Читать книгу Searching for Normal in the Wake of the Liberian War - Sharon Alane Abramowitz - Страница 10
ОглавлениеChapter 2
Clusters, Coordination, and Health Sector Transitions
Orientations
In September 2006, I climbed up and down the back staircases of the World Health Organization (WHO) in Monrovia after receiving a referral from UNHCR. I was looking for the authorities responsible for managing the implementation of trauma-healing and mental health services in Liberia, but at the senior levels of the WHO’s country offices, the Ministry of Health and Social Welfare (MOHSW), and the few professional offices of psychiatry and psychology, no one wanted to talk to me. I was lost, embarrassed, and worried that someone was going to notice me and kick me out of the building. After hundreds of efforts to request audience with the various leaders reported to be involved in Liberia’s mental health coordination, I was at an impasse.
Soon, two Indian GIS experts who worked for UNMIL helped me find my way to the appropriate office, and I noted the striking difference between the UNHCR’s offices and the WHO’s offices. During my interviews with UNHCR officers, I was seated in a spacious, clean, blue-carpeted and white-walled office with intense air-conditioning; while at the WHO, the office of the Liberian staffer responsible for mental health was dim, narrow, and covered with papers and news clippings, and it was stiflingly dank and humid. The spatial metaphor was apparent: in on-the-ground humanitarian action, how services were prioritized translated directly into space, manpower, technological sophistication, and public access. Mental health received far less attention than the tremendous movement of refugees and internally displaced persons in 2006, but oddly, UNHCR officials argued that mental health interventions were key to the postconflict recovery, while WHO officers contended that it was “not a priority.”
When I arrived in Liberia to conduct my research, I broadly wanted to understand the relationship between individual trauma and collective trauma in Liberia’s postconflict recovery. Just a few years before, I had spent two years (2000–2002) as a Peace Corps volunteer in the northern Korhogo region of neighboring Côte d’Ivoire, where I stood by as a witness to a republic in crisis while its populace talked itself into civil war. Prior to that, I had worked in domestic violence, rape crisis, and transitional residence programs for women and abused teenage girls in the United States. From these experiences, I became intellectually concerned with the empirical linkages between collective trauma and individual trauma, and with questions of survivorship, recovery, and reconstruction. With my newfound understanding of violence as a process of social change that took peaceful social spaces and opened possibilities for violent social action, I wondered how a country could reverse this process and, in effect, talk itself out of war and into a new form of social experience—postwar peace.
More intimately, my interest in this research emerged from my own inheritance of intergenerational trauma from Jewish parents, grandparents, and great-grandparents who had fled from pogroms, hid from Hitler, struggled under postwar anti-Semitism, rejected Israeli citizenship, and built a life in America, the new world. I wanted to understand how it was possible to rebuild a life, a people, and a nation after undergoing some of the worst crimes against humanity modernity could offer. Liberia gave me a path to gain insight into the road my family had taken. Trauma, to me, meant more than suffering. It meant managing suffering while making choices, planning for the future, struggling with the present, and holding on to the redemptive possibilities of hard work, hope, and renewal. Thinking of my grandparents, I had the sense that recovery from trauma had little to do with healing or therapy; it happened after fifty years, at the end of a family dining room table covered with food, when the survivors looked out protectively over three generations of descendants. Recovery meant autobiography, and even at the end of survivors’ lives, it was never complete.
My plan had been to act as a participant-observer of one humanitarian NGO’s mental health, trauma-healing, and psychosocial projects to study how Liberians understood their own experiences of war and reconstruction, and to examine how Liberian and humanitarian understandings worked themselves out in humanitarian practice. But soon after I arrived in Liberia, I learned that my contact, a Norwegian program officer, had left the country for six months. No one knew how to get in touch with her. The NGO was totally unprepared for my arrival, and it was utterly uninterested in hosting me. That plan was no longer an option.
As an anthropologist, the political economy of life in Monrovia made the management of basic needs nearly impossible. Living on a fixed stipend from a research grant, I found that rents in Monrovia were as high as rents in London, Tokyo, and San Francisco. My mobility and housing options were severely constrained by my gender and my lack of affiliation with a humanitarian organization. Consequently, I relocated eight times during my year of fieldwork: I shared dim apartments behind barbed-wire-covered walls, hotel rooms, short-term local housing under the constant surveillance of bandits, and I was secretly offered couches in friends’ embassy compound apartments, UNMIL bases, and NGO guest houses. Leaving my various residences on foot, I was routinely physically assaulted, verbally abused, or threatened, like many of the Liberians around me.
Directions
In order to get started, I called the only friend I had in the country, a consultant for UNMIL and the United Nations Children’s Fund (UNICEF), who set me up with a place to live and a general sense of the geography of the capital. With her help, I conducted an institutional inventory of international and local NGOs that reported having provided mental health and psychosocial interventions in their international media literature, marketing materials, and on their websites. Although NGOs often reported on the activities that they classified as psychosocial: ex-combatant education and retraining, GBV counseling, psychosocial curricula for elementary schools, civil society training, and human rights training, by 2006, most NGOs had ceased mental health and trauma-healing activities, and were intensely averse to providing financial, labor, or logistical support for mental health or psychiatric services. Few organizations were willing to claim any explicit involvement in mental health, and most took pains to separate themselves from those activities in situ, “on the ground.” Instead, in interviews, expatriate and Liberian NGO workers repeatedly used the phrase “destroyed human capacity” interchangeably with the word “trauma” in order to evoke a summary of the total human destruction wrought by the Liberian war.
