Saturday, May 31, 2014

Mental Health Inequality in Chiapas, Mexico

This is the room where a man has been incarcerated for five years, without ever leaving.  I don't call him a patient because I didn't meet him personally, but his story churns my stomach.  He is somewhere around 60 years old, and developed schizophrenia when he was 18.  He was odd but functional for many years, but in later years grew increasingly aggressive and threatening both to his family and to people in the community.  He had one psychiatric hospitalization, where they used injection medications that aren't available in the community.  Once he was discharged back home, he refused to take oral medications.  After he attacked his family, they decided he needed to be locked up, for the safety of everyone.  It took eight men to restrain him and secure him in the above room and he hadn't left this room in five years.  

Note the rope that is tied to the metal door... That is to keep it locked.  There is a hole where they pass him food and he uses the floor to go to the bathroom.  No shower, no grooming in five years.  As we walked near the house, it smelled of filth.  He yelled for his mother repeatedly and said that he wanted us to go away, whoever we were.  I don't know if he meant us or voices he was hearing, although we're the most likely culprits.

We were there to try and convince the family to let Compañeros en Salud try and get an injectable antipsychotic in the community that lasts for a month, in the hopes that it will make him calm enough to be able to come out of his locked room.  The proposal was that we get the police and lots of back up, open the door, sedate him, clean him and bathe him, give him the medication and return him to the room after it has been cleaned.  The hope is that he may be able to be calmed enough that he won't have to stay a prisoner for the rest of his life. 

His family was hesitant; they'd had lots of doctors try to fix him, and all of them had demanded large sums of money.  They also didn't want to be hurt.  Another big concern...  We would need to destroy the metal door, which had been solderd shut and they didn't have money for a new door.  But the seed has been planted, and hopefully they will make it happen.

The situation makes me feel physically ill. There is nothing humane about what is being done to him, which I say even as I understand why his family is doing it.  There simply are not places for people like this man to go in the long term in rural Mexico.   With only one psychiatric hospital, there are long wait times for a place in the hospital, and there are no discharge locations where patients who need interim care can go. While his family was trying to mitigate the harm he could cause, I can't imagine a more terrifying situation for a paranoid patient than to be locked in solitary confinement, essentially forever.  People of sound mind go crazy under those circumstances, let alone people with his degree of illness.  

I say this with deep respect for each of the individual players, who are doing their best in a terrible situation.  And yet the horrific inequality of how impotent we were in the face of this awfulness shows how large the problem looms.  And it is a hard measure of how well they are able to take care of the mentally ill, some of society's most vulnerable.

-Sarah Kimball, PGY-3
Internal Medicine, Brigham and Women's Hospital

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