October 2, 2012

II. Abuses

As soon as you get a mental disability, you nearly lose all your rights, even to give your opinion.

—Doris Appiah, national treasurer, Mental Health Society of Ghana, Accra, Greater Accra Region, November 2011

Human Rights Watch found that people with mental disabilities in Ghana suffered a number of human rights abuses, some of which are detailed in this section.

Involuntary Admission, Arbitrary Detention

I was arrested from my home by two men who came with police. They never gave me any reason, and they handcuffed me, took me to police where I spent three days.[62]

—Peace, a 55-year-old woman with schizophrenia, Pantang Psychiatric Hospital, November 2011

Individuals with mental disabilities in psychiatric hospitals and prayer camps in Ghana are routinely institutionalized against their will by family members or police, and denied the opportunity to refuse or appeal their confinement.[63]

It was not clear whether persons with mental disabilities under prolonged detention, both in hospitals and in prayer camps, had been before a judge to review or challenge their detention. Some of the leading local organizations working with persons with mental disabilities that Human Rights Watch interviewed were unaware of any such cases.[64] Dr. Akwasi Osei, chief director of the Ghana Health Service and director of Accra Psychiatric Hospital, told Human Rights that the old mental health law did not make any provision for people who are voluntarily admitted (with consent of relatives) to challenge such admission or any resulting treatment.[65] The new Mental Health Act, however, establishes a tribunal mandated to hear complaints of people with mental disabilities detained under the act, through which persons detained against their will in psychiatric hospitals can challenge such detention. While the new Mental Health Act will allow those detained in institutions to challenge admission and treatment, the law does not expressly cover persons with mental disabilities detained in other settings such as prayer camps.

Some of the individuals who are involuntarily admitted were perceived to be a danger to themselves, property, or others, which according to Dr. Akwasi Osei, chief psychiatrist at Accra Psychiatric Hospital, is determined based on “information given to the doctors of the patient’s conduct at home, his or her level of anxiety, rapport with the hospital staff, and the nature of psychopathology (causes and processes of mental disorder).”[66]

Some have problems of drug abuse and addiction. Others are outcasts in their communities or families, and are perceived as being “different” or “difficult.” According to Dr. Akwasi Osei, if an individual is brought to the hospital by police, psychiatrists determine whether or not to admit the person depending on their symptoms, behavior, and diagnosis, without seeking the patient’s consent, and without an independent judicial review.[67]

Peace, a 55-year-old woman with schizophrenia at Pantang Psychiatric Hospital, told Human Rights Watch, “Hospital is not a place where anyone would like to live … but I have no right to leave the ward.”[68]

Police, working with local government assemblies, also round up persons with actual or perceived mental disabilities when Ghana hosts important visitors.[69] One mental health expert said, “When President [Barack] Obama was coming to Ghana in 2008, police rounded up persons with mental disabilities because they did not want him to see mad men.”[70]

Aisha, an articulate woman in her mid-50s, was taken to Mount Horeb Prayer Camp by her adult children because she was not sleeping at night, and she lived there for two months before Human Rights Watch met her. “I don’t want to be here even for one week,” she said, adding that she would prefer treatment in a psychiatric hospital, but camp administrators would not let her go.[71]

John, who had been living in Mount Horeb Prayer camp for two months, told Human Rights Watch, “I want to go home, but they don’t discharge me, and they don’t give me any reason.”[72]

Richard, an 18-year-old man who was brought to Edumfa Prayer Camp by the police, said that his mother “told police to arrest me as I was sleeping. I was handcuffed at 5 a.m. and brought here. They locked my leg in a chain.”[73]

Under the 2012 Mental Health Act, voluntary patients (people who go to a mental health facility on their own with or without referral) in psychiatric hospitals have a right to seek release by filling out a Discharge against Medical Advice Form (DMAF), a process they should not need to undergo because they had voluntarily admitted themselves for treatment. However, patients who are forcibly “committed” (taken to a facility for treatment without consent, such as by a family member or the police, or without a court order following the commission of a crime) to the hospital do not have such a right under both the prior 1972 Mental Health Law and the new 2012 Mental Health Act.[74] While discharge of voluntary patients against medical advice is allowed in Accra Psychiatric Hospital, a nurse at Pantang Psychiatric Hospital told Human Rights Watch that a doctor’s assessment is required for even voluntary patients to be discharged.[75] There are no such formal discharge procedures in the prayer camps that Human Rights Watch visited; people are allowed to leave only when the prophet considered them ready to be discharged. However, relatives of persons with mental disabilities admitted to prayer camps could ask for their discharge at any time.

The Constitution of Ghana prohibits deprivation of liberty except in circumstances permitted by law.[76] Among these circumstances, a person can be deprived of liberty if he is of “unsound mind … or a vagrant, for the purpose of his care or treatment or the protection of the community.”[77] Furthermore, under the 2012 Mental Health Act, a police officer can arrest a person who leaves a psychiatric facility without being discharged.[78] In cases where the person is not an imminent danger to herself or others, or is not detained because of pending criminal charges, or is not brought before a court, this may result in arbitrary and prolonged detention of persons with mental disabilities, in contravention of the African Charter on Human and Peoples Rights (ACHPR) and the UN Convention on the Rights of Persons with Disabilities (CRPD).

In the three public psychiatric hospitals, the majority of the staff said that involuntary admission, and subsequent continued detention, was not a violation of patients’ rights, and defended a paternalistic approach to psychiatric care that gives deference to health care providers to determine what is in the best interests of the patient.[79] Dr. Osei, head of Accra Psychiatric Hospital, told Human Rights Watch, “Involuntary admission is good because the state is exercising its mandate to protect someone, their family, the public, and property.”[80] This is not a violation of rights, he added. “Sometimes it’s wrong to defend rights without looking at the broader picture.”[81]

Prolonged Detention

I was tricked into coming here by my mother. I would never have accepted, but I have been here for more than one year.

—Raymond, 35-year-old man at Nyakumasi Prayer Camp, Central Region, January 2012

Some individuals, especially those taken to hospitals by police on court order, remained there even after discharge—often because they had been abandoned by families and could not return to their home communities.[82]

Bentil, a 26-year-old woman with schizophrenia, had been in Ankaful Psychiatric Hospital for four months and was cleared for discharge, but she was still there because she had nowhere to go.[83] “No one has come,” she said. “I want to go and stay at home.”[84] In Accra Psychiatric Hospital, Human Rights Watch saw a letter from a clan leader to hospital management requesting that his relative never be discharged, even when his condition improved.

Human Rights Watch learned that doctors in psychiatric hospitals met with patients in general wards every two weeks, in some cases resulting in long delays for discharge and prolonged detention.[85] Sarah, a woman who had voluntarily come to Pantang Psychiatric Hospital and was ready for discharge, said, “The nurses tell me a doctor will come and discharge me, but it is now two weeks and I have not seen any.”[86]

People also remained for long periods in prayer camps, where they told Human Rights Watch they wanted to leave and either go home or go to a psychiatric hospital, but they could not because their families refused or because the prayer camp leaders did not deem them fit to do so. John, for example, a person with a mental disability at Mount Horeb Prayer Camp, said that he was chained for one year without any treatment. He said: “I want to go home, but they don’t discharge me and they don’t give me any reason.”[87]

Most prayer camps that Human Rights Watch visited do not have formal criteria for determining that an individual is ready to leave. Instead, the prophet determines when people can leave, based on his assessment or “a message from God.”[88] According to one prophet, people are allowed to leave when they are “completely okay,” depending on “how someone speaks and what they do.”[89] Another religious leader told Human Rights Watch, “God shows a prophet a patient who has completely healed and he goes to the sanatorium to discharge such a person.”[90]

Conditions of Confinement

Overcrowding and Poor Hygiene

Overcrowding has long been a major problem in Ghana’s psychiatric hospitals and continues to be a problem at its largest hospital, Accra Psychiatric Hospital.[91] Intended to accommodate 600 patients,[92] it has, at times, housed up to 1200 patients, and had 900 patients in November 2011.[93] Lillian, a 41-year-old woman with schizophrenia, told Human Rights Watch, “Most of us don’t have beds. I sleep on a mat and I have no blanket.[94]

The ward for long-term patients at Pantang Psychiatric Hospital had 40 beds for 50 patients.[95] In the Special Ward at Accra Psychiatric Hospital, which houses people brought by police on court order, the situation was even worse. One nurse said, “We currently have 205 patients, and they have to share the 26 functional beds.”[96] As a result of overcrowding, patients sleep on thin mattresses, mats, or on the floor without a bed sheet.[97]

Overcrowding leads to a host of problems, such as supply shortages and health and sanitation hazards such as bed bug infestations and scabies.[98] In some wards in Accra and Pantang Psychiatric Hospitals, Human Rights Watch researchers saw toilets filled with feces and cockroaches.[99] From the gates of these wards, there was a powerful stench of urine and feces. “We experience shortages of basic items like gloves and detergents. Sometimes we don’t have water,” one nurse said.[100]

A nurse at Pantang Psychiatric Hospital told Human Rights Watch, “When we run out of protective gear such as gloves, we ask other patients to clean the ward.”[101] He added that this includes removing feces of other patients and using their bare hands to wash other residents, some of whom have open wounds.

