Psychiatric Power. Exclusion and Segregation in the Brazilian Mental Health System
Abstract
This text seeks to provide a historical analysis of Brazilian psychiatry. My purpose here is to emphasize the inherent connection between (un)democratic processes and social understandings of the figure of the “mad.” The structuration of the system of psychiatric care indeed would seem to be inseparable from human rights concerns and the need to consider all individuals as worthy of care. Without a doubt, social acceptance of the “mad” is intrinsically related to concerns for democracy, and de-democratization, for its part, begins by targeting “deviant” figures.
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15 Psychiatric Power Exclusion and Segregation in the %UD]LOLDQ0HQWDO+HDOWK6\VWHP Marlon Miguel 1 1. Introduction The history of the Brazilian psychiatric system is closely connected to the develRSPHQWRIWKHFRXQWU\¶VGHPRFUDWLFSURFHVVHVWKURXJKRXWWKHWKFHQWXU\± the inequalities, racism, and exclusions at the foundation of the nation, along with its instabilities, advances, and retrogressions. Brazil’s military dictatorVKLS±UDGLFDOL]HGDV\VWHPEDVHGRQWKHSULQFLSOHVRISULYDWL]HG care, isolation, and segregation of mentally ill patients, transforming psychiatric institutions into something like prisons or concentration camps. That situation would only begin to improve with the re-democratization period, in LQZKLFKGHEDWHVDURXQGWKH%UD]LOLDQ3V\FKLDWULF5HIRUPEHJDQWRDOLJQ ZLWKWKHVSLULWRIDQHZSURJUHVVLYH)HGHUDO&RQVWLWXWLRQ7KH5HIRUPPRYHment aimed then to transform the social perception of madness and advocated for looking at the mentally ill through the lens of citizenship. It furthermore HPSKDVL]HGWKHVXEMHFW¶VFRQFUHWHH[SHULHQFHRIVX൵HULQJWKHFXUUHQWVWDWH experienced by the mentally ill, rather than their “condition” or “disorder”; “care,” “social bonds,” and “relationality,” rather than “isolation,” were the privileged concepts. These shifts drew inspiration from anti-psychiatry and institutional reform movements in Europe, as well as some exceptional Bra- ]LOLDQ¿JXUHVVXFKDV1LVHGD6LOYHLUD7KH5HIRUPODZ¿UVWSURSRVHGLQ ZRXOGRQO\EHLPSOHPHQWHGLQWKHV$QGLWKDVEHHQXQGHUDWWDFN HYHUVLQFHWKHFRXSGLUHFWO\UHÀHFWLQJWKHGHGHPRFUDWL]DWLRQWKDWWKLV event unleashed. Brazil has witnessed a strong return of forced hospitalization, the use of violent treatment and the dismantling of public mental health structures. This chapter seeks to provide a historical analysis of Brazilian psychiaWU\0\SXUSRVHKHUHZLOOEHWRHPSKDVL]HWKHLQKHUHQWFRQQHFWLRQEHWZHHQ XQGHPRFUDWLFSURFHVVHVDQGVRFLDOXQGHUVWDQGLQJVRIWKH¿JXUHRIWKH³PDG´ The structuration of the system of psychiatric care indeed would seem to be inseparable from human rights concerns and the need to consider all individuals as worthy of care. Without a doubt, social acceptance of the “mad” is intrinsically related to concerns for democracy, and de-democratization, for its part, EHJLQVE\WDUJHWLQJ³GHYLDQW´¿JXUHV
Psychiatric Power 251 Beyond expressing a determinate social understanding of madness, I claim WKDWPHQWDOKHDOWKPRGHOVGLUHFWO\FRQGHQVHWKHDFWXDOIRUPVRIDQXQGHPRcratic regime. Indeed, undemocratic regimes tend to create enemies and transform them into pathological beings, casting them as disrupting the natural order. The image of the enemy is thus constructed through a medical vocabulary as a pathological intrusion, to be combatted through treatment. In presentGD\%UD]LO±DIWHUWKHFRXSDQGLQWKHPLGVWRIDQDXWKRULWDULDQFOLPDWH LQDXJXUDWHGZLWKWKHHOHFWLRQRI-DLU%ROVRQDUR±LQWHQVL¿HGGLVFRXUVHVRI pathological abnormality and the renewal of exclusionary mental health policies go hand in hand, expressing a radical shift towards the de-democratization of Brazilian society. 