Global Health: The Dadaab Camps - The Daemon In The Detail
Dr Osman Dar, October 2011
The World Today, Volume 67, Number 10
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In recent weeks the tragedy unfolding across the Horn of Africa following
prolonged drought in the region has been a prominent news feature around the
world. The increased attention has been critical in raising funds for the
aid effort and prioritising the disaster in the global conscience.
The most effective strategies for mitigating the effects of the drought have
not been given sufficient media coverage or discussed critically enough in
the public arena. Instead, while important and necessary, the focus has
largely remained on emotive pleas for increased aid using graphic images of
emaciated African children and wide-angle shots of the skeletal remains of
livestock strewn across a barren, hostile landscape. This, unfortunately
detracts from a considered discourse on the most effective interventions in
the current circumstances and reduces scrutiny of the performance of the
primary agencies responsible for coordinating the relief effort.
These concerns are best highlighted in the Dadaab refugee camps, located in
the North Eastern Province of Kenya approximately fifty miles from the
Somalia/Kenya border and about 320 miles from the capital, Nairobi. The
three camps, Ifo, Dagahaley and Hagadera were established in the early
nineties following the fall of the Said Barre regime and onset of inter-clan
conflict in Somalia. The vast majority of refugeesare Somalis from central
and southern regions of Somalia. The populations in the camp remained
relatively stable from 1994 to December 2006, when approximately 177,000
refugees were accommodated in total. Further political changes in 2006 and
2007 in Somalia led to increased numbers seeking asylum.
With the population of the three camps having recently crossed 400,000
according to the United Nations High Commissioner for Refugees (UNHCR) - the
primary agency responsible for overall co-ordination of NGO service
provision in the camps - Dadaab is now the largest refugee camp complex in
the world. In response to the current crisis, and after much negotiation,
the Government of Kenya, as of July 2011, has approved in principle the
opening of a fourth camp, Ifo-2, in an area of land between the Ifo and
Dagahaley camps. However, persisting government fears around the new camp
becoming a permanent settlement for refugees has meant that as of the end of
August the camp has still not become fully operational, with only a trickle
of refugees being allowed to settle in it.
The paediatric age group continues to be the most badly affected in terms of
severe acute malnutrition and global acute malnutrition rates amongst newly
arriving refugees. With constant anecdotal reports of children dying and
being buried along the route to Dadaab from Somalia, sometimes within a few
miles of Dadaab following days of walking, the location of the new camp was
an issue of crucial importance. A recently concluded rapid assessment of
mortality survey amongst new refugees conducted by the Centre for Disease
Control at the Dadaab camps during July and August similarly attests to this
concern. The study found a Crude Mortality Rate (CMR) amongst refugees of
1.94 deaths per 10,000 people per day for the time period during their
journeys versus a CMR of 0.86 prior to departure - a more than doubling of
the risk of death upon undertaking the journey.
One of the most effective interventions to reduce this continuing morbidity
and mortality would have been to open a processing centre or camp on the
border with Somalia at Liboi, where many of the refugees cross and where
they could be registered and provided with initial care and food rations.
Inflexibility in UNHCR regulations on the placement of new camps have in
part been responsible for such a facility not being established.
Site selection guidelines recommend refugees be "settled at a reasonable
distance from international borders as well as other potentially sensitive
areas such as military installations." In practice this translates to at
least fifty miles from an international border. While security concerns for
refugees and humanitarian workers are legitimate given the conflict in
Somalia and the associated rampant lawlessness, the current movement of
refugees is being driven primarily by drought and not the fighting.
With many reports of deaths of children and rapes of women occurring en
route to the camps within Kenya and the risks of refoulement (forcible
repatriation of refugees by the host country) being small, a refugee centre
at the border may well have been the best option for new refugees.
Furthermore, any risks to humanitarian aid workers for a border camp could
have been mitigated by having it run and relief coordinated by a strictly
neutral agency with the involvement of a mixture of international and local
NGOs acceptable to both parties in the conflict in Somalia.
Equality In Access
The other major area of concern in Dadaab is equity in the distribution of
relief aid and service provision within refugee camps and adjacent areas. In
the surrounding districts of Dadaab, Liboi and Faffi, the Host Community has
also been suffering the consequences of the same drought plaguing the rest
of the Horn.
It, however, does not have equal access to services and relief routinely
available to refugees. Healthcare services in the region exemplify these
inequalities in aid provision. The three camps are serviced by three
hospitals with a total of 320 inpatient beds, three operating theatres, and
specialist outpatient services manned by doctors and visiting specialists. A
structured referral system for specialised surgery and medical care in
Garissa, the provincial capital, and Nairobi is also available to refugees.
The Host Community, which is approximately 150,000 strong and of a similar
ethnic background to the majority of refugees, only has access to outpatient
health facilities within the camps.
The only in-patient hospital service the Host Community has access to is a
thirty bed district hospital (open to both the Host and refugee community)
with one operating theatre. The most senior routine medical staff providing
clinical care at this hospital are two clinical officers - not medically
qualified doctors. A single Red Cross ambulance serves all three districts.
These disparities are mirrored across other service sectors with old and new
refugees having access to free food rations, water, sanitation and housing
in an impoverished area where host communities are not routinely provided
with any of these services by the government or NGOs.
Dadaab The City-State
Supported almost entirely by international NGOs, a perversely functioning
artificial city-state has thus developed where after years of free utilities
and services older refugee camp residents have developed successful
businesses and even rent out their refugee shelters to newer arrivals or
Host community members and who can undercut any Host Community business with
lower overheads. Host Community Kenyans often register as refugees
themselves in order to avail improved healthcare services and obtain rations
when necessary. In light of these circumstances the incentive for eventual
repatriation for refugees is minimal, and the drive for more people to
arrive in an area of barren land not best equipped for naturally settling
such large numbers of people is greater. Current abstractions at Dadaab from
the Merti aquifer that provides the groundwater for the region have already
led to measurable reductions in both water quality and quantity locally. All
this in a town traditionally just one stop on the route of pastoralist,
nomadic tribes used to traveling in search of water and fresh pastures for
The large collections of food and clothing being organised by longer-term
refugee camp residents and the Host Community to help badly suffering newly
arrived refugees is inspirational for any witness to the relief effort.
Given the generosity of spirit and selflessness on display amongst these
groups - people themselves suffering the effects of drought - it becomes
even more important that an equitable distribution of relief aid and service
is ensured by both international donors and national authorities. Guidelines
for the development of refugee camps in the future should necessarily give
due consideration to the resource and service circumstances of local host
communities, as well as incoming refugees. This will ensure that equitable
provision based on identified need can be ensured comprehensively for both
It is easy to forget in the far removed air-conditioned meeting rooms of
global health and development institutions that defining a 'Somali refugee'
in the current tragedy, in essence, stems from a British colonial decision
to reward a newly fascist regime in Italy with a vast territory extending
westwards from an older colonial border - the Jubba River in southern
Somalia. In this vast region where national borders are artificial and
arbitrary and often divide communities of similar ethnicity, famine and
disease have unfortunately remained common calamities. Under such conditions
there cannot be any distinction made between 'refugees' and 'host
communities' when providing relief.
Dr Osman Dar is a physician and public health specialist working at the
Health Protection Agency in England. He recently returned from Dadaab where
he carried out an emergency needs assessment as a volunteer for Doctors
Worldwide - an international medical charity operating in Kenya.
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Received on Tue Oct 04 2011 - 18:59:58 EDT