Several days ago I returned from Borno state in northeast Nigeria, where a catastrophic humanitarian emergency is quietly unfolding.
I was there to assess the situation and help set up Médecins Sans Frontières’ aid activities in one of those towns—Bama, approximately 70 kilometers southeast of Maiduguri, the state capital. On arrival, we found high numbers of people on the brink of death and in urgent need of food and medical care.
Until recently, Bama and the surrounding area had been under control of Boko Haram and completely inaccessible. For close to two years, people in the region had extremely limited access to medical care and food. When an earlier MSF team first reached Bama last month for a few hours on 21 June with a military escort, they found children dying of starvation and people living in squalid, unhygienic conditions with little to no access to food.
During that first visit, the team determined that the mortality rate was significantly above the United Nations’ emergency threshold, which is one death per 10 000 people per day. This rate was calculated based on information gathered from the Nigerian authorities and on a count of new graves in the camp cemetery. This is particularly troubling because Bama’s official population count—27 000 people—seems to be an overestimate, based on a visit to the site that shelters internally displaced people. The site where the displaced now stay measures about 400 meters per side, and possibly only houses about 12 000 people.
A rapid nutritional assessment conducted during the June visit was also alarming. It showed that 153 of 804 children examined (19%) were suffering from severe acute malnutrition (SAM). During my visit in July, we conducted a second assessment and found a comparable rate of 15%. These are very alarming figures: a SAM rate of 5% is considered a nutritional emergency.
Since March, the State Emergency Management Agency (SEMA), UN agencies, the Red Cross, MSF teams, and a few other humanitarian organisations in Bama and other towns in Borno have performed these assessments. These figures are the only reasonably reliable benchmarks we have to analyse the health situation. Without better epidemiological surveillance systems and regular, improved access for aid teams, we will have only such fragmentary information, estimates, and weak statistics.
However, the few indicators we do have and the things we can observe have all the hallmarks of other serious crises we have seen in Africa and elsewhere.
In Borno state, as in other major crises, we see violence leading to population displacement and interruption of farming and raising livestock; we see a displaced population left completely isolated and entirely dependent on inadequate humanitarian aid; we see high mortality, severe acute malnutrition, and outbreaks of diseases such as measles and diarrhoea. In this regard, the situation we observe in Borno recalls other health disasters, such as those in Somalia (1992), Darfur (mid-2000s), South Sudan (1998), and Ethiopia (1984-85), where MSF teams responded.
Direct observation of the context can also be very telling. I was in Bama for two days and I did not see any men or adolescent boys, apart from a few militiamen, a group of traditional hunters, and religious and traditional leaders. What happened to the other men and adolescents? Did they go off to fight? Did they flee? Are they dead? This almost complete lack of young men and boys is very specific to Bama, and not something I’d frequently seen in other humanitarian contexts.
Finally, it is important to understand a group’s baseline health status in order to assess the true impact that emergence of violence, displacement, and lack of access to food has had on a population’s health. In this case, we do have high quality data.
We know that northern Nigeria is a chronically fragile region, exposed to recurring food and nutritional crises and to epidemics (including meningitis, measles, and diarrhoea). During the rainy season there is a dramatically high prevalence of malaria, which inevitably causes complication for those suffering from acute malnutrition. The birth rate is seven to eight children per woman. This structural vulnerability has concrete health consequences. In Jigawa state, west of Borno, for example, 60% to 70% of women treated in an MSF supported maternity unit present severe complications related to childbirth.
Given the extreme humanitarian situation in Bama today, and in the context of an inadequate aid system, medical actors must adjust their protocols and practices to provide as much assistance as quickly as possible during the limited time teams have in these highly insecure areas of Borno state. On the preventive side, measles immunisation urgently needs to be expanded to all children under the age of 15, as well as malarial prophylaxis and pneumococcal vaccination. On the curative side, doctors used to delegating certain aspects of care must provide it themselves—examining patients, taking vital signs, making a probable clinical diagnosis, and administering treatment. This is “frontline” medicine—it is minimal, but it can be very effective.
To illustrate: one of the first cases I dealt with in Bama was a young pregnant woman who was having seizures. She had already been treated for preeclampsia. A rapid test led to a malaria diagnosis. After administering an anti-malarial drug via intramuscular injection, we arranged for her to be transferred to Maiduguri. I later learned that she could not be admitted to any of the city’s hospitals because they were full. Instead, she gave birth in the clinic managed by MSF and both she and her baby survived.
Sometimes we had to wait two or three days before we could transfer patients or children suffering from malnutrition to the hospital in Maiduguri. Some of them could die during that period—an inherent risk in this kind of intervention. But as the above example shows, there were occasions we could save lives by doing very basic medicine with the little we had at our disposal.
The objective of a medical humanitarian response in Borno state should be to deliver food aid to approximately 600 000 people, the equivalent of approximately 300 tons of food per day. We are far from providing that volume today. Access to these populations is still extremely limited and only possible through military escort. As we gain access to the population, we’ll continue to gradually discover the extent of this crisis, but at this point we know the needs are dire. A massive aid operation is urgently needed to avoid catastrophically high numbers of death from starvation and lack of access to healthcare.
Jean-Hervé Bradol is emergency coordinator for Borno state, research director at the MSF Center for Reflection on Humanitarian Knowledge and Action (CRASH), and a former president of MSF France.
Competing interests: None declared.