社會精神衛(wèi)生法：對非洲的思考外文翻譯

1、社會精神衛(wèi)生法：對非洲的思考Peter Bartlett, Rachel Jenkins, and David Kiima精神衛(wèi)生系統(tǒng)國際期刊2011,5:21摘要：新的聯(lián)合國殘疾人權利公約創(chuàng)建了精神衛(wèi)生法立法的新模式，這種新的立法模式將原來的那種以制度關懷為重點的模式發(fā)展成為現(xiàn)在的以社區(qū)為基礎的精神病關懷服務。本文的寫作目的在于思考這種模式在非洲國家的具體實施。依傳統(tǒng)而言，精神衛(wèi)生立法在國內(nèi)和國際上都是以機構關懷為焦點，尤其以精神病制度關懷為焦點。從這個角度而言，精神衛(wèi)生法的作用在于確立合適的實體和程序標準而非通過立法的方式強制精神病患者住院。就最新的精神衛(wèi)生法而言，它的作用在于確立精神病患

2、者入院后的醫(yī)療看護標準。就歷史角度而言，這種立法方法與政策相對應。政府對比較嚴重的精神病人都會給予精神護理，由精神病收容所對精神病人進行長時間的看護。這種精神衛(wèi)生立法模式從保護精神病人利益的角度考慮顯然是不夠的。近幾十年來，政府對待相對較嚴重的精神病患者的政策的重點已經(jīng)從制度關懷發(fā)展到社會對人的關懷，這種轉(zhuǎn)變從新的聯(lián)合國殘疾人權利公約可以看得出來。與先前的國際文件（如聯(lián)合國精神病指導原則）不同，聯(lián)合國殘疾人權利公約不僅僅是一個指導原則，它是一部國際法，它擁有正式的法律淵源，簽署該公約的國家應當遵守該公約的約束。聯(lián)合國殘疾人權利公約將法律的焦點從法律對精神病患者的強制發(fā)展成為對精神病患者的社會服

3、務上，并將殘疾人的權利與社會相融合。顯而易見，社會生活制度化的立法模式與國際立法發(fā)展的趨勢相背。對于這種新的國際精神衛(wèi)生立法，非洲國家得到了特別的機遇和挑戰(zhàn)。與國際發(fā)達國家相比，非洲國家將聯(lián)合國殘疾人權利公約所規(guī)定的內(nèi)容制度化并實施的概率很低（見附錄文件一中的表1）。在經(jīng)濟發(fā)達的國家，制度模式的關懷向社會關懷模式的轉(zhuǎn)變是伴隨著分散的以社區(qū)為基礎的精神衛(wèi)生保健的發(fā)展而形成的。在1980年，英聯(lián)邦每100000人中就有一名心理醫(yī)生；而發(fā)展到1990年，這種比例已經(jīng)發(fā)展成為50000：1；到了2010年，在英聯(lián)邦每10000人中就1人是心理學家。然而，大規(guī)模的心理學專家提供的精神病服務并不是符合非洲

4、發(fā)展實際的模式。在非洲，大部分國家的人均國內(nèi)生產(chǎn)總之低于2000美元每年，而且這些國家的心理咨詢師，心理學家，精神科護士，社工等的數(shù)量都相當有限。精神科專家提供的社區(qū)服務往往是在省級或者市區(qū)級的社區(qū)單位里，這些服務由熱心的致力于為精神病患者提供服務的專家提供。然而，這種由專家提供的社區(qū)服務只能滿足很小一部分的精神病患者需求。一些非洲國家，例如坦桑尼亞，肯尼亞，馬拉維，贊比亞，正在嘗試將心里健康融入初級保健制度的立法。這種立法模式，將可以將專家的比例調(diào)整為每250000人一個心理學護士，每1000000人一個心理醫(yī)生。本文著眼于新的精神衛(wèi)生法律立法模式在非洲國家可能表現(xiàn)形式。這種立法模式刻意不注

