Acti­vi­ty report SAMENTACOM 2019–2020

The cur­rent annu­al acti­vi­ty report of the SAMENTACOM project.

The MCF com­mit­ment in Pié­la / Bur­ki­na Faso

Case reports from the work of Yenfaabima.

Annu­al Report 2019–2020

Here you can find the annu­al report 2019–2020 of our foundation.

Report on our trip to Côte d’I­voi­re in April 2019 and the sta­tus of the SAMENTACOM project

Gesi­ne Heet­der­ks and Micha­el Hup­pertz 
Mind­ful Chan­ge Foundation


From April 1 to 11, 2019, we tra­vel­led to Côte d’I­voi­re to gain an insight into how the SAMENTACOM pro­ject, fun­ded by our foun­da­ti­on, has pro­gres­sed and how it can be deve­lo­ped. SAMENTACOM aims to imple­ment a social-psych­iatric-ori­en­ted care for peop­le with men­tal ill­nes­ses and epi­le­psy. The pro­ject was initia­ted during our stay in Côte d’I­voi­re in Janu­a­ry 2018 — trig­ge­red by the dis­tur­bing reports of mental­ly ill peop­le living without medi­cal help under the most degra­ding con­di­ti­ons in the poor coun­tries of Afri­ca and Asia — and has star­ted work sin­ce then.

Our cur­rent visit was care­ful­ly pre­pa­red and orga­ni­zed by the pro­ject lea­der, the Ivo­r­i­an psych­ia­trist Prof. Koua from the Uni­ver­si­ty of Bouaké, and his staff. In addi­ti­on to Prof. Koua, the team in char­ge inclu­des ano­t­her psych­ia­trist, two psych­ia­trists still in trai­ning, a socio­lo­gist, an Agent de San­té (staff mem­ber in one of the health cen­ters), a phar­ma­co­lo­gist, a lawy­er, two geo­graph­ers and an assi­stant. We were invol­ved in the work on all the con­struc­tion sites rele­vant to the pro­ject. We par­ti­ci­pa­ted in several dis­cus­sions with staff, but also with pati­ents and rela­ti­ves, and sug­ges­ti­ons from our side regar­ding the ongo­ing work and fur­ther deve­lo­p­ment of the pro­ject were wel­co­med. Cri­ti­cal ques­ti­ons were also wel­co­me. 

The main topics of our trip were:

1. The deve­lo­p­ment of psych­iatric and neu­ro­lo­gi­cal work in the exis­ting health cen­ters;

2. Fur­ther trai­ning on psy­cho­so­cial aspects of the tre­at­ment and fur­ther deve­lo­p­ment of super­vi­si­on;

3. Coope­ra­ti­on with the Camps de Priè­re –Pray­er camps (CdP);

4. Coope­ra­ti­on with the natio­nal phar­maceu­ti­cal aut­ho­ri­ty to ensu­re the sup­ply of medicine


1. The deve­lo­p­ment of psych­iatric and neu­ro­lo­gi­cal work in exis­ting health centers.

In Côte d’I­voi­re, the­re is nati­on­wi­de care with small, simp­le health cen­ters that are respon­si­ble for all health issu­es, but gene­ral­ly do not tre­at psych­iatric or epi­lep­tic pati­ents. The­re­fo­re, the aim is to enab­le the­se health cen­ters to take care of the­se pati­ents. SAMENTACOM has the­re­fo­re initia­ted a pilot pro­ject in 10 health cen­ters, most­ly in the rural area of Bouaké. So far, it has been inves­ti­ga­ted what psych­iatric help is alrea­dy avail­ab­le the­re, psych­iatric con­sul­ta­ti­on hours have been set up and regu­lar super­vi­si­on by Prof. Koua’s staff in form of joint local tre­at­ments has begun. One of the main pro­blems of the pro­ject was to find the pati­ents in the vil­la­ges and pray­er camps, to make them visi­ble and to enab­le them to recei­ve tre­at­ment. In the future, this must be one of the tasks of the Agents de San­té, who will be trai­ned as part of the project.

The drug tre­at­ment of psy­cho­ses and epi­lep­sies repres­ents an indis­pensable pro­gress. The need for addi­tio­nal psy­cho­so­cial trai­ning for tho­se who work with the mental­ly ill has beco­me clear, not only so that they can bet­ter respond to their men­tal situa­ti­on and social envi­ron­ment, but also so that they them­sel­ves can cope bet­ter with dif­fi­cul­ties in dealing with the mental­ly ill. We were impres­sed by a mee­ting with about 50 Catho­lic sis­ters, some of whom are in char­ge of a health post and some of whom have recei­ved psych­iatric trai­ning from Prof. Koua. They see­med high­ly moti­va­ted, and at the same time they tal­ked about many situa­tions with mental­ly ill peop­le, in which they felt hel­pless and some­ti­mes sca­red. The desi­re for mon­th­ly super­vi­si­on was expres­sed and it beca­me clear that they nee­ded a lot of support.

2. Trai­ning on psy­cho­so­cial aspects of tre­at­ment and fur­ther deve­lo­p­ment of supervision

We expe­ri­en­ced super­vi­si­on in one of the ten health posts of the pro­ject. One of the nur­ses of this post  had taken part in the basic psych­iatric trai­ning with Prof. Koua. The con­sul­ta­ti­on was con­duc­ted by this nur­se tog­e­ther with a psych­ia­trist from the team. This will take place once a mon­th in the future. During the con­sul­ta­ti­on most pati­ents had epi­le­psy, some had rel­ap­ses becau­se they had stop­ped taking their medi­ca­ti­on, and others were trea­ted for the first time. One pati­ent had been chai­ned up three times, trea­ted once with anti­psy­cho­tic medi­ca­ti­on and then taken to a pray­er camp during ano­t­her psy­cho­tic episode.

