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

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