GUATEMALA CITY — DONALD RODAS, a baby-faced man in his late 20s with
paranoid schizophrenia, arrived at Guatemala’s only public psychiatric
hospital last year after being charged with murdering his parents. He
says he often wanders freely through the sprawling facility of
dilapidated one-story buildings and wooded courtyards, where detainees
charged with crimes mingle with ordinary patients and the
developmentally disabled.
He sees ugly things. Those who refuse their medication are beaten and
put in the “little room,” a barren isolation cell, he said. Desperate
women sell their bodies for as little as 5 quetzales, or less than a
dollar, to afford basic necessities.
“I see when they have sex for money,” Mr. Rodas said in halting English. “To buy food. All they have is beans.”
The United States began emptying out its vast asylum system in the
1960s, spurred by scathing reports of abuse and neglect, like a 1946
Life magazine exposé that described many institutions as “little more
than concentration camps.” The transition to community-based care cut
the institutionalized population by more than 90 percent by 1994.
But community care resources failed to match demand in the United
States, leading to widespread homelessness and an influx of the mentally
ill into jails and prisons. Even so, deinstitutionalization is widely
credited with ending the abuse and neglect that made mental institutions
synonymous with a nightmarish netherworld.
Yet this asylum-based model of mental health care remains the standard
across much of the globe. In many poor and developing countries,
thousands of mentally ill people are warehoused in dirty and dangerous
institutions. Health experts and advocates who monitor such facilities
say the picture varies little from country to country: overcrowded wards
lacking in privacy; poor sanitation; physical and sexual abuse; routine
use of restraints and long-term solitary confinement; and forced
treatment, including electroshock without consent. The rights of
patients judged to be mentally ill are easily stripped by the courts and
are difficult if not impossible to regain.
“People need to wake up to the sad story of widespread human rights
violations against people with mental disorders in a number of
countries,” said Dr. Shekhar Saxena, director of the World Health
Organization’s department of mental health and substance abuse. “We need
to bring these people out of the shadows so the world can see how badly
we are treating them.”
Institutionalization is just one facet of the broader catastrophe of
mental health care in the developing world. According to the World
Health Organization, in low- and middle-income countries, up to 85
percent of those with severe illnesses like schizophrenia, bipolar
disorder and major depression receive no treatment.
Government and humanitarian funding to treat the most severely afflicted
is almost nonexistent. In a world where an average of 80 children die
every hour because of a lack of clean water, the absence of a
coordinated global response to the mentally ill may represent a triage
mentality, in which scarce aid dollars are directed at the most
immediate threats to life, like malaria and AIDS.
But governments that have put their minds and money to the task can make
a difference. In the past decade, under pressure from Disability Rights
International, a Washington-based advocacy group, Paraguay, one of
Latin America’s poorest nations, reduced the population of its national
mental hospital by almost half while creating a system of
community-based group homes. Far larger countries like Brazil have
accomplished even more impressive transitions.
Recent developments suggest that a turning point on institutionalization
may be at hand. More than 130 countries have ratified the United
Nations Convention on the Rights of Persons with Disabilities, a binding
treaty that stipulates that the disabled, including the mentally ill,
must not be arbitrarily detained or segregated from society. In May, the
health ministers of the W.H.O.’s 194 member states voted unanimously in
favor of a global mental health plan that calls on signatories to move
from centralized asylums to community-based care. 
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