TABLE OF CONTENTS

Acknowledgements
Foreword
Executive Summary
Preface: Goals & Methods of this Report

1. Introduction
   1. Mental Disability Rights: An International Concern
   2. Uruguay's International Treaty Obligations
   3. Political & Historical Context of Uruguay
   4. Organization of Uruguay's Mental Health System
      1. Mutualistas
      2. Public hospitals
      3. Disability pensions
      4. Professional resources
      5. Services for victims of human rights abuses
2. Human RightsConditions
   1. Structure of Public Services
      1. Custodial institutionalization
      2. "Social patients"
      3. Lack of community-based alternatives
   2. Civil Commitment
      1. Lack of criteria for commitment
      2. Lack of procedural protections
      3. Indefinite length of commitment
      4. Additional problems of judicial commitment
      5. Conditional discharge
   3. Conditions in Institutions
      1. Poor physical conditions
      2. Inadequate number of professional staff
      3. Treatment practices
      4. Patient choice and patient rights
   4. Oversight
      1. No standards for quality control
      2. Inadequate regulation of service providers
      3. No procedures for reporting or investigating unusual incidents
3. Hope for Reform:Strengths of Uruguay's Mental Health System
4. Recommendations

Supplemental Bibliography

Acknowledgements

MDRI is indebted to many people in Uruguay who took the time to offer MDRI their observations and insights. To protect their privacy, most of the individuals MDRI interviewed are not named in this report, including many people who use or reside in Uruguay's mental health facilities, members of their families, mental health service providers, members of psychiatric and nursing professional associations, representatives of the Uruguay Ministry of Public Health, the judiciary, and their staff.

MDRI's work in Uruguay would have been impossible without the invitation and assistance of the Instituto de Estudios Legales y Socia/es del Uruguay (IELSUR) and without the close collaboration and invaluable guidance of Francisco Ottonelli, Executive Director of IELSUR, and Sylvia Cousin, a member of IELSUR's Board of Directors. Thanks to the many staff members at IELSUR who arranged all aspects of the MDRI fact-finding mission in Uruguay and offered their open hospitality. Special thanks to Mariana Terra for her long hours of translation and for her warm, thoughtful, and thought provoking introduction to the history, culture, and sights of Uruguay. Christian Courtis, Legislative Aide in the Senate of Argentina, also provided valuable support as a translator and as an active member of the fact-finding mission in Uruguay.

Professor Herman Schwartz, Co-Director of Washington College of Law (WCL) Center for Human Rights and Humanitarian Law provided the support and vision that made the creation of MORI possible and that assured the success of the Uruguay project. Professor Robert Dinerstein of the Washington College of Law provided detailed comments on an early draft of this report. Professor Claire Morel-Seytoux of the University of Monterrey, Mexico, Karen Bower of the Women's Law & Public Policy Program at Georgetown University Law Center, and Melissa Crow, Schell Fellow at Human Rights Watch also contributed valuable comments on the draft. Thanks to Felipe Michelini of the Center for Justice and International Law (CEJIL/Sur), Montevideo, Uruguay, for advising MDRI on this project. Dr. Peter Statsny, Einstein Medical College, reviewed the report and contributed psychiatric references.

Angelica Moncada and Simon Abromovici conducted valuable background research on the mental health law of Uruguay. Peter Hansen helped proof the English text of the report. The report was translated into Spanish by Jerome V. Luhn, Laura Noriega-Martin, Alejandra Segura, and Professor Guillermo Ramirez, Laura Bergman, Valentina Delich, Monique Byrne, and Dr. Luis Byrn. Christian Courtis and Liliana Obregon painstakingly reviewed and prepared the final Spanish translation of the report for publication.

The Washington College of Law Center for Human Rights and Humanitarian Law funded the publication of this report. MDRI's work on the Uruguay project was funded by the Echoing Green Foundation, the Nathan Cummings Foundation, the Bazelon Center for Mental Health Law, and the Washington College of Law Center for Human Rights & Humanitarian Law. Clarence J. Sundram, Leonard S. Rubenstein, and the University of Miami School of Law generously contributed to the cost of travel and research in Uruguay.

Foreword

After centuries of indifference, human rights concerns are now recognized as essential to a free, democratic and humane society, of concern to all decent people everywhere. Because human rights issues arose originally in political contexts, primary emphasis has understandably been given to political rights like speech, press and association. The rights of institutionalized persons were of concern only if they were associated with political abuses.

