Kazakhstan: Doctors Both Treat and Maim
Marat's story
1996. Kostanai
Marat Ibraimov (not his real name):
- I was 17, I was the student of the Higher School of Police at Kostanai. Once someone stole a star from my cap badge and I started to have a fight with other students. Afterwards, my head ached and I asked them to give me some tea.
They added some psychoactive drug to my tea and I became aggressive. Also, the sergeants were nagging at my marching, although I was marching correctly.
Once at night, when I was sleeping, the students took me outdoors by the arms. The ambulance car was there. They tied my hands and legs with a rope and took me to a psychiatric hospital. They fastened my hands and legs, and then the nurse made an injection of a psychotropic drug to my right leg.
Afterwards, I was crying for three days "Let me go, let me go!". But no one let me go. Then my older brother came. Doctors told my relatives at first that I was in the intensive care unit, but I wasn't there – they kept me at the psychiatric hospital. As soon as my brother came, he took me, and I quit the police school and got back home.
A couple of months later, in spring, I felt bad again – my pressure got high, I couldn't sleep. That's how it all started.
Marat Ibraimov (not his real name):
- I was 17, I was the student of the Higher School of Police at Kostanai. Once someone stole a star from my cap badge and I started to have a fight with other students. Afterwards, my head ached and I asked them to give me some tea.
They added some psychoactive drug to my tea and I became aggressive. Also, the sergeants were nagging at my marching, although I was marching correctly.
Once at night, when I was sleeping, the students took me outdoors by the arms. The ambulance car was there. They tied my hands and legs with a rope and took me to a psychiatric hospital. They fastened my hands and legs, and then the nurse made an injection of a psychotropic drug to my right leg.
Afterwards, I was crying for three days "Let me go, let me go!". But no one let me go. Then my older brother came. Doctors told my relatives at first that I was in the intensive care unit, but I wasn't there – they kept me at the psychiatric hospital. As soon as my brother came, he took me, and I quit the police school and got back home.
A couple of months later, in spring, I felt bad again – my pressure got high, I couldn't sleep. That's how it all started.
How does psychiatry work in Kazakhstan?
Since 2017, Kazakhstan started structural changes in the mental health care service. They developed and approved the Road Map for the mental health care service development for 2017–2018.
It helped to organise the patient-centred model of health care to persons with mental and behavioural disorders.
It helped to organise the patient-centred model of health care to persons with mental and behavioural disorders.
Mental Health Care Service (SOPZ) of Kazakhstan consists of:
According to the Department of Health Care Organisation of the Ministry of Health.
1
Republican research and practical centre of mental health;
republican specialised psychiatric hospital with intense observation,
republican specialised psychiatric hospital with intense observation,
17
Regional mental health centres (RCPZ)
72
Primary mental health centres (PCPZ)
219
Mental health rooms at central district hospitals.
By 2025, the number of available PCPZ is going to reach 92. The mental health care service will be further developed under the Road Map for the mental health care service development for 2019-2020 in Kazakhstan.
However, according to experts, the country lacks the staff in rehabilitation institutions. They lack recreation therapists, child psychiatrists, competent teaching, medical and social workers, special psychologists for children with disabilities.
According to Gulzhan Amangeldinova, expert of 'Psychoanalytic Association' Public Association, Kazakhstan does not have professional standards for recreation therapists. There are no higher and secondary educational institutions to train professionals in habilitative and rehabilitation services.
"There is no training of staff in such important disciplines as occupational therapy, physical therapy, physical and rehabilitation medicine. The classification of tertiary level disciplines does not include such occupations as teacher of the deaf, recreation therapist, etc. Meanwhile, the lack of rehabilitation and habilitative centres contributes to the fact that the graduates in social disciplines do not have guaranteed jobs with decent wages," said Amangeldinova.
In addition, according to experts, the attitude towards mental medicine specialists is very stigmatised. People do not want to visit them and turn to them only as a last resort.
"People are ashamed of going to a psychiatrist, counsellor or psychologist. But compared to the situation 20 years ago, we can see some changes. Most of the people who understand and want to change resort to them. At the same time, I think, too many cases of schizophrenia are diagnosed. I meet patients with dementia regularly, and they have been diagnosed with schizophrenia," said psychotherapist Zhibek Zholdasova.
