Merlin Update on Liberia: November 1999

Situation Report
Originally published
At a Glance
  • Seven years of civil war have devastated Liberia's infrastructure
  • Rebuilding the country's health services is key so that current and future needs are met
  • Life-threatening diseases may reach epidemic proportions if left unchecked
Merlin Programme
  • Supports 9 clinics in Nimba county
  • Provides preventive health services to Sierra Leonean refugees and is prepared to cope with further refugee influxes
  • Runs disease control programme and maintains the capacity to control possible outbreaks of disease.
Merlin's Response

Merlin began work in Liberia in May 1997 in response to a lack of basic health care for over 300,000 people in two counties: Lofa, which borders Sierra Leone in the remote north-west; and Nimba in Liberia's central highlands. Both counties had received little medical assistance in the past; had suffered severe looting during the war; and would have to accommodate the return of 225,000 Liberian refugees living in neighbouring countries.

Working with Liberia's Ministry of Health and Social Welfare (MoHSW), our experienced team of national and international staff have helped to rebuild and re-equip health services to meet current and future health needs. Ongoing insecurity in the volatile Upper Lofa border region has now forced many Sierra Leonean refugees to move to camps elsewhere. In Nimba county Merlin continues to support clinics and provide training to the county health team.

Helping to restore a basic health care network includes the structural restoration of a building, but also ensuring that health facilities have access to a reliable and appropriate stock of medicines; basic surgical and laboratory supplies; and well-trained and supported staff. Merlin teams regularly visit and supervise activities in the health facilities and provide refresher training to MoHSW staff. On-going training includes workshops in rational drug use to prevent the over-prescription of drugs; how to gather and analyse key medical data to warn of impending epidemics; vaccination techniques; and the cold storage of vaccines using Kerosene refrigerators.

Training and support is also extended to health staff such as local midwives who work in communities and who are key to ensuring that important health messages such as the importance of breast-feeding are understood and practised by mothers. More specialist training in surgical emergencies and complicated childhood infections is given to hospital medical staff.

While Merlin's activities focus on the need for prevention rather than cure, our teams have an in-built capacity to respond to medical emergencies. They provided additional health screening and treatment to cope with an influx of over 100,000 Sierra Leonean refugees into Lofa county in 1998 and have provided emergency mass vaccination to protect against yellow fever, measles and polio.

Merlin has recently embarked on a programme to control and prevent the risk of life-threatening epidemics such as Lassa fever, yellow fever and malaria. Efforts to date include improvements in the diagnosis, surveillance and treatment of these diseases through the training and education of health staff and the general population; rodent control; and improvements in rubbish disposal. In addition, the distribution of 30,000 mosquito nets will help prevent malaria.

Health Overview

Large scale population movement in and around Liberia and Sierra Leone over the last decade has increased the threat of outbreaks of epidemic diseases in West Africa. Pregnant women and young children are most at risk of contracting Lassa Fever, malaria, yellow fever and measles. Reasons for this increased risk include overcrowding following population movement; poor access to clean water and sanitation; and a disruption to immunisation programmes and general health service provision. Good diagnosis, treatment and prevention are key to the reduction of this threat.

Disease does not respect international borders. Merlin works to control and prevent the spread of disease in close co-operation with West Africa disease control experts from the London School of Tropical Medicine, Pasteur Institutes in Paris and Senegal, the Liberian Institute of Biomolecular Research and the World Health Organisation.

Lassa fever, for example, is a highly contagious, viral disease spread to humans through direct contact with rats or through the contamination of water or food by rat urine. It affects over 100,000 people a year in West Africa and, if allowed to reach epidemic proportions, is likely to kill one in three of those who contract it. No vaccine exists, making prevention crucial. Vulnerable communities are being targeted and efforts made to trap rodents, dispose of rubbish effectively and promote the need for better hygiene in the home. Communities and health staff are taught how to recognise the symptoms and early treatment is being improved within health facilities. In the case of measles and yellow fever, additional improvements will also be made to enhance vaccination coverage.

With the gradual return of Liberian refugees and a potential influx from Sierra Leone, there is a serious risk of epidemic disease taking hold. Merlin and its partners are acting now to ensure that health services are adequately equipped to prevent and, if necessary, cope with this eventuality.

Country Background

Liberians have paid a heavy price for seven years of civil war since factional fighting began in December 1989. By the time of democratic elections in July 1997, up to 150,000 people had died; 700,000 had sought refuge in neighbouring countries; and 800,000 fled to safer parts of the country. The economy was at a standstill and people were unable to plant or harvest crops in sufficient quantities as they were constantly on the move or in hiding.

With up to six factions fighting for control of the country, Liberia was divided along ethnic lines for much of the war. Despite numerous ceasefires and peace accords, the fighting continued unabated. ECOMOG, the West-African regional peacekeeping force, intervened in August 1990 and remained until May 1998 in an effort to maintain some level of security and stability for the population.

Charles Taylor, a former faction leader, won the presidential elections in July 1997. Tension between ECOMOG and the newly elected government mounted in early 1998 over issues of sovereignty, the deployment of Liberian security forces, responsibility for restructuring Liberia's Armed Forces and the escalating conflict in neighbouring Sierra Leone. Despite this tension, Liberian refugees gradually began to return. There has been renewed optimism amongst the population; an optimism mirrored in the return and resettlement of those previously displaced by the war and international attempts to help Liberia revitalise its infrastructure and services. However there remains the potential for further regional, as well as internal instability.

Key Indicators
Population (millions)
Population under 18 years of age (%)
GNP per capita(US$)
% Adult literacy rate (male/female)
Death rate for children under 5 years of live births age per 1,000
Women dying in childbirth per 100,000 live births
Life Expectancy at birth (years)

Source: Unicef "State of the World's Children" 1999