_arquivos/image003.jpg)
Mental
health in ultra-neoliberal times
Saúde
mental em tempos de ultraneoliberalismo
_arquivos/image005.png){kind=small}
https://orcid.org/0000-0003-0477-6386
https://orcid.org/0000-0003-1680-5009
Keywords: Mental Health. Ultra-neoliberalism
Necropolitics.
Resumo: O processo de
agudização da barbárie permeado pelo conservadorismo, reacionarismo e as faces
da discriminação trouxeram à tona não somente a amplificação do cenário de
violência e fome, mas também as plataformas antes silentes no que se refere ao
adoecimento psíquico. O artigo objetiva
tecer discussões acerca da saúde mental em tempos de ultraneoliberalismo, o
qual emergiu de forma mais efetiva com a ascensão da extrema direita na
realidade brasileira. Por meio de uma reflexão teórica, com o uso de dados secundários,
o estudo vislumbra o cenário de necropolítica potencializado cotidianamente na
arena da saúde mental e seus rebatimentos na sociedade, frente ao capitalismo em
sua face mais voraz.
Palavras-chave: Saúde Mental.
Ultraneoliberalismo. Necropolítica.
Submitted on: 31/01/2023. Revised
on: 5/4/2023 e 11/6/2023. Accepted on: 12/6/2023.
Introduction
|
T |
he
capitalist system reveals hardships evidenced by expressions of the social question.
The discussions involve the economy, social historicity, platforms, and the
culture of recognition. The reality of human survival becomes evermore
challenging. Hunger, violence, and lack of social protection stalk everyday
life. There is a silent challenge, surrounded by taboos and prejudices, that spreads
in the subject’s subjectivity. That is, mental suffering, which was comprehensively
exposed by the pandemic, and revealed itself as an urgent social issue within
the scope of capitalist sociability.
The
article discusses the reality of mental illness in times of worsening barbarism
under ultra-neoliberalism, as evidenced in the Brazilian reality, as well as
its repercussions on mental health policies in a situation of heightened
necropolitics under the Bolsonaro government. Its methodology is theoretical
reflection based on mixed focus research. This, according to Prates (2012),
differs from purely quantitative or qualitative analyses, in that it considers
characteristics of both types of research, with the linking of the data; sometimes
taking a statistical or numerical perspective, and sometimes supporting
qualitative arguments necessary for understanding the problem in question. Among
the sources of secondary data that foster this mixed analysis are, reports from
the World Health Organisation, the Pan-American Health Organisation, the Ministry
of Health, and quantitative data from the Transparency Portal of the Federal
Government and SIGA Brazil. SIGA is a system that includes information on federal
budgeting and planning.
The
study focuses on the contemporary capitalist system, the evident expressions of
social issues, the silence around the discussion of mental illness, data on
budgets in the health area, and the challenges in implementing a psychosocial
care network that can effectively meet the demands of the Brazilian population.
It provides criticism of the issue of mental health, with a view to considering
the limits and possibilities that could put us on the path to a societal order.
A daydream? Perhaps. But as Carlos Drummond de Andrade would say: “[...] I only
have two hands and the feeling of the world”.
Capitalism
in times of heightened barbarism
The
capitalist system today seems to have reached boiling point. The growth of the
industrial reserve army, a subject discussed by Marx in the second half of the 19th
century, exposes not only the current situation, but also the presence of something
considered reality almost two centuries ago. Brazil’s unemployment rate has worsened,
data shows more than 14 million unemployed during the pandemic. Resulting in
increasing in poverty and Brazil’s return to the hunger map. Neri (2022) points
out that in 2021, 62.9 million people were living with a per capita income of
R$ 497.00 per month (US$ 99.40 at time of publication), representing around 30%
of the Brazil’s vulnerable population, this has caused food insecurity.
The
hardships of capital are also reflected in the data for the expression of
violence. Brazil ranks fifth globally for the highest number of femicides and ranks
first among Latin American countries (Organização Panamericana de Saúde, 2022).
