Orphans in post-conflict Liberia: Seeking care in fractured communities

Abstract

Orphans in post-conflict settings have unique needs that have not been well-characterized. In post-conflict Liberia, maternal orphans are more likely to be without care than paternal orphans. This study examined the experiences of maternal orphans in Liberia, as they attempted to care for themselves and seek care from others, and the barriers they faced. Indepth interviews were conducted with 75 post-conflict Liberian orphans. We performed a secondary narrative analysis of interview transcripts from all maternal or double orphans (n = 17). We identified similar elements across narratives: traumatic loss, disconnection from family and community, and the desire for a savior. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing. Sex also played a role in the provision of caregiving; substitute care was provided by women. Findings highlighted the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions are needed to improve access to mental health care, sober communities, housing, and education support. The need to integrate these services into indigenous institutions and address barriers related to stigma is explored.

Introduction

There are approximately 132 million orphans worldwide (UNICEF, 2015); sub-Saharan Africa (SSA), which accounts for 14% of the world’s population, has an estimated 56 million orphans (UNICEF, 2013), over 40% of the global total. Much of the available data on SSA orphans come from those who were orphaned by HIV and AIDS, who are commonly cared for by extended family networks (Abebe & Aase, 2007; Evans, 2005). These orphans experience frequent neglect, abuse, and exploitation at the hands of substitute caregivers and perceive inferior treatment compared with the caregivers’ biological children (Ansell & Young, 2004; Cluver & Gardner, 2007; Morantz et al., 2013), all of which puts them at even greater risk for mental health problems, including depression and suicidal ideation (Cluver & Orkin, 2009; Cluver et al., 2007, 2008).

Post-conflict orphans in SSA face many of the same challenges as HIV orphans, related to poverty and stigma, in addition to unique factors related to war. War normalizes violence, contributing to the persistence of violence in the post-conflict setting (Panter-Brick et al., 2011). Family violence is associated with worse mental health outcomes among post-conflict youth (Panter-Brick et al., 2011). Positive family relationships and community engagement, including school attendance, can protect mental health following war exposures (Betancourt, Agnew-Blais, et al., 2010; Betancourt, Brennan, et al., 2010; Betancourt et al., 2013). Unfortunately, in many cases war destroys the extended family networks and community institutions to which orphans would otherwise turn (Betancourt et al., 2013; Muller et al., 2017).

Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war characterized by ethnic killings, sexual violence, and the use of child soldiers. More than 250,000 people were killed (BBC News, 2018) and nearly a million were displaced, of a total population of 3.5 million (LISGIS, 2009). In 2008, five years after the war ended, there were an estimated 340,000 orphans in Liberia, 18% of the total child population of the country, and many more children were separated from their families (LISGIS, 2009). It is estimated that an additional 6,000 Liberian children were orphaned by the Ebola epidemic of 2014–2015 (Collins, 2015).

The Liberian Ministry of Health commissioned the development of a national mental health policy, and the Liberia Needs Assessment Survey was conducted in 2009 to inform the policy. It sought to characterize and quantify the mental health burden of the war on the children of Liberia (Borba et al., 2016; Levey et al., 2013). Key informants including teachers, clinicians, and public officials were asked to describe the most emotionally disturbing events or experiences to have affected young Liberians. Orphans and homeless youth were recognized as needing both housing and care; recommendations included state invervention to provide foster care as well as institutional care (Levey et al., 2013).

In a previous study, we explored the impact of the loss of a parent or other primary caregiver on psychosocial health and daily functioning. The sex of both the parent and child was linked with psychological functioning in orphans. Most paternal orphans were cared for by their mothers, whereas maternal orphans and double orphans were frequently homeless or experienced abuse or neglect from substitute caregivers. Furthermore, while male orphans more commonly found themselves without substitute caregivers and reported feeling alone, female orphans were frequently pressured by caregivers to engage in transactional sexual relationships (Levey et al., 2017). These findings highlighted maternal orphans (including double orphans) as a high-risk group and illustrated some of the adverse conditions they face.

The present study represents a sub-group analysis of interviews with post-conflict Liberian youth; it concentrates specifically on maternal orphans. The aim of this research is to examine the narratives of high-risk orphans to determine how their experiences of trauma and loss during the war have shaped their ability to care for themselves and seek care from others and to characterize the impact of barriers imposed by the post-conflict environment.

Methods

Participants and procedures

The methods for the aforementioned study focused on post-conflict Liberian youth have been described in detail in a previous publication (Levey et al., 2016). Briefly, a convenience sample of 75 adolescents (38 girls, 37 boys) ages 13–18 were recruited from schools and community centers in Monrovia, Liberia in 2012. Semi-structured interviews were conducted in a private setting for approximately one hour each. Participants were asked about school, family, peers, war experiences, and future plans. The interview guide was reviewed after each interview to refine and deepen the questions. Interviews were conducted by the principal investigator together with a Liberian medical student, who acted as a linguistic and cultural interpreter (Levey et al., 2016).

Interviews were digitally recorded, and notes were taken by the interviewers regarding participants’ affect and nonverbal communication. The interviewer reviewed the notes and recordings after each interview, compared it to the previous interviews, and revised the interview guide until theoretical saturation was reached (Hennink et al., 2011). The interviews were transcribed verbatim by Liberians living in the United States; transcribers annotated transcripts to provide context for local words or phrases. Oversight, guidance, and approval were provided by the University of Liberia Institutional Review Board (IRB) and the Partners Healthcare IRB.

