War wounds left to fester

Five years after the end of the war in Liberia, many of the hundreds of thousands of injured survivors say they are still suffering from physical wounds that were never properly treated.



Shootings, stabbings and beatings were rife during Liberia's 14-year conflict. Although medical aid agencies and bare-bones medical facilities have treated many people for life-threatening injuries, few can offer longer-term treatment.



Necessary treatments could include antibiotics, amputations and minor or major surgery, according to health workers in Liberia.



“We still see infections and illness due to injuries sustained during the war, including bullet wounds that have not been properly treated and then become severely infected,” said Roland Suomie, a physician’s assistant at the non-profit EQUIP’s health clinic in Ganta, Nimba county, 250km north of the capital Monrovia.



Tenneh Dolocon was under one year old when she was shot during the height of fighting in 1996. Strapped to her mother's back, she took two bullets – one passed through her shoulder, the other lodged in her thigh.



For most of her childhood Dolocon suffered chronic infections. In 2006, she was diagnosed with osteomyelitis, characterised by infected tissue migrating towards bone. Doctors at Mercy Ships, an international medical charity that operates a fleet of hospital ships, operated to remove the dead tissue and the bullet lodged in her thigh.



Too costly



Although basic healthcare is free in Liberia, more complicated operations such as the removal of bullets usually carry fees which most Liberians cannot afford. An X-ray to pinpoint the location of a bullet costs US$10 at the JFK hospital in Monrovia, the country’s largest hospital, but the average Liberian earns under $1 a day according to the United Nations development agency, UNDP.



Some government- and NGO-run health clinics provide free treatment, but most of the country’s clinics are not equipped for complicated surgical procedures.



"I have had a bullet lodged in the back of my arm since 1990,” a man who was injured in the early stages of the war and asked to withhold his name, told IRIN. “It causes me severe pain and occasional bleeding… I come to the hospital when the pain gets really bad, but when they tell me the price of treatment, I usually leave again.”



Health providers say complications from bullet wounds – which can include high fever, feeling faint and generally unwell – may emerge only years later.



In one of the war’s notorious massacres, troops loyal to former Liberian President Samuel Doe in July 1990 stormed St Peter's Lutheran Church in Monrovia where 2,000 people had sought refuge. Up to 600 people were killed with guns, knives and machetes, and 800 or more were injured, according to Peterson Sonyah, who heads a survivors’ group.



Sonyah says many survivors of the attack have not been able to afford long-term medical treatment.



"Many of them have been left with lasting injuries, ranging from brain damage to high blood pressure. Last week a survivor died from a bullet that had been lodged in her brain ever since the massacre," Sonyah told IRIN. "Few survivors have had access to counselling and many still carry bullet wounds. Those who were most badly injured were left unable to work.”



Infrastructure destroyed



The government is keen to improve its healthcare system, according to aid officials, but is struggling to cope. By the end of the conflict in 2003, 95 percent of the country’s health facilities had been destroyed or rendered non-functional, according to the US aid agency, USAID.



Currently only 30 professionally trained government medical doctors work in the country alongside 46 NGO doctors, who collectively must serve Liberia’s population of 3.3 million. As of June 2007 NGOs still operated more than 70 percent of health facilities, according to USAID.



Many of the health-oriented aid agencies that remain in Liberia have shifted from an emergency to a development phase, focusing on long-tem issues such as maternal health. Agencies and donors, including USAID and the medical NGO Merlin, are supporting the Liberian government to implement its basic healthcare services plan and to develop its healthcare strategy.



Mercy Ships, which runs a fleet of roving hospital ships, treated 35,000 people Liberians over 2008, many of them war wound victims, but has now moved on to provide medical services to Benin.



Unmet needs



While funding for basic healthcare is nearly on target – $29.9 was spent on basic healthcare per capita in 2007 against an estimated need of $34 according to the Ministry of Health – funds to bridge the “astonishing scarcity of doctors and health workers” and to set up training facilities in clinics, medical universities and teaching hospitals remains outside this figure, according to Dr Asmat Ullah Khan, country health director for Merlin.



The country has few training facilities for medical doctors, Khan said.



Merlin has been supporting 43 health clinics and four hospitals across Liberia with preventive, curative and surgical services, providing equipment, and training health staff, since 1997.



Khan points to a dangerous potential gap in overall funding for healthcare services. “Beyond 2010 there are indications that there will not be such high support from international donors under healthcare financing…but there are still a lot of unmet needs.”



The vast majority of the country’s 389 functional health clinics are basic clinics or health centres that can provide only limited services. The same goes for some of the country’s 12 county hospitals, according to the Health Ministry’s 2008 rapid assessment of the health situation in Liberia.



Bridging the gap



Khan described Liberia’s Health Ministry as “one of the best I’ve ever worked with,” but said the government cannot improve healthcare without significant investment.



In the meantime, to address the doctor shortage in the short term, the ministry is bringing in 50 Cuban doctors.



Amid the plans to shore up Liberia’s health system civil society groups are working to raise awareness of war wound survivors’ plight.



The Lutheran Church Massacre Survivors' Organisation will hold workshops in Monrovia in 2009 to generate awareness among local and international NGOs of the need for ongoing medical treatment and of the loss of income among many survivors.



The survivors’ group’s Sonyah, who called the health system “very fragile”, said he hopes international donors will also hear their message.



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