Additional Information on MASL project goals

1) Provision of medical and other support for women with vesico-vaginal fistula (VVF).

2) Reducing maternal mortality.

3) Provision of support to people affected by HIV/AIDS.

4) Facilitating access to treatment for unusual conditions

Support for women with vesico-vaginal fistula (VVF)

United Nations agencies have sounded what they call a 'global alarm' about this condition which condemns women to a life of ill-health, solitude and despair, often driving them and their children into deep poverty. As Dr McColl, former head surgeon at Guy's Hospital in London who has carried out VVF repairs in Sierra Leone, explains: 'The women realise that if they drink less they will leak less, so they become dehydrated and are then susceptible to infections.

If they don't die of that, they may find the whole thing completely intolerable, and take their own lives. We're not sure about how many do this, but we keep hearing about it, and in terms of the numbers of people with this condition, it may well be that tens of thousands of them are committing suicide' .

It costs only about £100 to carry out fistula surgery, but Elizabeth Hunter of Mercy Ships, a mobile mission hospital that recently carried out about ninety such operations in Sierra Leone, says that at the present rate it would take 50 years to repair just the existing cases . In March 2005 Mercy Ships established a permanent clinic in Freetown, with two dedicated surgeons, to carry out VVF surgeries. It is likely that some of the worst violations of the decade-long conflict, including the large number of girls and women forced into sexual slavery and the widespread use of rape as a weapon of war, have resulted in high numbers of VVF among those women and girls who survived their ordeal.

MASL intends to:

• Carry out a review of medical support available for women affected by VVF;
• Identify ways in which the current services can be expanded;
• Develop a strategy, including the identification and coordination of personnel and resources, with the aim of carrying out an additional 500 VVF repairs a year by the end of 2007
  (This may for example include funding a clinic attached to a hospital, arranging for volunteer surgeons to spend short periods in Sierra Leone, to carry out operations and train medical personnel)
• Pre and post-operative counselling will be provided and supported, through a local women's NGO Amazonian Initiative Movement, with whom MASL has a close working relationship.

Reducing maternal mortality: support to the expansion of maternal health services As detailed, Sierra Leone has the worst maternal mortality rates globally. Only 42% of births in Sierra Leone are attended by trained personnel and, set in the context of entrenched poverty, poor transport systems and low knowledge levels, each pregnancy and birth is a risky and potentially fatal experience for thousands of women each year. Healthy women die in the prime of their lives - women upon whom young and old may depend. The consequences of maternal mortality are wide-ranging and long-term. It is, as UNICEF points out,

'the most neglected tragedy of our times'.

MASL will consult widely with partners in Sierra Leone on targeting resources. The provision of support will include:

• Funding of training for nurses, midwives and doctors;
• Facilitating access to appropriate training for other medical personnel;
• Support to outreach clinics and mobile midwives;
• Provision of relevant supplies and equipment, including mosquito nets to pregnant mothers, and ambulances where appropriate;
• Construction of maternity rest houses in grounds of hospitals for women where problematic pregnancies (eg multiple births) can stay prior to delivery. These have been shown to reduce maternal deaths where they have been introduced - eg Nepal.
• Support and expansion of maternity wards - some maternity wards have two mothers to a bed;
• Support for education and information campaigns related to above.

Support to people affected by HIV/AIDS,

Especially for women & children HIV/AIDS represents a major threat to communities in Sierra Leone, and currently affects three times as many young women as men.

The HIV prevalence rate among age males age 15 -24 is 2.49 and amongst females is 7.54 (UNFPA 2002). The impact of HIV/AIDS on communities affected by the disease is complex and multi-faceted, affecting all areas of home and community life, access to services (including health and education) and resources and creating severe psycho-social distress. The simultaneous pressure on the extended family system and the erosion of the ability to care for and support additional members as whole communities become affected creates a cycle of escalating poverty, leaving the most vulnerable, particularly children, unprotected.

The extent of the medical care required to impact on those affected by HIV/AIDS is unprecedented, including clinical and preventive health care services, nutritional support, home-based care, and relevant health care information. In short the package of support that can be provided determines the life span of the patient .

Stephen Lewis, special envoy of the UN Secretary General for HIV/AIDS in Africa, has urged the international community to strive to keep mothers in Africa alive - it is not possible, he says, to tolerate a situation where everyone in the West has access to anti-retroviral (ARV) drugs but they are not available to those who need them most: 'I can't get over the way women and children are the targets - 67 per cent of those who carry the virus. Whole sections of this continent will be depopulated of women. There has never been anything like this pandemic in human history. There has never been the numbers, never been one gender so targeted, so many orphans.'

