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War-Torn Liberia Struggles to Care for Mentally Ill

October 5, 2011 at 12:00 AM EDT
After decades of civil war, Liberia struggles to provide mental health care for its citizens. In partnership with the Bureau for International Reporting, special correspondent Kira Kay reports.
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JEFFREY BROWN: Next tonight, the mental health challenges of an African nation after 14 years of civil war.

From Liberia, special correspondent Kira Kay has this report.  

KIRA KAY: This Friday morning at a rural Liberian health clinic feels routine. Kids are getting their vaccinations. Pregnant women and new mothers are here for their checkups. Malaria tests are under way.

But this nervous-looking young woman is here for a startling reason.

In a private session…

WOMAN: Anything really worry you?

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KIRA KAY: … she tells a group of visiting clinicians that she has trouble sleeping, and feels insects crawling under her skin.

NYAMAH, Liberia: It pinched me.

KIRA KAY: Twenty-five-year-old Nyamah grew up during Liberia’s civil war. She says rocket explosions shook the walls of her home, she saw dead bodies in the street.

Counselor Larwou Quaye (ph) thinks Nyamah’s anxiety is caused by post-traumatic stress disorder.

NYAMAH: It didn’t really start until after the war.

WOMAN: After the war?

NYAMAH: Yes. It comes with small, small bumps.

DR. JANICE COOPER, Carter Center Mental Health Program: I think there is probably nobody in Liberia who wasn’t impacted and experienced trauma as a result of the war.

KIRA KAY: Dr. Janice Cooper is a mental health specialist based in Liberia.

DR. JANICE COOPER: The research suggests that 40 percent of Liberians actually have experienced post-traumatic stress disorder, which is a very, very high rate of PTSD.

There’s a tendency when we think about the war and we think about trauma to forget that there is post-conflict trauma that continues to go on. Even today, there are people who regularly, regularly encounter their perpetrators.

KIRA KAY: Liberia’s 14 years of civil war were a nightmare of atrocity and chaos. Rape and the use of child soldiers was prevalent. Very few Liberians escaped being either victim or aggressor.

Now, eight years after the violence, Liberia is putting itself back together physically. The streets are full of activity. New businesses are getting up and running. But Dr. Cooper says the trauma permeates.

DR. JANICE COOPER: Liberians tend to be extremely edgy and angry. And, sometimes, it’s hard to understand why, because we’re a very friendly, fun-loving society. But sometimes anger will manifest itself in something as simple as you know people in the market, and they are selling something, and, you know, the difference in price and who got there first and who didn’t, and it explodes into something that’s way out of proportion.

KIRA KAY: Despite the dangers a traumatized population presents in a still fragile country, Liberia has only one psychiatrist and a single mental hospital, with a total of 80 beds.

RODNEY PRESLEY, E.S. Grant Hospital: We are the only inpatient facility in the country, so people who are desperate come from far away.

KIRA KAY: Rodney Presley, the director of the public E.S. Grant Hospital, says his facility receives the hardest cases.

RODNEY PRESLEY: We have schizophrenics. We have those with anxiety, a large number of young men who are brought here by family members, mostly for drug-induced psychosis. Just two weeks ago, a patient was brought in hands tied and mouth gagged.

KIRA KAY: New arrivals are put under observation, administered what medications are available and given counseling in group sessions aimed at preparing them for a return to the outside.

One former resident is Bill Jallah (ph), who was institutionalized six times over several decades.

MAN: I had a relapse due to stress, in 1990, a relapse due to a lack of medication, the wartime then.

KIRA KAY: So the war started and all the medication went away?

MAN: Yes, there was no hospital.

KIRA KAY: Bill was like many Liberians with mental illness, who remain sick due to lack of consistent treatment, and who suffer the scorn of society.

MAN: They believe that mental illness is because of witchcraft, also believe that because you are involved in bloodshed and so you got mentally ill. So you have to live with that stigma.

RODNEY PRESLEY: So how have you been feeling since your last visit?

MAN: The medicine is doing fine.

KIRA KAY: Bill is finally on the right medicine, and receives regular care on an outpatient basis. But despite such success stories, Grant Hospital is still struggling.

RODNEY PRESLEY: We are lacking adequate supply of medication on a consistent and regular basis. We are lacking mental health professionals. It would be great if we were able at this time to provide mental health services in the various communities in the country, so that people wouldn’t have to travel so far.

KIRA KAY: Liberia must balance many health challenges. Infant and maternal mortality, malaria and waterborne illnesses compete for limited government dollars. But, in 2009, Liberia added mental health care to its national policy.

