Before Katie Meyler came to West Point, Liberia, the children living there had little hope for the future. The crowded township, which lies on a peninsula that juts into the Atlantic Ocean at the northern end of Monrovia, Liberia's capital, is the worst slum in the country. Less than two square miles in size, West Point is home to more than 75,000 people crammed into decaying tin shanties without electricity, running water or sanitation.
“It's no place for a child,” says the 32-year-old Meyler, a native of Bernardsville, N.J. “But the kids who live there don't have a choice. West Point is their home.”
For decades, West Point has been a blight on an already battered Liberia, a small, impoverished country that suffered 14 years of civil war. A walk through its congested, meandering mud passageways is like a visual assault; indelible images of abject poverty and crime appear at every turn. Visitors to Liberia are cautioned to avoid West Point altogether, and those who do venture there are hard-pressed to forget the barely clothed children who wander aimlessly in search of food or clean water or the residents who defecate on the public beaches next to swelling, fetid mounds of garbage.
But the same community that can make even the steeliest aid worker blanch tugged at Meyler when she first traveled to Liberia as a college student with Samaritan's Purse, an international Christian relief organization, in 2006. “I was completely drawn to it,” recalls Meyler, who speaks and gesticulates with the bubbly enthusiasm of a teenager. “Where other people saw suffering, I saw beauty and resilience.”
Liberians' resilience would be sorely tested, however, when their country faced its worst-ever public health battle in 2014, one that tore a path of death and destruction through a community that Meyler and others had been tirelessly trying to rebuild. The crisis would force Meyler to change course and face the terror head-on and, in its wake, combat a mental health crisis marked by widespread depression, post-traumatic stress disorder and fear.
Learning to heal
Meyler's nearly instant connection with Liberia rose out of her own upbringing. Raised by a single mother, Joann, who worked two jobs to support her family of three, Meyler grew up in the clutch of poverty. The family would have gone hungry without food stamps, and the kids depended on charitable neighbors in their mostly affluent town to drop garbage bags filled with clothing on their doorstep. Meyler, in turn, devoted herself to community service. As a high school student, she spent her summers traveling with faith-based aid organizations to developing countries and logged more than 500 hours as a volunteer, which earned her a college scholarship.
After graduating from North Central University in Minneapolis, Meyler found herself back in Liberia—first with Samaritan's Purse, then with the Shine Foundation, which assigned her to West Point to develop a mentoring program for ex-combatants and an educational program for 150 youngsters who lacked access to school. Working in the squalid community, Meyler grew incensed at the violence against young girls and their lack of opportunity. Although the country boasts the first democratically elected female president in Africa, Ellen Johnson Sirleaf, violence against women and girls remains alarmingly high. Rape is one of the most frequently reported crimes in Liberia, with most victims between eight and 18. Many of the girls in the country's ghettos, including West Point, are forced into prostitution in exchange for basic needs. “I had to do something,” Meyler says.
Meyler befriended dozens of girls in West Point, posing a question to them that no one had ever cared enough to ask: If you could have anything in the world, what would it be? Their unanimous answer took Meyler by surprise: an education. Although the law mandates free primary education for all Liberian children, most schools charge fees for operating costs, books and teacher salaries—fees most Liberians cannot afford. “They could have asked for so many things, like clean drinking water or food,” Meyler says. “I wasn't a good student and didn't like school much. But to these girls, an education meant a chance at life.”
Before leaving Liberia in 2007, Meyler promised the girls she would get them into school. Yet when she returned to the U.S., she realized she had no idea how. “I didn't have any of the things I thought I needed to start a nonprofit—no celebrity status, no Ivy League education, no trust fund,” Meyler says. One day, as she continued to agonize over her lack of credentials, a friend offered the following advice: “It's not about you, Katie.”
