Berkley Center

Background: Sister Barbara Brillant played a central role in the Liberian response to the 2014-2015 Ebola crisis, participating in national coordinating efforts and involved in mobilizing communities. She brought to this work her long experience with primary healthcare and during the wars and conflicts that dominated Liberia over many years. This discussion with Katherine Marshall on December 10, 2016 in Rome took place in the margins of a Catholic Church assessment of the Ebola experience, with particular reference to longer-term implications for health delivery and policy. She describes different phases of the Catholic Church response to the Ebola crisis and the involvement of religious organizations with the government and international NGOs. She focuses on the legacy of trauma, from both the war and the Ebola crisis, and the importance of addressing it.

“I define resilience in this way: ‘When you are overwhelmed, you are exhausted, you are tramped down, you’re fed up. And you get up.’ That is the power of resilience.” - Sister Barbara Brillant, TedX Monrovia, November 2016

Let’s start with what took you to Liberia!  

I am a Franciscan Missionary of Mary, which is a missionary order. You follow your vocation! I entered the religious life in 1968, out of Providence, Rhode Island. I was a nurse before I went in, so I had my profession. I went to a little school in Bangor, Maine (Eastern Maine General), and then I finished my bachelor’s at Boston College.    

How did you come to enter the order?  

I was teaching at what was then the Boston Lying In hospital (which is now Brigham Women’s). That was when I met the sisters. I must say that I did not immediately hear God calling from the top of the mountain, but I did hear it!  

Being a missionary order, we know we go to missions. One of my friends founded Frontier Nursing Service, in eastern Kentucky, a lovely place, and it prepares you for midwifery and as a nurse practitioner. They sent me there for two years, and they prepared us for missions. Then they wrote to me and asked, “Would you like to go to the Amazon or to Africa?” I said Africa, and that’s how I ended up in Liberia.  

Normally we do not stay in one place for that long; in religious life, after eight or ten years they normally move you around. But, for whatever reason, I stayed and spent 13 years, at first doing primary healthcare. I arrived on August 15, 1977. I should have moved in December 1989, but I had just finished my master's degree in public health at Boston University of Public Health, and I was supposed to be reassigned to a different place, as I was changing areas. But the archbishop of Monrovia asked for me to open a nursing school. So I ended up going to Monrovia to start things on December 10, 1989. And as history has it, the war started on December 26, 1989. And I have not left Monrovia since, though I was evacuated twice. I’d like to think they kind of forgot me there.    

Can you tell me a bit about the order?    

It was founded by a Frenchwoman, Hélène de Chappotin de Neuville. She was sent as a young person to India, at the time of the British Empire. She focused on what we would call women’s promotion today. She was rather avant-garde, and was one to push poor women to develop life skills. She ran into a lot of difficulties with the clergy and was pulled back to Rome. She ended up leaving the order that had sent her (the Sisters of Mary Reparatrix), deciding that was probably not what God wanted her to do, and she started the Franciscan Missionaries of Mary. One of our focuses ever since is women’s promotion. So that’s how we started, with 12 or 16 other women that separated from the group, most of them from India. At one time the order had about 11,000 sisters. We are one of the biggest, if not the biggest, of the women’s missionary orders. Today we are about 6,000. They come from all over the world, less, obviously, from the United States than in the past (because there are fewer vocations there).     

How many sisters are there in Liberia?  

There are 13 sisters in Liberia, and one of them is Liberian. We have three other Liberians missioned out of country. We have had no new vocations since the war. There was a lot of trauma, the war, and now Ebola, which is an important factor. But we are starting to do what we call vocation promotion again.    

How did your work in Liberia unfold?  

I was in Liberia for 13 years before the real war started. Samuel Doe started in 1980 or so, but the uneasiness started in 1980 to 1981, and it did not really blow up until 1989. I was a nurse practitioner in a little primary care clinic in Nimba County in north central Liberia. Running the clinic was the base, but my main mission was to train traditional midwives. It was a lovely time because I was able to get to know the country, and especially the rural area and the people well, and to understand the culture. It was a peaceful period, though we had some rumblings of tension and uneasiness, most obviously in political tensions, before the violence began. It was most obvious in Nimba County because that is where Charles Taylor entered.    

