“The government will not be closing El Borda. You don’t have anything to write about.”
This was the response from the Ministry of Health for the City of Buenos Aires when asked if anyone would be available to discuss the plans to close El Borda Hospital. The government may not be closing the hospital any time soon, but there is plenty to write about. The hospital has been mired in controversy and concern since the government announced two years ago that there were plans to close the largest and most famous psychiatric hospital in Argentina.
El Borda Hospital (or the Municipal Hospital of José Tiburcio Borda) is 148 years old and occupies 20 hectares of land in Las Barracas. The hospital admits around 1,300 patients each year and discharges roughly the same number. The director of the hospital, Dr. Juan Garralda, informs me that most are discharged within two weeks. There are currently around 840 long term patients.
As well as offering mental health care, the hospital is a research centre with links to the University of Buenos Aires medical school, as well as a variety of other universities and nursing schools. It is also home to La Colifata Radio, Pan del Borda and a cultural centre, social organisations that enable patients to interact with the community outside the hospital.
Nearby sits the Mental Health Hospital of Braulio Moyano, another psychiatric institute that specialises in care for women and children, particularly victims of domestic violence.
The Powerpoint Plans
In April 2008 the mayor of Buenos Aires, Mauricio Macri and his health minister, Jorge Lemus, announced their new mental health plan. According to this plan, El Borda and Moyano Hospital would be closed within two years. The hospitals would be replaced by ten smaller hospitals with 48 beds each, monitored by closed circuit television, halfway houses for 500 people and health centres in different neighbourhoods.
There was a furious reaction from the public as well as many health professionals associated with the two hospitals. Jorge Cafferatta, director of Moyano, gave an interview with Perfil newspaper, in which he criticised the lack of consultation and the government’s way of announcing the closure: “From all this, all I know is the press release that the ministry sent, no one called us. I think to make a viable mental health plan there needs to be discussion with the various sectors. It is elementary, but in this case it has not been done.”
He made no effort to conceal his anger about the situation, criticising the Macri government: “Perhaps the ‘Macrista’ is a model of non-participatory management… But they have to realise this is a hospital, not a cookie factory.”
Macri insisted that “the current situation is shameful. We want Buenos Aires to have a mental health system that ensures human dignity and respects the human rights of patients. Within 24 months we will change this anachronistic system with a new model.”
Despite this, critics have not been appeased. Alfredo Olivera is the director of La Colifata Radio and has been similarly outspoken in his criticisms. Like Cafferatta, he is highly dismissive of the way in which the plans were drawn together: “We believe at La Colifata that we have never received a health plan from the city government. A powerpoint presentation cannot be considered a formal mental health plan.
It seemed there was very little consultation inside or outside El Borda. Olivera said, “The government asked us what our position was after the news was announced,” Hugo Cohen, mental health assessor for the Pan American Health Organisation (PAHO), said the government took little heed of their advice: “The authorities took the decision… it is not what we recommended. We recommended a mental health system, but the authorities decided to take another path.”
PAHO recommended that the government build their plans according the the 1990 Declaration of Caracas, which outlines rules for restructuring psychiatric services within Latin America. According to this declaration, if an institute is closed, there must be other services available and ready to replace them.
At the time, no new hospitals were being built and there were no concrete plans to build new institutions, so it would have been quite a feat to build ten small hospitals within two years.
Cohen cited the US in the 1970s as an example of the detrimental effects of bad mental health planning. In the process of deinstitutionalisation, hospitals were closed, but because no other care was offered, many of the patients became homeless. Cohen believes that if El Borda were to close without the government creating a substitute network of care, it would be “a violation of human rights because they (the patients) are abandoned in the streets”.
Olivera agreed, whilst maintaining that the current situation is not ideal. Deinstitutionalisation has happened across many parts of the world because it is seen as better for the patient than keeping them locked up in an institutions, but if no other services are ready, El Borda may be the lesser of two evils: “The position of La Colifata is that it is negative to make an announcement talking about closure, it would be positive to make an announcement talking about the opening of something – open other structures that consider the complexity of the mental health of our residents, that conserves space for internment when it is necessary. Admission forms part of a system of orientation, trying to reestablish health conditions so that they can sustain a life in community. So what we think is that before you announce closures, you should announces openings. Before you close a public psychiatric hospital, conserve the public space and promote public health, forming public institutions.”
The Civic Centre
There were no distinct plans for new hospitals, but around the same time, plans were presented to make a civic centre in the hospital complex with government offices being housed in the Amable Jones pavilion. The Society of Architects was also asked to submit projects for redeveloping the site once the hospitals were closed as part of an effort to develop the south of the city.
Olivera believes that the government’s plans have more to do with urban development than mental health and that El Borda is regarded as an obstacle to urbanisation: “This is exclusive urbanisation, rather than inclusive. Barracas was designated for the marginalised, the lonely, the poor, the forgotten. Today, they realise that 15 minutes from Microcentro lies land that is worth a thousand times more now than it did before.” Although both Cohen and Garralda declined to comment on the possible alternative motives of the government, both acknowledged that this could be viewed as a possible land-grab.
