armenia a country report by peter kampman

8/6/2019 Armenia A country Report by Peter Kampman

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ContentsAcknowledgements......................................................................................3Background ................................................................................................4Introduction ................................................................................................5Economic, Social and Political Situation.....................................................6Mental Health Problems in the Armenian Population...............................10Organisation of Services...........................................................................12Into Bedlam ..............................................................................................15The Legislative Context.............................................................................18Non Governmental Mental Health Organisations in Armenia...................19The Future of InterMinds Work in Armenia..............................................21

Appendix 1 - Russian Law No 225 & Vardenis Bylaw...............................23Appendix 2 - People and Organisations....................................................36Appendix 3 - Organisations Visited...........................................................37Appendix 4 - Out of Country Contacts.......................................................38Appendix 5 - References...........................................................................39

Appendix 6 - Romanian League for Mental Health...................................40Strategic Plan (Extract)


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AcknowledgmentsIn producing this report I gathered information from a wide range of sources. (Thesesources are listed in appendix 2 (people and organisations), appendix 3 (institutionsvisited), appendix 4 (out of country contacts) and appendix 5 (references). I wish tothank each and every person who so generously gave of their time and shared theirviews with me and to acknowledge my debt to the wisdom and effort of others inexploring this little known country.I wish to particularly thank Dr. Arman Vardanyan and his colleagues from the MentalHealth Foundation and Miguel de Clerck and his colleagues from Medecins sansFrontieres (Belge) for their kindness and support. Without them the task of producingthis document would have been significantly more difficult. In common with many posttotalitarian countries information and knowledge seems to be closely guarded.I also wish to thank my family for supporting my absences from home and LizKampman for her help in pulling together this report.I thank the Charity Know How Fund in the UK for financing the visit that made thisreport possible.

This document has been circulated to key contributers and I hope that it will in a smallway add to the widening of contacts and networks in, and for, Armenia.Finally, I acknowledge that this is the work of someone who lives and works in WesternEurope and has seen Armenia through those eyes. They do not always see things asthey are!


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BackgroundArmenia is one of three internationally recognised states (Armenia, Georgia andAzerbaijan in the central Caucasus region of South-western Asia; north of Iran, south ofGeorgia and the Ukraine, east of Turkey and west of Azerbaijan. It is a small Christiancountry surrounded by Muslim neighbours; a landlocked country cut off from the widerworld, whose people have been scattered to the Four Corners of the globe. Thecountry has a proud and important place in the history of civilisation. It has existed as anation state for over 2750 years and was the first (301A.D.) nation on earth to embraceChristianity as the national religion. It is now only one tenth of its former size and thepopulation of 3,557,284 (July 1995 est.) lives on the high Armenian plateau surroundedby mountains. The Armenian Diaspora, by contrast, numbers some seven million(including one million in the US alone) and can be found from Argentina to Scotland,from Detroit to Bangkok.

The Diaspora tells a tragic story. Philip Marsden, in his fine book, The CrossingPlace; a journey among the Armenians, writes, No other people has been quite so

haunted by the demons of disorder as the Armenians, with their centuries ofinvasions, exile, massacres, earthquakes.


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Introduction

I visited Armenia in October 1997, as part of my research and development work onbehalf of InterMinds, a Scottish Mental Health organisation. Mental Health issues in

Armenia were a mystery to everyone I asked about the country. From what I coulddetermine mental health services had not been visited or assisted by any of the widerange of aid agencies I have come across in other countries of Eastern Europe. Thenotable exceptions to this are the Red Cross, Oxfam and Medecins sans Frontieres,who have provided material and food aid particularly from the time of the earthquake in1988 onwards.

When discussing my proposed trip to Armenia with people who know something aboutthe country, I was given the strong impression that mental health services werecollapsing, even though the Armenian diaspora and American government had pumpedin millions of dollors in aid and humanitarian assistance. This gave me a confusedpicture as to what I would find. In addition, given that Armenia is an ex-member of the

former Soviet Bloc, I anticipated finding a country struggling with economic and politicaldislocation and a mental health infrastructure in decay and disintegration, much as Ihad seen in Romania and Bulgaria.

In Armenia I visited psychiatric services, I talked and talked, laughed and drank, madefriends, and perhaps one or two enemies. I had difficulty putting together in my mind anunderstanding of what I saw on my visit. The knowledge that significant humanitarianand other aid had been given to Armenia contrasted starkly with the grim realities thatfaced me as I travelled about the country and spoke to people. In particular, I witnesseda Mental Health service of the most rudimentary kind having its meagre fundingwithdrawn wholesale from under it and being forced to become increasinglyeconomically self-supporting. The impact of this on the users of the service was at its

best to enhance a corrupt system of access to services and an absence of food,medicines and care. At its worst, something is happening which sounded ominously likethe early stages of a slave regime in at least one hospital I visited.

So I could better understand why and what is happening to mental health services, itseemed important to obtain a rudimentary understanding of some of the economic,social and political realities facing the country. My reading and experiences haveconvinced me that Armenia today is in crisis, as it has not been for many years. Ibelieve that, despite the help afforded by the Diaspora and international aid, the humanrights and basic human needs of its most vulnerable inhabitants are sorely threatenedby the impact of global economic policies and local politics, war, blockade and naturaldisaster. So in this report I make no apology for describing the current economic andpolitical situation in Armenia as I perceive them and the background to this situation,before describing the current realities in mental health services. I will then describe theactivities of NGOs in this field and offer suggestions as to possible future work forInterMinds.


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Economic, Social and Political Situation

Armenias relations with her neighbours are a key factor in her current economic crisisand the siege state in which she finds herself has deep roots. When one also reminds

oneself of the political and cultural impact of her recent history as a Soviet satellite, therepercussions of the 1988 earthquake and the pressures engendered by the neweconomic realities for former members of the Soviet empire, one begins to get aflavour of things.

Armenia was divided between the Romans and the Iranians in 387 AD but regainedindependence in 885 AD. The Byzantine Empire overran Armenia in 1064. A new

Armenian state was established in Cilicia that survived till 1375. The Ottoman Turkssubsequently dominated Armenia. The Russians loosened the Turkish stranglehold inthe 19th century through a series of wars. Between 1915 and 1918 Turkish genocidewas responsible for the death of over 1,500,000 Armenians and the loss of great partsof its territory as Kemal Attaturk, the Turkish leader established the secular Turkey that

exists today. (In 1923, the last 164,000 Pontic Greeks from Trebizond on the BlackSea, were returned home to Greece from Turkey after a stay of 3000 years!) TheTurks have never acknowledged their guilt for these atrocities. Large parts of what waspreviously Armenia became Turkish soil. This included Mount Ararat, of religious andterritorial, and profound symbolic significance to the Christian Armenians. Armenianshave a deep-seated resentment, if not hatred of their Turkic neighbours, Turkey and

Azerbaijan.

The further carving up of Armenia and its absorption into the Soviet Union followed abrief period of independence from 1918 to 1921. During the seventy-year period of theSoviet deep freeze, the country had the classic features of a satellite Soviet State.The centrally planned economy was heavily dependent on the Russian market. A

barren, mountainous country, Armenia was a net importer of grain and other basicfoodstuffs and her exports to her Soviet neighbours were mainly chemical andelectronic products made from imported raw materials. Her citizens had noconstitutional rights and human rights were abused. Albeit that there was an oversupplyof hospital beds, no mental health legislation existed and care was often repressive.

On 7th December 1988 a devastating earthquake in which 25,000 people died hitArmenia and 500,000 were made homeless and destitute and whole towns weredestroyed. Outside help was immediately required and was forthcoming, but theintrinsic weaknesses of the economy were sharpened by this disaster.

Also in 1988, three years before Armenia finally regained independence, 130,000

ethnic Armenians in the Karabagh enclave, deep in neighbouring Azerbaijan, claimedthe right to self-determination, as they constituted some 85% of this small mountainousarea. The ensuing war raged in the Karabagh until May 1994 and embroiled

Azerbaijan, Armenia, Iran, Turkey, Russia, the OSCE, other governments and the US,Both sides carried out forcible deportations (ethnic cleansing). 35,000 Armenians werekilled. 400,000 refugees have flooded into Armenia from Azerbaijan and the Karabagh,increasing the problems of homelessness and destitution.


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Ever the Crossing Place (as Philip Marsden puts it), Armenia has traditionally allieditself with Orthodox Christian Russia in its conflict with its Turkic neighbours.Nevertheless, in 1991, with President Gorbachovs perestroika and the disintegration ofthe Soviet Union, Armenians seized the opportunity to re-establish their independentnation on the national boundaries drawn by Stalin. (The western powers seem contentto seek resolution to the area conflicts on the basis of these arbitrary boundaries).With independence, Armenias traditional ability to import and export into the Sovietblock collapsed leaving her with a looming crisis as to how to feed her people.