However, according to experts, the country lacks the staff in rehabilitation institutions. They lack recreation therapists, child psychiatrists, competent teaching, medical and social workers, special psychologists for children with disabilities.
According to Gulzhan Amangeldinova, expert of 'Psychoanalytic Association' Public Association, Kazakhstan does not have professional standards for recreation therapists. There are no higher and secondary educational institutions to train professionals in habilitative and rehabilitation services.
"There is no training of staff in such important disciplines as occupational therapy, physical therapy, physical and rehabilitation medicine. The classification of tertiary level disciplines does not include such occupations as teacher of the deaf, recreation therapist, etc. Meanwhile, the lack of rehabilitation and habilitative centres contributes to the fact that the graduates in social disciplines do not have guaranteed jobs with decent wages," said Amangeldinova.
In addition, according to experts, the attitude towards mental medicine specialists is very stigmatised. People do not want to visit them and turn to them only as a last resort.
"People are ashamed of going to a psychiatrist, counsellor or psychologist. But compared to the situation 20 years ago, we can see some changes. Most of the people who understand and want to change resort to them. At the same time, I think, too many cases of schizophrenia are diagnosed. I meet patients with dementia regularly, and they have been diagnosed with schizophrenia," said psychotherapist Zhibek Zholdasova.
According to official data of the Department of Health Care Organisation of the Ministry of Health, in the last 5 years 50,039 mental disorder cases have been recorded in Kazakhstan. Moreover, every year the country records about 10 thousand new cases.
Most of the disorders are qualified as 'organic', including symptomatic, psychiatric disorders. The next widely spread disorder is mental retardation and developmental disorders.
In 2019, 190,066 patients with border psychic disorders were registered with mental health facilities, 47,789 patients were treated in hospitals, and the number of visits to PCPZ were nearly two million.
Most of the disorders are qualified as 'organic', including symptomatic, psychiatric disorders. The next widely spread disorder is mental retardation and developmental disorders.
In 2019, 190,066 patients with border psychic disorders were registered with mental health facilities, 47,789 patients were treated in hospitals, and the number of visits to PCPZ were nearly two million.
"Doctors both treat and maim"
Marat Ibraimov:
- In the last 24 years, I check into a psychiatric hospital every three months every year. I was prescribed psychiatric observations for life. I became dependent on tablets and injections. If I don't get them, I could die.
My diagnosis is paranoid schizophrenia. I have a second category disability. I cannot work, but I work as an unskilled labourer. Generally, people react well to my diagnosis because this is life.
Conditions in hospitals are similar to prisons. I just walk and think there. They feed us three times a day, but the food is not good. Ward attendants take our parcels, cigarettes. They beat everyone but those who are linked with the gangs. On the contrary, ward attendants bring cigarettes to them.
There are many people there – young, old, and children. Doctors both treat and maim.
- In the last 24 years, I check into a psychiatric hospital every three months every year. I was prescribed psychiatric observations for life. I became dependent on tablets and injections. If I don't get them, I could die.
My diagnosis is paranoid schizophrenia. I have a second category disability. I cannot work, but I work as an unskilled labourer. Generally, people react well to my diagnosis because this is life.
Conditions in hospitals are similar to prisons. I just walk and think there. They feed us three times a day, but the food is not good. Ward attendants take our parcels, cigarettes. They beat everyone but those who are linked with the gangs. On the contrary, ward attendants bring cigarettes to them.
There are many people there – young, old, and children. Doctors both treat and maim.
Treat with medications and isolate
According to Gulzhan Amangeldinova, the main problem of psychiatry in Kazakhstan is the historically established medical approach to mental health: to treat with medications and to isolate.
Moreover, treatment of psychiatric diseases is rather expensive for the state. According to the Department of Health Care Organisation of the Ministry of Health, the centres for mental health are being financed at the complex fee of medical services – payment is per one patient who is registered with CPZ and the Register of mental and narcological patients.
