Correspondence
Boko Haram insurgency:
implications for public
health
Nigeria has been involved in a 6 year
conflict with the group Boko Haram,
responsible for many attacks, the most
widely reported being the kidnap of
276 school girls in April, 2014. Boko
Haram currently controls an area the
size of Belgium across three states in
northeast Nigeria: Adamawa, Borno,
and Yobe. Health indices, such as
maternal and child mortality are worst
in the northeast region compared with
elsewhere in Nigeria.1 The substantial
gains Nigeria has made to control polio
might be lost if these issues of health care
are not urgently addressed in northeast
Nigeria. In 2013, 53 cases of polio were
recorded in Nigeria, more than half of
which were in Borno and Yobe. In 2014,
only one case was detected in Borno and
Yobe.2 This change suggests that cases
of polio might be going undetected
because of the insurgency.
The Nigerian Government estimates
the number of internally displaced
people in northeast Nigeria (as of
January, 2015) to be 981 416.3 At least
153 000 refugees have fled to Niger,
Cameroon, and Chad.4 These internally
displaced people live in (official and
unofficial) camps, often with illnesses,
physical and psychological trauma,
and minimal access to health care and
basic essentials, such as food, clothing,
shelter, clean water, and sanitary
conditions. Reports on the ground
(Welye H, unpublished) suggest that
diarrhoea is the main ailment, and so
far, two clinical cholera outbreaks have
occurred—these were never confirmed
because health workers had no access
to laboratory tests. Apart from a
few official camps (housing about
150 000 people) with potable water
supplies, internally displaced people
must access water from streams. In
our experience of the Malkohi camp
in Adamawa, for example, about
50 cases of diarrhoea occur per week
in a population of about 1000 people.
www.thelancet.com Vol 385 March 14, 2015
Respiratory tract infections rank
second, with about 30 cases per
1000 people per week.
A measles outbreak with hundreds of
cases is ongoing in northeast Nigeria.5
Cases of malaria are more difficult
to ascertain because the diagnosis is
often recorded as fever, especially if a
qualified health worker is not available
to examine the patient. Estimations of
the incidence of injuries are uncertain,
mainly because only individuals with
major injuries present for treatment.
However, from our experience, about
one in five people in the camps are
severely malnourished, including
children and nursing mothers. No
facilities are available for pregnant
women; they give birth under risky
conditions and all the maternal deaths
on record in the Adamawa camps have
been caused by excessive bleeding. We
have also heard reports of spread of
HIV infection. In Adamawa state, some
individuals with HIV and other chronic
diseases, such as hypertension and
diabetes, have been off medication for
at least 3 months.
The Boko Haram insurgency is an
urgent wake-up call for policymakers
in Nigeria and global health agencies
to provide humanitarian aid. In the
short term, health workers and health
supplies, including vaccines, need to be
deployed to both official and unofficial
camps. In the long term, efforts should
be focused on how to reintegrate
returning refugees, and on building
capacity for early preparedness for
future humanitarian emergencies in
Nigeria. The public health implications
of the insurgency are dire, and the world
cannot afford to sit by and watch. The
Nigerian authorities have so far been
unable to contain the insurgency. Nigeria
and its neighbours, whose health-care
systems are being stretched by the influx
of refugees every day,3 need support for
their health systems to respond to the
unique challenge posed by the conflict.
We hope that this letter will awaken
and engage the world to prevent the
looming public health disaster.
We declare no competing interests.
Oluwatosin Omole, Hamira Welye,
*Seye Abimbola
seyeabimbola@hotmail.com
Department of Family and Community Medicine,
Howard University Hospital, Washington DC, USA
(OO); Adamawa State Emergency Management
Agency, Yola, Nigeria (HW); and National Primary
Associated Press
Health Care Development Agency, Abuja 900247,
Nigeria (SA)
1 National Population Commission, ICF
International. Nigeria demographic and health
survey 2013. Abuja: National Population
Commission and ICF International, 2014.
2 Etsano A, Gunnala R, Shuaib F, et al. Progress
toward poliomyelitis eradication—Nigeria,
January 2013–September 2014. Published Online
MMWR Morb Mortal Wkly Rep 2014; 63: 1059–63. March 5, 2015
3 United Nations Office for the Coordination of http://dx.doi.org/10.1016/
Humanitarian Affairs. Nigeria: northeast crisis S0140-6736(15)60207-0
situation report no. 1 (as of 30 January 2015). See Editorial page 916
2015. http://www.humanitarianresponse.info/
system/files/documents/files/OCHA%20
Nigeria%20SitRep_January%202015.pdf
(accessed Feb 12, 2015).
4 Internal Displacement Monitoring Centre.
Nigeria IDP figures analysis. 2015. http://www.
internal-displacement.org/sub-saharan-africa/
nigeria/figures-analysis (accessed
Feb 12, 2015).
5 Sani D. Measles break out in Adamawa IDP
camps. http://www.thisdaylive.com/articles/
measles-break-out-in-adamawa-idp-
camps/199275/ (accessed Feb 28, 2015).
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941