One of the sayings the Romans used was “mens sana in corpore sano”, meaning “a healthy mind in a healthy body”. Yet in fact it works both ways: you cannot have a healthy body without a healthy mind. Some fifteen years the World Health Organization developed a slogan that captured this precisely: “No health without mental health”, and it became one of the most successful campaigns of this international governmental body.
Yet what counts for the human body, counts equally much for society as a whole. Mental health is a mirror of society, and when a country is unable to provide adequate mental health care services to those citizens who are in mental distress, it means there is something fundamentally wrong. In Soviet times, people with mental illness were discarded, locked up in large institutions, usually outside urban areas, separated and hidden from the rest. They were “unproductive elements”, only costing money and not providing anything to the building of a radiant Communist future.
Only when the Soviet Union disintegrated, it became fully clear how rotten the Soviet mental health care system was. In 1988, ten million Soviet citizens were on the psychiatric register, while the number of people locked up in closed institutions was estimated to be at least half a million. When Ukraine became independent, the Ministry of Health did not even know how many “social care homes” existed in the country, as all the data were kept in Moscow. Eventually it transpired that Ukraine had at least one hundred of these “social care homes”, with an average population of 300 persons. Simple mathematics shows how big the problem actually was. And still is, because most if not all of these institutions are still there.
When I first visited these institutions in Ukraine, in the early 1990s, I was shocked. I remember one just outside Kyiv, where four nurses cared for some 300 patients, plus one doctor who visited the institution one day per week. Half of the patients were bed-ridden, so one can imagine what an impossible task these nurses had. The stench of human misery was indescribable, and I felt terribly sorry for both patients and staff: both were victimized by a fundamentally inhumane system. In psychiatric hospitals the situation was not much better, and thus the conditions in the institutions was very symbolic for the decay in society as a whole. Indeed, mental health was a mirror of society.
The past twenty-five years we have tried in every possible way to improve the conditions and modernize mental health care services. In some places it worked, new initiatives gave hope for a better future both to patients and to staff, with better conditions, more care and more humanity. Numbers became people; people became life-stories and life-stories turned people into individuals with needs, hopes and desires: a fundamental change. Yet in other places conditions remained more or less the same, and corrupt practices prevented a real reform from taking hold. Again, mental health remained a mirror of society.
Over the past two years, a lot has happened. The leadership of psychiatry is changing; a young generation has appeared on the scene with new ideas, with new energy and above all with a desire to end corruption and the lack of humanity. After twenty-five years of working in psychiatry in Ukraine there is for me no bigger present than seeing young professionals entering the field who have left the Soviet inertia behind, who believe in their skills and ability to have an impact, and who refuse to be subdued by a fundamentally bureaucratic and depersonalized monster. I see change happening before my eyes. Small steps, yet significant ones, that give hope that finally the long shadow of Sovietism can be left behind.
Again mental health is a mirror of society. These changes are happening not only in mental health. In fact, psychiatry is probably a part of society that is the most resistant to reform. People talk of the “ivory tower” of medicine, a science that is detached from society as a whole, remaining a bit aloof. For me this “ivory tower” has the form of a television tower as we see in Berlin, Vilnius of Moscow, with a spire at the top. That spire is psychiatry, even more detached than the rest of medicine. If psychiatry starts to move, to open up to reform, it means that society as a whole is changing, it is as symbolic as the pink blossom on the Sakura trees in Japan in March, indicating that the winter has been left behind.
Change is happening in Ukraine. Yes, it is slow, and it is painful. It is not as quick as we would like to see. Yes, corruption is continuing, there are still many who prefer to have the safety of the Soviet system back, because it makes personal initiative superfluous and above all gives ample possibilities to bribe, steal and accumulate illegal wealth. But the emerging new – post-Soviet – generation is increasingly making an impact, and is increasingly tilting the balance in favor of a new Ukraine. For me mental health is the litmus test: when things start moving in psychiatry, it means society is changing as a whole. But you need to be there to see it, to feel it, you need to go down to grassroots level to understand what happens.
What irritates me endlessly is the fact that those who organized the Dutch referendum on the EU-Ukraine Association Agreement have in fact no idea what is happening on the ground. In fact, I wonder how often they have been to Ukraine, and if they did – with whom they met and talked (and in which language). My guess is their knowledge of Ukraine is similar to the average knowledge of a Ukrainian of The Netherlands, although the latter might know more because of the prevailing interest in what happens outside the country’s borders. They sit in their cosy Dutch chairs and judge, totally unaware of the importance of this agreement to Ukraine, both in practical and in psychological terms. This agreement was the initial reason why people went to Maidan, why tens of thousands mastered the freezing cold, why thousands were wounded and more than a hundred Maidanovtsy lost their lives. Putting this at risk, while leading their comfortable Dutch lives, makes me wonder whether they deserve the freedom and democracy they claim to be defending.