Issues in Mental Health Nursing, 36:247–248, 2015 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2015.1023616
FROM THE EDITOR
Ebola and Mental Health Sandra P. Thomas, PhD, RN, FAAN, Editor
At first glance, the title of this editorial may have given you pause. Ebola and mental health? Mental health issues surely were not foremost in our minds in the summer of 2014 as news media brought us horrifying stories of doctors fighting a disease that was claiming thousands of African lives. Psychiatrists, psychologists, and mental health nurses were not the valiant professionals later pictured on the cover of Time magazine as ‘Persons of the Year’ (Time, 2014). Time’s journalists (Gibbs, 2014; Von Drehle, 2014) very appropriately hailed the bravery and selflessness of caregivers, such as medical doctors Kent Brantley and Jerry Brown; nurses Augustine Bindi and Princess Ideko; and ambulance driver Foday Gallah. I am filled with admiration when I read of their heroism. A patient who survived Ebola shared what the simple act of bathing meant to him: That night was the worst night. I had 46 episodes of diarrhea and 26 episodes of vomiting. I was in a sea of mess. The next day there was this physician’s assistant—I will never forget him. His act of love toward me, to wash me, was so much that I will never forget it in my entire life. He cleaned me totally. He dressed me, put me in a clean bed. And I felt that was so, so, so nice. (Dr Philip Ireland; Time, 2014, p. 95)
We, in the field of mental health, are not the caregivers who provide these direct bodily ministrations. Yet, we have our own roles and responsibilities with regard to the Ebola outbreak, and a recent article published in the Journal of the American Medical Association (JAMA) called attention to these (Shultz, Baingana, & Neria, 2015). As news of escalating deaths began to spread across the African nations afflicted by Ebola, fear became a contagious disease in itself. As mental health nurses well know, fear can energize human action or cause denial of reality and virtual paralysis. The saga of the Ebola outbreak provides examples of both. Actions propelled by fear included families hiding their sick loved ones and performing secret burials (Shultz et al., 2015). Fueled by irrational fear that foreign health workers had come to kill them rather than help them, residents of Guinea attacked and murdered some of them (BBC News, 2014). On the inaction side of the coin, denial of the gravity and scope of the Ebola outbreak caused costly delays in mobilizing the responses of governments (e.g., “President Ellen Johnson Sirleaf appeared stunned, frozen in place, unable to declare an emergency,” Time,
2014, p. 87). Furthermore, the World Health Organization said the outbreak was under control and turned away a team from the US CDC – according to its director Dr Tom Frieden: “WHO didn’t want us there, so we left” (Time, 2014, p. 107). WHO did prepare an Ebola Response Roadmap (2014), but it did not contain recommendations about alleviating the aforementioned fear behaviors that allowed the Ebola outbreak to escalate. Nor did the report provide guidance on meeting the urgent mental health needs of the survivors. Thousands of people were traumatized by seeing their family members die a gruesome death. Their grieving was complicated by poverty, food insecurity, and lack of psychosocial support services (Shultz et al., 2015). Scant resources for mental health treatment exist in countries such as Liberia and Sierra Leone, despite efforts in the past decade, for example, those by the Carter Center, to train mental health nurses and community workers (see ‘Development of Mental Health Services in Liberia’, retrievable from www.cartercenter.org). In their JAMA article, Shultz et al. (2015, p. 2) recommend trauma signature analysis, which “assesses a population exposure to an extreme event, providing actionable guidance for highly targeted support programs.” Subsequently, a 4-part intervention should be mounted, including restoration of services to the population, strengthening of communities, providing general stress reduction modalities, and delivering more specialized mental health treatment for severely traumatized individuals (Shultz et al. 2015). The stories of survivors of Ebola, including healthcare workers, illustrate the daunting task that lies ahead. One such story, from a ‘Doctors Without Borders’ health promoter, illuminates the anguish of the worker herself, as well as the anguish of a child who had lost her entire family to Ebola. The story haunts me:
247
Guinea broke my heart. I was not prepared for the level of mortality. I wasn’t prepared to watch entire villages die. There was a village in Guinea where on the left side of the road, the houses were empty. It was an entire extended family. And there was a graveyard in the village, and I knew all of the graves. The darkest day [was] probably in Guinea . . . An important person had come back to the village . . . When he died everyone came to the funeral. I think it’s very normal for humans that we don’t want to bury someone covered in vomit and feces. We want to wash the body. So the first week,