To follow the meaning of psychosocial intervention in Liberia’s postconflict reconstruction, my research gradually expanded from interventions that could narrowly be defined as mental health and psychosocial to a consideration of any program or action that was classified, by anyone, as “mental health” or “psychosocial.” My emerging ambition was to study mental health and psychosocial intervention in a multiscalar and processual way, using a multisited ethnographic approach (Falzon 2009; Hannerz 2003). I first sought to examine the implementation and governance of mental health and psychosocial interventions vertically, from global and national decision makers, to Liberian and expatriate psychosocial and mental health workers, to Liberian program beneficiaries, and to Liberians who were excluded from psychosocial interventions (Marcus 1995). I also sought to examine mental health and psychosocial interventions cross-sectionally by looking at the experience of humanitarian/local interactions around psychosocial intervention at the point of their convergence in daily life.
The goal of this chapter is to contextualize the mental health and psychosocial interventions described in the remainder of this book in the prewar, wartime, and postconflict histories of Liberian mental health, trauma-healing, and psychosocial rehabilitation. Therefore, the primary task of this chapter is to write a “history of the present” for Liberian mental health in order to provide a framework for understanding the postconflict paradigm that emerged after 2003 by following the discontinuities, conflicts, and uncertain progress toward the creation of a Liberian national mental health policy, a WHO priority for national mental health systems. As the processes of humanitarian coordination, prioritization, and distribution of resources unfolded, they revealed the uncertainties and ambiguities of the postconflict moment. These processes were rooted in a dynamic of global-local engagement that was fractious, complicated, and bidirectional, and always filled with a sense of unknown ends (see Chapter 4).
In the data collected for this chapter, nearly all of the historical material from the era before 2004 is the result of archival work, retrospective interviews, and publicly available NGO documentation (also known as the gray literature). In contrast, nearly all of the material post-2005 is based on participant observation, key informant interviews, and a careful process of cross-validating informants’ accounts with NGO, local informant, documentary, and international sources. This process of tracking down the “living history” of humanitarian implementation was a side pursuit to my multisited ethnographic fieldwork, in which I tracked mental health, psychosocial, and trauma-healing interventions in clinics, hospitals, NGO offices, government ministries, shantytowns, rural villages, and UN bases. My research transected four counties in Liberia (Montserrado, Bong, Lofa, and Nimba), and in them, I tracked patients with mental illness from clinics to hospitals; studied the financial and physical flows of aid from the capital to the country’s “most-affected areas” (Nimba, Bong, and Lofa counties); and followed the movement of mental health workers through their various assignments. I tracked the movement of policy documents through institutional hands, the gradual expansion of safe space, the availability of over-the-counter psychoactive medications from local markets to urban ghettos, and the usage of psychiatric medications inside and outside of mental health facilities. In my characterization of “the psychosocial” as a nonhuman actor that has agency, yields symbolic, interactional, and material effects, and creates logics of momentum, expertise, and resources in the decentralized, deinstitutionalized, and heterogeneous context of Liberia’s postwar humanitarian world, I owe a considerable debt to the work of Bruno Latour, and to actor-network theorists (Callon 1991; Callon and Law 1997; Latour 2005; Law 1992; Law and Hussard 1999).
My movement through Liberian mental health, trauma-healing, and psychosocial work has been shaped by intuition, by access, and by my understanding of the concept of “the interventionscape” (Abramowitz and Benton 2005) as a nexus of complex, chaotic, deterritorialized humanitarian institutional interactions and global processes (see also Appadurai 1996) that constitute the culturally distinctive domain of “networked interaction” (Hall et al. 2001; see also Duffield 2001 on global governance) we have come to think of as humanitarian intervention. Across the interventionscape, flows of resources, personnel, bureaucratic protocols, administrative practices, financial mechanisms, and ethical guidelines shape the space of mental health, trauma-healing, and psychosocial intervention in the unique Liberian postconflict landscape and give it its meaning, form, and impact. I entered the theater of mental health intervention through interviews or fieldwork visits with prominent agencies in Liberian mental health like the Center for Victims of Torture ([CVT] a U.S.-based NGO), Cap Anamur (a German emergency medical NGO developed on the model of Médecins Sans Frontières [MSF]), and Médecins du Monde ([MDM] a French medical NGO), through Liberian institutions like the Ministry of Health and Social Welfare (MOHSW) and the Mother Patern College of Nursing and Social Work, through expatriate psychiatrists, consultants, and aid workers, and through Liberian psychiatrists, psychologists, mental health social workers, psychiatric nurses, gender-based violence advocates, trauma healers, and psychosocial workers.
Figure 1. Katherine Mills Hospital. Photo by author.
1994–2003: Postconflict Mental Health
During Liberia’s prewar existence, the country’s mental health infrastructure resembled that of many other sub-Saharan African countries. Formal mental health care in the nation’s capital often meant psychiatric hospitalization, while traditional mental health care in urban and rural areas often meant herbalists, witchcraft or sorcery trials, traditional medicine treatments, or fairly primitive methods of physical containment, using chains, ropes, or blocks of wood as anchors or foottraps. There was one center of modern psychiatric care in the national capital, the large, modern Katherine Mills Rehabilitation Institute in Monrovia, which was part of the Monrovia-based John F. Kennedy (JFK) Hospital system.1 There was also a small, private, in-patient psychiatric hospital called Grant Hospital, owned and managed by Dr. Edward S. Grant. The hospital had a forty-bed capacity and was adequately furnished in a limited sense; it had dormitory rooms, a kitchen, outdoor and indoor recreational areas, and a medical dispensary.
Between 1994 and 1997, as Liberia’s health infrastructure crumbled under the weight of civil war, the international community made its first foray into managing trauma in Liberia and into surrounding refugee sites in Sierra Leone, Côte d’Ivoire, Ghana, and Guinea. These early psychosocial interventions, then conceived of as trauma healing, ex-combatant demobilization, and psychosocial stabilization, were seen as novel, legitimate, and necessary. In Liberia, the WHO and the Lutheran World Federation/World Service (LWF/WS) were leaders in trauma management. The WHO provided short-term support for technical guidance, hired consultants to run trauma-healing training sessions, and oversaw pilot projects in ex-combatant rehabilitation. In contrast, the LWF/WS Trauma Healing Program built a large, community-based trauma-counseling program that operated continuously during the war, and developed a positive reputation across Liberia. Neither set of interventions were monitored or evaluated, and their efficacy remains unknown.
