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Mental Health and Psychosocial Support in Guinea-Conakry

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Abstract

he World Health Organization (WHO) requested a Mental Health and Psychosocial Support (MHPSS) literature review of countries impacted by the Ebola virus, including Sierra Leone, Liberia and Guinea. International Medical Corps expressed an interest in completing the review for Guinea and commissioned a rigorous review of the literature on pre-existing information relevant to mental health and psychosocial support (MHPSS) in Guinea, in the French and English languages. This report presents the findings using an integrated psychological and anthropological framework that is instrumental in understanding MHPSS needs, and how to devise culturally-appropriate MHPSS interventions in Ebola-affected areas. The report outlines the key findings of the existing academic and grey literature related to Guinean mental health and psychosocial issues and services, with a specific emphasis on the recent Ebola humanitarian crisis. The review was conducted in June-July 2015 and identified relevant academic publications using academic search engines and databases (Google scholar, Medline, Pubmed, PSYCHinfo, APA psycNET, and Anthrosource). The search was extended through manual searches on Google in French and English, and in the journals: Social Science and Medicine; Culture, Medicine, and Psychiatry, Transcultural Psychiatry; and Medical Anthropology. Researchers with relevant expert knowledge were also consulted. The overall search identified academic sources, but also relevant reports, policy documents and internet resources. The report introduces general background information regarding the population of Guinea, its religions, history, politics, economics and health. It subsequently summarizes information on mental health and psychosocial issues including prevalence, local nosologies, help-seeking strategies, formal and informal resources of MHPSS sources of support. There is discussion of the ways in which causes and course of illness and misfortune are intertwined with plural cosmologies and with individuals’ relationships with the living, the dead, the spirit world, and nature itself. Finally, the humanitarian crisis of Ebola in Guinea is explored, alongside responses to it, and its social and psychological ramifications for the affected population. The scholarly and grey literature available on MHPSS specifically in Guinea was limited and thinly spread over many documents. This presented a challenge when writing this report and we acknowledge that there may have been further relevant material to be found in sources that did not focus specifically on MHPSS, but which it was not possible to obtain within the timescale of the review. Nonetheless, we hope the report can provide useful insights for policy-makers, donors, governments and service-providers.
1
A LITERATURE REVIEW
Mental Health and Psychosocial
Support in Guinea-Conakry
Dr. Emilie Medeiros, Dr. David M.R. Orr and Jasmine Van Deventer
December 2015
1
TABLE OF CONTENTS
List of Acronyms .........................................................................................................
Acknowledgements ....................................................................................................
Executive Summary ....................................................................................................
1. Introduction ..............................................................................................................
2. Socio-cultural context ............................................................................................
2.1. Land and people ...............................................................................................................
2.1.1 Land
2.1.2 Population structure
2.1.3 Religious and cultural groups
2.2 Political, historical, economic aspects .........................................................................
2.2.1 Brief history
2.2.2 Political history
2.2.3 Economy
2.3 General health aspects ...................................................................................................
3. MHPSS frameworks, issues and services ...........................................................
3.1 Frameworks for formal biomedical mental health services ....................................
3.2 Concepts of the self, person and life course .............................................................
3.3 Specific mental health issues .........................................................................................
3.4 Local conceptions and nosologies of distress, loss and trauma ..........................
3.5 Risk and protective factors for mental health issues ..............................................
3.6 The healing landscape ....................................................................................................
3.6.1 Non-allopathic health system: Type of healers
and therapeutic landscapes
3.6.2 Government and NGOs in mental health care
3.6.3 Help-seeking strategies
4. Mental Health and Psychosocial Support before
and during the Ebola Crisis ...................................................................................
4.1 MHPSS-related humanitarian history ...........................................................................
4.1.1 Summary history of humanitarian crisis
4.1.2 Humanitarian responses
4.2 Experiences with the 2014-2015 Ebola crisis ............................................................
4.2.1 Prevalence
4.2.2 Political and humanitarian response to Ebola
4.3 Ebola-related beliefs and practices .............................................................................
4.3.1 Funeral beliefs and practices
4.3.2 Ebola-related social attitudes and stigma
4.3.3 Psychosocial support needs Related to Ebola
5. Conclusion ...............................................................................................................
Appendix ......................................................................................................................
References ...................................................................................................................
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3
4
5
6
6
8
12
14
14
15
16
17
20
21
24
24
25
27
32
33
34
2
LIST OF ACRONYMS
Centre National de Recherche Scientifique (France)
Centre for Victims of Torture (United States)
Democratic Republic of Congo
Department of Traditional Medicine
Ebola Treatment Units
Ebola Virus Disease
Fraternité Médicale Guinée
Female Genital Mutilation
Guinée Forestière
Guéckédou region
Human Immunodeficiency Virus
International Committee of the Red Cross
International Organization for Migration
Mental Health and Psychosocial Support
Médécins Sans Frontières (Doctors without Borders)
National List of Essential Medicines
Psychological First Aid
Purchasing Power Parity
Revolutionary United Front (Liberian and Sierra Leone-based)
World Health Organization
United Nations
United Nations High Commissioner for Refugees
United Nations Children’s Fund
UN Mission for Ebola Emergency Response
CNRS
CVT
DRC
DTM
ETUS
EVD
FMG
FGM
GF
GR
HIV
IRCRC
IOM
MHPSS
MSF
NLEM
PFA
PPP
RUF
WHO
UN
UNHCR
UNICEF
UNMEER
3
ACKNOWLEDGEMENTS
We would like to thank Dr. Sonali Gupta and Dr. Inka Weissbecker from International Medical Corps
for their comments and patience during the review process. We are grateful to Prof. Alain Epelboin
(CNRS-MNHN Paris) for sharing with us his precious bibliography on Ebola in Guinea and other parts of
Africa.1 We are also grateful to Dr. Mark van Ommeren (WHO, Mental Health and Psychosocial Support in
Emergencies), Dr. Capucine de Fouchier (WHO, Consultant on Mental Health and Psychosocial Support),
Dr. Abdoulaye Sow (Director of Fraternité Médicale Guinée (FMG), and François de la Roche (Country
Director – Guinea, International Medical Corps) for their review of the report.
1 See ethnographic documentation online, CNRS-MNHN Paris (UMR7206) “Santé, maladie, Malheur” in Canal U: le
webtele de l’enseignement supérieur et de la recherche :http://www.canal-u.tv->Key words «SMM, Ebola, Marburg»
4
EXECUTIVE SUMMARY
The World Health Organization (WHO) requested a Mental Health and Psychosocial Support (MHPSS)
literature review of countries impacted by the Ebola virus, including Sierra Leone, Liberia and Guinea.
International Medical Corps expressed an interest in completing the review for Guinea and commissioned
a rigorous review of the literature on pre-existing information relevant to mental health and psychosocial
support (MHPSS) in Guinea, in the French and English languages. This report presents the findings
using an integrated psychological and anthropological framework that is instrumental in understanding
MHPSS needs, and how to devise culturally-appropriate MHPSS interventions in Ebola-aected areas.
The report outlines the key findings of the existing academic and grey literature related to Guinean mental
health and psychosocial issues and services, with a specific emphasis on the recent Ebola humanitarian
crisis. The review was conducted in June-July 2015 and identified relevant academic publications using
academic search engines and databases (Google scholar, Medline, Pubmed, PSYCHinfo, APA psycNET,
and Anthrosource). The search was extended through manual searches on Google in French and English,
and in the journals: Social Science and Medicine; Culture, Medicine, and Psychiatry, Transcultural
Psychiatry; and Medical Anthropology. Researchers with relevant expert knowledge were also consulted.
The overall search identified academic sources, but also relevant reports, policy documents and internet
resources.
The report introduces general background information regarding the population of Guinea, its religions,
history, politics, economics and health. It subsequently summarizes information on mental health and
psychosocial issues including prevalence, local nosologies, help-seeking strategies, formal and informal
resources of MHPSS sources of support. There is discussion of the ways in which causes and course
of illness and misfortune are intertwined with plural cosmologies and with individuals’ relationships with
the living, the dead, the spirit world, and nature itself. Finally, the humanitarian crisis of Ebola in Guinea
is explored, alongside responses to it, and its social and psychological ramifications for the aected
population.
The scholarly and grey literature available on MHPSS specifically in Guinea was limited and thinly spread
over many documents. This presented a challenge when writing this report and we acknowledge that
there may have been further relevant material to be found in sources that did not focus specifically on
MHPSS, but which it was not possible to obtain within the timescale of the review. Nonetheless, we hope
the report can provide useful insights for policy-makers, donors, governments and service-providers.
5
1. INTRODUCTION
Rationale
The largest outbreak of Ebola in the world to date emerged in Guéckédou, South-East Guinea, at the end
of 2013 and was ocially declared an epidemic by the Guinean Ministry of Health on 22nd March 2014.
The overstretched public health system and international NGOs struggled to cope with responding to
the epidemic, as political and social divisions and cultural factors contributed to the virus’s spread. As of
2nd August 2015, 3327 confirmed and 452 probable cases of Ebola had been identified in Guinea, with
2522 recorded fatalities. The virus has now been brought under control, but the extent of the deaths,
damage to the social fabric, economic loss, disruption to normal grieving practices, and stigmatization
that it caused still presents considerable challenges to the Guinean population, and to providers of
mental health and psychosocial support. It revealed how little institutional capacity existed to deal
with crises of this kind and the need to strengthen health systems and provision. It also showed the
importance of contextualized information about the MHPSS needs of the population when responding
to a humanitarian emergency.
This report aims to assist governments, UN agencies, and local or international NGOs in a holistic
understanding of mental health and psychosocial support in Guinea. We outline key anthropological
and psychological points to help understand relevant factors related to MHPSS. We focus on how these
dimensions shape some of the challenges that are faced during the Ebola crisis. We therefore present
information about the socio-cultural context (Populations, History, Politics, Economy, Health), MHPSS
(Prevalence, local notions of the self, nosologies of distress, and the healing landscape), and MHPSS
issues in the context of the Ebola crisis (Humanitarian context, History and interventions, and Ebola-
related beliefs and practices). The report aims to consolidate MHPSS interventions in Guinea by informing
policy-makers, donors, and service-providers’ understanding of the various dimensions at stake.
Methods
The method implemented was in line with a suggested methodology from the World Health Organization
(WHO) and United Nations High Commissioner for Refugees (UNHCR) toolkit for the assessment of
mental health and psychosocial needs and resources (Tool 9). The review of the academic and grey
literature was conducted in June-July 2015 in the French and English languages. The following terms
were entered in both languages: Guinea (Conakry), mental health, mental illness, psychology, psychiatry
and psychosocial. We used the following academic search engines and databases (Google scholar,
Medline, Pubmed, PSYCHinfo, APA psycNET, Anthrosource). We complemented these searches with
manual searches on Google in French and English, and in the journals Social Science and Medicine,
Culture, Medicine, and Psychiatry, Transcultural Psychiatry and Medical Anthropology, which provided
us with additional sources of information (reports, policy documents and internet resources). We used
the following key words: Guinée (Conakry), santé mentale, maladie mentale, psychologie, psychiatrie,
psychosocial (Boolean operators: AND, OR, NOT). Key professionals familiar with MHPSS issues in
Guinea were consulted, making use of the first author’s professional networks. Particular thanks are due
to Prof. Alain Epelboin, CNRS, who kindly shared with us his bibliography on Ebola, from which we drew
on the sources with direct relevance to Guinea (See Appendix 1).
6
2. SOCIOCULTURAL CONTEXT
2.1 Land and People
2.1.1 Land
Guinea is a coastal country located on the Western side of the African continent (See map below).
