Mortality in Somalia during food insecurity and famine (2010-2012)

Women and children wait for assistance from the drought/famine in Dolo, southern Somali

The report summarised below on mortality rates during the Somali famine of 2010-12 casts a long shadow over the effectiveness of humanitarian response systems. An online blog written by Andy Seal and Rob Bailey is appended as a form of post-script as it raises a critical political dimension to the Somalia famine which has not been a significant part of the discourse since these events and warrants urgent further discussion in the context of future complex emergencies (Ed).

Location: Somalia

What we know: Southern and central Somalia was affected by severe food insecurity and famine in 2010-2012 with excess mortality. Mortality estimates to date have not covered the entire affected population or the full period during which food security emergency and famine conditions occurred.

What this adds: The study estimates that 258,000 (244,000 to 273,000) excess deaths attributable to the emergency occurred in southern and central Somalia (October 2010 - April 2012 inclusive). Of these, 52% (133,000) were among children under 5 years old. More than 90% of estimated deaths occurred inside south and central Somalia. Excess mortality began to increase in late 2010, well before humanitarian relief began to be mobilised. A timely and adequate humanitarian response was absent.

A report commissioned by FEWS NET and FAO/FSNAU on the mortality among populations of southern and central Somalia affected by severe food insecurity and famine during 2010-2012 has just been published¹. The report contextualises the famine which followed a prolonged period of drought resulting in the poorest harvests since the 1992-1993 famine. The effects of the drought were compounded by various factors including decreased humanitarian assistance and increasing food prices. Furthermore, this emergency occurred against a backdrop of heightened insecurity and persistent high levels of acute malnutrition, and affected populations whose resilience mechanisms had already been weakened over the past few years by a protracted crisis featuring a combination of armed conflict, natural disasters and adverse economic conditions. The evolving humanitarian emergency situation was detected in a timely way by existing early warning systems run by the United Nations Food and Agriculture Organisation’s Food Security and Nutrition Analysis Unit for Somalia (FAO/FSNAU) and the USAIDfunded Famine Early Warning Systems Network (FEWS NET). By July 2011, based on criteria established by the multi-partner Integrated Food Security Phase Classification (IPC, an analysis template used globally for deterÃ¥mining relative severity of food insecurity), the United Nations declared famine in several regions of Somalia. Based on further data and information collected on food security and nutritional status, disease and mortality, additional regions were designated as famine-affected over the subsequent two months. As a result of this emergency, during 2011 large numbers of people were internally displaced within Somalia or migrated to already overcrowded refugee camp complexes in Dollo Ado (Ethiopia) and Dadaab (Kenya). Measles, cholera and other epidemics, which typically accompany situations of greatly deteriorated nutritional status of the population, were also reported from nearly all affected regions.

The authors assert that there is consensus that the humanitarian response to the famine was mostly late and insufficient, and that limited access to most of the affected population, resulting from widespread insecurity and operating restrictions imposed on several relief agencies, was a major constraint. Based on numerous individual surveys conducted throughout southern and central Somalia by FAO/FSNAU and partners, and in the refugee camps by various other agencies, it was assumed that the impact of these combined events on human health would be severe. Indeed, the surveys indicated that both death rates and the prevalence of acute malnutrition among children were well in excess of emergency thresholds and far surpassing any value observed in Somalia during the previous five years, at least. However, the estimates of mortality from available surveys did not cover the entire affected population, nor the full period during which food security emergency and famine conditions occurred. During the emergency, the United Nations did not issue real-time death toll estimates. In 2012, improved conditions presented an opportunity to take stock of lessons learned and document the effects on health and mortality of exposure to severe food insecurity and malnutrition during 2010 and 2011. Therefore, this study was commissioned by FAO/ FSNAU, with substantial technical and financial support from FEWS NET.

The study provides estimates of overall and excess mortality over a period of 19 months between October 2010 and April 2012, during which time severe food insecurity and famine conditions prevailed. The analysis considered the 28-month period from April 2010 to July 2012 inclusive. The starting point for the analysis was determined by when the prevailing food security situation first began to deteriorate, while the end point reflected more pragmatically the timing of when this study was conducted. In practice, harvest and market data indicated that by July 2012, food security in nearly all regions of southern and central Somalia had returned to pre-emergency levels.

The study sought to quantify deaths that occurred above and beyond the number expected in the absence of the emergency (also known as excess deaths or excess mortality). Excess mortality can be estimated by combining three pieces of information: (i) the total death rate (i.e. number of people dying per population and per unit time) during the emergency period; (ii) what this death rate would have been if the emergency had not happened (this is also known as ‘baseline’ mortality); and (iii) the population living in the affected areas. Excess mortality is then given by the difference between the total and baseline death rates, multiplied by the population living in the region of analysis. These pieces of information were not immediately available for Somalia due to lack of systematic birth and death registration and incomplete tracking of population movements, and hence, had to be estimated. The study used a variety of previously collected data and statistical techniques in order to do so.

