Malnutrition and other illnesses were on the rise in the past weeks due to the lack of food, water and medical care for tens of thousands of internally displaced persons living in camps in Montserrado county around Monrovia. Unfortunately, as of Friday, July 18, insecurity forced MSF to close its health clinics in the Seighbe, Plumcor, and Rick's camps in Montserrado that were serving approximately 21,000 internally displaced Liberians. Located directly on the frontlines of the fighting, the camps offered little security and many of the displaced have fled to already overcrowded shelters in Monrovia. MSF's work on a therapeutic feeding center with a capacity to treat up to 500 patients for severe malnutrition in Seighbe camp also had to be halted due to insecurity, as did a program offering support to victims of sexual violence.

Fighting between government forces and Liberians United for Reconciliation and Democracy (LURD) rebels in and around the Liberian capital of Monrovia that has lasted for more than a week continues to take a heavy toll on civilians.

Mortars and stray bullets hit densely populated areas of the city on a daily basis, killing and injuring scores of civilians. Medical treatment for wounded civilians is limited and transporting patients to the few medical facilities still functioning in the city is dangerous. With the country's health system in a shambles and international humanitarian organizations limited to a small area of Monrovia city, the health status of Liberians in more than 75% of the country remains unknown.

"Not only do we not have a good sense of what the health situation is like in most of Monrovia, we have no idea what people are going through in the rest of the country where there is little or no medical care available," said Pierre Mendiharat, MSF head of mission in Monrovia.

Working under increasingly difficult conditions, 12 MSF international aid workers, including one surgeon, an anesthetist, and four doctors, continue to work with over 300 Liberian staff and 600 MSF-supported public health workers to provide some of the only health care available in they city of Monrovia, as well as in Bong county.

This latest round of fighting - the third in less than two months - has forced MSF to evacuate seven international staff members, and cut back on relief activities. Before fighting in and around Monrovia began again in June, MSF and other international aid organizations had access to less than one-fourth of the country. The current fighting has reduced this access even further.

Mortar shelling in civilian neighbourhoods

Two MSF residences in the Mamba Point area of Monrovia have been transformed into hospitals with in- and out-patient services, an emergency room, maternity and pediatric wards, and a surgical theater. Both facilities have received dead and wounded civilians every day since the fighting restarted on Saturday, July 19.

On Monday July 21 alone, when a mortar hit a nearby building housing displaced people, the MSF Mamba Point hospitals received 155 wounded civilians and 13 dead. This past Saturday (July 26), Liberian National Day, a mortar hit Newport Road School where some 6,000 displaced persons were living, killing eight and injuring ten.

Over the last week, the two MSF Mamba Point Hospitals received over 400 war wounded civilians, including children, the majority injured by mortars and bullets.

The few medical facilities still operating in Monrovia have not been immune to the fighting. Last Friday, a mortar landed just meters from the MSF hospitals, leaving 11 dead and over 50 wounded. Dozens of stray bullets have fallen in the MSF compounds and hospitals. One passed through the emergency room of one hospital and another through the pediatric ward, both narrowly missing patients and medical workers. An MSF surgeon injured herself while operating when she was startled after a mortar landed nearby. On Saturday, July 19, a MSF Liberian staff member was killed when a mortar hit his home.

Transporting civilian casualties of the fighting is also proving extremely difficult. In the West Point area of the city where fighting has been heavy and movement on the streets is dangerous for civilians and MSF staff, one of the oral-rehydration teams that MSF had set up in West Point has transformed itself into a wheelbarrow ambulance brigade. They have taken it upon themselves to bring severely injured patients to the MSF hospital in Mamba Point by stretcher and wheelbarrow. On their return trips to West Point, they carry medical supplies, food and drinking water that MSF sends to help support the Catholic Mission Clinic there.

Cholera, malaria and other illnesses going untreated?

"There are many people dying of war injuries, but this is just the tip of the iceberg," said Nathalie Civet, MD, MSF medical coordinator in Monrovia. "There are also a lot of anonymous deaths due to a severe lack of medical care in the city and the rest of the country."

Poor sanitation, a dearth of clean water and overcrowding in the abandoned buildings and stadiums where tens of thousands of displaced Liberians had taken shelter in and around Monrovia led to an outbreak of cholera in June. Before the latest fighting broke out, MSF was treating more than 350 cholera patients per week in four cholera treatment units in the city. Two of these units were forced to close last week, decreasing MSF's ability to monitor the outbreak and treat those affected by the epidemic.

Before the fighting restarted, MSF set up a system of six 'lazarets' - emergency cholera treatment kits - equipped with oral-rehydration solution, chlorine, and other cholera treatment materials, as well as eight rehydration points around Monrovia to treat dehydration and screen for cholera. Despite its present limited mobility, MSF has received reports that public health workers are utilizing these emergency preparedness measures in several parts of the city.

As an indication of how the current fighting has drastically reduced access to medical care for Liberians, before MSF was forced to evacuate Redemption Hospital in northern Monrovia, surgeons there performed over 100 cesarean sections a month. But since the hospital facilities were relocated to Mamba Point, the MSF surgical unit - one of the only still functioning in the city - has performed less than 20 cesareans per month.

At Redemption Hospital, MSF received at least ten new pediatric cases in need of blood transfusions due to severe malaria every month, but over the past six weeks, only three have been performed.

"We can only imagine how many children, mothers, and adults are dying due to lack of primary health care, obstetrics, and transfusions," said Dr. Civet.

Medical Care for Internally Displaced Persons greatly reduced

Malnutrition and other illnesses were on the rise in the past weeks due to the lack of food, water and medical care for tens of thousands of internally displaced persons living in camps in Montserrado county around Monrovia. Unfortunately, as of Friday, July 18, insecurity forced MSF to close its health clinics in the Seighbe, Plumcor, and Rick's camps in Montserrado that were serving approximately 21,000 internally displaced Liberians.

Located directly on the frontlines of the fighting, the camps offered little security and many of the displaced have fled to already overcrowded shelters in Monrovia. MSF's work on a therapeutic feeding center with a capacity to treat up to 500 patients for severe malnutrition in Seighbe camp also had to be halted due to insecurity, as did a program offering support to victims of sexual violence.

MSF staff continues to provide medical care, cholera treatment, and water in the Samuel K Doe Stadium where the numbers of internally displaced persons seeking safety has swelled to an estimated 25,000. Unconfirmed reports state that large numbers of displaced persons are fleeing the fighting in Monrovia and Montsserado county and heading to Bong county, east of Monrovia.

In Bong county, MSF Liberian staff continue to run out-patient clinics serving approximately 50,000-60,000 displaced persons in the Salala, Maimu, and Totota camps, and provide water and sanitation support in the camps.