After nearly two decades of civil war in Liberia, the nation is now recovering from a history of devastation characterized by ethnic killings and massive abuses. However, the damage extends far beyond the physical losses. According to a health expert, war-related violence has resulted in significant mental health problems among the Liberian population, particularly among former combatants. In an eye-opening presentation to U.S. Africa Command staff on June 18, 2009, Dr. Lynn Lawry, the Senior Health Stability and Humanitarian Assistance Specialist in the International Health Division of the Assistant Secretary of Defense Health Affairs , revealed findings from a study examining the mental health impacts of Liberia's civil war and of sexual violence to former combatants as compared to the civilian population. Her findings were based on a three-week cross sectional study conducted in May 2008 using structured interviews and questionnaires. "What we wanted to do was to gain data that would help guide rehabilitation community-based programming, and inform government and policy makers about the needs that existed and what was still needed," Lawry explained. According to Lawry, a third of the Liberian population, or approximately 1,000,000 people, reported serving with the nation's fighting forces. The majority of these combatants were recruited by abduction and kidnapping, making them both participants in and victims of the atrocities. The study focused on the psychological impacts of the segment of the population that was forced into combat, which is an area that has been largely ignored, said Lawry. Before 2008, there was no population-based assessment of health and mental health. "The goal is trying to make sure that people start living normal lives post-conflict and focusing on things that most people don't focus on. You can focus on the basic needs--food, shelter, clean water--but that's only a part of what you need." According to the survey data, symptoms of major depressive disorder, post-traumatic stress disorder, and traumatic brain injuries are high among former Liberian combatants. Additionally, the report concludes that "both male and female former combatants who experienced sexual violence had worse mental health outcomes than noncombatants and other former combatants who did not experience exposure to sexual violence." Of particular interest was the finding that 32% of male combatants were survivors of sexual violence, a statistic which challenges the traditional belief that only women and girls are the victims of sexual violence. "I had never seen this figure before, partly because most people don't ask when they do the survey. What's happened over the years is that gender-based violence has become (associated with) violence against women," Lawry explained. "The original UN definition of gender-based violence is actually sexual violence against anybody…What most people have been doing is focusing their research on females and not looking at males." Following are health-related statistics based on Lawry's 2008 study. In the Liberian household-based population:40 percent met symptom criteria for major depressive disorder 44 percent met symptom criteria for post-traumatic stress disorder 8 percent met criteria for social dysfunction 33 percent reported having served time with the fighting forces 33 percent of former combatants were female 42 percent of female former combatants experienced sexual violence 32 percent of male former combatants experienced sexual violence 33 percent of both combatants and non-combatants experienced inadequate access to healthcareOf those former combatants who experienced sexual violence:74 percent of female former combatants experienced symptoms of post-traumatic stress disorder; 52 percent experienced major depressive disorder 81 percent of male former combatants experienced symptoms of post-traumatic stress disorder; 64 percent experienced major depressive disorderAdditionally, former combatants have higher rates of head trauma than non-combatants as well as a higher reported use of drugs and alcohol. In spite of the widespread mental health issues among Liberian adults, there are few services or policies in place to adequately deal with them. The Disarmament, Demobilization, and Reintegration (DDR) program, led by the United Nations, is a post-conflict reconstruction program meant to deliver health care, education, skills training, and to reintegrate ex-combatants into civilian life. DDR also responds to the needs of women and girls who are victims of sexual and other physical abuse. Unfortunately, DDR's effectiveness in responding to the needs of Liberian combatants has been limited due to the fact that many former soldiers were forced to quit the program because of lack of funding. Lawry stated that there are also large gaps in both DDR and Liberia's mental health policy, neither of which addresses mental health, head trauma, and gender-based violence. Lawry said, "With more than a million Liberian ex-combatants and 270,000 persons with possible head trauma, it's going to be a challenge for Liberia to deal with these issues, particularly with a mental health policy that doesn't address it." "This, to me, is a stability issue. If you have this many people that are upset, sad, willing to commit suicide, you have to deal with it." She added that the U.S. military can play an important role in assisting Liberia with these issues, especially with head trauma, an area of expertise for the Department of Defense. Lawry's suggestions to the Liberian Ministry of Health include using "out-of-the box" programs to address mental health issues. For instance, in response to the shortage of psychiatrists in the region, she advised the involvement of religious leaders and community health workers to aid in mental health counseling. She also stressed the importance of creating interagency standing guidelines written by the United Nations and non-governmental organizations to guide the Liberian government in dealing with mental health issues. Lawry's presentation was part of the U.S. AFRICOM Office of the Command Surgeon's speaker series, aimed at educating staff at health-related issues affecting stability on the African continent. Lawry is the senior health stability and humanitarian assistance specialist for the Assistant Secretary of Defense Health Affairs. She has researched health and human rights issues in Taliban-controlled Afghanistan, Sierra Leone, Iraq, Nigeria, Darfur, Hurricane Katrina communities, and Liberia. The complete text of Lawry's study, "Association of Combatant Status and Sexual Violence With Health and Mental Health Outcomes in Postconflict Liberia," is available on http://www.jama.com.