Implementing of mental health services in an area affected by prolonged war and Ebola disease outbreak: case of North-Kivu province, Democratic Republic of Congo

Implementing of mental health services in an area affected by prolonged war and Ebola disease outbreak: case of North-Kivu province, Democratic Republic of Congo

Bives Mutume Vivalya^1,2,&, Martial Mumbere Vagheni³, Nolbert Gumisiriza¹, Germain Manzekele Bin Kitoko³, Astride Lina Piripiri⁴, Célestin Kaputu-Kalala-Malu³

¹Department of Psychiatry, Kampala International University, Ishaka, Bushenyi, Uganda, ²Masereka General Hospital, North-Kivu, Democratic Republic of the Congo, ³Department of Psychiatry and Neurology, University of Kinshasa, Lemba, Kinshasa, Democratic Republic of Congo, ⁴Department of Public Health, Faculty of Medicine, University of Kinshasa, Lemba, Kinshasa, Democratic Republic of Congo

^&Corresponding author
Bives Mutume Vivalya, Department of Psychiatry, Kampala International University, Ishaka, Bushenyi, Uganda

Commentary    

Mental health in chronic conflict areas: violent conflicts and disasters devastate communities and their social networks; induce physical and psychological damage to the population and increase their morbidity and mortality [1]. A World Health Organization (WHO) study estimated that one person out of five in conflict-affected areas suffers from a mental disorder [2]. Prolonged exposure to armed conflict is associated with a significant linear increase in mental disorders like post-traumatic stress disorders, depression and exacerbation of existing mental health problems. The commonly presented psychological symptoms are intrusive thoughts, severe negative appraisals, self-depreciating, social withdraw and reliance on cognitive avoidance as a maladaptive coping mechanism [3]. In these affected communities, the availability of mental health services is none existent or severely limited at best. However, there should be programs for mental health promotion and primary prevention of psychopathology. These programs should be sensitive to the socio-cultural perspectives of mental health and psychosocial problems of a given community. For acceptance and sustainability, all the stakeholders should be involved in the designing and implementation of these [4]. For more than two decades, the eastern Democratic Republic of Congo (DRC) has experienced armed conflicts orchestrated for their socioeconomic benefits [5]. This has negatively impacted all social services including health amenities and modified their health-seeking behaviors. These factors include abject poverty, severe human rights abuses, weaponized sexual violence, kidnappings, and destruction of property, starvation, social stigma, isolation and displacement [3].

Mental considerations in an outbreak setting: case of an Ebola epidemic: ebola disease is a highly infectious viral hemorrhagic. The mortality rate ranges between 25% and 90%with an average of about 50%. Historically, DRC has had at least ten outbreaks of ebola since 1976, with the latest in eastern DRC since August 2018 to date [6]. Diverse sequelae of Ebola disease outbreak (EDO) include physical and psychosocial complications to the patients, their families, and the entire community. The persons involved in the management of Ebola outbreaks should also be considered for mental health care [7]. The experiences of severe acute respiratory syndrome, EDO, and coronavirus (COVID-19) have shown negative effects on people´s mental wellbeing. The community norms of economic activities, social interactions, and belief systems are severely disrupted. The persons involved in the management of Ebola outbreaks should also be considered for mental health care [8].

The mental healthcare situation in North Kivu: North Kivu is a province in eastern DRC, bordering Lake Kivu and sharing borders with Uganda and Rwanda to the east. This area is larger than Belgium in total area and has a total population of approximately 10 million people. The health system in North Kivu is impaired by several factors like massive national poverty, destabilization of social services by the protracted wars, geopolitical factors, poor infrastructure, and roads. The health system is hinged on primary health care and supported centrally by the Ministry of Health (MoH) and various stakeholders like the WHO. The accessible and integrated quality health care as proposed by the MoH, with coordinated participation of the community, falls short in North-Kivu [5]. The current EDO has further put a strain on the health infrastructures, including the deaths of the already scarce health workers. Mental health services have insufficiently been catered for in the region considering the massive need for the services. There are nearly no surveillance, treatment, and outreach systems dedicated to mental health prevention, management, and promotion. There is also a lack of infrastructure and specialized human resources like psychiatrists, clinical psychologists, social workers, counselors, and community mental health workers [3]. To the best of our knowledge, there is no functional work plan that addresses mental health in a region plighted with both armed conflicts and an EDO. In view of the increasing occurrence of global pandemics like Coronavirus, it is imperative to draw up emergency, short, and long term plans to address mental health issues in abnormal situations like that of North Kivu. The mental health services are affected more than other services due to longstanding neglect and underfunding.

