What happened in the end?

By Steve Dennis (CivE 9T9)

August 20, 2008

Hello Mom and Dad,

So whatever happened in the end? I write this from about 35,000 feet above the Atlantic Ocean, heading west. I'm much more rested than a month ago when I left Nairobi. Today I still cry thinking of the fate of the project, as again today a decision will be made to continue at high risk to our staff, or close the project with life-threatening consequences to our patients. I still wonder, as I will for months to come, whether the last six months of my life were a dream: some good parts, some inspiring moments, and some horrible realities realized. And I wonder, wearing wet eyes, of the future of the staff I never got to meet in person, but talked with on the phone everyday, and often while gunshots could be heard in the background.

Maybe it is best to update from the middle of June. I was just coming back to Nairobi from a wonderful vacation in Holland and was cautiously asking how things were from the people covering for me in my absence. 'It's not good, Steve', was the summarized report.

Fighting had come closer to our clinic area, and NGOs (Non-Governmental Organizations) were becoming more targeted. Why would NGOs become targeted?

Well, because there is a deterioration of all structures and norms in Mogadishu, including clear recognition of neutral, impartial organizations offering assistance to those that need it. How could this happen? Summarizing a long story, there are many foreign interests in Somalia, and many foreign military and political involvements trying to support those interests. Some of these involvements are very public, including U.S. warplanes and cruise missiles bombing villages, the UN training and paid salaries to one side of this conflict, as well as the Ethiopian army shelling civilian neighbourhoods.

(Note: The Transitional Federal Government is felt not to represent the people. The UN funds the police force that is reported to be responsible for much crime in the country. Our experience with them has been difficult. Our mobile clinic minivan was robbed by them twice with staff assaulted. Also, just two months ago, two people walking to the clinic to visit a patient were shot just outside our clinic door by them (one killed) for no reason. People report many more instances of their undisciplined actions, and reasons why most Somalis would like the international funding of this group to be stopped).

Needless to say, many Somalis want nothing else but for all foreign involvements in Somalia to leave. I understand this position quite well, as the benefits we can provide are belittled by the horrendous killings that are supported by other foreigners. They say, in similar tones as we do, 'we're just trying to help the people'.

We had been questioning for some time, at what point is the situation too insecure to run a program? In most projects with MSF it is easier to determine this. Most other projects need expat (international) staff presence most of the time to ensure a base level of quality and accountability. If the security situation does not allow expats to be present and, therefore, the quality and accountability would be unacceptable, the project would close. Fortunately in Somalia, the Somali medical, administrative and logistic staff are very skilled and reliable. (Note: January 26, 2008 was the last day MSF-Holland expats were present in Mogadishu. Two days later, three expats were killed in Kismayo, and a country-wide evacuation was called. When the aftermath from the killings settled down, the security situation in Mogadishu deteriorated such that expat visits were not possible). As well, from the beginning of the project, certain systems were put in place to allow for more remote control of the project (i.e. no petty cash was kept in the project, but rather money transfers from Nairobi were made for all purchases; staff were more involved in reporting and stock monitoring, etc..) So assuming a base of quality and accountability was present without expat presence, then the question would have to be raised, what level of insecurity was no longer acceptable for national staff?

There are differences in risks to foreigners and nationals, as well as to different staff in the project. But there is a base assumption that if people are targeted because they are working for MSF in Mogadishu, then that is too much and the project should not continue.

I have to note at this time a bit about the project. We run a very basic outpatient and inpatient clinic for under-12-year-old children, and anti-natal consultations for pregnant women. There are only estimates of the remaining population in Mogadishu right now but at one time there were more than a million people living there (some estimate up to three million). There are very few other options for healthcare in that area. We do approximately 300 consultation for children per day, we care for approximately 40 inpatients, and monthly do about 800 anti-natal consultations. One or two days a week, many people are turned away as the clinic is too busy with the numerous sick that can't wait till later (people risk a lot to travel to the clinic: they could be robbed, assaulted or shot at roadblocks, hit by stray shootings, or roadside bombs). People don't usually come to the clinic unless they are very unwell. So to sum up, there is a justifiably good reason to continue the clinic.

