How counterterrorism policies endanger the most vulnerable in Nigeria

"Doctors shouldn't be forced to make judgments about who is a good or bad patient."

Young patients being treated for malnutrition rest at MSF's inpatient therapeutic feeding center in Fori, in the south of Borno state's capital Maiduguri.
Nigeria 2019 © Yuna Cho/MSF
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Bertrand Perrochet, director of operations for Doctors Without Borders/Médecins Sans Frontières (MSF), recently returned from a visit to northeastern Nigeria, where a decade of conflict between the military and non-state armed groups has taken a heavy toll on local communities. He witnessed firsthand the impact of counterterrorism policies on the delivery of humanitarian aid—and on the lives of children and other vulnerable groups with serious medical needs.

Five children were dying every week in just one of our feeding centers in Borno state during my recent visit to northeastern Nigeria. Many come in too sick and too late to be saved. On average, ten severely malnourished kids were being admitted per day to our intensive care unit in Maiduguri, the state capital. I saw my colleagues forced to break the news to families that the war that they fled from had not only destroyed their homes but had literally wasted their children away.

These children are the ones that have a chance of survival. They are the ones that we are allowed to reach. But there are many more outside of the “garrison towns,” as the enclaves controlled by the Nigerian military are called. Humanitarians cannot access other areas outside these towns—more than three-quarters of Borno state. These children who live behind what the military defines as enemy lines are also considered the enemy, simply because of their geographic location. They are condemned as unworthy of receiving care. And if humanitarians try to reach them, they could be accused of "aiding and abetting" terrorism.

Humanitarian organizations like MSF were created to reach all of these children—whichever side of a conflict they live on. But in counterterrorism operations such as this one in northeastern Nigeria, humanitarianism is being buried together with the children dying in our treatment centers.

That's because on the one hand, the Nigerian government controls where we go, who we can talk to and how we operate. In their fight against terrorism, it is “with us or against us.” People who cross into the garrison towns are given access to assistance. Those outsides are denied it, with entire communities designated as hostile. Nigeria is not alone in doing this. States fighting terrorism across the globe often try to use humanitarian action as a tool to achieve their military goals, from winning the "hearts and minds" of some communities to purposefully excluding others.

On the other side, we are faced with fragmented armed groups that don't want to talk to us, have indiscriminately assaulted civilians, attacked health structures, and kidnapped and killed aid workers.

Humanitarian action is being squeezed by all sides, and it is the people in need who pay the price. In navigating this challenging environment, we don't find many allies.

For its part, the United Nations aid system has decided that saving lives is valuable when it simultaneously builds the state and ensures peace. The problem with this is that it entails choosing sides. The UN mantra may be to “leave no one behind,” yet eyes remain closed to the needs of more than one million people who don't find themselves on the UN-backed side of the conflict. This is all justified in the name of the war on terror.

We are told by the Nigerian military that being neutral is not possible because they consider the enemy evil. But even wars have rules.

Our concerns are pragmatic. When humanitarian aid is controlled by one party to the conflict—in this case the government of Nigeria—it loses both the trust of the civilian population and the willingness of the people with guns to see it as independent.

This is not about specific cases where access was requested and then denied. Rather it is how the entire aid system in Nigeria is set up and designed to serve the counterterrorism operations of one party to the conflict. It's not the first time we are seeing this—similar approaches were taken in Mosul, Iraq, for instance—and I fear it won't be the last.

Doctors shouldn't be forced to make judgments about who is a good or bad patient. That is prohibited by both medical ethics and international humanitarian law. Our role should be to treat whoever needs us, across whatever front lines different groups have drawn. But in Nigeria today, before a doctor gets to assess a patient's needs, a soldier assesses their political allegiance before allowing access. Fear of the screening process ensures that the sick and wounded who are entitled to medical care are often left behind. And arbitrary screenings mean that even civilians with nothing to hide fear coming forward.

To use a metaphor, our ambulance has been hijacked, and we are not in control of its destination. We are still saving lives, but we are only saving the lives of those who can reach us. The children we see in our feeding centers shouldn't have to find their way to the ambulance—we should be able to reach them before it is too late.

I believe we need to take back the steering wheel of the ambulance. If we don't, I fear we will be contributing to the death of humanitarianism. Then the million out of reach today in Nigeria will multiply into millions more in countless global counterterrorism operations of tomorrow.