2. Early Brazilian Psychiatry: A Project of Isolation, Racial and Social Exclusion The history of Brazilian psychiatry is marked by the coexistence of, on the one hand, early progressive and even vanguard clinical practices, and on the other, a heavily exclusionary, violent, and carceral psychiatric system. Already in WKHV6LJPXQG)UHXG¶VZRUNZDVWKHVXEMHFWRILQWHQVHGHEDWHLQ%UD]LO DQGLQWKH%UD]LOLDQ3V\FKRDQDO\VLV6RFLHW\ZDVIRXQGHG7KHXVHRI DUWDVDWKHUDSHXWLFWRRODOVRDSSHDUVGXULQJWKLVSHULRGDQGLQ2VyULR &pVDUZRXOGSXEOLVKKLVVHPLQDOERRNA expressão artística nos alienados: contribuição para o estudo dos símbolos na arteThe Artistic Expression of the Alienated: A Contribution to the Study of the Symbols in Art±DSXElication contemporary with Hans Prinzhorn’s Bildnerei der Geisteskranken :DOWHU0RUJHQWKDOHU¶V(LQ*HLVWHVNUDQNHUDOV.QVWOHU$GROI:|OÀL DQG-HDQ9LQFKRQ¶VL’art et la folie:KHUHPRVWGRFWRUVRQO\ recognized a disorder, non-sense, and absurdity, by observing the work of the mentally ill it became possible to envision a new way of examining delusions, behaviors, and pathologies. The artwork of the “mad” thus became a central LQÀXHQFHLQ%UD]LOLDQPRGHUQLVPDQGDORQJZLWK&pVDUWKHDUWLVW)ODYLRGH &DUYDOKRRUJDQL]HGLQWKHH[KLELWLRQMês das Crianças e dos Loucos Month of the Children and MadDWWKH0RGHUQ$UWLVWV&OXELQ6mR3DXOR7KLV ZDVWKH¿UVWLQDVHULHVRIH[KLELWLRQVZKHUHWKHZRUNRIPHQWDOO\LOOSDWLHQWV migrated from psychiatric institutions to the world of arts. Furthermore, with WKHVHZRUNV&DUYDOKRVKLIWHGWKHYHU\XQGHUVWDQGLQJRIDUWFODLPLQJ³WKH RQO\DUWLVDEQRUPDODUW´'H&DUYDOKRZLWK&DEDxDV :KLOHWKHVHHOHPHQWVUHÀHFWHGWKHHPHUJHQFHRIDQHZUDGLFDOUHODWLRQDO and progressive understanding of madness, most 20th-century Brazilian psychiatric institutions continued operating along the lines of the grand renfermement model described by )RXFDXOW2 As Foucault has shown, a radical GLYLVLRQHPHUJHGLQWKHWKFHQWXU\EHWZHHQQRUPDODQGPDGSHRSOHZKHUHLQ the latter are to be isolated and receive treatment. A psychiatric discourse such as Philippe Pinel’s was certainly progressive for the time period, focused as it was on “liberty” and on “unchaining” the mad. However, their liberation,
252 Marlon Miguel based on “adequate” treatment, was conditioned by disciplinary practices. In addition, Pinel proposed a correlation between “mental alienation” and the unhealthy social milieu in which the subject lived. In that sense, his argument called for the subject’s isolation from these causes. As consequence, this disFRXUVHSURPRWHGLVRODWLRQDQGWKHLGHQWL¿FDWLRQRIPHQWDOGLVRUGHUV with certain social milieus. 7KH¿UVWSV\FKLDWULFLQVWLWXWLRQVFUHDWHGLQ%UD]LOLQWKHWKFHQWXU\DGKHUHG to this isolationist logic while targeting particular parts of the population.3 0RUHRYHULQWKH%UD]LOLDQFRQWH[WLWFOHDUO\LQWHJUDWHGUDFLVWGLVFRXUVHV 7KH 3HGUR ,, +RVSLWDO ZDV WKH ¿UVW DV\OXP FUHDWHG LQ %UD]LO LQ 5LR GH -DQHLURLQIROORZHGE\PDQ\RWKHUVVXFKDVWKH6mR3HGUR+RVSLWDO LQ3RUWR$OHJUHDQGWKH-XTXHU\&RORQLDO+RVSLWDOLQWKHVXEXUEVRI 6mR3DXOR7KHVHLQVWLWXWLRQVPDLQO\UHFHLYHGORZHUFODVV%UD]LOLDQV Following behind “schizophrenia” and “alcoholism,” the third most common FDXVHRIKRVSLWDOL]DWLRQZDV³XQNQRZQ´,%*()XUWKHUPRUHPRVW of the patients that entered an asylum would never leave. For example, under WKHGLUHFWLRQRI)UDQFRGD5RFKD±DURXQGRIWKHSDWLHQWV WKDWHQWHUHGWKH-XTXHU\+RVSLWDOZRXOGDOVRGLHZLWKLQWKHLQVWLWXWLRQ(YHQ PRUHVWULNLQJLVWKDWWKLVQXPEHUVZRXOGJRXSWREHWZHHQDQG DPRQJ EODFN SHRSOH 0DFKLQ DQG 0RWD 3DWLHQWV ZHUH RIWHQ VHQW to asylums by the police, for seemingly random reasons or simply based on “social disorder.” The early history of Brazilian psychiatry was also marked by a eugenics SURMHFW&RVWD; 5HLVEDVHGRQWKHFRQFHSWRI³UDFH´DQGWKHFODVVL¿FDWLRQRIGLVRUGHUVDFFRUGLQJWRHWKQLFLW\7KLVSURMHFWZDVUHSUHVHQWHG E\SURPLQHQWPHGLFDO¿JXUHVLQ6mR3DXOROLNH5HQDWR.HKOFUHDWRURIWKH 6mR3DXOR(XJHQLFV6RFLHW\-RVp3DUDQKRV)RQWHQHOOH3HGUR0RQWHOHRQH 2WiYLR*RQ]DJDDQG'D5RFKDKLPVHOIRUWKH%UD]LOLDQ/HDJXHIRU0HQWDO +\JLHQHFUHDWHGLQLQ5LRGH-DQHLUR7KHGLVFRXUVHDURXQGWKH³PHQtal disturbances of black people” was commonplace, as was the attempt to SVHXGRGLDJQRVH³%UD]LOLDQUDFLDOUHDOLW\´5R[R-XOLDQR0RUHLUDZLWK 5HLV9HU\RIWHQWKHVHGLVFRXUVHVFRQWDLQHGFDWHJRULHVRIPHQWDO disorder associated with “race” and the “degeneration” of the human species. 6RPHSV\FKLDWULVWVVXFKDV5DLPXQGR1LQD5RGULJXHVGHIHQGHGLPPLJUDtion control in order to progressively limit miscegenation, “whitening” the %UD]LOLDQSRSXODWLRQDQGZLWKLWUHGXFLQJPHQWDOSDWKRORJLHV5HLV; 2GD Eugenicist ideologies, sanitation concerns, and mental hygiene discourses weighed heavily during this period in Brazilian society, which in turn was FKDUDFWHUL]HGE\UDGLFDOWUDQVIRUPDWLRQVWKHDEROLWLRQRIVODYHU\WKH HDUO\ \HDUV RI WKH 5HSXEOLF LQGXVWULDOL]DWLRQ VLJQL¿FDQW LPPLJUDWLRQDQGUXUDOH[RGXV±6mR3DXORIRUH[DPSOHGRXEOHGLWVSRSXODWLRQLQWKH ¿QDOGHFDGHRIWKHWKFHQWXU\(XJHQLFVDQGSV\FKLDWU\ZHUHIXVHGLQDQ attempt to reorganize urban centers, with particular concern for “pathologies RIWKHSRRU´±GHOLQTXHQF\DOFRKROLVPSURVWLWXWLRQDORQJZLWKWXEHUFXORVLV