In 2008 Meyler filed the paperwork for the Liberia-based nonprofit More Than Me foundation, with the goal of getting girls off the streets of West Point and into school, where they would be protected from the endemic violence and learn the skills necessary to get jobs. In 2010 she launched More Than Me on a shoestring budget of grants, individual donations and prize money from a few charitable contests, which she used to send more than two dozen at-risk Liberian girls to schools in Monrovia. Traveling back and forth between Liberia and the U.S., Meyler and her staff of 13 volunteers also began planning for a school of their own. In between hastily organized fundraisers, Meyler juggled several jobs, including waitressing and cleaning gutters for a roofing company.
Meyler was on a mission to provide something even scarcer than education to the children of Liberia: hope.
Hope is hard to come by in Liberia, where the war took the lives of more than 250,000, displaced millions and destroyed the country's infrastructure. In the years since the conflict ended in 2003, Liberians have continued to struggle, crippled by grief, poverty and lack of access to basic needs such as food, running water, electricity and paved roads. In a survey of 1,600 adults published in 2008, physician Kirsten Johnson of McGill University and Harvard University's Humanitarian Initiative and colleagues found that 44 percent of the country's four million people met the clinical criteria for post-traumatic stress disorder (PTSD), reporting symptoms such as nightmares, feelings of hopelessness, anger and self-destructive behavior. Forty percent qualified for a diagnosis of major depressive disorder; indeed, more than 10 percent of those Johnson surveyed said they had contemplated suicide. News reports and at least one scientific paper, as well as my own interviews with police and civilians, suggest that Liberia also has a major problem with substance abuse, particularly among former child combatants.
And yet despite the lingering physical and psychological wounds, the population has virtually no recourse for healing. In addition to the damaged education infrastructure, the country's health care system remains fragmented and heavily dependent on international donors. Mental health care barely exists. The country has just one practicing psychiatrist—University of Liberia professor Benjamin Harris—one small psychiatric hospital, in Monrovia, and fewer than 100 clinicians working in neurology or mental health.
In 2009 the Liberian Ministry of Health and Social Welfare made an effort to address the country's dire need for psychiatric care by passing a National Mental Health Policy, but without adequate clinicians or drugs, the new measure could not effectively deliver treatment. In 2010 the Atlanta-based Carter Center began a five-year initiative to train 150 nurses and physician's assistants to be mental health clinicians in a six-month intensive crash course in Monrovia. After graduating from the program, the clinicians fanned out across the country to deliver basic mental health services such as psychotherapy, counseling for addiction and support for PTSD. By spring 2013, when the fourth class graduated, all 15 counties in Liberia had access to at least one locally trained and credentialed mental health clinician.
Meanwhile, by the end of 2011, More Than Me was funding tuition for more than 50 at-risk girls and had started construction on a school of its own, renovating a war-damaged building donated by the president. Then, in 2012, the organization won the coveted Chase Community Giving grant of $250,000.
On September 7, 2013—Meyler's 31st birthday—the More Than Me Academy opened to 120 girls between the ages of five and 17, with a ribbon-cutting ceremony attended by President Sirleaf. The curriculum included health care, an after-school program and two meals a day. “This whole thing feels like a crazy dream but a really beautiful one,” Meyler told me then. More Than Me made waves among global charities. A check came from Microsoft Corporate Giving, and U2 front man Bono, who co-founded the ONE Campaign to end extreme poverty, dropped by for a visit. Residents of West Point begged Meyler to enroll their daughters, and the girls in the school begged Meyler not to send them home at the end of the day.
A visit to the school in February of last year was marked by the sound of children laughing and singing, their voices echoing through the brightly painted hallways of the once decrepit cement building just outside the border of the township. The girls hugged visitors, beckoning them into their classrooms. “They love to be held,” Meyler said, as a gaggle of girls, some as old as 18, clung to various pieces of her flowing skirt like babies to a mother duck. Outside, on a three-story whitewashed wall facing the school, someone had used bright-red paint to write the word “HOPE.”
Some mornings Meyler's students arrived sleep-deprived and bruised—marks of abuse—but they came and completed their work, and they seemed inspired to learn. Meyler appeared ebullient. “I believe in miracles,” she said. “We're growing so fast, and we have so many plans for the future.”