That has changed somewhat, but the rights of the mentally disabled are still not on advocates' radar screens. Yet, if experience in the United States is any indication, few groups are subjected to as much discrimination, cruelty, and just sheer neglect and indifference. Only pretrial detainees are treated as badly, and as to them, there is at least a suspicion of wrongdoing, despite the presumption of innocence. People with mental disabilities are, however, completely innocent. The only crimes in which they are involved are those that are perpetrated upon them.

Nor is it likely that the United States is unique in this regard. Even in other free democratic societies like Uruguay, where the mental health workers are dedicated to humane treatment of the mentally disabled, this report finds that:

Conditions in Uruguay's psychiatric institutions violate a broad range of rights codified in the [United Nations Principles for the Protection of Persons with Mental Disabilities], including protections against harm and unjustified medica­ tion, respect for personal dignity, privacy and choice, and the right to treatment directed toward the preservation and enhancement of personal autonomy.

So little attention has been paid to these unlucky people, that despite international treaties, United Nations action, and other well-intentioned initiatives, human rights advocates know little about the treatment of the mentally disabled, and have done even less.

That must change. Those of us concerned about human rights must become aware of the inhumane treatment that even the most civilized societies inflict on the mentally disabled, and start doing something about it. This may be an especially auspicious moment for that, for there is increasing international interest in the treatment of the disabled, as reflected in Article 22 of the Declaration of the United Nations World Conference on Human Rights in Vienna in June 1993, and in the appointment of a U.N. Special Rapporteur on the Equalization of Opportunities for Persons with Disabilities.

This report by the Mental Disability Rights International project of the American University Human Rights Center on the treatment of the mentally disabled in Uruguay is a major step in that direction. It documents the combination of neglect, indifference and outright cruelty that is perpetrated on these helpless people in one country, and it charts a strategy for change that takes into account the economic and social situation in that country. It is indispensable reading for all who are concerned about what has been, until now, a dark corner of human rights abuse. With luck it will be just a beginning.

Professor Herman Schwartz

Executive Summary

This report documents human rights conditions in Uruguay's mental health system and recommends steps necessary to bring the system into conformity with internationally recognized human rights standards. The report is the product of a fact-finding mission conducted November 29 - December 8, 1993 by a Mental Disability Rights International (MDRI) team of attorneys and a psychiatrist. The team came to Uruguay at the request of the Instituto de £studios Legales y Socia/es de! Uruguay (IELSUR), a human rights group based in Montevideo, Uruguay.

The identification of human rights violations in this report should not detract from the impressive efforts of the individuals who work in Uruguay's mental health system who have devoted themselves to the care and concerns of people with mental disabilities. Nor should this report undervalue the strengths of Uruguay's mental health system, its great human resources, and the widespread interest in the rights of people with mental disabilities which together hold promise for Uruguay to be a leader in mental health system reform.

A. Structure of Services

The public mental health system of Uruguay relies almost exclusively on large in-patient institutions at the expense of community-based care. There are more than 2,000 people in Uruguay's public psychiatric institutions (from a total population of 3.1 million people) of whom 1,300 to 1,400 live in asylums (known as "Colonias") in remote parts of the country. Most patients in the Colonias remain there for life.

A few impressive public and private community mental health programs exist in Uruguay. Public programs serve fewer than 200 individuals, however, and they cannot accommodate the large numbers of people who need community services. By official accounts, one-half to two-thirds of people in Uruguay's mental health system are "social patients" without any need for psychiatric hospitalization.

Many "social patients" are not mentally ill but are detained in institutions because they happen to be homeless or have no place else to go. People are held in institutions for committing petty crimes, for alcoholism, epilepsy, old age, or mental retardation. Institutional­ ization of people with retardation in Uruguay's psychiatric facilities is particularly inappropriate and harmful, because these individuals receive no services tailored to their special needs.

Uruguay's medical and social service systems do not accommodate the needs of people with mental disabilities living in the community, creating added stress that leads to further institutionalization. Mental health coverage other than psychotropic medication is not included in mainstream health care. Disability pensions are terminated for people who obtain a job of any kind, even if such employment does not provide subsistence income.

