WORLD HEALTH ORGANIZATION

Health Update Sierra Leone 8 September 2000

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Displaced peopleSecurity doesn’t assure health Aid workers in the southern area of Sierra Leone say health is still in emergency even in apparently secure places.According to Dr Sandra Simmonds, medical co-ordinator for Médicins sans Frontières Belgium, her team were shocked by the level of illness and malnutrition they found when they opened a hospital into the southern town of Mattru Jong in June this year. “Mattru Jong has been one of the most secure places since 1997. But if you saw what came through the door when we opened the hospital, you would almost say it is an emergency. Our therapeutic feeding centre has 50 severely malnourished children. Everyday we send an ambulance to Bo Hospital with people in terrible conditions. No one would declare an emergency here because it is so secure, but it is an emergency because these people have never had access to health care.Dr Adriana Zarrelli, head of health programmes with UNICEF says having emergencies inside the normal situation“ is a peculiarity of Sierra Leone. “Even inside Freetown there are pockets of crisis, so you have to have several different approaches ranging from emergency activity through to development and all the transition activities in between,” she adds.While WHO Representative to Sierra Leone, Dr William Aldis says the fact that large numbers of displaced people have been absorbed into the community, and are relying on the help of family and friends who are often little better off than those displaced, adds to the effects of difficult access due to transport or financial constraints.“It is a misunderstanding if people believe that the crisis has only caused problems for the people in the camps,” says Dr William Aldis, who believes solutions lie in a dual approach of emergency response and health sector reform (see page 11).

New influxes strain services east…Displacement camps in the frontline town of Kenema have swollen by almost 15% over the past month as military and militia activities to the east around the new RUF headquarters town of Segbwema continue to drive people from villages. Mike Von Swarray, humanitarian co-ordinator in Kenema, says all the six camps have far more people than facilities to cater for them, though the influx has slowed.The town too is at bursting point with estimates that at least as many new arrivals have been absorbed into the community. Hygiene and sanitation is the most pressing problem with rats

abounding and communicable diseases a constant concern.

Kenema CampsAug 2000

Registered (ie. counted for food & services)

Unregistered(ie. not counted for food & services)

Naiwama 26,000 931Blama 12,996 2,052Lebanese 10,487 1,860Nyandeyama 9,589 2,850Konia 916 400Gofor 780 325Total 60,728 8418

Plans have been on the drawing board for several months to expand the smallest camp at Gofor, six kilometres east from Kenema Town and about a kilometre beyond the last UNAMSIL checkpoint, to take 5,000 more people. But a WHO visit last week found inherent problems including the lack of water on site and planting on the planned expansion area.

…. and westThe problem is not confined to the east. Half an hour’s drive from Freetown, the population of Waterloo Camp run by the NGO ADRA has more than doubled in the past month. Assistant camp manager Samuel Hubbard told a WHO assessment team last week the camp currently has 12,854 “registered and verified” people for whom food supplies are available, and 13,100 who have been registered by the camp process but not yet verified by the World Food Programme and therefore cannot receive food distribution.“Some come to beg at the distribution lines or from relatives, some sell firewood or make gardens. If there is anything left over from the official food distribution we give it to them and sometimes we get donations of food from other organizations.”Accommodation is a major problem in the camp built for a far smaller population. Some 2,600 are supposed to be in transit and have been clustered in one big ‘booth’ since May, while others are crammed several families per house. There are 58 water taps and 10 pumps making roughly one water source per 400 people.At the ADRA medical centre, Argentinean surgeon Dr Rubin Rostrand says the team is now using 4000 chloroquine tablets a week compared to 2000 a week last month. “We are having serious trouble keeping up with medicines and are talking to our medical co-ordinator about how we can increase supply. Many of the new people coming in are sick with malaria and infectious diseases.”But, he adds, it is also very difficult to control abuses of the system with trade going on in IDP registration card. “We have pretty sharp staff and used to be able to recognise most of the

faces but these new influxes make it more difficult.”

Health promoters need protectionWork done by NGOs such as Oxfam, Care and Action Contra La Faim to develop a cadre of health promoters in each IDP camp is paying dividends in some of them, but one year on from the start of the initiative, volunteers say they desperately need more tools to continue their work.In Bo’s Splendid Camp, for example, Dominique Lebbie, and over 80 colleagues are managing to keep the nearly 8000-person camp surprisingly neat. An unannounced visit by WHO found common areas and huts swept clean, showers scrubbed and water pump areas spotless. “It’s not good to self praise,” says Mr Lebbie, “But I think we are doing a good job, and the health of the people is much better than it was a year ago when we had just arrived. We have no excess of disease right now”But, says Mr Lebbie, the team carries out the often dirty work with no gloves or boots to protect them, and cleaning groups in other camps echo his plea for support.. Health promoters generally receive no payment for their work.

Access to healthSickness stalks rebel-held areasHealth workers fear populations still living in Northern rebel-controlled provinces of Sierra Leone are becoming sicker and sicker due to virtually non-existent access to health care.Mike Downham, director of the Bo-based Medical Research Council of Sierra Leone primary care centre rehabilitation programme which has recently extended activities into the newly accessible Bonkolenken chiefdom of Tonkolili district, says he has been amazed at the variety of sickness in the isolated rural area.“We found 60 to 70% of the population are sick. You see diseases that you don’t see anywhere else anymore, like scrofula because there has been no attempt at TB control for 10 years. Another example is the number of cases of unexplained blindness.“Our intervention has helped in Bonkolenken but if it’s like this there, right on the edge of the inaccessible area, what’s it going to be like further north?”Funded by the UK Department for International Development (DfID), MRC Sierra Leone has rehabilitated and equipped five clinics in Bonkolenken, one of the few chiefdoms in Tonkolili to remain loyal to the government and therefore accessible. This work follows a more extensive £400,000 programme rehabilitating a total of 15 health

units in Bo district over the past four years. All are now manned by returned Ministry of Health staff, are radio linked to the Bo base and have access to an MRC ambulance. “Every chiefdom in Bo district has at least one health centre and we are now starting on the maternal and child health posts,” says Mr Downham, who has been in Bo since the late 60s. The programme also helps villages set up health development committees which with the district health management team should gradually take responsibility for the service. And it encourages committees to set up small revolving credit funds by charging minimal user fees, to help those who find hospital care charges almost impossible to raise. A researcher with the British Medical Research Council unit in Bo until it withdrew its staff eight years ago, Mr Downham has spent much of recent years helping local health staff run mobile clinics to dispossessed and frightened people wherever they are“We set up by the side of the road or in deserted villages and people appear, first one or two, then crowds out of the forest, and then they disappear again as quickly as they came,” he says.Bo is now one of the most secure areas of Sierra Leone with as many health units as before the war. Mr Downham’s next mission from DfID, if he chooses to accept it, is to try and find away to get basic health services further north to people who desperately need them.