The need for integrative training programs: alleviating the symptoms associated with mental disorders requires treatment interventions in both mental health and primary health care settings. Integrative approaches are involved by adopting the recruitment of community-based health workers (CHW) for the purpose of providing early detection and management, care, and referral systems. The CHW should connect communities to health care services and promote mental health programs at the community level. The CHW requires training on how to conduct home visits, screening of common mental illnesses, mental health sensitization and follow-up of discharged patients [4,9]. The protective interventions should focus on identifying subgroups with the highest risk of developing mental disorders, basing on biological, psychosocial, and familial risk factors. Grounded on the WHO policies of comprehensive psychological assessment, the structured intervention will improve the early detection of mental health problems. The mental health services require cooperation and integration between the community, primary care providers and specialized mental health workers. Creating grassroots associations in the affected community is a viable strategy to increase mass mobilization. Well-oriented management of mental disorders should be targeting the reduction of premature death, disability and the prevention of the relapse of existing mental disorders. The importance of the psychosocial approach in war and disaster settings remains helpful to face community resistance [1,3]. Delivery of mental health services should put into account the challenges of; shortage of well-trained health workers, a poorly motivated workforce, and poor health infrastructures and systems. These measures are further challenged by very inadequate financing of mental health services at the primary health care level [4, 9].

Proposed solutions to problems of integrative mental healthcare: majorly, the main problems are constituted by the poor awareness of mental health problems, inadequate mental health resources, and exposure to both the war and Ebola epidemic..To face these problems, the proposed strategies could include but not limited to advocacy, mobilization of stakeholders, task shifting, provision of psychosocial emergency care, and community outreach.

Advocacy and social mobilization: the advocacy for the alleviation of mental health problems in areas experiencing both war and infectious pandemics amplifies the voices of the affected communities. The awareness of the short- and long-term psychological consequences of conflict and outbreaks should be explored through clear communication by various means like; radio programs, flyers, leaflets, physical meetings, social media, and the internet. The advocacy programs should also cover topics of mental health-seeking behavior, the need to establish peer or social support groups, and the need for emergency mental and routine health services [4, 9]. The applied strategy of advocacy will require the involvement of the MoH of DRC supported by its local and international partners. Various stakeholders can play a role in addressing the mental health challenges of those areas. These include the native communities; local, federal and government leaders; rebel and government armed forces, Non-government organizations (NGO), religious and cultural leaders, plus international partners [4]. All these important persons and organizations have an important stake in the cause, management, and prevention of mental illness in North Kivu. Their intellectual, financial and organizational capabilities should, therefore, be harnessed under one organizational umbrella. The leadership composition should be all-inclusive and its objectives plus responsibilities clearly stipulated. Mental health preparedness and response interventions in conflict and epidemic settings require important explanations for the affected community.

Task shifting: the problem of limited human resources who are specialized in mental health can be mitigated through “Task shifting”. This is done by integrated training of community health volunteers and primary health care practitioners on the basics of mental health. The training should pay more emphasis on mental illnesses linked to the war and EDO. It also requires setting up referral systems that link the persons identified by the community health volunteers to specialized mental health care [10]. The first responders during emergency conditions such as the International Community of Red Cross, Medecins Sans Frontières, WHO, United Nations, European Union, e.t.c need to also routinely integrate screening of mental health problems and refer the affected persons to these established specialized centers. Expected outcomes include addressing the provision of basic needs to enable positive coping mechanisms; social support and emphatic behavior of mental health workers [4].

Provision of emergency mental health services: these communities are constantly exposed to severe psychological and physical trauma that calls for immediate psychological intervention. These situations may include witnessing or experiencing rape, death, torture and other situations that make the victims feel very helpless and hopeless. These early interventions are in the form of psychological first aid and are aimed at giving psychosocial support to the victimized person at the earliest time possible. This emergency intervention reduces the chances of exposed persons from developing a severe mental illness like post traumatic stress disorder in the future. This emergency psychological intervention can be taught to various community health volunteers, religious and cultural leaders through the task-shifting program above [9].

Community outreaches: community outreaches are also an important component of the management of mental illness in an area like North-Kivu where the conventional health systems fail to capture or follow-up on persons who need mental health services [4, 9]. The community outreaches serve the purpose of surveillance of mental illness in the communities, to provide care to the vulnerable populations (i.e. very sick, elderly, refugee camps), and to treat old cases of mental illness that cannot reach the health center due to infection quarantines or war. The analysis of social stigma, public misinformation, and mental risk behavior should be applied to remove the barriers to health-seeking among the survivors of war and infectious disease outbreaks. Community protection and reporting systems against different psychosocial stressors like gender-based violence; sexual abuse, physical maiming, and psychological torture should be included in these programs [1]. Emotional and physical support may be key to providing good communication during emergencies, monitoring the stress and reinforcing early management.

Conclusions     

Prolonged wars and highly infectious epidemics are very distressing to the affected community. The chain of psychological distress may lead to an assortment of mental health problems. This article highlights the application of an integrative public mental healthcare approach in North-Kivu, a region devastated by war, EDO, and now coronavirus pandemic. The proposed strategies could include; advocacy and social mobilization against mental illness, expanding the mental health workforce through task shifting, the, establishment of a specialized mental health center, and community outreaches. These interventions should be spearheaded by the DRC government in conjunction with local and international partners. The programs should put into consideration the biological, psychological and social aspects of mental illness. We envision integrating mental health services into the primary health system, with a future aim of setting up a specialized mental health facility in the region. In view of the multiple challenges in North-Kivu, it is crucial to develop mental health systems for the management of psychological emergencies, surveillance of mental illness in the communities, and capacity building of specialized and non-specialized personnel through training.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All authors designed the study, wrote the initial draft, contributed to this study and read and approved the final manuscript.

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