On March 30, 2007, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) opened for signature.* Argentina was one of the first countries in the world to sign the CRPD. The following are some of the important rights protected by this historic new convention: 
States Parties undertake to ensure and promote the full realization of all human rights and fundamental freedoms for all persons with disabilities. . . . – Article 4(1) 

States Parties shall ensure that persons with disabilities, on an equal basis with others: 
(a) Enjoy the right to liberty and security of person; 
(b) Are not deprived of their liberty unlawfully or arbitrarily . . . and that the existence of a disability shall in no case justify a deprivation of liberty. – Article 14(1) 

States Parties shall take all effective . . . measures to prevent persons with disabilities, on an equal basis with others, from being subjected to torture or cruel, inhuman or degrading treatment or punishment. – Article 15(2) 

States Parties to this Convention recognize the equal right of all persons with disabilities to live in the community, with choices equal to others, and shall take effective appropriate measures to facilitate full inclusion and participation in the community. . . . – Article 19

TABLE OF CONTENTS

Executive summary

Methodology

1. Background
   1. Argentina’s health system 
   2. Mental health legislation
2. Inappropriate institutionalization
   1. The “medicalization” of social problems and the lack of community services 
   2. The right to community integration 
   3. A lost opportunity 
3. Conditions and abuses in institutions
   1. Deaths in institutions
   2. Dangerous use of isolation cells 
   3. Physical and sexual violence
   4. Dangerous conditions
      1. Lack of medical care 
      2. Unsanitary conditions 
      3. Unsafe conditions 
   5. Lack of rehabilitation 
   6. Lack of appropriate treatment and referral
   7. Overcrowding in psychiatric institutions
4. Arbitrary detention in psychiatric institutions
   1. Overbroad and ill-defined grounds for commitment
   2. Insufficient procedural protections
      1. Lack of an independent hearing within a reasonable period 
      2. Lack of representation by counsel
      3. Lack of independent periodic review of admissions 
5. Insufficient oversight and monitoring of detainees’ rights 
6. Mental health reform 
   1. Promising mental health reform initiatives 
      1. National sphere 
      2. The Autonomous City of Buenos Aires 
      3. The province of Buenos Aires
      4. The province of Rio Negro 
      5. The province of San Luis 
   2. Deinstitutionalization movement
      1. Consumer and ex-patient groups 
      2. Active professional organizations
      3. Institution directors 
7. The right to self advocacy 
8. Conclusion

Recommendations

Acknowledgments

Executive summary 

The philosophy of the asylum still predominates. The people who entered the institution, died here.1 
– Jorge Rossetto, Director, Colonia Montes de Oca 

I had a good job. I don’t know if they’ll ever let me go. My life is ruined.2 
– Person hospitalized at Cabred Hos

Ruined Lives: Segregation from Society in Argentina’s Psychiatric Asylums, documents human rights violations perpetrated against approximately 25,000 people detained in Argentina’s psychiatric institutions. More than 80 percent of these people are detained4 for more than a year—and many are detained for life. Two-thirds of all psychiatric beds are part of the public health system. While large psychiatric asylums have been closed down in much of the world, 75 percent
of people in Argentina’s public mental health system are still detained in facilities of 1,000 beds or more.

This report documents egregious cases of abuse and neglect in Argentina’s psychiatric institutions, including people burning to death in isolation cells, the use of sensory deprivation5 in long-term isolation, and physical and sexual violence. This report also details dangerous, filthy and unhygienic conditions, including the lack of running water, non-functioning sewer systems, and fire and safety hazards in institutions. The vast majority of people detained in Argentina’s psychiatric institutions languish in conditions of near total inactivity, and without the possibility of a future outside the institution.

This large-scale institutionalization and the accompanying abuses are due, fundamentally, to decades of investing in large, segregative institutions rather than the creation of policies and the development of necessary community-based mental health care services and supports.

Segregation from society in psychiatric institutions

"Very recently, I was at Open Door, Colonia Cabred. There, talking to the director, he told me, “here there are around 1,064,” or a number thereabouts, “of institutionalized persons.” He said, more or less 750 are poor; that is, they’re there because they’ve been there for a long time, and they’re there because no one goes to look for them, and because they don’t have anywhere to go if they leave. All told, the time they’ve spent there, the loneliness, becoming accustomed to this loneliness or this way of life and not having family members that are interested in them . . . so, they’re not crazy, they’re poor and alone, which is a good way to make someone crazy. 6" 
– Felipe Solá, Governor of the province of Buenos Aires

The permanent segregation of people in Argentina’s psychiatric institutions violates international human rights standards and contributes to increased disability. Cut off from society, people lose the ties that bind them to family, friends, and their communities. Once subjected to the regimented life of the institution, people lose essential life skills that they would otherwise need to survive in the community, thus facing even greater difficulties in rehabilitation.

The large-scale segregation from society and poor treatment in Argentina’s mental health system are unjustifi able, given the country’s wealth of trained mental health professionals and the existence of alternative community-based programs in different regions of the country. Per capita, Argentina ranks among the countries with the greatest number of psychiatrists and psychologists in the word. Large numbers of Argentina’s urban population pay for their own long-term, individual psychotherapy. Nevertheless, these vast resources do not translate into appropriate public policies. People with mental disabilities7 who lack funds to pay for these services are forced to receive attention in the public mental health system that frequently is inadequate, segregates them from society, and violates their fundamental human rights.

The development of innovative strategies in mental health care—such as economic subsidies for housing, psychosocial rehabilitation, and peer support—has proven that the vast majority of individuals with mental disabilities can live and thrive in the community. Yet these alternative services are almost entirely absent in Argentina (although this report discusses exceptions to this general rule in the provinces of Rio Negro, San Luis and Buenos Aires). Without personal resources or a family to pay for private care, many people with mental disabilities have no option but the asylum.

The high rate of long-term hospitalization in large institutions saps public resources that should instead be used for developing services in the community. There are a handful of communitybased programs, which demonstrate that Argentina has the technical resources necessary to reform services and successfully integrate people with mental disabilities into the community. Yet based on interviews with authorities and mental health professionals, as well as an examination of implemented mental health policies, investigators conclude that there are still no general policies conducive to the widespread community integration of people with mental disabilities. As example, within the city of Buenos Aires, the three largest psychiatric institutions account for 80 percent of the city’s mental health budget.

Impact of the economic crisis

We had a shaky situation when the crisis hit. Problems came when many employees lost their jobs, so there was no funding for the [social security system]. The number of people who needed health care in the public sector shot way up. This resulted in a total collapse of the system.8 
– Dr. Julio Ainstein, then Director of Mental Health for the province of Buenos Aires

We have a “medicalization” of social problems in today’s mental health system.9 
– Dr. Ricardo Soriano, then Director of Mental Health for the city of Buenos Aires

Argentina’s social and economic crisis—with the resulting increase in unemployment and attendant loss of health insurance—led to an increase in the number of people requiring attention in the public mental health system, putting even greater pressure on an already inadequate system. Authorities concede that between 60 and 90 percent of people detained in institutions are “social patients,”10 kept in the institutions because they have no place else to go. Institution directors reported that the majority of people now institutionalized could be discharged if the necessary services and supports were available in the community. In the absence of these services, people detained in institutions have little or no hope of ever returning to their communities. The large number of “social patients” makes it even more difficult for people in need of acute mental health services to receive the care they need.

Arbitrary detention

Argentina’s national involuntary commitment laws fall short of international standards that protect persons against arbitrary detention. In Argentina, people may be detained for life without ever getting a judicial hearing. National laws do not regulate the right to independent or impartial review of a psychiatric commitment. The Argentine Civil Code is so broad that it permits the detention of anyone who could “affect public tranquility.” Individuals committed to psychiatric facilities are not guaranteed the right to counsel or to present evidence on their own behalf. In the absence of these basic legal protections, nearly everyone in Argentina’s psychiatric asylums is arbitrarily detained.

Abuses within institutions

We need to prevent violence and abuse, which is now a problem in the institution.11 
– Jorge Rossetto, Director, Colonia Montes de Oca 

In one room, I found a 16 year-old boy in a crib with his arms and legs tied to his body with strips of cloth. He was completely immobilized. Staff on the ward told me he had been kept that way since being admitted to the institution a year ago.12 
– Investigator’s observations, Colonia Montes de Oca

Over the last three years, investigators documented a wide array of abuses against persons detained in Argentina’s psychiatric institutions. When confronted with serious violations, some authorities have taken signifi cant steps to address them. Yet there are still insuffi cient oversight mechanisms necessary to monitor people’s treatment and the conditions of their detention, and to ensure that their rights are enforced. As such, abuses of the kind described in this report doubtless are still taking place in the majority of institutions in the country. Among the most egregious abuses investigators documented are:

• Uninvestigated deaths in institutions

At Diego Alcorta Hospital, in the province of Santiago del Estero, between 2000 and 2003, four people died while locked in isolation cells: three burned to death in unrelated incidents, and the fourth died from unknown causes. At Colonia Dr. Domingo Cabred Interzonal Psychiatric Hospital (Cabred Hospital), in the province of Buenos Aires, three people were found dead in and around the asylum during the fi rst six months of 2005. The fi rst body was found in the woods, the second in a fi eld, and the third was discovered in an abandoned warehouse on the hospital grounds. Authorities determined that the third individual had died fi ve to ten days before the discovery of the body.

Also at Cabred as of 2006, there were approximately 70 deaths a year, out of an inpatient population of 1,200 men. The death rate was four times higher during the winter months than in the summer. Authorities attributed these deaths to “old age” and offered no explanation for the seasonal spike in deaths.

• Detention in isolation cells

At Psychiatric Penal Unit 20 (Penal Unit 20),13 in the city of Buenos Aires, in June 2004, investigators observed men locked in dark, tiny isolation cells. These cells measured less than oneand-a-half meters by two meters and had no natural light or ventilation. They were so overheated that the nearly naked detainees were drenched in sweat. There were no toilets and the men had to urinate and defecate in small plastic jugs on the fl oor. The cells were fi lthy and infested with cockroaches. Detainees’ only contact with the outside world was through a tiny peephole in the door. In Psychiatric Penal Unit 27 (Penal Unit 27),14 in the city of Buenos Aires, investigators also observed the abusive use of isolation cells.

