Tuesday 14th November Part 2

After JFK we had a second meeting with Dr Amegoshie, at the hotel. We learned that the Dr is also a General Surgeon at Harper, where he is called on to operate in emergencies, and is the County Health Officer, which brings a significant administrative burden. These, together with a range of practical problems, were leading to the low cataract surgical rate.

We identified a few blocks, such as failure to order drugs in good time, resulting in them running out, and transportation problems. We still sensed though that a significant problem was Dr Amegoshie simply feeling isolated and overwhelmed. We offered help from the ophthalmologist /cataract surgeons in Sierra Leone to set up and run an eye camp in March next year. I was very pleased that the doctor embraced this offer with relief – there was no question of any ego getting in the way.

1. This evening was our last as a travelling group, as we were all going our separate ways the next day. The key priorities for Verda were agreed to be
   Get tough on the ‘skippers’ – as tough as you need to be
2. Push the ministry forward on hiring the Programme Manager, to ensure we have a good person driving things into the future.
3. Make sure the Sierra Leone liaison happens, and provide as much support as possible to Dr Amegoshie to make it a success
4. Make sure the school screening happens

Tuesday 14th November Part 1

We began the day with a visit to the Deputy Minister of Health where I met Dr Guize, the National Eyecare Coordinator. He spoke a lot about the problems of lack of equipment nationwide. The Deputy Minister also spoke about setting up a national secretariat for recruitment, which should help with the issue of ‘skipping’, (see post of Monday 13th) and about the need to de-centralise river blindness control to the districts and ensure it became more integrated with eye-care.

Following this meeting, we were very privileged to be given an audience with the President, Dr Ellen Johnson Sirleaf. We had a very positive meeting with her – not just an introduction. She too was very keen on our focus on the south east, and offered to help in any way she could, particularly with the problem of keeping trained people in the country.

We went from the President to visit JFK hospital – the main referral hospital in Monrovia. The eye clinic here is run by Dr Guize. He was right in saying that there was very little equipment there. The ground floor building was reasonably spacious, with enough consulting rooms, and there were several nurses. Half of the eye clinic was occupied by Chinese opthalmologists, although they had gone for the day and padlocked all their rooms, so we could not see what equipment they had. Dr Guize said he was able to use their operating theatre once a week.

Monday 13th November Part 2

We are planning to rebuild the eye unit in Harper (hopefully with UN Mission in Liberia funding, although we must submit the plans for this to them as a matter of great urgency), but it was clear that staffing would be a huge challenge.

All of us were feeling pretty depressed at this stage, and once our flight was formally cancelled we went to see Verda’s office at the National Drugs Service. Our depression was further exacerbated as Alex, the Finance Officer, had just received an eviction letter saying we had to leave our current office space by the end of the year. (We have since received some good news – the Ministry of Health have offered us some much better office space).

We went on to visit the Minister of Health, and I was impressed by their openness and eagerness to address the issues.

Sightsavers has offered funding to support the eye-care secretariat, in the form of a full time Programme Manager. The Minister was keen that this post should be openly advertised with the salary clearly set out in the advert, rather than having someone appointed via patronage. We agreed to help them organise this. He was very keen on our proposal to become tougher with ‘skippers’, and said the Ministry itself was planning to take a similar line. I felt reassured that the Minister and his staff had the right mindset and were honest and reliable.

Today amply demonstrated the difficulty of trying to operate in a post conflict country.

Monday 13th November Part 1

We woke this morning to no water. Given everything I had seen it did not feel appropriate to complain to the hotel. I did however regret my decision of the day before to put my only source of water – a large bottle – into the fridge. It woke me up I guess…

The intention today was to fly to Harper, on the South East corner of Liberia, where we are supporting an eye clinic. UN Mission in Liberia (UNMIL) have free helicopter flights to Harper which Non-Government Organizations can use. Unfortunately the weather was not in our favour, and we waited in vain the whole morning at the heliport. We were joined by Dr Amegashie, the ophthalmologist (and general surgeon) at the clinic and had something of an ad hoc meeting in the departure area.

