Mental Health in Latin America: Conflict and crisis
A risk to dribble into meaningless generalizations is always present when writing about the sociological, legal, religious, ethical, or cultural aspects of the life of a large number of peoples from different countries, ethnic, and cultural backgrounds. Generalizations do no justice to the peculiarities and idiosyncrasies of each group or country. Cultural characteristics and ethical values vary from country to country and even from region to region in a given country. Despite this risk, however, the objective of this paper is to describe some of the characteristics and values of Latin American peoples in order to draw some conclusions about mental health systems and practices and the challenges facing mental health professionals in this vast region of the Americas.
Latin America, the portion of the Western Hemisphere south of Rio Grande, comprises more than 20 countries distributed in the mainland and among the islands that dot the Caribbean Sea. Although, conceptually, the Caribbean countries, with the exception of Cuba and the Dominican Republic, constitute a different geopolitical and cultural area, for purposes of this paper, they are all included under the general rubric of Latin America. Altogether, this region has about 480 million people with projections to 810 million in 2050. The main languages of these countries are Spanish and Portuguese, but English, French, Dutch, and Creole are the official languages in some of the Caribbean countries and in the Guianas, and native American languages such as Mayan and Quechua are recognized in some Central and South American countries. The language reflects the cultural heritage of these countries, which is Spanish in most of the countries, and Portuguese in Brazil. As a reflection of the Iberian heritage, the most important religion in the region is Catholicism. Yet, describing Latin America by, what appears, on the surface, to be the most obvious characteristics: heritage, language, and religion would be very simplistic. Each country is host to multiethnias, and the true characteristic of each one is the heterogeneous nature of their populations. Most of these countries, possibly with the exception of Guyana and Trinidad and Tobago, lay claim to a European ancestry in varying degrees that depend on the proportion of Europeans in the population. Yet, indigenous or native populations that were already inhabiting the Americas when the European settlers arrived in 1492, could be considered nations unto themselves, different from the European settlers, or from the mix that has resulted afterwards. Different as well, are the African descendants who make large portions of the population in several of these countries.
Still, the three basic characteristics mentioned above, heritage, language, and religion brought to the Americas by the Europeans form the basis for the legal systems and the institutional traditions in all of these countries. Furthermore, although allowances have to be made for minor local variations, the ethical discourse in the region is very much based on Judeo-Christian, mostly Catholic, beliefs and values. Similarly, as part of the European institutional traditions, the management of the mentally ill in all of these countries reflects the styles and periods of reform found in North America and Europe. Thus, while culture, folklore, and beliefs about the nature of health and illness may vary from country to country, general characteristics could be discerned that impact on the understanding Latin Americans hold on mental conditions and the systems they have set up for their management.
Societies tend to conceptualize illness holistically and usually take into considerations the impacts of the environment, religion, family attachments and values, gender assignments, and sociopolitical changes; these forces shape health seeking behaviours among the members. In this respect, there are social and cultural factors in Latin America that are important to review in order to understand how inhabitants of the region conceptualize health and illness and how they go about seeking help for their medical problems
General Health Beliefs. Opler and Rennie pointed out that since the time of Kraepelin, it has been known that psychopathological illness varies in content and in type with culture." A society exists when many persons interact regularly and continuously on the basis of shared values and behaviours whose meanings have been previously established. The limits of a society are those of social interaction which itself is, essentially, a process whereby two or more human beings take each other into account. Culture, social system and personality are functional variables that are interdependent and interrelated. Within the context of social interactions, the interdependence of these three variables provide a reference frame for people in different cultures and social groups to explain the causes of ill-health, the treatment they believe in, and to whom they turn when they become ill. Members in a social group explain to themselves how these beliefs and practices relate to biological processes and psychological changes in the human organism, in both health and illness. Thus, cultural explanations and beliefs about health and illness tend to be more holistic and to take the environment more into account than the merely biomedical explanations. This explains why many alternative health systems define health and healing in ways that reduce distinctions between the health of the individual and the health of their environments. In many cultures, the advances in Medicine and our scientific understanding of illness have not erased Hippocratic teachings that involucrate an ecological understanding of health and illness. In Latin America, these teachings coexist extensively with the medical model. Protection from bad airs, the quality of the waters, timing of nutrition and types of food are considered either determinants of illness or adjuncts to recovery.