Clinic survives on Daru ‘island’The only way to get secondary care in Daru is to walk the 46 fraught miles to Kenema through rebel-held territory or, if you are lucky – and very sick – to get a lift in a UNAMSIL helicopter. Not surprisingly in the past six months, only six people have been referred to hospital.A UNAMSIL protected island in the middle of rebel territory, uncomfortably close to the new RUF headquarters town of Segbwema, the only way in or out is by air, or taking a risk on the footpath – the road itself has been cut. But if secondary care is out of reach, primary care is not, thanks to a dedicated bunch of local health workers and the support of the International Medical Corps.Since July, Daru’s population has swelled from around 1,500 people to almost 10,000 due to conflict in the surrounding area, and according to health statistics collected by the clinic, over 20% of this population has attended the clinic with malaria in the past two months.Dysentery, acute respiratory tract infections and sexually transmitted diseases are the next most common conditions in the clinic, which though Spartan, has kept going throughout all strife and

is a lifeline for the population. Drugs and supplies are flown in by IMC, ante natal clinics are held twice a week and routine childhood immunization restarted two months ago after UNAMSIL offered to store vaccines in their fridge. As well as the static services, the clinic team run a mobile clinic to the village of Malema across the river four times a week which serves people who travel from 15 other villages outside the UNAMSIL boundary – though mobile currently means on foot since scarce fuel has pushed prices beyond even OPEC’s wildest dreams.But the main concern right now, say health workers, is food supply. A rapid nutritional screening exercise of 544 children carried by British NGO Merlin last month, put global malnutrition of 7.6 and severe acute malnutrition at 3.7. But these figures hide higher rates for the new arrivals with rates for children resident less than six month reaching 9.6 global and 5.2 severe malnutrition. IMC maternal and child health aide Marima Kanneh fears things are going to go rapidly downhill as the consequences of poor food kick in. Already she estimates around 35% of children are born sick in part due to their mothers’ poor nutritional status.Help may be at hand, however. The World Food Programme, Merlin and IMC are meeting to try and work out how, in spite of the logistic difficulties, to start a programme of supplementary feeding to target the most vulnerable.

Rebels delay Kabala effortsPlans by Médicins Sans Frontières Belgium to re-strengthen their support for six peripheral health units in the Kabala region in coming weeksreceived a set back when rebels again attacked the town in late August.

Accessibility updateThe security situation, particularly in the northern provinces of Sierra Leone changes from day to day. However, other areas of the country – including a broad swathe of the south – are stable and are accessible by various means.“People think of Sierra Leone as a place where nothing can be done, so secure places like Bo suffer,” says Bo District Medical Officer, Dr Amara Jambai. “It may look impossible from outside but there is a lot we can do in these areas.”StableWestern Area: Freetown city and the rural suburbsLungi BoKenemaPujehunUnstable but accessible Port LokoMile 91

Unstable and difficult to accessKambiaMakeniKabalaKonoKailahun Daru

The NGO pulled out international staff earlier this year after they were taken hostage for a day, but have supported national staff to continue a skeleton programme, particularly supplying essential drugs. Medical co-ordinator Dr Sandra Simmonds said they had hoped a newly arrived international logistician would be able go into the area this week after the area had been calm for almost two months, but the renewed instability has put plans on hold. A recent WHO assessment visit to health facilities in Kabala found the hospital functioning, but in dire need of basic surgical equipment including lighting – operations are being carried out by flashlight. Training in the integrated management of childhood diseases would also be a priority when access is possible, the WHO team said.

Reproductive healthTriple attack on maternal deathsUN agencies are throwing their weight – and more money than ever before – behind a new assault on Sierra Leone’s tragic record of deaths in childbirth.The rate of maternal mortality in the country has been stuck at more than 18 deaths per thousand live births – one of the highest statistics in the world – despite efforts over the years to reduce it.At this rate, a Sierra Leonean woman who gives birth to six children has over a 10% risk of dying in childbirth.Now, after a major re-analysis of the root causes of these figures, the three UN agencies involved in the health of women and children – the United Nations Population Fund, the United Nations Children’s’ Agency and the World Health Organization – have come together in a fresh collaborative approach which they hope, this time, will have a real impact.“The trouble is,” says WHO representative to Sierra Leone, Dr William Aldis, “that you can train any number of traditional birth assistants in how to make childbirth safer but if they don’t have a hospital to refer to that is skilled and equipped to deal with the complications of birth that kill, TBA’s can’t make a difference to maternal mortality.” Training community birth assistants and midwives does reduce risk factors such as

