Life in Pulka is anything but easy. The town is close to the frontline of the conflict between the military and non-state armed groups that has devastated northeast Nigeria for the past decade. Of its population of around 71,000, more than 40,000 are people who have been displaced from their homes elsewhere in Borno state.
With no civil authorities present, Pulka is completely controlled by the military. People's movements are limited to a short distance beyond the town's perimeter to farm, but many people do not feel safe going even that far.
The inhabitants' most basic needs - especially for shelter, clean water and sanitation - are not properly covered. Some 12,000 displaced people are currently staying in Pulka's 'transit camp', some of them living in the open for months on end. They are surviving on less than three litres of water each day, far below the 15-20 litres of water per person per day recommended by international humanitarian standards for emergencies.
The displaced people have already fled violent conflict and lost their livelihoods. Coming on top of this, the desperate living conditions and lack of protection in Pulka are exacerbating people's acute mental health needs.
Mohammed Abba, aged 50, fled his village, along with his two wives and 10 children, after it was taken over by an armed group, leaving behind everything he owned. His family are now in Monguno, while Abba is 200 km to the south, in Pulka's camp number four.
When Abba arrived in Pulka, he felt very alone and was despondent at having to depend on aid for his survival.
"[I felt] heaviness on my chest, as if my heart was swelling up," says Abba. "I was doing too much thinking - sometimes I'd just be shedding tears - and I found it difficult to sleep at night. When I eventually found sleep, I always dreamt of my nine relatives who were killed in front of us by armed men in Nguroseye before we fled the town."
The traumatic experiences that Abba went through have brought on mental health problems, for which he is receiving support from Médecins Sans Frontières (MSF) - one of the 1,863 people to receive mental health and psychosocial support from us in Pulka between January and June this year.
"None of my children will bury me when I die"
Mariya Duniya and Zainab Audu are also receiving mental health support from MSF. For 80-year-old Mariya, life seems meaningless after four of her nine children were killed during the crisis. Eventually, only elderly people were left in their village, she says.
The Nigerian military arrived in their village on patrol and transported them to Pulka. Without her children, Mariya is depressed and anxious about the future. "None of my children will bury me when I die," she says.
We are addressing people's mental health needs because they generate high levels of suffering and, if neglected, could metamorphose into severe mental health problems. Retsat Dazang, MSF clinical psychologist
Zainab, aged 32, has seen four of her 10 children die during the crisis. When the family arrived in Pulka, her husband was detained by the military. Left on her own to care for her six remaining children, one of whom was very sick, Zainab felt overwhelmed. Our mental health staff at the reception centre noticed the state she was in and have been providing her with counselling.
Mohammed Abba, Mariya Duniya and Zainab Audu have all seen improvements in their mental health condition and outlook since starting counselling, and all three are finding ways to make a living in Pulka: Abba is engaged in small trading; Duniya sells peanuts; and Audu makes embroidery caps.
There is an urgent need for reinforcement of the humanitarian response in Pulka... we need other organisations to help cover people's basic needs. Stine Jensen, MSF project coordinator, Pulka
"There's no health without mental health"
Most of the mental health disorders amongst MSF's patients in Pulka are directly linked to the violence. Over half of patients treated within the first half of 2019 had symptoms of depression, ranging from feeling sad to having suicidal thoughts.
One in five had symptoms of anxiety, such as constant worry or excessive fear, and one in five had symptoms of post-traumatic stress disorder, including flashbacks.
One in 25 patients had a severe mental health disorder with psychiatric symptoms. As well as counselling, we provide treatment with medication for patients with severe mental disorders.
Many children in Pulka have experienced very distressing situations - such as losing parents and relatives to the violence and witnessing killings. Our mental health team provides indoor and outdoor recreational activities for children and encourages them to express themselves, for example in drawing sessions, to help identify who needs their support.
"We are addressing people's mental health needs because they generate high levels of suffering and, if neglected, could metamorphose into severe mental health problems that can only be treated with psychotropic drugs," says Retsat Dazang, clinical psychologist and supervisor of MSF's mental health and psychosocial support team in Pulka. "Mental health is as important as physical health, because there's no health without mental health."
Unfortunately, mental healthcare is just one of a range of needs in Pulka. MSF project coordinator Stine Jensen says there are major gaps in the humanitarian response in Pulka that are having a huge impact on people's lives.
"There is an urgent need for reinforcement of the humanitarian response in Pulka," says Jensen. "We need other organisations to help cover people's basic needs, especially in terms of shelter, water and protection, and including mental healthcare."