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Stories From The Field

Paul Spiegel, UNHCR Ethiopia

Can you tell us about your recent mission to the Horn of Africa?

I went to Dollo Ado refugee camp after receiving reports of very high malnutrition rates. We had sent an emergency team of doctors, nutritionists and water and sanitation experts, and I wanted to better understand the situation and help the team to come up with a practical plan to deal with this emergency and negotiate with the Ethiopian government on how to move things forward.

What did you see there?

All together it is a very difficult situation because of the amount of people arriving each day. All our camps are full and new ones are being built. On average between 1,500 and 2,000 new people arrive daily. We opened a new camp called Kobe but we did not have time to sufficiently prepare it so there is insufficient water, latrines and even basic infrastructure. All new arrivals were sent there and Kobe quickly became full.

Was the situation worse than you expected it?

Although the data I received ahead of time pointed to a very bad situation, I found a situation which was much more severe than what I had expected. When you see it personally, it makes a big difference.

What is the state of health of the new arrivals?

They are coming with almost nothing; just the few clothes they have on their back and a few jerry cans. They came over a long period, some after walking for over 1 month, so they were in very bad shape - exhausted. Unfortunately, because they were so many all at once, both the government and UNHCR became overwhelmed in our abilities to register everyone. Since then, we have stepped up our resources and the waiting time has been reduced. We also make sure that people, both at the reception and the transit centers, now receive hot meals.

Are there particular groups in the camps that are more vulnerable to malnutrition?

The children, by far, like it is the case in most crises. This is particularly true for those who are under five and who have just stopped being breastfed.

How do you help them?

We do blanket feeding, which means that we distribute a type of porridge that has blended foods with some vitamins to all children under five. We also decided to target pregnant and lactating women very quickly so they receive pre-natal and post-natal care as well as blanket feeding.

Between 40 and 50% of the Somali refugee children in Ethiopia and Kenya are severely malnourished. Can you explain to us what severe malnutrition means?

Acute malnutrition occurs when children don't have enough food and/or become very ill, usually due to communicable diseases. They start using their body fat and muscle in breaking it down, it's a natural reaction of the body. They come in, looking very thin and because it takes all of their energy, it also weakens their immune system and they become much more vulnerable to infections. There are different levels of malnutrition, but those acutely malnourished are at a significantly higher risk of dying.

Can children suffering from severe acute malnutrition fully recover if treated on time?

For the most part they can fully recover if treated early and correctly but this might be more on a physical level. There are also less-known psychological aspects. [Our implementing partner] MSF has a clinical psychologist to help the mothers and the children bond once they are getting better and the child can go back to the breast, which is the best solution.

What happens once a malnourished child has been identified?

When new arrivals are registered, we immediately measure the mid upper arm circumference (MUAC) to identify acutely malnourished children. We also do some community work to search for children that would have been missed at the registration. Depending on the severity of the case, they are moved to Dollo hospital, otherwise they are out-patients and they are being followed in Kobe camp. All these children need more than just food. They are given iron, treatment for worms and antibiotics. Some of them are so severely malnourished that they need naso-gastric tubes. Those who are being treated as outpatients have a much better chance of survival than those in a more complicated state, where it is a difficult fight for many of them to survive.

How long does it take them to recover usually?

We have been noticing that the children take longer to recover than normal; sometimes up to 6 to 8 weeks to recover. This could be because of the horrendous state they are coming in.

Is this situation different from other emergencies you have seen?

Yes. I have been to many emergencies before - in fact I am just back from a two month emergency mission in Côte d'Ivoire - but I have not seen such magnitude of death and malnutrition for many many years.

We heard that some children die of exhaustion after reaching our camps. Is this still happening?

They die of many factors that interact to make the situation worse. Last week there were 7 deaths at the reception center in one day. The problem is that it is often too late when they come in. The situation is slightly better now, possibly because the refugees are leaving earlier and not waiting until the last possible moment.

And in Dadaab, Kenya?

The situation there is very serious as well. The mortality rate is 4 times higher than last year but the magnitude is not as bad as in Dollo Ado. Overcrowding is really a major issue in Dadaab as it facilitates disease outbreaks.

Do you think the situation can evolve quickly?

This is a very unpredictable situation, with the conflict and famine ongoing inside Somalia. Access remains a key issue. We need to be able to distribute ready-to-use therapeutic food to the severely malnourished children inside Somalia. It will likely take a while before the situation gets better as we have not been able to access some areas in Somalia for a very long time and we have, therefore, very limited information on the situation there.

Apart from malnutrition, where are the other needs in the refugee camps you visited?

Needs are almost everywhere. Core relief items, including shelter, mats and kitchen sets are needed. There are not enough latrines, which increase the risks of diarrhea. The lack of water is also a problem. In one of the older camps called Melkadida there are two water treatment centers, that allows refugees to receive approximately 15 liters per day per person in that camp. But there are no treated water sources in an older camp called Bokolmanyo and in the new camp called Kobe, which means we have to truck water. This is very expensive and very difficult as road conditions are really bad. There are constant breakdowns and people don't get enough water.

What are your core priorities?

Our main challenge is to work closely with the host governments and make sure that proper systems are in place. In Dollo Ado, the priority is clearly to focus on the situation in Kobe and in the new camp Hilowen that will open soon. We have to make sure we have the proper organization and coordination in place including water, latrines and that the health system is functioning. We are not yet there.

Is there any individual story you remember that encapsulates this situation?

We were doing tour of the camp when a man who had just arrived collapsed in front of us. He was a very old, tall and emaciated man. We all crowded around him to see how we could help. He was brought to the feeding center nearby which was open. The look in his eyes haunted me.

Do you think humanitarian organisations are responding adequately to the current emergency?

For now yes, there is a strong mobilsation but tomorrow, when the attention shifts to inside Somalia, media will lose interest in the refugee situation. We need to continue out work when the media is not there.