Lake Chad: Years of Forgotten Crisis

Located in west-central Africa at the junction of Chad, Nigeria, Niger, and Cameroon, Lake Chad was once among the continent’s largest bodies of water. Owing to a combination of climate change and overuse, however, Lake Chad’s size has steadily dwindled, putting the region’s population of roughly 30 million people under increasing strain. But diminishing resources are not the only thing they have to fear.

Already plagued by chronic underdevelopment and a general lack of access to health care, the region has also in recent years endured the campaign of terror begun in northern Nigeria in 2009 by Boko Haram, now known as the Islamic State in West Africa (ISWAP). This has grown into a cross-border crisis that has killed thousands, displaced millions, and drawn a military response that creates problems of its own.

These days, even people who try to flee the conflict — and the suicide attacks and massacres that characterize it — cannot escape, no matter where they go. At least 1,300 people were killed in fighting and bombings in 2015 alone. Abduction and sexual abuse of women and girls is frighteningly commonplace. According to the United Nations High Commission for Refugees (UNHCR), more than two million people have been displaced within Nigeria. Tens of thousands more have fled to Cameroon, Chad, and Niger — countries that are trying to send some of them back to their homelands.

Though much of this has occurred far from the public eye, MSF staff in the Lake Chad region have seen the toll up close. Over the past year, MSF has expanded its services for the injured, the displaced, and residents of the overstretched communities hosting them. The situation remains incredibly volatile, however, and insecurity renders certain areas off limits, meaning even fewer people can access even basic health care services.

Nigeria: A Violent Spark

The epicenter of this conflict is Nigeria’s Borno State. Heightened insecurity forced MSF to leave its projects there in 2013, but the organization returned the following year. MSF’s operations are now based in Maiduguri, the state capital, where around 1 million people have sought refuge. MSF teams in Maiduguri support State Ministry of Health (SMoH) health centers in Maimusari and Bolori, providing outpatient services, malnutrition and malaria screenings, vaccinations, primary health care, and maternity services. MSF also runs an intensive therapeutic feeding center, a pediatric inpatient department, and an intensive care unit.

“We need more support. We have repeatedly called on other humanitarian and aid organizations to assist displaced persons in Borno State and are again issuing this appeal, which has gone unanswered.”

Last September, MSF also began managing the emergency room in Maiduguri’s Umaru Shehu Hospital, where staff now carries out trauma surgery — often for people wounded in suicide bombings. What’s more, MSF provides essential medicines and supplies, has refitted one operating theater, and is establishing a mass casualty plan for the hospital, in coordination with the SMoH.

The strife is leading to other health issues as well. In August 2015, cholera appeared in displacement camps, which are customarily overcrowded and sorely lacking in resources. MSF collaborated with Nigerian health authorities to provide emergency medical and sanitation activities.

“The living and hygienic conditions in the camps were and remain ripe for the outbreak of this type of epidemic,” said Chibuzo Okonta, MSF emergency projects manager. Though MSF teams treated 1,705 patients, two dozen people also died. “We need more support. We have repeatedly called on other humanitarian and aid organizations to assist displaced persons in Borno State and are again issuing this appeal, which has gone unanswered.”

This was not the first time MSF called for greater assistance in the region, alas. In the meantime, though, teams prioritized improving hygiene and sanitation in the camps, providing chlorine solution for handwashing and chlorinating water sources. When case numbers dropped, the cholera treatment center was closed.

MSF also monitors sanitary and health conditions in 15 other camps that are currently “home” to some 100,000 internally displaced people (IDPs), one-quarter of whom are believed to be children under the age of five. In nine of these camps, MSF logisticians have provided water-and-sanitation services, trucked in clean water, drilled boreholes, constructed latrines, and installed water pipes and tanks.

Up until this past January, MSF medical teams provided primary health and antenatal care in the ATC and Teachers Village IDP camps, carrying out some 40,000 consultations. In addition, staff distributed around 6,600 non-food item kits, including soap, mosquito nets, blankets, and other essentials to 32,000 families in four IDP camps. As of January, MSF began offering medical services to Dallori Camp and continued doing so in the aftermath of a terrible attack in the area at the end of the same month.

Chad: Assistance for the Displaced

In March 2015, MSF launched its emergency response in Chad for people displaced by violence. Teams based in the towns of Baga Sola and Bol focus on primary health care and mobile clinics that treat respiratory infections, malaria, diarrheal disease, and other conditions. Teams also distribute basic relief items and provide water treatment kits.

In December 2015, Chad’s military stepped up efforts to relocate displaced people from small islands in Lake Chad, resulting in a 50 percent spike in consultations by MSF teams. The “lucky” displaced people find shelter in host communities, though the influx of people has overstretched already-scarce resources. The majority gather in spontaneous settlements without any kind of organized assistance.

The small islands in Lake Chad are no safer than the mainland, however. On December 5, 2015, a triple suicide attack in a busy market area on Koulfoua island killed 30 and wounded more than 100. MSF teams in the area immediately mobilized to support Chad’s MoH.

“I had never seen these types of injuries. Men, women, and children had their bodies covered in sharp splinters. Pieces of glass, nails, and metal scraps were embedded in their faces, their chests, their limbs. Many were disfigured by the lacerations . . . all of the victims are in shock. They are very scared and fearful about what the future holds for them.”

The wounded were evacuated by boat and taken to the town of Guitté. Forty-two were later transferred to the district hospital of Mani, on the Cameroonian border. Another 36 — including 14 children — required advanced surgical care and were transferred by ambulance to N’Djamena, Chad’s capital, where MSF supports hospitals with supplies and training.