In the mid-1980s, shortly after Uruguay's return to democracy, the Ministry of Public Health brought together a National Commission to study the need for mental health reform. The National Program for Mental Health put forward by the Commission in September 1986 recommended that Uruguay "abandon the hospital" as the primary locus of mental health services and develop community-based services integrated into the national health system. The National Program for Mental Health was adopted by the Ministry of Public Health, but funds were never allocated for its implementation.

Uruguay's near-exclusive reliance on institution-based treatment results in the unjustified, unnecessary, and potentially harmful institutionalization of people capable of safely living and working in the community. The structure of Uruguay's mental health system thus violates internationally accepted medical and human rights standards adopted by the Pan American Health Organization (PAHO) in the Declaration of Caracas, and the United Nations General Assembly in the Principles for the Protection of Persons with Mental Illness (Ml Principles). The detention of "social patients" at the discretion of hospital authorities constitutes arbitrary detention prohibited by the International Covenant on Civil & Political Rights (the ICCPR) and the American Convention on Human Rights (the American Convention). The improper and unjustified hospitalization of individuals capable of living in the community results in decreased social functioning and violates the right to the "highest attainable standard of ... mental health" protected by the International Covenant on Economic, Social, and Cultural Rights (ICESCR).

International law requires that the detention of "social patients" be terminated and community-based alternatives to psychiatric hospitals be established. Resources currently available for mental health care must be re-directed to ensure the enforcement of internationally recognized human rights. Uruguay is under a legal obligation to invest additional resources for mental health system reform, if this is necessary to enforce the full protections of the ICCPR and the American Convention. To bring Uruguay's mental health system into line with internationally accepted human rights standards, MDRI recommends that Uruguay:

A-1 End the detention of "social patients";

A-2 Conduct a system-wide review of all current commitments to psychiatric institutions;

A-3 Create community-based mental health care and other alternatives to psychiatric institutions;

A-4 Create services to allow people with mental retardation to live in the community; 

A-5 End disincentives to work in pension benefits;

A-6 Include psychiatric coverage in mainstream health care.

With or without a further legislative mandate, Uruguay's Ministry of Public Health should:

A-7 Take a leadership role in restructuring the mental health system; 

A-8 Involve system users and families in reform efforts;

A-9 Publicly present a plan to the legislature for implementing reforms, including a budget and a timetable.

The Ministry of Public Health's plan should estimate both the cost of creating services in the community and the savings that will arise from closing institutions. Uruguay may need to invest additional resources to restructure its mental health system, particularly to create community-based mental health services, and the implementation plan should include a realistic estimate of these new costs.

B. Civil Commitment

The civil commitment law of Uruguay (entitled the "Law of Assistance to Psychopaths") does not provide the minimum substantive or procedural protections required by the MI Principles.

Uruguayan law allows commitment upon medical certification (requiring the consent of an institution director, two physicians, and a relative). There is no requirement that a patient be dangerous or in need of psychiatric treatment. The only criterion for such commitment is a medical finding of "mental illness," a provision that is not enforced, since large portions of the patient population are not mentally ill. Uruguayan law does not provide a right to independent, periodic review of civil commitment, nor does it provide a right to counsel in commitment proceedings, as the MI Principles require.

On its face, the mental health law of Uruguay violates the minimum requirements of the MI Principles and the protections against arbitrary detention in the ICCPR and the American Convention. Thus, Uruguay must:

B-1 Revise the mental health law to include the establishment of proper substantive commitment standards and procedural protections (including a right to independent, periodic review of commitment, and a right to counsel in commitment proceedings) as required by the MI Principles.

C. Conditions in Institutions

For individuals committed to psychiatric institutions, the experience can be destructive rather than helpful. For most patients, psychiatric services do not enhance personal autonomy or support reintegration into the community. Treatment is often inappropriate and unnecessarily dangerous.

Psychiatric treatment in public institutions is almost totally limited to somatic therapies (psychotropic medications and electroconvulsive therapy (ECT)). These treatments are often administered with no medical justification, e.g. on individuals with mental retardation and no psychiatric diagnosis. The absence of complete treatment records, the lack of specific diagnoses, the shortage of professional staff, and the inadequate monitoring of side-effects render the safe and effective use of psychotropic medications impossible for many patients.

