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Nigeria, Maiduguri: action against malnutrition in Borno

    Treating exceptionally high numbers of malnourished children

    In Maiduguri, the capital of Nigeria’s Borno state, Médecins Sans Frontières (MSF) cared for exceptionally high numbers of malnourished children throughout 2021 as conflict and a major measles outbreak exacerbated the already massive health needs. These and other factors have driven a spike in hospital admissions and outpatient consultations for malnutrition higher than that of recent years and may signal a broader health emergency in the region.

    MSF first intervened in Borno the height of the nutrition crisis in 2016. Since then, MSF has run the largest therapeutic feeding centre in the city of Maiduguri, which, today, is home to more than two million people. 13 MSF international staff, alongside 214 Nigerian colleagues, are also the main responders to epidemics in the city and the surrounding areas.

    There are frequent outbreaks of measles and cholera in Maiduguri, especially after its population more than doubled as a result of the mass displacement from across Borno. In 2019, the project in Maiduguri adopted a comprehensive mother and child healthcare approach, with the objective to integrate malnutrition treatment into a sexual and reproductive healthcare project.

    More than two million people uprooted by continued violence and armed conflict

    Nigeria is the most populous country in Africa;[1] its inhabitants constitute one per cent of the world's population. It is a country of high inequality, for example in north-east Nigeria the maternal mortality rate is 1,549 deaths for every 100,000 births, while in the south-west of the country it is 165. Nigeria is one of the most dangerous places in the world to give birth and MSF team’s assessment of various health facilities revealed high mortality rates in Maiduguri, especially for women over the age of 20.

    It has the fourth highest maternal mortality rate in the world, behind Sierra Leone, Central African Republic and Chad. However, the rate of maternal mortality varies a great deal between regions. In north-east Nigeria, the maternal mortality rate is estimated to be twice the national rate.[2]

    The state is exceptionally volatile in terms of security, especially Maiduguri, which was the former base of the armed group Boko Haram. Boko Haram was created in 2002 by Mohammed Yusuf, a Sunni Islamic cleric. The conflict in north-east Nigeria broke out in 2009 when Boko Haram began indiscriminate attacks against civilians and military forces in Borno state. Since then the Boko Haram insurgency and the counter-insurgency by the Nigerian military have led to violence, property damage and the displacement and deaths of many civilians. In 2015, one faction of Boko Haram insurgency group announced its allegiance to the Islamic State and further extended its control across the state.

    [1] An estimate of more than 182 million inhabitants

    [2] 814/100 000 at national level versus 1549 for North-East (APHRC 2017)

    Today, most cities under government control can be considered as enclaves, where residents’ movements are severely restricted and most depend on humanitarian aid for survival. Civilians have not yet begun to move en masse to the refugee camps, as a possible sign of a lack of trust in protection mandate of the army. In Maiduguri, an influx of displaced people from across the region has led to the population doubling from one to two million in only a few years. Most of the displaced live in host families while the existing are overcrowded, with makeshift and temporary shelters built near each other.

    People are struggling to access emergency and essential health services. The lack of properly qualified staff, medical supplies and financial resources are some of the main barriers to accessing healthcare.[1] The COVID-19 pandemic poses a high threat in a place where prevention measures are impossible to follow, as access water and sanitation are way below any standard and where social distancing is impossible for so many people, notably the displaced living in overcrowded camps.

    [1] Healthcare is not free of charge in public facilities and all the facilities work with a cost recovery model.

    Providing critical medical care for people trapped in areas of armed conflict

    MSF arrived in Maiduguri on 21 November 2016 in response to a worsening nutritional crisis. The target populations of this project are to internally displaced people (IDPs) (489,469 registered people) and the host community living in Greater Maiduguri. Figures are not very reliable, but the UN estimates the combined population to be at least 1.5 million. However, various organisations estimated population of Maiduguri to be around 1.9 million people, with some even placing the figure as high as 2.5 million. 

    In December 2016, MSF started with the rehabilitation and construction of Inpatient therapeutic feeding (ITFC) programmes, and with the recruitment and training of staff. With 120 beds, MSF’s ITFC is today the largest single provider of hospital care for malnutrition in Borno state and represents a third of all beds available for malnourished patient.

    One important medical factor contributing to the high malnutrition admissions was an outbreak of measles, which began in February 2021. From January to October 2021, MSF teams at the only paediatric hospital in Gwange treated 2,974 children for measles on an inpatient basis, while 2,545 more received care at the outpatient department within the same period. During outreach activities in Zabarmari village in Borno state’s Jere local government area from mid-February to the end of July 2021, MSF’s mobile clinic team treated to 2,517 children suffering from measles.

    While the traditional hunger gap period typically occurs from June until November, MSF admitted 60 to 150 percent more patients per month from March to May in 2021 compared to 2020. Meanwhile, the numbers of malnourished patients needing treatment have remained higher than previous years throughout the entirety of the hunger gap period.

    Outpatient therapeutic feeding (ATFC) programmes provide medical care and therapeutic food to children, which reduces the risk of life-threatening medical complications if they get sick. MSF is currently providing ATFC care in five locations in Maiduguri but the drastic increase in enrolment is a clear sign that more availability of care is needed. Severely and moderately malnourished children, aged six months to 10 years, constitute the direct beneficiaries of the MSF ITFC and ATFC.

    MSF also provides emergency medical assistance to IDPs and hosts communities in North Maidiguri. The purpose of this emergency intervention was to increase access to quality healthcare and restore dignity to IDPs staying in north and south of Maidiguri in the informal and host community camps. MSF mobile clinics have provided medical care three days per week in seven settlements in communities hosting large numbers of IDPS.

    With a budget of €4.781.707 for 2022 and by employing analysis, lessons learnt and operational research, the project is aiming at influencing health policies at both state and national level through advocacy around the issue of free mother and child healthcare in conflict areas; and the proper implementation of provision for prevention of mother-to-child transmission (PMTCT) activities.