Primary analysis

A directed content analysis was employed (Hsieh & Shannon, 2005), based on the existing body of literature about factors impacting resilience in youth. The data were coded thematically by a team of four coders, with at least two coding each interview independently (Levey et al., 2016). The interviews highlighted a number of individual characteristics that were associated with resilience in the overall study population, including emotion regulation, cognitive flexibility, social intelligence, agency, and meaning-making (Levey et al., 2016, 2018). The interviews also supported the crucial role of early caregiving relationships in promoting resilience (Levey et al., 2017).

Secondary analysis

Of the 75 study participants, we identified 28 orphans; of these, 17 were maternal or double orphans, which we refer to as the “high-risk” group. Using the coded data available from the prior study, we conducted a secondary analysis to examine and compare sociodemographic and behavioral characteristics among non-orphans, paternal orphans, and “high-risk” group orphans, 15 of whom became homeless or suffered abuse, neglect, or exploitation at the hands of a substitute caregiver. Narrative analysis was then employed to examine each of the 17 interviews for multiple layers of meaning (Riessman, 1993, 2012). The transcripts were broken into stanzas and examined for narrative structure, flow, and intention of the narrator. This process led to the identification of the common narrative of trauma, disconnection, and wish for a savior. These themes, which had been previously identified and coded in the prior study, were noted to be more prevalent in the high-risk group.

The narratives of six participants from the high-risk group were then selected for presentation in this manuscript. These particular narratives were selected to illustrate the diversity of the experiences among this group and for the exceptional level of detail provided about their life experiences. Portions of the interviews (narrative excerpts) relevant to the aims of this study were identified. Each excerpt was analyzed in the context of the entire interview and the aggregate content of other interviews within this subgroup in order to explore both explicit and implicit meanings. The names used are pseudonyms, and identifying information has been redacted from the interview data to protect confidentiality.

Findings

Descriptive data

Of the 84 youth who volunteered for study participation, 78 (93%) met inclusion criteria; six were over 18 years of age. Seventy-five (96%) of those who met inclusion criteria completed the study; three expressed initial interest but did not return to be interviewed. The descriptive data presented here were extracted from the findings of the primary analysis. Of the youth who were interviewed (N = 75), 28 had lost one or both parents (11 paternal; nine maternal; eight double orphans); of these, 17 (n = 8 girls and n = 9 boys) met criteria for the high-risk group. The rate of drug use in the high-risk group was more than double that of the overall study population. Out of a total study population of 38 girls, 13 (34%) reported engaging in transactional sex, including prostitution or an ongoing sexual relationship for promised financial support, or being pressured to do so. Nine (69%) of the 13 orphan girls and seven (87.5%) of the eight girls in the high-risk group experienced this. No boys reported engaging or being pressured to engage in transactional sex. Among the high-risk group, 38% reported violent behavior; no other participants did. Table 1 summarizes these findings.

Table 1.

Demographic and behavioral risk data.

	Total	Drugsa	Sexb	Violencec
All participants	75	15 (20%)	13 (17%)	6 (8%)
Non-orphans	47	6 (13%)	4 (9%)	0
Orphans	28	9 (32%)	9 (32%)	6 (21%)
Paternal orphans	11	2 (18%)	2 (18%)	0
High-risk group	17	7 (41%)	7 (41%)	6 (38%)
Maternal orphans	9	1 (11%)	3 (33%)	2 (22%)
Double orphans	8	6 (75%)	4 (50%)	4 (50%)

^aNumber of participants who reported using drugs regularly.

^bNumber of participants who reported engaging in or being pressured to engage in transactional sex.

^cNumber of participants who reported engaging in violence or other criminal behavior to survive.

Table 2 illustrates how many participants were housed, employed, attending school, and had a supportive person in their community. Two-thirds of high-risk orphans were homeless, which left them vulnerable to sexual exploitation and was also associated with lower rates of school attendance and community support.

Table 2.

Community engagement and social functioning.

	Total	Housinga	Jobb	Schoolc	Communityd
All participants	75	62 (83%)	31 (41%)	46 (61%)	33 (44%)
Non-orphans	47	42 (89%)	22 (47%)	34 (72%)	20 (43%)
Orphans	28	20 (71%)	9 (32%)	12 (43%)	l3 (46%)
Paternal orphans	11	9 (82%)	4 (36%)	7 (64%)	6 (73%)
High-risk group	17	11 (65%)	5 (29%)	5 (29%)	7 (41%)
Maternal orphans	9	8 (89%)	4 (44%)	4 (44%)	4 (44%)
Double orphans	8	3 (38%)	1 (13%)	1 (13%)	3 (38%)

^aNumber of participants who reported stable housing.

^bNumber of participants who reported regularly engaging in income-generating activity.

^cNumber of participants who were enrolled and regularly attending school at the time of the interview.

^dNumber of participants who connected with a supportive person in their community.

Thematic data

In our secondary narrative analysis of the high-risk group, we identified a master narrative: traumatic event followed by disconnection and the wish for a savior. All interviews from the high-risk orphans contained a traumatic event and a wish for a savior, and 15 of 17 contained an experience of disconnection, with the exception of two participants who remained with their fathers following the deaths of their mothers. Of 11 paternal orphans, only one had all elements of this narrative. By definition, all of the orphans had experienced a traumatic event: the loss of one or both parents. For the majority of the high-risk group, the loss was followed by a sense of disconnection from a stable caregiver (n = 15). Nearly half of this group experienced disconnection from their communities (n = 8), and several were homeless (n = 6). Finally, they described their ideas of how they would escape from these difficult and painful circumstances with the help of a wished-for savior. The wish for a savior was present in every interview in the high-risk group, but it took different forms. More than half of the high-risk group believed they needed someone to rescue them (n = 9). The rest (n = 8) also wanted to find someone who would help them but had ideas about how to help themselves.

Traumatic event.

