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martes, 8 de marzo de 2011

MENTAL HEALTH POLICY IN COLOMBIA: HIGHS AND LOWS

David Alberto Campos Vargas, MD

President Carlos Lleras Restrepo (1966-1970) was the foundational figure for the improvement of mental health conditions in Colombia. One of the greatest Colombian statesmen ever, he led an impeccable presidency from a coalition between liberals and conservatives within the framework designed by Laureano Gómez Castro and Alberto Lleras Camargo at Sitges and Benidorm (the National Front agreements).

The National Front intended, among other aims, to heal the wounds inflicted by partisan violence, which had degenerated into barbarism since the murder of popular leader Jorge Eliécer Gaitán in 1948, but actually much older (e.g. the Thousand Days' War or the numerous civil wars of the 19th century). Although a radical liberal in his youth, President Lleras decorously assumed his commitment to the National Front duties imposed on his term. This was why he allowed co-governance between liberalism and conservatism, as had his predecessors Alberto Lleras Camargo and Guillermo León Valencia (son of the remembered poet and statesman Guillermo Valencia), and as would his successor Misael Pastrana Borrero.

Being a learned man and an economist, Carlos Lleras strived for a "technical" style of leadership, oriented towards economic recovery, social stability and the then-needed social and land reforms. He was perhaps the first politician who was truly concerned with improving the people's mental health conditions by addressing the basic problems underlying underdevelopment at several fronts: a) Stability policy, both by continuing the cease-fire proposed by the "Peaceful President" Guillermo León Valencia, and by securing the parity of public positions and quotas between liberals and conservatives; b) A stable economic expansion, with no jolts, with a controlled inflation and meeting the World Bank's requirements; c) Farm loans for the peasants (still impoverished, recovering from the onslaught of partisan violence and with disadvantaged access to health services; d) Efforts against unemployment (considering the high rate of violence refugees coming from rural areas into the cities); and e) Decrease in the mortality rate.

As he pointed out, the key factor was "Keeping the people in harmony and the cities in balanced strength (...) improving the living conditions of immigrants and encouraging their permanent settlement." This moved him to seek conciliation between liberals and conservatives and work to promote the cause of peasants. He was the first to create clearly defined assistance programs for mothers and infants, as well as family planning services.
Besides, he allowed the emergence of Movements for Communal Action and Peasant Organizing, which his successor Misael Pastrana Borrero (1970-1974) would continue to support. Pastrana appropriated Lleras's rural objectives, created the Rural Fund and enacted policies to promote and support the peasantry.

Pastrana's charisma and humanness embodied the yearning for peace that Colombians felt during the early 1970s. His intentions were clear: "We require a social front to integrate a divided Colombia (...) a fraternal march towards common progress, a nationwide rally against misery, ignorance, disease, unemployment and gloom (...) economic development cannot be divorced from social development and the improvement of the masses as a social group."

Pastrana delineated clearly his plan, called the "Four Strategies." One of them, that of Social Welfare, had indirect beneficial consequences on the mental health of Colombians:
- Increase in life expectancy.
- Incentives against brain drain.
- Inclusion of women in the economy via "the creation of mechanisms to offer equal opportunities for women in social, economic and politic life."
As he himself said during one of his speeches, "We need a renaissance, a re-creation of existence. A happy people is a people called to meet a prosperous future."

The 1974 elections were an interesting match between three children of former presidents: Alfonso López Michelsen (son of Alfonso López Pumarejo), Álvaro Gómez Hurtado (son of Laureano Gómez Castro) and María Eugenia Rojas (daughter of dictator Gustavo Rojas Pinilla). López Michelsen eventually won, and placed his bets on a socialist government inspired by the "progressive" liberal faction: the Liberal Revolutionary Movement.
López's concerns included the precarious conditions of Colombian children (60% undernourishment rate), which moved him to create the National Alimentation and Nutrition Plan. He was convinced that a good mental development required a sufficient protein intake. Via the Law 27 of 1974, he created the Centers for Integral Services to Pre-schoolers. His efforts to build aqueducts and drainage systems were key in the improvement of sanitary conditions for all Colombians.

He also devised a program of Rural Promoters of Health, designed to offer health services for women and infants. His goal was "to lessen the health services gap between urban and rural populations." Indeed, his administration's motto was "To close the gap."