The escalation of violence is amplified in all its aspects, every twenty-three
minutes a young black man dies in Brazil. This is the aspect that the poor,
black, and peripheral population feels first.
With
the rise of the extreme right in Brazil, the discussion around human rights
became associated with communism, a word distorted by of common sense and
criminalisation bias and legitimised by the federal administration. For Marx
(2015), communism must be considered as a real and necessary factor for the
emancipation of man and is enhanced “[...] by the positive expression of
overcome private property; first of all, as universal private property” (Marx,
2015, p. 341). Communism, therefore, represents the overcoming of
self-alienation, whether in terms of family, religion or any other ideological
devices existing within the aegis of the capitalist system. Such a situation
may not yet be realised in crude communism, but certainly in its process of
improvement through the search for effective human emancipation.
As
barbarism becomes more acute, so expressions of the social issue are trivialised
and seen as arising from a population that perpetuates its own incapacity. The foundations
of conservatism were listed by Edmund Burke (1982), and they reinforce the
thesis that to achieve something it is necessary to seek, with
meritocracy as the starting point and achievements as the goal, in which man,
in the generic sense, must exercise freedom in the search. All within legal prerogatives
and limited to the perspective of becoming conservative, bourgeois, and guided
by the normalisation of inequality. We forget, however, that in an unequal
system, in terms of access to health, education, social security, social services
and other protoforms of inclusion policies, there is no way to treat unequal
people equally, as Aristotle said (2001).
As
such, barbarism is not only reproduced, but is based on human daily life, on
the spectacularising of life, a phenomenon that Debord (2007)) states is
capable of perceiving appearances as statements, which are massified and
conducted as being reality. They are characterised as pseudo-concrete elements.
Social networks can carry this characterisation, with spectacularising expressed
through messages, videos, and texts that promote the contemporary fake news
industry.
In
the process of spectacularising, some lives are considered more worthy, while
others become ostracised or even subjected to the process of social death, as
Agamben (2007) points out when portraying homo sacer as a generic man with
a sacred life, biologically, which should not be eliminated by legal
prerogatives. Based on these judgments, life becomes socially killable,
for example, Agamben states that social deaths arise from the creation of
ideological concentration camps, constructed daily and which can give rise,
among other things, to prejudice, discrimination and, hate speech.
Homo
sacer ceases to exist as a protagonist in the process of
capitalist sociability. When opening the curtains on the theatre of life, it is
assumed that man builds his own history, however, as Marx (2011b) said, he does
not do it the way he might want, as there are issues from the past that impact
the structure of present realities and past generations are present in the
daily actions of the living.
The
course of the building of the historical process depends on the human place within
class society, as there are variables that may or may not be accessible to
humans. The class struggle, territorial disputes, the legitimisation of
violence, discrimination against and criminalisation of popular demands, among
other issues, corroborate the historical-social practice in creating inequalities.
In this context, writing one’s own history is daring in the face of an
exclusionary, alienating, and controlling system.
The
result is reflected in necropolitics, which, according to Mbembe (2016), becomes
evident when a government decides who deserves to live or not, who can have
access to something or remain on the margins of society. These considerations
are part of the Brazilian reality, mainly due to the emergence of the extreme
right, nostalgic for the military dictatorship, and which demonises communism,
feeds beliefs about meritocracy and the supremacy of the white race, and is
intolerant to expressions of human diversity, whether through class, race, or gender.
For Lowy (2015, p. 663) “[...] the capitalist system,
especially in periods of crisis, produces and reproduces phenomena such as
fascism, racism, coups d’état and military dictatorships”, demonstrating that
the production and reproduction process is a strategic part of capital to further
encourage inequality, mechanisms of intolerance, ideologies, the contemporary production
of fake news, and trigger authoritarian proposals.
In
the Hegelian Reflections, Marx and Engels (1998) point
out that civil society, and not the State, is the basis of all history. To make
history, people must first satisfy their needs, such as food, clothing,
housing, and health, as without satisfying the minimum there is no way to make
history. Marx (2015) highlights that it is necessary to transform the world;
however, for such a change to happen, it is necessary that the interpretation
of the world is correct and coherent, based on its variables and historical,
social, and economic contexts. That is, it is necessary to analyse reality
through the lens of critical materialism, go beyond appearance, and overcome
limits to truly capture the real.
