Abstract
This article critiques the Mental Health Policy in Brazil with emphasis on the history of struggle for the right of people who have mental disorders and against violence in psychiatric institutions. The article is divided twofold; firstly, addressing exclusion, violence and exercise of citizenship, highlighting the Psychiatric Reform Movement in Brazil from 1970; secondly, contextualising the Ximenes Case with the hospital-centred model in Brazil, bringing information about the National Inspection Report in Psychiatric Hospitals. The legal framework against torture about the deprivation of liberty of people considered ‘mentally ill’ and the social division between desirable and undesirable as a characteristic of this reality. It contextualises the Mental Health Policy and the ongoing counter-reform in the Brazilian Scenario by presenting an item about the Bolsonaro Government and the attacks on Brazilian Mental Health Policy. It is pointed out in the final considerations that torture materialises in the counter-reform underway through the ‘New Mental Health Policy of Brazil’, which masks a new form of torture and suffering exposed by the structuring inequalities of capitalist society. As for the processes of resistance, the fundamental defense of community and participatory policies is pointed out in the face of challenges and complaints against human rights in institutions and logic in the Brazilian government.
Keywords: mental health; human rights; inequality; violence; Ximenes; Brazil.
Introduction
This article addresses the Mental Health Policy in Brazil, its trajectory and inflections based on bibliographical research on the subject, including reflections ranging from exclusion, violence, protagonism to the exercise of citizenship. In the sequence, it problematises the Ximenes case and the hospital centric model in Brazil, which stigmatises the desirable, undesirable aspects of the legal framework of torture, addressing some legal precepts related to the subject. Subsequently, the discussion addresses the Mental Health Policy and the counter-reform in progress in the Brazilian scenario, especially in the Bolsonaro Government with its attacks on the Mental Health Policy.
It is known that public policies, in order to achieve some success in their objectives, need administrations to provide them funding, considering the interests of the population over the interests of the private sector. From this perspective, the adequate infrastructure of the health-care system depends on the political will of governments, the participation of social control, the training and commitment of professionals and also on the articulation among the various intersectoral public policies aiming to guarantee a humanised care, especially at the current political scenario of setbacks and deterioration of public policies. In this standpoint, we highlight some of the societal transformations that have happened in Brazil, through different governments to the current Bolsonaro administration. The considerations and criticisms are theoretically based on dialectical-historical materialism and aim to update the discussion of the subject during a political moment of serious attacks on human rights and a setback for policies that protect the population.
Historical background: From exclusion and violence to protagonism and the exercise of citizenship
It is important to place the reader on historical aspects of regarding ‘madness’ in Brazil. Following the European model, the care of people with mental suffering or mental disorders, or the treatment for ‘madness’ in Brazil, was supported by traditional psychiatric thinking, emphasising the medicalisation of bodies, social isolation, capture of freedom and the pathologisation of ordinary and cultural experiences and of feelings and behaviours that are a part of people’s growth and development. In Brazil, the rupture of this model began at the end of the 1970s with the Psychiatric Reform Movement and an effervescent period of redemocratisation and, therefore, of great social and political mobilisation.
The Brazilian Mental Health Policy was implemented with the approval of the Psychiatric Reform Act (RP – Law 10216/2001), which placed the asylum model in the spotlight, proposing significant changes to the notion of care centred on the institutionalisation in a psychiatric hospital. At the time, asylums and colony hospitals received orphans, ‘beggars or troublemakers who, through a local political or police chief, found the definitive solution in their referral to the asylum’ (Resende 1987:52), therefore, all unwanted behaviour was a requirement for admission into asylums. Psychiatric hospitalisations handled social demands more than psychological ones, excluding from society what was uncomfortable for them.
The movement ‘for a society without asylums’ broke with these norms and advocated for a better society, an end to exclusion, greater tolerance, understanding and care for the vulnerable and, finally, more social justice. This movement involved society, educational and health institutions, but mainly healthcare professionals who took on the front of Psychiatric Reform. According to the recommendations of the Psychiatric Reform Movement, caring for people with mental disorders should primarily be on a basis of outpatient and therapeutic care and prevent hospitalisation, with psychiatric hospitalisation being the last resort. This movement was supported through the criticism of practices of isolation and exclusion, which gave rise to complaints of maltreatment, regarding involuntarily institutionalised patients for long periods and in different asylum facilities in the country (Brito 2017). These long hospitalisations brought up the exclusion of such patients once they returned to their homes and communities, as many no longer had their space and place with these families.