With some heavy discussions with the staff, it was accepted that the time to close the project would be if MSF Holland was targeted.

On Wed., July 9, we received word that MSF Holland was mentioned on a warning letter distributed in parts of Mogadishu. Specifically, it warned our staff to resign publicly or be killed.

Warning letters are common in Somalia where the reason for the warning, as well as the actions the persons or organization must do, are stated clearly. Sometimes they are hoaxes and sometimes not.

This was our deepest fear for the program, the topic of many late night discussions and later night distractions to sleep, and it was happening.

Back on January 28, MSF was targetted when three staff were killed in Kismayo, Somalia, by a roadside bomb. This came without notice and was a shock to all. In discussions afterwards, people prayed for warning letters, instead of direct actions, like that. [The thinking was] if someone doesn't want me in the country and they are serious, don't waste your time making a bomb and risking your life, send me a letter and I'm out of here!!! If ever there is a warning letter, clinics stop, all expats are brought to the base, security is raised, elders or other authorities are summoned and heavy talks are had. Usually the author of the note is called to a meeting and, only after agreements are made between him and the elders, with a strong retraction of the threat, do clinics resume. Sometimes those talks don't progress fast enough and the team evacuates until agreements are made again. With the hope for a warning letter, instead of an attack, we couldn't ignore that we received that warning now. Now was the time to act.

The Thursday is normally a half-day, and Friday (as the holy day) is the day off, so we had a little time to discuss this warning before making decisions [of whether or not to open] the clinic on the Saturday. Through those days, much information was gathered, but you can't ever get it all. As well, if this letter was false, it does represent a reality of the drastic deterioration of the neutral space we need [in which] to work.

On the Friday afternoon we took an informal vote within the capital management team in Nairobi. The majority voted to close the project. This was our reluctant recommendation to Amsterdam at that time. With some discussions from Amsterdam, they wanted the Somali staff consensus before deciding.

• We cannot escape Mogadishu, and likely we will die here. Before that happens, we can do something, we can keep coming here to run this clinic
• Everyone dies at some point, but not everyone has the opportunity to help their people like we do
• I help 300 people a day live. What is more important, my life, or the lives of 300 people?
• Please don't close the clinic; allow us to continue it

Of the 50 people, three suggested we temporarily suspend activities for two weeks, but the rest pleaded to continue the clinic. After the phone meeting, the staff went to work, and I sat with the others from the Nairobi team. I was thoroughly saddened. After we had come to a consensus to close, our team's courage and acknowledgement of their desperate situation changed everything. How could we close now? People most likely would die if we continued, but on the other hand, they would not be any safer if we closed the clinic and certainly patients would die without our assistance. We decided to take the rest of Sunday off to let this settle, and Monday night a decision would be made. Three hours later, three cars from other remaining NGOs in Mogadishu were stolen. Again, despite my reluctant optimism after talking with the staff, the reality of the situation came back.

Monday, many discussions were held with staff, contacts in Mogadishu, and other MSF sections working in other areas of Mogadishu. That night, my Head of Mission and I talked with Amsterdam. There was a reluctant decision at that point not to close the clinic. Further analysis would be made to reduce any remaining source of risk to staff, and this decision could be reversed at any future time if the situation deteriorated further.

I alerted that all the staff should try to come to the clinic for another phone meeting on Tuesday morning. At that meeting I again stressed our concern, however at that point, the clinic would continue. The staff were pleased with this, and recognized the need (both for them personally and for the project and MSF's country-wide involvement) for them to remain safe.

After a decision like that, there is plenty of room for second guessing. I felt that it was the right decision at the time as the staff appreciated the risks to themselves and they accepted them. Yet still, I wasn't pleased about the situation. I was further stirred when the early afternoon fighting nearby led to a stray RPG (Rocket Propelled Grenade) hitting our clinic and blowing a hole in a room. Fortunately our security procedures saved everyone from getting hurt but it was again further reason to worry.

