Sana’a, Yemen, March 2015 –
Jamila, 40, leans against the wall at Al-Amal Hospital for Psychiatric and Mental Illnesses in Sana’a.She is physically disabled and can hardly move her lower limbs. She had been abused by her husband who kept her in isolation for half her life. Her eyes show deep suffering.
Dr. Mohammad Al-Ashwal, a psychiatrist, says Jamila had been chained and locked up in an animal shed because her husband thought she went mad and could not be cured.
She never got to see a medical doctor until her son became of age and brought her to this hospital. “She was in a devastating state when she arrived”, recalls Dr. Ashwal. She had to undergo intense physiotherapy sessions to relieve her from living for years in chains. Days later, Jamila’s son gave up on her and left.
She is among 20 women at who rely on charity for treatment after being forsaken by their families in a male-dominated society which coins psychological illness with madness. Suffering from psychiatric disorder for two decades, Salwa, 35, was kept inside a dark room in her home in Irtel village, a suburb of Sana’a. Her family wanted to avoid the social stigma associated with mental illness.
Five years ago, Salwa received treatment for six months at al-Amal Hospital, thanks to a generous fund from an anonymous donor.
Her younger sister, Yasmine, recalls that Salwa suffered a serious relapse when she was forced to leave hospital before completing her treatment as the donation ran out. Hanan, 20, was forced to drop out of university to stay at home. She was treated by a “popular” healer who had been helping her sister, Sumaya, for 30 years. Jamila, Salwa and Hanan have all experienced biased treatment by their families in a conservative society.
The national medical insurance system is further complicating the situation of Yemeni men and women who suffer from mental illness. Around six million of Yemen’s 24 million population do not enjoy free national health insurance. And the Ministry of Health is not following up on a 2008 draft law that defines treatment and protection for Yemen’s mental patients. The draft law has not been referred to parliament.
Leading officials have not seen the draft law Dr. Mohammad Al-Khalidi, Director of the Psychiatric Health Department at the Ministry of Health insists the miniser sent that bill to parliament for discussion and approval back in 2010. Dr. Muteei Jubayr, the official in charge of drafting laws at the Ministry of Legal Affair says the Health Ministry is not following up on the 2008 draft legislation “because it is neither a political nor a popular issue”.
Dr. Samir Reda, Head of Parliament’s Committee on Health and Population, said the assembly has not received the draft law. Dr. Jamed Juneid, Deputy Health Minister offers another justification: It takes a long time for draft laws to go through the legislature. “Unfortunately, psychiatric disorders are not a priority. And relevant health services including therapy sessions and medicines are limited”. Former Health Minister Ahmad Al-Ansi declined to be interviewed by this reporter. His deputy, Dr. Nasir Baoum, who took office in 2013, told the journalist he had not been “informed of the draft bill and hence, he did not study it”.
Dr. Ghazi Ismail, Deputy Minister in charge of medical therapy at the Ministry since 2008, also says never saw the draft bill. He admits to lack of “insufficient action on the part of the Ministry of Health as well as negligence concerning the requirement for treatment of such disorders”.
Impotent draft law This reporter got hold of a copy of the draft law from the Ministry of Legal Affairs. Lawyer Mohammad Massouri, who evaluated it, said he found the draft law full of “pitfalls and contradictions. Any misinterpretation could violate principles of human rights. Article 36 under chapter two says: “Patients have the right to object to being forced to undergo psychiatric/psychological evaluation. They could also exercise this right through an attorney, within two weeks of being placed in a hospital”, he says.
Mr. Massouri argues that “a person who is not mentally fit has no right to assign power of attorney to a lawyer”. Any decision by such a person is legally null and void. The draft bill, he says, is full of errors related to language, legal conditions and technical regulations that the state should enforce”.
He says it needs a complete review. “It neither identifies the rights of patients and their families nor society’s obligation towards them.” Raja’a Musabi, Director of the Arab Association for Human Rights, agrees.
“The bill does not protect women’s rights.” Furthermore, she does not see the need for such a draft law if the national strategy for mental health care was properly applied.. However, Dr. Mohammad Al-Khalidi, Director of the Psychiatric Health Department at the Ministry of Health, disagrees with Musabi’s position.