Figure 2. Entry, Katherine Mills Hospital. Photo by author.
Figure 3. Main gate, E. S. Grant Hospital. Photo by author.
Both the WHO and the LWF/WS oriented their psychosocial education to “scale,” targeting communities and groups rather than individual mental health counseling or treatment. Both also espoused a “training-of-trainers” (TOT) model meant to promote the sustainable dissemination of psychosocial knowledge. In the TOT model, short-term topical training sessions were offered to Liberian participants, who were then encouraged to go into their communities as local trainers, or health educators, and share their findings about trauma and mental health. But the LWF/WS’s long-term presence in Liberia and its rapid shift from an expatriate staff to a local Liberian staff seemed to have the effect of “indigenizing” the program, giving it a quality of local ownership that WHO initiatives seemed to lack. The LWF/WS program repeated training sessions in communities, had a long-term relationship with communities, and often spent the night in those communities. In the quiet night hours, after the official end of the training day, trainers would provide individual counseling to community residents. They also ran “after-hours” women’s encounter sessions where women recounted experiences of rape, or of sending family members to war. Eventually the LWF/WS shifted its training materials’ emphasis on PTSD theory and basic counseling skills to the meaning of trauma, to local problems like drug addiction and “human brokenness,” to the meaning of violence and the war, and to the meaning of the postconflict period. WHO materials never followed suit and instead upheld the priorities set by international consultants and elite Liberian psychiatrists and psychologists, such as HIV/AIDS and conflict management (see Table 3). But even with the local sensitivity exhibited by LWF/WS trauma-healing activities, by the end of the war, communities and trainers alike were growing tired of talking about violence, rape, traumatic memory, instability, and poverty, while nothing ever seemed to change.
Table 3. LWF/WS and WHO Trauma-Training Manuals
| LCL-LWF/WS Trauma Healing and Reconciliation Program Peace Building Training Handbook |
| Training Trainers Human Brokenness Understanding Liberian History: Highlights of the Various Periods The Meanings of Conflict and Violence The Meaning of Post-Conflict Dealing with Trauma Substance and Drug Abuse The World of Communication |
| Psychosocial Skills Training Manual (WHO and UNESCO) |
| Stress Management Handling of Drug and Alcohol Problems HIV/AIDS, STDs Trauma Counseling including: General Concepts of Counseling Confronting Sensitive Issues Learning about Stress and Trauma Conflicts and How to Manage Conflicts |
The end of the postconflict demobilization process (DDRR) in 1997 did not lead to peace in Liberia, but it did serve to justify massive humanitarian withdrawal. Consequently, many trauma-healing and DDRR projects “on the ground” closed shop, while a few, like LWF/WS, continued to function. As the war gradually expanded again between 2000 and 2003, trauma-healing and psychosocial assistance projects were provided to Liberians living in refugee camps in Guinea and Sierra Leone, while the interior of Liberia became a no-man’s-land for all but the most determined aid organizations.
By 2003, for example, CVT had been operating a trauma-healing counseling program for four years in the Kissidougou, Guinea, refugee camp, which housed an estimated 81,000 refugees (most of whom were Liberians), and across Sierra Leone. In order to recruit participants into the screening process, approximately 20 Liberian CVT psychosocial agents (PSAs) and 120 volunteer peer counselors were individually responsible for recruiting approximately 25 Liberians per month for six- to ten-week counseling sessions, which would have totaled approximately 18,000 screened participants. Many more thousands of friends, cohabitants, or bystanders witnessed the semi-public screening process, which included verbal training in how to recognize PTSD, depression, anxiety, and suicidal thoughts.
These numbers give a sense of the density of trauma-healing interventions for Liberian populations outside of Liberia, and the paucity of services available inside of Liberia, at the war’s conclusion. The situation was indicative of the state 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. These critiques painted trauma-healing and psychosocial programs as having a prima facie intervention ready for the problem of PTSD without consideration for the character of the crisis, the experience of people within those crises, and the sources of authority and power that backed up PTSD diagnoses and interventions. Consequently, despite a strong climate of support for mental health in other humanitarian settings (e.g., Palestinian Territories, Sri Lanka, Nepal, Uganda, and Rwanda), funding was not forthcoming for Liberia.
As a result, the “continuum” of mental health and psychosocial support turned into a fragmented, partial landscape of services that created vast aporias of care. Trauma-healing and psychosocial programs were willing to see people with low-level, commonly occurring mental illnesses like moderate depression, anxiety, and PTSD, but refused to address more serious mental illnesses and symptoms like psychosis, severe depression, catatonia, or substance abuse. One NGO director of a trauma healing program told me that he explicitly directed his psychosocial workers to focus on high-functioning clients who could participate in the NGO’s group therapy activities, and to turn away anyone with a serious mental illness, because managing their needs was “beyond our capacity.” Other NGOs that offered trauma-healing services screened out Liberians exhibiting symptoms of serious mental illness, and redirected them towards a dizzying web of fruitless referrals to medical humanitarian NGOs or regional hospitals. Medical humanitarian NGOs and regional hospitals, in turn, treated Liberian mental illnesses only when patients presented at their clinics for other medical problems, and solely in order to proceed with a physical examination. On those occasions, doctors or nurses administered sedatives or antipsychotic medications in order to proceed with their physical examination, and then released the patient without further psychiatric support or follow-up. Then, having focused exclusively on physical maladies or injuries, they referred mental illness cases back to trauma-healing or psychosocial NGOs. Non-medical NGOs working in the domain of psychosocial rehabilitation avoided the issue of mental health altogether, and instead opted for cost-effective public health “sensitization” projects that emphasized psychosocial counseling and education, and targeted “at-risk” populations for rehabilitation activities.
