COVER STORY

The real cost of mental health care in the Philippines

The passage of the mental health bill in the Senate has been widely celebrated by the general public. But what does this mean for professionals, staff, and patients of mental health facilities?

 

Manila (CNN Philippines Life) — Some of the teenage boys ram into the grills of their newly painted cells at Pavilion 14, the mental facility for male patients under 18 at the National Center for Mental Health (NCMH) in Mandaluyong. Others waved, others stared, and a few are indifferent to our arrival. Most of them are either pacing their rooms or squatting on the ledge of their quarters — either looking everywhere or staring at one thing.

The boys’ heads are shaved. “Kailangan close to the scalp hair cut kasi baka magsabunutan,” says Dr. Joanna Borja, a third year psychiatry resident at Pavilion 14. The sleeping quarters in this facility are empty — no beds or mattresses, just a massive space separated by dark brown metallic grills.

Wala silang beds kasi hindi pwedeng maglagay. Kasi ano ‘yun, material ‘yun to harm themselves or harm others,” explains Borja. “Kumot nga maingat kami dun. ‘Yung iba may banig pero binabantayan namin ‘yan kasi magagaling ‘yang mga ‘yan, minsan dinudugtong-dugtong para magbigti. Kahit toothbrush hindi sila allowed humawak … Kasi hindi mo alam takbo ng mga isip nila.”

Photo-24 (3).jpg The sleeping quarters in this facility [at the National Center for Mental Health] are empty — no beds or mattresses, just a massive space separated by dark brown metallic grills. “Wala silang beds kasi hindi pwedeng maglagay. Kasi ano ‘yun, material ‘yun to harm themselves or harm others,” explains Dr. Borja, a psychiatry resident at NCMH. Photo by JL JAVIER

Pavilion 14 is one of the 35 pavilions at the NCMH, the biggest mental hospital in the Philippines. Carrying 4,200 beds, the NCMH looks like a 20th century university campus, with various buildings and facilities scattered across a vast expanse of land. Like universities that have shrines dedicated to people who signify the thrust of the institution, a monument of a woman also greets visitors of the Mandaluyong mental hospital. The woman, dressed in a neoclassical night dress, is Jose Rizal’s Sisa, with a marker below that reads, “A mother who became insane because of the hardships and sorrow she suffered.”

From the shrine of Sisa, cemented roads lined with trees stretch out into the property. “The facility is sprawling over 47 hectares of property in Mandaluyong,” says Dr. Bernardino Vicente, who has been the director of NCMH for 19 years. He sits on his black, leather couch in the administration office of the hospital, and beside his couch are piles of old, hardbound books that have seen the many changes that the NCMH has undergone — from being a home for the aged, a correctional facility, a boys town, to being a mental hospital.

Photo-3 (4).jpg “Nagagalit sa’kin ‘yung iba if I say this eh, it's because rights-based siya ['yung Mental Health Bill] … wala sa panahon, it's not timely. This is not the time to talk about human rights," says Vicente, the director of NCMH, when asked about his opinion on the Mental Health Act of 2017. Photo by JL JAVIER

Aside from the pavilions that house the patients, there are also dormitories for staff who live inside the property, a designated building where all of the patients’ food are prepared, and a sports arena for patients who are well enough to engage in activities. Just a few steps away from this sports center is a rehabilitation pavilion for adult women. It looks like a public elementary school, with the ‘classrooms’ as wards, with the ‘quadrangle’ as their common area, and with doors that are doubly secured by steel gates.

The women are in pink hospital dresses, all doing a myriad of things — showering, playing sungka, watching T.V., sleeping, conversing, staring at empty spaces. They start asking us questions simultaneously (“Taga-saan kayo?”Anong channel kayo?”Koreana ka ba?”) while some remain seated in plastic chairs or in corners of hallways, oblivious to our presence. Besides their uniforms, the only thing they have in common is their slow, leisurely pace.