Promise not to touch
In late March 2014 news broke worldwide that citizens of a neighboring country, Guinea, were dying from a mysterious illness with symptoms resembling those of both malaria and cholera: fever, vomiting and aching joints. There were also reports of cases in Sierra Leone and Liberia, which both share porous, highly trafficked borders with Guinea.
Médecins Sans Frontières responded immediately, sending blood samples to the Pasteur Institute in Lyon, France, to identify the cause of the affliction. Results confirmed the worst: the infectious organism was Zaire Ebola virus. This highly contagious and deadly agent had killed 70 percent of its victims when it struck Sudan and the Democratic Republic of the Congo (formerly Zaire) in 1976, leaving 431 people dead. In the late stages, after organ failure, symptoms can include profuse bleeding from the nose and mouth.
The first medical teams, under the umbrella of the World Health Organization (WHO), were on the ground by the end of the month. Initially the disease moved slowly in Liberia; between March and April only six cases were recorded, followed by six weeks of none at all. By the end of May, however, Ebola arrived in Monrovia, where it quickly took hold and spread like brushfire. Still, Meyler says she was not overly concerned. “I'd never even heard of Ebola,” she says. “I remember thinking it sounded weird and scary, but at the time I didn't think it could destabilize an entire country.”
In July she flew to the U.S. to spend several months fundraising and meeting with More Than Me donors, advisers and board members. Later that month an American lawyer named Patrick Sawyer died of the disease in Lagos, Nigeria, the stopover for his flight home from Liberia, where he had been caring for his sick sister. Reacting to the death of an American, the Peace Corps pulled all its volunteers from Liberia, Guinea and Sierra Leone, and the U. S. Centers for Disease Control and Prevention warned against all “nonessential” travel. The WHO declared an international health emergency. The Carter Center put the breaks on its mental health program, redirecting all in-country resources to the Liberian government's campaign to contain the disease.
Meyler watched the news in horror. “The more I heard, the more I began to freak out,” she says. During one weekend, Friday, August 1, to Monday, August 4, 45 additional cases cropped up in the region, most of them health workers, according to a WHO report. In response, President Sirleaf declared a 90-day state of emergency in Liberia and ordered the indefinite closure of all schools, including More Than Me. Meyler called for the evacuation of all the school's foreign volunteers from the country, then booked herself a ticket on the next flight back to Liberia. “Just because you can escape, it doesn't mean you should,” she says. On the plane, Meyler drafted a living will.
Meyler returned to a country trapped in dread heaped on poverty. Health workers dressed in head-to-toe protective gear trolled villages and city streets for the infected and the dead. The screams of those who had lost loved ones to Ebola echoed in the streets. “It's worse than the war,” Quendi Appleton, a nurse trained in mental health at SOS Children's Clinic in Monrovia told me at the time. “People are terrified to go out of their homes. They feel lonely, scared, confused. It's like a nightmare.”
On August 20 the Liberian government put the residents of West Point under quarantine to stop Ebola's spread, encircling the slum with barbed wire and armed troops. Home from Liberia in California, Janessa Wells, a More Than Me teacher, ran across newspaper photographs of angry, frightened West Point residents, some of whom were her students. “My heart filled with dread,” Wells recalls. “Even if they didn't get the virus, I knew they'd be impacted—physically, emotionally and psychologically.” Wells booked a flight back to Liberia.
More Than Me staff pushed their way into the slum to track down every one of their 124 students. All the kids had clean bills of health. The team took them bottles of chlorine bleach and began to organize grassroots Ebola awareness and education efforts in the township. Meyler and Wells made the girls promise not to touch anyone and to wash their hands often. They stood with them, resisting the urge to embrace them tightly, and assured them that everything would be okay. “I craved a sense of normalcy, the ability to give a hug to an old friend or a sad child,” Wells says. “The very first thing I did was put my hands behind my back or cross my arms to restrain the urge to pull them close.”
Restrictions on physical contact is yet another punishing aspect of the Ebola crisis. Culturally, West Africans are gregarious and physically demonstrative, quick to embrace or shake hands. In Liberia, the customary greeting is an elaborate handshake culminating in the “finger snap,” which involves the two people clicking their fingers together. “In a culture where touch and physicality is not just a nicety but a way of life, [the lack of physical contact] seems like the cruelest type of message,” Wells says.
