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Nigeria's Invisible Crisis

Flying into Monguno, a recently “liberated” town in a forgotten corner of a forgotten state in northeastern Nigeria, all you can see is a vast expanse of nothingness. There is no horizon, just a haze of sand whipped up by the hot, harmattan winds blowing from the Sahara Desert. No green, except for the curious mossy splotches where groundwater rises to the surface. All else is dust. The only signs of farms are the faint outlines of what were once fields etched into the desiccated land. Every so often the charred remnants of a village come into view.

This is what scorched earth looks like, a legacy of more than 8 years of terror by the extremist group Boko Haram, which, until recently, held the region in a vise. The world began to wake up to the full horror of that legacy last year, as the Nigerian army started ousting the insurgents from their strongholds here in Borno and the two adjoining states of Yobe and Adamawa. As survivors began straggling out, the few humanitarian workers already on the ground were shocked at what they saw: millions sick and near starvation, fresh graves that hinted at an untold number of dead. “We started seeing the state of the people coming out and got a sense of what the magnitude of the crisis might be,” says John Agbor, UNICEF's head of health for Nigeria in Abuja.

Exact numbers are hard to pin down, but across these three states 8.5 million people are in need of humanitarian assistance. About 5.1 million are malnourished, half a million children so severely that without treatment 75,000 more will die by June, warns the U.N. Office for the Coordination of Humanitarian Affairs (OCHA). About 1.8 million people have been internally displaced and are on the move, more than half of them children. In Borno, the hardest hit state, 1.2 million have crowded into the capital city of Maiduguri alone, doubling the population in a matter of months.

The uprooted are crammed into squalid camps and towns already too destitute to deal with the influx. Food, water, and sanitation are scarce or nonexistent, leaving few options other than open defecation. The camps and slums provide a perfect breeding ground for disease. In a deadly cycle, malnutrition renders children more susceptible to infection and less able to fight it. Epidemics of measles and malaria rage, and polio has resurfaced. Child mortality is off the charts, “two, three, four times” above the emergency threshold, says Marco Olla, a pediatric specialist with Médecins Sans Frontières (MSF) in Paris. Malaria has been the biggest killer, accounting for about half of all deaths, but acute respiratory infections and diarrhea are now vying for the top spot.

It is hard to rank human tragedies, but by all accounts this is one of the worst on the African continent today. “It is really, really, really bad for a lot of people. It is a crisis of great severity and magnitude,” says Jorge Castilla of the health emergencies program at the World Health Organization (WHO) in Geneva, Switzerland. Yet it remains remarkably unrecognized and hugely underfunded, leaving aid workers struggling with how to deliver lifesaving interventions when the needs are so great and the resources so paltry.

NIGERIA IS A NATION SPLIT IN TWO. The oil-rich, largely Christian south has all the trappings of Africa's wealthiest country, whereas the Muslim north rivals the poorest in the world. Literacy hovers around 20% or 30%, and it is far lower among women, who bear, on average, about seven children. The population is swollen with a generation of young adults with no education and few prospects, leaving them vulnerable to extremist ideology.

Boko Haram emerged in this environment around 2009. Its full name translates into “People Committed to the Propagation of the Prophet's Teaching and Jihad,” but the group is better known by the shorter one, which means “Western Education is a Sin.” The size of its army is unknown, though estimates place it at 15,000 or more. It rules by its own warped and cruel version of Sharia law.

At first, Boko Haram's attacks were sporadic, but the insurgents soon ratcheted up the intensity and seized more and more territory across the north. The group announced its presence to the world in 2011 by bombing the U.N. headquarters in Nigeria's capital, Abuja, and then gained further international notoriety in April 2014 when it kidnapped more than 250 schoolgirls in Chibok, Borno.

Even before he took office in August 2015, newly elected Nigerian President Muhammadu Buhari, a former general, declared war, vowing to crush the insurgents. The fighting has been brutal—innocents have been slaughtered by both sides. But the military has regained considerable territory, including Maiduguri, the birthplace of Boko Haram. Most recently, the army boasts of retaking Sambisa Forest, the insurgents' once-impenetrable sanctuary.