Dr. Bernice Dahn is the country’s chief medical officer.

DR. BERNICE DAHN, Liberian chief medical officer: If people are not stable enough to do their work, it will affect our economy, it will affect our country, it will affect homes, it will affect families. It also has security implications. There’s a large group of young people who have resorted to violence. They are in the streets.

KIRA KAY: Dr. Dahn says the goal isn’t to build more inpatient facilities, like Grant Hospital, but to integrate mental health efforts into the country’s 500 primary care clinics.

DR. BERNICE DAHN: If you have it at the primary level, most of the basic things that do not need hospitalization can be addressed right there, and is much comfortable for the patient because they avoid the stigma, because they are going to the health facility like any other patient that is going to the clinic for treatments.

KIRA KAY: To implement its strategy, the Liberian government has turned to the Carter Center created by former President Jimmy Carter and his wife, Rosalynn, a longtime mental health advocate.

Dr. Janice Cooper, a Liberian who fled to the states during the war, has returned to lead the program.

DR. JANICE COOPER: We recruited a cohort of 21 students who were physicians, physician assistants and nurses in clinics and hospitals, as well as in schools of nursing, to be part of our first cohort of mental health clinicians.

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DR. JANICE COOPER: They spend many weeks learning about, identifying and treating mental health disorders and all the major mental health disorders in Liberia. They learn all the basic tools that you need for screenings and assessments.

TEACHER: Be very aware of sound-alike, look-alike drugs.

DR. JANICE COOPER: They also learn medication management. And for some of them, this is really the first time that they’re learning pharmacokinetics and how particularly psychotropic medications work in the body.

KIRA KAY: One member of this first class is 34-year-old Quendi Appleton.

QUENDI APPLETON, mental health clinician: I wanted to be a part of that, being able to bring back hope to the hopeless, seeing them, you know, being able to go to school, to work like any other person in the community.

KIRA KAY: Fresh from completing the program, Quendi is back at the clinic where she had already been a nurse, but now she has a mental health expertise.

QUENDI APPLETON: Anybody, when you hear the word depression, what do you think about?

KIRA KAY: Quendi immediately puts her new training to use when a woman who came in for diabetes treatment begins to show signs of psychosis. Quendi puts the patient, Pauline, through a mental status examination she learned in class.

QUENDI APPLETON: Do you know where you are presently? Do you know where you are presently?

KIRA KAY: Pauline thinks the current year is 1979, and that a child crying in the neighboring ward is her own daughter. Quendi and her supervisor decide to get Pauline’s diabetes under control first, then, if she still shows signs of mental illness, put her on psychotropic drugs and into counseling.

QUENDI APPLETON: Normally, what used to be done in the past, the patient would come. Even if they have mental illness, nobody care about that. You were only concerned about a physical ailment. So this is really a new hope for her, that we are able to discover the mental aspect and treat her, you know, the physical and the mental.

KIRA KAY: The goal of the Carter Center program is to have 150 clinicians just like Quendi fanning out all over the country within five years.

Treating remote, rural populations remains the biggest challenge. One organization working to cover that need is the French group Medecins du Monde, working alongside Liberian Health Ministry trainees.

Here, in a war-torn part of the county, they present awareness programs.

WOMAN: And this sickness, yes, the only thing that can help the people, that is medicine.

KIRA KAY: And see patients for one-on-one counseling sessions, such as this 13-year-old boy who says he sees spirits.

MAN: So, how the jinna is like?

BOY: Black.

MAN: Black?

BOY: Yes.

MAN: Dressed in black or he’s black?

BOY: Looking black.

MAN: Looking black.

KIRA KAY: And Alex, whose violent behavior was fueled by drug use that started during the war.

EDMUND SOKPAH, nurse: He was hearing commanding voices.

KIRA KAY: He was hearing voices.

Nurse Edmund Sokpah says Alex’s improvement has been dramatic.

EDMUND SOKPAH: He was very much psychotic. You could not see him like a human, a human who — someone who has that dignity. So seeing him at present, very calm, stable, coming on regular visits, as compared to the past, he has changed.

KIRA KAY: And then there is Nyamah, the 25-year-old PTSD patient. She is also receiving medication and counseling, but the clinicians say she has yet to truly open up about her wartime experiences.

As Liberia works to put the trauma of its past behind it, Quendi and her recently graduated Carter Center classmates say they will lead the way. And a new class of trainees is just getting started.

JUDY WOODRUFF: Kira Kay’s story is part of our partnership with the Bureau for International Reporting.