# Health crisis in Liberia - the long road to recovery

## Following years of civil war in Liberia, access to safe drinking water and a coordinated health response are at the core of WHO's work in the country.

18 September 2003 -- WHO Office, Monrovia, Liberia

Chlorinating community wells to provide clean drinking water in Monrovia

Carefully, a young man unrolls a long green cord and lets it down a well. Weighted by a stone at one end, the cord has many small knots along its length. The distance between each knot is exactly one foot. "We use this to measure the depth of the well and to calculate the height of the water inside", he explains. To do this, he first counts the number of knots until the stone touches the water. Afterwards he lets the stone down to the bottom of the well and subtracts the difference. "We have to do this in order to determine the amount of chlorine needed to purify the well water", he adds. To clean this particular well, a tablespoon of chlorine is sufficient. His colleague pulls up some water in a bucket, adds the chlorine powder, and throws the water back down the deep well.

Nearby, a mother is washing her two young daughters. With a curious smile, she approaches the men and asks what they are doing. One of the men explains that they are cleaning the well water and asks her to tell the community not to use the well within the next hour. She nods and yells something in a local language to her neighbour. The two men then pick up the bag of chlorine and walk down the earth path that leads them through thick bamboo bushes to the next well.

The two men are part of a city-wide water chlorination campaign team that WHO and partners are carrying out in the Liberian capital, Monrovia. Five thousand wells have to be purified to provide the population with safe drinking water and limit the spread of the cholera epidemic that has been ravaging the city for weeks.

"This is a huge task! The teams have to walk from community to community, locating and chlorinating all the wells", says Dr Omer Jeabah, Assistant Director for Planning, Research and Training at the Liberian Ministry of Health. He supervises 24 people who chlorinate wells in the east of the city. "We don't have bicycles - that makes the work even more cumbersome. I walk at least six hours through the city just to make sure that the teams are doing their job properly", he adds.

Dr Omar Khatib, WHO Representative in Liberia, explains that the city is very polluted and that garbage can easily be washed into the wells during heavy rains. "To avoid this, we have to rechlorinate the wells every four days", he says.

 Cholera A cholera outbreak is ravaging Liberia's capital, Monrovia. To date, since hostilities started in June 2003, 10 043 thousand people have been affected and about 110 people are reported to have died of cholera. According to reports from NGOs working in the camps for displaced people in Monrovia, there are over 2000 new cholera cases every week (see also disease outbreak news). Seeking safety and shelter, the movement of thousands of people to the capital has led to a complex situation with insufficient water and sanitation for the displaced people. Cholera is transmitted through consumption of contaminated food and water. It results in a massive loss of liquid, and can be fatal if left untreated. To decrease the risk of a larger outbreak, WHO and health partners are undertaking a massive campaign to chlorinate wells in Monrovia.Cholera has also been reported outside of Monrovia and WHO is now assessing the situation in towns surrounding the capital in order to get more information on how many people are affected.

WHO has a provision of 1350 kg of chlorine in its warehouse in Monrovia, which is being used for the campaign. A team of environmental health technicians, supervised by WHO, are responsible for monitoring the water quality in the wells following chlorination. UNICEF and partners under the Water and Sanitation Committee are taking the lead in the garbage clean up.

### Live-saving immunization

Meanwhile, in the rebel-held city of Tubmanburg, 60 km north-east of Monrovia, WHO, UNICEF and the Ministry of Health are carrying out a life-saving measles vaccination campaign. Following the breakdown of national measles immunization programmes, only 29% of Liberia's children are protected against this killer disease.

During just one week in Tubmanburg, health workers vaccinated about 3000 children aged from six months to fifteen years, and gave over 1400 vitamin A doses to children below five years of age.

"We could have done more, but shooting among rebels caused panic among the civilian population," says Roland Tuopilay, one of the health workers. "On Saturday, for example, militiamen were fighting for looted goods and one of them was shot. Several mothers from surrounding villages and other parts of the region were scared and returned home."

 Measles There is a great risk of a measles outbreak in Liberia as immunization coverage has dropped dramatically during the past years. Measles counts among the biggest child killers in Africa. To avoid a major outbreak, WHO and health partners are carrying out emergency measles vaccination campaigns.The first mass vaccination campaign for children aged 6 months to 15 years was held in Tubmanburg. A second campaign was held in Grand Cape Mount and Gbarpolu counties, where 458 children were vaccinated and 207 received vitamin A supplements. The campaign will continue in Bomi county.

### Remnants of war

The war has left bitter traces in Tubmanburg. Child soldiers walk through the dirty streets carrying guns bigger and heavier than themselves. Others try to dismantle looted cars to sell the different pieces on the local market. Bullet holes in all of the decayed buildings are the most visible scars of the war and remind the population constantly of their bloody and violent recent past.

The operating room at the looted Tubmanburg Government Hospital

In a makeshift rebel clinic in the center of town, patients lie silently in pain on old blankets on the floor. Most of them are war-wounded. Nurses without proper training try to give them some relief with the little medication they have. This is the only clinic in town. The Tubmanburg Government Hospital, a few hundred meters outside of Tubmanburg, is in ruins. It was completely looted and vandalized.

One hour's drive from Tubmanburg is the small village of Lofa Bridge. The village is virtually deserted. During the war most inhabitants abandoned their homes and walked for four days to Monrovia. Displaced people from other regions and returning refugees from Sierra Leone now live in Lofa Bridge. Their stomachs are empty. "We can not plant anything during the rainy season and we can not burn the land to prepare it for farming", explains an elderly man sitting with a couple of friends on the porch of his house, watching the rain. "There is nothing left here. The clinic was looted, the school is closed and our water pumps and wells are contaminated".

### Daily life in Monrovia’s largest camp for displaced people

Back in Monrovia, in the huge Samuel K. Doe (SKD) football stadium that currently provides shelter to about 50 000 internally displaced people, the tranquil life of Lofa Bridge seems like a distant dream.

Life in the SKD football stadium, currently the largest camp for internally displaced people in Monrovia

Daily heavy rainfalls make living conditions harder than ever. People cook and sleep in small covered areas and the tiny spaces under the stadium seats.

Humanitarian aid agencies and nongovernmental organizations (NGOs) work around the clock to improve water and sanitation in the SKD camp. On a daily basis, Médecins Sans Frontières pumps 120 000 liters of water into the camp water outlets, providing each person with about three litres. Outside the stadium, 22 latrines have been built in small plastic huts, but these are not enough to serve the needs of the whole population in the camp.

The health centre at the SKD stadium is completely overwhelmed. Up to 400 patients visit every day to see the six nurses. In a small hot waiting cabin they sit for long hours on wooden benches, brushing away the flies with their patient cards. Mothers try to calm their crying children; severely ill patients sit sighing and sweating in dark corners.

The most common health problems seen at the health centre are malaria, diarrhoea, skin infections due to poor hygiene, and acute respiratory infections. The health centre also provides antenatal care to an average of 40 to 50 women per day.

Through its NGO partners, WHO is providing large emergency health kits to the camps in Monrovia. With just one kit, nurses can provide basic health care to 10 000 people for a period of three months. In addition, WHO is distributing trauma kits, Ringer lactate intravenous solution and oral rehydration salts to treat cholera, and other basic medication and medical supplies.

Last week a mother gave birth to twins in the health centre. Life continues in Liberia.