The 2010-2011 drought and crop failure affected mainly southern Somalia (Bakool, Banadir, Bay, Gedo, Hiran, Lower Juba, Middle Juba, Lower Shabelle and Middle Shabelle regions), and to a lesser extent, the central regions of Galgadud and Mudug, as evident from multiple data sources. All of these regions were included within the analysis, as well as the 11 refugee camps around Dollo Ado, Ethiopia and Dadaab, Kenya. For the purpose of analysis, the population of each of the included regions were classified into the major livelihood types present in the region (pastoralist, agro-pastoralist, ‘riverine’ or agriculturalist, internally displaced (IDPs) and urban), thereby creating 42 separate ‘strata’ within Somalia, plus a further 11 strata consisting of each refugee camp in Ethiopia or Kenya.

Key findings

Based on the most plausible set of population denominator data, the study estimated that 258,000 (244,000 to 273,000) excess deaths attributable to the emergency occurred in southern and central Somalia between October 2010 and April 2012 inclusive, of which some 52% (133,000) were among children under 5 years old. The highest estimated death tolls were in Banadir, Bay and Lower Shabelle regions. The full toll of the emergency is easier to visualise when considering the percentage of the population estimated to have died as a result: these are about 4.6 percent overall, peaking in Lower Shabelle at 9 percent for all ages and at 17.6 percent among children under 5 years old.

Prior to 2011, available surveys done in Somalia yielded a crude death rate for all ages (CDR) and an age-specific death rate for children under 5 years old (U5DR) that remained consistently below 2 and 4 deaths per 10,000 people per day respectively, though many of the values recorded were already indicative of emergency conditions. In southern and central Somalia (but not in the rest of the country), a striking peak in recorded mortality is apparent in July-October 2011, with individual survey CDRs and U5DRs reaching 5-6 and 10-15 per 10,000 per day respectively, and a CDR value of around 2.5 per 10,000 per day for southern and central Somalia, as estimated for all strata combined through direct and indirect methods. By contrast, the counter-factual baseline CDR was estimated to oscillate between 0.5 and 0.8 throughout the period, while the Sub-Saharan Africa 2010 average was 0.37. A higher baseline in southern and central Somalia compared to regional averages likely reflects underlying factors related to the chronic crisis, including inappropriate feeding practices, limited access to health infrastructure, inadequate water and sanitation services, armed conflict, etc.

As shown in Figure 1, excess mortality visibly began to accrue in October 2010. Between May and October 2011 inclusive, greater than 20,000 excess deaths per month (i.e. the difference between total and baseline deaths in Figure 1) were estimated to occur in southern and central Somalia. While this is considered the main famine period, it should be noted that excess mortality in the population began to rise well before, as conditions deteriorated over time, including in areas where famine was not declared.

In Dollo Ado and Dadaab refugee camps, excess mortality estimates ranged between minus 1000 to +5700 and minus 1300 to +8800 respectively, suggesting that either fewer or many more deaths occurred in these camps than would have if no emergency had occurred. Due to limitations in the available mortality and population data, no single best estimate can be provided for the camps, though most of the uncertainty range clearly falls within the positive region, indicating that many excess deaths (probably in the thousands) may have occurred in these camps as well.

Conclusions

This study suggests that severe food insecurity and famine in southern and central Somalia over a 19-month period in 2010-2012 resulted in a very large death toll, with a majority of excess deaths among children under 5 years old and a peak in excess mortality during mid-late 2011, which coincides with the declared famine period.

The estimate of about 244,000 to 273,000 excess deaths is similar to that for the 1992-1993 famine in Somalia. However, percent mortality during 2010-12 was about half, the population affected was larger and the definitions of famines were not consistent in the two events. Peak death rates were similar to those observed in other recent famines in Ethiopia and South Sudan. Excess child deaths, as estimated by this study, are about two to three times the annual amount in all industrialised countries combined. More than 90% of estimated deaths occurred inside south and central Somalia, where internally displaced people and riverine populations, particularly in Lower Shabelle, Bay and Banadir regions, were disproportionately affected. Notably, excess mortality began to increase in late 2010, well before humanitarian relief began to be mobilised and possibly earlier than previously recognised.

Children under 5 years accounted for over half of the deaths

The study relied on a unique dataset of more than 200 nutrition and mortality surveys conducted by FAO/FSNAU and partners in difficult conditions within Somalia using a mostly standardised approach. These were complemented by rich data on food security and other variables generated by the FAO/FSNAU and FEWS NET. Findings are highly dependent on the accuracy of mortality survey data, variables used for statistical modelling, and population denominators, which could only partly be assessed. Estimates for the refugee camps should be considered far less robust, as they are based on investigator assumptions rather than a formal statistical approach.

These findings place the 2010-2012 Somalia emergency among the most severe affecting humanity over the last decades, at least using a mortality metric. They broadly illustrate the potential health effects of drought and largescale food insecurity in the absence of a timely and adequate humanitarian response. This evidence should be used to ensure such deficiencies never occur again in the future. These estimates provide renewed justification for ensuring that adequate humanitarian assistance reaches all populations in Somalia, and for vigorously pursuing a resolution to the ongoing armed conflict.

¹Checchi. F and Robinson. W (2013). Mortality among populations of southern and central Somalia affected by severe food insecurity and famine during 2010-2012. A study commissioned by FAO/FSNAU and FEWS NET from the London School of Hygiene and Tropical Medicine and the Johns Hopkins University Bloomberg School of Public Health, 2 May 2013.