Psychiatrists and other mental health activists have been working in various countries around the globe to bring an end to unjust psychiatric incarceration for political beliefs and to improve living conditions for those patients in psychiatric hospitals. The former Soviet Union, China and India are all current targets of focus for this human rights movement. What are human rights organizations doing and how can psychiatrists help?
"In some countries, the basic human rights of people with mental illnesses are not realized, often in the institutions designed to care for them--the psychiatric hospitals." This observation, made by Gro Harlem Brundtland, M.D., M.P.H., while she was director-general of the World Health Organization (WHO), is shared by many.
In its report on mental health, WHO (2001) reported:
Human Rights commissions found 'appalling and unacceptable' conditions when they visited several psychiatric hospitals in Central America and India during the last five years. Similar conditions exist in many other psychiatric hospitals in other regions, in both industrialized and developing countries. They include filthy living conditions, leaking roofs, overflowing toilets, eroded floors, and broken doors and windows. Most of the patients visited were kept in pyjamas or naked. Some were penned into small areas of residential wards where they were left to sit, pace, or lie on the concrete floor all day ... many patients were observed tied to beds ... Patients were referred to as inmates.
At least one-third of the individuals in the psychiatric hospitals, the report said, did not have a psychiatric diagnosis to justify their presence there. Recently, a journalist in the Los Angeles Times noted that some of the 1,400 patients in Al Rashid Psychiatric Hospital, Iraq's only psychiatric hospital, were political dissidents (Rubin, 2003).
"Mohammed Abdul Sattar, an assistant manager at the hospital, said that about 50 of the 650 male patients before the war had been sent by the courts, 'because some of them had attacked the government, and so the judges have them brought here to evaluate whether they are a mental patient,'" Rubin wrote.
World awareness of the political use of psychiatry developed in the late 1970s and early 1980s as reports surfaced that the Soviet Union and some Eastern European countries, such as Romania, were locking up dissidents and religious followers in psychiatric institutions.
"This practice represented a systematic use of a health profession to incarcerate healthy individuals into Special Psychiatric Hospitals, administered by the U.S.S.R. Ministry of the Interior, or the police, and not the U.S.S.R. Ministry of Health," the Geneva Initiative on Psychiatry (GIP) (2003b) explained in its statement about political psychiatry.
The first committee to oppose political abuse of psychiatry was founded in 1974 and eventually became the Netherlands-based Geneva Initiative on Psychiatry. From then on, pressure on the Soviets and bloc countries mounted, with condemnations by the British Royal College of Psychiatrists (BRCP), the American Psychiatric Association and the World Psychiatric Association (WPA), among others.
In 1977, the WPA not only officially condemned political misuse of psychiatry, but also issued the Declaration of Hawaii, which set forth a set of basic ethical standards guiding the work of psychiatrists everywhere (Okasha, 2003). The standards were further refined in the Madrid Declaration of 1996 and at subsequent WPA meetings.
In 1982, facing imminent expulsion from the WPA, the Soviets withdrew voluntarily. The following year, the WPA passed a resolution placing strict conditions on the Soviet's return. In 1989, Soviet delegates to the WPA's World Congress finally agreed to acknowledge that the systematic abuse of psychiatry for political purposes had indeed taken place in their country. The All-Union Society of Psychiatrists and Neuropathologists, the Soviet psychiatric association, promised to discontinue these abuses, rehabilitate the victims and democratize the psychiatric profession, and was allowed to return to the WPA (van Voren, 2002).
The splintering of the Soviet Union in 1991 into independent republics (the Russian Federation) brought even more reforms. With the help of the GIP, the Network of Reformers in Psychiatry was established in 1993 as a support group and think tank for mental health care reform for countries of Central and Eastern Europe and the New Independent States (CCEE/NIS) (WHO, 2001). The network now unites some 600 mental health care reformers in 29 countries. Through the network, a pool of experts in the region has been developed and reform programs in various fields of care provision, such as nursing, substance abuse, psychogeriatrics and deinstitutionalization have been initiated.