2004–2006: Struggle and Stasis
From 2004 to 2006, medical humanitarian NGOs coordinated with each other through UNMIL’s Health Cluster. The Health Cluster, as part of the broader United Nations Cluster Coordination system for UNMIL, was an institutional mechanism for bringing together competing NGOs under a single umbrella for the purpose of metalevel coordination on issues like the geographic distribution of services, epidemic control, and policy discussions regarding international aid and the local conditions of health care provision. The Health Cluster system was also intended to provide an organizational framework that would allow humanitarian aid organizations to support, rather than supersede, the Liberian state in its effort to provide health services and set health policy agendas. As time passed and NGOs worked more closely with the MOHSW, the relevance of the Health Cluster system declined, but it had a constitutive role to play in the first five years of medical activity in postwar Liberia.
Initially, the plan for managing the Liberian health sector’s transition from humanitarianism to development was presumed to be in place. In public statements, the Health Cluster asserted that it was working in partnership with the MOHSW and that it intended to transfer responsibility for national health care over to the MOHSW when the Liberian state had the capacity for self-management. The WHO served as a technical advisor to the Liberian state and provided guidance, policy recommendations, and ethics protocols.
All parties agreed that, eventually, the MOHSW should assume full responsibility for health care in the country, and international NGOs should defer to its leadership in matters of nationally determined health priorities and legislative mandates. In the course of “handing off” health care responsibility, the international community was to work with the MOHSW to “build capacity” so that by the time of their departure, the MOHSW would be an effective state bureaucratic organization in practice and principle. The goal was to transition the Liberian state from postconflict dependency to development-appropriate autonomy.
International and local health care leaders had a vague sense that mental health, trauma-healing, and psychosocial intervention fell within their domain of responsibility, but the scope of their responsibility was never defined. Mental health, trauma-healing, and psychosocial intervention did not fall within the purview of the UNMIL Health Cluster or within the scope of the Office of Coordination of Humanitarian Affairs (UN-OCHA), nor was it formalized under the WHO and MOHSW joint administrative agreements. It was, in effect, in an administrative vacuum. Periodically, bids would be made to move “psychosocial” over to the Ministry of Youth and Sports (in 2008) or to consolidate trauma healing under the social welfare division of the MOHSW, but external forces had prompted a plan of action that was being weakly advanced by the WHO and the MOHSW. In accordance with recently issued international “best practices,”2 Liberia was to develop a national mental health policy, establish a national mental health budget, and facilitate the passage of national mental health legislation that would affirm mental health care as a legal right.
In a world in which every humanitarian action was potentially an administrative placeholder for a government priority in “the transition from humanitarian aid to international development (H2D),” mental health did not have a home. Without an international or Liberian advocate for mental health who could build a constituency among aid organizations, motivate administrative attention, or inspire political or legislative movement, there was no engine for advancing mental health through postconflict institutions. Moreover, there was no authority “from the top,” within UNMIL or the MOHSW, who had an interest in the oversight and coordination of psychiatric, mental health, and psychosocial services and research. The advancement of postconflict mental health’s legislative, policy, and coordination agendas seemed to have stalled. For mental health in Liberia to be treated as a legal and procedural priority meriting the international commitment of resources, the country’s commitment to mental health needed to be stipulated in national law and in state health policy. But in order to stipulate the importance of mental health in Liberian policy, material evidence of donor interest needed to be forthcoming.
In order to render Liberia commensurate with WHO recommendations, the MOHSW needed to take certain bureaucratic steps. It had to identify local experts—specifically, a Liberian psychiatrist—who could shoulder responsibility for the indigenization of the mental health policy process and ensure that mental health legislation would be nationally “owned,” culturally sensitive, and contextually relevant. The MOHSW had to establish ownership over the health sector by coordinating acting humanitarian aid organizations to ensure coherence, nonduplication, and full partnership and support. But its main responsibility was to commission the development of a national mental health plan by issuing a terms of reference to the Liberian Mental Health and Psychosocial Support Coordination Committee. The draft of this plan was to serve as a template for a national mental health policy, which would then be parlayed into national mental health legislation.
Although international consultants needed to be brought in to advise the MOHSW on mental health policy, priorities, and the overall architecture of the mental health sector, donor representatives, humanitarian workers, and Liberian officials involved in managing the postconflict health sector transition were distrustful of handing over mental health to expatriate leadership. In interviews, aid workers and local officials repeatedly told me that “It wouldn’t be right to bring in a non-Liberian to build Liberian mental health” or that mental health policy in Liberia needed to be directed by a Liberian psychiatrist. Unfortunately, however, after Dr. Grant’s death, there was just one Liberian psychiatrist left in Liberia—Dr. Jarvis Brown, a contentious figure at the WHO and the MOHSW who will be introduced shortly.
To provide guidance, Soeren Jensen,3 a Danish psychiatrist and psychotherapist (who had spent fifteen years working in the fields of trauma treatment, mental health coordination, and mental health policy in war zones and postconflict areas like Bosnia, Northern Uganda, Southern Sudan, and Sierra Leone), arrived in Monrovia in 2004 as a WHO consultant specialist postconflict mental health. His contract stipulated that he would work with local stakeholders to develop a mental health policy for Liberia over a six-month period. Jensen knew postconflict environments gave rise to an algae-like bloom of disparate international NGO projects bearing the labels of mental health, trauma-healing, and psychosocial, and that they were often implemented by poorly prepared local actors. But he hoped to “stay on for a while, to do what he could to help Liberia.”
