What's Special About Global Mental Health

The African heat had finally lifted a finger from around the neck of the day, and I leapt out of the hotel like a skydiver out of an airplane and into the early evening air. I had worked up the nerve to be running in Liberia again, this time not on red earthen roads of the countryside but on the main thoroughfare of the capital, Tubman Boulevard. We were just a few blocks from the beaches of the Atlantic Ocean, but I had been warned about running there and marking myself a lonely target for “street boys.”

I am running in Liberia again because I am in Liberia again. It’s been eight years, first of sending other psychiatrists and psychologists in my stead and then of waiting out the COVID-19 pandemic. As the head of our program in global mental health, I am overdue here, having been a neglectful parent to this partnership. In fact, my resident and I are here to assess exactly what impact we have collectively had in the intervening years of conducting annual cognitive-behavioral psychotherapy trainings of the country’s mental health clinicians (MHCs). They are nurses and some physician assistants and midwives who have been trained to be the de facto psychiatrists in a country that has two en facto psychiatrists for over 4 million people.

Liberia has for too long existed for me as powerful memories frozen as stories and pictures in PowerPoint presentations for lectures on global mental health. But it has come alive for me again as though thawed from a flash freeze. I am struck by how the same people are here still trying to carry the flag of mental health in a place that functions under a national flag left tattered by civil war, Ebola, and, to a lesser degree, COVID-19. One of the poorest countries on earth, Liberia is a place so dominated by poverty, scarcity, and crime that I assumed the rivers of bad luck that run across the land would have long since borne my colleagues away.

But there was Sando the driver picking us up at the airport after having dropped me off there at the end of my last trip in 2015. Yeplen was one of the two MHCs whom we had first met in 2011 as we helped install them at JFK Hospital as consultants to that tertiary-care hospital’s pediatric and OB/GYN services, only to see that program collapse due to lack of ongoing support from JFK. Now, there she is as the assistant director of JFK’s sister, E.S. Grant Psychiatric Hospital, the only psychiatric hospital in the country. There is Alex, the MHC who works as part of the Carter Center Mental Health Program here in Monrovia and who accompanied me on my two-week training for new MHCs out in rural Bong County in 2015, as helpful as ever in getting us underway with our CBT program assessment. Maybe most striking of all is the psychologist who came up to me at a meeting to reintroduce himself as one of the students from that 2015 training and to ask to take a picture with me.

We have come bearing our CBT expertise and our research tools. Psychiatry residents being trained in the country’s first and still-nascent residency program at E.S. Grant Hospital ask us for help with addiction psychiatry, child-adolescent psychiatry, and forensic psychiatry. We come as experts with technical know-how and more resources, human and otherwise, in our one Department of Psychiatry than in all of Liberia by far, but what really seems to make a difference is how we have also persevered over the years and not given up on Liberia.

Time after time we have been introduced this week as a program that stands out from others that have come and gone and that collaborates with rather than dictates to local partners like the Ministry of Health and the Carter Center. Our psychiatric connection provides the language for our human connection, not its substance. It reminds me of the oft-made suggestion that process trumps content as the driver of psychotherapeutic progress. And, like I once also saw written of psychotherapy, our commitment to the mental health of Liberians lets our mental health colleagues here know they are not alone.

I am anything but alone running along Tubman Boulevard. The swarming, honking herds of motorcyclists and motor rickshaws warn against daring to set foot off the sidewalk. Women with baskets of everything perched on their heads still manage to talk on cell phones as I slalom around them with some fear that the sight of a white guy zipping past might jar them into losing their balance.

And there are the unpredictable moves of children milling around on the crumbling sidewalks alongside parents under Coca-Cola umbrellas selling their wares. It is not a run that fosters meditation, let alone a runner’s high, but I have shed the luxurious security of my hotel for an immersion in the street life of Liberia. I have connected to something bigger than me, and I hope Liberia feels bigger for it.