These individuals were civilians traumatized by the rebel forces that moved through the country from the border of Liberia to ultimately enter the Freetown and assumed power in a shared arrangement after peace negotiations. The arrangement failed after the people demonstrated against continued atrosites committed by the then security forces. The were fired upon and 18 people were killed during a peaceful demonstration. The UN Peacekeepers intervened and the fomer rebel leader went into hiding to escape arrest and charges of human rights violation. He was captured inprisoned and died after going insane in prison.
The Truth and Reconciliation effort has provided victims the opportunity to confront those guilty of these atrosites. This is a national effort to promote healing. Many people speak of forgiving these abuses. However there is still ambivalent feeling as one would expect.
One man who had been a driver all his life having been taught to drive by his father, was now unable to pursue his trade because he has only a stump on his left upper limb. He was fitted with a prosthesis by an NGO in Freetown and given two weeks of functional assessment but no transitional work placement. He is now in the resettlement camp without gainful employment. His vocational rehabilitation is a necessary aspect of his overall medical and psychiatric treatment plan. The ideal rehabilitation effort would be to arrange for robotic prosthesis combine with micro-loans to restore functional and economic productivity.
The restoration of pre-morbid functioning is the ideal and ultimate goal. This would require complete reintegration of the war wounded , especially the amputees , into the general community. Currently they reside in camps that were established to mitigate against the psychological stress of marginalization and stigmatization by providing a group support system.
The pictures above reflect the current and historical resilience and hardiness of the people of Sierra Leone. The picture on the right is of the symbolic Cotton Tree in Freetown planted by the early settlers to reflect their freedom. The opposite picture reflects the basic tenacity and diligence of the people in the village of Yele.
The demographics of the victims reflected the plurality of the general population. The psychosocial stressors in the ambient environment derived from the poverty traps in the rural and urban areas was confounded by the functional disability resulting from the amputations. The need or vocational rehabilitation in the context of a micro-credits economic structure is critical to restore the health and reduce morbidity and mortality. For example people are unable to afford medicine under the cost recovery system.
The above represent a cross section of the clinical experience during the very limited 10 day medical mission. The need for systematic screening in both the Yele Village and the Makenie Camp for hypertension. Obesity , hypercholesterolemia, hyperlipidemia, elevated blood sugar is apparent from the high prevalence of hypertension and the high starch content of the diet.Immunization efforts for the young and old were reflected in the presence of preventable conditions like tetany.Smoking cessation interventions are indicated. The provision of cataract removal and hernia repair is an extremely important and needed service.
The co-morbid psychiatric disorders and sub-clinical symptoms are masked by the cultural and socioeconomic priorities, Anxiety manifests as gastro-esophageal reflux.Pain is the most common chief complaint and one has to determine if it is psychic pain or physical. In most cases it is both.
Makeni project 2008 report
MAKENI WAR WOUNDED PROJECT <ul><li>PRIMARY CARE INTERVENTION FOR THE SEVERE PHYSICALLY AND PYCHOLOGICALY TRAUMATIZED </li></ul>
PROFILE OF TRAUMA <ul><li>People were displaced as they fled into the bush to escape the rebels </li></ul><ul><li>Displaced people went into desparate survival mode to secure food, shelter, safety and security. </li></ul><ul><li>They moved from village to village avoiding the rebel advance </li></ul><ul><li>When apprehended by the rebels in the bush they were raped, amputated, and/or killed </li></ul><ul><li>The survivors carry physical and psychological wounds. </li></ul>
THE AMPUTEE <ul><li>There are the surgically amputated who required removal of their limb(s) after sever gunshot injury became gangrenous. </li></ul><ul><li>There are those who were amputated by the rebels with machete and axe. </li></ul><ul><li>Those who survived eventually arrived in Freetown seeking the protection of the government forces. </li></ul><ul><li>Displaced people were sheltered in a large camp in Freetown </li></ul><ul><li>When rebel forces entered Freetown amputations continued to occur </li></ul><ul><li>Amputees are either displaced from the hinterland villages or from the urban areas such as Makanie or Freetown. </li></ul>
MEDICAL CARE AFTER THE AMPUTATION <ul><li>Those who received surgical amputations in hospital due to gunshot wounds developing gangrene received the medical and surgical services available at the time. </li></ul><ul><li>Those who suffered amputations at the hand of the rebels went for extended periods of time without medical care. </li></ul><ul><li>Some patients describe having to pay to have their stump washed, antibiotics, and pain medications. </li></ul><ul><li>Some have been fitted with prosthesis. However functional assessments and vocational retraining is critically needed </li></ul>
PREMORBID FUNCTIONING <ul><li>Those from the villages were farmers, traders, drivers, crafts-persons, parents, grandparents, husband, wives, etc. </li></ul><ul><li>As one woman described bitterly “ I was a person of status”. She was a trader, wife, and mother. </li></ul><ul><li>Those from the city described similar roles and relationships prior to trauma and diplacement </li></ul><ul><li>The President of the Association of Amputees lived with his wife and children in his home in Freetown on the day the rebels came to his door. They threatened to take his 14 year old daughter. She escaped and he fought them. He subsequently lost both arms in below the elbow amputations. </li></ul>
Displacement <ul><li>People displaced lost most if not all their pre-morbid roles </li></ul><ul><li>They lost relationships, community and family. </li></ul><ul><li>They lost the capacity to provide for basic needs. </li></ul><ul><li>They lost hands, arms, and legs. </li></ul>
PSYCHOSOCIAL PROFILE <ul><li>The victims were from multiple ethnic groups, Limba, Temne, Mandingo, etc. </li></ul><ul><li>Their prior roles were that of farmers, miners, traders, tailors, drivers, </li></ul><ul><li>They were from the Western area, Southern , Northern, and Eastern Providences </li></ul><ul><li>They were male, female, mother, grandmother, father,and grandfather. </li></ul><ul><li>Some had amputations after gunshot wounds became gangrenous. </li></ul><ul><li>Some had amputations at the hands of the rebels as a tactic to induce fear and hence control and expose the powerlessness of the government to protect </li></ul><ul><li>They suffered above the elbow, below the elbow, above the knee, right left, and bilateral amputations. </li></ul>