Updated November 30, 2017
The conflict between the Nigerian military and armed opposition groups known as Boko Haram has convulsed Nigeria's Borno state for more than eight years, with serious humanitarian consequences. According to OCHA, more than 1.7 million people are internally displaced in Nigeria’s northeastern states of Borno, Adamawa, and Yobe. Of these, 78 percent are in Borno.
Over the past year, the provision of humanitarian assistance has improved but, overall, remains inadequate as security and access challenges hamper the delivery of aid in some areas. Hundreds of thousands of people remain heavily dependent on aid for their survival. In some places, people have been stranded for over two years with little prospect of returning home. Needs are particularly acute in isolated enclaves outside the state capital, Maiduguri. Any disruption to the provision of this assistance could have deadly implications.
Doctors Without Borders/Médecins Sans Frontières (MSF) has expanded operations in accessible areas of Borno state that are heavily controlled by the military. However, other parts of the state that are under the control of armed opposition groups remain unreachable. There is very little information available about the needs in these areas, but displaced people who have recently left report that medical and humanitarian services are limited.
Refugees from camps in neighboring Cameroon and people from across Borno state continue to arrive—not always by choice—in towns controlled by the military. Many of these towns are already overstretched in terms of providing basic amenities. Aid must be scaled up in these places, to prevent health risks to new arrivals and existing populations.
MSF provides medical care to vulnerable groups in Borno state, including women during pregnancy and childbirth. Teams also run nutrition programs for children, provide mental health support, respond to disease outbreaks, and provide emergency pediatric care. The nutritional situation has generally stabilized in Maiduguri, the capital and largest city of Borno state, due to a massive deployment of aid. But vulnerable pockets remain.
Access to adequate nutrition is more precarious in isolated enclaves such as Pulka, Banki, Bama, Dikwa, and Rann. Freedom of movement is restricted, so people are unable to farm or fish, leaving them heavily dependent on humanitarian assistance. MSF provides medical aid in these locations, either through permanent health facilities or frequent visits by dedicated emergency teams.
Maiduguri is home to around two million people, one million of whom are internally displaced, having fled other parts of Borno state. The vast majority (90 percent) live with the city’s original population, with the remainder living in official and unofficial camps.
MSF operations in Maiduguri focus on maternal and child health, including nutrition, and conducting surveillance activities to ensure the provision of food, shelter, water, and medical care. In preparation for the rainy season, MSF provided malaria prevention doses for children under five years old, as well as for pregnant and breastfeeding women.
Since August, MSF has been responding to a cholera outbreak in Maiduguri and Monguno and preparing to tackle any spread of the infection in other parts of Borno. Until November, MSF operated two cholera treatment centers (CTCs) in Maiduguri and one in Monguno, treating a total of 3,253 patients. Teams also established two oral rehydration points in two camps in Maiduguri. In Mafa, MSF opened a four-bed cholera treatment unit (CTU) and treated 20 patients while continuing water and sanitation activities. MSF’s cholera treatment activities in Borno state have now concluded, and the government is soon expected to declare the end of the outbreak.
In Fori, a southern district of Maiduguri, MSF runs a 100-bed inpatient therapeutic feeding center (ITFC). This ITFC, which opened in January, currently treats between 70 and 80 severely malnourished children, often with complications, each week, and has a high bed occupancy rate. MSF also runs an outpatient feeding center in Fori for less severe cases. More than 2,000 children are currently enrolled. This program saw 1,292 admissions from January to September 2017.
A second outpatient feeding center in Dala, set up in anticipation of more children needing treatment throughout the summer (the traditional “hunger gap” period), was handed over to international humanitarian organization Terre des Hommes in September. Around 900 children were enrolled in the program until the end of August and more complicated cases were referred to the Fori ITFC. The outpatient feeding centers in Dala and Fori have seen 5,021 admissions since the beginning of the year. MSF also began operating an 80-bed CTC in Dala, which saw 531 admissions before its closure in September.
Borno Emergency Support Team (BEST)
BEST is a dedicated MSF team that monitors and responds to health care needs across Borno state. Its operations include targeted vaccination campaigns, survey coverage, nutritional screenings, distribution of therapeutic and non-therapeutic food, malaria prevention doses—known as seasonal malaria chemoprevention (SMC)—medical consultations, outbreak response, and water and sanitation interventions.