During
this process, neoliberalism enters the scene. According to Dadot and Laval
(2016), this system extends far beyond solely economic policy, it is configured
with far-reaching norms and extends to all aspects of everyday life, from
social relations to work, and obeys the logic of capital as a prerogative. For
Casara (2021), Brazil is already experiencing the hardships of
ultra-neoliberalism, which appears as the ugliest face of the neoliberal model,
because prior to being characterised as an ideology or new expression of
economic policy, it likes to present itself as rational, responding to the
process of restoring capital in the face of yet another crisis affecting human
sociability.
Ultra-neoliberalism
deconstructs the bases of social, political, civil, and fundamental rights with
greater intensity. It amplifies the centrality in the market, creates
symbolisms based on imaginary norms by which everything can be achieved without
limits, including dictatorship, in the real and virtual world. It encourages
the decline of ethical-political values in the name of ‘progress’, postulates democracy
in a reductionist way or dismisses it, considers people only from the
perspective of their utility, naturalises chaos, and trivialises life.
This
political-economic perspective does not reflect a minimal State, as
exactly the opposite occurs. Its strengthening leverages greater power for the
market and asserts the position of the dominant elites, and it is at the heart
of the de-civilization process (Casara, 2021).
Dardot and Laval (2016), reflect that:
This is not a monocausal action (from
ideology to the economy or vice versa), but of a multiplicity of heterogeneous
processes that resulted, due to ‘phenomena of coagulation, support, reciprocal
reinforcement, cohesion, integration’, it is this ‘global effect’ that is the
implementation of a new governmental rationality (Dardot; Laval, 2016, p. 31).
These
multiple processes develop in a way that involves the social, economic, historical,
and cultural situation. It is a model that pulsates in the depths of capitalist
sociability and reaches the human sphere through a fiction that promotes simplistic
answers to complex problems. It advocates acceptance and conformity in the face
of realities, acts to plasticise reality, and purveys the need for adaptation without
deeper questioning.
We
are witnessing a movement towards worsening barbarism, a path along which some
lives matter and others are worthless. The trivialisation of life and the
belief that State intervention through public policies is outdated issue is
encouraged. As Marx (2011a) would say, where the capitalist mode of production
prevails, the result that appears is limited to a large collection of merchandise.
Thus, people are reified, objectified, oppressed, and excluded, and all eyes are
turned to the god of the market, a situation that became even more evident
during the Covid-19 pandemic, when Brazil recorded the second highest number of
deaths globally with over 700,000, and an average of 135,000 cases daily (Organização
Panamericana de Saúde, 2023). The unemployment situation worsened, emergency support
was suspended, and millions of families returned to the hunger map.
The
chaos opened wounds from another perspective, a silent epidemic affecting
millions of people. At a time when lives were being lost, contempt for science
was the order of the day, religious fundamentalism had rooted itself into
political bases, the economy was collapsing, and contempt for death indicated
the darker side of necropolitics, what could be so relevant?
With
intense suffering, deeply ingrained in human subjectivity, and arising from
historical, social, and cultural taboos, this was mental illness. A subject rarely
raised, spoken of, or discussed, but which emerged from the hardships of
capital and devastated the population to the core. The 21st century
revealed this silent epidemic and highlighted the need to discuss mental health
as a social issue.
Mental
health and necropolitics
Once
again, the curtains of capitalist sociability were opened and the pandemic tore
away the veil of taboo on issues related to mental health, issues which had become
appallingly evident in the lives of people already struggling to survive the
coronavirus. What had been historically forgotten and culturally covered-up regarding
psychological suffering was no longer sustainable. Social distancing appeased
both minds and bodies confronted by a devastating increase in cases of
depression, anxiety disorders, panic syndrome, and other mental health problems.