It was a pretty depressing story. Dr Amegashie had only managed to do three cataract operations in October, and the biggest problem was staff. We had trained several nurses, most of whom had ‘skipped’ after training. One had simply not returned from Ghana. The cataract surgeon who was supposed to be there was also no longer working. We asked Dr Amegashie if he could suggest anyone else to train, and the answer was ‘no’.

It was clear that we need to be much tougher in enforcing the bond for people we train (we are entitled to recover all costs from the individuals if they don’t return immediately after training). We have never done this before, and now we must be prepared to see it right through to court action if necessary. Otherwise the problem of ‘skipping’ will persist.

Sunday 12th November

We had lunch today at Verda’s house, with a range of people from other International Non-Government Organizations (INGOs). Save the Children, Africare, World Vision and the EC were all there. We spent most of the afternoon discussing some of Liberia’s problems, and the full horror began to sink in. Here are some statistics/facts:

1. 75% of women are thought to have been raped over the last few years.
2. Unemployment is currently running at 85%.
3. A whole generation has not been educated, and many are child ex combatants, who have essentially gone feral.
4. Many women and girls (and boys?) are now reduced to selling their bodies to get food (a handful of Liberian dollars depending on the ‘riskiness’ of the practice on offer)There are around 26 doctors for the whole country of 3.5 million people.
5. Life expectancy is 39 for men and 41 for women.
6. Currently around 30 – 40% of children are not enrolled in school, and teachers earn $20 a month. As a result, there are few teachers, and around 40% of them hadn’t even finished high school.
7. Around 24% of people have access to clean water and only 5% to sanitation
8. An estimated 24% of children do not live to see their fifth birthday.
   

These are very sobering facts, and it made me quite concerned as to how we could get the government to give any priority to eye-care, when there were so many other problems to deal with. Having said that, the plight of the visually impaired here is particularly acute, and they need strong advocates.

Saturday 11th November Part 2

We visited the Liberian School for the Blind on our way to the hotel. This was a deeply depressing place – the buildings were fairly new, but there was absolutely nothing inside them as far as I could see. The children sat on benches around the walls and all looked depressed and hopeless. We donated four Braillers and two globes – the school only had one brailler and this was only used by the teachers. None of the children had been screened to check whether they just had refractive error – it was agreed that Verda would arrange for this to be done as soon as possible.

We then drove on to Monrovia, and I had my first sight of how badly Liberia has been damaged by the 14 years of war. The only way I can describe it is to say that everything is broken, and all the buildings are burnt. There is rubble and rubbish everywhere, and every few miles there is a UN Mission in Liberia (UNMIL) checkpoint. Many buildings are empty and occupied by squatters. The atmosphere on the streets is a mixture of despair and menace – very different from Sierra Leone which has a feeling of recovery. We stayed at the Mamba Point hotel, where the local US Marines were having a birthday party that night. It seemed utterly incongruous to see all these people in dress uniforms and gaudy frocks with a huge cake.

Saturday 11th November Part 1

Today we drove to Liberia. The first hour was fine, on tarmac roads, but after that the road was unmade and got worse as it went on. There had been heavy rain in the night which added to the problems, and it took us five hours from the end of the tarmac to the Liberian border, even though the distance was about the same.

We met Verda Tarpeh, Sightsavers Country Representative for Liberia, at the border, and crossed without too much difficulty (about two hours). Verda was called upon to shout at the customs people as there was some discrepancy between the chassis number of the Sierra Leone vehicle and that shown on the paperwork. Apparently shouting is the only way here, although I sense it wouldn’t have worked quite as well if I had done it….

Friday 10th November

We drove to Kenema to see the small clinic there, and to view the site of the proposed new unit (which we now know will receive Irish Aid funding). The hospital staff here said that river blindness was actually a bigger problem than cataracts in this district. They also had a major problem with Lassa fever. Their Ophthalmic nurses and Cataract Surgeon had been trained in The Gambia – apparently this had been a good course.