infection and can result in quicker reaction to potential problems he says, “But once a woman’s life is at risk, what she needs to save her is beyond the skills of community workers. What she needs is access to a functioning hospital – and in Sierra Leone that means solving some deep structural problems.”Dr Abu Pratt, health project officer with UNICEF, says the problem of maternal mortality is so big no one agency can do it. “What we have done with the other two agencies is divide the responsibility for specific levels of care.“In the new project, UNICEF is focusing on raising skill levels for safe and clean birth in the community while WHO and UNFPA have taken on the task of improving the skills, equipment and access to hospital care that can make the difference between life and death once complications set in. If we enable traditional birth assistants to identify who needs hospital care in time then the WHO role is to make sure that they get safe care once they get there,” he says.This says Dr Aldis, involves some fairly obvious activities. Obstetric and surgical equipment has been ordered, for example, and plans are being made to update key staff in life-saving techniques. But the harder task is the less obvious one of reforming and revitalising hospitals that are barely functioning due lack of resources, lack of motivation and corrupt financial practices. “It may seem a million miles from a mother’s life, but without reforming hospitals, we cannot solve the problem of maternal mortality,” says Dr Aldis.To back the new approach WHO is dipping deep into its regular budget to put five times as much money – some US$340,000 – into the pot as last year, while UNFPA have committed $1.2 million and UNICEF over $250,000.Despite this year’s crisis, some health sector reform is in fact already taking place with the introduction of cost recovery (see page 11). By working with key NGOs and the Ministry of Health, WHO hopes to promote this change of culture more widely and through it reduce the tragedy of maternal death.

Training for traditional birthersUNICEF’s reproductive health training programme complete with a newly revised manual for Sierra Leone started last month. Participants are supplied with food during the six week training but no per diem or incentive. Despite this 40 women have recently completed the six week training of trainers course. At the end of the course each participant is given a essential birthing kit and a unusual record keeping device designed for the largely illiterate assistants – a box with pictures of

different outcomes of labour with holes through which small stones are posted to record the event.

Sex for soap and keroseneWith women and children making up some 60 to 70% of displaced populations and around 10 per cent having to perform sexual favours to get the basic essentials for their family, setting up dedicated reproductive health clinics in the camps is an priority, according to International Medical Corps medical co-ordinator Elizabeth Manga.Mrs Manga takes her estimates from months of carrying out interviews with women in the camps while supervising IMC’s clinic activities which are mainly in Port Loko, Lungi and Daru. But one good thing about the camps, she says, is that it provides an opportunity to reach women with information on reproductive health.“We shouldn’t be waiting until these women go back to their area to help them with reproductive health. They need it now – and they are in some ways a captive audience.”While most camp clinics do provide rudimentary reproductive health care, Ms Manga, who was herself displaced from Kono with four children after her husband was killed, says most women are too embarrassed to ask for help at general clinics. She is advocating for camps to create specific reproductive clinics where women can be treated but more importantly educated about protective and preventative measures.

Communicable diseasesAction on yellow fever outbreakSierra Leone moved this week to build up its defences against the potential spread of a yellow fever outbreak from Liberia.Disease control experts from the Ministry of Health and WHO are carrying out crash training in identifying and managing the disease with health workers in the at-risk districts of Kenema, Pujehun and Bo next week and NGOs such as Médicins Sans Frontières Belgium and France, Merlin, Goal and the International Medical Corps who are supporting peripheral health units clinics are disseminating guidance and sensitising staff.Meanwhile, WHO headquarters in Geneva has despatched 180,000 doses to WHO Liberia for a mass vaccination campaign due to start there this week and is raising funds for at least further 50,000 doses to extend vaccination into Sierra Leone.The outbreak in Liberia, which was first reported on August 16 in the coastal county of Grand Cape Mount which flanks Sierra Leone’s Eastern Province, has now spread into six of Liberia’s 14 counties.

The risk of widespread transmission is high. Both countries have a large unvaccinated population, the area is notoriously insecure and hard to access due to rebel activities, and there are large numbers of displaced and weakened people moving across the border.One of the index cases – a four-year-old child – is thought to arrived in Liberia from Sierra Leone with fever but died before diagnosis could be confirmed.“We have to assume that it is already with us,” says Dr Abdul Rahman Wurie, WHO Sierra Leone’s Disease Prevention and Control Adviser who, with the Ministry of Health, is leading the response. “So we want to move fast to try and prevent any further development.”Health workers are being asked to immediately report any suspected case with fever and yellow eyes. The last outbreak of yellow fever occurred in 1995 and caused 49 cases and four deaths.

Death prompts new lassa unitA lassa fever isolation unit is to be set up in Freetown after the capital witnessed another death from the disease in the last weekend of August. The victim, a man from Kenema in Freetown for a funeral, arrived in Freetown with fever. He was rapidly diagnosed via examination and liver function tests by doctors in the outpatient department of Connaught Hospital but advised to return to Kenema where Sierra Leone’s only lassa fever treatment unit is sited for treatment. However he died on the journey, two days after first reporting.“We are not saying this patient could have been saved – given the speed of his death. But it is important that we establish a treatment unit in Freetown so that cases can be started on the treatment quickly,” says Dr Abdul Rahman Wurie, WHO’s disease prevention and control adviser.. The new isolation unit will be sited at the ministry of health’s Waterloo Clinic in buildings which used to house the Western District’s health management team, now relocated to Freetown.A number of agencies have already come forward to help provide the new unit with trained staff and equipment.Two ministry of health doctors and six nurses from Freetown are to join the Lassa Fever Treatment Centre in Kenema for an intensive hands-on course on managing the disease. Run by British health NGO Merlin, the centre is the only specialist lassa fever unit in Africa and staff are among those with the greatest experience of treating the disease in the world.

While Merlin has agreed to sponsor training, WHO will support the trainees financially during the course, supplying transport and per diem. WHO will also provide continued technical assistance once they are established at the Waterloo site.To establish the unit itself, Médicins Sans Frontières Belgium has agreed to provide beds, mattresses and bedding, while UNICEF has promised disinfectants and utensils and other day-to-day equipment. WHO is to give the protective equipment essential for barrier nursing with extra gloves and other furniture coming from the UN AIDS programme and Irish NGO Goal is being approached to help set up disposal facilities for clinical waste at the new unit.

