The Dadaab refugee camps, located in the North Eastern Province of Kenya approximately 60 miles from the Somalia/Kenya border and about 320 miles from the capital, Nairobi highlight concerns around the delivery and distribution of relief and aid. The three original camps, Ifo, Dagahaley and Hagadera were established in the early nineties following the onset of inter-clan conflict in Somalia. The vast majority of refugees present are Somalis from Central and Southern regions of Somalia. While the populations in the camps remained relatively stable from 1994 to December 2006, this year in particular has seen hugely increased numbers of refugees arriving over the border as a result of the drought. With over 160,000 new refugees having arrived in the first eleven months of 2011 alone, the camp complex now (as of November 2011) holds in excess of 460,000 refugees in total according to UNHCR - the primary agency mandated with coordinating relief activity within the camps.
Using a combination of focus group discussions and one to one interviews with refugees and members of the host community and following detailed discussions of comprehensive assessments carried out by NGO service providers within and outside the camps the authors conducted a rapid needs assessment over July 2011. The following discussion draws from those results as well as from more recent assessments and developments in the months since.
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.
A recently concluded rapid assessment of mortality survey amongst new refugees conducted by the Centre for Disease Control (CDC) in the Dadaab camps during July and August similarly attested to this concern.
Furthermore, the perceived risks to humanitarian aid workers from the establishment of border camps and outposts could have been mitigated by having them run and coordinated by strictly neutral agencies with the involvement of a mixture of international and local NGOs acceptable to both parties in the conflict in Somalia. The kidnap of two female Medicins Sans Frontiers aid workers from within the camps in October and the recent explosion of an Improvised Explosive Device in camp Hagadera highlights the ineffectiveness of simply trying to ensure security by concentrating all service delivery in the geographically confined area of the camp complex.
Another 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 Fafi, the Host Community has also been suffering the consequences of the same drought plaguing the rest of the Horn. They, however, do 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 main camps are serviced by three hospitals with a total of 320 inpatient beds, 3 operating theatres, specialist outpatient services manned by doctors and visiting specialists. A structured referral system for specialized 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 have access to outpatient health facilities within the camps. The only in-patient hospital service the Host Community has access to is a 30 bed district hospital (open to both the Host and refugee community) with 1 operating theatre. The most senior routine medical staff providing clinical care at this hospital are 2 clinical officers (not medically qualified doctors). A single Kenya 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 any of these services by the government or the NGOs.
A perversely functioning artificial city-state has thus developed supported entirely by international Non- Governmental Organizations (NGOs) where older refugee camp residents after years of free utilities and services 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. A jointly commissioned report by the Danish and Norwegian Embassies and the Government of Kenya in 2010 estimated that at least 40,500 (out of 150,000) host community members hold refugee ration cards.
While the stated aims of individual organizations operating in the Dadaab camps are firmly grounded in public health principle, the effects of focusing on their own individual spheres of operation and the lack of long term planning or an exit strategy has resulted in the increasingly unsustainable situation now developing. One reason for Kenya’s recently initiated military intervention into Somalia may well be to stem the flow of Somalis coming into the country and to the Dadaab camps in particular. Guidelines for the development of refugee camps in 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 groups.
The long term key to resolving the situation in Dadaab lies in recognizing that pastoralist Somalis have ancient patterns of movement which involve crossing to and fro across the artificial line that divides Kenya and Somalia and that services designed to cater for this group should facilitate and take account of their nomadic lifestyle. NGOs, local or otherwise able to operate on both sides of the border should thus be supported in their efforts to provide this service. UNHCR itself should be encouraged to view the situation holistically and look beyond its remit of catering specifically to refugee needs by partnering with organizations with a wider mandate that includes the Host Community. This will ensure that Somalis that cross into the territory of Kenya are both willing and able to cross back into bordering Somali provinces and obtain equitably provided services there as well.
The authors have declared that no competing interests exist.
The authors would like to thank the team at Doctors WorldWide in Kenya for facilitating the field assignment to the Dadaab camps in July 2011.