It was noti­ce­ab­le that the nur­se tur­ned more to the rela­ti­ves with their ques­ti­ons than to the pati­ents them­sel­ves. The tone was short and con­cise, the­re was litt­le reco­gniz­ab­le sym­pa­thy. The­re were fre­quent inter­rup­ti­ons due to mobi­le pho­ne calls. The pati­ents beha­ved rather sub­mis­si­ve­ly. —  Other employees take a lot of time tal­king to pati­ents and their rela­ti­ves, show a lot of pati­ence, but of cour­se it takes less time when you talk to the rela­ti­ves ins­tead of the pati­ents. Our impres­si­on is that decisi­ons are not made or even nego­tia­ted with the patient.

Par­al­lel to the con­sul­ta­ti­on, Prof. Koua, tog­e­ther with an employee, con­duc­ted an initi­al trai­ning cour­se for the Agents de San­té the­re on how to reco­gni­ze and deal with mental­ly and epi­lep­ti­cal­ly ill peop­le. Their task will be to go to the vil­la­ges and encou­ra­ge the sick to come to the cli­nic, talk to the fami­lies and stay in con­ta­ct with the sick during the tre­at­ment. This trai­ning is an important part of our pro­ject. The­re were 8 Agents de San­té pre­sent, inclu­ding a woman. The Agents were very invol­ved, they descri­bed pro­blem cases. The mes­sa­ge from Prof. Koua was very clear: in the future they should also be given the task to report sus­pi­cious cases to their cen­ter, but they do not have to make a dia­gno­sis and of cour­se they should not car­ry out any tre­at­ment. Rather, it is a mat­ter of estab­li­shing con­ta­ct bet­ween the pati­ents and their vil­la­ges and the health cen­ters and accom­pany­ing them. They know all the pati­ents in the vil­la­ges and in the pray­er camps.

With regard to the psy­cho­lo­gi­cal trai­ning and fur­ther edu­ca­ti­on of the SAMENTACOM team in dealing with mental­ly ill peop­le, we have suc­cee­ded in recrui­t­ing a cli­ni­cal psy­cho­lo­gist from Abidjan. The idea is that tog­e­ther with Prof. Koua he will pro­du­ce a brochu­re in which the important ele­ments of the psy­cho­lo­gi­cal tre­at­ment will be exp­lai­ned. The team of Prof. Koua can then take over the trai­ning in the health posts.

3. Coope­ra­ti­on with the Camps de Priè­re (CdP) pray­er camps

The pray­er camps are vil­la­ges with spi­ri­tu­al offe­rings, which usual­ly accept mental­ly and epi­lep­ti­cal­ly ill peop­le against pay­ment, most­ly for long peri­ods of time, even against the will of the peop­le con­cer­ned, at the request of their rela­ti­ves. Men­tal ill­nes­ses and epi­le­psy are reli­gious­ly inter­pre­ted in Afri­ca often as pos­ses­si­on by evil spi­rits, and so the tre­at­ment con­sists of pray­ers and some­ti­mes also tor­tu­re to which the sick are sub­jec­ted in order to dri­ve the evil spi­rits out of them. They are often chai­ned to trees in the open air, some­ti­mes for years, so that they can­not run away and cau­se any dama­ge. The path of the pati­ents usual­ly leads via hea­lers who prac­ti­ce tra­di­tio­nal medi­ci­ne to the pray­er camps, which are most­ly evan­ge­li­cal­ly ori­en­ted, with tra­di­tio­nal reli­gious ele­ments play­ing a more or less important role. In view of the hel­pless­ness of many rela­ti­ves in dealing with men­tal ill­nes­ses, the accom­mo­da­ti­on of the sick in pray­er camps often seems to them to be the only pos­si­ble solu­ti­on. The Camps de Priè­re are the­re­fo­re of cen­tral impor­t­ance, and the deve­lo­p­ment of con­struc­ti­ve coope­ra­ti­on with them, if suc­cess­ful, is an oppor­tu­ni­ty for the deve­lo­p­ment of psych­iatric care in West Africa.

So far, the­re is no over­view of how many Camps de Priè­re the­re are and whe­re they are loca­ted. They are not regis­tered any­whe­re, and anyo­ne can set up such a camp. The aim must the­re­fo­re be a natio­nal sur­vey in this mat­ter. To this end, SAMENTACOM con­duc­ted a pilot sur­vey in the Bouaké area and pre­sen­ted it in a very suc­cess­ful brochu­re. 71 pray­er camps were recor­ded and map­ped, 40 of which were visi­ted. If this is extra­po­la­ted for Côte d’I­voi­re, the­re should be around 2000 pray­er camps in this country.

Accord­ing to the pilot sur­vey, the vast majo­ri­ty of the pray­er camps are wil­ling to coope­ra­te. We have visi­ted several pray­er camps, inclu­ding one we visi­ted last year. Howe­ver, after a very friend­ly recep­ti­on it tur­ned out that the reli­gious lea­ders had deci­ded to pray only with the pati­ents and not to allow any more medi­cal tre­at­ment by the SAMENTACOM team. In a con­ver­sa­ti­on with the vil­la­ge elders, Prof. Koua urged ever­yo­ne to allow the tre­at­ment; other­wi­se they would come into con­flict with the law. We saw three pati­ents chai­ned to the camp — one of whom we had seen chai­ned the­re a year ago — living the­re without psych­iatric help. One can only spe­cu­la­te about the direc­tor’s moti­ves for refu­sing to coope­ra­te. In any case, perhaps a more regu­lar con­ta­ct and regu­lar talks could have pre­ven­ted such a break — also with the clear mes­sa­ge that detai­ning pati­ents and refu­sing to help them at the same time is a vio­la­ti­on of the law and a vio­la­ti­on of human rights that will not be tole­ra­ted. Howe­ver, the legal situa­ti­on and, in par­ti­cu­lar, the human rights dimen­si­on of such action appears to be gene­ral­ly rather unknown. For future con­flicts of this kind with pray­er camps, it is the­re­fo­re important to find out about the legal basis and also to sen­si­ti­ze the rele­vant poli­ce aut­ho­ri­ties to this problem. 