In a 2006 interview, Jensen told me that he drew on his experience in Sierra Leone to identify several priority tasks for his six-month tenure. These included: completing a population-based mental health needs assessment; establishing a mental health and psychosocial coordination committee; commissioning a study of local attitudes to mental health; strengthening psychiatric services; establishing a pilot project showcasing community-based mental health; and developing a draft national mental health policy for Liberia. In postconflict transitions, these kinds of activities are carried out in government agencies across the spectrum and are vitally important. The performance of these tasks and the allocation of resources to them served to act as a “bookmark” for the emerging postconflict state bureaucracy, and the failure to implement these activities meant that the domain of care they represented might be left out of postreconstruction state bureaucracies altogether.
But problems arose. Having brought Jensen in, the WHO then refused to provide Jensen with a budget for mental health activities, transportation, any means of communication (like cellphones or short-wave radio), logistical support, or the permission to employ a research staff. His superiors made it clear that the WHO had no interest in financing or supporting mental health coordination at an operational level or for providing oversight for psychiatric care. According to expatriate officials from both organizations, no international aid funds had been allocated to support psychiatric care in Liberia. Thus, while the WHO engaged in supervising other aspects of the Liberian medical sector, like epidemic outbreaks, infectious disease programs, and vaccination campaigns, Jensen was unable to make substantial progress on mental health.
To make matters worse, Jensen’s newly designated Liberian partner, the psychiatrist Dr. Jarvis Brown, was uninterested in moving the mental health agenda forward. Dr. Brown held prestigious pedigrees in psychiatry and global health. After his undergraduate medical training at the University of Liberia, he went to London to study at the Institute of Psychiatry and at Bethlehem Royal Hospital, where he specialized in alcohol addiction. In 1984, when many educated Liberians were fleeing Liberia to escape political violence, he returned to Liberia to work at Katherine Mills at the invitation of JFK Hospital. In one of two extended interviews with me, Brown recalled that working in Liberia was difficult before the war. Salaries came late, most medical professionals had fled the country, and by 1989 he claims that he was the only doctor left. When the war broke out in 1990, Dr. Brown left Liberia to join his family in the United States.
During the war, Dr. Brown was recruited for a number of consultancies with the WHO and became a psychosocial counseling specialist for various UN HIV/AIDS programs. He was assigned to Malawi from 1990 to 1994, but from 1994 to 1996 Dr. Brown returned to Liberia at the request of the WHO and the United Nations Observer Mission in Liberia ([UNOMIL] the 1990s predecessor of UNMIL). As Liberia entered its first demobilization campaign (described earlier), the WHO intended to support a strong mental health and counseling component. Toward that end, the WHO supported the co-drafting of a guidance document for mental health in Liberia’s first DDRR process and sought the engagement of Dr. Brown, Dr. J. Oliver Duncan (a psychologist who died in 2006), and the aforementioned Dr. Grant in demobilization, substance abuse, and HIV/AIDS projects. Clashes erupted between Dr. Brown and Dr. Grant as each sought to be recognized as the Liberian psychiatrist. When war broke out again in 1996, Dr. Brown fled again to the United States, where he lived with his family while periodically consulting for the UNAIDS program over the next several years.
Dr. Brown returned to Liberia in 1998 and continued his consulting work with UNAIDS, and opened several private businesses in Liberia, including (reportedly) a discothèque, an ice cream shop, a stationery store, and a private psychiatric practice. He did not speak much of his role in Liberia under the Taylor administration, but when the war ended, the MOHSW repeatedly invited Dr. Brown to become its national mental health advisor. According to Brown, he repeatedly turned down this request because the position carried no salary. Others, including deputy ministers at the MOHSW, WHO officials, and local community leaders, disputed that claim. Dr. Brown had accepted this position and was drawing a salary but was failing to fulfill his responsibilities. Other participants in postconflict mental health policy activities reported to me that as of 2008, Dr. Brown was drawing a salary of approximately US$40,000 per annum to act as a consultant on mental health to the WHO. (I attempted several times to obtain confirmation on this from the WHO and from Dr. Brown but received no response.) Thus, from 2004 to 2008, Dr. Brown held the titular role as the “head of mental health in Liberia,” but his businesses competed for his attention. As late as 2012, a senior USAID official confirmed that Dr. Brown was receiving a salary from the WHO, while Dr. Brown continued to publicly protest that he provided mental health–related work for little or no compensation.
Although the intricacies of Dr. Brown’s professional compensation and occupational history may seem to be a sideline, his stonewalling on matters of mental health led Jensen (and later the MOHSW, the WHO, the Mental Health and Psychosocial Coordination Committee [MHPCC], and humanitarian aid organizations) into an effective dead end for nearly five years. Without Dr. Brown’s engagement, Jensen’s work in Liberia was systemically discouraged and counteracted. In 2005 Jensen’s contract was not renewed, and he departed for Europe to await additional contracts and mandates from Liberia that never materialized.
Four of Jensen’s goals were, however, achieved during his time in Liberia. First, he worked with UNMIL to close the Holy Ghost Mental Home, a sham operation run by “Sister Sarah,” a madwoman with impressive political connections who ran the only mental health institution in Liberia at the end of the war. Sister Sarah’s strategy was to find psychotic people on Broad Street (a busy shopping thoroughfare in downtown Monrovia), offer them charity, and then manacle them and remove them to her “hospital.” At her hospital/ministry, patients were chained in abusive and unsanitary conditions, but Sister Sarah used her hospital as a means to obtain international charitable donations (see Jensen 2004a, 2004b). Jensen explained that without a national mental health policy, it was nearly impossible to persuade either the UNMIL police forces or the NTGL to rescue mentally ill patients suffering severe human rights abuses from a woman with an extensive corruption network. When UNMIL police finally took action, Sister Sarah was tipped off by a contact in government and managed to escape with all but two of her wards, and her operation was driven underground, but continued to thrive.
