Saturday, January 15, 2011

Russia: An Overview of Modern Mental Health Challenges

Russia is a country of unimaginable distance, stretching 11 time zones from Europe to the Pacific Ocean, with a population of only 140 million. According to World Bank criteria, Russia is a lower middle income country with almost 100% literacy rates, yet the average life expectancy at birth is 65.94 years. Much of Russia’s population lives in poverty, victims of a huge disparity between rich and poor. The elderly, disabled, children, and people living with HIV bear much of the poverty burden with poor access to services and discrimination.

The proportion of health budget to GDP is 5.4%, but there are no budget allocations for mental health and there is no information on expenditures on mental health care. The Ministry of Health has a mental health policy, which was developed in 1992, focusing on promotion, prevention, treatment and rehabilitation. A national mental health program was developed in 1995 and a specific program came up with recommendations on structural reorganization of psychiatric care in 1997, but there were limited funds to implement the recommendations. There has been a reform process across the country, focusing on lowering the number of beds in psychiatric institutions and creating outpatient clinics. Funding is the biggest barrier to reform.

According to the WHO Mental Health Atlas, mental health is part of the Russian primary health care system and some primary care providers do receive mental health training. A social rehabilitation system exists and there are community care facilities in place, including rehabilitation units in industrial firms and residential homes for around 125,000. Day care facilities are available for 15,000 people and home care is provided in some cases. There are 11.5 total psychiatric beds per 10,000 populations, with 10.1 of those in psychiatric hospitals.

Although the economic situation has improved in the past, this has not reached the most vulnerable, those who do not have access to suitable medical care. And despite the Russian government’s increasing cash reserves, little investment in infrastructure (health or otherwise) has been initiated by the country’s leaders. The Russian people face health and mental health care challenges resulting from natural and manmade disasters, drug and alcohol abuse, street children, refugees, and the legacy of political psychiatry.

Natural and Manmade Disasters

Tragedies resulting from manmade and natural disasters produce victims in need of mental health care in every corner of the globe. Plane crashes, floods, forest fires, industrial accidents and acts of terrorism such as the Beslan school incident in 2004 are all examples of such disasters in Russia. The Russian Ministry of Emergency Situations (EMERCOM) oversees response to such disasters, but lacks a comprehensive strategy for carrying out mental health care in crisis situations. The International Federation of the Red Cross is working with the Russian Red Cross disaster management division to increase its capacity as related to integrating psychosocial support as a standard deployable component of disaster response. This program will be based on the experience gained in this field in the aftermath of the Beslan tragedy.

Drug and Alcohol Abuse
Russia also faces a serious illegal drug problem where several million people are believed to be drug users. HIV has spread rapidly among injection drug users in Russia since the early 1990s and more than 10 percent of injection drug users are believed to be living with HIV. A 2007 Human Rights Watch Reports characterized treatment offered at state drug treatment clinics as very poor, concluding that drug addicts are left virtually to their own devices in their battle with this serious disease. The growth of HIV and Tuberculosis is epidemic and Russia occupies the second place in Europe with regard to rising rates of HIV infection, much of which can be contributed to illegal drug use.

It could be argued that alcoholism has always been Russia’s biggest health problem and some studies indicate that 30% of its men and 15% of women are addicted to alcohol.In 2007 it was estimated that 40,000 die annually from alcoholism and that every fifth crime in the country is committed under the influence of alcohol. Soviet leaders recognized this, but efforts at prohibition failed. Addiction was viewed as a crime under Soviet rule and people could lose their jobs or apartments or be locked up in a psychiatric hospital if they sought treatment. Though there are programs to treat alcoholism, there is not really a prevalent “society of recovery” in Russia, although Alcoholics Anonymous is active in the country. AA first came to Russia in 1986 and has spread throughout the country with over 300 groups in 100 cities and towns at last count. Drug and alcohol abuse is a critical and pressing mental health disaster that needs more attention from the Russian government.

