The Ebola epidemic in West Africa may be fading, but its impact on mental health could linger for years. Survivors are often haunted by traumatic memories and face rejection by society when they return home, and those who never contracted the disease may grieve for lost relatives or struggle to cope with extreme anxiety.
Aid groups and governments are battling to address the situation in a region that has little in terms of mental-health infrastructure. There has been some progress: on 25 February, for example, the World Bank and the governments of Japan and Liberia announced a US$3-million plan to provide psychosocial support in Liberia. But the fear and distrust of authorities that have helped Ebola to spread also make it difficult to manage the toll on mental health. And measures to contain the virus, such as quarantines, can limit access to the necessary treatment.
“We’re still seeing anxiety, and people in survival mode,” says Georgina Grundy Campbell, a mental-health nurse with the non-profit International Medical Corps (IMC) in Lunsar, Sierra Leone. “The majority of psychological problems are because the country is frozen, with nothing moving forward,” she says.
West Africa is no stranger to crises. In the past two decades, the countries hit by the Ebola epidemic have seen civil war and unrest as well as torture and other human-rights abuses. These events have sparked efforts to improve the nations’ limited mental-health-care systems, including a programme funded by the European Commission in which the first 20 psychiatric nurses graduated from the University of Sierra Leone in 2013. But clinical expertise is still scarce in the Ebola zone: Liberia has just one psychiatrist; Sierra Leone has none.
Even the simplest interactions between people with Ebola, their families and health-care workers are complicated by the precautions needed to prevent infection. Because doctors and nurses can wear their heavy personal protective equipment only for short periods, they focus on providing treatment. Tasks such as counselling bereaved families are often left to mental-health providers from aid groups. In Sierra Leone, for instance, the non-governmental group Community Association for Psychosocial Services (CAPS) has redirected its 18 employees from assisting war survivors to helping people with Ebola and educating communities about the disease. “In this emergency, everyone’s kind of in slow motion, making sure that the health staff are safe,” says Cynthia Scott, a psychologist with Médecins Sans Frontières (also known as Doctors Without Borders) who recently returned from Sierra Leone.
Surviving the virus presents its own challenges. Some patients refuse to eat or leave their beds. Many blame themselves for contracting the disease. And those who return home are often barred from housing complexes or workplaces. That is a distinct contrast from the way in which communities hit by war or natural disasters typically rally around victims, says Inka Weissbecker, psychosocial adviser at the IMC in Washington DC.
Non-governmental organizations are working to decrease the stigma using approaches such as portraying Ebola survivors as heroes. They are also addressing another contentious issue — regulations that outlaw traditional burial rites — by providing families with photos of their loved ones’ bodies, which offer some comfort. “I have heard people say, ‘If we cannot bury our people properly, we feel our community is sick’,” Scott says.
“The majority of psychological problems are because the country is frozen, with nothing moving forward.”
But some actions taken to limit Ebola’s reach are harder to deal with. Fear of spreading infection among doctors and patients prompted the E. S. Grant Mental Health Hospital in Monrovia — Liberia’s only such facility — to cease most of its operations last autumn. The facility has discharged most of its patients, including several dozen with psychotic conditions. “There’s no doubt there’s an increase in the number of people in the streets because the hospital is still not functioning at the normal level,” says Benjamin Harris, Liberia’s only psychiatrist.
Efforts to build treatment capacity in West Africa are showing encouraging signs. The programme in Liberia will, over a three-year period, deploy mental-health clinicians in schools, among other actions. The Liberian Ministry of Health lists mental health as a priority in its Ebola-recovery plan, along with issues such as maternal care (see page 24) and HIV. And in Sierra Leone, CAPS has treated roughly 1,500 people affected by Ebola.
These developments are part of a broader shift in the global health community’s attitudes toward mental health. The World Health Organization increasingly addresses psychological care in its reports, and donors to groups such as the IMC are becoming more amenable to supporting mental-health programmes. But there is still much work to be done to ensure that psychological care is a priority in the Ebola response, Weissbecker stresses. “We have to be vigilant about this,” she says, “and make sure it stays on the radar.”
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