Robert van Voren, general secretary of the GIP, recently told Psychiatric Times that the political abuse of psychiatry "has come to an end in the former U.S.S.R., although there are sometimes cases in the Central Asian Republics, such as Turkmenistan." According to Human Rights Watch (2003), one of the largest human rights groups based in the United States, political dissidents in Turkmenistan were being arrested or committed to psychiatric hospitals against their will.
This year, the U.N. Commission on Human Rights adopted a resolution expressing grave concern about the serious abuses of human rights in Turkmenistan and requested the Turkmen government to undertake systematic reforms to fully comply with its international human rights obligations (Human Rights Watch, 2003).
In Uzbekistan, another Central Asian republic, reports surfaced last year that two human rights activists were arrested and then transferred to a locked ward of a psychiatric hospital in Tashkent. Medical staff at the hospital confirmed that both women had been given psychiatric drugs since their detention.
In other parts of the Russian Federation, there are still isolated incidents of the abuse of psychiatry for political purposes, according to van Voren.
"Recently, a Russian officer was declared unaccountable in order to avoid a court-martial for raping a Chechen girl. It was clear this diagnosis provided by the Serbsky Institute [for Social and Forensic Psychiatry] was politically motivated," he said.
The GIP, according to van Voren, has established regional offices in Vilnius, Lithuania, and Sofia, Bulgaria. Soon it will open one in Tiblisi, Georgia. It helps manage more than 100 projects in 30 countries. Many of those projects are directed toward training in modern mental health care practices, antistigma campaigns, creation of family and client organizations, and improving overall structures of mental health care.
For example, the GIP has taken charge of the reform of psychiatric services in the prison system of northwest Russia, starting with Kresti prison in St. Petersburg. According to documents van Voren supplied:
The prisoners with mental disorders are locked up under circumstances resembling the Middle Ages and without any medical treatment as a result of a shortage of personnel and the absence of medication. Together with the Russian Ministry of Justice, the Head of the Prison system and the Center for the Treatment of Torture Victims, Geneva Initiative will start to humanize the ward by supporting small renovations, staff training, and lobbying for changes in legislation that will decrease the amount of time for a detainee [now approximately 2-3 years].
As reforms move forward in Russia and Eastern Europe, the GIP has begun a campaign to end the political abuse of psychiatry in the People's Republic of China (GIP, 2003a).
In an interview with Radio Netherlands (2002), van Voren said that the Chinese "consider reformist ideas and struggle for the truth, or deviant religious thoughts like Falun Gong, as being a form of mental illness." He went on to say, "People are being injected with neuroleptics, with psychotropic drugs, they're beaten up, they're raped, they are wrapped up in wet linen, and when it dries, they are squeezed like an orange. That creates excruciating pain. It's punishment, it's maltreatment, it's torture."
To document the abuse, the GIP, together with Human Rights Watch, published Dangerous Minds: Political Psychiatry in China Today and Its Origins in the Mao Era (2002), by Robin Munro, a London-based expert on China's human rights issues.
The official psychiatric literature in China unequivocally records that in many cases since the 1950s ... detained dissidents, non-conformists, 'whistle-blowers,' and other dissenters have additionally been subjected to forensic psychiatric evaluation by the legal authorities, found to be criminally insane and then forcibly committed to various types of psychiatric institutions.
Since mid-1999, Munro charged, Chinese authorities also have forcibly sent more than 300 members of the Falun Gong spiritual movement to mental asylums, and three have died as a direct consequence.
The Chinese government condemned the Falun Gong as a "heretical cult organization" and an "evil cult" in 1999 after 10,000 Falun Gong members participated in a silent vigil outside the Beijing compound where China's top leaders live and work (Mirsky, 2003). Falun Gong, also known as Falun Dafa, consists of meditation and exercises, with teachings based on the universal principlesof truthfulness, compassion andtolerance.