Good
mental health is associated with the ability to connect, develop common activities
in a productive way, and have quality of life (Organização Mundial de Saúde,
2022). It is important to criticise this concept, because when living in a
capitalist, exclusionary, and oppressive sociability, how is it possible to develop
all these potentials whilst maintaining mental health?
The
spectre of unemployment, hunger, and violence in its most diverse forms,
whether affecting children, adolescents, women, LGBTQI’s, the elderly, the black
population, or indigenous peoples, increased the scope of the struggle to fight
back and survive. The situation worsened with the restriction and reduction of
some services and healthcare considered non-essential. This can be analysed using
the data in Technical Note No. 22 of Monitora COVID/FIOCRUZ
(Fundação Oswaldo Cruz, 2021) regarding healthcare for the period 01/01/2020 to
06/30/2021.
Table 1 - Service Groups in the pre-pandemic and
pandemic periods.
|
Service Groups |
2018/2019 |
2020/2021 |
% |
|
Health
promotion and prevention |
450,744,591 |
291,524,710 |
-35,30% |
|
Diagnostic
procedures |
1,419,336,493 |
1,236,482,184 |
-12,90% |
|
Clinical
procedures |
2,037,133,703 |
1,481,019,025 |
-27,30% |
|
Surgical
procedures |
68,625,495 |
31,928,491 |
-53,90% |
|
Organ,
tissue, and cell transplants |
2,603,727 |
2,080,749 |
-20,10% |
|
Medicines |
1,456,778,458 |
1,696,439,964 |
16,50% |
|
Orthoses,
prosthetics, and special materials |
10,602,061 |
11,684,178 |
10,20% |
|
Complementary
healthcare |
51,218,779 |
43,717,994 |
-14,60% |
Source: Fundação Oswaldo Cruz (2021).
The
data shows that alongside the collapse of healthcare services related to cases
of COVID-19, other services were blocked because they were not considered
essential. According to the table, only services aimed at the acquisition and
delivery of medicines, and orthoses, prosthetics, and the like, increased
between 2020 and 2021. Other services, such as clinical, surgical, and health
promotion actions, saw a drop in the number of procedures due to the need to
suspend or reduce the services offered. This is all understood within the
context of a global health emergency. There were, nonetheless, other fronts in
health services that could not be implemented within the scope of the Unified
Health System (Sistema Único de Saúde - SUS)
According
to the WHO (Organização Mundial de Saúde 2022), in 2019, almost one billion
people were living with some type of mental disorder, of which 14% were
adolescents. Globally, suicide was the second largest cause of death among those
aged 15 to 29, and in Brazil it was the third. Globally, there are more than
800,000 cases annually, and around 13,000 cases in Brazil (Suicide Worldwide in
2019: global health estimates, 2019).
This
data is probably not accurate given the level of underreporting, which is particularly
prevalent in cities with a higher rate of poverty and in small and more
isolated municipalities which do not have resources and mechanisms for police
investigation or the legal medical apparatus to respond to deaths that may be
suspected suicides.
Data
from the WHO (Organização Mundial de Saúde, 2022) indicates that during the
pandemic there was an increase in psychological disorders of at least 25%, with
an increase in depression and anxiety figures worldwide. Also, according to the
WHO (Organização Mundial de Saúde, 2022), it is estimated that one in every
eight people suffers from some type of mental disorder, an emerging issue for
debate, as people in psychological distress live between 10 to 20 years less
than those who do not have the framework.
As a consequence of mental illness, people
lose productivity, which for the capitalist system is a defining factor for
unsustainability. Marx (2015) states that man acts on nature to produce what is
relevant to meet his needs. The first challenge for those who find themselves suffering
from mental illness involves exactly the process of human productivity in the
sphere of survival demanded by the current system.
According
to the WHO World Mental Health Report (Organização Mundial de Saúde, 2022), there
are gaps in information and research regarding mental health globally, and that
on average countries invest 2% of their public health budget on mental health.
Around 70% of this is allocated to psychiatric hospitals, indicating that the
hospital-centric vision is the preferred intervention. The report also shows
that half of the global population lives in countries where there is one
psychiatric medical professional for every 200,000 inhabitants or more, and
that the availability of medication for treatment, especially psychotropic drugs,
is limited.