Armenias internal political climate continues to reflect its traditional dependency onRussia, although there have been many moves to legislate for change. Armenia has aconstitutional government in which the President has extensive powers and the role ofthe legislature relative to the executive branch is severely circumscribed. Democracyexists, but the Governments human rights record is uneven. Election laws have beenbreached and freedom of speech is limited. Although the Soviet legal system is beingreformed, courts still operate largely as a rubber stamp for the prosecution. People arearbitrarily arrested and detained. There is evidence of the torture and ill treatment of

political detainees. Although the 1993 Law on Invalids provides for the social, politicaland individual rights of the disabled, the government does not have the resources tomake good its commitments in this area. The family is valued in Armenian society andthere have been attempts to shelter large families from the impact of the economicsituation, but disabled people are discriminated against by the wider population.Political power is increasingly concentrated in the hands of local appointees of theGovernment, for whom humanitarian issues may or may not be a priority.

There is currently a cease-fire in the Karabagh with Armenian and Karabagh troopsoccupying significant (10%) Azeri territory. (It is said that 60% of GDP is spent on thearmed forces.) For their part, Azerbaijan and her ally Turkey are still blockading

Armenia, from either side, although Turkey has recently allowed an air route to open up

to Istanbul. All goods must go in and out of the country through Iran or by air, becauseof the continuing tense situation in Georgia, where, just as in the Karabagh, the

Abkhazians have waged war to establish an, unrecognised, independent Republic,which also enjoys a fragile cease-fire. Latterly the Georgian port of Batumi has begunto be used for trade purposes, particularly for the import of wheat for Armenia.

Armenias ability to secure any future benefit from the anticipated economic boomengendered by the discovery of abundant supplies of gas and oil in the Caspian Sea isseverely compromised, not to say hijacked, by the war and by its siege status inrelation to its Turkic neighbours. Oil rich Azerbaijan is the regions centre of economicattention and activity. A search for the wars solution is tied to the struggle to control oilexploration and transhipment. Russia will exploit gas supplies in the area and plans tobuild a pipeline as joint venture with Armenia, to carry this gas via Armenia to Turkeyand Middle Eastern markets. Armenia wishes to continue its ties with Moscow and tocollaborate with the Russians on this venture, which would also enable Russia totransport Azeri gas and thereby to tap into Azeri oil and gas revenues. The stalematewith the Azeris threatens these plans. It also means that Armenia has virtually nochance of hosting the new pipeline planned by the Azeris to carry their oil to the worldmarkets via the Black Sea and so charging a levy on the passage of Azeri oil.

Armenias economic future would appear to depend on a speedy resolution to the


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Nagoro-Karabagh issue. But, if resumption in fighting seems unlikely, a resolution tothe issues appears even less so. Internal Armenian politics are profoundly confusingfor the outsider, but in essence hard-line intransigence over the Karabagh issue, borneout of old wounds, battles with pragmatism over oil issues. Time is running outbecause the route of the oil pipeline will have been decided before the nextparliamentary elections in 1999.

Armenias relations with its neighbours have other economic implications. Thecountries export profile is a disaster with jewellery accounting for 33% and 25% of hertrade going to Turkmenistan, mainly in the form of barter. Most foreign investors arewary of setting up in Armenia if it means jeopardising business opportunities in

Azerbaijan.

There There have been some recent improvements on the economic front. Compared

to the cumulative decline in measuredoutput between 1990 and 1995 of 75%; growth is high and inflation is low. Foreigncapital is being encouraged and the sell off of state enterprises continues. Rottinginfrastructure is being replaced. (American Armenians have contributed to this to thetune of tens of millions of dollars through the Armenia Fund). A Nuclear Power stationhas re-opened and energy sources are being enhanced. The I.M.F. and the WorldBank disbursed funds recently and look favourably on Armenias programme forwithdrawing state subsidies and intervention in the economy and Public services.

However the problems are huge. There is 80% unemployment (Univ. of Michigan)(90% according to BBC TV - 12/11/97) and a similar percentage living in absolute orrelative poverty or impoverishment.(UNDP) Armenian industry is working at 30% of

capacity. Growth in GDP is likely to slow to 3% this year because of the continuingdepression in the countrys industrial base. Inflation is on the rise as a result of the

loosening of monetary and fiscal policy. A consumer boom, supported in large part bythe Diaspora, is fuelling imports leading to a $500,000,000 current-account deficit, andrising. But none of this changes a bleak long-term outlook according to thecommentators.


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Once Armenia has sold its few prize assets it will be faced with the same toughquestions it needs to ask itself now... Why should investors be interested in Armeniawhen neighbours are outperforming them economically? Why can an Armenian BankerI met give no hint as to what an outsider might successfully invest in at the moment?How can a landlocked country describe itself as an important regional crossroads whenmost of its borders are closed? The graphs attached give some indications of theproblems being faced by Armenia.

Against this backdrop and in line with many other countries that are adjusting to thenew economic realities dictated by the IMF and the World Bank, major changes aretaking place in the Armenian Health service. 80% of the beds in medical institutions areapparently empty because people have no money to pay for services that used to befree. It is clear that change needed to happen. In all medical and psychiatric sectorsthere was significant overprovision of beds. Experts suggest that Armenia couldmanage with 10,000 beds as compared to the existing 28,000 if the smaller numberwere efficiently and effectively utilised. The tragedy appears to be the impact of theWorld Bank reforms on the way services are financed. State subsidies to Health are

said to create undesirable market distortions, which benefit the rich! The WorldBank argue that user fees for primary health care to impoverished rural communitiesshould be exacted on the grounds ofgreater equity and efficiency. It is clear tome that whilst such cost recovery schemes may ensure the limited and temporaryoperational viability of a select number of health centres, the clear tendency is towardsincreased social polarisation in the health care delivery system and a major reductionin health coverage and an increase in the already large percentage of the populationwhich has no access to health services at all. In other words, the strict adherence tomacro economic policy is leading to a major disengagement of human and materialresources in the health sector. There is evidence of these facts wherever one goes inthe Mental Health services in Armenia.


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Mental Health Problems in the ArmenianPopulation

The effects of recent history on the nations outlook are fairly obvious. Problems withmental health abound and are on the increase. The psychological trauma of war, death,earthquake, homelessness, extreme poverty and totalitarianism are everywhere.Depression is endemic, particularly among the refugee population and suicide rates arerising. For example, studies have revealed that more than 90% of refugees aresuffering from depression. The picture bears some comparison with other formerSoviet Block countries. The following tables from a paper by Dr T Tomov, a BulgarianPsychiatrist, and based on a WHO-Europe database, sheds some (unreliable) light onthe situation. Armenia it is suggested, has the lowest number of psychiatric beds per1,000 inhabitants. It also has the lowest number of psychiatrists and the lowest numberof admissions in the group of countries reported on, and the second highest number ofout-patient attendances. What is clearly missing from this picture in Armenia is anyservice in the community to meet needs that might in other situations and countries bemet through the institutional route. This may provide Armenia with a uniqueopportunity to consider adopting more care in the community orientated options andsolutions to the nations current mental health difficulties.

Psychiatric beds per 1000 inhabitants by country Admissions to psyshiatric wards and psychiatric wardsin general hospitals per 100,000 inhabitants by country

1982 1992 1982 1992

Albania 0.3 Albania 90.2

Armenia 1.0 0.7 Armenia 182.0 126.5

Belarus 1.2 1.0 Belarus 452.3 515.3

Bulgaria 0.9 1.0 Bulgaria 516.1 554.2

Croatia 1.3 1.0 Croatia 541.1 666.7

Georgia 1.0 0.9 Georgia 264.0 81.5

Kazakhstan 0.8 1.2 Kazakhstan 371.3 421.5

Latvia - 2.2 Latvia - 814.8

Lithuania 1.7 1.4 Lithuania 878.9 760.8

Moldova 1.0 1.0 Moldova - 468.8

Romania 2.4 2.8 Romania - -

Russia 1.5 1.3 Russia 458.8 428.1

Slovakia 0.9 0.9 Slovakia - -

Psychiatrists per 100,000 inhabitants by country Admissions per psychiatrist by country

1982 1992 1982 1992

Albania - 6.16 Albania - 38.3

Armenia 5.57 5.38 Armenia 32.8 23.5

Belarus 7.55 8.31 Belarus 59.9 62.0

Bulgaria 6.16 7.99 Bulgaria 83.8 69.4

Croatia 4.76 7.08 Croatia 113.6 94.1


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Georgia 9.04 8.66 Georgia 29.2 9.4

