On a bed in the field hospital run by Médecins Sans Frontières (MSF), an emaciated child, barely more than a stick figure, reaches out shakily to its mother's back for support. But the mother is sitting on the edge of the bed with her back to the child, staring into space. She does not turn around.
In the next bed, another refugee, Khadija, holds her 10-month-old son. They are doing slightly better, although the child is so thin he barely looks human, but things have stabilised now, she says. Her son became ill during the trek from Somalia, 17 days on foot, with little food or water. They made the journey after all her family's animals died.
The famine in Somalia that has sent a tide of refugees into the Dadaab refugee camps 100 km across the border in Kenya has recently drawn international attention, but in fact the problem has been building for years, and reached a crucial point months ago.
The current drought, the worst in 60 years, was forecast in 2010. By April, 2011, there was a huge increase in the number of refugees piling up on the outskirts of the already overcrowded camps, said Edward Chege, the medical director of the MSF hospital. MSF and others warned the international community that the situation for the new arrivals was reaching a critical point, because the people on the outskirts were receiving insufficient water, sanitation, medical care, or shelter. But the response "was inadequate," said Chege. The number of children receiving therapeutic feeding in the MSF hospital increased from 20 in January this year to more than 130 by July.
The grim situation in the tent hospital in the Dagahaley camp, one of the three camps that make up the Dadaab refugee complex, is not expected to get better any time soon. According to a report on Aug 4 by the US Government's famine alert agency, FEWSNET, the "current humanitarian response is inadequate to meet emergency needs," and the famine is expected to spread throughout southern Somalia in the coming weeks. A total of 3·7 million people are considered to be food insecure, and most of these are in need of "immediate, lifesaving assistance." More than 390 000 children are estimated to be acutely malnourished, nearly half of them severely. The agency has called for "extraordinary measures" to deal with the crisis.
On Aug 5, WHO warned of a high risk of disease outbreaks in the drought-affected areas because of poor sanitation, a lack of clean water, overcrowding in the refugee camps, and the weakened immune systems of malnourished children. 4000 cases of acute watery diarrhoea are a major concern, according to WHO officials, both on their own and because they indicate the potential for a cholera outbreak. So far, there have been outbreaks of both visceral leishmaniasis and measles, with more than 17 500 cases of measles reported.
The Dadaab camps are receiving an average of 1300 people a day. 6 months earlier the camps were receiving about 10 000 a month, which was already double the average in 2010. Ethiopia is also receiving refugees from Somalia, of which one in three children is acutely malnourished.
Predictable disaster
The conflict in Somalia has dragged on since 1991, and according to UN estimates violence and drought now affects nearly half the country's population. A UN briefing document early this month warned that the famine in southern Somalia "could quickly spread across the country and may affect other areas of the Horn of Africa if not addressed through rapid action."
The current situation was a long time in coming. The drought chipped away at people's livestock, even as most people, very poor and with few options, held on as long as they could. But the failure of the rains in April and May finished off the livestock for many, and whole villages were abandoned as people were forced to flee with literally nothing left to eat.
The severity of the crisis is underlined by the fact that large numbers of children older than 5 years are malnourished. The UN is going to start therapeutic feeding programmes for these children as well as the younger children, which is highly unusual.
In July, nutrition screening in Ifo, one of the three camps that makes up the Dadaab complex, found a global acute malnutrition rate of 29% and a severe malnutrition rate of 6·9%. The rate is far worse in the outskirts—about 15% of children are severely malnourished, according to MSF.
Health services are overwhelmed. The mortality rate for children younger than 5 years has increased. In the Ifo camp, the rate went from 1·2 deaths per 1000 children a month to 1·8 per 1000.
Relief workers on the ground expressed frustration at the laggard response by the international community, which had ignored the festering problems for years. Already, by January this year, the number of refugees arriving into Kenya had doubled from the previous year to 10 000 a month. With more funding, relief agencies could have hired more staff, prepared food and shelter, and set up intake centres closer to the Somali border, say agency officials. Cash transfers within Somalia itself could also have made a big impact and alleviated the current mass exodus, said famine analysts.
By March of this year, UN World Food Programme chief Josette Sheeran announced a US$36 million shortfall to feed 1·2 million people in Somalia, warning that "we have already reduced the size of rations for vulnerable groups including the displaced in Mogadishu because of the shortfalls."
Conditions are particularly bad in the outskirts of the official camps, where more than 70 000 refugees have been forced to set up makeshift housing ever since the overcrowded camps were closed to new entrants in 2008 (see webvideo). On the outskirts of the Ifo camp, there are 300 latrines shared by 20 000 people—and of those, 100 are full, according to Alexandre Izart, field coordinator for MSF. He warns that the area where people are living in the Ifo outskirts is a floodplain, meaning that rain could easily cause the latrines to flood, which would be an ideal breeding ground for infectious diseases such as cholera. Even drinking water is hard to come by in the outskirts, said Izart: "sometimes it will take people 7 hours to get water."