The “national strategy is independent from the law and is restricted to a 2011-2015 timeline”. Lack of state funds for mental health To date, the government has failed to adopt this strategy in a country where 2.8% of the $753 million allocated by the 2014 state budget to the Ministry of Health is spent on psychiatric disorder.
Only $11,059,810 in the ministry’s budget for that year was allocated for purchase of life-threatening medications. Of that, only $308,000 is earmarked for medicine needed to treat mental and psychological illnesses as well as epilepsy.
Only three types of medicines used for treatment of chronic mental disorders are sent to local health clinics, hospitals and jails with psychiatric wards. Of 164 state and private hospitals, only 11 have wards treating mental and psychological illnesses, according to a study published by the Social Development Fund in 2008. Conflicting figures on the mentally ill.
In Yemen, 630,000 males and females are reported to be suffering from psychological illnesses and are frequenting private and public psychiatric disorder clinics, according to a July 2008 study published by professors of psychiatry – Dr. Mohammad al-Tashi, Dr. Ali Tareq, and Dr. Balqeis Jbari.
The study was based on government statistics gathered and compiled in 2006. The doctors point to the fact that the current available treatment is “not sufficient”; it only covers the basic treatment of “mental illnesses”.
According to the study, 32.60% of the total number of patients are females suffering from schizophrenia compared to 37.71% males. However, thousands of patients are not receiving treatment. Instead, they have been cut off from society and are confined to their homes.
There are no accurate statistics on the number of patients suffering from mental disorders among Yemen’s population of 24 million. According to government figures, the number of psychiatric patients is estimated at 7%. Around 1% of these are reported to be suffering from schizophrenia; a severe imbalance that affects rational thinking, behavior and emotional expression.
Shortages in medical staff There are 44 psychiatrists in Yemen out of 8,534 registered medical doctors. This means that each psychiatrist care for almost half a million cases compared to international standards of two doctors per every 10,000 patients as set by the World Bank. Frame/Box 1: The treatment of mental disorders in Yemen is complicated by lack of interest in this field. Dr. Abdallah Shweiyl says. “Psychiatry as a specialization is the last resort for any post-graduate medical student”.
In interviews with 20 medical students conducted by the reporter at Sana’a University’s Faculty of Medicine, all excluded this specialization on ground they were not interested in specializing in a field in a society which regards mental illness patients as “mad”. The few who are interested in this field are driven by personal reasons or a deep desire in helping patients suffering from psychiatric disorder.
Dr. Ali al-Miri, deputy dean of the Health Sciences at Sana’a University says that, “students are interested in specializations that are more appealing and financially rewarding”.
Trading accusations Dr. Mohammad Al-Khalidi, Director of the Psychiatric Health Department at the Ministry of Health says that “the government is responsible” for the plight of Yemen’s mentally ill. He says the ministry has a supervisory role. But neither the government nor the Ministry are doing enough to help Yemen’s mentally ill. “There is no one responsible for this sector of patients”.
Dr. Ghazi Ismail, Deputy Minister in charge of medical therapy at the Ministry since 2008 blames the ministry for “not doing enough to provide sufficient drugs needed for treating patients who are forced to pay for those drugs out of their own pockets.” During this investigation the reporter found that Sana’a only had one clinic for treatment of the mentally ill: at the capital’s main jail.
Dr. Ahmad No’man, previously the managing director of health services at the central prison, says: “The biggest issue facing the psychiatric unit is lack of specialized staff to treat men and women (patients).
” Psychiatric disorder wards at jails Colonel Mohammad Al-Idrissi, deputy director at the Central Prison, says despite agreement between the Ministries of Health and Interior: “We are paying the price due to lack of sufficient medicine, specialized doctors and hygiene materials”.
Lieutenant Abdel Salam Ali Saleh for the Central Prison disagreed. He says that the agreement was only a verbal one whereby the Ministry of Health “would provide the medical staff and medicines, while the Interior Ministry is to assume a supervisory role as well as provide hygiene material.