Victims stay high despite rainsLassa fever is continuing to cause concern in Sierra Leone as the number of cases fail to drop to normal rainy season levels.Lassa is endemic in this area of the country but cases normally peak in March, when rats flourish with the dry season harvest, and drop away with the onset of the rainy season. This year, however, numbers have remained high. In June and July, the Lassa Fever Treatment Centre in Kenema treated 56 and 53 cases respectively. compared to 12 and 22 in June and July 1999, though these figures are also unusual due to the conflict in the area. One explanation for the high figures is the huge influx of people into Kenema town and camps, says Nichola Cadge, medical co-ordinator for Merlin. But it’s also likely the intensive public awareness work and training of health workers done by Merlin, the ministry of health and WHO in the wake of deaths of two expatriates and four Sierra Leoneans from Lassa fever in Freetown early this year is bringing more cases to light. “There’s no doubt that the overcrowding and poor sanitation not only in the camps but also in Kenema Town where large numbers of people have recently been absorbed into the community, make ideal conditions for rats.,” says Ms Cadge. “But we have been very proactive in health education and have been doing active case finding in previously inaccessible areas.”Roughly one in five patients who contract lassa fever die from it and early diagnosis and treatment is a key factor in survival. The 32-bed centre, which was originally set up by the US Centers for Disease Control and Prevention in 1994, is the only specialist lassa fever unit in Africa and is now supported by Merlin with funds from the European Community Humanitarian Office, the US Office of Foreign Development

Aid (OFDA) and the Dutch Department for International Development. Its small local and expatriate staff have great experience of treating the disease But Sierra Leonean unit head, Dr Aniru Conteh, is concerned about the unit’s future“Merlin is an emergency relief programme and this is a long term problem for us. I’m worried about what will happen when they go.”One of the problems in gaining long term commitment to tackling the disease, says one observer in the capital, is that the Lassa Belt is a long way from Freetown. “The government only really sit up and take notice when there’s a case on their doorstep. So we are taking as much advantage as possible of the attention raised by the Freetown and expatriate cases to press for long term public health activities.”

Shigella epidemic under controlCases of shigella dysenterie type 1 have dropped from epidemic levels seen at the turn of the year, but some NGOs are now concerned about the increases in other diarrhoeal diseases.The Ministry of Health surveillance unit reported 1,856 cases of shigella in June for the whole country compared to over 2,200 cases a month reported between July 1999 and February 2000 by one NGO, Merlin. Médicins Sans Frontières France in Kenema, where the outbreak was first recognised, confirms their clinics are seeing around three cases a week down from 150.The outbreak was controlled after an investigation in January by a combined team from WHO African Region, headquarters and the Parisian communicable disease centre, Epicentre helped identify the strain and prompted training in management and laboratory techniques. WHO also provided a further 100,000 tablets plus $10,000 for the field response and health education campaigns, oral rehydration solutions and IV fluids.MSF-France has closed the five temporary isolation clinics it had opened in hard-to-access areas close to the Liberian border, but it is maintaining its Dauda isolation camp in Kenema because of worrying levels of cholera and typhoid fever, says MSF-France medical co-ordinator Ariane Bauernfeind.“We saw around 100 cases of cholera in July, which is enough to be worrying because the town is extremely congested, latrines are full and an epidemic could explode. We have also had around 10 patients who we believe have typhoid fever. But confirmation is difficult because there is nowhere in Sierra Leone which can culture blood for typhoid.”

Catching the diseases – earlySierra Leone needs a fresh approach to disease surveillance if it is going have a system that really produces effective planning and action against infectious outbreaks, according to WHO.“Sierra Leone has a well developed system of data collection,” explains Dr Abdul Rahman Wurie, WHO’s disease prevention and control adviser. “But very little analysis is done, so trends and opportunities to act are missed. What we need is data collection for action so that it’s possible to shift from routine surveillance to active surveillance and investigation when epidemic threats are identified.” Surveillance has suffered from the disruption of the conflict but lack of analytical skills, data equipment and motivation are also a major problem. To remedy the situation WHO is working with the ministry of health on a programme that will improve skills at all levels. In the community, the project involves refining reporting forms so that health workers can concentrate on fewer, high priority diseases. A new surveillance manual is almost complete, says Dr Wurie. But speed of communication is also fundamental to effective surveillance, and WHO is also working to develop selected rural health facilities as reporting centres, equipped with radios through which smaller ‘satellite’ facilities can report.At district and ministry level, the focus is on developing the analytical and computer skills needed to turn data collection into an effective early warning system Dr Wurie says it is crucial to make a start despite the fact that half the country is inaccessible. “We will start in pilot areas “where we are most likely to succeed and expand from there.”The first pilot sites are most likely Freetown, Lungi, Moyambe, Pujehun, Bo and Kenema. Much of the ground work, including the placing of disease surveillance officers in each district management team has been funded by WHO, and the next stage will be supported with funds from the Italian Government.Dr Wurie says the new system will not just boost disease surveillance but by improving communications, will also improve other aspects of care such as emergency referrals and the ability of more isolated units to seek technical support and advice.

Blue flags wave for disease controlDisease prevention experts are to call on the services of a Sierra Leone’s dynamic cadre of community health workers known as Blue Flag

volunteers in their drive to get infectious diseases under control.The organisation is the brain child of UNICEF and the Ministry of Health who originally recruited and trained people from communities in the mid 1990s to detect cholera and administer oral rehydration solutions. The volunteers identify their house in the village with a blue flag and agree to be available day and night.Now the Ministry and WHO hope to add surveillance of other diseases to the skills of the volunteers, many of whom have also now been involved in both polio immunization days and watching out for acute flaccid paralysis, the marker sign for potential polio virus. At a recent meeting in Pujehun to explain the plan, volunteers received the idea enthusiastically, though they pointed out the biggest problem for them was simple getting from A to B with the information.Dr Abdul Rahman Wurie, WHO disease prevention adviser, says the new approach will counter this problem by setting up local radio-linked networks to cut travelling distances.