Street Children
Street children refers to children under age 18 for whom ‘the street’ (abandoned buildings, industrial wastelands) has become home and source of livelihood, and who are inadequately protected or supervised. Official statistics state that the number of homeless children is 700,000, but experts estimate the population of street children much higher in the realm of 1 to 3 million. A 2007 study found that 37% of street youth in Russia were infected with HIV.

This epidemic of homeless and diseased children is a crisis in Russia and outreach, prevention, access to care, and crisis intervention services need to be expanded to impact this tragedy. The non-profit organization, Doctors of the World, spearheads an effort to bring attention to the social, behavioral and medical factors contributing to this epidemic and are partnering with private foundations (Ford Foundation, MAC AIDS Fund), corporations (Johnson and Johnson), USAID, and local government and non-profit organizations to provide vital services to this population. More collaborative effort, capacity building, and funding are needed to truly make a difference in the lives of the majority of Russia’s street children.

There is also a crisis situation resulting from the war between Georgia and Russia in August 2008. Although most of the original 30,000 refugees have returned to South Ossetia in Georgia, many remain living with relatives and in hospitals in the Vladikavkaz area in Russia. Russia has specific mental health programs for refugees and disaster victims. These programs, like the one assisting refugees in need of treatment to minimize the psychological effects of the war, are carried put by EMERCOM. The Russian Red Cross and the International Federation have both contributed financially to this program focused mainly on psychosocial support and the International Committee of the Red Cross is coordinating the operation. However the operation is scheduled to end on February 28th, 2009 so the need may go unmet in the future.

Political Psychiatry – Past or Present?
During Soviet rule, psychiatry was used to treat and imprison healthy, sane people who spoke out against the government. Authorities used psychiatric hospitals as prisons and subjected patients to electric shock, electromagnetic torture, radiation torture, forced drugging that caused long lasting side effects. Such methods were employed to isolate political prisoners from the rest of society, discredit their ideas, and break them physically and mentally.
This practice supposedly ended with the dissolution of the Soviet Union, but there have been reports in this decade about alleged imprisonment of people "inconvenient" for Russian authorities in psychiatric institutions. Larisa Arap, a Russian writer who spoke out against mistreatment of children in psychiatric clinics, was forcibly confined at a psychiatric clinic in 2007. There have been many reported cases of political psychology and the International Helsinki Federation for Human Rights said in 2004 that people are being institutionalized in psychiatric hospitals unlawfully. “Not only did punitive psychiatry exist during the Soviet period, and not only does it exist today, but unfortunately there are no grounds to hope that it will disappear in the foreseeable future.”

There are approximately ten NGOs focusing on mental health advocacy, promotion, prevention and rehabilitation in Russia and religious organizations also provide social support. The Russian Orthodox Church is especially active in the drug abuse field and has several psychiatric hospitals in St. Petersburg. The Russian Red Cross is also very active in the mental health field. Of the six national priorities, two involve psychosocial components. The first goal involves the mitigation of the psychological consequences of disasters. The second goal is to increase the organization’s capacity to provide psychosocial support by expanding this component from disaster response to other areas involving health care and social inclusion.

Within this brief overview, it is easily demonstrated how dire the situation in Russia is with regards to mental health care. Mental health is intertwined with all aspects of physical health, as well as social and behavioral issues. Many sectors of vulnerable populations with urgent needs overlap one another. For example, there are street children abusing drugs and alcohol infected with HIV and/or Tuberculosis. By addressing mental health issues along with one of the critical health issues, it is possible that the other issues could be resolved with minimal effort.

Looking at mental health challenges in Russia like natural and man-made disasters, drug and alcohol abuse, street children, refugees and the legacy of political psychiatry, it is apparent that Russia, like most other countries, is suffering from the absence of a strategic and effective national mental health plan. Although some steps have been taken to reform the psychiatric system, funding and capacity have not been provided to do so. Many local and international NGOs are active in the Russian mental health community, but it will really take a concerted effort by the Russian government to make a meaningful and significant positive impact on the mental health of its citizens. It is time for the Russian government to invest not only in natural resources like oil and gas, but in their most precious resource – the Russian people.