Silence Supressing the Screams
Croatian government remains tight-lipped about how, or even if, it is going to address the appalling situation in the country’s psychiatric hospitals and social care homes
by Yana Buhrer Tavanier in Zagreb, Lobor Grad, Rab, Vojnic, Osijek and Ugljan
It is a magnificent summer day in Ugljan, an island just opposite the stunning city of Zadar, in central Croatia. Zadar is famous, besides it’s rich history, for its sunset, Alfred Hitchcock once called it “the most beautiful sunset in the world”. There’s nothing horrid in Zadar, or in nearby Ugljan. At least not until you dig.
To reach Ugljan’s psychiatric hospital from the mainland, you need to take a ferry, and then drive for about half an hour. The hospital itself, a place for about 400 patients, some of whom have been here for more than ten years, is tucked away from the main road, almost at the beach, it’s breezy garden bursting in green.
Green is also the colour of the grimy wrinkled uniform V. has on, while lying coiled up in his bed in the ward’s isolation cell. He has been in here for months. The room is tiny, it’s size just enough to sqeeze a bed into, it’s door locked and heavy, with a small window for supervision. However, no human has peeked through that window for a very long time, as all of the isolation cells at Ugljan are under constant video-surveillance.
V. has one arm in a cast, the staff explaining that “he fell out of his bed while sleeping”. The staff also say that V. often turns (auto) aggressive, and that he’s been in and out of the isolation cell for almost a year now, though mostly in. “It is the psychiatrist’s decision that he stays here”, is the staff’s response to why V. is stripped of all freedom for such an absurd period of time and completely denied privacy by being video-monitored 24/7. “There is no maximum time. And he is mostly not tied. Just locked in”, one technician says reassuringly.
In Croatia there are no state-imposed policies on restraint and seclusion. What’s worse is that hospitals have not developed such policies on their own, meaning that there are no maximum periods of time for which someone can be tied up with a magnetic belt, put in a strait-jacket or locked inside a claustrophobic isolation room. The answer: “It is on a case by case basis”.
And there’s more. Not unlike other countries in the region, Croatian institutions have a shortage of staff, and thus a lack of real care. Limited freedom, forced routines and lack of privacy deprive people of their dignity. Many live in such poor conditions that could cause them physical or mental harm, and some suffer inhuman and degrading tretment and abuse by staff and other patients.
Despite it’s promises to promote the rights of people with disabilities, Croatia has completely failed to end institutionalization and provide community-based alternatives for more than 9000 persons with intellectual disabilities and mental health problems. People are forced to live in prison-like establishments, abide by prison-like rules, sometimes in worse-than-prison conditions, having committed no crime. They are very often stripped of their legal capacity and have no option to ever leave. And some have not even left their rooms for years.
Croatia is currently in the final phases of negotiations to the join the European Union. Closing down institutions and development of community-based services are not exactly part of the accession talks, but respect for human rights is a prerequisite for entry, and deinstitutionalization is in the Joint Inclusion Memorandum between Croatia and the EU, though there has been painfully little progress in implementation over the past number of years. The European Commission could demand more, and now. The problem is that the EC – in this case, as with Bulgaria, Romania, Macedonia and Serbia – doesn’t really want to see it that way.
The Silence of The Slams
“Thousands of people in Croatia with intellectual disabilities or mental health problems are forced to live in institutions that strip them of their privacy, autonomy, and dignity. The Croatian government has done little to provide alternatives to institutions, despite promises to the European Union and United Nations, and the number of people in institutions is growing”, said Human Rights Watch, an international non-governmental organisation, in a report on Croatia published last September.
The report noted that the government is not only funneling money towards longstanding institutions, it also appears to be building new ones — a home in Dubrovnik opened in 2008; and HRW was told by institutions and civil society groups of plans for the construction of at least three more institutions.
The recommendations of HRW to the Croatian government were clear: replace institutions with support programs that provide housing and assistance for life in the community, now disparagingly few.