Kazakhstan 4.61 5.75 Kazakhstan 80.5 73.3

Latvia - 8.10 Latvia - 49.5

Lithuania 13.45 15.03 Lithuania 65.4 100.6

Moldova 6.74 7.88 Moldova - 61.4

Romania 5.45 6.26 Romania - -

Russia 8.00 8.78 Russia 57.4 48.8

Slovakia 6.74 7.70 Slovakia - -

Outpatient attendences per 1000 inhabitants by country

1982 1992

Albania - -

Armenia 61.6 65.3

Belarus 14.9 17.2

Bulgaria - -

Croatia - -

Georgia 67.6 83.5

Kazakhstan 26.2 12.8

Latvia 71.6 52.4

Lithuania 11.1 52.8

Moldova - -

Romania - 7.3

Russia 52.0 -

Slovakia 148.8 -


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Organisation of Services

Lack of everyday resources is the first key issue for Mental Health services. In 1995WHO European Regional office had as one of its priorities the "treatment andimprovement of care in psychiatric institutions. Of particular concern to WHO in theCaucasus countries are the living conditions of mental health patients inpsychiatric institutions. Most institutions have only two wards one for men and

other for women, which are usually unheated. For many of the patients, the onlyclothing they possess are their pyjamas. They receive only small rations of breadand occasionally soup. Even in summer, patients are confined inside for 24 hoursa day. Staff in the first Psychiatric Hospital I visited told me that food provided for thepatients came from the Red Cross, as the funds provided by the state were insufficientto feed people. Medicines are in extremely short supply. When available, modecateby depot injection is used in large amounts as a chemical straitjacket because of lackof staff.

The infrastructure of Mental Health services and the thinking behind them are verypoorly developed. There is absolutely no evidence of any form of communityorientation, or the recognition of the importance of the social dimension. The influence

of what is called the Moscow School of Psychiatry is everywhere. (Dr Salatian, anArmenian psychiatrist working in Scotland was told on a recent visit that Insulin therapyis still used in a hospital in Yerevan.) There is one small recent textbook on Psychiatryavailable in Armenian. The Psychiatry textbooks translated into Russian by the GenevaInitiative on Psychiatry have not appeared.

As a result of these two factors the Armenian Mental Health System is largely custodialtoday. As an individual citizen experiencing Mental Health problems ones first port ofcall is the Polyclinic where one may occasionally find a Psychiatrist. This the Sovietequivalent of the UKs primary care services and the model provides for a wide rangeof specialist services to be available at any clinic, which covers a much largerpopulation than a Health Centre in the UK. The model, though excellent, is severelycompromised when the specialist services arent available.

The next port of call is the nearest Regional Psychiatric Dispensary (hospital), of whichthere are four. These vary considerably in standard. (I go on to describe two in thenext section). As in other ex-communist countries, there is an unlocked hospital calledNeuroses Hospital for people with neuroses and depression in Kasakh (nearYerevan). The future of the Stress Centre, formerly the Institute for Mental Health inYerevan is also in doubt. Should you require any other more long-term services thenthe options diminish to three institutions for chronic patients (two of which I describelater.)

There are no community based mental health services of any sort. There is no evidence of

any team approach to mental health care. There is no special training of psychiatric nursesand there are no social workers and few professionally trained psychologists. Psychiatristsin training at the Medical University in Yerevan have only sporadic contact with the west.

The WHO Report on the Caucasus which I have quoted above, went on to suggest that theWHO is organising intensive courses on post-traumatic stress disorders and psychologicalrehabilitation, and in some psychiatric hospitals, WHO is setting up demonstration projectsaimed at small groups of patients. I did not see any evidence that this programme hasreached Armenia.


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FINANCING OF HEALTH CARE IN ARMENIA COMPARED TO SELECTED COUNTRIES

Armenia Rep-ublic ofKorea**

Costa-Rica**

Argentina

Paki-stan**

1993

Actual

1994

Actual

1995

Estim-ated

1996

Project-ed

1990 1990 1990 1990

1. GDP per capita (PPP$) 510.0 365.0 616.0 791.0 6,733.0 4,542.0 4,295.0 1,862.0

2. Public expenditure on healthcare (as % of GDP

3.6 1.4 1.1 2.4 2.7 5.6 2.5 1.8

3. Total expenditure on healthcare (as % of GDP)

- - - - 6.6 - 4.2 3.4

4. Public expenditure on healthcare per capita in absoluteterms (PPP$)

18.4 5.1 6.8 19.0 182.0 254.0 107.0 33.5

5. Total expenditure on health(PPP$)

- - - - 444.0 - 180.0 63.3

* Calculations based on data provided by the ROA Directorate of Statistics

** Source HDR 94,94

Another key area of concern is the way in which services are now funded. As part ofthe changes required to adapt to the new economic realities the budget, which isannually voted on (the voted budget as it is known in Armenia) is now no longerdisbursed through the Ministry of Health. In line with the new policies ofdecentralisation, the budget is passed to Governors of Regions. These are unelectedand personal appointments of the President. In their own areas they are establishinglittle local ministries of health and the relationship between centre and periphery inthis area is unclear. It is interesting to note that although the state appears to beheading for a 90% plus spend on the voted budget this year, local psychiatricinstitutions will be doing well to receive 50%! In some months only 35% of that monthsbudget actually appears. Significant arrears of wages are therefore an ongoing part of

the pain. One may well wonder what is happening here.

One of the key changes to have been unleashed in Armenia is the transformation ofstate services into public enterprises. This seems a crude attempt to privatise bystealth, (appendix) and is full of dangers for the future. I will illustrate this point in moredetail because it is a central concern of mine in Armenia. Issue 40 (8 Oct.1997) of theEnglish language weekly, the Noyan Tapan contains an article entitled, Number ofPsychoes growing in Armenia. It says that German POWs built Sevan Hospitalwhich I visited (in 1943). It now apparently has all the basic necessary conveniencesfollowing refurbishment by IFRCRC and the Red Cross of Armenia with funding fromthe EU ECHO programme. This view may not be shared by anyone who has actuallyseen the place and I shall return to this institution later. Included in this programme itwould appear that funding was used to develop Greenhouses on the Hospital site,ostensibly to provide activity for the patients. The reality may be a little moreproblematic and potentially embarrassing for the European Union which funded theseactivities trhough the ECHO prorgramme. The bylaws governing these Hospitalsdescribe them as a Public Enterprise, organised and conducted in compliance withthe Republic of Armenias laws on Enterprise and Entrepreneureship. Theseenterprises have the following main objectives:


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planning of internment activities

providing chronic neuro-psychiatric patients older than the age of 18 and normalold people with medical services and care;

organising work therapy of the patients and the elderly;

Undertaking production-economic, business and other activities notprohibited by the Republic of Armenias Legislation.

Comments about this type of production were made to me by a number of peoplethroughout my visit. For example The unfortunate trend of those occupationalactivities is to switch over to cheap forced labour exploitation orthis is a slaveregime. This suggests that Directors of Institutions (earning $36 month) when facedwith the grim financial situation in which they find themselves are resorting to usingpsychiatric patients as the means of production to generate income. This will and isleading to exploitation and worse. I felt that a new form of slavery is in the process ofemerging in Armenia.

Another unintended consequence of the changes can be found at Vardenis Hospital(one of the three institutions for the chronically ill). The free for all that currently

characterises the system has led to the existing 200 or so staff being turned into 400 orso part timers! The reason for this has nothing to do with the needs of the patients butreflects a means of extending a greater degree of political control and patronage byproviding employment. It is about buying votes!

The new system of paying for mental health services is an area that is still far fromclear though I did make strenuous efforts to understand what is going on! Pay for apsychiatrist is about $20 per month at present, so the need to supplement ones incomeis great, given that a basket of basic necessities is calculated at $70 per month.Under the heading of increasing the control of treatment costs the Ministry of Healthhas deemed that treatment foracute psychiatric cases is free for a maximum stay of 80days in patient care and the only outpatient treatment remaining free is that for

Schizophrenia and to a limited extent Epilepsy. After 80 days the patient is supposed toleave hospital but I was told that in practise he/she is simply discharged and readmittedthe same day. On average the length of stay for acute patients is in fact much less,some 20 to 30 days. It would appear that the hospitals for chronic patients are stillsupposed to be free. Non acute care is available on payment. Because medication is insuch short supply, particularly in the chronic hospitals, grave problems exist when itcomes to the availability of medication and many mentally ill people are simplyincarcerated and not treated. This then leads to visits to these institutions having aboutthem the quality of bedlam. (Bedlam is a corruption of Bethlehem, a priory inBishopgate, London which was converted in the last century into a lunatic asylum andthe word now means: mad-house; a mental institution; a scene of uproar;

pandemonium.)


