‘The first human rights legal resolutions did not address rights of mental health consumers’

A paradigm shift is perceived as having occurred in mental health in the latter half of the 20th century. It is attributed to three factors: the strides made in psychopharmacology, with the discovery of new classes of drugs; the human rights movement, which became an international phenomenon under the sponsorship of the United Nations; and efforts to incorporate the mental component into the concept of health, spearheaded by the World Health Organisation.

Health & Human Rights Adv Kamayani Bali Mahabal

The first human rights legal resolutions, such as the 1948 Universal Declaration of Human Rights, did not specifically address the rights of mental health consumers.

They codified more general, but still relevant, rights like the right to life and liberty and the right to be free from inhuman, degrading treatment.

Later resolutions, such as the Declaration on the Rights of Mentally Retarded Persons (1971) and the Declaration on the Rights of Disabled Persons (1975), began the process of establishing international minimum standards for the treatment of persons with mental disabilities.

In the last decade, the field of human rights took a big step forward with the adoption of several new human rights resolutions specifically addressing mental disabilities. In 1990, the Pan American Health Organisation adopted the Declaration of Caracas, which called upon nations to take specific actions to protect the rights of people with mental disabilities.

The Declaration of Caracas stated that mental health systems relying exclusively on psychiatric hospitals “isolate patients from their natural environment generating greater social disability” and called on states to “promote alternative service models that are community-based and integrated into social and health care networks.”

The World Health Report (2001) advocates, for instance, a recognition of the interconnectedness between physical and mental health, and seeks spaces in policy, law and resource commitments, which have been the near-exclusive preserve of physical health so far. It calls for an integration of mental health care into the primary health care system and makes a pitch for a public health approach.

Emphasising the burden of mental and behavioural disorders, it advocates an altered paradigm of care. The principles of care pertain to diagnosis and intervention, continuity of care, provision of a wide range of services, partnerships with patients and families, the involvement of the local community and integration into primary health care. Pharmacotherapy, psychotherapy, psychosocial rehabilitation, vocational rehabilitation and employment, and housing have been identified as the ingredients of care relevant to those experiencing an absence of mental health.

The Indian experience with institutionalisation has not been edifying. A report prepared for the National Human Rights Commission (NHRC) in 1999 after an empirical study of mental hospitals in the country made a damning indictment of the state of mental health institutions. “The findings reveal that there are predominantly two types of hospitals,” the report said.

“The first type do not deserve to be called ‘hospitals’ or mental health centres. They are ’dumping grounds’ for families to abandon their mentally ill member, for either economic reasons or a lack of understanding and awareness of mental illness.The living conditions in many of these settings are deplorable and violate an individual’s right to be treated humanely and live a life of dignity. Despite all advances in treatment, the mentally ill in these hospitals are forced to live a life of incarceration.”

“The second type of ‘hospitals’,” the NHRC report continues, “are those that provide basic living amenities. Their role is predominantly custodial and they provide adequate food and shelter. Medical treatment is used to keep patients manageable and very little effort is made to preserve or enhance their daily living skills. These hospitals are violating the rights of the mentally ill persons to appropriate treatment and rehabilitation and a right to community and family life.”

Although the exact number of disabled people in India is still not known, the 2001 census findings will provide the first accurate figure, it is estimated at five per cent of the population, as is the case worldwide. This makes for a whopping 50 million.

The conditions of persons with mental illness in institutions have been cause for human rights concern. In Gwalior Mental hospital, for instance, it was found that persons with mental illness were left in nakedness; the explanation was that they tore their clothes if they were given them. The press raised the issue. Chaining of mentally ill patients was also a practice, and this was outlawed by an order of the court. There is accumulating evidence of the high levels of disability that is imposed by mental illness.

Forty-three per cent of the disability in developed countries is, for instance, due to mental illness. If it is lower in other parts of the world, that is because of the heavy burden that other illnesses, such as Aids (in Africa) impose. Disability Adjusted Life Years (DALY) is an evolving index that helps to quantify the burden of disease. Of the 20 conditions identified as leading causes of disability adjusted life years, three are related to mental illness, according to WHR 2001.

One of the most recent international developments regarding disability rights is the formation of an Ad Hoc Working Committee on the proposed United Nations Convention on the Rights of People With Disabilities. This proposed Convention was the context for the examination of disability at the seventh annual meeting of the Asia Pacific Forum of National Human Rights Institutions (APF).

For the meeting, the New Zealand Human Rights Commission requested that the subject be included on the current agenda so that the APF may contribute to the possible formation of this new international human rights treaty.

In contrast, India’s Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, suffers acutely from vague terminology and the absence of a supporting framework. The Act includes provisions for access to education, government employment, and state-funded public infrastructure such as transportation and hospital facilities.

However, it does not contain adequate provisions for an effective monitoring system and undermines state directives with the qualification that they shall be undertaken “within the limits of [the state’s] economic capacity.”

Each State should have a Mental Health Authority but most do have it. For the mentally ill, absolute human rights can only be guaranteed within an ideal political and social order.

The consequences of change in this environment have to be understood from a health perspective and the availability of effective mental health-care needs to be assured.

It could be argued that when one is dealing with health-care there is no ground for debates surrounding justice and what is a right.

Rather, one is dealing with someone’s health and care of the individual and how best to do this. The position held is that the rights of the mentally ill can only be attained or understood if it is acknowledged that the context within which one lives is crucial to the distribution, enforcement and understanding of these rights.

The translation of rights for the mentally ill ultimately entails the provision of human and material resources that require enormous financial expenditure. This corresponds with a view that considers the fact that rights have a social or economic value, and that social constructs used to administer these rights are limited in supply.

From a humanitarian perspective the right to mental health-care should not be limited. However, reality dictates that such care is compromised. In India there exist many areas, such as health and education, which have been grossly neglected and require urgent attention.

(The writer is with Centre for Enquiry into Health and Allied Themes (Cehat). email: kamayani@cehat.org)