Some prayer camps also had overcrowded living quarters, where most people interviewed did not have mattresses, blankets, or mosquito nets. At Mount Horeb and Edumfa Prayer Camps, small rooms that could reasonably accommodate only about eight people had over twenty.[102] People spent all day and night chained in small, hot rooms of about six by four meters, with little to no ventilation.

Personal hygiene was also a major problem in most of the prayer camps visited by Human Rights Watch. In Mount Horeb and Edumfa Prayer Camps, individuals urinated and defecated in buckets in each room. While prayer camp administrators said they empty the buckets three times a day,[103] residents said that the buckets were emptied once daily, usually early in the morning, leaving a pungent odor in the room for most of the day.[104]

Peter, a 21-year-old man chained to a wall in Mount Horeb Prayer Camp, said, “You can’t have a good bath with a chain. We shit here and they don’t come to clean up.”[105] He added, “It smells a lot inside here. I don’t know when I will leave this place.”[106]

Abigail, a staff member and former resident of Mount Horeb Prayer Camp, said, “People who are aggressive or violent don’t get buckets because they have a tendency to throw the feces at each other.”[107] She added that instead they defecate on the ground near where they are chained.[108]

In Nyakumasi Prayer Camp most persons with mental disabilities were chained to trees in the compound, and they had to urinate in the open and defecate into small plastic bags, which were later thrown into surrounding vegetation. Those who were chained in stalls at Edumfa and Mount Horeb Prayer Camps had to shower in the stalls where they slept and ate. Aisha, a 56-year-old woman at Mount Horeb Prayer Camp, told Human Rights Watch, “I bathe only two times a week, but I want to bathe every day.”[109]

Chaining

I have been chained in one sitting position. I have been here for two years.

—Isaac, a 28-year-old man with schizophrenia, Nyakumasi Prayer Camp, Central Region, January 2012

In the prayer camps visited by Human Rights Watch, many of the patients were chained inside fully built and semi-permanent structures or chained to a tree or concrete floor outside until the pastor or prophet declared them “healed.”[110] There was no movement beyond the length of the chains—usually about two meters. People had to bathe, defecate, urinate, change sanitary towels, eat, and sleep on the spot where they were chained.

Approximately 20 men in Edumfa Prayer Camp were chained and confined in rooms locked with padlocks, even during the day. Kofi, an 18-year-old man, said, “Why do they keep this fasting room locked with padlocks during the day? Even if they treat us like criminals, serving sentences for the worst crimes, we deserve to see some daylight.”[111]

About 120 of the 135 individuals at the Mount Horeb Prayer Camp were chained 24 hours a day (there were only approximately 10 who were not chained during Human Rights Watch’s visit in January 2012). Some told researchers they had been restrained in chains for several months.[112] Human Rights Watch researchers found an individual chained in exactly the same spot where he had been interviewed, three months later.

Elijah was chained to a tree in an open compound at Nyakumasi Prayer Camp for over five months. While describing his experiences, the 25-year-old man said, “This chain is more than a death sentence. At night it gets too cold, when it rains you can’t run to a shade, and we have lots of mosquitoes.”[113]

Aisha, a 56-year-old woman at Mount Horeb Prayer Camp, told Human Rights Watch, “When I defecate in the bucket, it makes everyone in this room uncomfortable. Why chain me when I can walk and go to the toilet?”[114]

Prayer camp personnel consistently told Human Rights Watch they used such restraints because most people in the camp were aggressive or would otherwise try to escape. Prophet Paul Kweku Nii Okia, founder and director of Mount Horeb Prayer Camp, acknowledged that it was illegal to chain an individual, but he attributed the practice to a lack of better means of restraining persons with mental disabilities. He told Human Rights Watch that “if a person comes and he is very wild, there is no way to cool them down, so we have to chain them, with approval of their families.” He added, “The constitution [of Ghana] does not allow us to chain, but we do it with the consent of families.”[115]

Rev. Rebekah Bedford of Edumfa Prayer Camp said the camp’s lawyer advised them to ask family members to sign forms consenting to the chaining of their relatives. “Human rights people don’t agree with people being locked in chains. Because some illnesses are chronic and go on for as many as 15 years without healing, their families give consent.”[116] It should, however, be noted that consent of a relative to chain someone does not render the chaining legal.

The Constitution of Ghana guarantees freedom of movement and only permits restrictions to one’s movement in instances of lawful detention.[117] While it permits a person to enjoy, profess, and practice religion, such enjoyment must be within the limits of the constitution, which prohibits all practices that dehumanize or injure the physical and mental well-being of another person.[118] In the same regard, the 1960 Criminal Code Act makes assault (which includes imprisonment) a crime.[119] A person is considered to have imprisoned another person if,

[I]ntentionally and without a person’s consent, he/she detains another person in a particular place of whatever extent or character, whether enclosed or not, with the use of force or physical obstruction from escape; or compels him or causes him to be moved/carried to another direction.[120]

Forced Seclusion

I am praying to God never to go into seclusion again. There is no toilet, so you have to be there with the shit and urine, yet you eat there as well; they clean [the room] after you have left.

—John (pseudonym), a 37-year-old man with schizophrenia, Pantang Psychiatric Hospital, November 2011

Seclusion is one of the many forms of solitary confinement, which is defined by the United States’ Center for Medicare and Medicaid Services as the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.[121] The UN special rapporteur on torture regards any prolonged isolation of an inmate from others (except guards) for at least 22 hours a day as amounting to torture.[122]

In all three public psychiatric hospitals, Human Rights Watch found that people were isolated for varying periods, ranging from 24 hours to three days; some were given sedatives.[123] A nurse at Pantang Psychiatric Hospital said, “We use prolonged seclusion when an individual continuously refuses to take medication, is aggressive, restless, or is a danger to themselves, others, or the environment.”[124] A nurse at Accra Psychiatric Hospital said, “The seclusion rooms are in poor condition, the walls are not padded, and the lighting and ventilation is poor.”[125]

Harriet, a 25-year-old woman who was seven months pregnant, spent six months at Accra Psychiatric Hospital. While there, she was put in a seclusion room for 12 hours. She told us, “The seclusion room … always dirty, very dark and you would not go in without being beaten by nurses.”[126]

Staff in all three public psychiatric hospitals said they had no choice but to put people in seclusion or to administer sedatives to patients who are aggressive and thus a danger to themselves, nurses, and other patients.[127]

The former UN special rapporteur on torture clearly stated that seclusion or solitary confinement in psychiatric hospitals as a form of control or medical treatment “cannot be justified for therapeutic reasons, or as a form of punishment.”[128]

While the 2012 Mental Health Act limits the use of restraints on persons with mental disabilities, it does not abolish restraints completely. An act by one person to restrain another person is generally criminalized, and in such extreme instances where restraint is permitted, specific compliance criteria should be defined, including who has the authority to restrain another person. All acts of restraint that do not meet these criteria, for example assault or unlawful detention, clearly amount to a crime.

Lack of Shelter

In some wards in the three psychiatric hospitals visited by Human Rights Watch, especially Accra Psychiatric Hospital, shelter was inadequate.

At the Accra Psychiatric Hospital, several buildings lacked windows, doors, or shade during the day. Many had old and leaking roofing. Individuals were either crowded in the few spots where there was shade, or baked in the sun. No fewer than 50 individuals in the Special Ward slept outside.[129] A nurse explained, “Patients move in and out of these structures at any time, just as other potential threats like mosquitoes and reptiles move in.”[130]

Some of the rooms in the eight prayer camps that Human Rights Watch visited were only half-built; others had holes in the walls and roofs that would allow in rain, mosquitoes, and cold air at night. A few patients or their families had fashioned bamboo beds and grass-thatched shelters under a tree to get protection from the sun, but many slept on cold, hard concrete floors with no mattress or bedding.[131]

Denial of Food

I’m really, really hungry and they won’t feed me. I don’t understand…. Why can I not eat? They give me porridge at night, but that’s not enough food.[132]

—Afia, 32, Mount Horeb Prayer Camp, January 2012

Administrators and pastors of seven of the eight prayer camps that Human Rights Watch visited said they believed fasting was key to curing mental disability.[133] Doing so, they said, would starve evil spirits and cleanse them.[134] “Fasting helps weaken the demons, making it easier for the spirit of God to enter and do the healing,” one pastor said.[135]

Doris Appiah, national treasurer of the Ghana Mental Health Society and former resident of a prayer camp in Kumasi, told Human Rights Watch that some pastors use fasting as a means to force patients to confess past sinful acts, which are presumed to be responsible for their mental disabilities.[136]She explained that some pastors would beat them to confess that it was their sinful acts that led to their mental disabilities , and those who refused to confess would be forced to fast for up to four days.

