Sunday, April 19, 2009

Look into the Eyes of a Somali Refugee

Currently, Somalia is in the thoughts and minds of many Americans.  Of course, most Americans are thinking about the rescue of a ship captain and the thwarted plans of the Somali pirates who tried to take the Maersk Alabama hostage.  But long before Somali piracy brought this East African nation to the forefront of the American consciousness, Somalia has been a troubled land.  

Somalia has basically been in a state of civil war for over a generation. Many Americans remember that in 1992 and 1993, American forces (as part of a UN team) came to the aid of Somalis who were suffering from this civil war as famine had become widespread from the ongoing conflict.  Initially these operations were successful, but eventually these peace-keeping/humanitarian forces came to be seen as a threat and the conflict between the Somali warlords and the UN forces became bloody, most famously in a raid in Mogadishu in October 1993 that led to 18 American casualties. (This part of the conflict was the basis for the 2001 movie, Black Hawk Down.)  By 1995, the UN had largely abandoned peacekeeping efforts in Somalia, but not because order had been restored.  In fact, the last 15 years have essentially been lawless with clan loyalties and regional authorities exercising most control while weak externally recognized central governments have been ineffective at maintaining any consistent national order.


In the setting of this civil war, a refugee camp opened up in the desert region of Kenya near the Somali border in a place known as Dadaab.  The last 15 years have seen steady growth of the camps in Dadaab, and today Dadaab is probably the largest refugee camp site in the world in terms of population.   At the beginning of 2008, approximately 160,000 refugees were in the camps, but new arrivals continue to pour in and just one year later, the number of refugees is above a quarter million.   I recently had the opportunity to visit Dadaab on a brief 3 day medical mission trip. It was very eye opening to learn more about the suffering of the Somali people, and even more helpful to understand some of the situations that are currently facing Somalia such as Islamic fundamentalism and offshore piracy.

Me and my two colleagues from Kijabe Hospital took a small plane from the cool comfortable Nairobi airport, and landed on a lonely air strip in the sweltering desert of Eastern Kenya. Dadaab is not actually a refugee camp.  It is a small town that serves as a base for the organizations that operate the camps.  Outside Dadaab there are three camps  (Ifo, Dagahaley, and Hagadera) with a fourth camp being planned in the near future.  UNHCR (United Nations High Commission for Refugees) is primarily in charged of the camps, but they have several implementing partners (NGOs) that work with them, most notably CARE which implements food distribution, education, social services, water and sanitation programs. 

 The UN airplane on the desert airstrip in Dadaab

Another implementing partner that specializes in medical services in Dadaab is GTZ (Deutsche Gesellschaft fur Technische Zusammenarbeit or German Technical Corporation).  GTZ was our host organization.  GTZ provides medical staff for the camps. The three camps each have a doctor and medical facilities, but 3 doctors for more than 250,000 refugees (who have more health problems than most, because of what they have been through) is not nearly enough.  GTZ also staffs a small health center in Dadaab that serves to care for refugees and also the local Kenyan community. Kijabe hospital has a relationship with GTZ, and they send us many patients who need inpatient care that is too complex for the camp's simple facilities. In addition, we routinely plan trips every 2 months to the camps to do screening for certain diseases that need specialized care.  Usually a surgeon comes along on these trips and does surgery in the in the single operating room in the Dadaab town health center. 

On this trip, I was this surgeon.  They basically have a long back-log of patients that need surgery (that is doable in this setting) like hernias and lipoma excisions, and my job is to operate continuously from arrival to departure and try to do as many cases on the list as possible.   While, I do not like being a technician who merely operates on patients who are brought in front of me, the circumstances dictate that more people can be helped in limited time this way.  To be honest, it was a privilege to be able to participate in the surgical “assembly line” and while Dadaab is the dustiest, hottest, poorest place I have ever been, the operating room was an oasis of air conditioning and cleanliness in the midst of this austere outpost.  There were still some unusual challenges to adjust to like flies landing all over the sterile field while I was operating and working with very little limited supplies and technology, but we managed to do quite a few substantial cases.  

OR list for the day in Dadaab

While mostly, there were hernias, hydroceles, and lipomas, the cases were all quite challenging, because they were all big.  (I was very happy I had brought some hernia mesh with me, because I operated on some giant scrotal hernias that would have been near impossible to fix without prosthetic materials.)   One case was a 32 year-old man who supposedly had a groin hernia, but when I examined the patient, he only had one testicle.  Upon exploring the groin lump that was suppose to be a hernia, I found his undescended testicle (which we removed because the vessels were too short to relocate it to the scrotum, and cryptorchidism is associated with increased risk of malignanacy). 