Some repercussions of the Psychiatric Reform Movement, according to data from the Federal Council of Medicine, released in 2017, on the Agência Brasil website (https://agenciabrasil.ebc.com.br/), were the shutdown of 15 845 psychiatric inpatient facilities. The Brazilian National Mental Health Policy (PNSM) aimed, after the Psychiatric Reform, to develop a model of mental healthcare with a territorial base that would provide the free circulation of residents, not removing them from living with family and the community and even, if possible, continuing with work activities. These initiatives and changes were the result of the resistances present since the previous decade in the context of mental health care (Devera & Rosa 2007). Therefore, ‘madness’ in Brazil is no longer the target of exclusion and violence, and defense of human rights and rescue of citizenship start to occupy the place of protagonism.
The Ximenes case and the hospital-centred model in Brazil
A case in example is the Ximenes case that showed the violence and abandonment of people who were hospitalised in psychiatric institutions to the world. The violence experienced by Damião Ximenes denounced, at an international level, the refusal of the country to face the prerogatives of the Psychiatric Reform to break with the ‘asylum logic’. The Brazilian government, in addition to not accepting its responsibility, increased its inertia in the face of public mechanisms.
News published on the G1’s website, in August 2016, reports information regarding the Damião Ximenes case, who was killed on 04 October 1999, at Casa de Repouso Guararapes (Guararapes Rest Home), in Sobral, a municipality in the north of Ceará. This was the only psychiatric clinic accredited by the Unified Health System (SUS) at the time. The article shows that the patient died as a result of torture, maltreatment and serious violation of human rights. The report indicated that he had died of cardiorespiratory arrest, and the autopsy revealed that he had been tied with his hands behind his back and suffered several blows, with excoriations on his body.
Psychiatrist Lídia Dias Costa, who followed the case and its exhumation at the request of the Legislative Assembly and the Public Ministry of Ceará, reported that ‘injuries were found on the skull of Damião, which pointed to death as a result of traumatic brain injury’ (Almeida 2016). When questioned about the cause of death, the doctor stated that Damião was a victim of torture. And to support the argument, the psychiatrist mentioned the ‘Istanbul Protocol’, an international document that depicts conduct related to the practice of torture.
According to a report written and approved by the Inter-American Commission on Human Rights, in the Ximenes case, the Brazilian government violated five articles of the American Convention on Human Rights, to which the country is a signatory. In the face of such violations, Brazil was found guilty by the Inter-American Court of Human Rights with seven votes to zero. In the sentence, the following violations were mentioned: the right to personal integrity of the patient and his family; the right to judicial guarantees and judicial protection for family members. Finally, the government was sentenced to pay compensation for moral and material damages to the family of Damião Ximenes. The Inter-American Court also demanded for an agile investigation of those responsible for Damião’s death and determined the creation of training programmes for professionals in psychiatric institutions in Brazil (Almeida 2016).
According to the news on the Justiça Global website, on 22 April 2021, about a hearing that would take place on April 23 of the current year: ‘Brazilian State will be questioned at a hearing for failure to comply with the sentence in the case “Ximenes Lopes v Brazil”’ (CAMILA 2016). The news showed a report from the patient’s mother, who claimed to have found her son lying down, naked, with his hands tied and unconscious. And when she asked the clinic’s doctor for help, he joked, saying ‘we’re all going to die’. Therefore, the patient died in the face of the negligence and institutional violence of those who should have taken care of his health. However, 15 years have passed since the 2006 sentence and the Brazilian State has not fulfilled its obligations. On the contrary, it has increased its attacks on the Mental Health Policy by promoting setbacks, such as the dismantling of the RAPS and the strengthening of therapeutic communities, private and freedom-restricting institutions that work under the bias of coercion and repression (CAMILA 2021).
An article published on 30 April 2021 mentions that the ‘Brazilian government is embarrassed during a hearing at the Inter-American Court of Human Rights’ and points to some problematisations from the hearing. The representative of Brazil, even in the face of the accusations and serious complaints presented, only reaffirmed: the commitment to the Inter-American System of Human Rights concerning the delivery of mental healthcare services, based on the recognition of human rights and the intrinsic quality of its users. (CAMILA 2021)
After the answer, the President of the Court questioned twice whether that was all the Brazilian State would declare in the face of the numerous complaints presented. Brazil was twice interrupted for not answering the questions raised by the Court.
