Cablegate: Somalia Humanitarian Update - Health In

DE RUEHNR #2214/01 1440629
R 240629Z MAY 07






E.O. 12958: N/A

REF: A) Nairobi 02007

NAIROBI 00002214 001.2 OF 003

1. Summary: Despite years of chaos, insecurity and
absence of a functioning Ministry of Health, Mogadishu
continues to benefit from a serviceable, if limited,
health system for those with sufficient resources to
access it. Despite significant challenges, such as
heavy fighting, limited access, and the withdrawal of
international staff, health facilities were able to
provide emergency services in response to the recent
cholera and conflict emergencies. UN agencies and non-
governmental organizations supplemented local health
facilities during the crisis period through the
provision of supplies and, in some cases, staff.
Ongoing challenges to the health sector include a
limited pool of qualified technical staff and continued
insecurity. End summary.


2. Five non-governmental organizations (NGOs) and
three UN agencies are currently providing emergency
health services in Mogadishu. Emergency health
facilities and services include three mobile health
teams, two cholera treatment centers, two maternal and
child health centers, two out-patient departments,
support for two surgical referral hospitals, and
essential medicine and supplies, such as oral
rehydration treatment.

3. Due to ongoing insecurity, most humanitarian
agencies have prohibited international staff from
traveling to Mogadishu. The one exception is the
International Committee of the Red Cross (ICRC), which
sent an international surgical team to assist at the
Keysaney Hospital. Well-trained national staff are
currently managing most emergency health programs;
however, agencies agree that additional oversight and
supervision are required.

4. During periods of intense fighting in Mogadishu,
health services were limited due to restricted
movements in the city. Several health facilities
reported that national staff were unable to open
clinics or staff hospitals for fear of getting caught
in the fighting. At the same time, many people in need
of health care were also unable to access facilities
due to the heavy fighting.

5. In addition to emergency health services, Mogadishu
residents benefit from several public and private
health facilities. According to the UN World Health
Organization (WHO) and UN Children's Fund (UNICEF),
health services in the capital are significantly better
than in the rest of southern and central Somalia. WHO
reports that there are 56 medically certified doctors
in Mogadishu working at 28 health facilities, including
hospitals, clinics, and maternal and child health
centers. Of the 56 physicians, only 14 work in public
or NGO-managed facilities while the remaining 42
practice in Mogadishu's thriving private health sector.
Only two of the city's 24 hospitals are public and
provide health care at minimal cost. Additionally,
there are reports of Muslim charities providing medical
assistance and supplies in Mogadishu; however, accurate
information regarding the staffing or treatment
capacity of these facilities is unavailable from the UN
and other sources.

6. Health agencies cite an increasing concern for the
future availability of trained, qualified health care
providers. Most of the currently employed health care
staff, including nurses, laboratory and x-ray
technicians, and support staff were educated prior to
the collapse of all formal training institutions nearly
two decades ago. Without formal technical educational
programs functioning in Somalia since the early 1990s,
the availability of qualified health staff is virtually
non-existent in Somalia today. Many of those currently
employed were trained through informal and on-the-job

NAIROBI 00002214 002.2 OF 003

initiatives of the UN and NGOs. The Joint Needs
Assessment in Somalia, funded by the World Bank in
2006, identified the lack of a technically capable pool
of health care providers as one of the greatest
challenges faced by the health sector country-wide for
the foreseeable future.



7. An outbreak of acute watery diarrhea (AWD) surfaced
in Hiran Region north of Mogadishu in early January and
has spread throughout south and central Somalia
affecting more than 30,200 people, according to WHO.
Health facilities in Mogadishu began diagnosing cases
of AWD and laboratories confirmed the presence of the
cholera bacterium in early March. A steady increase in
new cases was reported through mid-April. WHO reports
that nearly 12,000 cases, representing 40 percent of
all cases, and 161 related deaths were reported in
Mogadishu between January 1 and May 11. Although
Mogadishu reported the most cases of all Somali
regions, the overall case fatality rate of 1.35 percent
was well below the national average of 3.2 percent.

