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

Чтение книги онлайн.

СКАЧАТЬ 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 СКАЧАТЬ