Like Pastrana, López was resolute to increase the capacity of hospitals, create more health services, and multiply the paramedic and auxiliary personnel. He managed to pass the law that transfers the profits from alcoholic beverages and lotteries to the hospitals.

Julio César Turbay Ayala, a liberal party-liner and a friend of López's, served as President since 1978. Seeing that health coverage was still scarce, he supported the creation of Employee Benefit Funds to address Social Security's missing coverage. He continued Lopez's battle against undernourishment of mothers and infants, and shaped a National Policy for Services to Minors.

With a style clearly opposed to his father's, Álvaro Gómez Hurtado proposed a conciliatory approach. From the Senate and the media (the newspapers El Siglo and El Nuevo Siglo and the 24 Horas newscast) he was an advocate for education in Colombia. His motto, “Education towards Labor,” may explain the unusual support the popular class gave to this conservative. His intensive non-formal education programs, aided by radio programs and rural schools, helped a sizable portion of the proletariat to overcome illiteracy and enter elementary education. He also devised educational programs for the minorities (a proposal that was heeded only a decade later) and special educational programs for children with learning disabilities. However, he was suprisingly defeated in the Conservative Party primary elections by a unique pre-candidate, Belisario Betancur Cuartas.

The Liberal Party went divided to the 1982 elections. One one hand, young members of New Liberalism (among them Rodrigo Lara Bonilla, whom Betancur would appoint as Justice Minister) supported lawyer Luis Carlos Galán Sarmiento; on the other hand, the liberal “heavyweights”, fully supported by the then-extant administration, supported ex-president López Michelsen. With his oratory and his innovative style, Betancur Cuartas won.
Despite the continuing mishaps (M-19's assault upon the Justice Palace, escalation of drug terrorism, the Armero catastrophe), Betancur's government seems to have had the best of intentions. He sought integration with several factions of the Liberal Party: ex-president Lleras, supporters of Galán, some dissident supporters of Turbay. He even came close to Gómez Hurtado, who as Presidential Designate and Senator was key in the realization of the policies of his National Education System: a) National Instruction Campaign, which encompassed formal and non-formal education initiatives, b) the creation of Colciencias, Colcultura and Coldeportes; c) the creation of the National University Open and Distance.

Betancur was fond of speaking of “greater opportunities for human self-improvement,” and his skillfully woven discourse (which was once described by poet and statesman Germán Arciniegas as “Social Democrat for the liberals, Democratic Christian for the conservatives”) always emphasized “family and community,” without abandoning the typical Latin American assistentialism, but also with some hints of developmentalism---perhaps influenced by Álvaro Gómez.

Betancur's pacification efforts should not be forgotten. His measures were sometimes merely symbolic (the memorable peace doves painted all throughout Colombia), other times pragmatic (peace talks with guerrilla groups), in ocassions technical (the National Commission for Crime Prevention). Sadly, they ended up not being enough for the degree of chaos and social disintegration then ailing Colombia. The Medellín Cartel murdered his Justice Minister Rodrigo Lara Bonilla, who had managed an unprecedented restructuring of the Ministry of Justice and the National Institute of Forensic Medicine, the signing of the extradition law and an increase in the number of courts, specialized judges and criminal law judges. By the end of Betancur's term, sanitation services had had their coverage expanded from 50% to 70%. His desire to give Colombians access to potable water resonated in engineer Virgilio Barco Vargas, a liberal veteran who defeated Álvaro Gómez in the 1986 elections.

Barco's achievements in health policy include notably the Basic Health For All program, which achieved an expansion from 70% to 80% in hospital bed availability, as well as numerous civil works and new medical equipments. However, community health, maternal/infantile nutrition and health promotion programs were severely restricted because his administration was focused on attaining economic and military alignment with the United States, expressed mainly in the war against drug cartels and in the upcoming economic opening.

Within that tense ambiance, the proposals of Luis Carlos Galán Sarmiento were gaining majoritarian favoritism. As was Lara, Galán was a symbol of integrity and all-out war against drug traffic. He represented a new generation in politics---a self-made outsider with a likable style, halfway between Gaitán and Lleras. His victory was already taken for granted. Pardo Leal's murder had evidently weakened the Unión Patriótica party, and opinion polls bade poor results for Álvaro Gómez Hurtado despite his daring multi-party proposal (the National Salvation Movement, a patchwork collection of old supporters of Laureano Gómez, Catholic liberals, university students, leftists and even some indigenists).