We met their river blindness focal person who had begun his community awareness work and started training the CDDs (volunteers trained in each village to distribute the drugs, as opposed to the old system using health workers).
He was waiting to hear when he would get his Mectizan® – apparently this is the last area to be treated.

We drove then back to Bo for a fairly early night.

Thursday 9th November

We began the morning by visiting the Eye department at the Bo government hospital, and met Mr Sandy who runs the clinic. There is a lot of river blindness in the area – this is second only to cataract as a cause of blindness here. They typically perform 40 cataract operations a month, although at busy times after a camp (there are two free camps a year) this can rise to as much as 40 in a day. The optical centre seemed to be very well run.

After the hospital we went to Paul’s School for the Blind. This had recently had new buildings and was apparently in a much better state than when Sightsavers had last visited. The children seemed pretty lively, and this is one of the schools to which we will roll out the Inclusive Education Programme pilot if it works well at Milton Margai.

After lunch we drove out to Bumpeh to meet a number of people who had benefited from the Community Based Rehabilitation project (partnered with Sierra Leone Association for the Blind - SLAB). All had been trained in some kind of handicraft – such as weaving, hammock making, and these were being encouraged to train others.

Wednesday 8th November

We drove out to Moyamba to visit a village in an area where river blindness was prevalent. Almost all the rivers in Sierra Leone are infested with the black fly, and it is very noticeable that there are no villages anywhere near the river banks. When driving over the rivers, somehow the beauty of the landscape took on a sinister hue, when you realise the menace associated with the waters.

The last part of the journey was undertaken by canoe, and we were welcomed by drums and singing. We went into the local schoolroom for a village meeting, to discuss concerns that the people had. The first three rows of the audience were mainly blind from river blindness, and I was shocked at how young some of them were (women in their twenties). However it was gratifying to learn that everyone knew about Mectizan®. People wanted to know why we couldn’t spray to get rid of the fly – the biting still caused great irritation. They also wanted to know what to do about a nearby village where a number of people were refusing to take the medication, as they understood the need for full community coverage. The biggest issue, as in most places we went, was that the volunteers (CDDs) wanted to be paid - but we explained that given the scale of the distribution, this was unaffordable by the government (or Sightsavers), and that it was the responsibility of the community to show gratitude in other ways. This will become a much bigger issue with the integration of Neglected Tropical Diseases.

River blindness seems a strange disease – at this village there were many blind people, yet we visited others equally near a river infested with river blindness where there were hardly any.

Tuesday 7th November Part 2

After this we moved on to visit the Minister for Education. The main topic discussed was the Education policy, as we are keen to ensure that children with special needs are not forgotten. The Minister assured us that this was not the case, but we are still worried as we have not seen the redrafted version of the new policy. We took the Minister through our IEP, stressing that the initial work with Milton Margai was a pilot, and that we intended to roll this out to the other schools for blind children.

We then visited Milton Margai – you may have seen this school featured on breakfast television as it is twinned with a school in Kent which had some media coverage last year. A great deal of work had been done over the last year or two to spruce up the buildings. The children all seemed very cheerful and lively (a real contrast to those we met later at the school for blind children in Liberia), and in general it was a place of optimism. I asked the headmaster whether there were many children with multiple disabilities – apparently not. His view of why not was pretty stark – they will probably have been abandoned and left to die….

Tuesday 7th November Part 1

We began the day with a meeting with Graine O’Neill at Irish Aid who seemed very supportive, and had just been asked for comments on our proposal regarding the Kenema eye unit. Fingers crossed! (Since this trip we have discovered that we have been successful in winning this – thank you Irish Aid!)

We then visited the British High Commissioner, Sarah Mackintosh, and put forward the possibility of the Commission funding a pilot integrated education project (IEP), with the Milton Margai School, (a special school for blind children) where we will provide equipment for the children leaving the school and going on to secondary education. Unfortunately it is unlikely that they will be able to fund this as she said they had already provided a lot of funding to the school. However, she was certainly a supporter, and could be a useful contact into the future.