But, army assurances aside, Boko Haram is hardly gone. On 16 January, the day before I arrived in Maiduguri, two suicide bombers attacked the university in the middle of the town. The first, a teenage boy, detonated his vest in a mosque during early morning prayers, killing five people, including a well-regarded professor of veterinary medicine. At about the same time on the other side of campus, a girl of about 10 approached the security gate. When she refused to stop, the guards shot her in the leg. Her vest went off, killing her instantly. “Anyone on the street could be Boko Haram,” says Doune Porter, a UNICEF spokesperson in Abuja. Ten-year-old girls are now Boko Haram's weapon of choice. “It's sad and scary,” Agbor says. “How do you see a 10-year-old girl who comes up to your gate?

The army may have retaken towns and wards, but its hold is precarious. Even in Maiduguri, U.N. and nongovernmental organization (NGO) staff travel in bulletproof cars. Some roads have been officially “reopened,” but only with military escort—and even so, humanitarian convoys have been ambushed. The only way relief workers can get to the town of Monguno, some 100 kilometers northeast of Maiduguri, is by U.N. Humanitarian Air Service helicopter, which is how a photographer and I got there on a scorching January day. Whole areas of the state are totally inaccessible by any means, and an estimated 400,000 to 800,000 people are still trapped there living in unthinkable conditions.

The stories people tell of life under Boko Haram will break your heart. Women and girls were raped and abducted, boys conscripted to terrorize and kill their own people. Husbands were murdered on a whim, which is why women and children far outnumber men in the camps. Children saw their parents' throats slit.

Villages were pillaged and burned, and farmers forbidden to farm. A 60-year-old great-grandmother in Maiduguri's Gubio camp says she used to raise okra and sell groundnut and sorrel soup for a living in her home in the district of Marte. But the insurgents stopped all that. They “stole everything—clothes, crops, animals. One mistake by anyone in the family, they kill you.”

Schools and teachers were early targets. Across Borno, 35% of the health care facilities have been destroyed and another 30% damaged, according to a recent WHO survey. For years, women went without antenatal care, and children without treatment, medicine, or any immunizations at all, which is why disease outbreaks rage so fiercely.

Some families escaped at night, taking their chances on perilous roads. “You could be killed by hunger or run and be killed by Boko Haram,” says a father in Muna Garage camp in Maiduguri, a sprawling mess of precarious stick huts built almost on top of each other. He wants to get back to his land and farm. “At least we are safe,” he says. “We are hungry but not as before.”

AT UNICEF'S DALARAM FEEDING CENTER in Maiduguri, a health worker slips a multicolored measuring tape around a child's upper arm. Green signals a well-nourished child. Yellow shows the child has moderate acute malnutrition. If the tape falls in the red zone, the child has severe acute malnutrition (SAM), the most dangerous form. Left untreated, one in five will die.

The children with SAM who make it to this screening center are the lucky ones. If they are unable to eat, they are immediately admitted to a stabilization center for emergency treatment. Those who can eat, even just suck a dab of goo off a mother's finger, are admitted to the outpatient program here or others run by NGOs across the city. The children receive vitamin A, a key micronutrient, and the deworming tablet albendazole. More important, each mother leaves with pouches of a calorie- and protein-dense paste of nuts and milk, the ready-to-use therapeutic food (RUTF) that has transformed the treatment of malnutrition (Science, 3 October 2008, p. 36). Every week for 8 weeks, or longer if needed, the child is rechecked and the mother receives more food. When the tape reaches the green zone, the child is released from the program.

“It is a marvelous food,” says UNICEF's Porter. After 8 weeks, 85% of the children fully recover, she says. Even in 2 weeks, the difference is striking. But one young mother, who recently escaped from Bama and looks little more than a child herself, is worried today that, with two other children to feed, her 12-month-old will slip back into SAM after she is released. “I am not happy to think about it,” she says.

Conditions vary enormously from place to place, but quick surveys offer a snapshot of malnutrition in a particular place at a particular time. In August and September 2016, Epicentre, the research arm of MSF, reported that 9.5% of the children in Muna Garage camp and 4.3% in nearby Custom House camp had SAM. Anything above 2% is considered an emergency. Even worse, this January, UNICEF conducted a survey in a previously inaccessible district known as Kala-Balge: Thirty-two percent had SAM. OCHA has concluded that famine had “likely occurred” in parts of the state and is probably still occurring, but no one has been there to record it. The office reports that more than 55,000 people could experience “famine-like” conditions from June to August.