Psychiatric Power 253 DQGV\SKLOLV±DQGWKHUHSHDWHGFRUUHODWLRQEHWZHHQPDGQHVVDQGUDFLDODQG SV\FKLFGHJHQHUDWLRQ/RZHUFODVVSRSXODWLRQVEHLQJPRVWO\EODFNRUPLVcegenated, these ideologies associated the project of racial cleansing with PDLQWHQDQFH RI VRFLDO RUGHU DQG FULPH UHGXFWLRQ 0HGLFDO GLVFRXUVH IXQFWLRQHGGXULQJWKHSHULRGDVDPHDQVIRU³VRFLDOGLVTXDOL¿FDWLRQRIEODFNSHRSOH´%LUPDQ7KHDIRUHPHQWLRQHGHXJHQLFLVW.HKOZKRODWHUPRYHG WR5LRZDVDQDFWLYHPHPEHURIWKH/HDJXHIRU0HQWDO+\JLHQHLQWKHV DQGVDQRUJDQL]DWLRQZKHUHRWKHULPSRUWDQW¿JXUHVSDUWLFLSDWHGVXFKDV -XOLDQR0RUHLUD3HGUR,,+RVSLWDO¶VGLUHFWRU0LJXHO&RXWRSUHVLGHQWRIWKH 1DWLRQDO$FDGHP\RI0HGLFLQH&DUORV&KDJDVGLUHFWRURI2VZDOGR&UX] ,QVWLWXWH(GJDU5RTXHWWH3LQWRGLUHFWRURIWKH1DWLRQDO0XVHXPDQG0RQWHLUR/REDWRZULWHUDQGFXOWXUDO¿JXUH 7KH/HDJXHIRU0HQWDO+\JLHQHUHPDLQHGYHU\DFWLYHLQWKHVGXULQJ WKH9DUJDV(UDZKLFKVDZVHYHUDOUHIRUPVDIWHUWKH&RQVWLWXHQW$VVHPEO\7KH/HDJXHIRUPHGDSRZHUIXOOREE\DGYRFDWLQJIRUWKHLGHQWL¿FDWLRQRI health with eugenics, and sought to turn terms such as “eugenetics,” “eufreQLD´³HXJHQLFV´³G\VJHQLFV´LQWRFRPPRQSDUODQFH6WHSDQ7KHLU project consisted in an attempt to “extend the methods of mental hygiene to WKHHQWLUH%UD]LOLDQSRSXODWLRQ´&RVWD)XUWKHUPRUHWKHLUPHPEHUV ZRXOGRFFXS\LPSRUWDQWDGPLQLVWUDWLYHSRVLWLRQVLQ0LQLVWULHVRI(GXFDWLRQ DQG3XEOLF+HDOWKDQGWKH0LQLVWU\RI:RUN,QWKH$VVLVWDQFHIRU3V\- FKRSDWKVDQGIRU0HQWDO3URSK\OD[LVZDVFUHDWHG7KLVPDUNHGDPRPHQWLQ ZKLFKSV\FKLDWU\DFTXLUHGIRUWKH¿UVWWLPHDSURPLQHQWVWDWXVDPRQJRWKHU areas of public health. 7KHVDOVRVDZWKHHPHUJHQFHRIWKH,QWHJUDOLVWVDNLQGRIORFDOIDVFLVW PRYHPHQWOHGE\WKHSROLWLFDODQGOLWHUDU\¿JXUH3OtQLR6DOJDGR&KDUDFWHUL]HG by strong anti-communist sentiments, the movement disseminated a discourse LQZKLFK FRPPXQLVWV ZHUHLGHQWL¿HG ZLWKSDWKRORJLHV RULQIHFWLRXV DJHQWV 0RWWD± This discourse would return, even stronger, decades ODWHUGXULQJWKHSUHFRXSHUD The Estado Novo±ZRXOGHPSKDVL]HWKHSUDFWLFHRISUHYHQWLYH medicine, education, and individual care, while at the same time suppressing more openly racist and eugenicist discourse.5 It also confronted the Integralist PRYHPHQW)XUWKHUPRUHDIWHUWKH%UD]LOLDQVWDWHFHQWUDOL]HGDOOSXEOLF VDQLWDU\DGPLQLVWUDWLRQDQGFUHDWHGWKH1DWLRQDO6HUYLFHRI0HQWDO'LVRUGHUV 61'07KH%UD]LOLDQ+HDOWK&RGHSURSRVHGLQDOVRH[SOLFLWO\FRQdemned terms such as asilo and hospícioDV\OXPDQGKRVSLFHSURSRVLQJWR UHSODFHWKHPZLWK³KRVSLWDO´8QGHU-XVFHOLQR.XELWVFKHFN¶VJRYHUQPHQWWKH 61'0ZRXOGODWHUH[SDQGSV\FKLDWULFVHUYLFHVDFURVVWKHFRXQWU\LQDQH൵RUW to prevent dislocation, with patients having to travel to urban and economic centers, as well as reducing hospital over-population. Finally, this period saw an important expansion of medical posts providing outpatient care for the prevention of mental disorders. While this broad trend saw a marked shift towards prevention in the mental KHDOWK¿HOGWKDWVDPHSHUVSHFWLYHZDVXQGHQLDEO\K\JLHQLFDQGUDFLVWDWLWV
Marlon Miguel foundation. And that same view would continue to structure Brazilian psychiatric policy for years to come. 3. Nise da Silveira: An Exception to the Psychiatric Order :KLOHHDUO\%UD]LOLDQSV\FKLDWU\ZDVJHQHUDOO\DGLVPDOD൵DLURQHLPSRUWDQW ¿JXUHUHSUHVHQWHGDQH[FHSWLRQ'U1LVHGD6LOYHLUD%RUQLQ0DFHLyLQ VKHEHJDQZRUNDVDSV\FKLDWULVWLQWKHHDUO\VLQ5LRGH-DQHLURDWWKH 3UDLD9HUPHOKD3V\FKLDWULF+RVSLWDOLQWKH1DWLRQDO'HSDUWPHQWRI0HQWDO +HDOWK'LQVDPDQGLQWKH%UD]LOLDQ)HPLQLVW8QLRQ8)%$IHOORZWUDYHOHU RIWKH&RPPXQLVW3DUW\DQGPHPEHURIWKH8)%VKHZDVSHUVHFXWHGE\WKH 9DUJDVUHJLPHKHOGLQSULVRQIRUPRQWKVDQGVSHQWVHYHUDO\HDUVOLYLQJ underground. She was eventually accepted back into the public health system, LQDQGEHJDQZRUNDWWKH3HGUR,,+RVSLWDO$OWKRXJKDUHDGHURI)UHXG KHUZRUNLVEDVHGUDWKHURQWKDWRI&DUO*XVWDY-XQJ±ZLWKZKRPVKHFRUUHVSRQGHG±DVZHOODVWKHZRUNRI$QWRQLQ$UWDXGDQG6SLQR]D±ZKRVHZRUN she read with particular devotion during her time in prison. ,QLQFROODERUDWLRQZLWKWKHDUWLVW$OPLU0DYLJQLHU6LOYHLUDRSHQHGD painting studio at the Pedro II Hospital. There, they organized exhibitions and HQFRXUDJHG¿JXUHVRIWKHDUWZRUOGWRYLVLW±DPRQJWKRVHLQYLWHGZHUH%HOJLDQ FULWLF/pRQ'HJDQGDQG%UD]LOLDQFULWLF0iULR3HGURVDDVZHOODVWKHSDLQWers Ivan Serpa and Abraham Palatnik. The collaboration with Pedrosa would SURYHHVVHQWLDOWRWKHVWXGLRDQGODWHUWRWKHIRXQGDWLRQLQRIWKH0XVHXP of Images of the Unconscious. The museum, housed within the hospital, contained the work of Silveira’s patients, which she considered crucial instruments IRUIXUWKHUVFLHQWL¿FVWXG\RISV\FKRVLV6LOYHLUDHPSKDVL]HGWKHFUHDWLRQRID favorable