(Sourced from https://commons.wikimedia.org/wiki/File:Un-guinea.png, Open Source material)
To the west of Guinea lie Guinea-Bissau and the Atlantic Ocean, while it is bordered in the north by
Senegal and Mali, to the east by the Ivory Coast, and to the south by Sierra Leone and Liberia. Possessed
of a diverse landscape, Guinea boasts four natural regions: Maritime or Lower Guinea (in French, Guinée
Maritime), Middle Guinea (Moyenne Guinée), Upper Guinea (Haute Guinée), and Forest Guinea (Guinée
Forestière, GF). Lower Guinea is formed of coastal marshes, an alluvial plain, and the foothills that rise
towards Middle Guinea. Middle Guinea consists of the Fouta Djallon highlands, formed of cross-cutting
plateaus and valleys. Upper Guinea is mainly characterized by savannahs, and GF features rainforest,
highland peaks and some rolling plains around Beyla and Nzérékoré. The country encompasses a total
area of 245,857 kilometers within which 10,628,972 inhabitants reside, according to the 2014 census. [1,
3]
7
2.1.2 Population structure
Guinea’s population has undergone important demographic, linguistic, and geographical changes in
recent years, with the rise of urban-based forms of livelihood and the eects of a shift in national policy
away from socialist principles and towards a more capital-friendly, free market regime.
The country’s population is predominantly rural, with 71% of people living in rural areas and sustaining
themselves through agricultural subsistence. In recent times, large numbers of young people have
migrated to urban areas and mining zones. One particularly attractive hub is Guéckédou, the regional
capital of GF and a significant commercial center situated near Guinea’s borders with Sierra Leone, Liberia
and Côte d’Ivoire. Traders come to Guéckédou from across these countries and the rest of Guinea. A
number of non-governmental organizations have also been based here to serve the Liberian and Sierra
Leonean refugees. [1, 2]
According to figures from 2009, the sex ratio is 102 men for every 100 women. Nearly 50% of Guineans are
under 18 years of age, while only 3% of the population is over 60 years of age. Average life expectancy is
51 years of age for men and 54 years for women. An important factor in the high mortality and morbidity
is the low level of economic resources available to Guinea. [19, 69]
Literacy rates were reported in 2008 as 67% for men and 51% for women. However, there is considerable
variation by area, with literacy rates in rural zones being considerably lower than those in urban zones.
[1, 4]
French is Guinea’s ocial language. Around 24 other languages, each roughly corresponding to the
ethnic groups represented in Guinea, are present in the country. Prominent among these are Pular,
Malinké, Soussou and Kissi, which constitute vehicular expressions allowing communication amongst
people having dierent languages as their principal modes of communication. Other languages not
indigenous to Guinea are also spoken, most notably Bambara, Dioula, Wolof, Krio and Arabic. Nearly
three quarters of the country is at least bilingual, while a significant number of people are tri-lingual and
even quadri-lingual. French prevails amongst the country’s vernacular languages, a fact attested by the
fact that 86% of the population claims to know and speak it. [1, 16]
2.1.3 Religious and cultural groups
Guinea’s society is fractured along religious, ethnic, and gender-based lines. Religious and ethnic groups
are often identified with specific geographical areas of the country. This can lead to regional rivalry
exacerbating the other aspects of social division, particularly when political power and the allocation of
economic resources and infrastructure between regions is in question. [23]
Regarding the country’s religious makeup, 85% of the population proclaims its adherence to Islam. Animist
traditions are practiced by 5% of the population and Christianity is observed by 4%. Three quarters of
Christians follow Catholicism and 1% observe Protestant evangelical beliefs. Islam is generally observed
by city-dwellers and those from the country’s upper social classes. [4, 25] Amongst the animist traditions,
the religion of the Kissi GF dwellers figures prominently. Their religion is based on the cult of ancestors.
Their practices incorporate the use of sacred places in rocks, trees, and ponds as cult sites and spaces
of initiation. These may be referred to as Funda tana or Luando sola in the Kissi language. The Kissi
underwent Christianization in tandem with colonization, initially led by Catholic missionaries and later
by Protestant churches, a process that produced a number of syncretic practices within which certain
taboos are observed. For example, gboe and gbera are “tabous” indicating that the sacred places
8
known to harbor deceased persons, djinns or tutelary spirits are forbidden sites, which should only be
approached or entered by those “initiated” or “trained” in communicating with such beings. Any others
would suer harm at such places. [20]
Guinea’s ethnic composition is quite varied, with the country’s population generally schematized into 24
distinct groupings. The largest ethnic group is the Peul, represented by 40% of the population, and the
other major groups are the Malinké and the Soussou, which respectively constitute 30% and 20% of the
population, followed by the “Forestiers” (the communities that make up the country’s forest region). GF
residents are often referred to as the common minority populations of the GF region: Kissi (in Kissidougou
et Gueckédou), Toma (in Macenta), Guerzé, Kpélé (in N’Zérékoré), Kono, Kopo, Mano (in Yomou), Kônoé
(in Lola) Malinké, Konianké (in Beyla). [4, 20]
Gender roles are embedded within a patriarchal familial structure, which implies that the wives of the
head of the family technically belong to their own father’s family, even if they live within their husband’s
household. The nuclear family has not attained predominance in more traditional parts of Guinean
society, wherein most families form part of clan-like structures encompassing the entire extended family,
excepting married women, of the male head of the family. [26, 32]
In addition, gender inequality manifests itself in a variety of domains, notwithstanding the armation of
gender equality and equity in Guinea’s constitution. Women are predominantly married early or forcibly.
As of 2005, 37.9% of girls between the ages of 15 and 19 were married, divorced or widowed. 63%
of women aged 20-24 had been wedded before the age of 18. While women are legally allowed to
divorce, shared assets and the right to custody for children over 7 years of age are generally awarded
to their husbands. Customary rural practices exclude women from land ownership and disallow them
from obtaining bank loans, even though they are constitutionally guaranteed the same rights to financial
services as men. According to ACAPS, at least 92% of women between the ages of 15 and 64 have
suered at least one act of violence perpetrated by a man, a figure that speaks to the significant degree
of gender-based violence women experience. [4] The US Department of State notes that a survey in
2005 showed as many as 96% of women in Guinea may have undergone some form of female genital
mutilation (FGM); although the practice has long been illegal, only slow progress has been made towards
reducing its prevalence. [62] In terms of their mobility in the socioeconomic sphere, only 18 % of women
are represented in the non-agricultural labor industry. On the other hand, a majority of women (74%)
dispose of their financial resources according to their own will. Finally, there are gender-based disparities
in education, where there are only 83 girls for every 100 boys in primary school and 57 girls for every 100
boys in secondary school. [4]
2.2 Political, Historical, Economic aspects
2.2.1 Brief History
From slavery to independence
Slavery and, in its aftermath, colonialism have proven to be major forces in the creation of socio-political
dynamics in Guinea. The European-American slave trade assimilated what is now Guinea into its
transnational extractive grip beginning in the 15th century. Guinea was ocially named as a French colony
in 1893, soon followed by French African regiment incursions into the Kissi, and then Toma and Guerzé
lands of the area that presently constitutes Guinea. Northern Guinea was progressively conquered and
occupied by the French military into the 1920s. Colonial military invasions were not the only invasive
force; Christian missionaries initiated their proselytizing and civilizing campaigns in the region at the
beginning of the 19th century. Prominent among them figured the Mendé mission headed by former
9
slaves who had been emancipated from the notorious Amistad ship2. [23]
Guinea ushered in its independence in 1958, the first of the France’s former colonies in West Africa to
do so, by voting in a referendum organized by the French government. Guineans voted for immediate
full-fledged independence. In doing so they were unlike all their West African counterparts, who initially
chose to remain under France’s economic tutelage and not to seek full-fledged independence until
1960. [4]
Post-independence
The country’s recent history can be divided up by three major events. The first of these was its
achievement of Independence, won in 1958 and ocially establishing the First Republic of Guinea.
The first republic lasted until 1984, for the most part under the dictatorial regime of Ahmed Sékou
Touré, who came to power upon Independence. Implacable nationalist and pan-Africanist, and great
grandson of the celebrated Muslim anti-colonial campaigner and war hero, Samory Touré, Sékou
Touré embarked on an ambitious programme to modernize Guinea according to socialist principles.
Declaring “Our society is achieved by getting rid of the failings inherited from the past: from
the fetishist past, from the colonial past, and from the feudal past,” he launched campaigns aimed
at the elimination of many traditional spiritual beliefs, practices and social hierarchies, leading to the
destruction of many venerated magical objects (‘fetishes’) and the dismantling of local cults [34, 46]. This
‘modernizing’ legacy stoked tensions between GF, where traditional practices were particularly strong,
and central government. [4] Over time, his dictatorship became increasingly repressive. After Touré’s
death in 1984, a military coup led by Lansana Conté inaugurated a new government, forging the Second
Republic Guinea. Conté’s reign was characterized by a strong emphasis on pro-market policies, notably
in order to attract investors in the mining sector. In 2008, upon Conté’s death, the military dictatorship
of Moussa Dadis Camara came to power, promising reforms. In 2010, Dadis Camara suered gunshot
wounds to the head in an assassination attempt, was flown to Morocco for treatment, and then exiled
to Burkina Faso. A transitional government was appointed pending the holding of viable elections. The
Third Republic under Alpha Condé emerged following elections in 2010 and continues today. [4]
2.2.2 Political history
Political landscape
The colonial period lasted from 1893 until 1952 and left a deep imprint upon Guinean history. The country’s
current political situation is rooted in a colonial and postcolonial context that led to the fragmentation of
the sociopolitical sphere along ethnic lines. Its social landscape today is influenced by the population’s
experience with ‘Western’ influence and its own complicated inter-ethnic relations. [20]
Colonialism in its formal sense did not begin until 1893, when French Guinea became an ocial colonial
territory after having been an administrative dependency of French Senegal since the 1860s. However,
the region’s incorporation into an exploitative transnational economy dominated by Europe was first
initiated in the 15th century with the exportation of iron and, soon thereafter, the slave trade. Local
Manding warlords battled against one another, all while simultaneously exploiting colonial rivalries, for
shares of the slave market that extended from the country’s interior to its coast. The French African
regiment occupied GF in the 19th century, in what became a prolonged military occupation that endured
until the 1920s, though the region maintained a vigorous resistance. Christian missionaries also attempted
to spread their influence as early as the 19th century, though they were never able to eclipse Islam and
Arabic scholarly and medical schemas, which had been salient aspects of regional life for centuries
already. [20, 23]
2 This ship was the site of a famous slave revolt in 1839 by Mendé captives enslaved in Sierra Leone.
10
Some have asserted that the slave trade acted as a major influence on the development of cultural
and religious practices, as well as political traditions, in the region. Such schemas include: the fear of
anthropophagous, unpredictable spirits (thought to be transposed representations of murderous slave
traders) and suspicions of deception by witches who may harm or exploit their communities (figures that
likely echo slave-era betrayals or breakdowns in community bonds precipitated by communities’ selling
of their own members into slavery). Initiation societies born of local political and religious orders may
also been formed partly in reaction to slavery, as local leaders sought to develop alternative political and
cultural structures to those of the ocial colonial government, by developing local cults and regional
political federations defined by freedom from slavery, trade monopolies, and military infrastructure.
Indeed, political and religious orders became intertwined, beginning with the collusion between Manding
(Muslim warlords) and colonial slave-traders, forging a local religious configuration against white Christian
(colonial) and Muslim (Manding) groupings. [23] Though Sékou Touré’s government strove to suppress
these societies, along with many forms of traditional practices in the name of modernizing the state,
some have been partially revitalized following Touré’s death as government policy became less hostile.
