INVITED EDITORIAL
Brief history of psychiatry in Brazil: from the colonial period to the present
Luiz Salvador de Miranda-Sá Jr.
Psychiatry comprehends three types of concepts that are different, although being correlated: care, knowledge and teaching of psychiatric knowledge. Since it is not possible to include this whole universe, this editorial will only deal with one aspect of the first concept: public psychiatric care.
Care to patients in colonial Brazil was extremely precarious. Most cares were provided by healers of all types, including catholic priests (especially Jesuits). Graduated physicians were very rare, and even licensed surgeons and barbers were hard to be found, unless in large cities, and mainly served important people. There were no specialists in psychiatry, but hospitals part of Irmandade da Santa Casa sheltered, more than provided care to, most critical patients. Those who were homeless and had no resources. The poorest of all did not even have a grave in a churchyard to be buried, so they had to be buried in common graves. "Decent" burials only started occurring outside churchyards in the 19th century. Until the 18th century, hospitals worked as shelters for sick people who had nobody to take care of them. Hospitals part of Irmandades das Santas Casas de Misericórdia sheltered these patients under very poor sanitary conditions, even for that historic and social moment.
Between the late 18th century and early 19th century, with the advancement of the scientific knowledge and social awareness, medicine started acquiring its current shape. The French Revolution, in the political context, and scientific advances related to the Industrial Revolution, in the economic context, were the most significant influences in this process. It was at that moment that care to mental patients became medical. It has its origins in France, with the reform sponsored by Pinel and established by Esquirol, and that served as a model for changes in psychiatric care all over the Western world. At that time, care to mental patients became a medical and state responsibility. In Brazil, it was also at that moment that public psychiatric care was born, already reformed according to current values.
Brazil had gone through major social, economic and political changes. The Portuguese court had fled to Rio de Janeiro in a hurry, moved by the invasion of Napoleonic troops; the country was no longer a colony and had been transformed in a united kingdom between Portugal and Algarve, which represented a great promotion in its political status. Opening of harbors, the end of prohibition of economic and educational activities that had characterized the colonial regime originated a new economic, cultural and political situation. Independence, overcoming of absolute monarchy and adherence to economic liberalism were characteristics of that moment and had consequences in all aspects of national life - including in psychiatric care.
Beginning of urbanization, a premise and consequence of that change, transformed the physiognomy of Rio de Janeiro, Ouro Preto and Salvador (the only Brazilian cities that could really be considered "urbanized") and, on the other hand, created, expanded and exposed new sanitary problems. One of them concerned psychiatric patients, who were inoperative in small rural communities, but became visible and disturbing in an urban environment. Taking care of them became a burden hard to be endured even by their own families, both in objective and subjective aspects.
Hospício do Rio de Janeiro was inaugurated as part of the celebration of Emperor Pedro II's Declaration of Majority and was already created modern, since it was based on the French model and served as a paradigm for others who came next. It was a medical establishment with the aim of recovering diseased individuals. It is now used by Universidade Federal do Rio de Janeiro. It is a luxurious palace, more than any other from that time, more than the Royal Palace at Praça Quinze or São Cristóvão's palace, and was compared to Palácio Guanabara, built to serve as housing for D. Isabel, crown princess, when she got married many years later. A similar situation occurred in the provinces. As in Rio, many of those hospitals were wonderful palaces for that time.
Those are the facts about severe mental diseases, which curiously originated two opposed interpretations. Optimistic historians explain them as being a result from Christian charity, from the desire of mitigating suffering, of sympathizing with those who suffer from a disease that is feared by all. Pessimistic historians, in turn, attribute them to a desire of hiding poverty and madness, of increasing the patient's suffering. They are both probably partially right.
Despite majestic buildings, lack of efficacious resources to treat individuals and patients' poverty determined their progressive deterioration and decline, even if increase in diseased population demanded a system expansion, by enlarging their units. Between the 1920's and the 1930's, a first reforming effort could be seen: Juliano Moreira and Ulisses Pernambucano were the pioneers. Ulisses distinguished services for acute and chronic psychotics, established an open service for a treatment in a free-pension regime, created a special education system and a mental health service. But he did not live long enough to follow the development of his work, neither to see his creation deteriorate.