Howe­ver, it has also beco­me clear how important it is to sup­port pati­ents and their rela­ti­ves in lear­ning to arti­cu­la­te and repre­sent their own inte­rests. In a vil­la­ge we show­ed the impres­si­ve film: “La Mala­die du demon” by Judith Kug­ler. A sug­ges­ti­on made by Prof. Koua at this mee­ting with pati­ents and their rela­ti­ves to found a self-help group and to invi­te the local aut­ho­ri­ties and the poli­ce to par­ti­ci­pa­te, met with a broad respon­se. The foun­ding mee­ting was sche­du­led for the end of May. 

4. Coope­ra­ti­on with the natio­nal phar­ma­cy aut­ho­ri­ty to ensu­re the sup­ply of medicines

Tog­e­ther with Prof. Koua we had a mee­ting with repre­sen­ta­ti­ves of the Natio­nal Phar­ma­cy Aut­ho­ri­ty for the Public Sec­tor (NPSP). The aim was to reach an agree­ment with the NPSP that would lead them to order, pay for and deli­ver the medi­ci­nes to the cen­ters invol­ved in our pro­ject (and pos­si­b­ly for more cen­ters in the future) at a lower cost than in the phar­maci­es. So far, we have sent medi­ci­nes to Côte d’I­voi­re in col­la­bo­ra­ti­on with Mede­or. Mede­or is a Ger­man NGO that deli­vers medi­ca­ti­on to poor coun­tries at low cost.

At the mee­ting it beca­me clear that the NPSP only wan­ted to get invol­ved if the quan­ti­ty of drugs nee­ded was so lar­ge that it was worth the effort. To this end, the NPSP wants to collect data on the drugs used and tho­se nee­ded in the future. In the mean­ti­me, it has been deci­ded that this data collec­tion by the NPSP will soon be car­ri­ed out in all known cen­ters that tre­at pati­ents with epi­le­psy and seve­re men­tal ill­nes­ses in rele­vant num­bers, and that on this basis the drugs will then be pro­cu­red by the NPSP its­elf in the future. 

Results and tasks:

1. We have seen the balan­ce sheet for 2018/19 (until 31.3.2019), it is ok. The plan­ning for 2019/20 is out­lined, a detail­ed plan­ning will fol­low. 

2. The pay­ments of the pati­ents for medi­ci­nes sup­plied by us or Mede­or will be regis­tered and retur­ned to the pro­ject. They are to be used to finan­ce any fur­ther medi­ca­ti­on that may be necessa­ry and also for the work of the cen­ters, e.g. to finan­ce motor­cy­cles or agents’ sala­ries.

3. 20 Agents de San­té will be spe­cial­ly trai­ned for mental­ly and epi­lep­ti­cal­ly ill peop­le. Of the­se, 10 will be finan­ced by us in the future (2 each for 5 cen­ters). We are also wil­ling to pay the mate­ri­al cos­ts for the agents. The main pro­blem of the pro­ject will still be to find the pati­ents in the vil­la­ges and pray­er camps and to enab­le them to recei­ve tre­at­ment. This func­tion can and must main­ly be ful­fil­led by the agents. 

4. A mon­th­ly super­vi­si­on by the psych­ia­trists of the pro­ject is plan­ned

5. For the time being no fur­ther cen­tral trai­ning cour­ses will be car­ri­ed out becau­se suf­fi­ci­ent nur­ses have alrea­dy been trai­ned for this pha­se of the pro­ject. Ins­tead, the­re will be decen­tra­li­zed trai­ning cour­ses on site in the health cen­ters and trai­ning cour­ses for CdP staff. The idea is to con­ti­nue using the pray­er camps, at least in part, by upgrading them as real sana­to­ri­ums with con­trols and con­di­ti­ons. Howe­ver, it remains to be seen how many CdPs are pre­pa­red to do so and under­stand the the­ra­peu­tic con­cepts. Whe­re pos­si­ble, poli­ce trai­ning could and should also be offe­red.

6. In addi­ti­on, a gui­de for psy­cho­lo­gi­cal trai­ning should be drawn up by the psy­cho­lo­gist and Prof. Koua, which should first be bin­ding for the SAMENTACOM team and then for the staff in the health cen­ters. 

7. We will sup­port a Natio­nal Enquê­te on the Camps de Priè­re. It will be car­ri­ed out by the end of the year. The Uni­ver­si­ty of Bouaké is the sup­por­ting body. Prof. Koua sub­mits the app­li­ca­ti­on and makes the cal­cu­la­ti­on. We take care of the finan­cing, be it through us and/or through coope­ra­ting foun­da­ti­ons. 

8. Medi­cal the­ra­py will be con­ti­nued in a more dif­fe­ren­tia­ted form. More atten­ti­on should be paid to side effects, and more atten­ti­on should also be paid to com­pli­an­ce, inclu­ding that of rela­ti­ves and the pray­er camps. 

9. Data on drug demand in the cen­ters will be collec­ted by the NPSP. It is plan­ned that the NPSP will then, as with all other dise­a­ses, take over the sup­ply of medi­ci­nes for mental­ly and epi­lep­ti­cal­ly ill pati­ents.