BEST manages interventions in camps for displaced people in Bama, Dikwa, Gajiganna, and Maiduguri, as well as screening points and settlements in Maiduguri and other parts of Borno. In August and September 2017, BEST was involved in the scale-up of cholera activities until the arrival of a dedicated cholera response team.
As the situation in Maiduguri stabilizes, MSF has handed over its outpatient feeding center in Gwange to the Ministry of Health and children enrolled in the outpatient feeding program will be referred to the center in Fori, which has increased its capacity. In Gwange MSF now focuses on secondary pediatric health care, running an 88-bed pediatric inpatient department with an intensive care unit for children up to the age of 15. The capacity and occupancy rates have recently increased with the peak in malaria cases following the rainy season.
Maimusari health facility, which included a maternity ward, outpatient department, and an outpatient therapeutic feeding center, has also been handed over to the Ministry of Health. A pediatric outpatient department, an outpatient feeding center, and an emergency room will continue to operate in Bolori until a handover at the end of 2017. Between the beginning of the year and September 2017, 100,332 consultations were carried out in the two pediatric centers in Maimusari and Bolori.
Since January, 11,588 malnourished children have been admitted in the outpatient nutritional program, with an average of 297 admissions per week. Antenatal consultations totaled 41,803, while 5,697 deliveries were assisted.
In August and September, a dedicated cholera response team managed two oral rehydration points and a 100-bed CTC. As of November 2017, the cholera treatment center at Muna (which was later moved to Bolori) has admitted 1,110 patients. All cholera treatment activities have now wound down as patient numbers have dropped considerably.
According to the International Organization for Migration (IOM), displaced people in Monguno comprise over 122,000 who fled conflict from other local government areas (LGAs) in Monguno and are unable to return to their homes. The majority of internally displaced people live in four camps. Others are in non-registered sites or the host community.
MSF is the only organization providing secondary pediatric health care in Monguno, where 6,049 emergency consultations were provided and 2,684 children were admitted to the inpatient department up to September. MSF also operates an outpatient department for adults and children from camps and villages outside Monguno. In total, 34,623 consultations were carried out between January and September. MSF opened a CTC and two oral rehydration points in September, treating 1,612 patients until the end of November 2017.
The Bama LGA in Borno state is completely under the guard of the military and Civilian Joint Task Force (CJTF). According to the IOM, the estimated number of internally displaced persons in Bama is approximately 56,000. They are completely dependent on humanitarian assistance for survival.
BEST reduced its interventions in Bama as other organizations stepped in to provide food and medical aid. This year, the team improved water and sanitation activities in January, distributed food in February, and provided SMC to 4,671 children under the age of five in July. A second round of SMC covered 4,567 more children in August. BEST also conducted mobile clinics and nutritional screenings in Bama.
Most of Dikwa town has been destroyed and the population of 120,000 now lives in a military-controlled enclave. The entire population—which includes approximately 75,000 internally displaced people, according to the IOM—is completely dependent on food distributions.
BEST regularly visits Dikwa to provide emergency support, including monitoring outbreaks of diseases such as cholera, distributing food (January), and running mobile clinics (April and May). In addition, 45,456 people between one and 29 years of age were vaccinated for meningitis and 3,553 children were immunized against measles. In June, BEST supported the primary health center and improved water and sanitation conditions in Dikwa. MSF conducted additional activities in Dikwa in October.
Ngala town was retaken from Boko Haram by the Nigerian armed forces in February 2015. According to the IOM, approximately 44,000 internally displaced people live in Ngala. The military is in charge of the security of the camp, but a token system allows people to leave during the day. When MSF started working in Ngala in September 2016, teams found an alarming situation in which access to food, water, shelter, and medical care was extremely limited. This situation has considerably improved and, since February 2017, MSF has a permanent team in Ngala.
MSF runs a 54-bed inpatient department which includes maternity, delivery, and neonatal care services. Teams also provide primary health care, blood bank services, support for survivors of sexual and gender-based violence, nutritional care, and outpatient consultations.
Living conditions in the camp are poor. As a result, MSF treats patients for illnesses such as hepatitis E, admitting 41 patients suffering from the disease since an outbreak was declared over the summer. From January to September, MSF provided 19,953 outpatient consultations and 1,254 inpatient admissions, with 6,213 patients enrolled in therapeutic feeding programs.