” Article number 25 in chapter 5 regarding prison regulations pertaining to prisoners’ care, both Ministries “are to agree on a detailed program; regulating both medical and health issues in prisons, whereby the role of assistant medical staff is identified, procedure of transferring prisoner patients to public hospitals in addition to specifying schedules for assigning food, clothes, bedding, as well as furniture needed for prisoners:. Lt. Saleh blames the deteriorating situation at the prison due to the lack support in implementing the law which clearly identifies the responsibilities of each player.
One hundred and twenty mentally ill males are at the Central Prison’s psychiatric ward, 25% above capacity. Another 80 prisoners are treated at the general medical ward despite the lack of medicine and doctors. There are no figures for female inmates with psychiatric disorders.
Only three psychiatrists and one specialist are available for their treatment, says Al-Idrissi. “The prison is over-crowded. The actual capacity is 1,100 prisoners, meanwhile it houses 2,500”. Only four female patients have been treated at this prison – three of whom are suffering from schizophrenia.
They were treated at the female section of the jail as there is no there is no allocated space for their treatment at the dedicated clinic. Psychiatric jails wards cannot replace hospitals Mrs. Raja’a Musabi, a human rights expert, criticizes the presence of psychiatric wards at disciplinary institution.
“It is difficult to treat psychiatric patients at a prison, which is considered to be a social taboo, not to mention that women are looked upon as second degree citizens”. Ministries of Health and Interior under fire. Families of patients also complain that the Ministry of Health lacks a supervisory role. Around 27% of 167 medical institutions do not even have a file documenting the conditions of mentally ill patients.
This, they say, proves the state of negligence of both the Ministry and the government regarding services and rights for the mentally ill patient, especially women. Psychiatrists’ findings Mr. Al-Juneid justifies the lack of files for schizophrenic patients: “The Psychiatric Health Unit at the Ministry of Health should not be documenting these cases. These should be complied within the information on the general health of patients.” Both Dr. Mohammad Al-Tashi, professor of Medicine and Dr. Abdallah Shweil, professor of Psychiatry at Sana’a University, confirm that female psychiatric patients suffer more than their male counterparts.
Doctors confirm that schizophrenics could be cured if there’s family support. In fact 10% of patients could recover fully, according to local doctors, unless the cause is hereditary. Early treatment as well as family care/support could help enhance the patient’s full recovery. There is a 50% to 60% chance of improvement in the condition of the patient, if the treatment procedures were followed regularly. However, 20% of patients receive no treatment for lack of facilities.
Salwa’s plight Dr. Al-Tashi, who is supervising the treatment of Salwa says the latter is suffering from withdrawal symptoms due to chronic schizophrenia and depression, a consequence of multi-social factors. His patient is showing no signs of communicative skills, cannot relate to her surroundings and shows despair. In order to recover, she needs a lengthy sustained medical supervision that cares for her basic needs as well as cognitive therapy and rehabilitation.
Hanan’s story Dr. Jamila Issa, psychiatrist at al-Thawra Hospital confirms that the lack of personal security in a broken family forced Hanan, 20, to leave school. Her condition worsened when she had to accompany her elder sister to visit a “popular” healer who used to beat her up to rid her of ‘evil spirits” he claimed had haunted her.
One day Hanan was slapped on the face by her father while praying for the recovery of her sister who going through severe reaction to a medication prescribed by the local healer.
This slap led to her becoming mentally ill and confined to living in her own private world. Even if funds were available and social stigma against mentally ill females would change, there will still be a problem with the quality of psychiatric care/support in Yemen. Laws violated Dr. Adel Huweidi, a psychiatrist at the Central Prison clinic, says that mentally ill females are examined and treated “inside the women’s prison” in a clear contradiction with the law on the rights and care for prisoners.
Article #26 of that law states: “If a prisoner suffers from mental or psychiatric illness, they should be transferred to the psychiatric hospital, as per the regulations,” says Lt. Abdel Salam Ali Saleh, deputy director at the Central Prison.
He believes that “a prison is not the place for treating psychiatric patients. Moreover, there are no human rights organizations that would support treating patients at a prison, especially after his facility received support from the Geneva-based International Committee of the Red Cross (ICRC) in 2005, he claims.