In 2005, following investigators’ complaints, authorities began to renovate Penal Unit 20 and amend the policies for the use of the isolation cells. Nonetheless, at the time of the writing of this report, the renovations to these cells had not been completed, and the legal reforms necessary to prevent similar abuses from recurring in this or other institutions had not been implemented.

• Physical and sexual abuse

At Penal Unit 20, detainees told investigators that security staff rape and beat them. Investigators observed large bruises on several detainees’ torsos and backs, and one detainee had stitches in his head; all reported that their injuries were the result of staff abuse. At Braulio A. Moyano Psychiatric Hospital (Moyano Hospital), in the city of Buenos Aires, a psychiatric hospital with more than 1,000 beds,15 investigators documented—through authorities’ statements and those of various women institutionalized there—reports of sexual abuse against the women perpetrated by staff and by people outside the institution.

• Lack of medical care

At Penal Unit 20, Diego Alcorta, Jose Tiburcio Borda Interdisciplinary Psychiatric Hospital (Borda Hospital), and Moyano Hospitals, investigators observed large numbers of institutionalized persons with open, infected sores, and rotting or missing teeth. Investigators also documented instances of people whose limbs were in advanced stages of decay from gangrene. At Diego Alcorta Hospital, investigators arrived the morning that a woman institutionalized there died due to lack of medical attention; she had waited two months to have an operation on a dislocated leg. At Penal Unit 20, a detainee reported that he had not received the specifi c medications that he needed to treat his HIV/AIDS while he was detained in isolation.

• Dangerous physical conditions

At Diego Alcorta Hospital, during a visit in December 2004, bathrooms were unusable, toilets overflowed with excrement and the floors were flooded with urine. Sink handles were broken, showers did not work, and in some places there was no running water. The grounds of the facility were littered with piles of excrement and reeked of urine. When investigators returned in September 2006, Diego Alcorta had new bathroom fixtures, which appeared to improve the institution’s hygienic conditions; nevertheless, the grounds remained covered with excrement and still reeked of urine. At Moyano Hospital and National Colonia Dr. Manuel A. Montes de Oca (Colonia Montes de Oca), during visits in 2004 and 2005, investigators observed decaying roofs, broken windows, loose cables hanging from the roofs and walls, and places that reeked of urine and feces. Following an intervention at Moyano Hospital in December 2005, the government of the city of Buenos Aires began repairs to the wards, which, at the time of the writing of this report, has not been finished.16 In visits during 2007, investigators observed physical improvements at Colonia Montes de Oca.

• Lack of rehabilitation

At most institutions, no meaningful rehabilitation is provided to the vast majority of the institutionalized persons. Pervasive inactivity is the most common problem, evidenced by the overwhelming number of persons lying in their beds or on institution grounds, completely idle.

• Misuse of medications

Authorities, mental health workers and institutionalized persons reported that psychotropic medications are frequently used for punitive rather than therapeutic purposes. At Penal Unit 20, detainees reported that, as punishment for any minor offence, such as “answering back” to staff, they are injected with heavy doses of tranquilizers that leave them immobilized for days.

• Overcrowding

Overcrowding in institutions is commonplace. During three separate visits to Penal Unit 20 in 2004, 2005 and 2006, for example, the ward was overcrowded by approximately 75 percent, 40 percent, and 30 percent respectively. In 2007, according to information provided by the National Prosecutor in charge of Prisons,17 the overcrowding had risen again to 40 percent. The director of Dr. Carolina Tobar Garcia Children’s Hospital (Tobar Garcia Hospital), a psychiatric hospital in the city of Buenos Aires, stated that, with a capacity of 64 beds, the hospital was also providing intensive ambulatory care for an additional 100 children and adolescents.18

Hope for reform

Notwithstanding the size and complexity of the challenges detailed in this report, Argentina is a promising country for mental health reform. The highly trained base of mental health professionals currently providing services on an individual basis are an invaluable resource that, with redirection, could be mobilized to provide community-based care.

Argentine lawyers and mental health professionals have often taken the lead in developing profoundly innovative laws, policies, and service programs. On a municipal level, in the city of Buenos Aires, the 1996 Constitution, the Basic Health Law No. 153, and the Mental Health Law No. 448 call for progressive deinstitutionalization and the creation of community-integrated services.

Importantly, there are significant resources to implement mental health reform in the city of Buenos Aires. During a meeting in January 2006, the then offi ce of the city’s Secretary of Health, which became the Ministry of Health in April 2006, declared its intention to collaborate in the social reinsertion of institutionalized persons, stating that the local government would provide the necessary resources through different programs and subsidies to implement mental health reform. Recognizing that, historically, there has been a lack of political will to carry out reform efforts, the Head of the Cabinet of the city’s former Secretary of Health stated, “There is money [to implement reform], we have to make the changes, we have to do it now.”19 Another step toward the implementation of Mental Health Law 448 has been that what was formerly the Direction of Mental Health has become the General Direction of Mental Health. As a result, the agency should have more resources, a larger budget and greater authority within the area of health to implement the Law.

Argentina also has an array of policymakers, service providers, specialized academics, and human rights organizations lobbying for far-reaching, sustained and integral mental health reform. Some of the continent’s most recognized mental health reform initiatives have been implemented in the provinces of Rio Negro and San Luis. These programs are models for reform in other parts of the country, and the individuals driving these mental health reforms are now working with institutions elsewhere in Argentina to help them in their reform efforts.

Tremendous potential support also exists among families of people with mental disabilities, as well as among consumers of mental health services and ex-patients. Families are the mainstay for most individuals with mental disabilities. Nevertheless, without government support, many of these families are left impoverished and socially marginalized. Likewise, there are a number of active consumer or ex-patient groups, including the Frente Artistas del Borda (Borda Artists’ Front), Radio La Colifata (Radio Colifata), and Pan del Borda (Bread of Borda). These groups provide hope and a legitimate voice for change in mental health services. With a small investment, family member and consumer or ex-patient groups could be a tremendous and low-cost resource for developing community support and advocacy initiatives.

Despite these hopeful circumstances, some opportunities for reform have already been squandered. Buenos Aires city authorities reported that a loan from the Inter-American Development Bank (IDB) was being used to renovate four psychiatric institutions in the city. According to these authorities, the amount being spent on these renovations was more than 60 percent of the annual mental health budget for the entire city. Instead of rebuilding inpatient facilities—with the exception of reconstruction and repairs that are absolutely necessary for safety reasons— international funding should be invested in furthering the transition to a community-based system of care, as required by the city’s laws and international human rights standards. Authors urge the government of Argentina to respect its own legislation and internationally accepted standards and invest existing resources in the implementation of deinstitutionalization programs. The IDB, in order to comply with international human rights norms, should shift course and dedicate itself to the development of services that promote the full community integration of people with mental disabilities.

As long as resources remain directed almost exclusively toward institutional care, widescale reform will be unachievable and the segregation and abuses such as those documented in this report will continue unabated.

Summary of recommendations

The following recommendations propose concrete measures that should be adopted to implement a profound reform in Argentina’s mental health services. MDRI and CELS recommend that the government of Argentina take immediate action to end conditions that violate the human rights of those institutionalized.

The government of Argentina should: 

• Eradicate the dangerous, fi lthy and inhuman environments in which institutionalized persons are forced to live; 
• Guarantee adequate food, medical care and staffi ng to protect the health and safety of institutionalized persons; 
• Investigate recent deaths and establish protocol to ensure full investigations of any future deaths; 
• Eliminate the use of long-term isolation cells and sensory deprivation in these cells and ensure that the use of involuntary seclusion20 and physical restraint21 adheres strictly to international human rights standards; 
• Create independent oversight mechanisms toward the prevention of abuses in institutions and establish procedures that will protect institutionalized persons from sexual and physical abuse; 
• Adopt procedures for psychiatric commitment that strictly adhere to international standards, including the right to independent review in all commitment proceedings; 
• Adopt enforceable mental health laws that will apply throughout the country, consistent with international human rights standards.

The government of Argentina should commit to the full inclusion of people with mental disabilities into all aspects of Argentine society, including people with both psychiatric and intellectual disabilities. Protecting the human rights of this population will require a paradigm shift from custodial institutionalization and arbitrary detention to the development of services that are comprehensive, community-based, include mental health attention as part of primary care, and provide social services that contribute to strengthening social networks. Investigators recommend that the national government create a high-level national commission to plan and implement mental health service reform that would allow people with mental disabilities to live, work and receive health and mental health attention in their own communities.

At the end of this report, these proposed recommendations are developed in greater detail. 

Methodology 

This report is the product of research conducted jointly by Mental Disability Rights International (MDRI) and the Center for Legal and Social Studies (CELS). During six factfi nding trips to Argentina—which occurred in June 2004, December 2004, June 2005, January 2006, September 2006, and July 2007—research teams visited numerous facilities for people with psychiatric and developmental disabilities in the city of Buenos Aires, and the provinces of Buenos Aires, Santiago del Estero, Rio Negro and San Luis. These institutions included: Jose Tiburcio Borda Interdisciplinary Psychiatric Hospital, Braulio A. Moyano Psychiatric Hospital, Dr. Carolina Tobar Garcia Children’s Hospital, the half-way house Centro Psicopatologico (Psycopathologic Center) Aranguren, and psychiatric Penal Units 20 and 27 in the city of Buenos Aires; a psychiatric ward in Paroissien Hospital, the National Colonia (a public asylum located in the countryside) Dr. Manuel Montes de Oca, the Colonia Dr. Domingo Cabred Interzonal Psychiatric Hospital, Jose Estevez Interzonal Hospital (Estevez Hospital), San Gabriel Neuro-psychiatric Medical Center, and a half-way house in Moreno in the province of Buenos Aires; Diego Alcorta Hospital, a psychiatric ward in Independencia Hospital, and a private clinic in the province of Santiago del Estero; and mental health system reform models in the provinces of Rio Negro and San Luis.