Each participant in the high-risk group described the loss of one or both parents. In some cases, this loss had been sudden: “The rocket killed my father and my mother instantly.” In other cases, parents suffered a protracted illness before finally succumbing, and participants described the experience of knowing that their parents were ill and dying. Following the death of a parent, participants experienced grief and loneliness: “I feel discouraged because I am a lonely human being.”

Some participants also related additional traumatic experiences that occurred both during and after the war. These included being captured by fighting forces, being physically abused, and being sexually exploited. One male participant who was captured by fighting forces recalled being beaten and drugged. A female participant who was living with her aunt received inferior treatment compared to the aunt’s children. The aunt’s children teased and insulted her. When she tried to defend herself, her aunt “knocked [her] with a [cooking] stick on [her] head,” requiring stitches.

Disconnection.

During the war, communities were destroyed and families were separated, so children often found themselves alone. Because so many children were being separated from their families at once and amid such chaos, they turned to one another, forming their own peer communities. Together, they learned to support themselves by engaging in transactional sex, and, often in exchange for sex, they obtained shelter and drugs. Homeless youth in these communities referred to where they lived as the “ghetto.” After the war ended, schools and churches reopened, and community institutions reconstituted. Young people in the ghetto quickly found that they were not “part of society,” as several participants reported.

This separation was conveyed with imagery of cleanliness and dirtiness. Youth in the ghetto were often physically dirty because they lacked access to places where they could bathe and wash their clothing. They believed they were contaminated by the drugs and needed to be taken to the hospital and given treatment in order to be cleansed: “I want to be normal because I am not normal right now. I have drugs mixed up with my blood.” Girls in particular were also identifiable because they were “wearing short things,” which suggested that they were engaging in transactional sex, which is considered dirty, both morally and because of the risk of contracting sexually transmitted infections (STIs). In this way, being a part of the ghetto community left them outside the “normal” community. They expressed shame and a sense of isolation, and above all, a feeling of being stuck.

Wish for a savior.

Unable to envision a way out of this trap, high-risk orphans frequently expressed a wish for someone to rescue them. This fantasy appeared to be fueled in part by the many foreign aid workers who have come to Liberia since the war ended. Participants described surrendering control of their lives to someone else in order to stop using drugs and leave the ghetto, similar to the way that they have surrendered control to the drugs. As one boy explained, “I think the best thing to do for us is to take us somewhere that we will go for two to three months and clean out the drugs from my system.”

High-risk orphans who were not living in the ghetto also expressed a wish that someone would support them financially, but they were more actively doing things for themselves, like connecting with “Old Mas,” who serve as maternal figures in their communities. They were not able to fix all the problems the orphans faced, but they made them feel that they were not alone with their problems: “I can call my aunty, and I called her aunty because when I have problems I can go to her.” These relationships provided them with emotional support and some sense of enhanced financial security. Participants described doing chores to help these women and sometimes giving them money. In exchange, the women would feed them and welcome them into their homes. As one boy explained, “If I don’t even go to hustle [make money], she can give me food to eat.” While goods and services are exchanged, the relationship is not purely transactional but also conveys a sense of care.

Narrative data

Among the six participants whose narratives are presented below, three were unhoused, two were living in marginal housing without a caregiver, and one was being abused by her caregiver. The participants also expressed a wish to be rescued, but they differed in their conception of a savior: 1) Two boys had Old Mas to whom they felt connected; 2) Two girls had supportive relationships with younger women but faced threats from others; 3) There was a boy and a girl who had encounters with aid organizations and were waiting for the aid workers to return and save them.

Feeling supported: Stories from Bernard and Christopher.

These two examples illustrate the exceptional nature of the experiences of orphans who are able to make connections and the challenges they still face. Bernard is an 18-year-old homeless boy with no formal schooling beyond kindergarten. His parents were both killed during the war when he was about six years old. After that, he was recruited by fighting forces. After the war, he was living in the “ghetto” and using drugs and got arrested for a crime he did not commit. His crime was being disconnected; he was living in the ghetto and had no one to defend him. In jail, he had to stop using drugs and had the opportunity to establish new connections.

After I lost my father and mother, I went astray […] I was at the creek to get water and when I came back, I [found] the entire house on fire and my mother and father dead. I [stayed] in the town until the men captured the town. They wanted to kill me, and one of them said no, so when they went in the house and saw my parents’ bodies, they decided to take me with them […] I was a child soldier. I don’t know [if I killed anyone], but we exchange[d] bullets […] So when I started to grow up, I just feel that I don’t have any family in my life. I can feel like paying back and doing bad things to others for what they did to my parents. I don’t have mercy on people because at the times I did not know who killed my parents. So anyone I see I executed them […] After the war, I started to think about my parents. I was thinking that now that the war is over, who I will go to? Nobody.

After his parents were killed, Bernard “started to grow up,” and became aware of feelings of loss, anger, and a desire for revenge. He felt “like paying back and doing bad things to others” as a child soldier. After the war, he could no longer fight to distract himself, or feel connected to them by avenging their death, and feelings of missing his parents returned. He felt lonely and began using drugs. He was then arrested and taken to jail:

We were caught in the ghetto and were caught for a crime that someone [else] committed, so we were arrested and all the crimes were on us. People who had family got them out, but I stayed there because I had no one. My legs were getting paralyzed, and even now my eye sight [is] dull. […] I was sick and taken to [hospital name]. One woman from [aid organization] was the one that saw my condition and asked about my parents. And when I told her about my parents, that they were dead, she felt sorry and ran after [pursued] my freedom […] God made it so I can go to jail so that I can stop smoking. I stayed in the streets because I have no family. I started to take drugs, but after I had the problems and I went to jail, I decided to leave the drugs because I knew that the drugs were not good for me.

