Indonesia: the practice of sequence is less frequent but continues
(Jakarta) – Le gouvernement indonésien a pris d’importantes mesures pour mettre fin à la pratique consistant à enchaîner les personnes qui présentent un handicap mental, a déclaré Human Rights Watch aujourd’hui. Mais de nombreuses personnes restent enfermées dans des institutions, au lieu de pouvoir vivre au sein de leur communauté. Ces deux dernières années et demie, le gouvernement a promis des mesures contre l’utilisation de chaînes. En avril 2016, la ministre de la Santé Nila Moeloek s’est engagée à rendre accessibles les traitements de santé mentale dans les centres de santé communautaires de tout le pays.
The number of people with psychosocial disabilities (corresponding to a mental health problem) who are chained or locked in confined spaces has increased from nearly 18,800, the last figure reported, around 12,800 in July 2018,After Indonesian government data.This drop is partly due to community awareness that 16.2 million households have benefited.
"The Indonesian government has made great efforts to tackle the use of channels and the lack of community mental health services," said Kriti Sharma, senior researcher with the Division's Division of Human Rights Watch."But as there are few inspections, thousands of disabled people are always chained or locked up in institutions throughout Indonesia.»»
Dans son rapport de 2016, « Living in Hell: Abuses against People with Psychosocial Disabilities in Indonesia»» (« Vivre en enfer : Les mauvais traitements à l’égard des personnes en situation de handicap psychosocial en Indonésie»»), Human Rights Watch avait constaté que des milliers de personnes ayant des handicaps psychosociaux étaient enchaînées et, pour beaucoup d’entre elles, détenues dans des institutions surpeuplées et insalubres.Although the state has banned the use of channels in 1977, this practice persisted due to the stigma of these people and the lack of community support and mental health services.
Since then, Human Rights Watch has led five visits to Indonesia in order to observe the progress made by the government in the response it is trying to bring to the problem.Human Rights Watch conducted 19 interviews with people with psychosocial disabilities and 48 with relatives, caregivers and other personnel of institutions, health professionals, defenders of the rights of the disabled and government officials, in Jakarta, Bekasi, Bogor, Cianjur, Brebes and Tegal.
En janvier 2017, le ministère de la Santé a lancé le programme Indonesia Sehat dengan Pendekatan Keluarga (« Indonésie en bonne santé avec une approche familiale»»), un programme de sensibilisation communautaire où les professionnels de santé utilisent une « approche basée sur la famille»», allant de maison en maison pour collecter des données, sensibiliser et apporter des services en lien avec 12 mesures de santé familiale, dont la santé mentale.
On the date of September 2018, the program had affected 16.2 million Indonesian households - or about 25 % of households.The collected data indicate, however, that only 16 % of people with psychosocial disabilities participating in the survey had access to mental health services.
Parmi les nombreuses personnes à qui les professionnels de santé de la communauté ont porté secours à Cijeruk, près de Bogor, se trouvait une femme de 52 ans, handicapée psychosociale : « Nous l’avions enfermée dans sa chambre pendant cinq ans»», a déclaré sa sœur.“She was sleeping on the ground;She couldn't walk because her muscles had stopped working.We had given him a bucket to urinate and defecate.He felt very bad.It saddened me a lot.»»
Stop an unfair practice in Indonesia.
#BreakTheChains (ang)The family felt that there was no alternative to confinement.But after receiving the visit and help from the awareness team, the family let him out of his room in February 2017.She is now treated in the community.
« Il est crucial d’intégrer la santé mentale aux soins médicaux de base, mais ce n’est pas suffisant»», a déclaré Kriti Sharma."In order to eliminate the use of channels, the government must educate the public on mental health and provide people with psychosocial disabilities of services going beyond medical treatment, including access to education,Housing and employment.»»
Human Rights Watch found that people with psychosocial handicaps continued to be arbitrarily detained in healing centers by faith, social protection institutions and psychiatric hospitals. En l’absence de contrôles réguliers, il n’y a eu guère de changement dans les centres de guérison par la foi, où les gens sont enchaînés, victimes d’abus et forcés à recevoir des « traitements»» alternatifs, comme des décoctions d’herbes, de vigoureux massages administrés par des guérisseurs traditionnels et des récitations coraniques.In private institutions, people with psychosocial handicaps undergo routine abuses, including physical and sexual violence, hospitalization under constraint, restraint and forced isolation.