Investigators met with Argentine government offi cials responsible for providing health and social services to people with mental disabilities, as well as with representatives of non-governmental advocacy groups, including human rights organizations, mental disability rights groups, and family and professional organizations. During hospital visits, investigators interviewed hospital directors, medical directors, psychologists, psychiatrists, nurses, social workers, institutionalized persons and family members. Investigators also reviewed medical histories and collected data through direct observation.

This report analyzes the data collected and Argentina’s laws and policies under international human rights standards that are binding on Argentina.22 Particular attention is given to the rights contained in the American Convention on Human Rights (American Convention),23 the International Covenant on Civil and Political Rights (ICCPR),24 the International Covenant on Economic, Social and Cultural Rights (ICESCR),25 and the Inter-American Convention on the Elimination of all Forms of Discrimination against Persons with Disabilities (Inter-American Convention on Disability).26 In addition, the report identifi es human rights principles applied directly to persons with disabilities under the Convention on the Rights of Persons with Disabilities (CRPD), adopted by the United Nations (UN) General Assembly December 13, 2006 and signed by the Argentine government on March 30, 2007.27

The report also analyses conditions, treatment, and legislation in light of specialized standards adopted by the UN, such as the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (MI Principles),28 and the Standard Rules on the Equalization of Opportunities for Persons with Disabilities (the Standard Rules),29 as well as policy documents drafted by the World Health Organization—including the Declaration of Caracas30 and the Montreal Declaration on Intellectual Disabilities31—and the Recommendation of the Inter-American Commission on Human Rights for the Promotion and Protection of the Mentally Ill.32

Based on this analysis, and in consultation with local advisors, the report details recommendations to help bring Argentina’s mental health system into compliance with international human rights standards, and proposes specifi c steps Argentine actors can take to transform the asylum-based care model. These recommendations are grounded in authors’ past experience, and incorporate interviews with service providers, consumers, ex-patients, family members, and government offi cials over the course of the investigations. The report draws from extensive international experience in the areas of mental disability rights specifi cally and international human rights more generally, as well as local expertise, to recommend strategies to complement and build on the resources available in Argentina.

Over the course of the research for this report, investigators met many mental health workers who are dedicated to delivering quality services to people with mental disabilities, including several professionals who are engaged in pioneering reform efforts. Investigators recognize that conditions in institutions that are harmful to persons with mental disabilities can also be harmful to the staff employed there, and that care models and services must be transformed to protect and enhance the rights of the consumers and providers of mental health services alike. Increased funding for community-integrated mental health services and social supports, housing alternatives to segregative institutionalization, oversight to enforce human rights protections, and enhanced training will benefi t staff as well as those receiving services.

These fi ndings and recommendations are based upon observed mental health systems and services. Investigators could not visit all mental health programs in the country, and this report does not intend to provide an evaluation of all existing programs. Authors recognize that there can be tremendous variation between the mental health services of different provinces, as under Argentine law each province determines its own mental health policy and there is still no national mental health legislation. This report focuses heavily on services in the city and province of Buenos Aires, where the largest institutions are located.

In the interests of brevity and clarity, this report does not discuss every facility visited. Rather, the report describes some key areas for broad-based reform, documenting several egregious violations encountered as well as highlighting some successful reform models. Authors hope that this report contributes to promoting mental health reform throughout the country.

I. Background

During much of the twentieth century, Argentina was one of the most prosperous countries in Latin America, with relatively low levels of poverty, inequality and unemployment.

Over the last three decades, however, the country has experienced a sharp deterioration of labor and social conditions. Inequality, poverty, and unemployment increased even during periods of economic growth.33 During the 1990s, the country underwent a series of social and economic changes that led to a downturn in the growth of the labor force, extreme variations in income distribution, and an increase in the percentage of the population living in poverty.34

The economic and social crisis that deepened during the fi nal years of the 1990s “exploded” in the month of December 2001, when Argentina experienced a series of events that marked its institutional and political history. This economic and political instability brought about the rapid downfall of successive governments in 2001 and 2002, until the current president, Nestor Kirchner, was elected in 2003.

Despite the sustained economic recovery of the country since 2003, a deep social divide between the wealthiest and poorest sectors of the population remains intact, and high levels of poverty, indigence and social exclusion persist.35

This economic and political instability has affected all sectors of Argentine society. However, economically and socially marginalized populations—such as people with disabilities— have been even more vulnerable to the effects of this instability. Poverty not only accentuates some of the negative consequences of disability, but it is also a factor leading to increased incidences of disability, as accessing health care, education, and rehabilitation services becomes more difficult with the growth in unemployment and poverty.36 As these ripple effects of Argentina’s socio-economic collapse manifest, vulnerable groups such as people with mental disabilities are particularly susceptible to abandonment and abuse.

A. Argentina’s health system

Argentina’s health system is complex, fragmented, and decentralized. Each of the country’s 24 provinces has its own Ministry or Secretary of Health, which controls most of the health policy decisions for its region. Health care in Argentina is fi nanced largely through payroll deductions. For approximately 50 percent of the population, “obras sociales sindicales,” or union-sponsored not-for-profi t employee benefi t programs regulated by the government, fi nance health care. Yet since the economic crisis, many people have lost their jobs and the income for these programs has decreased drastically, while the population without any health insurance coverage has seen a dramatic increase. In addition, programs that previously recovered costs through collective quotas paid by those who used their services are no longer able to do so, as their members can no longer afford to pay for the services.37

Federal mental health planning in Argentina is carried out by the Unidad Coordinadora Ejecutora de Salud Mental y Comportamiento Saludable del Ministerio de Salud de la Nación (Mental Health and Healthy Behavior Executing Coordinating Unit within the federal Ministry of Health, hereinafter, Coordinating Unit). The Coordinating Unit’s total annual budget for 2006 was a mere 700,000 pesos (approximately US$233,000).38 In 2005, the Coordinating Unit lacked suffi cient resources to implement policy or collect and centralize mental health data from the provinces.39 Without reliable data about the scope of mental health issues and available mental health services, policy planning and implementation are practically impossible. Most policy decisions and budget allocations are therefore made at the provincial level. At present, the Coordinating Unit has signed an agreement with eight national universities to carry out epidemiological research on psychic malaise in children, which has demanded nearly 65 percent of its total budget. In addition, in the framework of the National Mental Health, Justice and Human Rights Roundtable,40 the Coordinating Unit is participating in a series of regional colloquia to determine how to prioritize mental health policies from a human rights perspective. 41

The World Health Organization recommends that 10 percent of a country’s health budget be allocated to mental health.42 However, several provinces allocate only a fraction of this amount for mental health services. In the province of Buenos Aires, for example, according to figures from 2005, only 2 percent of the health budget was allocated to mental health.43 For 2007, the budget for mental health had increased to 4.2 percent.44

The rise in poverty since the 2001 economic and political crisis has led to an increase in demand for public health services. Whereas before the crisis 40 percent of the population received attention through public hospitals, since the crisis, 60 percent of the population has been using public hospital services.45 At the same time, the health budget has been cut, compounding the problem of rising demand. There has been an increase in psychiatric symptoms and the prevalence of certain illnesses associated with poverty and unemployment, as the socio-economic situation in Argentina has worsened.46

In the last few years, the Argentine government has taken a number of measures in an effort to minimize the impact of the economic crisis on the health sector. These measures have focused on access to pharmaceuticals. The national Ministry of Health, the principal producer of medications consumed in Argentina, increased its production of medications as a response to the crisis.47 The Ministry also centralized the purchase of medicines allowing for lower prices through bulk purchases, whereas previously each hospital purchased for its own use.48 Additionally, the Ministry has instituted a policy of using generic medicines whenever possible, and is taking part in a program to purchase medicines through the United Nations Development Program (UNDP).49 Participation in the UNDP program has resulted in a 21 percent savings for the government, as there is no value added tax paid on the medications.50 These government initiatives are important, but access to medications does not address the basic needs of many institutionalized individuals, which include healthy and hygienic conditions and personalized rehabilitation. Even more important, pharmaceuticals alone are no substitute for the range of community supports—such as access to affordable housing and employment opportunities—needed to prevent unnecessary hospitalizations.

Today, two out of three of the country’s 25,000 psychiatric beds are publicly managed, and three out of four of those public beds are found in large institutions of 1,000 beds or more.51 There are eight psychiatric institutions with more than 1,000 beds each, four of which are located in the province of Buenos Aires and two in the city of Buenos Aires.52 The vast majority of individuals housed in Argentina’s psychiatric institutions are long-term residents. People who have been institutionalized longer than one year occupy 80 percent of psychiatric beds.53 Only 5 percent of people are hospitalized for less than three months.54

B. Mental health legislation

Argentina has a federal form of government. As such, the national Constitution, the international treaties ratifi ed by the federal government, and national laws have superiority to laws enacted at the provincial level.55 Provincial governments, however, maintain all powers not delegated to the federal government by the Constitution.

Argentina boasts progressive federal mental health legislation, which establishes guidelines for the implementation of mental health reform. The Programa de Asistencia Primaria en Salud Mental ley 25.421 (Program for Mental Health Services in Primary Care, Law 25.421), enacted in 2001, establishes that all persons have the right to receive mental health care as part of primary care services, and provides for the rehabilitation and social reinsertion of persons with mental illness.56 The Law also establishes the Program of Mental Health Services in Primary Care, and designates the national Ministry of Health as the agency responsible for enforcing the Law.57 However, at the time of the writing of this report, the federal government had not yet established the regulations for Law 25.421, and the Law had yet to be enforced.