When the camp did provide food, people with mental disabilities told Human Rights Watch that it was too meager—at times, just one meal a day.[137] Some pastors reported sharing the little food available on a day among all the patients, especially because some families did not provide food for their relatives, and camps did not have enough money to buy enough food for everyone.[138] Asked why the food was not enough, Prophet Winfred said, “Some people are brought here by police, with no relatives and yet they need to eat; some families are very poor and they can’t feed some people they bring for healing; therefore, we share the little food we have on a given day.[139] The expectation was that families would regularly bring food for relatives at the camps; pastors said this seldom happens. Many interviewees appeared undernourished and complained of hunger.

Prayer camps had different ways of funding their work. Edumfa Prayer Camp, for example, charged a registration fee of 5 Ghana Cedis (US$2.50) to everyone who visited the camp; some had residential facilities which they rented out, and others operated small businesses such as bakeries and shops selling herbal products.

Fasting schedules varied in each camp, depending on why a person was brought into a prayer camp and the prophet’s healing plan.[140] For example, Human Rights Watch found that some individuals in Mount Horeb, Edumfa, and Nyakumasi Prayer Camps were compelled to fast for 36 hours over 3 consecutive days in 12-hour stints from morning until dusk. Others, mainly the elderly, fasted from 6 a.m. until noon.[141] Such fasting regimes lasted from 7 to 40 days.[142]

People in the prayer camps had no choice but to fast as it was considered a mandatory component of the healing process. “I have never fasted in my life because I don’t see any value in it,” said Elijah, who lived in Nyakumasi Prayer Camp, “but here, it is a must.”[143]

Fasting had consequences for people with mental disabilities besides hunger, including being unable to take prescribed medication.[144] One person with bipolar disorder described his experience at the Victory Bible Church Camp: “I had to fast from morning to evening for two years. I wasn’t allowed to take my medication for the entire time.”[145]

In the one prayer camp where fasting was not allowed, the prophetess said, “I don’t let the mad people fast because when I give them medicine, they have to eat well.”[146] As part of her treatment regime, she distributed local herbs and homemade concoctions.

In psychiatric hospitals nurses said that people (especially those on medication) needed some food between 5 p.m. and 9 a.m. (between dinner and breakfast), which hospitals do not provide, and patients are supposed to buy from canteens. One nurse told Human Rights Watch, “Those brought by police usually come with no money and yet they need to eat something between meals; they become so aggressive when they are hungry, and we have nothing to do about it.[147]

Ghana is a state party to a number of international and regional treaties, including the International Covenant on Economic, Social and Cultural Rights (ICESCR), which require Ghana to respect and protect the right to food.[148] The Constitution of Ghana does not expressly recognize the right to food, neither does it provide for the right to health. It does, however, make provisions for the rights to life and adequate livelihood, which imply the right to food.[149]

Denial of Adequate Health Care

Access to health care for both physical and mental health problems was a major challenge for persons with mental disabilities in psychiatric hospitals, prayer camps, and the community.

Drug shortages bedevil all three public psychiatric hospitals in Ghana, mainly because of limited government supply, including medications for conditions such as malaria and skin infections.[150] Some patients in psychiatric hospitals needed alternative means of treatment that were either unavailable, or nurses did not have the proper skills to administer them.[151] Lillian said, “I get Largactil [a psychotropic drug], which I don’t like; doctors tell me I can’t get any other type [of medication], yet I get side effects like loss of sleep when I take it.”[152]

Persons with mental disabilities living within the community after having been discharged from mental health facilities also reported shortages of medications, generally provided to them by local NGOs. Suleiman Ayiku, an elderly man with bipolar disorder living in Greater Accra Region, told Human Rights Watch,

I get my drugs from BasicNeeds [a local mental health organization], but these run short, so I end up taking medications every three or four days as opposed to every day because I can’t afford buying the remainder [from a private pharmacy] to run me on a daily basis.[153]

Prayer camps that Human Rights Watch visited had varying policies and practices regarding the provision of adequate medical care for both mental health problems and other medical conditions. Some camps reportedly coordinate with nearby hospitals to ensure some medical care in the camps, and some take persons in severe mental health crises to the local hospital.[154] However, the frequency of visits by medical professionals is inadequate. For example, a psychiatric nurse who works at Tetteh Quarshie Memorial Hospital only visits Mount Horeb Prayer Camp once a month and must attend to both the physical and psychiatric health issues of the more than 100 individuals in the camp.[155] The nurse said, “We just sacrifice the services. The maximum I spend at Mount Horeb is two hours.”

In Edumfa and Charity prayer camps, management claimed to have a good working relationship with Ankaful Psychiatric Hospital and said it referred persons with serious mental health conditions to the hospital. However, hospital management said that camp officials are not cooperative and do not refer patients.[156] In other prayer camps, there was no arrangement whereby persons in the camps obtained professional psychiatric services.[157] According to Dr. Akwasi Osei, chief psychiatrist at Accra Psychiatric Hospital, “The main challenge is that [prayer camps] want a mutual referral of patients between prayer camp and institutions, which is not possible.”[158] He claimed that no doctors referred patients to prayer camps.[159]

Administrators of three camps said that they mainly give herbal concoctions to people who demonstrated aggressive behavior.[160] Some camp leaders said they had learned of the medicinal value of these herbs through a dream or vision.[161]

In Nyakumasi Prayer Camp, which housed about 30 persons with mental disabilities at the time of Human Rights Watch’s visit, the use of orthodox medicine was not permitted; people only had access to traditional medicines.[162]

Honorable Mubarak Muntaka, chairperson of the Health Committee of Ghana’s Parliament, told Human Rights Watch that parliament was currently reviewing legislation to improve regulations of health care professionals, health facilities, and traditional medicine practitioners.[163] The new Mental Health Service established under the 2012 Mental Health Act is charged with working with both non-orthodox service providers (such as prayer camps and traditional healers) and professional mental health providers to ensure effective monitoring of centers that provide services to persons with mental disabilities.[164]

The 2012 Mental Health Act also makes provision for the establishment of a visiting committee to conduct inspections of facilities and centers that provide services to persons with mental disabilities.[165] However, it is unclear how this committee will address human rights violations in prayer camps or manage a regular schedule for inspection given that there are so many camps, including those that are not registered with the government. Implementation of the Mental Health Act is, however, dependent on the passage of a legislative instrument to guide that implementation, which at the time of writing had not yet been passed.

Involuntary Treatment

I receive medication twice a day, and I only take it because it is the rule. If I don’t take it, they will give me an injection.

—Lillian, a woman with schizophrenia, Accra Psychiatric Hospital, November 2011

Some of those interviewed by Human Rights Watch in psychiatric hospitals said that they were forced to take medication against their will. Sarah, a 25-year-old primary school teacher who voluntarily checked herself into Pantang Psychiatric Hospital, said, “Taking medication is compulsory here. I take it because I wouldn’t want to be coerced again.”[166]

Staff at all three public psychiatric hospitals admitted that they use force in different ways, from physical coercion to, in extreme cases, involuntary sedation via injection.[167] One nurse said, “We request them kindly to take the medication and when they refuse, we hold them and force the drug into their mouth.”[168] Nurses and individuals in the hospitals also said that if someone resisted medication, it was sometimes hidden in food.[169]

In some cases, patients were forced to take medication, even when they said it failed to work or produced serious side effects.[170] Peace told Human Rights Watch, “I don’t like the medicine I receive; the drugs cause my legs to swell, eye pains, and insomnia.”[171]

Persons with mental disabilities in psychiatric institutions and prayer camps, as well as hospital and camp staff, reported that family members or staff routinely decided on a person’s admission to, treatment within, and discharge from mental health facilities even when they voluntarily brought themselves to such facilities, effectively denying them their legal capacity to make their own decisions.[172]

In prayer camps, herbal concoctions are commonly administered to persons with mental disabilities without any explanation or consent.[173] The herbs are mixed with water and either administered in drops through the nose, smeared over the body, or given to them to drink.[174]

Doris Appiah, treasurer of the Mental Health Society of Ghana and former resident at a prayer camp in Kumasi, told Human Rights Watch, “I was given herbs in the nose and forced to drink some. I didn’t like them because they were bitter and had terrible side effects. My tongue swelled and came out [of her mouth].”[175]

The former UN special rapporteur on torture, Manfred Nowak, in his 2008 interim report, observed that forced and non-consensual administration of psychiatric drugs, particularly neuroleptics, for treating a mental condition needs to be closely scrutinized.[176] Depending on the circumstances of the case, the suffering inflicted and the effects upon the individual’s health may constitute a form of torture or ill-treatment.[177]He added that,