[10, 46, 47]
People’s contentions with ocial authority are rooted in colonial history and have partially shaped their
resistance to the policies and practices instituted by formal governmental authorities to manage the
Ebola crisis. The former sites of labor recruitment under colonialism are now the places where Ebola has
taken its greatest toll. This is attributable to the fact that such extractive policies as forced labor were
achieved under the colonial regime by placing local political chiefs from powerful families in roles that let
them further exploit subordinate families, who themselves were often direct descendants of slaves. From
this arrangement emerged two strategies of resistance to ocial political authority, which are still seen
today: 1) bribery and secret societies, oshoots of those undertaken during the slavery era as means
of undermining the eective exercise of power by local appointees representing central authority and
2) the organization of political appointments in such a way as to ensure that those designated to hold
ocial positions under the colonial regime held little real sway within local communities. Communities in
GF may sometimes prefer the traditional justice system – presided over by village chiefs and elders – to
the ocial one, although there is often considerable movement of cases between the two. [4, 23]
In the aftermath of colonialism, this framework of tensions persisted with the nominally revolutionary
politics heralded by Ahmed Sékou Touré’s Revolutionary Communist State. Distrust of state actors,
and the popular perception that any influence they might try to exercise over local aairs had no real
legitimacy, persisted after independence. The country’s first post-colonial government engaged in
practices that closely resembled those of the formal colonial regime - forced labor taxes with an emphasis
on production. Some of these programs were even amplified under his regime, motivating the departure
of numerous Guineans to Liberia and Sierra Leone. [23]
Today, internal conflict between ethnic groups associated with specific political parties continues. The
presidential elections of 2010 and legislative elections of 2013 provoked massive contestation and were
the sites of electoral violence along ethnic lines. Since then, ethno-political tensions have continued. The
2015 presidential election took place as scheduled in October 2015, and was won by the incumbent,
Alpha Condé. [4, 14]
Recognizing the social and political challenges that the country faced, in 2011 Guinea became the
first country ever to refer itself – as opposed to being referred by the Security Council – to the UN
Peacebuilding Commission. This took place in response to violent repression and organized rape
against pro-democracy protestors by the military on 28th September 2009 and to the legacy of military
dictatorship. The Commission’s involvement reinforced work to strengthen civil society and human rights
in Guinea, though many challenges remain. [61]
11
Inter-ethnic tensions
Inter-ethnic tensions often lie at the core of political tensions. The ethnic groups residing in GF, for
example, have forged political structures in response to specific colonial experiences. In this region, a
fragmented, non-hierarchical and uncentralized structure existed amongst the Kissi ethnic group prior to
the arrival of French colonizers. French attempts to impose their political authority thus met with fervent
resistance. The Peul, on the other hand, had more hierarchical forms of sociopolitical organization prior
to the arrival of French colonizers and were thus more receptive to the political structures that the latter
brought with them. This dierence is reflected in the relative absence of reticence in the area inhabited
by the Peul, namely Fouta Djallon region, to observe the counter-measures of the Ebola response. [4]
Socio-political tensions are marked, as well, in formal politics. In this sphere, two principal ethnic groups,
the Peul and the Malinké, compete for power, while forest-dwelling groups have been less represented
(save for the brief military government of Captain Moussa Dadis Camara, of Kpéllé origins, in 2008-
2009). In the forest region, defiance of central government has persisted, and some inhabitants proclaim
their deeper communal and familial ties to inhabitants of Sierra Leone and Liberia, where some of their
ancestors fled during the colonial period to escape imperial authorities. Lack of trust in state-based politics
and authorities was fuelled in the region by memory of campaigns under Sekou Touré’s government
to eradicate traditional belief systems. The survival of traditions in the face of persecution has often
reinforced a sense of distinctive identity and the deeply held importance of cultural practices. [4, 23, 34]
2.2.3 Economy
Severe poverty, obdurate impediments to accessing fundamental social resources and services, and
persistent sociopolitical strife, have had a profoundly negative and systemic impact upon social and
economic development programs in the country. Despite being endowed with natural resources and
minerals, such as bauxite, iron, gold and diamonds, Guinea is among the region’s poorest countries, and
is classified as a low-income country according to the World Bank’s 2010 criteria. Until the 1990s, and
again in recent years, mining has provided more than 20% of the country’s GDP. However, a remarkably
small proportion of the revenues acquired through the industry have benefited the local population and
corrupt contracting and exploitation practices have played a role in stoking ethno-political tensions. In
2011, just after Dadis Camara’s departure from power, the Condé administration passed policy measures
in an attempt to reduce such corruption, to little or no avail. The implementation of policies favorable
to foreign investors and enterprises motivated large mining companies to recommence their activities,
which they had halted during the international trade embargos and economic sanctions imposed on
Camara’s regime. Within the year, mining made up more than 25% of GDP and 95% of exports, while the
economy’s annual growth has proceeded at a feeble rate of 2.97% and local consumption has continued
to decrease. [4]
Over the last decade, the country has undergone a degenerative and unrelenting economic crisis.
The majority of the population subsists through agricultural means, though recent modernization has
encouraged the flight of younger generations from the countryside into the cities. Common crops in
Forest Guinea include rice, cassava, sweet potatoes, plantains and corn, which are farmed for subsistence
or for income. In more urban settings, small-scale professions, such as mechanics, wood-working, and
craft activities abound, fashioning objects for both local and distant markets. [1, 4, 32]
In terms of class divisions, homes and familial networks range from comparatively auent to suciently
resourced, to impoverished. According to the World Bank, Guinea was 179th in the world in equality of
income distribution in 2013. Against this backdrop of poverty and minimal state provision, urban and rural
households alike rely heavily upon large kin structures for both socioeconomic support and protection
against vulnerabilities associated with ill health. [32, 63]
12
Poverty and social unrest have been aggravated with the institution of a clandestine narcotics tracking
network in Guinea, which over recent years has become a major transit point for drugs being funnelled
from Latin America to Europe. The informal narcotics economy was initiated in the 1980s and has
recently gained momentum through the constitution of stronger tracking networks. Young urban
dwellers, casualties of the economic crisis, bereft of job opportunities, and suering from boredom and
the hardships that bear unremittingly upon their daily lives, are particularly vulnerable to these drug
tracking-schemes. Farmers suering the eects of the economic crisis have also turned to cultivating
marijuana, a sack of which can oer proceeds that amount to one year’s worth of traditional agricultural
crops. [1, 3, 20, 32]
2.3 General health aspects
Maternal and infant mortality
Women and children represent particularly vulnerable groups when it comes to morbidity and mortality
outcomes in Guinea. Maternal mortality reaches a figure as high as 724 for every 100,000 live births
in 2012 while infant mortality rates might reach 67 per 1000 live births. Such deaths are mostly due to
transmissible infectious diseases – malaria, HIV, tuberculosis - for which treatments remain dicult to
access. [1]
Mortality and morbidity across the population
Diseases that have posed significant recent threats in Guinea include meningitis, yellow fever, measles,
and cholera. During the first trimester of 2014, Southern Guinea became the epicenter of an epidemic of
Ebola hemorrhagic fever that struck West Africa in full force, displacing these aictions as primary public
health priorities. [1]
According to a 2001 census, the number of people aged 15 to 49 living with HIV throughout the country
was 55,000, which translated to a global prevalence rate among adults of 1.5% in 2000. Studies have
suggested that an important factor in this is lack of information regarding modes of transmission, which
gives rise to false beliefs and ideas about risks that cause heightened susceptibility to infection. Religious
messages have sometimes promoted such false beliefs and ideas. [56]
Chronic diseases, such as diabetes, have also become significant. 3.5% of the adult population suers
from diabetes, with urban-dwellers twice as likely to develop the disease as those living in the country’s
rural zones. [31]
Health system
The formal health system operates through a pyramidal framework integrated within the government’s
larger administrative apparatus. The Ministry of Health designs health policies and allocates central
funds to regional administrators. They in turn implement policy on a regional level. Below this is the
Prefectoral health administration, homologous with the role of the WHO’s health district, and operating
through village health centers. [4]
Since the 1980s, primary health care has indeed become a focal point for Guinean governmental policy,
which has tended to place a great emphasis on prophylactic, therapeutic, and health-maintenance
services. The village health centers are reachable by 90% of the population, and assure 75% of the
13
population’s healthcare costs.3 They partake in the prefectoral health system cited above and provide
the principal source of care for people outside of the capital. Administrators attempt to compensate for
operating expenditures by charging for therapeutic services. NGOs have also taken on a significant
role in providing resources for such centers in the form of personnel, infrastructure, or delivery support.
Because medicines and treatments have been largely eliminated from public expenditures, non-state,
informal markets have emerged in the form of private pharmacies in urban streets and “table-top sellers”4,
in urban and rural markets who purvey biomedical, as well as non-biomedical medicinal products. These
unocial health workers include Islamic practitioners, herbalists, and local healers venerated by the
public for their specific expertise and ability to wield such unorthodox therapies. [31]
Guinea’s national policy on traditional and complementary/allied medicine dates from 1994. [64] Formal
organizations exist to support, manage and/or regulate traditional healing. A Department of Traditional
Medicine (DTM) exists within the Guinean Ministry of Health and has collaborated with traditional healers
on primary health care in the country since 1979. [55] However, there are some tensions between the
DTM and healers; the latter recently accused the Department of mismanaging funds intended to support
their training and activities [54], and researchers have found that few individual healers choose to register
with the DTM [17]. Healers may seek to join the national Traditional Health Practitioners’ Association or
local associations. Public health ocials have found working with these associations and healers on
training and community education to be an eective strategy in dealing with health crises such as HIV/
AIDS and Ebola. [55, 68]
3 There is a gap in the information available regarding the forms of correspondence that occur between prefectoral
community health centers and the various health structures. There is, however, a system of correspondence between psy-
chiatrists and neurologists operating in Conakry and N’Zerekore, where the two main mental health facilities are located.
4 The term “table-top sellers” generally refers to merchants selling a mixed collection of formerly discarded medica-
tions or medical goods, ordinarily arranged on tables in large collective marketplaces.
14
3. MHPSS FRAMEWORKS, ISSUES AND SERVICES
3.1 Frameworks for biomedical mental health services
Mental health policy and national plan
The mental health policy and national plan in Guinea was initially formulated in 1995 and further developed
in 2000 and in 2013. The tenets set out in the plan were advocacy, promotion, prevention, treatment,
and rehabilitation. It was organized around decentralization and integration of mental health services
into primary health care. Mental health services and resources were to be transferred from hospitals to
community-based facilities, including a provision for children and adolescents with disabilities. However,
the Ministry of Health still needs to agree and validate it ocially and the plan is not currently operational
[49]. The process of agreement and validation has been obstructed by the Ebola epidemic becoming
the country’s public health top priority. Nonetheless, the crisis has perhaps also provided space for the
possibility of integrating mental health within the overall health package within primary and secondary
care structures, where it is not currently included, and a revision process of the national mental health
policy is in progress in late 2015, with WHO involvement. [1, 59]
A working group on MHPSS was created in February 2015 under the lead of WHO [1], but has since
merged with the Ebola survivors group (Capucine de Fouchier, personal communication). This working
group recommended the establishment of a coordination structure for all organisations involved in
mental health and psychosocial support, in the form of a national consultative committee under the lead
of the national coordinator for mental health within the Ministry of Health. However, at the time of this
review, concrete steps had not yet been taken to realize it. The child protection working group within
the Ministry of Social Aairs, is active [1], but there is little coordination with MHPSS activities focused on
adults (Capucine de Fouchier, personal communication).
The WHO is providing several trainings to frontline health professionals. Physicians and nurses in primary
health care are receiving training on the management of mental health disorders using the mhGAP
Intervention Guide. As of the end of October 2015, 25 national mental health actors and 245 primary
health care physicians and nurses had been trained in the Ebola-aected areas and more training is
planned (Capucine de Fouchier, personal communication).
