I più, deboli, gli ultimi sono coloro che pagano più duramente le conseguenze della guerra combattuta nell’Ucraina orientale, dopo la rivolta dei filorussi diretti, fomentati ed equipaggiati dal regime di Putin. Le condizioni igieniche e la sottoalimentazione sono comuni a tutti, ma le estreme condizioni di disagio delle zone di guerre provocano una regressione nella qualità dell’assistenza e nella tecnica delle cure, che stanno ritornando ai livelli dell’epoca sovietica. Per i tanti ricoverati in seguito ad eventi traumatici di guerra, si pone la necessità di un piano urgente di recupero e di soccorso.
Mental health in Eastern Ukraine: the ravaging effects of war
by Dr. Semyon Gluzman, Dr. Irina Pinchuk and Prof. Robert van Voren
Over the past year, Ukraine has been in the news almost on a daily basis. What started as a student demonstration on the Maidan square in Kyiv soon turned into a national uprising against the Yanukovich government. In March the conflict deepened when Russia annexed the Crimea and a military conflict erupted in Eastern Ukraine between the Kyiv government and Moscow-backed separatists. Now, a year later, the country is engaged in an undeclared war with its big neighbor, at least 5,000 of its citizens were killed and approximately 900,000 citizens have become internally displaced persons (IDPs). The Eastern part of the country, in particular the Donetsk and Luhansk provinces, has been devastated by indiscriminate bombardments and looting of completely factories. Unemployment is widespread; food shortages are increasing rapidly and death as a result of frostbite or starvation have become regular occurrences.
As is not unusual in such areas of conflict, persons suffering from mental illness are particularly vulnerable and have become victim of the existing situation. Psychiatric hospitals have found themselves in the line of fire, patients have been shaken by the constant bombardments and services are overwhelmed by the number of people whose mental health has been affected by the acts of war.
The pre-war situation
More than twenty years after the collapse of the Soviet Union, in Ukraine much of the highly institutionalized and biologically oriented psychiatric service of the USSR is still in place, and resistance against the introduction of modern, community-based and user-oriented services remains strong. Since 1991, the Ukrainian Psychiatric Association (UPA) has initiated many attempts to reform the mental health care system, yet in many cases failed because of this resistance. In some cases reforms were even reversed. The main success has been in opening world psychiatry to Ukrainian mental health professionals. The Kyiv-based publishing house Sphere, closely linked to the UPA, managed to publish more than 100 manuals and books on mental health practice in the Ukrainian and Russian languages.
Paradoxically, until the conflict, the Donetsk region had the most developed network of mental health institutions in Ukraine. It served a target population of 4.5 million people and comprised of ten psychiatric hospitals, a regional psycho-neurological hospital and the Donetsk Center for forensic psychiatric examination. In addition, the outpatient care comprised of 22 day care centers with a total of 1,105 beds, a rehabilitation and diagnostic center in Konstantinovka, 3 municipal outpatient clinics, 7 outpatient units as part of a psychiatric hospital, 6 outpatients units based in municipal or district general hospitals and 38 psychiatric desks in other municipal and general hospitals. Mental health services were provided by a total of 387 psychiatrists, 37 child psychiatrists and 37 psychotherapists. In 2013, 11,723 persons asked for psychiatric help for the first time, of whom 2,901 persons were children under 18 years.
Starting in May 2014, as a result of hostilities the mental health care services gradually deteriorated. The first “victim” was the psychiatric hospital in Slavyansk that between April and July 2014 was completely destroyed as a result of the fighting. Patients and staff were evacuated to other psychiatric hospitals in the region. In spite of the adverse conditions, the outpatient department was however never closed and continues to help all those in need.
Most of the hospitals in the region battled with the supply of medicines and food. Staff was not paid and as a result some employees were forced to leave the region. During the summer for three weeks no mobile phone connection was available and also the delivery of electricity and water was interrupted. The fighting continued to spread throughout the region, and soon the staff and patients in Gorlivka, Donetsk, Yenakiyevo, Mariupol, Makeyevka and Zhdanovka were facing the same hardships. In Kramatorsk, a provincial town not far from Slavyansk and also right in the battle zone, the staff of the psychiatric hospital listened to gunfire, prayed for peace and continued to work, unpaid, despite the lack of medication and food. Although in July the Ukrainian army liberated the city, until now the delivery of both food and medication for the patients remains irregular. The target population has increased 2,5 times, while in addition also IDPs need to be served (Currently, there are over 16,000 IDP’s in Kramatorsk alone).