At same hearing, the expert from the National Mechanism for the Prevention and Combat of Torture, Lúcio Costa, released data from the I National Inspection of Psychiatric Hospitals in Brazil carried out in 40 psychiatric hospitals in 2018, in the five regions of the country:
[…] 459 people died in Brazil’s largest asylum center in Sorocaba. People died of hunger, cold, victims of iron bars, all within the facility. Of the 40 psychiatric hospitals, 33 did not have any therapeutic activity; 37 did not meet the minimum for a team to care for these people. In 60% of the hospitals, it was identified the use of these people’s labor, that is, they forced people to work in situations similar to slavery. We found a child who had been hospitalized at the age of seven, and, at the time of the visit, it was ten years old! (CAMILA 2021:n.p.).
Such information demonstrates that, despite the advances and the Psychiatric Reform, inhuman and degrading treatments persist. And in addition to serious violations of human rights, this exposes that the asylum paradigm still exists and is financed by the Brazilian government, whose actions are materialised in the ongoing counter-reform and as a ‘coup on health’ according to Fleury. The health policy suffers severe blows and, as a result, lives are lost because of private interests.
The Regional Council of Psychology – 23rd Region organises the general data of the National Inspection Report:
[…] that at least 1185 people are hospitalized on a long-term basis in Brazilian psychiatric hospitals. 82.5% of the inspected hospitals have people living there, with a 10-year-old child and a 106-year-old elderly woman in such condition, both women, in the same hospital in São Paulo […] 52% of the institutions inspected in December 2018, were opened during the military dictatorship in Brazil. 83% of these facilities are private, most of them non-profit […] 45% of the facilities lack or share basic hygiene supplies, bathrooms without a door and cold showers. In 40% of the cases, these people have restricted access to a living and leisure environment, in addition to being often isolated from their families. 87% of these people suffer violations regarding the free access to have contact with family members during hospitalization. The right to exercise civil capacity, liberty and personal security is also among the violated rights found by the experts, with situations such as compulsory hospitalization carried out arbitrarily or illegally, in addition to evidence of kidnapping, false imprisonment and misappropriation of financial resources from the people committed to these institutions. According to the report, people in psychiatric hospitals are subjected to overmedication, daily mechanical restraint and isolation in unsupported rooms. Violence such as rape, lgbt-phobia, vexatious searches and religious intolerance was found. The document also shows the exploitation of labor of the hospitalized patients, as well as the hospitalisation of children and adolescents in these institutions. (CRP 23rd REGION 2020)
Such information highlights the violence that patients suffer in these institutions, through forced labour, inhumane conditions of survival, in addition to excessive medication. The Ximenes case, whose patient died after being institutionalised for three days, demonstrates the serious threat to life within the walls of asylums. Facilities that defend their interests under the false discourse of healthcare and shelter, while, in contradiction, propagate violence and death.
As Angela Davis states, we do not ‘[…] recognize the fact that psychiatric institutions are often an important part of the prison-industrial complex; nor do we recognize the intersection between the industrial-pharmaceutical complex’ and the industrial-prison complex (Davis 2018:101). These institutions function as the great industry of madness by arresting it and producing it under the bias of the medicalisation of suffering and the suppression of illness.
The desirables, the undesirables and the legal framework against torture
This sub-item addresses the legal frameworks that define and regulate the fight against torture and human rights violation against the undesirables, and the undesirables through the asylum logic under neoliberal rationality. The logic of exclusion and deprivation of liberty of people considered ‘mentally ill’ in psychiatric institutions had its genesis in Brazil during the 1900s when, in 1842, the first psychiatric hospital was built in the city of Rio de Janeiro, Asylum Pedro II. Historical data demonstrate that, for approximately 180 years, the Mental Health Policy was based on the idea of segregating people in psychiatric hospitals (CRP 2020). Psychiatric hospitalisation gained institutional characteristics that made it a protagonist in the country’s Acts.
