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© Scott Hamilton/MSF
12 Dec 19 12 Dec 19

Nigeria: The end of malaria season, and the need for functioning health infrastructure in Borno state

Each year Borno state sees a massive spike in malaria during the rainy season, affecting children under 15 most severely. A combination of limited or non-functioning health infrastructure, inadequate preventive measures, and obstacles in reaching healthcare providers have created a situation where malaria-related deaths are all but inevitable.

Over ten years of conflict between the Nigerian military and armed opposition groups have compounded the challenges people face in accessing healthcare, with vast swathes of the population displaced, and millions of lives disrupted.

From July to December this year, MSF has provided over 85,000 children under five with seasonal malaria chemoprevention (SMC); the goal of SMC is to prevent patients ever contracting malaria. In Bama alone, MSF’s malaria response included SMC for an average of 12,054 children, over four rounds of treatment, and more than 1,000 inpatient admissions for the treatment of severe malaria.

Malaria treatment activities

This year MSF ran SMC and malaria treatment activities in Banki, Rann, Ngala, Pulka and Bama, as well as treatment for severe malaria and malaria with complications in the state capital, Maiduguri. Despite predictable spikes in malaria (more than 270,000 cases of uncomplicated malaria were recorded across Borno state in 2019) treatment services from organisations like MSF remain necessary, because patients have little alternative.

In Bama, a state-run comprehensive general hospital appears ready to admit patients. However, with few drugs or human resources, the treatment of patients in this facility remains rare for now. The costs of the public health system present an additional barrier for many, who simply do not have the means to pay for medical treatment. This hospital represents the only permanent health infrastructure for the population of Bama, which is now home to some 35,000 internally displaced people (IDP) due to the ongoing conflict, as well as the host population.

Challenges in obtaining healthcare

When Yagana brought her daughter to MSF’s malaria treatment centre in Bama in November, she spoke about the challenges in obtaining healthcare for her family:

It’s not as if there are no other providers in Bama but MSF treats us without us paying anything. In other facilities, it is always paracetamol and a prescription to buy the mostly out-of-stock drugs in the drugstore and we don’t have the money.

The lack of functioning health infrastructure in Borno is further compounded by the number of medical cases seen in the state capital, Maiduguri. From July to November, MSF’s paediatric hospital in Gwange treated more than 5,000 confirmed cases of malaria, while MSF’s feeding centre for malnourished children in Fori admitted and treated 146 children with malaria, who were also suffering from malnutrition. While there are certainly other hospitals in Maiduguri, few offer secondary healthcare services, or secondary paediatric care services that provide treatment for complex malaria cases, and fewer still provide healthcare that the general population can afford.

Despite starting as a project for the treatment of malaria, MSF’s work in Bama also grew to encompass more general paediatric secondary healthcare, admitting 192 additional patients for inpatient care due to the lack of treatment options for the population. However, adults too are in need of healthcare services – women’s leader, Famata lives in an IDP camp in Bama, and is the first port of call in times of crisis for many women in the camp:

If we become seriously ill here, there is nowhere to go. I have diabetes, but there is no-one here who can treat me. I went to the general hospital here in Bama town – they tested me and told me I had diabetes, and then gave me a prescription for the drugs to buy – but I can’t afford the medicine. Many women are also suffering from issues like fistula, but I don’t know where to take them, the same goes for HIV. I treat my diabetes by being careful with my diet – I only eat beans – but I really need drugs.

The absence of comprehensive healthcare

The absence of comprehensive healthcare in Bama and other ‘garrison towns’ (towns that are inhabited and guarded by the Nigerian military) is a serious issue for the population, however, they remain visible and able to voice their concerns; if the challenges of those living in garrison towns are dire, it raises difficult questions over the healthcare situation for those outside of military-controlled areas with limited humanitarian support, many of whom are living in areas controlled by armed opposition groups:

“If  the state health authorities are able to ensure the day-to-day functioning of their hospitals in towns like Bama, it would allow organisations like MSF to boost other aspects of healthcare coverage in Borno state, such as malnutrition, outbreaks of epidemic disease or maternity care.”

David Therond MSF Head of Mission

If greater healthcare coverage is to be realised, with fewer preventable deaths, more must be done to ensure that affordable healthcare services are available to the general populace in Borno. With an emphasis on appropriate human resources, and the provision of medicines, there is a lot more that can be done.

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With the end of the rainy season and the peak of malaria prevalence, MSF’s project in Bama has now closed. MSF has been continuously working in Nigeria since 1996, and in Borno state since 2014. The organisation currently runs medical activities in eight states throughout the country. MSF first opened a therapeutic feeding centre in Bama in 2018 to treat malnutrition. From July to December 2019, MSF reopened the Bama project to treat severe malaria. From July to November, MSF provided SMC over the course of four rounds of treatment in the following locations:

  • Banki: 14,243 patients
  • Bama: 12,054 patients
  • Rann: 11,639 patients
  • Ngala: 35,533 patients
  • Pulka: 12,023 patients

Please note that the numbers given above indicate the averages of four rounds of SMC in each location.

patient stories

Bawagana Goni, an MSF Malaria patient in Bama, and her mother, Yagana

Yagana waits for her daughter, Bawagana (left) to receive a blood transfusion as part of her malaria treatment.

As her mother, Yagana, speaks about their experiences, Bawagana Goni is undergoing a blood transfusion as part of her malaria treatment in MSF’s clinic in Bama. After days of suffering from malaria she is visibly weak.

Bawagana has just begun secondary school and hopes to be a doctor one day. Her mother supports her hopes and aspirations, along with those of her six other children.

“My husband was killed by Boko Haram four years ago, leaving behind our six children. We’ve gone through a lot since this crisis began. At one point we were staying with relatives in Gwange, Maiduguri, and later moved to Dalori IDP camp, also in Maiduguri, where we stayed for about four years.