As the lack of specific medication for psychiatric patients continued, the process of public psychiatric care deterioration in Brazil, as in the rest of the world, progressed and worsened. Deterioration could only be stopped with discovery of psychotropic drugs, which allowed effective treatment of mental disorders. This was the psychopharmacological revolution. After penicillin, which effectively treated syphilis, neuroleptics and antidepressants followed, changing individuals with major psychoses into outpatients. But such advancement caused another problem: public psychiatric care was divided into two: care sponsored by the State and that maintained by public social welfare, which was multiplied solely or predominantly due to a search for profits. Mental patients became an inexhaustible source of profit for businesspeople that made a living out of that condition.
Regarding direct public care, confrontation of that problem lied in the attempt of providing treatment in outpatient clinics. The National Service of Mental Diseases, since its first management, by Professor Jurandyr Manfredini, attempted another reform, electing as main goal the replacement of hospitalization by outpatient care. In the 1950's and 1960's, those resources were multiplied, especially in sanitary units and as appendices of public psychiatric hospitals. The main criticism against this system was maintenance of patient segregation and psychiatric disease, besides care network caretakers. Meetings of Preventive and Care Psychiatry, which were held at congresses of the Brazilian Psychiatric Association (ABP) and the Brazilian Society of Neurology, Psychiatry and Mental Hygiene, witnessed such effort, which was not carried forward because the Brazilian State had a privatization attitude in this area. For that reason, in welfare care, the process went in an opposite direction: hospitalization was prioritized only because it was more profitable for those who promoted it. This fact had its consequences in direct public care, since it was transformed into a therapeutic paradigm in social awareness and ideology of many therapists. There was also the phenomenon of transferring patients without a hospital in the public network to be hospitalized in services accredited by the public social welfare. This situation got much worse after the military dictatorship was established and by advancement of the neoliberal ideology, about which much has been reported.
The National Department of Mental Health (DINSAM), managed by Hamilton Cerqueira, seconded by ABP and supported by federal and state organisms leaded a reforming attempt that could place technical advances at patients' service. Carlos Gari de Faria was the representative of Rio Grande do Sul in that attempt, which started a vigorous transformation process responsible for psychiatric care.
With the end of dictatorship, there were better conditions for a more efficacious reaction, except for the division of reforming efforts. Reaction to poor psychiatric care occurred in three frequently antagonistic levels: medical/psychiatric level, antipsychiatric level and technocratic level. ABP was responsible for the psychiatric reaction, antipsychiatric being represented by agents of an anarchistic nature sheltered in the Labor Party, and bureaucratic reaction had its representatives in managers of public services and in some agents of the so-called Sanitary Movement. They all faced the powerful Brazilian Federation of Hospitals, which supported maintenance of the existing status.
ABP prepared a Bill to establish what would be a Psychiatric Patient Statute, which predicted progressive dehospitalization, as primary (at sanitary units), secondary (at polyclinics and general hospitals) and tertiary (specialized hospitals and habilitation and rehabilitation centers) care services were installed, all of them integrated in the general network of medical and social care (integration that was considered essential to prevent discrimination and exclusion).
That proposal was run over by Project Paulo Delgado, strongly supported, since the beginning, by left-wing parties, by large number of physicians, by the sanitary movement and by federal sanitary bureaucracy. Antipsychiatrists' answer was this project, which was not technical nor medical and delayed procedure of APB plan: 10 years went by until project approval, and it was almost entirely decharacterized. One might believe that bureaucrats supported the anarchist project because it was less expensive and allowed the federal power to delegate the responsibility to municipalities, evading the responsibilities assumed since 1930.
That is the end of its origins and beginning of its modernity.
Publication Dates
-
Publication in this collection
13 Dec 2007 -
Date of issue
Aug 2007