It was a horrific scene. “I had never seen these types of injuries,” said Dr. Silas Adamou Moussa, MSF deputy head of mission. “Men, women, and children had their bodies covered in sharp splinters. Pieces of glass, nails, and metal scraps were embedded in their faces, their chests, their limbs. Many were disfigured by the lacerations . . . all of the victims are in shock. They are very scared and fearful about what the future holds for them.”

“In Mani, the hospital did not have enough space or medications and equipment to deal with the number of wounded,” said Federica Alberti, MSF head of mission in Chad. “An MSF team composed of a surgeon, a doctor, a nurse, and two logisticians arrived to support the Ministry of Health in the response, and teams are now working around the clock to provide lifesaving care.”

To expand Mani Hospital’s capacity, MSF installed three tents with a total of 30 beds. The team assisted hospital staff with surgical care for 37 wounded patients, and an MSF logistics team ensured that the electricity and water kept running.

Elsewhere in Chad, MSF teams work in the sweltering Dar es Salam refugee camp, in the middle of the desert, where some 7,000 refugees have settled with little in the way of protection. Many had been displaced multiple times already, moving from village to village in Nigeria before crossing into Chad. MSF mental health care workers conduct individual and group sessions with adults and children in hopes of salving psychological wounds inflicted by months of fear and displacement.

In Bol, MSF works with Chad’s MoH to provide maternal and child health care.

Cameroon: Displacement and Insecurity

In February 2015, MSF staff started providing pediatric and nutrition care at a camp run by UNHCR in Minawao, Cameroon, near the Nigerian border. While numbers have dipped of late, newly displaced people continue to arrive on a daily basis. They cannot outrun the violence, however; attacks and suicide bombings plague the area, frequently targeting markets and mosques. Cameroonian armed forces have launched counteroffensives, adding to the volatility of the situation.

“The situation is very volatile and people are living in fear. This is a crisis with large-scale humanitarian consequences. It’s underreported and we’re doing what we can, seeing how far we can go.”

The frequency of suicide bombings picked up last summer, when two deadly blasts rocked the city of Maroua three days apart. MSF deployed immediately to assist the local health authorities and has continued to work with the Ministry of Health to train local health staff on mass casualty management — expertise that has proven crucial.

As in other countries, the throngs of refugees and IDPs now in Cameroon have taxed already-neglected host communities. At Mokolo District Hospital, MSF runs an inpatient therapeutic feeding center and provides pediatric services. It does likewise in Kousseri, in the far north, where staff provide surgical care as well. Three health centers in the town also provide care for IDPs living in host communities.

MSF is one of very few organizations providing health services in Cameroon, but insecurity cuts off huge swathes of the north from assistance. Many people are almost certainly stranded with little or no access to any health care services.

“The situation is very volatile and people are living in fear,” says MSF head of mission Hassan Maiyaki. “This is a crisis with large-scale humanitarian consequences. It’s underreported and we’re doing what we can, seeing how far we can go.”

Niger: “A Devastating Situation”

Since February of last year, more than 47,000 people have fled villages in southeastern Niger, according to the UN Office for the Coordination of Humanitarian Affairs. Niger’s Diffa region now hosts tens of thousands of Nigerian refugees and is also struggling to reintegrate some 72,000 Nigeriens who have returned home from Nigeria amidst the violence. Border villages are attacked on a near-daily basis, which complicates efforts to register new refugees and returnees.

MSF, which has worked in Niger since 1985, is supporting Diffa’s main maternal and pediatric health center, the district hospital pediatrics department in Nguigmi town, and several health centers in Diffa, Nguigmi, and Bosso districts.

At the mother-and-child health center in Diffa, MSF provides free health care for the local population, refugees, and IDPs, supporting inpatient and outpatient departments for children under 15 years of age. What’s more, MSF teams in the maternity department assisted more than 400 deliveries during the third quarter of 2015 alone.

MSF also supports health centers in Assaga Camp and in two villages near the border with Nigeria. Between August and the end of December 2015, staff at the three sites carried out more than 18,000 medical consultations; 43 percent were for children under five years of age. They also conducted more than 2,200 antenatal consultations, facilitated 137 deliveries, and provided routine immunization activities. In addition, teams conducted a measles vaccination campaign in Assaga Camp, immunizing 2,440 children from six months to 14 years old, and worked to improve access to water and sanitation by building latrines and drilling boreholes. Psychosocial teams carried out 840 mental health consultations between August and October 2015 as well.

In the second half of 2015, ISWAP launched more than 60 attacks in the Diffa region alone, which, coupled with reprisals from the Nigerien armed forces, displaced tens of thousands. Attackers raided the village of Gogoni in late November, for instance, killing 18 people, wounding 16 more, and burning down 100 houses. MSF also organized referrals for severely wounded patients to Diffa, while an MSF nurse and a mental health counselor visited a health center in Bosso to evaluate needs.

“The already vulnerable situation of the population in Diffa, who are facing current peaks of malnutrition and malaria, has further deteriorated due to the ongoing violence,” said MSF program manager Luis Encinas at the time. “More and more of our patients are describing a devastating situation.”

A Bleak Future

There seems to be little hope in the Lake Chad region right now. On December 27, 2015, Maiduguri was hit by a coordinated attack that included a wave of suicide bombings. The MSF team at Umaru Shehu Hospital immediately began performing trauma surgery, treating some 40 patients — including seven critical cases — over three days.

“While many adults were treated, our team was struck by the number of children presenting with shrapnel wounds,” said MSF emergency coordinator Peter Orr. “The addition of our surgical team allowed us to treat patients on-site rather than refer them to the International Committee of the Red Cross surgical unit, which was already faced with an equal number of cases.”

As the conflict enters its seventh year, MSF plans to further expand its operations to provide more comprehensive health care in addition to its emergency response. However, without significantly more attention from the international community, the deadly cycle of violence and displacement around Lake Chad seems likely to continue.