Mental health in the Lula government

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By PAULO CAPEL NARVAI*

Lack of direction in mental health may not be just Lula's stumbling block. Government can and should review the path it has chosen

The National Health Council (CNS) recommended the federal government to revoke the creation of the Department of Support for Therapeutic Communities (DACT), in the Ministry of Development, Social Assistance, Family and Fight against Hunger (MDS). The nomination was made at the end of January, but has not had any effect so far. also the Brazilian Collective Health Association (Abrasco) took a stand against the Department of Support for Therapeutic Communities, stating that its creation “creates an internal conflict in federal management, undermines the implementation of existing policies and threatens the principles of psychiatric reform and the defense of the human rights of people in mental suffering”.

A Brazilian Mental Health Association (Abrasme) repudiated the creation of the DACT, pointing out that “after a transition process marked by listening to social movements, and a proposal for the dialogue construction of a policy that effectively takes care of the Brazilian population, it is paradoxical that a department is created whose specific function is to support an asylum device such as the so-called therapeutic communities that, in recent years, have been the target of several inspections that produced reports pointing to serious violations of human rights”.

Despite the opposition to DACT, everything indicates that the body will have a long life in the Lula government, in the ministry commanded by Wellington Dias, whose annual budget is around 90 billion reais and has in the National Social Assistance Fund a strategic instrument to the management of actions in this area in Brazil. There remains the tacit acceptance that the actions of “therapeutic communities” are valid in dealing with mental health problems.

The Department of Support for Therapeutic Communities (DACT) was created by Decree nº 11.392, of January 20, 2023 in the MDS, linked directly to the executive secretary of the portfolio, with the mission of “(i) advising and assisting the Minister of State, within the scope of the Ministry's competences, regarding the actions of the Government and the National System of Policies on Drugs related to the care and social reintegration of drug users and addicts; (ii) support the Ministry of Justice and Public Security and other bodies of the federal executive branch, within the scope of their competences, in the execution of actions by the Government and the National System of Policies on Drugs related to the care and social reintegration of users and addicts drugs; (iii) support care and treatment actions for drug users and dependents, in line with the policies of the Unified Health System and the Unified Social Assistance System - SUAS, in conjunction with the Ministry of Justice and Public Security and the other bodies of the federal executive branch;

(iv) develop, coordinate and monitor the implementation of actions and projects in the area of ​​care, support and mutual help, within the scope of the Ministry's competences, in accordance with the guidelines and guidelines of the National Policy on Drugs, of the Ministry of Justice and Security public and other bodies of the federal executive branch; (v) propose to the Executive Secretary the execution of contracts, covenants, agreements, adjustments and similar instruments with federative entities, public and private entities, institutions and national organizations, and international agreements, within the scope of its competences; (vi) propose partnerships with governmental and non-governmental bodies that carry out activities aimed at care, in conjunction with the Ministry of Justice and Public Security and other bodies of the federal Executive Branch, in order to integrate the actions developed nationally, within the scope of their Skills; (vii) propose, plan, analyze, coordinate, support and monitor partnerships and contracts in the area of ​​care; and, (viii) analyze and propose the updating of the legislation related to its area of ​​activity”.

However, none of this was proposed, during the transition period of the federal government, to the group of specialists in charge of assessing the health situation in the country, and of the Unified Health System (SUS) in particular. Specifically for mental health, the health group recommended that the area, historically a coordination within the structure of the Ministry of Health (MS), be raised to the status of Department of Mental Health (DSM), a proposition that was praised in the four corners of the country .

