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

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СКАЧАТЬ 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 СКАЧАТЬ