Going to jail forced him to stop using drugs. While he endured extremely rough conditions in jail, he also experienced care for the first time. He makes meaning out of the experience, believing that God sent him to jail to help him stop using drugs. He stops using drugs because they “are not good” for him, and he starts to feel that taking care of himself matters, after he receives care from the woman who procures his freedom. However, he continues to feel lonely and to seek help:

The Old Ma that I give my money to keep, she can cook and give me food because when I come from hustling I give her money. If I don’t even go to hustle she can give me food to eat. All her children in the house have high respect for me while I have the same respect for them […] You know, as a child, your parents are no more, so that human and motherly feeling isn’t there all the time.

Bernard has an “Old Ma” who helps him. When he has money, he gives it to her and she feeds him; when he has no money, she still feeds him. He has found someone who takes care of him. This is a source of comfort but also a reminder of the loss of his own mother and the “motherly feeling” he had for her.

Christopher is a 16-year-old boy who works to pay for his own apartment. During the war, he was separated from his parents at age nine and captured by rebel forces who tried to recruit him, but he was able to escape. After the war, he learned that his mother was dead, and his father was seriously injured. He had been an outstanding student before the war, skipping two grades. Since the war, he has been supporting himself with occasional assistance from his uncle. He has been able to return to school but has had to leave school on a few occasions when he has not had enough money to pay the fees. Christopher has not become as disconnected as others, but his connection is tenuous. Christopher describes being captured by fighting forces during the war:

During the war, […] when they captured us, they beat us and [put] cigarettes in our mouth. They force us to go so they started to beat us. They gave us cocaine. I threw it out of my mouth, and that was how they started beating me and saying you have to smoke it. […] After they put the cigarette in our mouth, they beat us and they did not give us anything again. They kept us there for one day, and that was the next day they were about to carry us. They carried people who did not know anything about guns so that was how plenty people was dying.

Christopher was separated from his parents, kidnapped, drugged, and beaten. He never saw his mother again. Christopher describes these events in vivid detail. While the events were clearly traumatic, he is trying to make sense of them when he explains that so many people died because “they carried [took] people who did not know anything about guns.” By this he means that the untrained child army led to greater casualties. He was able to escape, but then he was alone. He learned later that his mother had died and his father had suffered a spinal cord injury:

I was just on my own now because I had nothing to do at that time. So I was just sleeping under market tables and passing around. When I help somebody to work, they will give me money, and then I will buy food so that I can eat. My uncle helped me with some money to help to support me. But the first money he gave me, I started with business first, and when I got small profit I decided to go school. […] But really it is hard. Because when I think about it, it pains me so that is why I keep myself busy.

Christopher has learned that staying busy helps him to avoid being overwhelmed by traumatic memories: “Because when I think about it, it pains me so that is why I keep myself busy.” He has learned to take care of himself in many ways and has also found comfort in an “Old Ma” who helps him:

One time she was getting in a car and I helped her to put her load in the car. She showed me her house because I explained some problems to her so she told me when I need help I should go to her house. […] She can help me with food and sometimes money. But she herself she doesn’t have it, but she can still help me. […] I can tell her [if I feel bad] because she is free with me and she said anything I should tell her. She can encourage and say one day this condition will change.

Christopher can go to this woman for material help, when he needs food or money, and he can also go to her for emotional support and encouragement. The fact that she helps him although “she doesn’t have it” herself is meaningful and makes Christopher feel that she truly cares. Nonetheless, he struggles financially and worries about his future:

Sometimes I can ask myself if God hates me because people my age doing things and we serving the same God. So then I ask God why the others are prospering and we all are serving you. So sometimes I can feel bad and think that there is no God sometimes. But when you go to church the pastor will say you should not think that way because everything has time. Maybe it is not my time for God to bless me, so I continue to praise God.

While Christopher is working to support himself and pay his educational and housing expenses, he worries that if he is not able to earn enough money, he will have to leave school. He is able to remain hopeful by giving his suffering a particular meaning; it is not that God wants him to suffer but that his time to prosper has not yet come. His relationship with God is not one of passive waiting but rather of active engagement and ongoing struggle to understand.

Limited support: Stories from Ellen and Frances.

These two vignettes illustrate the experiences of girls who had supportive connections but lacked the resources to protect themselves from threats to their health and safety. Ellen is a 15-year-old girl who lives with her maternal aunt. Her mother died during the war when Ellen was very young, and her father died two years ago. Her aunt treats Ellen differently from her own children. She withholds food, forces her to work, and tries to pressure her into transactional sex work. She has also been physically violent. Ellen wants to leave and prays for God to send a savior. Ellen describes painful memories of feeling loved by her father and then losing him:

He used to buy things for me when he comes from work, and now I have no one to do that for me again. […] Before he got sick he used to explain to me about my mother. He said they were together and when they went to [another neighborhood] and that was where my mother died. So that was how he took me and carry me to her sister’s place. He said my mom was easy and good. He also said she used to love friends and did not like confusion [conflict, fighting].

Ellen has few memories of the war; it is in the post-conflict period that she has lost her father and experienced daily threats, physical abuse, and neglect by her aunt:

If [my aunty] asks me to wash the dishes and I say I am tired, she will not give me food sometimes. When she is washing I can help her, but she can want me to follow my friends on the road to go and hustle [prostitute]. But I can tell her I am not able to do that. So when I say I am not able to do that sometimes she gets mad and starts to talk to me.[…] So she can say all your friends are going on the road to hustle but you are just sitting here all day. I have a friend and she can tell me that some of the men have sickness and that I should not follow any friend to go on the road. […] [My aunty] has one boy in the yard, and she ask him to cut my hair. So after that she went and bought dye, and I told her I didn’t want to put dye in my hair. But she forces me and cut my hair, and she put the dye there. And then when the girls were going on the road at night she told me to follow behind them. I said I was not following them, so I went to my friend’s place and stayed there for two days before I came back home.

