A year after one of the “worst famines”UNICEF, Humanitarian Action for Children 2012, http://www.unicef.org/hac2012/hac_somalia.php, accessed December 6, 2012 Somalia has ever known, the attention of the international community has turned elsewhere. While the food and nutrition situation is slowly improving, it remains fragile: according to the United Nations' Food Security and Nutrition Analysis Unit, one in five children are acutely malnourished, and more than two million people are still facing acute food insecurity.

60,000 people have fled fighting and a lack of access to water and food in Somalia since the beginning of 2012. They join one million Somali refugees in neighbouring countries – mainly Kenya, Ethiopia and Yemen – and a further million displaced within Somalia.

For relief organisations such as Médecins Sans Frontières (MSF), providing assistance to people in distress in Somalia remains a challenge. In the centre and south of the country, it is possible to identify at least three types of context, each posing significant constraints for humanitarian workers

As a result of a massive military deployment, Mogadishu is currently experiencing a period of relative stability, not seen since 2006, when the Union of Islamic Courts took control. Restaurants have reopened, foreign traders are in business again, and scaffolding testifies to economic investment by the Somali diaspora.

But the city is still not secure. Bombings and targeted assassinations are frequent, clashes between militias continue in some areas, and Al-Shabaab fighters have intensified attacks against pro-government forces. In addition, living conditions for the majority are atrocious – in particular for the 300,000 to 400,000 displaced people. Many are still living amid the rubble, in makeshift shelters of plastic sheeting supported by pieces of wood. As land comes up for development, those living in these makeshift camps have to relocate; some have moved several times. Access to drinking water is insufficient and irregular – it is not uncommon for taps in the camps to remain dry for several weeks at a time – while the few hospitals in the capital struggle to cope with large numbers of patients from all over the country. Following the evacuation of its staff due to heavy fighting in April 2012, Daynile hospital – supported by MSF – reopened in September.

The second context is in the Somali cities that have been ‘liberated’ from Al-Shabaab administration over the past year by the joint military mission of the African Union in Somalia (AMISOM), Ethiopia and the Somali Transitional Federal Government. Today the security of these urban populations is probably more fragile than it was a year ago. Assassinations, attacks, robberies, extortion and intimidation are commonplace. Access to health facilities remains a problem, and few people will brave the journey to hospital after dark.

Finally, in many south and central rural areas, Islamist fighters still hold sway. Most are opposed to the presence of foreign aid organisations and, after successive waves of bans and expulsions, only a few humanitarian organisations – including MSF – are just about able to continue working in these areas.

Working in Somalia means, first of all, accepting to work in dangerous conditions. For our staff, it means assessing the risks linked to their assignment, on an individual basis. Incidents can happen for a number of reasons – related to the drugs trade and to the fight for jobs, and just being in the wrong place at the wrong time, among other reasons.

At the time of writing, two MSF staff are still being held in Somalia, more than one year after they were kidnapped from Dadaab, Kenya. In December 2011, two members of the MSF team in Mogadishu – Philippe Havet and Dr Andrias Karel Keiluhu – died from their wounds after being shot by a Somali colleague.

The situation leads us to reduce the activities we would normally want to carry out given the needs, for two reasons.

The first is a choice we have made to prioritise medical emergencies and nutrition until the release of our kidnapped colleagues who are being held in the country.

The second is a practical reaction to the risks our staff face: we have to limit the scope of our projects and the number of international staff, who are particularly vulnerable to abduction. This can mean accepting that we have less control over our activities than we would wish, or have less assurance of the ??medical quality of our programmes. The choice to provide support mainly to hospitals and surgical centres also reduces the movement of our teams, and therefore their exposure to risk.

In addition, and very unusually for MSF, we use armed guards in Somalia to deter attempted kidnapping or attacks. This is itself not without risks, notably the possibility of lives being lost in crossfire.

Insecurity is not the only constraint for aid organisations working in Somalia. It is difficult to identify reliable partners with whom to create alliances and negotiate the access we need to work, while weak and disorganised medical facilities, a lack of trained health workers, and an incomplete understanding of medical needs all represent obstacles for aid organisations.

Finally, while it is essential that MSF’s resources are for the benefit of patients, we must be aware that humanitarian aid can be a source of power for local stakeholders, and that taxes, diversion of aid and attempted extortion are all common practices in Somalia.

Away from generalisations and clichés, these are the issues that define the limits to MSF’s work in Somalia, which we believe is still possible and still useful. This is the price we have to pay to do our work. Rather than lamenting these limits, we need to accept the fact that they exist and to learn how to deal with them.