Sierra Leone

The signing of a peace accord between the Government of Sierra Leone (GoSL) and the Revolutionary United Front (RUF) in Lome on July 7^th 1999 has led to improved security conditions throughout much of the country. The accord maintains the previous commitments of the parties to guarantee safe humanitarian access and facilitate the fielding of independent assessment missions by registered agencies. Sierra Leone remains the least developed country in the world with a life expectancy of 37 years, and per capita income of less than US $200/year. It is hoped that the peace process may create an enabling environment for change and that, in turn, relief activities will contribute to the establishment of a durable peace (OCHA - 12/07/99; UNDP - 1999).

Security problems persist despite the accord and these have delayed humanitarian assistance in some areas. There have been reports of attacks on civilians and villages in the Northern Province. In Freetown, the GoSL continues to restrict movement at night. Given the significant problems with command, control and communication among the forces on both sides, it seems likely that there will continue to be problems even if the leadership of both sides make a good faith effort to adhere to the terms of the peace agreement (IRIN-WA - 01/09/99; USAID - 10/08/99).

Two of the most important challenges foreseen in the new environment are (1) assessing the conditions and needs of the population sections which have been inaccessible to relief organisations for long periods of time, and (2) re-settling and re-integrating the nearly half a million Sierra Leoneans who have become refugees in neighbouring countries.

Access

Assessment missions and emergency food distributions to many of the areas previously inaccessible have been undertaken during the reporting period. These include Bo, Kenema, Lunsar, Masakia, Tasso Island, Kandu Lieppiama Chiefdom and Dama Chiefdom. The opening of the road linking Freetown, Bo and Kenema was particularly important allowing traffic eastwards again (CARE -13/09/99; CRS - 19/08/99; OCHA - 18/08/99; WFP -10/09/99).

It is estimated that access to the currently closed areas could increase the beneficiary caseload by at least three times the present level of approximately 500,000. Although food aid agencies believe that sufficient stocks will be available to cover the projected needs of the currently targeted groups, WFP has proposed a further protracted relief and rehabilitation operation of assorted food commodities for the extra needs now anticipated. Current estimates put the number of displaced people at around 700,000-1,000,000 including some 370,000 in what were previously government-held areas (OCHA -12/07/99; USAID - 10/08/99; WFP - 10/09/99).

Freetown

In Freetown, relief organisations and the GoSL have sought to encourage people to return to their houses, rather than live in shelters, by providing assistance for rebuilding. Some shelter construction at IDP sites continues in order to stop IDPs residing in public buildings. There are currently 11 IDP sites in Freetown (USAID - 10/08/99).

Food aid in Freetown continues in the form of feeding for IDPs residing in officially approved shelters, and food-for-work activities to support the reconstruction of homes, schools and clinics. If peace holds, programmes for IDP shelters will be phased out by the end of the year. Food aid will continue for programmes such as hospitals and therapeutic feeding centres (USAID - 10/08/99; WFP -10/09/99).

Kenema

Due to improvements in the security situation there are more people coming into Kenema from rebel-held areas, and thus numbers of admissions to the feeding centres are still increasing. A survey in early June estimated the prevalence of malnutrition (<-2z scores and/or oedema) to be 19.9% (see RNIS 27). MERLIN is hoping to increase and decentralise the supplementary feeding to cope with the increased numbers, depending on logistics, funding and security (MERLIN - 27/07/99).

Bo

A survey among the resident and displaced population (estimated at 5,000) in Bo Town, conducted by ACF-F in early May, estimated the prevalence of acute wasting at 7.1%, which included 0.7% severe wasting. No oedema was recorded. These results represent an improvement in the prevalence of wasting when compared to April and October 1998. This is despite the fact that, between December 1998 and June 1999, Bo was cut off from Freetown, and unable to receive humanitarian assistance for many months, resulting in an increase in market prices of food. At the time of the survey, the market continued to function, and local foods were available, albeit in small quantities. The population of Bo has established coping mechanisms including: sending family members to live in rural areas to decrease household sizes in Bo township, developing gardens, and collecting 'bush yams' (ACF-F - 05/99).

The authors of the Bo survey stressed that the nutritional situation was fragile, particularly as the "hunger gap" approaches (prior to the harvest in October/November). The coverage of the feeding programmes was low at 18%. Moreover, mortality rates of the population surveyed were relatively high. CMR (estimated over three months prior to the survey) was 0.72/10,000/day and under-five mortality was 1.95/10,000/day. The main cause of mortality in the under-fives was malaria, despite health facilities being available in the town. Measles vaccination rates were low when confirmed by card (23.2%) but increased significantly when confirmed by parents/guardians (84.3%).