working environment for artistic endeavors and organized permanent exhibitions. The exhibition space was not however conceived for teaching art, but rather as encouraging the patients’ artistic production. Silveira managed, against great adversities, to develop her work over the course of several decades. She struggled constantly with the so-called “modern” psychiDWULFPHWKRGVLQVXOLQVKRFNWKHUDS\&DUGLD]ROLQGXFHGFRQYXOVLRQVSV\FKRVXUJHU\DQGORERWRP\WKDWZHUHFRPPRQSUDFWLFHGXULQJWKHSHULRG1RWRQO\WKDW her patients’ exhibitions too served to call attention to the violent practices and precarious conditions of psychiatry. Here too Pedrosa played a vital role. His conception of modern art was crucial for the critique he would develop of rationality, as well as the methods of modern psychiatric institutions. Underlying Pedrosa’s critical project was an interesting tension: he insisted on the autonomy of form, paying close attention to the work of art, while simultaneously critiquing bourgeois rationale justifying the exclusion of the mentally ill. The “mad” are here neither outside modern art nor a model of transgression, but as Pedrosa puts it, echoing Goethe’s Denn was innen, das ist außen³7KH\>SDWLHQWV@VHHHYHU\WKLQJ VLPXOWDQHRXVO\IURPLQVLGHDQGIURPRXWVLGH´3HGURVD Silveira’s “rebellious psychiatry,” as she herself described her method in her XQ¿QLVKHGDXWRELRJUDSK\0HOORLVQRWMXVWWKHLQWHJUDWLRQRIPDGQHVV
Psychiatric Power 255 into humanistic practices, but, based on her Spinozian monistic “unity of WKLQJV´'D6LOYHLUDZLWK0HOORLWLVDOVRDFULWLFDOLQTXLU\ into the separation of nature and culture, and the hierarchical categorization of WKLQJV±DQGZLWKWKHPKXPDQV+HUSV\FKLDWULFPHWKRGFRQVLVWHGLQLQYHVWLJDWLQJDSRVVLEOHUHFRQ¿JXUDWLRQRIOLYLQJWKLQJVDFFRUGLQJWRWKHLUVLQJXODU and plastic forms. For her, “creative activity” mobilizes “several aspects of WKHSV\FKH´DQGLQSDUWLFXODULWV³RUGHULQJDXWRKHDOLQJIRUFHV´LELG Furthermore, she recognizes the necessity, when treating mental disorders, of UHFRQQHFWLQJSDWLHQWVZLWKDVRFLDOHQYLURQPHQWLQFRUSRUDWLQJWKHVX൵HULQJ body into a certain community. Hence, we might call her a kind of “ecological GRFWRU´Pordeus 2018 Silveira’s practice and thought anticipated by several decades many of the principles that would later appear in the Brazilian Psychiatric Reform, as well as resonate with the global institutional reform and anti-psychiatry movements.$OUHDG\LQVKHFUHDWHGWKHCasa das Palmeiras to host former patients of psychiatric institutions. She advocated for the importance of the externato, or outpatient halfway house, crucial for the deinstitutionalization of patients. This dimension will prove central to the Reform project, as we shall soon see. ,Q6LOYHLUDVHQWDOHWWHUWRWKHQ3UHVLGHQW-kQLR4XDGURVSURSRVLQJD national reform work program. Her aim there was to completely rethink the existing psychiatric structure, focusing on the isolationist practices of hospitals: The hospital is reinforcing the pathology, because it does not help at all in re-establishing connections between the patient and their milieu, from which they are being separated because of the pathology. . . . The Hospital EHFRPHVDQH[WUHPHO\H൶FLHQWDSSDUDWXVIRUWKHFKURQL¿FDWLRQ>FURQL¿- cação@RIGLVHDVH 'D6LOYHLUDZLWK0HOOR :KLOH4XDGURVH[SUHVVHGLQWHUHVWLQ6LOYHLUD¶VSURSRVDOKHUHQRXQFHGLWVRPH days later and no further progress was ever made. Her project would be completely forgotten, existing for decades as an exceptional, alternative project. 4. Barbacena and the Military Dictatorship Years The structure of Brazilian psychiatric institutions would remain stable from WKHHQGRIWKH9DUJDV(UDXSWRWKHPLOLWDU\FRXS,Q%UD]LOKDG SV\FKLDWU\KRVSLWDOVRIZKLFKZHUHSULYDWHDQGSXEOLF±WKRXJKSXEOLF KRVSLWDOVZHUHUHVSRQVLEOHIRURIKRVSLWDOEHGV,QWKHQXPEHURI total hospitals approached 135, with 81 hospitals in the private sphere and the UHPDLQLQJSXEOLFDFFRXQWLQJIRURIKRVSLWDOEHGV7KH\HDUVIROORZing the military coup would see the radical redistribution of private and public KRVSLWDOVE\WKHSULYDWHKRVSLWDOVZRXOGUHSUHVHQWRIKRVSLWDO EHGV3DXOLQ7XUDWR
