Donald Rodas, a baby-faced man in his late 20s with paranoid schizophrenia, arrived at Guatemala’s only public psychiatric hospital last year after being charged with murdering his parents. He says he often wanders freely through the sprawling facility of dilapidated one-story buildings and wooded courtyards, where detainees charged with crimes mingle with ordinary patients and the developmentally disabled.
He sees ugly things. Those who refuse their medication are beaten and put in the “little room,” a barren isolation cell, he said. Desperate women sell their bodies for as little as 5 quetzales, or less than a dollar, to afford basic necessities.
“I see when they have sex for money,” Mr. Rodas said in halting English. “To buy food. All they have is beans.”
The United States began emptying out its vast asylum system in the 1960s, spurred by scathing reports of abuse and neglect, like a 1946 Life magazine exposé that described many institutions as “little more than concentration camps.” The transition to community-based care cut the institutionalized population by more than 90 percent by 1994.
But community care resources failed to match demand in the United States, leading to widespread homelessness and an influx of the mentally ill into jails and prisons. Even so, deinstitutionalization is widely credited with ending the abuse and neglect that made mental institutions synonymous with a nightmarish netherworld.
Yet this asylum-based model of mental health care remains the standard across much of the globe. In many poor and developing countries, thousands of mentally ill people are warehoused in dirty and dangerous institutions. Health experts and advocates who monitor such facilities say the picture varies little from country to country: overcrowded wards lacking in privacy; poor sanitation; physical and sexual abuse; routine use of restraints and long-term solitary confinement; and forced treatment, including electroshock without consent. The rights of patients judged to be mentally ill are easily stripped by the courts and are difficult if not impossible to regain.
“People need to wake up to the sad story of widespread human rights violations against people with mental disorders in a number of countries,” said Dr. Shekhar Saxena, director of the World Health Organization’s department of mental health and substance abuse. “We need to bring these people out of the shadows so the world can see how badly we are treating them.”
Institutionalization is just one facet of the broader catastrophe of mental health care in the developing world. According to the World Health Organization, in low- and middle-income countries, up to 85 percent of those with severe illnesses like schizophrenia, bipolar disorder and major depression receive no treatment.
Government and humanitarian funding to treat the most severely afflicted is almost nonexistent. In a world where an average of 80 children die every hour because of a lack of clean water, the absence of a coordinated global response to the mentally ill may represent a triage mentality, in which scarce aid dollars are directed at the most immediate threats to life, like malaria and AIDS.
But governments that have put their minds and money to the task can make a difference. In the past decade, under pressure from Disability Rights International, a Washington-based advocacy group, Paraguay, one of Latin America’s poorest nations, reduced the population of its national mental hospital by almost half while creating a system of community-based group homes. Far larger countries like Brazil have accomplished even more impressive transitions.
Recent developments suggest that a turning point on institutionalization may be at hand. More than 130 countries have ratified the United Nations Convention on the Rights of Persons with Disabilities, a binding treaty that stipulates that the disabled, including the mentally ill, must not be arbitrarily detained or segregated from society. In May, the health ministers of the W.H.O.’s 194 member states voted unanimously in favor of a global mental health plan that calls on signatories to move from centralized asylums to community-based care.
Making international commitments a reality can require extraordinary outside pressure, however. One example is Guatemala, which ratified the United Nations treaty in 2009 and endorsed the W.H.O.’s mental health plan in May. Yet the country allocates only about 1 percent of its modest national health budget to treat mental illness, compared with an average of 5 percent or more in high-income countries like the United States. More than 94 percent of Guatemala’s funding goes to run its national psychiatric hospital. Local human rights advocates had pressured the government for years to reform the institution, with little success.
Then, in 2011, Disability Rights International began an investigation with help from local advocates. In October 2012, the group filed a scathing complaint with the Inter-American Commission on Human Rights, an arm of the Organization of American States, documenting widespread mistreatment of patients, including sexual assaults and exploitation, beatings, prolonged use of solitary confinement, deaths from infectious diseases and overdoses of psychiatric medication.
The Guatemalan Health Ministry initially rejected many of the allegations. But the commission found the charges credible and directed Guatemalan authorities to improve safety and health at the hospital immediately. A year of negotiations concluded last week with a groundbreaking agreement by Guatemala to overhaul hospital policies and restructure the country’s mental health system.
Guatemala pledged to establish a pilot program of community-based group homes for the mentally ill and disabled and to significantly reduce its long-term institutionalized population within two years. New inpatient psychiatric units are to be opened at general hospitals, while outpatient mental health care and support, including free medication, will be made available at dozens of community health centers throughout the country. Conditions at the national mental hospital are to be improved, and criminally charged psychiatric detainees separated from ordinary patients. Finally, a law codifying substantial new legal protections for the mentally ill and disabled is to be introduced in the national Legislature within a year.
“The government accepts that people with disabilities need to be integrated into the community,” said Eric Rosenthal, executive director of Disability Rights International. “They recognize that the only way to make people safe is to get them out of the facility. That is really the historic approach here.”
He added, “If we can do it in Guatemala, we can do it everywhere.”
To achieve that goal, a global effort will be required to expose abuses and shame governments into enacting serious reforms. If and when that fails, international human rights law can and should be used to compel action. Governments and international advocacy groups must also elevate public awareness and dispel myths and prejudices about the mentally ill. Until then, this deeply vulnerable and powerless population will continue to suffer terribly in the shadows.
John Rudolf is a freelance writer based in Portland, Me.