In June, 1999, Dr. Anastas Suli, chief psychiatrist at Tirana University Hospital, sent out a plea to colleagues and health workers around the world for assistance in improving the system of mental health services in Albania. Despite his and other physicians' commitment to better care, quality education, and ethical practice, people with mental disabilities in Albania live in extremely poor conditions, with minimal treatment and without hope for the future.
We at UC Berkeley responded directly to Dr. Suli, saying that we felt that a human rights analysis might be effective in raising awareness and encouraging the Albanian government to channel resources into this marginalized segment of Albanian society. Dr. Suli commissioned us to examine the mental health system in Albania and submit our recommendations to him in a report.
For the most part, health-policy makers direct resources at infectious disease control while ignoring the far-reaching effects of severe mental disability. What has been missing in the discourse on reforming mental health services is a recognition that the human rights of some of the most vulnerable of the world community are violated daily. The profound degradation and assaults on human dignity suffered by those with mental disabilities are a disgrace to the human rights regime.
Here is what we found: Despite an alleged commitment to human rights and the ratification of major human rights instruments, the Republic of Albania does not take seriously its commitments to the rights of people with mental disabilities. Albanians have little awareness of human rights principles and their own domestic laws protecting the mentally disabled. Under Article 41 of the Mental Health Law of Albania, "persons with mental disorders who have committed a penal act and are condemned by the Court to suffer the punishment in psychiatric institutions, benefit from medical care according to the dispositions of this law." The Prison Hospital in Tirana illustrates some of the more egregious human rights violations against the mentally disabled. Although Albanian law stipulates one year of treatment to be followed by a re-evaluation, the average length of stay is five years.
The general conditions in this psychiatric unit are appalling. This is not a treatment facility; it is a unit within the prison where those prisoners with mental illness are warehoused. Patients live five to a room and spend most of their days in their cells. There is one bathroom for twenty-five people and showers are available twice a week. Family contact is rare. The rules of the hospital are the same as those of the prison. As with other prisoners, individuals with mental disability are not allowed any music or reading material other than religious tracts. The administration of the health facility is under the Director of Prisons-not the Ministry of Health. Appropriate treatment is thus not a high priority. Health providers are doing their best under circumstances that violate all ethical principles. Our observations suggest that the law is not being observed.
While we cannot compare the conditions in Albania's prisons with those in other countries, we can say that there is a marked discrepancy between the laws pertaining to the treatment of those suffering from mental disability and the conditions under which they actually live. Further, although we focus on the prison conditions in this article, a similarly poor physical environment and lack of treatment options are present as well in all the psychiatric institutions that we visited.
Resistance to change in the country stems from many sources, including a lack of political will and financial resources. Furthermore, policy-makers do not give mental health a high priority in resource allocation. We met with the Ministry of Health and the Parliamentary Committee on Health to encourage them to overcome the effects of stigma, bureaucracy and narrow vision by giving more attention to the abuses of human rights suffered by those incarcerated in substandard facilities. We met Ministry representatives who expressed mild interest, but were much more concerned about prevention and treatment of infectious disease. The parliamentary committee was not surprised by our findings and acknowledged the gap between the laws and reality. However, they described significant barriers to change such as years of social unrest, the Kosovo crisis, a lack of political will, and a lack of public awareness.
In addition to evaluating treatment facilities and talking with government representatives, we talked with human rights groups in an effort to enlist them in examining the state's non-compliance with international human rights obligations to the mentally disabled. The Institute for Policy and Legal Studies, the NGO most involved with drafting legislation and affecting public policy, expressed great interest in working with mental health professionals to effect change. However, the Project to Implement Mental Health Law, the NGO working towards implementation of legislation, appeared to be only beginning to develop an advocacy function. Other NGOs also appeared to be somewhat tentative about directly confronting human rights violations.
Two barriers to a human rights approach exist in Albania. First, Albanian human rights organizations are inexperienced in using the legal system to effect change. Capacity-building and organizational development are critical to their future success. Advocacy is approached with reticence, although there has been adjudication of property rights violations. Advocating for the rights of the mentally disabled is less prevalent and may reflect a combination of inexperience, the legacy of passivity that colors societies emerging from totalitarian repression, and perhaps fear of the violence that remains an undercurrent of Albanian society. Further, it appears that these groups have taken a cautionary stance and have avoided an adversarial relationship with the government. Second, the Albanian judicial system does not appear well-equipped to deal with human rights cases. The courts are fairly independent but not highly professional, although they will follow the legal code if it is clear. While many new and reasonable laws have been drafted in Albania such as the comprehensive Mental Health Law, they are rarely implemented.
Holding the government accountable to international human rights principles is a new concept in Albania. Human rights themselves are a new idea in a country emerging from 50 years of repression, anarchy, blood feuds, and overall chaos. Albanians are aware of the international conventions and other documents and seem committed to using them; yet people told us several times that they are hesitant to adopt the human rights approach because they do not want to challenge authority yet. It is one step to recognize the international human rights regime, and quite another to apply it in a country where there has been so much effort to suppress dissent and confrontation of authority. Some people feel that former Communists involved in human rights work may be "in bed" with the government and will only skirt the edges-not challenge human rights abuse directly. When we brought our concerns about the Prison Hospital in Tirana situation to the attention of one of the human rights organizations, its executive director called the prison director to ask about these issues. The prison director denied there were problems and the NGO director accepted his denial, despite our eyewitness reports. The NGO director did not respond further to our inquiries.
Our report argues that a human rights analysis utilizing the international standards and treaty obligations of a country may be a powerful framework for health reform, particularly in the area of mental disability. We hope it will offer a new perspective on how to secure attention for those with mental disability in Albania and other countries, and at the same time confer legitimacy on the human rights approach and support the work of local organizations. The report was translated into Albanian and has been circulated widely across the country to members of Parliament, relevant ministries, mental health, medical and social service professionals. Dr. Suli continues to use the report to try to influence his colleagues, the Albanian government, and the World Health Organization. Yet, despite his enthusiasm, Dr. Suli remains pessimistic that change is possible.
We do not think the problem is one of local legitimacy for human rights, but one of timing and transition. Albania is emerging from a period of repression and anarchy. Restoration of the rule of law and democratic principles is in its infancy. All of this is new. Few know about human rights and few have tried to use human rights law or international instruments to hold government accountable and to effect change.
The positive aspect is that there is an emerging civil society that is working to apply international human rights law. These organizations are only beginning to learn how to flex their muscle. Despite the truly horrific conditions that exist for many people with mental disabilities, there are mental health, human rights, and legal professionals who are committed to change. The international human rights community can support their efforts by advocating worldwide for the rights of those with mental disability and particularly, in Albania, by supporting the findings of our report. We must also engage multilateral funders such as the World Health Organization to attend to these concerns and hold government decision-makers accountable by continuing to expose shameful conditions. Finally, international human rights organizations can do much to support human rights and mental health professionals through visits, reports, and capacity-building mechanisms.