Substance abuse policy
A substance abuse policy has existed since 1999 but it is uncertain whether it has been reviewed, and
what type of standards on treatment and prevention it is using. Treatment centres specialised in substance
abuse or alcohol consumption and harm reduction programs are unavailable nationally, though one
psychiatrist based at Donka hospital has specialist training. Consequently, the Donka psychiatric ward
serves as the national reference unit for alcohol and substance abuse (Capucine de Fouchier, personal
communication). A few NGOs are involved in treatment but the main challenges remain in training and
funding. [1, 8, 41]
Mental health legislation
There is no legislation specific to mental health in Guinea. It is instead incorporated within the wider
general health legislation with a dedicated chapter that specifies provisions relating to prevention,
protection, and treatment (Chapter 11, article 209-221, Public Health Code, Republic of Guinea) enacted in
1997. Measures related to mental health are absent from other existing legislation (e.g. welfare, disability,
general health). [18, 41, 66]
National therapeutic drugs policy/Essential list of drugs
A National List of Essential Medicines (NLEM) from the WHO’s List of Essential Medicines (2009) is used
15
in the country. The list5 consists of psychotropic medication and anticonvulsants/anti-epileptics. The
medicines recommended on this list at secondary health care level are: carbamazepine, phenobarbital,
phenytoin sodium, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, and lithium. From
this list however, only phenobarbital, chlorpromazine and diazepam are usually available at primary care
level. These medicines are expensive and frequently unavailable, which in turn pushes patients and their
families to purchase cheaper unregistered medicines that are available in local markets.
Psychiatrists and generalists can prescribe medicines from the above list, apart from lithium carbonate
which only psychiatrists can prescribe. Primary health care doctors and nurses can prescribe and/or
continue the prescription of psychotropic medication with certain restrictions. However, the Ministry of
Health does not allow primary health care nurses to diagnose independently and treat mental illnesses
in primary care settings. [18, 41, 66]
There is limited training available in Guinea for the various professionals involved in the field of mental
health. For example, most primary health care nurses and doctors have not received any in-house related
training for the past five years, though this is currently being remedied by the WHO mhGAP training
mentioned above. Ocially approved procedures for referral between tertiary/secondary care and
primary care are also lacking. [41, 66] It is not possible to undertake medical specialization in psychiatry
within Guinea [2] and the 5 psychiatrists in the country all studied their specialty in Ivory Coast (Capucine
de Fouchier, personal communication).
Mental health expenditure
Guinea has limited financial and human resources with which to put into action its national plan to
strengthen mental health support services. Overall health expenditure is limited to 5.73% of Gross
Domestic Product and $9 per capita government expenditure on health (PPP [Purchasing Power Parity]
$). Details on the Ministry of Health’s expenditure for mental health and for psychiatric hospitals are
unknown. A dedicated budget is not allocated to mental health as a whole and the government only
budgets for sta’s salaries. Guinea does not have provision for mental health disability allowances, which
has a direct impact on the accessibility of services. As a result, the patients or their family are the primary
funders of mental health-related expenses, when it comes for example to food, medicines and hygienic
products during hospital-stays. [1, 41, 66]
Mental health and psychosocial human resources
Human resources in the MHPSS sector are limited in Guinea as Table 1 demonstrates. There is limited
training available to train clinicians in mental health to strengthen support services in the country.
For example, there is no psychologist training or specialization in psychiatry available. [1] Moreover,
the workforce is concentrated in Conakry; all 5 psychiatrists are based at Donka hospital [49]. These
figures are below the average for the West African region.
5 See details in the Public Health Code produced by the Republic of Guinea in 2012, page 28 and 8-9.
16
Table 1: MHPSS professionals available in Guinea according to the 2014 census (adapted from Abaakouk,
2015 and Psychology in Africa, 2013) [1, 41]6
Mental Health professionals Number available in
Guinea
Number per 100,000
population
Psychiatrists
4 [.038]
(WHO, 2011 median rate: 1.27)
Child psychiatrist 1 [.0094]
Trained generalists 13 [.122] 0.122
(WHO, 2011 median rate: 0.34)
Psychologists 10 or 1170.1 0
(WHO, 2011 median rate: 0.30)
Psychiatric nurses
0 0
Trained nurses 12 [.113] 0.112
Social workers 2
(Based in the ministry of
social aairs)
[.019] 0.018
(WHO, 2011 median rate: 0.23)
‘Educators’/Youth workers 1 [.0094] 0.009
Neurologists (and neurologist
specialists)
9 [.085] 0.04
Neurosurgeon 3 [.028]
Generalists trained in Neurology 4 [.038]
Nurses 6 or 7 .06
3.2 Specific mental health issues
Prevalence in the general population
There is currently a real gap in the availability of epidemiological data on the prevalence of mental
health issues in Guinea within the published academic literature, and in policy in the past years. [41, 63]
Neuropsychiatric disorders contributed to 6.5% of the global burden of disease in 2008. During the
mental health consultations completed throughout the country in 2014, the most frequent descriptions
of mental health issues were manic episodes, delusional disorders, confusion, psychosis and epilepsy.
Consultations were also sought for psychomotor retardation, depression, and follow-up for diculties
related to HIV and experiences of sexual violence. Information related to the suicide rate is not available.
[63] In terms of addictions, the most highly consumed drugs are cocaine, cannabis and alcohol. In Donka
hospital, a general public hospital with the only psychiatric ward in the country, 80% of the patients that
consulted for psychiatric care between 1984 and 1994 did so for drug addiction. [8, 20, 56]
6 The most recent version of WHO Mental Health Atlas (2014) gives all mental health workforce figures for Guinea as
‘Not provided.
7 This number was calculated retrospectively from the size of the 2014 population census and the number of psychol-
ogists for each 100 000 people. [1]
17
Prevalence in the conflict-aected population
Guinea has also been aected by the armed conflicts and civil unrest that occurred in its neighbouring
countries, starting first in Liberia (1989-2004), and spreading across Sierra Leone (1996-2002) and Ivory
Coast (2002-2007 and 2010-2011) (See Section 4.1.1). Violence also spread across Guinea in 2000-2001
led by both the Liberian and the Sierra Leone-based Revolutionary United Front (RUF). The communities
mainly aected were in the region of GF, Guéckédou in particular. A 2004 study focusing on predictors
of psychological and physical distress of these communities, identified the importance of understanding
locality, local histories, type of traumatic experiences populations were subjected to, and the ways in
which these traumatic events shaped social relations. The authors argued that 65% of the individuals
interviewed from these war-aected communities presented with significant psychological distress.
Respondents reported the following symptoms: 84% traumatic symptoms, 79% physical anxiety, 74% the
presence of three or more somatic symptoms with sadness and guilt, 62% a majority of symptoms of
emotional anxiety/fear, and 48% reported two or more symptoms of depression as ‘present’. [2] Another
study in GF that focused on the marginalized children in this region who were mostly conflict-aected,
indicated that 75% had wished to be dead on at least one occasion, 70% of girls and 80% of boys were
considered to be at serious risk of suicide, and 30% had already tried to kill themselves. [9]
The suering of these conflict-aected communities was amplified by a feeling of abandonment from
their government and NGOs in assisting them in the reconstruction of their homes, market places,
and in making available the necessary public infrastructure. Similar to the refugee population, these
communities’ struggle for economic survival and their inability to contribute meaningfully to their
communities heightened their emotional distress. [2, 15, 53] Their concern also impacted on their ability
to participate in social rituals and practices (e.g. Poro or Sande [men and women’s secret societies,
respectively], funerals, baptisms, family meetings and other social events) and therefore to access
informal social coping mechanisms.
Prevalence in the Ebola-aected population
At the time of writing, no results were identified from available prevalence studies of mental health
issues in Ebola-aected areas of Guinea. However, it is widely acknowledged that MHPSS is a significant
concern in the wake of the Ebola virus outbreak (see Section 4.3.3).
3.3 Local conceptions and nosologies of distress, loss and trauma
In many parts of Guinea, people draw on a wide variety of frameworks to understand health and illness.
Biomedical models are only one among many accounts that may be drawn on to understand the
causes and course of illnesses and misfortune. Co-existing frameworks reflect cosmologies in which
the individual person is situated within a constellation of relationships with the living, the dead, the spirit
world, and nature itself. Thus possible causative factors that might be considered in cases of sickness
are the consequences of violations of the natural order the actions of the dead, of non-human spirits
(djinns), sorcery, divine punishment, and experiences of violent conflict.
Violations of the natural order
In GF, there is a natural order that should be observed. When actions are committed that do not respect
these restrictions, they may bring on maa, a disruption of harmony that can lead to such consequences
as sickness or economic misfortune. [11] For example, the reproductive cycles of humans, plants and
animals are part of this order and Fairhead describes how imperative it is that each respects the proper
boundaries of space and time. Hence people should not have sexual relations in the bush (the domain
of animals) rather than in the village; mothers should not have sex while breast-feeding a child, as such a
lack of self-control would be to start a new cycle before the previous one has completed and it is feared
18
that the man’s semen may enter the breast-milk and sicken the child [36]; pregnant women should not
care for the dying, as this is to confuse the cycles of birth and death [22]; menstrual blood should not
enter the fields where crops grow; seeds from one year’s harvest should not be mixed with the next.
To disregard these obligations is to court infertility, drought and / or sicknesses that may aict the
perpetrators, the child, or the crops.
Ancestors
Illness or misfortune may also be brought about by the dead. It is as important that people die ‘correctly’
as it is to maintain order in the natural world. Examples of infractions that can have serious consequences
include: death occurring in the bush rather than the village; debts and credit not being settled correctly
before the deceased is ready to leave for the next world; the dying not being given the food and drink
they request [22]; the appropriate funerary gathering and farewell not being held. [23] Any of these,
whether intended or not, may prevent the deceased from moving on to the afterlife, causing them to
remain as a wandering spirit and punish the negligent, as well as other relatives.
Family and social bonds are as important when dealing with dying and death as they are in life. It is
important to care appropriately for the dying, to take note of and honour their last words, to settle
outstanding debts and other matters, and ideally to transport them back to their home town for funeral
and burial arrangements to take place. In GF, consultations may take place with the deceased (or with
a substitute made from their clothes, hair and nails) through the intermediary of a diviner, if there are
reasons to ask about the cause of death; this may reveal whether sorcery was implicated and whether
there is a need to counter it [23]. Many funeral practices are intended to help the soul on the long journey
to the afterlife and the deceased may therefore be buried with money or provisions. [13] If procedures
are not carried out correctly or adequately, the soul may not be able to depart and may remain to haunt
the living as a wandering spirit.
Djinns
Djinns are spirit beings that inhabit areas of the bush. For example, the Baga of the Upper Guinea Coast
describe them as the original inhabitants of the land. [46] Also known as diables (devils), they are not
necessarily evil as such, but may cause serious harm to people – sometimes in the form of illness – if not
treated with respect or if the whim takes them [22, 33]. Past cases in Conakry and Labé where groups of
young women experienced possession trance have been attributed to djinns. [20] Among other illnesses
sometimes attributed to djinns in GF are idiocy, madness, paralysis and convulsions. [36]
Sorcery
It is not just djinns and the dead who have supernatural powers to harm, but also some of the living.
Belief in sorcery is common in Guinea. Sorcerers are distinguished by their selfishness in the pursuit of
power or wealth, and suspicions of sorcery sometimes fall on those who appear reclusive or accumulate
rather than share what they have, thus failing to fulfill their social obligations. Belief in sorcery thus
expresses core values of egalitarianism and community [46], and provides a way of making sense of how
some individuals in the modern world seem to enrich themselves very suddenly while most remain poor.
