Mental healthcare suffers chronic neglect

  • 2005-03-09
  • By Elizabeth Celms
RIGA - Inga doesn't wake up to a cold tray of pills sitting at her bedside anymore. She doesn't have to wait for mealtime if she's hungry, or attend a craft workshop if she's sad. And if Inga wants to go off on her own, for a walk around town, she can. But it wasn't always this way.

After months of living in the Strenci Psychiatric Hospital, one of eight hospitals in Latvia for the mentally ill and disabled, Inga is finally independent again. The 37-year-old, diagnosed with schizophrenia, lives in her own apartment, pays her own bills (with help from a disability pension), and works voluntarily - at the hospital she walked away from two years ago.

Inga finds this life difficult. Harder, even, than her life at Strenci. But she wouldn't go back for the world.

"In the morning, when I lived at Strenci, I didn't want to wake up so early. I didn't want to take so many pills, to always eat at a set time. It seemed to me like living in the army," she says, as if those days are a safely distanced memory in a not so distant past.

Inga, however, is an anomaly. Only a handful of Latvia's patients have successfully reintegrated into a society that, in all honesty, doesn't want them there. For the 64,000 others diagnosed as mentally ill or disabled, the outlook is discouraging.

According to Ieva Leimane-Veldmeijere, director of the Latvian Center for Human Rights and Ethnic Studies' Mental Disability Advocacy program, state support for this particular minority is seriously lacking. To say that this frustrates her would be putting it mildly.

"For me the hardest thing is feeling such a lack of political will from the government. Sure, we can do all of these nice projects. We can go on, and we will go on. But if there's no political support for these activities, nothing can improve," she explains.

Passing the buck

Yet 2004 saw a start. According to Leimane-Veldmeijere, the Ministry of Health has finally become aware of the need to develop a comprehensive mental healthcare strategy.

"They now understand the importance of including people from other ministries, such as the Ministry of Education and the Ministry of Welfare, in the strategy development," she says.

But this is where things get complicated. The mentally ill have traditionally fallen under the Ministry of Health's responsibility, says Leimane-Veldmeijere. However, it's the Ministry of Welfare's job to develop - and fund - the community-based services these people so badly need.

As is so often the case in Latvia, neither ministry can agree on where the line of responsibility should be drawn. The issues consequently get pushed back and forth between the two, until lost in disorder. It's a bureaucratic story all too familiar, all too Baltic.

"The Ministry of Welfare has tried to provide community-based services for people with mental disabilities, but in practice has only provided them for people with mental retardation or intellectual disability," Leimane-Veldmeijere explains. "This is because since Soviet times, the mentally ill have been under the Ministry of Health's scope. But this ministry always says, 'It's not our business, we should provide only treatment, not social services. And they're right, it's not exactly their responsibility."

When asked with whom which responsibility really lies, Ministry of Health press secretary Guna Rudzite laughs, clearly aware of the absurdity behind this ministerial mix-up.

"The system isn't perfect and we're working to improve this," she says. "We must share the responsibility together."

When compared to Estonia and Lithuania, the situation in Latvia appears even more primitive. Although all three Baltic states are struggling to bring their mental health sectors up to European standards, at least Latvia's neighbors have a modern system in place.

Estonia has 24 institutions taking care of people with mental disabilities. In 2003, a total of 3,943 patients were treated, according to the Ministry of Social Affairs Web site. State-supported services ranging from 24-hour care to employment for the disabled far surpass those in Latvia. The government's "everyday life support" system, developed to reintegrate mentally disabled patients into society, has so far helped 1,035 people.

Meanwhile in Lithuania, similar systems are in place, shaped most recently by the Helsinki Ministerial Conference in January. The conference's primary focus was the European Mental Health Declaration and Action Plan, approved by the World Health Organization and European governmental delegations. All three Baltic states joined the manifesto, saying 'Yes' to the proposed reform.

"We are in quite a bad position when you look at Estonia and Lithuania. Both countries have done much more because there's been influence on reform from the government," says Leimane-Veldmeijere.

But healthcare workers in Estonia and Lithuania are no more satisfied than she is.

"If government officials in all three Baltic states read the [Helsinki] plan, they have to recognize that, if we want to cope with the epidemic of poor mental health and to stop the tradition of stigma, discrimination and institutionalism, huge political will is needed," says Dainius Puras, associate professor of child psychiatry at Vilnius University.