In the Autonomous City of Buenos Aires, the Ley Básica de Salud, Nº 153 (Basic Health Law 153) requires that the city government implement progressive deinstitutionalization.58 Toward this end, Law 153 calls for the implementation of alternative mental health models focused on social integration, such as half-way houses, protected workshops, therapeutic communities and day hospitals.59

In 2000, in compliance with Law 153, Ley de Salud Mental de la Ciudad de Buenos Aires, Nº 448 (Mental Health Law of the City of Buenos Aires, Law 448) was passed. Law 448 guarantees the right to mental health, and calls for deinstitutionalization and the rehabilitation and social reinsertion of institutionalized persons.60 This Law also establishes that the mental health system in the city of Buenos Aires be one based principally on prevention, promotion, and the protection of mental health.61 Article 3 of Law 448 sets forth human rights protections specifi c to persons with mental disabilities and looks to transform the current asylum-based model and promote community mental health services.62

Despite the language of Laws 25.421, 153 and 448, the model of public mental health provision, both nationally and in the city of Buenos Aires, continues to be based almost exclusively on institutional care. Throughout the country, there is a dearth of adequate mental health attention within primary care. With a few exceptions,63 no strategies or action plans exist for the incorporation of mental health into primary care, and there is no training of primary care health professionals in mental health issues.64 The 2007 working budget for the city of Buenos Aires, presented in October 2006, allocated less than 2.2 billion pesos (approximately US$722 million) to health;65 of which, 146 million pesos (approximately US$49 million) would be allotted to mental health, representing 6.9 percent of the total health budget.66 Of the overall health budget, 81 percent would be designated to hospital services and 4.2 percent to primary care.67 Taking the city of Buenos Aires as an example, only two general hospitals of the 33 hospitals in the health network provide in-patient mental health services.68

II. Inappropriate institutionalization

A. The “medicalization” of social problems and the lack of community services 

Social factors, more often than psychiatric considerations, can be decisive in admissions to and discharges from psychiatric hospitals.69 Government authorities and hospital directors told investigators that the majority of people in institutions remain institutionalized for long periods due to social problems.

In 2004, at Estevez Hospital, a women’s psychiatric hospital in the province of Buenos Aires,70 then Assistant Director Dr. Patricia Esmerado estimated that 70 percent of the institutionalized persons are “social patients,”71 meaning that their continued hospitalization is grounded in socioeconomic considerations rather than medical or mental health criteria. Dr. Ricardo Soriano, then Director of Mental Health for the city of Buenos Aires, reported that approximately 60 percent of the individuals institutionalized are in this situation because of a “medicalization of social problems,”72 and Dr. Antonio Di Nanno, Coordinator of National Mental Health Coordinating Unit, reported that 80 percent of those hospitalized are there because of failures in the social support system.73 Dr. Carlos de Lajonquiere, General Director of Mental Health for the city of Buenos Aires, cited a list of persons hospitalized in Borda and Moyano Hospitals that had been drawn up based on evaluations by different ward directors from both hospitals, stating that between 15 and 20 percent of those institutionalized would be able to be discharged were it not for social factors.74 Nonetheless, he considered these numbers very low, and not reflective of reality.75

One woman at Moyano Hospital described her plight:

I have been here for ten years. I was admitted after I tried to commit suicide. I had a job as a professor of English and Italian, but I had to quit my job after ten years to care for my elderly parents. After they died, I fell into a deep depression and tried to end my life. I have had a medical discharge for fi ve years, but there is a little paperwork that remains to be done.76

At Borda Hospital, a man in a one of the “chronic” wards told investigators:

I’ve been going from hospital to hospital since 1985. I was discharged in 1998, but my father died the following year and I fell [into depression]. This time I have been hospitalized for fi ve or six years. I have four sisters. One sister is my legal guardian. If I have a place to go and a way to control [my medication] I can leave. My sister is doing the paperwork for my release. The paperwork is very expensive. For the last fi ve years she has been working for my release.77

The ward director countered,

The paperwork is not the problem; we do the paperwork from one day to the next. The problem is that [the patients] don’t have anywhere to go because they don’t have anyone or their families reject them. . . . Sixty percent of them are in conditions to have a medical discharge but they don’t have anywhere to go. They are “social cases.” In no other specialty does this problem exist. When someone is hospitalized for an appendectomy, the family does not abandon the person in the hospital.78

In 2004, at Colonia Montes de Oca,79 in Ward 3, one member of the nursing staff estimated that approximately half of the people were then hospitalized due to social problems. Some people were unable to afford medication and some were malnourished due to poverty, she reported.80 In 2007, the governor of the province of Buenos Aires estimated that more that 70 percent of the 1,070 persons institutionalized at Cabred Hospital were there because of poverty.81

During interviews conducted in 2004 at Estevez Hospital, in an acute ward housing 78 women, staff informed investigators that 30 percent of the women in the ward had a medical release, but there was nowhere for them to go.82 In 2006, at Penal Unit 20, staff said that of the 114 persons institutionalized, 20 were in conditions for discharge, but they were not released because there were no intermediary places to release them to. Penal Unit 20 staff also said that there was no average period of institutionalization and they reported cases of persons who had been housed on the Unit for more than 20 years.83

Based on interviews with authorities, professionals, family members and institutionalized persons, investigators deduce that approximately 70 percent of those institutionalized remain segregated from the community for social reasons. Within this percentage exists a large number of people hospitalized who receive no medications or other treatment, yet continue to be institutionalized for decades. As such, this report fi nds that Argentina’s psychiatric institutions have become “human warehouses” for people who lack the means to support themselves, or family members able or willing to take them in.84

The main factor contributing to long-term institutionalization is the lack of adequate services and support mechanisms in the community. According to a member of the Foro de Instituciones de Profesionales en Salud Mental de la Ciudad de Buenos Aires (FORO—Forum of Mental Health Professional Institutions of the City of Buenos Aires), “there are patients who need assisted residences who will need monitoring. They need half-way houses and economic subsidies. [If these are] well implemented, it will lead to the resocialization of a patient who has been isolated.”85 Adequate community services would enable individuals with initial outbreaks of mental illness to receive appropriate care before their health deteriorates, and allow those who have been institutionalized for many years to become reintegrated into the community.86

This lack of community-based services is complicated by the fact that, in general, mental health training in Argentina focuses on psychoanalysis. As a treatment modality, psychoanalysis is oriented toward individual therapy rather than psycho-social rehabilitation, which is an important element of what people discharged from psychiatric institutions need. Further, based on interviews and a review of the programs offered at national universities, investigators found that interdisciplinary mental health treatment is generally not taught in Argentina’s universities.87 Investigators collected information regarding how professionals trained in psychoanalysis have diffi culty working in interdisciplinary teams. They see patients on an individual basis, are not trained to work with groups, and are resistant to working in promotion and prevention.88 One FORO member commented, “The tendency is to hospitalize people with psychiatric illness, and there is a lack of training in alternatives.”89 The General Director of Mental Health for the city of Buenos Aires reported that the creation of interdisciplinary teams, day hospitals and psychiatric beds in general hospitals, all commitments made by the city’s Ministry of Health in 2005, were not implemented due to budgetary shortfalls. He reported that there was only one interdisciplinary team formed in one general hospital in the city.90

At Moyano Hospital, staff and residents reported that hundreds of women remained hospitalized for many years. One psychiatrist interviewed stated that of the 1,750 women institutionalized at Moyano, 1,500 were in chronic wards, where they stayed indefi nitely.91 He estimated that 60 to 70 percent of them could be discharged if there were adequate mental health services and housing alternatives in the community.92 A psychiatrist who has been working at Moyano for 25 years stated:

There are no half-way houses, there is no place [the women] can go. Law 448 is not enforced. [The women] would need to have a subsidy to rent a room in a hotel or a small apartment.93

The lengths of hospitalization in the city of Buenos Aires range from three months to 66 years. Of the 2,424 persons institutionalized in August 2005, almost 10 percent had been institutionalized longer than 25 years; more than 25 percent between 10 and 25 years. The average institutionalization was nine years.94 During the fi rst six months of 2007, the average number of persons institutionalized in the public system was approximately 2,460.95 Disaggregated by hospital, the average lengths of stay are:

Hospital - Average length of hospitalization

Torcuato de Alvear Emergency Hospital - 1 month, 3 weeks

Borda Hospital - 10.5 years

Moyano Hospital - 9 years, 3 months

Tobar García Hospital - 4 months, 3 weeks

One woman’s story illustrates the urgent need for housing alternatives in the community:

I have been hospitalized here for four years, since 2001. They hospitalized me because I heard voices. [My family] threw me out of the house because they didn’t want to take care of me. I went to look for my grandmother. When I got to Buenos Aires I got lost looking for her house. The police found me in the street. I was hearing voices and I had just started menstruating and I was all bloody and delirious. The police called my house and my mother said that it had been four years since they had seen me and they didn’t want to have anything else to do with me. When I entered [the hospital] I was in the admissions unit for 15 days and then they hospitalized me in [the ward] Bosch I. It’s a ward that has a little bit of everything. . . . I don’t have anywhere to go. I have had a medical discharge for two years. I work in the protected workshops. I want to study now that I don’t hear voices. I want to study to be a technical assistant in odontology.96

In 2006, the city of Buenos Aires initiated the Programa de Externación Asistida para la Integración Social (PREASIS—Program on Assisted Discharge for Social Integration) to help reintegrate persons formerly institutionalized into the community.97 By July 2007, this program had opened two half-way houses for women who had been discharged from Moyano Hospital within the Dirección General del Sistema de Atención Inmediata del Ministerio de Derechos Humanos y Sociales (General Direction of the Immediate Attention System of the Ministry of Human and Social Rights).98 Both houses accommodate up to eight people. The creation of a third house for men is planned before the end of 2007.