As an example, there is the Civil Code of 1961 that declared the ‘mad’ individual as incapable, and Decree No. 24559, from 03 July 1934, which framed the classification of diseases and new psychiatric institutions. With regard to drug use or criminal practices, regulations ruled according to the asylum and isolation logic without furthering the implications. Later on, in 1987, with the organisation of the Movement of Mental Health Professionals, the reports of violence in psychiatric institutions became public. During the Second National Congress of Mental Health Workers in 1987, the Anti-Asylum Movement was born, consisting of professionals, patients of mental healthcare services and their families. They exposed the violence in asylums, the commodification of madness, the hegemony of the private sector and proposed the collective construction of critical thinking regarding psychiatric knowledge and the hospital-centred model. The First National Conference on Mental Health in 1987, the Federal Constitution of 1988, Federal Law No. 8080, of 19 September 1990 (SUS) and the Paulo Delgado Act, presented in 1989, defined the principles to redirect mental healthcare, with such policy being emancipated as a federal policy, and not only a government policy (CRP 2020). In the meantime, in 2006, the International Convention on the Rights of Persons with Disabilities emerges, influencing the paradigm shift from the biomedical model to the social model, also broadening the public with mental disorders and including those with problems arising from the use of alcohol and other drugs. In 2015, the Brazilian Inclusion of Persons with Disabilities Act (LBI) was also approved, which covers the rights of people with mental disorders and people with problems arising from the use of alcohol and other drugs.
The Prevention and Combat of Torture National Act (Federal Law No. 12847/2013) instituted the National System for the Prevention and Combat of Torture, whose fundamental aspects for national inspection are the concept of torture and deprivation of liberty for people in psychiatric hospitals.
Article 3 for the purposes of the aforementioned Act, torture and deprivation of liberty are considered:
Torture: the criminal types provided for in Law No. 9455, of April 7, 1997, respecting the definition contained in Article 1 of the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, enacted by Decree No. 40, of February 15, 1991.
Persons deprived of liberty: those obliged, by a warrant or order of a judicial, administrative or police authority, to remain in certain public or private place, from which they cannot leave out of their free will, including places of long-term internment, permanence, detention centers, penal establishments, psychiatric hospitals, custody houses, socio-educational institutions for adolescents in conflict with the law and disciplinary detention centers in the military, as well as in the facilities maintained by the bodies listed in article 61 of Law No. 7210, of July 11, 1984 (BRASIL 2013).
It is noteworthy that the deprivation of liberty is also constituted, in addition to involuntary or compulsory hospitalisation, in long-stay situations, when they surpass uninterruptedly the period of one year. With the exception of crimes of military nature, deprivation of liberty according to the Federal Constitution is conditioned to two situations, according to Article 5, item LXI: ‘flagrante delicto or by written and reasoned order of a competent judicial authority’. Exceptionally, in the second case, the measure is applied in a situation of alimony debt. In turn, misdemeanour is defined as a crime and any infraction is attributed. As deprivation of liberty is preceded by legal process, which does not happen in situations involving involuntary psychiatric hospitalisations (BRASIL 1988:Art. 5).
According to Article 1 of the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1984) and Decree No. 40, of 15 February 1991, torture is defined as follows:
[…] any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person in order to obtain, from him or her or a third party, information or a confession; to punish him or her for an act he or she or a third party has committed or is suspected of having committed; to intimidate or coerce this person or others; or for any reason based on discrimination of any kind; when such pain or suffering is inflicted by a public official or other person in the exercise of public functions, or at his instigation, or with his consent or acquiescence. Pain or suffering, that is the sole consequence of legitimate sanctions, or that is inherent to such sanctions or arises from them shall not be considered torture. (BRASIL 1991; OAS 1984)
The Inter-American Convention to Prevent and Punish Torture defines torture in its second article:
[…] act intentionally performed whereby physical or mental pain or suffering is inflicted on a person for purposes of criminal investigation, as a means of intimidation, as personal punishment, as a preventive measure, as a penalty, or for any other purpose. Torture shall also be understood to be the use of methods upon a person intended to obliterate the personality of the victim or to diminish his physical or mental capacities, even if they do not cause physical pain or mental anguish. (OEA 1985:Art. 2)
Even if they do not directly cause physical or mental suffering, institutions, through their personnel, commit torture when performing cruel, inhuman and degrading actions or treatments that diminish the patient’s personality or physical and mental capacity.
