1994: four years after the reunification of the royalist north
and the socialist south, civil war erupted, prompting a large-scale
humanitarian operation. The ICRC sent Dr Jean Rey-Bellet,
a retired former director of the psychiatric hospital in Monthey
(Switzerland), to Yemen to assess psychiatric needs in prisons.
Two years earlier, he had carried out a mission to Tuzla in
war-torn Bosnia and Herzegovina with a similar brief. There,
mentally ill patients had been driven out of a hospital in
a Serb area and left to fend for themselves. Urgent solutions
had to be found on the spot to assist a group of people who
are particularly vulnerable in wartime.
“In Yemen for 25 years, the ICRC had been receiving
regular reports on the situation of the mentally ill in the
country’s prisons, where they received no specific treatment,”
recalls Dr Rey-Bellet. “But for a long time no action
was taken. It wasn’t until the civil war in 1994 that
it decided to do something.” Dr Rey-Bellet therefore
went to Yemen and visited the main prisons and all the psychiatric
institutions in the country. Once a month a Yemeni doctor
would visit the prison in the capital Sana’a, where
conditions were horrific. They were even worse in Hodeida
prison, where the mentally ill were piled on top of one another.
Concrete blocks served as beds. In some cases, the inmates
were chained. “Overall, the hygiene conditions were
appalling,” he recounts. In Aden, meanwhile, in what
had been South Yemen and under Soviet influence for years,
the situation was better. “Mental illness was recognized.
Inmates thus afflicted were given occupational therapy, which
in the West formed an important part of the treatment 30 years
Dr Rey-Bellet came up with a rapid plan of action and submitted
it to the ICRC’s Geneva headquarters, which accepted
it despite some reservations. And so he headed once again
to Yemen to put it into effect, first in Sana’a, from
1995, and then gradually extending it to two other prisons,
Taïz in 1996 and Ibb in 1997. “It would have been
impossible, and pointless, to set up a psychiatric unit in
each prison. From the start, the idea was to group all the
mentally ill inmates in the country in these three prisons.”
In the capital, the ICRC hired a psychiatrist and a nurse
to follow up each case regularly and supply them with the
necessary drugs, which were very costly. Their first task
was to determine which of the inmates were genuine detainees
and which were mentally ill people who had simply been picked
up in the street. They then had to establish each patient’s
identity in order to create individual medical files.
The ICRC had already substantially refurbished the Sana’a
prison (installing electricity, sanitation, running water
and drains). It rounded off this work with the wing for mentally
ill inmates: buildings were repainted, an exercise yard kitted
out and a kitchen garden created to enliven their existence.
Following a training period, Yemen Red Crescent Society volunteers
served as nurses. “When we started in Sana’a prison,
there were 102 mentally ill inmates, of whom 14 were not proper
detainees, in that they had not been through the courts. As
the programme took effect, the number of ‘non-detainees’
increased because the families put pressure on the warders
to let them in so that they could receive free care”,
says Dr Rey-Bellet.
Today, the project is fully financed by the Netherlands Red
Cross. In 2000, Dr Rey-Bellet passed the baton on to his son,
a doctor at the Geneva psychiatric hospital, thus ensuring
the continuity of a programme that had reached cruising speed.
Looking back, he wonders why the ICRC was so reluctant to
get involved in this project. “It didn’t fit into
the institution’s mission, since it is more of a development
issue,” he ponders.
In any case, the dynamic set in motion in Yemen has achieved
is main goal. “Instead of being ‘guarded’,
the patients are treated — even if the treatment is
sometimes quite basic. At the same time, the different actors
in the health sector in Yemen have organized themselves to
work in a concerted manner,” he says.
In the psychiatric section of the Taïz
central prison in Yemen.
©Till Mayer / ICRC
Sana’a central prison, psychiatricsection.
Since 1995the ICRC, together with theYemen Red Crescent Society,
has supported mentally ill inmates through various projects,
including sports programmes.
©Till Mayer / ICRC
From theory to practice
Dr Jonathan Beynon, head of prison health at the ICRC in
Geneva, explains the current thinking in the field of psychiatric
care in prisons, as well as the main challenges.
Does the ICRC have a specific doctrine on the
subject of psychiatry?
Jonathan Beynon: Strictly speaking, no. However, psychiatry
as such is only one aspect — albeit an important one
— of mental health, which should be viewed as a whole.
The ICRC’s concern is to promote the mental health of
everyone in the prison environment — not just of the
inmates, but also of the warders and the management. After
that, its aim is to provide a targeted response to the mental
problems suffered by detainees by finding alternatives to
imprisonment: treatment outside the prison system, coordination
between the prison system and the public health service, etc.
With this in mind, in 2004–2005 we came up with a more
formal approach, outlined in a document produced jointly with
the World Health Organization, which tackles the subject from
both the theoretical and the practical points of view. If
we did have an official doctrine, this document would form
the core of it.
What does it consist of?
It begins with a brief exposé of the current state
of affairs: the rate of mental illness in prisons is proportionally
higher than in the rest of society. In many countries, detention
has a very damaging effect on mental health; in some cases,
mental patients are kept in prison because no suitable medical
alternative exists. On the practical level, the document recommends
that, as a basic rule, people suffering from mental illness
be directed first to ad hoc medical facilities, even if it
means they are sent to prison at a later stage, provided that
once there they receive appropriate treatment. For example,
one country in Africa had plans to build a prison specifically
for the mentally ill and asked the ICRC for its advice. We
replied that it was the wrong approach. Basically, our view
is that the public health system should be the first port
of call and not prison.
What is the main challenge today?
It is the application of the theory rather than the theory
itself, for the simple reason that in every country in the
world, including in the West, prisons are the most poorly
resourced. Our main challenge is therefore to change the attitude
of those in power towards prisons.
Is psychiatry sometimes used for non-medical
ends in prisons?
Yes, in the way it was practised in the Soviet era, it is
still used in some countries to neutralize dissidents under
the guise of medical diagnosis. In other cases, psychiatrists
or psychologists are used during interrogation of prisoners
to detect possible mental weaknesses so that they could be
used to extract information. Many people have protested that
this is contrary to medical ethics.
Interview by Samuel Gardaz