At Estevez Hospital, investigators interviewed women who appeared able to live in the community, yet had been institutionalized for many years. In Ward 1, deemed by administrators to be a “mid-term” ward—with average stays between three and six months—investigators interviewed several women who had been hospitalized much longer:

I’ve been here nine months. There are people who’ve been in this ward for 11 years.99

Another woman reported:

My family abandoned me here eight years ago when my mother died. They don’t visit me, don’t send me anything. I don’t know if they sold my house. I want to leave this place. I’ve lived in Ward 1 for eight years. . . . There’s an old woman who’s been here for about 40 years; she’s about 90. There are at least ten women who’ve been in this ward for many years; they’re left over from the past, when this wasn’t a mid-term ward.100

The vast majority of women at Estevez Hospital remain hospitalized for many years. In October 2006, of the hospital’s 1,020 beds, more than 800 were located in the “asylum” sector of the hospital. Once there, women typically remain for life.101 The hospital, however, is involved in a program to help reintegrate these women into the community. The Programa de Rehabilitación y Externación Asistida (PREA—Program on Rehabilitation and Assisted Discharge), operating under the Ministry of Health of the province of Buenos Aires, helps women integrate into a collective environment in houses in the community and assisting them in learning or re-learning essential life skills. As told by one of the PREA participants:

I’ve been hospitalized here for three years. I’m now in the PREA program; there are only six of us in the program at the hospital. I’ve been in PREA since January 1, 2003. They spend a year or so teaching you how to deal with money, with living outside [the hospital]. I’m going to live with three other women. We don’t know yet when we’re moving out.102

According to Estevez Hospital staff, at the time of investigators’ June 2004 visit, there were 45 women living in houses in the community as part of the PREA program.103 In October 2006, the number of persons discharged living in these communal residences had increased to 50.104

At Tobar Garcia Hospital, 70 to 80 percent of the children and adolescents receiving treatment at the hospital come from outside the city of Buenos Aires.105 There are no mental health services specifi c to children and adolescents outside the city limits, and there is no infrastructure to provide follow-up on an outpatient basis. Tobar Garcia Hospital’s Director, Dr. Roberto A. Yunes, reported, “The province of Buenos Aires has absolutely nothing” in terms of mental health services for young people.106

The lack of services for children in their local communities contributes to the diffi culty in discharging them, and complicates rehabilitative treatment exponentially.107 Dr. Yunes added that the economic crisis has further complicated the problem: “people don’t have money for food, don’t have money for transportation, much less for psychiatric attention. . . . It takes one to two hours to get to Tobar [Garcia from the province of Buenos Aires].”108 Once children are discharged, often their families do not have the resources that would allow them to continue a recommended course of treatment.

At Borda Hospital, staff complained about the lack of services for the persons discharged. According to one staff member in Ward 14.22,

The problem is that the patient in condition for discharge doesn’t have a path for reintegration into the community where he can recuperate. Where will they go? Who’s going to give them work? It’s discrimination. They say that if they’re from 14.22, worse yet. There would have to be a space for rehabilitation. When [Penal] Unit 20 is full, they’re sent here. There’s a lack of follow-up, without this, nothing can move.109

At Colonia Montes de Oca, 85 percent of the nearly 1,000 persons institutionalized have intellectual disabilities.110 As with persons diagnosed with mental illness, once admitted, persons with intellectual disabilities generally remain institutionalized for life. In the aggregate setting of the institution, people lose any skills or independence they may have had. During investigators’ visits to Colonia Montes de Oca in 2004, there were practically no community-based services in the area to support people with intellectual disabilities, thus all but guaranteeing a lifetime of institutionalization.

Beginning in 2005, however, proactive steps have been taken toward the creation of community-based health services for people with intellectual disabilities. In September 2006, Jorge Rossetto, Director of Colonia Montes de Oca, informed investigators that the institution had begun a day treatment program in a nearby town. The program accommodates 30 people considered to have the greatest disabilities. He noted that these individuals were making tremendous progress with the more individualized attention they received from the program. By July 2007, fi ve day hospitals—one in the nearby town of Torres—and a hostel had been created. A second half-way house was projected by the end of 2007. Between 2004 and 2007 the census at Colonia Montes de Oca decreased from 961 to 864.111

The lack of community mental health services also impacts individuals with intellectual disabilities. Generally, neither those hospitalized nor persons with intellectual disabilities who remain in the community receive the necessary attention that would allow them greater independence. Members of the nongovernmental organization Red por los Derechos de las Personas con Discapacidad (REDI—Network for the Rights of Persons with Disability) informed investigators that, despite the fact that the right to health is recognized in Argentina, this right is largely unfulfi lled for people with intellectual disabilities.112 There are no early intervention programs in public hospitals, and children with intellectual disabilities do not receive adequate habilitative therapies at an early age. In general, professionals are not educated in diagnosing intellectual disabilities, and most universities do not have faculty trained to address the needs of children with intellectual disabilities.113 Without early intervention programs and other specialized supports available in the community, the chances that children with intellectual disabilities will become participating members of society are vastly diminished.

B. The right to community integration

Throughout the world, there is a growing consensus that the overwhelming majority of people with mental disabilities—including both people with psychiatric and intellectual disabilities— can live in the community with appropriate services and support systems.114 The United Nations’ Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (Special Rapporteur on the Right to Health) Paul Hunt has observed that:

As a result of increased knowledge about mental disabilities and new models of communitybased services and support systems, many people with mental disabilities, once relegated to living in closed institutions, have demonstrated that they can live full and meaningful lives in the community. People once thought incapable of making decisions for themselves have shattered stereotypes by showing that they are capable of living independently if provided with appropriate legal protections and supportive services. Moreover, many people once thought permanently or inherently limited by a diagnosis of major mental illness have demonstrated that full recovery is possible.115

These ideas have taken hold in the Americas and have been endorsed by the Pan American Health Organization (PAHO). In 1990, PAHO organized a regional conference on restructuring psychiatric care in Latin America, which brought together legislators, health authorities, mental health professionals, jurists, and non-governmental activists. That conference adopted the Declaration of Caracas, which called on all governments to restructure mental health care to promote “alternative service models that are community-based and integrated into social and health networks.”116 The Declaration found that:

[T]he mental hospital, when it is the only form of psychiatric care provided, hampers fulfi llment of the forgoing objectives in that it: 

• (a) isolates patients from their natural environment, thus generating greater social disability; 
• (b) creates unfavorable conditions that imperil the human and civil rights of patients; 
• (c) absorbs the bulk of fi nancial and human resources allotted by the countries for mental health care; and 
• (d) fails to provide professional training that is adequately geared to the mental health needs of the population, the general health services, and other sectors.117

Over the last few decades, not only has community mental health come to be regarded as good mental health practice, but the right of persons with disabilities to community integration has been identifi ed as a basic human right, and the denial of this right has been recognized as discrimination.

As early as 1971, the UN adopted the Declaration on the Rights of Mentally Retarded Persons to promote the integration of people with intellectual disabilities “as far as possible” in community life.118 In 1991, the UN General Assembly stated that “[e]very person with a mental illness shall have the right to live and work, as far as possible, in the community.”119 The very purpose of the Inter-American Disability Convention, which entered into force in 2001, is to promote the full integration into society of persons with disabilities.120 The Montreal Declaration on Intellectual Disability, adopted in 2004, states that “[f]or persons with intellectual disabilities, as for other persons, the exercise of the right to health requires full social integration. . . .”121 Most recently, the CRPD, adopted by the UN General Assembly in December 2006, mandates that States party take “effective and appropriate measures” to promote the “full inclusion and participation in the community” of persons with disabilities.122

The Inter-American Disability Convention defi nes discrimination against people with disabilities as “any distinction, restriction, or exclusion based on disability . . . which has the effect or objective of impairing or nullifying the recognition, enjoyment, or exercise by a person with a disability of his or her human rights and fundamental freedoms.”123 In order to achieve the Convention’s objectives of eradicating discrimination against persons with disabilities and promoting their complete integration into society,124 the States party commit to collaborating in developing “the means and resources to facilitate or promote the independence, self-suffi ciency, and total integration into society of persons with disabilities, under conditions of equality.”125

The CRPD mandates that States party take “effective and appropriate measures” to promote the “full inclusion and participation in the community” of persons with disabilities, including guaranteeing that:

• (a) Persons with disabilities have the opportunity to choose their place of residence and where and with whom they live on an equal basis with others and are not obliged to live in a particular living arrangement; 
• (b) Persons with disabilities have access to a range of in-home, residential and other community support services, including personal assistance necessary to support living and inclusion in the community, and to prevent isolation or segregation from the community; 
• (c) Community services and facilities for the general population are available on an equal basis to persons with disabilities and are responsive to their needs.126

In General Comment 5, the UN Committee on Economic, Social, and Cultural Rights recommends that to protect against discrimination, States should adopt policies and legislation that “enable persons with disabilities to live an integrated, self-determined and independent life.”127 Quoting the World Programme of Action concerning Disabled Persons, General Comment 5 establishes that:

Anti-discrimination measures should be based on the principle of equal rights for persons with disabilities and the non-disabled, which implies that the needs of each and every individual are of equal importance, that these needs must be made the basis for the planning of societies, and that all resources must be employed in such a way as to ensure, for every individual, equal opportunity for participation. Disability policies should ensure the access of [persons with disabilities] to all community services.128

The Special Rapporteur on the Right to Health has recognized that, “Decisions to isolate or segregate persons with mental disabilities, including through unnecessary institutionalization, are inherently discriminatory and contrary to the right of community integration enshrined in international standards.”129 To avoid such discrimination, “[s]tates should take steps to ensure a full package of community-based mental health care and support services conducive to health, dignity, and inclusion.”130

C. A lost opportunity

Recently, the city of Buenos Aires government may have lost an opportunity to stem the tide of discrimination and invest in the creation of community-based mental health services.

During a period of transition to community-based services, signifi cant additional funding will be needed to maintain existing services while the necessary community supports and services are created. Dr. Ricardo Soriano, Director of Mental Health for the city of Buenos Aires, informed investigators that the Inter-American Development Bank (IDB) was furnishing the city government with a loan of more than 40 million pesos (US$14 million) to renovate and equip the four large mental health hospitals in the city. This loan, however, allotted no money for the creation of community-based services.131 The amount of the IDB loan, at the time of its approval in 2004, was equivalent to 60 percent of the entire mental health budget of the city for one year (approximately 68 million pesos or US$22.7 million).132

III. Conditions and abuses in institutions

Over the course of the research for this report, investigators documented a range of inadequate conditions of detention and abuses of people with mental disabilities in psychiatric institutions in Argentina. These abuses violate the rights to life, personal integrity, liberty, health and rehabilitation.