In the book How Fascism Works, Stanley describes the treatment given to people considered useless to the State because they suffer from some mental disorder. Although the author refers to the 1930s, it is known that such vision lasted for a long time and was used in different historical periods to exclude, mistreat and sterilise those citizens ‘considered worthless’ by the national-socialist ideology once their value for society was confirmed through work. For the:
Nazi ideology, those who depended on the state for their survival were worthless. Fascist governments were responsible for some of the worst displays of cruelty ever seen by humanity towards populations with disabilities. (Stanley 2018:171)
The Prevention of Progeny with Hereditary Diseases Act stands out, which was enacted in 1933 in Nazi Germany and legalised the sterilisation of disabled citizens, followed by the ‘secret program T4, which gassed German citizens with disabilities, and finally, in 1939, doctors were ordered to kill them’ (Stanley 2018:171). It is estimated that by the end of the T4 programme, around 70 000 patients with physical and mental disabilities, both German and Austrian, were murdered. And even though the programme had officially ended, the execution of the disabled continued to be conducted secretly on an individual basis (https://encyclopedia.ushmm.org/pt-br). Nazi ideology took advantage of wartime to justify murdering people who, by their characteristics, threatened the delusion of Aryan genetic purity. This placement of what is ideal, pure and superior carried out by fascist governments takes place in a historical line-up of discourses and practices that define what is ‘normal’, ‘healthy’, ‘functional’ and what is ‘abnormal’, ‘madness’, ‘dysfunctional’, therefore, ‘madness’ was created and framed by a normativity that defined what is right and acceptable and what is not in society. Such definitions are built as truths, norms of coexistence imposing adequacy and obedience to imposed models in order not to fit the labels of ‘abnormal or criminal’. This logic turns citizens into goods, having use and exchange value, some being desirable and others, undesirable (Casara 2021).
It establishes a utilitarian relationship: on the one hand, the citizen is undesirable as workforce; on the other hand, such citizen can be convenient and profitable for the drug industry – which has significantly increased the sale of antidepressants, as reported by the Federal Council of Pharmacy – for studies and research and also for the occupations whose object of attention is psychological suffering. Historically, the person suffering from mental disorder is used as a source of information and learning, both body and speech are analysed, interpreted and generate profitable products, but the individual is not considered a being with rights, thus masking the attention given to ‘its’ suffering.
For Marx (2017:281) ‘[…] every man dies 24 hours a day’, because it is a commodity similar to a machine that could be replaced whenever it has no use as workforce. This statement portrays the placement of subjects and their usefulness in society. The useful and the not useful as workforce for the market, the desirable and the undesirable under the logic of this normativity. In Brazil, it is possible to affirm that the protection and attention given to ‘madness’ has been fetishised by past governments, as they use misinformed speeches and actions with the intention of moving and convincing the population about arbitrary decisions regarding measures considered outdated and not respecting legal precepts already regulated. When creating assistance to the problems generated by itself, the State offers insufficient solutions not comprised in the set of priorities of governments, administration and public policies designed during the counter-reform of the Mental Health Policy, that is, it is characterised as a ‘neoliberalism with a democratic veneer […] the answer to the problems generated by the “old” neoliberalisms’ (Casara 2021:154). A rationality in favour of objective normativity is configured, readjusting people and disciplining behaviours by imposing the internalisation of norms within the conservative neoliberal ideology (Casara 2021). Similarly, through this conservative neoliberal rationality, society repudiates everything that contradicts the standard established as an ideal, and that threatens its status quo, not offering shelter to those perceived as ‘deviations of conduct’ and ‘abnormal’. A rationality that corroborates the order established by the societal project, maintaining class division and perpetuating the oppression and control of bodies that demand care through the Mental Health Policy.
Mental Health Policy and the ongoing counter-reform in Brazil
The ongoing counter-reform, supported by conservatism and its precepts against the acquired rights and care in freedom, demonstrates the rationality present in the societal transformations during past governments, which consequently causes repercussions in various public policies, especially the Mental Health Policy. The SUS, based on a concept of broadened health, includes mental healthcare in its priorities, provided by the services that make up the RAPS: primary care, strategic psychosocial care, urgency and emergency care, hospital care, bridging residential care, deinstitutionalisation and psychosocial rehabilitation strategies. Specialised mental healthcare is provided at the Psychosocial Care Centers (CAPS).
