Raising the alert in Borno State, north-eastern Nigeria

On 22 June 2016, Médecins Sans Frontières (MSF) issued a press release describing a catastrophic humanitarian emergency unfolding in a camp for internally displaced people (IDPs) in the town of Bama, in Borno State in north-eastern Nigeria. See http://www.msf.org/en/article/nigeria-least-24000-displaced-peopledire-health-situation-bama. The previous day, an MSF team had travelled to Bama and ‘discovered’ a health and nutritional crisis. Detailing hundreds of fresh graves, alongside photographs of severely malnourished children, the press release caught national and international attention. Over the following days, major news outlets reported the hidden starvation crisis being uncovered in areas previously controlled by Boko Haram. Similarly dramatic instances of severe malnutrition, food insecurity and high mortality were subsequently ‘revealed’ in towns throughout Borno State, as well as in informal settlements in Maiduguri, the state capital. By late 2016, the UN had named north-eastern Nigeria as one of four potential famine regions, alongside South Sudan, Yemen and Somalia.

A year later, malnutrition and mortality rates in Bama are below the emergency threshold. The World Food Programme (WFP) is providing food assistance to 1.8 million people in north-eastern Nigeria, and all five of MSF’s operational centres responded to the emergency by opening health and nutritional programmes in various locations around Borno State. Borno appears to be a successful example of the positive impact of emergency humanitarian communications and response: the alert of a ‘hidden crisis’ was raised in timely fashion, one year later the response appears appropriate and, for now, widespread famine has been averted. Yet both the timeliness and the impact of the ‘Bama alert’ should be critically assessed. Did it really have a significant impact? If the alarm had been raised earlier, could a more adequate and timely humanitarian response have been implemented, and would this have prevented some of the massive loss of life from malnutrition and disease?

Could the alert have been raised earlier?

Most of the June 2016 press coverage of Borno’s nutritional emergency followed a similar narrative: according to the publicly acceptable version of events, since 2015 the Nigerian army had retaken territories that had been under the control of Boko Haram, gradually uncovering pockets of people who had been unable to access food or health care. These people remained trapped in areas of extreme insecurity, under constant risk of attack and protected only by the troops who had recently liberated them. Also according to the June press accounts, MSF (Operational Centre Paris), despite working in Maiduguri since 2014, first became concerned by the severity of the situation outside Maiduguri when several hundred emaciated people arrived in the city from Bama. Shocked by the condition they were in, the MSF OCP team decided to visit the IDP camp in Bama via the only means allowed: a military escort. In the few hours they spent there they gathered enough information to raise an alert about the scale of the problem.

Except that MSF was neither the first international humanitarian actor to visit Bama camp, nor the first to collect similar data. The existence of enclaves of people living in extremely precarious circumstances had been discussed during humanitarian sector meetings since late 2015. In April 2016, at the request of the Nigerian government, a joint UN multi-sector assessment was conducted, including visits to Bama, Dikwa, Damboa and Monguno. Toby Lanzer, the UN Regional Coordinator for the Sahel, stated that ‘the suffering of some 30,000 people in Bama is as acute as I have seen’. See http://www.un.org/apps/news/story.asp?NewsID=53661#.Waren7JJapo. The assessment report detailed a catastrophic situation in parts of Borno State, with pockets of extremely high levels of malnutrition. See https://www.humanitarianresponse.info/system/files/documents/files/joint_un_multi-sector_assessment-_summary_report_borno_yobe_nigeria_april_2016_final_lowres.pdf. Most organisations working in Nigeria were aware of the report, yet little changed in terms of the actual aid response. The report also did not tally with information from the state and federal authorities to the effect that the situation was under control, no international assistance was required and improvements were imminent.