Marlon Miguel Indeed, the psychiatric model implemented during the Brazilian dictatorship ±ZDVEDVHGRQWKHSULQFLSOHRISULYDWHFDUH7KHVWDWHLWVHOILQYHVWHG in the private system, providing the working classes with access to these services through social security policies, subcontracting those same services ZLWKLQSXEOLFKRVSLWDOV7KHSXEOLFV\VWHPZDVWKXVQHJOHFWHGUHD൶UPLQJ once again, the idea of the public psychiatric hospital as a place of isolation, VHJUHJDWLRQDQG³FKURQL¿FDWLRQ´RISDWLHQWVWUHDWHGLQWKHVHLQVWLWXWLRQV±D ]RQHRI³VRFLDODEDQGRQPHQW´Biehl 2005$WWKHVDPHWLPHDQGEHFDXVHRI WKHFDWDVWURSKLFVWDWHRISXEOLFVHUYLFHVWKHGLVFRXUVHHPSKDVL]LQJWKH³H൶ciency” of the smaller, private services began to gain ground. The privatization of the psychiatric sector was accompanied by a huge LQFUHDVHLQKRVSLWDOL]DWLRQV%HWZHHQDQGWKHKRVSLWDOSRSXODWLRQ VZHOOHGE\±DOWKRXJKWKHVDPHQXPEHUMXPSHGWRLQSULYDWHLQVWLWXWLRQVidem3ULYDWHKRVSLWDOEHGVIXQGHGE\WKHVWDWHLQFUHDVHGIURP LQWRLQUHDFKLQJLQWKHQXPEHURISV\FKLDWULF VSDFHVODFNLQJLQSURSHUKRVSLWDOEHGVleito-chão, translated euphemistically DV³JURXQGEHGV´FOLPEHGWRLQWKHSULYDWHKRVSLWDOVidem; Resende 7KHVHQXPEHUVDUHVLJQL¿FDQWLQVRIDUDVWKH\DOVRUHYHDOWKHGRPLQDQW perspective structuring psychiatric discourse: hospitalization. The dominant psychiatric ideology during this period held that the proper place for the mad was away from the public eye and enclosed in the asylum. Lacking in other clinical services to assist, host, and treat patients with mental disorders, the only remaining option was to send them to hospitals. And, furthermore, hospitalization in this discourse implied long-term hospitalization. As all these transformations were taking place, the psychiatric system became a very lucraWLYHEXVLQHVVIRUSULYDWHKRVSLWDOVUHFHLYLQJPRQH\IURPWKHVWDWH±EXWODFNLQJLQJRYHUQPHQWRYHUVLJKW±IRUWKHSDWLHQWVWKH\UHFHLYHG7KHSHULRGLQ TXHVWLRQWKXVEHFDPHNQRZQDVWKHERRPRI³PDGQHVVLQGXVWU\´0HOOR; &HUTXHLUD; Amarante 2011 6WDWLVWLFDO¿JXUHVIURPWKHSHULRGDOVRUHÀHFWWKHDEVHQFHRIVWDWHFRQWURO ,QWKHVLWZDVFDOFXODWHGWKDWPRUHWKDQKRVSLWDOL]HGSV\FKLDWric patients lacked a bed, that hospitalization periods on average lasted seven PRQWKVDQGWKDWWKHPRUWDOLW\UDWHDWSV\FKLDWULFIDFLOLWLHVZDVWLPHVKLJKHU WKDQLQRWKHUKRVSLWDOVIRUFKURQLFGLVHDVHV3DXOLQ7XUDWR$OOWKH while, given the military dictatorship, any type of dissenting voice against the VWDWHRIDV\OXPVZDVRIWHQSDLGZLWK¿ULQJVSHUVHFXWLRQDQGH[SXOVLRQIURP public service. Higher rates of hospitalization during the dictatorship were linked in turn with the shift towards the so-called preventive orientation of prior decades, a SROLF\WKDWDVZHKDYHVHHQZDVSUHPLVHGRQDUDFLVWPRGHO1RWXQOLNHWKH PRGHOLPSOHPHQWHGE\WKH8QLWHG6WDWHVLQWKHVSV\FKLDWU\DLPLQJDW SUHYHQWLQJVRFLDOLQVWDELOLW\WDUJHWHGFHUWDLQSRSXODWLRQSUR¿OHV,QWKH86$ these were segregated minorities: black and poor people, hippies and the drug GHSHQGHQW7KLVSKHQRPHQRQUHÀHFWHGDYHU\SUREOHPDWLF³FRQFHSWXDOVOLSpage,” wherein “social deviation, a by-product of the individual’s political and
Psychiatric Power economic maladjustment” was correlated with “the behaviour of the mentally LOO´%LUPDQ&RVWD7KHSV\FKLDWU\LQVHUYLFHRIWKHVWDWHDQGDV ³PDQDJHURIULVNV´&DVWHOEHFRPHVDGDQJHURXVWRRODQGWKHLQÀXHQFH of this ideology is very present in the Brazilian context. 7KH V DOVR ZLWQHVVHG WKH XSGDWLQJ RI WKH FRPPXQLVWDVHQHP\GLVcourse. This same discourse was accompanied by the revival of a discourse FRQFHUQLQJWKHSDWKRORJLFDODQGLQIHFWLRXVLQ¿OWUDWLRQRIIRUHLJQDJHQWVUHSresenting a disruption of a supposedly natural, organic order. These elements, WRJHWKHUOHQWZHLJKWWRDGLVFRXUVHLQZKLFKWKH¿JXUHRIWKH³PDG´ZDVVWLJmatized, while expanding on the notion of madness and deviation and emphasizing the need for exclusion and isolation. Perhaps no other institution better represents the dramatic situation of the %UD]LOLDQSV\FKLDWULFV\VWHPDVWKH&RORQLDO+RVSLWDORI%DUEDFHQDLQ0LQDV *HUDLV8SRQKLVYLVLWWR%DUEDFHQDLQ)UDQFR%DVDJOLDFRPSDUHGWKH KRVSLWDOWRD³FRQFHQWUDWLRQFDPS´$UEH[DQGLQGHHGLWZDVD SHUIHFWH[DPSOHRID³WRWDOLQVWLWXWLRQ´*R൵PDQQ7KHKRVSLFHZDV IRXQGHGLQDORQJZLWKWKHFUHDWLRQRIWKHFRXQWU\¶V¿UVWSV\FKLDWULFKRVSLWDOVDQGZDVGHVLJQHGDFFRUGLQJWRWKH³FRORQ\´PRGHO±LVRODWHGIURPWKH urban centers, the asylum would be a place where patients were meant to work as part of their treatment, according to the motto Labor/Praxis Omnia Vincit:RUN&RQTXHUV$OO7KHFRORQ\KDGLQLWLDOO\EHHQSURMHFWHGWRKRVW SDWLHQWV'XULQJLWV¿UVWWKUHHGHFDGHVDOPRVWRIWKHKRVSLWDO¶VIXQGLQJ FDPHIURPWKHFRPPHUFLDOL]DWLRQRISURGXFWVKDUYHVWHGWKHUHEHDQVFRUQ SRWDWRHVHWFDVZHOODVIURPWKHSDWLHQWV¶ODERUIRUFHHPSOR\HGIRUDYDULHW\ of activities, such as road maintenance. The colony started to become famous DURXQG DQG JRWTXLFNO\ RYHUSRSXODWHG$URXQGWKLV SHULRG LW ZRXOG