Garralda pointed out that El Borda is an open hospital, where patients, as well as staff and the public, are able to walk around with some freedom. It seems likely that this would not be possible in other, smaller locations, so the patients would be far more sectioned off from society. Although Olivera believes that admission into a psychiatric institute is sometimes necessary, he also believes that integration and social interaction are key to helping those with mental health issues. La Colifata Radio works to create a bridge between those within the hospitals and the general public in an effort to help patients communicate and to de-stigmatise mental health problems. Olivera feels that in renovating this area the government is undoing his work, as well as the work of numerous others because the patients are again forced to move further away from society: “They return to excluding those who are already excluded. There is this idea of danger, criminalisation, so people try to distance them… To return to expulsion is tremendously negative.”
Only Central Heating
The government eventually withdrew its plans, perhaps as a result of protests and an adverse reaction from health officials and possibly because they came up against the economic crisis and had funding problems. The reasons remain unclear. When the Ministry of Health was asked to comment, they maintained that El Borda will not be closing, but would not elaborate.
Although the plans are no more, some have noticed a deterioration in the hospital in the last two years. Olivera has noticed that there are fewer patients and he hears that they increasingly end up in private clinics after being discharged from El Borda.
Although he was speaking generally, rather than about El Borda in particular, Cohen did point out that private clinics are the source of money and it can be sign of corruption when people are unnecessarily sent to private institutions, rather than public ones. He emphasised that “private clinics should not be one of the steps towards public health”.Even more concerning was the news that there was no gas in several parts of the hospital. When I spoke to Olivera in May he told me: “Today we don’t have gas and winter is coming. Therefore they want to move all the patients into the middle and demolish parts of it so that it becomes smaller.”
The hospital is built in the shape of the letter ‘H’ and the sides of the ‘H’ did not have gas at the time we spoke. Olivera said: “If it’s not true, then I’ve made a mistake, I’m sorry. But if we care about human rights, it is important that the hospital has gas.” He believed that the problem with the gas was a sign that the government might start remodelling anyway.
Again, Cohen did not comment on what the government might have planned, but agreed, commenting: “You can’t leave people waiting for three years without gas just because they are going to a different home.”
When I spoke to Garralda at El Borda this month, he denied there being any problem with the gas. Pointing at a new heater in his office, he said: “Today we don’t have gas because the heaters are being changed. But we do have gas.” Asked if the change of heaters was the choice of the government or the hospital, he replied: “The direction of the hospital is not centralised. The hospitals are not directed by the government, but the purchase of the heaters was made by the government.”
Garralda refused to be drawn into discussion about the government’s plans and made it very clear that he did not think that the hospital would close any time soon, saying abruptly: “No, the hospital will not close in the next few weeks or months because we have 1,300 patients a year that come from the province of Buenos Aires, as well as the capital. It is impossible. It cannot close soon without having anything else to replace it.”
He explained that to comprehend the situation, “there are certain political things you have to understand, certain contradictions… It is very subjective… What is concrete is that to improve mental health you have to provide other services. It’s very expensive to make new hospitals so the government desisted.”
All these three health advisors and practitioners placed huge emphasis on the importance of providing a new network of services to help integrate patients into the community and sustain their care. However, this depends on the Buenos Aires city government complying to Law 448, a mental health law that recognises the need for an interdisciplinary network within the city that recognises the complexity of mental health.
Olivera tells me: “I don’t believe the hospital will close. What I want to believe is that they will follow Law 448. If they develop a political agenda to de-stigmatize that takes into account international access to medication, economic inclusion, the hospital will continue to play its role in mental health.”
However, Cohen highlighted the fact that the government does not comply with the law and has no need to. In 2009, a national health act ratified by in New York at the UN Convention of Rights for the Disabled reached the Chamber of Deputies in government, but was never recognised. Law 448 is also rarely publicised or discussed.
Cohen explains, “There is a problem with recognition of law. No-one knows about the law so the government has no incentive to discuss the law or implement it. People should be informed. There should be a commission of those who are familiar or capable to keep track of how people are doing and and where they are going after they are discharged.”
As Garralda said, new hospitals cost money and as it stands, the government seems to be struggling with funds already. In April health minister Jorge Lemus had to respond to claims by representatives from hospitals and neighbourhood associations about the critical condition of hospital facilities. He defended himself in front of the government health commission: “Ninety percent of what is referred to existed before my administration. There is an infrastructure and equipment backlog of more than 30 years.”
If the government is struggling to maintain other hospitals within the city, it will be difficult to source funds for improving the mental health care network. Until such a time, it can only be hoped that El Borda and Moyano are not left to deteriorate and that the city government eventually finds a way to comply with its own mental health law. In the meanwhile, the words “No al cierre” (‘No to closure’) are still sprayed over the main entrance to El Borda: a constant reminder, not only of the protestations over the closure of the hospital, but also of the patients’ need not to be closed off from the community, the need for something better than what they have at the moment.
The full text of Law 448 can be found here: www.aeapg.org.ar
Find out more about La Colifata Radio programmes here: lacolifata.openware.biz
See what is happening at El Borda Cultural Centre: www.centroculturalborda.blogspot.com/