MalariaKick start for Roll Back MalariaAfter two years of piecemeal activities disrupted by conflict and erratic funding, health players in Sierra Leone are determined to get the Roll Back Malaria programme, agreed upon in 1998, back on track this year.According to the new plan of action, drawn up by Ministry of Health national programme director Dr Sarian Kamara and WHO malaria focal point Dr Abdul Rahman Wurie, the next two months should see intensive activity to get national and international health and community partners on board, produce information kits and develop district action plans.Four districts have been selected to pilot the programme scheduled to start in early 2001. These are the Western district including Freetown, Bo, Kenema and Port Loko.WHO consultants were in Sierra Leone recently to train ministry programme leaders and will return in November to train the RBM taskforce in driving the programme forward.Sensitization workshops funded by WHO are also starting up. In Bo last week some 40 district health team staff, community health officers and laboratory technicians were put through their paces on current prevention, diagnosis, management and investigation techniques.The Roll Back Malaria created by WHO focuses on the fact that most victims of malaria die simply because they do not have access to

health care close to their home, or their cases are not recognized as malaria by health care workers. Among its key principles are prevention using impregnated bed nets and household protection, improved supply of anti-malarials at local level and improved skills for diagnosis and management.

Nets and information are key toolsMalaria is the number one cause of reported illness in Sierra Leone. District medical offices report an average of 30-40% of visits to health facilities are prompted by malaria.Merlin is one of the organizations distributing bed nets and training local people in impregnation in displacement camps in Sierra Leone. The nets are distributed on a cost recovery basis and after six months there has been a 95% retention rate in the three Kenema camps they have supplied. Merlin outreach teams have also been promoting prevention messages to camp and town populations. “We have been concentrating on child to child activities, on reaching women’s groups and on training health volunteers on the community-based management of childhood fevers,“ says Nichola Cadge, Merlin medical co-ordinator.A knowledge, attitudes and practices survey carried out by the team in February showed there is plenty of need for education. “For example, a large number of women don’t know that it is mosquitoes that transmit malaria, many thought it was a stomach disorder,” says Ms Cadge, noting that Merlin is currently planning to extend its activities to Newton Camp near Freetown in collaboration with the Ministry of Health and Oxfam.Other myths common even among medical professionals, according to Dr Abdul Kargbo, a malariologist and WHO’s co-ordinator for the East and Southern districts, are that drinking beer, palm wine or orange juice, and the presence of menstruation increases susceptibility to malaria.Results of a prevalence and knowledge, attitudes and practices survey for the Kenema camps/district should be available from Merlin in mid September, ph: 232 22 231 738, email merlin@serratel.sl

Surprise sensitivity results Doctors from the United Nations Mission in Sierra Leone’s Jordanian battalion (UNAMSIL) are reporting high cure rates for malaria using chloroquine, a therapy thought to be ineffective due to increasing resistance. In recent weeks, medics say 50 of 50 cases treated with chloroquine as first line therapy have achieved full cure.

This supports several chloroquine resistance studies carried out by WHO in 1998 and 1999 which found resistance to be under the threshold of 30%. WHO continues to support sentinel site surveillance of resistance patterns in the Western District,

Polio eradicationPartners will make or break it Partners in the campaign to rid Sierra Leone – and the world – of the polio virus are concerned that, with just two months to go to planned national immunization days, vaccinator access to large areas of the countries is still not assured.Last year, Sierra Leone achieved what many in the outside world believed impossible – the agreement and support of all the conflicting parties and a coverage rate of 84%.But the breakdown of the Lomé Accord has removed contact points on the rebel side and despite the appointment of new RUF leader General Isa Sesay, the lack of agreement is forcing international organizations to raise the alert that Sierra Leone may again slip to the bottom of the polio league.So far, intensive negotiations with health and local authorities have assured access to most of the Western and Southern districts plus Kenema town where immunisation will be carried with a combination of house to house and static sites. But WHO medical officer for the expanded programme of immunization Dr Mekonnen Admassu says the team has had no contact in either Bombali or Kambia and can reach only three of 11 chiefdoms in Tonkolili. Kono and Koinadugu are better covered two thirds of

Vaccine virus in Kono shows reachProof that polio vaccine has reached the remotest corners of Sierra Leone came earlier this year with the recovery of a vaccine-related virus from a child in the diamond-mining district of Kono.Double the number of children were vaccinated against polio in national immunization days in 1999 compared to 1998 simply because all political entities committed themselves to getting vaccinators into every part of Sierra Leone. President Kabbah, Revolutionary United Front chairman Foday Sankoh, Lt Col. Johnny Paul Koroma, head of the Armed Forces Ruling Council and Brigadier General Maxwell Khobe, Chief of Defence Staff not only gave their support to the campaign but even posed together for the poster picture.The three 1999 rounds reached 76, 85 and 84% of the almost 822,000 children in the target age group compared to only 45% in 1998 when only

seven out of Sierra Leone’s 13 districts could be reached.

the chiefdoms with assured access at present. Polio co-ordinators from Guinea and Sierra Leone are meeting this week to see whether closed areas may be accessed from across the border. Thirty-two cases of acute flaccid paralysis have been investigated so far this year. Two samples – one from the Port Loko area, the other from Kenema – have proved to be wild polio virus with another reported as an non-polio enterovirus.“The defining characteristic of the last place on earth to have a case of wild virus polio is that it will be a complex emergency,” says Dr William Aldis. “We don’t want that place to be Sierra Leone.”

HIV/AIDSSurvey to pin down HIV impactThe US Centers for Disease Control and Prevention are to carry out a customised seroprevalence survey to try and pin down the real impact of HIV/AIDS in Sierra Leone.The survey – funded by the World Bank – will extend beyond normal target groups to include groups such as child combatants and displaced people.“Past figures suggest that Sierra Leone is at 8-10% seroprevalence which is about the level at which cases start to grow exponentially,” says WHO representative, Dr William Aldis. ”But figures are unreliable and we really need solid information if we are to target activities effectively.”Sierra Leone’s emergency situation is a “lethal mix for HIV transmission” according to the Ministry of Health national programme manager. “Population displacement, rape, occupying troops, women in desperate circumstances, insecure blood supplies, drug abuse, unsafe sex practices and insufficient control activities all add up to a disaster,” says Dr Patrick Moses, who spends most of his time on the road evangelising about prevention. Substantial funding – over US$1.3 million has been allocated by the World Bank to developing the AIDS programme in Sierra Leone and a further US$100,000 has been promised by the US Bureau for Population, Refugees and Migration to establish safe blood transfusions services in all government hospitals. This supplements the US$150,000 start-up grant provided by UNAIDS earlier this year.

