Amina arrived in Dadaab in 1992, when she was one year old. Born in Afmadow, Somalia, she fled from her own country because of violence, drought and a lack of food. In the refugee camp, she shares a shelter with her husband, her young daughter and another 12 members of her extended family.
Amina thinks there is a lot that could be improved in the camps: the overcrowding, the water shortages, the food, the quality of the shelters, the poorly trained teachers in the camps' primary schools. Living in the camps, she is often afraid: there are frequent attacks by bandits, and she has heard of incidents of looting, stealing and women being raped while out collecting firewood.
In 20 years she has never left the camps. She believes that, had she been able to continue her education, she could have had a bright future. Now her only hope for the future is to be resettled in a third country. For the past two decades, the lives of ordinary Somalis have been devastated by armed conflict. The drought and escalating violence of 2011 only made an already desperate situation worse. Hundreds of thousands of Somalis have been displaced within their own country or have fled to neighbouring states to escape.
During 2011, nearly 200,000 people arrived at Dadaab, in Kenya's northeastern province, bringing the total population of the camps to almost half a million. The camps proved ill-equipped to support such a huge influx of people. As a result, most newly arrived refugees suffered from severe shortages of water, food, shelter and medical care. It was not until July 2011 that the aid agencies were able to respond properly to the huge needs of the refugees.
Even after that, there were outbreaks of measles and cholera, with more than 1,500 cases of measles amongst refugees of all ages. In our mental health programme - just one part of the medical activities run by Médecins Sans Frontières (MSF) in Dadaab - we have enrolled more than 1,500 patients and we carry out more than 700 mental health consultations each month.
Security conditions have got a great deal worse since October last year, leading most aid agencies to significantly reduce their operations. Refugees have had to fend for themselves, in many cases taking over the services previously provided by humanitarian organisations, despite lacking the necessary experience or training. Since the closure of the registration facilities last October, assisting new arrivals has become extremely difficult, as there is now no structured system for recognising and keeping track of new refugees.
Some of the newcomers are receiving food rations, but none have been given shelter materials or helped to find a place to stay. In addition, over the past nine months, refugees have not received immunisations or medical check-ups on arrival. Combined with the basic living conditions in the camps and the overcrowding, this raises the risk that refugees' health will deteriorate, as well as making outbreaks of disease more likely. This is why it is crucial that registration centres in each camp are reopened on a permanent basis.
One year after the emergency, we at MSF are still alarmed by conditions in Dadaab and concerned for the welfare of the refugees sheltering there. While mortality rates are coming down, and we have fewer severely malnourished children in our nutritional programmes than before, the refugees are still in an extremely precarious situation. Their circumstances make them vulnerable to a host of external factors, including epidemics, natural hazards, or another large influx of refugees to the camps, as happened in 2011.
Dadaab's refugees are by no means out of danger. We still have 850 severely malnourished children in our nutrition programme, indicating that one in every 60 children is so severely malnourished that they are at risk of dying. The number of people with multidrug-resistant tuberculosis is also on the rise. How many more nutritional crises or measles epidemics will it take before we start looking for a solution? Assisting refugees in Dadaab while simply waiting for the next emergency to happen raises more ethical questions than medical ones.
Carefully considered planning for the future of this refugee population is crucial. It seems clear that the paradigm of the camp has to be challenged. A large-scale voluntary return of refugees to Somalia is not a realistic option today. Alternatives - such as more generous quotas for resettlement abroad, and providing refugees with opportunities for self-reliance - definitely require further development; in such a complex situation, one size does not fit all. Meanwhile, in the short term, the immediate needs of the Somali people must not be forgotten, and their right to seek asylum must be protected.
Dr Elena Velilla is the Medecins Sans Frontières head of mission in Kenya.