Doctors, nurses flee as Boko Haram gets deadlier •Nigeria: Election season and multiple conflict arenas

Persistent attacks by Boko Haram militants in Nigeria’s Borno State have forced dozens of clinics to shut down and hundreds of doctors to flee, leaving many residents to seek medical attention across the border in Cameroon, health professionals and residents told a United Nations agency, Integrated Regional Information Networks (IRIN).

Musa Babakura, a surgeon at the University of Maiduguri Teaching Hospital (UMTH) in Maiduguri, told IRIN: “There is a growing health crisis in northern Borno, where most doctors and medical personnel have left the area due to security threat[s] from Boko Haram, forcing thousands to seek medical services across the border into Cameroon.

“The whole healthcare system in northern Borno has collapsed.”

As a result of doctors fleeing, many health structures in Borno are run by community health extension workers, which could have a detrimental impact on the reliability of epidemiological surveillance systems as well as the quality of care, said aid agencies. Non-governmental organisations (NGOs) are particularly concerned about the break in procurement chains for anti-malarial drugs and bed nets.

“All the medical workers fled for fear of being attacked or kidnapped by Boko Haram, leaving empty health centres and clinics with no one to attend to the sick,” said Modou Faltaye, local chief of Wulgo, a village near the Cameroon border.

In January 2013, Boko Haram seized control of a wide area in northern Borno, including Marte, Mobbar, Gubio, Guzamala, Abadam, Kukawa, Kala-Balge and Gamboru Ngala local government areas, prompting residents, including medical personnel, to flee southward to Maiduguri and southern part of Borno, where Boko Haram activities are not currently as persistent.

Despite a sweeping military offensive against Boko Haram in the area, underway since May 2013, the militant group has stepped up its attacks on civilians.

 Many doctors and nurses fled after the militants stormed several hospitals and clinics, taking medical personnel to hideouts in the bush, where they were called on to treat Boko Haram’s sick and injured, said Babakura. This put medical staff at risk of attack by the military, he said.

Drug access hindered
Most of the private clinics in northern Borno State, where the Boko Haram insurgency is currently concentrated, are closed, while public hospitals in the area have been emptied of medical staff.

Pharmacies, which were largely owned and run by members of the Christian Igbo ethnic group, have largely closed down, as they were often targeted by Boko Haram, with frequent looting and killings, said Gamboru Ngala resident, Idrissa Kaka.

Uchenna Okonkwo relocated his drug store from Gamboru Ngala to Jalingo, in northeastern Taraba State, hundreds of kilometres away, to escape Boko Haram looting and killings. “At first, Boko Haram gunmen would storm our chemists and demand huge sums of money, up to N200,000, which we would pay to avoid being killed,” Okonkwo said.

“They later got crazier by opening fire on drug store owners and taking money and drugs. A number of my colleagues were killed in this way,” he told IRIN.

Resident Kaka told IRIN that, as a result of these attacks, the price of medicines has gone up by at least a third.

Babakura, the surgeon, said the same was true in Maiduguri, as transporting drugs now requires paying off the military at the numerous checkpoints that have been set up en route from Kano and the eastern city of Onitsha, the two main drug sources for the city.

Fleeing to Cameroon
Inhabitants of villages and towns on the Nigeria-Cameroon border – among them Kala-Balge, Wulgo, Zannari, Kwalaram, Logomani, Musuni, Fuye, Ndufu, Gambo Ngala – are crossing over to the nearest Cameroonian towns and villages with a health post, said residents.

There they pay four times as much as they would pay for treatment back home, but they have no choice, said Jummai Sylvanus, a nurse who fled to Maiduguri from her post at Gamboru Ngala General Hospital.

Chief Modu Faltaye, a local chief in Wulgo, told IRIN: “Our people travel as far as Kusiri, 100 kilometres into Cameroon, to get medical care because all our health facilities have closed for the past one year.”

Some villagers use donkeys to transport their sick residents across the Cameroon border; others use rickshaws up until the border, where the authorities ban them from crossing, so they organise moped taxis to ferry the sick to hospitals.

“By the time the sick reach the [Cameroonian] hospital, they are in worse health state, which is why we lose a lot of our sick,” said Faltaye.

Though no studies have yet been completed, Babakura predicted the rate of maternal and infant mortality was bound to rise as a result of the complications.

Routine childhood immunisations in the region were already abysmally low, said a state immunisation official who asked to remain anonymous in Maiduguri, but the Boko Haram violence has further worsened the “pathetic situation,” he told IRIN.

Polio and deadly fever
Routine vaccinations are now limited to the Maiduguri metropolis. And polio campaigns have stopped in many parts of the state, especially northern Borno, as vaccinators are too terrified to work there, said the immunisation official.

Borno State accounted for 14 of the 53 polio cases recorded in Nigeria in 2013, according to the Global Polio Eradication Initiative.

On 14 September 2013, Borno State Health Commissioner, Salma Anas Kolo, blamed Boko Haram violence for the spread of polio in the state.

“For the eradication of polio in Nigeria and the world, we cannot afford to miss Borno and Yobe states,” Pryanka Khanna, UN Children’s Fund (UNICEF) spokeswoman in Nigeria, told IRIN.

Since December 2013, the fishing town of Baga, near Lake Chad, has been gripped by what residents suspect is cerebral fever. Without medical intervention, scores have died.

“People keep dying like fowl. It is acute fever characterised by severe headache and very high temperature, which kills within a few hours of contracting it,” Baga resident, Husseini Goni, told IRIN.

Attacks along Maiduguri
People living in villages near the capital, Maiduguri, say they constantly face highway attacks by Boko Haram en route.