“This is the worst malnutrition I have seen in my 28 years,” WHO's Castilla says.

The combination of malnutrition and infectious disease is particularly deadly. Malnutrition clobbers the immune system, leaving the victim more prone to infections and more likely to die from them. Illness, in turn, often renders the child unable to eat or drink, worsening malnutrition. A child with SAM is nine times more likely to die of an infectious disease than a well-nourished one.

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Graphic courtesy of G. Grullon/Science; Data Courtesy of Family Early Warning Systems Network.

Graphic courtesy of G. Grullon/Science; Data Courtesy of Family Early Warning Systems Network.

IN A TENT in one of the many primitive camps in Monguno, a formerly small town now bursting with tens of thousands of people who have fled Boko Haram, a mother sits with her baby on her lap while a health worker scribbles a brief case history. How long has the child been sick? What are her symptoms? Diarrhea, fever, coughing, the mother replies. A few moments later, the health worker renders her diagnosis: malaria. At the next table the mother picks up a package of drugs called artemisinin combination therapies (ACTs), the best antimalarial treatment, together with antibiotics for any secondary infection and an analgesic to dull the pain and bring down the fever. As soon as the first mother stands up, another takes her place. Again, the child's symptoms are fever and cough. And again, the diagnosis is malaria. She, too, leaves with ACTs, antibiotics, and analgesics.

Treating every fever as if it is malaria—known as presumptive treatment—used to be common. Today, because of concerns about drug resistance, the recommended protocol is to give ACTs only after malaria is confirmed with a finger prick of blood and a rapid diagnostic test (RDT). But the health worker explains she doesn't have that option: At this UNICEF clinic, the RDTs are expired. (Many of the sick children also need treatment for malnutrition, but the clinic ran out of RUTF 3 weeks ago.)

Already a huge and chronic problem in Nigeria, malaria soars during conflict and natural disasters. The displaced often sleep outside or in makeshift huts that offer no protection from disease-carrying mosquitoes, which breed in the plentiful stagnant water in camps and slums. Well-known interventions can help: Bed nets and indoor pesticide spraying can thwart mosquitoes, and rapid diagnosis and treatment can cure malaria in just 3 days. But in a crisis few people have access to those.

Malnutrition makes everything worse. The interplay between malnutrition and malaria is poorly understood, but the risk of death is certainly higher in children with acute malnutrition, at least among those who make it to a hospital, says Larry Slutsker, who directed the malaria and parasitic diseases program at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta and now runs the malaria program at PATH in Seattle, Washington. (Many children never get medical treatment and either recover or die at home.) Several studies suggest parasite density is higher in acutely malnourished children, an indicator of more severe disease. And some acutely malnourished children have no fever or other malaria symptoms initially—but can quickly develop severe, life-threatening disease.

Desperate to bring down the toll in the northeast, WHO experts have been advocating an antimalaria strategy known as mass drug administration, or MDA. In an MDA, everyone in an entire population is given ACTs 3 days in a row, whether or not they are infected. The approach is complex and expensive, however, and offers only a short-term fix. WHO does not recommend MDA broadly but has recently endorsed it for outbreaks this deadly when health systems are as broken as they are here. Although questions of cost-effectiveness remain, recent evidence from the West African countries ravaged by Ebola suggests it helps.

Reaching millions of people on the move with any intervention is tough, so one idea was to pair MDA with a planned measles vaccination campaign. But logistics proved too daunting, and by January, when plans for the MDA were finally scrapped, the urgency had waned: The rains had stopped, and malaria, though by no means gone, was declining.

But the rains, and malaria, will come again in June. It's not clear whether MDA will be back on the table, or whether by then it might be possible to ensure that every family has a bed net and every clinic has testing kits and drugs. Either one will be a stretch.

EVERY BED IS FULL TODAY in the ward at MSF's makeshift hospital in Monguno, the children sprawled out, listless, while their mothers sponge them with tepid water to bring down the fever. Their eyes are red, teary, and swollen with conjunctivitis. Some have bronchopneumonia and are on oxygen. Others are on IVs, their diarrhea so intense they are severely dehydrated. Their bodies are covered in the hallmark rash of measles.