"Ang problem lang kasi dito sa mental hospital is that we’re perpetually on sale ... the concept is since you're going to be for sale, no funding was given to the hospital so since 1968, dilapidated ‘yung facilities.” — Dr. Bernardino Vicente

 

Unlike the pavilion with adolescent boys, this pavilion has mattresses and beds, similar to typical public hospital wards. In one of the rooms, a few female patients are being taught how to make fried potato balls. “‘Yung mga occupational therapy o different activities for rehabilitation, that is to prepare them ‘pag labas nila in order to be better equipped na maka-adjust ulit sa society,” says Dr. Jose Loveria, the head psychiatrist of the rehabilitation pavilion for women.

 

A few kilometers away is a freshly coated building called the Psychosocial Rehabilitation Program and Training Center, a site where patients are taught vocational activities like making soap out of guava leaves or making screen-printed shirts, which they then sell to the community within the hospital property.

Photo-22.jpg “‘Yung mga occupational therapy o different activities for rehabilitation, that is to prepare them ‘pag labas nila in order to be better equipped na maka-adjust ulit sa society,” says Dr. Jose Loveria, the head psychiatrist of the rehabilitation pavilion for women at the NCMH. Photo by JL JAVIER

As we enter this brightly lit building, Robert [full name not disclosed], a 48-year-old patient with an incomplete set of teeth and thinning hair, waves hello. The staff leads us to a room of around 10 male patients sitting on a communal table, wrapping citronella soap with plastic. In another room is where they display their wide array of products — tote bags, shirts, soaps, lotions — which Robert proudly shows off.

“With the help of [this center], I am developing skills. I used to be a bad salesman. I used to work also [as] a real estate person, so here, I learned how to market, how to barter, how to haggle with customers,” he says. After working as a salesman, Robert went on to work as a call center agent before he was diagnosed with schizophrenia, and was later admitted by his family during the summer of 2009.

“I had an experience with illegal drugs. I took it once with my girlfriend, so I had a relapse …  They brought me here and I was brought in Pavilion 6, which is like the receiving area of the hospital. I do admit I was in bad condition. I could not tell reality and my imagination. I could be talking to you right now but in my brain I was already in the States, or I was flying away,” he recalls.

This center was only opened in 2014 and parts of the women’s pavilion are currently under renovation. While this may be a promising movement towards better facilities and services, there are still structures around the property that have been left to gather cobwebs and weeds. This comes as no surprise to Vicente, the director, as he knows that the NCMH has always been up for sale, which has made it hard for the hospital to receive proper funding.

Ang problem lang kasi dito sa mental hospital is that we’re perpetually on sale,” he says. “In 1968, there was a law that mandated the sale of the NCMH and in fact, the entire welfare bill property and the proceeds should go to child welfare. That has been news for many, many years ... the concept is since you're going to be for sale, no funding was given to the hospital so since 1968, dilapidated ‘yung facilities. Wala kasing capital outlay being given.”

***

The newly approved Senate Bill No. 1354 or the Mental Health Act of 2017 sponsored by Sen. Risa Hontiveros may help NCMH to get adequate funds, as the bill mandates the Department of Health (DOH) to provide psychiatric and neurological psychosocial services to all regional, provincial, and tertiary hospitals, while also increasing the capacities of mental health professionals and all health service providers. The bill also mandates educational institutions to run anti-stigma and discrimination programs on mental health in schools and universities.

But Vicente is not entirely convinced by the bill, saying that the bill is still more rights-based, a feature that, for him, isn’t necessarily of paramount importance. “That version is basically rights-based eh because understanding where Risa Hontiveros is coming from. So ‘yung effect niyamas maraming emphasis on the rights of the mentally ill patients. And just a segment of the bill that [is] devoted to the services … a few pages but maraming rights, rights,” Vicente explains. He would rather have the bill shift the focus toward the services that can be offered since the rights of mental health patients are already covered by the anti-torture law.

Section 2 of the Anti-Torture Act of 2009 states that “the human rights of all persons, including suspects, detainees and prisoners are respected at all times; and that no person placed under investigation or held in custody of any person in authority or, agent of a person in authority shall be subjected to physical, psychological or mental harm, force, violence, threat or intimidation or any act that impairs his/her free will or in any manner demeans or degrades human dignity.”

