In recent years the service gap of mental health in developing countries has been highlighted by WHO. Up to 90% of people with mental disorders do not have access to treatment. Another commonly neglected concern is the quality of service available for patients who do gain access.

 

Outpatients are usually only given short consultations without proper examination in crowded settings after spending hours or days travelling or stuck in long waiting queues. For inpatients the situation is even worse. They typically become long-term residents of poorly-maintained, crowded wards with no privacy. They may have to spend weeks, months or even years in squalid conditions. Inpatients often have to sleep in unkempt beds constantly attacked by lice and bed bugs and unprotected from heat or cold. They are poorly fed and commonly treated inhumanely. Patients are rarely examined by doctors or mental health professionals. Their medical condition can remain undiagnosed for long periods of time, they are offered few rehabilitative therapies, and are not prescribed even essential medications. If they are prescribed medications, they are not checked for the side-effects of these medications.

 

Freedom to move about to avoid environmental discomfort is one of the basic defence mechanisms of all living creatures. Many inmates of mental hospitals are denied this simple right by being restrained. All people need at least moments of privacy and yet people with mental illness rarely enjoy any.

 

Restraints can take different shapes. The most classic, and one of the harshest, which is still common in some resource-poor countries is to chain a person to a post or a bed, or to chain both legs together.

 

Even at home, people with mental illness are commonly chained in their homes by their parents or other relatives. This practice and associated attitudes towards patients are often learned from the mental hospitals. This is not a harmless cultural preference, many people are physically or emotionally damaged as a result and it is humiliating indignity to the person who is subjected to it.

 

In the Erwadi tragedy in India in 2001, over 20 people with mental illness were burned to death after a fire swept though the healing temple in which they were chained to their beds.

 

The whole environment becomes an unsafe place for a person with mental illness. The rights of these people continue to be denied by many sectors in society. The stigma associated with mental illness is strong, especially in developing countries. People with mental illness are mostly unable to find a job, finish schooling, get married, live independently, or have their care paid for by the public sector or even insurance companies.

 

Hence, the chain-free initiative evolved in response to the dire and pressing need to provide technical and financial support for: hospital reform (chain-free hospitals); enabling families and communities to provide improved domestic conditions for people with mental illness (chain-free homes); and the development of community care programmes, raising mental health literacy in the community and among health workers, and ensuring that basic rights are monitored and guaranteed (chain-free environment).  

The chain-free initiative is a pilot project currently implemented in Afghanistan and Somalia by the WHO Regional Office for the Eastern Mediterranean.