A. Deaths in institutions

During the December 2004 visit to Cabred Hospital, hospital administrators told investigators that death rates were four times higher in the winter months than in the summer. Cabred Hospital’s director, Dr. Leo Zavattaro, said that, on average, 70 people institutionalized there died each year.133 Dr. Zavattaro claimed that 99 percent of the deaths were due to old age, with other causes being heart attacks and sudden deaths among the young men.134 However, on average, during the winter, approximately two people died per week, while during the summer one person died every two weeks.135 These statistics suggest that wintertime deaths may not be due primarily to “old age” but rather to insufficient heating, or contagious diseases spread in colder environments. Dr. Zavattaro informed investigators that autopsies are not generally performed for these deaths.136 During investigators’ follow-up visit in July 2007, Dr. Zavattaro told investigators that the number of deaths had fallen, although he could not say by how much.137

 Also at Cabred, according to news reports, three people were found dead in and around the hospital during the fi rst six months of 2005.138 The first body was found in the woods surrounding the hospital on January 25, 2005, and the second body was found in a fi eld on the hospital grounds on February 15, 2005.139 The third body was discovered in an abandoned warehouse on the hospital grounds, dressed in pajamas and barefoot, as reported in La Nación online on June 15, 2005.140 In this case, the police determined that the individual had died five to ten days before the discovery of the body.141

In 2005, Cabred Hospital administrators reported that judicial investigations were being carried out in relation to these suspicious deaths. Yet during investigators’ visit to the institution more than two years later, in July 2007, Dr. Zavattaro told investigators that he did not know the outcome of the judicial investigations and that no administrative indictments had been undertaken by the institution.142

In 2004, then Interim Director of Diego Alcorta Hospital, Dr. Abraham Stoliar, informed investigators that in the previous fi ve years, four people detained in isolation cells had died.143 Hospital staff told investigators that in 2000, an individual—who had no mental illness but was sent to the institution by a judge as a form of punishment—burned to death in an isolation cell after setting fi re to a mattress.144 Eight months later, a second individual who was sent to the hospital for drug addiction problems burned to death in an isolation cell.145 In 2001, a third person, who, according to hospital staff was agitated, was placed in an isolation cell and later found dead; the cause of this death was never clarified.146 In 2003, a fourth individual burned to death in an isolation cell.147 None of these deaths has been fully investigated, and no individual in a position of authority has assumed responsibility or been attributed liability for the suspicious circumstances of these four deaths.148

At Moyano Hospital, administrators and staff reported that in 1991, within a span of one-and-a-half months, 32 women institutionalized died of malnutrition. In 1991-1992—during a government intervention in the hospital—an investigation was initiated into these deaths, yet investigators confirmed that no one was held accountable, and the administrators that had directed Moyano Hospital before the intervention returned to the directorship when the intervention ended in 1992.149

These deaths suggest a disturbing pattern of abuse, neglect, and lack of accountability. Individuals who are in state custody—theoretically for their health and safety—are not receiving the personalized care and protection that they should. The failure to investigate and document the causes of deaths in these cases makes it impossible for the institutions to take measures that would prevent these kinds of deaths in the future.

Under the American Convention, the failure to protect against deaths of this kind violates the right to life.150 The Inter-American Court on Human Rights (the Inter-American Court) has interpreted the right to life broadly, recognizing a State’s duty not only to refrain from arbitrarily depriving an individual of life, but also to take affirmative measures to guarantee life and life opportunities. The Inter-American Court has determined that, while in State custody, the State is the “guarantor” of the right to life.151

B. Dangerous use of isolation cells

An additional problem investigators documented is the improper and prolonged use of isolation cells without adequate staff monitoring, which represents significant risks to the rights to life and humane treatment of those so detained.152

In Penal Unit 20—during visits in 2004, 2005, and 2006—investigators documented the use of tiny, barren, and very hot isolation cells. Investigators found persons locked naked in these isolation cells, which measured approximately by one-and-a-half by two meters.153 During the June 2004 visit, staff reported that these persons had been locked inside these cells for periods ranging from ten days to more than one year; one man told investigators that he had been locked in an isolation cell since November 2003.154 Another man had been detained in isolation for the previous three months as the result of a suicide attempt.155

These cells possessed neither running water nor toilets.156 Detainees were given plastic jugs in which to urinate in lieu of regular access to bathrooms.157 Staff asserted that detainees were unclothed to “prevent suicide” and that this isolated detention was used “for observation.”158 These isolation cells were devoid of natural light, had no ventilation, and “observation” would have been possible only through a tiny hole in the door.159 There was no staff stationed in the area of the isolation cells, making regular observation impossible.160 Staff justified this isolated detention as “necessary” for assessing the status of new detainees prior to placing them in a communal cell with others.161 In fact, the staff’s inability to observe conditions in the cells rendered it impossible for them to conduct the close assessment necessary to determine what measures were appropriate to protect others. As a result of a number of follow-up actions investigators undertook, the use of these isolation cells in Penal Unit 20 is being reformed.162

In Penal Unit 27, investigators also observed a troublesome use of isolation cells. According to staff, cells were used, at maximum, for two days. Nevertheless, during a visit in 2004, investigators observed two women in isolation cells, one of whom had been detained in isolation for over a year by judicial order because she was considered a danger to herself and others. The other woman had been detained in isolation for a year-and-a-half due to her difficulties relating to others.163

At Colonia Montes de Oca, also in 2004, staff informed investigators that people were detained in isolation cells for several days at a time.164 A number of psychiatrists at the institution defended the use of isolation cells, and stated that sometimes the cells were used because there was insufficient staff.165 Investigators were able to corroborate the insufficient staffing; in several wards 80 to 100 persons were institutionalized with only one or two staff on duty.166 Upon a return visit in July 2007, investigators found that the isolation cells had been dismantled.167

The inappropriate and prolonged use of isolation cells without sufficient staff monitoring constitute violations of the right for all persons to be free from “cruel, inhuman or degrading treatment.”168

Long term isolation and sensory deprivation—the total or partial restriction of stimuli on one or more of the senses—can exacerbate psychiatric symptoms or induce severe psychiatric harm, including intense agitation, anxiety, paranoia, panic attacks, depression, disorganized thoughts, and antisocial personality disorder. The harm caused by isolation and sensory deprivation “may result in prolonged or permanent psychiatric disability, including impairments which may seriously reduce [one’s] capacity to reintegrate into the broader community upon release. . . .”169 Furthermore, seclusion and restraint should never be used as a form of discipline or coercion, for staff convenience, or as a substitute for adequate staffing or active treatment.170

The MI Principles require that all instances of seclusion and restraint be documented in a patient’s medical record, along with the reasons for, nature, and extent of usage.171 Such detailed documentation allows for the monitoring of the use of seclusion and restraint, and the implementation of essential safeguards. Argentina has no legislation that addresses the topics of seclusion and restraint, and during the research for this report investigators found no evidence of the use of uniform standards to govern the use of seclusion and restraint.172

C. Physical and sexual violence

During visits to Penal Unit 20, detainees reported incidents of physical and sexual abuse, including rapes, beatings, and other forms of physical violence. Two detainees reported having been raped while they were in the admission cell block.173 One of these detainees also reported that guards had forced him to parade in women’s lingerie and act effeminate for them.174 During the June 2004 visit, investigators observed large bruises covering vast areas of the backs and torsos of several of the detainees.175 These men reported that they had been beaten by staff.176 A number of detainees specified that guards had forced them to sit under showers of freezing water, while the guards beat them with nightsticks or other blunt instruments.177 One man with stitches in his head reported that he had been clubbed by a guard.178

At Moyano Hospital, investigators received reports of sexual abuse of the women institutionalized allegedly perpetrated by hospital staff. One woman told investigators:

This is what happened to me in 2002, when I was offered work in the kitchen. I was told that I would be a helper in the kitchen, and that they would pay me for holidays and weekends. I went to collect my pay from the hospital “cooperadora.” I didn’t have money to buy soap, sanitary napkins, toilet paper, or shampoo or anything and it seemed good to begin working. The fi rst week, everything was fi ne. The second week also. The third week my supervisor closed the door when I tried to leave and said, “Now we’re going to have sex.” I said no, how are we going to have sex if we haven’t agreed to it beforehand? He said that if we didn’t have sex they weren’t going to continue giving me work. This happened between 2002 and 2003. In 2003, I registered a complaint. It was an improper use of my body. I didn’t understand why I had to have sex with them if I was paid by the “cooperadora.” He also made me have sex with his brother, and another brother who worked in maintenance in the ward. Then they brought in another man from outside [the hospital]. They raped me between the four of them.179

In December 2005, there was a government intervention in Moyano Hospital after complaints of serious human rights violations against the women hospitalized there. These complaints included allegations of staff forcing some women into prostitution, drug trials on the women without their informed consent, rape presumably committed by hospital staff, and women dying of malnutrition.

These complaints are currently under judicial investigation. When interviewed in July 2007, the General Director of Mental Health of the city of Buenos Aires did not know the status of these investigations.180

Dr. Luis Osvaldo Mazzarella, a member of Moyano Hospital’s interim directorship of 2005, told investigators that he had received a complaint of sexual abuse from a woman institutionalized there. Dr. Mazzarella said that the woman had been raped by two staff members.181 The staff denied this, and fabricated a story that the rape had been the result of a fight between two women. Dr. Mazzarella told investigators that the woman who had been raped was then transferred to Psychiatric Penal Unit 27 to “shut her up.”182 Eventually she was transferred back into the Hospital, but continued to receive threats of reprisals.183

Several newspaper articles and television stations reported allegations of prostitution of women institutionalized in Moyano Hospital by staff.184 Investigators were not able to document fi rst hand accounts of such abuse. One woman said that she knew of others who had been prostituted, saying, “They’re afraid to talk.”185 She also remarked that some women were prostituted or prostituted themselves to staff.