The recommendation was accepted and, when restructuring the Ministry of Health with the edition of Decree nº 11.358, of January 1, 2023, the government created the Department of Mental Health and Combating the Abusive Use of Alcohol and Other Drugs, subordinated to the Secretariat of Specialized Care to Health (SAES), with the attribution of “(a) coordinating the processes of implementation, strengthening and evaluation of the National Policy on Mental Health, Alcohol and Other Drugs and the psychosocial care network for people with suffering or mental disorders and with needs resulting from the use of alcohol and other drugs within the scope of the SUS; (b) elaborate technical instruments and participate in the elaboration of normative acts to subsidize the development, implementation and management of strategic actions and health networks linked to the Department; (c) encourage articulation with social movements, non-governmental organizations and similar institutions, to encourage popular and social participation in the formulation, monitoring and evaluation of strategic programmatic actions and health networks linked to the Department; (d) encourage research related to strategic programmatic actions; and, (e) promote technical cooperation with research and teaching institutions for the development of innovative management and health care technologies for strategic programmatic actions for the psychosocial care network”.

However, in less than three weeks the DSM was amputated from the attributions related to “combating the abusive use of alcohol and other drugs”, which migrated from the Health portfolio to the Social Development portfolio. Decree No. 11.391, of January 20, 2023, changed the name of the Department, but formally maintained the DSM's attribution of "coordinating the processes of implementation, strengthening and evaluation of the National Policy on Mental Health, Alcohol and Other Drugs (...) under the SUS”.

As the SUS is, technically, a national system and not a national service, its actions do not need to stick to the so-called “health sector”, and can be articulated and organized in an intersectoral way. In practice, however, the SUS is predominantly managed as a sectoral health service. This means that, while the MDS is responsible for “developing, coordinating and monitoring the implementation of actions and projects in the area of ​​care” related to the use of “alcohol and drugs”, it is for the DSM to act in matters related to the “implantation and management of actions strategies and health networks linked to the Department”.

Mental Health is one of the most tense areas of the Ministry of Health. According to the researcher Paulo Amarante, one of the main references in this area, when taking office in the presidency of the Republic, Michel Temer “appointed a coordinator who is absolutely in favor of the asylum model”, whose inadequacy to the mental health policy, from the perspective of the SUS, has been recognized since the 1st National Conference de Saúde Mental (1987), which rejected the asylum model and, according to Amarante, consolidated the motto “For a Society without Asylums” and, proposing the “participation of users, family members, activists of human rights movements, began to envisage a society without violence, without exclusion, conceiving the asylum as not just the building of the hospice or other institutions of reclusion and repression, but the practices and social mentalities of oppression, absence of solidarity, empathy and recognition of difference and diversity”. For this reason, there were reactions to the model imposed during the Temer period, but the worst would come in the government of Jair Bolsonaro, who “solved” the difficulties by simply extinguishing the mental health coordination of the Ministry of Health.

Mental health now divides the Lula government. But this division goes back a long way.

It is true that health problems require intersectoral actions and, therefore, the set of public, social and economic policies must converge to promote collective health. In this case, mental health. But there is also a consensus that the coordination of health policies is the responsibility of the SUS and its sole command at the national level, which is the Ministry of Health. It makes no sense for a Department, with “therapeutic” in its name, that is not linked to the Ministry of Health, that is, to the SUS.

Or does it make sense? It depends on who is looking for meaning. The National Health Council, Abrasco and Abrasme evidently defined their institutional positions based on contemporary scientific knowledge that indicates that “mental health” stems from multiple aspects that can be summarized in the expression “social determination”, not being restricted to the only biological aspects involved.

For the CNS and the entities, although the social aspects of mental health-illness are recognized, therapies in this area imply recognizing the biopsychosocial dimensions of the problems and, therefore, the need for action by professionals and health institutions that must guide their actions according to ethical and humanization precepts that refuse incarceration, abstinence and religious grounds as the basis of the approach and other procedures considered therapeutically inadequate, such as the systematic and trivialized asylum option and the absence of perspectives for the patient's social reintegration. In summary, the aim is for the mental health policy to ensure free, secular, humanized, integral, anti-prohibitionist, anti-racist and anti-gbtphobic care.