The difference between a ten year old and a seventeen year old losing a mother are significant, in both psycho-social and development terms. Mothers recognise this - a World Vision report from Uganda found that significantly more women were coming forward for testing than men. Research concluded that 'the women come forward for testing because they want to live longer to care for their children' (Davidson 2002). Providing a package of ARVs with nutritional support and treating opportunistic infections would slow down the death rate, and in turn reduce the orphan crisis. Certain low cost medical interventions can impact significantly on the spread of the disease, such as the administration of nevirapine to mother and child at birth which costs just a few pence.

In South Africa alone this injection would prevent 35,000 each year children being born with HIV (The Guardian 1 November 2002) . The standard antibiotic cotrimoxazole was recently shown to have a significant role to play in preventing potentially lethal respiratory infections that strike HIV-positive children with weakened immunity - and at a cost of just $7 a year. A study in The Lancet (vol 364, p1865) showed that when given regularly for 19 months to HIV-positive children aged from 1 to 14, the drug almost halved their risk of dying from secondary infections compared with children receiving a placebo. As cotrimoxazole is a cheap, safe and effective first line of defence to compensate for a weakened immune system, it could be a huge help in countries like Sierra Leone where ARV drugs are not yet easily available. Nutritional support can also play a key role in prolonging lives. Health information addressing food taboos and shifting the emphasis on carbohydrates in the diets of many poorer communities in Sierra Leone can reduce malnutrition and improve resistance to opportunistic infections. Intervention programmes for people affected by HIV/AIDS often aim to ensure that those affected receive two meals a day; this is seen as essential to maintaining levels of health, but is not easy to achieve in areas reliant on subsistence agriculture, reduced labour and competing demands for household expenditure. Sierra Leone, in common with many low and middle-income countries, has yet to implement basic minimum essential services for the care and support of people with HIV/AIDS.

MASL will work with The Ministry of Health, NGOs and other agencies to support the development of a 'Core HIV Service' defined as the following range of services :

1. Universally accessible voluntary HIV-testing and counselling service;
2. Effective HIV prevention, including provision of condoms, early treatment of sexually transmitted diseases ;
3. Information and education;
4. Accurate disease surveillance;
5. Training for health professionals;
6. Access to support groups for people living with HIV/AIDS.

Support for individuals suffering from rare and unusual conditions

As detailed, the health problems facing communities in Sierra Leone are enormous. There are inadequate numbers of medical personnel and limited areas of specialisation. Those with rare and complex conditions face little prospect of getting treatment. Providing access to medical specialists has been the key focus of our work to date. MASL made a commitment in 2003 to assist a young man in Sierra Leone to get treatment for a condition that he has had since birth. Anthony McCarthy is a twenty year old, born with a rare condition known as exstrophy which renders him doubly incontinent. We researched Anthony's case and made contact with a consultant Dr CJ Woodhouse, based at the Middlesex and Lister Hospitals, who is one of only two UK specialists in the condition. We raised enough funds for Anthony to come to the UK in January 2005 for initial tests to determine the range of treatment options available to him. Sadly, because of the complex nature of his condition, an operation to create a stoma for his urine was the only appropriate surgical option.

As Anthony would still require incontinent pads for other waste, he decided that that he would not go ahead with the operation. We will continue to facilitate access to advice and treatment for those with rare or complex conditions. We aim to balance the 'unstrategic' nature of such a response - focusing, as it does, so many resources on one individual - with the need to respond to and recognise the right to health for all. In time we expect to assist in building up health service capacity in Sierra Leone and also to establish better and more effective relationships with appropriate bodies and medical personnel in the UK and elsewhere that may enable such specialised treatment to be accessible to those who require it.

We expect to support 1-2 individuals per annum by 2007 to access medical assistance for a condition not treatable in Sierra Leone. Where appropriate, we will make use of appropriate medical facilities in neighbouring countries, such as Nigeria and Ghana, where the health service infrastructure is in many cases stronger than in Sierra Leone.

Millennium Development Goals

Without urgent support, Sierra Leone looks unlikely to meet the targets for the Millennium Development Goals. These eight Millennium Development Goals (MDGs) were agreed at the United Nations Millennium Summit in September 2000 and range from halving global poverty and hunger to protecting the environment, improving health and sanitation and tackling illiteracy and discrimination against women.

They were introduced as part of a wider attempt to encourage the international community to stop talking about making a difference in the developing world and join forces to start doing something about it. Alongside the Goals, a series of 18 targets were also drawn up to give the international community a number of tangible improvements to aim for within a fixed period of time, and also make it easier for progress to be measured.

The intention is that almost all of these targets will be achieved by 2015. Unfortunately, while some significant progress is being made towards meeting some of the targets in some of the affected countries, in many cases progress is patchy, too slow or non-existent. For Sierra Leone which still faces an enormous national reconstruction and rehabilitation programme and a massive reduction in key personnel, the Goals are looking increasingly less attainable.