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Sierra Leone is a small country of 5 million inhabitants on the west coast of Africa. It is in the process of recovering from 10 years of a brutal civil war which ended in 2002. This war was about diamonds and the recent Hollywood film Blood Diamond gives an insight—albeit over-dramatised—of events at the time.
I am fortunate to have had the opportunity of working in Sierra Leone before the war started, and to continue working there during the mayhem before finally leaving in 1997. Since the cessation of hostilities I have visited regularly, up to twice a year. I am therefore in a unique position to assess changes in healthcare, with particular reference to neurology, brought about by the civil war.
Neurology was not practised as a specialty until the mid 1980s. At that time, as a UK trained Sierra Leonean neurologist, I had the opportunity of starting a service. Our initial facilities included EEG and EMG. There was no CT scanner but a radioisotope scanner was available with its severe limitations. The service was located in the capital, Freetown, but a referral system ensured that cases from the provinces were also seen. There was no specialised neuropathology, however personal contacts with centres in the UK helped with difficult investigations including muscle biopsies, and CSF oligoclonal bands. Special neurology clinics were run in the main Connaught Hospital weekly, and one EEG and one EMG clinic a week were also conducted.
A wide variety of neurological conditions were seen and documented. Epilepsy was common, but it was not due to cysticercosis which is rare in Sierra Leone. Strokes reflected the high prevalence of hypertension in both urban and rural areas; 24% in Freetown and 14% in rural villages.1 Ataxic neuropathy due to cyanide poisoning from cassava was uncommon although widely described in neighbouring Nigeria. As expected, multiple sclerosis was rare and I only diagnosed with certainty two patients over a 12-year period. Parkinson’s disease was also uncommon, but was seen in younger patients compared to the west. There were severe problems in managing chronic conditions such as epilepsy due to poor patient compliance, both with clinic visits and with medication. Only 35% of epileptic patients were still being seen after 6 months and of these only 25% were seizure-free after one year. Problems with medication included availability, cost and quality. Although phenobarbitone and phenytoin were the backbone of treatment, even these drugs were at times difficult to procure, or were unaffordable.
It was during this time that the medical school, the College of Medicine and Allied Health Sciences, was started. Its humble beginnings saw the first eight doctors graduate in 1994. The curriculum was sound and had a strong community medicine base. Many graduates (somewhat unfortunately for the country) have found their way into august institutions in the US such as the Centers for Disease Control in Atlanta and Georgetown University, and particularly into the UK National Health Service. The College also trains graduate nurses, pharmacists and pharmacy technicians.
THE NEUROLOGY OF WAR
The escalation of the war in the mid 1990s brought with it medical complications unique to the war. Atrocities, mainly from the rebel factions, included limb amputations which became the legacy of the conflict. There were other atrocities with neurological manifestations. One was what I refer to as “ligature neuropathy”. Prisoners, usually government soldiers, captured by rebel factions were bound round their arms, sometimes with cables with such severity and duration that they developed ischaemic damage to the peripheral nerves with complete wasting of the small muscles of the hand (figs 1 and 2). The damage was irreversible with the functional outcome no better than the amputees. Gunshot and shrapnel injuries to the head and spinal cord presented other specific neurological problems. Combatants also appeared from the bush with poorly aligned healed fractures of the upper limbs, usually the humerus, with radial nerve palsies (fig 3). HIV rates increased during the war as a result of many factors: more professional sex workers, sexual abuse by fighting factions, and the importation of foreign soldiers from areas of high prevalence such as Eastern Africa. In spite of this the prevalence of HIV remains one of the lowest in Sub-Saharan Africa. One wonders if the high frequency of circumcision among Sierra Leonean males, now recognised as significantly reducing transmission, may be the explanation. I never came across a case of HIV neurology during the pre-war years.
The war devastated the health infrastructure of the country. Hospitals were burnt down and those remaining fell into disrepair. The century-old Connaught Hospital, the main teaching hospital in the capital, was left with very little equipment and even less specialist medical staff (fig 4). A large number of consultants including the only neurologist—myself—left for safer environs. The medical school was closed for almost a year and even some of the students left the country. It is against this background that the current efforts at rebuilding must be viewed. The Connaught Hospital has been completely renovated with new areas added for clinical teaching (fig 5). The shortage of indigenous faculty staff in the medical school is now bridged by lecturers from abroad, mainly from Egypt and Nigeria. Four sets of doctors have graduated since the end of the war.
So where does neurology stand? At present there is no neurology service in the country. I have been giving neurology lectures and seminars to medical students on an ad hoc basis during my visits. General physicians cope with clinical problems as well as they can and where the need arises and funds are available, patients are sent to neighbouring countries, mainly Ghana, for investigations and treatment. The hope is that local graduates will be trained to specialist level in the subregion under the West African Colleges of Physicians and Surgeons. Already one graduate has completed his training in Nigeria and is now specialising in cardiology in South Africa. But the lure of the West looms large and the country is haemorrhaging locally trained doctors to the UK and US. In spite of this it is heartening to see young doctors manning health centres and district hospitals, and they have to be encouraged to stay. Working conditions and remuneration are poor and are being reviewed. The health service will benefit immensely from a link with a UK hospital, such as that between Ipswich and Mozambique, highlighted in a recent issue of this journal.2 Neurologists may then visit for short periods to see patients and give lectures. The recent immigration law restricting non-European Union doctors working in the UK may indirectly give a lifeline to developing countries like Sierra Leone.
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