At the Yayasan Galuh rehabilitation center in Bekasi, a woman in her thirties, psychosocial disabled, said: "Before, I was chained to the house.My family cheated on me to come here.They told me that my mother died and that they took me to her burial.Instead, they brought me here.I was placed in an isolation room for four weeks because I had fought with someone.»»
The mediator (Ombudsman), the National Commission for Human Rights and the Commission on violence against women should immediately order inspections and regular monitoring of all institutions, public and private, and take appropriate measuresAgainst those who commit abuses, Human Rights Watch said.The Ministry of Social Affairs is also responsible for regulating private institutions and ensuring that they do not endorse abusive practices.
« Malgré les avancées, le gouvernement a du pain sur la planche pour faire cesser les abus des institutions»», a conclu Kriti Sharma."The Ministry of Social Affairs must adopt a policy of deinstitutionalization, turning away from the practice consisting in storing people in institutions, to ensure that they live independently within the community.»»
Informations complémentaires
Progress made by the government in the fight against the practice of sequence
In 2017, Indonesian interior, health and social affairs ministers, the head of the national police as well as the Indonesian health insurance organization signed an agreement to work in concert to fully apply the'1977 ban on the practice of sequence.The Ministries of Social Affairs and Health have both planned campaigns to put an end to the use of channels, for 2018 and 2019 respectively.
They carried out awareness -raising activities and trained teams at the provinces of all the country.Human Rights Watch found that many community health centers have also launched their own initiative to eliminate this practice at the local level. Le centre Puskesmas Banjarsari à Ciawi, par exemple, a initié une ligne directe par textos appelée « aidez à combattre l’enchaînement»» afin d’encourager les gens à dénoncer les cas de personnes enchaînées.
The researchers of Human Rights Watch returned to several communities where they had noted such cases, to note that people had been released and lived in the community.In 2014, when Human Rights Watch has visited Sodikin for the first time, a 34 -year -old man with a psychosocial handicap, he was locked in a tiny hut near the family home in Cianjur, in the west of the islandjava.Initially, the family had tried to have him treated, but the local health center did not have psychiatric drugs and the hospital was too far away.Sodikin spent more than eight years chained in the cabin, nourished through a hole in the wall, before being released in May 2016 thanks to the intervention of a local non -governmental organization.
Sodikin's brother-in-law said: "Sodikin had become very thin.When we released him, his legs were stiff and he couldn't even stand up, not to mention walking, so I had to wear it.Sodikin spent six months of convalescence in a refuge managed by a non -governmental organization before being able to return home.He now works in a textile factory, sewing buttons on school uniforms. « Nous sommes tellement contents qu’il vive à nouveau à la maison avec la famille !»», a déclaré son beau-frère."We would never have thought he could recover.His father saw him as a burden, and now it is he who wins the most to feed the family.»»
According to the Indonesian Mental Health Directorate, the number of people who are chained or confined in 32 provinces (all except Papua and Western Papua) decreased, from 13,528 in December 2017 to 12,832 in July 2018.However, it is difficult to obtain precise data on the sequence, since it is often practiced in remote areas and that families are not inclined to talk about it, given the shame and the stigma that surrounds mental pathologies.In addition, the people to whom we help sometimes end up being chained again due to the lack of community aid services.
Human Rights Watch found that one of the risks of the government method to eradicate the sequence is that people who are released can find themselves in the psychiatric hospital, where they are likely to be arbitrarily detained or treated without their consent.
As explained by a nurse from the Bogor psychiatric hospital: "When we intervene in a case where someone is chained, the patient does not always want to come to the hospital, or is not able to communicate,So it is a member of his family who makes the decision.»» Pourtant, le consentement éclairé de l’individu concerné est un principe clé de la déontologie médicale et du droit international relatif aux droits humains.Not allowing people with a psychosocial handicap to make their own medical decisions is a violation of their rights.