But this understanding of problems in the area of ​​mental health does not seem to predominate in the MDS, where the perspective of the performance of the DACT, defined in its attributions, calls for itself the coordination of “actions of the Government and of the National System of Policies on Drugs”, and support “the Ministry of Justice and Public Security and other bodies of the federal executive branch”, “actions for the care and treatment of drug users and dependents, in line with SUS and SUAS policies”, in addition to “developing, coordinate and monitor the implementation of actions and projects in the area of ​​care, support and mutual help, within the scope of the Ministry's competences, in accordance with the guidelines and guidelines of the National Policy on Drugs, the Ministry of Justice and Public Security and other bodies of the federal executive branch.

To deal with all of this, the DACT/MDS will sign “contracts, agreements, agreements, adjustments and similar instruments with federative entities, public and private entities, institutions and national organizations, and international agreements” in addition to “proposing partnerships with government agencies and non-governmental that carry out care-oriented activities”, as well as “proposing, planning, analyzing, coordinating, supporting and monitoring partnerships and hiring in the area of ​​care”. Although it is stated that everything will always be done “within its competences”, the DACT will still be able to “analyze and propose the updating of the legislation related to its area of ​​action”.

At this point, with good reason, the reader will be asking themselves: but, then, what is it up to the SUS and the health services network?

One of the main challenges faced by the reformists who, in the second half of the XNUMXth century, idealized the SUS was precisely to ensure that the proposed health system effectively unified everything related to health, under the national command of the Ministry of Health. It wasn't easy, but we made progress, although the military health units remained on the sidelines of the SUS, as well as many university hospitals and health services that, even today, express strangeness at seeing themselves included in the SUS, as a “system”.

But now, DACT/MDS seems to return SUS to the pre-SUS period. More than “an institutional problem”, however, the maintenance of the DACT in the MDS and the deepening of the asylum perspective that surrounds it, lights a huge yellow signal regarding the role of religious institutions in mental health policy, notably with regard to the coping with the use of “alcohol and drugs”. There are frequent reports of mistreatment and recurrent violations of human rights practiced in “therapeutic communities”, notably in remote, relatively isolated and unsupervised locations, or poorly controlled by public authorities.

It is well known that the vast majority of “Therapeutic Communities” are linked to religious entities, which create, organize, maintain and give them identity. According to the newspaper Folha de S. Paul, 74% of the entities are either catholic or evangelical. This is not, in itself, a problem. The problem is that, in many of these institutions, science is often replaced by faith and values ​​related to the morality adopted by the respective religious segment.

Faith enters through one door, science leaves through another. Not that coexistence, mutually respectful, is not possible, but religious vulgarization, almost always fundamentalist, seeks the submission of scientific knowledge to some religious ideology. Not to mention some situations – fortunately exceptional – in which religious deformation for political-ideological purposes or mere corruption in the use of public resources is flagrant, as sadly verified, even recently, in episodes involving religious leaders.

In Brazil, the separation between the State and the Roman Catholic Church, politically produced by the Proclamation of the Republic, in 1889, was not enough. Despite the formal separation, for decades and even today, different religious currents consider themselves entitled to receive privileged treatment by and civil servants, a practice widely tolerated in the country. It is as if public policies needed the endorsement of institutions and religious leaders to be implemented. Such is the case of the alleged institutionalization of “therapeutic communities”, as assistance resources with functions in public mental health policy. If several social segments reject this possibility, it is true that for many others this is a path to be followed.

The government's silence to the demands for the extinction of the DACT in the MDS must be understood in the light of this dilemma that befalls the State and rulers in Brazil, aggravated by the fragility of our democracy. Confronting, as a public authority, the power of religious leaders can have consequences (at least electoral ones) that shut up and hold the hand of many rulers.

In this perspective, the lack of direction of the Brazilian government's mental health policy may not be just a stumbling block by Lula, but indicate a course that, deliberately, the current government chose. But that it can, and according to several segments linked to the struggle in defense of the SUS and the right to health, it should be reviewed.

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic).


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