Healthcare hits new lows in Somaliland as conflict continues

Las Anod, Somaliland – Eight months into a conflict between armed forces of the breakaway state of Somaliland and local Dhulbahante militias in Las Anod, Somalia, hospitals in the embattled city are desperately working to maintain lifesaving supplies.

Although the conflict has been effectively reduced to a deadlock, with neither the Somaliland forces nor the Dhulbahante militias able to decisively shift the balance of the fighting, the Somaliland army has continued to indiscriminately target civilian areas of Las Anod with mortars and artillery.

On July 8, after the Las Anod General Hospital was targeted in the fifth sporadic shelling in a six-month period by the Somaliland army, the international aid organisation Doctors Without Borders (Medecins Sans Frontieres, or MSF) announced it was ending support to the hospital because it was too dangerous to work there.

The latest attack wounded seven hospital staff and three caretakers but caused no fatalities, hospital staff said. It also caused “very, very significant” damage to the facility, leading to the MSF’s “very difficult” decision to withdraw its staff and support, said Dana Krause, the organisation’s representative for Somalia.

“At the end of the day, when the situation has become so unpredictable and hospitals are no longer a safe space and patients are no longer safe, it becomes problematic [to keep working],” she told Al Jazeera.

Fighting started early this year, after protests against Somaliland’s control of Las Anod snowballed into an independence movement by the local Dhulbahante clan. Somaliland claims the city as part of its self-declared independent state, based on the pre-1960s colonial boundaries of British Somaliland, while the Dhulbahante clan see the city as the capital of their would-be region of SSC-Khaatumo, within the Federal Government of Somalia.

Early on in the conflict, mortars and artillery shells had knocked out the hospital’s solar power panels, incapacitating the blood bank and operating theatre. In response, doctors and nurses decamped to the adjoining medical university to continue emergency care for casualties brought in from the battlefield.

Local volunteers said they tried to find stronger, concrete buildings to operate from but were unable to fit hospital beds and medical equipment into the potential locations. With MSF’s withdrawal, they will continue operating within range of Somaliland’s attacks.

Las Anod General is the only public hospital in the city and is both a hub for treatment of casualties collections as well as public health. There are four smaller private hospitals in Las Anod that treat the wounded, including a women’s and maternal health clinic that has been converted into a trauma ward. Additionally, classrooms at Nugaal University have been made into recovery wards for wounded soldiers.

‘A big war’

Krause cited danger to both patients who feel unsafe travelling to the hospital for care and to the staff working at the site. The withdrawal means a loss of 13 staff, she said, although not all were working in the hospital. Some were supporting MSF’s mission in Las Anod remotely.

At the hospital itself, the organisation was paying the salaries of doctors and surgeons working for the Ministry of Health and funding medical supplies like kits to treat battlefield trauma. MSF plans to make one last “massive” donation of supplies to the hospital before leaving, including the standardised war trauma kits.

Dr Ahmed Abdi, director general of the hospital, said he hoped the local staff would remain at the hospital, working in a volunteer capacity. Abdi was among those wounded in the July 8 mortar attack although he dismisses his injury as small – the result of a small piece of shrapnel to the leg. His main concern is what happens when the hospital’s supplies run out.

“Currently, the big challenge we are facing is the supply of drugs and even food for patients,” he said. “The supplies are not enough. We are in a big war, and in upcoming days, with serious fighting, 200, 300 wounded cases would use up our whole supply.”

Fighting has been sporadic in recent weeks without major clashes, but the city is still besieged and the economy at a near standstill. Food and supplies are trucked in from neighboring Puntland on an arduous trip that avoids the fighting by snaking along dirt roads in the Somalian backcountry for hours on end with heavily laden lorries bogging down in the mud or rattling through carved-out ravines.

Despite the challenges, the trips are essential for the delivery of supplies. All the private hospitals in Las Anod have been fundraising to keep their shelves stocked with everything from medicines to bed linens, which have to be delivered from Garowe, the capital of Puntland.

A call for support

Donations have come from businesspeople and community members across Somalia, but much of the money has been raised from abroad. Somalis in the diaspora have organised via social media to buy supplies and ship them to Las Anod.

Aliya Fardus, a nurse working in London, travelled to the conflict zone soon after fighting broke out. Her family is from Las Anod, and although she has spent the majority of her life overseas, she is now on the ground organising logistics at the private hospitals.

And she’s encountering donor fatigue.

“What we are worried about are supplies and food, just the basic things,” Fardus said. “After eight months of war, when we are fundraising from civilians that might not have that much, the donations have gone down.”

She predicted that adding the needs of Las Anod General, the area’s largest hospital, will require a 50 percent increase in materials and, consequently, donations. That means not only drugs but food and care also for those who are injured and recovering in the hospital.

Normally, families are on hand to cook for relatives in the hospital, but with the majority of the population displaced by the fighting, Fardus has had to hire almost 30 staff to keep up with the basic demands of food and laundry – all of which requires funding.

After leaving Las Anod General Hospital, MSF will shift its support to Kalabaydh, a nearby city where thousands of residents of Las Anod have been displaced and are struggling to access food, water and medical attention in makeshift camps.

The local clinic was overwhelmed by the influx of new residents, and now MSF will work to provide emergency healthcare and maternal support to the displaced people, most of whom are women and children.

The conflict has been condemned by the United Nations Security Council, and Amnesty International has called for an investigation into Somaliland’s shelling of both the hospital and civilian areas – a potential crime against humanity – but even after eight months of fighting, neither the government of Somalia nor international actors have made any moves to intervene.

Without an end in sight, the greatest victims of the conflict remain the civilians. Drought continues to plague the Horn of Africa, and even if the vulnerable populations of women and children are able to find food, the lack of adequate medical care will have devastating repercussions.

In Las Anod, volunteers like Fardus are doing the best they can, but they can’t work here forever. The would-be new state of SSC-Khaatumo, recently moved from a transitional governing council to an elected leadership of 45 men.

“They are trying their best,” Fardus said, “but it’s not something civilians can manage to cover.”

The ersatz state can’t collect taxes from a besieged capital with few residents and little business, and with water and power intermittent in the city, the possibility of financing hospitals is far down the line. Fardus has been planning a trip abroad to raise funds directly from donors but can’t find time to leave behind hospitals in dire need of assistance.

“I’m doing this job by myself with the support of the diaspora, but I need to hand it over to them and show them how important it is,” she said. “I won’t be able to carry on without support.”