During Sierra Leone's violent decade-long war, the warring parties used amputation, especially of arms, as a means of terror. In a camp for amputees in the capital city Freetown, Médecins Sans Frontières established a clinic and a treatment programme for neuropathic pain.

Insecurity and cultural and language barriers have complicated this work, but medical and humanitarian benefits have been demonstrated. Pain services are virtually non-existent in less-developed countries. There have recently been no major treatment advances for neuropathic or phantom pain; however, the general body of knowledge about amputation pain can be increased by observations from these difficult settings.

Clinics devoted to the treatment of chronic pain syndromes are a relatively new development. The scientific knowledge behind the treatment of pain is growing through the work of organisations such as the International Association for the Study of Pain and the Pain Society in the UK.

For both medical and humanitarian reasons, there are acute pain services in most hospitals in the UK. There is growing evidence that improved treatment of acute pain can reduce the incidence of chronic pain. In less-developed countries, where basic medical services may be in disrepair, pain services are virtually non-existent, although interest in the subject is growing. A chronic-pain clinic in Tanzania recently reported a mixture of cases similar to that seen in UK clinics.

Non-governmental organisations also contribute to pain treatment services. Douleurs Sans Frontières, for example, has worked in various places particularly with landmine victims.

Aid organisations provide a large part of the aid to victims of humanitarian crises in less-developed countries. In recent years, these agencies have become more reflective about the quality of care provided. How agencies distribute their limited resources in the face of overwhelming need is constantly being re-evaluated.

Their goal is not simply to increase the availability of health care, but also to focus on particular areas of need that, for reasons of marginalisation, stigmatisation, or the injustice that results from limited resources, may otherwise be left unaddressed.

Médecins Sans Frontières (MSF) is an emergency medical relief organisation that runs around 500 medical relief programmesin over 80 countries worldwide. It responds to humanitarian crises where there is broad abuse of freedom, and where violence and war lead to social injustice. For several years MSF provided surgical support to the main government hospital in Freetown, Sierra Leone. This article describes the work, beginning in early 2000, of an anaesthetist (PL) and a local community health officer working for MSF surgical programme in a pain clinic in the Murray Town Amputees'camp in Freetown.

Sierra Leone's violent past

In 1991, civil war broke out in Sierra Leone between the government and the Revolutionary United Front (RUF), which was formed by people who felt excluded from government because of corruption and nepotism. In the ensuing decade, the government of Sierra Leone became weakened and after several military coups the national army became discredited.

All parties involved in the war have been implicated in the perpetration of war crimes, 7 and civilians have been the victims ofvarious human rights abuses, including rape, abduction, and violent amputation. 8,9 Furthermore, armed forces present as part of regional peacekeeping organisations have not been innocent.

The West African peacekeeping force known as ECOMOG were present in Sierra Leone at the invitation of the government. In January 1999, they were nearly thrown out of the country by the RUF during the campaign "Operation no living thing". During their fight back for control of Freetown, ECOMOG were widely involved in killings and beatings.

This decade of conflict has claimed thousands of lives and produced more than 400,000 refugees. Over 1 million people are estimated to have been displaced. 10 Criteria for human development and life expectancy-access to improved water sources, immunisation rates, and access to essential drugs-place Sierra Leone bottom in the world tables. One of the most distressing legacies of this war is the large number of amputees.

The origins of amputation in Sierra Leone

The number of people in Sierra Leone who had amputations is not known, and some exaggerated figures have been produced. However, more conservative estimates put the numbers at fewer than 1,000 people who have lost an arm or a hand in the country, many of whom may not have been seen by medical or rehabilitation services.

However, an unknown number have died from infection or associated injuries,isolated from any assistance by distance and insecurity. In January 1999 alone, Freetown's main hospital treated 97 victims of amputation by axes and machetes. MSF, working in one hospital, treated over 40 cases of serious lacerations to the arms and legs that were caused by attempted amputations.

Various accounts are given for how the amputations started. 12 Some accounts suggest that, in their early days, the RUF needed to influence the civilian population; for example, to discourage them from taking in the harvest in a particular area. Amputation of the hands of people who defied their orders would intimidate all the people in an area.