The one who drives the ambulance . . . ropes in the patients to prostitute them. He gives them money, fi ve pesos and has sex with them. . . . I know seven women that are prostituted. One patient from the ward got pregnant by a man who works in plumbing. . . . The women that smoke, who need money to smoke, [the men] pay them fi ve pesos for oral sex.186

At Diego Alcorta, in December 2004, investigators observed two women in the later stages of pregnancy. Upon review of their medical records, it was clear that both women had become pregnant after being committed to the hospital. In response to investigators’ questions, a male member of the support staff commented, referring to the size of one of the women’s bellies, “She drinks a lot of water.”187 During investigators’ return visit in September 2006, one of the women who had been pregnant in December 2004 was recovering from a caesarean section she had undergone the day before. The Director of Diego Alcorta, Dr. Marta Mocchi, told investigators that she had ordered that the woman have a tubal ligation, “because she’s promiscuous.”188

At Cabred Hospital, the Director informed investigators that three nurses had recently been transferred to other hospitals as the result of abuse. Although these employees were not dismissed, he stated that this is the fi rst time that any action had been taken against staff, despite union opposition.189 During investigators’ visit in July 2007, the Director said that there were no new complaints against the staff.190 However, one man investigators interviewed said that on several occasions staff beat the men “when one of them gets upset.” He said that when this happens, staff apply “knots” by choking the men with strips of cloth or rope to stop them from breathing and “calm” them. He said that eight months before investigators’ visit, a man had died of strangulation inside Cabred Hospital’s Medical Clinic as the result of a “knot” applied by a nurse with the help of other patients.191

The existence of physical and sexual abuse against institutionalized persons in State psychiatric institutions is undeniable, and violates the American Convention and the ICCPR, which provide that no one shall be subjected to torture or to cruel, inhuman, or degrading punishment or treatment.192 Argentina does not have effective mechanisms to protect institutionalized persons, in State custody, from these abuses. As such, the State is failing in its obligation to prevent human rights violations and to investigate and punish those responsible.193

D. Dangerous conditions

During visits to several institutions, investigators documented dangerous conditions that violate individuals’ rights to health and to humane treatment. These conditions included the lack of adequate medical care, and unsanitary and unsafe conditions of confinement.

1. Lack of medical care

The lack of medical care is a serious concern in many of the institutions investigators visited. At Penal Unit 20, Diego Alcorta, Moyano and Borda Hospitals, investigators observed large numbers of institutionalized persons with open sores, rotting or missing teeth, and even some with extremities in advanced stages of decay from gangrene.

While investigators were visiting the province of Santiago del Estero in December 2004, Digna Ledesma, a woman who had been institutionalized in Diego Alcorta Hospital for the previous 24 years, died.194 Information obtained through investigators’ interviews indicated that Ms. Ledesma’s death was most probably due to extreme neglect by personnel at Diego Alcorta Hospital, as well as the discriminatory attitudes of personnel at other hospitals in the area.195 According to Dr. Lucia Abdulajad, the treating physician, Ms. Ledesma was admitted to Independencia Hospital on December 3, 2004, malnourished, fi lthy, and in critical condition.196 Dr. Abdulajad reported that Ms. Ledesma had arrived at the hospital without a complete clinical history, and with an infection in the femur of her left leg, a consequence of a recent operation that had not been properly treated or cleaned.197 Dr. Abdulajad stated that Ms. Ledesma’s leg still had sutures near her left hip from the operation and that her leg was loose in its socket.198 Dr. David Yanelli, a former director of Diego Alcorta Hospital, informed investigators that Ms. Ledesma’s leg was fractured during an accident inside the hospital, and that she had waited two months for the surgery at the Regional Hospital.199 Ms. Ledesma died during her transport in ambulance from Independencia Hospital to the Regional Hospital.200

During a visit to Moyano Hospital in January 2006, a woman institutionalized there told investigators, “Another patient was complaining about headaches but they didn’t attend to her. Then it was found out that she had a tumor, but she never received [medical] attention.”201

Investigators also received reports of the denial of medical care at Penal Unit 20.202 In June 2004, one HIV positive detainee reported he was not receiving antiretroviral medications. A doctor escorting investigators through the Unit responded, “Not all people with HIV need antiretrovirals.” This doctor did not state whether the necessary medical exams had been conducted that would determine whether or not a specifi c medication was indicated.203 During investigator’s June 2005 visit, a detainee reported that for four days, while he was locked in an isolation cell, staff did not provide him with his antiretroviral drugs for HIV/AIDS.204

The failure to provide adequate medical care violates the right to health, which is guaranteed under article 42 of Argentina’s National Constitution205 and international treaties ratifi ed by Argentina.206 Under the American Convention, the right to humane treatment entails the right to have one’s “physical, mental and moral integrity” respected. 207 The Inter-American Commission on Human Rights (Inter-American Commission) has determined that a State violates the right to physical integrity when it denies medical care to an individual in its custody. 208

2. Unsanitary conditions

During investigators’ December 2004 visit to Diego Alcorta Hospital, the infrastructure of the institution was in a state of extreme disrepair and was devoid of minimum conditions to guarantee proper hygiene. Bathrooms in the men’s ward were unusable: toilets overflowed with excrement, the floors were flooded with urine, the sink handles were broken, and the showers did not work. Piles of excrement overflowed in the non-functioning toilets, and urine inundated the floors. The bathroom’s stench made the atmosphere practically un-breathable. As a result, many individuals hospitalized in the institution preferred to use its grassy areas and walkways to defecate and urinate. Thus, the garden, patios, and areas surrounding the hospital’s installations were littered with piles of human feces and reeked of urine.209 Days after this visit, investigators sent a letter to the province’s Interim Minister of Health describing these atrocious conditions and calling for immediate action to remedy the clear health hazards implicit in such conditions.

Investigators returned to Diego Alcorta in September 2006 and found that the bathrooms had been renovated and that the hygienic conditions in the institution appeared to have improved. Nonetheless, staff disclosed that the institution had been thoroughly cleaned in preparation for the visit, and that, under normal circumstances, conditions were “never” that clean.210 Investigators noted that the gardens of the institution still reeked of excrement and urine.211

During visits to Penal Unit 20 in 2004 and 2006, investigators observed that the Unit did not provide detainees with the minimum conditions essential for proper hygiene. In June 2004, detainees reported that they had been without water to wash or bathe for fi ve days.212 Investigators observed a lack of hot water, soap, towels, and implements of personal hygiene. Investigators also observed a multitude of cockroaches crawling over the walls, door jambs, and throughout the isolation cells and communal cells.213 In September 2006, investigators observed that reforms were taking place and that new communal cells were being built with bathrooms; nevertheless, many detainees remained housed in communal cells without bathrooms and they continued to have diffi culty obtaining access to basic items necessary for personal hygiene.214

The failure to provide clean and healthy conditions to individuals in detention also violates the right to health and the right to humane treatment.215 In addition to the rights provided by international human rights instruments, the Constitution of Argentina provides that prisons shall be healthy and clean, and maintained for the security and not the punishment of detainees.216

3. Unsafe conditions

The infrastructure of many wards at Moyano Hospital was in a state of extreme disrepair at the time of investigators’ 2004 and 2006 visits. The installation’s precarious physical conditions presented dangers for staff and the women detained in the facility. These precarious conditions included electrical and gas safety hazards, structural failings, broken windows, and loose cables hanging from the walls and ceilings.217 When investigators returned to the hospital in January 2006, a nurse on one of the wards reported being struck on the head with a block of masonry that fell from the ceiling. She reported that since this incident she has had epileptic seizures and has not been able to return to work.218

According to a report by the Federal Police’s Superintendent of Firemen, the buildings of Moyano Hospital presented exposed cables and did not have suffi cient fi re extinguishers.219 According to the newspaper Clarín, “The problems of infrastructure in the hospital are of such magnitude that the city’s general guardianship advisor of the Public Ministry of the City of Buenos Aires, Roberto Cabiche, requested that Aníbal Ibarra [then Mayor of Buenos Aires] close Moyano Hospital as soon as possible.”220 At the time of the writing of this report, repairs to the infrastructure at Moyano Hospital had not been completed.221

Torcuato de Alvear Emergency Psychiatric Hospital (Alvear Hospital), in the city of Buenos Aires, also presents dangerous conditions.222 In 2007, the legal counsel of the city’s Contentious Administrative Tribunal presented a complaint ordering the city of Buenos Aires’ government to renovate the Hospital, which presented serious structural, security and quality of care issues. The court upheld the right to health guaranteed by the National Constitution and various international treaties, and determined that allegations of budgetary shortfalls did not excuse human rights abuses.223

E. Lack of rehabilitation

At most institutions, no meaningful rehabilitation is provided to the vast majority of persons hospitalized.224 Pervasive inactivity was the most common problem investigators observed at Diego Alcorta, Borda, Moyano, Domingo Cabred, and Estevez Hospitals. At these institutions, investigators found an overwhelming number of persons lying in their beds or on the institution grounds, completely idle.225

Persons who are institutionalized are not provided with the supportive care or assistance they need to develop or relearn the personal skills needed to become independent or return to the community. In the absence of such support, people lose ties with their communities over time and become more dependent on institutions. As a result, custodial institutionalization diminishes autonomy, contributes to the chronicity of illness and increases disabilities, making it all the more diffi cult for these individuals to reintegrate into the community.226

The failure to provide individuals with disabilities appropriate services to ensure their integration into community life and enhance their independence violates the right to rehabilitation, guaranteed in national law and under international treaties to which Argentina has binding obligations.227 National Law 25.421 calls for the provision of mental health services in primary care, with an aim toward the rehabilitation and social reinsertion of persons with mental illness.228 In the case of the city of Buenos Aires, the city’s Constitution guarantees the right to rehabilitation as a component of the right to health,229 and Law 448 provides for the right to rehabilitation along with the right to community reinsertion.230

F. Lack of appropriate treatment and referral

Long-term hospitalization accentuates the deterioration and chronicity of mental disability, which mental health practices that are solely oriented to medicating illness often reinforce.231 The Training Team for PREA has documented that psychotropic medications, which should be considered as a part of an individual’s overall rehabilitation plan, are used as a “tool of discipline and control. . . .”232 One ex-patient described his experience, saying, “[t]hey gave me 20 pills a day in the clinic so that I would stay half dumb, so that I wouldn’t bother anyone.”233

In Penal Unit 20, one detainee reported that as punishment for any minor offense, such as “answering back” to staff, detainees were injected with heavy tranquilizers that left them immobilized for days.234 The seven other detainees in his cell confirmed his allegation.

