Author: Ashley Catanzarite
Conflict Background
Sitting in the horn of Africa and bordered by water on two sides, the country of Somalia has a war-tainted and impoverished history. Recurrent droughts and floods as a result of climate change have made food insecurity the norm, and steady violence in the area has made responding to the growing humanitarian emergency exceptionally difficult. This steady violence has been ebbing and flowing for decades. Since its creation, Somalia has known border disputes and regime changes. The violence plaguing Somalia, including a civil war and waves of militant groups, including al-Shabab, is compounded by regional famine and food insecurity.
Somalia was created from an Italian colony and a British protectorate in 1960, though many of those who considered themselves Somalis were left outside of the country’s borders and instead found themselves within Ethiopian territory. When the British- and Italian-controlled halves of Somalia were merged, a president was elected. In the years following, border disputes with Ethiopia broke into hostilities on a number of occasions. The president elected in 1967 was assassinated in 1969, and Muhammad Siad Barre took control of the government via military coup. Subsequent years were in the pursuit of a “Greater Somalia” during which violence broke out over disputed claims of the Ogaden, the area situated directly between Ethiopia and Somalia. Somali forces, supported with arms from the Soviet Union, attacked Ethiopia in an attempt to claim the Ogaden in 1977, killing and displacing thousands. Though the Somalis were successful at first, the Soviets began providing support to Ethiopia instead; the United States, in turn, began backing Somalia and a result of the human rights violations perpetrated by the new Ethiopian regime, driving away U.S. support. Ultimately, the Soviet support outnumbered the support provided by the U.S., and the Ogaden region was reclaimed by Ethiopia.
While Somalia and Ethiopia fought over the Ogaden, their citizens were starving. A severe drought in the regioneffected both Ethiopia and Somalia. After the war, ethnic Somalis in Ethiopia fled to Somalia because of the famine brought about by the drought and the economic issues brought about by the war. Barre was losing the support of Somali citizens as the government resources were waning and strained. Opposition groups formed against Barre and became violent, leading to the 1991 ousting of Barre and the fall of the military one-party government in Somalia. The northern part of Somalia broke away in 1991, claiming itself to be autonomous, though the sovereignty of this region, the Republic of Somaliland, is not recognized by foreign powers.
The power vacuum that followed the removal of Barre left competing clan warlords to injure and kill thousands of civilians. The 1990s in Somalia saw the rise of numerous clans, the continuation of violence brought on by Barre’s actions, a civil war, and failed interventions by the United Nations, United States, and Ethiopia. The instability and violence in the region continued through the decade. The lack of central government allowed Somalia to become a home to separatists, jihadists, and warlords.
An internationally recognized transitional government was put into place in 2004, the fourteenth attempt to do so since independence. This government operated in neighboring Kenya for some time before attempting to return to Somalia in 2005, though this was met with a failed assassination attempt on the Prime Minister. This creation of this new, fragile government did not stop the advance of the militant groups already taking up residence in Somalia. The Islamic Courts Union (ICU), partnered with al-Shabab as their youth militia, seized control of the capital in June 2006, leaving neighboring countries to worry about this new threat of violence. Ethiopian troops backed by the transitional government, the African Union, and the U.S. removed ICU from Mogadishu in December of 2006, causing al-Shabab to retreat south and declare jihad against Ethiopia. The next several years saw a violent back and forth between Islamists attempting to come to power and the international community (including the UN, Kenya, and Ethiopia) attempting to empower the recognized government of Somalia. In 2012, the first formal government in two decades was sworn in after the first election since 1967. This was met with pushback from al-Shabab, and violent attacks continue to this day.
Today, Somalia faces continued battering from al-Shabab. Many government officials involved in the 2016 elections were assassinated, and al-Shabab claimed responsibility for some of these killings. In April, Somalia’s parliament voted to postpone national elections for two years, retaining their own seats and the current president’s position. This power grab impedes the democratic process and potentially puts pressure on an already unstable political situation. Much of the country is operating under “mixed, unclear, or local control,” and these areas dwarf those controlled by the federal government coalition. The political situation in Somalia is still delicate after nearly a decade of attempting to restore a centralized government.