5、重對精神衛(wèi)生機構的監(jiān)管。當然這些精神衛(wèi)生機構在非洲國家也存在，他們一般都處于省會城市。這些機構在精神病患者的準入和醫(yī)療看護方面的做法和標準都導致許多人權問題的發(fā)生。把整個國家的社會立法當作一個整體，無論是否通過首要關懷或者其它的方式，都不能使人們被允許進入這些被忽視或者遺忘的機構。但是，這些擔憂已經(jīng)吸引了國際社會的關注。這篇文章的焦點在于依靠一些獨特的問題，比如如果精神衛(wèi)生立法的焦點超出了機構的范圍，那么它將是什么樣子的。同時該篇文章焦點也在于依靠社區(qū)和首要的關懷服務。然而殘疾人權利公約所規(guī)定的新的立法模式又使這一相關問題國際化，本文將社區(qū)環(huán)境中的精神衛(wèi)生立法所存在的問題和非洲服務發(fā)展中存在的

6、特殊問題結(jié)合起來予以闡述。 非洲國家的精神衛(wèi)生關懷立法正如表格顯示，在非洲國家資源有限的問題是不可避免的。人均國民生產(chǎn)總值在2000美元以下是很普遍的。然而非洲聯(lián)盟的成員國已經(jīng)確定了在衛(wèi)生上花費15%的財政預算的目標，許多國家在近些年是不太有可能達到這一目標的。政府每年在衛(wèi)生上的人均支出一般低于50美元，并且在某些情況下每年甚至會低于10美元。通過比較，發(fā)達國家的政府每年在衛(wèi)生上的人均支出一般在1500美元到2000美元不等。在非洲，衛(wèi)生經(jīng)費通常提供給一些少部分的國家醫(yī)院，給遠離主要城市中心的醫(yī)療服務提供了很少的經(jīng)費。例如，在肯尼亞，在內(nèi)羅畢的國家醫(yī)院消耗了近90%的國家衛(wèi)生支出。反過來，精神

7、衛(wèi)生的預算僅僅是全體衛(wèi)生預算的一部分。在2000年，精神衛(wèi)生在全球疾病的負擔中所占的比例是12%，預測到在2020年將會增長到15%。在國際上對精神衛(wèi)生的預算往往都沒有達到這一比例。但是這一比例在非洲國家卻驚人的低通常情況下低于衛(wèi)生預算的1%，并且整個衛(wèi)生預算每年可能僅僅在人均10美元左右。在如此低的衛(wèi)生預算的背景下，結(jié)果就是僅有及其少的資金用于精神衛(wèi)生服務。產(chǎn)生這種情況的原因是醫(yī)院職工的工資很低以及可用于住院的病床有限所致。例如在肯尼亞，40萬的人口卻只有少于1000的病床可供使用，而且在這些病床中，內(nèi)羅畢占絕大部分。每個省有4到5萬的人口，卻只有20個精神科住院病床。每個區(qū)有25萬人口，卻

8、只有1到2個精神科護士，而且有精神科住院病床的區(qū)域不足10%。在一些非洲國家，并不存在國家投資的精神服務的存在。 結(jié)果是最低限度的精神衛(wèi)生服務。根據(jù)2005年世界衛(wèi)生組織的研究表明，盡管馬拉維已經(jīng)聘請了心理科醫(yī)生，但在安哥拉和馬拉維沒有精神科醫(yī)生。一般來說，在非洲1萬個人中才有一個心理醫(yī)生，并且這種情況已大大加劇了人才外流。在肯尼亞有23衛(wèi)心理醫(yī)生為40萬人口提供公共服務。在馬拉維有13位心理醫(yī)生為42萬人口服務。心理科護士，社會工作者和心理醫(yī)生的工資待遇都很低。在肯尼亞有250名心理科護士開設了精神病學，但是產(chǎn)出的比例是遠遠低于退休的比例，從而導致了大量的人才外流。進一步來說，在2009年，

9、肯尼亞在所有接受培訓的12人之中，僅僅為國家培養(yǎng)了一名精神科護士，但是絕大部分的人是來自于其它非洲國家。近些年來，由于學生沒有足夠的支付課程的費用，精神科護士的學生人數(shù)不斷的下降，但是在2010年這一人數(shù)很幸運的重新增長起來。 地理因素加劇了這些問題。在南非共和國之外，撒哈拉以南的非洲地區(qū)，其每名精神科醫(yī)生所在的平均面積范圍是不同的，斯威士蘭是每17,000平方公里一名醫(yī)生，而剛果則是每342,000平方公里一名精神科醫(yī)生。在相同背景之下，澳大利亞的相應數(shù)據(jù)是2600平方公里，而美國是230平方公里，法國和英國是每40平方公里一名精神科醫(yī)生。當然，對于這方面的平均水平，我們必須要小心求證。實際