Living with her aunt, Ellen faces constant pressure to engage in transactional sex. Her aunt withholds food, telling Ellen that she cannot afford to take care of her if she is not earning money. She even cut and dyed Ellen’s hair to make her look older. Ellen believes the only way to protect herself is to leave, but she has nowhere to go:

I think that in the future God will send somebody to help me. I can go to church, the same church my father used to go to. The pastor can talk to me. My father was an usher in the church. I told them [about my aunty], and they said they will help me to look for room, and they will pay my rent, but it’s hard to find a room. It will be better to live on my own. Because I am not pleased where I am.

Ellen locates her hope for a savior in her belief in God and her relationship to her pastor. These have special meaning for her because they are associated with her memory of her father.

Frances is an 18-year-old girl in an unstable living situation who has faced ongoing trauma and disconnection as well as offers of help from saviors. Her mother was mentally ill throughout her childhood. After the war, there was a period when her mother became increasingly confused, and her behavior was bizarre. She eventually died of a seizure. Her father remarried and distanced himself from Frances and his other children. Her brother found her a place to live with his mother-in-law, but then she died and Frances was left in the house with only strangers. During the war, soldiers used to come into her village at night and rape women and girls. She and her family would leave the village in the evening before the rebels came and return after they left. Since the war ended, Frances has not felt any safer. An older man in the house has approached her for sex, and she thinks he may try it again. She has a boyfriend at school. He has not asked for sex, but she wonders if he will. There is a neighbor woman who has offered financial help, but Frances feels alone emotionally. Frances describes what it was like to live with her mother:

My mother was sick. She used to talk by herself, like to say the person going mad. […] No good talking from her mouth. Anybody talk, she jumped in to fight you, cheek you up [disrespect you]. So we not used to go close to her.

Her mother was not like a mother; she could not “go close to her.” So when she died, Frances lost a mother she never had. Her father remarried, and then she also lost his support. After her mother died and her father remarried, he would not “look at his children.” He did not want her to go to school, so in order to go, she had to do it herself. Indeed, Frances has to do everything herself. She is alone, with no one to protect her from exploitation or abuse:

That one papay [old man], that the same, in our house that one man wanted to try it there. He was trying. Each time he can send me to buy something for him. If I bring the something I give it to him, he says I should enter, he can close the door. That one he used to do it. Sometimes he used to tell me say that after school if I come, I should take [off] my uniform, I shouldn’t wear no clothes. I should go to him inside. He used to tell all that one. […] Right now, I can say I not worry, because right now if he try it, meaning I will call police on him. When he comes and try it again. But I sure he come back he can’t try it again.

After telling the story of this man threatening to rape her and no one helping her, she ends by affirming that she can keep herself safe and take control of the situation by calling the police, another imagined savior. She also accepts help from others, but she worries that being indebted could compromise her agency:

I can say right now, [there is] one boy who is helping me. And he want me as his girlfriend. But any, right now anything I ask him he can take it and give to me, he can help me. […] Right now, as he give it [money/help], I can feel fine because I not getting it for myself. If he can wait I finish with school, no problem. Then two of us we can make it. But if he can’t wait, then myself I can’t make it right now. […] But one day he not tell me say come let’s do this one [sex] so I can give you this money. He never tell me yet. So I like his ways, his behavior, right now I like it. He can make me happy.

Frances sees the possibility that she cannot depend on this boy, that he will expect sex, but she has no other options. As she says, “I not getting it for myself.” She needs his help, despite the risk. When a woman in her community offers help, she accepts this as well:

That one girl to our house there […] If I washing my clothes, I can tell her to bring her clothes, I wash it. She sent me some. Right now, what she want me to do I can do it. So I came here now, she say any amount they call for in this school here, I should tell her; she will pay it. […] That’s how come I say, “No problem. Anytime you get any work, just call me. Send for me. I will come help you so we can do.” So I take her as sister and mother. So anything happen to me, that she the one can be the first I can tell before I can tell anybody.

This woman is a kind of savior; she helps Frances take care of herself by bringing her work. Frances also feels supported emotionally. She says that this woman is like her “sister and mother” and that she can tell her anything. Later, when asked what she does when she “feels bad,” Frances says: “If I’m feeling bad, I can tell nobody. I can be inside whole day crying. They can ask me, I can say nothing happen. I can’t explain it to them.”

Potential saviors offer to help Frances. Frances accepts help out of necessity, but in this post-conflict setting where resources are scarce, she worries that anyone who offers to help her must want something in return—most likely sex—which could threaten her health, her freedom, and her pursuit of education. While she wants a savior, she also doubts that such a person could exist.

Waiting for a savior: Stories from Abraham and Diane.

These two vignettes are examples of orphans who are unable to access the support they need. Abraham is a 17-year-old boy who is homeless. His parents were killed during the war when a rocket-propelled grenade hit their home. Abraham began using drugs to escape this traumatic loss, often stealing to support his habit. The rest of his family then disconnected from him. He received money from an international organization but no other assistance. He spent the money on drugs and then had to leave school. He explained how he felt when his parents died:

I was shocked, because I used to love my father and mother, to hear that they were dead. […] I was small, but I remember my mother used to hold my hand for walk, and my father used to take me sometimes to his working place. But since the war I have been with friends from ghetto to ghetto trying to survive. […] And through friends I started smoking drugs, and that’s how I just got used to it. My sister did not have anything to cater to me, so I started to go from place to place and stealing. Anywhere I go I have to steal. […] I have brothers and sisters, but no one cares about me. They say I am on the street so I can’t see them.

