Having worked and volunteered for small development NGOs for a few years now, I have become more and more interested in NGOs that work more in the field of humanitarian aid. One of the largest humanitarian NGOs is Médecins Sans Frontières (MSF) or Doctors Without Borders, an NGO founded in 1971 in response to a humanitarian crisis Nigeria, a country where MSF is still working 50 years later. In November 2021, I joined this work myself when I went to Nigeria for a six-month mission as Construction Manager for the Belgian section of MSF.
There has been an ongoing conflict in Northeast Nigeria for many years now due to the Boko Haram insurgency, and MSF is one international NGO that has been responding to the resulting humanitarian crisis. In addition to the healthcare needs created by the conflict, Nigeria has one of the world’s highest maternal mortality rates. As a medical NGO, MSF has decided to respond to this need by building a new maternity hospital in the northeastern city of Maiduguri. While designing this new maternity hospital and managing its construction, I learned more about humanitarian crisis response and what my role can be as an architect.
How Médecins Sans Frontières has responded to the humanitarian crisis in Nigeria
Nigeria is Africa’s largest country and disease outbreaks of all kinds – from cholera and measles to yellow fever, lassa fever and many more – are common all over the country. As a result, medical NGOs like Médecins Sans Frontières have to decide where to work because they can’t be everywhere. Currently the worst humanitarian crisis in Nigeria is in the northeastern state of Borno, where the Boko Haram insurgency and resulting violence have forced more than a million rural residents to flee their homes. These displaced people, or IDPs, have fled to refugee camps in the state capital of Maiduguri – doubling the population of the city in the process while services like healthcare have remained constant.
Living in refugee camps in Maiduguri has meant that IDPs have lost access to their farms. This is turn has led to a shortage of food and a malnutrition problem. To respond to this need, MSF Belgium started a malnutrition treatment project in Maiduguri in 2016. The project still continues today, and the MSF Therapeutic Feeding Center offers both inpatient and outpatient treatment for malnourished children. Approximately 80% of the patients are IDPs.
Malnutrition is not a disease that can spread out of control. Rather, malnutrition is a man made problem, and once the underlying causes of the problem – in this case conflict – are removed, then malnutrition should also go away. For this reason, the agreement between MSF and the Borno State Government is that the nutrition center is a temporary project, and hence all the buildings are also temporary.
Just before my arrival the nutrition center had been moved to a new location. The new buildings are a mix of techniques, dominated by light wooden structures covered with a cladding of roofing sheets on the exterior and aluminium or chip board on the interior. Even though these buildings will not last long and they are also not always optimal for the users, a major benefit is that they are fast to construct, hence ensuring a quick response to a crisis. The MSF nutrition center also has some prefabricated structures and tents.
In December 2021, the government closed most of the IDP camps Maiduguri and some 75% of the displaced people were moved out of Maiduguri. But the humanitarian crisis in Northeast Nigeria remains, and relocating IDPs makes it harder for NGO’s like MSF to reach their patients. Indeed, many of the IDPs are still staying in Maiduguri and simply relocating to more informal camps that lack basic services. When I left Maiduguri at the end of April 2022, the nutrition center was just preparing for the start of high season as last years crops were starting to finish before the next harvest. The patient numbers were already high compared to previous years, showing that the humanitarian needs are far from gone.
New maternity hospital of Médecins Sans Frontières in Maiduguri
The Therapeutic Feeding Center of MSF in Maiduguri is responding to the needs of children impacted by the conflict, but MSF Belgium has also decided to expand its services in Maiduguri to address a related need, namely the health of mothers. When it comes to development of low-income countries, investing in women and mothers generally pays off, and maternal health is a key indicator of how well a country is developing. Due to Nigeria’s large population, high fertility rate, persisting poverty and conflict, up to one fifth of the world’s maternal deaths happen in Nigeria. Médecins Sans Frontières is now responding to this need by building a new 87-bed CEmONC – Comprehensive Emergency Obstetric and Newborn Care – facility in Maiduguri, on the same grounds as the existing Therapeutic Feeding Center.
There are public CEmONC facilities in Maiduguri, but they are not always functioning, their performance is weak, and they are not free for the patients. The new MSF CEmONC will respond to this need by treating the most complicated, high risk cases, and cases not meeting the criteria will be referred to government hospitals that MSF will also support. The plan is for MSF to run the new CEmONC for five years and then hand over the hospital to the Borno State Ministry of Health.
Unlike the nutrition center, the maternity hospital is thus going to be a permanent hospital and hence the buildings will also be permanent. My task as a Construction Manager was to design the CEmONC and to kick-start its construction. During the design stage I learned a lot about hospital design, such as the importance of infection prevention and control (IPC) and having finishes that are smooth, washable and easy to disinfect. As an architect, it was also important to understand the flows and life inside the hospital, from the flow of waste to the living space needed for new mothers caring for premature babies.
Development in a humanitarian crisis
Maternal health is not a humanitarian emergency like malnutrition. Rather, poor maternal health is mainly a result of poverty, and improving it will require time and addressing multiple issues. But Médecins Sans Frontières is a humanitarian NGO used to responding to emergencies and doing so as quickly as possible. If the hospital can be built faster, more patients can be treated and more lives saved, and at the end of the day this applies to both an emergency project like the nutrition center and a long term project like the maternity hospital.
Hence, it was necessary for us to finish the design and start construction as fast as possible. But building permanent buildings takes time, and so in order to facilitate an earlier opening, it was decided to build the CEmONC in phases. The first phase of the hospital will open when the first few buildings are completed, and the rest of the buildings will be replaced by temporary buildings or tents while waiting for all the construction to be finished. This way the hospital can open earlier and even if the number of beds will only be half of the final hospital, more patients can be treated and potentially more lives saved.
The tight timeline and phasing approach posed extra challenges on our construction team. It was important to work closely with the local contractors to optimize the construction timeline while keeping it realistic and ensuring the safety and quality of the construction. For me, it was also important to have a plan for what would happen to the temporary buildings once the whole hospital is complete, such as turning them into new offices or extra wards for the nutrition center.
Even with the permanent buildings, it was important for us to keep in mind how these buildings would function in the future, in particular after the first five years when MSF plans to hand over the maternity hospital to the Ministry of Health. The building techniques, materials and services like HVAC had to be designed and built with the local conditions and skills in mind, in order to ensure easy and affordable maintenance. The CEmONC may have been created in the midst of a humanitarian crisis, but hopefully it will continue to promote improved maternal health in Northeast Nigeria long after the conflict is over.