Monday 6th November Part 2

Next we toured the Connaught Eye clinic, directly below the office, and it seemed to me that they are clearly achieving a lot without the sort of equipment I saw on my trip to India.

One of the biggest frustrations in Sierra Leone is around training, there is no ophthalmic nursing course, and the nurses all go to The Gambia. Before the war it was a centre of excellence. There are high hopes that the nurses college will reopen and it has moved from the Ministry of Health to the Ministry of Education recently.

After the Connaught Clinic we went to meet Mr Kabakeh Noah, who is the Community Based Rehabilitation (CBR) Programme Manager, and a member of Sierra Leone Association of the Blind (SLAB). He is totally blind himself. Sightsavers has a major project with SLAB, part funded by Comic Relief. A major advantage is that SLAB is the single, accredited organisation of the blind in Sierra Leone (unlike in Liberia where there are several competing organisations).

We paid a joint visit to the Minister of Social Welfare, Gender and Children’s Affairs. There is a Disability Bill in draft, which the Minister believed could be put before Parliament before the end of the year. This seemed pretty optimistic to me, particularly given the number of other bills (eg Domestic Violence, Child Protection) that the Ministry were trying to get through. SLAB was essentially behind the bill, but felt that there had been inadequate consultation.

We then went on to a courtesy visit with the Deputy Minister of Health (the Minister was in Geneva for the vote on the new Director General of the World Health Organization).

We spent the afternoon at the SLAB training centre, where they were teaching skills such as baking, soap making, sewing and tie dying. SLAB membership is growing, and there is clear demand for more training centres outside Freetown.

A couple of e-newstories from Zambia:

http://english.people.com.cn

http://www.upi.com/AfricaMonitoring/

Monday 6th November Part 1

Our first visit was to the onchocerciasis coordinator, Dr Koroma. The oncho (river blindness) programme in Sierra Leone
had been disrupted for 12 years due to the conflict. There had been some administrative problems in 2005, so 2006 is the first year for some time that there has been a distribution. The evidence gathered is that the disease has returned with a vengeance – if anything it is worse and more widespread than before the war.

The lesson here is clear – we must not be tempted to think that because river blindness has dropped to 0.8% of world blindness we can now stop supporting Mectizan® distribution. If we do this the scourge will return.

Treatment for river blindness relies on treating as many people as possible to stop transmission. It is not the case that someone who is treated is protected – they are only protected if the vast majority of the people nearby have been treated too. This is why we have issues around border areas – a village can be re-infected if we don’t treat the next village across the border.

Next year Sierra Leone will be combining river blindness and
lymphatic filariasis treatments. (confusingly in many places river blindness is referred to as ‘filaria’). This is the beginning of the major push by the World Health Organization (WHO) for the integration of treatments of a wide range of so called ‘neglected tropical diseases’ or NTDs. They are starting with lymphatic filariasis and river blindness as the drug treatments are closely related.

After the visit to Dr Koroma I met with the Country Office staff. What an incredibly warm welcome! I was very touched. We had a brief meeting to give me some of the history of the office, which had remained open all through the war. People had slept at the office on mattresses, in rat infested conditions. It really brought home to me how much some of our overseas staff are prepared to sacrifice for Sightsavers.

Travelling to Sierra Leone and Liberia

The purpose of this trip was to meet some of our partners in Sierra Leone and Liberia and gain an understanding of the issues faced, to meet a number of beneficiaries (with a particular focus on onchocerciasis), to gain an appreciation of the difficulties of working in post-conflict countries, and to compare Liberia (where the conflict is more recent) with Sierra Leone (where there has been some time to rebuild) as well as to meet the staff at the Country offices.

I left on the evening of 5th November on a flight to Freetown via Brussels, arriving in the evening. The journey was uneventful, and I arrived together with my luggage around half an hour earlier than expected!

An interesting peice in the Gambian Observer about the Integrated Education Programme in The Gambia: http://www.observer.gm/enews/index.php?option=com_content&task=view&id=7436&Itemid=33