Abraham draws a dramatic contrast between his life before and after the traumatic loss of his parents. He speaks about holding his mother’s hand, an image that recalls the “motherly feelings” described by Bernard. There was no one to “cater” to (take care of) him, so he had to steal. Using drugs was a way of coping with grief and loneliness, as well as making friends. He was using drugs and stealing to support his habit, which led his siblings to sever contact. In this way, he is saying that he uses drugs because he lost his parents, and he lost the rest of his family because he uses drugs.

Some organization came and gives us money. So I got a room with my friend, but [when we ran out of] money we started to sell all the things including the mattress, and we started doing the same drugs again. If you don’t have money and you want to take drugs, you can want to sell your own brief on your butt just to take in some drugs. So we are praying to God that one day we can leave the drugs. […] They gave us US$150 just to re-establish ourselves, but since they gave us the money we haven’t heard anything. […] When will you people really come and help us? Because lots of time people come here and ask us these same questions and say they will come and take us to hospital and they can’t [don’t] come back.

Originally perceived as a solution to loneliness, drugs became a problem. Addiction has taken control of his life; Abraham believes he needs a savior to take control and help him get treatment for the addiction. He received US $150 (enough to pay for school fees and living expenses for several months) that was meant to help him return to school, but he spent it on drugs. He asks the interviewer, another potential savior, “When will you people really come and help us?”

Diane is a 15-year-old girl who is homeless. When she was not more than six years old, both of her parents were killed in front of her during the war, while she hid in the ceiling of their home. Diane was taken in by a woman, but she did not feel cared for by her. She had to sleep on the porch and was not fed consistently. The woman did not send her to school, although she sent her own children, so Diane eventually left. She joined friends who were engaging in prostitution and using drugs. Now she wants someone to help her stop using drugs and go to school. Diane describes watching as her parents were killed:

My mother had [my brother] under her, and the rebels enter and killed [my parents], and when they look under the bed my brother was there. They carried [took] him, but they did not kill him in front of me. I heard the gun sound and my mother yelled. When my mother yelled, they shot again, and I heard my father’s voice. […] My mother feelings make me to think about it; when I see my friends and their mother I think about it. I can still remember her face and her whole body can come in my eye, and my father. I remember when you put me up in the ceiling before the rebels came and told me not to come down.

When she relates the events, her posture stiffens and her gaze becomes distant, as though she is being transported in time and space and re-experiencing the events as she speaks. She says she can still remember her mother’s face, and then she misspeaks, saying, “I remember when you put me up in the ceiling.” “You” suggests she is talking to her parents rather than to the interviewer. Like Bernard, she talks about her “mother feelings,” suggesting the pain and vulnerability she felt losing her parents as a young child in the middle of a war. After they died, she was alone until a woman offered that Diane could live with her:

I did not have anybody; I was passing around. She was passing with her children and she asked me why I am sitting down there, and I told her I did not know where my people were. I told her my mother and father died. So she said come and follow me, and that was how I followed her. […] I left because she was not sending me to school and sending her children to school. And when I go to play, when she cooks, she will not take out food for me. She never used to treat me good. […] So my friend came and said you can’t be sleeping here and this woman treating you like this. So that was how I went to my friend. […] I never knew that she was bringing me to the ghetto. So that is how I have been there and smoking drugs. When I was staying with [the woman] it was better. I decided to leave the street and go back to her, but she is not there [anymore], and she didn’t tell anyone where she is living.

Diane feels she has no good choices. She was living with a woman who was not taking care of her. She realized that being homeless in the “ghetto” was worse, but there is no way for her to leave. She has a rash on her hand, and she explains that she must engage in transactional sex in order to afford medicine to treat the rash:

These few days I don’t know what kind of sickness coming on me, and it’s right on my hand. Sometimes I go on the streets and look for men to pay me, and then I go buy tablet and take it. I look for men to have sex with me and pay me to buy medicine. Every blessed day I do that. […]Some people don’t like condoms so they love to do flesh to flesh, and we can’t say no because we don’t want them to carry [leave with] the money, so we say yes. […] I like the condoms because I don’t want to get sickness. I don’t want to get AIDS or infection.

Diane has to have sex with multiple men every day in order to earn enough money to survive. She explains that “anything the man decides, that is what we will go by because he is the one bringing the money.” She has unprotected sex in order to afford medicine for the “sickness” which has affected her hand; she then worries about contracting STIs. She prays for someone to rescue her, but she cannot go to church because of the “short clothes” she wears. Diane explains that “it is not good to carry [wear] short things like this to church.” Her clothing signals that she is engaged in sex work, which keeps her disconnected from community institutions like church. Instead she prays alone for a savior:

I am praying to find someone to take care of me, and I will leave the ghetto because I was not born in the ghetto. […] I want someone who, even if they don’t have money, but to help me to leave the drugs habit, and I will be happy to move from in it. […] [Drugs] can remove the worries from me because I was worrying too much. I was worrying about my parents because none of my [relatives] have come out to look for me, so I started to smoke, not worry, and I did not worry again. […] One woman came here and said that she was coming back, but since then she didn’t come back. She was also a white woman. She came and gave me money and said that she will come back but since she went she never came back.

Diane describes how using drugs took away her worries after her parents were killed. She became dependent on drugs to regulate her emotions and now worries that the drugs have changed her body. She wants someone to help her so she does not need to rely on drugs to manage her worries. Diane explains that a white woman, like the interviewer, came to her before. She said that she would return and help, but she did not return. Diane waits for someone from outside the ghetto, and perhaps outside Liberia, to help her.