10. The legal situa­ti­on regar­ding human rights vio­la­ti­ons must beco­me clea­rer. In this respect, we must beco­me more awa­re of natio­nal law.

11. We have been recom­men­ded to nego­tia­te a con­ven­ti­on bet­ween our Foun­da­ti­on and the Ivo­r­i­an Sta­te; our reco­gni­ti­on as an NGO in Côte d’I­voi­re can faci­li­ta­te our work in this coun­try with the aut­ho­ri­ties. This is in pre­pa­ra­ti­on.

12. The num­ber of cen­ters in the pro­ject is not yet to be incre­a­sed, but rather the qua­li­ty and quan­ti­ty of work in the cen­ters is to be impro­ved. We may then gra­du­al­ly add indi­vi­du­al cen­ters, if pos­si­ble tho­se that are alrea­dy at work and pos­si­b­ly also reli­gious­ly ori­en­ted, even if we agree that this is a model for the who­le coun­try and that soo­ner or later it should and can be exten­ded nationwide. 


April 2019



Bur­ki­na Faso: A psych­iatric nur­se has star­ted work in Piéla

With the sup­port of our Mind­ful Chan­ge Foun­da­ti­on, the asso­cia­ti­on Yen­faa­bi­ma in Piéla/Burkina Faso was able to employ a psych­iatric spe­cia­list sin­ce 1 March 2019. Timo­thée Tinda­no, who tog­e­ther with the pas­tor Tank­pa­ri Guitan­ga on his initia­ti­ve has set up an out­pa­ti­ent psych­iatric con­sul­ta­ti­on in a rural regi­on in the nor­the­ast of Bur­ki­na Faso, will take over this work. His mis­si­on and wish is to deve­lop com­mu­ni­ty-based psych­iatric care that inclu­des exis­ting health care faci­li­ties. In this way, many sick peop­le recei­ve afford­a­ble pro­fes­sio­nal help. The Mind­ful Chan­ge Foun­da­ti­on will accom­pa­ny and expand the deve­lo­p­ment of this work.

Amnes­ty Inter­na­tio­nal Symposium

Human rights vio­la­ti­ons against peop­le with men­tal ill­ness, epi­le­psy and disa­bi­li­ty – Amnes­ty Inter­na­tio­nal’s Action Net­work for Health Pro­fes­si­ons orga­ni­zed an inter­na­tio­nal sym­po­si­um in Kassel

On 16.02.2019 a sym­po­si­um on human rights vio­la­ti­ons against peop­le with men­tal ill­ness, epi­le­psy and men­tal disa­bi­li­ty took place in the Gieß­haus of the Uni­ver­si­ty of Kas­sel. The con­fe­rence was orga­ni­zed by Akti­ons­netz Heil­be­ru­fe, finan­ced by Amnes­ty Inter­na­tio­nal and simul­ta­ne­ous­ly trans­la­ted into two lan­guages (Eng­lish and Ger­man). Mem­bers of Amnes­ty Inter­na­tio­nal, repre­sen­ta­ti­ves of NGOs and other inte­res­ted par­ties were pre­sent, many from the­ra­peu­tic professions.

La mala­die du demon — dise­a­se of demons

On the evening befo­re the con­fe­rence, direc­tor Lilith Kug­ler took the audi­ence to Bur­ki­na Faso with her award-win­ning debut work and pre­sen­ted the situa­ti­on of peop­le with men­tal or epi­lep­tic dise­a­ses. Peop­le suf­fe­ring from psy­cho­sis are hid­den in sheds for their own pro­tec­tion and that of the com­mu­ni­ty and are tied to trees the­re or in natu­re. In some cases, pray­er camps are used which are loca­ted far out­side the com­mu­ni­ty, are only known in the immedia­te vicini­ty and are not sub­ject to any con­trols. The­re they are pro­vi­ded with food by their rela­ti­ves or, if they do not visit them, by mem­bers of the camp. The “tre­at­ment” usual­ly takes place exclu­si­ve­ly with pray­ers in order to expel the evil spi­rits. The­re is no psych­iatric sup­ply of medi­ca­ti­on. The sick often spend years under a tree and the film shows an examp­le of a per­son dig­ging deeper and deeper into the earth and others tal­king to them­sel­ves or even silen­cing com­ple­te­ly.  Sen­si­tively and without any pathos, Lilith Kug­ler, accom­pa­nied by a parish priest, Guitan­ga Tank­pa­ri, pres­ents the situa­ti­on and the back­ground for the expe­ri­ence and action of the local peop­le.  The pas­tor visits some pati­ents and tri­es to free them from their chains and to find a place for them in their com­mu­nities again. The Chris­ti­an pas­tor tri­es to com­bi­ne the tra­di­tio­nal cul­tu­re with human accom­p­animent and the achie­ve­ments of medi­ci­ne in order to bring peop­le back to com­mu­ni­ty and reco­very. Medi­cal care is pro­vi­ded by a psych­iatric nur­se, Timo­thée Tinda­no, who tra­vels from far away and has an out­pa­ti­ent con­sul­ta­ti­on two days a mon­th. The sup­ply of medi­ca­ti­on is a major problem.

Also affec­ted per­sons and the con­se­quen­ces of the ill­ness for them and their fami­lies are pre­sen­ted. The situa­ti­on of the hel­pers in the local aid pro­ject is also addres­sed.  The dise­a­ses are inter­pre­ted in the local tra­di­ti­on as an expres­si­on of obses­si­on, which leads to the fact that the demons must be dri­ven out or tamed. The demons can also jump over to other peop­le and so the hel­pers are some­ti­mes also suspec­ted of being infec­ted by the demons. But the film also shows how ele­men­ta­ry care can be deve­lo­ped with simp­le means. This care is cur­r­ent­ly being expan­ded with the help of two Ger­man NGOs.