Rann was attacked and destroyed by Boko Haram in 2015, which led to the town’s population fleeing to other towns in Borno and to neighboring Cameroon. Rann was recaptured by the Nigerian armed forces in March 2016, and people started returning in April 2016. According to OCHA, around 50,000 people currently live in Rann.
The population has doubled since April as people have fled ongoing military activity in the surrounding areas. MSF provided medical care in Rann in January this year when the town was bombed, killing 100 people and injuring around 150. The Nigerian military later claimed responsibility for the bombing, saying it was a mistake. Three staff working for an organization subcontracted by MSF were among those killed.
Following the Rann bombing, MSF mobile teams delivered medical care in Rann on a regular basis. Since September, MSF has had a permanent medical team in Rann and is now the main health provider in the town. The humanitarian situation in Rann is worrisome, as the town was cut off from the rest of the country during the rainy season. Humanitarian assistance has since been sporadic. By September, MSF had conducted 2,887 outpatient consultations and provided preventive treatment for malaria to 17,280 children.
People who fled the violence between Boko Haram and the military now reside in the camp and main town in Banki. It is under the control of the military and people can leave only to collect firewood in organized, supervised groups.
Most of the town’s original population fled in 2015 after it was taken by Boko Haram, with many crossing the border into Cameroon. The number of Nigerians returning from Cameroon, some by force, has risen in past months. In May alone, 12,000 people arrived. MSF started working in Banki in July 2016 after finding an extreme humanitarian situation with health and nutrition indicators far beyond emergency standards. Teams provided emergency medical care, screened children for malnutrition, distributed food, and worked to improve the water supply.
In March, as the situation stabilized, MSF handed over medical activities to UNICEF but continued water and sanitation support through flash visits several days per month. During the rainy season, from July to September, MSF distributed mosquito nets and conducted malaria prevention activities for 33,200 children under five.
In November 2014, armed opposition groups attacked Damasak, forcing residents to flee to neighboring Niger and other areas in Borno state. The Nigerian armed forces recaptured Damasak in July 2016 and people began to return. MSF started providing medical care in Damasak in April, with a mass nutrition screening of 5,986 children between the ages of six and 59 months. Teams also provided care for 884 children with severe and moderate acute malnutrition, vaccinated 8,700 children between six months and 15 years of age for measles, and immunized 11,219 people for meningitis.
MSF also led the medical response to a hepatitis E outbreak, referring complicated cases to MSF hospitals in Niger. To prevent the spread of malaria during the rainy season, 28,241 children under five received four rounds of SMC.
Damaturu is a town in Yobe, a state bordering Borno. Although it is relatively stable, it is always under threat from Boko Haram. The main health care needs are malaria and malnutrition.
In Damaturu hospital MSF operates a 25-bed emergency pediatric unit and a 50-bed stabilization center that treats children under five suffering from severe malnutrition with medication complications. From January to September, MSF admitted 1,235 patients to the inpatient department and conducted 33,469 outpatient department consultations, 4,122 maternal health care consultations, 601 deliveries, and 4,430 admissions to therapeutic feeding programs.
In Kukerita, MSF runs an outreach health center and provides comprehensive primary health care, including an outpatient department, emergency room, observation room, vaccinations, antenatal care, and deliveries. Patients requiring referrals are moved from Kukerita to Damaturu hospital, but movement remains challenging.
In Jakusko, MSF supports secondary health care ranging from emergency to inpatient department services. Teams screen nutrition levels and conduct referrals, epidemiological surveillance, and health promotion activities.
Benisheikh is a relatively stable town and home to around 28,000 displaced people. People are free to move and markets are open. Given the relative stability of the area, MSF has handed over operations in Benisheikh to the Ministry of Health and various partners.
Until September 2017, MSF operated therapeutic feeding centers and supported a pediatric inpatient department. Teams also provided sexual and reproductive health and monitored health indicators in the community. From January to September, MSF admitted 800 inpatients and provided 3,152 antenatal consultations—with 261 deliveries—and 6,566 outpatient department consultations. Three-thousand two-hundred patients were enrolled in therapeutic feeding programs during this period.
MSF continues to provide water and sanitation services in some of the town’s camps. Nearby, MSF supports a therapeutic feeding center in Ngamdu and provides outpatient department care for all age groups and an outpatient feeding program in Mainok.