Suite à sa visite de mars 2017, l’expert de l’ONU sur la santé, Dainius Puras, a appelé le gouvernement indonésien à « faire passer à la vitesse supérieure»» sa campagne contre l’enchaînement, mais en veillant à ne pas la « remplacer par d’autres formes de contention et de confinement qui violent également les droits humains»».
In partnership with the Indonesian psychiatric association and non -governmental groups, the World Health Organization (WHO) is currently trained in Indonesia psychiatrists, doctors, nurses, social workers and defenders of the rights of the disabled, in theExecutive of his Quality Rights initiative which aims to offer alternatives to coercive practices such as hospitalization under constraint, isolation and restraint in psychiatric hospitals and social protection institutions.
In May 2018, WHO started internet training of 61 people from 19 different provinces.In November, 80 other participants will be trained in person.Even if this WHO training represents an important effort to eliminate the coercion of hospitals and institutions, Indonesia should amend its 2014 Mental Health Law in order to ensure that people with a psychosocial handicap cannotbe arbitrarily detained against their will, in accordance with its obligations arising from the international convention relating to the rights of disabled people.
Government's efforts in mental health
Le gouvernement a démontré sa volonté de faire de la santé mentale une priorité en l’intégrant aux 12 indicateurs de son programme national de santé communautaire, le Programme Indonesia Sehat dengan Pendekatan Keluarga (« Indonésie en bonne santé avec une approche familiale»»).This program is an ambitious government initiative which wants to ensure that even the most rural, isolated and refractory communities have access to medical care.The home visits provided for in the program are of crucial importance: thanks to them, families no longer need to take on their working time or spend money to go to the health centers.
For the national launch of the program, the Ministry of Health has formed 25,000 executive trainers responsible for training five employees in each community health center in Indonesia.The fact of being able to count on community workers, such as midwives or social workers, to provide basic mental health care made it possible to remove the obstacle that constituted the lack of psychiatry professionals.Trained employees in turn inform other members of the program of health centers on the program and on mental health.At the end of 2018, 6,205 community health centers will have set the program in place.The government's objective is to have covered all Indonesian households, more than 65 million, through the 9,909 community health centers, for the end of 2019.
L’approche innovante « basée sur la famille»» se penche sur 12 mesures qui, prises ensemble, sont révélatrices de l’état de santé de la famille : l’accès à l’eau potable, l’hypertension, la tuberculose, le tabagisme, le planning familial, l’accès à l’assurance maladie d’État, la santé maternelle, la nutrition infantile, la vaccination, l’allaitement, l’assainissement et la santé mentale.If a family has a bad score for only one of these indicators, it is identified as requiring help.This system really gives the same importance to mental health as to all other indicators and guarantees that community health professionals provide immediate and continuous mental health care to achieve their 100 % coverage target.
Since the program has been planning home visits, medical workers can more easily detect chained people and release them.DR.Tina Yustiniarsih, doctor in a health center, said that she had intervened to help Asep, a 34 -year -old man chained for three years in the village of Banjarwangi near Ciawi:
We found Asep chained in an abandoned house with dilapidated.The chain around its size was so thick that it took us a quarter of an hour to cut it with a saw.I advised the family, I explained to them that someone who has symptoms of mental illness is like them, he has human rights.We also informed the whole village to ensure that everyone knew that people with mental illness should not be chained.
Asep's sister said: "I felt sad to see him chained.I immediately agreed to detach it, I wanted him to heal.If the medical team had not come, we would never have released it.»» Elle n’était pas au courant des avantages apportés par la carte d’assurance maladie ni des soins existant à l’hôpital.
As for ASEP, he testified: "I felt cramped, very stiff, when I was chained.I don't remember what happened to me, but I was happy when I was released.»»
During home visits, the community medical worker collects data, informs the family in matters of mental health, advises and helps them obtain a national health insurance card giving access to free or subsidized care.In addition, the person with psychosocial disability - or a family member - can go to the community health center to benefit from psychological help with a doctor or nursing staff, receive medication and take partto occupational therapy sessions or other activities.In some cases, the health center facilitates the training of mutual aid groups through the WhatsApp messaging application, serves as a relay so that people can learn to set up a small business and help them find funding to start it.
According to Siti, a 39 -year -old woman with a psychosocial handicap living in Ciawi near Bogor, "[the staff] help people a lot.I am happy that they gave me a capital of 2,800,000 rupees [190 USD] to launch a hair salon.In this way, I can earn a little money.»»