Hernia repair in the beautiful Dadaab Health Center Operating Room

During the time when I was between operations while the room was being cleaned, they brought an endless parade of patients for me to see for surgical consultations.  There was an array of ailments, many of which were problems from violence suffered in Somalia like complications from gunshot wounds or burns.  It overwhelmed me to see what burden of untreated disease exist in the camps.  The most memorable was a 12 year boy with soft hypervascular tumors growing from multiple parts of his skeleton including his skull.  I had never seen anything like that in my life, and despite his condition clearly warranting medical attention, he had essentially received no care up to this point.

Boy with soft tumors on skull, right shoulder, and knees

Despite working continuously from breakfast until supper every day, there were always more patients to be seen when we had to return to the GTZ camp, and it left me wondering how many sick people remained in the camps that were simply being ignored due to the massive numbers of refugees.

The most relaxing part of the trip though was the evenings.  We had dinner with our host who told us many of the overwhelming problems in the camps.  To hear the stories of the numbers of people fleeing Somalia, and the amount of resources it would take to continue to support them in the camp is very discouraging.  Somalia’s population is estimated at just under 10 million, and the largest city (Mogadishu) has about 3 million of  those people, but if things continue to grow at the rate they have been for another 10 years, Dadaab will be the most populous “Somali” city on the map. 

Also, another interesting thing about the evenings was visiting the NGO camps.  Our trip happened to occur around March 17th, and we left the GTZ camp to go visit the UN camp that night for a little St. Patrick’s Day celebration.  We drove by half a dozen NGO camps to the sprawling UN camp.  Seeing how much money, personnel, and infrastructure  are required just to “support the supporters” was overwhelming.  The financial costs of supporting a refugee camp in the middle of the desert is mind boggling.  To see how many resources are needed just to provide the most basic of services for this humanitarian crisis makes you realize the scope of the problem. 

But for the entire trip, the most meaningful part for me was the time I got to interact with the refugees, in particular the patients I operated on who were kept in the health center over night, so I could check on them in the morning.  I operated on several children and I got to see them with their parents.  These were the most encouraging moments, because I had been able to fix the child’s problem surgically, and the parents were so grateful…  While it was nice to see some patients get help, most of the Somalis I met had problems I could not fix.   I was deeply troubled to see patient after patient (in particular the children) with terrible problems that desperately needed attention, but was beyond my scope to help.  I would write on the small bit of paper they were using for a chart to refer the patient to some hospital or clinic, but in my heart I knew there were no resources or money to pay for such a referral. 

All the while, the Somali refugees were very accepting of my inability to help them.  It seemed they were accustomed to suffering.  They had become used to people not being able to help them.  They had no expectations or demands that their problems be fixed.   When I would look into the faces of these patients, their expressions were so blank.  It’s difficult to describe what you see when you look into someone’s eyes, but there was something subtle missing in their eyes, and I sensed it over and over again.  There were no smiles, or frowns for that matter.  Many Africans are stoic, but this was different.  When I looked into their eyes, I could not see any hope…they were merely trying to survive, and to some degree I think many had even loss the desire to survive; they merely wanted to suffer less. 

I don’t mean to depress you by writing these things, but I have to be honest.  Life in a refugee camp is harsh and the hopelessness is pervasive, but there are moments when humanity can be restored…when you see a smile break across a child’s face or see a need met and the individual feels cared for.  This happens too infrequently though.  What is needed is so much more.  More education, more health care, more services, and most importantly, an opportunity to escape the refugee camp for a better life. 


I was not able to take many photos of the camps due to the operating schedule but these are some photos of Dadaab that I borrowed from others: 

