Searching for Normal in the Wake of the Liberian War. Sharon Alane Abramowitz

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СКАЧАТЬ 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 СКАЧАТЬ