The dream crumbled down with Galan's murder, the final act in a most sanguinary presidential campaign (two other candidates, Carlos Pizarro and Bernardo Jaramillo, had been killed too). The appointment of César Gaviria Trujillo as his successor diminished the campaign's strength, but those stray votes did not suffice for tne National Salvation Movement: amid popular disillusionment, the “Galán-less Galánism” won the presidency in 1990.

Gaviria's administration (1990-1994) was aimed towards what he termed “The Peaceful Revolution.” Its joking name in the media was “The Whirl.” He began by appointing a civilian as Defense Minister---a dexterous maneuver, particularly necessary in coup-prone Latin America; and then he selected a set of young professionals, some of them previously unknown in politics, who were nicknamed the Kindergarten Cabinet. President Gaviria summoned a Constituent Assembly and proclaimed, not without some affectation, “Welcome to the Future.”

The National Constituent Assembly was an undertaking that filled several social factions with illusion. Three representatives were included from the the then-strongest political parties (Horacio Serpa from the Liberal Party, Álvaro Gómez from the Conservative Party, and Antonio Navarro from the M-19, which had abandoned guerrilla warfare a few years earlier). Its final product, the 1991 Constitution, turned out to be an ideological step forward---yet unfortunately a project still to be fully realized. That Constitution states that health is part of all instances of national activity and has a relevant effect on the present and future lives of all Colombians.

The 1991 Constitution clearly affirms a new conception of mental health from a rights perspective, rather than a service one. Article 49 establishes health attention and environmental sanitation as public services, as well as the State's role in guaranteeing access to health promotion, protection and recovery.

During Gaviria's term, pension funds were created, a new Labor Code was signed into law, ethnoeducation and professionalization of Natives were promoted, and women's education was emphasized under the premise that educated women would result in smaller families and healthier children.

However, the Constitution required an overhaul in the national sanitation system. Thus, in 1993 Law 100 was passed. This law, termed General System for Social Security Act, and mostly prepared by Health Minister Juan Luis Londoño de la Cuesta, and then ratified by Labor Minister Luis Fernando Ramírez and President Gaviria, followed along the same lines as the Constitution devised by Gómez Hurtado and the rest of he Constituent Assembly: the welfare of individuals, families and collectives.

Before Law 100 of 1993, sanitation services depended on the Ministry of Health. Now they are independent from the State and are subject to the law of markets, under which they must earn their financial sustainability. This also applies to mental health services.

The principles of this law (equity, solidarity, mandatory status, integral protection, quality, social participation) are yet to be fulfilled, as is the case of many laws in Colombia.

In 1994, former Development Minister Ernesto Samper Pizano was elected with a slight advantage over Andrés Pastrana Arango. As soon as the links between his campaign and the Cali Cartel were made evident, the legitimacy of his mandate was questioned. The accussations against his government escalated up to the resignations of his Vice-president Humberto de la Calle and his Defense Minister Fernando Botero Zea and an impeachment investigation (the 8,000 Process). The power crisis became unmanageable; strikes and popular discontent, as well as the hard criticism from the opposition, made his administration impracticable. Samper hardly managed to stay in power amid a heavily polarized citizenry.

After the murder of Álvaro Gómez Hurtado (still under investigation), the other visible head of the opposition, Andrés Pastrana Arango, won the 1998 elections against Horacio Serpa Uribe, former minister under Samper and also involved in the scandals surrounding the impopular president. A National Policy on Mental Health was implemented in 1998. This milestone in the history of mental health in Colombia was the first time in which the government proposed a planning methodology with clear guidelines and concrete goals (which was an advance if compared with the isolated efforts of previous administrations). It had a goal of developing regional mental health policies, and included European-style measures, such as the creation of associations for persons with mental illnesses and their families.