How were you affected by the conflict?  

The war started in 1980 and 1981, and when the war began it became very difficult. We were evacuated twice, and our religious order ended up moving to the Ivory Coast, across the border from Liberia. We set up a house there to help those who came across the border. Being a nurse, I used to sit on the porch there, watching the cars of Médecins sans Frontières (MSF) going back and forth every day. I finally found them, and they were working in the north of Liberia, where Charles Taylor was. So I asked Rome and I joined them, and I went back to Liberia. For two to three years I was working with MSF. At first they had me working in the emergency room in Kakata, which was the front line for Charles Taylor at the time. I did operating room and I even did anesthesia a few times, although I had no training for it. You learn in a hurry when they have nobody else.  

We then moved on to food distribution. Catholic Relief Services (CRS) was bringing in food through one of the ports, and MSF was asked to help distribute it. I was in charge of food distribution because I knew a little bit of the dialect up there, and I spent almost a year doing that. It was insane, because people were truly starving, and they were flocking out of Monrovia to try to get to safety. We had trucks bringing rice from the port. I had to go up to the border with Cote d’Ivoire, with these huge 10-ton trucks, and accompany them down to Kakata, which was over a mountain road. But we managed. There were soldiers at barriers along the way. They were all child soldiers who were manning these little gates that they would put up. We said to the truck drivers, "Cut the bags in half, and as you get to the security crossings dump half a bag out of the truck." And they let us through. And CRS said, “Sister, you just can’t do that.” And I said, “Why can’t I do that? How do you expect to get five or six trucks full of rice in when these young boys are just as hungry as the others? They will never open the gate for us. They’ll just keep us there all day and all night.” So finally one of the younger workers said, “Sister, don’t tell them you are doing it. Just call it lost food.” So that’s what we did, and I spent almost six months working there.   

Then when the road reopened and they were able to come through, they relocated us to Monrovia, and I went back to the convent school in Monrovia. I was the first one back in, and I worked for a year with orphans and vulnerable children. My role was to try to relocate the children back to their families or get them to safety. So again, I would go up and down the road.  

Some of things that happen in a war are so ridiculous. I would go up to the north, where Charles Taylor had his whole government set up, with a minister of health, education, and so on. When you went up there you could get past the barriers with an MSF car. One day I was coming down in a car with four or five Nigerian children; we were trying to sneak them back, because the Nigerians and Ghanaians were being thrown into camps. I managed to get passes for them, because the minister of health was a doctor, one of our girls, so I knew her.  

We got to a gate, one of kids had a chicken, and the young guy said to me, “Where is pass for the chicken?” With all this tension, we all started to laugh. I could not believe it. So we went back, an hour and a half, and got a pass for the chicken. I still have the pass and look at it sometimes, remembering the things that happen in midst of chaos. Even the children could not believe it, but I told them not to make a sound. But they did not care about the children, just the pass for the chicken. In a way, the ridiculous little stories kept you going.  

When things got a little better, we reopened our school. We have a huge women’s school in Monrovia, and after a while the sisters came back. And I have been there ever since. There are a thousand girls, from kindergarten to high school. The college is on the same campus. It is for health sciences: nursing, social work, medical laboratory technology, and pre-med biology. That’s my real job, as dean of the college.    

What are your other jobs?  

I am acting chair of the National Catholic Health Council, which was set up just before the Ebola crisis. I will be turning it over and will get an executive director soon. We have changed the whole set up, and it would be lovely if it continued. It depends, to tell the truth, on the bishops. Each bishop has his own territory, and each bishop is an entity in itself. We have 20 health facilities: in the Archdiocese of Monrovia, there are 12, and in the other dioceses three and five. All the clinics in each territory would report to their bishop. The National Catholic Health Council was set up so we could look at issues like salaries and advocate for certain things, so that as the Church we could be sure that we were acting for the common good of the health workers and patients.  