[The] suffering inflicted should be assessed with reference to the patient’s subjective experience or display of fear and terror, grief, and disturbing sensations of body and mind produced by the drugs, and long-term consequences such as traumatic reactions and the loss of significant relationships and opportunities.[178]

Nowak further said “protocols for informed consent need to be developed to ensure that accurate and unbiased information is provided to individuals who are considering treatment with psychiatric drugs, including information about less intrusive alternatives.”[179]

In situations where a person cannot give consent to admission or treatment at that moment, and their health is in such a state that if treatment is not given immediately, their life is exposed to imminent danger, immediate medical attention may be given in the same manner it would be given to any other patient with a life threatening condition who is incapable of consenting to treatment at that moment.[180]

It therefore follows that separate standards should not be set for persons with mental disabilities. Special measures should be in place to ensure that a person in such a situation is given the earliest opportunity to consent to treatment as soon as they attain or regain a status capable of doing so.[181] In instances where States P arties employ preventative detention measures to protect a person with a disability or society from imminent danger, the basis for such detention should not hinge upon his or her disability, but rather his or her behavior.[182] Even then, there needs to be clearly defined rules premised on the side of capacity and avoidance of harm, and these rules need to be enforced.[183]

The Criminal Code Act (as amended) permits a guardian of a person with a mental disability to “consent to the use of force against a person for purposes of medical or surgical treatment, or otherwise for his benefit.”[184] This and other relevant laws must be amended in order to comply with the CRPD.

Stigma and Its Consequences

Life negatively changes as soon as people know that you have a mental disability. That’s why we hide it.

—Dora Ashong, 43-year-old woman with a mental disability who is a disability advocate, Accra, Greater Accra Region, January 2012

Persons with mental disabilities in Ghana experience stigma and discrimination in the health sector, at home, and in the community. Religious leaders often described them as incapable, hostile, demonic, evil, controlled by spirits, useless, and anti-social.[185] “It is a real challenge to persuade the public that mental disability is not a spiritual crisis, but a medical condition,” one religious leader said.[186]

Bernard, a 49-year-old man with schizophrenia who has received mental health treatment since 1982, told Human Rights Watch,

The stigma is too much. When you go to Accra Psychiatric Hospital, it is like you are not a human being. Families don’t have anything to do with you anymore; they don’t need you no matter how brilliant you are … my elder brother still insults me; he says my friends are also mad because they go to church with me; and because of this, when I speak, my siblings don’t listen to me.[187]

One significant consequence of such stigma is that relatives abandon persons with mental disabilities in psychiatric hospitals and prayer camps.[188] Many family members do not visit, do not pick up relatives after discharge, and even give a false address so they cannot be traced.[189]

Stigma also deters persons with mental disabilities from seeking professional support in psychiatric hospitals. Bernard told Human Rights Watch, “People look down upon you; those who know you will not want you to speak in society. That’s why I go to Meprobi general clinic and not a psychiatric hospital.”[190]

Nearly all persons with mental disabilities with whom we spoke identified stigma in their families as one of their main worries about being discharged from a psychiatric hospital or prayer camp. Some also expressed fears of hostility when they go back to their respective communities. Peace, a 55-year-old woman with bipolar disorder at Ankaful Psychiatric Hospital, said,

For the two months I have been here, my family has informed people, and I don’t know how harsh they are going to treat me. No matter what you do, they say, ‘After all, you have been at a mental hospital.’ That’s why when I left Ankaful Psychiatric Hospital last time, I went to a hotel and not home.[191]

As a result, some people even opted to live in institutions or prayer camps, where they were not questioned about their mental health status and where their conditions were better understood. Describing the stigma faced after being discharged from a psychiatric hospital, one woman said, “As a patient, you have to struggle with very low self-esteem and also have to fight with negative attitudes from society … it is like a death sentence.”[192]

Some family members also considered mental disability as a disgrace to the family.[193] Even family members face discrimination from community members and fear ostracism. For example, John Kwabena, brother to a woman with a mental disability said, “People don’t want to marry into a family where there is someone with a mental disability.”[194]

Nurses working in psychiatric institutions also reported experiencing stigma in their home communities, where they said people considered nurses to be “mentally ill” since they work with persons with mental disabilities. “They think we are also like our patients,” a nurse at Ankaful Psychiatric Hospital said.[195] Psychiatric nurses and doctors are stigmatized even among their peers. A nurse who works in a psychiatric unit of a general district hospital said that her colleagues at the hospital call her abodamness, which means “craziness.”[196] Indeed, stigma against psychiatrists is so strong that many medical students opt for other specialties.[197] Dr. Anan, head of Ankaful Psychiatric Hospital, said it took him over 15 years to enter the psychiatric field because of the related stigma.[198]

Some religious leaders attributed stigma to the lack of community awareness. Robert Amo, director of programs and advocacy, Christian Council of Ghana (CCG), said, “Citizens are not well informed about mental disability.”[199]

The government of Ghana has done little to minimize the effects of stigma endured by persons with mental disabilities, their caregivers, and the medical staff who treat them. While there is scattered information about mental disabilities on the radio, television, and in newspapers, the government does not have a systematic plan to address this challenge.

Gifty Anti, a senior presenter at Ghana Broadcasting Corporation, explained her experience covering mental health issues. She said,

Media coverage of mental health issues is nothing near good; in fact, on a scale of ten, it is about three if not less. It only comes up when an event surfaces. I try to invite both survivors and service providers, but they fear to come to TV shows because of the stigma. They say that when they appear on TV programs, stigma increases.

Physical and Verbal Abuse

Human Rights Watch documented severe cases of physical and verbal abuse of persons with mental disabilities in the family, community, and hospitals and prayer camps.

Abuse from family members is especially acute. Sarah, a 25-year-old primary teacher who voluntarily checked herself into Pantang Psychiatric Hospital, told Human Rights Watch, “Whenever I get hallucinations, I expect to be beaten. I got this scar when my brother beat me because I had refused to go to the family house.”[200] Aisha, a 57-year-old woman at Mount Horeb Prayer Camp, told Human Rights Watch, “Three months prior to coming to this prayer camp, my brother beat me, and my skin color changed.”[201]

In the three public psychiatric hospitals, three patients reported being beaten by nurses when they did not take their medication or follow hospital rules.[202] Michael, a 38-year-old man with schizophrenia at Pantang Psychiatric Hospital said, “We are beaten by the security men and the male nurses. They beat me when I tried to escape from the ward.”[203] Harriet, the pregnant woman at Ankaful Psychiatric Hospital, told Human Rights Watch that nurses threatened physical abuse. She said, “Yesterday they were drawing blood from me and I was feeling a lot of pain and I said, ‘You are killing me’; the nurse said ‘if you shout again, I will put the needle in your mouth.’”[204]

One nurse explained that some patients are at times aggressive and assault the staff, so nurses beat them in self-defense.[205] One former patient of Accra Psychiatric Hospital told Human Rights Watch, “I saw some people being beaten like animals. Those who failed to follow the instructions of nurses, they would beat them mercilessly. Whenever I saw this, it would frighten me.”[206]

Ghana’s domestic laws, such as the Criminal Code Act of Ghana, criminalize all forms of assault and battery.[207] Human Rights Watch attempted to obtain data from the hospitals, the Attorney General’s Office, the chief psychiatrist for the Ghana Health Service, and the Ministry of Justice about any ongoing or previous allegations, investigations, or prosecutions of staff at hospitals or prayer camps for assault against persons with mental disabilities. However, at the time of writing, we had not yet heard a response from some of the authorities.[208]

In his response, Dr. Akwasi Osei, Chief Psychiatrist, Ghana Health Service, attributed the reported abuses to the fact that the old mental health law did not make provisions for patients to challenge involuntary admission and treatment in psychiatric facilities.[209] He added that this made it difficult for people who were not admitted under court order to challenge such admission especially because the old law required consent of a caregiver or relative.

As noted earlier, the new Mental Health Act now establishes a tribunal and an appeal procedure which seeks to address this. It remains to be seen how structures will be set up to ensure that persons with mental disabilities can challenge both admission and treatment against their will.