Dr. Abdel Aziz al-Mikhlafi, deputy general director of Rehabilitation and Correction at the Central Prison says that the ICRC, which operates at an international level, provided the Central Prison between 1995-2005 with medical aid, medicines, and support services to all inmates. “This was the golden era for these inmates But a year after the state took over, business went back to usual: insufficient treatment, lack of bedding as well as insufficient cleaning tools and personal hygiene material. State of medical care According to Dr. Howeidi, a psychiatric, jails lack medical supplies.
“Sometimes, we rely on the families of patients to provide medicines needed to avoid having to suddenly stop the medication. However, some patients do not have anyone who could provide the drugs they need. Furthermore, the patient remains at the prison clinic for no longer than one month. Then he has to go back to his cell to complete the sentence while taking the needed medications.
“But soon after, they do not fully recover and have to return to the clinic for a second time”. Treatment options Three state-run hospitals in Sana’a have wards for the mentally ill, but the treatment is not for free.
In the case of independent hospitals, such as Al-Thawra, the psychiatric ward can neither accommodate chronic nor advanced cases. The maximum period of stay is one month at a cost of $84. The medicines required are not available, says Dr. Abdallah al-Sharaabi , head of the psychiatric ward at Al-Thawra Hospital.
Al-Amal is a private psychiatric hospital run by a charity organization, the only one that can care for schizophrenic patients. Treatment, however, if not free. The hospital gets $126.000 a year in state subsidies. It has 200 beds, 50 of which are allocated to female patients.
There are no females on their waiting list since this is considered social taboo. Al-Rashad hospital has 30 beds reserved for advanced mentally ill patients. There are no beds for female patients, according to the director of the hospital, Dr. Abdallah Shweil. Treating schizophrenic patients costs $640 a month in a single room and $210 in a shared accommodation.
A deposit of $327 is paid in advance in a country where 18% of the population live below the poverty line; each earning $1.25 a day. The figure does not include medicine or tests. Frame/Box 2 According to UN statistics of December 2013, a third of the population in Yemen, live at the poverty line.
In 2011, 54% were living at the poverty line. In 2013, a UN report stated that poverty in Yemen is a humanitarian reality that needs to be looked at by the international community. There are six millionYemenis who cannot receive free health care. Dr. al-Teshi confirms that most mentally ill Yemenis are treated at private clinics, rarely at hospitals. “There is not enough care given to psychiatric health in Yemen”.
He recommends having “specialized units at state-run hospitals for psychiatric patients.” Dr. Abdallah Shweil, director of al-Rashad Hospital, supports this idea. “Internationally, independent clinics are not encouraged. Patients with psychiatric disorders should get treatment at general hospitals, apart from patients with chronic schizophrenic who need housing at specialized institutions.” The national strategy put forward by the Social Development Fund and the Ministry of Health and Population, aims at “providing and supporting psychiatric health services, treatment and rehabilitation as well as raising awareness of Yemenis to this issue”.
Dr. Al-Khalidi says the national strategy for psychiatric health supports and strengthens the Psychiatric Program, making it more inclusive. However, the budget for implementing this program is $37,383 and it is being spent elsewhere”. Funding saga Mr. Ali Mohammad Jhaf, director of Family Health, who is supervising the Psychiatric Health Program at the Ministry of Health, says that the program was approved by the cabinet in 2004. However, the funding needed for implementing the program, was not provided and the Ministry did not take the needed steps to support the strategy. “It seems that government’s priority to care for mentally ill patients is far away”.
He adds that the national strategy achieved nothing in reality and did not ease the suffering of female patients, especially those suffering from schizophrenia. “We are still waiting for laws that protect and serve psychiatric patients”. Suffering continues Salwa, the patient who has been kept in a dark room and Jamila who spent half her life chained and confined to the boundaries of an animal shed are still suffering from their mental illness.
The physical abuse that Hanan has experienced, continues, and so does the pain of so many mentally ill women whose stories have not been told in a society that considers discussing rights of women as a “taboo”, the government lacks funds and the Health Ministry remains negligent .
This investigation was completed with support from Arab Reporters for Investigative Journalism (ARIJ) www.arij.net.
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