The concepts of health and mental health can be approached from two frameworks: the biomedical one and the social production of health. The biomedical framework has ‘madness’ as the object of study of the psychiatric specialty and focuses its efforts on the disease and its manifestations. The framework of social production of health privileges aspects of the social, economic, cultural and environmental scope (Gaino et al. 2018) in order to understand the health/disease processes.
Historically, the mental health field sits between both frameworks, as it interests economically because of the excessive cost of psychiatric medications and psychiatric hospitalisations in private institutions, becoming a commodity desired by the market. Beyond definitions, the ambiguities surrounding mental health/illness have harmful effects that negatively influence the quality of life of subjects assisted.
In this whirlwind of disputes, the Mental Health Policy is in the process of counter-reform in past governments, with changes in funding procedures, control actions and hospitalisations that perpetuate the model contested by the Psychiatric Reform Movement. The investment in ‘therapeutic communities’ now receiving federal funding is highlighted, many of which do not follow the precepts of SUS and, contradictorily, have repercussions on the emptying of investments in the services that make up the mental healthcare network (Mota & Teixeira 2020).The PNSM, enacted through Law 10216 in 2001 and known as Paulo Delgado Act, marked a great achievement and, especially, a new paradigm in the relationship between society and the person with mental disorder, regarding structural changes in the organisation of mental healthcare and services.
A scenario of considerable progress concerning the implementation of this policy took place during Lula’s term of office (2003–2010), with the allocation of resources for services of extra-hospital nature, the closing of psychiatric beds and regulation of ordinances aiming for the expansion of mental health services (Mota & Teixeira 2020). Between 2003 and 2016 (Lula administration and Dilma administration), Brazil was internationally recognised for its successful experiences in RAPS, restructuring psychiatric care and the care for users of alcohol and other drugs. The administration of the mentioned presidents presented peculiar conditions regarding the management, financing and consequently expansion of services (Brasil 2011).
During the coup, in Temer’s administration (2016–2018), and the forces contrary to the psychosocial care model retaking power, the achievements of the Psychiatric Reform were attacked. A ‘new mental health policy’ advocated in Ordinance GM/MS No. 3.588/2017 and approved without popular participation by the Tripartite Inter-Management Commission began to include provisions contrary to the precepts of the Brazilian Psychiatric Reform, such as the financing of asylums and underfunding of community-based services. These changes, which de-legitimise the advances of the Psychiatric Reform, were strengthened in Bolsonaro administration, when the setback of the PNSM gets more destructive (Cruz, Gonçalves & Delgado 2020).
Bolsonaro administration and the attacks on Mental Health Policy
The discussion presented in this item exposes the private interests opposing care in freedom, which are reinforced by a context of violation of rights and intolerance of differences, forgetting of history, denial of achievements, return of institutionalisation, isolation and incarceration of people with mental disorders. During the pandemic, President Bolsonaro revoked approximately one hundred ordinances, edited between 1991 and 2014, threatening programmes and services of the SUS. This attack on public policy on mental health encourages the return of the asylum logic through the reinforcement of psychiatric hospitals, funding ‘therapeutic communities’ for alcohol and drugs, hospitalisations of adolescents with adults. Actions such as ‘electroshock’, which are a violation of human rights, reignite the commodification of ‘madness’ and push away care in freedom (ABEPSS 2021). The suffering of the Brazilian population in relation to living and subsistence conditions, such as loss of employment, work, income and housing, was already present in the Brazilian context, considering the economic crisis that the country has faced since 2013, and particularly because of the dismantling of public policies caused by neoliberal governments, especially the current government, that reawaken and perpetuate the counter-reform in the Mental Health Policy (Mota & Teixeira 2020).
In 2019, evidently in opposition to the struggles and achievements legitimised by society, the current president declared as a priority action of his government ‘to deconstruct and undo a lot of things and then restart’ (Marin 2019). Effectively, a ‘deconstruction’ was expressed in Technical Note No. 11/2019, signed by the General Coordination of Mental Health, Alcohol and Other Drugs of the Ministry of Health, aiming the incarceration and emphasis on medicalisation for mental illnesses and proposing mechanisms for the RAPS and the National Policy on Drugs (Cruz et al. 2020).