Data
from Medical Demography of Brazil expressed by Scheffer et al. (2018) shows
that Brazil has 10,396 psychiatric medical professionals, which represents 5.01
professionals per 100,000 inhabitants with the highest concentration in the
Southeast, with 53.4% of psychiatric doctors, followed by the South with 24.1
%: the Northeast with 12.6%, the Central-West region with 7.8% and lastly the
North with 2.1% of professionals. In the case of the North region, the rate of
specialists per 100,000 inhabitants is between 0.69 and 1.62 professionals. The
data reflects the lack of balance in the distribution in Brazil. Compared with
35 other countries, Brazil is in third to last place in the rate of
psychiatrists per population, only ahead of Turkey and Mexico. Switzerland,
Finland, Norway, and Sweden occupy the first places.
One
challenge of ultra-neoliberalism is the resourcing of public policies.
Regarding the allocation for health, data from SIGA Brasil is important, it holds
data on the federal budget through the Integrated Financial Administration
System (SIAFI) in conjunction with other federal government plan and budget
platforms, which show the following data:
Graph 1: Ministry of Health budget (Values in Billion
Brazilian Real)
Incurred
(IPCA) Incurred Planned
(IPCA) Planned
_arquivos/image007.png)
Source: SIGA Brasil ([2023]).
Produced by the authors.
The
graph shows, in billions, the resources allocated to public health over the
last five years. The increase in 2020 and 2021 refers to the pandemic period, the
2022 data shows that expenditure had already fallen to near pre-pandemic
levels. The index for 2018 shows R$ 131.5 billion, increasing to R$ 166.8
billion in 2022. When adjusted for the Broad Consumer Price Index (Índice de
Preços ao Consumidor Amplo, IPCA) this shows incurred expenditure of R$ 170.5
billion in 2018 R$ 171.1 billion in 2022, which highlights the cut in health
resources after 2021, especially in expenses incurred. This reduction occurred despite
Brazil having recorded around 700,000 deaths from COVID-19 between March 2020
and March 2023, with an average of around 4,400 deaths per week; and presents a
picture of 87.9% of people with at least one dose of the vaccine, falling to
81.4% of people with the entire vaccination schedule (Pan American Health
Organisation, 2023).
A
key milestone in the dismantling of rights was the austerity policy introduced
by the Temer Government in Constitutional Amendment 95, known as the Fiscal
Adjustment Policy, which established a spending ceiling and froze public expenditure
for up to twenty years. The measure envisioned greater market rationality,
amplified by encouraging competition and the defunding of social policies by reducing
primary expenses. Furthermore, it restricts resources and makes it impossible
for the State to fulfil obligations set out in the 1988 Federal Constitution, as
such it is a neoliberal plan that eliminates the State as the guarantor of the
minimum social rights (Menezes; Moretti; Reis, 2019). In synthesis, the Unified
Health System, which was already suffering from underfunding, is now dealing
with defunding, which was leveraged by a war budget based on the
economic and fiscal measures adopted by ultra-neoliberalism and which operate
in an overwhelming way.
Regarding
mental health, the Transparency Portal (2022) and SIGA Brasil do not hold
accurate data, because there is no way to separate the budget and resources
applied within the specific scope of the policy. In July 2022, in a hearing
reported by the human rights commission of the Federal Council, scientists
criticised what they called a blackout in mental health data, given the
lack of transparency in the management and presentation of data, as well as in the
provision of resources to therapeutic communities (TCs), (Souza, 2022).