10、上，精神衛(wèi)生專業(yè)人員（特別是精神科醫(yī)生）可能都集中在城市地區(qū)。對于這些城市的人來說，他們比市區(qū)以外的人更容易得到專業(yè)服務。而對農(nóng)村地區(qū)的人來說，專業(yè)服務集中在城市稀疏的初級保護覆蓋范圍（每一萬人口有一個診所）意味著最近的醫(yī)療設施可能確實都需要走很長的路，而有限的公共交通基礎設施更加劇了困難。 現(xiàn)有的治療方法是有限的。由于價格原因，新一代抗精神病和抗抑郁藥物是不太可能在公共部門中得到的，而且盡管他們有更好的作用，但也不是在任何情況下都能取得更好的結(jié)果。如果政府和客戶之間都會分擔成本的話，那么老年人的藥物一般是由兩者共同支付的。但是，即使是這樣也經(jīng)常出現(xiàn)供不應求，而公共分配也會出現(xiàn)各種問題，這是因

11、為國外采購比較困難，且質(zhì)量較差，而進口的藥品也缺乏質(zhì)量管理，分配機制又在不斷變化，如在肯尼亞的衛(wèi)生設施就由藥物包推式系統(tǒng)轉(zhuǎn)變?yōu)槔接嗁徬到y(tǒng)。這不僅造成精神衛(wèi)生設施的缺乏，而且造成抗瘧藥的短缺。新的心理療法的培訓（如CBT）是有限的。研究表明，如果新的心理療法培訓的實施是有效的，它就需要持續(xù)的監(jiān)督。因此，只有密切監(jiān)督的時間足夠長才能使得這種培訓成為更有效地一般心理技能，從而支持CBT和其他特殊療法的實施。Mental health law in the community: thinking about AfricaPeter Bartlett, Rachel Jenkins, and Davi

12、d KiimaInternational Journal of Mental Health Systems 2011, 5:21Abstract: The new United Nations Convention on the Rights of Persons with Disabilities creates a new paradigm for mental health law, moving from a focus on institutional care to a focus on community-based services and treatment. This ar

13、ticle considers implementation of this approach in Africa. Traditionally, mental health law at both domestic and international levels has focused on institutional care, and particularly psychiatric hospitalisation. In this vision, the role of mental health law has been to ensure appropriate substant

14、ive and procedural standards prior to involuntary admission, and, more recently, to ensure standards of institutional care following admission. Historically, this approach to legislation corresponded to the policies regarding the psychiatric care of people with relatively severe mental illness, whic

15、h had a central focus on detention in psychiatric asylums, often for extended periods. This paradigm of mental health law can however be seen as increasingly insufficient. The political emphasis in recent decades has moved from institutional to community care for people with relatively severe mental

16、 illness, and this shift is reflected in the new UN Convention on the Rights of Persons with Disabilities (CRPD). Unlike many previous international documents such as the UN Mental Illness Principles, the CRPD is not mere guidance: it is international law, with a formal review body to which countrie

17、s that have signed the convention will be held accountable. The CRPD moves the focus of law away from detention and compulsion, to the provision of community services and the right of a person with disabilities (a term which expressly includes mental disabilities) to integration into the community.

18、Clearly, a legislative focus on institutionalisation to the exclusion of community life is now out of step with the developing international law. Africa presents particular opportunities and challenges for this new legal paradigm. Its rates of institutionalisation tend to be very low by internationa

19、l standards: see additional file HYPERLINK /pmc/articles/PMC3189124/?tool=pmcentrez l S1 1, table 1. In rich countries the move from an institutional model of care to a community model of care has been achieved through the development of decentralised community-based dedicated mental health care alt

20、ernatives provided by specialist professionals in liaison with a strong primary care infrastructure. In 1980 there was around 1 psychiatrist per 100,000 population in the UK; by 1990 this had increased to 1 per 50,000 and by 2010 this ratio is around 1 psychiatrist per 10,000. However, large-scale s

21、pecialist mental health care provision is not a practical general model for Africa, where per capita GDP is often less than US$ 2000 per year, and where consultant psychiatrists, psychologists, psychiatric nurses, and social workers are strictly limited (see further table 1). A little specialist com

22、munity provision is often found in the close neighbourhood of psychiatric provincial and district units, practised by enthusiastic specialists who devote some time to following up clients in the community-however, logistically such a specialist delivered community service can only cover a tiny fract