A new initiative to move the refugees stuck on the outskirts to new camps should relieve some of the pressure. In fact, a brand new camp had been ready since last year, but political squabbles with Kenyan authorities had prevented its opening, despite the desperate overcrowding. The recent spate of media attention has now broken the logjam, but even so it will be at least until November before the UN's refugee agency, UNHCR, can relocate a planned 180 000 people to new camps.
"We are very aware that we are not responding to the needs as fast as we should be," said UNHCR spokesman William Spindler. He said that the agency is badly overstretched both because of the volume of the new refugees and because the health of the new arrivals is exceptionally poor. The slow response of donors to the crisis has made matters worse, he said. "Our pleas for help were not being listened to. We have been warning about this situation for many years now."
Meanwhile, new arrivals keep coming from Somalia. The current backlog of people waiting to be registered is 30 000, and registrations could take up to a month. Until then, people have to exist on temporary rations and fend for themselves in the outskirts.
Contrary to popular perception, much of the problem in Somalia is not always due to a lack of food, but rather its high price and the inability of the population to afford it. The prices of local grains have risen more than 300% in several areas. Rice is actually available in many markets throughout the country, but is even more expensive, according to international famine monitors.
That dynamic, a problem of poverty and price rather than simply an absence of food, means that relief agencies are now considering trying to get people in Somalia cash, so that they can buy food in local markets. It could potentially be more widespread, more effective, and ultimately more stabilising than airlifts of food currently taking place, which are inefficient, expensive, and have a limited scope.
Meanwhile, "People are one by one falling into poverty, losing their assets, and becoming dependent on food aid," said the World Food Programme's Pippa Bradford.
Beyond the refugee crisis
Attention has been focused on the plight of people fleeing the conflict in Somalia in the Horn of Africa crisis. But the total number of people affected by the drought in the region is about 12 million, and only about a third of those are fleeing war-torn Somalia. The rest are in places like Wajir, a northern province of Kenya that is rural and poor. There is no war here, just hunger, brought on by a cruel mix of poverty, lack of infrastructure, climate change, and skyrocketing food and fuel prices. A tepid response by Kenyan Government and international donors has made things worse.
Mohamed Hassan, one of three doctors at the Wajir District Hospital, said that the chaotic response to the drought has been frustrating. "We should have a proper programme in place so that at times like this we deliver food stuff predictably, along with other basic needs."
The drought has forced herders to search further and further away for pasture and water—many herders are even taking their animals to Somalia. But those long journeys, of hundreds of kilometres, often wipe out a substantial portion of the animals on which people's livelihoods are based.
The carcasses of cows, camels, and goats line the roads, some of them with plastic bags exposed in their intestines—the refuse was all the starving animals could find to eat. At a watering hole, where a herder had just walked 3 days with his flock on the way back from Somalia, one camel leaning down to drink the brackish water had a hump that sagged off to the side of its back, lying flaccid like a deflated balloon, a sign of the animal's depleted condition.
Lucy Gitonga, a nutritionist at the district hospital in Wajir said she started seeing problems in February this year. By June, the clinic had become jammed with 30 severely malnourished children with complications, including diarrhoea, malaria, pneumonia, and generalised oedema. She says the children are discharged and then sometimes come back as their problems re-occur. She suspects this happens because the therapeutic foods that the children are sent home with often get shared between the entire family.
The children come from all across Wajir, in some cases travelling 7 h by car. Gitonga said she has never seen such high numbers of starving children: "In fact, I am surprised, I'm very surprised. And the numbers are increasing." Normally, at this time the number of severely malnourished children would be about ten, she said. Gitonga said that she is even seeing malnutrition in adults, which is normally quite rare.
In one bed, 28-year-old Idhey Sheikh is holding her 2-year-old son Mohamed Ibrahim. At 8·3 kg, he is painfully thin (he should be 11·9 kg). His skin is discoloured, and he suffers from oedema and pneumonia. Sheikh said that her family, a husband and three other children, had lost their animals in the drought, and now they are dependent on handouts from relatives to survive.
According to the US Government's famine monitoring agency, 1·2 million people in Kenya "are unable to meet basic needs because their livelihoods can no longer support household food security" and 2 million more are approaching this state, currently classified as being in "crisis."
The drought is not a sudden occurrence that has caught people unawares—it has been dragging on for the last two seasons. That means that people's already precarious livelihoods are degraded, as their animals die, their savings are used up, and their children are undernourished for prolonged periods. The drought here is worse than it has been in the past, more unpredictable, and longer—"the seasons have become confused," as one woman put it. But the underlying issues that are causing the current crisis—poverty, lack of infrastructure, climate change, and poor services—are well known, including to US President Barack Obama, who visited the region during a drought in 2006.
