Lake Chad crisis

Around 17 million people live in areas affected by violence resulting from the conflict between non-state armed groups and military forces in the Lake Chad region.

After several years of violence in northeast Nigeria, in 2014 the conflict between military forces and non-state armed groups in the region expanded into Cameroon, Chad, and Niger.

So far, the states involved have focused on security and a strategy of military containment to fight against the armed groups. They have barely addressed the humanitarian consequences of the crisis, although the armed conflict across the region has had direct consequences on people subjected to indiscriminate violence at the hands of all warring parties and forced displacement.

Food production and distribution has been seriously disrupted and people’s health and living conditions affected, including widespread psychological trauma.

What's the situation today?

Across Nigeria, Cameroon, Chad and Niger, violence has uprooted more than 2.5 million people from their homes. Some 1.7 million people are internally displaced within Nigeria, while hundreds of thousands of internally displaced people (IDPs) and refugees can be found in Cameroon, Niger, and Chad. 

The UN refugee agency, UNHCR, reports that, as of August 31, 2020, a total of 299,314 Nigerian refugees are living in Chad, Cameroon, and Niger. According to the Armed Conflict Location and Event Data Project (ACLED), more than 37,500 people were killed in the conflict in the Lake Chad Basin between May 2011 and July 31, 2020.

Many of the displaced have found refuge in host communities, putting a heavy strain on people in a region already suffering from poverty, extreme vulnerability, food insecurity, recurrent disease outbreaks, and almost non-existent health care systems.

According to OCHA, 10.7 million people are in urgent need of food, safe drinking water, shelter, health care, protection, and education.

A significant increase in the number of security incidents and attacks, as well as military operations against armed groups, has led to the further displacement of people across the four countries of the Lake Chad Basin.

Attacks targeting civilian locations in Nigeria, including sites for displaced people, increased significantly in 2017, putting more pressure on the population. The attack on Rann town on March 1, 2018, is the latest example and one which led humanitarian organizations, including MSF, to temporarily suspend activities and evacuate their teams.

The provision of aid remains stretched, due to security and access issues. Some camps for displaced people in Nigeria’s Borno state still lack basics such as food, clean drinking water, shelter, and sanitation. Needs are particularly acute in isolated enclaves outside the state capital, Maiduguri.

The rainy season in 2017 saw a rise in malaria and other epidemics such as cholera and hepatitis E, and the provision of humanitarian aid in remote locations was hampered by the waterlogged roads. The town of Rann was completely cut off from the outside world and no assistance was brought in during the four months of rain.

People from across Borno state, as well as refugees from neighboring Cameroon, continue to arrive–not always by choice–in towns controlled by the military. They have limited freedom to move outside these areas and are dependent on humanitarian assistance to survive. In some areas, people have been stranded for over two years, with little prospect of returning home.

In Cameroon, Chad and Niger, the ongoing presence of armed groups threatens the livelihoods of both the local populations and people displaced in the area. The majority of displaced people have found refuge in communities already facing challenges, putting more pressure on scarce local resources and overstretched infrastructure. Due to the ongoing insecurity, families are frequently forced to look for new places to live, making them even more dependent on humanitarian assistance.

In Niger, more than 60 percent of the displaced and refugee populations living in and around Diffa have settled in informal sites where living conditions are harsh and there are unmet needs for proper shelter, clean water, food, sanitation, and health care. A ban on various economic activities and restrictions on people’s movements further hamper the ability of locals, displaced people, and refugees to be self-sufficient.

In Cameroon, the security situation remains very volatile. The far north region is frequently affected by attacks and suicide bombings. We have scaled up our emergency surgical activities in response. In the area bordering Nigeria, health facilities lack staff and medical supplies, and many have been abandoned altogether.

Chad’s Lac region, one of the poorest areas in the country, hosts thousands of Nigerian refugees and internally displaced people. After a peak in 2015 and 2016, the humanitarian emergency is slowly receding, and relative calm has been restored.

What are we doing in the region?

Our teams are providing medical care to vulnerable groups–both displaced people and host communities–across three of the four countries of the Lake Chad Basin.