Political intention is a term mental-health workers are all too familiar with. Action, on the other hand, is something yet to be heard of, says Leimane-Veldmeijere.

"Signing [the Helsinki declaration] is just a symbol. In practice, you have to follow up on this," she explains. "My colleagues and I don't get the feeling that there's a real commitment from the government to do this."

And there is good reason for such skepticism. For years now, Latvia has been in violation of Article 5 of the European Convention of Human Rights. The law stipulates that if a mentally disabled or mentally ill person is detained, he has the right to challenge this either in court or an independent court-like tribunal. According to Latvian law, Leimane-Veldmeijere says, no such system exists.

"We have organized several training seminars, and have even been writing letters with international partner organizations to convince the Ministry of Health to put this law in place," she explains.

Yet, not everyone at the Ministry of Health seems to understand the problem - a disparity that Leimane-Veldmeijere finds shocking.

"They do have rights," Rudzite says. "If the person is ill, he must go to the hospital. But if he thinks he's healthy, he has the right to argue this decision."

The first draft law on mental healthcare in Latvia was written up in 1998. Since then the law, which governs all psychiatric services in detail and includes a rights catalogue for the mentally ill, has been changed several times and has yet to be approved by the Cabinet of Ministers and Parliament. The latest version, written in 2002, received strong criticism as it again failed to comply with international human rights standards. It wasn't until the end of last year that the Ministry of Health rewrote the draft to include a new court-rule system for the mentally ill, among other changes.

But the draft still has a long road ahead. It must first pass through a line of ministers before even reaching Parliament's door.

"I can only hope that this will all be finished in 2005, but I'm not very optimistic anymore because it's not a governmental priority. We also can't be sure everything currently in the law will be kept," she adds. "It's not over yet."

Puras shares similar concern for Lithuania's progress. The problem, he says, comes down to a lingering Soviet mentality.

"Because of our tragic history in the 20th century, we are still hostage to ineffective solutions that create a vicious circle. Several generations have been living in a situation of passive adaptation to the former system. There is a lot of intolerance to all marginal groups, including the mentally ill," he explains.

Instead of creating community-based systems for children and adults with mental disorders, Puras notes, the government continues to invest funds in closed psychiatric institutions. A perfect example of backward growth.

"More than 80 percent of all financial resources put into the system go toward priorities we had 20 or 40 years ago," he explains.

Puras adds, however, that compared to the other Baltic states, Lithuania has seen the most improvement within psychiatric institutions.

"The basic question for policy makers will be whether it's advantageous or disadvantageous to invest huge amounts of the budget into a system that will be gradually shut down by the EU and WHO," he says with a touch of sarcasm. "Sooner or later we have to understand that we must change our investment priorities."

A small step forward

Despite drawing little more than apathy from the state, Leimana-Veldmeijere admits that in nongovernmental areas, things have started to move ahead. Slowly.

The Mental Disability Advocacy program, backed financially by the Soros Foundation-Latvia, has accomplished more community-based projects for the mentally ill and disabled over the past three years than the past decade.

The Jelgava daycare center, although recently taken over by the Jelgava municipality, is one such example. Set up in 2004, the Jelgava Mobile Treatment Team 's a group of on-call psychiatrists, psychologists, nurses and social workers 's is one of the few examples of mental healthcare in Latvia that complies with European standards. Bringing professional therapy to the patient's home, the client doesn't have to be hospitalized 's something most, understandably, dread.

"This system should be administered throughout all of Latvia," Leimane-Veldmeijere says. "But again, it's a question of funding."

Even more attention has been drawn to the Akniste Psychiatric Hospital, one of two hospitals for long-term patients. The institution is one of the most forward-thinking in the country, and accommodates 430 patients.

"This is the only mental hospital in Latvia that has a patients' council where patients can make decisions and are heard by the administration. They really have changed some things in their daily life," says Leimane-Veldmeijere.

The Akniste half-way apartment, located several hundred meters from the hospital, is one of the center's latest projects. The apartment provides an opportunity for patients to live off their own pension for three to six months - an experience of life outside the hospital.

But if you ask Akniste patients what they're most excited about, many will tell you it's the arts and crafts shop they opened last May where they sell their own work. The next plan is to open a small cafe adjacent to the gallery - yet another opportunity for the patients to work outside the hospital.

The main goal, Leimane-Veldmeijere says, is to involve more patients in these working groups and activities. That's where the changes begin.

"It's important that they have their voices heard," she says. "These services are for them, and sometimes, they are the best experts in the field."