The U.S. Department of State's Bureau of Democracy, Human Rights and Labor (2003), in its report on human rights practices, supported some of Munro's concerns. It said that China has 20 Ankang institutions high-security psychiatric hospitals for the criminally insane directly administered by the Ministry of Public Security.
"Credible reports indicated that a number of political and trade union dissidents, 'underground' religious believers, persons who petitioned the government for redress of grievances and hundreds of Falun Gong adherents were incarcerated in such facilities during the year," the report said. It went on to describe how a Chinese judge was fired from his job and admitted to a psychiatric hospital in 1999 for refusing to renounce his belief in Falun Gong. The judge remains in an Ankang facility and has been given daily injections of narcotics, although he has displayed no signs of mental illness.
In addition, more than 30 people were committed against their will to Harbin Psychiatric Hospital during 2002 after petitioning authorities for redress of various personal grievances, according to information from nongovernmental organizations (U.S. Department of State, 2003).
In February 2002, Juan Jos Lpez-Ibor Jr., M.D., then-WPA president, went to China to discuss the situation of the Falun Gong with the Chinese Society of Psychiatrists (CSP) and the Chinese deputy minister of health.
At the August 2002 meeting in Japan, the General Assembly of the WPA voted to send an international delegation of psychiatrists chosen by the WPA's executive committee to China to investigate alleged abuses of psychiatric diagnoses. More than 500 complaints of abuse in Falun-Gong-related cases were submitted to the WPA's Committee for the Review of Abuse of Psychiatry. According to Lpez-Ibor, CSP members attending the meeting supported the action and helped gather information on cases cited in the Munro book, as well as hundreds submitted by the WPA (Mirsky, 2003).
Two months later, an official with the Chinese Information Office of the State Council told China's official news agency, Xinhua News Agency (2002), "The accusation made by some overseas organizations about China using psychiatric hospitals for political purposes or detaining different kinds of dissidents as psychopathic patients lacks evidence and is totally irresponsible."
With regard to the Falun Gong, the official said the organization "has all the features of a cult and has been banned by the Chinese government, according to law." The official then said, "There are certainly some Falun Gong practitioners whose behaviour has become abnormal from being obsessed with the cult for [a] long time and who have later been sent to hospitals by their relatives."
In May, after months of no response from the Chinese government on its request to send an investigatory group, WPA members held a news conference in front of the Chinese Consulate in San Francisco. They read a stronger statement than the one issued in Japan. The WPA strongly demanded that the Chinese government unconditionally accept the WPA's independent inspection regarding the misuse of psychiatry to violate human rights.
A few months later, the WPA held a press conference in Austria and issued a press release calling on the new Chinese Minister of Health, Wu Yi, to facilitate an external visit to psychiatric hospitals. The press release stated:
The World Psychiatric Association informs the international psychiatric community that the plans for the site visit to China aimed to explore the alleged political abuse of psychiatry have been delayed during the past eight months by the limited collaboration on the part of the Chinese health authorities, in spite of the efforts of the Chinese Society of Psychiatry, which are gratefully recognized.
The WPA addressed a public appeal to the health minister, who is also China's deputy prime minister, asking her to authorize a visit of a WPA task force to China, with "free access to mental health institutions, including those in forensic settings." The task force's purpose "is to ascertain whether any abuse of psychiatry is taking place and to produce, with the Chinese Society of Psychiatry and the Chinese health authorities, specific guidelines aimed to prevent any abuse of psychiatry in the future. The application of these guidelines will then have to be monitored jointly."
Ahmed Okasha, M.D., FRCP, FRCPsych, president of the WPA, recently told PT that a letter from him with the above-cited press release attached, was sent to Wu Yi. Because there was no reply, another letter was sent on Sept. 14 expressing an urgent need on the part of the WPA's Executive Committee and Review Committee to meet with her to "discuss plans for educational visits to different sites with members of the CPS." To date, the only response he has received has been notification that a new president of the CPS was to be elected in September.
