What’s killing the children of Freetown?
Because it’s not Ebola.

Written by Kieran McConville

Mahommad Samba Kamara stands outside a small tin shack in the pouring rain, watching his team suit up in protective gear to collect another body in the back streets of Freetown, capital of the West African nation of Sierra Leone.

This time it’s nine month old Aminata Samura. According to local social worker Claudia Fofana, she was sick with a fever for three days, had attended hospital, but died early this morning. Aminata’s mother is staying with relatives — too upset to attend her little girl’s funeral.

“When you bury so many children it’s like seeing the country deteriorating…”

As the safe and dignified burials team carry Aminata’s body to a waiting hearse, it’s difficult to even see the outline of her tiny form inside the white plastic body bag.

Members of Concern Worldwide burial team six remove the body of nine month old Aminata Samura

Members of Concern Worldwide burial team six remove the body of nine-month-old Aminata Samura, who died on September 9th, 2015 in the New England area of Freetown, Sierra Leone. A social worker said she had been sick with a fever for three days and had been to hospital. Photo: Kieran McConville

“When you bury so many children it’s like seeing the country deteriorating… it’s very, very sad… very discouraging,” Mahommad says quietly. “We are collecting children every day — children are dying more than adults.”

“This is the first time we see actual numbers we can monitor on a monthly basis.”

And his impression is not wrong. One result of the government’s decision during the Ebola outbreak to have all burials around Freetown carried out by medical burial teams is a ready supply of indisputable data.

“What you see here is fact. Even if you don’t know about figures, you see this is not a story — it’s fact.” In a small hut on a hillside just outside the city, Amadu Turay is slowly turning the pages of the large hardback book which serves as the register for Waterloo cemetery. Column after column lists the names and details of those buried here, many of them children, many very young. This is one of only two burial grounds that has been operational over the past year in Freetown and its hinterland, both managed by international NGO Concern Worldwide.

Amadu Turay, manager of Waterloo cemetery, outside Freetown, with the burial register.

Amadu Turay, manager of Waterloo cemetery, outside Freetown, with the burial register. Photo: Kieran McConville

Back at Concern’s office, country director Fiona McLysaght sits in front of a computer screen. “Because we have been solely responsible for managing cemeteries here, it’s given us a unique opportunity to see exactly how many people are dying, who they are, and their ages,” she says. “Up until now, this information just wasn’t there.”

What’s most disturbing is that the latest available data… shows the highest numbers of child deaths.

The analysis of those figures has revealed some startling statistics. Hundreds of children under the age of five are dying every month. And what’s most disturbing is that the latest available data – for the months when only a handful of Ebola cases were being recorded – shows the highest numbers of child deaths. In June of this year, 744 children under the age of five died in Western Area. The figure for July was 849.

Burial workers at the grave of nine month old Aminata Samura

Burial workers at the grave of nine month old Aminata Samura. Photo: Kieran McConville

Emily Cummings, who works with Concern’s Child Survival Project, has been responsible for analyzing the figures. “We’ve known for a long time that the infant mortality rate in Sierra Leone is one of the worst in the world, but when you calculate a rate, you are basically taking a sample and producing an abstract. This is the first time we see actual numbers we can monitor on a monthly basis.”

 “Staggering.”

Exactly how bad the problem is and whether it’s improving or worsening is hard to tell. The absence of reliable data from past years and the delay in conducting a census — caused by the Ebola crisis — makes it difficult to calculate a real rate. But Sonnia Magba Bu-Bukeijabibi, one of the country’s most senior statisticians, calls the figures revealed in Concern’s data “staggering.”

Entries in the burial register of Waterloo cemetery

Entries in the burial register of Waterloo cemetery outside Freetown, Sierra Leone. “S/B” denotes a stillbirth. Photo: Kieran McConville.

“If this is happening in Western Area, where you expect to have the most sophisticated facilities, imagine what’s happening in the provinces. We need studies to find out the underlying causes [and] focus group discussions. We need to talk to communities.” Magba Bu-Bukeijabibi works for the government-run agency Statistics Sierra Leone.

“In the U.S. we can’t imagine a child not living long enough to celebrate their fifth birthday. Here it’s very common.”

