Kyrgyzstan: Psychiatric Patients Abused

Patients in psychiatric hospitals throughout Kyrgyzstan are poorly fed, live in dreadful conditions and are often forced to work either for hospital staff or the local community, IWPR can reveal.

IWPR contributors visited three different psychiatric establishments. One lies in the northern Chuy region, in the village of Chymkorgon, while the second is in the village of Kyzyljar in the southern Jalalabad region. The third is the Osh Regional Psychiatric Hospital, also located in the south of the country. All told, they hold about 1,400 patients.

Hospital managers were reluctant to divulge information about their patients, especially to a media organisation. But staff and patients related their experiences, often with indignation.

The Chymkorgon lies 85 kilometres from the capital, and the hospital serves all of Kyrgyzstan and the southern regions of Kazakstan as well. It currently has 500 patients, well below its capacity. It is something of a showcase because it is often visited by non-government organisations and journalists.

But it still has a pervasive atmosphere of poverty and deprivation, and is badly in need of complete renovation.

Patients at Chymkorgon are usually locked up in squalid rooms with barred windows and stone floors. The rooms are overcrowded, holding up to 15 in one room. A single nurse is routinely left to supervise 10 to 15 people. Staffing shortages mean that patients are deprived of the right to a daily walk and physical exercise.

Outside, the destroyed fences and open gates contribute to the air of neglect.

Visits must be agreed with the hospital administration – and with good reason. A staff member confided to IWPR that the day before outside guests arrive, the wards are cleaned and put in order.

“We hide patients who complain and take only those who will praise the hospital to meet journalists. On those days they serve a good meal, for example dumplings,” she said.

Kyzyljar, which houses 750 patients, is fairly remote and has poor connections to the outside world. That has clearly had an effect on conditions there. One woman, Jarkyn, recalled the 18 days she spent there in April 2002.

“Patients who did not obey attendants were tied to beds,” she told IWPR. "They might lie there tied up for days on end. They could also be left without food and not allowed to go to the toilet during that time. The attendants don’t care.

“Patients are made to clean their wards themselves. If they don’t, hospital attendants get angry.”

The hospital in the centre of Osh is relatively well off, as it houses only 150 patients. However, lack of space still means that it resembles a jail. The effect is heightened by the bars placed on the windows. Patients are not allowed to walk around freely, and children and adults are placed in the same rooms.

Overall, though, patient conditions in Osh seemed better than at the two larger hospitals that the team visited.

THE ENVIRONMENT FOR PSYCHIATRIC CARE

Patients at Osh say supervised exercise is "like being in a zoo".

Mental hospitals in Kyrgyzstan are officially termed “centres of psychiatric health”. The unofficial names “durdom” (nut house) and “psikhushka” (loony bin) are sadly more reflective of public attitudes. According to Azimjan Askarov, a human rights activist from the Bazarkurgan district of Jalalabad region, popular stereotypes remain unchanged, “The average person has inherited the Soviet-era stereotypical idea that psychiatric illnesses are incurable and mental patients are hopelessly ill.”

Such prejudices mean that patients are seen as outcasts and there is little public interest in how they are treated. Mental health is already low on the list of priorities for a government that is hard pushed to fund basic social and healthcare services.

“The state would love to increase the funding for psychiatric hospital – but it can’t,” said Bubusara Ryskulova, who runs the Sezim women’s crisis centre. “It’s no secret that the country is going through an economic crisis. Of course the government selects the top-priority areas of social sector funding. Mental patients have never been a priority.”

Lack of funding also affects the quality of staff that the hospitals can recruit. Doctors, nurses and auxiliaries receive pitifully low wages – and these are often paid two or three months late.

“They have a big staffing problem,” human rights activist Yrysbek Omurzakov told IWPR. “It’s not everybody who can stand such working conditions and such low pay levels. So they have to hire people who have not had a specialist education and who may be very far removed from medicine. Sometimes, they have no idea how to deal with the patients.”

The result is gross abuses of patients’ rights. “The rights to adequate living standards, appropriate treatment and environment, and to obtain information are all violated in mental hospitals,” said Nazgul Turdubekova of the Youth Human Rights Group, which has surveyed the state of mental healthcare in Kyrgyzstan.

PATIENTS USED AS FREE LABOUR BY HOSPITAL STAFF

Recovering alcoholics used as free labour.

Patients in mental hospitals are made to perform hard, manual labour on the private farms of hospital staff members. Staff even lend their patients out to local farmers.

Bakirjan, a patient at the Osh hospital, told IWPR that he and other patients had been taken several times to work at the homes or farms of doctors and nurses. “Some need to clean up their homes, others need to dig up their gardens," he said. “Yesterday, I and four other patients went to the house of the medical attendant and laid the foundations for his house.” Patients like him receive no payment for labour.