Second, Jensen and Immanuel Ballah, Grant Hospital’s chief psychiatric nurse, recruited the German medical NGO Cap Anamur to take over, repair, and reopen the E. S. Grant Mental Health Hospital in the national capital, which had fallen into decline after Dr. Grant’s death. Though Grant Hospital, like other emergency medical organizations, often had trouble maintaining consistent supplies of psychiatric medication,4 it was able to ensure the presence of an expatriate psychiatric nurse, and it worked hard to stock generic psychiatric medications, antibiotics, and malaria medications from the WHO’s essential medicines list. Thus Grant Hospital, under Cap Anamur, became the go-to resource for any NGO with a psychiatric case, anywhere in the country. Cap Anamur and MDM, a provider of outpatient psychiatric care, became the sole providers of psychiatric treatment in Liberia, and financially supported their psychiatric services through private charitable donations rather than waiting for nonexistent international humanitarian grants.
Third, Jensen organized the MHPCC. Founded around the failed “Greenfields Project,” an attempt to create a dedicated space at JFK Hospital for outpatient psychiatric care and referral, the MHPCC soon assumed an important “ownership role” for mental health and psychosocial visibility in national health policy. In principle, the MHPCC was founded in an attempt to institutionalize mental health and psychosocial coordination in conformity with emerging standards (IASC 2007) and to compensate for the lack of mental health coordination within the UN cluster rubric and within the MOHSW. It was, in effect, a “shadow cluster,” voluntarily organized by constituent NGOs and UN partners, the MOHSW, and Liberian organizations like the newly founded Liberian Social Work Association. Under the auspices of the MHPCC, NGOs offering mental health and psychosocial services were to meet monthly to coordinate mental health and psychosocial activities, to lobby government and international organizations, and to establish standards for the licensing and professionalization of a new class of counselors, trauma healers, and psychosocial workers that had emerged during the years of the conflict. After Jensen’s departure, the MHPCC’s ownership transitioned into a joint chairmanship led by Sister Barbara Brilliant, dean of Mother Patern College, and Dr. Brown, which they held for the next five years.
Finally, Jensen developed and circulated a draft mental health policy to include in Liberia’s national mental health plan, a crucial document for facilitating the health sector’s transition from humanitarianism to development, but without Dr. Brown’s authorship, the documents were viewed as invalid. After Jensen left, the document was lost, as were the completed needs assessments, mental health policy justifications, and network contacts for Liberians and expatriates working on mental health and psychosocial issues. While deputy ministers at MOHSW continued to assure me that mental health was important but “not a priority,” mental health continued to be excluded from coordination at the uppermost levels of the Liberian health sector.
2007–2009: Mental Health as a “Non-event”
At the end of 2006, I sat in another air-conditioned, blue room in a quiet corner of JFK Hospital, in the new resource center for the MHPCC. Empty bookshelves and new office furniture, computers, and printers were shoved against a wall, waiting to be used. Behind me were plastic-wrapped printers and chairs, and to my left sat my friend Frank Joscheck, the German psychiatric nurse running Grant Hospital for Cap Anamur. Attendees also included delegates from USAID, the Mother Patern College of Nursing and Social Work, Cap Anamur, CVT, Dr. Brown, a delegate from the WHO, and representatives from Action Against Hunger and MDM. My presence there was unusual but ignored—Frank had insisted that I come as his guest and as a researcher, and no one else seemed to mind.
Before the meeting opened, Dr. Brown turned to Frank to ask him if he could get him atypical antidepressants not readily available in Liberia. Frank muttered a diplomatic response but complained later to me that Dr. Brown wanted to use Frank’s NGO to gain access to “good drugs” for Brown’s private practice. Frank was particularly annoyed because his own hospital was barely able to obtain these drugs and because Dr. Brown had been invited many times to advise the hospital on matters of care but regularly refused—and then asked for favors.
The meeting commenced with two items on the agenda: (1) the requirements for social work certification and (2) the drafting of the national mental health policy. The first issue soon became a quagmire of dissent. On the issue of certification, MHPCC members were reacting to the efflorescence across the country of thousands of Liberians who claimed to be “trauma counselors” after participating in one of the hundreds of “trauma-healing” training sessions that had taken place during and after the war. In the entrepreneurial environment of postwar Liberia, “trauma counselor” was a new professional category that could be potentially exploited, and many people carried TOT completion certificates as evidence of their professional credibility. The issues of ethics, qualifications, and professional competency were at stake. MHPCC members feared that “fake” Liberian trauma counselors waving worthless certificates of training completion were a threat to traumatized Liberians. They had good reason to worry. Several participants had heard reports of charlatans, acting as trauma healers, who engaged in Sister Sarah–like human rights abuses like “beating the demons” out of people experiencing posttraumatic stress. Under the guise of counseling, trauma healers in churches, in private practice, or as community members were also reported to be involved in recommending exorcisms, beatings, starvation, sexual violence, witchcraft ordeals, and religious shaming (see Heaner 2010).
Although these reports were still just rumors, the MHPCC felt a strong need to consolidate professional authority around the title “counselor” to prevent the domain of mental health from becoming an object of ridicule. The debate, this day, was over the MHPCC’s recommendations on the length and types of training, formal or informal education, and professional experience that would merit the title “counselor.” Ultimately the goal was to bureaucratically mainstream thousands of Liberian counselors into a singular regulatory structure.
The MHPCC’s efforts to develop national standards for counseling and accreditation soon devolved into a nasty case of infighting. One NGO, CVT, recommended that strict state regulations be bypassed or amended, given the institutional flux of the postconflict moment. As long as meaningful and effective efforts were being made to build human and institutional capacity, CVT—a trainer and employer of dozens of Liberian psychosocial workers—felt that on-the-job training and expatriate professional supervision should be recognized as the equivalent of a formal university degree.