Months later there has been no response from Croatian government. There were no official responses to the accusations in local or foreign media.
The office of Mr. Ante-Zvonimir Golem, the State Secretary of Croatia’s Ministry of Health and Social Welfare, never provided answers to my questions, though I was asked to submit them in writing, and was explicitly promised a response.
So it remains unclear what the government’s next steps will be regarding the process of deinstitutionalization and the development of community-based alternatives in the country; how it will finance the process; and whether it has concrete plans for people to be deinstitutionalized in the next couple of years.
The European Comission also kept silent after the report was published.
«Now I’m Only Waiting For Death»
Croatia was amongst the first countries to sign and ratify the UN Convention on the Rights of Persons with Disabilities, which sets out their right to live in the community. The country has also promised the EU to bring people with mental health problems and intellectual disabilities out. While there is speculation about an existing government plan for deinstitutionalization, it has never been made public. Also, unlike for institutions, there is no specific budget line for deinstitutionalization.
Like many European countries, Croatia has been affected by the economic crisis and has experienced cuts in government spending. However, many claim that the reason for the slow pace of reform is not the lack of money, but the lack of leadership, vision and political will.
“Croatia needs to stop building new institutions and stop undertaking significant refurbishment projects of old institutions. This will free up funding to expand community-based services for persons with intellectual or mental disabilities”, says Amanda McRae, a fellow at Human Rights Watch and the author of the report.
The alternative programs are cheaper than institutions – getting about 5400 kuna (729 euro) per month per resident, compared to the 7100 kuna (959 euro) a state-run facility would get.
The main building of Lobor Grad – a social care home for 350 people with mental disabilities, is a 17th century castle in poor condition that could one day be used to attract tourists. However, it is totally unsuitable for housing the 120 people now packed inside it’s huge rooms.
«The rooms are too big, they are inadequate» – admits one social worker. Regulations state there should only be five beds per room, but in almost all institutions visited it was common to see ten beds in a room. The social worker also says the institution lacks all kind of staff – nurses, defectologists, psychologists, qualified therapists, but because of the financial crisis there is a government-imposed freeze on new employment.
Three years ago Lobor Grad’s director used money from the Swedish government to rent and refurbish a house in the nearby village. Now there are four such houses where 17 people live. When we visit one, a resident had just baked a poppy-seed cake, that she proudly presented to us. When she lived in the castle she was not able to cook at all. Five more houses for supported living were planned for 2011, but this project, together with several similar projects across the country, is currently on hold because of the financial crisis.
Back in the institution, in the ward for immobile people, one elderly woman murmurs: «Now I’m only waiting for death».
«The Worst I Have Seen»
Kornelia Videc, owner of the relatively new, private institution NADA in Vojnic does not share the desire to deinsitutionalize that her colleagues in Lobor Grad have. «Bigger institutions give people choices – you can choose friends, you can choose partners… People are placed in community living in an artificial way, they are not friends, they did not choose eachother», she says.
The Center for Rehabiliation NADA houses 175 people with dual diagnosis: intellectual disabilities and mental health problems, between 18 and 80 years old, and has 200 more on a waiting list. The housing of residents is «permanent», meaning that people come here and they die here. It remains unclear why the Croatian government supports the existance of privately-run institutions, which share most of the problems of the state-run facilities, and doesn’t support more community-based living programs.
NADA has an isolation cell on the top floor, «in case someone becomes aggressive». It is an inhumane cupboard-like space, about 4 square meters in size, with thick green plastic insulation covering the walls and floor, no bed, no window, low ventilation and low light. The staff insist that they use it «very rarely, only as temporary placement». There is no maximum time someone could spend there, we’re told, «it’s individual».
The staff claim that the isolation cell has been used just once in the last 12 months, and that they do not tie anyone to the bed. However, several people say that they have been restrained, or know someone who was. A male resident claims staff has tied him to his bed on several occasions. Another resident, M., tells us that people are in diapers in the isolation cell. She was there for a day one year ago, in diapers. Someone mentions a case in which two people were placed in the cell.