Gwoza is heavily controlled by the military and bordered on one side by the Sambisa forest and on the other by mountains. Boko Haram is said to be active in both. The town often receives arrivals of displaced people from other areas and from Cameroon. Gwoza is only accessible by helicopter or by road accompanied by military escort.
In recent months, more organizations have joined MSF in Gwoza. To avoid duplication, MSF handed over some activities while continuing to provide emergency room, nutritional care, inpatient care, and sexual and reproductive health services.
Figures from January to September include 1,596 inpatient department admissions, 16,554 outpatient department consultations, and 3,233 antenatal care consultations with 571 deliveries. Five-hundred seventy-seven children were enrolled into the outpatient therapeutic feeding program and 141 were admitted to the stabilization center.
According to OCHA, Pulka town hosts 27,529 internally displaced personsin the camps and the host community. The town is heavily controlled by the military, which allows people to go a short distance beyond the town’s perimeter to farm. Many do not feel safe enough to do so.
Pulka experiences regular influxes of people because of its proximity to the border. As a result of the unplanned and large-scale movement, shelter is lacking in Pulka. More than 25 percent of IDPs do not have shelter, according to an IOM estimate at the end of August 2017. New arrivals in Pulka are vaccinated and provided with non-food items like jerry cans and mosquito nets, and children undergo nutritional screenings.
MSF provides primary and secondary health care, including outpatient care, emergency room services, ante- and postnatal care, and referral services. Teams also provide mental health activities, community surveillance, and water and sanitation services for people living on the hospital grounds. From the start of the year until September, MSF admitted 1,536 patients to inpatient department care, carried out 24,749 outpatient consultations, and conducted 3,588 antenatal care consultations (with 601 deliveries). During this period, 1,072 children were admitted to therapeutic feeding programs. MSF also implemented an emergency team to tackle malaria and cholera.
In response to the cholera outbreak, MSF continues to provide water and sanitation services, including the construction of showers, latrines, and a borehole.
This information is excerpted from MSF’s 2016 International Activity Report.
The conflict between Boko Haram and the Nigerian military has resulted in massive displacement and a catastrophic humanitarian emergency across the northeast. In several areas of Borno State, high mortality rates were linked to severe malnutrition and preventable diseases. Although security within Maiduguri, the state capital, improved slightly, active conflict, mass displacement, and disease outbreaks continued outside the city.
MSF scaled up emergency assistance in Borno and the surrounding region. Insecurity limited MSF activities in some of the hardest hit villages, leading teams to carry out rapid interventions. MSF scaled up services in camps for displaced people in Maiduguri and in 10 nearby towns, running clinics to remote locations where access was possible. MSF admitted 20,760 children to therapeutic feeding centers, carried out 290,222 outpatient and 2,764 emergency consultations. MSF conducted over 56,000 antenatal care consultations and assisted in 5,181 deliveries. Teams provided over 1,099 tons of food to displaced people in the last half of 2016, vaccinated approximately 130,000 children against measles and 10,052 against pneumococcal pneumonia, and provided 18,754 with SMC.
In Kukareta village in Yobe state, MSF offered a range of care, referring complicated cases to Damaturu hospital in the state capital, where MSF operated a nutrition program and reached 3,717 children in an SMC campaign.
In Jakusko local government area, MSF vaccinated 143,800 children against measles and started working in four therapeutic feeding centers. MSF began working in Zamfara state in 2010, responding to lead poisoning in children. In 2016, MSF teams treated children in five clinics and in Anka general hospital.
Following an outbreak of lead poisoning in Niger state, MSF opened the safer mining pilot project in November and worked with miners to reduce exposure to lead and off-site contamination.
In the Kebbe area of Sokoto state, MSF supported Kuchi health care center to treat pregnant women and chidren until May, when the project closed due to insecurity. In Sokoto, MSF provided surgical care for 388 patients with noma and other diseases and worked with the MoH and the World Health Organization to respond to a meningitis outbreak, vaccinating 113,030 people.
In Port Harcourt, Rivers state, MSF provided the comprehensive package of care for survivors of sexual violence, which included PEP for HIV and sexually transmitted infections, vaccinations, emergency contraception, and counselling. MSF continued to run its vesico-vaginal fistula and emergency obstetric program in Jahun general hospital in Jigawa state. The team treated 400 women with fistulas, performed 2,660 obstetrics-related surgical procedures, and assisted in 7,365 births. MSF also set up basic emergency obstetric services in surrounding health centers.