In Chad, living conditions for IDPs have significantly improved, people are progressively returning to their villages of origin, and development programs have been put in place by aid agencies. We therefore decided to withdraw our teams from Chad’s Lac region in 2018.

Women and children are the most vulnerable, so our activities focus on maternal and child health. Our teams also respond to outbreaks of disease, and provide medical care and mental health support to victims of violence.

Malnutrition

We have had a small team based in Maiduguri, in Nigeria’s Borno state, since 2014, treating malnutrition, providing maternal health services, and responding to outbreaks of cholera and measles.

Epidemiological surveys conducted in informal settlements in the city revealed evidence of extreme malnutrition and mortality during the first nine months of 2016, affecting children in particular.

In June 2016, we also observed extremely high levels of malnutrition and mortality in Bama, Borno state’s second largest town, and raised the alarm about the humanitarian needs in Borno state, which led to a large deployment of aid to the area.

While the nutritional situation has generally stabilized today in Maiduguri, vulnerable pockets still remain there and elsewhere in Borno state. Access to adequate nutrition is more precarious in isolated enclaves such as Pulka, Gwoza, Banki, Bama, Dikwa, Rann, and Ngala, as people are unable to farm or fish, and their freedom of movement is restricted, making them heavily dependent on humanitarian assistance.

We ran nutritional programs in enclaves such as Pulka and Gwoza, and continue to work in a 100-bed inpatient therapeutic feeding center in Fori, a southern ward of Maiduguri, which aims to serve as a referral point for severe acute malnutrition cases in Maiduguri. We also operate a 50-bed inpatient therapeutic feeding center in Damaturu hospital, in the capital of neighboring Yobe state.

In 2017, our teams distributed food and provided nutritional screening and care for over 35,700 malnourished children through inpatient and outpatient therapeutic feeding centers in Borno and Yobe states.

In Cameroon, more than 1.5 million people (or one in three) are "food insecure" to the point of crisis or emergency. The situation in the departments of Logone and Chari, in the far north of the country, is particularly alarming: 10.9 percent of children suffer from global acute malnutrition and 2 percent from severe acute malnutrition. In 2017, we admitted 2,065 children to our inpatient therapeutic feeding center in Kousseri, and 4,496 to our outpatient feeding programs in Kousseri and Mora.

In Niger, we support five ambulatory therapeutic feeding centers, as well as the inpatient therapeutic feeding center (ITFC), pediatric and general medicine departments in Mainé-Soroa district hospital. We also support Nguigmi district hospital’s ITFC, as well as its pediatric and obstetric wards.

Pediatrics and maternal health

A total of 11,842 children under five were admitted for care at MSF facilities across northeast Nigeria’s Borno and Yobe states in 2017, and over 9,000 deliveries were assisted by MSF staff–almost double the total number of the previous year. Our teams also vaccinated children against measles, pneumococcal pneumonia, and other preventable diseases.

We provide emergency pediatric care, mental health support, and nutritional programs for malnourished children at permanent health facilities in Rann, Ngala, Monguno in Borno, and Damaturu in Yobe.

In the far north region of Cameroon, we have been providing specialized nutritional and pediatric care at Mora district hospital since August 2015. We also provide obstetric care, nutritional care, and inpatient pediatric care at the district hospital in Kousseri, where 3,451 children were admitted in 2017–almost a quarter more than in 2016.

In Chad, we supported the Ministry of Health in the pediatric, nutrition, and maternity wards of the regional hospital in Bol from November 2015 to June 2018, when we gradually started handing over our activities to local health authorities.

In Niger, we support the mother and child health center in Diffa and Mainé-Soroa district hospital and have set up community “listening spaces” in villages around Diffa, in order to provide advice and medical assistance for sexual and reproductive health issues. This is just one example of the community approach we take throughout the region, using mobile clinics and involving the community as much as possible.

We also conduct malaria prevention activities in the Lake Chad region, including seasonal malaria chemoprevention.

Responding to disease outbreaks

Outbreaks of disease are a major concern, as sites are overcrowded, shelters are inadequate, and the water and sanitation infrastructure is insufficient for the large numbers of people living in the sites.