Photo-34 (1).jpg “I had an experience with illegal drugs. I took it once with my girlfriend, so I had a relapse …  They brought me here and I was brought in Pavilion 6, which is like the receiving area of the hospital. I do admit I was in bad condition," recalls Robert*, a 49-year-old patient at NCMH. Photo by JL JAVIER

Na-pass na ‘yung [anti-torture] law na ‘yun and it covers already that aspect [so] it's just a duplication,” he says. “’Yung services, mas may emphasis on community-based mental health services. So on the part of the services ng hospital, it doesn't speak about modernization or developing a new mental hospital, wala.”

The 2016 data of DOH’s Bureau of Health and Facilities Services show that there are only two government-owned psychiatric health centers, Mariveles Mental Hospital in Bataan and Cavite Center for Mental Health. The NCMH on the other hand is classified as a specialty mental hospital, as it is the only tertiary medical center for mental health disorders, which is why it is not under this list. The same report reveals that there are 58 private psychiatric health facilities across the country — 32 of which are all in NCR, and the rest scattered among Regions 1 to 5, 7, 10, and the Cordillera Administrative Region.

While Vicente agrees that community-based mental health services are imperative in making mental health services more accessible to people outside of the city, he still thinks that talking about human rights at this time in the Philippines is futile. “Nagagalit sa’kin ‘yung iba if I say this eh, it's because rights-based siya … wala sa panahon, it's not timely. This is not the time to talk about human rights.”

***

Sen. Hontiveros is signing a document in her beige-carpeted office in Senate when I arrive. She fixes her pink and purple skirt suit, sits down on a cushioned chair, and clips her tortoise-shell eyeglasses.

I ask her about claims such as that of Vicente’s that the bill is more about the rights and awareness of patients’ rights, rather than the improved services of mental health hospitals. “As with all the bills I work on, that my team works on, it's important for us that it's rights-based,” she says. “Certainly, it and must begin from the rights of each person including persons with mental health problems, and as a way of realizing those rights, then it proposes services within programs that will be mandated by law.”

 

Hontiveros, still quite surprised by assertions that the bill isn’t service-oriented, further explains that even if services are crucial, rights of patients should always be of utmost priority. “[It is important to focus on] the one that will change our orientation about mental health, so it would be combating until eliminating stigma and discrimination, because from that paradigm shift I believe all the others [will follow].”

As the fight for a mental health policies makes it way to the political sphere, Dr. Gundo Aurel Weiler, the World Health Organization (WHO) country representative, believes that the issues surrounding the bill are inconsequential to its existence, especially since mental health has been overlooked in the public agenda. “[Mental health] wasn't a very popular theme that politicians would run on, and I think that's changing now as more and more people speak out about mental health issues,” he says.

Photo-2 (10).jpg Dr. Gundo Aurel Weiler, the World Health Organization (WHO) country representative, believes that the issues surrounding the bill are inconsequential to its existence, especially since mental health has been overlooked in the public agenda. Photo by JL JAVIER

Even so, Weiler agrees with Hontiveros’ statement that the rights of the patients are important — if not the most important — planks of the bill. “We need to treat people with mental health disorders not just as people to be taken care of, but to empower them to be very active in their own process of managing their disease and recovery,” he says.

Traditionally, there have been many involuntary admissions against the expressed wish of the patient, says Weiler. But with a mental health act like that of Hontiveros’, he trusts that there will be less involuntary admissions because people are more empowered.

Photo-19 (2).jpg The rehabilitation pavilion for adult women looks like a public elementary school, with the ‘classrooms’ as wards, with the ‘quadrangle’ as their common area, and with doors that are doubly secured by steel gates. Here, they undergo occupational therapy programs, among others. Photo by JL JAVIER

***

For a private mental health facility like Metro Psych, a nondescript khaki-colored building with tinted windows in Pasig, patient admissions have generally been involuntary. Dr. Fareda Flores, the co-founder of the facility, says involuntary admissions are normal as one of the symptoms of mentally ill patients is their denial of their condition.