Role of the Family. In Latin America family values and closely-knit communities play a role both in curbing behaviour, placing limits, and imposing duties on the individual and in helping to define health related behaviours among the members of the family. The sense of family for Latin Americans extends beyond the immediate nuclear family of parents and children, and include extended others such as grandparents, uncles, aunts, cousins, nieces, grandchildren, and even the compadres (co-parents) and their respective families. The institution of compadrazgo, for example, implies that a person, usually outside of the immediate family circle, will act as a father or as a mother, compadre or comadre (godfather or godmother) by accepting to represent, or stand on behalf of the parents, at the moment the child is baptized. The child becomes the ahijado(a) - like a son or like a daughter - a designation that carries a serious responsibility in that it enjoins the compadres to become parental surrogates with a moral duty to protect the child and to provide an example to the child as he or she grows into adulthood. In addition, through the relationship between the co-parent and the child, a bond of brotherhood develops between the parents and the compadres so that, eventually, these become full, active members of the family.
While in Latin America, rigid adherence to traditional and ancestral hierarchies, or respectful deference of family decision making to the eldest, is not the norm, individual actions are still shaped by group pressure and moral suasion. Strong traditional family ties and a sense of obligation to provide mutual support among the members are lifelong expectations. Not paying attention to these duties is a sign of bad faith leading to reprobation and oprobium. Members of the family have orgullo (pride), and should abide by the accepted mores of respeto (respect) and dignidad (self-worth). Family traditions of this nature have an impact on health seeking behaviours, especially when the medical condition could bring shame on the family, such as mental illness, teenage pregnancies, or AIDS, or in a different area, imprisonment of the black sheep of the family. Health seeking behaviours are, then, determined by interplay between the individual, the immediate family group, and the social beliefs on the determinants and the best treatment prospects for the illness.
Religion. In general, religious attitudes and beliefs impart a sense of belongingness and acceptance, and they foster community values of togetherness and participation. Among Latin Americans, religious beliefs help the person to cope with illness, death, and other calamities. They draw strength and support from their beliefs in God, whose will is not disputed, whose beneficence is expected and, indeed, taken for granted, but whose wrath is feared as it visits on the unfaithful and unbeliever. Hope and faith, Esperanza y Fe, for example, are religious concepts that are equally deeply entrenched in the health belief system of Latin Americans. These are two concepts that are not included in our modern scientific paradigm. Scientific constructs based on rationality and uniformity of natural laws do not leave much room for their expression. Science has placed them aside, or has negated them, possibly out of blindness, or out of frustration at not being able to measure them, or to structure them in scientific terms; but for Latin Americans at least, they are basic to their understanding of our human existence. A lack of scientific grasp, however, does not deny the role hope and faith in health and illness for they constitute the je ne sait quoi of recovery, that unmeasurable variable that is so vital an ingredient to bring a patient back to full functioning. Hope and faith, in fact, may be the reason why double-blind studies are needed, and why it is necessary to control the placebo effect in randomized control trials. For hope keeps chronic patients believing on a cure, whether scientific or miraculous, and faith gives them the strength to overcome their adversity. Religious beliefs in Latin America, Esperanza y Fe, dictate that patients accept their illness with resignation and that they hope for a cure that is based not so much on the healer and the treatment, but on faith on the Creator.