According
to Technical Note No. 21 of the Institute of Applied Economic Research (IPEA)
(2017), there are 1963 therapeutic communities in Brazil, which together have
more than 83,000 treatment locations. The largest number of institutions is
found in the Southeast region of the country, with 41.64%, followed by the
South, with 26.36%; the Northeast with 16.51%; the Central-West with 8.82% and
the North region in last place with 6.67% of communities. Around 78.8% of the
units have shared rooms that house 4 to 6 people; 80% are for men, 15% for both
sexes and 4% for women. Other relevant data refers to sexual diversity, around
90.9% of therapeutic communities stated that they welcome homosexuals, 51.6%
serve the transvestite population and 43.6% say they offer places to
transgender people (Community Profile Brazilian Therapeutics, 2017). The data
reflects the low rates of inclusion when the subject involves expressions of
sexuality, especially gender identities. Another evaluation shows the
communities’ sources of financing, as shown below:
Table 2: Source of Funding for Therapeutic Communities
(TC’s)
|
SOURCE
OF FINANCING |
% OF TC’S RECEIVING |
|
|
Donations from individual supporters |
75.4 |
|
|
Voluntary contribution from clients and/or
their families |
66.6 |
|
|
Donations from churches and other religious
bodies |
63.5 |
|
|
Client payments |
46 |
|
|
Resources of the TC or directed by them |
44.7 |
|
|
Fund raising from parties, bingo, or lotteries |
42 |
|
|
Municipal government funding |
41.1 |
|
|
Donations from private national entities |
33.9 |
|
|
Production and sale of products made in the
TC’s |
32.4 |
|
|
State government funding |
27.8 |
|
|
Federal government funding |
24.1 |
|
|
Donations from private international
entities |
6.1 |
|
Source: Profile of
Brazilian Therapeutic Communities (2017).
The
data show that of the institutions surveyed by IPEA in the Profile of Brazilian
Therapeutic Communities (Perfil das Comunidades Terapêuticas Brasileiras, 2017),
24.1% receive funding from the federal government, 27.8% from state governments
and 41.1% from the municipalities, this is the portion of resources allocated
to Brazilian mental healthcare that are directed to therapeutic communities, this
can also be evidenced with data from Conectas Human Rights and the Brazilian
Centre for Analysis and Planning (Centro Brasileiro de Análise e Defesa, 2020).
Graph 2: Federal financing of Therapeutic Communities
_arquivos/image009.png)
Source: Report on Public Financing of
Therapeutic Communities 2017-2020
from the Brazilian Centre
for Analysis and Planning (2020).
The
graph shows the increase in government funding for TC’s by region. When comparing
2017/18 with the period 2019/20, there is an increase of more than 100% in the resources
allocated to these services, this is relevant as these resources are no longer
directed to other arms of the Psychosocial Care Network under the responsibility
of the State.
Graph 3: Percentage of resources paid to TCs by region
_arquivos/image011.png)
Source:
Report on Public Financing of Therapeutic Communities 2017-2020
from the Brazilian Centre for Analysis and Planning
(2020).
The
highest concentration of public financial resources for TCs is found in the
Southeast region with 36%, while the lowest is the North, with just 5%. In
addition to this funding there are further resources, resulting from
parliamentary amendments, for the purchase of vehicles, training of technical
teams of professionals, maintenance of buildings and materials, and purchasing resources
for use in professional courses (Centro Brasileiro de Análise e Planejamento,
2020).
According
to Passos et al. (2020), TCs work is based on a tripod of work, discipline,
and spirituality. Most communities impose the basic religion adopted by the
institution as part of the treatment, while work is based on unpaid activities
imposed as ‘occupational therapy’. People in recovery are, however, carrying
out work with none of the usual labour guarantees and replacing the hiring of workers.
This violates law 10. 216/2001, a law which provides for the rights of people with
a mental health disorder and steers the mental healthcare model.
Regarding
the use of religion as a platform for intervention in recovery, Ribeiro and
Minayo (2015) state that this is controversial. |Managers of these services
believe that when chemical dependency is viewed as a sin to be renounced, clients
develop the potential to exit their dependency through austerity and religious
experiences imposed daily. In a further negative analysis, the imposition of
participation in religious activities violates freedom of belief. There is also
institutional violence through conversion rites, submission to moral principles,
and discrimination on grounds of sexual and gender identity.
