in three out of the five camps. However, we are still concerned with people’s nutritional situation. There is still so much to improve in terms of nutrition. In reference to the drought, there has been some rain in Somalia. Do the refugees want to return?   Some want to return and in fact some are returning despite the war. They go back to benefit from the recent rainfall and to try and make a new life for themselves. Nevertheless, there are still new arrivals, about 70 a day on average – far from those 23,000 a month registered last year, but they are still coming.

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