Machismo. The role assigned to men in Latin American culture is not only that of provider, they are also the ones responsible for the welfare of the family, the protectors, and most importantly, they take responsibility for the honor of the family. These roles, subsumed under the term machismo, are culturally operationalized in two ways. First, it is expected that males are the social representatives of the family and that they work outside of the home to provide for the family needs. Females, on the other hand, remain at home to tend after the children, to look after their husbands, and to provide emotional support. The role of the male, therefore, is to deal with the world outside while the role of the female is to cement the family ties from within the home. A loss of the provider role because of unemployment, or reversal of roles when the female leaves the home to work outside, causes the male to lose value among the other men and may lead him to emotional discomfort often associated with alcoholism. Men drown their pain through drinking, females sit at home and cry. Second, machismo is tied up to respeto and orgullo, hence it imposes a duty on men not to back down in front of an insult to the honor of a family member. Backing down brings upon the male vergüenza (shame), a stigma that extends to the whole of the family group. Thus, to be macho is to be tough, to have cojones, to kill or to die for honor. In terms of health, macho also means, that when it comes to medical needs, men try not to appear ill and postpone seeking help until it becomes absolutely necessary.
Sociopolitical Disruption. Finally, a major factor to understand cultural attitudes to health and illness in Latin America, and most specifically, in the area of mental health, is the role of major socio-political upheavals and financial crises besieging most of the countries in the region. These upheavals and crises have brought, or threaten to bring a radical change to the formalized power structures and political institutions in many of these countries. Rapid urbanization, many times resulting from warfare guerrilla activity in the countryside, has led to social disorganization and lack of cohesion. Family units have been broken down and children are often found abandoned in the large cities. These upheavals have resulted in veritable epidemics of violent behaviour in many countries, as will be described expanded later in this paper.
Conditions peculiar to a particular social group and that do not have immediate biomedical explanations are illness without disease; they have been called folk illnesses. Rubel defines them as syndromes from which members of a particular group claim to suffer and for which their culture provides an etiology, a diagnosis, preventive measures and regimens of healing." Folk illnesses are more than clusters of symptoms and physical signs; they also have a range of symbolic meaning moral, social, or psychological for the sufferer. They link the suffering to changes in the environment or the working of supernatural forces, and may signal, in a standardized, culturally acceptable way, social conflict or disharmony at home, with friends, or at work . In this respect, Mezzich and Lewis-Fernández have emphasized their importance as explanatory links of the person-in-his-circumstance. These authors advise that DSM-IV should develop components for a cultural formulation that would take into account, among other things, the cultural identity of the individual and the cultural explanations of the illness.
In Latin America, however, cultural beliefs and popular conceptions of illness and health do not relate only to physical illness, they also include a host of psychiatric symptoms and reveal a peculiar understandings of psychiatric illness. Furthermore, because of the intense prejudice and stigma associated to mental illness in many of these countries, folk illnesses may be used as a socially acceptable alternative to be mentally ill without incurring social sanction. Therefore, a review of some major cultural and folklore ways in which mental illness is conceptualized in Latin America will be illustrative.
Susto or Espanto (magical freight) is found all over Latin America, whether in urban or rural areas, and it affects males and females alike without any respect for ethnic background. This condition is also found among Hispanic Americans in California, Texas, Colorado and New Mexico. Susto is a whole syndrome that includes somatic and psychological symptoms attributed to a traumatic event. The core belief is that, because of a sudden freight or, most often, because of an unsettling experience, the immaterial part of the human being separates from the body and starts wandering about. The resulting soul loss produces restlessness at night, anxiety, depression, listlessness, lassitude, inability to carry out the expected functions, loss of appetite, and lack of interest in previously enjoyed activities or in personal decorum. The condition is related to social situations where the individual cannot meet social expectations. Susto is a vehicle by which Latin Americans, from peasant or urban groups, manifest their reactions to self-perceived stressful situations. Kiev, in an attempt at cross-walking folk illnesses to western terminology, classified susto as an Anxiety Reaction. The treatment for susto, ordinarily carried out through folk treatments, includes the expected assumption that the soul will be captured and returned to its rightful place within the owner.