DOUHDG\KDYHDERXWSDWLHQWV-RVp&RQVHQVR)LOKR0LQDV*HUDLV6WDWH 1DWLRQDO'HSDUWPHQWRI1HXURSV\FKLDWU\¶VGLUHFWRUDWWKDWPRPHQWGHFLGHG to replace the usual hospital beds by “ground-beds” made of grass, something WKDWZRXOGEHODWHULQDGRSWHGE\RWKHUDV\OXPVRIWKHVWDWH The situation would progressively worsen in the following decades, with LQFUHDVLQJO\PRUHSHRSOHVHQWWRWKHFRORQ\7KHDV\OXPEHFDPHD¿WWLQJV\Pbol for the use of psychiatry as tool for power, beyond its supposed treatment RIPHQWDOLOOQHVV,WLVFDOFXODWHGWKDWRIWKHSDWLHQWVKRVSLWDOL]HGGLGQRW HYHQKDYHDSURSHUPHQWDOGLVRUGHUGLDJQRVLV$UEH[3DWLHQWVZHUHVHQW there for a variety of unrelated reasons: epilepsy, alcoholism, homosexuality, SURVWLWXWLRQVRFLDOGLVRUGHURUWRXQEXUGHQLQÀXHQWLDOPHPEHUVRIVRFLHW\ 0DQ\SUHJQDQWZRPHQZHUHDOVR³KRVSLWDOL]HG´GXULQJWKDWSHULRGWKHYLFWLPV RIUDSH±E\WKHLUERVVHVORYHUVHWF±RUWKHGDXJKWHUVRILQÀXHQWLDOODQGRZQers who had engaged in premarital sex. At least 30 babies were born inside the asylum and were taken from their mothers. 3HRSOHZHUHRIWHQVHQWWR%DUEDFHQDE\WUDLQV±WKHVRFDOOHGtrem dos loucosWUDLQRIWKHPDG±WKDWZRXOGOHDYHFURZGHGDQGUHWXUQHPSW\0RVWRI the individuals were sent there to die or to remain enclosed forever. With one SV\FKLDWULVWIRUHYHU\SDWLHQWVRYHUSRSXODWHGVSDFHVIULJKWIXOFRQGLWLRQV
Marlon Miguel all these elements that were central to the Reform, the hospital-centric model DJDLQUHDUVLWVKHDGDORQJZLWKWKHDOOSRZHUIXOSV\FKLDWULVW±DPHUHSXSSHW DFWLQJRQEHKDOIRIDUDGLFDOO\DXWKRULWDULDQLGHRORJ\WKDWKDWHVGL൵HUHQFH Acknowledgment ,DPJUDWHIXOWRWKH)&7³)XQGDomRSDUDD&LrQFLDHD7HFQRORJLD,3´IRU WKHLU¿QDQFLDOVXSSRUW6WLPXOXVRI6FLHQWL¿F(PSOR\PHQW,QGLYLGXDO6XSSRUW &((&,1'&3&7 Notes 1. IWKDQN1LFRODV$OOHQIRUSURRIUHDGLQJP\WH[W 2. And even inside psychiatric institution employing more humane and experimental DSSURDFKHVWKHVHSUDFWLFHVZHUHWKHH[FHSWLRQ,QWKH\HDUV±IRUH[DPSOH DWWKH-XTXHU\+RVSLWDOZKHUH&pVDUZRUNHGRQO\RISDWLHQWVZRXOG WDNHSDUWLQWKH$UWV6HFWLRQ&DEDxDV 3. Foucault notes that the appearance of the psychiatric hospital in Europe and “masVLYHKRVSLWDOL]DWLRQV´ZHUHDOVRD³SROLFHD൵DLU´LQVSLUHGE\FRQFHUQVYHU\GLYHUJHQWIURP³KHDOLQJ´)RXFDXOW In fact, colonial asylums in particular were conceived as places not only for the PDG EXW IRU DOO WKRVH EUDQGHG XQGHVLUDEOH 5RGULJXHV &DOGDV UHVSRQVLEOH IRU PRYLQJWKH-XOLDQR0RUHLUD+RVSLWDOWRWKH-DFDUHSDJXiQHLJKERUKRRGFODLPHG LQWKDW³EHVLGHVDOFRKROLFVPDGUHWDUGHGGHOLQTXHQWV´WKH$V\OXPZDVDOVR meant for “the undesired enemies of order and the public good, possessed by the red delirium, fanatics of the bloody and dangerous anarchists and communists docWULQHVRI0DU[LVPRU%ROVKHYLVP´5RGULJXHV&DOGDVZLWK+LGDOJR 5. Framed by a cultural and social perspective, although also impacting policies and ideologies, the eugenicist discourse was progressively replaced by that of racial democracy, thanks to authors such as Gilberto Freyre. Freyre’s celebrated formulation emphasized, on the contrary, the positive aspects of Brazilian miscegenation. Despite that, psychiatric institutions would remain a locus of sanctioned exclusion, UHÀHFWLQJWKHVRFLRHFRQRPLFVWUXFWXUHRI%UD]LOLDQVRFLHW\ )RUH[DPSOHDIWHUYLVLWLQJWKH0XVHXPRI,PDJHVRIWKH8QFRQVFLRXVLQ Ronald Laing would recognize her work as essential to the study of psychosis. This was the case of, among others, Paulo Amarante, who, along with two colOHDJXHV ZDV ¿UHG DIWHU GHQRXQFLQJ WKH FRQGLWLRQV LQ WKH DV\OXP ZKHUH WKH\ ZRUNHG$PDUDQWHRU)UDQFLVFR%DUUHWRSHUVHFXWHGE\WKH5HJLRQDO &RXQFLORI0HGLFLQHDIWHU¿OLQJDUHSRUWRQWKH&RORQLDO+RVSLWDORI%DUFHQD $UEH[ 8. Ronald Laing takes a similar stance when he claims that mental illness should not be taken as the natural object that psychiatry takes it to be, but rather an experience of the subject in their relationship with the socius. However, his position concerning pathology seems much more relativistic, where the division between the “norPDO´DQGWKH³SDWKRORJLFDO´DSSHDUVWREHH[WUHPHO\EOXUUHGFI/DLQJ 2QHFDQUHYLVLWWKHWHUP³SV\FKRVRFLDOPHGLFLQH´DVLWDSSHDUVLQWKH%ULWLVKFRQWH[WDURXQGPLGWKFHQWXU\LQ-DPHV/+DOOLGD\¶VZRUN 10. The USA, for example, saw the emergence of “deinstitutionalization” practices PHDVXUHVWDNHQWRKHOSWKHSDWLHQWVZKHQWKH\OHDYHWKHKRVSLWDODQGDFRPPXQLW\ care logic, in which the creation of mental health centers, outpatient care, clinical residences, shelters, and day-hospitals ended up contributing to the medicalization of life and even more demands from people concerning these services.