Child HealthImmunization at rock bottomRoutine childhood immunization has almost completely collapsed in some areas of Sierra Leone and even the best performing districts are managing to vaccinate less than 30% of all eligible children - a far cry from 1991 when with coverage of over 75% the country was an example to the region.Latest figures from UNICEF show that while around a quarter of children in districts like Bo, Kenema and Bonthe have had BCG vaccination, and between 13% and 33% received DPT 3 and measles, the Western District which covers Freetown and its rural surround has among the worst coverage – down to single figures for both DPT 3 and measles and as low as 6% for BCG. This coverage is as bad as the frontline conflict districts of Kambia, Bombali and Port Loko.Despite these figures, a national campaign funded by the Christian Children’s Fund which completed its second round last month, has drawn substantial criticism. This is partly because the campaign was sprung on partner agencies with little warning and both undermined vaccine supplies for normal immunization activities and strained human resources, since health workers were pulled out of clinics to carry out the campaign, but also because of its questionable effect.“The trouble with a campaign like this is that it can raise the coverage, but it does nothing to keep it up. The money and effort spent on the campaign would have been better spent on strengthen routine immunization activities in the areas of lowest coverage,” said one officer involved who did not wish to be named.

Schools in – worms outOver 250,000 children in the Southern district appearing for their first day of school on 11 September will also receive their first treatment to banish worms in a campaign that is part of a UNICEF project to rebuild school health services. Over the past two years, the agency has worked to revive the programme in Freetown and the Western Area, and it is now expanding into the Southern District, targeting schools in Bo, Bonthe and Pujehun.So far 250 teachers have attended training courses on first aid, use of oral rehydration solutions and de-worming as well as how to promote health messages in areas such as hygiene and protection from AIDS/HIV.

Mental HealthCulture can help child soldiers Care givers working with former child combatants and abductees do not need to be inundated with psychological training, according to the International Rescue Committee’s new field co-ordinator. But what they do need is support to discover how they can tap their own cultural resources to the benefit of the children and to themselves.Over 1800 children have passed through the demobilisation, disarmament and rehabilitation process this year and almost all stay some period of time in the interim care centres set up to be a home while the possibilities of family reunification or other solutions are explored.Here local people trained by various NGOs care for the children and help them readjust to normal life. Some have suggested that the strain on the relatively unskilled caregivers, many of whom have themselves experienced violence perpetrated by children, makes it impossible for both the child combatants and the caregivers.But IRC psychologist Dragan Markovic who directs the psychosocial care programme for five interim care centres in Bo and Kenema believes with the right support, the experience can be beneficial to both. “We need to reinforce for local staff that it is not us – the outsiders – who bring the solutions but them and their own culture that has the tools to deal with what is happening with these children,” he saysIRC caregivers receive a basic training in counselling, but more important than days of concepts and techniques in workshops, says Mr Markovic, is having a system of day to day support which allows care-givers to talk through the issues their work throws up.“This kind of close support enables people to understand and develop their knowledge of the cultural patterns and their knowledge of the children and themselves. If this system is in place, I don’t see it as at all tragic to have a person dealing with a child combatant who may have had their own experiences with them in the conflict.”What is more disturbing, says Mr Markovic, is the lack of continuity in the DDR process. “It’s possible for a child to be dealt with by five or six agencies from demobilisation to interim care centre. We plant to reassess all the 90 children in the Bo and Kenema houses to try to build a more coherent strategy for each one.”Other critics say that the real gap is lack of follow-up for those children who do return to the community. “We talk to them about things like returning school but when they get home, who’s going to pay their school fees,” noted one

international worker at the Lungi transit centre, while others say there’s little help for ex combatant children who face community hostility if tensions start to rise again in the area Official estimates around 5,400 children have been involved in combat by the rebels, though some dealing with the children believe there are many more.

Colleagues for lone psychiatristThe US Bureau of Population, Refugees and Migration has donated US$50,000 to improve services for the mentally ill in Sierra Leone.Currently Sierra Leone has just one psychiatrist who manages the country’s only mental hospital together with an almost completely untrained staff. Kissy Mental Hospital itself is severely run down and overflowing with mentally handicapped patients. Lack of skilled staff at district hospital level means many patients who could be managed outside of hospital are referred to the overburdened hospital while the trauma of the war tends to increase the risk of sub-clinical illness becoming manifest.The BPRM programme, managed by WHO, will focus on developing the skills of ministry of staff at the eight district hospitals. Nurses will be selected to train in community-based psychiatry and the facilities are to be supported with basic equipment and supplies for psychiatric care as well as specialised drugs.A consultant psychiatry is currently being recruited to work alongside the Ministry of Health, particularly to support the development of case management protocols

Better solutions needed for amputeesThere are growing concerns about the impact of the ‘amputees camp’ in Murraytown and future of its inhabitants. Set up by the NGO ADRA in early 1999, the camp was meant to be a temporary solution for the overflow of patients undergoing surgery for violent injury in Connaught Hospital, who needed care post-surgery, but had nowhere to live and no relatives to care for them.However, efforts to reintegrate its inhabitants back into the community are proving difficult for a number of reasons not least the high level of care they receive in the camp and the fact the site has become a lucrative ‘business’ in itself with residents making substantial amounts of money from both official and unofficial donors.The compound currently houses 200 amputees, 200 war wounded and 600 relatives, all of whom receive food rations from the World Food Programme. A number of other organizations are providing vocational training and other

services including a dedicated health clinic run by Médicins Sans Frontières France.However, though most of the residents have now been fitted with prostheses by Handicap International, many refuse to use them particularly in the presence of visitors. Residents have also refused attempts to relocate some of their number to Grafton to ease overcrowding or, where it has become possible, to return to their villages.Médicins Sans Frontières France, which took over management of the camp from ADRA, last month handed over responsibility for it to the National Committee for Rehabilitation, Redevelopment and Reconstruction which received it reluctantly. But says MSF-France medical co-ordinator Ariane Bauernfeind the amputees really need to be part of a reintegration process that MSF does not have the capacity to offer. “It has to be done by the government,” she says.MSF also hopes to pull out of operating the on-site clinic as soon as alternative care can be arranged. “The clinic is serving only 1000 people and we think there are more urgent needs elsewhere.