When Ebola came, we said to the bishops that we had to keep our health workers safe because Ebola can go everywhere in the country. It was not a question of saying to a clinic that is in the epicenter, “You need a certain kind of training.” I am rather forceful! I told the bishops that we had to do it this way; nationwide was the only way to do it. You must allow us to do it 100 percent. You need to give us the power, the authority, everything, including control of all the money, donations, and all funds that come to any facility. And they agreed. We were all at the same meeting, on the same day. Dr. Tim Flanigan [professor of medicine and professor of health services, policy and practice in the Division of Infectious Diseases at Rhode Island and the Miriam Hospitals and Brown Medical School within Brown University] came in. The bishops all agreed that as of now the National Catholic Health Council takes the lead. All the money goes through it. I think this national, unified approach made all the difference.    

Has National Catholic Health Council survived post Ebola?  

Yes, it has survived and we are now a legal entity, with a constitution, by-laws, etc. The bishops have signed off on this. Our hope is that we can now present it to the government so that the government will recognize the council as the advocacy body for all the Catholic health facilities.    

What are the Catholic health facilities?  

The 20 total facilities include two hospitals: the large hospital is operated by the St. John of God order, St. Joseph’s Catholic Hospital, and we the national TB and leprosy hospital for the government.     

How did the Catholic health system in Liberia get started, and how did it develop?  

What has normally happened through the whole history of Liberia is that a bishop tends to open a church, and then a school and a clinic, whether or not there is a government facility or another Christian facility in that area. That’s how they tend to operate. But unifying all these facilities and working as a cohesive group did not happen until now. What happened during the Ebola crisis was that we were the ones that sent out the supplies and did all the training. Since I had a college of health sciences, Tim Flanigan trained my staff: he gave then a full week of almost constant training, putting on PPE [personal protective equipment] and taking it off and so on. This staff went out to all the health facilities. They trained, trained, and retrained until every worker felt comfortable that if they did these things they would not get Ebola.     

How does this Catholic system fit within the broader Christian and national health care systems (and incidentally, what percent of the Liberian population is Catholic)?  

[An estimated 40 percent of Liberia’s population of about 4.5 million {World Bank data, 2015} is Christian, though some estimates are as high as 86 percent. Almost 6 percent of the total population is Roman Catholic. The largest Christian denomination is Methodist.]   

The Catholic facilities are part of the Christian Health Association of Liberia (CHAL), which includes the Episcopalians, the Methodists, the Baptists, Lutherans, and so forth. They have 72 Christian members—meaning facilities—and of those, 20 are Catholic. That predates Ebola. We were all members of CHAL before the Catholic Council was established. But I feel strongly that the Catholic institutions must be organized, centered, and focused. We will still, eventually, be part of CHAL, but first we need to be clear on how we, the Catholic system, want to do things, and how we want to respond to the challenges.    

How does the government system work today? And what is the relationship between the Catholic facilities and the public system?

That is the challenge. I’ve been in Liberia for 39 years now and as a nurse midwife and dean of the college I have served on a lot of commissions for health. I’ve been on some of the highest level task forces of the Ministry of Health. I am now the first vice chair of the Global Fund in Liberia and that keeps me quite busy. In that position I am on the highest task force to advise the minister of health, and I know her well. I have a very good relationship with them. But it is very hard to convince them that we are big players in the system and that they should see us as that. Before the war, when I was working at the local level, we had very good relationships. The government provided stipends to the Christian facilities to help them run the health system. But after the war that all changed, with what I call the INGO [international non-governmental organization] mentality.     

Are the donors responsible for that change?

Yes. The large international institutions came in, to help of course, but during the war they literally became the Ministry of Health. And even when the ministry became stronger again, that situation continued. During Ebola, the ministry stayed in charge, but there were huge numbers of INGOs, and it was as if we didn’t exist any more.     