Psychiatric Power 11. 7KH¿UVW&$36XQLWRSHQHGLQLQ6mR3DXOR6HYHUDOXQLWVZHUHDOVRFUHDWHG LQ6DQWRVDIWHUWKH&DVDGD6D~GH$QFKLHWDZDVVKXWGRZQ7KH&$36DUHORFDOWHUritorial, outpatient assistance structures. Their guiding inspiration was to open up the PHQWDOKHDOWKVHFWRUDQGFRQQHFWZLWKFLYLOVRFLHW\7KHUHDUH¿YHW\SHVRIVWUXFWXUHV DQGVRPHIXQFWLRQKRXUVZLWKWKHFDSDELOLW\RIWUHDWLQJVXEMHFWVGXULQJFULVHV'LIferent from hospitals, they are open spaces and allow the patient to be accompanied E\UHODWLYHV7KH&$36DUHDOVRHQFRXUDJHGWRFUHDWHGL൵HUHQWNLQGVRIUHODWLRQDO clinical, and expressive activities, with the aim of reducing medication and preventing hospitalization. They are open to professionals of other areas, such as artists who can organize activities there and are invited to interact with the local territory. 12. 3V\FKLDWULVW4XLULQR&RUGHLURVHUYHGDV7HPHU¶VJHQHUDOFRRUGLQDWRUIRUWKH0HQWDO +HDOWK$OFRKRODQG'UXJV6HFWLRQRIWKH0LQLVWU\RI+HDOWKDQGLVQRZ%ROVRQDUR¶V1DWLRQDO6HFUHWDU\RI&DUHDQG'UXJV3UHYHQWLRQLQWKH0LQLVWU\RI&LWLzenship. He is a clear supporter of forced hospitalization and defends that mental healthcare should be separated from drugs-addiction policies transforming drugs LQWRDSULPDULO\³SROLFHD൵DLU´ References Amarante, Paulo, ed. 2011. Saúde mental e atenção psicossocial5LRGH-DQHLUR)LRFUX] Arbex, Daniela. 2018. Holocausto Brasileiro. Genocídio: 60 mil mortos no maior hospício do Brasil. São Paulo: Geração Editorial. ———. 2013. Holocausto Brasileiro. São Paulo: Geração Editorial. %DVDJOLD)UDQFRHG³&RUSVUHJDUGHWVLOHQFH/¶pQLJPHGHODVXEMHFWLYLWpHQ psychiatrie” [Body, viewpoint, and silence: The enigma of subjectivity in psychiaWU\@L’Evolution Psychiatrique± ²²²A instituição negada: relato de um hospital psiquiátrico5LRGH-DQHLUR Edições Graal. %LHKO-RmR*XLOKHUPHVita: Life in a Zone of Social Abandonment2DNODQG 8QLYHUVLW\RI&DOLIRUQLD3UHVV %LUPDQ-RHO³2QHJURQRGLVFXUVRSVLTXLiWULFR´,QCativeiro e liberdade, edited by -DLPH'D6LOYD3DWUtFLD%LUPDQDQG5HJLQD:DQGHUOH\±5LRGH-DQHLUR8(5- %LUPDQ-RHODQG-XUDQGLU)UHLUH&RVWD³2UJDQL]DomRGHLQVWLWXLo}HVSDUDXPD psiquiatria comunitária.” In Psiquiatria social e reforma psiquiátrica, edited by $PDUDQWH3DXOR±5LRGH-DQHLUR)LRFUX] %UDVLO &RQVHOKR )HGHUDO GH 3VLFRORJLD Hospitais Psiquiátricos no Brasil: Relatório de Inspeção Nacional: 2018%UDVtOLD&)3$YDLODEOHDWhttps://site.cfp. org.br/publicacao/hospitais-psiquiatricos-no-brasil-relatorio-de-inspecao-nacional/. %UDVLO0LQLVWpULRGD6D~GH³1RWD7pFQLFD(VFODUHFLPHQWRVVREUHDVPXGDQoDV QD 3ROtWLFD 1DFLRQDO GH 6D~GH 0HQWDO H QDV 'LUHWUL]HV QD 3ROtWLFD 1DFLRQDO VREUH 'URJDV´ &RRUGHQDomR 1DFLRQDO GH 6D~GH 0HQWDO ÈOFRRO H 2XWUDV 'URJDV 1RYHPEHU$YDLODEOHDWZZZDEUDVFRRUJEUVLWHZSFRQWHQWXSORDGV BBBB1RWDB7H&&FQLFDBQRBB(VFODUHFLPHQWRVBVREUHBDVB PXGDQF&&$DVBGDB3ROLWLFDBGHB6DX&&GHB0HQWDOSGI. &DEDxDV.DLUD0DULHLearning from Madness: Brazilian Modernism and Global Contemporary Art&KLFDJR7KH8QLYHUVLW\RI&KLFDJR3UHVV &DVWHO5REHUWLa gestion des risques3DULV/HVeGLWLRQVGH0LQXLW &HUTXHLUD/XL]Psiquiatria social: problemas brasileiros de saúde mental. São Paulo: Atheneu. &RVWD-XUDQGLU)UHLUHHistória da Psiquiatria no Brasil5LRGH-DQHLUR*DUDPRQG