About a year ago the government said we should go back to our homes as the military had recaptured the town and so we returned to our home in Tandari Yara ward, Bama town.

We came back, salvaged what was left of the house and did some repairs. Five of the children are going to school here now - every term I have to pay 600 naira in fees. We have survived this far by the grace of Allah, and the children also help by selling beans, peanuts and other items which I prepare for them.

It has not been easy for me to take care of them without their father. After we returned to Bama, I married another man and we had a seventh child – he takes care of his child, but the other six are my responsibility. Since we are not staying in the IDP camp, we don’t receive anything from the government or any other organisations. I’m glad that MSF is here though, otherwise I don’t know where I’d get the money to pay for the blood that will be given to my daughter – all the treatment here is free, and we are fed three times a day in the clinic.

My daughter is now getting better and I believe she’ll be alright after the blood transfusion. I would like to stay much longer in the hospital because we are looked after here, I hope MSF will stay.

It’s not as if there are no other providers in Bama but MSF treats us without us paying anything. In other facilities, it is always paracetamol and a prescription to buy the mostly out-of-stock drugs in the drugstore and we don’t have the money.

I want to start trading again like I used to. I used to sell women’s clothing, but I couldn’t maintain the business and take care of the children at the same time.”

Yeza Husseini, a mother waiting for her daughter to be treated for severe malaria in MSF’s clinic in Bama

“We’ve been in this ward for five days now. My daughter has malaria; before I brought her in for treatment she had a fever and was vomiting. We went to other clinics first, and the general hospital too, they gave us some antimalarial drugs and sent us home, but then the MSF health surveillance workers came to the camp and told me I should bring the children here for treatment. It’s better for us to be in the malaria ward, because we eat three times a day – in the camp we only eat twice a day, and we often have to beg for food and firewood – if we want to buy firewood, it costs 50 Naira each time. But things are still better than they were before; the lack of food used to be a real issue in the camp.

We’ve been living in the camp here for two years – we used to live in Bulangu, but we came here because there wasn’t any medical care there – there were no drugs, and no doctors or nurses, and we needed malaria treatment there too. I have four children, but my husband was put in prison by the military when we arrived, as a suspected member of Boko Haram.

We received mosquito nets when we arrived here, but we’ve had nothing since then. I want to leave Bama – there isn’t enough food here, we don’t have any basic necessities and there is nothing to enjoy.”

Yakura, mother of two boys who are patients in MSF’s malaria clinic in Bama

We came here from our town, Jauderie, a year and a half ago. We came because Boko Haram took over our village and said we should join them – my husband agreed, and became one of them, but I didn’t want to. I took the children one night around 10pm, when their fighters were out on patrol, and we ran. We got to Bama at about six in the morning. It was hard for the children to walk for such a long time – I gave them Panadol Extra to keep them going. When I arrived in Bama, I was already five months pregnant. Later I received a letter from my husband divorcing me for leaving. Now that we’re here, the military won’t let us leave.

One of my children is in this ward for malaria, and the other is being treated for diarrhoea. I wish we could stay here in the hospital – it’s better than the camp, there’s more food and I know that if anything goes wrong my children will be treated immediately, but in the camp it would take too long.

Before coming here, I took the children to other healthcare providers – they gave us paracetamol. Then the MSF health surveillance team told me to bring the children here. We only came yesterday – my boy was vomiting and had a fever – he couldn’t even sleep.

When we arrived in the camp, they gave us food, but we sold some for firewood. When we finish our food rations, we have little option but to be hungry. We are not allowed to go outside the camp

We are suffering in the camp here – I wish there was medicine available there. When our food is finished, we survive by begging.

Falmata Babakura, an MSF malaria patient in Bama, and her mother, Fatima

Nine-year-old Falmata has been unconscious since her mother brought her to the MSF clinic in Bama, where she is receiving treatment for cerebral malaria. At the time of writing, she is gradually emerging from a coma while her mother, Fatima, waits at her bedside.

“Falmata has been sick for six days now”, says Fatima, “and she was unconscious when I brought her here on Sunday but now her condition is starting to improve.

When I brought Falmata here two days ago, she couldn’t talk, and she didn’t even know where she was, but now she’s beginning to open her eyes and move her body – I’m positive that she’ll make a full recovery now. Her sister had the same condition about two weeks ago – she was unconscious as well, and it took two days to treat her.

 If it wasn’t for MSF, I wouldn’t know what to do – we have nowhere else to go if we want to receive free medical treatment. When my daughter was admitted here, we were given a blanket, a mosquito net and soap. We are a family of eight with only three mosquito nets.

It’s not as if there are no other health care facilities in Bama but none can give us the kind of attention and care we are getting from MSF. All the drugs prescribed by the MSF doctors are given to us free while in other places, we would be asked to purchase them in drugstores, which we cannot afford.

My husband used to buy and sell smoked fish, but he can’t trade on the same scale as he did before – he lost his money with the Boko Haram crisis. At one point there was a complete ban on fish trading.

Life before was much better for us – things were easier. My husband was always travelling to Maiduguri to purchase smoked fish which he would sell here in Bama.

When Boko Haram took over our community about five years ago, my husband fled to Maiduguri and we followed two weeks later. We only had five children at the time, and one of them had left with their grandmother before the invasion.

We left Bama in the morning at about nine, trekked for the whole day and arrived at a village called Yawuri at about eight in the evening. The village leader gave us a place to sleep and we left the following morning at about five and arrived in Konduga around ten the same morning.

From there we took a car to Maiduguri where we were initially taken to another internally displaced persons (IDP) camp but later transferred to the Dalori IDP camp where we stayed for about four years before the government asked us to go home as the military had recaptured Bama.”