in Freetown. Simon Townsley Photographer 6:00am BST ormented by pain from severe internal burns, Amza Kebbie is one of thousands of children in Sierra Leone damaged for life by an aid intervention which went horribly wrong.

It has been five days since the four-year-old boy drank caustic soda, one of the two main ingredients for making soap, after mistaking it for drinking water. The highly corrosive liquid, also known as sodium hydroxide, has stripped the lining of his oesophagus and part of his stomach, causing life changing damage.

He’s now in intensive care, clinging precariously to life. An intravenous drip provides fluids and there’s a nasal cannula that enables him to breathe. Medics and relatives look over him around the clock.

If he can gather enough strength (which the nurses say is by no means guaranteed) the dangerously sick child will undergo a gastrostomy, an operation that will see a tube directly inserted into his stomach so that he can be fed long term.

Amza drank caustic soda while being looked after by a neighbour who was making soap at home Credit The Telegraph/SImon Townsley He can no longer swallow properly and may never be able to do so again, say his doctors.

This is not an isolated tragedy. Across Sierra Leone, there are thousands of children like Amza, and their number is growing every year.

At the Goderich Surgical Centre in the capital Freetown, around 200 children are admitted annually with caustic soda poisoning. Many more are thought to die in remote regions where emergency medical treatment is unavailable.

Behind the calamity is a humanitarian initiative that has spectacularly backfired. It’s a prime example of the law of unintended consequences; of a seemingly sensible and undoubtedly well meaning public health intervention doing more harm than good.

Fatmata Kamara accidentally drank caustic soda at her grandmother’s house in 2014 and has had a feeding tube ever since The story starts in the aftermath of Sierra Leone’s vicious civil war, which ran between 1991 and 2002.

Fought between the government and the Revolutionary United Front – backed by Liberian warlord Charles Taylor – the war claimed an estimated 50,000 to 70,000 lives, displaced 2.5 million people and left the country brutalised and in ruins.

In its aftermath, international aid agencies and NGOs desperately sought ways to revive the country and alighted on DIY soap making as a way of killing two birds with one stone.

Siblings Aminata Fofana and Salieu Bangura help out with the family soap-making business Organisations including UNHCR, UNICEF and World Vision thought the practice would both improve sanitation in the country’s disease-ridden shanty towns and provide home-bound women with the means to earn a sustainable income.

It seemed like an obvious “win-win”, and schemes to help women set up in the soap making business rapidly proliferated.

nual report by the International Federation of the Red Cross, published in May 2002, promoted a micro-finance scheme to fund small-scale soapmaking.

Saieu Bangura, 13, with a tub of soap flakes In 2005, the Centre for War Affected Women in Sierra Leone’s Kono district, backed by the UNHCR, listed soap making as one of the main training courses for war widows and female amputees.

And at about the same time, the Freetown-based Safer Future Youth Development Programme, supported by UNICEF and the charity War Child, provided “a tool kit for soap production” at its training workshops.

As recently as 2020, Action Aid ran a promotional article on its Sierra Leone website showing how soap making had enabled women to become financially independent of their husbands.

The article ran under the headline: “With Soap Making Skills – I'm Empowered!”Mabinty Bangura is taken to theatre for an endoscopy It is for good reason that the ancient Greek physician Hippocrates urged doctors “first, do no harm”.

To follow the rule literally is not possible as all health interventions entail some risk but it's a reminder never to underestimate the capacity of a new intervention to backfire. There are plenty of examples from history to choose from.

During the British Raj in India, the government offered a cash bounty for every dead cobra as a way of reducing the danger of venomous snakes.

The surgical team examine the internal damage via an endoscopy But rather than leading to a decline in snake numbers, the plan resulted in entrepreneurial individuals breeding cobras just so they could kill them and then claim the reward.

Once officials realised what was happening and the scheme was stopped, thousands of the then worthless cobras were released into the wild, greatly increasing the risk of snakebite.

In the late 1950s, the Chinese Communist regime introduced an equally calamitous public health campaign involving sparrows.

They issued a directive ordering the birds to be destroyed because they were thought to spread disease and destroy crops.