Siti's sister said their lives had changed clearly after receiving the program help:
Before, we had to make a long trip to the psychiatric hospital to obtain medication.Sometimes we didn't have time to go, or transport was too expensive.Since we have received the help of the Community Health Center, Siti is much better.In addition to drugs, the center has provided psychological help, put us in touch with support groups and help him find support for his business.My dream for Siti is that it is completely independent.
Even if the program really has the potential to easily give access to voluntary mental health care in the community, it is still at an early stage.Even in the districts where the program has been launched, many health centers are always to collect data on the 12 indicators and have not passed in the services phase of services.The success of the program depends on the efficiency of training, implementation and regular monitoring, said Human Rights Watch.
Local community health centers have developed creative initiatives to support people with psychosocial disabilities.Thus the PuskesMasmas Cilandak center, south of Jakarta, has created E-Magents, an Android application which allows community health professionals to intervene early with people with psychosocial disabilities and to help them within the community.Community medical workers visit families with a simple survey based on 29 questions to determine if someone could benefit from psychosocial support and that person needs immediate assistance.
The program benefited 1,025 people, providing 97 % of them care within the community.Only one case was sent to a hospital.The application allows community health professionals to follow people systematically and to develop community support systems and adaptation strategies that are not only based on drugs.Community medical workers provide psychological aid, inform about psychosocial support and put people in contact with professional training so that they can become financially independent.
The Minister of Health has also created a mobile application to inform on mental health.In July, this application had been downloaded 20,000 times and had 15,000 active users, according to government data.
People placed in an institution
According to Indonesian law, it is relatively easy to have a person with a psychosocial handicap hospitalized under stress.In 2016, Human Rights Watch visited 16 institutions located on the Java and Sumatra islands and analyzed 65 cases of persons prisoner arbitrarily in psychiatric hospitals, public and private social institutions and healing centers by faith.Two and a half years later, there was very little improvements.
The Yayasan Bina Lestari Mandiri Brebes center, a healing center by the faith approved by the State and located in Brebes, in the province of Java Central, which already described the 2016 Human Rights Watch report, continues to chain people presentinga psychosocial handicap.In September 2018, all of the 50 residents of Bina Lestari were chained.People are chained almost 24 hours a day, unable to move more than 2 to 4 meters in all directions.They do not receive any medical assistance or psychiatric care, the food given to them is of poor quality and they are exposed to the risk of undergoing physical and sexual violence from other residents or staff.
The local social affairs department is aware that people with psychosocial disabilities are chained to Yayasan Bina Lestari.From time to time, he even sends people there.The decision to admit or let the patients come out entirely to the healer by faith.The National Human Rights Commission led an observation visit to this institution in December 2017, but its report has not yet been made public.
Human Rights Watch has also already published a report on the Yayasan Galuh rehabilitation center, a private institution located in Bekasi, in the suburbs of Jakarta.This center currently has, arbitrarily, around 436 men, women and children with psychosocial disability.People are brought to Galuh by their family or by local police, in case they were found living in the street.Unless the family comes to get the person out, they can stay there indefinitely.
Galuh residents are also exposed to various abuses and negligence, hospitalization under stress, isolation and restraint.They are forced to live in conditions of overcrowding and unhealthiness.They are detained in great promiscuity, without being able to go out or wash regularly, which contributes to the spread of lice and scabies.Women living in this center are particularly exposed to the risk of sexual violence, since the toilets have no doors and that male staff monitors the Women's section.During the visit of Human Rights Watch, men members of the staff observed while the naked patients bathed.
Ratih, a woman with a psychosocial handicap that has been detained in Galuh for years, said:
I was chained here three times.The staff told me that if I was handcuffed, it was for my good.I was struck by staff members and handcuffed for an entire week.I couldn't even go to the toilet, I had to urinate on site, in my clothes.I had to ask my friend to help me eat, but she was too afraid...I want to go home, my place is not here.
Recommendations
The mediator's office (Ombudsman), the National Commission for Human Rights and the National Commission on Violence with regard to Women should:
The Ministry of Health should:
The Ministry of Social Affairs should:
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