Mal de Ojo. Although not specific to Latin America and known for centuries in many other cultures, mal de ojo (evil eye) relates to the fear that others will have envy of ones own possessions. Envy is in the eye of the beholder . A person possessing evil eye can harm unintentionally or intentionally, and is either a stranger, or a local person whose attitudes or appearance are different from the rest of the people, specially if the person stares rather than speaks. Mal de Ojo could cause emotional distress, physical illness, or make the sufferer prone to disease or injury. Children, especially, when affected by mal de ojo, fail to thrive and start suffering from one ailment or infection after another. Somewhat this condition reflects a xenophobic attitude that is stigmatizing to those who look different or odd, including mental patients in the community. Evil eye could be prevented by averting the eyes, by distracting attention or, if affected, through the use of sympathetic magic.
Nervios. An attack of nerves (ataque de nervios) is a common condition found in many countries in Latin America that affects individuals regardless of class, ethnicity, or gender. The attacks usually have an acute onset of shaking, paraesthesiae, numbness of the face, inability to move, heat sensation, a feeling of dread, and a feeling that the mind is going blank. There is usually a gradual build up of uneasiness about family or financial problems, until the whole attack takes place. This condition could be construed as a cultural characterization of Panic Attacks.
Pena Moral. In Latin America, widows and spurned lovers sometimes die of pena moral (broken heart). Literally, the person, after experiencing a major loss, closes the inner self to the outside world by not leaving the home or bedroom, not eating, and not communicating. Slowly, the sufferer withers away as the desire to live disappears so that no amount of encouragement or pleas to snap out and start living again are enough to bring the person back. Pena moral is the equivalent of a deep sense of bereavement ending up in major depression.
Curanderismo. An important factor to consider is the way Latin Americans seek help when illness strikes a member of the family. Often, a person attends, simultaneously, two healing systems, the holistic alternative system through the curandero (healer), and the Western model through the physician; Western medical practices are seldom used alone. Patients do not only go to the physician and take the prescribed medications; they may also go to curanderos, or use a variety of herbs or other remedies. Curanderismo (from curar, to heal) and ethnopharmacological practices are part and parcel of the culture. Typically, the curandero, akin to a shaman, conducts a diagnostic interview that consists mostly on learning about the life circumstances of the patient, makes a formulation, and prescribes some behavioural change and herbs. Patients suffering from susto, mal de ojo, pena moral, or other folk conditions go first to curanderos who act, then, not only as primary care practitioners, but also as psychiatrists. The importance of their role cannot be minimized given that many of these conditions mask serious physical or mental problems.
Along these traditions that are mostly based on Iberian and Amerindian beliefs, there are others brought in by the Africans and continued by their descendants. Thus, for example, people in Cuba and other Caribbean basin countries seek to manage life problems and circumstances including folk illnesses, with the help of the santero, or practitioner of santeria. This is a belief system that incorporates African and Catholic beliefs and is based on prayers and magic approaches to images of santos (saints) or other religious icons. In the Caribbean, especially in Haiti, African descendants of the Yorouba who were originally from Congo, practice Voodoo, a religion whose rituals are officiated by a priestess called the mambo from whence came the name of a popular dance in the fifties. Similar ritualistic dances, the Ubanda and the Candomble that are officiated by an Exu are found in Brazil where they have a syncretism of African beliefs with Catholic rituals. These communal events produce emotional cleansing and rebirthing through ritualized dancing to monotonal chanting or playing of drums and the ingestion of drugs that produce trance states or dissociation. In Trinidad and Tobago, Bhugra describes a mix of Hindu beliefs in demonic possession with similar Christian beliefs that, of late, is resulting in the popular use of exorcisms for the treatment of psychiatric disorders practiced in some Christian churches in that country.
It may be assumed that beliefs on health and illness, the limits to individuality imposed by the culture, the demands of gender roles, and the existence of folk illnesses, could eventually interfere with the scientific management of medical conditions. It is proposed, however, that, for Latin Americans, these cultural norms provide a sense of ownership of the illness that is shared by the family and the community and that constitute a peculiar cultural way of mastering the healing process.
