The eight year conflict in Sierra Leone has claimed thousands of lives and caused more than 400,000 people to flee to neighbouring countries. Following democratic elections in January 1997, the government of President Kabbah was brought to power, only to be toppled in a coup by the Revolutionary United Forces (RUF) five months later. A counter-coup, assisted by the Nigerian-led regional intervention force ECOMOG in February 1998, succeeded in taking back the capital and other key towns, but guerilla war continued throughout the provinces.
Early last November, anaesthetist Eric Vreede left London to work with MSF in Freetown, the capital of Sierra Leone. His letters describe the human cost of a particularly savage conflict and MSFs' efforts to provide relief.
13 November 1998
I am now settled here, and I like the place. There is fighting up country, but we don't notice it much in Freetown. Nevertheless, we are aware that not that far from here people are killing and mutilating each other in the most horrible ways. Nobody is spared. You see people who have had both arms amputated. They are completely helpless and depend on others even to eat. I am the only anaesthetist here and have been asked to teach at the university. At the moment I spend most of my time preparing lectures and teaching medical students.
All over the country there has been a lot of fighting. At present the fighting is only 45km from us, maybe closer. Last week we received around 25 fresh casualties from the north. They seem to have stopped the mutilations and we are now dealing mainly with gunshot wounds.
Fighting is just outside town and yesterday we received eight casualties. I spend most of my time running around organising things and distributing drugs and materials. Yesterday, the International Red Cross evacuated about 20 of their 35 expat staff. We also decided to decrease our expat staff and as I write I am waiting to hear what time they are leaving.
I am in the hospital and at the moment it is quiet, but we know there has been an aerial bombardment this morning, so we can expect some casualties if they are allowed to enter town. I hear the spotter plane flying overhead all the time. I have finished teaching the medical students. Last week they had their exams in surgery. It is nice to be on the other side of the table after years of struggling with exams myself. I am very happy that my class scored 5 out of 5.
I do not know what Christmas is going to bring. The number of expatriate staff is rapidly dwindling and I don't know what will happen if many casualties arrive over Christmas. On 26th December the remaining international aid workers, including Eric, were evacuated to the Ivory Coast. Fierce fighting between the rebel RUF forces and government troops supported by ECOMOG raged throughout the city. MSF left medical supplies with the local hospital staff who kept programmes running despite heavy fighting.
At the end of January a small MSF surgical team of very experienced medics, including Eric, returned to Freetown. For a month they were alone: it was was several weeks before other international aid workers began to return to Freetown.
4 February 1999
Back in Freetown exactly five weeks after we evacuated. A few weeks [fighting] has destroyed approximately one third of the city, most of this damage in the east where we do not travel.
The most visible changes are the burnt-out cars and the large number of checkpoints - between the hotel and the hospital we cross at least 15 checkpoints. It takes a lot of time every day. The hospital is packed with war casualties: there is a backlog of approximately 200 people needing urgent surgery. Many have been deliberately mutilated.
There are virtually no new casualties coming in - most were injured weeks ago and have had to wait for surgical care to become available. Virtually all the wounds are infected and there is an awful stench of rotting flesh that you can smell even outside the hospital. Lots of work for us.
Today we operated on one woman who was shot in both her ankles three weeks ago. The wounds were very messy - there were still leaves inside - but we managed to save her feet and she may walk again. There are just four of us in the team now, and as far as we know we are the only humanitarian expats around. Everyone is fearful of another attack by the rebels. However, in spite of the poor security we feel relaxed and are cautiously optimistic about the work. The co-operation with the local surgeons is good because both the expat surgeon and myself are well known at the hospital.
1 March 1999
The security situation has improved a little and we have been working flat out to clear the backlog of surgical cases at the hospital. There are not so many new casualties nowadays, but there is still plenty to do as many patients need several operations to repair their injuries. In general the local surgeons here are undertaking the regular, elective surgery, and MSF deals with the war-wounded. We have saved a few lives, and many more limbs.
The hospital is slowly returning to normality - the general medicine wards are now clear of surgical patients so people with other problems, like malaria, are getting treatment. A small 9 year-old girl was shot in the foot during the fighting and it has taken several weeks of constant care to save her foot. Twice a week she needs to have the wound cleaned and dressed and each time she has to come into the operating theatre and I anaesthetize her. She is very brave and never complains.
Small children have not been spared the violence here. We even have a girl of 18 months who has had her arm amputated. I worry a lot about these amputees. Many have lost both arms. In England, with all the latest technology, life would be very very hard. Here in Sierra Leone, it will be virtually impossible.
Along with the return of the MSF surgical team to Connaught hospital at the end of January, other MSF programmes resumed in Sierra Leone: surgical support at Brookfield hospital, pyschological care for trauma victims, medical clinics for the local populations and health care for some 40,000 displaced people in Freetown. The military situation in Freetown has stabilised, but the humanitarian situation is deteriorating and most of the country remains under rebel control.