Sorcerers may send harm to others through magical means. [23, 31]
Divine punishment
It is sometimes said that all illnesses come from God, as do all cures. Illness may then be a form of
punishment for not observing one’s obligations to God. [60]
Experiences of violent conflict
The violence suered by communities in GF as the result of attacks by Sierra Leonean and Liberian
forces has been blamed for some forms of ill-being there. In the aftermath of those raids, it was reported
19
in some towns and villages that ‘craziness’ had increased among the residents as a result of the trauma
of what they went through. Constant fear, inability to think clearly, substance misuse, reluctance to talk
to each other, and sadness were highlighted, particularly where there was a sense of abandonment by
outside help and where collective community cohesion had not recovered [2]. Experiences of trauma were
also reported among residents of the refugee camps that existed in GF, with the condition haypatεnsi
(‘hypertension’) popularly used to label the symptoms that resulted from thinking too much about the
fears and suering resulting from the war. Haypatεnsi is linked to the older condition known in Mendé as
‘spoiled heart’ and though it is clearly influenced by biomedical notions of ‘hypertension,’ diers from it
in important ways. It is characterized by heart pain and rapid heartbeat and cramps, which stem from the
damage that heavy emotional turmoil inflicts on the heart, and may be treated either pharmaceutically or
by resting and trying not to dwell so much on one’s losses and anxieties. [28]
A study carried out into how epilepsy is understood illustrates the range of interpretations that may exist
for a mental health condition. 320 respondents were interviewed and asked to what causes they would
attribute epileptic symptoms. The range of answers included: the person’s mother failing to observe
certain precautions around bathing during pregnancy; sorcery; the action of a night-bird called the
mamadabi; eating the meat of an animal which had been bitten by a dog; sexual relations between
the person’s mother and her brother-in-law; the person’s parents having sexual relations after a funeral
without first bathing; whirlwinds sent by a djinn; failure to observe Koranic laws; and transmission through
the saliva of another epileptic person. There was a degree of consistency in answers given by members
of the same ethnic group, but even here there could be considerable variation. Among the Manding,
it was suggested that epilepsy was a sign that the person aected would become a king later in life.
However, strong stigmatization of epilepsy was more common. This was not limited to members of the
public, as many health professionals also expressed wariness of people who have epilepsy. [50]
3.4 Concepts of the self, person and life course
It is dicult to generalize about concepts of the self, person and the life course, as they may vary
significantly among the many dierent ethnic groups and communities of Guinea. Two historical processes
have influenced selood in ways that vary between communities: Islamization and the First Republic’s
modernization campaigns. Both eroded traditional practices and worldviews that centered on local cults
or initiation societies. These societies had previously held secret religious, ritual and magical knowledge,
and guided the initiation practices that marked individuals’ progress through the life course. Islamic
reformers from among the Peul, Malinké and Sousou had already started to erode traditional practices
and views of the self, which they viewed as heathen, among other ethnicities before independence was
gained. Sékou Touré’s modernizing ‘demystification’ campaigns (1958-1984) then further suppressed
the initiation societies, burning ritual objects and publicly exposing their secrets. However, the initiation
societies were never fully suppressed in GF, as people had cross-border links with Liberia and Sierra
Leone where the societies’ practices were not forbidden. [10, 23] In other parts of Guinea too, notably on
the coast among the Baga, some groups have recovered former ‘customs.’ However, both on the coast
and in GF, some community members strongly condemn traditional practices as un-Islamic or backward,
though there are often disagreements about this within communities. [10, 46]
Initiation societies institutionalized a pathway through which young men could gradually achieve the
power and respect owing to older men. Though initiation rituals varied from one area to another, they
commonly took place for young men at around the age of fifteen. These young men would spend several
weeks away from their families in the woods, during which time they symbolically died and were reborn,
in order to enter into adulthood and progress over time to a position of seniority [24, 46]. Today, women’s
societies are in some areas more vital than those of men, perhaps because it was primarily men’s societies
20
that were targeted under Sékou Touré. Women’s societies, like men’s, structure initiation rituals for their
members, though forms of initiation are dierent and girls have never undergone the long internment
in the woods that boys experienced. Other ritual practices of women’s societies manage relations with
the spirit world (sometimes through possession rituals) and bring about healing and protection against
sorcery [10, 23, 46].
Family, social and community bonds and obligations play a very important role in the conceptualization
of the self for many Guineans. If one does not – or is perceived by others not to – respect these bonds,
one is likely to incur anger and resentment (occasionally even leading to curses) and sometimes lead to
suspicions of being a sorcerer. In GF, illness, drought or misfortune for whole villages can result from the
infractions of no more than one community member if they disrupt the natural order of things [23], which
reinforces the importance of observing collective obligations. This is not of course to say that these
norms are always respected, but does suggest why the wider community may feel that they have a stake
in the behavior of individuals. Thus the self is commonly seen in relational terms and, while individual
success may be valued, strong individualism may be discouraged as selfishness. The extreme example
of selfishness is witchcraft. [45]
3.5 Risk and protective factors for mental health issues
In Guinea, the determinants identified for mental health and psychosocial well-being pertain to the
degree to which one’s community acts as a solid support system during and in the aftermath of crises.
An individual’s access to familial and parental support structures has been and is critical in assuring
positive mental health results in the face of traumatic events. Other social factors include socioeconomic
conditions, such as the extent of poverty endured both individually and by one’s community. [31]
In the conflict-aected communities of GF, social activities that fostered community ties proved critical
in determining positive mental health outcomes in the aftermath of the Sierra Leonean and Liberian
wars that spilled over Guinea’s borders. Communities that elaborated narratives that promoted healing
by explicitly rejecting the violence they had faced, demonstrated greater resistance to mental health
problems, both on a collective and individual level. Conversely, narratives that reinforced a sense of
powerlessness and defeat when confronted with uncontrollable catastrophes were shown to have an
overall negative impact on mental health outcomes. In addition, infrastructural, logistical and financial
resources that promoted a sense of security and the ability to endure during and after the wars, were
vital elements in the promotion of favorable mental health results. Risk and protective factors with
respect to mental illness and disorders were deeply intertwined with the mediating processes between
communities and individuals as conduits for psychosocial resources that enable the reconstruction of
both community and self in the aftermath of debilitating events. [2]
In a study of the Guéckédou region which was aected by the conflicts in 2000/2001, researchers
examined the ways in which a number of the region’s villages dealt with the brutalities they were
subjected to throughout the war which included executions, rape, destruction of local infrastructure,
abduction, forced labor, dehydration, and exhaustion. They demonstrated how the enduring eects of
these assaults were processed dierently depending on the mechanisms and resources employed by
communities to cope with the aftermath. For example, in the villages of Nongoah, Tékulo, and Yendé
narrative accounts described how the communities viewed themselves as largely powerless in the face
of the violence they had faced and had little hope that the resources and places that had formerly
served as supports for community life – public infrastructure, homes, shops, clothes, and goods – could
be reconstructed and thus restore the continuity of social life in the aftermath of war events. These
communities demonstrated the greatest vulnerability to trauma-related mental illnesses. Economic
21
deprivation as a result of conflict hindered the preservation of critical social practices that had forged
and sustained previous community dynamics, traditions such as funerals, baptisms, family meetings and
other social events, leaving community members susceptible to a “loss” of their “social selves. [1, 2]
In this same study, 65% of respondents irrespective of their home villages, reported experiencing
significant distress mainly manifested through physical and trauma-related symptoms, as well as a
vulnerability to psychological distress and mental disorders. Social variables figure significantly amongst
these influences. For example, the absence of familial support systems represents a major determinant
of mental health outcomes. The study reported that 70% of girls and 80% of boys participating in the
research who lacked a real parental presence presented with a significant risk for suicide. By contrast,
10% of the girls and 5% of the boys who were supported by parental structures demonstrated suicidal
tendencies. [2]
Studies in Guinea have identified other protective factors. These include: strong communal ties; familial
and kin networks and parental support structures in the case of children; and community narratives of
resistance to the eects of social crises, such as war and persistent socioeconomic deprivation7 Non-
governmental organizations have also played a major role in furnishing communities and individuals
with the economic and logistical means to achieve a level of security. These factors, ensured both by
governmental and non-governmental apparatuses, have proven critical in mitigating individuals’ and
communities’ vulnerability to events that threaten to break down social ties and communal and moral
worlds. Overall, the most significant determinant of well-being resides in resources - financial, political
and psychosocial - that allow communities and, by extension, individuals, to maintain the communal and
moral universes in which they are embedded, especially in the face of catastrophe, whether it be of a
sociopolitical nature, such as war, or a public health crisis, such as the recent Ebola epidemic. [1, 2, 8]
Gender, age, socioeconomic status, and related variables are significant dimensions for understanding
risk and protective factors at play in MHPSS issues in Guinea. However, these variables do not appear to
have been a focus of systematic studies to date.
3.6 The healing landscape
3.6.1 Non-allopathic health system
In addition to the biomedically-trained doctors, pharmacists and allied health professionals in the allopathic
health system, Guineans may seek help from a variety of other healing practitioners. Islamic religious
healers (marabouts), herbalists, traditional healers and diviners, and community elders are commonly
consulted to diagnose and treat illness and distress, or for preventive, strength-building measures. [31]
They may draw on a variety of practices to address the problem, including prayer, incantations, herbal
washes and medicines, the use of protective amulets or ‘fetishes,’ particular foods and cleaning practices,
or cleansing rituals and sacrifices. [5, 31] In addition to working with the physical dimension of illness,
these techniques often also intervene at the psychological, social and spiritual level. [18]
When the cause of an ailment is unclear, it is common for help-seekers to go to dierent practitioners in
the hope that at least one will prove eective. [31] Thus, it is common to consult non-allopathic healers
before, simultaneously with, or soon after resorting to allopathic services. Help-seekers themselves do
not necessarily draw clear distinctions between allopathic and non-allopathic treatments as, from their
perspective, these forms of healing overlap and they may not make a distinction between scientific and
magical procedures. [23]
8 The absence of state-based support in the form of financial and infrastructural resources, contribute to create a
sense of insecurity and powerlessness for individuals and communities, especially in the context of crisis.
8
22
3.6.2 Government and NGOs in mental health care
The main center for mental health care in Guinea is the psychiatric service at Donka, a general hospital
with mental health services based in Conakry, which includes inpatient and outpatient services. The
inpatient service consists of 62 beds, though often far fewer are available (Capucine de Fouchier, personal
communication). In 2014, the service engaged with a total of 1365 patients, admitted 435 in-patients, and
carried out 5460 consultations. [1] The health service as a whole is significantly under-funded and state
funding only covers the salaries of the mental health service workers. Therefore for individuals who are
hospitalized, families must meet the expenses of food, medicine and toiletries [1] and a relative must
often accompany and care for the patient for the duration of their hospital stay. Despite the lack of funds
the poor hospital conditions that result, psychiatrists at Donka have expressed pride in not relying on
physical restraints. [40]
There is also a community mental health service called Boma, at N’Zérékoré. This center was set up to
treat residents of the refugee camps in that geographical area. In the past, the World Lutheran Federation
– ACT was involved in providing mental health care to refugees, but their involvement ended in 2005.
The service now has 18 beds. [1]
Some primary care health centres oer community mental health treatment and interventions. These
services are provided by the Ministry of Health in collaboration with Fraternité Médicale Guinée (FMG),
an NGO founded in 1994 specializing in mental health care in Hamdallaye. FMG has collaborated with a
number of international and national organizations, and works directly to provide interventions at health
centres in Conakry, Kindia and Labé. It also works in partnership with health centres at Boma, Yomou,
Samoé, Guecké, Pita and Timbi madina. [49]
In Kindia, FMG opened a ‘therapeutic complex’ for people with mental health disorders in the village of
Moriady, located at a distance of 123 km from Conakry. This complex provides a health center staed
by one doctor, two nurses and a laboratory technician, and is closely integrated with the surrounding
community in the support it provides for residents. 53% of residents at the complex, who come to
Moriady from many dierent regions of Guinea, have had a diagnosis related to psychosis, 29% have had
epilepsy and 18% have had other neuropsychiatric disorders. Pharmaceutical treatments are provided
and therapeutic activities include rehabilitation workshops, use of the community bakery and farming
work, where residents learn or re-learn practical skills and work towards full community reintegration.
The complex is highly distinctive in the Guinean context in this integration of medical and psychosocial
interventions. [18, 48, 51]
There are no specialized treatment centers dedicated to drug addiction and consumption, nor any
dedicated harm reduction programs, although some NGOs are active in this area [8].