A child’s gastrostomy scar with a feeding tube in place What those behind the idea failed to consider was that sparrows are natural predators. As their numbers declined, the locust population exploded, decimating agriculture and contributing to the Great Chinese Famine in which millions died.

So what went wrong in Sierra Leone? What did those behind the soap making scheme fail to foresee?

Experts say the initiative simply failed to consider the danger inherent in encouraging people to use toxic chemicals in their homes.

The brightly coloured buckets in which caustic soda is made, and then mixed with oil and scent to make soap, are the same buckets used across the country to fetch and hold drinking water. And just like drinking water, the lethal solution is cool, clear and inviting.

Just a drop is enough to cause the most horrific burns. So when a thirsty young child like Amza runs in from play and mistakenly scoops up a cup of it to quench their thirst they will lose their oesophagus, if not their lives.

Giuseppe Meucci, chief surgeon at the Goderich Surgical Centre Giuseppe Meucci, chief surgeon at the 56-bed Goderich hospital in Freetown where four year old Amza is being cared for, has been treating patients burned by sodium hydroxide nearly every day since arriving in Freetown in 2019.

Three quarters of patients seen by the hospital’s specialist programme for oesophageal burns, set up in response to the crisis and run by the Italian medical charity Emergency, are under five. “It’s a struggle in this country,” says Dr Meucci.

“Almost every family knows someone who has suffered because of this problem. But they just keep coming.”Hospital director Jasna Sundic“In most countries you remove the source of danger for the child, but here that doesn’t seem to happen,” he says. “It’s one of the main health problems of this country. Soda is there with malaria, malnutrition and typhoid complications. It’s one of the reasons why so many children die before they reach five years old.”

“This is a very severe issue but one which is very preventable,” she tells the Telegraph. “[But] however much we do here, we have not been able to decrease the overall number of soda patients being admitted. “We cannot stop mothers who have no other source of income except making soap.”Ibrahim Kerah is fed by his father Mohamed In a handful of rare cases, burns victims are sent abroad for complex oesophageal reconstruction surgery but this is not an option for the vast majority of children injured in Sierra Leone. More than 60 per cent require surgery, but for these children, like Amza, a feeding tube that bypasses the oesophagus is the only option.

The hospital has many of these gastrostomy patients. Critically underweight Mabinty Bangura In a ward dedicated to soda burns, four-year-old Ibrahim Kerah is being fed through his stomach tube by his father Mohamed.

They travelled together on the back of a motorbike taxi for nearly 10 hours to get here for his third check-up appointment.

The Telegraph watches as Mohamed carefully prepares his son’s meal, adding spinach leaves to the porridge-like mix which is fed into a syringe at the end of the tube.

At an adjoining bed two-year-old Mabinty Bangura is critically underweight after ingesting soda about six months ago. Nurses have put her on a high protein drip so she can regain enough strength to undergo the same bypass surgery.

In the courtyard outside, mothers whose children have just had a gastrostomy are being taught how to prepare the liquid food.

Ibrahim and his father Mohamed endured a 10-hour motorbike journey to attend his hospital check-up Isatu Alie, 24, has been living with a stomach tube for 12 years, and now works for Emergency as a patient ambassador.

She is eight months pregnant with her second child and proud to have overcome her injury and the stigma of having to feed through a tube.

“I remember what happened so well,” she says. “I had just got back from school. I took my cup and dunked it into the water bucket. My aunt made soap and, on that day, I didn’t ask about the liquid in the bucket. The pain was incredible”. More than a decade has passed since her surgery, and Isatu has adjusted well. “I’m okay with it now. I feel like a normal human being; I’m blessed to be here,” she says.

“Now I speak to children and their parents who have just experienced the same thing and tell them not to lose hope.”Pregnant Isatu Alie now works as a patient ambassador A small proportion of the patients needing treatment following caustic soda burns are adults.

Among them is 21-year-old Junisa Bundeh, who is on a follow-up visit to check his stomach tube. He explains that he gulped down what he thought was a cup of water from a basin while eating at his grandmother’s house three months ago.