So why are all these young children dying? Sister Josephine Pewa, a veteran nurse midwife, is based at George Brook peripheral health unit in one of the Freetown’s poorer neighborhoods. “Respiratory tract infections, diarrhea, malaria, poor feeding practices,” she says, listing some of the most common ailments that kill infants and children here. “Often, the mothers will delay coming to us and go instead to traditional birth attendants in their community.” This delay in seeking medical care, for whatever reason, is definitely a factor. But the story is more complicated than that.

Baby Tricia Povere

Baby Tricia Povere was four months old when she died on September 2, 2015. She had been sick for three days and visited hospital twice. Here, her mother, Hawa Jawara, holds a cellphone with a picture of Tricia. Photo: Kieran McConville

Across the city, in another back alley, another Concern burial team removes the body of another child from a scant tin dwelling. Tricia Povere was four months old. Her mother, Hawa Jawara, tells us her daughter became sick with diarrhea and vomiting on Sunday evening. She brought her to the local health facility on Monday and was given drugs. “But she got worse and on Tuesday she was vomiting blood,” Hawa says.

“These children are dying from things that are preventable, that are easily treated… We need to start asking ourselves very seriously why.”

Then she recounts how they brought Tricia to a different hospital on Wednesday, where blood tests were carried out and she was given a prescription for a different set of medicines. “She died on the way home,” Hawa says simply. What exactly Tricia died of and why it happened is unclear. But, according to those who work among the Freetown’s poor, cases like this are not unusual.

Hawa Jawara (22) with her three year old son, Julano

Hawa Jawara, 22, with her three-year-old son, Julano, in the Lumley district of Freetown. Hawa’s daughter, four-month-old Tricia, died on September 2, 2015, having been sick for three days and visiting hospital twice. Photo: Kieran McConville

“In the U.S. we can’t imagine a child not living long enough to celebrate their fifth birthday. Here it’s very common — it’s as though it’s somehow expected that at least one child or more in a family will not live to the age of five,” says Megan Christensen, health advisor for Concern Worldwide US.

She feels that extreme poverty and sub-optimal health care are the root causes. “These children are dying from things that are preventable, that are easily treated with the appropriate care and supplies. We need to start asking ourselves very seriously why this is and what are we going to do about it.”

“We’ve begun to gather data from community health workers and bring it back to leaders… this is a powerful way to get their attention.”

Emily Cummings points out that the introduction in 2010 of free healthcare for pregnant women, breastfeeding mothers, and children under five seems to have had little impact on the problem. “It’s frustrating,” she says. “A lot of work and money and people’s efforts and time have gone into addressing this over the past decade, and still the numbers are so bad and in some cases getting worse. Sometimes you ask yourself what’s left to do.”

Some of the children's graves at Waterloo cemetery

Some of the children’s graves at Waterloo cemetery, just outside Freetown, the capital of Sierra Leone. It was one of two cemeteries in Western Area used for medical burials during the Ebola crisis and is managed by Concern Worldwide. Photo: Kieran McConville

One solution, Cummings says, may be to try to use the information on child mortality to galvanize communities. “People’s behavior here is so influenced by people of status, by leaders in the community,” she says. “We’ve begun to gather data from community health workers and bring it back to those leaders. Often they don’t realize how bad the problem is, and this is a powerful way to get their attention.”

“We simply can’t ignore what we’ve discovered. This is a crisis as big as Ebola.”

Elsewhere, in one of Sierra Leone’s more rural districts, a pilot project to use former traditional birth attendants as health promoters is seeing some positive results. These women, who are influential within their own communities, have been trained to encourage pregnant women and mothers to attend clinics regularly and in a timely way.

Megan Chistensen at Kingtom cemetery in Freetown

Megan Chistensen, health advisor with Concern Worldwide US, at Kingtom cemetery in Freetown, one of two cemeteries used during the Ebola outbreak. Many of those buried here are children under five. Photo: Kieran McConville

Back in Waterloo cemetery Megan Christensen walks through the children’s section, which stretches across a wide area of the rain-soaked hillside. “It’s startling when you come out here and see all of these tiny graves,” she says. “Each one represents someone’s child… this is horrible. The Ebola outbreak has given us a glimpse of what’s happening to children and mothers in Sierra Leone and, as the international NGOs start to scale down and leave, we simply can’t ignore what we’ve discovered. This is a crisis as big as Ebola.”

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