A young man cleaning the yard of the house of an official of Chymkorgon hospital turned out to be Valery, a patient sentenced by the courts to compulsory treatment for a violent crime. “I have worked for four months at the doctor’s place," he said. "He does not give me money but he feeds me – I work for food. It is better than the hospital food, which dogs would not eat.” Valery works for the doctor every day and returns to sleep in the hospital.

Another hospital patient who works for the same doctor has been put in charge of cattle. Every morning he turns about 10 cows out to grass and drives them back in the evening.

A third patient we met confirmed he worked in a doctor’s home. “I’ve just dismantled the motor of his washing machine,” he said.

Interviewed by IWPR, Janybek Ajybekov, recently appointed head of Chymkorgon hospital, admitted that such “labour assignments” do take place, especially at the homes of doctors and medical personnel. But he insists the problem is being put right.

Patients at Kyzyljar also work regularly in doctors' households. We found one hospital patient working at the home of the head doctor, Abdujalil Begmatov. Local residents described him as the doctor's “malai”, or “slave”, performing all the menial tasks for the household, such as tending cattle, chopping firewood and so on. We could not interview him, as he cannot hear or talk.

IWPR met Aibek at the house of Sapar Mombekov, chief medical officer of the reception department at Kyzyljar. He said he had been working there for three years. “When there is work to be done, the doctor takes me with him," he said. "In return for my work, Mombekov helps me with food and other things. When there is too much work, he takes more people from the section. In general, Mombekov treats me as if I were his own son.”

When journalists met him, the patient was preparing soup over a fire. A few metres away, we could see the freshly-cut skin, head and innards of a dog. Aibek said other doctors sometimes visited to taste smoked dog. “It’s excellent with vodka,” he said.

IWPR found Abdy - undergoing compulsory treatment ward after a court deemed him irresponsible following a violent act - working in the garden of hospital stores manager Emil Aitmyrzaev.

“I am helping the head of stores to manage the garden,” said Abdy. “I don’t get any payment. Why would I need payment? The main thing is that my days are going past somehow. It is better to work here than stay in the hospital and do nothing.”

The IWPR contributor also met three psychiatric hospital patients digging up a field belonging to Altynbek Ryskulov, who heads another department in the hospital. It was hot, and as the workers took a tea break they told IWPR that it was better to work in the fields than stay in hospital. “Here we can have some tea with sugar. Additionally, the master feeds us bread and curdled milk. If we stayed in hospital, we would go hungry,” said one of them.

Abdykerim Temirberdiev, a psychiatrist from the southern city of Osh, who has been in practice for more than 20 years, told IWPR that patients have been exploited in mental hospitals for years.

This exploitation has nothing to do with legitimate work therapy, which he defends. “Labour therapy exists as a discipline,” he told IWPR. “It should be used on particular patients for two to three hours a day to work out their reflexes.

“For labour therapy to make sense, the patient should understand that his work is needed by society. It does not make sense to assign them routine labour just to kill time. You cannot force patients to work, it is wrong.”

In reality, though, that is not what happens. “The attitude towards patients at psychiatric hospitals is that if you live and eat there, you should also work,” he said.

CONSTRUCTION WORK

Patients working on a construction site at the Osh hospital.

Recovering drug addicts at the hospital farm taking a break.

Psychiatric patients during a break on a private farm.

Kyzyljar inmate working in the fields.

Osh hospital was built in 1949. Under the guise of labour therapy, its patients are routinely used to demolish and clean up old parts of the building. The IWPR contributor witnessed several workers clearing up the rubble and collecting bricks under the supervision of a medical attendant.

Abdurahman Omurzakov, head of the rehabilitation section, told IWPR that the labour force would shortly be used to build a bathhouse for the hospital. “To save resources, the bathhouse will be built by employees and patients. If we work hard, we could finish construction in two or three days,” the doctor said.

USE OF PATIENTS IN HOSPITAL FARM FIELDS.

Three patients from the addiction treatment department at Kyzyljar were working in a field belonging to the hospital. Sadyk, who is being treated for alcoholism, said work starts at six in the morning and finishes at sunset. “We do what the doctors tell us," he said. "They tell us it is labour therapy and that it is necessary. We eat three times a day, mostly boiled macaroni or pearl barley. I get no medicine.”

Another patient, Aman, joined in the conversation, “We plant maize and dig gardens but get no money. Sometimes we get cigarettes and an additional piece of bread”. He showed the journalist a piece of bread which he had saved for lunch.

ASSIGNMENT TO FARM WORK

Medical staff at Chymkorgon told IWPR in confidence that patients are often used to work on private fields and farms. For years, nearby villagers have taken advantage of this free labour force. Patients do simple construction work, tend gardens and look after cattle – and all for nothing. Those who are more aware of what is going on around them get assigned the more complicated tasks.

Staff say most patients are glad to have a change of environment, eat homemade food and get cigarettes from their bosses. The luckiest might get a bottle of vodka, in spite of the potential damage that might cause to their condition.

“It has become hard to get workers after things got stricter there,” one Chymkorgon resident complained in the market place. “After an incident in the hospital when one patient killed another, they are not being allowed out of hospital.”