The direc­tor was pre­sent during the fol­lowing dis­cus­sion and ans­we­red the nume­rous ques­ti­ons. Mean­while she is back in Bur­ki­na Faso, showing her film the­re — also to the peop­le who par­ti­ci­pa­te in the film — and she and we are loo­king for­ward to the reso­nance the­re. The film can be reques­ted for scree­nings in cine­mas and events in order to reach a broa­der public for the topic in other coun­tries as well.

Amnes­ty Inter­na­tio­nal’s Posi­ti­on on Men­tal Health and Human Rights. Star­ting point and questions

Micha­el Hup­pertz, psych­ia­trist, psy­cho­the­ra­pist, socio­lo­gist and mem­ber of the Akti­ons­netz Heil­be­ru­fe, intro­du­ced in his intro­duc­to­ry lec­tu­re the topic of long hid­den human rights vio­la­ti­ons against peop­le with men­tal and epi­lep­tic dise­a­ses in coun­tries without rele­vant psych­iatric care. He spo­ke from a human rights per­spec­ti­ve about the pro­blems that ari­se on the way to impro­ving their situa­ti­on. If in the past deca­des the­re was pro­test against abu­se of mental­ly ill peop­le, it was in con­nec­tion with cri­ti­cism of arbi­tra­ry and vio­lent tre­at­ment wit­hin psych­iatric insti­tu­ti­ons. But many more peop­le out­side psych­iatric insti­tu­ti­ons than wit­hin them are depri­ved of their basic rights. This is sim­ply due to the fact that the­re are around 1.5 mil­li­on beds in psych­iatric insti­tu­ti­ons world­wi­de, inclu­ding homes, but at least 200 times as many severely mental­ly ill peop­le in poor coun­tries who have no access to psych­iatric tre­at­ment. It is only sin­ce about 10 years that the pro­blem, which has been known to experts for a long time, has been brought to the public by inves­ti­ga­ti­ve jour­na­lists. Human rights orga­niz­a­ti­ons, inclu­ding Amnes­ty Inter­na­tio­nal, have also paid litt­le atten­ti­on to the situa­ti­on of this lar­ge part of the popu­la­ti­on to this day. So it is also about an inclu­si­on of this group in the human rights move­ment. Using the deve­lo­p­ment of Amnes­ty Inter­na­tio­nal as an examp­le, he exp­lai­ned how the orga­niz­a­ti­on initi­al­ly devo­ted its­elf to poli­ti­cal pri­so­ners and civil and poli­ti­cal rights, and later on gene­ral­ly cam­pai­gned for the aboli­ti­on of tor­tu­re and the death penal­ty. In 2001, the man­da­te was exten­ded to the pro­tec­tion of all human rights. 

Some­ti­mes, but never com­pre­hen­si­ve­ly, the situa­ti­on of mental­ly ill and dis­ab­led peop­le was taken into account. Recent­ly, howe­ver, the issue seems to be gai­ning more atten­ti­on at the inter­na­tio­nal level, which has been pro­mo­ted by important inter­na­tio­nal con­ven­ti­ons. Various pro­blems have ari­sen with regard to coope­ra­ti­on with regio­nal and sta­te actors, the plau­si­bi­li­ty of the modern con­cept of human rights in rural regi­ons, the pos­si­bi­li­ties of NGOs to influ­ence inter­na­tio­nal nego­tia­ti­ons and natio­nal health poli­cy. Espe­cial­ly NGOs that are prac­ti­cal­ly acti­ve on the ground have to bear in mind that they do not con­tri­bu­te to the mista­kes of Wes­tern psych­ia­try being repeated in the deve­lo­p­ment of psych­iatric care in deve­lo­ping coun­tries. In par­ti­cu­lar, the estab­lish­ment of lar­ge, sepa­ra­te psych­iatric insti­tu­ti­ons should be rejec­ted becau­se it is inef­fi­ci­ent and expen­si­ve and becau­se such insti­tu­ti­ons are par­ti­cu­lar­ly vul­nerable to human rights vio­la­ti­ons under pre­ca­rious con­di­ti­ons.  In addi­ti­on, the­re is a dan­ger that the governments of the coun­tries con­cer­ned, which gene­ral­ly spend very litt­le or not­hing on men­tal health, will be relie­ved of respon­si­bi­li­ty for the issue of men­tal health. In the effi­ci­ent and afford­a­ble deve­lo­p­ment of psych­iatric care wit­hin gene­ral decen­tra­li­zed and out­pa­ti­ent health care, on the other hand, one can refer to the inter­na­tio­nal exper­ti­se of the WHO, for examp­le. At the end, Micha­el Hup­pertz for­mu­la­ted nume­rous ques­ti­ons for the par­ti­ci­pants of the con­fe­rence, the ans­wers to which could be important for a pos­si­ble future enga­ge­ment of Amnes­ty International. 