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Into Bedlam

Regional Dispensaries

These are found in Yerevan, Vanadzor, Gyumri, and Kapan. These cater for in and outpatients, both acute and chronic. I visited two.

The Psychiatric Hospital in Vanadzor by contrast to other institutions seems to reflect

some degree of humanity and care for people. Seriously damaged during the 1988earthquake it has been restored and strengthened. As a building it therefore looksmore appealing and its location in the suburbs of Vanadzor means that it is accessiblefor local people. The Hospital supports a vast number of out patients and Psychiatristsregularly see 35 to 40 people per day. Having only 35 beds means that the staff areable to more readily individualise their care. The Director of the hospital, Dr. GayaneKalantaryan, also a member of the Mental Health Foundation is trying very hard tomaintain reasonable standards in the face of overwhelming odds. This year has seen a25% reduction in her budget for running the Hospital and significant pressure from theMinistry of Health to move chronic patients to Sevan and/or Vardenis Hospitals, bothlong distances away from Vanadzor. A basement area previously used as a workshop

for patients remains restored and unused due to lack of funds. The hospital used tomake pillows and sheets for other hospitals and there is desire to renew this activity asa means of generating income and activity for the patients.

The Avan or salt mine Hospital was so named because of its proximity to a salt mine.This hospital in Yerevan is also slowly being put to the torch. Bed numbers aresystematically being cut from 250 to 90 and staffing is down from 300 to 150. The RedCross of Armenia provides food. A Psychiatrist carries a caseload of 2400 patients!There is no heating in winter though efforts are underway to rectify this. Chronicpatients are being moved to Sevan Hospital. In all respects the standards at thisHospital show signs of age, decay and collapse.

Hospitals for the Chronically Sick

The Psychiatric unit at the Vardenis complex, in a remote rural area about 170kms eastof Yerevan, is housed in a building on the outskirts of the village, that resembles atypical communist block (of flats). This area has an edge of the world feel about it.

As one enters the building a noise begins to erupt. Not certain at first where it comesfrom ones eyes cast about in the gloom of the lobby and spot a hole that patientshave gouged out of the stone work. Roughly triangular in shape, some 15-20cms, itforms the frame round a pleading mouth. The mouth speaks with urgency and growingvolume as the noise inside increases. As the door opens to let us in a seething mass of

humanity beseeches us. I finally realise what it is all about. Cigarettes! This is a lockedmale ward and the desperation is about a smoke. This desperation even leads tosmoking the cotton inside mattresses.

Vardenis Hospital is a Hospital for chronic psychiatric patients recently the subject of areport sponsored by the United Nations High Commissioner for Refugees and theUnited Nations Department of Humanitarian Affairs. Medecins sans Frontieres


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(Belge/Greece) and the Young Medics Association of Armenia carried out thisinteresting report (Feb.1997). It reported that Vardenis has been assigned toaccommodate 150 beds for 1997. At present there are 140 beds occupied by 124patients. There are 4 wards, 2 each for men and women. About 110 people areadmitted and discharged each year. In 1996 there were 18 deaths recorded or about15% per annum. There is one nurse for each 30 patients and one auxiliary nurse foreach 18 patients. There is one Psychiatrist who is supported on demand by a GeneralPractitioner, dentist and Surgeon. Of the 124 patients a recent report suggested that

there are 39 people who should be discharged. (29 to the Internment and 10 out of thehospital).

Vardenis Internment is a Hospital refuge for mentally retarded or physicallyhandicapped people older than 18. It is assigned 120 patients and currentlyaccommodates 94 of whom Kharbert Orphanage recently transferred 7 to theinternment. Instead of the 33 auxiliary nurses that should be available there are atpresent only 24 and instead of 9 general nurses there are only 5. At least one elderlyrefugee from the Karabagh is housed in this institution even though she suffers nopsychiatric illness or mental retardation.

The smell of urine is everywhere. On entering the Internment I find myself in a small

room. There is a mattress in the corner on which are huddled a pathetic group ofphysically and mentally handicapped youngsters. Several are rhythmically bangingtheir heads against the wall. There are four bare newly painted walls and no staff inevidence. There is nothing to do and nowhere to go. The Ministry of Health hasdecided that a further 15 kids should join this group from the Kharbert Orphanage.

The Hospital complex is currently undergoing renovation and repair thanks to Medecinssans Frontieres. A new roof and windows means that patients may survive the winter ina modicum of greater comfort. At present funding for heating fuel is not available andappeal letters have been sent far and wide.

Conditions in both Institutions are much the same and fall well short of any reasonable

standards in all aspects.A story is told of Hospital staff recently discovering that a female patient was sevenmonths pregnant with twins. The pregnancy went to term and she went to a medicalhospital for delivery. The babies were born alive but by the next morning they weredead. Sexually active women in the Vardenis complex have since received IUDs.

Sevan Psychiatric Hospital and Alcoholics Dispensary is much larger and could behome for up to 590 patients. At present it houses about 400 but numbers are growingas the Ministry of Health forces transfers of chronic patients from Hospitals in Yerevan.It consists of 2 departments each for men and women, a department for children, and 2departments for drug addicts and alcoholics (1 for general treatment and one for

obligatory treatment, although there are no obligatory patients at present). Assignedfor 120 patients these 2 departments currently only have 15 patients. The childrensunit is assigned 30 patients and currently has 9.

The hospital is housed in a German POW camp dating from 1943. Patients areaccommodated in rooms of up to 30 each. Much basic work remains to be done to theinfrastructure of the Hospital to bring it up to acceptable standards. I was only allowed


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to see the best parts of the hospital. In a small courtyard a large group of variouslydejected and angry women became silent as we approached. On my way out a womenwith crystal clear eyes and an educated voice said to me in perfect English, please,please help me leave this place.. Typhus continues to be a serious problem.

I did not visit the third institution for chronic patients, Noubarashen in Yerevan.


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The Legislative Context

The simple answer is that there is no specific Armenian mental health legislation.Russian Law No 225 of 21 March 1988 (see appendix) is the general guidance thatpsychiatrists are supposed to adhere to. It is not enforceable as Armenian Law.

Culturally the family would still seem to hold significant sway and influence admission

and discharge. Psychiatrists are extremely reluctant to take the risk of dischargingsomeone if the family hasnt taken back the responsibility. In Vardenis Hospitalbecause of communication difficulties nurses often admit patients. Some Psychiatristsbecome very upset when one questions the current situation. Stories are certainly toldof Psychiatrists admitting people, particularly troublesome wives in this highlypatriarchal society, in return for payment. Gathering real evidence of such malpracticewould be extremely difficult. The climate certainly seems right for such type of activity.

As in Romania it seems reasonably clear that one way to avoid military service is topay a Psychiatrist to find you mentally ill. Because of visa problems with the US newincome can now be generated by disappearing the previous diagnosis and file! It isalso clear that individual Psychiatrists in Armenia collaborated with the KGB andindividuals were sent to Forensic units in Armenia or the Ukraine for treatment for

political and other reasons.

Typical of the communication problems in Armenia is the activity that is taking place inan attempt to draft a law on Mental Illness/Health. Unbeknown to each other the MentalHealth Foundation of Armenia is busily trying to get the Geneva Initiative on Psychiatryfrom Hilversum, Holland interested and involved whilst Medecins sans Frontieres hasestablished a working group with Toralf Hasvold, WHO Public Health Advisor in

Armenia.

It is a matter of great concern that no law exists. However in a situation where theindependence of the Judiciary from political pressure is so seriously in doubt, onewonders how much difference the best law in the world would make. (US Department of

State report.) I have no evidence that there is any ongoing abuse of psychiatry forpolitical reasons now.


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Non Governmental Mental HealthOrganisations in Armenia

The Mental Health Foundation. A recent entrant on the scene, exists more as adream of its members than a measurable reality. They have no staff and no Office. Noequipment and no money. But they do have experience and a passionate willingness to

do something; particularly to bring more modern thinking into play. They are particularlyconcerned about the lack of mental health legislation. They are also keen to see thedevelopment of the NGO sector in Mental Health, particularly the establishment oforganisations for Users/ Survivors and for Relatives. The organisation would appear tohave a significant range of highly useful connections. I had the pleasure of meetingwith a large group of members of this organisation and was impressed by the crosssection of interest it represented; psychologists & psychiatrists in the main with one ortwo users and parents/relatives.

