15 September 2015

Provoking a mental health revolution in Buenos Aires

Argentina’s mental health system needs shaking up. I spent a few days with its savvy public defenders. They’re ideally-placed to create legal havoc.

Read the post in Spanish

One of the incredible privileges of my job is that weird and wonderful invitations drop out of the blue. At the invitation of the Public Defender of Argentina, I popped over to Buenos Aires at the end of law year (I know, I know, massive delay in getting this blog post written!) to give four presentations in 2½ days at various seminars on human rights.

Dr Stella Maris-Martinez, the Public Defender General of Argentina, is an impressive leader. She has recruited to her office some skilled, passionate and humble group of lawyers I have ever met. They kiss each other on the cheek (only one cheek in Argentina: head to the left rather than the right in Europe. No wonder they wanted me to talk about the Kiss case). They fearlessly sue the government. They take cases to the Inter-American Court on Human Rights. They take risks. They celebrate victories with Malbec wine. They take visitors to eat in restaurants that serve the most preposterous amount of bloody steak. These people work hard and smart and work as a team. Unusually for lawyers, they are also lovely people. After two and a half days they were not simply LinkedIn contacts, but friends. 

Dr. Stella Maris-Martinez Source: Inforegion.com.arDr. Stella Maris-Martinez Source: Inforegion.com.ar

Probably Argentina is unique – perhaps with the exception of the USA’s protection and advocacy system – to have a State-funded service which “promotes and implements policies that will ease access to justice on the part of discriminated sectors”, as the Public Defender’s Office (PDO) founding document says. The PDO is an eclectic mix of functions. Some lawyers are guardians representing adults who are under guardianship. Others are gutsy criminal defence lawyers. Others spend most of their time in psychiatric hospitals. 


The 2010 Mental Health Act provides access to a lawyer for anyone detained in mental health facilities. In the City of Buenos Aires, it the FPDO fulfils this function. The team includes ten lawyers working full time, and a range of specialists working 9am to 5pm every day: three psychiatrists, three psychologists, and three social workers. These people cover more than 25 private facilities and fifteen government hospitals for adults three of which are big institutions: “José T. Borda” which houses around 700 men, and “Braulio A. Moyano” which has around 800 beds for women, and “Torcuato de Alvear” for almost 100 adults and around 30 children. Of the 1,500 adults in government hospitals, the vast majority are known as ‘social patients’ who are only in hospital because there are no resources in the community.

I visited Moyano hospital. It’s a typical mental institution. It was built in 1895 for “alienados”, a fantastically good word to describe the insane system being established all over the world in the late nineteenth century. At that time outside Buenos Aires, thanks to the rapid expansion of the city the hospital is now situated in a poor suburb. Set in luscious gardens with palm trees, I’m sure the formerly-glorious buildings offered the aliens a charming sense of asylum. 


Within three working days of admission a public defender sees the newly-admitted patient, and thereafter roughly every ten days. “We tell clients that we’re here for them,” explained Soledad Valente, a public defender who works in Moyano three days per week. The defender becomes this person’s lawyer and the patient can instruct the lawyer to do all sorts of things, like get them out of the institution, sort out property issues which may prevent the person returning to the community, or deal with guardianship issues. Gabriela Spinelli, the other public defender who came with us, said that their objective is to support their clients in whatever way they can.


A resident shuffled towards us, both of her arms visibly shaking. She approached Valente who was talking to me, and Valente attended to the woman’s needs, accompanying her to a building. In other countries I’ve seen lawyers tell patients not to bother them. Not here. We went to a department called “Pinel”, named of course after the French psychiatrist who famously unchained the Parisian mad. I wonder what he would have thought of his name being used on a department which houses warehouses people in grotty communal environment, where not chains, but straps are used. 


Public Defenders are magistrate-grade lawyers, hired through public examinations. Their positions are as stable as those of judges or prosecutors and their positions are independent from those bodies, and from government. They are therefore truly fearless. Hospital administrators know that the defenders can launch litigation on any issue at any time, so is therefore often collaboration which I haven’t seen in other countries. Some hospitals go a bit too far to please the defenders. “In one private hospital we found out that the director had instructed all the staff to note everything carefully in the patients’ medical records,” said Valente, “because the public defenders are watching us carefully!” 

The results of the advocacy service have been impressive. The service started in 2011 and this week they helped their 10,000th client. They’ve cracked down on sexual abuse and the use of seclusion and restraint, investigated electroshock treatments, and got medical treatment for people who were being ignored. They’ve got rid of restrictions for visitors and mobile phones, they’ve reduced the duration of inpatient stays and increased the information which the hospital gives to patients.

They’ve improved many people’s lives when they are at their most vulnerable to abuse. But with three years experience under their belt, the service wants to get more strategic. The Mental Health Act commits the government to closing large psychiatric institutions by 2020. The Buenos Aires Mental Health Director is on record as saying she “doesn’t agree” with the law. It’s nearly halfway point between 2010 and 2020 and what progress has been made in the Buenos Aires city on evacuating the institutions and developing community-based services? Nothing. Ninety percent of the city’s expenditure on mental health goes towards maintaining the mental hospitals, and ten percent on community services, despite improvements elsewhere in the country. 


“These large institutions are from a different era”, explained María Florencia Hegglin, a public defender who has just coordinated a project on the political participation rights of people with disabilities. “People have the right to live in the community, but the government of the City of Buenos Aires is failing them. We need a change in society.”

Could the Public Defenders Office be the change they want to see? So many pieces of what is needed for strategic litigation are in place: an engaged and trained judiciary (the PDO has developed a manual for judges and already rolled out training on disability rights for them). A cadre of gutsy lawyers with statutorily-guaranteed access to hospitals. And 1,500 people locked up in the city’s hospitals.

As we were leaving Moyano hospital a patient came up to Gabriella and Soledad. “Excuse me, what time is it?” the woman asked. Gabriella looked at her watch and said, “Four o’clock.” The woman looked dejected. “Still?” she asked. One day of mooching around all day doing nothing is bad enough, but if you’ve been institutionalised for months, for years, time slows right down. How long will this woman have to wait to get out and lead a life in the community?