Drought and famine persisted through much of the ongoing violence, driving up the numbers of internally displaced persons and refugees. The 2011 drought is “widely regarded as the country’s worst in 60 years” and further exacerbated the food insecurity issues in the region. Between the famine and the violence, more than 640,000 Somali refugees have fled to neighboring countries and 2.9 million individuals are internally displaced. An estimated 5.9 million people are in need of humanitarian assistance in Somalia, and the violence in the region makes getting them the help they need difficult. The United States alone has given upwards of $3 billion in assistance since 2006 just for humanitarian purposes. After years of providing aid and support, donor fatigue and other ongoing issues make humanitarian and political stability in the region seem like a far-off and daunting task.
Cholera
Infectious diseases are capable of crippling populations in the best of conditions. Somalia, a country plagued by violence, militant groups, and climate change implications along with a whole host of infectious diseases, is operating in less-than-ideal conditions. Diseases that are transmitted by aerosols, like respiratory infections, can propagate easily in cramped conditions associated with internally displaced populations. Where access to clean water and sanitation is difficult or impossible, diarrheal diseases are common. Cases of vaccine-preventable diseases often rise in the absence of reliable health systems. In the case of Somalia, all three of these health risks threaten the wellbeing of Somalis. The alternating periods of drought and flooding exacerbated by climate change contribute to the internal displacement of citizens, lack of clean water, and unstable health systems. Cholera in Somalia continues to burden many individuals, despite being considered a generally preventable illness and an easily treatable one.
Cholera is very closely associated with inadequate sanitation practices. It primarily affects individuals who lack access to clean water. It can be present anywhere with brackish water and is both endemic to some countries and the source of outbreaks in others. It is most common in the Democratic Republic of Congo, Yemen, and Somalia. An estimated 1.3 to 4 million cases of cholera occur every year, causing between 21,000 and 143,000 deaths worldwide annually. It is caused by ingesting food or water contaminated with Vibrio cholerae, a bacterium. Symptoms appear between 12 hours and 5 days after ingestion of contaminated food or water. The primary symptom of cholera is severe watery diarrhea, but those who show symptoms can present in a range from severe to mild diarrhea. Severe cholera can lead to severe dehydration, which can result in death if ill individuals are not rehydrated. Conversely, some individuals present with no symptoms, but can still contribute to transmission of the bacteria. The bacteria can be found in feces for 1 to 10 days after infection. Reintroducing the bacteria into the environment where sanitation is poor allows for others to be infected.
Caused by inadequate access to clean water, the supportive treatment necessary for cholera recovery and rehydration is not always obtainable. Most people can be “treated successfully through prompt administration of oral rehydration solution,” which can require up to 6 liters of clean water. The most severely ill individuals may need intravenous fluids and antibiotics. Cholera cases can be confirmed by laboratory PCR or culture or can be identified by a less sensitive dipstick rapid test in areas without laboratory testing capacity. Suspected cases of cholera include cases of acute watery diarrhea leading to severe dehydration and potentially, death. Where cholera is common and testing capacity is limited, cases often remain classified as suspected without being confirmed.
There are several oral cholera vaccines (OCVs) approved by the World Health Organization for the prevention of cholera. All three of the OCVs require more than one dose for complete protection. This can make it slightly more challenging for those with limited access to healthcare to be completely vaccinated, as a second encounter with a vaccination site is not always guaranteed to internally displaced and other at-risk populations.