Glo­bal men­tal health and human rights — an over­view of the cur­rent situation

Wolf­gang Krahl of the Inter­na­tio­nal Net­work for Deve­lo­p­ment Coope­ra­ti­on in the Field of Men­tal Health e.V., psych­ia­trist and foren­sic sci­en­tist, who has been acti­ve for deca­des in various emer­ging and deve­lo­ping coun­tries in rese­arch, edu­ca­ti­on and coope­ra­ti­on pro­jects, impres­si­ve­ly demons­tra­ted, based on the Decla­ra­ti­on of Human Rights, that men­tal health has long been neglec­ted in the rea­liz­a­ti­on of the­se human rights. Fami­lies, espe­cial­ly in poor coun­tries, are the only sup­por­ters of mental­ly ill peop­le who, for their own pro­tec­tion and that of others, resort to nume­rous human rights vio­la­ti­ons, for examp­le by chai­ning their rela­ti­ves to chains and locking them away. The best anti-Stig­ma­pro­gramm is a good tre­at­ment and reha­bi­li­ta­ti­on! It also takes the bur­den off the affec­ted fami­lies, relie­ves them for other tasks and acti­vi­ties and is a con­cre­te deve­lo­p­ment aid. Accord­ing to the WHO’s cata­lo­gue of objec­ti­ves, this inclu­des good initi­al care for mental­ly ill peop­le right into the local com­mu­nities, the pro­vi­si­on of psy­cho­tro­pic drugs, the trai­ning of men­tal health experts, who do not have to be psych­ia­trists, and then also edu­ca­tio­nal work and psy­choe­du­ca­ti­on. This requi­res sta­te imple­men­ta­ti­on and net­wor­king of various sec­tors, moni­to­ring and fur­ther rese­arch. He poin­ted out that in Euro­pe, too, the deve­lo­p­ment of psych­ia­try was a long pro­cess that began in the 18th cen­tu­ry and led to the first libe­ra­ti­ons of the mental­ly ill from their shack­les. Wolf­gang Krahl also recal­led the most com­pre­hen­si­ve and orga­ni­zed human rights vio­la­ti­ons in Ger­ma­ny bet­ween 1933–1945. Wit­hin the frame­work of the T4 pro­gram, 200,000 sick peop­le were sys­te­ma­ti­cal­ly mur­de­red, many of them for­ci­b­ly ste­ri­li­zed, with the signi­fi­cant par­ti­ci­pa­ti­on of psych­ia­trists and nur­sing staff. 

Wolf­gang Krahl pre­sen­ted how much money sta­tes spend on psych­iatric care and how the gap bet­ween coun­tries with high and low per capi­ta inco­mes diver­ges. Low and lower midd­le inco­me coun­tries usual­ly spend less than 1% of their low health bud­gets, some­ti­mes not­hing at all, on the tre­at­ment of the­se dise­a­ses. As a result, bil­li­ons of peop­le would have no access to psych­iatric care. After infec­tious dise­a­ses and inju­ries, men­tal ill­nes­ses are the most com­mon dise­a­ses. He show­ed what drastic con­se­quen­ces this can have for tho­se affec­ted. As a rule, tra­di­tio­nal hea­lers are the first port of call for tho­se affec­ted and their fami­lies. Tra­di­tio­nal healing methods could also be some­ti­mes suc­cess­ful for mild forms of depres­si­on, depen­den­cy dise­a­ses and neu­ro­tic sym­ptoms. In the case of seve­re depres­si­on, schi­zo­phre­nia, bipo­lar psy­cho­ses and epi­le­psy, on the other hand, psych­iatric tre­at­ments, inclu­ding psy­cho­tro­pic drugs and anti­epi­lep­tic drugs, would have to be used not too late.

Men­tal health and human rights in Côte d’Ivoire

Natha­lie Koua­k­ou from Amnes­ty Inter­na­tio­nal Côte d’I­voi­re spo­ke about the situa­ti­on in her coun­try, whe­re she has been cam­pai­gning for several years for the imple­men­ta­ti­on of human rights stan­dards in the health sys­tem. Espe­cial­ly mental­ly ill peop­le are impai­red in the per­cep­ti­on and defence of their rights and are the­re­fo­re par­ti­cu­lar­ly pre­desti­ned to beco­me vic­tims of human rights vio­la­ti­ons. Alt­hough the WHO defi­nes the right to men­tal health as a cen­tral com­po­nent of well-being, tho­se affec­ted by men­tal ill­ness, epi­le­psy or redu­ced intel­li­gence are still often stig­ma­tised, exclu­ded from edu­ca­ti­on, poli­ti­cal deba­tes, elec­tions, star­ting a fami­ly, etc. The WHO also defi­nes the right to men­tal health as a cen­tral ele­ment of well-being.  In Côte d’I­voi­re, the who­le issue of the life situa­ti­on of the mental­ly ill is marginalised.

Natha­lie Koua­k­ou pre­sen­ted the UN Con­ven­ti­on on the Rights of Per­sons with Disa­bi­li­ties and the Men­tal Health Action Plan, which call for social impro­ve­ments for peop­le affec­ted bey­ond medi­cal tre­at­ment and aim to break down bar­ri­ers to inte­gra­ti­on. They want to draw the atten­ti­on of tho­se respon­si­ble and decisi­on-makers, encou­ra­ge them and point out ways in which they can help to imple­ment appro­pria­te gui­de­li­nes and pro­tect and gua­ran­tee the rights of tho­se affec­ted. In par­ti­cu­lar, howe­ver, the Con­ven­ti­on aims at the housing, living and tre­at­ment situa­ti­on, the stan­dards of which must meet today­’s incre­a­sed know­ledge. A dif­fe­rent pic­tu­re of men­tal ill­ness should also be brought into socie­ty, for examp­le through impro­ved edu­ca­ti­on of the popu­la­ti­on. Degra­ding tre­at­ment and accom­mo­da­ti­on should also be punis­hed, as it should be pos­si­ble for tho­se affec­ted to com­p­lain about it. The government should pro­vi­de instru­ments to streng­t­hen pati­ents and their fami­lies, for examp­le in the form of asso­cia­ti­ons and self-help groups. Lar­ge psych­iatric insti­tu­ti­ons in lar­ge cities should be repla­ced by psy­cho­so­cial and medi­cal care clo­ser to home. In order to gua­ran­tee all of this, government offices for coor­di­na­ti­on and plan­ning would have to be crea­ted in the admi­nis­tra­ti­on. The Afri­can Uni­on had also lar­ge­ly joi­ned the pos­tu­la­tes of the WHO, but the­re was still a lack of visi­bi­li­ty of the pro­blem in the coun­try and a lack of com­mit­ment on the part of the Minis­try of Health. The pre­ca­rious situa­ti­on of the lacking resour­ces on the one hand and the litt­le com­mit­ted approach to the imple­men­ta­ti­on of the gui­de­li­nes on the other hand pro­mo­tes the con­ti­nua­tion of the tra­di­tio­nal prac­ti­ces of the reli­gious-cul­tu­ral under­stan­ding of men­tal impairments with the dan­ger of the con­ti­nued mistre­at­ment, dis­re­gard and exclu­si­on of the affec­ted per­sons. This also inclu­des sexu­al abu­se wit­hin the frame­work of magi­cal thin­king as well as kid­nap­pings and the remo­val of organs. 