Unfortunately, that awareness did not translate into swift, broad action. Although the response of international donors and the Kenyan Government is now picking up, as images of emaciated children blanket the airwaves, relief workers say that the response so far by the Kenyan Government and international donors has been insufficient to meet the extent of the crisis. "As usual in disasters, the government did too late, too little," said Abdifatah Yare, an aid worker with WASDA, a local non-governmental organisation (NGO).
There was a lot that could have been done. Like most of northern Kenya, the village of Hassan Yarrow has been hit hard by the drought. It is a collection of grass and stick huts in a flat, arid landscape. Life here feels slow and somewhat empty, as if something is missing—and it is. Many of the animals that provide the community's livelihood have perished. The remaining animals and the men that care for them are gone, seeking pastures and water, forced to range dozens of kilometres beyond their normal feeding grounds.
52-year-old Habiba Mohamed is a widow and mother of ten children. She said that since April, the drought has whittled her herd of goats down from 200 to only 20. The previous year's droughts had already weakened the animals' health, she said. Her family has very little access to milk and that has affected the children's health. Influenza and diarrhoea are now common, she said. But getting to the hospital in Wajir is difficult—a whole day's journey by donkey cart.
The family had been benefiting from a scheme funded by the European Union to provide vouchers for staple foods, which she said was better than traditional food aid because she had control of the amounts and timing of when she would access the food. It also cut down on the corruption and theft that occurs in a normal food distribution, said Mohamed. The vouchers also give the family stability, allowing the women and children to stay in the village while the men range with the animals seeking new pastures. Unfortunately, the vouchers have not come recently, she does not know why.
The limited amounts of food aid available also mean that feeding programmes for malnourished children are being undermined. In recent years, aid programmes have given food not only to malnourished children younger than 5 years, but also to the entire family, since the food usually ends up getting shared anyway. But that requires sufficient funding for food, which Wajir does not have. Mathias Wamoto, a nurse based in the village of Kursin, says that more than 30% of the 1500 children younger than 5 years in his area are malnourished. He says that the special foods small children receive end up being shared by the entire family. The result is that the most undernourished children are not getting the help that they need: "so the cure rate at the moment is zero."
Five children a month are dying of malnutrition, he said, and that does not count the many more who never make it to the hospital.
Early assistance by the central Kenyan Government was not sufficient, said Kennedy Nyaiyo, the district commissioner for Wajir's eastern section, which has 600 000 people. In February, it seemed like they would need to provide food assistance for 60% of the population, if the May rains did not arrive. They did not, but so far they have only received food to sufficiently feed 30% of the population, he said. "The situation is getting worse every day."
The future
There are signs of progress in some places, but so far they have been on too small a scale to make a big difference. In the Moyale region of Kenya, for instance, drought mitigation strategies promoted by the European Commission (EC) have led to malnutrition rates that are half of what they are in neighbouring districts. "Where we spent this money, you can see the results," said Kristalina Georgieva, the EC's commissioner for International Cooperation, Humanitarian Aid and Crisis response. There is "no question that the best way to build resilience is development," she said.
Unfortunately, the amounts put toward long-term development and infrastructure have not been sufficient to prevent the current crisis, which was anticipated by international agencies and the Kenyan Government in autumn, 2010. In 2011, the EC provided €20 million for drought mitigation, preparedness, and nutritional programmes.
But the scope of the crisis far exceeds the amounts of funds and resources being directed to address it. An estimated 3·5 million people in northern and eastern Kenya are "extremely food insecure", according to international assessments. Those most affected are pastoral communities, overwhelmingly poor people who have no buffer for the two seasons of drought, inflation of 12%, and skyrocketing food and fuel prices of more than 200%. These regions, home to many ethnic Somalis with little political power, have long been neglected by the central government in Nairobi. They lack basic infrastructure, from water to roads, toilets to hospitals.
Aid groups say that in addition to more food aid, the government and donors could have made a big difference if they had dug emergency borehole wells for use during the drought, as well as increased support for child and animal health. In the long term, the biggest help would come from better basic infrastructure, particularly a good road that would connect the northern provinces to Nairobi. This would serve to give pastoralists a market for their animals and would lower the price of importing goods (the cost of fuel is nearly 50% higher in Wajir than it is in Nairobi).
Currently, plans are underway to build a new highway, according to the Kenyan Government. It will be built by the Chinese. As Abdirizak Adow Adan of the Arid Lands Development Focus, a local NGO that works with Oxfam, notes, an overall economic boost would do more for giving the communities here resistance to drought than one-off feeding and health programmes.