Then came Law 715 of 2001, which put health promotion and prevention activities within the framework of the Basic Assistance Plan, which was a new tool for allocation of resources. However, Pastrana's focus on the failed peace talks with the FARC guerrillas and the overall instability caused by their (and other groups') large-scale terrorism affected his popularity seriously. Unlike his father, Misael Pastrana Borrero, Andrés Pastrana ended his term with a high disapproval rate: his presidency would be remembered as one of the worst in Colombian history.
In 2002, while Colombia underwent an alarming insecurity situation, where the State was powerless to contain outlaw groups, Álvaro Uribe Vélez emerged as a savior figure. His center-right leanings (despite his Liberal Party affiliation), his “Democratic Security” discourse and his firm aversion to guerrilla groups arrived at the precise moment to gain him massive voter support---54% of the votes gave him an easy victory in the first round of elections, defeating more experienced contenders as Horacio Serpa and Noemí Sanín. His efforts were immediately channeled towards refurbishing and reorganizing the military forces and implementing a confrontational policy against subversives, which ensured his popularity. He established a communitarian state system with fascist undertones and some ingredients from Latin American populism (convergence among development policies, assistentialism and state paternalism), in which the figure of the president stands out for his austerity and closeness to the people via Communitarian Councils to raise sympathies even in remote regions.
His “strongman” image, his achievements in national security and the public perception of having a solid, combative leader, willing, in his own words, to “work, work and work,” determined his rising popularity. He continued the efforts to consolidate the National Policy on Mental Health of 1998, even though it was not among his governmental priorities. He appointed Juan Luis Londoño as Health Minister and began a continuing disassembly of outlaw groups, a task which was trusted to the High Commissioner for Peace, psychiatrist and writer Luis Carlos Restrepo.

Minister Londoño always insisted that “the mental health conditions of Colombians have a significant influence on the economic and social development of the country.” Unfortunately, he was not able to realize his project: while still serving as Health Minister, he died in an aircraft accident.

Luis Carlos Restrepo did have the chance to meet his goals and achieved the disassembly of a sizable portion of the United Self-Defense Forces of Colombia. In an unprecedented event, hundreds of paramilitary troops surrendered their weapons and submitted to the new Justice and Peace Act.

President Uribe, despite his criticized right-wing and openly pro-American positions, secured a place for himself in Latin American politics: he established key military and economic alliances, as well as the support of many nations for the negotiations with subversives. He deftly maneuvered to have the Constitution modified for him to be allowed a second term. His wide citizen support, an immense political infrastructure behind him, and the goal to continue his “Democratic Security” policy of warfare against the guerrillas, he won a landslide re-election in 2006. Uribism was surpassing all expectations: it had reached a 72% domestic approval rate and a righteous statesman image abroad, in spite of Europe's strong criticism of his human rights record.

Once the disassembly of the United Self-Defense Forces was nearly accomplished, Luis Carlos Restrepo faced another hardship: the emergence of new far-right and paramilitary groups, such as the Black Eagles band. Opposition parties (like Polo Democrático Alternativo) disapproved of his work, and Uribe himself gave him increasingly less support. He ended up becoming a figure of no transcendence.

Some members from the Colombian Psychiatric Association (Cecilia de Santacruz, Carlos Iván Molina, Deyanira Ortiz, Sara Ardila, José Posada, Jorge McDouall, María Cristina de Taborda) convened to propose a National Policy on the Field of Mental Health. They pointed out the status of mental health as global capital and warned of the dangers of not having state intervention on the pursuit of mental health (limited growth of global capital, impeded social and living conditions, perpetuation of negative conditions affecting the country).

This proposal views mental health as a transformative force that contributes to solve the national problems (armed conflict, deterioration of social conditions, poverty, suffering, disability, and so on). This means going from an understanding of mental health as assistance of mental illness to one of the possibility of emotional well-being for all Colombians.

The proposal was built on the pillars of development, human rights, social inclusion and the concept of global capital, which encompasses all economic, social, cultural and symbolic wealth. This makes Colombians responsible for spreading a wider view of mental health and its social implications, transcending disease and health facilities. Mental health thus becomes a complex field that involves health, disease, problems, resistance and physical resources, diverse froms of emotional and relational well-being and distress. It is no longer merely about the assistance of psychopathology.