Summary of findings

The high-risk orphans interviewed in this study described the loss of their parent(s) and subsequent distress and feelings of isolation. Some attempted to re-gain connection within their communities, while others used drugs to cope with persistent feelings of loneliness and traumatic memories. All wished for additional help from an outside savior. Those who experienced stable connections with Old Mas fared better but still experienced loneliness. In Bernard’s case, going to jail forced him to leave the ghetto and stop using drugs, and a chance intervention by an aid worker was what freed him. Christopher had unique confidence from early success in school as a young child, but he has struggled to stay in school. Although he has emotional support from an Old Ma, his financial situation is precarious. He faces the constant risk of homelessness and being forced to drop out of school. Ellen and Frances both face financial precarity. Without support from their families, they must depend on others who are concerned with their own interests, and as a result their agency is limited and the pressure to engage in transactional sex is strong. Abraham has been unable to regulate himself without drugs. He received money from an aid organization, but he needs a relationship with someone who can help him learn to regulate himself and cope with trauma symptoms. Otherwise he will continue to depend on drugs and the family he has made for himself in the ghetto. Like Abraham, Diane waits for a foreign aid worker who has not returned. She wants someone to help her leave the ghetto by taking control of her life. She sees no other path out of addiction and transactional sex; stigma prevents her from accessing support from substitute caregivers or community instutions.

These findings demonstrate that while there are some sex-specific differences within the high-risk group of orphans, boys and girls both struggled to find the help they needed. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. In some cases this meant more support, but respondent narratives also indicated that some were more dependent on abusive or exploitative caregivers, like Ellen. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing (Old Mas). Sex also played a role in the provision of caregiving. All high-risk orphans had lost their mothers, an indication that maternal orphanhood presents particular challenges in this context. Participants spoke about their “mother feelings,” referring to the deep sense of loss they experienced following the death of their mothers. Substitute care in the community also came from women, both formally and informally.

Participants also spoke of God as a potential savior. They engaged with God and religion consistent with their engagement with other potential saviors. For some, their relationship with God was a place to locate feelings of gratitude, anger, and worry in a way that allowed them to continue taking care of themselves as best they could. Bernard believed God had saved him by sending him to jail so he would have to stop using drugs. Christopher struggled actively with the question of why he was suffering and whether God was punishing him and came to the conclusion that he had to keep working and be patient. Others wanted help from God but had no power to act. For Ellen, her relationship with God and with her pastor connected her to her father but did not empower her to do anything for herself. Abraham and Diane, meanwhile, prayed that God would send someone to save them.

Discussion

Liberian orphans in this study described their experiences of trauma, disconnection, and a wish for a savior. While some were able to connect with parental figures in their communities, others sought connection with groups of youth who were engaged in substance use and criminal activity, further isolating them from their communities due to stigma.

The interaction of material, social, emotional, and medical problems faced by the high-risk orphans is most aptly characterized by the syndemic model. The term syndemic combines “synergy” and “epidemic” to represent the interaction of multiple social and health epidemics (Mendenhall, 2012; Singer, 1994). In the case of orphans in post-conflict Liberia, the war destroyed infrastructure, disrupted social networks, and inflicted psychological trauma, creating the conditions of material deprivation and trauma symptomatology that have led to ongoing violence, transactional sex, and substance misuse. The epidemics of substance use, transactional sex, and violence have trapped these youth in a cycle of poverty, re-traumatization, and addiction, preventing them from re-engaging in their communities and identifying other income-generating opportunities (see Figure 1). Material deprivation leaves orphans dependent on transactional sex and violent crime for survival. Violence is a risk factor for transactional sex (Sileo et al., 2019), transactional sex can involve violence, and both add to the trauma burden; substance use is a way to escape traumatic memories and overwhelming emotions. Addiction then fuels the need for money to support the habit while stigmatizing users and preventing them from engaging in other work.

Figure 1.

Syndemic model of multiple social factors impacting post-conflict orphans.

Some orphans caught in this syndemic were offered material resources from NGOs, but because other syndemic factors were not addressed, they were not able to make use of these resources. Figure 2 depicts the interventions needed to address this syndemic as a pyramid. Current resources are only offering interventions that address a single level. As these data demonstrate, offering material resources alone is not effective. And yet material resources are a necessary ingredient for an intervention to be successful.

Figure 2.

Pyramid of needs for post-conflict orphans.

Some orphans were able to access social support through existing community resources, including schools, churches, and substitute caregivers, but the threat of the syndemic was ever-present. Girls were pressured to engage in transactional sex. Orphans attending school worried about whether they could afford to continue. They knew that once they left school, lost their housing, or began engaging in drug use or transactional sex, they would be stigmatized and cut off from the resources in their communities that sustained them, and they would become trapped in the syndemic. This idea is supported by the finding that Liberian students use substances, most commonly alcohol and cannabis (Harris et al., 2012), to manage the pressure of performing academically while managing other responsibilities, and those caught using substances are punished, expelled, and frequently drop out of school (Petruzzi et al., 2018; Pullen et al., 2016).

Aid organizations are engaging youth caught in this syndemic, but many are operating independently, outside a system of care. There are more than 1,000 NGOs operating in Liberia, most of which focus on health and education for women and children (Alenichev, 2018). Their offerings primarily target the top level of the pyramid (see Figure 2), leaving foundational needs unmet. This misalignment between what these organizations offer and what orphans need has been observed and critiqued elsewhere as well. Mark Schuller has written about this problem in Haiti, where NGOs are organized to be responsive to their foreign donors rather than the local community (Schuller, 2017). The foreign donors want to see tangible results demonstrating rapid return on investment, and this is not accomplished by rebuilding sustainable indigenous institutions.

