Health Medicine Network – Edited extracts | PNG Attitude | 4 March 2016
ESTIMATES of the number of war deaths attributable to the Bougainville civil war vary considerably, but a figure of between 15,000 and 20,000 appears to be most widely accepted in Bougainville. Most deaths involved civilians.
Other events relevant to mental health were the displacement of more than half of Bougainville’s population; the perpetration of wide-scale human rights abuses; undermining of the traditional authority of elders and women, cultural values and relationships; property damage; and major disruptions to education and the economy.
Absence of epidemiological data, with the exception of information regarding domestic violence and sexual assault limits the extent to which the prevalence of the problems identified can be specified.
Nevertheless, Mr Beleh (a local politician) and Sr Garasu (a Catholic Nun) reported that they had identified 232 ex-combatants as manifesting one or more mental health problems arising from the conflict in one of Bougainville’s 33 political constituencies.
Those who were children or adolescents during the war (‘the lost generation’) were reported as having limited education, a lack of engagement in traditional values and activities and displaying aberrant behaviours all of which contribute to their marginalisation in the community.
Many of this group experienced events during the war likely to have been traumatic and, while the numbers who continue to be impacted by these experiences is yet to be determined, an expatriate Marist Brother teacher/counsellor noted that most of 50 male students he taught had been involved in combat and appeared to be suffering from symptoms of post-traumatic stress.
Various reports, largely based on community perceptions, have highlighted the detrimental effects of the conflict on subsequent risk of substance abuse.
Gender-based violence including sexual violence is considered a significant issue in Bougainville and thought to continue at a higher rate compared to that prior to the war.
The number of people missing presumed to have died during the war is unknown, but the inability to conduct customary burial ceremonies was reported as resulting in complicated grief for the surviving relatives and as having broader impacts including land title and use issues.
Meetings with senior police personnel highlighted the difficulties the police force experience in carrying out their duties amongst a community impacted by the war and its aftermath and by some officers who continue to be impacted by their personal war experiences.
People continue to be displaced since the war and family separation, separation from traditional land, insecure living circumstances and the strain on host communities/families were reported as continuing impacts.
Finally, our informants reported a trans-generational impact on those born after the war through their exposure to a range of trauma-related aberrant behaviours displayed by parents and within the community at large.
Collectively, the mental health issues identified were described as having a broad impact on the social fabric of Bougainville society and, indirectly, on economic recovery.
There was a broad consensus concerning the priority need to address mental health issues to reduce the distress experienced by individuals and the burden of associated disturbed behaviours on families, community, health services, the police, the judiciary and educational institutions.
The overarching view of our informants was that addressing mental health issues, particularly trauma related aberrant behaviours, had the potential to: assist in healing relationships damaged during and since the conflict; support efforts to maintain and enhance the peace process; and encourage the re-engagement of those affected in purposeful and productive family, community and economic activity.
It was recognised that, in addition to the need for mental health and psycho-social services, traditional reconciliation ceremonies in which perpetrators compensate victims might play a complementary role in achieving healing for sides of the conflict.
While a range of government and non-government services, agencies and groups are confronted by mental health issues in their daily work, only a few agencies are specifically focused on assisting people with these problems.
Two such agencies are the Nazareth Centre, which provides refuge for women and other survivors of family violence, youth who have substance abuse issues and treatment for former combatants; and the Leitana Nehan Women’s Development Agency who provide counselling and referral related to gender based violence, trauma-related awareness raising programs and training for community based organisations.
In addition to the limited number of trained staff to address mental health issues across Bougainville, there are minimal resources to attend to people with severe mental disorders including those with psychotic disorders (schizophrenia, bipolar disorder, and other psychotic disorders), neuropsychiatric conditions/brain disorders, severe mood disorders and chronic traumatic stress disorders that are typically found in low-income, post-conflict settings.
At the time of writing, there is only one mental health nurse for the total Bougainville population of 254,000. Patients referred to the national hospital are assessed and treated by the mental health nurse supported by hospital physicians, noting that the hospital is distant from and difficult to access from many areas of Bougainville.
The only options for care for the more severely disturbed patients referred to the hospital are short-term accommodation in a centre designed principally to provide refuge for women experiencing domestic violence; being held in police cells with criminal offenders; or being transported by air (with medical and police escort) to the national capital, Port Moresby, for specialist treatment.
The inadequacies of the system add credence to observer reports that the mentally ill are at risk of neglect (and in some cases abuse) throughout Bougainville.
This brief overview indicates that while key individuals and agencies have worked valiantly over many years to address mental health and psycho-social issues, it is evident that the capacity within Bougainville to address them is severely limited relative to the demand.
On the positive side, important facilitating factors were made evident. A clear recognition of the need to address mental health was identified throughout the consultation process as was a strong interest in building Bougainville’s capacity to address these needs and the government’s interest in developing the necessary supportive policy and legislative framework.