NutritionPockets of hunger cause concernLevels of nutrition are generally under control in displacement camps, say international experts, but there are still concerns over vulnerable groups that require emergency action.A survey in Bo District early in the rainy season by French NGO Action Contra La Faim found 4% of children were globally malnourished and 1% were severely malnourished. This is not an ‘alarming’ level nor dissimilar to the circumstances prior to the war, says UNICEF head of health programmes and nutritionist Dr Adrianne Zarrelli. But she warns that even if district figures seem normal, they are likely to hide ‘pockets’ of hunger that must be taken seriously.“In Bo, for example, there were at the same time as the survey 140 children in the therapeutic feeding centre – and the situation is likely to be worse in rebel-held or hard to access areas like Bombona or Bonthe.”The ideal, says Dr Zarrelli, is for health workers to be supported by a system of rapid links with humanitarian food agencies such as the World Food Programme so that they can call for targeted food supplementation when they identify need.

Kenema influx fills feeding station

Roughly 25% of the 450 children being fed by Merlin’s therapeutic feeding centre and 2500 attending its supplementary feeding programme in Kenema are from the town itself.Kenema town has absorbed an unknown number of displaced people in waves over the months since the May crisis. The most recent influx came in July when almost 10,000 are thought to have flooded into the town over a few days after Operation Khukri took place to free captured UNAMSIL troops.Mrs Millicent Juana, the state enrolled community health nurse who now runs the centre with support from Merlin nutritional and outreach co-ordinator Alison Day, has first hand experience of displacement, having had to escape to the bush herself several times as conflict overwhelmed the hospital. She says they are coping with the influx, but often have to feed mothers as well as children.The ‘temporary’ centres – now four years old – are housed in three large booths of grasses, plastic sheeting and corrugated iron in a compound in the grounds of Kenema Hospital. One is given over to therapeutic feeding, one to supplementary feeding clinics while the third is currently ‘invaded’ by over 300 recuperating children who are overflow from the Merlin-supported paediatric unit, where admissions have tripled from 200 to 600 a month since May.Despite the huge numbers who pass through, the compound with its kitchen, toilets, washing area and small isolation ward for cases of severe diarrhoea are spotless – the combined work of the 32 ministry of health staff and the mothers.Merlin is currently awaiting results of a 2000-child nutritional survey carried out in July which targeted families in the camps since June last year. This will allow analysis of the impact of food aid and supplementary feeding programmes, says Merlin medical co-ordinator Nichola Cadge But, she cautions, this survey will not indicate the level of malnutrition among new arrivals to the camps.For further information, please contact Nichola Cadge, medical co-ordinator Merlin on +232 22 23 17 38 or email:

Health financingCost recovery in actionA new cost recovery scheme now has three months worth of fees in its bank account.The first thing you see of Bo Government Hospital are two large boards listing the fixed patients fees for public and private sector services. Inside the hospital similar lists are displayed in every department and, at the cashiers’ booths, uniformed staff collect the fees and dispense triplicated receipts – one for the

patient, one for the hospital, one for the management board – in return.The fee scales are visible evidence of an experiment in cost recovery that has evolved arduously over 18 months against a background of changes of government, conflict, displacements and evacuations. Since starting in June, it has returned some 22 million leones a month (US$11,000) to the hospital coffers. Key players in the development have been the 20-person management committee of the hospital – itself a new concept with its 50:50 split between hospital staff and external members and Médicins Sans Frontières-Belgium, the international NGO with support from WHO and the Ministry of Health.Cost recovery and an emergency NGO like MSF may seem odd bedfellows but, explains MSF-B medical co-ordinator Dr Sandra Simmonds, “working in the hospital we started to realise that it was okay for those who could pay because they went privately, and it was okay for the destitute or displaced because we looked after them, but there was this huge group of ‘normal’ people in the middle who had no access to health services. Our own MSF staff couldn’t get medical care. Since so many people were outside our target group but still needed help, we had to think about whether we would leave or stay and really support the hospital to serve its population.”The only way to do that, says Dr Simmonds, was to try and bring in a system which redirected the money changing hands into the hospital itself.Now, fees for public and private, inpatient and outpatient care, laboratory investigations and drugs are all fixed. Patients from displacement camps and the destitute are excluded because they are covered by MSF-Belgium’s humanitarian mandate All emergency patients also get the first 24 hours care free. In reality, private fees are still open to negotiation but regardless of the price settled on, private patients are supposed to pay the whole amount to the hospital cashiers who deposit 60% for the doctor involved and 40% into the hospital finances. Doctors also receive 30% of the income generated from public patient fees as an end of the month bonus while other staff receive a percent of the combined public and private income as a salary top-up.While observers hail the hospital as a model for the country, there are not surprisingly still some teething problems. For example, says hospital superintendent and consultant gynaecologist Dr Samuel Sidique, current income is around 50% of what it should be.“The workers and nurses are on the side of cost recovery because they benefit in a way they