That decision-making process was the last time I would have had to close the project if the decision was made. By Friday that week, I was on a plane heading out for my end of mission. My replacement was coming in just after that, and I left the project to him. In Amsterdam, I rested the Saturday and Sunday with friends that understood the situation there. Good food, caring friends and privacy to let my emotions come out, and they did.

Monday and Tuesday I debriefed in the office. Many people wanted more discussion on the situation, and I spent much time briefing people on the realities going on in Somalia and Mogadishu specifically. The highlight of those briefings was a discussion with the General Director of MSF Holland. He asked did we make the right decision? Yes. What more can we do? Would they welcome a letter from me with some money for a good meal? They would appreciate that more than anyone I know in the world. There wasn't much more to say. He knew what was going on and no more discussion would improve that. I was happier leaving Amsterdam knowing that future decisions would be cared for in the same way I would want them cared for. I could leave having done my best and handing off to competent people.

The following day I boarded a plane to fly to Australia to meet up with Kara. I landed early Friday morning to a daze of jet-lag, culture shock (Nairobi, working in Somalia, passing through Amsterdam, Frankfurt, Singapore, then Brisbane tosses your head a little), and a new country. I sleepily met her parents and then we loaded into her car and started driving north 1300kms. Sunday morning, we awoke onboard Beachhouse, a 32-foot long sailboat, in the Whitsunday Islands (off the NE coast of Australia). And then it happened. Then with the wind on our side, food, fuel and fresh water in the boat, a chart showing our destination, and a loving, understanding Kara by my side, Somalia drifted away, and I could start recovering from the troubling situation there.

This trip was the best re-introduction back to home I have had yet from a mission. To leave and be alone with someone I know and trust, to talk of things and be reassured of the division of the multiple worlds we pass through, is the best way back (geographically and mentally) home. After a week on the boat, we did some camping, heading south by car, then into Brisbane city for some time, then I started the four flights back to Toronto, where I am writing from now.

February 2, 2009, Toronto

After writing the above, my laptop battery ran out. Then with the deluge of visits, the culture shock of arriving back home, and completing a semester of university, this letter got left unsent.

So what happened in the end? The project in Mogadishu ended soon after I left due to increased fighting in the area. None of the staff were injured, but their struggle is not over yet. The situation in Somalia continues to deteriorate almost daily. People mostly know of Somalia these days because of the piracy off its shores, but it is difficult to appreciate the dire situation on shore that is driving people to those desperate measures (I call the situation desperate, since many navies of the world, including Canada's, are off-shore and sinking these pirate boats frequently. The rate of loss is high, yet still people continue to try this means of making money).

Besides the project, other situations are deteriorating. The hospital I worked at in Kilinochchi, Sri Lanka, was damaged during the recent government take-over of that area and others. Right now, the government is pushing for a final leg of a military victory over the LTTE rebel group, trying to end 25 years of war.

These two places disturbed me greatly before and continue to now as well. I am sometimes caught off guard, drifting into thought of the people I knew, the horrible situations I know exist, and question how this can happen.

Last semester I took some courses with U of T to expand my academic skills before applying for a Masters degree in International Relations for next September. Those courses went well and started giving me more of an overview of the political structures that influence the world (and conflicts within it).

And now, I am out of courses but staying in Toronto. Kara is here and will be taking a Masters in International Public Health. We will stay in Toronto for the next little while (at least until April 2010!!!).

For me, in the meantime between now and September, I am compiling my previous writings, researching some themes and structuring all that into a book. I think over the last six years I've been exposed to many situations others would be interested in hearing about. Further, I believe there are some issues that need some light brought to them, and I will do that too. Lastly, for myself, I believe the process of looking backwards will give better direction for future steps forward. Writing a book is as much a process for me as it is a book for others.

So there is the conclusion of my time in Nairobi. As well, this marks six years working with MSF, and the start to a long contemplative pause for now. I hope everyone is very well.

Take care and lots of love,

Steve

P.S. Not sure if you saw I had an article published from a visit I did to a Somali refugee camp in North-East Kenya. Here's the link.

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