“It was so painful,” recalls Junisa. “I realised what it was straight away because it was so harsh. I tried to spit it all out but the liquid was already going down my throat.”Mothers are taught how to prepare liquid food; Junisa Bundeh shows his feeding tube In the muddy lanes of Freetown’s Waterloo district there are makeshift soap making operations all over. The coloured plastic buckets full of either soda or water are everywhere.

Against the backdrop of the rainy season’s persistent gloom, the containers symbolise a measure of cleanliness for families sheltering from torrential downpours under mouldy concrete awnings.

As the Telegraph watches Yabom Kapro, a village elder, making soap, the risks involved are immediately obvious.

Chief Yabom Kapro makes soap at her Waterloo town home, near Freetown As she tips a purple bucket of caustic soda solution into a large basin and then adds palm oil from a plastic jerrycan, local children hover round the cluster of colourful containers.

Yabom uses a wooden paddle to stir the mixture into a creamy paste and then pours it into a mould held in place by an old motorcycle tyre.

Buckets containing caustic soda dissolving, top. Caustic soda crystals, below Once set, the beige-coloured cake of soap is cut into blocks which are then grated on a wire mesh contraption to be sold at the local market.

“When you dilute the caustic soda, it is completely clear like water at first,” says another soap maker, 43-year-old Cilina Bangura.

“Afterwards a white scum forms on the top, but you cannot be watching all of the time, [even] with all of these children around.”Cilina knows the risks but says she can't afford to stop making soap. It has, as the NGOs intended, become an economic lifeline for her and her family.

“I want my children to continue making soap when I stop working,” she says. “I took out a loan to buy everything I needed, and now it is the only way I can make a living.

“Of course, I know how dangerous soda is – it has burned my skin many times – but I don’t have another option.”Home-made soap, in Waterloo Maimunatu Sankoh, three, whose family lives in a nearby tin-roof shack, is sadly too well aware of that danger from her own bitter experience of soda poisoning.

As she feeds her daughter through a stomach tube, Maimunatu’s mum Iyesatu complains: “I have never seen any public information about soda.

“There are warnings on the packets but that is no use once the product is dissolved in water. They need to tell people to keep buckets out of the way.”Iyesatu Kamara feeds her daughter Maimunatu Sankoh at their home Incidents of children consuming harmful chemicals are not confined to developing countries and were once common in the west.

In the US, the Poison Prevention Packaging Act was introduced in 1970, mandating childproof containers and the labelling of harmful household products.

The UK followed suit in 1975 with the introduction of child-resistant safety caps on containers of caustic soda and most other noxious household substances.

Despite the risks, Cilina says she can't afford to stop making soap Such legislation is still a long way off in Sierra Leone and is anyway far too late for four-year-old Amza. Under heavy sedation in the intensive care unit, his glazed eyes open only occasionally.

The only visible evidence of his injuries is some scarring on his lips, but the doctors say his throat, oesophagus and stomach have all been seared by several large gulps of soda.

The boy’s mother, Mamie Kebbie, 30, keeps a watchful vigil, stroking his listless head tenderly. She says he used to be a playful and vivacious child.

If they are taken to hospital quickly, children with soda burns are normally given an oesophageal dilation endoscopy – a procedure which aims to keep the oesophagus open – but for Amza this has not been possible.

Freetown, Sierra Leone“This is a very severe case,” explains nurse Annette Turay, who heads the hospital’s intensive care unit. “When he was brought in, about 10 hours after he had ingested the soda, we were unable to conduct an endoscopy because he already had respiratory problems. “He has pneumonia and he cannot feed through his mouth. He cannot even swallow his own saliva.

Mamie Kebbie keeps a vigil at her son's bedside“It will be a week before he is strong enough for us to be able to operate. We will insert a gastric tube into his stomach. He will have to keep this as his main way of being fed for a long time, potentially forever.”But nurse Turay has seen worse. “I have seen so many children suffering a lot after ingesting soda, so many dying too. “A few weeks ago, we had a child in the ward who died because his stomach was completely gone”.

The Telegraph contacted all the NGOs involved in the setting up of and promotion of soap making schemes in Sierra Leone that are mentioned in this story for comment. Protect yourself and your family by learning more about Global Health Security