In Maiduguri a similarly grave situation was going unacknowledged. Retrospective surveys carried out by Epicentre and MSF document rates of child mortality far above recognised emergency thresholds in two large informal IDP settlements within the city. The UN joint assessment report noted that people living in Maiduguri’s informal settlements had no access to health or nutritional care, yet even months after the Bama press release there was little obvious recognition of the extreme suffering of many of the one million IDPs in the city, despite the fact that Maiduguri was under government control, air and road links were open and international organisations including MSF were present. In hindsight, it seems that, at least two months before the June press release, there was sufficient information to indicate grave alarm about the situation of much of the population of Borno State, including Bama.

Obstacles

Although the extent of the humanitarian crisis in Borno prior to June 2016 may now appear obvious, there were genuine obstacles in the way of an earlier recognition of the severity of the situation. There were clear difficulties around access and insecurity. The UN, NGOs and the population of Borno were traumatised by years of large-scale Boko Haram attacks. Humanitarian organisations, if present at all, had small teams of mainly local staff, whose movements were restricted to ‘safe areas’ of Maiduguri. MSF OCP had a team in Maiduguri from 2014, including international staff, but almost daily suicide attacks meant that security rules remained tight. Control of aid was difficult due to a lack of experienced supervisors on the ground, and MSF as much as other organisations struggled to manage finances and supplies.

While levels of malnutrition and mortality in some areas could be catastrophic, in others life continued as normal. The informal IDP settlements in Maiduguri containing the most vulnerable people are on the most insecure peripheries of the city, and aid visits to these camps draw crowds which offer an easy target to suicide bombers. The authorities were reluctant to allow MSF to work in these settlements, directing us instead to more accessible ‘formal’ camps, where malnutrition rates were not serious enough to cause concern. The failure to identify the most vulnerable pockets in the city meant that the crisis was hidden in plain sight. Meanwhile, most areas outside Maiduguri were – and still are – deemed inaccessible by the Nigerian military; major towns are under military control, but access is only granted if escorted by the army. Since August 2016 these towns can also be accessed by helicopter, with army approval. When MSF and other aid actors were finally able to visit locations outside Maiduguri, security concerns meant that teams could stay for only a few hours or days, prioritising the provision of emergency aid over data collection, and leaving agencies with little more than a snapshot description of conditions.

That the alert was not raised earlier can also to some extent be attributed to the language and methods used to describe the situation in Borno. Reports from UN agencies, FEWSNET and NGOs were full of technical jargon, and in the UN assessment report pertinent information on access to food and protection was hidden among descriptions of ongoing interventions and response plans. There may also have been a problem of trust, and a desire by organisations such as MSF to witness the suffering for themselves before contradicting the authorities’ claims that they could manage the situation without international assistance. Most telecommunications across Borno State had been cut by the Nigerian army, making it impossible to contact civilian interlocutors to verify information without a direct visit, and NGOs only accepted the armed escorts insisted on by the authorities after teams had witnessed the condition of the Bama inhabitants brought to Maiduguri.

Recognition

Once the alert had been raised, international organisations and state and federal governments felt under significant pressure to act, and questions began to be asked about the effectiveness and accountability of existing aid efforts. Although less a calculated move than a knee-jerk reaction to severe suffering, the MSF alert, along with strong epidemiological information and efforts to describe mortality rates, seems to have succeeded in raising national and international attention. Since then, MSF has tried to avoid appearing to dictate the appropriate response, preferring to implement a direct response ourselves, press for access to people in need and share information gathered in areas where we have been active. Fears that our decision to use the national and international media to move beyond internal discussions between UN agencies, NGOs and donors about how best to respond were largely unfounded, despite initial accusations that we were scaremongering and exaggerating the severity of the crisis in order to raise funds. Relations with state and federal authorities have been complex and at times tense, but open and constructive dialogue has in general always continued towards the same aim: relieving the suffering of the civilian population.

The impact of the alert seems clear – according to OCHA, 6.5 million people in north-eastern Nigeria will be targeted for life-saving assistance in 2017, with the cost of $1.1 billion being nearly 50% funded. See http://www.unocha.org/nigeria. Contrast that with Toby Lanzer’s concerns in April 2016 that a much smaller aid intervention costing $248 million was only 12% funded. See http://www.un.org/apps/news/story.asp?NewsID=53661#.Waren7JJapo. The response has not been perfect, and raising the alert has not succeeded in securing access to the whole of Borno State. Nor has it had any discernible impact on the causes of the crisis. Even so, recognising and then publicising the severity of the situation has seen millions more people receive life-saving food and medical care. When faced with extreme human suffering, speaking out still seems to be, not only the most human, but also the most effective response.