Cholera in Somalia
Historically, cholera is not new to Somalia. First reported in Somalia in 1970, large outbreaks have been reported more than 6 times and have increased in size in the last two decades. Cases have been reported in nearly every region of Somalia, with the largest number of cases in the Banadir region, most notably in the capital city of Mogadishu. Cross-border outbreaks have become increasingly common, as Somalia shares long borders with Kenya and Ethiopia. In 2017, Somalia had only 0.87 hospital beds per 1,000 people and the country has never had more than 7.1 physicians per 100,000 people. Their health system lacks the capacity to provide primary care to their people, making the detection, prevention, and treatment of disease difficult.
Somalia is faced with repetitive periods of droughts and floods. In 2016, the first half of the year saw flooding and an increase in suspected cholera cases and case fatality rate. When the flooding ended, the number of cases fell. However, it was not long before a drought began in October 2016, resulting in another resurgence of cases. The flooding and droughts make access to clean water difficult, contributing to the incidence of cholera. In January 2017, cholera cause more than 3,000 cases and 47 deaths. The WHO has been heavily involved with cholera outbreaks in the region, providing leadership and support to the Somali Ministry of Health.
This outbreak of cholera spurred the first OCV campaign in Somalia. This campaign was quite successful in achieving its goal of 2-dose coverage in 11 districts that were high-risk for cholera. Vaccine coverage in the targeted districts was 95.5%. This was quite an impressive feat, proving that vaccination goals can be achieved even in “acute humanitarian settings.”
The oral cholera vaccine campaign in March through October of 2017 was incredibly successful but did not stop the floods in December of 2017 in the Jubba and Shabelle river basins from causing another outbreak. The floods in December 2017 were responsible for the outbreak that continues to plague Somalia. The success of the vaccination campaign likely prevented thousands of infections but has not stopped cases altogether. The populations targeted for vaccination were most at risk but was not entirely comprehensive; other at-risk populations went without vaccine coverage.
The December 2017 floods caused an outbreak that was mostly contained to 5 regions, with active transmission taking place in Banadir, where Mogadishu is located. Additional flooding following rains in April 2020 led to contamination of additional water sources. In 2021, the total suspected number of cholera cases is around 3,858, and the number of deaths is 27. This is a drastic improvement from the 3,000 cases reported in January 2017 alone. This improvement likely comes as a result of the OCV campaign.
The World Health Organization and “The Global Action Plan for Healthy Lives and Well-being for All,” a plan with 12 signatory agencies to strengthen primary health care, has made progress in strengthening Somali health systems in recent years. This progress, along with the continuation of vaccination of at-risk populations in Somalia will keep the number of cases of cholera manageable. However, the flooding and droughts continuing and increasing in severity as a result of climate change will make it very difficult to ensure access to clean water. Taking steps to provide reliable, safe, and clean water sources to Somalis despite these floods and droughts is a way to reduce incidence of cholera and other diarrheal diseases. The number of cholera cases is unlikely to reach zero because of the cross-border outbreaks and persistence of drought-flood cycles, but further reducing the number of cases could reduce the burden on the already fragile Somali health system.
The Future of the Somali Conflict
In my opinion, the slow and ineffective response to the Somali civil war recovery efforts contributed to the ongoing crisis today. A transitional government was only put in place after more than a dozen failed attempts. Once it was established, the delayed reintegration of the internationally backed government to the country of Somalia allowed militant groups more time to secure their foothold. A lack of conflict resolution between al-Shabab and the government is an obvious driver of violence, and more effective military and diplomatic actions should have already taken place to stop the fighting in the region. If not for the sake of government stability, it should have occurred for the sake of the millions of Somali people starving and falling ill. I do not believe that the military coup that allowed Barre to come to power in the first place should not have been supported. It was under his regime that violence was allowed to percolate, and it was the destabilizing effects of his ousting that led to the civil war and militant presence in the country. Removing him from power and supporting a democratic process early on could have prevented the violent decades that followed.
This article was prepared by the author in their personal capacity. The opinions expressed in this article are the author's own and do not reflect the view of their place of employment.
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