Des­pi­te the other­wi­se dyna­mic pro­cess in the deve­lo­p­ment of the coun­try, the magi­cal thin­king of guilt, magic and obses­si­on pre­vails here. In addi­ti­on to the alrea­dy weak medi­cal care in the coun­try, which was still affec­ted by the mili­ta­ry coup of 1999, various cri­ses and the civil war of 2002–2011, the­re is an incre­a­sed inci­dence of trau­ma dis­or­der. Psych­iatric care is scar­ce, and only 25% of health districts have any form of psych­iatric care at all. On the other hand, Côte d’I­voi­re has a new con­sti­tu­ti­on in 2016 which sti­pu­la­tes that all peop­le with disa­bi­li­ties must be pro­tec­ted from discri­mi­na­ti­on and that no one must be dis­ad­van­ta­ged becau­se of their men­tal or phy­si­cal condition.

In her con­clu­ding deman­ds, Natha­lie Koua­k­ou under­li­ned the need for fur­ther rese­arch into the epi­de­mio­lo­gy, socio­lo­gi­cal data and legal sta­tus of the dise­a­ses in ques­ti­on in Côte d’I­voi­re, impro­ved acces­si­bi­li­ty of the initi­al con­ta­ct points in the muni­ci­pa­li­ties, also for men­tal ill­nes­ses, for invest­ment in trai­ning for spe­cia­list staff, but also for vol­un­te­ers in the vil­la­ge struc­tures, in order to build up a good sup­port net­work and edu­ca­tio­nal work.

From West Afri­ca to Sou­the­ast Asia: Trans­forming access to men­tal health care through WHO Qua­li­ty Rights and CBM’s men­tal health work

Car­men Val­le works as a con­sul­tant for men­tal health pro­jects of the Christof­fel-Blin­den-Mis­si­on (cbm), in par­ti­cu­lar with regard to human rights edu­ca­ti­on, in various coun­tries in Afri­ca and Asia. She fol­lo­wed her orga­niz­a­ti­on’s expe­ri­ence and solu­ti­on models. She descri­bed how it can be pos­si­ble to crea­te basic net­works on the ground, to sup­port decisi­on-makers and peop­le in the care of peop­le with disa­bi­li­ties. Cbm reli­es among other things on so-cal­led peer groups, i.e. on peop­le who are expe­ri­en­ced in life and enjoy the respect of the com­mu­ni­ty and at the same time are open-min­ded for the imple­men­ta­ti­on of social psych­iatric care in the com­mu­nities and often have a prac­ti­cal the­ra­peu­tic effect. She impres­si­ve­ly pre­sen­ted a well thought-out con­cept at the various levels of how the coun­tries could con­ti­nue to main­tain and deve­lop the sys­tem inde­pendent­ly without the sup­port of NGOs. Men­tal health care and con­si­de­ra­ti­on of the situa­ti­on of mental­ly ill, stig­ma­ti­zed peop­le with epi­le­psy and men­tal impairment should be inte­gra­ted into the over­all con­cept of deve­lo­p­ment work, for examp­le in edu­ca­tio­nal pro­jects in schools and kin­der­gar­tens. The idea of inclu­si­on can also be intro­du­ced at an ear­ly sta­ge here, as well as at parent and com­mu­ni­ty mee­tings. This also streng­t­hens awa­reness of the par­ti­cu­lar vul­nera­bi­li­ty of tho­se affec­ted to ass­ault and abu­se and thus social con­trol, which can ser­ve as pro­tec­tion. The con­cept of their orga­niz­a­ti­on is to pro­vi­de emer­gen­cy aid in thres­hold and deve­lo­ping coun­tries, for examp­le after ear­th­qua­kes, tsu­na­mis, etc., in addi­ti­on to the so-cal­led basic needs, and to focus sepa­r­ate­ly on men­tal health and local work. World­wi­de, on-the-spot trai­ners are trai­ned in first aid for first aid after trau­ma­tiz­a­ti­on accord­ing to WHO guidelines.

The situa­ti­on of trau­ma­ti­zed peop­le in Liberia

Susan­ne Gros­se, social sci­en­tist at the Uni­ver­si­ty of Kas­sel, as hos­tess of the event in the Gieß­haus of the Uni­ver­si­ty of Kas­sel not only ensu­red a plea­sant con­fe­rence atmo­s­phe­re, but in view of her forth­co­m­ing rese­arch stay in Libe­ria she not only repor­ted on the simi­lar­ly dis­astrous situa­ti­on of tho­se affec­ted the­re with vivid film and pic­to­ri­al mate­ri­al, but also made it clear on the basis of the stan­dards of care in Ger­ma­ny that we our­sel­ves have not been far away from poor care for so long. The psych­iatric enqui­ries and visi­tor com­mis­si­ons had pro­vi­ded for more trans­pa­ren­cy and stan­dards, but nee­ded con­stant impro­ve­ment. It is pre­cise­ly the peop­le affec­ted who find it dif­fi­cult to stand up for their rights. In pro­jects in Libe­ria, peop­le are trai­ned for psy­cho­so­cial sup­port, espe­cial­ly for the nume­rous trau­ma­ti­zed peop­le in the coun­try. Thousands of for­mer recrui­ted child sol­di­ers have now grown up and have fami­lies of their own, but often car­ry trau­ma sequel dis­or­ders with them — with serious con­se­quen­ces for them­sel­ves and society.

