Cooper Personal reflection Mental health and psychosocial support in the face of Ebola in Liberia: the personal and professional intersect. A personal account Janice L. Cooper Thispersonalre£ectionisbasedontheauthor’sexperi- anti-stigmaprogramme that has apolicysup- ences,anativeLiberian,inhercountryatthebeginning port component, which has trained mental of the 2014 Ebola epidemic. It includes heraccount of healthcliniciansfromacrossthecountry.Inla- events as Ebola cases and related deaths began to rise teJune of 2014, I was asked to join the Ebola and the response appeared inadequate. Examples are National Taskforce, now called the Incident presented where a robust psychosocial and mental Management System, as the Co-Chair for health response was critically required, but most often the Psychosocial Pillar.1 Since joining the lacking.This re£ection focuses on the points where Ebola response, my o⁄ce is now at the Ebola the author’spersonal and the professional life met as Command Center in Sinkor, Monrovia. Ilive she co-led the psychosocial pillar of the national in my family home, located approximately 8 responseteamonEbola.It alsoexploresthechallenges kilometres from Monrovia. This house and of leading the mental health and psychosocial com- its yard has a long history, much of it rooted ponent of a complex emergency within a fragile, post in di⁄cult times, some in happier ones. In con£ictstate,wherethe medicaland infectiousdisease 1980, my mother was arrested here and taken component of the response often takes precedence. to jail. In 1988, friends and family attended Additionally, the author’s irnternal struggle that my wedding reception here and, in 1990, occurred when she was forced to evacuate at the out- this is where I £ed with my husband and tod- break’speak is explored. dler when ¢ghters came to my house. This is where we stayed, along with nearly 200 other Keywords: Ebola, Liberia, mental health, people, until caught in a ¢re¢ght between personal protective equipment, psychosocial the‘peacekeeping’forcesofTheEconomicCom- response, social reactions munity of West African States Monitoring Group (Ecomog) and the ‘freedom ¢ghters’ of Introduction Charles Taylor’s National Patriotic Front My job as support to mental health pro- of Liberia (NPFL). When forced to £ee gramme in Liberia is a dream job. Through again it was into what was then called‘Greater it,Ihavemetmanywonderfulpeopleandbeen Liberia’. involved in the training of nearly 145 clini- cians. In that respect, my work has allowed First days me to substantially contribute to dealing with When Iand my team ¢rst heard about Ebola the threat of Ebola on both individual and in Lofa County in March 2014, the north of society levels. I work in a suburb of Monrovia the country, it was with no real alarm. called Congotown, less than 1.6 kilometres Within days we found out that a Me¤decins from the Ministry of Health, in a compound Sans Frontie' res (MSF) team was on the with other nongovernmental organisations way, and most people relaxed into the notion (NGOs). I lead a mental health training and that the Ebola Virus Disease (EVD) would 49 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health and psychosocial support in the face of Ebola in Liberia: the personal and professional intersect. A personal account, Intervention 2015, Volume 13, Number 1, Page 45 - 84 Figure 1: Political map of Liberia (source: http://www.mapsofworld.com/liberia/maps/ liberia-political-map.jpg). now be contained far away from us schools were still operating and although (Figure 1). she had notbeen in contact with her children During early April 2014 it seemed that the since becoming symptomatic, there was a outbreak was contained, but then it came move to keep her children from school. closer. We heard the story of a woman with Understanding the disease was new to every- EVD and her young baby, they had taken a one, and the natural reaction was panic taxi a long distance to meet her husband in and fear. As more education reached the Firestone, site of the famous rubber planta- public, there was clear vacillation between tion. On the way, they had stopped and the denial and over reaction. taxi driver found a place for her to sleep. She had been vomiting and the taxi driver Denial, mistakes and fear was her default caretaker, cleaning up after Ebola got my attention when, as part of the her. When she ¢nally reached her destina- continuing education component of our tion, the stigmawas immediate.The hospital mental health training, we held a workshop initially refused to treat her, even though on communications disorders in children at her husband was an employee. At this time the prestigious Cape Hotel in Monrovia on 50 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Cooper 12 April 2014, led by a professor from Maker- conditions. On top of that, as