Context and causes

In an attempt to define situations of crisis, MSF and other humanitarian actors can fall into the trap of describing suffering people as if they exist in a humanitarian, apolitical silo, ascribing their problems to a lack of emergency aid and/or development. Ignoring any political background to the crisis, the automatic generic solution is then usually the implementation of an emergency international humanitarian response, with the only obstacles inadequate funding or the reluctance or incompetence of international aid actors. In the short term, this approach can produce positive results in terms of a rapid, generic response, but as time passes this failure to understand the context of a crisis ignores its causes and discourages the development of innovative context-specific proposals to overcome the obstacles to an effective aid response.

MSF did not initially attempt to explain the cause of the crisis, or what had happened over the preceding months and years to create the extreme levels of malnutrition encountered in Bama. The June press release only detailed the precise level of acute suffering in Bama, with images and simple evidence, and did not assign responsibility for the situation, or for the provision of assistance. Even today, there are few open discussions outside humanitarian organisations regarding the impact of the clearance operations the Nigerian army launched in late 2015, which gather people from rural towns and villages and deposit them in military-controlled enclaves, where movement restrictions make them entirely dependent on aid. Whilst recognising the precarious situation many IDPs in Maiduguri find themselves in, aid actors rarely acknowledge the impact of population screening and control by the military and vigilante groups, the widespread diversion of aid, the fear of violence and sexual abuse which limits free movement outside the camps or the demeaning coping strategies that displaced people living in extreme poverty are forced to adopt.

Today, the authorities are talking of rehabilitation and reconstruction, but the causes of the crisis remain. New displacement continues, including people returning from Cameroon, either involuntarily or in search of aid. Hundreds of thousands of people are still prevented from returning to their villages and remain completely dependent on aid. People in Bama IDP camp are still held behind a fence, which appears designed to keep them in more than to protect them from attack. It is not clear that they would even wish to leave. Many have lost parents or spouses and are unable to provide for themselves; others remain terrified by the risk of Boko Haram attacks, and most have nothing to return to. Meanwhile, media attention is fleeting, distracted by crises elsewhere in the world. It is easy to understand in a few photos and news headlines the need for starving children to be fed. It is less easy to continue to use similar images and dramatic statistics to explain why, when the Nigerian army considers Boko Haram ‘technically defeated’, See https://www.thecable.ng/boko-haram-technically-defeated-burataiinsists. most people in the region still cannot feed themselves.

The crisis in Borno State demonstrates yet again that raising the alert is not easy, but seems necessary to produce a meaningful aid response. In order to raise the alert, we portrayed Borno as an acute emergency – and it worked; previously the discourse was around development, and the aid response was utterly inadequate. MSF’s press release succeeded in changing the narrative, but in reality the situation in Borno was not acute-onset and had been developing over months and even years. There was also adequate information to enable us to act sooner with lifesaving interventions, and to accept the need to compromise our usual principles of neutrality and independence, at least after the UN assessment in April 2016. MSF, along with most aid actors, had known for months that there was a serious problem in north-east Nigeria, but this information was either intentionally hidden from the public, or was not well enough communicated, which meant that there was no effective aid response and thousands of people died. There were very real obstacles in the way of a proper understanding of the situation, the prime one being the mandatory use of armed escorts, which every NGO operating in Borno refused to accept for reasons of neutrality until June 2016. However, in doing so we did not even try to meet the needs of people outside Borno.

Dr Natalie Roberts is Emergency Cell Manager, Médecins Sans Frontières Operational Centre Paris. The views expressed here are the author’s, based on her experience managing MSF OCP’s emergency operations in Borno State since July 2016. They do not reflect the institutional position of MSF.