Forms of political intimidation have also been cited. In his election campaign, Ahmad Tejan Kabbah (President of Sierra Leone since 1996) is alleged to have said, "use your hand to vote for me". Many people said that after amputation their hands were put into a bag and the perpetrators said they would send the bag to the president. The practice of amputation across the palm, leaving just the thumb, may derive from a closed-fist thumbs-up sign of another political group, called "One Love".

Initial pain assessment

Murray Town Amputees' Camp in Freetown has been home to 2,000 people, about 140 of whom have lost an arm or hand, and a further 80 have had leg amputations. Together with their families, they have been displaced from their homes by the war. Visited by foreign journalists and VIPs, they have become a symbol of Sierra Leone's troubles; they are famous.

MSF decided to assess chronic pain among the large cohort of arm amputees after the community health officer (a trained primary healthcare provider) confirmed a pain problem.

Interviews were conducted via interpreters who had worked as physiotherapy and prosthetics assistants for Handicap International who witnessed daily the problem of amputees being unable to use prostheses owing to chronic pain. The interpreters were trained in the general characteristics of pain and use of the questionnaire that was used to assess pain. A local nurse explained the patients' information sheet to the study participants, making clear that, at this stage, we were offering nothing in the way of treatment. We wanted amputees' own descriptions of the pain they felt.

During our week of assessment (May 2000) the political and security situations deteriorated. The peace agreement signed in 1999 failed as fighting between all parties was resumed. Conflict was especially intense where United Nations (UN) forces were moving into RUF-controlled areas.

In some rural areas, UN peacekeepers and some non-governmental organisation personnel were kidnapped. Quite quickly over 500 UN troops were captured, their vehicles, weapons, and uniforms were stolen. There was a feeling of anxiety and suppressed panic. Following this, many non-governmental organisations including MSF took the decision to partially evacuate.

Therefore, the pain assessment was hurriedly completed. Nevertheless, 40 questionnaires were gathered (table 1) and examined back in the UK.

These early results showed that many of the amputees were still living with pain. Their amputations had happened between 10 and 48 months previously. The "chop" was with a machete in most cases, or with an axe in some; a few were the result of a bullet wound. We hoped very much that with the deterioration in security a new cohort was not in the making.

All of the 40 people we assessed had stump pain. 13 had phantom pain ( table 1). Both stump and phantom pain were described in ways similar to those in which they are described in other parts of the world. The explanations for the pains were both practical and consistent, the latter probably reflecting the discussion between amputees living closely together inside the camp.

Descriptions of stump pain

Pricking, shocks, nervous, trembles, one point tender

Heavy, drawsThe word "draws" in Krio translates as stretching., can radiate up arm

Bite bite, shocks, runs down arm, easier when he hangs the arm down

Swell up, cry, thunder, bites, made worse by the sun

Scratches, stiff, warm, worse in heat, worse after drinking water

Current, feels like it has been freshly cut

Explanations for stump pain

"Because some of my nerves and veins have been cut off and as a result I am not getting complete blood circulation."

"Sometimes [I] think that because I walk under the sun, which is hot that is why I feel the burning pain. When I get the desire to work with my hands and there is no way for me I then feel the pain"

"I believe it is because the blood is not circulating properly due to the amputation done to my hand"

Descriptions of phantom pain

Numb, vibrates, stiff, like being hit by a stick, hot water, massage and bandage helped

Scratching, warm, a painful scratch

Like something growing bit by bi t-the hand and so it hurts, at the same time the stump shakes

Hot pepper

Warm, pepper, needles

Explanations for phantom pain

"Because I still have the memories of my normal hand in my mind, since I was not born like this"

"Because I still have the memories of this missing part in my brain"

Pain scoring was a central part of the research. In our initial assessment, we had found that a number scale (0 for no pain; 10 for worst pain imaginable) seemed comprehensible, whereas a word scale (none, mild, moderate, severe and extreme) was not understood.

Translations into Krio (a language based on English that is the first or second language of most Sierra Leonians) and other languages were not exact or not available. We subsequently developed word scales for both mood and pain in Krio.