248
S. P. THOMAS all of his male relatives came in, and all of them died. Then all the female members of the family came in, and all of them died. And then the children came in. We had three young children in the treatment center, completely alone. The 12-year-old turned her face to the wall and she wouldn’t speak and she wouldn’t eat. She was so devastated by the loss of her entire family that the only thing she would say to us was ‘Just let me go join my mother.’ (Ella Watson Stryker; Time, 2014, p. 76)
Orphans, such as this girl, must be helped to find a place to live as well as a reason to live. As I write this editorial, hope can be derived from a recent report describing grassroots initiatives to help Ebola survivors reintegrate into their communities, including efforts to place orphans in homes with relatives, such as aunts and uncles (Mogelson, 2015). Another source of hope can be derived from news reports that cases of Ebola in Guinea, Liberia, and Sierra Leone are declining (see, e.g., ‘UN: New Ebola cases decline’, 2015). Yet the after-effects of the Ebola outbreak of 2014 will be with us for years. It is essential that we ponder the lessons learned from this. Says Time’s editor, Nancy Gibbs, “This was a test of the world’s ability to respond
to potential pandemics, and it did not go well” (Gibbs, 2014, p. 68). Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. REFERENCES BBC News. (2014). Ebola outbreak. Guinea health team killed. September 19. Retrieved from http://www.bbc.com/news/world-africa-29256443. Gibbs, N. (2014). The choice. Time, December 22/29, 184(24–25), 67–68. Mogelson, L. (2015). Letter from West Africa: When the fever breaks. The New Yorker, January 19, pp. 38–49. Shultz, J. M., Baingana, F., & Neria, Y. (2015). The 2014 Ebola outbreak and mental health: Current status and recommended response. Journal of the American Medical Association, 313(6), 567–568. Time. (2014). Person of the year. Time, December 22/29, 184(24–25), 67–68. UN: New Ebola cases decline. (2015). Knoxville News Sentinel, January 18, p. 14A. Von Drehle, D. (2014). The ones who answered the call. Time, December 22/29, 184(24–25), 70–107.
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
FROM THE EDITOR
Ebola and Mental Health Sandra P. Thomas, PhD, RN, FAAN, Editor
At first glance, the title of this editorial may have given you pause. Ebola and mental health? Mental health issues surely were not foremost in our minds in the summer of 2014 as news media brought us horrifying stories of doctors fighting a disease that was claiming thousands of African lives. Psychiatrists, psychologists, and mental health nurses were not the valiant professionals later pictured on the cover of Time magazine as ‘Persons of the Year’ (Time, 2014). Time’s journalists (Gibbs, 2014; Von Drehle, 2014) very appropriately hailed the bravery and selflessness of caregivers, such as medical doctors Kent Brantley and Jerry Brown; nurses Augustine Bindi and Princess Ideko; and ambulance driver Foday Gallah. I am filled with admiration when I read of their heroism. A patient who survived Ebola shared what the simple act of bathing meant to him: That night was the worst night. I had 46 episodes of diarrhea and 26 episodes of vomiting. I was in a sea of mess. The next day there was this physician’s assistant—I will never forget him. His act of love toward me, to wash me, was so much that I will never forget it in my entire life. He cleaned me totally. He dressed me, put me in a clean bed. And I felt that was so, so, so nice. (Dr Philip Ireland; Time, 2014, p. 95)
We, in the field of mental health, are not the caregivers who provide these direct bodily ministrations. Yet, we have our own roles and responsibilities with regard to the Ebola outbreak, and a recent article published in the Journal of the American Medical Association (JAMA) called attention to these (Shultz, Baingana, & Neria, 2015). As news of escalating deaths began to spread across the African nations afflicted by Ebola, fear became a contagious disease in itself. As mental health nurses well know, fear can energize human action or cause denial of reality and virtual paralysis. The saga of the Ebola outbreak provides examples of both. Actions propelled by fear included families hiding their sick loved ones and performing secret burials (Shultz et al., 2015). Fueled by irrational fear that foreign health workers had come to kill them rather than help them, residents of Guinea attacked and murdered some of them (BBC News, 2014). On the inaction side of the coin, denial of the gravity and scope of the Ebola outbreak caused costly delays in mobilizing the responses of governments (e.g., “President Ellen Johnson Sirleaf appeared stunned, frozen in place, unable to declare an emergency,” Time,