Needless to say, psychiatric hospitals in the region had no emergency plans how to evacuate patients in emergency situations. There were no shelters or evacuation facilities for patients during the attacks and thus the hospital staff was forced to equip the basements, bring the patients to a safer place during attacks and to find food for them. The patients who were evacuated from the Slavyansk hospital did not find peace in the hospitals of Gorlovka and Donetsk, to which they were transferred. One of the hospitals in Donetsk was partially destroyed, and patients were again transferred to a neighbouring hospital. In Gorlivka patients and staff hid in the basement of the hospital during the bombardments. There were periods when there was no electricity and no water. Staff and patients ate crackers and canned food, waiting for better times. As a result of the shooting both the roof and the windows of the hospital were completely destroyed.
After the beginning of October 2014 the situation took a new turn. In the area controlled by Ukraine only the psychiatric hospitals in Kramatorsk and Mariupol remained, together with some outpatient psychiatric services in Slavyansk and the psychiatric desks in general hospitals. While the shortage of medication, food and mental health professionals became more and more acute, the demand for mental health care was growing rapidly.
In the “Donetsk People’s Republic” (DNR), controlled by separatist forces, a Ministry of Health of the DNR (Donetsk People’s Republic) was formed. The Donetsk Regional Psychiatric Hospital was renamed as the Republican Psychiatric Hospital and the psychiatric hospitals in Makeyevka, Gorlivka, Yenakiyevo, Zhdanovka, as well as the psychiatric hospitals No.1 and 2 in Donetsk and the psycho-neurological outpatient clinic in Donetsk became part of the Republican Ministry of Health. During the first month, the number of beds in some psychiatric hospitals was reduced. Plans were tabled to beds for some comorbidity programs, e.g. mental patients suffering from tuberculosis and HIV/AIDS. Existing methadone programs are under serious threat and new DNR mental health legislation is under preparation.
Because of the state of war, long-lasting professional and personal connections were ruptured. Information from separatist-held areas is becoming increasingly scarce. We know that in the DNR mental health services suffer from lack of medication and food (there were some reports on hunger strikes among patients). Another problem is the lack of staff, as many mental health professionals have fled to Ukraine-held territories. The payment of pensions, social security and other benefits has been halted and the bombings continue to be a daily occurrence.
On the Ukrainian-held territory the situation is not much better. Not only is the infrastructure destroyed and the delivery of of medication and food supplies interrupted, in places such as the coastal town of Mariupol fighting is still continuing.
After the liberation of Slavyansk on July 5, 2014, psychiatric desks were opened in all municipal and outpatient family clinics. Also the Day Care Center resumed its activities. In addition, the hospital staff visited homes in search of people in need of assistance, assisted in delivering humanitarian aid and solved social issues. Mental health professionals actively participated in the trainings conducted by foreign professionals and by the State Emergency Service of Ukraine.
During the period of July 15-October 31, 2014, the staff of the psychiatric hospital assisted 1,530 patients who applied for help at the psychiatric offices of general somatic care, and 6,916 patients at the outpatient department. In 66.5% of cases the diagnosis was the post-traumatic stress disorder. The hospital nurses visited 5,723 people at home. Also special multi-disciplinary teams visited IDP centers.
In order to rebuild destroyed psychiatric care services, including the provision of inpatient psychiatric care, premises have been rented at a sanatorium and at a polyclinic. The staff of the hospital decided to renovated these premises themselves. After the renovation, two general psychiatric units, one psychosomatic unit and a Day Center were opened. In these units there are wards with 2-3 patients in each ward, each with a separate bathroom and shower in each ward. Patients dine together in the dining room. Currently a building in Semyonovka is renovated where a special unit was housed for tuberculosis patients. The roof has already been restored and new windows are placed. However, there is no funding yet available to build a boiler room to provide hot water. Also a former evening school was transferred to the hospital administration and will house a Child Mental Health Center. This Center should comprise of an inpatient unit with 30 beds, a children’s day hospital with 30 beds and a consultative-diagnostic polyclinic and rehabilitation center for children with disorders of the autistic spectrum and eating disorders.
The challenge ahead is not only to rebuild mental health care services while the military conflict is still on-going and the country is as a result of the war going through a serious economic crisis, but also to make use of the crisis to introduce more community-based and user-oriented services. Until now, many reform programs in mental health were halted or obstructed by remnants of the old Soviet psychiatric nomenklatura or as a result of lack of proper education of mental health staff. To restore services and at the same time introduce the necessary innovations is a double challenge that is very hard to accomplish in a time of such stress and hardships. The services that are functioning are there mainly as a result of the extreme dedication of the remaining staff, and to put an extra burden on them by means of re-training and changing existing practices might have an adverse effect. At the same time, extreme situations also provide the possibility for change. It is hoped that international aid organizations and donors will see this opportunity and provide the stimulus necessary to take the necessary steps.