For those who have lost family members to Ebola, the constraint on touch is especially harsh, robbing them of a powerful source of comfort during the mandatory 21-day quarantine. According to a number of studies, some led by behavioral scientist Michael Meaney of McGill, children deprived of physical contact from a parent or caregiver in a time of stress can suffer long-term psychological and developmental damage that makes them prone to depression and anxiety.
Some of this damage involves an alteration of the stress response. In a study published in 1997 neurobiologist Mary Carlson and child psychiatrist Felton Earls of Harvard and their colleagues found that children in a Romanian orphanage who had been deprived of touch and attention by their caregivers developed abnormally high levels of the stress hormone cortisol, which led to long-term developmental and cognitive challenges.
“There are significant effects on kids when they go even a few days without the physical affection of a parent,” says developmental psychologist Tiffany Field of the University of Miami School of Medicine. “I can't imagine the impact after 21 days. It's an extreme situation, and I predict these kids are going to need real help.” Ironically, she adds, the protective quarantine for suspected Ebola cases, and the resulting physical separation from caregivers, could ultimately boost a child's vulnerability to the virus (and other infections) because impairment of the ability to regulate stress can also suppress immunity.
To manage their own stress and fear, Meyler and Wells say they swam in a hotel pool, wrote in their journals and, when they returned home at night, watched funny movies and television shows.
Despite having no background in medicine, disease or disaster aid, Meyler found herself leading the township's assault on Ebola. The Liberian Ministry of Health and Social Welfare recruited her to head a coalition to end Ebola in West Point; aid workers trained her to wear gloves and protective gear and to wash her hands in bleach, which she did up to 15 times a day. Her team acquired an ambulance and set out to retrieve scores of Ebola victims who were dying in their homes and take them to a hastily constructed emergency unit at the nearby Redemption Hospital. She helped to transform the More Than Me school building into a warehouse for food and medical supplies and a training facility for the coalition of volunteers working to stamp out Ebola in the slum.
It was the one-year anniversary of the More Than Me Academy, but no one was celebrating. Meyler says, “I felt like the world left Liberia to die.”
Orphaned by ebola
Throughout August and September, Ebola continued to spread in Liberia. At Redemption Hospital many of the patients were already dead, lying in pools of their own blood, vomit or feces. Small children—some confirmed Ebola patients, others suspected—lay on cots next to the deceased, their vacant stares and slumping bodies bearing all the signs of trauma. Some were on the verge of death themselves, too young to understand what was happening and too terrified to utter a sound. More were dying outside the hospital's doors. The emergency unit was full, as were all the other government-run units in the country, leaving many of the sick with nowhere to go. A hotline set up by the health ministry in June for reporting suspected cases and locating treatment centers was by August receiving too many calls to answer.
Whenever Meyler visited the units, she sat with every child, offering comforting words no matter their truth. “I would tell them that their parents had sent me to say how much they are loved,” she told me. One day she purchased $500 worth of toys and candy, which she handed out to critically ill kids in the treatment centers.
At one point, Meyler walked outside the hospital and began to vomit. Within minutes she had convinced herself she had Ebola. She tested negative, only to return for another test weeks later when she again began vomiting unexpectedly. It was not until later that she realized the true cause of her sickness—her own trauma. “This was my body's way of dealing with the fact that I was seeing people die every day,” she says.
Meyler used her blog—Racing Heart—to put a human face on the crisis. In one post, she described the moment she spotted Berlinda, age three, wearing a pink dress, sitting in the back of an ambulance watching her mother die. She was free of Ebola, but no one would take in the toddler for fear of contagion. Meyler brought her home. Then came Miatta, age six, who was found alone, screaming and crying because everyone in her family had died. Then she rescued Esther, age 10, who had lost her mother, father and entire extended family. Meyler chronicled her efforts to care for them—and herself:
Polka-dotted sheets can't bring back Esther's mother, father, aunt, uncle and four cousins, but they sure will make her sleeping room brighter.
