Searching for Normal in the Wake of the Liberian War. Sharon Alane Abramowitz
of the entire health sector. When UNMIL assumed authority in Liberia at the end of 2003, all that remained of the MOHSW was the crumbling edifice of a building on Capital Bypass Road in Monrovia, a gutted national infrastructure of clinics and hospitals, thousands of emigrated or displaced medical professionals, and a backlog of salaries that had not been paid in years. The ministry’s main assets—its health clinics—had been stripped of their wiring, roofs, benches, doors, and sinks, as well as all medications, equipment, and supplies. Humanitarian medical organizations sent staff and supplies to JFK Hospital to keep it running, and health care across the country was administered by a patchwork quilt of medical humanitarian NGOs. Even after UNMIL’s quick restoration of the MOHSW with a fresh coat of white paint with blue trim, generators, vehicles, and a few computers, the MOHSW still confronted a significant labor crisis. Its “human assets,” medical professionals, had found employment as “volunteers,” social workers, counselors, translators, logisticians, or educators with humanitarian NGOs. There were legal and administrative barriers to hiring new medical staff, and many Liberian health workers preferred to work for NGOs, where materials, medicines, salaries, and physical security were somewhat assured. This would have implications for the debates around the professionalization of mental health services in just a few years’ time.
Psychiatric care, like the rest of the medical sector, was in a state of collapse. The Katherine Mills Rehabilitation Institute had been completely destroyed during the war (see Figures 1–3) and transformed into a squatter settlement for 250 people. The WHO Mental Health Atlas noted in 2005 that Liberia lacked all of the following: epidemiological data, a mental health policy, a substance abuse policy, a national mental health program, mental health legislation, mental health financing, and mental health facilities. Serious mental illnesses were managed in alternative spheres like churches and mosques, among traditional healers, and within families and communities. Epilepsy and madness were explained with reference to witchcraft and sorcery by all of Liberia’s tribal and ethnic groups.
By 2003, trauma-healing activities had been under way in Liberia for nearly a decade, and Liberian NGO workers told me that mental health and psychosocial interventions were being widely questioned. Phalanxes of international experts again descended upon Monrovia to conduct short-term (four-day to two-week) trauma training sessions. Liberians noted that vast sums of money seemed to be spent on these trainings, and on the salaries of psychosocial workers who were purportedly trying to meet recruitment quotas. Intensive trauma counseling was giving way to more cost-effective “community-based ownership” models, or TOT approaches, which could shallowly capture a wide audience, and did not require long-term investments in treating serious mental illnesses or psychosocial disorders. Therefore, the flurry of activity around trauma-counseling TOT consultants and DDRR ex-combatant rehabilitation kept trauma-healing and psychosocial intervention locally relevant, while donors continued to share the sentiment that mental health was “not a priority.”
The biggest site of expenditure on mental health was in the DDRR process, where for approximately eighteen to twenty-four months, monies flowed freely. From the outset, UNMIL, the U.S. government, and the NTGL had committed rhetoric and financing to psychiatric assessment and psychosocial interventions for demobilizing combatants in the cantonment sites, to education programs, and to job retraining projects that they sponsored from 2003 to 2006 (see Richards 2005).
Despite the fact that international donors knew that the Liberian state could not possibly assume responsibility for mental health or psychiatric care, it left ambiguous the locus of authority for psychiatric interventions, trauma-healing programs, and psychosocial activities. Within the DDRR process, the WHO sought to have a supervisory role over the health—and the mental health—components of demobilization. It tried to recruit Dr. Grant, then known as “the Liberian Psychiatrist,” to participate in the WHO DDRR Project, and to lead mental illness diagnosis efforts among the more than one hundred thousand ex-combatants who were contained at the many dispersed cantonment sites for disarmament and demobilization. Although the WHO was quite keen to have a Liberian psychiatrist involved, Dr. Grant died just before DDRR, and his position was left empty. A WHO report commented,
In the initial agreement it was contemplated to have a total of six staffs, two national medical coordinators instead of one and a national psychiatrist specialist. For the first phase of the process we reviewed the question and agreed upon the need of just one national doctor, but for the mental health component it was a different situation. The director of the Monrovia Psychiatric Hospital was contacted by WHO to be in charge of the mental health part of the programme, but unfortunately passed away some days before the start of the DDRR process. It was impossible to find a reliable national candidate to do the work and finally, mid September, an international psychiatrist was engaged, but at that time the demobilization exercise was in a very advanced status and almost close to an end. This lack of a specialist could have biased our findings regarding mental diseases. (Larrauri 2004, 15)
Despite the fact that there was no diagnostician present to identify serious mental illness among the ex-combatant population, the WHO reported,
Regarding the group of ex-combatants suffering of mental disabilities, it was true that no psychotic diseases (schizophrenia, paranoia) were seen at the cantonment sites and just some minor signs of neurosis (anxiety, aggressiveness) were detected. The suspicion for these last ones was the lack of cannabis (marihuana) but due to the fact of not having an appropriate mental health specialist working with us we could not make any conclusion regarding the prevalence of traumatic reactions. Some few cases of epilepsy were identified. (Larrauri 2004, 42–43)
Without any Liberian psychiatric expertise readily available, the two bureaucracies overseeing DDRR, UNMIL’s Joint Implementation Unit and USAID, redirected their attention away from psychiatry and back towards trauma-healing and psychosocial rehabilitation. They issued a rapid call for proposals from any Liberian organization that could do trauma-healing work with ex-combatants in the cantonment sites, and they promised full financing. Suddenly, thousands of Liberians living in Liberia in 2003 were transformed into local experts on trauma, ex-combatant demobilization, and psychosocial recovery. Within weeks, nearly everyone, everywhere, had posted a shingle advertising themselves as local Liberian NGOs providing mental health services, trauma healing, counseling, and psychosocial rehabilitation. Nearly one thousand Liberian NGOs registered themselves with UNMIL’s Humanitarian Information Center, with several hundred expressing an intent to provide psychosocial care, trauma healing, and rehabilitation, and several dozen having specifically listing the word “trauma” in their organization titles. After surviving the competitive bidding that drove the NGO selection process for DDRR contracts, many of these Liberian NGOs fell victim to financial mismanagement, ran afoul of Liberian government regulations, or were physically chased out of the cantonment sites by former soldiers who were enraged over demobilization payments or were in the throes of drug detoxification.
How did the mental health component of DDRR come to be characterized by inefficiency, a lack of expertise and oversight, and ineptitude? Funding—specifically, the low prioritization of mental health needs—seems to have been an issue. NGO leaders and donors told me that they regarded psychiatric care as a secondary issue relative to urgent humanitarian concerns like securitization, water sanitation, primary health care, and rebuilding government capacity. Medical humanitarian organization directors presumed that treating serious mental illnesses like schizophrenia, drug addiction, post-traumatic stress disorder, and major depression was prohibitively expensive, would take too long, and demanded complex medication and patient surveillance protocols. Patients were unlikely to recover quickly, psychiatric consultants were expensive and difficult to recruit for humanitarian aid work, and long-term health care was largely seen as the responsibility of the state. Donor institutions reminded me that they wanted to avoid committing to forms of aid that could not be sustained beyond the postconflict transition. International NGO headquarters were reluctant to invest in Liberian mental health for unstated reasons—the recent critiques of trauma-healing interventions in postconflict settings (see Summerfield 1996, 1999; Bracken, Giller, and Summerfield 1997, Bracken, Petty, and Save the Children Fund 1998) may have cast doubt on the legitimacy of psychiatric interventions in postconflict African contexts.