Centre Datev 95 has been in existence for a number of years. Impressivecommitment and real involvement with groups of Refugees means that it is the onlymental health organisation that I met which was actually working as an NGO

exclusively in Mental Health. Of course they have no resources either but this hasntstopped them from having a symbiotic relationship with a private organisation doingreflexology training for Armenians. From this relationship they have obtained officespace and other practical support.

In the period May 1996 to May1997 they have offered psychological assistance to agroup of 18 refugee teachers, counselling to 165 war victims, assistance to 223children in a range of institutions, psychotherapy for 56 people in Yerevan, training for190 teachers and other professionals in a variety of courses.

Datev 95 suggests, like others I spoke to, that foreign organisations left Armeniawithin a couple of years of the earthquake. This meant the end of significant foreign

material, humanitarian and other assistance. The situation remains critical in their view.There is a complete absence of decent psychological services. This means that thegrowing number of people with totalitarian trauma, post-traumatic stress disorders,phobias, neuroses, psychosomatic disorders, and suicidal behaviour amongst thegeneral population have no where to go for help. Also the obvious problems associatedwith refugees, orphanages, street children, elderly, earthquake victims and the mentallyand physically ill/disabled and handicapped are overwhelming and with no hope ofresolution in the current climate.

Mission Armenia, created in 1993, is a well-established and highly regarded ArmenianNGO although only tenuously placed under the heading of mental health. It has beenactively supported by Oxfam and undertakes a range of community based work, mainly

for up to 3000 elderly people. It employs its own Doctors, Nurses and Social workers.They suggest a growing problem of suicide amongst elderly people who wish to avoidbeing a burden on their relatives in these hard times. They do not have experience ofworking in the Mental Health field. Medecins sans Frontieres are in discussions withthem about taking over responsibility for running the therapeutic workshop at theVardenis Internment. Mission Armenia have worked with Medecins sans Frontieres onthe renovation of the hospital using money received from Save the Children Fund.Mission Armenia expresses the hope of becoming more actively involved in the area of


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mental health. Mission Armenia identifies training for their staff and public educationand attitude change as growing concerns.

Professor Hasmik Gevorkian established the NGO for Social Work and SociologicalResearch in October 1997. I am not clear if it exists as a legal entity. It suggests it hasan interest in the growing numbers of people committing suicide in Armenia and workwith injured people, the handicapped, elderly houses, terminal illness, institutions foryoung people and womens centres, particularly for those suffering from maritalviolence. I was unable to obtain any further written information about this organisationor its activities.

Apart from these organisations I heard about the Armenian Psychiatric Associationfrom Prof. Melik-Pashayan at the Medical University of Yerevan. I take this to be aprofessional association. I also heard about the Society of Psychoanalytical Studies(Dr. Ara Chalikyan).

The concept of an NGO and the rules that should apply to its activities would appear tobe poorly understood and developed in Armenia. There is significant blurring of rolesand boundaries in organisational life. Members of the board of one organisation arealso the paid senior staff of the same organisation. A model that is familiar in theprivate sector but less so in a not for profit NGO. This does not apply to the MentalHealth Foundation of Armenia. There is no evidence of networking or the exchange ofideas amongst NGOs and during my visit I was at times facilitating the beginnings oftentative contact between local and local as well as between local and internationalNGOs. People seem quite ready to embark on major schemes without the benefit ofany organisational infrastructure. There is innocence about the understanding of theNGO sector and its activities.


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The Future of InterMinds work in Armenia

In our work in Eastern Europe we use our limited resources to work at a macro andmicro level in developing the NGO sector in mental health. At a macro level wesupport the work of a national NGO (for example the Romanian League for MentalHealth). An extract of their current strategic plan is in the appendix. As a nationalmembership organisation it has important developmental, advocacy, educational and

campaigning roles in Mental Health. It develops its own policies and practices as wellas proposing legislation. It raises awareness and combats stigma, prejudice and humanrights abuses through Mental Health promotion and other work. Together with theRomanian League for Mental Health, InterMinds (previously Penumbra International)(at a micro level) entered a partnership to establish a Romanian community based andservice providing NGO that could innovate and develop pilot and demonstrationprojects. In Romania this is the Estuar Foundation which is now a highly regarded andsuccessful organisation both in Romania and further afield. This model has clearapplicability in Armenia and in particular the development of the NGO sector in mentalhealth.

The need for clear local advocacy and champions for change is obvious. The

importance of the political agenda must not be under-estimated. A major politicalstruggle looms. To pressure both national, and of increasing importance, localgovernment in to adopting policies and practices that begin the long process of meetingthe needs of people with mental illness and mental health problems. This is anenormous task and requires serious commitment from organisations from outside

Armenia. This is not a hit and run scenario. Political will is the engine of thechange process.

InterMinds, in its Board members, staff and UK and international partners, intend tobring their significant project and organisational development experience into workingactively in partnership with the Mental Health Foundation. We would, throughworking with it closely and advising it, assist it in becoming the leading nationalumbrella NGO in the Mental Health sector in Armenia. As there are alreadyorganisations on the ground which wish to develop their activities we will work withthem to achieve their aims. In particular this would be Centre Tatev 95.

We would assist in the establishment of a national user organisation as well as anational organisation representing the interests of parents and relatives in order todevelop their capacity as stakeholders. As a priority in our view however, significantenergy should be expended on developing local stakeholder groups, bringingconcerned people together who are prepared to take on the political agenda in theirareas and campaign for appropriate policies, practices, resources and services.

We would assist with the working group established in Armenia to draft new mentalhealth legislation.

Appropriate training would be provided to Board and staff members of these emergingorganisations. This would include organisational development and management,financial management, fundraising, quality and evaluation, campaigning and lobbying,media relations, advocacy (safeguarding, empowerment) and human rights in mentalhealth. Care in the Community, alternatives to institutional care, assessment of needincluding self-assessment and risk assessment would also be covered.

A programme ofexchanges and study visits would be established and seconded staffmay be used for particular purposes such as the early stages of a project not previously


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tested in Armenia.

Specific project proposals were received from organisations to do work with youngpeople, adults, war victims and refugees with Mental Health problems. (A synopsis ofthese is found in the appendix)

InterMinds would actively assist these organisations in reviewing their plans andpriorities and would enage itself closely in their struggle to bring real hope and changeto mental health services in Armenia.

In his book, Passage to Ararat, Michael J. Arlen writes, I realised at that moment tobe an Armenian, to have lived as an Armenian was to have become somethingcrazy. Not crazy in the colloquial sense of quirky or charmingly eccentric ., oreven of certifiably mad. But crazy: crazed, that deep thing-deep where the deep-sea of souls of human beings twist and turn.


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APPENDIX 1

The Legislation

1. General Considerations

1.1 Vardenis Internment Public Enterprise has been founded with the objective oflooking after neuro-psychiatric patients and the elderly.

1.2 Vardenis Internment public enterprise (hereinafter referred to as Enterprise,is the legal heir of RA Social Welfare Ministry Vardenis No 7 budget basedboarding house for neuro-psychiatric patients.

1.3 Founder of Enterprise is Gegharkunic Marz of Republic of Armenia.

1.4 Enterprise activity shall be organised and conducted in compliance with RA lawon Enterprise and Entrepreneurship, other RA legislative acts, decrees, ordersdirections of Geharkunic Marz and the Rules herein.

1.5 Enterprise is a juridical person, possesses a balance of its own, bank account,round seal and with the National Emblem, other requisites.

1.6 Enterprise has Armenian as official language, English and Russian aslanguages of international communications.

1.7 Enterprise official name is:

full name - RA Gegharkunic Marz Vardenis Internment Public Enterprise

Short name - RA Gegharkunic Marz Vardenis Internment PE

1.8 Enterprise Juridical Address:

Republic of Armenia, Gegharkunic Marz, town of Vardenis, Andranik str.1

2. Enterprise Main Objectives

2.1 planning internment activities;

2.2 providing chronic neuro-psychiatric patients older than the age of 18 and normalold people with medical service and care;

2.3 organising work therapy of the patients and the elderly;

2.4 undertaking production - economic, business and other activities not prohibitedby RA legislation.

