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

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