Electroconvulsive Therapy

Psychiatrists in Ghana continue to use electroconvulsive therapy (ECT), a method of treatment which involves passing electricity through one’s brain, to treat persons with severe depression.[210] Dr. Akwasi Osei, chief psychiatrist for the Ghana Mental Health Service and head of Accra Psychiatric Hospital, explained the process of administering the electroshocks:

We don’t give anesthesia because we don’t have a machine and personnel. ECT is a little uncomfortable, but it gets better. Some patients get four to six shocks, two or three times a week and not more because it can lead to permanent memory loss.[211]

Former UN special rapporteur on torture, Manfred Nowak, has noted that unmodified ECT (without anesthesia, muscle relaxant, or oxygenation) is an unacceptable medical practice that may constitute torture or ill-treatment, as it may cause adverse effects such as cognitive deficits and loss of memory.[212]

Nowak concludes that, even in its modified form (where seizure is not induced by the maximum dose of electrical charge),[213] “it is of vital importance that ECT be administered only with the free and informed consent of the person concerned, including on the basis of information on the secondary effects and related risks such as heart complications, confusion, loss of memory and even death.”[214] Like those who have undergone unmodified ECT, survivors of the modified form in different parts of the world have found severe and permanent memory loss devastating to personal identity.[215]

Dr. Osei told Human Rights Watch that before treatment is administered, the patient’s consent is sought. In cases where hospital staff deem patients incapable of giving their informed consent, family members (if they are accompanied) consent on their behalf; unaccompanied patients are treated without consent.[216]

The 2012 Mental Health Act offers some protection against involuntary admission and treatment, although it is not absolute. While the act creates a mechanism through which someone who is involuntarily admitted and given treatment can challenge both admission and treatment, some of the circumstances under which such admission and treatment is permitted are susceptible to abuse; for example, the act allows for involuntary admission and treatment where the person’s condition is deemed as expected to deteriorate. While the act empowers a patient or primary caregiver to appeal involuntary admission or treatment, it still remains to be seen how persons with mental disabilities seeking to challenge admission and treatment will be supported by the state to ensure effective implementation of the law, including access to courts, as well as the enjoyment of rights by persons with mental disabilities.

The act makes provision for appointment of a guardian with full powers to make decisions on behalf of an individual, as opposed to a support person, on the basis that a person for whom a guardian is appointed is presumed, by a clinical team of mental health professionals, as lacking capacity. The retention, in the 2012 Mental Health Act, of guardians making decisions rather than moving towards assisted decision-making for persons with disabilities violates the CRPD. Although criminal statutes outlawing assault might, in theory, be used to prosecute instances of forced treatment, it was unclear at the time of writing whether authorities had ever pursued criminal charges against psychiatric hospital staff for use of ECT.[217] Ghana therefore needs to align provisions of the mental health law with the CRPD and create a system through which the laws can be implemented, including access to legal aid.

Violations against Children with Disabilities

Children with mental disabilities experienced similar conditions to adults in psychiatric hospitals and prayer camps. Some children that Human Rights Watch saw in Accra Psychiatric Hospital had multiple disabilities, which exacerbated their vulnerability to human rights violations.

Despite its name, the Children’s Ward at Accra Psychiatric Hospital houses people ranging from 14 to 40 years of age. At the time researchers visited, there were 22 patients; 13 of them were brought by their parents, the majority of whom never visited.[218] Almost half of the patients in the Children’s Ward were actually adults; those younger than 18 ranged in age from 12 to 17. A nurse said that some of the adults had been in the ward since 1980.[219]

Most patients in the ward have been diagnosed with mania, epilepsy, or intellectual disabilities such as Down syndrome. In only a few cases had children had been diagnosed with bipolar disorder or schizophrenia.[220]

The staff shortage was particularly pernicious in the Children’s Ward, given the complex needs of the people kept there. The ward has five morning staff, fewer than five staff in the afternoon, and only two staff at night. A nurse in the ward said, “It is harder at night since most of the children and individuals don’t sleep.”[221] People in the Children’s Ward received medication, but not all who did so needed it. According to one nurse,

While no one on current admission has a psychiatric condition, some of them receive psychotropic drugs because they are so restless. We don’t have access to alternative services that would stimulate these children. In any case, we lack the necessary skills to handle children with intellectual disabilities since we [were] train[ed] to deal with psychotic adult cases.[222]

Dormitories in the ward were dirty, and patients slept on thin mattresses on the floor. At the time of Human Rights Watch’s visit, some children and adults were lying down naked next to their feces. The nurse said they had reacted negatively to their prescribed medicines.[223]

In the prayer camps visited by Human Rights Watch, the situation was even worse for children, who were subjected to restraints and other abuses. Victoria, a 10-year-old girl, shoeless and covered with dirt, had been chained to a tree at Nyakumasi Prayer Camp.[224] She had a serious skin disorder with crusting and bumps on both arms. When asked about this condition, the prophet said it was up to Victoria’s mother to buy medication.[225] Children in prayer camps were subjected to the same regime of fasting as adults and they were chained in the same conditions. These conditions were particularly difficult since some rooms were noisy and some adults would sometimes strip naked.

Ghana’s constitution expressly prohibits subjecting a child to torture or other cruel, inhuman, or degrading treatment or punishment.[226] It also prohibits depriving a child of medical and other benefits on the basis of religious or other beliefs.[227] The constitution empowers parliament to enact laws to ensure that every child, regardless of disability, has a right to the same measures of special care, assistance, and maintenance as is necessary for their development.[228]

The 1998 Children’s Act prohibits discrimination against a child on the grounds of disability or health status, among others,[229] and guarantees the best interest of the child in any matter concerning his or her welfare.[230] The act further prohibits treating a child with a disability in a non-dignified manner and entitles children to a right to special care that can develop their maximum potential and self-reliance.[231]

 

[62]Human Rights Watch interview with Peace (pseudonym), patient, Pantang Psychiatric Hospital, November 19, 2011

[63]Human Rights Watch interview with Prophet Paul Kweku Nii Okia, Mount Horeb Prayer Camp, November 19, 2011; Human Rights Watch interview with Rev. Rebekah Bedford, January 19, 2012; Human Rights Watch interview with Prophet Charity Donkor, January 19, 2012; Human Rights Watch interview with Prophet Appiah Kubi, Mount Horeb, November 19, 2011; Human Rights Watch interview with Prophet Leo Baidoo, Nyakumasi Prayer Camp, January 19, 2012; Human Rights Watch interview with Prophet Charity Donkor, Charity Ministries, January 19, 2012.

[64] Human Rights Watch email correspondence with Dan Taylor, executive director, Mindfreedom Ghana, August 13, 2012.

[65] Ibid.

[66]Human Rights Watch Interview with Dr. Akwasi Osei, January 17, 2012.

[67]Ibid.

[68] Human Rights Watch interview with Peace (pseudonym), November 24, 2011.

[69]Human Rights Watch interview with a Dr. Akwasi Osei, January 19, 2012.

[70]Human Rights Watch interview with Dr. Anan Armah Arlob, medical director, Ankaful Psychiatric Hospital, November 25, 2011.

[71]Human Rights Watch interview with Dr. Anan Armah Arlob, medical director, Ankaful Psychiatric Hospital, November 25, 2011.

[72]Human Rights Watch interview with John (pseudonym), resident, Mount Horeb Prayer Camp, Mamfi, Eastern Region, January 19, 2012.

[73]Human Rights Watch interview with Peter (pseudonym), resident, Edumfa Prayer Camp, Central Region-Cape Coast, January 19, 2012

[74]Human Rights Watch interview with Dr. Akwasi Osei, November 16, 2011.

[75]Human Rights Watch interview with psychiatric nurse, Pantang Psychiatric Hospital, November 19, 2011.

[76]Constitution of the Republic of Ghana, 1992, art.14 (1)

[77]Constitution, art.14 (1) (a)

[78] Mental Health Act, No. 846, 2012.

[79]Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 14, 2011; Human Rights Watch interview with Patience Nsatimba, nurse, Pantang Psychiatric Hospital, November 19, 2011; Human Rights Watch interview with a nurse, Ankaful Psychiatric Hospital, November 24, 2011.

[80]Human Rights Watch interview with Dr. Akwasi Osei, November 16, 2011.

[81]Ibid.

[82]Human Rights Watch interview with Dr. Anan Armah Arlob, medical director, Ankaful Psychiatric Hospital, November 25, 2011; Human Rights Watch perused the file of Margaret (pseudonym), who could not see and or hear well. Human Rights Watch interview with a nurse, a ward in charge, Ankaful Psychiatric Hospital, November 25, 2011. The nurse said that the woman who had been there for 35 years could have been discharged a few years ago, but she had nowhere to go.

[83]Human Rights Watch interviews with Bentil (pseudonym), patient, and a nurse, a ward in charge, Ankaful Psychiatric Hospital, November 24, 2011. Human Rights Watch also perused the individual’s file.

[84] Human Rights Watch interview with Bentil (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011

[85] Human Rights Watch interview with Dr. Akwasi Osei, November 16, 2011.

[86] Human Rights Watch interview with Sarah, (pseudonym), patient, Pantang Psychiatric Hospital, November 19, 2011.

[87] Human Rights Watch interview with John (pseudonym), resident, Mount Horeb Prayer Camp, Eastern Region, November 19, 2011.

[88] Human Rights Watch interview with Elijah (pseudonym), resident, Mountains Jesus Divine Temple Mission, Nyakumasi Prayer Camp, Cape Coast, Central Region, January 19, 2012.

