An exceptional year: With the rise and fall of the Union of Islamic Courts, the establishment of a weak Transitional Federal Government and Ethiopian troops crossing the border to fight in Somalia, the turbulent past year briefly placed Somalia on the international agenda.

But despite the international interest, the deplorable humanitarian conditions that Somalis are forced to endure remain grossly underreported. Floods, wars and droughts only exacerbate the suffering in a country where one in 10 women dies during childbirth (Lifetime Risk of Maternal Mortality) and approximately 22.5% of children die before their fifth birthday.

Somali health standards are among the worst in the world. Malnutrition is chronic and in many places above the threshold that would cause an emergency intervention in other countries. Tuberculosis (TB) infection is rampant. Rare but fatal diseases like kala azar are endemic in certain areas. Many children die from easily curable disease every day, including malaria and respiratory infections.

A vast majority of Somalis have no access to healthcare. What little medical aid there is, is privatised and costly and therefore out of reach for most.

Since the country's last President with widespread authority, Siad Barre, was ousted in 1991, the estimated 11.5 million Somali people have been without a functional central government providing any kind of public health services. 350,000 people are thought to have been internally displaced and 300,000 have sought refuge abroad. An additional 321,000 were displaced by the fighting in Mogadishu in early 2007.4 MSF has worked in Somalia for over 17 years.

At the time of going to press, we have over 50 international and around 600 national staff working in 10 out of 11 regions in south and central Somalia, covering basic medical needs for tens of thousands of people. Each location is unique in the clan makeup, the people in charge, the security arrangements necessary and, in some cases, the prevalence of diseases. All locations share huge needs and a war economy that has not allowed a governmental structure to provide any social services for over a generation. But many areas are inaccessible to MSF due to insecurity. For the same reason, patients are not always able to reach our facilities. 2006 was an exceptional year for MSF's projects in Somalia.

Our staff performed more than 300,000 outpatient consultations and 10,000 inpatients were admitted in our hospitals. Many of MSF's established projects have increased and expanded their activities in the past year. For instance, in Xudur health centre (Bakool region), consultations for kala azar patients rose by 530% between 2004 and 2006. In the same period, adult inpatient admissions rose by 83%, overall outpatient consultations by 58% and children under 5 consultations by 65%. Quality indicators, such as cure rates, have also risen dramatically in the same period.

Many of MSF's other projects throughout Somalia have seen similar growth. In 2006 and early 2007, MSF also opened new projects in the regions of Galgadud (Dhusamareeb and Guri El), Hiraan (Belet Weyne) and Lower Juba (Jamaame). Likewise, in 2007 activities were also opened on an emergency basis in Afgooye, Hinder, Gal Hareeri and Mogadishu in response to outbreaks of cholera and/or displaced people fleeing the capital.

MSF's presence shows that it is possible to provide both primary and, in many cases, secondary health services in Somalia. Even so, MSF is sometimes forced to suspend its medical activities and evacuate international staff due to growing insecurity.

At times of international staff evacuation, MSF projects continue to run under the management of Somali personnel, who make up the backbone of our work in Somalia.

This document provides a closer look at MSF's efforts to alleviate the desperate medical situation Somalis continue to endure; a dramatic situation that receives little attention from either international donors or the international media. It provides a comprehensive overview of MSF's activities in Somalia in 2006 and early 2007.

MSF has increased its operations tremendously in Somalia in the past years, but our efforts are still a mere drop in the ocean compared to what is needed. We hope that our commitment to providing quality medical care in Somalia is not the exception and call on the international community to do more to assist the Somali people.