As previously indicated, violencia (violence) has adopted veritable epidemic proportions in Latin America. External reasons for death, accounted for by accidents and homicides, are among the highest reasons for death in these countries. In all countries with more than one million people, excepting Colombia, accidents are the number one reason for death among women and men in the age group of 15 to 24. Among men in the age group of 25 to 44, accidents are the number one reason for death in all countries. As a comparison, while in Canada and the United States deaths due to external causes account for about 5% of all deaths, in Brazil and Mexico they make about 12%, and in Colombia and El Salvador about 25%. In these two last countries, homicide is the largest contributor to external deaths well above motor vehicle accidents or any other type of accident. Among men, homicide is the leading cause of death in Guatemala, and it is the second most important one in Ecuador, Mexico, Brazil, El Salvador, Venezuela, Paraguay, Panama and other countries, but it only ranks fifth in Canada and the United States.
On the other hand, while the rate of homicides is well above that found in North America and European countries, suicide is not a common cause of death in Latin America, a fact that may be related to their religious beliefs. In Canada, for example, the rate of homicides per 100,00 per year is 1.3 and for suicide 10.6 and in the United States 7.5 and 8.9 respectively. To the contrary in Colombia they are 29.7 and 3.4, in El Salvador 41.6 and 12.2, in Brazil 13.3 and 2.8, and in Mexico 19.6 and 2.1. Clearly, Latin Americans do not commit suicide, but they murder each other much more often.
Large areas in many countries, and practically every major city, are no-man lands where people venture into at their own peril. Some countries, such as Colombia, Mexico, and countries in Central America, have been most affected, and the morgues in some cities such as Sao Paulo and Caracas are similar to war zones. For example, the Folha de Saõ Paulo, an important paper in this city, quoted figures from the Secretaria da Segurança Pública indicating that, on average, about 54 persons are murdered in the city every week. Fear and apprehension have superseded the gentle and rather careless living of Latin Americans. In Colombia, practically everybody has been touched by violence. Few families in the country have remained immune to the loss of a member of the family, close friends, neighbours, or work associates. The wave of violence and homicides that has gripped the country for over thirty years is the result of guerrilla warfare driven, originally, by political ideologies, but lately responding more to the economical interests of powerful drugs lords. Poverty, inequalities, social exclusion and social unrest are more important factors for the violence in Colombia than personal acts or terrorist manifestations. The same could be said for many other countries in the Caribbean or in Central and South America.
While the cost of violence on the general health system has been enormous, the human cost of suffering has not been estimated. Neither has been the social damage caused by displacement of thousands of people from the countryside to the cities where they contribute to further overcrowding in the slums and put further strains on the already overburdened sanitary and public utilities services. The abandonment and abuse of street children, including the "disposal" of street urchins, with the consequent damage to future generations, is a new phenomenon that is also contributing to the social and moral decay in the inner cities. Post-traumatic stress disorders in Colombia and other Latin American countries have only begun to be tallied. The cost of lost lives and the potential years of life lost (PYLL's) especially young men in their most potentially economically productive years, the social and economic costs, and the impact on the already strained health services are making violence the number one health priority in Latin America. These costs have already been recognized internationally. The Pan American Health Organization (PAHO), the arm of the World Health Organization in the Americas, has come up with a Regional Plan of Action on Violence and Health. As part of this plan, the "Inter-American Conference on Society, Violence and Health" issued a Declaration in which it was considered that:
1. Violence constitutes a threat to peace, security and consolidation of democratic ideas in the Region of the Americas as it strains the social fabric and invites the adoption of repressive policies.
2. It is widespread and expresses itself in a multitude of ways.
3. It affects negatively quality of life, creates fear, destroys family structures, and curtails the autonomy of individuals.
4. It constitutes a growing problem for public health as demonstrated by the alarming increase of rates of mortality, morbidity, and disability, as well as in the overwhelming loss of potential years of life and psychosocial effects.