didn’t before but doctors are losing money keen and 10 to 20% are not co-operating with the scheme. Some are not contributing at all, some are not contributing the whole fee they negotiate with the patient. We have to find ways to penalise them for this. What we really need is for the ministry of health to step in and make it clear to them that they must co-operate.”In addition acute staff shortages means there is one doctor on staff to screen public patients and the resulting long queues can make ’choosing’ public care an unrealistic option – a situation borne out by the fact that in June paying ‘customers’ outnumbered public patients two to one.There are also other problems. Outside agencies referring to the hospital say money still changes hands for public care despite assurances from hospital management that patients should not pay above the printed rates. Others say the charges set by the community may be reasonable for townsfolk but they are entirely beyond the reach of country folk.“Bo’s charges are too expensive for people in the villages,” says Mike Downham, head of the UK Department for International Development’s primary care rehabilitation project in Bo district. “Village people delay first hoping they won’t have to go, then again while they to try and get the money together. As a result we are losing about 30% of the people we transfer to hospital.”Doctors in Bo also question why their incomes should be in the firing line before anyone else. But while this is a legitimate complaint, says Dr William Aldis of WHO, the answer is to get cost recovery moving in more places. The bottom line, he adds, is that health facilities need to start changing the culture and create an income flow while they have international support to underpin them.Full fee lists are available from the Bo Hospital management team or Médicins Sans Frontières-Belgium in Freetown, msfbfreetown@sierratel.sl

Directing money back to healthDistrict hospitals are receiving increasing attention in terms of both financial viability and concrete structures.Sierra Leone has had health sector reform on paper for many years, says Dr William Aldis of the World Health Organisation, but the crisis has given it a boost. “People are realising that the only way to sustain the level of care and incentives currently being provided with the help of international agencies is to take the money people typically pay to individuals to obtain health care in Sierra Leone and redirect it into the healthcare facilities.” Involvement of the community is one of the keys to success, says Dr Aldis. “The need for payments has to be brought into the open and

debated with the community. If you pretend that care is going to be free for everyone, nothing can change. There will still be people who cannot pay and the system can be designed to provide full care for them. But a solution will never be found under the old system of irregular practices and hidden fees.” Another essential feature of introducing cost recovery in Sierra Leone is the support of NGOs willing to give the day to day support and supervision essential to making the new system work, while WHO and the Ministry of Health work to extend standardised practices gradually across the country.Kenema, Lungi Hospital and Sierra Leone’s main tertiary hospital, the Connaught in Freetown are likely to be the next focus of attention for cost recovery in secondary care. In primary care some NGOs are also trying to prepare units and their community for the introduction of low level fees later this year. One problem, however, is the dearth of clear guidance and standards from central level, while another is the entrenched level of ‘business’ activities, particularly in hospitals such as Connaught where very little free care is available, say NGOsIn addition to moves to strengthen viability, district hospitals are also due to get a structural boost from the US Bureau for Population, Refugees and Migration which has allocated US$100,000 to WHO to help strengthen and rehabilitate buildings and equipment.

Human resourcesTo pay or not to pay?The dilemma of ‘incentives’ and whether they do more damage than good is becoming acute in Sierra Leone.Government salaries are erratic and when they arrive, very low. Junior doctors at Connaught Hospital, for example, earn less than US$50 a month and senior specialists around US$100. Nurses and other health workers earn even less.As a result many NGOs supporting health facilities are paying incentives to their staff ranging from US$25 to $100 a month.Not only, says one NGO co-ordinator, does this improve motivation but it also brings ministry of health staff earnings closer to the amounts earned by the staff directly employed by the NGO.However, well meaning though incentives might be, there are problems looming.Top-ups are breeding a reluctance among MoHS staff not connected to NGOs to do anything to extend their activities unless it is accompanied by an incentive, says District

Medical Officer for the Western District Dr PAT Roberts who notes that while there are plenty of displaced people on the MoHS role to staff re-established clinics, many refuse to work unless the clinic is supported by an NGO.In addition, some donors believe the levels of incentives being paid are too high and are demanding a drop. This means some NGO-supported community health workers, for example, are likely to see their incentives fall from around 150,000 leones (US$75) to 90,000 leones ($45) by the end of the year which is likely to cause dissatisfaction.While moves towards cost recovery may be one way for both primary care clinics and hospitals to sustain the extra payments to staff when NGOs leave, low income levels for the majority of the population means this may prove difficult.

Skill drain hurts districtsDistrict hospitals are suffering from acute shortages of senior specialist medical staff “It’s been a problem since 1994,” says Dr Samuel Sidique, medical superintendent of Bo Hospital. “But is getting worse. Some doctors have left the country while others who have run to Freetown for safety and new medical officers being trained there are reluctant to come to the districts because of the security situation.”Bo Hospital itself Iacks specialists in paediatrics, internal medicine and ENT and is in dire need of extra generalist doctors to man its admissions department which.Erratic payment of hospital staff is another problem and Bo’s situation may also be exacerbated by its leading role in an innovative cost recovery programme part of which seeks to regulate what is called in Sierra Leone doctors’ ‘intramural private practice’ (see page 11) – a problem that will remain an issue until the ministry manages to standardise the scheme throughout the country.

Contact WHO in Sierra LeoneWHO Office Freetown21A/B Riverside Drive, off Kingharman RoadPh: +232 22 24 12 59 or 22 31 88Fx: +232 22 22 73 13 Email: who@sierratel.sl

WHO representativeDr William Aldis Mobile: +232 23 50 05 63Email: aldisw@yahoo.comDisease Prevention and Control AdviserDr Abdul Rahman Wurie:Mobile: 232 23 50 10 73Email: wuriefs@hotmail.comEmergency and Humanitarian Action Adviser

Dr Bona Hora

Health EconomistMr Ade Renner

Human ResourcesMr Sebora Kamara

Health Information and media liaisonMr Rod MacJohnson

Northern Provinces Co-ordinatorDr Jalloh

Bo Sub-office Southern & Eastern Provinces Co-ordinatorDr Abdul Kargbo

This update was researched and written by Hilary Bower, information officer with the Department of Emergency and Humanitarian Action, WHO Geneva. The opinions expressed do not necessarily reflect official WHO policy. For further information, phone +41 22 791 3451, mobile +41 79 249 3528, email bowerh@who.ch or hbower26hotmail.com.