Time to focus on institutional reforms in low and middle income countries.

Mental asylums, exported from Europe and implanted across the world as an integral part of the colonial enterprise, represent the most decisive instrument for the globalisation of psychiatry. In more recent times, while the narrative of deinstitutionalisation – closure of institutions and the move towards community-based services has been dominant in most high income countries (Fakhoury & Priebe, 2002), mental asylums (and later hospitals) in many current low and middle income countries (LMICs) have somehow been left behind to their country specific devices. In the context of minimal investments in mental health services in LMICs, many of these institutions, burdened by their history and institutional ethos, remain in a time warp. The powerful themes of alienation, segregation and institutionalisation, inherent in the construct of mental asylums, have also cast a long shadow on the cultural landscape and popular imagination globally. The stigmatisation of these institutions and, by extension, people with mental disorders and those treating them, is a profound historical legacy that continues to be an important barrier for the social inclusion and citizenship of people with mental disorders. In the West, highly influential critiques of mental asylums by Basaglia (1987) challenged their legitimacy as curative facilities and identified the harms that came to be known as ‘institutionalisation‘(Chow & Priebe, 2013). These and other compelling criticisms provided the intellectual rationale and the ethical imperative for the social, and ultimately, political program of deinstitutionalisation. In contrast, the issue of reform of mental hospitals was largely bypassed in most LMICs, possibly in the context of the very many other pressing national priorities. Consequently, many mental hospitals in these countries continued to be neglected, with dreadful conditions and, often, as places of profound human rights violations. However, human rights abuses are certainly not unique to mental hospitals but are widely prevalent in traditional healing facilities, in social protection centres and communities. Indeed the more fundamental problem is the highly skewed mental health systems in many LMICs with tertiary care institutions being the major, or sometimes the only, treatment option available. Without a significant investment in developing concomitant and closely linked community services and social care, isolated reforms of mental hospitals are unlikely to lead to substantial changes. In a welcome development, in the last two decades, there have been significant reforms in mental hospitals and other institutional care facilities in some LMICs. This has largely been in response to the growing global prominence of human rights and the broad international ratification of various binding instruments that uphold the citizenship rights of people with disabilities (Human Rights Council, 2016), including the right to receive treatment in the community. A good example is the Caracas Declaration, in 1990, which led to the large-scale reforms in mental health services in South America, especially in Brazil and Chile (Araya et al. 2006; Cavalcanti, 2008; Barros & Salles, 2011; Loch et al. 2016). In more recent times, similar institutional reform processes and provision of community care have spread to Greece (Loukidou et al. 2013; Fiste et al. 2015) and some Eastern European countries (Puzynski & Moskalewicz, 2001; Tomov, 2001; Aleksandrova, 2007; LecicTosevski et al. 2007) with the funding support of the European Union, although substantial challenges remain (Murawiec & Krysta, 2015). These provide striking illustrations of what can be achieved through adequate financing methods and political will. However, while there are such examples, in many other LMICs, the fundamental barriers to change, such as the critical absence of financial and human resources and political commitment, continue to persist (Saxena et al. 2007) as significant bottlenecks. In this context, the two Editorials in this issue of Epidemiology and Psychiatric Sciences highlight the need for renewed attention – both global and within * Address for correspondence: S. Chatterjee, Consultant Psychiatrist, Parivartan Trust, India (Email: [email protected]) Epidemiology and Psychiatric Sciences (2017), 26, 1–3. © Cambridge University Press 2016 doi:10.1017/S2045796016000718 EDITORIALS IN THIS ISSUE