In Niger, a hepatitis E outbreak was declared by the Ministry of Health on April 19, 2017. In response, we have been helping to train health staff and community workers in the Diffa area and support communities, health centers and hospitals with the early detection of cases, referrals to health facilities and case management.

At the water points located in MSF’s areas of response, the teams conduct water and sanitation activities, and our teams conduct awareness-raising campaigns about preventing the spread of disease among displaced people and refugees, both in camps and in the villages of the districts where we work.

From August to December 2017, we responded to a cholera outbreak in Nigeria’s Maiduguri, Monguno, and Mafa. Our teams treated 3,942 patients and operated four cholera treatment centers and two oral rehydration points across the Borno state. We also constructed water and sanitation facilities to help curb the spread of disease. In 2018, we have responded to outbreaks of cholera in Borno, Yobe, and Adamawa states. In 2019, we continued to respond to an ongoing cholera outbreak in the North and Far North regions of Cameroon.

The onset of the rainy season poses higher risks of outbreaks such as cholera and malaria. The water and sanitation infrastructure must be strengthened in order to increase access to safe drinking water to prevent spread of water-borne diseases.

We monitor potential disease outbreaks in all the areas where we work, run vaccination campaigns and undertake water and sanitation activities in hospitals and communities. This includes the construction of waste management sites, the construction or rehabilitation of latrines and the chlorination of water points, as well as the provision of safe drinking water.

Our COVID-19 activities in the area

COVID-19 is spreading across the Lake Chad Basin. The major risk of COVID-19 in Africa will probably not be the virus itself, but its indirect consequences, such as the limited response to malaria, diarrhea, respiratory infections, and malnutrition, as well as other diseases and medical conditions.

Since the beginning of the COVID-19 outbreak, we have been concerned about its effects on routine vaccination activities and campaigns because of restrictions on movements and gatherings, and a lack of protective equipment. Misinformation about the virus has led communities to fear becoming infected as a result of visiting health centers.

MSF teams have adapted our ongoing projects, while supporting national responses to COVID-19. In places where the needs are the greatest, we have opened or contributed to the creation of COVID-19 treatment centers.

We are also supporting many existing health facilities by helping them to recruit and train medical staff, establish isolation units and triage systems, and strengthen hygiene and prevention measures. In facilities across Niger, Chad, and Cameroon, we have installed oxygen generators to help treat severe cases.

Mental heath care

Mental health care is an increasingly significant part of MSF’s work in the Lake Chad region, given the psychological suffering of the host, refugee, and internally displaced populations.

In Niger in 2018, we introduced a new community approach, with mental health agents at camps, schools, water points, and other places, in order to reinforce the identification of people in need of psychological support. In 2017, we provided more than 15,700 mental health consultations across the Diffa region. The main symptoms detected by the team were post-traumatic stress disorder (PTSD), anxiety, and depression.

In Chad, psychological support has been offered at all our mobile clinics, where staff reported that deep psychological traumas were quite common. This prompted the launch of a specific mental health program to provide psychological consultations and follow-up.

In Cameroon, we provide mental health care in the health centers of Mora and Kousseri, and in the surgical department in Maroua regional hospital.

In northeast Nigeria, we conducted mental health activities in Pulka and in Gwoza, and provided mental health care for survivors of sexual and gender-based violence. 

In 2021, MSF made the hard decision to close our medical activities in Pulka and Gwoza due to security developments in the area and accrued threats to humanitarian workers.

Emergency care following attacks

In Cameroon in particular, we provide emergency care to victims wounded in violent attacks. In Mora, we are working in the local district hospital and have established a special ambulance service to transfer severely injured patients who require lifesaving surgery to the hospital in Maroua.

We continue to provide support to local health authorities to help respond to mass casualties following violence, by means of an emergency response plan implemented with all relevant medical providers in the area and by training local medical staff in how to manage influxes of wounded.

In northeast Nigeria, we run emergency rooms in Maiduguri, Damaturu, and Monguno. 

Surgical resources are very scarce in the overall region, particularly in the enclaves of Borno state, Nigeria. This is particularly an issue for pregnant women in urgent need of Caesarean  sections, and for wounded patients who need urgent referrals after being stabilized, which are not always possible