Interventions aimed at post-conflict Liberian orphans need to be integrated into systems of care. The following four intervention components are needed: 1) Comprehensive mental health and addiction treatment; 2) Longitudinal support to build and sustain sober communities; 3) Financial support for basic needs, housing, and education; 4) Addressing stigma in order to re-integrate youth into their communities so they can access existing resources. The Liberian health care system has faced challenges in integrating mental health into the existing healthcare system, including weak infrastructure and limited resources (Gwaikolo et al., 2017). NGOs can offer technical expertise and financial resources to support the development and integration of these services into indigenous institutions.

There were a number of limitations to this study. First, participants were recruited from Monrovia only. Children in other parts of Liberia were not included, and the data may not be representative of their experiences. Second, there is the possibility of selection bias, as children who chose to participate may be different from those who did not. Third, the interview guide was refined after each interview. This likely impacted the number of participants who endorsed the experiences reported in the descriptive data, particularly substance use, leading to an underestimate of these experiences in the interviews conducted prior to the revisions. Finally, no collateral information was obtained from family members or others in the community, so we were not able to obtain a complete picture of their circumstances, nor to understand the perspectives of the Old Mas, and what motivates them to become involved in caring for orphans.

Conclusion

These findings highlight the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions need to address mental healthcare, the development of sober communities, housing, and education support. These services need to be integrated into indigenous institutions. Barriers related to stigma also need to be removed in order to address syndemic effects and re-integrate orphans into their communities so they can access existing resources. Future research should examine how informal substitute caregiving arrangements are negotiated. It will be important to engage the caregiver perspective regarding how they enter into these relationships and what motivates them to provide substitute care. These findings can offer insight into approaches for re-integrating orphans who currently lack care.

Biographies

Elizabeth J. Levey, MD, is an Instructor in Psychiatry at Harvard Medical School, a child, adolescent, and adult psychiatrist in the Chester M. Pierce, MD Division of Global Psychiatry at Massachusetts General Hospital, and a member of the Center for Bioethics at Harvard Medical School. She is currently the Principal Investigator of an NIMH-funded K23 Early Career Award, a pilot intervention study for adolescent mothers in Lima, Peru. Her published works focus on resilience among post-conflict youth and perinatal interventions designed to address intergenerational trauma.

Benjamin L. Harris, MD, DPM, is Professor of Psychiatry and serves as President of the Liberia College of Physicians and Surgeons. Dr. Harris worked as a consultant to the World Health Organization on the development of Liberia’s National Mental Health Policy. His research focuses on the mental health needs of post-conflict youth and the substance use patterns of Liberian youth.

Lance D. Laird, ThD, is Assistant Professor in the Department of Family Medicine at the Boston University School of Medicine and in the Graduate Division of Religious Studies. He is also Assistant Director of the Master of Science Program in Medical Anthropology and Cross-Cultural Practice in the Graduate Medical Sciences Division of Boston University School of Medicine. Dr. Laird’s research at Boston University has focused on multiple intersections of Muslim identity with healing professions and public health in the US. He was a leader in the Greater Boston Muslim Health Initiative and is currently working on projects with the American Muslim Health Professionals; and with local immigrant communities in response to the COVID-19 pandemic.

Isaac Kekulah, MD, graduated from A.M. Dogliotti College of Medicine in 2018 and completed internal medicine residency at the Liberia College of Physicians and Surgeons in 2021. He plans to pursue further training in cardiology. As a medical student, he participated in data collection for this study.

Christina P. C. Borba, PhD, MPH, is Associate Professor and Director of Research for the Department of Psychiatry at Boston Medical Center. Until 2016, she was the Director of Research at the MGH Division of Global Psychiatry. She is an Assistant in Psychology (Psychiatry) at Harvard Medical School and an Assistant in Research at MGH. Dr. Borba has extensive experience in mixed methods research, teaching and training, and development and management of randomized clinical trials. Dr. Borba’s current research focuses on psychotic disorders and cultural psychiatry in low-resourced settings in the US and abroad, women’s mental health, and gender differences in care.

David C. Henderson, MD, currently serves as Psychiatrist-in-Chief, Division of Psychiatry, at Boston Medical Center and Professor and Chair, Department of Psychiatry, at Boston University School of Medicine. Dr. Henderson previously served as Director of the Chester M. Pierce, MD Division of Global Psychiatry at Massachusetts General Hospital (MGH), Director of the MGH Schizophrenia Clinical and Research Program, and Medical Director of the Harvard Program in Refugee Trauma. He serves as Co-Director of the NIMH T32 MGH-BUSM Global Mental Health Clinical Research Fellowship. He has conducted research and training programs in Bosnia, Cambodia, East Timor, Ethiopia, Haiti, Liberia, New Orleans, New York City, Peru, Rwanda, Somaliland, and South Africa, among other places. His work has consisted of field studies, needs assessments, mental health policy development and strategic planning, quantitative and qualitative surveys, mental health capacity building programs for specialized and primary health professionals, and skill-transfer program evaluation.

Anne E. Becker, MD, PhD, ScM, is the Maude and Lillian Presley Professor of Global Health and Social Medicine at Harvard Medical School, where she serves on the MD-PhD Program Leadership Council. She is also founding and past director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital. She was named HMS dean for clinical and academic affairs in April 2020. Dr. Becker is an anthropologist and psychiatrist whose research focus includes the social and cultural mediation of presentation and risk of eating disorders, social barriers to care for mental disorders, and school-based mental health promotion. She has led investigations of the impact of rapid social transition on eating pathology and other youth health-risk behaviors in the small-scale indigenous iTaukei population of Fiji and has served as co-PI on school-based mental health interventions in Haiti and Lebanon. Dr. Becker is author of Body, Self, and Society: The View from Fiji, which probes the cultural mediation of self-agency and body experience, and is co-editor of a forthcoming book on global mental health training.