The prac­ti­cal signi­fi­can­ce of inter­na­tio­nal human rights con­ven­ti­ons for the deve­lo­p­ment of psych­iatric care 

Mar­gret Oster­feld, reti­red psych­ia­trist and com­mit­ted to Akti­on Psy­chisch Kran­ke e.V., was not only a com­mit­ted cri­tic at pre­vious lec­tures, but also spo­ke about her work at the UN Sub­com­mit­tee on the Pre­ven­ti­on of Tor­tu­re, in the frame­work of which teams regu­lar­ly visit care insti­tu­ti­ons in various coun­tries and draw up reports on the extent to which cor­re­spon­ding stan­dards of care are obser­ved or dis­re­gar­ded and impro­ved. The­se teams usual­ly have access to all men­tal health faci­li­ties and pre­pa­re reports on the human rights situa­ti­on in the­se faci­li­ties. If they do not get free access, they stop working. The reports are for­war­ded to the com­pe­tent aut­ho­ri­ties and pro­po­sals are made to impro­ve the situa­ti­on. A publi­ca­ti­on bey­ond that is aimed at, but the orga­niz­a­ti­on renoun­ces it, if the addres­sed governments do not agree, in order not to end­an­ger the fur­ther co-operation.

Dis­cus­sion on the podi­um and with the audience

The lec­tures — mode­ra­ted by Mir­jam Ibold, psy­cho­lo­gist and mem­ber of the Action Net­work of Health Pro­fes­sio­nals — were accom­pa­nied by lively dis­cus­sions for which the­re was ple­nty of time. The con­clu­ding panel dis­cus­sion — mode­ra­ted by Gesi­ne Heet­der­ks, psych­ia­trist and neu­ro­lo­gist — focu­sed on the ques­ti­on of what the con­se­quen­ces would be for the pos­si­ble invol­ve­ment of Amnes­ty Inter­na­tio­nal. The­re was a con­sen­sus that a dual stra­te­gy would make sen­se for impro­ving the situa­ti­on of peop­le with men­tal ill­ness and epi­le­psy. On the one hand, a sus­tainab­le chan­ge in their situa­ti­on can only be achie­ved if appro­pria­te influ­ence is exer­ted on the government. The sta­tes con­cer­ned have signed various con­ven­ti­ons of human rights signi­fi­can­ce, inclu­ding the important Con­ven­ti­on on the Rights of Per­sons with Disa­bi­li­ties of 2008. They can and must be made awa­re that the situa­ti­on of the­se peop­le is a vio­la­ti­on of ele­men­ta­ry human rights. On the other hand, howe­ver, human rights vio­la­ti­ons such as chai­ning peop­le are gene­ral­ly not the result of sadistic moti­ves, but rather of a lack of alter­na­ti­ves and hel­pless­ness in dealing with the mys­te­rious dise­a­ses. The­re­fo­re, such a poli­ti­cal stra­te­gy can only be suc­cess­ful if it is accom­pa­nied by sui­ta­ble pilot pro­jects demons­tra­ting that in poor coun­tries such as Bur­ki­na Faso, Côte d’I­voi­re or Ethio­pia, medi­cal care for the­se peop­le is also pos­si­ble at afford­a­ble cos­ts and can the­re­fo­re be incor­po­ra­ted into government health pro­grams. So it is not a ques­ti­on of pil­lo­ry­ing governments, but of using such pilot pro­jects to per­sua­de them to coope­ra­te, in their own inte­rest, becau­se in this way a fun­da­men­tal human rights pro­blem in their coun­tries can be tack­led and perhaps resolved.

It is a ques­ti­on of pro­mo­ting an encou­ra­ging and hel­pful approach to the­se peop­le through edu­ca­ti­on about men­tal ill­ness, epi­le­psy and men­tal disa­bi­li­ty and, abo­ve all, through real impro­ve­ments in the tre­at­ment and care of tho­se affec­ted. This infor­ma­ti­on and encou­ra­ge­ment should invol­ve tho­se affec­ted and their fami­lies, the health workers, but also the aut­ho­ri­ties and civil socie­ty. The mot­to “Don’t bla­me” should be taken into account as far as pos­si­ble. Comments should be face-saving and rea­listic for the respon­si­ble governments, so that fur­ther inves­ti­ga­ti­ons, deve­lo­p­ment reviews, new pro­po­sals etc. can be made in con­stant coope­ra­ti­on with the administrations.

Gud­run Brünner

Docu­men­ta­ry “La Mala­die du Démon”

The film “La Mala­die du Démon” (2018) by direc­tor Lilith Kug­ler shows the situa­ti­on of mental­ly and epi­lep­ti­cal­ly ill peop­le in Bur­ki­na Faso as well as an aid pro­ject that we sup­port (see “Pro­jects”). The film is also used in the pro­jects in Bur­ki­na Faso and Côte d’I­voi­re to train health workers and rai­se awa­reness among the popu­la­ti­on and the public.

If you would like to show the film, plea­se con­ta­ct us or Lilith Kug­ler. Star­ting in autumn you can also buy the film as a DVD.