“People with special ailments like HIV, diabetes and hypertension need to access drugs at regular intervals, and those drugs can only be found here in Maiduguri,” said Kaibur Ibrahim, a doctor at the University of Maiduguri Teaching Hospital. “Many of them are denied their chance to come if Boko Haram carries out a highway attack.”

Maiduguri hospitals, meanwhile, are straining under the surge in patients, just as their health staff has dropped, said Babukura.

Two of the hospital’s three orthopaedic surgeons have resigned, and a number of senior consultants have taken special leave due to the continuing insecurity, said Ibrahim.

During the week, Boko Haram gunmen killed nine Nigerian soldiers after launching an ambush on a military convoy in the troubled North-East.

The Agence France Presse (AFP) quoted Maina Ularamu, a local government official in the area, as explaining that the troops were responding to a distress call late Wednesday in the Madagali area of Adamawa State when they were bombarded by Islamist rebels armed with anti-aircraft weapons mounted on the backs of trucks.

 “There was heavy fighting yesterday evening between soldiers and Boko Haram gunmen,” Ularamu said.

He added that the Islamists “ambushed a military convoy on a mission to avert a planned attack... on Izhe village.”

A source at the Federal Medical Centre in the state capital, Yola, told AFP the hospital “received nine bodies of military personnel on (Wednesday) night from Madagali district.”

Ularamu said the fierce gun battle that followed the Boko Haram ambush caused “casualties on both sides” but could not provide figures.

The clash was the latest in Boko Haram’s extremist insurgency which has caused thousands of deaths since 2009, especially in the North-East.

On Tuesday, in neighbouring Borno State, at least 43 people were killed in two separate attacks blamed on the Islamists.

The deadliest raid struck the town of Konduga, where scores of gunmen razed more than half the village, spraying gunfire on fleeing civilians and killing 39.

‘No schools, healthcare services in Dikwa’
Boko Haram insurgency has kept children out of school in Dikwa Local Government Area of Borno State as well as denied residents access to healthcare.

The newly sworn-in Caretaker Chairman of the council, Alhaji Modu Ali Gana, has, however, promised to bring back the lost glory of the council by ensuring that students in primary and post-primary schools in the area return to school.

He lamented that the situation has been a setback to the  educational development of the area, as, according to him,  children are “the leaders of tomorrow.” Gana also disclosed that  the council would soon organise a stakeholder’s meeting with such leaders as the Shehu of Dikwa, Mohammed Ibn Masta II to ensure that students and teachers return to their classrooms.

Speaking in Maiduguri on Friday, Gana reiterated his plan to address some issues affecting the council, including insecurity, health care, education and poverty.

“Education is wealth, but it is unfortunate that for the past two years, no school has been functioning in Dikwa. Students have remained at home because of Boko Haram. This time round, we will not only renovate the schools, we will also see to it that our students return to classrooms, and their teachers motivated with the scarce resources at our disposal,” he said.

He also spoke of plans to renovate and fully equip the healthcare centres with necessary modern facilities and provide adequate drugs.

“We will continue to give much priority to the reduction of maternal mortality rate by providing free ante-natal care to all clinics in Dikwa, even as the welfare of staff will be enhanced to motivate them in the course of their responsibilities/duties,” he stated.

He added that since people in the local government are mainly farmers, government would also provide them with fertiliser and other farming inputs such as tractors, water pumps, and others. According to him, such gesture will create employment opportunities for the teeming youth in Dikwa.

He also spoke of plans to procure poverty alleviation materials, including sewing machines, spaghetti making machines and tricycles to be distributed free to women and youths, irrespective of party affiliations.
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Nigeria: Election season and multiple conflict arenas

Because of an American pre-occupation with the threat of jihadist Islam in the Sahel, much US attention is directed towards “Boko Haram” in northern Nigeria and whatever links it might have with other groups, such as al-Qaeda in the Islamic Maghreb. As I blogged on February 6, there has in recent weeks been a dramatic upsurge in violence related to Boko Haram.

However, there are also other nodes of violence that friends of Nigeria, and Nigerians, should watch.

The two most important areas outside the North are ethnic and religious conflicts in the Middle Belt and the threat of renewed insurrection in Nigeria’s oil patch. Nigeria is in a pre-election season–national elections will take place in February 2015. Nigerian elections involve elite politics, with little reference to the vast majority of the population. Even in non-election times, some politicians exploit societal cleavages to advance their own agenda. In a winner-take-all political environment where holding an elected office almost guarantees personal enrichment, motivation can be especially strong for a no-holds-barred election strategy involving violence between now and February 2015.

Some of the violence in Nigeria is also at the grass-roots level, where the enemy can be the elite. This is a dimension of Boko Haram, for example. Sometimes, elite and grassroots violence intersect. In the North and Middle Belt, politicians have been accused of trying to manipulate the grassroots–then losing control of the process: if you try to ride the tiger, you may find yourself in its stomach rather than on its back.

Politics, conflicts, rivalries, and ambitions in many African countries are intensely local; much (if not most) of the time, they are based on much more than just ethnic, religious, or political identities or on economic issues such as land use, access to water, or to markets. And, in many places, family politics are the basic lens through which everything else is viewed. Friends of Africa should be cautious about over-valuing ethnic or religious issues and under-valuing individual ambition.

These realities should make us wary about fitting the current high levels of violence into a single framework. Violence in the North, the Middle Belt, or the Delta may be largely unconnected, driven instead by more local realities. However, it does take place in the context of weak government and the heightened political tension of a pre-election period. This can make it explosive.

Campbell is a former US ambassador to Nigeria.