Flores also says, however, that there are patients who have already been left by their families in Metro Psych since they opened in 1999. “Nandiyan lang sila, kasi iniisip namin may kapalit naman ‘to eh,” says Flores. “Naawa din kami kasi parang ‘yung iba pinagtataguan na eh. That's actually one of the dangers of running a psychiatric facility kasi you gave the family the freedom, parang na-unburden mo sila.”

She also shares that the kind of service they provide in Metro Psych may be better by default than public hospitals like NCMH because of the volume of patients. “Kami dito non-negotiable talaga ‘yung patient care … primary priority is patient welfare and care,” she says. In her facility, they don’t exceed 200 patients, as opposed to NCMH where the adult male pavilion alone already houses 600.

Out of the 200 patients, Flores says that almost 50 percent are cases of drug abuse and the rest are diagnosed with schizophrenia, bipolar disorder, or depression. She voluntarily notes that there has been a drop in the number of drug abuse patients since President Duterte was elected into office.

Photo-9 (4).jpg “Kami dito non-negotiable talaga ‘yung patient care … primary priority is patient welfare and care,” says Flores, the co-founder of Metro Pysch, a private facility. She says they don’t exceed 200 patients, as opposed to NCMH where the adult male pavilion alone already houses 600. Photo by JL JAVIER

“For the record, most of the rehabs running in the Philippines have a decline in their admissions because of the programs of the president. So a lot of people are asking, ‘Siguro ang dami-daming patient?’ Actually, hindi. There's a tremendous drop. Kahit kausap ko ‘yung ibang mga facilities in other parts of the country, sabi nila talagang bumaba,” she says.

Does she think that the president’s drug war has a factual and direct correlation with the number of drug abuse patients in their facility? “I think what I see with our experience is there's no new substance abuser so far. Walang mga bago unlike mga three years ago na talagang 11, 12 16, or 18 years old. Now, wala pa kaming nakikitang ganon since na-upo si President Duterte,” she says. “Maybe because of the campaign? Fear? Whatever it is, it's effective. And nag-target kasi siya dun sa mga big time na pusher eh, diba? So I think it's doing good.”

While Flores may be firm in her belief that it is through the president’s programs that they’ve seen a decline in patients, she also says that 65 to 70 percent of those who abuse drugs have an underlying psychiatric problem. “Chicken and egg … Hindi lang natin alam kung ano ‘yung nauna pero basta ‘pag nandiyan na sila, 65 percent of people who abuse drugs have an underlying psychiatric problem — that’s a worldwide stat.”

In Metro Psych’s lobby, there are 10 televisions that hang on the wall, slightly similar to control rooms of news agencies. The staff, wearing blue pique shirts and denim jeans, have two-way radio transceivers at hand while they sometimes observe patients through the screens.

MORE PHOTOS IN GALLERY gallery-picture gallery-picture gallery-picture gallery-picture gallery-picture gallery-picture gallery-picture gallery-picture  

 

Shown on the television are live footages of the facility’s halls with CCTV cameras, displaying what the patients are doing in real time. One T.V. exhibits the patients who are lining up in two straight lines, preparing to perform a dance number.

“When inside, patients would undergo dance lessons, music, arts, drama … they showcase their talents, parang ibabalik mo ulit ‘yung confidence kasi minsan aloof na sila, minsan ‘yung parents di alam na may ganito palang talent so binabalik ulit sa kanila ‘yun, so dahan dahan,” Flores says.

 

The Philippine Psychiatric Association (PPA), where Flores is also president, initiated the #MHActNow initiative, which gathered mental health advocates and personalities to urge the swift passage of the mental health act that can promote the rights of mentally ill patients. 

“We started that endeavor under Dr. Ed Tolentino [previous president of the PPA], but you know, unlike other previous mental health acts ... it's not only the rights of the mentally ill or the ones who are seeking help, but it was also highlighted in the bill, the rights of the ones who are helping like mental health professionals,” she says.

