* Any views expressed in this opinion piece are those of the author and not of Thomson Reuters Foundation.
Liberia, with a history of post-traumatic stress disorder due to civil war and the Ebola epidemic, has one practising psychiatrist for its 4.6 million people
Sumah, a vegetable farmer in Liberia, stared out the window of a van enroute to an Ebola Treatment Unit (ETU). Her joints ached. She reached out to hold her husband’s hand, but he wasn’t there. A few days earlier, he had returned home from the farm not feeling well. He had grown progressively weaker, and was taken to the ETU. Sumah was looking forward to seeing him, but her mind was also on her three children at home. She worried they would have to be pulled out of school because she would not be able to pay their fees.
Ebola killed 4,810 Liberians and 1 in every 375 people contracted the virus. The disease left “enlarging circles of victims” – people who faced emotional turmoil due to their loved ones being infected or having died – including 4,500 orphaned children who may still face stigmatization and discrimination. Layers of emotional trauma have taken their toll on people like Sumah, who recovered from the disease but lost her husband.
Post Traumatic Stress Disorder (PTSD) is not a new phenomenon in Liberia. Fourteen years of civil war left the country—and its people—in ruins. According to a study, 44 per cent of adults showed symptoms of PTSD five years after the war ended in 2003.
Despite widespread need, Liberia has one of the worst mental health systems in the world.
In a country of 4.6 million people, there is just a single practicing psychiatrist, several dozen mental health nurses and approximately 100 trained paraprofessionals, like thirty-two year old Aaron Debah, who assess and manage common mental disorders. To put these numbers in perspective, there are 2,582 mental health outpatient facilities in the UK – a rate of 4.94 for every 100,000 people. How can Liberians get support for the psychological implications of trauma with so few resources available to them?
LACK OF SKILLED PROFESSIONALS
The country must examine its approach to mental illness and address the psychological damage that Ebola left in its wake. Donors, multilaterals, and implementers must prioritize support for victims if Liberia, and its people, are ever to recover. The international community and the Liberian government need to outline an agenda and commit resources to make mental illness treatment available for those who need it.
The Carter Center helped the Liberian government draft their first mental health law, which protects and promotes the human rights of people with mental illnesses and provides a policy platform for future work. The bill states, “ the lack of skilled mental health professionals in Liberia cannot be overstated.
The services outlined in this policy will be ineffective and futile unless providers can accurately diagnose, evaluate and treat mental disorders, and appropriately respond to the psychological and psychosocial needs of the population.”
Although the government has made progress by creating a strategic plan for mental health, and President Sirleaf has asked the legislature to pass the bill, it remains unapproved. Dr. Janice Cooper from the Carter Center’s Mental Health Initiative said “certain things cannot be done by us for persons with mental disorders in the absence of the passage of the mental health legislation.”
The trauma that accompanies a crisis is felt at a community level, and so too must the response. Community-based and community-led interventions have an enormous impact and allow for those most affected to shape the solutions. These approaches can also be highly cost-effective, group-based therapy has been shown to improve mental health outcomes in low-resource settings. While only the government can reach national scale, given the extent to which Ebola has ravaged the country, non-government actors should step up their efforts to assist the Liberian government and help those suffering gain access to basic services. With non-governmental actors and the government working together, hope can indeed be kept alive.
“The people refused me that I should not be in their town because I had the virus,” said an anonymous survivor in Bong County. “I left from there.”
BRAC, has worked in Liberia since 2008 and now reaches approximately half a million people. In communities where BRAC works, Ebola left children orphaned, and survivors were treated with fear and hostility when they returned home.
In January 2015 in collaboration with the Ministry of Health and WHO, BRAC launched a psychosocial project funded by USAID who recognize the deficit in, and urgent need for, mental health care and committed extensive funding. BRAC made use of its vast community network and knowledge of working in the remote villages in Liberia, to facilitate reintegration of survivors back into their communities, support Ebola orphans and educate the community about the risks posed by Ebola survivors.
The project built on the capacity of government mental health clinicians, social workers, BRAC staff, and Ebola survivors to provide psychological first aid and support to the community. Group and individual counselling gave survivors and orphans the chance to share experiences and adopt coping strategies and skills. The aim was to improve the community’s attitudes and perceptions about Ebola survivors and to educate affected communities about the risks presented.
After completing her treatment for Ebola, Sumah was trained to deliver psychological first aid, which reduces the symptoms of stress, builds resilience following a traumatic event, and assists in a healthy recovery. Working with people suffering in the community helped Sumah improve her own self-esteem and start to recover from her trauma. She got a financial incentive for her volunteer work and started a business selling oil, which was more profitable than selling vegetables. Sumah is using the money to send one of her children back to school.
“In my community here, I can say now I am not stigmatized,” said one anonymous survivor in Grand Bassa county who participated in BRAC’s programme. “I sell small at community market and people coming around me the same way it was before coming down with the virus, and buy it.”
Sensitization and counselling provided during the post Ebola period let to community acceptance. A community leader in Boe, Nimba commented, “they used to be afraid of them but because of our counselling with the family along with community dwellers, the community willingly accepts these survivors and their families and their children usually play and go to the same school.”
Results of BRAC’s monitoring support the community leader’s claim; 67 per cent of survivors had attended a social gathering, a party, or a wedding ceremony and 61 per cent mentioned engagement in civic matters. The psychological first aid programme showed a marked improvement in society’s acceptance of the individuals whose lives, in one way or another, were scarred by Ebola.
However, a significant amount remains to be done: 60 per cent of survivors and 42 per cent of orphans experience anxiety that hampers their daily activities. Some have developed coping mechanisms while others refuse to eat or, cry frequently.
“When I go to bed, sleep just cut from my eyes and I think, why,” said an anonymous survivor in Grand Bassa County.
POVERTY HAMPERS RECOVERY
How a person reacts to a crisis situation depends, amongst other things, on the nature and severity of the event, their experience with previous distressing events, their physical health and most crucially, the support they have from others.
Lund and Breen, 2010, found that in 73 to 79 per cent of the 115 studies they examined, there is an association between poverty and mental disorders; the poorer an individual is, the greater the chance that they experience a common mental disorder. A lack of education makes people most susceptible. In countries like Liberia—places that have witnessed considerable trauma and face pervasive poverty—efforts mitigating the psychiatric effects of a crisis such as Ebola are crucial.
A recent study by the Overseas Development Institute suggests mental health policy needs to be re-framed – mental health should not be seen as the responsibility of the afflicted individual, but rather as society’s responsibility to create health systems that work.
The WHO has advised categorizing people with mental conditions as its own vulnerable population, separate from the current broad classification of ‘people with disabilities’. This would make them eligible for targeted development aid, which can help respond to their specific needs. This is an important first step, but must be followed by a broader call to action. Governments, funders and iNGOs must step up and make mental health a priority. We cannot afford to be silent during a crisis, nor in its aftermath.
Tarini Mohan is program adviser at BRAC USA and a native of New Delhi, India. Her work focuses on fundraising for the agriculture program in sub-Saharan Africa, for which she assists in proposal writing. Tarini also works on fundraising for a range of BRAC programs, including BRAC’s Ebola response and road safety. She joined BRAC Uganda as a volunteer in 2010 and became a part-time employee in March 2014.