3.6.3 Help-seeking strategies
General health-seeking pathways
In deciding whom to consult about health issues, people make use of their own past experiences,
observations, and advice from others. When the nature of the problem is perceived to be clear (e.g.,
wounds, snakebites, malaria, conjunctivitis), there is usually little hesitation in resorting to treatments
viewed as standard for that condition. When the nature of the problem is not so easily identified, or if it
fails to respond to initial treatments, people may then resort to a number of dierent healers to see which
one, if any, is eective. [31]
23
A number of considerations influence how people may view the available treatment options:
• Cost: Cost and forms of payment are sometimes significant issues for families. While many
pharmacists, market dealers in medicines, marabouts and medical workers charge up-front fees
for their products or services, others may allow credit or even payment when the patient gets
better. When family finances are running low, as is often the case before harvest, willingness to
accept delays in payment may determine who is consulted. [31]
• Quality: Certain medicines or cures are thought to be of better quality than others. This often
corresponds to the reputation of the individual healer or vendor who provides them. Some ethnic
groups in Guinea (e.g., the Baga of the coast [47]) are known for their medical prowess. In GF and
possibly elsewhere, the quality of the medicine is believed to be linked to the eects of the sun
on the medicines. Although plants that grow in full sunlight in the savanna develop more potency
than those that grow in the forest, keeping medicine in sunlight for too long can weaken it and so
medicines stored in buildings (pharmacies, health centres) are seen as stronger. [31]
• Nature of the treatment: Injections are seen as the strongest treatments, because they enter
the bloodstream directly. Treatments designed to be swallowed are perceived as less powerful,
and those applied to the skin less powerful still. The mode of delivery can play an important
role in what treatments are considered appropriate. In particular, injections may be considered
unsuitable for illnesses that aect bodily fluids, such as those that produce swelling or aect the
blood. In these cases, injecting further liquids is thought to worsen the condition. [31]
• Gender: Health centres have become closely identified with women and infants, perhaps partly
as a result of the emphasis placed on maternal and infant health. Because many aspects of the
social order in Guinea are dierentiated by gender and men feel awkward entering into women’s
space, men may tend to actively avoid the female- and infant-dominated health centres. Men and
boys over 5 tend to prefer to consult pharmacies directly, without attending a health centre. [31]
Mental health pathways
Where mental health service users are admitted to hospital, this is invariably done at the request of a
third party rather than through self-referral. [66] However, little is known about referral patterns, as no
single data collection system exists across the sector. [1] The creation of such a system is currently under
consideration. [41]
Awareness of available mental health services is not always prevalent among the population. For example,
a study by the International Organization for Migration (IOM) found that among returning Guineans who
had attempted to emigrate irregularly to Europe, less than 30% knew of state or NGO-provided mental
health services, despite the heightened psychological risk factors for this group. The study calls for an
action plan to enable preventive measures to reach out more eectively to this group. [29]
24
4. MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT BEFORE AND DURING
THE EBOLA CRISIS
4.1 MHPSS-related Humanitarian History
The Ebola crisis has overwhelmingly dominated humanitarian eorts in Guinea since early 2014. Before
this outbreak, humanitarian eorts largely focused on addressing the needs of Liberian, Sierra Leonean,
and Ivorian refugees. There have also been lower levels of humanitarian activity focusing on community-
building and addressing gender-based violence.
4.1.1 Summary history of humanitarian crises
Much of the humanitarian work done in Guinea in the last two decades has been in response to the
eects of the regional armed conflicts centred in neighbouring countries. Civil wars in Liberia, Sierra
Leone and Ivory Coast saw huge flows of refugees into Guinea. In 1999, ocial UN figures put the number
of refugees and asylum-seekers in the country at nearly 502,000, which was the largest concentration
within Africa at the time. [58] Large refugee camps were established in GF, though refugees’ movements
were generally not restricted and some settled outside the camps. Many refugees had experienced
or witnessed summary executions, maiming, systematic sexual violence and the destruction of entire
communities, giving rise to significant mental health and psychosocial support needs. At times, violence
spilled across the border into GF, with, in 2000-2001, attacks by both the Liberian and the Sierra Leone-
based Revolutionary United Front (RUF), in retaliation for perceived Guinean government complicity
with rebel forces in the camps. The Guinean army repulsed this invasion with the help of sizeable youth
militias (the ‘Young Volunteers’) and the rebel militarisation of the camps was slowly brought under
control. However, problems remained, in addition to the direct eects of the violence: the diculties of
demobilising up to 30,000 armed young people (among whom some were ‘child soldiers’) in a context
of high unemployment gave rise to concerns over citizen insecurity, more than 100,000 Guineans were
left internally displaced, and there was an upsurge in harassment and abuse of refugees during the
conflict [37]. Many people from the aected communities were left with symptoms of ‘trauma’, while also
having to deal with the socioeconomic impacts of the destruction [2]. Refugee numbers have reduced
significantly since then, as many have settled or been repatriated, and the regional conflicts fuelling their
migration have stabilised to some extent. However, the consequences of this dicult history still exert
an influence on communities in the area.
Though Guinea has experienced relative social stability compared with its neighbours, there are
nevertheless important tensions (see Section 2.1.2). Inter-ethnic tensions have intensified during and
since the 1990s. Often these have been tied to fears of political exclusion. This was the case in 1993,
when ethnicity played a role in violent clashes during the presidential election of that year, and again
in 2010 during the first democratic presidential elections [30]. During this period, GF has also seen
sporadic violent clashes between Guerzés and Koniankés, which took 95 lives in 2013, and the Toma
and Tomamania [20, 38].
The organized rape on the 28th September 2009 by Guinean soldiers of more than 100 women and
girls during a political demonstration (see Section 2.2.2) highlighted Guinea’s high rates of gender-based
and sexual violence and the unpreparedness of services to deal with this problem became a focus of
interventions [42].
25
4.1.2 Humanitarian Responses
Among the assistance provided by UN and other agencies to the residents of Kissidougou and N’Zérékoré
refugee camps were mental health care and trauma counseling. Of note is the US-based Centre for
Victims of Torture’s (CVT) 1999-2005 psychosocial program for Liberian and Sierra Leonean survivors.
This program employed paraprofessional counselors, supervised by on-site expatriate clinicians,
to address trauma symptoms using a relationship-based group counseling model that drew on both
Western and indigenous practice. The groups incorporated traditional forms of communication such as
stories, music and song, symbols and healing rituals [53].
Following the events in September 2009, some interventions were funded by international partners,
including training in medical and psychosocial care for medical teams at mother and child clinics and
legal aid for victims of political violence [61]. One noteworthy response was the RESPOND project, led
by Guinean agencies and USAID. The project provided medical care and psychosocial support to the
aected women and worked to build capacity in dealing with gender-based violence in the health sector
and with partner agencies. It particularly identified inconsistency of responses to sexual violence across
the health sector and sought to address this problem. [42]
Some eorts were also made to address ethnic and community tensions in the GF region by promoting
inter-community conflict prevention and human rights awareness. [61]
4.2 Experiences with the 2014-2015 Ebola crisis
The Ebola virus is transmitted through contact with the body fluids of an infected person and can lead to
abrupt-onset fever, headache, joint and muscle pain, weakness, diarrhea, vomiting, rash, impaired organ
functioning, internal haemorrhaging, and death [52]. The emergence of the West African Ebola epidemic
at the end of 2013 turned into the largest ever outbreak of the disease and posed severe challenges for
which overstretched public health systems in the region were unprepared. Guinea, Liberia and Sierra
Leone were the countries worst aected, though a handful of cases of the virus have been found in
Mali, Nigeria and Senegal, as well as the United States and European countries. GF was the epicentre
of the outbreak and the Ministry of Health ocially declared an epidemic there on 22nd March 2014.
Subsequent events revealed how political, cultural and economic factors played important roles in the
course of the virus’s spread. This has important lessons for on-going intervention, as well as a broader
range of future work.
4.2.1 Prevalence
The start of this outbreak was traced by epidemiologists to the Guéckédou region in GF. [52] Unlike
in previous outbreaks in central and eastern Africa, the virus soon spread over a wide area in and
beyond Guinea, as a consequence of the high mobility of the general population; cross-border trade,
regular visiting among widespread family networks, and the custom of transporting dead bodies to their
hometown for burial were all common features of life in GF [35]. As of 2nd August 2015, 3327 confirmed
and 452 probable cases of Ebola had been identified in Guinea, with 2522 recorded fatalities [69]. The
overall case-fatality rate for this strain of Ebola (the EBOV-Z form) is estimated at 60-90% [52]. At the
time of writing, the number of new cases reported by the WHO had greatly decreased and experimental
vaccine trials had shown promising results [27], though monitoring of contacts remains on-going.
26
4.2.2 Political and humanitarian response
Government and Aid Services Provided
decins sans Frontières (MSF) and the International Committee of the Red Cross (ICRC) played an
important role in providing care for Ebola patients and bringing the epidemic under control, alongside
Guinean health care workers. MSF in particular raised concerns at an early stage, but did not meet with
a receptive response to foreign interventions and aid. The underfunded Guinean health system, like
other health systems in the region, struggled as neither available resources nor expertise on Ebola were
adequate to respond rapidly or eectively to the outbreak. MSF provided training for local health teams
in self-protection measures, safe care and safe burials. [35, 39]
MSF frontline teams were soon also spread thin. The scarcity of expert knowledge meant that MSF
had no option but to send coordinators to Guinea who had received only two days of intensive training
on Ebola. The response from multilateral organizations did not take place until the epidemic was well
advanced [39], with the World Health Organization declaring the outbreak “a public health emergency
of international concern” on 8th August 2014, and the United Nations establishing the first UN health
mission in September with the creation of the UN Mission for Ebola Emergency Response (UNMEER)
[35]. These steps brought greater input from the international community. MSF played a prominent
role in advocating for international assistance and provided training to sta from a number of other
international NGOs and organizations. [35]
A number of steps were taken to try to bring the outbreak under control, including:
• Isolation of infected patients and provision of care in Ebola Treatment Units (ETUs)
• Explanation and promotion of safe burial procedures, to minimise the risk of infection when
preparing the body
• Awareness raising with communities about the virus’ transmission and counter-measures
• Disease surveillance and disinfection of potential transmission sites
• Tracing the contacts of those who became infected, in order to contain the disease
• Putting in place policies to ensure that health care for other conditions can continue, while
controlling the risk of Ebola transmission through health facilities. [19, 35]
Where psychosocial support needs were addressed during the epidemic this was done by NGOs, often
with limited coordination of activities. A proposal in May 2014 to train health professionals to provide
psychological care alongside their role in fighting the Ebola Virus Disease was not developed. [1, 21]
However, as the Ebola response developed, more attention has been paid to capacity building to develop
Psychological First Aid (PFA) awareness among health and care sta and community workers. [e.g., 67]
A particular focus has been on psychosocial support for children, where UNICEF has helped to develop
play and recreational activities, training of community leaders, and the National Strategy for MHPSS for
Children and Communities. [59]
Problems in the provision of aid
Unlike previous Ebola outbreaks elsewhere in Africa, many people in GF are very mobile. The virus
therefore spread rapidly and presented unprecedented challenges to infection control. [39]
Response eorts encountered considerable non-compliance and sometimes violent resistance. Infected
individuals were sometimes concealed from response teams or avoided medical help. Some villages
in Guéckédou blocked roads and cut bridges to keep the response teams out. At the height of the
outbreak, the ICRC reported that its volunteers were attacked ten times within a month. A number of
27
deaths occurred as the result of other such assaults, notably at Womey where 8 people died [23]. Reviews
of the response have noted mistakes that contributed to these reactions:
• Initially public communication strategies were largely drawn directly from those used in previous
outbreaks in the Democratic Republic of Congo (DRC), where people were already familiar with
the disease and socio-political conditions were dierent; they proved ill-suited to Guinea. [3]
National and international experts leading the Ebola relief eorts were not familiar with local
cultural and social practices. [20]
• Early public communications said that there was no cure for Ebola and spoke of ‘isolation centres’.