"Conditions of stay in hospitals are not bad; patients are treated as new-borns, based on their apathy, laziness and self-neglect. "Medical supplies in hospitals are enough, the assortment is quite varied because the majority of drugs are delivered from abroad or are expensive," said Gulzira Smailova, head of the department of the Mental Health Centre of North-Kazakhstan region.
According to experts, people with mental disorders in Kazakhstan have a very limited choice: to sit at home or to get into an asylum. The country has no system of accompanied support, i.e. there is only a system of incapacitating of a person, which makes the person susceptible and helpless.
Moreover, treatment of psychiatric diseases is rather expensive for the state. According to the Department of Health Care Organisation of the Ministry of Health, the centres for mental health are being financed at the complex fee of medical services – payment is per one patient who is registered with CPZ and the Register of mental and narcological patients.
"Conditions of stay in hospitals are not bad; patients are treated as new-borns, based on their apathy, laziness and self-neglect. "Medical supplies in hospitals are enough, the assortment is quite varied because the majority of drugs are delivered from abroad or are expensive," said Gulzira Smailova, head of the department of the Mental Health Centre of North-Kazakhstan region.
According to experts, people with mental disorders in Kazakhstan have a very limited choice: to sit at home or to get into an asylum. The country has no system of accompanied support, i.e. there is only a system of incapacitating of a person, which makes the person susceptible and helpless.
“
«In general, our psychiatric system must change dramatically. For example, many efforts should be made to prevent such disorders. We need to reduce the level of stigmatization in the society so that a person could go to a psychiatrist without fear and shame. Many are afraid of being registered with a psychiatrist and remain in the database, which will exacerbate their situation. For example, they won't be able to get a job."
In general, persons with mental disorders encounter a lot of obstacles in their lives. According to the founder of the 'Kunde' social café, Maulen Akhmetov, they find it difficult to adapt within the society as there are social and legislative restrictions. For example, they may not be employed, or if they have a document that proves their legal incapacity, they may not sign documents, including a labour agreement.
"Even if a person is not qualified as legally incapable, they will have to provide a medical clearance certificate. If a person is registered with the psychiatrist, the employer won't look into the diagnosis, whether it is remission or rehabilitation. He'll just be scared.
Some employers are unfair. For example, if one works unofficially, one will work for 15-20 hours per shift. Then they say that the one worked for a month and they will not pay or give 20 thousand tenge (47 dollars). And that person won't be able to prove he was deceived because he is registered with the mental health service, and such a person is easy to deceive, defame.
If a person was robbed and reported it to the police, the police officer wouldn't even look into the case because he knows that you were registered with the mental health service and would not even trust you or w0uld be scared of you. We have so many problems of this kind," Akhmetov said.
Often if a person has a mental disease, they become incapacitated, which can lead to the deprivation of other basic rights to freedom, access to justice, celebration of marriage, employment, health, etc.
"Even if a person is not qualified as legally incapable, they will have to provide a medical clearance certificate. If a person is registered with the psychiatrist, the employer won't look into the diagnosis, whether it is remission or rehabilitation. He'll just be scared.
Some employers are unfair. For example, if one works unofficially, one will work for 15-20 hours per shift. Then they say that the one worked for a month and they will not pay or give 20 thousand tenge (47 dollars). And that person won't be able to prove he was deceived because he is registered with the mental health service, and such a person is easy to deceive, defame.
If a person was robbed and reported it to the police, the police officer wouldn't even look into the case because he knows that you were registered with the mental health service and would not even trust you or w0uld be scared of you. We have so many problems of this kind," Akhmetov said.
Often if a person has a mental disease, they become incapacitated, which can lead to the deprivation of other basic rights to freedom, access to justice, celebration of marriage, employment, health, etc.
"Currently, over 16 thousand people are deemed incapacitated and reside in closed facilities. However, these are just a part of all people because the official statistics is not complete. For example, only COSSU No. 1 (asylum) contains over 500 incapacitated persons. According to ASRIV NGO, over 200 people among 700 persons in COSSU are of working age and can fully exercise their rights," Tatiana Bazhova, an expert of 'Aman-saulyk' public foundation, said.
In addition, according to the expert, the legislation of Kazakhstan flatly refuse the right of incapacitated people to access legal aid. Once a person loses legal capacity, according to the Code of Civil Procedure, they fully lose their legal capacity to exercise and have their civil rights and obligations.