8. As fighting escalated in Mogadishu in April,
thousands of people fled the city and health facilities
suspended or limited activities. As reported reftel,
the number of new cases reported in Mogadishu dropped
dramatically in the second half of April. WHO
cautioned that the sharp decrease was not a sign of
improving conditions but rather a result of limited
reporting from health agencies and the outflow of
people from the city. As access and security improved
in May, health facilities resumed reporting into WHO's
surveillance system. The initial trend of decreasing
cases continued into early May.

9. Humanitarian agencies are responding to the
outbreak through prevention and treatment activities.
A cholera task force meets regularly to coordinate
response operations. Action Contre la Faim (ACF) and
Medecins Sans Frontieres-Spain (MSF/S) manage two
cholera treatment centers; ICRC and the Somali Red
Crescent Society (SRCS) run five temporary rehydration
treatment centers; Muslim Aid/UK operates four mobile
teams throughout the city; and WHO and UNICEF are
providing essential medical supplies and drugs to
health facilities. In addition, UNICEF and partners
are increasing access to safe water through
chlorination activities at the water source and
household levels.

10. The treatment of cholera in Somalia is complicated
by strong cultural beliefs that the only effective
treatment for acute diarrhea is with intravenous
fluids. Many people do not appreciate the value of
using oral rehydration salts and large volumes of oral
fluids in the early stages, but wait until severe
dehydration occurs, making recovery even more difficult.
Health education messages on hydration and water
treatment are critical adjuncts to cholera treatment.
WHO has been taking the lead on health education
programs in the media, but has been limited by the
recent insecurity.


11. Fighting in and around Mogadishu, including
indiscriminate mortar and rocket-propelled grenade
attacks, resulted in civilian injuries and deaths.
More than 2,250 people received treatment for weapon
wounds in Mogadishu between January and May, according
to ICRC.

12. The Medina Hospital, run by SRCS and supported by
ICRC, has the capacity to accommodate 67 in-patients.
However, at the height of the fighting in Mogadishu in
April, the hospital admitted more than 200 patients by

NAIROBI 00002214 003.2 OF 003

increasing beds per room, setting up beds in the
hallways, and erecting tents in the outside garden.

13. ICRC provides Keysaney and Medina surgical referral
hospitals with monthly consignments of surgical and other
supplies, salaries for staff, and support for maintenance.
In addition, ICRC is enhancing the capacity of the
hospitals' local staff through technical and medical
training. ICRC has deployed a cadre of international staff
to Mogadishu to assist overworked local surgeons to treat
the high volume of war-wounded. ICRC also supports other
medical facilities treating war-wounded patients on an
ad hoc basis.


14. In FY 2007, USAID's Office of US Foreign Disaster
Assistance (OFDA) has provided more than USD 5.6
million to UNICEF and WHO to carry out health,
nutrition, water, sanitation, and hygiene activities in
throughout Somalia. OFDA is supporting WHO to
coordinate emergency preparedness and response
mechanisms in southern and central Somalia, with a
particular focus on Mogadishu. This includes
coordinating the provision of health kits, cholera
kits, and essential medicines for clinics, cholera
treatment centers and laboratories. WHO also provides
technical staff who assist in direct health care
services and the training of local counterparts.

15. USAID/OFDA is supporting UNICEF to implement
water, sanitation, and hygiene programs in Mogadishu
and surrounding regions. UNICEF is providing safe
water, water purification equipment, water storage
supplies, and other non-food items for people displaced
both in Mogadishu and in other regions in southern and
central Somalia. UNICEF is supporting the health
sector through the distribution of health kits for
maternal and child health clinics and mobile health
service programs. With OFDA support, UNICEF is also
addressing the nutritional needs of underweight
children under five years of age, as well as lactating
and pregnant women in conflict-affected areas.


16. Compared to other urban centers in Africa, the
situation in Mogadishu is far from adequate. However,
health services are distinctly better in Mogadishu than
in areas outside of the capital. While national staffs
provide most of the hands on treatment, international
staff provide essential supervision, monitoring of
treatment protocols, and guide appropriate treatment
interventions when needed. The continued commitment
from international health organizations and the
dedication of the national staff allowed health
facilities to respond adequately to recent crisis
conditions. Long-term support to the health sector is
needed not only in Mogadishu, but throughout the country.


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