Patients live in dire conditions, two toilets for every 20 patients

KURILO, Bulgaria: Medical workers look on during an inspection of the European Psychiatric Association (EPA) in the psychiatric hospital.

KURILO, Bulgaria: At the psychiatric hospital in Kurilo in the mountainous countryside near the Bulgarian capital Sofia, around 100 patients languish on their beds in dilapidated surroundings. For hospital director Tsveteslava Galabova, the facility is "representative" of the state of psychiatric hospitals across the country. Of the 12 public hospitals treating people with psychiatric disorders, 11 are in remote locations like Kurilo, in a legacy of the communist era when patients were hidden away lest they mar the image of a socialist paradise portrayed in official propaganda.

Almost 30 years after the fall of the communist regime, Bulgaria remains the European Union's poorest country and still struggles to provide adequate mental health care. The country's psychiatric hospitals have 2,300 beds in total, while another 13 asylums offer space for around 1,000 patients-with another 900 on a waiting list. Built in the early 20th century, Kurilo's hospital is the biggest in the Sofia region, but the facility offers little respite from the bitterly cold winters or from the sweltering heat of summer. It may be situated in a lush green park but, as Galabova drily notes, that alone "can't treat schizophrenia".

Pervasive prejudice

Inside, the conditions are dire, with two toilets for every 20 patients, three patients per room and the metal beds they sleep on as their only personal space. As well as material privation, those suffering from mental health issues also have to deal with widespread prejudice. Interior Minister Valentin Radev recently sparked controversy after a high-profile murder case by saying "the mentally ill should be brought under control and locked up".

"The attitude of stigmatization is pervasive in society, even among doctors," says Professor Drozdstoy Stoyanov, a senior adviser on psychiatry to the ministry of health, who invited experts from the European Psychiatric Association (EPA) to Bulgaria to advise on reforming the system. In a 2017 report, the UN's Committee Against Torture expressed concern over "the high incidence of inappropriate or unnecessary non-consensual institutionalization" in Bulgaria while noting a lack of "independent inspection or monitoring mechanism for mental health institutions".

It also noted the ongoing problem of isolation, saying such institutions "continue to be located in remote locations"-a fact not lost on Galabova. "We asked for the hospital to be transferred to Sofia but the city authorities said that a referendum would have to be held first," she says, indicating that the idea was eventually dropped.

No funds for rehabilitation

"It is extremely dangerous for physical and mental health to spend hours and hours doing nothing," visiting EPA president Silvana Galderisi said. One of the main problems in Bulgaria is the fact that "this kind of institution (still) exists: they are very isolated, are very large and very understaffed for the number of people they have."

With few facilities located near the patients' communities, their families tend to leave them at the mercy of such institutions, often for years on end. Under the communist regime, there was a farm at Kurilo where the patients could work but it didn't survive the transition to a market economy. And now there are no funds for any form of rehabilitation.

Political will is crucial

"Our budget is ridiculous and absurd," says Professor Maya Stoimenova, director of the psychiatric clinic at the Medical University of Pleven in northern Bulgaria. Like many others, her clinic struggles to afford the wages of basic personnel to supervise patients and distribute medicine, let alone provide any further therapy. The average wage of a health worker specialized in rehabilitation is 630 leva a month, compared with 450 for a psychiatrist and 250 euros for a nurse.

In other European countries "they can earn at least two-and-a-half times as much," Galderisi says. It will remain difficult for Bulgaria to compete with other EU states in terms of salaries for specialist workers, with only around two percent of the country's health budget earmarked for mental health. The EPA recommends this portion should rise to 10 percent. As for reforming the sector, experts note that Bulgaria even lags behind other former communist countries such as Poland and the Czech Republic.

Under pressure from the EU and the United Nations, the government has outlined some steps to improve care for those suffering from mental disorders and disabilities. This year, it launched a three-year action plan which includes the closure of 10 understaffed and inadequate institutions and replacing them with day centers offering care within the community, as well as a smaller number of residential homes. But there is still a long way to go, and as Galderisi says, "political will is crucial".--AFP