Which were the big players?  

They included MSF (from Belgium, France, and Holland), and during Ebola it was MSF International. They have always been there. Then you have the International Red Cross and the Americans: the International Rescue Committee, Africare, Partners in Health, Last Mile...all with USAID funding and U.S. people, and of course CRS was there. And they all behave in pretty much the same way.     

What about World Vision?  

World Vision left Liberia during the war; there was a major corruption scandal, so they have not been involved recently at a significant level.  

CRS right now is not an implementer. They have come in supposedly to help the Catholic Church rebuild its health system, and that is their focus now. But as you well know, none of them can exist unless they have grants to pay administration fees etc. That’s the name of the game. Like Plan International, which I had not known before, but they are a co-PR [principal recipient] of the Global Fund, and I have got to know them quite well. They are into malaria. The majority of funding comes from outside. The government announced the other day that in their budget, the Liberian economy takes care of 47 percent. The rest is donors. That is kind of scary.     

And in this the religious actors are ignored in looking at the health sector?  

We’ve been sidelined. Having said that, they admit now, because of Ebola, that they have to look at health as a holistic thing. The new health minister—she was the chief medical officer—understands that we have to be part of the whole thing. It is, however, financial and political. With so much money coming in, it is understandable that they want to build up the public system first. But the public health system is not functioning so well. And they soon found out during Ebola that it has to be everyone.  

And it almost didn’t happen. I was at one of the health planning meetings during Ebola, at the beginning of it. And CDC [Centers for Disease Control] had just come in, and they were asking how many facilities there were. And you kept hearing a number, like 436 or whatever. And they were planning around this number: how much PPE did they need to get in, how much training? And it was a young woman from CDC asked if those were all the facilities in the country. And I of course said it was not; the number included only the government facilities. And the CDC person said to the minister that you couldn’t do it that way: you have to include everybody. So it came out that there were over 700 facilities. The rest were private and faith-based that were not counted in to the calculations. So they had to redo everything. And I said to them, "Thank goodness the young woman asked the question, because otherwise everyone would just have kept quiet as usual so that they could take care of all the public facilities first."   

When they did the 10-year health resilience plan, that is now operational, you will see both public and private institutions. We have asked then to put the faith facilities outside the private sector, because there are for-profit and not-for-profit facilities. They are going to separate that now. But the problem is that there is not enough money, so it will still be mostly public that will get help. Two or three years down the line when they are doing their planning, and the goal is that no person should walk more than five kilometers to get to a health facility, they will recognize that if there is a faith or private facility there they will not need to build another and they will maybe stipend that clinic so it can give discounts. So they are talking correctly, though I don’t know how that will work out in practice.    

Where is the priority now?  

The priority, as I understand it, is that for the first two years, they will try to reinforce what they have. Right now the priority is going to the development of community health workers. They used to be volunteers but now they are going to be salaried, I understand. They figure that if you have at least community health workers, even if there is no facility around, they can at least provide prevention, education, vaccination, and basic healthcare that they don’t have right now. Most of the energy is going into that.     

Who are these workers responsible to?    

They are to be employed by and responsible to the Ministry of Health. And that’s the problem. Right now they have asked all the international partners to pay community health workers for two years. The system, in my opinion, won’t be functional, because in two years, the government won’t have the money to pay them and won’t be able to absorb these people on the payroll. A good community based program would be better if the community chose and paid that worker. The problem is the economy. Before the war, the economy was rebuilding beautifully. There were timber and mining companies, Firestone, and so on. But most of them have not rebounded yet. The rubber plantations are functioning, but the larger mining companies are not back yet. And the price of rubber is down. How do you build an economy if you don’t have anything to sell? They are looking for oil, but that may end up being a bigger problem than a solution.  

You spoke at the Ebola review meeting yesterday very movingly about the trauma of Ebola, which you described as worse than the trauma left behind by war. Can you elaborate?   