Law 1122 of 2007 had already set a precedent in which all Public Health Plan must include actions aimed towards the promotion of mental health, treatment for the most prevalent disorders and prevention of violence, abuse, drug addiction and suicide. However, the new proposal speficies that “it is possible to lack mental health without suffering from mental illness,” according to which mental health must be perceived as a colective and individual valuable, of symbolic, emotional and relational nature, desirable inasmuch as it contributes to human and social development, generates global (social, cultural, symbolic, economic) capital and makes it possible to acknowledge, guarantee, exercise and restitute citizen rights.

Mental health is thus seen as a transformative force, capable of modifying living conditions and situations by taking actions aimed towards increasing global capital, social and human development and respect for individual, family and community rights. This would result in social achievements such as a) building an egalitarian, inclusive society; b) giving dignity to the life of every Colombian; c) full citizen participation; d) proper use and care of social goods and services; and e) widespread access to the means of production and development. However, in a country that is still polarized by conflictive actors entrenched in violent fanaticism, this utopia remains unworkable.
Our current situation is too far from the ideal: Uribe is preparing for a possible third term, with all his interest focused on continuing the war and establishing a full right-wing state. Citizens have still not internalized their legal rights and duties, and persist in their regressive, infantilized, politically immature lethargy, fostered by Uribe's paternalism. Human rights are not guaranteed, which makes adequate conditions for mental health not secure. Social exclusion still feeds the emergence of mental disorers. Poverty, war, migratino, margination, lack of education, crime and inequity still go on affecting the mental health of Colombians.

Mental patients experience a precarious situation of social vulnerability: they are poorly represented, still stigmatized and largely at the bottom of the economic pyramid. Public opinion still holds them to be violent and unpredictable, leaving them at the mercy of social drift and all its unemployment-related consequences.

Wealth distribution inequality in Colombia is alarming: the rich-poor gap has a huge Gini coefficient of 0.584. A 46% of Colombians live in poverty---half of which live in extreme poverty. A 27.63% of Colombians have their basic needs un met. Uribe's populism barely suffices to meet even a small portion of that population; state help (e.g. Families in Action) is often misallocated. But this is not only Uribe's fault: Pastrana erred, too, in favoring the big economic conglomerates; Samper erred in allowing that many privatizations and in leaving the peasantry helpless; Gaviria erred in opening the economy with no due previous examination; Barco erred in having served as the United States' puppet. The chain goes all the way back to Francisco de Paula Santander, whose loans from English bankers marked the beginning of our bundersome foreign debt.

An added problem is migration. A 20% of the Colombian population migrate, half of them abroad. The most frequent causes are poverty and violence. Colombia has the world's second-largest number of refugees, which is the visible consequence of war and intolerance, linked to the emotional pain of millions. Armed violence costs Colombia the 7.4% of its GDP.

There is another type of violence: besides the atrocities commited by outlaw armies, there is a violence which is less spectacular but just as harmful: the negation of the other, the lack of empathy and solidarity; that violence which leads to homicidal fanaticism and the denial of the other, polarization, insensitivity to needs and suffering, and the loss of the sense of community. That violence keeps us in underdevelopment, ignorance and unhappiness, and feeds from them as well, resulting in the loss of hope. Without hope we cannot be expected to make any progress.

To regain hope and attain mental health, we must work together, as a collective, as a nation, towards the path of peace, human development and welfare: this involves a common effort to increase our global capital and progress. This requires full citizen participation, with efficient community networks, better nutrition and housing, widespread access to education, the reduction, if not the elimination, of insecurity and armed violence and the definitive end of intolerance, indifference and economic disadvantagedness.

This presupposes an understanding of the reciprocal link between mental health conditions and the nation's social, symbolic, cultural and economic capital. This is why beliefs that sustain violence must be changed, family and social interactions must be improved, full citizen inclusion must be supported, and the multiple initiatives aimed towards human development, quality of live and citizen solidarity must be given free expression.

In other words, we need integrality, synergy and joint efforts; diverse interventions in various social intances: all the necessary actions to guarantee permanently and sustainably the rights of the entire population, lessen the psychosocial impact of armed conflict and forced migration, and improve the social welfare and quality of life. As said by the proponents of the new  National Policy on the Field of Mental Health, people need to "feel good where they are, access the services they need, perform the activities they choose, and attain the full realization of their autonomy and dignity."

Tomado de: David Alberto Campos, Translated works

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