A Chance to Get it Right: Addressing the Invisible Scars of Ebola Using Culturally Informed and Community Engaged Strategies
By: Gilberte (“Gigi”) Bastien, PhD , Assistant Professor of Psychiatry & Associate Director of Office of Global Health Equity at Morehouse School of Medicine
In 2016, in the wake of the worst Ebola outbreak in recorded history, I spent nearly a year in Liberia as a Fogarty Global Health Fellow seeking to better understand the psychosocial sequelae of the Ebola virus and disease (EVD) for affected populations. On my first day in the field, one of our Liberian research assistants came running to find me, per our protocol for managing individuals identified as needing targeted mental health support. Behind her stood a despondent young man, in his early 20’s. In speaking with this young man, I learned that despite having contracted EVD and survived himself, he had witnessed the death of his mother, father, siblings, aunts, and uncles, all of whom had also contracted the virus. In the space of a couple of months, this young man’s entire support network was wiped away by Ebola. He was tearful as he shared “Not a day goes by that I don’t ask why I’m still here and think about ending my life.”
Although this young survivor had received medical care at an Ebola treatment unit (ETU) and continued to be followed for on-going care, nearly 2 years out from his discharge from the ETU, he shared that no one had inquired about his mental health. With all of the supports and resources for survivors, he was left to deal with his grief, stigmatization, and suicidal thoughts on his own. His and the countless similar stories I heard during my time in Liberia painted a picture of a critical need to raise global awareness of the invisible scars of Ebola and on-going psychosocial impacts on affected populations well beyond the presence and attention of the international community.
Now, as the Democratic Republic of the Congo is confronting another EVD outbreak, which has been declared a public health emergency of international concern (PHEIC), the international community has an opportunity to move from lessons learned to lessons applied. As was the case with the 2014-2016 West African EVD outbreak, the current DRC outbreak represents a crisis in the midst of a complex humanitarian emergency. In the case of Liberia, the outbreak was set against the backdrop of the lingering consequences of a 14-year period of civil war, which left the country with a limited health system and public health infrastructure, as well as significant health workforce shortages. Meanwhile, the current DRC outbreak has been significantly complicated by a tense military situation and security challenges that have resulted in attacks on and even deaths of health workers responding to the outbreak.
An examination of these nuanced aspects of the cultural context in which the current response is unfolding reveals that in addition to the myriad of mental health and psychosocial challenges inherent to a humanitarian crisis in progress, affected communities are dealing with a host of pre-existing challenges to their mental health status stemming from long-standing health, development, and peace challenges. While these realities speak to very real and adverse challenges to mental health functioning, it’s important to bear in mind that the capacity for psychosocial resilience in strong in the midst of these types of humanitarian emergencies.
Our work in Liberia in 2016-2017 revealed that attempts to attend to the mental health and psychosocial aspects of humanitarian emergencies tend to focus on psychopathology (at the expense of resiliency), resulting in missed opportunities to optimize and leverage available resources in recovering communities. Cultural variables impacting population health outcomes are also often overlooked (e.g., religious/spiritual practices, etc). Understanding these factors helps ensure development of culturally informed and contextually responsive strategies for effective emergency relief, response, and recovery.
Despite the significant challenges they present to affected communities, emergencies like the recent West African and current DRC Ebola outbreaks provide unique opportunities to address long-standing mental health disparities in LMICs. The findings from our research suggest communities affected by Liberia’s 2014-2016 EVD outbreak continued to face significant mental health challenges (e.g., depression, substance use, and trauma symptoms) nearly 2 years after the end of the outbreak. Despite these challenges, surveyed communities also evidenced remarkable resiliency. Active Survivors’ advocacy organizations in both Liberia and Sierra Leone were found to be conducting successful initiatives around overcoming EVD-related stigma, re-engaging survivors in society, and promoting economic empowerment of survivors. Leveraging community resiliency capacity in attending to MHPSS needs empowers communities to be agents of recovery.
Mental health and psychosocial functioning should be a critical point of focus in the current DRC and future EVD outbreaks and should be addressed at all phases of emergency response and recovery. Effectively addressing the complex mental health challenges accompanying Ebola requires collaboration with affected communities. In addition to ongoing control of transmission and perhaps preventive vaccination strategies, we recommend the following:
- Government entities and aid organizations should engage trusted community leaders in emergency preparedness and action planning. Religious/spiritual leaders (RSLs) represent one such group. With appropriate training (e.g. anti-stigma training), RSLs can be empowered to attend to basic mental health needs in the communities they serve and can serve as cultural brokers between communities and entities rendering aid in emergencies.
- Liberia’s National Ebola Survivors’ Network can be a key resource and should be engaged in efforts to better understand and address survivors’ needs.
- Mental health response strategy should incorporate stigma-reducing interventions tailored to diverse groups/settings (e.g., EVD survivors, health workers, burial team members, etc).
- Mental health needs of children and adolescents must be addressed at all phases of response and recovery. Relevant governmental units should lead these efforts in collaboration with international aid groups (e.g., UNICEF)
- Integration of mental health and psychosocial support into school and church settings may maximize reach of such efforts.
- Greater attention should be focused on addressing social determinants (e.g., employment status, housing, etc.) contributing to MHPSS functioning within affected communities.
Despite the significant challenges they present to affected communities, humanitarian emergencies provide unique opportunities to address long-standing health, mental health, and public health disparities in LMICs. Our experience and work through Morehouse School of Medicine’s Office of Global Health Equity suggest opportunities to advance health equity in the context of humanitarian emergencies is best achieved through international cooperation and coordination that places community at the heart of developed strategies for intervening. Interventions much also be attentive to cultural considerations. Only in this way can the issues of community mistrust that persist in the current Ebola outbreak be overcome to support affected communities towards recovery and resilience.
ACKNOWLEDGMENTS: Morehouse School of Medicine’s President & Dean – Dr. Valerie Montgomery Rice, The Carter Center’s Mental Health Liberia Program, Drs. Steve Yeh & Jessica Shanta of Emory University, Dr. Jonathan Stiles & OGHE Team at MSM
The Emory Global Health Institute is a member of the Georgia Global Health Alliance.