The presence of humanitarian aid organisations is limited in both Mogadischu and the rest of Somalia. In this photo, Mainly woman and children wait to be fed with food provided by the World Food Programme and given to local NGO SAAID. SAAID has been running ten daily wet feeding distributions around Mogadishu and have plans to expand to all 16 districts.

With fighting causing huge amounts of displacement, SAAID's feeding programme is the the line between life and death for up to 80,000 people which they feed daily. Hundreds of local Somalis wait upward of three hours for their daily meals.

A dangerously widening gap between critical needs and humanitarian response

The gap between critical needs in Somalia, particularly in and around Mogadishu, and the level of humanitarian response is increasing due to aid agencies' extremely limited capacity to deliver assistance in this highly insecure and volatile environment.

MSF has experienced the impact of this insecurity first hand, with the loss of four colleagues in 2008. At present our activities in 12 locations throughout south and central Somalia continue to be run by our dedicated Somali colleagues, with the support of international staff based in Nairobi.

Yet the assistance that we are able to provide does not, and cannot, meet the ever increasing needs that our teams are seeing on the ground. Adding silence to the human tragedy, the unfolding humanitarian crisis in Somalia has not received the media attention it deserves despite repetitive calls from humanitarian organisations raising the alarm. The situation is critical now and a matter of life or death for tens of thousands of civilians.

It is shocking that one of the main consequences of the increased international involvement in Somalia over the last two years has been a continuous and significant deterioration in the health situation

A situation deteriorating fast

The humanitarian situation in Somalia, especially in the Mogadishu area, is a large-scale medical and nutritional emergency deteriorating fast.

MSF has worked in Somalia since 1991 and has been running an emergency medical programme in Hawa Abdi, along the road between Mogadishu and Afgooye, since April 2007. While malnutrition rates have been above emergency thresholds since the beginning of MSF's intervention in the area, over the last three months MSF teams have seen a 400 percent increase in the number of children under five years old being admitted to our programmes.

This paper provides the medical data from MSF's programmes in Hawa Abdi and Afgooye in order to sound the alarm about the nutritional crisis that we are witnessing in the suburbs of Mogadishu. Although this document focuses on Hawa Abdi and Afgooye, MSF's concern is not limited to these two areas. Throughout Somalia the population is facing a catastrophic humanitarian situation.

MSF teams are present in 12 locations in south and central Somalia. In all of these locations we have seen a drastic deterioration in the health situation over the last year, and increases in malnutrition over the last three months.

In Jowhar district, MSF runs four primary health care outpatient clinics and a maternity ward, providing primary healthcare including nutritional care, treatment of sexual violence, and expanded immunization programs.

The malnutrition levels that MSF are seeing are a symptom of a greater problem; the blurring of the lines between political initiatives and the delivery of humanitarian assistance in Somalia and the subsequent lack of respect for humanitarian action. Never has there been a more urgent need to keep humanitarian action strictly independent from any and all political initiatives.

A medical and nutritional emergency around Mogadishu

In 2007 an estimated 700,000 persons fled Mogadishu . Every month, thousands of people continue to abandon their homes to escape from the continuous violence taking place in the capital. Along the road between Mogadishu and Afgooye, more than 250,000 displaced people have built precarious shelters in crowded settlements lacking the most essential services.

MSF has been running an emergency medical programme in Hawa Abdi, along the road between Mogadishu and Afgooye since April 2007. Besides general outpatient consultations, our medical teams run a paediatric ward of 50 beds, an intensive therapeutic feeding centre (ITFC) with a capacity of 85 beds, and two ambulatory programmes for acute malnourished children under 5 years' old (1 ATFC in Hawa Abdi, 1 ATFC in Afgooye town). In April 2008, due to increasing numbers of diarrhoea MSF opened a Cholera Treatment Centre and has since treated over 1,100 patients.

For over a year now, malnutrition rates among children in the internally displaced person's (IDP's) settlements have been above internationally recognised emergency thresholds . And the problem is not limited to the IDPs. In May 20 percent of the admissions to the ATFC in Hawa Abdi had travelled to the programme from Mogadishu. Over the first three weeks of June this number increased to 55 percent.

Admissions have increased four fold in the last two months, and they continue to increase everyday. Seventeen percent of these are complicated cases, which need hospitalisation. Between 13 and 19 June, over 500 children under five years' old were admitted to this nutritional programme, suffering from acute malnutrition.

Following this trend, the number of children in the programme has risen sharply since the month of March. In April 2008, MSF teams treated more than 2,500 new children for malnutrition in Hawa Abdi and Afgooye

Factors that have and will continue to impact on the nutritional status of the Somali population include the following:

• Continuous and indiscriminate violence, particularly in the Mogadishu area, causing further displacement of the population. An extra 33,000 people have fled from Mogadishu since the 1 April 2008.
• Increasing prices of staple foods. Some items have risen by up to 200 percent since the beginning of this year.
• The food price increases have been compounded by the devaluation in the currency. One US$ cost SOS 15,000 in April 2007, and in April 2008 the cost increased to approximately SOS 26,600, a near 80 percent devaluation.
• The poor Gu rains (Apr - Jun) come on the back of very poor rains in the Deyr season (Oct - Nov), putting further pressure on the local food supply.
• An increase in supply ruptures for the agencies involved in food distributions