by Lynette Palmer

Working as a Clinician and Medical Director of a private healthcare institution in Sierra Leone over the past 19 years, I’ve experienced, first hand, the many and ongoing public health challenges facing the local population. While there have been some positive outcomes, e.g. a decrease in malaria morbidity, there is an overwhelming host of challenges that still need to be addressed. A key priority among these is environmental health and management.

One of the biggest changes in Freetown over the past ten years has been the exponential population growth, partly a result of displacement and rural-urban migration due to the decade long civil war. As increasing numbers of people moved to the city seeking security, shelter, and livelihood opportunities, (and without any formal support system), they settled in new or existing informal settlements in and around the city, including the hills surrounding Freetown, along the coastline, estuaries, and creeks.

The city’s poor infrastructure, already inadequate before the war, simply couldn’t cope with the increasing population. Since then, the situation has only deteriorated with a large proportion of Freetown’s residents without access to running water, electricity, adequate sanitation, and proper waste management. The Kroo Bay settlement in central Freetown is a good case study highlighting the environmental challenges faced by many of Freetown’s residents.

With an approximate population of about 15,000 residents, Kroo Bay sits at the edge of the Atlantic Ocean and is located at one of the lowest points in the city, on what is essentially a flood plain. The one gutter that intersects central Freetown, known as the Samba gutter, was originally designed to collect rainwater and act as a buffer for storm surges. It empties directly into one side of what is now Kroo Bay.

As well as rainwater, Kroo Bay has become the endpoint for waste disposal from the centre of Freetown and the mountains beyond. Since there is no organised system of waste collection, all the refuse collects in Kroo Bay, until it is eventually washed into the ocean during the rains — a situation that has worsened due to deforestation, soil erosion and water run-off.

The absence of an adequate water supply and sewage system results in the use of the Samba gutter as a means of waste and sewage disposal, and sometimes even an impromptu recreational space used by children. Huge mounds of rubbish deposited daily serve as easy pathways, or short-cuts, and playgrounds for the children of Kroo Bay and nearby neighbourhoods.

This scenario provides the perfect environment for diarrhoeal diseases such as cholera, typhoid, dysentery, and helminthiasis. It is therefore not surprising that children are the hardest hit with the infant and under five mortality rates accounting for the majority of child deaths in such areas. It is important to note that despite a community health centre being located in the heart of Kroo Bay, the infant and child mortality rates continue to be high as the environment itself acts as a vector for the spread of disease.

Other health hazards include pollution from charcoal and firewood leading to respiratory illness, stagnant pools of water and blocked drains become breeding grounds for mosquitoes, uncovered piles of garbage attract flies and rats, which together contribute to the spread of communicable and non-communicable diseases. This clearly demonstrates the relationship between the built environment and public health, and points to the need for urgent action in addressing some of these environmental factors. It’s important to note that these conditions are not limited to the Kroo Bay community alone, but are evident all across greater Freetown.

In my view, we need a cross-sectoral approach that addresses both public health and urban planning simultaneously. From a health standpoint, one of the most significant challenges to long term progress is the lack of a robust public health code, as well as a general failure to ensure that the policies that do exist are effectively implemented.

There is, therefore, an urgent need to develop a functioning public health framework that addresses the needs of the local population and involves experts from different disciplines, including clinicians and public health professionals, environmental engineers, urban planners, and policy makers. As well as funding, capacity development is key to ensuring that trained personnel — such as health inspectors and sanitation officers — are in place to enforce public health code and regulations.

In the absence of a comprehensive master-plan of Freetown, an urban management framework is needed to evaluate existing conditions, create a mechanism for regulating future growth, and ensure that people have access to water, effective waste disposal, and proper sanitation.

Unless we start taking steps now, our environment will increasingly become a public health hazard.