the clinician ere University in Uganda. Sixty mental had said, there were not enough PPEs, in health clinicians attended. The anxiety of fact, many had not even seen a PPE. the clinicians in the room was palpable, as the initial update session featured an update The spread of Ebola and lack of on the epidemic from Lofa County. A clin- support of health care workers ician who was leading the mental health Shortly after that training, I joined the and psychosocial support (MHPSS) side of response programme to support the existing the response from Lofa county outlined her psychosocial committee.Wemet daily and on work with the county health and social wel- weekends. More and more people from the fare team and reassured us that all was well. international community seem to appear at Everything was under control, and there thesemeetings.Few wereemergency,letalone was su⁄cient personal protective equip- EVD, specialists.There were polite acknowl- ment, known locally by the acronym PPE. edgements that MHPSS was important to Her presentation triggered many responses, the response, but most of the support was mostly protestations that even if this was focusedonfood,meetingbasicneedsandiden- the case in Lofa, it would not be the same tifying contacts of cases that could be listed in other counties. Then I asked a clinician and passed on to the contact tracing team. (referred to here asJonathan)2 from the epi- One of our international faculty conducted centre of the epidemic, Foya in Lofa trainingon Ebolaanditspsychologicale¡ects County,tospeak.Asoft-spokenman,he withthe Ministryof Health & SocialWelfare. discredited all that had been said by the In the regular response meetings the stories clinician from Lofa county, saying that he started to come. A whole family wiped out had seen no evidence of widespread avail- because they attended a funeral. Cleric after ability of PPEs. Jonathan was stationed in cleric became infected, and infected others, the hospital where the MSF Ebola Treat- as they carried out burial rites. During this ment Unit was built. He informed the group time, we continued to have classes and my of a case of a health care worker who had students brought in stories of their own. been infected, went home and later became The number of cases rose and then the sick, exposing his family without contact- dreaded fear happened, Ebola hit Monrovia. ing the centre or the supervisor.The worker Elsewhere across the country, regular health died. This was a telling sign that our down- services started to shut down amidst claims fall would be a health care system pieced of insu⁄cient protective gear and health together with the best intentions, but lack- care workers fear.Within a matter of weeks, ing the basic elements of what we mean by cases were coming in from theWest, the East ‘system’. Apparently none of the nursing and the South. supervisors had received the message that In Monrovia, my students spoke of their own when someone does not come to work, or experiences. One was threatened with evic- calls in sick, they should physically seek tion from her house and community because out this person. This mistake has been she had called an ambulance when a woman repeated throughout the epidemic. Follow- who was sick died after exhibiting symptoms ing Jonathan’s presentation, there was an of Ebola. She hung around to make sure animated discussion among the clinicians the community would not bury the body on the ways that this virus might permeate on its own. The ambulance took most of the a frayed health care delivery system. Most day to come and the clinician, a new mother, clinicians had not been paid for months, was threatened throughout this period. She and their union was in a dispute with the stood her ground, but no longer felt safe in government on issues of pay and working her community. 51 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health and psychosocial support in the face of Ebola in Liberia: the personal and professional intersect. A personal account, Intervention 2015, Volume 13, Number 1, Page 45 - 84 During daily re£ections students reported homes. In many cases, there were serious what they were hearing from their own com- concerns surrounding the absence of infec- munities across the country as they talked tion control procedures. constantly with family and co-workers about the epidemic. A group of clinicians from MHPSS not seen as an essential Gbarpolo County, north of Montserrado, component heard about colleagues at home that were Almost seamlessly our morning programme being instructed to conduct awareness-rais- had changed. Every day began with an ing sessions within the communities, but Ebola update that I delivered based on they were afraid because they had not been National Task Force meetings from the day given gloves nor any other basic protective before.