|
English Language Page This, first and foremost, concerns the judicial control over involuntary hospitalization. Instead of obtaining legal grounds for submission of patients to involuntary therapy by organizing appropriate court proceedings, a number of clinics obtain their patients’ consent to therapy by exerting pressure on them or generally misleading them and thus falsifying their voluntary consent to therapy. For example, the involuntary hospitalization rate in 55% of the clinics is below 5% instead of the natural 15—20%, whereas the rate of voluntary hospitalization in 64% of psychiatric clinics is almost 100%, which points to falsification. In a considerable number of psychiatric clinics, court proceedings on involuntary hospitalization occur in violation of the legally established timeframe and procedure (in the absence of an attorney, legal representative, and sometimes even the patient him or herself). At the same time, in certain clinics (Arkhangelsk, Vladimir, Kirov, Kurgan, Orenburg, Oryol, Smolensk, and Tver regions, Republic of Mordovia and the city of Moscow) the legal mechanism has begun to work. The situation of patients of Russian psychiatric institutions varies greatly depending on the region in question. The monitoring across the Russian regions has demonstrated a significant diversity which is first and foremost accounted for by the level of funding of psychiatric care. The majority of institutions except for the specialized ones are funded from local budgets which depend on the economic circumstances of the region. As a result, psychiatric institutions in some regions have three times more money than other regions to spend on basics such as medicines. 39% of the hospitals do not even have a guaranteed minimum of old-generation psychotropic and anti-convulsion drugs meaning that patients have to purchase the majority of their drugs themselves. Note, that the monitoring was conducted in the main central psychiatric clinic in each region or territory, not local clinics, where the situation is even worse. Head physician of the Stavropol territory psychiatric clinic, I. Bylim, stated: “Our central clinic is funded well, whereas the seven local ones languish in poverty having ten rubles per day per patient for food and nothing for years on end — for building maintenance.” This situation is supported by the official data, according to which one third of all psychiatric clinics of the country are acknowledged to be unsuitable for use in view of their decrepit condition. The most dispiriting situation was observed in the Altai republican hospital and the Tver regional hospital #1 which resemble a “city after bombing.” The lack of funding, which significantly affects the quality of therapy and everyday life of patients in institutions, is also felt in the hospitals that are located in the regions that are comparatively prosperous from a financial standpoint. The fact of the matter is that only the most necessary expenses (such as salaries, foodstuffs, and pharmaceuticals) unrelated to a fundamental improvement of the living conditions in the institution, maintenance, and supplies/ stocks of laboratory and therapeutic equipment, are fully funded. In the meantime, equipment in 38% of the hospitals is hopelessly out of date. Hospitals that do not have any difficulties with funding are a rare exception. In defiance of the existing law the majority of institutions are severely under-funded and this is the main reason for living conditions that undermine human dignity, adversely affect the quality of therapy, and deprive both patients and personnel of their elementary rights. Even the right to safety is not observed. The monitoring identified a number of hospitals which do not have disinfection rooms. Only 27% of the monitored hospitals had in place conditions required for disinfection. 7% of the hospitals lacked conditions to carry out any disinfections. Decisions of public health authorities are not complied with. Intercom and alarm systems necessary for the safety of patients and personnel are non-existent. Only 17% of the monitored hospitals keep journals registering application of physical restraint measures, and only 3% keep journals registering cases of aggression. Junior posts on which patients’ safety directly depends, are fully staffed in only 9% of clinics, although this is probably due to the level of unemployment in the given region. In the majority of clinics, understaffing has acquired catastrophic proportions: the acute deficit of personnel is combined with a high personnel turnover (up to 30-40% per year) which makes training and induction difficult. At the root of the problem are minuscule wages combined with difficult working conditions and the low prestige attached to the profession. The current funding of psychiatric care does not take into account the pressing need for urgent building maintenance in many psychiatric institutions. The monitoring identified that 21% of the buildings of psychiatric clinics are in a decrepit condition unsuitable for habitation and therapy of patients. As a rule, no maintenance has been done on these buildings since the day they were built and the majority of them were constructed before 1917 and designed to accommodate the needs of that era. For example, the kitchen unit of the Udmurtia republican psychiatric clinic which was designed to service 250 people and has been unsuitable for use for many years is currently servicing 800 individuals. The situation is exacerbated by the fact that half of all the psychiatric clinics are located in buildings unsuitable for the provision of psychiatric care. For example, the Adyg regional neuro-psychiatric dispensary is located in former stables. Buildings of many psychiatric clinics are former barracks, prisons, and correction facilities Even the pavilion style which is preferable from the standpoint of contemporary psychiatry, still has serious disadvantages if it is housed in a former concentration camp as is the case with the Dolgoprudny psychiatric clinic. It is not surprising therefore that many clinics do not have recreation facilities and meetings with relatives take place in the canteen, hallway, or on the staircase landing. Despite the current requirements, 68% of the clinics have preserved window bars — an echo of the era of repressive psychiatry. The majority of the monitored departments were without decoration and only 6% of them were found to be relatively cozy. Many hospitals are not in the position to provide their patients with sufficient living space and meet their elementary sanitation and hygienic requirements. In 34% of the monitored clinics there are departments in which one patient has less than 3 m2 of living space, and in 18% — less than 2.5 m.2 Only 3% of the surveyed clinics were found to comply with existing standards governing living space in modern hospitals. Instead of 25—30 beds per department in hospitals abroad and 50 beds that would be optimal for modern Russia, departments with 70—90 beds prevail. Wards contain 10-15 or more beds, in 8% of the clinics beds are crowded in hallways, and two hospitals (in Bryansk and Krasnoyarsk) have preserved two-level bunks. In 10% of the hospitals an unpleasant odor was identified which was accounted for by the wear and tear of sewer pipes. In three of the surveyed institutions — the Krasnoyarsk territory psychiatric clinic #3, the Rostov-on-Don city psychiatric clinic (Kovalyovka settlement), and the Yaroslavl regional psychiatric clinic “Afonino” — there was no sewage system as such at all. In eight clinics one toilet bowl was available per 50 patients, in the Krasnoyarsk territorial clinic #1 — one toilet bowl per 78 patients. Only in seven clinics the situation in this respect was found to be satisfactory. Partitions in toilets were found only in 21% of the surveyed clinics which places the majority of mental patients in a humiliating position. Diapers were referred to in the majority of clinics as an “extraneous luxury.” Due to the overcrowding and lack of furniture, patients do not have enough furniture in which to keep their personal belongings. The indifference of the state towards people with psychiatric disorders is clearly manifested in the amount of funding allocated for patients’ board. 