On January 1, the deadline established by law 26,657 of mental health expires almost a decade ago to close neuropsychiatric and replace them with care in general hospitals and a network of community-based services, as indicated by international standards , but everything remains more or less the same.
The gradual adaptation and transition to change the mental health system of Argentina that the law proposed were never carried out and now, within a few months of the hourglass being finished, there are 12,035 people in 162 asylum centers throughout the Country that are still waiting.
This issue is only one of several unfulfilled points marked by the law passed in 2010, but it is the one that makes the most noise. According to
Civil Association for Equality and Justice (ACIJ), in addition to the replacement of neuropsychiatric and the prohibition of creating more, there are five other outstanding debts that should not be lost sight of: lack of attention in general hospitals, which do not they are prepared to absorb demand; the absence of community devices, such as assisted housing, day hospitals, work reintegration workshops, etc .; the need to increase the budget (the law establishes that it must be 10% of the total for Health and is now 1.8%), the authorization of mental health services and addictions without hospitalization; and the little information that is available.
With respect to this last point, in the first days of August the Ministry of Government of the Nation published the results of the First National Census of Persons Interned for Mental Health Reasons (CNSM) carried out in public and private establishments during 2018 and 2019. Results make visible the very serious situation in which this population is found, historically relegated, segregated and stigmatized.
“This census is a historical fact and provides fundamental information to advance the full implementation of Law 26,657,” explains Luciano Grasso, national director of Mental Health of the Secretary of Health of the Nation. And he details: “The results corroborate the situational diagnosis of mental health in our country, which constitutes a historical problem, not yet solved. It shows the persistence of the model of prolonged hospitalizations and a logic of confinement.”
The data is devastating and overwhelming. 60.4% of the inmates did not sign consent to be in a psychiatric hospital, only 34.4% have a real criterion for hospitalization, that is, they present imminent risk to themselves or others; and 37.2% are hospitalized for social or housing reasons, in short, because they have nowhere to go. The average residence time is 8.2 years, a figure that increases to 12.5 in the public sector. Of the total, one in four people has been hospitalized for between 11 and 90 years: the case of a man who has been hospitalized since age 6 and today is 96.
Today there are 12,035 people admitted to 162 asylum centers across the country
“It may seem a lot or a little to live eight years in a psychiatric hospital, but beyond time, the conditions are worrying and the State recognizes it. The reading of the census must be harmonious with the indication that the Inter-American Commission on Human Rights made to the Argentine State last February during a hearing in Bolivia for allegations of torture, cruel, inhuman and degrading treatment in psychiatric hospitals. The sentence is clear: this situation must be structurally modified and the law implemented “, warns Macarena Sabin Paz, coordinator from the mental health area of
Center for Legal and Social Studies (CELS).
Grasso says that to modify this reality and comply with the law, it is necessary that the health systems of each province be strengthened, creating or strengthening integrated community-based health networks. “To contribute to these processes -details-, the main function of the National Directorate of Mental Health and Addictions is the rectory, for this, we are carrying out different actions and recommendations, such as the Integrated Network of Mental Health with Community Base or patterns of organization and operation of the devices “.
The challenge of externalization
Articles 14 and 15 make it clear that hospitalization is considered a therapeutic resource of a restrictive nature and should be as short as possible. It is proven worldwide that it only has to last what a person takes to stabilize, but the consequences can be much more serious and the picture more complicated to reverse. Sabin Paz explains that after a life in a psychiatric hospital, of subjective destruction and displacement resulting from the institutionalization and crushing produced by psychotropic drugs, the requirements for externalization will not be the same and as a result the confinement is prolonged.
What the law says is that people have to live independently. Once you are better you have to go back to your home or move on to another instance of less restrictive treatment.
Adelina Navarro Lahitte
“What the law says is that people have to live independently. Once they are better, they have to go back to their home or go to another instance of less restrictive treatment. And here the community devices enter the scene. It's like an intensive therapy, once the critical situation has passed, the person must get out of there; if he stays, he becomes more ill, “explains Adelina Navarro Lahitte, public curator, who carries out different protections against the State and also actions to prevent constant violation of the rights of people staying in these institutions, such as helping them to vote (see separately).
Proyecto Suma is an NGO that was created before the enactment of the law, but has the same spirit focused on a perspective of human rights and social reintegration. It works as a day hospital, organizes support and peer groups, meeting spaces, workshops are held and awareness campaigns are carried out, for example on stigmatization, training and research projects. Per week, more than 800 people interact in the house they have in Palermo, between users (as they call patients), professionals and volunteers.
As there are not many places like that in the country, the work they do well can serve as a model and inspiration to create other similar spaces with the aim of shortening hospitalizations and thinking of a community care system. “To carry out the reform process and organize that patients can be externized, intermediate devices must be assembled and, at the same time, reallocated intelligently and logically to mental health workers in other sectors or incorporated into the new system. This requires management and money, “warns Gustavo Guardo, president of the organization. His look focuses on two key issues: political will and the budget.
Intermediate devices must be assembled and at the same time smartly and logically reassigned to mental health workers
According to a report made by ACIJ, in the 2014-2018 period, the budget allocated by the State for the activity “Support and Promotion of Mental Health” registered a decrease of 87%. On the other hand, the budget sanctioned for 2019 is 46.79% lower than the one that had been projected for 2018. “Everything is an economic issue. We try to reveal how much a bed comes out in the Moyano or on the Board to know how much there is to allocate to community devices. Disaggregated by person we could never know, we don't have the exact data, “warns Navarro Lahitte.
One of the lines raised by social organizations in the face of reducing the budget for mental health, and given the few political intentions to increase it to reach what is indicated by law and the international standard, is to readjust the large amount of money allocated to support the mental institution and direct it to other places, such as community centers and the construction of assisted housing.
Not all actors in the mental health system agree with the law. Many of them were promulgated at the time against some points, for various reasons.
One case is reflected in the minutes that the Association of Municipal Physicians signed with the Ministry of Health of the City of Buenos Aires in mid-July to refunctionalize neuropsychiatric hospitals and prevent closure in 2020. The main basis of this agreement is that it would have consequences for public health and patients would have nowhere to go. This, experts say, would have been avoided if a decade ago the gradual transition to a community model had begun.
Eduardo Quiroga, lawyer of the area of disability and human rights of ACIJ, explains that the act is contrary to the National Law of Mental Health that establishes that general hospitals are the only ones that can have hospitalization services for these reasons.
For his part, Sabin Paz believes that many groups resist the closure of monovalent because it is an accumulative model of medical power and the pharmaceutical industry, and resistance has to do with the abandonment of power. “If you think about it from the right of mental health users, that clearly has nothing to do with protecting anyone from anything, rather it has to do with putting it in that exceptional care by denying you the possibility of having a fairly medium life. the same as anyone else's. Here the agreements with the unions do not matter but there is no substantial public policy or plan, “he says.
Gustavo Lipovetzky, psychiatrist and founder of Proyecto Suma, emphasizes that the visibility of the rights enlightened by the law is not a minor issue and can touch the fibers of many institutions and professionals, because there are still asylum practices that account for the violation. “There are many clinics where patients are tied, a colleague told us that in institutions in the interior of the country there are handcuffed people and recently we were in a clinic in La Plata where all patients were ironed at 12 noon,” he says.
There are many clinics where patients are tied, a colleague told us that in institutions inside the country there are handcuffs
On the conversion of places such as Borda and Moyano in half-way houses, Navarro Lahitte believes that in this way segregation continues to be sustained and has nothing to do with what is provided by law or international experiences, because a community device It has to be rightly inserted in the community, not with the same zip code as the psychiatric hospital.