5. It exacts an enormous economic toll in society by generating growing expenditures on health and security.
6. It affects women in and out of the home.
The Conference concluded that the origin of violence is rooted in such factors as inequalities and social injustices that create frustrations, marginalizes populations, and perpetuates the conflicts in the Region. Furthermore, it indicated that violence reflects fragility in the social order that is fostered by widespread impunity and by political and terrorist actions often condoned by governments. As such, the Conference requested that the Heads of Governments redouble their efforts to ensure safety and to uphold the rule of law, and urged peoples in the countries to mobilize against violence by informing on events and by developing prevention and control mechanisms. It also encouraged the media and many other national organizations to support initiatives against violence by promoting a culture of peace.
It remains to be seen what effects the Declaration proclaimed by this Conference and PAHO initiatives will have in reducing violence in Latin America. On the other hand, all countries in the Region, the Governments, the Non-Government-Organizations (NGO's), and health professionals, including psychiatrists, can no longer turn a blind eye to this reality.
A large number of studies have already documented the widespread prevalence of mental conditions anywhere in the world, especially depression. The few reports from Latin America confirm that a similar situation exists in the Region and that alcoholism and violence are problems affecting mostly men. Yet, with few exceptions, epidemiological data from Latin America are hard to come by that would allow for comparisons, or that could be used for planing services based on population needs. Multiple historical, legal, financial, and sociopolitical factors have put pressure on the structure of psychiatric care and on the delivery of psychiatric services in Latin America over the past two decades. With some exceptions, however, at least in intent, countries in the region have been unable to rally behind a reform of psychiatric services and are still heavily dependent on outmoded mental hospital systems that consume large proportions of the total mental health budget in some places. Latin American countries are far behind the waves of mental health reform that have shaken traditional mental health structures in Italy, Great Britain, Canada, - - or the United States. Thus, the debates about mental health services and the rights of the mentally ill in Latin America are but distant echoes of what is already a way of life in the provision of mental health services in many countries in the developed world. On the other hand, strong feelings of stigmatization against the mentally ill held by large proportion of the population may have contributed to official inaction to modify the structures.
Responding to a cry to reform outmoded structures and thinking patterns, however, 17 Latin American countries sent delegates to a Conference in Caracas in 1990 that was convened by PAHO with the purpose of developing a consensus for the restructuring of psychiatric services in the Region. A Declaration was produced, now known as the Declaration of Caracas, that reviews the parameters of mental health services, sets up a set of recommendations, and provides guidelines for action.
It is hoped that the Declaration of Caracas will give impetus to change the traditional, institution-based, services in these countries. As in many other countries in the world, large mental hospitals that were built at the end of last century, or beginning of this century, have seen better days. Their physical structures have crumbled, and the financial support, often entirely dependent on government subsidies, has seriously eroded. At the same time, in some countries, dependence on the mental hospitals has brought the development of psychiatric thinking to a state of stagnation. For example, research is non-existing in many countries, although some notable exceptions are found in Mexico, Colombia, Brazil, Peru and Argentina, among others.
Poor distribution and poor utilization of human resources are also major matters of concern. Psychiatrists and other mental health professionals either work in private practice servicing the very small section of the population that could afford private services or they work in mental hospitals with a minor combination of activities in other health sectors such as social security or corporation-paid services. Members of either group, however, busy as they all are in their respective professional endeavours, have neglected to a large extent the behavioural pathologies that are accumulating in their societies as a result of poverty, overcrowding, drug addictions, alcoholism, or violence.
As a reflection of concerns about a painful reality in mental hospitals, a large section of the Declaration of Caracas is dedicated to protection of the rights of the mentally ill, an area that has badly lagged behind the accomplishments in other countries. Basic to the rights of the mentally ill is an examination of practices in mental hospitals. In Latin America, this is a contributory factor because the concentration of work in mental hospitals has lead to inertia and isolation from the hustle and bustle of general hospital psychiatry, outpatient activities and community involvement where violation of rights would be more easily confronted. Thus, the mental health systems in Latin America have to overcome a set of practices that are in many ways choking them off as a useful resource to the population. Those practices include cumbersome admission and discharge procedures that seek to control rather than to treat, commitment laws that are used as the preferred mode of admission, and the lack of privacy and loss of dignity experienced in many mental hospitals.