3. Enterprise Rights and Liabilities

With the consent of the Founder the Enterprise has the right to:


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3.1 in compliance with provisions of legislation obtain, reconstruct and by othermeans not prohibited by the RA legislation establish any kind of legal,organisational enterprises and through them conduct business transactions;

3.2 by any means not prohibited by legislation acquire properties, includingcertificates, possess and use them and the earnings received from them;

3.3 on contractual basis use the property and belongings of other organisations andindividuals;

3.4 establish own financial resources including loans, in RA and other countriesreceive bank and trade loans, also in foreign currency;

3.5 with the consent of the Founder give on rent, exchange and by other means notprohibited by RA legislation, transfer property rights, act as mortgagor andmortgagee;

3.6 sign contracts and discharge duties pursuant to provisions of RA legislation;

3.7 with the consent of the Founder choose transaction rules of its foreign economicactivity, and exercise it directly without any mediators, or through a mediatorspecialised in the foreign economic field, or another organisation establishingcontractual relations with it;

3.8 possess finances in foreign currency, obtain them in the result of externaleconomic activities, and by any means not prohibited by RA legislation possessthem having paid taxes and pursuant to provisions of RA legislation sell them toGovernment, organisations or individuals;

3.9 plan activity in compliance with provisions of RA legislation with obligatory andprior fulfilment of state order, determine volumes and prices of services beyondthe state order;

3.10 determine the in-structure, regulations, list of subdivisions and the internal

management system;

3.11 involve hire workers, sign labour contracts with them, fix their salaries pursuantto provisions of RA legislation;

3.12 establish rewards and pay them to enterprise workers, provide them withprivileges of enterprise services;

3.13 in legal form or through arbitration dispute activities of individuals, enterprises,banking corporations, financial institutions, other organisations andgovernmental bodies having caused damage to its interests, act as a claimant,respondent and mediator in court or arbitration tribunal.

4. Enterprise Liabilities

4.1 ensure high-grade diagnosis, preventive and rehabilitation assistance topopulation and their compliance with the established requirements;

4.2 ensure priority and quality in according to pursuing the signed agreement for thestate order and the requirements hereunder and RA legislation;

4.3 ensure protection of enterprise property and its optimal use;


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4.4 ensure optimal and rational expense of Enterprise transactions income;

4.5 conclude labour contracts with Enterprise hired workers or organisationsauthorised by them and presenting their interests, that according to RAlegislation are entitled to conclude agreements.

4.6 fully pay wages of all workers as signed their in labour agreements

4.7 ensure estimation and registration of conducted activities and services and

submission of monthly, quarterly and yearly reports on financial-economicactivities.

4.8 take actions towards expanding medical and other services beyond state order.

4.9 according to RA legislation bear responsibility and compensate damagescaused by the enterprise: breach or insufficient compliance with the agreements,including labour agreement, violating other persons propriety rights.

4.10 undertake the obligatory insurance of the hired workers in compliance withprovisions of RA legislation, ensure labour and leisure conditions for the hiredworkers according to the work agreement.

5. Enterprise Property and Financial-Economic Activity

5.1 Enterprise property, basic and circulating funds, financial means, target usefunds, are given to Enterprise on full management, disposal and use basiswithout right on property; sources of Enterprise property:

5.2 financial and material inputs of the Founder, transfer of rights of propertydisposal, its use and other property rights;

5.3 income from the realisation of goods, services and other economic transactions;

5.4 credits from banking corporations and other creditors;

5.5 capital investments from state budget, grants, additional payments, otherinvestments;

5.6 charity investments, donations by individuals and organisations;

5.7 other sources not prohibited by RA legislation

5.8 the Enterprise fulfills the State order providing the population with medical-preventive, rehabilitation assistance and service. Volumes of activity conductedwithin the state order, implementation and payment rules and conditions aredefined in State Order Distribution Agreement signed between Enterprise andthe Founder;

5.9 Sources of Enterprise financial means are: Founders financial and propertyinvestments, earnings from realisation of goods/work, service/depreciationcompensations, interests from banking corporations holding Enterprise means,insurance payments, other enterprise investments, as well as other monetaryinputs not prohibited by RA legislation.


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6. Management of Enterprise Activity

6.1 the Enterprise is in the custody of the Founder or his authorised body which isentitled to final decision in any enterprise activity referring issue

6.2 to Founders full authority refer:

defining Enterprise activity objectives and tasks

adopting and amending Enterprise Rules

verifying Enterprise activity annual results;

appointing and dismissing enterprise Manager;

issuing decrees on Enterprise activity suspension, appointing DissolutionCommittee, verifying dissolution balance;

6.3 Enterprise authorities are: Council and Manager acting within their powerstipulated herein;

6.4 Enterprise activity is controlled by Control Committee;

6.5 Council and Manager shall report to Founder. In case of insufficient activityresult, the Founder is entitled to withdraw the authority of Council members andManager and initiate new appointments before expiration of their periods;

Council Liabilities:

6.6 With the consent of the Founder and according to provisions of RA legislation,make resolutions on establishing, acquiring, reconstructing or, by any othermeans not prohibited by RA legislation, setting daughter and joint companies orany other legal-organisational enterprises; approve their institutional documents

and make changes or amending them;6.7 Approval of organisational internal structure of the enterprise and making

changes/amending them;

6.8 At least once annually, audit daughter enterprise activity results and makerespective decisions;

6.9 Appointment of Enterprise Control Committee members (on two-year basis) andtheir dismissal, auditing, at least once annually, the statement of controlCommittee and making relevant decisions;

6.10 Submission of suggestions to the Founder on changes or amendments in

Enterprise institutional documents;

6.11 fulfilment of assignments and other authorities issued by the Founder;

6.12 Council sessions are called on necessity but not less than once quarterly. AtCouncil sessions Manager acts as chairman; in case of his absence - once ofthe members by Council decision;

6.13 One third of Council members should be representatives not included in the


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administrative body;

6.14 Council sessions are valid if at least half of Council members are present;Council decisions are made by simple majority of members present, if Councilhas not set another rule for any particular issue. In case of equal votes Manageror the chairman has the final vote.

6.15 Enterprise Manager is at the same time Council chairman;

6.16 Enterprise Manager:6.17 within his authority without license acts in the name of the Enterprise, presents

its interests, maintains Enterprise property and financial resources;

6.18 concludes work contracts with enterprise employees and acts as employer;

6.19 issue licenses, opens accounts in banks;

6.20 approves/determines staff, issues decrees gives directions to Enterpriseemployees

6.21 directs Enterprise Counsel activities

6.22 within the requirements of the Rules herein and RA legislation fulfills his dutiesand tasks received from the Founder;

6.23 Enterprise manager and his deputies are appointed by Founder: Headaccountant is appointed by the Manager with the consent of the Founder;

6.24 On appointing the Manager a contract is signed between the Founder/hisauthorised body and the Manager which defines Managers rights, duties,responsibilities and his relationship to Founder, Managers payment terms,contract dates, resignation terms, contract suspension grounds and otherprovisions that parties may find necessary;

6.25 Control committee is established in the Enterprise and its members appointed bythe Council;

6.26 Enterprise Manager and Council members cannot be member of controlcommittee;

6.27 Control Committee elects a chairman amongst Committee members whoorganises Committee activities and keeps under observation the implementationof its decrees;

6.28 Control Committee authorised to: control over implementation of Foundersdecrees, as well as the compliance of committee-made decisions with Enterprise

Rules.;6.29 control over Enterprise property protection and financial economic activities;

6.30 control committee members are entitled to demand from Enterprise authoritiesand officials any data or records concerning issues within their authority;

6.31 Control Committee is obliged to at least once a year submit to EnterpriseCouncil a brief account on enterprise activity results, property protection etc.


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6.32 Control committee sessions are held on necessity but not less than once very sixmonths;

6.33 Control Committee sessions are valid if a least half of Committee Members arepresent;

6.34 Resolutions are carried by simple majority vote. In case of equal votesCommittee chairman ha the right to the final vote;

6.35 on issues at discussion the Committee makes resolutions, of which the Counciland the Manager are notified. If an issues is brought forward by the Founder heis notified as well.

7. Enterprise Activity Suspension

7.1 Enterprise discontinues its activity by the Founders decision or on any othergrounds anticipated in RA legislation;

7.2 Enterprise activity suspension is carried out through reformulation/division,separation, reorganisation or dissolution according to RA legislation;

7.3 Dissolution is carried out by Dissolution Committee set by the Founder; in caseof dissolution through court - by Dissolution Committee set by judicial bodies;

7.4 Dissolution date, rules and terms, as well as dissolution Committee rights andduties are set forward by RA legislation.


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The Law

Buildings, territory and structure of psychiatric hospital

19. The territory of psychiatric hospital, its buildings, premises, technical equipmentare arranged in compliance with the Rules on system and operation ofpsychiatric hospitals in practice and are maintained according to the

requirements of sanitary laws.20. To perform full inspection and social-labour rehabilitation of the patients, within

the psychiatric hospital medical, therapeutic-diagnostic, therapeutic-rehabilitation and other compartments, subdivisions and services will beorganised, the list of which is contained in section structure of hospital of Ruleson system and operation of psychiatric hospitals in force.