[89] Human Rights Watch interview with Reverend Mary Asamora, Church of the Lord Mission, Senya Breku Prayer Camp, Senya Breku, January 26, 2012.

[90]Human Rights Watch interview with Pastor Francis Bayadam, Good News Evangelicals Mission International, Accra, November 23, 2011. The sanatorium was a section of the prayer camp where persons with mental disabilities resided.

[91]Brandee Burler, “The Treatment of Psychiatric Illness in Ghana,” SIT Graduate Institute, African Diaspora Collection, 1997.

[92]Accra Psychiatric Hospital, http://accrapsychiatrichospital.org/pages/about-us.php (accessed June 29, 2012).

[93]Human Rights Watch interview with Dr. Akwasi Osei, November 16, 2011.

[94]Human Rights Watch interview with Lillian (pseudonym), patient, Accra Psychiatric Hospital, Accra Psychiatric Hospital, November 17, 2011. Lillian was in the Open Female Ward, which a Hawa (nurse on duty) said had 55 patients on admission at the time of Human Rights Watch’s visit, but had only 30 beds.

[95]Human Rights Watch interview with nurse, Pantang Psychiatric Hospital, November 19, 2011.

[96]Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 16, 2011.

[97]Ibid.

[98]Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 16, 2011.

[99]Human Rights Watch visit to the Special Ward (former Criminal Ward) and Open Female Ward, Accra Psychiatric Hospital, November 16, 2011. Human Rights Watch visit to the Female Chronic Ward, Pantang Psychiatric Hospital, November 19, 2011.

[100]Human Rights Watch interview with nurse, Pantang Psychiatric Hospital, November 19, 2011; Human Rights Watch interview with three nurses, Accra Psychiatric Hospital, November 16, 2011.

[101] Human Rights Watch interview with nurse, Pantang Psychiatric Hospital, November 19, 2011.

[102]Human Rights Watch visits to Mount Horeb Prayer Camp, Mamfi, Eastern Region, January 20, 2012; Human Rights Watch visits to Edumfa Prayer Camp (Central Region), January 19, 2012. At Edumfa Prayer Camp, patients were housed in open-plan concrete buildings about 23 meters long by 10 yards wide. All residents were chained in concrete stalls adjacent to each other and wide enough to fit a small mat or mattress. The first ward housed over 40 patients with serious mental health problems, and was completely full. Many patients were yelling, singing, shouting, or talking to themselves. About 10 men were housed in a separate closed but quite crowded room. About half the men were chained, and only a few could hold a conversation.

[103]Human Rights Watch interview with Abigail Kruvi, staff, Mount Horeb Prayer Camp. November 19, 2011.

[104]Human Rights Watch interview with Aisha (pseudonym), patient, Mount Horeb Prayer Camp, January 21, 2012.

[105]Human Rights Watch interview with Peter (pseudonym), resident, Mount Horeb Prayer Camp, Eastern Region, January 20, 2012.

[106]Ibid.

[107]Human Rights Watch interview with Abigail Kruvi, staff, Mount Horeb Prayer Camp, November 19, 2011.

[108]Ibid.

[109]Human Rights Watch interview with Aisha (pseudonym), Mount Horeb Prayer Camp, January 21, 2012.

[110]Human Rights Watch visits to Mount Horeb Prayer Camp (Eastern Region), Edumfa Prayer Camp (Central Region) and Nyakumasi Prayer Camp (Central Region-Cape Coast), between November 2011 and January 2012.

[111]Human Rights Watch interview with Kofi (pseudonym), resident, Edumfa Prayer Camp, Central Region-Cape Coast, January 19, 2012.

[112]Human Rights Watch visits to Mount Horeb Prayer Camp, Mamfi, Eastern Region, November 19, 2011 and January 25, 2012.

[113]Human Rights Watch interview with Elijah (pseudonym), resident, Mountains Jesus Divine Temple Mission, Nyakumasi, Cape Coast, Central Region, January 19, 2012.

[114]Human Rights Watch interview with Aisha (pseudonym), resident, Mount Horeb Prayer Camp, January 19, 2012.

[115]Human Rights Watch interview with Prophet Paul Kweku Nii Okia, founder, Mount Horeb Prayer Camp, Mamfi Mountains, Eastern Region, November 19, 2011.

[116]Human Rights Watch interview with Rev. Rebekah Bedford, director, Edumfa Prayer Camp, Central Region, January 19, 2012.

[117]Constitution, art. 21 (2) (g).

[118]Ibid., art. 26 (1) and (2).

[119] Criminal Code Act, 1960 (as amended in 2003), sec. 80.

[120] Ibid., secs. 88 (1) and (2).

[121]Code of Federal Regulations Part 482, Title 42 – Public Health, section 482.13, http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec482-13.pdf.The Centers for Medicare and Medicaid Services (CMS) is an agency within the US Department of Health and Human Services responsible for administering several key federal health care programs, including Medicare, the Children’s Health Insurance Program (CHIP), and Health Insurance Portability and Accountability Act (HIPAA).

[122] Mendez, Juan. Report of the Special Rapporteur on torture and cruel, inhuman or degrading treatment or punishment, A/66/268, August 2011, http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N11/445/70/PDF/N1144570.pdf?OpenElement,p.8http://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=11506&LangID=E June 24, 2012).

[123]Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 16, 2011.

[124] Human Rights Watch interview with Patience Nsatimba, deputy ward in charge, Male Ward, Pantang Psychiatric Hospital, November 19, 2011.

[125] Human Rights Watch interview with Kingston (pseudonym) nurse, Accra Psychiatric Hospital, November 16, 2011.

[126]Human Rights Watch interview with Harriet (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011.

[127]Human Rights Watch interview with Mary (pseudonym), psychiatric nurse, Ankaful Psychiatric Hospital, Female Acute Ward, Ankaful Psychiatric Hospital, November 24, 2011; Human Rights Watch interview with Daniel (pseudonym), psychiatric nurse, Accra Psychiatric Hospital, November 16, 2011; Human Rights Watch interview with Peter Atta, ward in charge, Pantang Psychiatric Hospital, November 21, 2011; Human Rights Watch interview with Jane (pseudonym), nurse, Accra Psychiatric Hospital, November 16, 2011.

[128] Interim Report of the Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment (SR Torture Interim Report), 28 July 2008, UN Doc A/63/175, para. 56. See Human Rights Committee, concluding observations on the second periodic report of Slovakia (CCPR/CO/78/SVK), para. 13 and on the second periodic report of the Czech Republic (CCPR/C/CZE/CO/2), para. 13, where the committee expressed concern about the persistent use of cage-net beds as a means to restrain psychiatric patients, recalling that this practice is considered inhuman and degrading treatment and amounts to a violation of articles 7, 9 and 10 of the International Covenant on Civil and Political Rights.

[129]Human Rights Watch interview with Daniel (pseudonym), psychiatric nurse, Accra Psychiatric Hospital, November 16, 2011.

[130]Ibid.

[131]Human Rights Watch visit to Nyakumasi Prayer Camp, Central Region- Cape Coast, January 19, 2012.

[132]Human Rights Watch interview with Afia (pseudonym), Mount Horeb Prayer Camp, January 21, 2012.

[133]Human Rights Watch interviewed Prophetess Charity Donkor, director, Charity Prayer Ministry, Central Region, Cape Coast. January 19, 2012; Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Greater Accra Region, November 21, 2011; Human Rights Watch interview with Rev. Rebekah Bedford, Edumfa prayer camp, Central Region, November 19, 2012.

[134]Human Rights Watch interview with Rebecca Norah, community psychiatric nurse, Tetteh Quash Hospital, Akwampim North district, January 25, 2012.

[135]Human Rights Watch interview with Pastor Paul Kweku, director International Christ Miracle Gospel Ministries, Mamfi, Eastern Region, January 21, 2012.

[136]Human Rights Watch interview with Doris Appiah, January 15, 2012.

[137] Human Rights Watch interview with Aisha (pseudonym), resident, Mount Horeb Prayer Camp, Eastern Region, January 19, 2012, Human Rights Watch interview with Joseph (pseudonym), resident, Mount Horeb Prayer Camp, Eastern Region, November 19, 2012,

[138] Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 21, 2011; Human Rights Watch interview with Rev. Rebekah Bedford, Edumfa prayer camp, Central Region, November 19, 2012; Human Rights Watch interview with Pastor Paul Kweku, director, International Christ Miracle Gospel Ministries, Mamfi, Eastern Region, January 21, 2012.

[139] Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 21, 2011. Human Rights Watch did not find evidence that police brought people to prayer camps as some administrators said. None of the people interviewed said they had been brought to the prayer camp by police.

[140]Human Rights Watch interview with Pastor Francis Bayadam, Good News Evangelicals Mission International, Accra, November 23, 2011.

[141]Human Rights Watch interview with Pastor Christian Addo, Mount Horeb Prayer Camp, January 21, 2012.