2014, p. 87). Furthermore, the World Health Organization said the outbreak was under control and turned away a team from the US CDC – according to its director Dr Tom Frieden: “WHO didn’t want us there, so we left” (Time, 2014, p. 107). WHO did prepare an Ebola Response Roadmap (2014), but it did not contain recommendations about alleviating the aforementioned fear behaviors that allowed the Ebola outbreak to escalate. Nor did the report provide guidance on meeting the urgent mental health needs of the survivors. Thousands of people were traumatized by seeing their family members die a gruesome death. Their grieving was complicated by poverty, food insecurity, and lack of psychosocial support services (Shultz et al., 2015). Scant resources for mental health treatment exist in countries such as Liberia and Sierra Leone, despite efforts in the past decade, for example, those by the Carter Center, to train mental health nurses and community workers (see ‘Development of Mental Health Services in Liberia’, retrievable from www.cartercenter.org). In their JAMA article, Shultz et al. (2015, p. 2) recommend trauma signature analysis, which “assesses a population exposure to an extreme event, providing actionable guidance for highly targeted support programs.” Subsequently, a 4-part intervention should be mounted, including restoration of services to the population, strengthening of communities, providing general stress reduction modalities, and delivering more specialized mental health treatment for severely traumatized individuals (Shultz et al. 2015). The stories of survivors of Ebola, including healthcare workers, illustrate the daunting task that lies ahead. One such story, from a ‘Doctors Without Borders’ health promoter, illuminates the anguish of the worker herself, as well as the anguish of a child who had lost her entire family to Ebola. The story haunts me:
247
Guinea broke my heart. I was not prepared for the level of mortality. I wasn’t prepared to watch entire villages die. There was a village in Guinea where on the left side of the road, the houses were empty. It was an entire extended family. And there was a graveyard in the village, and I knew all of the graves. The darkest day [was] probably in Guinea . . . An important person had come back to the village . . . When he died everyone came to the funeral. I think it’s very normal for humans that we don’t want to bury someone covered in vomit and feces. We want to wash the body. So the first week,
248
S. P. THOMAS all of his male relatives came in, and all of them died. Then all the female members of the family came in, and all of them died. And then the children came in. We had three young children in the treatment center, completely alone. The 12-year-old turned her face to the wall and she wouldn’t speak and she wouldn’t eat. She was so devastated by the loss of her entire family that the only thing she would say to us was ‘Just let me go join my mother.’ (Ella Watson Stryker; Time, 2014, p. 76)
Orphans, such as this girl, must be helped to find a place to live as well as a reason to live. As I write this editorial, hope can be derived from a recent report describing grassroots initiatives to help Ebola survivors reintegrate into their communities, including efforts to place orphans in homes with relatives, such as aunts and uncles (Mogelson, 2015). Another source of hope can be derived from news reports that cases of Ebola in Guinea, Liberia, and Sierra Leone are declining (see, e.g., ‘UN: New Ebola cases decline’, 2015). Yet the after-effects of the Ebola outbreak of 2014 will be with us for years. It is essential that we ponder the lessons learned from this. Says Time’s editor, Nancy Gibbs, “This was a test of the world’s ability to respond
to potential pandemics, and it did not go well” (Gibbs, 2014, p. 68). Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. REFERENCES BBC News. (2014). Ebola outbreak. Guinea health team killed. September 19. Retrieved from http://www.bbc.com/news/world-africa-29256443. Gibbs, N. (2014). The choice. Time, December 22/29, 184(24–25), 67–68. Mogelson, L. (2015). Letter from West Africa: When the fever breaks. The New Yorker, January 19, pp. 38–49. Shultz, J. M., Baingana, F., & Neria, Y. (2015). The 2014 Ebola outbreak and mental health: Current status and recommended response. Journal of the American Medical Association, 313(6), 567–568. Time. (2014). Person of the year. Time, December 22/29, 184(24–25), 67–68. UN: New Ebola cases decline. (2015). Knoxville News Sentinel, January 18, p. 14A. Von Drehle, D. (2014). The ones who answered the call. Time, December 22/29, 184(24–25), 70–107.
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