These practices have resulted in overcrowding of facilities and in the slow development of community alternatives. Shunting mental patients away to institutions gives the impression that governments are meeting their budgetary responsibility to mental health issues, when in fact, mental health budgets are usually meager and very low in comparison with budgets in other health sectors. To keep the mental hospitals alive on government handouts, and in the absence of treatment alternatives in the community, siphons off the energies of health care providers and patient advocates. Under these circumstances, rights become a secondary issue, or worse, an unaffordable luxury.
It could be argued that thinking about rights for mental patients would be no more than an exercise in byzantinism when entire populations in some Latin American countries are fighting for their own political rights for free expression and better economic conditions. Although most Latin American countries have moved away from military dictatorships and have embraced democratic forms of government, multiple levels of discrimination prevent large sectors of the population from being accepted as full partners in the political process and into the power structures in their countries. This volatile social situation when political rights are uppermost in the agenda of many nations certainly would push down any other social causes, especially by groups such as mental patients who, traditionally, have been marginalized and disenfranchized and who, usually, would require others to help them fight for their rights. Thus, sociopolitical problems, lack of government interest, lack of public advocacy, and lack of funds are all part of a vicious circle keeping patients in decrepit mental institutions where protection of rights is the last thing to be concerned about. Time has come for mental health professionals in Latin America, especially psychiatrists, to have a serious look at what is happening in the hospitals and to their patients, and to take charge of the required changes. Yet, apart from the care of the mentally ill, mental health professionals will also have to become activists in helping to redress the sociopolitical foundations of violence and other ills in their countries. They could join forces and ask for official status as members of NGO's, a new development in Latin American countries such as in Colombia where these organizations have requested a place for the general public at the table where major national and social issues are being discussed.
On the positive side, some projects have already been reported that deal with community treatment or with psychiatric rehabilitation programs. - - - - An interesting project in this regard is the one organized by PAHO to train Police Officers in the Caribbean countries to become experts in the recognition of mental pathology among persons they detain in the community. This program has been offered quite successfully in several countries in the area, both in English and Spanish.
From the point of view of medical associations, medical ethics has traditionally been understood in many of these countries as deontological pronouncements and rules of "etiquette" among the physicians themselves. Yet, these associations are already facing a need for change from paternalistic medical attitudes and a lack of consideration to the acceptance of patients as co-participants in the actus medicus. Reforms in the delivery of health care systems and the fact that, as in North America and Europe, patients are becoming more sophisticated and demanding of their entitlements in health are imposing these changes.
At a larger scope, the medical ethical discourse in Latin America has usually departed from a Judeo-Christian tradition, mostly Catholic, brought by European settlers of Spanish and Portuguese descent. - In Catholic ethics, morality is the basic foundation for our actions so that the goodness or badness of behaviour is measured on a polarity of virtue or vice. A leading treatise on ethics, for example, defines it as el estudio de la bondad o malicia de la conducta humana - the study of the goodness and evil in human conduct. In traditional Catholic ethics, relationships, including the doctor-patient relationship, are based on trust rather than on contractually tort-invoking arrangements. On the other hand, clinicians, medical researchers and ethicists all over Latin America have begun to grapple with the major issues of modern medicine and some have come to feel that traditional ethics cannot provide the answers. As in any other countries, these issues include abortion, euthanasia, organ donation, reproductive technologies, allocation of resources, and the ethics of physicians in health systems that impinge on the physician-patient relationship and on the sanctity of the secreto médico (medical confidentiality). Traditional ethics, according to some authors, may not have the answers to the dilemmas of modern medicine. These authors advocate a case approach, situationally based, in which rights and duties are explored within a covenant enjoining the parties. These new approaches to bioethical dilemmas have been supported by translations of North American or European books on bioethics. In this way, a humanistic ethical discourse has entered the field of ethics in Latin America and is colliding with traditional ethical concepts. An ethics or rights and duties, and the principles approach to ethics as styled in North America and Northern Europe, as well as the omnipresence of autonomy as the overriding principle for action, is an ethical discourse alien to most Latin Americans. It has created tensions among different ethical schools in several countries notably Argentina, Ecuador, and Colombia.