While trauma-healing NGOs wanted “their counselors” to be recognized as full-fledged professionals, colleges and social work organizations wanted counseling accreditation to fit within broader training and regulatory frameworks for nursing and social work. The Mother Patern College of Nursing and Social Work and the National Social Worker Association of Liberia asserted that the Liberian state had always existed, that it continued to exist during the war, and that ignoring formal processes of accreditation and credentialing was yet another attempt by the international community to undermine and deny recognition of the sovereignty of the Liberian state. They suggested that failing to recognize and engage with the state and to support formal educational institutions, certification processes, and oversight mechanisms might be an implicit attempt to keep the Liberian state dependent on humanitarian assistance and authority. The future of the state and the success of the postconflict reconstruction were entirely dependent on repositioning the state and local tertiary institutions at the center of regulation.
This debate reflected a core ideological divide about the role of the state in postconflict reconstruction. While some humanitarian aid organizations attempted to bypass state structures in the training and management of their labor force or, as Sister Barbara said, “pretended there is no state,” other institutions sought to integrate their institutional protocols into the state structure, with the explicit goal of strengthening the legitimacy of the state. However, rival institutions argued—quite reasonably—that many Liberians who lacked access to institutions of higher education during the war had transformed their professional experiences in trauma counseling into highly skilled vocations. They noted that these psychosocial workers had been intensively trained “in the field,” had received substantial NGO guidance and supervision, and had a valuable and specific skill set. Consequently, they felt that in the new world of postconflict Liberia, there should be an occupational location for this new kind of counselor.
With the MHPCC at an impasse on the issue of professionalization, Dr. Brown, the meeting cochair, introduced the question of drafting a national mental health policy for Liberia. For many months, the minister of health and social welfare had held the MHPCC responsible for drafting a policy document, which, in a sense, affirmed their status as a “shadow cluster.” But little progress had been made. At this meeting, Dr. Brown asked the group to list the domains of health care and social service provision that fell under mental health and psychosocial legislation. Attendees began to list areas that mostly reflected existing humanitarian funding priorities: psychiatric care, drug and alcohol abuse, mental health, trauma healing, psychosocial support, gender-based violence, ex-combatant rehabilitation, human rights, and so forth. The discussion turned to other departments and ministries that were also claiming the mantle of “rehabilitation”—like the Ministry of Youth and Sports and the DDRR offices. Soon Dr. Brown reminded everyone in the room that he wasn’t getting paid to manage mental health in Liberia, and the meeting was adjourned with a few general action points identified but with no clear plans for finalizing a draft of the document.
According to several meeting participants, by 2006 disputes like these had become routine and the MHPCC was deemed irrelevant—even by its members. Whereas initially most NGOs implementing psychosocial services felt compelled to participate in the MHPCC, by 2006, the committee had been reduced to a just a few international NGOs and local institutions. Important Liberian NGOs providing mental health and psychosocial care, like the LWF/WS and the National Ex-Combatant Peacebuilding Initiative (NEPI), were absent, were unaware of, or had long ignored the MHPCC. Under the joint leadership of Sister Barbara and Dr. Brown, the MHPCC’s monthly meetings failed to yield meaningful coordination, and in 2008 the MHPCC was defunct.
Since 2004, the MHPCC’s sole achievement had been to obtain funding for the psychosocial resource center within JFK Hospital where the meeting took place. The purpose of the resource center was to manage, aggregate, and disseminate mental health and psychosocial research and to serve as a seminar room, a library, and a centralized location for training. The project was funded through USAID subcontractor Development Alternatives International (DAI) (part of the USAID-sponsored Liberia Community Infrastructure Program [LCIP]). It is important to note that the LCIP coordinator specified that the grant was solely for establishing a psychosocial resource center and that his organization wanted nothing to do with anything labeled “mental health.” Just prior to his departure, the director of the LCIP told me, “We are not interested in mental health. We are interested in psychosocial intervention. We don’t want to go anywhere near mental health.”
Policy documents reflected the drift away from mental health and psychiatric care in coordination discussions. Mental health policy priorities now included: (1) ex-combatant psychosocial rehabilitation, (2) collective psycho-education (including peacebuilding, peace education, and conflict resolution interventions), and (3) civilian trauma healing, but notably did not include the provision of psychiatric care. Although the WHO had the institutional and technical leverage to press for mental health care, it lacked interest. Although the MOHSW had the political legitimacy to mainstream mental health and psychosocial interventions, it lacked the bureaucratic capacity. Although international NGOs like Save the Children, Christian Children’s Fund, and CVT, local NGOs, and Liberian training colleges were able to implement local programs, they lacked the institutional authority to change national policy or shift international funding priorities.
2010–2013: “Something Had to Be Done”
In 2006, when medical humanitarian NGOs began to withdraw from Liberia, senior health officials, humanitarians, and donor countries were startled into action at the prospect of a national health care void. Officials from the MOHSW, the WHO, and the World Bank convened a meeting for expatriate Liberian medical experts to craft Liberia’s national health plan in time for the 2007 Liberia Partner’s Forum in Washington, D.C., and Dr. Brown was again approached to craft a national mental health plan. With the prospect of substantive international support, Dr. Brown finally fulfilled the request. A document was rapidly drawn up and submitted to the ministry, and it was gladly received by several of the Liberian expatriates who had fought for the inclusion of mental health in the national health plan. According to one participant at the meeting, everyone reviewed the document together. The World Bank official noted the mental health policy recommendations and said, “This makes the national health plan seem … unconventional.” With that statement, mental health was removed from the national health plan. At a later date, Minister of Health Dr. Walter Gwenigale reinserted a statement about mental health in the national health plan, saying, “It would be an embarrassment to Liberia to not have mental health in the national health plan.” Then mental health was removed again, this time by another unnamed policymaker. The pendulum on mental health’s fate seemed to swing with whoever was holding the document.