No one knows the size of the measles outbreak sweeping northeastern Nigeria. Whatever disease surveillance systems existed crumbled under Boko Haram. “In July, we started hearing reports of outbreaks with very high fatality rates,” recalls Mark Papania, a measles expert at CDC who is advising the government. By January, more than 1500 suspected cases had been reported, but just a fraction of those were lab confirmed.

Olufemi Akinola has no doubt the outbreak is “huge.” A doctor from southwestern Nigeria, Akinola runs the isolation-turned-measles ward here at MSF's hospital—the only one to serve about 250,000 people—and he has been seeing about 60 cases a week.

The children are isolated because measles is the most contagious virus on Earth. Just five suspected cases are considered an outbreak. The virus's reproduction number—the number of cases a single infection will generate—is a staggering 12 to 18. For Ebola, it is 1.5 to 2.5. The virus is spread by respiratory droplets that can linger in the air for hours; virtually any unvaccinated person who comes in contact with it will become infected. That's why, when people are packed together in camps during a disaster, Papania says, the first thing you do is vaccinate for measles.

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Health workers give polio drops to children by the roadside in Monguno as they escape from inaccessible areas. Image by Andrew Esiebo/ Associated Press.

Health workers give polio drops to children by the roadside in Monguno as they escape from inaccessible areas. Image by Andrew Esiebo/ Associated Press.

What Akinola is seeing in Nigeria “is not your textbook measles,” he says—not the mild disease people commonly associate with the virus. In combination with malnutrition and vitamin A deficiency, measles is a killer. Like malnutrition, measles suppresses the immune system and, in a dreadful synergy, each makes the other worse. Vitamin A deficiency and measles both degrade epithelial cells, the protective coating on the organs, which is why secondary infections are much more common and much more severe in acutely malnourished children. Ulcerated corneas can cause blindness, and if the virus reaches the brain, encephalitis can ensue, leading to convulsions, deafness, and cognitive impairments. Measles causes sores in the mouth that can be so painful that children cannot eat. That's when Akinola resorts to feeding tubes. In disasters like this, the death rate from measles can shoot up from 2% to 10% and occasionally soar to 30%. So far, none of Akinola's young charges has died.

As soon as the first measles cases were reported, health workers immediately began vaccinating in the camps. But that emergency response protected just the 10% to 20% of people who ended up in these desperate settlements. The majority of the displaced have sought refuge with family or friends in communities across the state.

In October 2016 the government appealed to the Measles & Rubella Initiative, a partnership of the American Red Cross, the United Nations Foundation, CDC, UNICEF, and WHO, for enough measles vaccine and technical support to immunize every child between the ages of 6 months and 10 years in Borno and surrounding states. Almost all the children who were trapped there have never been vaccinated. But these massive campaigns are tough. Because the virus is so contagious, 95% of the population must be vaccinated to elicit enough herd immunity to prevent an outbreak. But 95% of what? “The population is so fluid, things change in a blink of an eye,” says Chris Ezenwanne, a consultant to WHO on the campaign in Maiduguri. “If the denominator is wrong, you're in trouble,” Papania agrees.

The campaign kicked off on 12 January, targeting 4.7 million kids in 25 of 27 districts in Borno and parts of Yobe and Adamawa, and 3.1 million in Borno alone. (Going in, the government knew it could not reach areas still controlled by Boko Haram.) The final analyses are not finished yet, but data suggest the campaign fell short of its goal. It provided much-needed protection to millions of children, but 95% coverage proved elusive. About 85% of the target population was vaccinated, estimates Seth Berkley, who heads GAVI, the Vaccine Alliance in Geneva—enough to temper outbreaks but not prevent them. And they will inevitably arise where there are pockets of unvaccinated children.

ON THE OUTSKIRTS OF MONGUNO, Maiduguri Road is busy today. Men walk with firewood on their heads, and women carry bundles and sometimes babies on their backs. Soldiers pull over the occasional car at frequent checkpoints. Waiting in the shade at the side of the road, two women greet any mother who passes and ask whether her child has been vaccinated against polio. If not, the child gets two quick drops of polio vaccine on the tongue, followed by a drop of vitamin A and a deworming tablet. Meanwhile, the recorder notes where the woman is from and asks whether she has seen any child, anywhere, with weakness in their legs.