[142]Human Rights Watch interview with Prophetess Charity Donkor, director Charity Prayer Ministry, Central Region, Cape Coast. January 19, 2012; Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 21, 2011; Human Rights Watch interview with Rev. Rebekah Bedford, November 19, 2012.

[143]Human Rights Watch interview with Elijah (pseudonym), Mountains Jesus Divine Temple Mission, Nyakumasi, Cape Coast, Central Region, January 19, 2012.

[144]Human Rights Watch interview with Linda (pseudonym), community psychiatric nurse, Tetteh Quarshie Memorial Hospital, Akwampim North district, January 25, 2012.

[145]Human Rights Watch interview with Mark Dodoo, member, Nyamg Adom Self Help Group, Dakuman Community, January 18, 2012.

[146]Human Rights Watch interview with Rev. Mary Asamora, Church of Lord Mission, Senya Breku, Central Region, January 26, 2012.

[147] Human Rights Watch interview with Avotri Seyram, nurse, Special Ward, Accra Psychiatric Hospital, November 16, 2011.

[148]ICESCR, art. 11.

[149]Constitution, arts. 13 and 36.

[150]Human Rights Watch interview with Dr. Anan Armah, director, Ankaful Psychiatric Hospital, Ankaful Psychiatric Hospital, November 23, 2011.

[151]Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 14, 2011.

[152]Human Rights Watch interview with Lillian (pseudonym), patient, Accra Psychiatric Hospital, November 17, 2011. Largactil is “used in the management of psychotic conditions. Largactil controls excitement, agitation and other psychomotor disturbances in patients with schizophrenia and reduces the manic phase of manic-depressive conditions. It is also used to control hyperkinetic states and aggression and is sometimes given in other psychiatric conditions for the control of anxiety and tension.” South African Electronic Package inserts, http://home.intekom.com/pharm/aventis/largact.html (accessed April 18, 2012).

[153]Human Rights Watch Interview with Suleiman Ayiku, member, Mental Health Society of Ghana, Accra, January 15, 2012.

[154] Human Rights Watch interview with Prophetess Charity Donkor, director Charity Prayer Ministry, Central Region, Cape Coast. January 19, 2012. Human Rights Watch interview with Rev. Rebekah Bedford, Edumfa prayer camp, Central Region, November 19, 2012. Human Rights Watch interview with Pastor Paul Kweku, director International Christ Miracle Gospel Ministries, Mamfi, Eastern Region, January 21, 2012.

[155] Human Rights Watch was told by Prophet Paul Kweku, that Mount Horeb Prayer Camp had 120 individuals in November 2011; and Pastor Christian said the camp had 135 individuals in January 2012. Tetteh Quarshie Memorial Hospital, Mampong- Akwampim, is a general hospital near Mount Horeb. It has a psychiatric unit, which is served by two psychiatric nurses and has been without a psychiatric doctor attached to it since 2010.

[156]Human Rights Watch interview with Ebu Blankson, psychiatric social worker, Ankaful Psychiatric Hospital, January 18, 2012.

[157]In Nyakumasi, Kordiabe, and Senya Breku Prayer Camps, prophets did not tell Human Rights Watch of any formal relationships with psychiatric hospitals. At Nyakumasi and Edumfa Prayer Camps, psychotropic treatment is not allowed in the camps.

[158]Human Rights Watch interview with Dr. Akwasi Osei, January 16 2012.

[159]Ibid.

[160]Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 21, 2011; Human Rights Watch interview with Rev. Rebekah Bedford, Edumfa prayer camp, Central Region, November 19, 2012; Human Rights Watch interview with Prophetess Charity Donkor, director Charity Prayer Ministry, Central Region, Cape Coast. January 19, 2012.

[161]Human Rights Watch interview with Prophetess Charity Donkor, director, Charity Prayer Ministry, Central Region, Cape Coast. January 19, 2012; Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 21, 2011; Human Rights Watch interview with Prophet Rebekah Bedford, Edumfa prayer camp, Central Region, November 19, 2012.

[162]Human Rights Watch interview with Prophet Leo Baidoo, proprietor, Nyakumasi Prayer Camp, and Elijah (pseudonym), resident, Nyakumasi Prayer Camp, January 19, 2012.

[163]Human Rights Watch interview with Hon. Mubarak Muntaka, chairperson, Parliamentary Committee on Health, Parliament of Ghana, Accra, January 21, 2012.

[164]Human Rights Watch interview with Dr. Akwasi Osei, January 17, 2012.

[165]Mental Health Bill, 2012, section 34.

[166] Human Rights Watch interview with Sarah (pseudonym), patient, Pantang Psychiatric Hospital, November 19, 2011.

[167]Human Rights Watch interview with psychiatric nurse, Accra Psychiatric hospital, November 16, 2011; Human Rights Watch interview with psychiatric nurse, Pantang Psychiatric hospital, November 19, 2011; Human Rights Watch interview with Dr. Akwasi Osei, chief psychiatrist and director, Accra Psychiatric Hospital, November 16, 2011.

[168]Human Rights Watch interview with Margaret Nartay, ward in charge, Ankaful Psychiatric Hospital, November 24, 2011.

[169]Human Rights Watch interview with Abigail Kruvi, staff Mount Horeb Prayer Camp, Mount Horeb Church, November 19, 2011; Human Rights Watch interview with Bentil (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011.         

[170]Human Rights Watch interview with Harriet (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011; Human Rights Watch interview with Peace (pseudonym), patient, Pantang Psychiatric Hospital, November 19, 2011; Human Rights Watch interview with Michael (pseudonym), patient, Pantang Psychiatric Hospital, November 16, 2011; Human Rights Watch interview with Elizabeth, patient, Pantang Psychiatric Hospital, November 19, 2011.

[171]Human Rights Watch interview with Lillian (pseudonym), Accra Psychiatric Hospital, November 16, 2011.

[172]Human Rights Watch interview with two nurses, Accra Psychiatric Hospital, November 16, 2011; Human Rights Watch interview with psychiatric nurse, Ankaful Psychiatric Hospital, November 19, 2011; Human Rights Watch interview with Michael (pseudonym), patient, Accra Psychiatric Hospital, November 16, 2011 and Sarah (pseudonym), patient, Pantang Psychiatric Hospital, November 24, 2011.

[173]Commonwealth Human Rights Initiative, Human Rights Violations in Prayer Camps and access to Mental Health in Ghana, August 2008. Concoctions or local herbs shown to Human Rights Watch included Nyamidea (God has blessed), Orunamu, Eme and Dya tree; Human Rights Watch interview with Prophet Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 21, 2011; Human Rights Watch interview with Rev. Mary Asamora, Church of the Lord Mission, Senya Breku Prayer Camp, Central Region, Ghana, January 26, 2012; Human Rights Watch interview with Prophet Rebekah Bedford, Edumfa Prayer Camp, Central Region, November 19, 2012; Human Rights Watch interview with Ebu Blankson, psychiatric social worker, Ankaful Psychiatric Hospital, January 18, 2012. Blankson conducted a survey of 4 of the 12 districts in Central Region, and registered over 40 prayer camps and found that herbs were widely used to treat patients.

[174]Human Rights Watch interview with Prophetess Winifred Buff, Kasoa Healing Center, Kasoa, Central Region, November 23, 2011.

[175]Human Rights Watch interview with Doris Appiah, January 15, 2012.

[176] Interim Report of the Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment (SR Torture Interim Report), 28 July 2008, UN Doc A/63/175, at [50].

[177] Ibid.

[178]See P.R. Breggin, Psychiatric Drugs: Hazards to the Brain (New York, Springer, 1983); D. Cohen, ‘A Critique of the Use of Neuroleptic Drugs’ in S Fisher and RP Greenberg (eds.), From Placebo to Panacea: Putting Psychiatric Drugs to the Test (New York, John Wiley, 1997); G.E. Jackson, Rethinking Psychiatric Drugs: A Guide for Informed Consent (Bloomington, Author House, 2005).

[179] Interim Report of the Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment (SR Torture Interim Report), 28 July 2008, UN Doc A/63/175, at [50], as cited by Tina Minkowitz, Abolishing Mental Health Laws to Comply with the Convention on the Rights of Persons with Disabilities, McSherry PAGE: 1 SESS: 7 OUTPUT: Wed Jul 28 10:48:01 2010. The American Medical Association defines informed consent as “a process of communication between a patient and physician that results in the patient's authorization to undergo a specific medical intervention.” This requires more than simply getting a patient to sign a written consent form; the physician performing the treatment and/or procedure (not a delegated representative) must fully inform the patient and discuss the ramifications of treatment. According to the AMA, the patient should thus know their diagnosis, if known; the nature, risk, benefit and purpose of a proposed treatment or procedure. A patient should be told about existing alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance); as well as risks associated with such alternative procedures. The patient should know the risks and benefits of not receiving or undergoing a treatment or procedure; and the patient should have an opportunity to ask questions. American Medical Association (AMA), Patient-Physician Relationship Topics, informed consent, accessed from http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.page, May 19, 2012.