21. The activity of some compartments of mental hospital (forensic-psychiatriccompartments, day time stationary, therapeutic-industrial (labour) workshopsetc) can be regulated by separate laws.

22. To realise compulsory treatment, under the decision of the court, of the mentally

ill, having made an offence of offering socially-dangerous behaviour, acompartment with strengthened supervision can be set within the psychiatrichospital.

The order of receipt, keeping and routine of the patient in the compartment withstrengthened supervision are regulated by special laws.

Admission

23. Patients who can be admitted to psychiatric hospital:

persons, whose mental condition requires therapeutic-rehabilitation measuresin a psychiatric hospital;

persons, sent by judicial bodies for compulsory treatment;

persons, sent by judicial-inquiry bodies for stationary psychiatric examination(evaluation);

persons, sent to stationary examination for precise diagnosis, examination ofcapability for work, fitness for service in the army, etc.

24. Patients, requiring stationary treatment, are put in psychiatric hospitals whensent by doctors-psychiatrists of psychiatric health centres (dispensaries,cabinets), doctors of specialised emergency psychiatric brigades, public healthagencies, and also in case of existing urgent medical indications tohospitalisation.

25. Persons, sent to stationary examination for specification of diagnosis, medical-labour or miliary-medical examination, are accepted in psychiatric hospitalswhen sent by public health agencies, regional doctors-psychiatrists, and alsomedical-labour or military-medical commissions respectively.


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26. The order of acceptance and discharge from psychiatric hospitals of persons,sent for stationary judicial-psychiatric examination; and the ill sent forcompulsory treatment, is regulated by the current legislation and appropriatedepartment instructions.

27. An obligatory condition for placing a patient in mental hospitals for treatment orexamination, except for cases, stipulated by the current legislation, is his/herconsent to hospitalisation. Placing patients in psychiatric hospitals(compartment) is performed exclusively by the doctor-psychiatrist. If the person,being subject to hospitalisation, has not reached the age of sixteen or becauseof his/her mental condition is not capable of telling his/her will, consent tohospitalisation should be received from his/her relatives or lawfulrepresentatives, in case of their absence - from the head psychiatrist of theterritorial public health agency.

28. Mentally disordered who offer direct danger to themselves or surrounding andneed compulsory treatment, can be put in psychiatric hospitals without theirconsent and without prior notification and consent of their relatives or lawfulrepresentatives, as stipulated in current legislation and directions on the order ofurgent hospitalisation of the mentally ill.

29. On putting a patient/hospitalising in mental hospitals, the treating doctor of thepatient during the first days of hospitalisation notifies the divisional psychiatrist,as well as the psychiatric dispensary (dispensary compartment, cabinets)according to the patients permanent place of residence, as well as to his/herrelatives or lawful representatives.

30. In case of absence of indications for hospitalisation in psychiatric hospitals, theon duty doctor refuses reception. Each case of a refusal with its motivation isregistered in the book of reception and refusals of hospitalisation with thesubsequent notice within a day, to the medical institution that sent the patient.

31. On receiving a patient the on duty doctor checks the medical order andidentification cards, carries out a thorough physical examination, as well as aninspection of the mental and somatic condition of the patient, collects necessaryanamnestic data both from the patient and accompanying him persons andenters the information into the book of reception and refusals of hospitalisationand the medical card of the stationary patient.

32. In case of detecting signs of poisoning, wound or violence the on duty doctorimmediately notifies the local body of internal affairs and the department ofpublic health services of the region where the mental hospital is located.


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33. In case of absence of documents on the patient, and therefore impossibility ofidentifying him/her, he/she is registered in the book of unknowns and the localbody of the police is informed about his/her admission in the psychiatric hospitalwith the exact description of his/her signs or photo for subsequent identification.

34. The question on necessity of sanitary treatment of the hospitalised person isdecided by the on duty doctor.

35. Belongings, documents, money and valuable items of the patient are accepted,

kept and given out in the order, established by the appropriate instruction ofMinistry of Health of the USSR.

36. According tot he discretion of the on duty doctor, afterwards of the head of thedepartment, the patient is authorised to use his linen, clothes and footwear, toiletand cosmetic articles.

37. Children aged 4-14 brought to psychiatric hospitals are put in departments ofchildren, teenagers (15-17 years) - in teenager departments and wards. Note -in case of absence of teenager departments or wards, teenagers are placed indepartments for adults.


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Provisional Directions

on the order of urgent hospitalisation of psychiatric patient

The necessity of preventing socially dangerous behaviour of the mentally ill requires ina number of cases their urgent placement in psychiatric hospitals (compartments) withthe purpose of taking special actions of Prophylactics and treatment, assigned on the

bodies of public health by article 36 of Bases of Legislation of USSR and SovietRepublics on Health Policy. Pursuant to Laws on conditions and order of renderingpsychiatric help, the urgent hospitalisation of the mentally ill is applied in the followingorder:

1. Mentally disordered who offer direct danger to themselves or surroundings, can,exclusively under the decision of psychiatrists, be placed in psychiatric hospitals(compartment) without their consent, and also without prior notification andconsent of their relatives of lawful representatives.

2. An indication for urgent hospitalisation is the patients socially dangerous behaviour(aggressive actions, psychomotor excitation, suicidal behaviour etc and alsohigh probability of such actions) caused by the following peculiarities of his/herabnormal condition.

a) Inadequate behaviour owing to his/her psychotic condition (psycho motorexcitation, hallucinations, delirium, syndrome of psychic automatism, syndromesof disordered consciousness, pathological impulsiveness, heavy dysphoria;

b) Systematic delirious syndromes, provided that there is the probability of sociallydangerous behaviour;

c) Depression, if it is accompanied by suicidal tendencies;

d) Maniacal and hypo-maniacal condition, causing infringements of the public orderor aggressive behaviour towards his/her surroundings;

e) Psychopath-like psychiatric diseases with pathology of inclinations andincreased conduct activity;

f) Condition of deep psychic defect, presenting mental helplessness, hygienic andsocial neglect, vagrancy.

The above listed abnormal conditions, fraught with obvious danger for the patienthimself and the society, may be accompanied by externally correct behaviour. it isnecessary to be very cautious, particularly when estimating the mental condition of

such persons to prevent, with due hospitalisation, the possibility of publicly-dangerous actions by the insane.

3. Patients with simple alcoholic intoxication, except for sharp intoxication psychosisand psychotic conditions are not subject to urgent placement in psychiatrichospitals (departments). Emotional reactions, litigious activity and antisocial


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forms of behaviour of persons, showing only psychopathic and neuroticdisturbances cannot serve as indications to urgent hospitalisation.

4. Persons, having committed publicly-dangerous acts specified by the criminal law andthere are doubts as to their being mentally healthy, are sent to forensic-psychiatric examination int he order, specified by the criminal-procedurelegislation.

5. Urgent hospitalisation (if directions by doctors-psychiatrists exist) is directly carriedout by medical workers, on whom the public health bodies assign thesefunctions. In regions, where there are not enough doctors-psychiatrists, theorder on urgent hospitalisation is issued by the doctors, which are entitled torendering psychiatric help to population. In these cases the final decision onnecessity of urgent hospitalisation is taken by the doctor-psychiatrists of thehospital, where the patient is brought. The doctor, sending a patient to apsychiatric hospital for urgent hospitalisation should, in legible handwriting,specify in his notice, that the patient is directed on urgent hospitalisation basis,give detailed reasons, in the conclusion specifying his position, place of work,last name and date of issuance of the order.

6. Bodies of internal affairs are obliged to assist, whenever addressed, the medicalworkers in realising urgent hospitalisation of the mentally ill in case of:

Resistance, aggression or their possibility, other actions on part of the insanefraught with danger to the life and safety of the medical workers, as well astheir attempt to escape.

Resistance to urgent hospitalisation of the insane on part of his relatives,lawful representatives or other persons;

Necessity of search and detention of the insane.

In case of urgent hospitalisation of a mentally ill, presenting obvious danger forhim/herself and surroundings, from the place of his residence is necessary and itis highly probable, that he or his relatives will offer resistance, workers ofpsychiatric-neurological dispensaries (dispensary departments, wards) andemergency groups, can address to agencies of internal affairs of the territorywhere the mentally ill is likely to be, for assistance. The head of the agency ofinternal affairs or the person, replacing him, provides the arrival of the police at afixed time and respective address for rendering assistance to medical workers.On hospitalising a mentally ill, having no relatives and friends, or livingseparately, the police workers together with the administration of the householdtake measures to ensure hereunder safety of the property of the mentally ill.