Marlon Miguel 'HOJDGR3HGUR*DEULHO³$SVLTXLDWULDQRWHUULWyULRFRQVWUXLQGRXPDUHGHGH atenção psicossocial.” In Saúde em Foco: informe epidemiológico em saúde coletiva. Saúde Mental: a ética de cuidar5LRGH-DQHLUR6HFUHWDULD0XQLFLSDOGH6D~GH9, ± ²²²³5HIRUPDSVLTXLiWULFDHVWUDWpJLDVSDUDUHVLVWLUDRGHVPRQWH´Trab. educ. saúde5LRGH-DQHLUR(SXE$YDLODEOHDWKWWSG[GRLRUJ VRO. )RXFDXOW0LFKHO+LVWRLUHGHODIROLHjO¶kJHFODVVLTXH. Paris: Gallimard. *R൵PDQ(UYLQJAsylums. Essays on the Social Situation of Mental Patients and other Inmates1HZ<RUN$QFKRU%RRNV Hidalgo, Luciana. 2011. Arthur Bispo do Rosário. O senhor do labirinto5LRGH-DQHLUR Rocco. ,%*(,QVWLWXWR%UDVLOHLURGH*HRJUD¿DH(VWDWtVWLFDVEstatísticas do século XX. /DLQJ5RQDOG'DYLGThe Politics of Experience and The Bird of Paradise0LGdlesex: Penguin. 0DFKLQ5RVDQDDQG$QGUp0RWD³(QWUHRSDUWLFXODUHRJHUDODFRQVWLWXLomR GHXPDµORXFXUDQHJUD¶QR+RVStFLRGH-XTXHU\HP6mR3DXOR%UDVLO±±´ In Interface. Comunicação, saúde, educação9RO%RWXFDWX$YDLODEOHDW KWWSG[GRLRUJLQWHUIDFH. 0HOOR&DUORV*HQWLOHSaúde e assistência médica no Brasil5LRGH-DQHLUR &(%(6 0HOOR/XL]&DUORVNise da Silveira: caminhos de uma psiquiatra rebelde. Rio de -DQLHUR$XWRPDWLFD(GLo}HV/WGD5LRGH-DQHLUR+yORV&RQVXOWRUHV$VVRFLDGRV 0RWWD5RGULJR3DWWR6i ³(P *XDUGD &RQWUD R 3HULJR9HUPHOKRR$QWLFRPXQLVPRQR±´'RFWRUDOGLVVHUWDWLRQ8QLYHUVLGDGHGH6mR3DXOR 2GD$QD0DULD*DOGLQL5DLPXQGR³$OLHQDomRPHQWDOHUDoDDSVLFRSDWRORJLD FRPSDUDGDGRVQHJURVHPHVWLoRVEUDVLOHLURVQDREUDGH5DLPXQGR1LQD5RGULJXHV´ 'RFWRUDOGLVVHUWDWLRQ8QLYHUVLGDGHGH&DPSLQDV$YDLODEOHDWhttp://repositorio.uni FDPSEUMVSXLKDQGOH5(326,3. 2XU\-HDQ³8WRSLHDWRSLHHWHXWRSLH´,QRevue Chimères6SULQJ±6XPPHU Les arts de l’éco. 3DXOLQ/XL])HUQDQGRDQG(JEHUWR5LEHLUR7XUDWR³$QWHFHGHQWHVGDUHIRUPD SVLTXLiWULFDQR%UDVLODVFRQWUDGLo}HVGRVDQRV´História, Ciências, Saúde 0D\±$XJXVW±5LRGH-DQHLUR)XQGDomR2VZDOGR&UX]$YDLODEOH at: KWWSG[GRLRUJ6. 3HGURVD0DULRArte, forma e personalidade: 3 estudos6mR3DXOR.DLUyV 3RUGHXV9LWRUZLWK+HULWDJH3DXO³µ0DGQHVV\HWWKHUH¶VPHWKRGLQLW¶7KH 6KDGRZRIWKH'RFWRULQ+DPOHW¶0LUURU´,QPsychoanalytic Perspectives on the Shadow of the Parent. Mythology, History, Politics and Art HGLWHG E\ -RQDWKDQ Burke. London: Routledge. 5HFKHUFKHV -RXUQDO Histoire de la psychiatrie de secteur ou le secteur impossible0DUFK&(5), 5HFKHUFKHV-RXUQDOHistoires de La Borde. L’organisation du travail à la clinique de Cour-Cheverny (1953–1963)0DUFK±$SULO&(5), 5HLV-RVp5REHUWR)UDQFR³+LJLHQHPHQWDOHHXJHQLDRSURMHWRGHµUHJHQHUDomR QDFLRQDO¶ GD /LJD %UDVLOHLUD GH +LJLHQH 0HQWDO ±´ 0DVWHU WKHVLV 8QLYHUVLGDGHGH&DPSLQDV$YDLODEOHDWhttp://repositorio.unicamp.br/jspui/handle/ 5(326,3.
Psychiatric Power 5HVHQGH+HLWRU³3ROtWLFDGHVD~GHPHQWDOQR%UDVLOXPDYLVmRKLVWyULFD´,Q Cidadania e loucura: políticas de saúde mental no Brasil, edited by Benilton Bezerra -~QLRU6LOYpULR$OPHLUD7XQGLVDQG1LOVRQGR5RViULR&RVWD3HWUySROLV9R]HV 5RWHOOL)UDQFRDQG$PDUDQWH3DXOR³5HIRUPDVSVLTXLiWULFDVQD,WiOLDHQR%UDsil: aspectos históricos e metodológicos.” In Psiquiatria sem hospício. Contribuições ao estudo da reforma psiquiátricaHGLWHGE\%HQLOWRQ%H]HUUD-UDQG3DXOR$PDUDQWH±6mR3DXOR5HOXPH'XPDUi 5R[R+HQULTXHGH%%³3HUWXUEDo}HVPHQWDLVQRVQHJURVGR%UDVLO´Brazil Médico±± 6WHSDQ1DQF\/H\V³(XJHQLDQR%UDVLO±´,QCuidar, controlar, curar ensaios históricos sobre saúde e doença na América Latina e CaribeHGLWHGE\&DULEH *LOEHUWR+RFKPDQDQG'LHJR$UPXV±5LRGH-DQHLUR(GLWRUD),2&58= :+2:RUOG+HDOWK2UJDQL]DWLRQ³$5HSRUWRIWKH$VVHVVPHQWRIWKH0HQWDO +HDOWK6\VWHPLQ%UD]LOXVLQJWKH:RUOG+HDOWK2UJDQL]DWLRQ±$VVHVVPHQW,QVWUXPHQWIRU0HQWDO +HDOWK 6\VWHPV:+2$,06´:+2DQG0LQLVWU\RI +HDOWK Brasília, Brazil. Available at: www.who.int/mental_health/evidence/who_aims_ report_brazil.pdf.