Psychiatric institutions provide no psychotherapy and little rehabilitation or vocational training.  Only a minority of patients receive case management to assist them in returning to their work, family, and community. Thus, patients sleep or sit by their bedside, wander the halls, or do nothing most of the day. Whatever social and vocational skills they may have had upon entry are generally allowed to deteriorate.

Living conditions are generally not respectful of the dignity and privacy of residents.

With the exception of a few bed areas where patients have put up a photo or kept a stuffed animal, institutions are almost completely impersonal, undecorated, and drab. Many of the institutions are in old and decrepit buildings, and in some areas the conditions are unhygienic (e.g. the Colonia Etchepare security ward, where clogged toilets flood hallways and where some patients sleep on bare, filthy floors).

There is no system for protecting patients' rights in institutions, and important decisions concerning their rights (including transfer to some locked wards) are made at the discretion of administrators without standards, guidelines, or oversight. Although physical restraints and seclusion appear to be rarely used, there are no established regulations for their use. Some individuals are reported to be held in seclusion for four to six weeks.

Patients are not notified of their rights, and there is a general lack of recognition that they have rights. No complaint mechanisms have been established, nor are there any mechanisms to investigate allegations of abuse or violence.

International pharmaceutical manufacturers are reported to be testing new psychotropic medications in institutions with permission from Uruguayan authorities. MDRI is concerned about potential risks to patients and possible lack of safeguards, including the patients' informed consent, as required by the ICCPR.

Conditions in Uruguay's psychiatric institutions violate a broad range of rights codified in the Ml Principles, including protections against harm and unjustified medication, respect for personal dignity, privacy, and choice, and the right to treatment directed toward the preservation and enhancement of personal autonomy. Improper and dangerous treatment practices and condi­tions in Uruguay's mental health system unnecessarily and unjustifiably cause great suffering, violating the ICCPR and the American Convention's protections against inhuman treatment. In certain cases, conditions or treatment may be life-threatening, violating the right to life guaranteed by the ICCPR and the American Convention. Conditions leading to the deterioration of mental health and social functioning violate the right to enjoyment of the highest attainable standard of physical and mental health as guaranteed in the ICESCR.

To bring Uruguay's mental health system into conformity with international human rights standards, Uruguay should:

C-1 Adopt treatment standards, including procedures for the proper and safe use of psychotropic medications and ECT;

C-2 Ensure broad-based involvement in development of standards; 

C-3 Refer to internationally accepted psychiatric practice guidelines; 

C-4 Use internationally accepted diagnoses;

C-5 Improve treatment plans and records; 

C-6 Establish a quality assurance system;

C-7 Implement treatment and service programs that build upon existing community supports; 

C-8 Conduct a thorough review of current medication and ECT practices;

C-9 Investigate pharmaceutical marketing/research practices; 

C-10 Establish continuing education requirements for staff;

C-11 Address problems of staff morale;

C-12 Attack public stigma and the pervasive problem of anomie (despair) in institutions.

D. Oversight

The Ministry of Public Health does not monitor treatment practices at public institutions, and the authorities report that there are no standards by which institutions can be assessed.

The only independent oversight of psychiatric institutions is provided by what is called the "Inspector General of Psychopaths, " a position that was vacant for twenty years. The new Inspector, who took office in October 1993, promised to review every psychiatric commitment in the country. He has only two professional staff members to support him. Patients do not have a right to participate in commitment reviews. Indeed, they may never know about the review, which may be-based solely on a telephone conversation between the Inspector and the institution director.

The government of Uruguay is responsible under international human rights treaties to ensure the safety and well-being of patients detained in mental health facilities. Given the poor conditions in psychiatric facilities, the dangerous treatment practices, and the lack of proper safeguards in the civil commitment process, the existence of independent oversight is particularly important. MDRI recommends that Uruguay engage in a thorough review of treatment practices and:

D-1 Create an effective oversight mechanism to ensure the enforcement of rights in institutions;

D-2 Publicly report on conditions annually;

D-3 Establish human rights committees in psychiatric facilities; 

D-4 Support consumer and family advocates.

E. Recommendations to Advocates and the International Community

To create political support for national mental health reform, advocates in Uruguay should:

E-1 Bring together a broad base of constituents for reform including system users, family groups, community providers, mental health professionals, and human rights advocates;

E-2 Re-establish momentum around Uruguay's 1985-86 National Reform Plan which called for the creation of community-based mental health care;

E-3 Educate the public about conditions in institutions and about the existence of alternatives to institutions.

