Persistent Psychopathology in the Wake of Civil War: Long-Term Posttraumatic Stress Disorder in Nimba County, Liberia

Objectives. We assessed the geographical distribution of posttraumatic stress disorder (PTSD) in postconflict Nimba County, Liberia, nearly 2 decades after the end of primary conflict in the area, and we related this pattern to the history of conflict.Methods. We administered individual surveys to a population-based sample of 1376 adults aged 19 years or older. In addition, we conducted a historical analysis of conflict in Nimba County, Liberia, where the civil war started in 1989.Results. The prevalence of PTSD in Nimba County was high at 48.3% (95% confidence interval = 45.7, 50.9; n = 664). The geographical patterns of traumatic event experiences and of PTSD were consistent with the best available information about the path of the intranational conflict that Nimba County experienced in 1989–1990.Conclusions. The demonstration of a “path of PTSD” coincident with the decades-old path of violence dramatically underscores the direct link between population burden of psychopathology and the experience of violent conflict. Persistent postconflict disruptions of social and physical context may explain some of the observed patterns.There is ample evidence that there is a substantial burden of psychopathology among those engaged in war—on combatants and civilians alike.^1,2 Several large studies conducted in low-income countries show that the prevalence of psychopathology overall and posttraumatic stress disorder (PTSD) in particular is substantially higher in countries and among populations that have experienced conflict or mass traumatic events.^3–6 Most recently, a study conducted in Liberia showed that 44% of the population had symptoms consistent with PTSD.⁷Studies in postconflict areas have shown that specific subgroups are at greater risk of PTSD than others, including, for example, women⁸ and those who experience severe traumatic event exposure.⁹ It has been suggested, however, that wholesale disruption to individual daily experiences and social context rather than isolated changes on any individual-level risk factor for psychopathology drives population health after conflict.¹⁰ Some evidence in this regard comes from observations that a disproportionate burden of mortality after conflict comes from indirect causes, including disruption in basic services, social functioning, and the provision of adequate health care.¹¹ A corollary of this observation suggests that areas most directly affected by conflict may have long-term disruption of these determinants of population health and show clear patterns of long-term psychopathology congruent with the history of conflict in the area. However, we are not aware of any study that has attempted to assess the geographical distribution of the long-term burden of PTSD in postconflict countries and its relation to the history of focal areas of violent conflict in a country.Liberia is a particularly apposite place to conduct such a study, given both its recent unfortunate history of conflict and the geographically circumscribed path of the early years of the Liberian civil conflict, particularly in Nimba County. On December 24, 1989, a little-known former civil servant in exile named Charles Taylor led a group of about 100 armed men from the Ivory Coast into the border town of Butuo in Liberia''s Nimba County (Figure 1).¹² Over the following days, the group, calling themselves the National Patriotic Front of Liberia (NPFL), engaged in fighting with government border officers and army personnel stationed in Butuo. There were civilian casualties, and the town''s infrastructure was reported to be “pounded to rubble.”^12(p16) Civilians who could do so fled over the border into the Ivory Coast.Open in a separate windowFIGURE 1Documented instances of civil conflict in Nimba County, Liberia, between December 1989 and May 1990.In the following weeks, the NPFL recruited members of Nimba''s predominant Mano and Gio tribes to join their growing rebel movement, playing on historical tensions with the Krahn, the tribe of Liberian President Samuel K. Doe, in their efforts. As the size of the organization grew, so did reports of NPFL “hit-and-run attacks on small villages, singling out members of the Krahn.”^13(p11) In an immediate response to these attacks, President Doe “dispatch[ed] two battalions of heavily armed troops to Nimba.”^13(p11)The stories of thousands of refugees streaming across the borders of Nimba County into Guinea and the Ivory Coast provide the most reliable information on what happened next. These refugees told of the armed forces of Liberia employing a “scorched earth” policy in their efforts to put down the rebels.¹⁴ On January 6 there was a report of Kahnla, a town less than 20 km inland from Butuo, being destroyed.¹⁵ On January 9, 2 towns neighboring Kahnla, Gbloulay and Lepula, were reportedly destroyed by fighting.¹⁶ However, the destruction of these larger towns was only the most visible product of a more widespread pattern of devastation, as reports claimed, “Government troops [made] daylight forays into outlying villages.”¹⁷ Though these forays were “ostensibly to track rebels,”¹⁷ in fact, confrontations between rebels and troops were rare.¹³ Rather, the army engaged in indiscriminant acts of terror, including summary executions, rape of civilians, and looting and burning of villages.^13,17,18This situation persisted over the following months, and more and more Mano and Gio individuals joined the NPFL, oftentimes in reaction to the acts of the army.¹⁸ A training camp for new recruits was established along the border with the Ivory Coast.¹⁹ Fighting continued along the primary road leading from Butuo and nearby villages. During this time many inhabitants of the northern part of Nimba County escaped direct conflict by becoming refugees. Though small outbreaks of violence did occur in the north, they were mostly limited to direct confrontations between rebels and the army.¹³On March 18, 1990, there were reports of fighting in Saclepea, a major town on the road from Butuo.¹⁸ The nearby town of Bahn was “flattened and burned,” 20 with dozens killed,^19,20 and on April 1, 1990, just south in Kpaytuo, 60 civilians were killed by “marauding soldiers.”²⁰ On May 8, 1990, fighting moved south and reached Tapita.²¹ Finally, after months of devastation in Nimba County, the NPFL advanced toward Monrovia, moving the conflict with it. Although lasting peace did not come to Liberia as a whole until 2003, Nimba County was largely spared major military confrontations after 1990.Our study sought to document long-term rates of PTSD in this region with a relatively brief but intense conflict 20 years previously; in addition, we explored the similarity between the geographical variability in prevalence of PTSD and the spatial patterns of conflict in Nimba County, Liberia.     

Availability of essential health services in post-conflict Liberia

Objective

To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war.

Methods

We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness.

Findings

Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county’s 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively.

Conclusion

Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.