Bioethical initiatives and activities in Latin America have developed around foci of intense work in countries such as Colombia, Chile, Mexico, Argentina, and Dominican Republic. In relation to psychiatry and mental health, these activities have followed lines not too different than in North America or Europe. Figueroa, for example, argues that psychiatry is limited to unmasking the falsifications of self-recognition that inhabits the moral life of the patient. He proposes that the question to psychiatric ethics is access to true discourse and that the true ethical value in psychiatry is la veracidad (veracity). Some other authors reflect on the softness of psychiatric diagnoses, the side effects of psychiatric medications, and the legitimacy of psychotherapy as it invades the privacy of the patient. Other authors have been pondering on the relationship between economical factors and ethical dilemmas as well as the crosscurrents between ethics and psychology in relation to motivation, character structure, the nature of the moral act, and moral responsibility and culpability.
A major development in Latin America in the field of bioethics has been the establishment of ethics programs organized by PAHO. Although not specific to psychiatry, this Program may have yet a major impact on the discourse on psychiatric ethics in Latin America. This program has been the response from PAHO to several situations that it had to face many years ago involving violations of research ethics rules. The PAHO/WHO Regional Program for Bioethics (Programa Regional de Bioética OPS/OMS), based in Chile for the past five years has been very active in disseminating ethical knowledge throughout the region. It has organized conferences, seminars, and publications, and has built capacity in ethical thinking through training students at the Masters level. Members of the International Bioethics Advisory Board established by the Director of PAHO in 1999, have been acting as consultants for the Program.
Along the different and, sometimes, contradictory tendencies in the field of medical ethics, psychiatric ethics also has developed a dialectic of its own whereby protection of the patients liberty and rights is considered fundamental to the physician-patient relationship and to the routines of daily psychiatric work. Although several Latin American authors wonder whether psychiatry can truly answer ethical questions of liberty and rights when double allegiances seem inevitable and even obligatory by law, an ethics of rights for the mentally ill, as defended by Brody, has already permeated the psychiatric ethical discourse in Latin America.
An ethics of rights is evident, for example, in the Declaration of Caracas when it proclaims that:
3. The resources, care and treatment provided must:
a) safeguard, in a definite form, the personal dignity and the civil and human rights (of the patients),
b) be based on rational criteria and be technically appropriate, and
c) aim at keeping the patient in the community of origin.
In another section, the Declaration calls for legislative change:
4. That mental health legislation in each country be modified so that it:
a) ensures the respect of civil and human rights of mental patients, and
b) promotes the organization of community mental health services where rights are also protected.
Despite these statements, there are places in Latin America where mental patients have their rights abrogated or abused by virtue of their condition. This is most obvious among chronic mental patients in mental hospitals where many are committed even when there is no psychiatric reason. In many other instances their rights are openly violated without clear conscience of wrong doing on the part of the perpetrators. To this effect, González Uscátegui and Levav point out that the law does not protect the rights of mental patients. These authors plead for legal protections that should specifically spell out the rights of the mental patients, develop mechanisms to ensure their protection, and specify penalties for their breach. These authors consider that only a legal approach could guarantee a stop to the abuses to which mental patients are often subjected to in mental hospitals in Latin America.
As stated at the beginning of this paper, the author has reviewed cultural, ethical, and programmatic issues that impact on the mental health of Latin Americans. Emphasis has been given to areas that the author opines are salient in order to give the reader an understanding of the lives of Latin Americans, their cultural values, their problems, and their ethical discourse as it pertains to mental health problems in the Region. The author hopes that by clustering together such diverse number of nations and ethnic groups and cultures he has not forced them into a Procrustean bed where they all would lose their uniqueness and idiosyncrasies.
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