[180] UN OHCHR, From Exclusion to Equality: Realizing the Rights of Persons with Disabilities, 90 (2007), http://www.ohchr.org/Documents/Publications/training14en.pdf, accessed August 12, 2012.

[181] Human Rights Watch phone interview with Professor Robert Dinerstein, director, Disability Law Clinic, American University, Washington College of Law, April 2, 2012.

[182] Office of High Commissioner for Human Rights, Information Note No.4: Persons with Disabilities, “Dignity and Justice for Detainees Week.”

[183] UN OHCHR, From Exclusion to Equality: Realizing the Rights of Persons with Disabilities, 90 (2007), http://www.ohchr.org/Documents/Publications/training14en.pdf (accessed August 12, 2012).

[184] Criminal Procedure Code Act, 1960, Sec. 42.

[185]Human Rights Watch interview with Harriet (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011; Human Rights Watch interview with Jane Quaye, executive director FIDA Ghana, November 23, 2011; Human Rights Watch interview with John Kwabena Arthur, relative and caregiver of a woman with a mental disability, November 20, 2011.

[186]Human Rights Watch interview with Reverend Richard Nii Kumu Ollennu, Ebenezer Presbyterian Church offices, Accra, January 16, 2012.

[187]Human Rights Watch interview with Barnard Akumiah, member Mental Health Society of Ghana (MEHSOG), Accra, November 20, 2011.

[188]Brandee Burler, the Treatment of Psychiatric Illness in Ghana, SIT Graduate Institute, African Diaspora Collection, 1997.

[189]Human Rights Watch interview with Jane (pseudonym), nurse, Accra Psychiatric Hospital, November 16, 2011. Jane told Human Rights Watch that the Open Female Ward had an individual who stayed for 20 years because her family never came to pick her up. At Ankaful Psychiatric Hospital, we examined a file of a 75-year-old woman who was believed to have lived on the ward for over 35 years.

[190]Human Rights Watch interview with Bernard Akumiah, person with a mental disability living in the community, Greater Accra Region, November 14, 2011.

[191]Human Rights Watch interview with Peace (pseudonym), resident, Pantang Psychiatric Hospital, November 19, 2011. Prior to coming to Pantang, Peace was first admitted to Ankaful Psychiatric Hospital.

[192]Human Rights Watch interview with Doris Appiah, November 20, 2011.

[193]Human Rights Watch interview with John Kwabena Arthur, Ministries, Accra, Ghana, November 16, 2011. John has a sister who has a mental disability and he takes care of her.

[194] Human Rights Watch interview with John Kwabena, relative of a person with a mental disability, Greater Accra Region, November 20, 2011

[195]Human Rights Watch interview with Millicent Asirifi, nurse, Ankaful Psychiatric Hospital, November 24, 2011.

[196]Human Rights Watch interview with Rebecca Norah, nurse at Tetteh Quarshie District hospital, who visits Mount Horeb Prayer Camp, January 25, 2012.

[197]Human Rights Watch interview with Dr. Akwasi Osei, January 17, 2012.

[198] Human Rights Watch interview with Dr. Anan Armah, director, Ankaful Psychiatric Hospital, November 23, 2011.

[199]Human Rights Watch interview with Robert Amo, director of programs and advocacy, Christian Council of Ghana (CCG), Accra, November 23, 2011.

[200]Human Rights Watch interview with Sarah (pseudonym), patient, Pantang Psychiatric Hospital, November 19, 2011.

[201]Human Rights Watch interview with Aisha (pseudonym), resident, Mount Horeb Prayer Camp, January 19, 2012.

[202]Human Rights Watch interview with Michael (pseudonym), a 38-year-old man with schizophrenia, Pantang Psychiatric Hospital, November 16, 2011; Human Rights Watch interview with John (pseudonym), patient, Accra Psychiatric Hospital, Accra, November 16, 2011; Human Rights Watch interview with Aisha (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011.

[203]Human Rights Watch interview with Michael (pseudonym), patient, Pantang Psychiatric Hospital, November 16, 2011.

[204]Human Rights Watch interview with Harriet (pseudonym), patient, Ankaful Psychiatric Hospital, November 24, 2011.

[205]Human Rights Watch interview with Daniel Kwame, ward in charge, Pantang Psychiatric Hospital, November 16, 2011.

[206]Human Rights Watch interview with Barnard Akumiah, member, Mental Health Society of Ghana, Accra, November 20, 2011.

[207]Criminal Code Act, 1960 (Act 29), as amended in 2003. Section 84 defines assault as “forceful touching of a person without their consent, and with the intention of causing harm, pain, or fear, or annoyance to that person” and according to section 86, the definition in section 84 provision applies regardless of whether the person is “capable of consenting due to a mental disability.”

[208] Human Rights Watch, letter faxed to Dr. Benjamin Kunbour, Ministry of Justice and Attorney General, Accra, Ghana, August 1, 2012. Human Rights Watch, email sent to Dr. Akwasi Osei, Chief Director, Ghana Health Service and director Accra Psychiatric Hospital, re: request for your opinion, July 29, 2012.

[209] Email communication between Human Rights Watch and Dr. Akwasi Osei, chief psychiatrist, Ghana Health Service, and director, Accra Psychiatric Hospital, in response to the email re: request for your opinion, August 21, 2012.

[210]Electroconvulsive therapy, also known as electroshock or ECT, is a controversial type of psychiatric shock therapy involving the induction of an artificial seizure in a patient by passing electricity through the brain. ECT is used to treat bipolar disorder and severe depression in cases where antidepressant medication, psychotherapy, or both have proven ineffective. See Doctors Lounge, http://www.doctorslounge.com/psychiatry/procedures/ect.htm, accessed on May 7, 2012.

[211]Human Rights Watch interview with Dr. Akwasi Osei, chief psychiatrist, Accra Psychiatric Hospital, November 16, 2011.

[212]Interim Report of the Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment (SR Torture Interim Report), 28 July 2008, UN Doc A/63/175, at [50].

[213]Hiroaki Inomata et al., Long Brief Pulse for Pulse-wave modified Electro-convulsive Therapy, arXiv:1112.2072v1 [q-bio.NC], December 9, 2011, accessed May 21, 2012). The World Psychiatric Association Position Statement on the Ethics of the Use of Unmodified Electroconvulsive Therapy (2009) explains the process of modified ECT to have emerged with the introduction of anesthesia and muscle relaxation prior to the administration of ECT. For more details, see, http://www.arabpsynet.com/Journals/ajp/ajp20.1-P57.pdf (accessed on June 29, 2012).

[214] Interim Report of the Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment (Special Rapporteur, Torture Interim Report), 28 July 2008, UN Doc A/63/175, at [50].

[215] Tina Minkowitz, “Abolishing Mental Health Laws to Comply with the Convention on the Rights of Persons with Disabilities,” in B. McSherry and P. Weller (eds), Rethinking Rights-Based Mental Health Laws (Portland: Hart, 2010) ch 7, p. 151.

[216] Human Rights Watch interview with Dr. Akwasi Osei, November 16, 2011.

[217] Human Rights Watch letter faxed to the Ministry of Health, Accra, Ghana, August 1, 2012.

[218] Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 16, 2011. The nurse told Human Rights Watch that parents bring children with disabilities because they cannot care for them. Other people in the ward have no parents, and are brought by the public. For example, one girl with an intellectual disability was brought by a nurse because community members threatened to kill her.

[219] Human Rights Watch interview with nurse, Accra Psychiatric Hospital, November 16, 2011.

[220] Human Rights Watch interview with Dr. Akwasi Osei, November 16, 2011. Mania is a mental condition marked by periods of great excitement, delusions, and over activity. See http://oxforddictionaries.com/definition/english/mania (accessed July 7, 2012).

[221]Human Rights Watch interview with a nurse, Accra Psychiatric Hospital, November 16, 2011.

[222]Human Rights Watch interview with a nurse, Accra Psychiatric Hospital, November 16, 2011.

[223]Human Rights Watch interview with Aminah (pseudonym), nurse, Accra Psychiatric Hospital, November 16, 2011.

[224] Human Rights Watch interview with Victoria (pseudonym), resident, Nyakumasi Prayer Camp, Central Region, January 19, 2012.

[225] Human Rights Watch interview with Prophet Leo Baidoo, director, Nyakumasi Prayer Camp, Central Region, January 19, 2012.

[226]Constitution, art. 28 (3).

[227] Ibid., art. 28 (4)

[228]Ibid., art. 28 (1)

[229] Children's Act, 1998 (Act 560), Ghana, December 30, 1998, art. 3, http://www.unhcr.org/refworld/docid/44bf86454.html (accessed September 11, 2012).

[230]Ibid., art. 2.

[231]Ibid., art. 10 (1) and (2)