The international community should press for the enforcement of international human rights law:

E-4 The United Nations Special Rapporteur on the Equalization of Opportunities for Persons with Disabilities should evaluate the conditions of people with mental disabilities in Uruguay and Uruguay's efforts to create services and programs that will provide people with mental disabilities the full opportunity to live and work community. The Special Rapporteur should provide technical assistance to Uruguay to create service programs in the community and should help raise international financial support for the development of such programs;

E-5 The United Nations Human Rights Committee should require Uruguay to report on the enforcement of rights of people with mental disabilities under the ICCPR;

E-6 The United Nations Committee on Economic, Social, and Cultural Rights should require Uruguay to report on the enforcement of rights of people with mental disabilities under the ICESCR.

Preface: Goals & Methods of this Report

Mental Disability Rights International (MDRI) sent a fact-finding team to Uruguay in November-December 1993 at the invitation of the Instituto de Estudios Legates y Socia/es del Uruguay (IELSUR), a human rights organization based in Montevideo active in advocating for the rights of people with mental disabilities in Uruguay. Long concerned with human rights violations in the mental health system, IELSUR is initiating a new effort to bring about major reforms in the mental health laws and services in Uruguay.

This report documents human rights conditions in Uruguay's mental health system and recommends steps necessary to bring the system into conformity with internationally recognized human rights standards. This report is the product of a fact-finding mission to Uruguay conducted from November 27 to December 9, 1993 by an inter-disciplinary team of four attorneys and a psychiatrist from the United States and an attorney from Argentina.1  Members of the MDRI team interviewed representatives of the Uruguay Ministry of Public Health, governmental and non-governmental service providers (institution and community program administrators, psychiatrists, social workers, nurses, and other staff), representatives of mental health professional organizations, the President of the Uruguay Supreme Court and attorneys involved in oversight of the psychiatric commitment process. The MDRI team also met with mental health system users and family members. 2

The MDRI fact-finding team conducted site visits at each of two "Colonias" (public psychiatric institutions or asylums located in the countryside), two public psychiatric in-patient facilities in Montevideo, one private psychiatric institution, one institution for boys and adult men with mental retardation and other disabilities, and two community mental health facilities.3 During these visits, team members met with administrators, toured the facility, examined custodial conditions, visited program areas, examined patient charts at random and interviewed system users and staff.

The MDRI team received full access to facilities, patients, and patient records without restrictions. MDRI team members were met with openness and interest by service providers, administrators, representatives of the Ministry of Public Health of Uruguay, members of Uruguay's judiciary, their staff, and all others we interviewed. In addition, representatives of the associations of psychiatric and nursing professions were extremely helpful.

Many of the individuals interviewed by the MDRI team were unsparing in the information and assistance they provided, and they spent a generous amount of their own time with the team, answering questions thoroughly, often with great candor. These individuals provided important insights as to the problems within the mental health system, and they demonstrated a genuine concern for people with mental disabilities. This report would have been impossible without this support.

Three members of the MDRI fact-finding team presented a summary of the report's findngs at a conference organized by IELSUR in Montevideo, Uruguay, August 17 and 18, 1994. Representatives of the Ministry of Public Health, directors and administrators of Uruguay's major public psychiatric institutions, officers of psychiatric and nursing associations, independent service providers, and community leaders (including psychiatric system users and their families) participated in a lively discussion of the report at the conference. Human Rights and Mental Health: Uruguay reflects many of the issues raised at the conference. An advance copy of this report was submitted to the Ministry of Public Health for comment in December 1994. MDRI offered to publish a response by the Ministry of Public Health and offered to wait until March 20, 1995 before going to press. MDRI received no response to our offer.

In individual meetings with government representatives, mental health system administrators, providers, family members, and system users, MDRI team members were encouraged by the widespread support for improving and reforming Uruguay's mental health system. This confluence of interest and concern presents the greatest possible hope for bringing the full protections of human rights law to people with mental disabilities in Uruguay.

This report is not intended to single out Uruguay for criticism but to examine the enforcement of international human rights law that applies to people with mental disabilities universally. The international human rights community should monitor these rights worldwide, and MDRI has begun to do so in South America, Eastern Europe and the United States. The views expressed in this report are those of Mental Disabilities Rights International and the authors and do not represent a position of the Washington College of Law or American University.