Personal views: Djibouti
Authors: Edwin Martin, Peta Martin
Journal: BMJ (2001)

It has been Eid, the Muslim festival, in Arhiba recently. People greeted each other, there was a great deal of noise, children were everywhere, and there was a perceptible lightening of the spirits.

Nothing much else changed. Arhiba, where we work, is the poorest area of one of the poorest countries in the world. The rate of undernutrition in the Somali area of the horn of Africa is 78%, compared with 68% in Afghanistan and 52% in North Korea (figures from the United Nations). In Arhiba the rate is about 90%. Twenty per cent of all children we see are so severely undernourished that they would probably die without special feeding; 26% of children in any case die before they are five years old.

Children suffering from kwashiorkor consult us every day, brought in by walking skeletons of parents. The area consists of huts and tiny houses made of tin sheets, wood, blocks, and stones. The ground is so arid that nobody can grow the odd tomato plant in his or her backyard—if you don't have money you starve.


The unemployment rate is 90%. The tracks between the houses are full of large puddles of raw sewage, unless it rains, of course. On the few days a year that it rains the whole place becomes a sea of mud. Forget the pictures of refugee camps you have seen on television. There are no neat rows of tents here put up by competent Save the Children Fund staff, and no well built latrines. You see, this isn't an emergency. This is normal. This is the way things are here. 





ALEXANDER JOC/AFP


We work in a clinic in the middle of this area. The clinic is built out of concrete, and has washbasins and taps, but when we arrived there was no water. Also when we arrived there was no light in the health education room, or the doctors' room.

We are told that the level of HIV infection in Djibouti is about 10%, and about 10% of people have tuberculosis, but as we are unable to wash our hands easily between one dirty dressing and the next, we may well be spreading rather than curing disease. At the end of December a sign appeared outside the clinic saying that the World Bank was to refurbish it. If that happens it will be a luxury to have running water.

If you see a half dead baby—we see about four a day—and if you want to admit it to hospital, the parents often haven't got the money to go across town by bus (50 francs, equivalent to 20p sterling) to get to the hospital, let alone the 3000 francs (£12) to get into the hospital. So they go away and the babies die. But they die quietly, so nobody really notices. This week we have seen a two year old baby weighing 2.9 kg and another weighing 4 kg. So far this week, as far as we know, only two babies whom we have seen have since died. You can only do so much with rehydration salts and education when you often have an empty pharmacy.

“So what?” one might say. C'est la vie, terribly sad and all that. The only problem is that it doesn't seem like that at all when you work out here. Walking away from insoluble problems—something that seems logical when you are in the United Kingdom—suddenly seems less logical when you have a dying baby held by a marasmic mother in front of you.

The trouble is not an uncaring government. There are several excellent projects such as the polio eradication and AIDS awareness programmes run by the government. But what can any government do in a tiny country, totally desert, surrounded by wars, and therefore swamped by refugees? Add to that only one source of income, the port, and the result is misery and starvation on a scale beyond belief.