The Brazilian government, through the aforementioned technical note, distorts events and reinforces its attacks with technical justifications that demonstrate the neoliberal rationality of dismantling:
[…] Such scenario is a direct result of the misunderstandings of closing psychiatric beds in Brazil, mainly in the last two decades. In addition to the increase of patients with serious mental disorders in Brazilian prisons, problems in the conduct of the former National Mental Health Policy also ended up contributing to an increase in suicide rates, an increase in patients with serious mental disorders in homeless condition, increase and proliferation of ‘cracolândias’ (regions occupied by drug users), increased mortality of patients with mental disorders and chemical dependency, especially crack, increase of sick leave of patients with mental disorders, overcrowding of Emergency Services with patients waiting for psychiatric hospitalization. (Brasil 2019b:5)
For Fiocruz researcher and member of the Brazilian Mental Health Association (Abrasme) Paulo Amarante, the content of the Technical Note confirms:
[T]he measures ‘undemocratic character’, imposed in an act in which there was no space for argumentation and not even the position of the National Health Council (CNS) was heard; the clearance for the hospitalization of children and adolescents; the suspension of the harm reduction policy and the adoption of electroconvulsive therapy (ECT) as a public policy. ‘The proposed resolutions fully open the door to the interests of the “madness industry”, companies that own psychiatric hospitals and “therapeutic communities” – which include religious institutions – to the drug and medical equipment industry’, the public health professional exposes. (Amarante 2019:35)
The setback is also in public funding for Psychiatric Hospitals, greater funding for ‘therapeutic communities’ and for electroconvulsive therapy, known as ‘electroshock’, whose instruments are now funded by the Ministry of Health. Such actions contemplate the interests and pressures of the Brazilian Association of Psychiatry and the Brazilian Medical Association, of the evangelical churches that coordinate the ‘therapeutic communities’, spaces responsible for the ‘treatment’ of drug users and other demands considered as ‘deviations of conduct’ (Mota & Teixeira 2020).
It is also worth mentioning that the strengthening of the therapeutic communities is another important move for Bolsonaro administration towards the consolidation of the political and social power of large neo-Pentecostal churches. To a large extent, these communities belong to religious leaders, who use them not only as a source of collecting public resources in the healthcare area, but also as important means of attracting new believers and maintaining power over vulnerable families, the ones seeking these services for family members in a condition of drug abusive and without access to the chronically insufficient and underfunded public mental health network (Laurito, Martins & Alves 2019a).
Within the de-legitimisation of the achievements of the Psychiatric Reform, a new CAPS AD IV is being created, over which Pedro Delgado commented on, in an interview given in 2019, to the project Analysis of Health Policies in Brazil, as a ‘sinister eccentricity of compulsory hospitalization and treatment of psychoactive substance users (SPA) at the scene of use’ (Observatory of Political Analysis in Health [OAPS] 2019:03). This service de-legitimises the internationally recognised reduction of harm resulting from abstinence and forced treatment.
The third quarterly accountability report of the Ministry of Health, in 2019, shows that the processes regarding deinstitutionalisation and mental healthcare had the lowest historical rate since 2003, with 75 CAPS’ units being implemented, and the granting of the benefit of the Going Back Home programme for only 62 beneficiaries. This was the smallest number of CAPS implemented, considering that during Temer’s administration there were 95 units, and 206 beneficiaries of the aforementioned programme (BRASIL 2019a).