An IWPR contributor visited a section of Chymkorgon hospital popularly known as the “labour camp”. Patients here have no relatives, or have been abandoned. Around 15 of them were seen busily planting tomatoes in a field, under supervision of a local man.

When the patients noticed the journalist, they began begging for bread and cigarettes. As a cigarette was offered, they all approached with outstretched hands. When the guard noted that the patients had stopped working, he yelled at them to resume their job. “Don’t give them anything,” he said. “Otherwise they will ask for everything. They are insatiable”.

Chymkorgon hospital director Ajybekov denied that patients were allowed out to work in local community, “Sometimes people say they need help to cultivate the land, set up fences, but we do not allow patients to go.

"People get offended but I try to dissuade them. I ask, 'Why do you need them? If the patient escapes, you will have to search for him yourself and spend money on petrol to do so. That is expensive! You'd better do that work yourself with your family.'"

WHAT THE LAW SAYS

All photos: U Babakulov and V Oseledko, May '03.

Working in a private home.

By law, doctors are supposed to use work therapy for rehabilitation purposes, to enable patients to re-adapt to society. “Work gives the patient a sense of being valued, raises his self-esteem and teaches discipline and cooperation with others,” said Temirberdiev.

A 1999 law on mental healthcare stipulates that people with psychiatric disorders can work, but requires special workplaces and training to be provided for them.

The law says such work should be remunerated, “All patients under medical treatment or examination at psychiatric hospitals have a right to receive compensation for work on an equal basis with other citizens, in accordance to the amount of work done and its quality, if the patient is engaged in production.”

PATIENTS GIVEN LIMITED NOURISHMENT

Those not involved in work assignments are fed poorly. The state budget allocates 13 soms (around 30 cents) per patient as a daily food allowance. When IWPR looked at the kitchen of the Osh psychiatric hospital, all that could be seen was boiling soup and bits of dough. A cook told us, “We do not add carrots, onions or spices – they are too expensive.”

After a long search, the cook found a small bone which was to be added for taste. Several rats were seen in the kitchen, though their presence did not alarm either staff or patients. “Rats run round my room as well, so that's no surprise,” said Sultan, a patient.

The same IWPR contributor, on a tour of Chymkorgon hospital at lunchtime, said patients begged for bread and extras to eat. That day, patients were given a yellow-brown soup for lunch, in which small worms could be seen.

Klara, who suffers from schizophrenia and has been a regular patient at Kyzyljar since 1995, said patients always went hungry, “They eat boiled rice or pearl-barley that is often full of worms. Some doctors take patients to make them work but at least they get decent food, and sweet tea with bread, and in the evening they come back to hospital.”

The woman's sister told IWPR that whenever Klara had to go to the hospital, she returned as skin and bones, “Her head and clothes are always full of lice.” Kyzyljar hospital patients said they barely survived the last winter. “We were so close to death from hunger,” one said.

CONCLUSION

IWPR's survey of three hospitals has revealed a catalogue of abuses, many of which our team witnessed personally. While there is relatively little evidence of malicious treatment by staff, it is clear that patients are routinely used for unauthorised labour in hospital grounds and for domestic service. Patients are frequently complicit with these arrangements simply because the standard food is so poor that any alternative is preferable.

Patients have few means of redress, and complaining may prove counterproductive. “Until recently, if a patient in a psychiatric hospital complained about the bad food, the rudeness of the doctors, the disappearance of personal belongings, or the violation of hospital rules, it would be attached to his or her medical record," a staff member at the Centre for Psychiatric Health said. In other words, complaints were used as additional evidence of anxious or aggressive behaviour. No one investigated the cited problems.

Jalalabad rights activist Abdunazar Mamatislamov says it is high time a system was put in place to provide patients with proper care and treatment, since the current provision is so bad that it would "make a healthy person mentally ill”.

Human rights activist Omurzakov agrees, “Kyrgyzstanis should not be so callous towards people with mental disorders and calmly allow their rights to be violated, so that they are forced to feed off dogs and clover.” He wants the issue to become the subject of a serious investigation and national debate.

Are there any signs of positive change? The fact that more agencies and NGOs are visiting these institutions is hopeful. Two days after IWPR was at Chymkorgon, the hospital received a visit from lawyer Deborah Dorfman and her colleague Craig Awmiller of the Mental Disability Advocacy Centre, based in Budapest

The visitors gave mixed reviews. “I don’t think that we were able to see the real picture of what is happening in Chymkorgon," Awmiller said. "But we could see the hospital does not offer adequate nutrition and medical coverage”.

Dorfman was more optimistic. “I saw very good relations between medical personnel with patients,” she said. “Despite the hardships and lack of financing, the personnel of the hospital, especially its directors, were very open with us. You can see their willingness to improve the current situation, even with the scant resources available to them.”

The names of all patients have been altered.

Ulugbek Babakulov, Natalia Domagalskaya and Asel Sagynbaeva are IWPR contributors in Bishkek.