When the messages changed to emphasise the possibility of surviving the disease and used the
term ‘treatment centres’, the public started to become more receptive to the response eorts. [3]
• A slow initial government response and some early broken promises over the supply of equipment
fed doubts about the commitment of outsiders to protecting the communities. [3]
• The government response largely bypassed existing local health governance institutions, which
led to confusion and made a joined-up response more dicult. [39]
• Control measures were instituted without adequate consultation, explanation, or regard for local
customs or sensibilities. There was inadequate recognition of family and community concerns,
particularly around funeral practices. Ocials appointed were often from outside the area and
had little insight into local concerns.
• Local surveillance committees often failed to represent the population properly; dierent
communities are often suspicious of each other and including important figures from some villages
does not mean that they will be trusted in others. [5] Particular concerns about representation
were expressed over the exclusion of women (whose traditional roles put them more at risk of
contracting Ebola and who in some villages led acts of resistance to the response) [5] and young
people (among whom disaection and distrust in the authorities were most marked). Where
community participation was more inclusive, populations engaged better with the virus control
measures. [3]
• Some politicians attempted to identify themselves with the Ebola control campaign for electoral
purposes; this only increased suspicion of the measures implemented. [3, 23]
• After some incidences of violent resistance, soldiers or police often escorted medical response
teams to communities, militarizing the campaign in the eyes of the civil population [3].
• The capacity of already over-stretched health workers was pushed to its limit by the epidemic.
195 health workers had contracted the disease as of 5th August 2015, with 99 dying of it [60].
There were concerns that this might further undermine the public’s faith in the care provided, if
the health workers were seen as unable even to protect themselves [35].
4.3 Ebola-related beliefs and practices
Communities in Guinea aected by Ebola were faced with a virus with which they had no prior experience,
a very dierent situation to that encountered in previous outbreaks in the DRC [12]. Because of GF’s long
experience of marginalisation, discrimination and repression of customary practices (see Section 2.2.2),
unsurprisingly they were not always willing to accept the ocial information provided about Ebola and
explanations of the public health measures being taken to combat it. This distrust partly explains why
many Guineans found other explanations for what was happening. Eorts to combat Ebola were soon
forced by public non-compliance and active resistance to take account of the political, social and cultural
factors that shaped these explanations. It was only when these were better understood that the health
campaigns were able to address community concerns more eectively, leading to improved outcomes.
Not all failures to comply with control measures were the result of distrust or lack of acceptance of
28
the ocial account. Sometimes very practical issues played a part; for example, people may have
been discouraged from seeking help by the diculties of finding someone to care for their children or
farm animals in their absence, or from fear of not being able to obtain the necessary resources to see
them through a quarantine period. [23] However, it is clear that deeply-held political sensitivities and
cultural values played an important role in much of the diculty encountered by the response to Ebola.
Findings from a survey of 1493 individuals from across 14 prefectures showed that while a majority of
respondents said that they did not know the origin of the Ebola virus, 21.1% blamed it on one or more of
the government, scientists, politicians, the ICRC, MSF or miners [60]. A number of dierent explanatory
models for Ebola outbreaks were documented as circulating among the population, besides the ocial
biomedical explanations for infection:
• Overseas Involvement: Guinea’s history as a colony of France, and more recent Western economic
policies and projects perceived as neo-colonial, have left a legacy of suspicion of Western
motives. Ebola control measures recall past forced and much-resented internments on public
health grounds (e.g., sleeping sickness control) in the colonial 1950s [3]. Some suggested that the
Ebola virus was a creation of whites to kill blacks, or accused MSF and the ICRC of deliberately
spreading the virus [13].
• Government Involvement: The inhabitants of GF have long resented their marginalisation from
power and many feel discriminated against by government, which has historically been dominated
by the Manding and Soussou ethnic groups. When Ebola emerged in that region, this provoked
suspicions that the virus was being used to attack the population of the region or as an excuse to
enable the governing party to postpone local elections [60].
• Bushmeat consumption: Ebola has been attributed by many Guineans to consumption of meat
from wild animals living in the bush (e.g., apes). That this is a practice closely associated with the
forestiers (i.e., the majority population of GF that includes for example the Toma and the Guerzé
ethnicities) has meant that other Guineans at first saw Ebola as a virus only of this ethnic group.
Prohibitions placed on eating bushmeat however, made the forestiers themselves feel that their
customary practices were once again being persecuted [20], in continuation of the long history
of marginalisation that the region and its inhabitants have experienced at the hands of central
government.
• Lack of hygiene: Some have attributed Ebola infection to poor hygiene practices by the aected,
such as not washing their hands after defecation. Like explanations based on bushmeat
consumption, this interpretation tends to stigmatise the infected, while giving others the mistaken
impression that they are not at risk [60].
• Sorcery: Sorcerers are believed to cause death to increase their magical powers or enrich
themselves, often through stealing people’s organs or blood. They are sometimes suspected of
involvement in causing Ebola cases [60].
• Divine punishment: Some suggest that the virus is God’s punishment for communities not
respecting traditional rules and prohibitions [60].
• Falsity of Ebola: Some have claimed that there is no Ebola virus. They argued that Ebola was
unknown before and that current cases were attributable to other, known viruses. Under this
interpretation, stories of Ebola are spread by the government, Western agencies, or sorcerers,
for their own ends. Often their aim is said to be to persuade people to seek tests or treatment, at
which point they become victims of organ or blood theft. Fears of organ theft by white people or
sorcerers are long-standing [60].
It is clear that many of these explanatory models are heavily influenced by historic and contemporary
distrust towards outsiders, and often this influenced community reactions to the Ebola response. Where
people attributed the virus to divine action or sorcery, this did not necessarily preclude seeking medical
care, but often help would be sought first, or instead, from traditional or religious healers. This was made
29
all the more likely by early public health messages that spread the message that there was no vaccine
or cure for Ebola; people may therefore have felt that they were more likely to obtain eective treatment
from non-biomedical sources.
Quite apart from the explanatory models that people held about Ebola’s emergence, several other
factors played a role in dissuading these communities from conforming to medical guidance. When the
message imparted by health workers was that no cure existed, it seemed to make as much sense to
stay at home, or consult traditional and religious healers, as it did to attend health clinics. Particularly
significant was the fear many held of entering the ETUs. Wariness of the quality of treatment provided
in the cash-strapped and overburdened Guinean health system was already endemic, with patients’
families frequently asked to make unocial financial contributions for care [3]. Blood transfusions are
generally only available if relatives are willing to donate, unless patients are wealthy enough to purchase
them, making blood a valuable commodity. Seen in this light, it is understandable why anxieties were
widespread that those in the ETUs would be killed so that their blood and organs could be extracted for
re-use or sorcery. Such anxieties were fuelled by practices of body disposal designed to minimise the
risk of virus transmission. Sealed into hermetic body bags, the dead were shown to few, if any, of their
relatives, before being buried. This lack of visibility is in stark contrast to the large gatherings who would
view the corpse at a typical funeral, leading to suspicions that the evidence of organ theft was being
covered up [20, 60]. Organ theft at the ETUs seemed to some people a risk not worth running when
there seemed little prospect of recovery there.
The infection control teams and medical workers who came to communities also inspired fear. Dressed
in protective suits and spraying houses and other localities with disinfectant, it has been suggested that
their appearance was reminiscent of the masks and costumes worn for traditional cursing rituals [23].
Often spraying activities were suspected of deliberately infecting, rather than disinfecting, the community
[3]. This fear played an important part in the attempts by some communities to isolate themselves from
the response teams.
4.3.1 Funeral beliefs and practices
Customary funeral practices have been contentious during the Ebola epidemic. Though funerary rituals
vary across Guinea, they are commonly a time to bring together relatives, friends and community members,
and reinforce social bonds, both among the living and with the dead. Close relatives wash and dress the
body, before it is publicly displayed and mourned. It is important to appropriately honour the deceased
by bringing people together and clearly showing the sense of loss felt, so that the person’s spirit parts
without regret. The burial site and positioning of the corpse are serious considerations in both Muslim
and autochthonous forestier traditions. Where funerary rites are carried out correctly, the deceased
person successfully makes the journey to the afterlife and becomes an ancestor. If this does not happen,
they may instead become a wandering spirit, and will punish the living who condemned them to this fate
by not treating them respectfully [20, 23]. These obligations are treated very seriously, as is shown by the
significant expenditure families make on funerals [25]. To fail to live up to their obligations not only runs
the risk of oending the deceased, but is viewed very negatively by other community members. Failures
to contribute to the funeral, to attend it, or to show appropriate grief are sometimes seen as behaviour
characteristic of sorcerers, who do not respect the normal social bonds between people [23].
WHO Ebola guidance advises on ‘safe and dignified’ burial in accordance with Muslim and Christian
traditions, but provides little discussion of animist funeral practices that may exist among some Guinean
communities and can vary hugely from place to place. [23, 65] The disjunction between customary
practices and Ebola-safe burial procedures led to conflict between health workers and communities on
30
many occasions. Virus control measures made it impossible to carry out the full washing and dressing
rites, and prevented all but close relatives viewing bodies after death. Hermetic body bags and quick
disposal of the dead both made people wonder what was being concealed and caused them to fear that
the deceased may not reach the afterlife. This is not a fate anyone would wish for their loved ones, but it
also may bring dire consequences in the form of misfortune for the community that let it happen.
These fears are exacerbated when Ebola response teams do not take them seriously, but can be
assuaged by openness to discussion and cultural sensitivity. Steps that improved the acceptability of
burials of victims of the virus without compromising safety included:
- The opportunity for ritual objects and gifts to be included inside the body bags by the burial team:
these could be of help to the deceased in making their journey to the afterlife [5], or be carried as
gifts for others who have already passed away [43];
- Pictures of the deceased were taken by the response team before placing in body bags, then
distributed to family members: this provided a token of the deceased and helped to quell rumours
of mutilation and dismemberment [5];
- Greater attention to family desires regarding where the body should be buried [5].
No generic guidance can cover the full diversity of situations that can arise, and so open discussion that
takes seriously local concerns is often vital in reaching mutually acceptable agreements [6].
4.3.2 Ebola-related social attitudes and stigma
Even if people recover from the virus, often their problems are not over. In Guinea, social networks are the
most essential safety net for life and well-being. The death toll had already reduced social networks, but
some Ebola survivors have also found that they were not readily accepted back into their communities.
Fear of infection certainly led to ostracism in these cases; the many associations of Ebola with sorcery,
Western conspiracies or government malevolence may also have led to survivors being considered
suspect. Reintegration can be further complicated where survivors find their homes and belongings
burned as an infection prevention measure, potentially leaving them destitute [7].
4.3.3 Psychosocial support needs related to Ebola
The psychosocial impact of the Ebola virus has been significant. There are often particular needs for
psychological support:
• At the point of diagnosis and afterwards, for the infected individual and their family members
who might have to deal with fear, grief and coping with stigma and marginalization within their
communities;
• With the grieving process following bereavement, particularly in the light of the disruption caused
by Ebola to customary grieving rituals which might ordinarily have helped adjustment;
• Following recovery from the virus, when stigma and fear of infection may make it dicult to
reintegrate into the community;
• And, for Ebola response teams who work with the infected and their families.
Psychosocial interventions at the community level may also be valuable in assisting with the reintegration
of Ebola survivors.
31
Many survivors have found themselves isolated, as a result of the stigma of having had the virus and
the disruption of social networks caused by the deaths and disruption to communities. This is often
compounded by the economic eects of the epidemic on livelihoods, with lost employment, possessions
or position in the community contributing to a decline in economic security and social standing [7, 43].
