Rampant abuse of international human rights standards plagues Kyrgyzstan's state-run mental health care system, according to a recent report by the Budapest-based Mental Health Advocacy Organization. To bring its psychiatric hospitals up to international standards, the organization has urged the Kyrgyz government to adopt a community-driven care system and abandon the overly centralized approach of the Soviet past.
The report, entitled "Mental Health Law of the Kyrgyz Republic and Its Implementation," is based on a June 2003 tour of mental health hospitals and multiple interviews with government officials, lawyers and psychiatrists. Written as a review of Kyrgyzstan's 1999 law on psychiatric care, the document focuses on the Republican Mental Health Center in Bishkek, the Kyrgyz capital's largest psychiatric care facility; a suburban branch of the Republican Mental Health Center known as Ward 12; and the Chim-Korgon Psychiatric Hospital and Issyk-Kul Oblast mental health hospital in the northwestern town of Karakol.
The report's conclusions are damning: "Contrary to its international human rights commitments, the Kyrgyz government is unable to provide even the most basic of human needs for persons detained in institutions: food, water, clothing, security, warmth and basic health care," MDAC board member Dr. Jan Pfeiffer, a Czech psychiatrist, stated upon the report's April 1 release.
"Without significant reform," the report states, "the situation will only grow worse and the current crisis will become catastrophic..."
A lack of legal protections for those confined in mental hospitals is among the leading concerns. Although the law establishes clear conditions for involuntary commitments to hospitals, these criteria are not enforced. Patients are routinely committed to mental hospitals by relatives an action deemed "voluntary" and, hence, with no need for court review.
Similarly, children who are too old to remain in an orphanage are often transferred to mental health facilities for care even when they have no mental health difficulties. Doctors refuse to release these "voluntary" patients unless they have family members who agree to care for them. In one case, a 28-year-old woman had been kept at the Chim-Korgon psychiatric hospital for 14 years after being discharged from an orphanage.
At both Chim-Korgon and the Republican Mental Health Clinic, forced labor occurs in violation of both the Kyrgyz Constitution and international law. Neither hospital pays patients for their work. At RMHC, patients take part in so-called "labor therapy" to improve hospital grounds. At Chim-Kogron, patients work the hospital's vegetable fields to diversify their diet. "If a patient wishes to have a diet that consists of anything substantially more than bread, pasta, or tea, he or she must work for this food," the report states. Yet only patients who have demonstrated good behavior and a stable psychiatric condition have access to the food.
Alternatives to these state-funded facilities do not exist. A government program created in 2000 to shift health care to localized, community-run institutions was scuttled after promised financing from the World Bank and the UK's Department for International Development fell through. The government has since merged RHMC with Chim-Kogron, leading to a further concentration of resources in Bishkek.
Living conditions in both hospitals are dire. At Chim-Korgon, one 14-year-old girl had been kept tied by her ankles and wrists to an iron bed for a month prior to the investigators' visit. At RMHC, holes in the floor serve as toilets. Insufficient space is another concern: as many as 16 people could be confined to a room designed to hold a quarter of that number.
Complaints about "a chronic lack of food" at both Chim-Korgon and RMHC were common among both patients and staff. Most meals consist of bread and pasta. According to the report, three patients at Chim-Korgon appeared to be suffering from malnutrition.
While staff at both hospitals appeared alarmed at their working conditions, few knew how to correct the situation, the report states. In contrast to international standards, medical treatment is not individualized and psychotherapy is not offered. Staff were not familiar with even the most common of anti-depression drugs.
Inadequate funding was the factor most often cited by hospital physicians and administrative staff for their problems, but one rural hospital suggested that administrators' outlook also plays a leading role. The report cited conditions at the 30-person Issyk-Kul oblast hospital in Karakol as "a pleasant surprise." Adequate living space, clothing, food and entertainment facilities were provided, and staff treated patients with respect. The hospital's location in a rural community was indicated as a contributing factor for patients' enhanced nutrition: relatives bring family members the bulk of their food.
Knowledge of international practices in law and mental health care could go a long way toward correcting the system's abuses, according to the report. "The failure to implement the 1999 Psychiatric Care Law appears to be largely the product of a widespread and serious lack of knowledge and understanding of the involuntary commitment procedures among clinicians, lawyers and judges" it reads.
In response, the report recommends that an independent agency staffed with activists and lawyers trained in mental health law be established to monitor practices within Kyrgyzstan's psychiatric clinics and hospitals. A separate non-governmental organization should address the issue of non-voluntary hospitalizations. At the same time, extensive training for both mental health professionals and their families in patient rights and treatments for mental illnesses should be provided.
Without additional funding, however, the report cautions that any reform initiative will fail. Pressure is placed on the Kyrgyz government to set aside some basic level of funding for the mental health care sector. It also recommends that the World Bank and the UK explain why earlier support was suspended and reconsider their decision.
Eurasia, May 07, 2004