They have not even got over the trauma of the war, and mental health in Liberia simply does not exist. And then you have the trauma of Ebola. It is so hard to explain. It was something we had never experienced, where we all could die. I went twice into 21-day observation because I had been in contact with people who had died of Ebola. Perhaps because we were health workers and were doing the training, we did not have the same fear as others. I walked into my office at the end of August (I had left in June when things were not so bad) and it was unbelievable, the look of panic and fear in people’s eyes. And they all had bleach on their desks and were washing their hands with it, so that they burned their hands. I said to my administrator, “You went through the war, hid your husband under the bed when they came looking for him, went out to the market to get food, not knowing if you would be stolen or raped. Why are you so scared now?” “But sister,” she said, “It’s killing everyone.”   

I remember the dead bodies in the street. Ebola was so different because you saw the families carrying the bodies and placing them down on the sidewalk because they didn’t know what to do with them. And the picture in my mind is: all the ambulances lined up outside the emergency treatment units [ETUs] with Ebola patients in them, but they couldn’t put them down because the ETUs were full and they had to wait first for someone to die and the ambulance could move up.  

It was mind-boggling. The turn came, of course, when the United States sent so many troops and CDCs and built more ETUs, and the situation got better. But there was a time in September and October when there were 60 deaths a day.  

Liberia unfortunately cremated the bodies, and until they stopped that and started to get the communities involved there was panic.    

How did they figure that figure that out?   

I think they looked at Sierra Leone and Guinea and realized you did not have to do it that way. But of course Liberia had many more cases and more deaths. When they had a bit better control they realized they could do some other thing besides cremation. The idea of cremation must have come from CDC or somewhere, because there were too many bodies. Perhaps it was the best decision to deal with the realities, but it destroyed community involvement for a long time.  

The Muslim community posed the bigger problem at the time, because of the importance of their rituals. Finally they got the Muslim Congress involved with the other clergy and asked how they could bury the dead in an appropriate way. That’s what started to turn it around, when they called the community to table. 

Who involved the community?  

The Ministry of Health and the WHO (they were effectively one at the time) did. In Lofa County, where it started to come across the border, the WHO doctor, Dr. Peter Clements, was one who said, "You simply have to get the community involved." People were burying bodies without telling anyone and hiding the sick in their homes. They were doing everything underground. It would never have stopped if they had not changed the approach.   

What was done to get the communities involved? Did they go through the churches?

The government started having a meeting every Saturday morning from 10:00 a.m. to 12:00 p.m. It was a networking event for all the partners, held in a huge hotel. Anybody could walk in. The idea was to report on what was new, what was happening. All the leaders were at the front table. The first two Saturdays it was all the INGOs, and some faith partners. But then you had a changing phenomenon. Some local groups started coming in. Everybody introduced themselves every time. Someone would say, “I am from Bethel Church, and we have an awareness program,” for example. It was only in October or November that people started to realize that they should use these communities to disseminate information. But they never financed them. The aggravating thing was that at the meeting they would tell you how much money coming in, millions, and it was visible. And they would report a program for something like WASH in markets, with three million or so. The little communities were not getting a cent. Finally, there was an effort to have some impact projects and they got a little money, $5,000 or so. But at least it was something and could pay for fuel and other things. They gave them training and proper equipment: boots, rubber gloves, and buckets. So they started to get communities involved, but it took a long time and came almost too late. I think the epidemic could have been halted earlier if things had been done differently. People in the communities began to understand that they should not hide a sick person, they should report it, and not try to bury a body if the government had not come to test them.  

I’ve said to WHO that now they have to keep these good community NGOs on their list. We hope that Ebola never happens again but if it does you have to know who you can go to.    

Did they have a network of any kind?   