Some have found new positions working with NGOs to sensitise and educate communities to the risks
posed by the epidemic, drawing on their own experiences; this usually provides both remuneration and
a valued role. Mutual support groups have also sometimes arisen among Ebola survivors that oer some
assistance (e.g., Association des personnes guéries et aectées d’Ebola en Guinée), for the most part
with little or no external funding or support [1].
As of 5th August 2015, UNICEF estimated that 5874 children had lost one or both parents to Ebola
[60]. UNICEF and its partner NGOs have provided training in child protection and psychological first aid
(PFA), organized play sessions, and organized follow-up visits and assisted with family reintegration [59].
These NGOs are Monde des Enfants (MDE), Enfance du Globe, Aide a la Famille Africaine and Action
d’Intégration Mères et Enfants [49].
There had been 195 cases of Ebola virus among health workers as of 5th August 2015, of whom 99 had
died [60]. These deaths added to the burden and anxieties of their colleagues, who were also dealing
with the almost unprecedented experience of seeing well over half their patients die despite their best
eorts [35]. Under such circumstances, health workers may be susceptible to traumatisation and develop
significant psychosocial support needs of their own [1, 67].
The extent of the deaths, damage to the social fabric, economic loss, anxieties, disruption to normal
grieving practices, and stigmatisation that the Ebola virus caused presents considerable challenges to
mental health and psychosocial support in Guinea.
32
5. CONCLUSION
Global economic forces, social divisions and inequality, and the eects of violent conflict have meant
that the people of Guinea have faced a number of challenges to their psychological, physical, financial
and cultural well-being in recent years and decades. Most recently, the Ebola virus outbreak posed an
unprecedented challenge to public health and to the existing resources and structures.
Moreover, it highlighted how indispensable it is for the success of interventions, whether in the area of
public health or in MHPSS, that they should be grounded in an understanding of the social, political and
cultural factors that shape people’s perspectives and decision-making. This report has established the
significance of situating the particular causes and course of illnesses, and misfortune, that the Guinean
population draws from making meaning of their experience. Co-existing frameworks reflect cosmologies
in which the individual person is situated within a constellation of relationships with the living, the dead,
the spirit world, and nature itself. The causative factors used in cases of sickness in Guinea vary due to
the consequences of violations of the natural order, the actions of the dead, of non-human spirits (djinns),
sorcery, divine punishment, and experiences of violent conflict.
Because of initial failure to take into account widespread suspicions of those in power or of outside
agencies, the intricacies of spiritual and social practices and worldviews, the need for meaningful and
representative engagement with a broad cross-section of members of individual communities, and the
practical diculties that recommended control measures often posed to individuals and families, eorts
to respond to Ebola faced numerous setbacks and significant levels of reticence or resistance from
local populations. It is to be hoped that the learning of these two lessons will lead in the future to more
sustained and resourced eorts to build capacity and to strengthen systems in health and in MHPSS,
and to redoubled endeavours to ensure more culturally informed interventions and care. At present the
research literature applying these lessons to MHPSS is limited, but the high profile resulting from the
tragedy of the Ebola outbreak may change that.
Practitioners should be aware that Guineans may draw on a range of perspectives to understand health,
suering and ill-being. Their decisions may be influenced by the bonds they value with family, with wider
communities, and with the dead, God and the spirit world, as well as by historical and contemporary
experiences of oppression and marginalization. Guinea is culturally diverse and clear generalizations
about these issues cannot be made across the population as a whole; however, it is important to recognize
that these are issues that are commonly key considerations for clients, although they may take varying
forms among dierent groups and sectors. In their work, MHPSS practitioners must engage with and
respect their importance if the outcomes they hope for are to be achieved.
33
APPENDIX
Appendix 1: Search engines, key words, total hits and number of relevant references for the review
process
Name of search
engine
Key words Date(s) Total hits Number of relevant
references
Google.fr Guinée (Conakry), santé
mentale, maladie mentale,
psychologie, psychiatrie, psy-
chosocial
30/05/15
09/07/15
8790 25
WHO Guinea mental health 09/7/15 34,400
(100 first hits
screened)
12
Google scholar Guinée (Conakry), santé men-
tale, psychologie, psychiatrie,
psychosocial
15/06/15 51 26
Pubmed Guinea (Conakry), mental
health, psychology, psychia-
try, psychosocial
AND
Guinea, mental health
12/06/15 0 0
Guinée Conakry 12/06/15 99 0
APA psychNET Guinea 12/06/15 106 2
PSYCHinfo
Medline and Ovid
Guinea Conakry 12/06/15 0 0
Anthrosource Guinea and Africa 3/07/2015 8 1
Social Science and
Medicine
(Journal search)
Guinea and mental health 3/07/2015 228 3
Culture, Medicine,
and Psychiatry
(Journal search)
Guinea and Africa 3/07/2015 36 0
Medical
Anthropology
(Journal search)
Guinea and Africa 3/07/2015 28 0
Transcultural
Psychiatry
(Journal search)
Guinea and Africa 3/07/2015 85 0
34
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39
CONTACT:
For general questions regarding this report,
please contact Dr. Sonali Gupta, Global Men-
tal Health and Psychosocial Ocer, Interna-
tional Medical Corps:
sgupta@InternationalMedicalCorps.org.
For technical enquiries, please contact Dr.
Emilie Medeiros, consultant first author of the
report:
Emilie.c.medeiros@gmail.com.
40
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... Community-led programming can fill gaps in knowledge and program delivery through the identification of organic community resources. In Guinea, ritual burials and grieving are considered to be a vital cultural tradition, wherein if these rituals are violated, community members may be cursed (Medeiros, 2015). However, during the Ebola crisis, traditional burial rituals were disrupted for the sake of public health and safety. ...
... However, in order to better understand how stigma functions as an impediment to developing sustainable positive change, it is important to understand the factors that influence stigma. For example, in communities where the stigma for mental illness is attached to negative karma (Kohrt & Hruschka, 2010) or a fault of an individual's own making such as not practicing the correct burial rituals (Medeiros, 2015), utilizing the existing CIDs may actually reinforce stigma, leading to more challenges supporting help-seeking behaviors. The trauma model under some circumstances can actually lead to the minimization of stigma, as it externalizes the reasons for internal suffering, for example the experience of PTSD is seen as a reaction to a traumatic event, rather than an internal imbalance between the heart-mind. ...
Article
Background: Armed conflicts and natural disasters can cause significant psychological and social challenges for affected populations. Displaced populations are extremely heterogeneous in terms of culture, language, and experiences of crises. Current diagnostic criteria is insufficient when evaluating the symptoms and treatment of mental health issues across contexts. Aim: This scoping review presents information about cultural idioms of distress across displaced populations. The review includes aspects of etiology, symptomology, and proposed intervention methods. Methods: I conducted a Boolean search of academic and grey literature for studies that described cultural idioms of distress among displaced populations. Results were analyzed using thematic analysis and grounded theory. Results: A shared sense of injustice, spirit possession, and karma are common etiologies for mental distress among displaced populations. Symptoms include somatic complaints, ‘thinking a lot’, and interpersonal challenges such as social isolation and a fear of others. Potential interventions are likely on a community-level, including the generation of community mechanisms for conflict-resolution, reconciliation, and culturally grounded healing rituals. Conclusions: It is vital to understand the ways displaced communities conceptualize their mental health in order to develop appropriate culturally grounded interventions. Understanding the etiology, symptoms, and proposed interventions can inform and improve humanitarian aid delivery of mental health and psychosocial support services.
Article
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Rapport de la La mission effectuée du 26 mars au 28 avril, soit 25 jours à Guéckédou et 4 jours au retour à Conakry.
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The communities of the coastal Republic of Guinea arose through the gradual incorporation of outsiders into rice farming areas where the gathering of 'wealth-in-people' by landlords was important and strangers were welcome to become farmers. This model of 'landlord and stranger' is not viable today for three main reasons: firstly, a political trend that started in colonial times made ethnicity rigid and incorporation difficult and not always desired; secondly, ecological changes and a land shortage are making strangers less and less welcome today; thirdly, democratic idioms of citizenship do not allow for such distinctions as 'landlords' and 'strangers.' As a reaction to all this, some communities, such as the Baga, are witnessing an emergence of the notion of an 'ethnic territory' to be controlled by the putative descendants of the original 'landlords.'.
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This book is an account of the circumstances that led to a Muslim religious movement on the Guinea coast and its legacies in today's Republic of Guinea. This book focuses on the political and religious changes that West Africa experienced and their impact on the continent's disrupted political and religious landscape.
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The article aims to show how ritual efficacy may rely on an intentionally produced, constitutive uncertainty. Drawing on the Bassari male initiation ritual, I argue that the central feature of initiation is not so much the achievement of an ontological transformation, than it is the creation of an unsettling context in which the uninitiated cannot but recognize the complex character of the initiates' identity. I describe two different devices whereby this is accomplished. The first relies on the donning of masks which enable initiated men to exhibit themselves in an opaque body associated with a highly predictable agency. The second is their presence as ritual tricksters characterized by an unproblematic body and disturbingly erratic behavior. In both cases, ordinary interactive scripts are perturbed. Initiation thus provides initiates with the means of mastering techniques that allow them to appear simultaneously as themselves and as not themselves. In doing so, they convey to the uninitiated the very idea of transformation itself.
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On 23 March 2014, the World Health Organization first announced a new Ebola virus outbreak that started in December 2013 in the eastern part of the Republic of Guinea. Human infections shortly emerged in Liberia, Sierra Leone, and Nigeria. On 30 September 2014, the Centers for Disease Control and Prevention confirmed through laboratory testing the first Ebola virus infection diagnosed in the USA, in a patient who travelled from West Africa to Texas. On 6 October 2014, the first human infection occurring outside of Africa was reported, in a Spanish nurse who treated two priests, both of whom died, and on 23 October 2014, the first human infection was reported in New York City. To date, the 2014 Ebola virus outbreak is the longest, largest, and most persistent one since 1976, when the virus was first identified in humans, and the number of human cases exceeded, as of mid-September 2014, the cumulative number of infections from all the previous outbreaks. The early clinical presentation overlaps with other infectious diseases, opening differential diagnosis difficulties. Understanding the transmission routes and identifying the natural reservoir of the virus are additional challenges in studying Ebola hemorrhagic fever outbreaks. Ebola virus is as much a public health challenge for developing countries as it is for the developed world, and previous outbreaks underscored that the relative contribution of the risk factors may differ among outbreaks. The implementation of effective preparedness plans is contingent on integrating teachings from previous Ebola virus outbreaks with those from the current outbreak and with lessons provided by other infectious diseases, along with developing a multifaceted inter-disciplinary and cross-disciplinary framework that should be established and shaped by biomedical as well as sociopolitical sciences. © 2014 John Wiley & Sons Ltd.
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Ethnopharmacological relevanceThis survey was carried out in the coastal lowlands of Guinea–Conakry in order to make an inventory of plants used by traditional healers, herbalists and diabetic patients for the management of diabetes mellitus.Materials and methodsFrequent ethnomedical and ethnobotanical investigations were conducted from June 2008 to December 2009 in Conakry, Kindia, Forécariah, Dubréka, Boke, Fria and Boffa. It is a cross-sectional survey and data collection is based on the interactive method. During this period a total of 112 people aged from 39 to 76 years old were interviewed.ResultsDuring this investigation 146 plant species belonging to 55 families were collected. The most cited plants were Anacardium occidentale L. and Ficus spp., while the Fabaceae family was the most represented, followed by the Euphorbiaceae and Rubiaceae. The most frequently plant parts used by the traditional healers and the herbalists were the stem-bark and decoctions the most common preparation mode.Conclusions It is clear that a variety of plants is used in the management and treatment of diabetes. Due to the increasing prevalence of type 2 diabetes, there is an urgent need for scientific investigations to rationalise the use of these traditional remedies, which could represent accessible alternative medicines for the Guinean populations.