The court's decision finding a citizen incapable means the essential change of their legal status, which can lead to restriction of the right to access legal aid, so that a person could not protect their rights and obligations, i.e. they cannot sign official documents (their signature does not have a legal effect). Only legal guardian can solve all matters relating to the life of an incapacitated person.
In cases when an incapable person lives in a boarding facility, the director of the boarding facility becomes the guardian. Often officers of the facility do not let visitors in to keep the 'image' of the organisation.
However, this Kazakhstan law does not differentiate the scope of legal capacity. There are no standards that allow the court to find a citizen as having limited legal capacity due to mental disorder. In fact, if a person has a psychosocial disorder, the presumption of legal incapacity applies. The person deprived of all civil rights in fact cannot have impact on the revision of their status.
In addition, according to the expert, the legislation of Kazakhstan flatly refuse the right of incapacitated people to access legal aid. Once a person loses legal capacity, according to the Code of Civil Procedure, they fully lose their legal capacity to exercise and have their civil rights and obligations.
The court's decision finding a citizen incapable means the essential change of their legal status, which can lead to restriction of the right to access legal aid, so that a person could not protect their rights and obligations, i.e. they cannot sign official documents (their signature does not have a legal effect). Only legal guardian can solve all matters relating to the life of an incapacitated person.
In cases when an incapable person lives in a boarding facility, the director of the boarding facility becomes the guardian. Often officers of the facility do not let visitors in to keep the 'image' of the organisation.
However, this Kazakhstan law does not differentiate the scope of legal capacity. There are no standards that allow the court to find a citizen as having limited legal capacity due to mental disorder. In fact, if a person has a psychosocial disorder, the presumption of legal incapacity applies. The person deprived of all civil rights in fact cannot have impact on the revision of their status.
Isolated from the society
According to experts, Kazakhstan has no alternative services for persons with mental disorders and they are actually dropped from the society. Now the system of support and social assistance to people with mental disorders is limited to treatment of acute disorders in closed mental facilities, isolation at home, treatment in health facilities and payment of some disability benefits.
"Kazakhstan is only making first steps to solve these issues. Local executive bodies, for example, in Almaty support a range of pilot projects of NGOs, parent groups and donor organisations to create services alternative to boarding facilities both for children with cognitive and mental development disorders and for adults. However, these are the attempts made by particular people and organisations. The market of alternative services is underdeveloped in Kazakhstan so far," Bazhova said.
At the national level, they only discuss the idea of removing people from closed health facilities and their further training and employment. According to NGO estimates, 66 per cent of persons with mental disorders living in boarding facilities in Kazakhstan can change their forms of stay and obtainment of services. At the state level, there is no mechanism of assessment of personal needs in case of transfer of a patient from a health facility to an open facility (for example, living in a small space, social hostels, clubhouses, social apartments, day care centres).
"Kazakhstan is only making first steps to solve these issues. Local executive bodies, for example, in Almaty support a range of pilot projects of NGOs, parent groups and donor organisations to create services alternative to boarding facilities both for children with cognitive and mental development disorders and for adults. However, these are the attempts made by particular people and organisations. The market of alternative services is underdeveloped in Kazakhstan so far," Bazhova said.
At the national level, they only discuss the idea of removing people from closed health facilities and their further training and employment. According to NGO estimates, 66 per cent of persons with mental disorders living in boarding facilities in Kazakhstan can change their forms of stay and obtainment of services. At the state level, there is no mechanism of assessment of personal needs in case of transfer of a patient from a health facility to an open facility (for example, living in a small space, social hostels, clubhouses, social apartments, day care centres).
Authors:
- Zulfia Raissova,
- Daniil Lyapichev,
- Mazhab Jum'a
Editor:
Natalia Lee
Illustrations:
Nasiba Karimova
Layout:
- Zulfia Raissova
This publication was produced as part of the mentorship programme under the Development of New Media and Digital Journalism in Central Asia project delivered by the Institute for War and Peace Reporting (IWPR) with support from the UK Government. It does not necessarily reflect the official views of IWPR or the UK Government