***

It’s clear for Hontiveros, Weiler, and even Vicente that the rights of mentally ill patients are at the heart of the mental health bill. But Janice Cambri, the founder of  Psychosocial Disability-Inclusive Philippines, does not think that the bill upholds the rights of patients at all.

“They are lured into believing that [the bill is rights-based] because the bills contain a big section on rights, but these rights are largely not divorced from the medical services and are largely situated in the context of health services rather than in the wider development and inclusion discourse,” she says over e-mail.

“For the record, most of the rehabs running in the Philippines have a decline in their admissions because of the programs of the president. So a lot of people are asking, ‘Siguro ang dami-daming patient?’ Actually, hindi. There's a tremendous drop.” — Dr. Fareda Flores

She highlights that Article 3, Section 13  of the Mental Health Act, which stipulates exceptions to informed consent, is a violation to the UN’s Convention on the Rights of Persons with Disabilities (CRPD). “The mental health legislation uses human rights rhetoric but still legitimizes coercion and renders exclusion and disqualification lawful. The mere fact that those people do not see what is wrong with the bill goes to show how oblivious they are to international human rights standards,” she says.

 

Cambri was not available for a face-to-face interview due to a recent surgical procedure, but she explicitly explained through e-mail why she was chronically suicidal for 12 years and the pains she endured because of psychiatrists who prescribed her medicines that, for her, only contributed to the worsening of her condition.

“I am sure that doctors did not become physicians to harm people but forced treatment is not treatment at all,” she says. “Oncologists do not lock patients up and force treatment to them against their will when they refuse chemotherapy, don’t they? I don’t think any doctor does from other fields. Why are we treated differently? That’s discrimination spelled out.”

Photo-15 (3).jpg All the women in the adult pavilion of NCMH are in pink hospital dresses, all doing a myriad of things — showering, playing sungka, watching T.V., sleeping, conversing, staring at empty spaces. Photo by JL JAVIER

Borja, the psychiatry resident at NCMH, thinks that it’s easier for people removed from the day-to-day of mental health institutions to fight for absolute rights than for psychiatrists whose lives constantly revolve around observing mentally ill patients, listening to their harrowing stories, and seeing firsthand the effects of inadequate medication. “Kung puro rights naman, ayaw tusukan ng gamot, paano ‘yan gagaling?” she asks, rhetorically.

Cambri also stresses that psychiatric treatment or medication must not be the default intervention because it diminishes other forms of healing. But Borja recalls that there have been families from provinces who go to NCMH as their last resort. She says that some have already visited albularyos and tried alternative medicines for cure, but once nothing works, most agree to have their family member admitted to the mental hospital.

When it comes to the effect of mentally ill patients to families, Vicente says that it can be very disabling for a Filipino household. “For the Filipino family, it will mean somebody not going to work, somebody has to take care of this chronic, psychotic patient nila,” he explains. “It's no joke when you have a brother or a son who is suffering from psychosis or schizophrenia or depression.”

Photo-28 (1).jpg “’Yung pinaka-nakakainis lang, ‘pag halimbawa sumpong, gustong iwan ng relative. Nakakainis talaga kasi minsan sasabihin sayo, ‘Doc, mas mabuting mamatay nalang ‘yan’ ... Hindi po ‘yan gamit, tao po kasi ‘yan eh," says Borja, a psychiatry resident at NCMH, on her frustrations about families who purposely leave their loved ones inside the facility. Photo by JL JAVIER

What frustrates Borja the most is when families purposely leave their loved ones in the hospital to unburden themselves, especially those families who have patients suffering from schizophrenia.

’Yung pinaka-nakakainis lang, ‘pag halimbawa sumpong, gustong iwan ng relative. Nakakainis talaga kasi minsan sasabihin sayo, ‘Doc, mas mabuting mamatay nalang ‘yan ... Hindi po ‘yan gamit, tao po kasi ‘yan eh, at saka anak niyo po ‘yan, magpalit nga po kayo?’” she says. “Minsan, eh sila ‘yung dahilan kung bakit nagkakaganyan ‘yung patient eh.”

