Somalia's impossible fight against cholera

Ahmed Hussein's perfectly white teeth seem too big for his mouth; his upper arms look like they belong to a little boy, not a 23-year-old man.

Propped up on an iron bed, Hussein laughs and says he always was slim. But he is clearly malnourished. Hussein arrived at Mogadishu's Bandir Hospital a day earlier with his mother and two sisters, all suffering from acute watery diarrhoea: a tell-tale sign of cholera. A nurse at the hospital told IRIN she believed the whole family got sick from the same water source.

This is Somalia's worst cholera outbreak in five years. So far, 71,663 cases have been counted, including more than 1,098 deaths, according to Doctor Ghulam Popal, the World Health Organization representative. In July, when Hussein was admitted, 5,840 cases of acute watery diarrhoea were reported at Bandir Hospital alone.

Cholera is an acute disease that can kill within hours if left untreated. Waterborne, it thrives in unsanitary conditions.

After nearly three decades of continuous conflict, Somalia has a barely existent government with no public health system and 800,000 people driven into unsanitary settlements by drought and insecurity - perfect conditions for cholera to thrive.

"[The] WASH infrastructure in Somalia is totally collapsed due to the absence of the government," explained Hassan Ahmed Ali, a Water Sanitation and Hygiene expert with the Norwegian Refugee Council, a development agency.

Unknown scale

The extent of Somalia's cholera crisis is likely to be a good deal worse than the official numbers suggest.

There are no health clinics or hospitals for 400,000 displaced people clumped in settlements along the two main arterial roads that feed into Mogadishu.

Ali of the NRC believes many people, not counted in the statistics, will have died before they could reach treatment. Neither are the cases counted in the swathe of territory controlled by the jihadist group al-Shabab, which is battling the government.

Compounding the effects of the war, three consecutive seasons of drought have served to tip Somalia into an even deeper food crisis. More than 6.2 million people - over half the population - need aid. That vulnerability increases their susceptibility to cholera.

Rules and regulations

"Unless the systems are strengthened, we can only save lives. Long-term social well-being cannot be achieved," said Mahboob Ahmed Bajwa, the head of WASH for the UN's children's agency, UNICEF.

"Systems" refers both to the federal government's loose relationship with the decentralised states, and the country's generally pitiful infrastructure.

National institutions are weak. In the absence of government, all water supply is privatised and unregulated. These profit-driven companies do not overly concern themselves with cleanliness or quality, despite the obvious risks.

Doctor Lul Mohamed, head of paediatrics at Bandir Hospital, points to the problem of open defecation, and to the lack of controls that allows what toilets are available to be built right next to wells.

The Ministry of Energy and Water Sources is creating new regulations to tackle contamination. But the bill has to go to parliament and will take at least three months to pass into law, according to Omar Shurie, an advisor to the ministry.

Besides the infrastructural deficiencies, recruiting qualified health workers and paying them regularly is yet another of the seemingly endless tasks on Somalia's to-do list. Doctor Mohamed, for example, does not receive a government salary. She earns money lecturing at a university in the city, only working at Bandir out of a sense of duty.

Stronger response

Despite the magnitude of the current food crisis and the cholera outbreak, the response of the humanitarian community and the generosity of the Somali diaspora have built a better ability to cope compared to previous disasters.

"Aid works, and it is critical that we continue providing this support throughout the remainder of 2017"

In 2011, drought led to a famine in which 250,000 people died from hunger and related diseases, including cholera.

"The drought in 2016/17 was worse than the previous one [in 2011] but the impact was [not as severe] due to improved overall capacity to respond," said Doctor Abdinasir Abubakar, head of the WHO's Communicable Disease Surveillance and Response.

"Similarly, the cholera outbreak could have been worse if appropriate preparedness and response interventions had not been implemented."

According to Thomas Lay, humanitarian director of Save the Children: "This collective effort has resulted in a positively different situation than we saw at the same point in the 2011 drought.

"Aid works, and it is critical that we continue providing this support throughout the remainder of 2017."

What lies ahead?

Over the past few weeks, the trend in acute watery diarrhoea and cholera has been declining, with some regions having no new cases.

Doctor Abubakar is confident: "The risk of another wave of cholera outbreak is high, but the preparedness and response capacities have been scaled up."

However, there is little ressembling a long-term silver lining here.

The WHO has warned that although the current rains have brought drought relief, the ensuing floods are now expected to increase the number of cholera cases.

Two-year-old Mohamed Yusuf is lifeless, but not dead. His brown eyes are glazed and unfocused, rolled back into bony sockets. His mother brought him to Bandir a day ago with acute watery diarrhoea. Now he's hooked up to an IV line and rehydrating.

Her son splayed across her lap, Mohamed's mother looks more angry than sad, batting flies off his angular face. He is getting better, but the endless war and cycle of drought mean the conditions that caused his illness are unlikely to improve anytime soon.