For years, Somalia has been a byword for anarchic violence, famine, and drought. It is depicted as an inhospitable, ungovernable country ripped apart by long-standing internal feuds and, more recently, as a harbor for terrorism and piracy. Yet not only is this portrayal superficial, but paradoxically it has served to obscure both the nature and severity of the current crisis. The unmitigated disaster that Somalis have experienced in the past two years is not just another episode of the country’s troubled history; it is the result of a particularly brutal and escalating war spawned by the clash of national, regional, and international political agendas.

In December 2006, the Ethiopian army, citing national security concerns, pushed deep into Somalia to oust the Islamic Courts Union (ICU)—a multi-faceted political and military movement displaying the diverse characteristics of contemporary political Islam—that had established various degrees of relative stability in south-central Somalia, including the capital Mogadishu. On the coattails of Ethiopia’s rout of ICU militias, the Somalia Transitional Federal Government (TFG), established under UN auspices in 2004 in Kenya, was installed in Mogadishu. Supported by the United States in the name of counter-terrorism, the Ethiopian-led regime change was welcomed on January 5, 2007 by the United Nations (UN), the European Union (EU), the African Union (AU), and the League of Arab States as “an historic opportunity for the Somali people to reach sustainable political solutions.”

Yet almost immediately, an armed insurrection led by former ICU supporters started to intensify, followed by counter-insurgency operations carried out by TFG and Ethiopian forces. A fierce, rapidly escalating war was launched, leading to catastrophic consequences for an already exhausted population. Mogadishu was further destroyed, with thousands killed and injured by the fighting, while hundreds of thousands were forcibly displaced only to face dire conditions in makeshift camps.

As a humanitarian organization, Doctors Without Borders/Mйdecins Sans Frontiиres (MSF) has no legitimacy to comment on the rationale for using military force in Somalia or elsewhere. Neither are we in a position to pass judgment on the relevance of decisions by the United Nations Security Council or other international players to support one belligerent or another. Our concern lies only with the manner in which conflicts are conducted and with their impact both on civilian populations and our ability to assist them. In that regard, not only has internationally-sponsored regime change led to the ratcheting up of unbridled warfare, including crimes that Amnesty International and Human Rights Watch have thoroughly documented, but it has also been supported by international governments and institutions in a way that has made it more difficult for humanitarian aid organizations, confronted with mounting security threats including targeted attacks, to help an increasingly beleaguered Somali population.

A Humanitarian Catastrophe

Since the overthrow of Siad Barre’s regime in January 1991, Somalis have periodically experienced severe hardship as a result of war and political instability, none more dramatic than the famine of 1991-1992 that cost hundreds of thousands of lives. While regional islands of stability have emerged since, mainly in the northern part of the country, and while intensive, unregulated trade since the mid-1990s has generated significant economic activity, the socio-economic, educational, health, and nutritional status of a majority of Somalis has remained poor. Socio-economic surveys conducted by the United Nations Development Program (UNDP) and the World Bank estimate infant and maternal mortality to be among the worst in the world.

This already precarious situation deteriorated further from December 2006 onward. It is difficult to ascertain the precise magnitude and extent of the crisis, as surveillance systems able to provide accurate population figures, mortality, morbidity, and malnutrition rates are nearly non-existent due to security constraints. However, field observations from MSF health facilities point to an ever-worsening situation, specifically in south-central Somalia, which is not only the most populated region but also the one most affected by current violence and instability.

In Mogadishu, the epicenter of the armed conflict, military operations carried out in densely populated areas without any regard for civilians are causing a high number of casualties and war-wounded. Between January and July 2008, the three surgical wards supported by the International Committee of the Red Cross (ICRC) and MSF in Mogadishu admitted 2,210 war wounded, an average of 300 a month. Women and children under fourteen accounted for 50 percent of the 500 war-related trauma cases operated on in MSF’s facility. These figures, though, only represent a small percentage of the injured as access of patients to hospitals is limited by extreme insecurity.

While health care has been insufficient in quality, quantity, and accessibility for years, in Mogadishu the situation further worsened with the intensification of the war. Out of the twenty functional inpatient facilities identified by MSF in January 2007, many of them privately-run hospitals that had been established in previous years, only six remained open nine months later. The number of health care professionals remaining in the city is dramatically low and far from sufficient for meeting even basic medical needs.

The intense fighting in Mogadishu has also generated the forced displacement of around 400,000 people (one third of the capital’s population) for the relative safety of its outskirts, particularly the Afgooye corridor and Daynile. Tens of thousands have fled further afield to towns in the interior of the country such as Beledweyne or Galcayo, often running a gauntlet of militia checkpoints along the way. The UN estimates that 870,000 Somalis have been displaced since January 2007.

The conditions in the makeshift displaced persons’ camps that have sprung up along Mogadishu’s periphery are nothing short of appalling. Emergency assistance has been far below public health minimum requirements to prevent a rise in mortality, with no measles vaccination, erratic general food distribution, insufficient provision of safe drinking water, poor sanitation, inadequate nutritional and health care coverage, and limited availability of shelter materials. An MSF retrospective survey conducted in November 2007 in Hawa Abdi, a camp housing some 32,000 internally displaced persons (IDPs) at the time, indicated an alarming mortality rate among children under five of 4.2 deaths per 10,000 people per day and a global mortality rate of 2.3 deaths per 10,000 people per day. Both are more than twice the emergency threshold. Diarrhea was the main cause of death in the camp (over 50 percent) due to disastrous sanitary conditions.