In
addition, isolation from the family and other forms of sociability, sexual
abstinence, and the moral behaviour of a religious person are demanded. Given
the isolation of TCs there is also a decline in access to education and more precarious
access to health services. Daily experiences are linked to discipline, ‘occupational
therapy’, and religious activities, which could be viewed as a violation of
human rights.
Regarding
religions, Marx (2010) called them the ‘opium of the people’, in that they have
the potential to anesthetise and dominate the individual as the protagonist of
their own history. It develops non-being from ‘being’. The concept, alone, of
religion being used specifically for the treatment of drug addicts is challenging,
and there is a lack of research confirming the scientific evidence that
abstinence linked to the impositions of religiosity in TCs demonstrates
significant improvements in treatment. There is fierce criticism, from various
perspectives, of the process of rights violations.
Despite
criticism of the TC model, and in accordance with Ministry of Health Ordinance
3,088 of 2011, which established the Psychosocial Care Network (Rede de Atenção
Psicossocial - RAPS) for those suffering mental health issues due to the abuse
of alcohol and other drugs, these institutions have become part of the Unified
Health System network, offering residential services to the adult population for
up to nine months (Brasil, 2011). The inclusion of TCs into RAPS indicates one
of the most perverse aspects of ultra-neoliberalism by channelling State
resources to organisations that deliver services of a hygienist and segregating
nature, including religious conversion.
Following
criticism regarding the blackout of information on mental health, the
Ministry of Health presented, through the Secretariat of Primary Healthcare
(SAPS), a report titled ‘Data from the Psychosocial Care Network in the Unified
Health System’, containing the following information: Brazil currently has
2,836 Psychosocial Care Centres (CAPS), distributed across 1,910 municipalities.
According to the report, the states of Mato Grosso and Rondônia do not have
24-hour care services and the states of Acre, Roraima and Tocantins do not have
Psychosocial Care Centres for children and adolescents (CAPSi); other data shows
the distribution of CAPS by region: the Northeast and South have the largest
number of services, with an average of 1.70 CAPS per 100,000 inhabitants in the
Northeast and 1.52 in the South; The regions with the lowest concentration of CAPS
are the Central-West with 1.01 CAPS per 100,000 inhabitants and the North with
0.97. The three states with the lowest number of care centres are Amazonas,
with 0.59 CAPS per 100,000 inhabitants, Amapá with 0.57 and the Federal
District with 0.42 (Brasil, 2022).
The
report’s data reveals a lack of investment in and the marginalisation of mental
health in Brazil. The number of CAPS does not cover even half of the existing
municipalities, only 1,910 of the 5,568 municipalities plus the Federal
District and the State District of Fernando de Noronha (Belandi, 2022). The
breakdown by region also presents challenges, as the North and Central-West
regions have the lowest number of mental health services in the network.
In
Brazil, there are only 224 multidisciplinary teams providing specialised mental
health care, this is an emergent framework for meeting population demand. This paucity
is distributed by region, in the North only the state of Pará has a team, the Centre-West
has two, one in Goiás and the other in Mato Grosso do Sul, only in the South
and Southeast regions are there teams distributed in all States (Brasil, 2022).
Regarding
the coverage of mental health beds in general hospitals, the states of Amapá,
Amazonas, Maranhão, Mato Grosso, Roraima and Rondônia do not have any
initiatives with proposals for spaces. The states of Pará, Rondônia and Roraima
have no specialised psychiatric beds (Brasil, 2022).
This
data indicates the potential achievement of necropolitics within mental health,
undermined, as it is, by ultra-neoliberalism in Brazil. From an economic perspective,
this model does not conform to the idea of the Minimum State, in this case the
State acts forcefully and directs the flow that exacerbates barbarism at every step,
including targeting mental health in the dismantling of public policies. The situation
is characterised by neoliberal rationale, which, according to Casara (2021),
exposes the deepest hardships of the capitalist system and encourages the
naturalisation of absurdity and chaos amid barbarism as part of the everyday.
Mental
healthcare is not just a contribution to civil society. But history is,
apparently, being rewritten by other determinants, given that mental healthcare
as a right remains inaccessible to the majority of the
population. Regarding the confronting of psychological suffering and mental illness,
there is an historical gap between rights and access.