23、ion of those in need. Some African countries eg Tanzania, Kenya, Malawi, Zambia are making systematic efforts to integrate mental health into primary care settings with support and supervision supplied by district level mental health staff, who where they exist, tend to be psychiatric nurses. Such a

24、pproaches make major logistical sense in the context of only 1 psychiatric nurse per 250,000 population, psychiatrist per million population, and often no psychiatric social workers or psychologists. This paper looks at what the new paradigm of law might look like in African contexts. It deliberatel

25、y does not focus on the regulation of institutions. Such institutions do of course exist in some African countries, generally in the capital cities, and the practices and standards concerning admission to them and care within them raise important human rights issues. A focus on community provision a

26、cross the country as a whole, whether through primary care or some other method, must not result in the people admitted to these institutions being forgotten or ignored, but such concerns have already attracted some international attention. This article focuses instead on the specific question of wh

27、at mental health law looks like if it focuses outside the institution, and instead on community and primary care services. While the new legislative paradigm enshrined in the CRPD makes this a relevant question internationally, this paper couples the issue of mental health law in community environme

28、nts with the practical issues of service development in Africa.Mental Health Care Provision in Africa As table 1 shows, the problem of limited resources is unavoidable in an African context. Per capita GDPs of less that US$2000 per year are common. While members of the African Union have affirmed th

29、eir objective of spending fifteen per cent of their national budgets on health, many countries are unlikely to reach that target in the near future. Government per capita expenditures on health are often less than US$50 per year, and in some cases are less than US$10 per year. By comparison, governm

30、ents of developed countries generally spend in the range of US$ 1500-2000 per capita per year on health. In Africa, health funding is often focused on a small number of national hospitals, leaving little for health care provision outside major urban centres. In Kenya, for example, the national hospi

31、tals in Nairobi consume 90% of the national health budget. Mental health budgets in turn are a small part of the overall health budget. The share of mental health of the global burden of disease was roughly 12 per cent in 2000, expected to rise to 15 per cent by 2020. Health budgets devoted to menta

32、l health internationally often do not reach this proportion, but the proportions in Africa can be startlingly small - often less than one per cent of the health budget, and the overall health budget itself may only be around $10 per capita per year. In the context of such small health budgets overal

33、l, the result is miniscule funding actually available for mental health services. This is largely devoted to staff salaries and a small number of inpatient beds. Kenya for example has less than 1000 beds for a population of roughly 40 million, and of these, most are in Nairobi. Each province of arou

34、nd 4-5 million population has only 20 psychiatric inpatient beds. Each district of 250,000 has 1-2 psychiatric nurses, and less than 10% of districts have any inpatient psychiatric beds. In some African countries, there would appear to be virtually no state investment in specialist mental health ser

35、vices. The result is minimal specialist mental health services. According to the WHO in 2005, (WHO, Mental Health Atlas, 2005) there were no psychiatrists in either Angola or Malawi, although Malawi has since successfully recruited a psychiatrist. On average, there is roughly one psychiatrist per mi

36、llion people in Africa, and this situation has been greatly aggravated by brain drain. Kenya has 23 psychiatrists in the public service for 40 million population; Tanzania has 13 for 42 million. Psychiatric nurses, social workers and psychologists are in similarly short supply. Kenya has 250 psychia

37、tric nurses deployed in psychiatry in the country, but the rate of production is far less than the rate of loss to retirement, mortality and brain drain (both overseas and internal). Indeed, in 2009, Kenya produced only one psychiatric nurse for the country. 12 were trained that year, but most were

38、from other African countries, to which they returned. Numbers of Kenyan student psychiatric nurses fell in recent years since students now have to pay course fees, but in 2010 numbers are fortunately rising again. These problems are exacerbated by geography. Outside RSA, the average area per psychia

39、trist in sub-Saharan Africa ranges from roughly 17,000 km2 per psychiatrist in Swaziland, to 342,000 km2 per psychiatrist in the Congo. To put that in context, the comparable numbers for Australia is 2600, the United States 230, and France and the UK are 40 km2 per psychiatrist. Averages in this con

40、text must of course be approached with care. In practice, mental health professionals, and psychiatrists in particular, are likely to be concentrated in urban areas. For these urban populations, specialist services will be considerably more accessible than for people outside these urban areas. For people in rural areas, the concentration of specialist services in cities and the sparse coverage of primary care (1 clinic per 10,000 population) means