Waking Up to Injustice in Mental Health Care

To mark this year’s WMHD, the Mental Health Innovation Network is running a month long series (#WMHD2015 Blog Series) highlighting dignity in four areas of global mental health where dignity is most often compromised and/or redeemed. This week’s subtheme is “Dignity in Health Services”. 

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I’ve been working in international development related to mental health for over 10 years, mostly in Uganda. Over the years, I have learned to quietly accept the slow pace of change when it comes to improving inpatient mental health care in low-income countries.

I have always worked alongside Ugandan health professionals and patients to support change. I’ve been against the shock tactics of Robin Hammond’s photo essays, which show people in degrading poses, shackled to poles. I’ve been dismissive of the possibility that external campaigning to shine a light on human rights abuse can bring positive change.  I’ve always harped on about working from inside out to create change.

A recent visit to Uganda forced me to question my position.

During April of this year, Rashid Male, a 25 year old singer and activist died whilst an inpatient at Butabika Hospital.  Rashid wrote an impassioned blog for World Mental Health Day on this very site, back in 2014. He sang about mental health, helped to manage mental health projects and worked in the ground-breaking HeartSounds Peer Support Worker programme to help others cope with the challenges of mental distress.

I feel the loss of a colleague—but more, the loss of a friend.  A leader of Uganda’s nascent ‘revolution in mental health’, Rashid saw the possibility of user leadership and peer working from the outset.

On the day of his burial, I visited the admission ward where he stayed before his death on the medical ward. 

The ward is set on manicured grounds and is surrounded by 6-metre high fences topped with razor wire.  I entered through thick metal gates with the permission of the askari (guard).  The entry of a white man creates an immediate buzz, which I was strangely detached from as I tried to adjust to the scene before me.   Various men, all dressed in thin, lime green uniforms moved towards me with dribbling, constricted mouths that couldn’t quite enunciate, due to the side effects of their medications.  Some retained some small personal touch, a cloth as a headband, a rough-made necklace or a bracelet.

Others lay fully or partly unconscious.  One man lay on his side with his arm askew beneath him.  Another fanned him roughly with the torn corner of a mattress before trying unsuccessfully to help him sit up.

I walked through to find the nurses’ office behind the main area.  The first office had no staff, and instead I found one man naked, just getting up from the ground—a group of other, clothed men surrounding him.  It is not necessarily unusual to see men wandering naked at the hospital, but whatever was happening was not for my eyes. Everyone quickly scattered when they spotted me.

I blinked, unable to register what I had seen.  Was this man vulnerable and being abused, or had it been an innocent gathering?

To the left and right of the office entrance are the dorms.  However many beds, you can count on them being oversubscribed. More often than not, you will see people sleeping two to a bed, or with one person underneath.  The metal gates of the dorms were locked. Two people were seemingly asleep in one dorm, while the other held around a dozen people who immediately started calling out to me to free them, to get them ‘a pass out’, to call relatives.

I imagined Rashid languishing in there.

The second office was alongside this dorm. Here, a nursing assistant was surrounded by a group of patients all making requests simultaneously.  She turned briefly, barely able to register my presence, before returning to the many conversations she was trying to have. 

I attempted to talk through the bars to the men locked up in the dorm.  People jockeyed to get a word in.  The men pleaded for me to get them out, saying they had been kept 2 or 3 weeks in the dorms.  I could see a man on his bed at the rear of the dorm rocking back and forth in some kind of trance. 

Through the grille I speak to the men and hear their stories of ostracism and alienation.  They ask in many ways to be seen and remembered in this place where they languish. 

I mentioned my Rashid and somehow I and three Muslim men found our way into a corner, where they chanted to mark his burial in Masaka.  When I walked outside, another service user, not in uniform, was moving through the yard, physically rounding people up to go for their medication.  Everyone receives their medication at the same time. 

I wondered about these “special roles”— good use of well patients, or a recipe for Kapo-style bullying? 

I met one of the psychiatrists on her way in.  Her distress was palpable.  She was moved by Rashid’s death, but with 150 patients on this ward alone, her responsibilities are many, and there was no time to grieve. She expressed her commitment to forge on in the face of this constant storm.  She cares for her patients, but who will care for her?

The lack of resources committed to mental health care in Uganda has put these staff and service users in this situation, and it is an outrage. We must make it our business to advocate for greater investment in mental health services. 

We become desensitized to pictures of people in mental distress, in abject conditions. But I am writing to tell you, that is no stranger behind those bars and razor wires. No stranger green pyjamas, hungry and sedated.

That is my friend Rashid.

Image courtesy of Valentina Iemmi. Copyright © 2015 Valentina Iemmi. All rights reserved

Specialist care
Human rights
Empowerment and service user involvement
All disorders
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