The displaced people living in camps around the town were not included in these surveys, and their nutritional situation is unknown.

Makeni

ACF-F returned to Makeni in late July for the first time since December 1998 when it had to evacuate the area after a rebel attack (ACF - 07/99). The evaluation mission team reported a catastrophic humanitarian situation. A rapid nutritional screening exercise in Makeni Town estimated that 34% of children under five were malnourished (see Annex). Of the 95 children assessed, 16% were moderately malnourished, and a further 18% were severely malnourished. Of the adults assessed, 25% were malnourished, 14% severely. These results were not based on a random sample, but nevertheless the authors suggested the nutritional situation had deteriorated in recent months. Further screening exercises were undertaken in the IDP camps on the outskirts of the town. In Magbenteh camp, which houses some 2,000 people, the MUAC of 97 children under five was measured; 52.6% were wasted, including 8% severe wasting. In addition, 52% of the adults assessed were wasted, 8.7% severely so.

The prevalence of malnutrition in four villages surrounding the town was crudely estimated, based on screening all children "around at the time". The average prevalence of malnutrition in the children under-five was 33.7%, 18% were severely malnourished. In one village, Makama, 45% of the children assessed were malnourished, 25% severely. The prevalence of oedema was very high in these villages. Of the 33.7% of children classified as malnourished, 76.3% had oedema.

The severity of the situation in Makeni is attributed to the fact that it has been cut off from commercial and relief supplies since December. A rapid food security assessment by ACF suggested that 75% of farmers in the area had been unable to plant this year, because seeds were in short supply due to looting. Fertilisers and tools were also lacking. The population was said to be eating only one meal a day consisting of cassava by-products, reptiles, larva (from composts and rotting trees), snails, rats, frogs and mushrooms. Rice, meat and fish were no longer available at the market. ACF predicted that the "hunger gap" between the two harvests will be particularly harsh this year in Makeni as the population has no food stores and hence are dependent on humanitarian assistance for survival. The report noted that the nutritional situation was worse in the villages surrounding Makeni than in the town itself, because the outlying areas have been subject to more looting in the past few months (ACF - 15/08/99).

The first inter-agency food aid convoy since late 1998 reached Makeni in mid-September. Distributions have started for 97,000 beneficiaries (WFP - 10/09/99).

Liberian refugees

No new information on the nutritional situation of the approximately 8,000 Liberian refugees in Sierra Leone is available. The last RNIS reported that their condition is not expected to differ from the local population.

Repatriation

UNHCR representatives from the four countries which house the majority of the 500,000 Sierra Leonean refugees met in early August. Organised voluntary repatriation, expected to last two years, will begin in February 2000. Half of the refugees are expected to repatriate voluntarily, 30% under a facilitated scheme, which does not involve transport and 20% under a scheme with transport. Currently not all returnee areas are accessible to humanitarian workers (IRIN-WA - 09/08/99; UNHCR - 20/09/99).

Overall, although the situation in Sierra Leone will, it is hoped, eventually improve as parts of the country become newly accessible it is probable that, in the short term at least, acute humanitarian needs will be uncovered as in Makeni. At present, information is still limited. In areas that were previously government-controlled, where surveys have been conducted, the population appears to vary between high risk (Makeni) and moderate risk (Bo) (category IIa and b). The nutritional status of the IDPs in the areas of the country where surveys have not yet been conducted is unknown (mainly previously rebel-controlled areas) (category III).

Priorities and Recommendations:

As agencies gain access to previously closed areas, a range of humanitarian interventions are likely to be required to improve public health and strengthen food security.

Public Health priorities include:

· Measles immunisation.
· Primary health care programmes.
· Rehabilitation of water supplies and sanitary facilities to prevent cholera.

· Therapeutic and Supplementary Feeding programmes to rehabilitate malnourished children.

· Increased attention to the conditions of secondary and tertiary roads. This will allow humanitarian assistance to be provided by road and generally make larger areas of the country accessible, and enable marketing networks to be re-established.

· Continue to treat children in the therapeutic and supplementary feeding centres in Bo.

· Follow up nutritional surveillance through Health Centres, and continue intensive screening of under-fives to improve the coverage of the feeding programmes.

· Promote immunization for children under five.

· Supply a general food distribution (full ration) to the population of Makeni and the surrounding villages and camps.

· Set up therapeutic and supplementary feeding centres.

· Set-up medical facilities both in central and rural areas.

· Assess the agricultural situation to decide what inputs/interventions are appropriate.