There
are many questions and few answers in the face of an ultra-neoliberalism that
not only leads to, but also naturalises, barbarism. Mental illness involves
expressions of the social question that demand interventions and the inclusion
of those with mental illnesses. This requires the implementation and monitoring
of public policies which have suffered year-on-year cuts, including the
implementation of necropolitics which has been leveraged with greater vigour under
the recent extreme right government. This is evidenced by Bolsonarism, which
dictated meritocratic standards, demonised the poor, black and peripheral population,
and encouraged the genocide of indigenous people and other population groups
including those struggling to survive mental illness.
According
to Marx and Engels (1998), the revolution takes place in the context of
practice, in materiality and not in discourse. It is urgent that the fight for adequate
mental health policies spreads across the community, as it is an emerging
issue, amply revealed by the Covid-19 pandemic. As Marx said, philosophers in
the past were concerned with considering the reality of the world, now it is
time to transform it.
Final considerations
The
hardships leveraged by the oppressive and exclusionary capitalist system indicate
that the boiling point has been reached. Necropolitics have not only been
introduced but legitimised at the hands of the extreme right, who took power in
Brazil under Bolsonaro. These hardships have not been eliminated with the recent
election and inauguration of a progressive government. Expressions of the
social issue have emerged and have been silenced by denialism and conservatism,
fuelled by contemporary reactionism.
There
are lives that matter and others that are worthless. The idea of homo sacer
expressed by Agamben (2007) no longer makes sense, as lives become killable,
physically, and not just socially or symbolically. An unhealthy daydream yearns
for militarism and wishes to eliminate minorities to guarantee the privilege of
the elites. The various forms of violence are revealed, but little is said
about the psychological illness that plagues millions, most of whom do not have
access to a network of psychosocial care services consistent with that
recommended in public policies.
The
root of the problem echoes the Brazilian historical process. Issues related to
mental health are shrouded in ostracism, discrimination, and almost absolute
silence within the scope of policies that for centuries kept people in asylum
institutions as a hygienist solution. The capitalist boiling point no longer
allows the issue to be hidden. Debate is necessary to develop intervention strategies
to contain this silent epidemic. It should, however, be emphasised that mental issues
are not solely linked to psychiatric pathologies, but also to expressions of
the social issue that emerge in this exclusionary and increasingly violent
capitalist system, enhanced by a neoliberal rationality.
Marx
(2006) portrayed how discrimination, inequality and oppression increase
psychological suffering, even triggering suicide. Illness is not new, and the
capitalist system encourages these more serious triggers. Overload, unhealthy
relationships, the objectification of man, the reduction of the labour force to
merchandise, surplus value, gender inequality, and poverty due to sex or colour,
are all conditions that raise the likelihood of depression, panic syndrome, and
anxiety disorders, among other psychiatric disorders widespread in the daily
life of the population.
It is not enough to expose that resources do not meet
the demands of mental healthcare in Brazil. It is necessary to resist, and to
enhance the constant search for the right to have rights, for confrontations
and possibilities in the face of the established capitalist order. We must
fight, because as Thiago de Mello (2006) said: “I know we have
to dream. A field without dew dries up the brow of those who don’t
dream.”
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________________________________________________________________________________________________
Lidiany de Lima CAVALCANTE
Worked on the concept, outlining, data analysis and interpretation, redaction,
critical revision, and approval of the published version.
Post Doctorate in Social Service from the Pontifícia Universidade
Católica do Rio Grande do Sul (PUCRS). Professor
at the Universidade Federal do Amazonas since 2014. Develops research and extension activities in the areas of gender,
sexualities, mental health, and confronting suicide.
Maria Isabel Barros BELLINI Worked on the concept, outlining, data analysis and interpretation,
redaction, and critical revision.
Professor on the Social Service and Social Sciences
programmes at the Pontifícia Universidade Católica do Rio Grande do Sul. Develops
research and extension activities in the areas of family, intersectorality,
health policy and health education.
________________________________________________________________________________________________
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