***

There are patients, who after months or years of medical treatment, do get reintegrated back to “the outside world.” Occupational therapy programs help in doing so, such as that of Loveria’s rehabilitation pavilion where female patients are taught to make fried potato balls. Vicente says that more awareness programs could be implemented this year with around ₱10 million funding from DOH.

“It's not merely creating awareness kasi madali ang awareness eh, sa T.V ka lang ano eh, we're saying that we will create programs that [don’t] just say ‘Say no to drugs,’ we will actually teach them how to say no to drugs,” he says. “Gagawin mo talagang program but this will entail not only from the Department of Health kasi kailangan niya ng cooperation niyan — DepEd, DOLE, the LGU, it has to be a collaborative effort. A little bit tricky, but with 10 million, I think we will be able to do something within the year.”

“It's not my fault I have my illness either so I don't blame myself, I don't blame my family, I don't blame society. It just happens, tough luck, I had an illness. So you know, you attack the illness.” — Robert

The funding will also go to psychosocial programs and activities in sites like the building where Robert, the recovering patient, mostly spends his time on. “Ang project here is to break the stigma kasi schizophrenia is curable, it is curable. It just depends on the therapy so when this psychotherapy came in, we improved a lot. We lost our inhibition, we lost our sense of not belonging in society,” he says, referring to other patients as his “brothers.”  

His confidence in the way he talks is palpable, reeling his audience in with his practiced American accent. “Unlike pavilions where there are nurse stations, there are attendants. Here, there [are] no nurse stations, no attendants, it's like ... a halfway house,” he says.

Robert attributes his return to ‘normalcy’ when he started observing and following how trainee nurses operate. When the hospital absorbed new nurses, he would imagine being a trainee in order for him to develop feelings of employment. Eventually, he learned how to handle himself, as well as how to pacify other patients. But more than imitating the nurses, he says that it was a conscious shift in mindset that helped him recover.

“I realized that I'm thankful [my family] brought me here. I would have ended up more sick when I was outside,” he says. “The way I see it, the real enemy is the illness. If someone has cancer, you cannot tell that person that it's their fault they have cancer or like if you [have a] cold, it's not your fault. It's not my fault I have my illness either so I don't blame myself, I don't blame my family, I don't blame society. It just happens, tough luck, I had an illness. So you know, you attack the illness.”

Photo-30 (2).jpg [Dr. Vicente of the National Center for Mental Health] says that more awareness programs could be implemented this year with around ₱10 million funding from DOH. The funding will also go to psychosocial programs and activities in sites like the building where Robert, the recovering patient, mostly spends his time on. Photo by JL JAVIER

In the course of the conversation, Robert seems to want to shrug off stories from his past, as he always goes back to discussing the benefits of the Psychosocial Center or psychotherapy even without me prodding. I asked if he is already itching to go out of the hospital so he can pursue his dream of becoming a real estate salesman. He smirks, shrugs a little, then answers: “I'm a very patient person because I don’t want to go out [and] not be useful in society. Other patients that are discharged, they just hang around the house, and then their job is you know, watch over the house.”

“They sit there and they have little money to buy cigarettes and they just eat and that's all — not very useful,” he adds. “I want to be useful in society. I want to get a normal job, handle the stress, and be capable again of earning so that maybe someday when my mom gets old, I'll be able to take care of her.”

Robert has been in the NCMH for eight years, but he’s still unsure when he’ll be released from the hospital. Simulating a parent talking to a child, he says, “[The doctor said,] ‘We will wait for your parents to decide and we will wait for the perfect day to discharge you.’’

For Robert, the perfect day may be tomorrow, a year later, or another five years from now. The shrine of Sisa may remain, the trees may continue to line the cemented roads, the structures may still be in a perpetual state of disrepair, legislators may continue to push for mental health bills, awareness campaigns may succeed or fail, but what will always hold true is the persistence of patients who, day in and day out, fight to silence the monsters in their minds.