The global health community was stunned last August when polio resurfaced in Borno after the country had gone 2 years without detecting a case. Nigeria had been one of the sweetest victories for the Global Polio Eradication Initiative (GPEI). After hammering the virus with relentless vaccination rounds for years, they thought it was finally vanquished in Africa, leaving just two countries as the last bastions of the disease: Pakistan and Afghanistan. Now, four children were paralyzed in Nigeria. What's worse, genetic analyses revealed that the virus had been circulating in Borno undetected for 5 years. Like everyone else, those running the polio initiative had no idea how many people had been trapped by Boko Haram, unable to leave and out of reach of vaccination and surveillance teams.

Now, GPEI is searching the five conflict-torn countries of the Lake Chad Basin for other places, like Borno, where people are trapped and the virus could be lurking. In northeastern Nigeria, GPEI has set up transit posts like this one on Maiduguri Road to catch children who were missed in the door-to-door vaccination campaigns—the families just escaping Boko Haram, or the Fulani nomads who move with the seasons in search of grazing land and water for their animals. They chose this place because Monguno sits at a crossroads, strategically placed between Marte and Abadam, two districts that remain under Boko Haram's control. “This is one of the only roads between Marte and Abadam,” explains WHO's Mohammad Yusef. “Everyone must pass this way.” He and others think the virus traveled down this road last summer: Two of the four cases occurred in camps in Monguno, a third in a camp near Maiduguri. All the families had fled from Marte.

Elsewhere in Borno, “hard-to-reach” teams sit poised outside inaccessible areas, waiting for word that it might be safe to dart in and vaccinate the children. In the riskiest places, the teams give the injectable polio vaccine in addition to the oral one. It's cumbersome and more expensive than oral vaccine alone, but recent studies show that the combination boosts immunity faster.

Meanwhile, scientists at CDC are trying to peer into places the polio teams still cannot go. Scanning razed villages with satellites, they look for a new roof going up, or an overgrown road freshly cleared of brush—anything to suggest the inhabitants have returned and vaccination teams should follow. In late March, GPEI launched its largest synchronized vaccination campaign ever, targeting more than 116 million children across 13 countries in West and Central Africa.

All this firepower might seem like overkill for a disease that seems to have affected just four children. “In the here and now, polio is not a big problem compared to measles and malaria,” says Steve Cochi, who, as senior adviser in CDC's global immunization division, has long fought both polio and measles. “But obviously, if polio is not addressed, it won't be four cases tucked away anymore.” And, he adds, a multibillion-dollar global eradication effort is at stake.

THERE IS NO END IN SIGHT for the broader crisis in Nigeria—in fact, U.N. officials predict it will get worse in the coming months. Much of Borno remains a wasteland. Fierce fighting between the army and the insurgents continues. In one of the few recent atrocities to capture international headlines, the Nigerian Air Force bombed a refugee camp in Rann in Kala-Balge district in January after mistaking it for a Boko Haram enclave. Accounts vary, but more than 90 civilians and aid workers were killed. Suicide bombers continue to strike every few days in Maiduguri, and as long as poverty and hopelessness persist across the north, there will be no shortage of eager recruits.

Relief efforts remain desperately underfunded. Overall, the United Nations requested $484 million for the three states in 2016, but it received only 54%. Health programs fared far worse, receiving just 22% of the 2016 request. For 2017, the United Nations is asking for $1 billion, but few are optimistic.

People on the ground here know Nigeria is only one of the horrific crises around the world that are vying for the same finite pot of money. Still, they wonder why this one, in particular, has been so ignored. Some speculate it's because the north has no oil and thus is of no strategic interest to the West. The poor Muslim population of the north has never been on anyone's radar screen, others add, and the government was silent until the crisis could no longer be ignored. “If it weren't for the Chibok girls, no one would have even heard of Boko Haram,” is a frequent comment. What's more, the conflict is local, and unlike the Islamic State and Al-Qaeda, Boko Haram does not pose a broader threat.

“2017 will be tough. Maybe in 2018 we will see some recovery,” UNICEF's Agbor says—“but only if the army continues to push out the insurgents and people can get back to their land to farm.” Already, the government has begun “repatriating” some of the displaced, and it plans to close all camps by the end of May. Many question, however, whether that is safe and whether people have anything to return to. And that still leaves the hundreds of thousands of people who have yet to escape from Boko Haram with no safe place to go.