In this manner, the development of a national mental health policy for Liberia continued to be a “non-event,” even as postconflict trauma-healing activities were defunded, psychosocial projects were streamlined into other domains, and psychiatric care remained limited to Grant Hospital in Monrovia and MDM’s outpatient services in Bong County. Nothing had led to the integration of basic mental health care into primary health care at the level of service provision or coordination. Expatriates observed that further progress could not be made on a national mental health policy due to a lack of Liberian “ownership.” Some senior Liberian officials felt a sense of helplessness against the tidal movements of humanitarian aid around mental health and psychosocial intervention. For example, in early 2007, Deputy Minister of Social Welfare Vivian Cherue told me, “Donors drove the Ministry of Health policy, and funding was driven by our partners. They didn’t bring in any experts on social welfare…. Donors drove the NCDDRR [National Commission on DDRR] process, but at the end of the day, it’s going to fall squarely back on us. We had a wave situation—people just wanted to help. We cannot provide the services as a government; we do not have the finances, or the human resources.”
Finally, in 2008, a new set of international collaborators including the Carter Center, researchers from Harvard University, Massachusetts General Hospital, and Columbia University came to Liberia hoping to become involved in building Liberia’s mental health sector. By this time, collaboration within Liberia had completely come to a halt. A year had elapsed without an MHPCC meeting, and when the guests were brought to the resource center, they found that the room had been stripped of its furniture and computer equipment. The MHPCC reconvened itself as a welcoming committee, and Dr. Brown was quickly sidelined from the proceedings. New possibilities were floated to revitalize mental health and psychiatric care in Liberia, including the creation of a psychiatric hospital within JFK Hospital, the reconstruction of Katherine Mills, and the development of a psychiatric training program at the University of Liberia.
International consultants were hired to produce a formal mental health policy, and in 2009, a national mental health policy was signed into law. The national mental health policy was hailed as a progressive achievement internationally for mainstreaming mental health care into basic health services, expanding psychiatric training to community-based healthcare providers, and committing to providing counseling to the entire population of Liberia. The national mental health policy has also attracted considerable attention from the international media. Its been lauded for its ambitions by global mental health activists and in profiles on NPR (2011) and in The Utne Reader (“Liberia’s Model” 2010), but it has garnered criticism from PBS (2011), The Nation (Ololade 2012), and FrontPage Africa (Maximore 2011) for its insufficient reach.
In 2010, the Carter Center launched a five-year initiative to help develop the mental health sector by supporting the MOHSW implementation of Liberia’s national mental health policy, creating anti-stigma campaigns, and financing and designing psychiatric nursing training for five hundred already licensed Liberian nurses and physician’s assistants employed by the MOHSW. The Carter Center resolved the “indigenization problem” in Liberia’s mental health policy by removing responsibility for mental health and psychiatry from a single Liberian psychiatrist and inserting psychiatric care into primary care. In addition, the Carter Center built alliances with donors and with international NGOs, who worked to revitalize the greater Liberian health sector, ensure bureaucratic efficacy, and sustain supplies of psychiatric medications from the WHO’s list of essential medicines. Cap Anamur left Liberia, and JFK Hospital assumed responsibility for Grant Hospital, which continues to operate as a psychiatric hospital with outpatient care, and has become a central training site for psychiatric residencies in the Carter Center training program. Most of the actors described here have participated in academic and epidemiological research initiatives to advance mental health in Liberia.
Today, Liberia has earned some recognition as an innovator in African mental health services, and all signs seem to point toward an effective “scaling up,” or nationalization, of basic mental health services. With the support of the Carter Center and the Walter P. Annenberg Foundation, monthly coordination meetings are held at the MOHSW, and they include most of the institutions actively involved in providing clinical mental health care. The next step in Liberia’s postconflict recovery involves political and administrative decentralization, and as part of that process, efforts are under way to ensure that inpatient psychiatric care is available through the county medical system. Further localization, to the district level, is on the horizon over the next decade. Thanks to the mainstreaming of mental health services into the general health services basket, the problem of donor whims and dedicated funding lines should be diminished in the short-term foreseeable future, as long as international support continues to finance the remaining 80 percent of the Liberian health sector. In a groundbreaking move, psychiatric medications are now included on the essential medicines list for Liberia, and as the Liberian health system strengthens, each county health office must have a trained mental health specialist to oversee all local mental health activities implemented by subcontracted NGO basic health service providers.
The MOHSW’s new headquarters, constructed as a gift from the Chinese government, now houses a full-time Mental Health Division that works with new health systems experts from USAID, but the afterlife of the early postconflict period remains. CVT departed in 2007, but it left behind several dozen psychosocial workers who insist upon their professional legitimacy as counselors. With the support of their previous employer, CVT, these psychosocial workers have founded a new national organization, the National Association of Psychosocial Workers, that is meant to rival the officially recognized National Association of Social Workers. In 2011, a Washington D.C.-based office of USAID awarded the new organization a US$5 million grant to engage in psychosocial activities without having consulted with the Liberia-based USAID office, which provides financial support to the Carter Center and the MOHSW through the Rebuilding Basic Healthcare Program, and is opposed to recognizing the new organization. At the same time, many former employees of CVT are trying to work within the MOHSW and other government agencies, while seeking donor support for independent counseling and research careers in Liberian mental health.
Occasionally, Dr. Brown appears in the international media as an expert on Liberian mental health, but in national mental health coordination activities, a prominent Ugandan psychiatrist has effectively replaced him. Harvard University, Massachusetts General Hospital, and the University of Liberia are planning to establish a Center of Excellence for Mental Health, but this initiative seems to be connected with Dr. Brown and is evoking longstanding rivalries with the newly strengthened Mother Patern College and Grant Hospital, both of which work closely with the Carter Center.