Grace's mom is fighting #ebola—let's pray she makes it. Grace didn't want to leave her side, but she had no choice. Ice cream isn't helping.
Rule #1 when fighting #ebola: stop every so often to act ridiculous in order to sustain yourself for the long run.
In early January the WHO reported that Ebola had killed at least 8,000 people in Guinea, Liberia and Sierra Leone. According to Save the Children, as many as 10,000 children had lost one or both parents to the disease. UNICEF is helping those governments train mental health and social workers, in addition to recruiting more than 2,000 Ebola survivors, now immune to the disease, to care for the children.
In October the Liberian government fast-tracked Meyler's request to register More Than Me as a holding home for children orphaned by Ebola. As more children were admitted, Meyler and her staff greeted them, as she puts it, with “love, candy, Disney movies and psychosocial support.” And so More Than Me officially shifted its focus to a new generation of Liberian orphans.
Youngsters orphaned by Ebola present a complex psychological challenge. The source of their trauma seems fathomless: the grief of witnessing the gruesome death of a parent or their entire family; the terror of being carried from their homes to an isolation-treatment unit by a faceless aid worker wearing what looks like a space suit. For children who test negative, after going through the ordeal of quarantine, most will not be able to return to their communities. They are outcasts, forever associated with the deadly disease. Even relatives and close family friends shun them out of an unfounded fear that they are still contagious.
So as with children of war, many of those who survive Ebola will be abandoned, without access to education or health care. “Kids need structure, routines and security,” says psychologist Theresa S. Betancourt, who directs a research program on children and global adversity at Harvard's T. H. Chan School of Public Health. “Right now we're seeing kids sleeping on the streets, rejected and orphaned. If we want these countries to build back better, we have to think long term and also focus on the psychosocial issues because right now they are exploding.”
“Of course, I could die”
To tackle this psychological burden, Betancourt is working with the Catholic aid organization CARITAS Freetown to launch an emergency Ebola relief program modeled on her work with youth affected by war in Sierra Leone and families by HIV/AIDS in Rwanda. Called the Family Strengthening Intervention, the program is rooted in research showing that in the aftermath of war or deadly disease, the most effective way to help children is to support their caregivers. To do so, Betancourt will send local health workers to coach caregivers on how to communicate with children and discourage the use of harsh punishment.
Such low-cost, easy-to-implement local mental health interventions can ease the burden of depression and anxiety in developing countries. In Uganda, a nonprofit organization called StrongMinds is recruiting local health workers such as physician's assistants, nurses and social workers to conduct group psychotherapy sessions for women with depression in the slums of Kampala. To date, the organization has treated 244 women in 16-week sessions run by four community facilitators. A week after the sessions ended, 94 percent of the women had been relieved of the symptoms of their depression, self-reporting better sleep, higher energy levels, increased productivity and an overall sense of hope. Such a strategy could work in Liberia, too. “This model can be quickly scaled to counter the anticipated depression epidemic that will follow Ebola,” says StrongMinds founder Sean Mayberry.
To sharpen their tactics, Betancourt and her team are conducting a longitudinal study in the Freetown area of Sierra Leone to investigate the contributions of stigma, social distrust and patterns of disease on distress and other mental health problems. Such ripples may continue to spread even after Liberia is Ebola-free. Betancourt's findings may be useful to Meyler then, as she seeks help from the Liberian government and aid organizations to find homes for the children orphaned by the disease. In the years to come, Meyler plans to expand More Than Me into a campus that includes health care, a boarding house and psychosocial support.
Meanwhile Meyler has more than 200 children in her care, some of them anxiously awaiting the results of their Ebola tests. She also faces the knowledge that one small mistake could make her the next victim of the virus. “Yes, of course, I could die,” she says matter-of-factly. “But if I did, it would be worth it. It would be a sign to the world to wake up.” And she adds, “There's a saying that if you haven't felt something worth dying for, it's not worth living. And I would die for these kids.”