The most recent action of Bolsonaro administration was Ordinance 1325/2020, which extinguished the service of evaluation and monitoring of therapeutic measures applicable to people with mental disorders in conflict with the law, within the scope of the National Policy for Comprehensive Health Care of Persons Deprived of their liberty in the prison system, without any technical basis by the Superior Court of Justice. This service provided monitoring and assistance to subjects with mental disorders during the execution of court sentences. The dismantling of such service, in addition to not having popular participation, was executed on the national Anti-Asylum Fight Day, an insult to the precepts of the Psychiatric Reform, highlighting a ‘coup on health’ (Fleury 2020; Mota & Teixeira 2020). According to the ‘Analysis of the Brazilian Health Reform Process between 2007 and 2016’ in relation to funding topics and results achieved, the OAPS informs:
From a funding perspective, 2017 began under the impact of changes in the funding model of social protection, as of Constitutional Amendment No. 95/2016, which freezes investments in areas such as health, withdrawing almost R$400 billion from SUS in 20 years. Research on the impact of fiscal austerity measures in European countries and prospects for Brazil indicate, consequential to EC 95, a dramatic increase in health inequities in the country. Additionally, there is the approval of the Annual Budget Law for 2017, creating a new source of funds relocated from areas such of Education and Science, Technology & Innovation. The budget for those areas is considered to be the lowest in the last 12 years, which causes an increase in technological dependence and widens inequalities in access to health technologies. (OAPS 2017)
The setbacks highlighted affect the quality of services provided through the health policy, and especially in mental healthcare. Whose context of commodification of suffering alienates those in need of care, as patients fear prolonged hospitalisations and the unnecessary and dehumanised prescription of medicines. Pedro Delgado, in an interview granted in July 2019 to the OAPS, states:
[…] as a psychiatrist, every day I come across reports of mental suffering directly associated with the economic crisis and unemployment. The economic crisis, and the subjective perception of lack of hope that results from it, aggravates the dramatic conditions of an unequal and violent society like ours. The culture of hatred and intolerance, stimulated by the mass media, creates the human environment in which we live today, which facilitates, as seen in previous serious moments in history, the capturing of institutions, minds, and politics by fascism (Delgado 2019:03).
It is noteworthy that ‘a core principle of fascist politics is that the objective of oratory should not be to convince the intellect, but to influence the will’ (Stanley 2018:64). On the contrary, a democratic State should advocate for equality without distinction of any kind, whether economic or access to the labour market. However, fascist logic emphasises hatred, intolerance and inequality in addition to the division between us and them. Where the desirable ones are those who obey the laws and standards of society. And those who do not fit these standards are the lawless and undesirable ones. These, by the very fact of their existence, are a violation of law and order:
[… T]o describe someone as a ‘criminal’ is to mark that person with a terrifying permanent character trait and, at the same time, expel the person from the ‘us’ circle. They are criminals. We make mistakes (Stanley 2018:64–116).
Therefore, the hospital-centred asylum logic of the counter-reform undergoing in the Brazilian government reinforces the criminalisation of suffering. It captures minds and institutions that reproduce this barbarian neoliberal rationality and serious violation of human rights. In this context, humanity is lost, lives are lost and the suffering caused by capitalist exploitation is used for profit. For, although it creates problems, it also develops the necessary antidotes to increase its profit, through the strengthening of the public–private interest through the expansion of psychiatric hospitals/beds and medicalisation of suffering.
Conclusion
The normative, excluding and oppressive society of men competing with each other has the neoliberal prescription perpetuated by different spaces and administrations. Which, through different public policies and institutions, end up reproducing practices and de-legitimising the mobilisation in favour of care, attention and protection of patients assisted by the Mental Health Policy. What remains are challenges in the wake of the counter-reform in the Mental Health Policy. More than ever, resistance is necessary in the face of challenges and accusations against human rights within institutions and the logic of the Brazilian government.
The precepts of the Psychiatric Reform are threatened by the constant and brutal blows against public healthcare, especially the Mental Health Policy, whose achievements are being de-legitimised for the benefit of private interests. The struggle not to lose what has already been conquered is necessary, and accordingly, new resistance strategies need to be planned in order to face the setbacks being accentuated. Torture, considered by the Inter-American Convention as physical and mental suffering, whether through punishment, investigation or even simple intimidation through actions that nullify the victim’s personality, or diminish physical or mental capacity (OAS 1985:Art. 2), materialises in the ongoing counter-reform that causes these impacts to patients with mental disorders treated in the various public–private services. At the same time, the inequality of capitalist society enhances exploitation and oppression, which are also sources of suffering. Therefore, the ‘New Mental Health Policy in Brazil’ masks a new form of torture, and a suffering exponentiated by the structuring inequalities of such capitalist society.
Resistance needs to be reaffirmed daily through the anti-asylum fight against the neoliberal rationality that violates the established rights in defense of care in freedom, quality of provided services and humanised care. The defense of community and participatory policies ‘aimed at people with mental suffering and not at those who exploit them’ is more than a struggle; it is the very survival of Brazilian people’s citizenship (Amarante 2019:35).
Acknowledgements
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
B.D.N. and M.I.B.B. contributed equally to this work.
Ethical considerations
This article followed all ethical standards for research without direct contact with human or animal subjects.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
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