7. On accepting a mentally ill in a psychiatric hospital (department), the on duty doctor-psychiatrist is obliged to make certain personally of the necessary indications forurgent hospitalisation and make a record on the title page of the in-patientsmedical card (form N003/y) and in the book of admission and refusals ofhospitalisation (form N001/y), that the patient is admitted as an urgentlyhospitalised.

In cases, when the on duty doctor-psychiatrist finds no grounds for urgent


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hospitalisation, and the patient or his relatives and lawful representatives do notgive consent to hospitalisation, the on duty doctor refuses to place such patientin a psychiatric hospital (compartment) and makes a motivated record in the log-book of admission of patient and refusals of hospitalisation.

8. The administration of the psychiatric hospital (department), (on days off and holidays- the on duty doctor) is obliged to immediately notify in writing or by phone therelatives of the patient or his lawful representatives, and also the higheragencies of public health services about his/her hospitalisation and a record ismade in the patients medical card on who, when, to whom and in which way hasforwarded the notice.

9.The mentally ill, accepted in a psychiatric hospital (department) on urgenthospitalisation basis, are subject, except for days off and holidays, toexamination by a commission of doctors-psychiatrists, consisting of the treatingphysician, head of the department, head of the institution (his deputy on medicalpractice or persons authorised by the head of the institution), which solves theproblem on validity of urgent hospitalisation and necessity of compulsorytreatment. The motivated conclusion of the commission, signed by all themembers of the commission, is entered into the medical card of the patient.

If the commission find necessary to leave the patient in the psychiatric hospital(department) for compulsory treatment, the administration of the hospital(department) forwards the motivated conclusion within a day to the mainpsychiatrist of the public health agency of the region (under whose authority thepsychiatric hospital (department) is located) for consideration and control, andalso informs the relatives of the patients or his lawful representatives.

The conclusion of the commission about no substantial basis for urgenthospitalisation and compulsory treatment will be followed by the patientsimmediate release. Such persons can be left for treatment in the psychiatrichospital (department) only with their consent, or with the consent of his/her

relatives or lawful representatives if the patient is unable to express his/her will.10. The mentally ill admitted in a psychiatric hospital (department) on urgent

hospitalisation basis, are subject, not less than once a month, to examination bya commission of doctors-psychiatrists, consisting of the treating doctor, head ofthe department and head of the institution (his deputy on medical practice orpersons authorised by the head of the institution) to decide the question ontermination or prolongation of compulsory treatment. The motivated conclusionof the commission is entered into the medical card of the mentally ill.

In the case these patients remain in the psychiatric hospital more than 6 months,decision on prolongation of compulsory treatment is taken by the main

psychiatrist of the public health agency of the region, according to the location ofthe psychiatric hospital (department) not less than once every six months, onsubmitting to him the motivated conclusion of the commission of the givenhospital (department).

11. The main psychiatrists of public health agencies are obliged to exercisesystematic control over strict observation of rules established hereunder,


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APPENDIX 2

People and Organisations

Vladimir Karmirshalian, Director, Centre for Democracy and Human RightsAnahid Tevossian, Chairperson, Datev 95 Psychotherapy and Counselling

Oliver Lacey-Hall, United Nations Department for Humanitarian Affairs

Miguel de Clerck, Head of Mission, Medecins sans Frontieres

Dr John Mitchiner, British Ambassador to Armenia

Hripsimeh Kirakossian, President, Mission Armenia

Dr Hasmik Gevorkian, Professor, Department of Sociology, Yerevan State University

Professor Marietta A Melik-Pashaian, Psychiatrist, Chair of Psychiatric DepartmentMedical University, Nork Psychiatric Hospital

Levon Nersisian, President of Union to aid the invalid children

Svetlana G Topchyan, MD, United Nations Population Fund

Sergei Yeritsian, Journalist and Member of Parliament

Dr Sebouh V Monjian, President, Young Medics Association

Dr Norayr Darbinian, Director, Yerevan Psychiatric Dispensary, Avan Hospital

Dr Marouch Eghiar, Vice-Director, 6th Childrens HospitalDr Gayane Kalantaryan, Director, Vanadzor Psychiatric Dispensary, Lory Region

Dr Horhannes Dourgarian, MP Vice-Chairman of the Commission on Health, SocialCare and Employment, Parliament of Armenia

Dr Arman Vardanyan, President, Mental Health Foundation of Armenia

Dr Gagik Horhannissian, Director, Sevan Hospital

Dr Miral Salatian, Psychiatrist, Forth Valley Health Care Trust

APPENDIX 3


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Organisations Visited

Mental Health Foundation of Armenia (NGO) Yerevan

Datev 95 (NGO) Yerevan

Mission Armenia (NGO) YerevanMedecins sans Frontieres (NGO) Yerevan

A refugee facility for elderly people and orphans in Vanadzor

Centre for Democracy and Human Rights, Yerevan.

United Nations Department for Humanitarian Affairs, Yerevan

Vardenis Psychiatric Hospital and Internment

Sevan Psychiatric Hospital, Sevan

Avan Psychiatric Hospital, Yerevan

Vanadzor Psychiatric Dispensary and Hospital, Vanadzor

British Embassy, Yerevan

Medical University, Yerevan

The Stress Centre, National Institute for Mental Health and Rehabilitation, Yerevan

Astghik Union, A Parents NGO


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APPENDIX 4

Out of Country Contacts

Armenian Ambassador, Brussels

European Regional Council of the World Federation for Mental Health, Mrs Josee vanRemoortel.

Geneva Initiative on Psychiatry, Mr Robert van Voren, Director

WHO Geneva, Dr Stanislas Flache

Amnesty International, UK

Oxfam UK

Department for International Development, Know How Fund, Foreign Office, London,UK

Jane Gabriel, Gabriel Productions- Independent film producer, UK

Mrs Ter-Petrosian, wife of President of Armenia (World Federation for Mental Health,First Ladies for Mental Health group, via Josee van Remoortel)


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APPENDIX 5

References

The Crossing Place Philip Marsden

Report on Vardenis Psychiatric Complex. 12-26 Feb.1997 MSF Belge/Greece and theYoung Medics Association

The Globalisation of Poverty. Michel Chossudovsky

Armenian Human Development Report 1996 UNDP 12 September 1996

Fact Sheet: Armenia The University of Michigan-Dearborn

Black Sea. Neal Ascherson

The lost Heart of Asia. Colin Thubron

Sketches of a Karabakh soldier 1918-1920. Zareh Melik-Shahnazarov

Report on the activities of the Datev 95 Charitable Centre for Psychotherapy andcounselling assistance. May 1996 to May 1997

Mission Armenia Report

Centre for Democracy and Human Rights Report

The Law governing the Buildings, Territory and structure of Psychiatric Hospitals.

The Vardenis Internment By-laws

Minutes of a variety of meetings including meetings concerning Mental Health

Legislation with Toralf Hasvold MD, WHO Public Health Advisor for Armenia andGeorgia

US Department of State Country Report on Human Rights Practices for 1996

Amnesty International Report for 1996

Helsinki Monitor 3/1995 Russia, the OSCE, and Security in the Caucasus

Helsinki Monitor 7/1996 A marriage of convenience: The OSCE and Russia inNagorny-Karabakh and Chechnya

EURO WHO (European Region) Report


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APPENDIX 6

ROMANIAN LEAGUE FOR MENTAL HEALTH

STRATEGIC PLANNING

OUR VISION FOR THE FUTURE IS: To become the leading membership basedorganisation shaping Government policy and promoting alternative practices in mentalhealth in Romania.

OBJECTIVES

1. Establish a critical mass of active individual members (powerful membershipbase)

2. Attract critical mass of organisations (powerful membership base)

3. Create programme and present to Ministry and Parliament (shaping governmentpolicy

4. Collect and distribute information on all alternatives (promoting alternativepractices)

5. Act as a catalyst for other peoples projects (promoting alternative practices)

STRATEGIES

Objective 1 Establish a critical mass of active individual members (powerfulmembership base)

Strategy 1 Enlarge membership

Strategy 2 Convert enough members into activists

Objective 2 Attract critical mass of organisations (powerful membership base)

Strategy 1 Draft and consult with balanced/mixed experienced outsiders andseek membership approval

Objective 3 Create programme and present to Ministry and Parliament (shapinggovernment policy)

Strategy 1 Share common government programme


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Objective 4 Collect and distribute information on all alternatives (promotingalternative practices)

Strategy 1 Create resource centre

Objective 5 Act as a catalyst for other peoples projects (promoting alternativepractices)

Strategy 1 Evaluate projects and find leader/team

armenia a country report by peter kampman

Documents