UNMEER was in charge of that. The UN established UNMEER: the United Nations Mission for Ebola Emergency Response, led by Peter Graff, from WHO. The minister of health was always a member of everything. UNMEER set up this group for the quick impact, working strictly through community based organizations, to continue the work on awareness, etc. But it was not sustainable: it began and ended. I am trying to persuade WHO or UNICEF to keep it going somehow. It does not take very much money. You could do a lot, say vaccine campaigns, or the girl child. I don’t think it would take very much.   

The communities had to be registered with the ministry of planning. It costs $300 a year or so, and they have to be licensed.    

How far was corruption a concern?  

I don’t know much about that. What I do know is that at the very beginning people in Liberia did not believe Ebola was real. They thought it was a government plan to get money from the donors. They saw what seemed like hundreds of blue cars on the roads, and the talk was about where the cars were going and who was benefiting. After a while they realized that this was not true and that Ebola was there. But there were huge amounts of resources. When the U.S. army came people would watch as they put up tents, watching for hours. It was the opposite during the war, when people begged for the army to come and it never came. But with Ebola they came. But they came so late.   

The issues were around trust. The talk about corruption stopped after awhile, but then there were so many political parties, saying that the government was eating all the money. And the audits are raising plenty of questions.    

What role did the interfaith organizations play?  

They are quite strong in Liberia. There are two, one with and one without the Muslims. And in general we have lovely relationships with the Muslims. The mainline Protestant churches are most active, though there are many many Pentecostals, mushrooming up all the time. Many of them are money-making operations. The Catholic Church is a major player in education, with over 100 schools across the country.   

As a last question, how are people approaching the trauma issue today?  

There are two big responses. The first is coming through the Ebola survivors group. The Carter Center is very active there, doing a lot, with psychosocial healing. Many of the churches are now doing psychosocial work. The Catholic Church has just started. We started six or seven months ago, working with some of the priests, and we are just starting a second phase now in some of the dioceses. Being priest does not give you skills to allow you to accompany someone who has lost 20 members of their family. I think it was one of the weaknesses of the Church: we did not respond well. Fear was one of the reasons. I think you had many priests who wanted to accompany the families, just to stand by them when they were cremating, just to be there, but the bishops said no. They did not want to lose them. Remember that we lost nine people in two weeks; four were missionaries. So people were afraid. Tim Flanigan came in and tried to persuade the bishops that they should train the priests and be safe but that did not go over. So now we are trying to provide training to the priests, so that they can understand trauma and have skills to heal. If not, it will be buried. Liberia is unfortunate because after the war they never had anything either, and the anger about the war is buried and now they will have Ebola on top of it. It’s like a cocktail ready to blow. And you can see it in the people. The Liberians were never an angry people, but now they are both angry and hurt. And you can’t do it with Band-Aids.  

And we only have one Liberian psychiatrist in all of Liberia! One.    

What works?  

What little is being done through the churches could work, though I don’t think any of it works yet. You have so many pastors, and they are ideal for this kind of healing. They have a certain background on forgiveness and so on. But we have to build on that. Whether it is a Lutheran or a Baptist pastor, we can build on it. The Catholic Church fell behind, and we have to catch up. The Lutheran church is quite good at it. They were also quite good in the HIV/AIDS work. We have a huge response on HIV. The Lutheran church had all their pastors trained on HIV; they had to come to training, and they had to know what HIV/AIDS was. They seem to be able to organize it better. That is now our duty to do that. And the bishops have agreed in principle.  

But then the question arises where to refer problems. There is a mental health strategy that is not a bad strategy. But there is only one mental health institution, in very poor condition, mostly for drug addicts. A lot of my energy is spent now on mental health, to see how we can move ahead. In the Catholic Church we will soon be opening what we call a step down unit. Part of the problem is that the government owns the psychiatric institution and when patients are discharged there is no follow-up or support. And they are back there within a month. The step down will allow the patients who have family to accompany them to come to our institution for a few weeks or whatever it takes. WHO is, I think, going to help us. It is a problem.  

But having said that, I find that the people’s resilience is amazing. Whether it is healthy resilience or not, I am not sure. They can get stomped on and get up. It is amazing.