But Kristijan Grdjan from Sjaj, a human-rights organisation, says that when passing the Act on Protection of Persons with Mental Disabilities the legislators did not permit social care homes to use measures restraints and seclusion.
Even when not in the isolation cell, people at NADA are extremely isolated. They are not allowed to go alone to the village, this happens only in groups, accompanied by staff. In the common room there are tens of people sitting at tables, doing nothing. Someone stretches out an arm to say hello to us, the arm is immediately pulled down by a staff member.
“I would say the situation in NADA is the worst I have seen in my four years of monitoring institutions. It has good material conditions, but completely lacks humanity. It looks more like a penal institution than a social care home. Opening such institutions should be prohibited by law”, Mr. Grdjan says.
Kristijan Grdjan was part of the monitoring team of the Mental Disability Advocacy Center, a Budapest-based international human rights organisation which inspected Croatian institutions during the Summer of 2010 and is due to produce a report in the Spring of 2011. I joined the MDAC team in these monitoring visits, as a representative of the Bulgarian Helsinki Committee.
«In the last five years I went to the yard twice»
The Home for Adult People with Mental Health problems «Osijek» is a social care home for permanent stay, housing about 200 people. According to staff, in the last 20 years only three people went back to the community. Most of the residents are between 35 and 65 years old.
But in Osijek I also meet R., a 19 year old woman who came here last year. R. looks like a typical teenager. She says she would like to leave the institution, and finish school. Instead she mostly sleeps during the day, obviously a side-effect of all the strong medications she is given. R. is a typical social case: At seven she was placed in a children’s home and later in a foster home – «it was horrible, I was always locked» – and now, because of the lack of alternatives to institutions in the country, she has nowhere else to go.
Osijek doesn’t have an isolation room. At least this is what the staff say. When we find it, in a dark corridor on the ground floor, they change the story, perhaps because according to the law they can’t have one – they use it only for admissions. But R. says she was placed in the isolation room on a number of occasions, the last time two months ago, when she left the institution and came back «a bit drunk». Several other residents confirm that the room is in active use.
In fact the whole ground floor of Osijek, where the immobile residents are, is one big isolation room. A., who has been here for 16 years, doesn’t have a mental disability; she had surgery on her spine and is a «neurological case». «In the last 5 years I went to the yard twice. I really, really have to insist that I am taken outside», A. says. One woman, who has been in the institution for almost two years now claims she has never been taken outside, the furthest she’s been is the corridor.
Back in A.’s room, she raises her hand in the direction of a silent elderly woman in a nearby bed, and says: «It’s getting worse. Before they washed her once a week. Now – once a month».
Talking about bathing and dignity, in one of the closed wards in Ugljan, the psychiatric hospital, all shampoo and soap are under staff control. Showers and toilets have no doors. Staff explains that when somebody takes a shower, the protocol is for staff to stay at the main door, with shampoo and soap, watching the person all the time.
There’s no deinstitutionalization in Ugljan. When people leave the psychiatric hospital, it is usually to be moved to a social care home, and rarely to a foster care home, but almost no one goes back to the community.
It’s the same in Rab, another psychiatric hospital. “There are no real possibilities for deinstitutionalization in Croatia, especially for people with mental disorders”, says Rab’s director. But the deputy director claims he does not know of «a country where deistutionalization produces positive results».
It is a magnificent summer day in Ugljan, the hospital’s garden breezy, and bursting in green. Inside an isolation room A. sits in his excrements on the floor, with a large wound on his foot from last week when he broke the window. «He mostly sleeps in the isolation room. There’s no maximum. It’s individual”, Uglijan’s staff say. Rab’s director added: “In psychiatry everything is indivdual».
But in fact, it is not. There is absolutely nothing individual in a warehouse for people.