Okasha, professor of psychiatry and founder of the Institute of Psychiatry at Ain Shams University in Cairo, Egypt, told PT that there are calls from some member societies to expel or suspend the CPS. In principle, the CPS is bound to adhere to the Madrid Declaration, which forbids introducing political judgments in psychiatric diagnosis.
He believes such expulsion or suspension would backlash, "as the WPA will lose all contact with the Chinese psychiatrists and subsequently, they cannot abide to any requests from the WPA. Furthermore, it will mean collective punishment to all our Chinese colleagues, the majority of which were not involved in any alleged abuse."
By applying continuous pressure and going through political channels, Okasha said the WPA hopes the Chinese government will allow an educational visit with colleagues from the CPS, preferably before the end of 2003.
"If we have the visit now, it will be to investigate the past events of alleged abuse, as the problem is currently very visible internationally," he said.
During recent years, the mental health scene in India "reflects the complexity of developing mental health policy in a developing country," according to R. Srinivasa Murthy, M.D., professor of psychiatry at the National Institute of Mental Health and Neurosciences in Bangalore, India.
In an article on India's mental health policy, Murthy (in press) pointed out that there has been a critical examination of the existing mental hospitals in the country. Four years ago, the National Human Rights Commission (NHRC) of India sought to document conditions in 37 government psychiatric hospitals. Among its findings: 38% of the hospitals still retained jail-like structures, and patients were referred to as inmates; less than half the hospitals had clinical psychologists and psychiatric social workers, and less than one-fourth had psychiatric nurses; 80% did not even have routine blood and urine tests available; floor beds were a common occurrence; and less than half the hospitals provided patients with any privacy. The NHRC concluded that there were so many deficiencies in the government psychiatric hospitals "that the rights of the mentally ill are grossly violated in mental hospitals."
The Supreme Court of India also began monitoring a wide variety of issues relating to mental health care following the Erwadi tragedy in 2001, when 28 people with mental illness burned to death while chained to pillars. The tragedy, according to Murthy, highlighted "the lack of meaningful ser-vices and the lack of regulation of mental health care facilities" (Murthy, in press). At the time of the tragedy, more than 400 people with various mental disorders were living in about 20 houses in the town of Erwadi, mainly due to lack of alternative facilities. The houses were under the care of laypeople, and no medical care was available. When fire broke out in one of the houses, those 28 people died.
In 2002, the Supreme Court of India directed all states to identify entities purporting to offer psychiatric/mental health care, review them based on prescribed standards and decide whether or not to license them (Murthy, in press). It also called for a comprehensive awareness campaign to educate people about the rights of mentally challenged people. Part of the campaign would inform the public that chaining of mentally challenged people is illegal, and that patients with mental illness should be sent to doctors and not to religious temples. In additional directives, the Supreme Court of India asked the states and union territories to assess existing mental health care personnel, types of mental health care delivery systems in place, and to estimate personnel and facilities needed to meet the needs of the population.
The National Health Policy of India is advocating the organization of a network of decentralized mental health services. Such services would include provision of mental health care in all general health care facilities; essential psychiatric drugs; and a mental health care team for training, referral support and supervision.
"Of the many initiatives, the integration of mental health with primary health care at the level of the district is the most important" (Murthy, in press).
With regard to helping patients who are mentally ill, the NHRC has been working with Action Aid India to start deinstitutionalization at three psychiatric hospitals (Dutta, 2003).
More recently, Justice A.S. Anand, the new chairperson for the NHRC, stressed that patients with mental illness continue to languish in improper settings without psychiatric treatment (NHRC, 2003). The NHRC, he said, had found "as many as ten States were holding non-criminal lunatics in their jails, which was a serious human rights violation." One non-criminal person with mental illness, for example, languished in a prison for 37 years. The NHRC requested that the chief ministers of these states transfer such patients to mental hospitals.
Anand said, "The police, the judiciary, the mental health professional and the human rights organizations, all have to play a role to ensure that the mentally ill persons are not ill-treated and that they are enabled to live a life of dignity."
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