LETS WALK THE TALK !
PSYCHOSOCIAL REHABILITATION
IN MONGOLIA
THE "GER" BASED PSR
Introduction
In most developing countries there is shortage of everything from food and clothing to medicines and hospitals. The limited budgets for essentials in health care means the life saving arts and sciences in medicine get priority for funds, staffing, equipment and skills. Those diseases that are long term thought "incurable" get nothing fancy. Their quality of care deteriorates with squeezes in the budgets and no new ideas are introduced to make needed changes. Institutionalism in medical care is seen far too often in mental institutions to make rehabilitation of the institutionalised mentally ill the norm rather than the exception.
In several places most of the mentally ill sent to chronic long stay hospitals remain as discharge is almost unheard of. Under such circumstances can anything be done ? Are there alternatives to mental health care for the chronically ill apart from low doses of medicines and ineffective quality of care ?
In 1999 the World Health Organisation (WHO) through its Nations for Mental Health Programme embarked on an effort to change mental health care for several countries. Mongolia under the Western Pacific Regional Office of WHO was tasked bringing about change in Mongolia which was undergoing changes from a Planned economy to a Market driven one with all the difficulties that ensued.
This post is based on the changes that took place with the Ministry of Health Mongolia's and WHO's strong support and that of several NGOs from many countries in Asia and Europe America - to make a difference for the chronically mentally ill in Mongolia. (written by a consultant to that programme - Dr. M P Deva of Malaysia, parameshvara24@yahoo.com)
Mongolia has an indelible place in world history as the origin of the the largest continuous empire the world has known brought together by swift and violent conquest by a country that may not have had more that a few million people at that time in 12th to 13th century CE.
The Vast Mongolian Empire of 13 CE Chinggis Khan
Successive Chinese Emperors built The Great wall
to keep out the war like Mongolians
.
It is a vast land with a harsh winter that nestles on a large 1000 meter high plateau between China to the south and the vast Siberian part of Russia.Its people totalling about 2 1/2 million are mostly herders of livestock - sheep, cows, horses, yak and double humped camel and depend on herding for their livelihood. Under the planned economy the herding was run like a huge cooperative that ensured every citizen got the basic necessities of life almost without cost- food, clothing, housing and medical care. Under the newly started market driven system the medical care faced major problems as costs rose with medical imports even from former socialist countries like Hungary which supplied most medicines in barter arrangements, becoming prohibitive with payments in cash, now demanded.
Many mentally ill only received medicines, with nominal cost when inpatients but had to buy the same when discharged from hospital. In rural areas where the herders and families lived access to medicines was difficult. Patients'illnesses relapsed from lack of medication and the rehabilitation programmes formerly available through the centrally planned administration of health care all but collapsed. In one of the ways to strengthen mental health care Psychosocial Rehabilitation was re-started by the consultant. But the biggest block to this was the lack of funds for occupational therapy material and space for a community based programme.
In winter the routinely cold Minus 30 degrees C temperatures excluded occupational therapy outdoors and popular rehabilitation practices such as gardening, walk and hikes and games were out of the question. So that only indoor activities were possible - if money for materials could be found. In the summer the mild Plus 17 to minus 10 C temperatures allowed more activities but once again space was a problem . Innovative solutions were needed and most solutions that cost money were out of reach.
Opening of First Ger - Lto R Director of state Mental Hospital, Prof M P Deva Visiting Consultant Psychiatrist from Malaysia, Dr Ayushjav deputy Director Mental Health, Dr Tsetsegdary Mental Health Officer MOH Mongolia, Dr Jenny P Deva Counseling Psychologist.
After much effort the donation of a Ger by the WHO opened 1999 December Christmas Day
led to its installation in the grounds of the State Mental Hospital
This was the start of the Psychosocial Rehabilitation Ger Programme in Mongolia
The Ger next to the State Mental Hospital
Traditional Mongolian houses are Gers both in rural grasslands and even in urban Ulaan Baatar the nations capital. They are padded tents that are portable and heated by one stove that is the kitchen and heater and the ger accomodates the whole family in the tented house
In a reverse thinking of modern rehabilitation, the innovation was to rehabilitate the mentally ill by going back to using the country's main occupation- herding livestock out of ger communities the herders used . Land is plentiful and animals were even owned by the mental hospital at Maant that housed the most chronic patients (picture below). Maant was sited in a penal colony which had the country's large prison and now also has a forced alcoholism treatment centre at an abandoned air base.
The livestock was looked after by trained herders employed by the hospital. The herding community was a source of support for the mental hospital that had to generate its own budget for at least 1 month a year and provide funds for its upkeep. Patients able to help the herders and learn the basics of herding were sent out to the vast rolling steppes of Mongolia in the summer where they had more food, fresh air and learned skills. They lived in insulated tented houses called Gers that could be collapsed and moved in hours as the herders and their herds moved from used pastures to new ones in search of grass and water in strategically available wells built by the government.
Practicing the art of catching an undomesticated horse
Patient and herder
The patients live with the herders in Gers or Yurts
Collecting water from well and rounding up horses by using long poles
For the young boys learning how to milk horses and for female patients collecting dung for fuel and domestic chores are common work duties allocated in the Ger community
Herders and patients being rehabilitated in the vast grasslands and living with herders families and a nurse who cares for their medication. They learn to care for animals, milk them and export the meat and wool for sale to the market in the summer.
Frozen Meat is staple food in Mongolia
Sheep skins and wool are in high demand as insulation for Gers
and carpet industry in Mongolia and valuable export
REHABILITATION IN MANT HOSPITAL
A Large Rug made out of waste cloth
Craft Work from Waste Cloth made by patients who are in Maant
The occasional camel is included in the animals herded
to provide transport when the community moves to new pastures
Head of the Ger Community a Mongolian Army Veteran
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URBAN Ger BASED PSR
In the capital of Mongolia Ulaan Baatar Gers were also set up at community health Clinics as PSR centres for treated but poorly functioning patients so that they could benefit from community based PSR
Ger at the Outpatient Unit at Ulaan Baatar that served a Day Centre
Occupational Therapy products from material donated by overseas agencies
Inside of a Community Day centre Ger in a Suburb of Ulaan Baatar below
Occupational Therapy Craft work
PSR Ger in Ulaan Baatar next to a Community Health Centre
in one UB's Urban Districts
State Mental Hospital Farm Ger in the Summer
A Farming Ger about a kilometer from the State Mental Hospital
for patients to stay in the summer to grow potatoes, vegetables
These pictures are from a visit to the farm on the hospital's own land
by the director of the hospital
The State Mental Hospital Ger Colony
a de-institutionalisation project
Cooking inside a Ger
Conclusions
The Ger Psychosocial Rehabilitation Project in Mongolia.
Started by a visiting Consultant Psychiatrist from Malaysia in 2000 the first Gers were started with WHO funding but by 2002, 7 Gers had been set up with a variety of agencies and donations in Hovd, Dornogobi, and in Ulaan Baatar. The original Gers in Maant closed and are in storage as the patients were re-located to outside the State Mental Hospital that afforded electricity from the hospital supply and food and other supplies and 6 Gers are in the community outside the hospital that the author visited in 2008 December
PSR Ger, at state Hospital 2008 Ulaan Baatar