While no one will argue that refugee camps are a tragic reality of the modern world that demonstrate man’s inhumanity to man, what many don’t understand is how closely the circumstances of life in a refugee camp are related to life in the developed world.  Somalia’s long lasting civil war is not merely the result of a nation not being able to get along.  It is also the residual effect of colonialism, and the result of present external forces that maintain conditions that foster conflict, because they can be profitable.  Where do all those weapons in Somalia come from?  They are not made in Somalia.  If large oil reserves are found in Somalia (as many believe there are), suddenly there will be a financial interest in stabilizing the nation (at least enough stability for Western industry to invest in Somalia), but until Somalia’s lawlessness led to the unforeseeable consequence of piracy costing hundreds of millions in international commercial trade revenue, the West had lost interest in stabilizing Somalia.  Now millions are being spent in ineffective policing of the waters off the coast of Somalia, but if the international community had been more interested in the suffering of the Somali people since 1995, then perhaps this situation might have been avoided and Dadaab might have been closed by now.  (Similarly, troubles in Afghanistan were largely ignored for years when the Taliban were running amok, but when that ignored suffering created an environment to train anti-Western terrorists, and the World Trade Center attacks occurred in 2001, the international community became suddenly interested in the suffering of Afghanistan.)  Incidentally, Somalia is also struggling with an Islamic fundamentalist insurgency, and is considered one of the potential new training grounds for terrorists (the weapons are clearly there).  Just this week, the Somali Parliament signed Sharia law into effect for the nation to appease the Islamic radicals.  (Strict interpretation of Sharia law forbids schooling for girls, television, and music, among other things.)  Somalia has slid into an anti-Western posture, while the international community was ignoring it.  The international community cannot continue to ignore large populations of people who are suffering and not expect repercussions.  Can you blame a young Somali from developing anti-Western feelings when he watches rich Western countries ignore his suffering, and even support it by profiting from Somali conflict?  


So the reason I am posting this today is not just to write about my trip to a Somali refugee camp, but more to write about what is going on in Somalia today.  Somalia is not a nation of thieves, pirates, and war-mongerers.  Most Somalis want peace, and they want to support themselves through honest means, but after a generation of chaos, one might see how the sentiment toward piracy and anti-Western values might proliferate.  What is required to prevent further sequelae of suffering is that Somalia be helped.  And not helped out of selfish reasons.  (Afghanistan was “helped”, but the primary motivation was hunting down terrorists and revenge, and now the situation in Afghanistan is dreadful.)  People are not stupid, they know when they are being used.  If the international community sends forces into to Somalia simply to secure the international waters outside Somalia, and then just build a couple of token schools, then nothing will change.  The West needs to undo what years of colonialism and external political tampering have created.  The West needs to truly serve Somalia.  That means more money for education, schools, health care, infrastructure, and more Westerners to help implement the programs.  Will this work?  I am not sure, but I believe in the principle of sewing and reaping.  If the international community sews seeds of good will into Somalia, I believe it will reap not only less suffering for Somalis, but good will back to the international community.  There will be no need to police international waters outside Somalia if Somalis determine they are not going to tolerate their countrymen being a menace to the world at large.  There will be no need to continue to support hundreds of thousands of Somalis in refugee camps.  And there will be no need to hunt down anti-western terrorists from within the country.

Maybe I am naïve to believe that complex problems can be solved so easily by merely taking care of the most poor and oppressed people of the world.  Maybe it’s foolish to believe that the hostility against Americans and Christians can be extinguished by acts of kindness, but I can tell you this for sure:     I took care of the child of a Somali man in the Dadaab camp.   Before I operated, the father looked cold and hopeless, but two days later, when I removed the bandage, and the child chuckled from the ticklish tape coming off, the father laughed too and looked into my eyes and said thank-you.  In that moment, I saw a glimmer of hope in his eye that everything was going to be okay.  So I know that an act of kindness has changed one heart, and that is there is at least one Somali who appreciates a Christian American doctor...because I could see it in his eyes.   


Yours in hope,



“To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds. And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to suffering outside our borders; nor can we consume the world's resources without regard to effect. For the world has changed, and we must change with it.”

~Barack Obama, Presidential Inaugural Address



At Tue Apr 21, 06:50:00 PM, Blogger Cherise said...

I have hope with you. We can't keep trying to do as much as we can, because if we give up then there really is no hope.

Thanks for sharing your experience, it just touches the heart and awakens the complacent mind.

At Mon Apr 27, 12:46:00 AM, Anonymous Anonymous said...

I guess we do have some philosophical discussions about Somalia, huh?


At Sun Jul 10, 12:43:00 PM, Anonymous Marina said...

Thank you for sharing your experiences in Somalia. Yes, it is so sad the situation there, and saddest to see that Western nations are not helping them as I am sure we can do it. It breaks my heart too see so much devastation in the area. I hope that help will be soon in the way.

At Mon Aug 08, 04:57:00 PM, Anonymous kamil kemal guller said...

l been to Denan camp its same but ethiopian gov gives special permission for the dick young made a good film in the area you must watch


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