19% of the surveyed clinics receive less than 20 rubles per patient per day which prevents them from providing their patients with a varied and balanced diet and forces relatives to supply additional food to the patients. Patients of some clinics are condemned to go hungry given that only 10 rubles are allocated per day to each patient. The Prokhladnensk district psychiatric clinic of Kabardino-Balkaria and the Kostroma regional psychiatric clinic have less than 10 rubles per day per patient to spend. The situation in other institutions is somewhat better but food almost everywhere is monotonous and unpalatable. In the context of under funding, the well-being of each psychiatric institution largely depends on the abilities and pro-activity of the hospital administration. People play a decisive role — chiefly head physicians, but also personnel from the regional and municipal authorities and all psychiatric care officials. The average Russian psychiatrist earns 2.6 times less than a construction worker. Practically all physicians and personnel are forced to work overtime caring for 50-60 patients which significantly reduces the quality of psychiatric care and the extent to which patients’ rights are observed. Otherwise the average salary of psychiatric care employees would be below the average cost of living. In 14% of the surveyed clinics, less than half of psychiatrist positions are filled which makes it impossible to provide the necessary level of qualified psychiatric care. In 16% of the institutions, there is a serious shortage of medical nurses (less than 50% of the required staffing level). Only 24% of medical nurse positions are filled in the Oryol psychiatric clinic. Low wages and difficult working conditions make it impossible for psychiatric clinics to employ lawyers, qualified social workers, and psychologists whose professional skills are in high demand among mental health patients. Ignoring legal requirements, the Russian Government has for over 10 years avoided adopting legislation to provide for mandatory health and life insurance of psychiatric care workers. Thus, the 2003 monitoring has demonstrated a gross non-compliance of the State at all levels with its obligations under Russian law. The “Program of immediate measures on the development of psychiatric care for 1995—1997,” meticulously developed by the RF Health Care Ministry and adopted by the Russian Federal Government has received only 0.2% of the promised funds which demonstrates the real level of priority of psychiatric care for the State. There was no programme in 1998-2002, subsequent to this failure. The new programme intended to be implemented in 2003—2008, focuses on an inventory of the existing psychiatric institutions — which had already been implemented in 1989. It is a known fact that such easy targets are set deliberately to ensure that the responsible party will be able to report on the successful completion of the project and, which is even worse, to extend the lifespan of buildings which have exceeded their ‘sell by date.’ There was no protest against the attitude of authorities towards psychiatric care and mental health of citizens. Moreover, the commission which has been working under the RF Ministry of Health Care since 1998 and developing the Russian Federation draft legislation On Amendments and Additions to Federal Law “On Psychiatric Care and Guarantees of the Rights of Citizens in Therapy,” submitted a privately modified text for the review of the RF State Duma in September 2003 which contained an attempt to reduce financial guarantees from the legal to the governmental level. Instead of funding the system of psychiatric care “in amounts sufficient to provide a guaranteed level and high quality of psychiatric care” the draft legislation proposed to limit itself to the “program of state guarantees of provisioning citizens with free health care approved by the RF Government in the established order” (Article 17), which in fact is a relinquishment of guarantees at the time when the survey identified gross and ubiquitous violation of not only the right to decent living conditions and adequate therapy, but also the violation of even the most fundamental rights to safety, voluntarism, and human dignity. A person who has found himself in a psychiatric institution is frequently severed from the external world the connection with which entirely depends on the attending doctor and the head of the department. Patients are forced to live in conditions that debase their human dignity, while specialists and personnel are forced to work in extreme and dangerous conditions receiving miserly remuneration for their labor. The life and health of physicians and personnel are not insured and the patients in fact are deprived of legal protection. Thus the survey confirmed the need to urgently create a Service for the Protection of Rights of Patients of Psychiatric Institutions which could efficiently and flexibly respond to at least the most serious violations. Today many hospitals even censor complaints, which is a direct violation of the law. The Ministry of Finance does not provide funds to support the implementation of Article 38 of Federal Law “On Psychiatric Care and the Rights of Citizens in Therapy” that provides for the establishment of the Service for the Protection of Rights of Patients of Psychiatric Institutions, i.e., the article that serves as the internal guarantee of the implementation of the entire Law. Overall, having adopted a democratic law the state does not provide the conditions that would enable the observation of the declared rights. As a result, the free medical, including psychiatric, care guaranteed by the state has become a nonsense because in reality the state passes the cost that it guarantees to cover to citizens and even patients themselves who frequently have to pay for their medical bills from their own pocket. At the same time physicians and personnel of the clinics also find themselves in a situation when their responsibility for the safety and therapy of the patients and observation and protection of their rights is not supported by state guarantees, when the doctors have to spend most of their time looking for funding to maintain their institutions in a normal condition instead of doing what they should really do — taking care of their patients. |
Íàøà êíîïêà  |
|