Cholera epidemic threatens Sierra Leone

BMJ 1995; 311 doi: (Published 08 July 1995) Cite this as: BMJ 1995;311:77

Sierra Leone faces the threat of a major epidemic of cholera with the onset of the rainy season, according to the World Health Organisation. The situation is particularly grave for the two million people displaced by the country's civil war. Already 1709 cases of cholera have been registered in the capital, Freetown, with 57 deaths.

Freetown's population has doubled since the start of the war in 1991, with 750000 refugees camping out in the town. The insurgent Revolutionary United Front is now within 32 km of the capital, and large tracts of the country are inaccessible to the various agencies and charities working there.

The military government is unable to guarantee safe conduct for aid by road even to sizeable provincial towns. Doctors and aid workers are forced to rely on a private helicopter service for personal transport.

“As many as 10000 people were affected by the disease last year,” said Dr Everest Njelesani, the WHO's representative in Sierra Leone. “We fear that this time, unless urgent measures are taken, it could be even worse. The rainy season has just started, provinces are cut off from the capital, medical supplies are scarce, and, on top of that, there are two million displaced persons who should be sheltered and fed.”

Little provision has thus far been made for the refugees, and many will face the rains without so much as canvas over their heads. Experts from the WHO who recently toured the country predict that pneumonia is likely to claim the lives of many children, and the standing water will also bring out the anopheles mosquito, which in this area carries a highly drug resistant strain of Plasmodium falciparum. But the greatest problems are the lack of safe drinking water and the attendant risks of cholera and dysentery.

At one site in Freetown the 6000 refugees have to fetch water from a source 20 minutes' walk away and have no latrines. As a result there have been 277 cases of cholera and two deaths already among that group. The health department has set up five centres to treat cholera in Freetown and is organising mobile clinics. The WHO's Sierra Leone office is assisting the government mobile health teams, which provide free primary care to displaced people. Medicines and vaccines, however, are lacking.

Many of the staff of the 13 district health authorities have been displaced to Freetown, and war and poverty have led to a brain drain of the country's doctors. Aid agencies such as Medecins Sans Frontieres and Oxfam have stepped into the role in many districts.

Dr Fabrizio Bassani, director of the WHO's emergency and humanitarian aid division, feared that logistic problems may scupper the best efforts of international agencies.

“None of the major roads are safe. Only a small proportion of the displaced population lives in camps. Some are absorbed into families in large towns, while others are hiding in makeshift camps. WHO urgently needs funds to continue and extend its work.” he said. The war has been a particularly brutal affair, with the Revolutionary United Front kidnapping teenagers and allegedly indoctrinating them with a combination of crack cocaine and Rambo videos. Last month a Revolutionary United Front unit went on a killing spree in the mining town of Koine, leaving up to 200 people dead.

Ironically, one of the Revolutionary United Front's main demands is for a free national health service.--OWEN DYER, freelance journalist, London

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