Approximately one-half of the population of Penal Unit 20 was drug dependent as of 2004.235 These individuals were presumably hospitalized in the Unit to receive treatment. Staff admitted, however, that these individuals could not receive suitable treatment as the Unit did not possess the human or economic resources to administer drug treatment and rehabilitation services.236

During the June 2005 visit to the Unit, investigators reviewed records registering the diagnoses of the detainees on the ward. Forty-six of the 104 detainees whose diagnoses appeared on a spreadsheet that staff shared with investigators had a dual diagnosis of drug addiction and personality disorder. Another eight detainees had diagnoses of mild mental retardation and drug addiction. Altogether, 54 people had no diagnosis of a major psychiatric disorder, and the Unit does not provide addiction treatment for them.237 During the August 2006 visit, staff confirmed that the number of detainees with drug addiction problems continued to be high—they commented that 50 percent of detainees were drug addicted. Several staff confirmed that the Unit is still unable to provide appropriate treatment for these persons.238

Staff at Penal Unit 20 also described a lack of follow-through with regard to referrals for detainees’ alternative placement. On the same spreadsheet recording diagnosis, staff had written that more than half of the detainees (74 of 128) should not be detained in the Unit. Staff indicated that 20 of the detainees should be in a normal prison, 19 should be placed in drug addiction centers, and 35 in non-forensic psychiatric wards. Only 61 of the 128 detainees had no indication for alternative placement from the staff.239 Staff told investigators that they had written many requests for discharge of these detainees to the district judge, but most of these requests had not been addressed. In some cases, this lack of response was due to the lack of places to send persons leaving the Unit.240

Under Argentine law, the national judiciary is obligated to verify that people with mental disabilities receive adequate treatment and that their fundamental rights linked to their hospitalizations are respected. Nationally, the Ley de Internación y Egresos en Establecimientos de Salud Mental, Ley 22.914 (Law of Hospitalization and Discharges in Mental Health Establishments, Law 22.914)241 guarantees the right to appropriate medical treatment.242 Under article 10, judges are required to verify that treatment is appropriate and that it is actually carried out.243 Article 12 requires that the Advisor for Minors and the Incapacitated verify the evolution of the detainee’s health, the medical treatment provided and conditions of care.244

G. Overcrowding in psychiatric institutions

During investigators’ visits to Penal Unit 20, the Unit was severely overcrowded. The Unit has a stated capacity of 87. In June 2004, staff reported that 158 individuals were detained on the Unit, representing an overcrowding level of more than 75 percent.245 By June 2005, the population of the Unit had dropped to 128, primarily due to discharges of drug addicted detainees,246 yet the Unit was still at more than 40 percent over capacity. By September 2006, the population had decreased to 114, which represented overcrowding by 30 percent, but by June 2007, the census had increased again to 121.247

The communal cells at Penal Unit 20 house between 7 and 12 detainees, but typically have only 6 beds. As a result, many detainees are forced to sleep on the floor on thin, dirty foam mattresses, one against the other, with almost no space between them to move. The dining room of Ward 2, which doubles as an activity room, housed two detainees sleeping on mattresses on the floor.248 Although the number of detainees decreased in 2006, there were still mattresses on the floor in several communal cells.249

Tobar Garcia Hospital also experiences severe overcrowding. Dr. Roberto A. Yunes, the Hospital’s director explained that Tobar Garcia has a total of 64 beds divided among three floors.250 At the time of investigators’ January 2006 visit, the hospital was providing treatment for approximately 150 children and adolescents. “We’re way over capacity,” Dr. Yunes stated, “There’s been a huge explosion in numbers in recent years.”251

Newspaper reports from July 2005 documented severe overcrowding at Alvear Hospital. According to press reports, one official responsible for defending the rights of minors and the incapacitated reported that in four surprise visits to the hospital, the overcrowding situation was so extreme that he found people sleeping on the floors in the hallways.252

Statistics provided by the National Ministry of Health indicate that Moyano Hospital has a capacity of 1,550 beds.253 In June 2004, the psychiatrist who accompanied investigators on a tour of the facility stated that there were 1,750 women institutionalized.254 Overcrowding was apparent in every ward, with the exception of the emergency ward and the night hospital. In the “chronic” wards of Moyano Hospital, expansive rooms were crowded with rows and rows of beds, with almost no room to walk between them. During the fi rst half of 2007, the average number of women institutionalized had decreased to 993.255 Nevertheless, overcrowding continued to be a problem, despite the fact that nearly 200 women had been sent to private clinics while renovations that had begun in 2005 were being completed.256

According to international standards on the rights of persons in detention, every person “shall, in accordance with local or national standards, be provided with a separate bed and with separate and suffi cient bedding which shall be clean when issued, kept in good order and changed often enough to ensure its cleanliness.”257 Overcrowding is one of the factors that contribute to violations of the detainees’ human rights, and can lead to serious health consequences. Disease transmission increases among people living in close proximity, and overcrowding and the associated lack of privacy are likely to aggravate mental disabilities.258

Several factors contribute to the severe overcrowding investigators documented in the psychiatric institutions they visited. These factors include, among others: government authorities’ lack of political will to promote change; overly broad admissions criteria; the lack of periodic review of involuntary hospitalizations; and the absence of adequate community-based mental health services and housing alternatives.

IV. Arbitrary detention in psychiatric institutions

Involuntary commitment to a psychiatric institution constitutes a massive deprivation of individual liberty—cutting a person off from family, friends, job opportunities, and all other aspects of community life. Accordingly, international human rights law provides important protections against arbitrary or improper detention in a psychiatric facility.259 Article 7 of the American Convention protects the right to “personal liberty and security” and makes clear that “[a]ny one who is deprived of his liberty shall be entitled to recourse to a competent court. . . .”260 In applying the general protections of the American Convention to people with mental disabilities, the InterAmerican Commission has established that the UN’s MI Principles should be used as a guide to interpret the Convention’s requirements regarding the protection of the right to liberty of people with mental disabilities.261

The MI Principles guarantee a right to independent judicial review of all psychiatric commitments and include an array of procedural protections for that review process, such as the right to representation by counsel. The MI Principles also create standards strictly limiting who may be involuntarily detained. Under the MI Principles, a person with a psychiatric diagnosis of “mental illness” can be detained only if he or she presents a “serious likelihood of immediate or imminent harm” to themselves or others.262 Involuntary commitment may also be allowable, under limited circumstances, where necessary to prevent “serious deterioration” of a person’s mental condition.263 Such detention is permissible only when treatment could not otherwise be provided in the community.264

Argentine statutory law on a national level falls signifi cantly short of what is required by international standards.265 National statutes permit the commitment of persons who could “affect public tranquility” and do not establish adequate procedural safeguards that would provide for a hearing within a reasonable period, the right to legal representation, or the right to periodic review of commitment decisions.266

In 2005, the Supreme Court of Justice issued a landmark decision on civil commitment in the case of Ricardo Alberto Tufano. 267 Under Tufano, civil commitments to psychiatric institutions must comply with international human rights standards with regard to the right to liberty. While some Argentine judges are beginning to apply the precedent in the Tufano case, this application is not uniform,268 and the vast majority of persons hospitalized in psychiatric institutions continue to be arbitrarily detained.

A. Overbroad and ill-defined grounds for commitment

The legal standards established in Argentina’s Civil Code on civil commitment are extremely broad and ambiguous, allowing the detention of persons in psychiatric institutions under a wide array of circumstances. The original text of article 482 establishes that “the demented shall not be deprived of personal liberty except in cases where it is feared that he will harm himself or others.”269 While the requisite of ‘harming self or others’ complies with international standards, article 482 never defi nes “the demented,” itself a term that is extremely ambiguous and highly stigmatizing. A legislative reform added two paragraphs to the law—the possibility of committing persons who could “affect public tranquility” or those who engage in alcohol or substance abuse— thereby expanding the parameters of who may be involuntarily committed under the Law.270 Article 482 of the Civil Code also permits a judge to hospitalize a person in a psychiatric facility if the judge determines that the individual “needs assistance,” regardless of whether the person is at risk of serious psychiatric deterioration, or whether less restrictive alternatives have already been attempted.271

When, as in Argentina, psychiatric commitment is not strictly limited to cases where people are an imminent danger to themselves or others, it opens the door to a wide array of abuses. People may be committed simply for the convenience of neighbors or family members, or because of others’ irrational fears of people with mental disabilities. And a person with a mental disability may be committed even though he or she is capable of living in the community. Furthermore, under Argentina’s legislation, commitment to a psychiatric facility is permissible for people without a diagnosis of mental illness if they have alcohol or substance abuse problems, even though the mental health facility may not provide appropriate treatment for these problems.

The Supreme Court of Argentina cited the MI Principles in the Tufano case, stating that grounds for involuntary commitment must be limited only to cases “when [there is] a serious risk of immediate or imminent harm to that person or others.”272 Despite this decision, in practice, the general and ill-defi ned clauses of Argentina’s Civil Code are still being applied in psychiatric commitment proceedings.

B. Insufficient procedural protections

Argentina’s legislation contains few procedural protections to safeguard the rights of individuals involved in involuntary commitment proceedings.273 This legislation does not guarantee the right to a hearing within a reasonable period, does not provide for the right to appoint counsel, and does not provide for a periodic review of involuntary commitments, as required by international human rights law.274

1. Lack of an independent hearing within a reasonable period

International law establishes that detainees have a right to a hearing from an independent and impartial tribunal within a reasonable period.275 However, Argentina’s Civil Code allows a broad array of people to initiate the commitment process, for almost any reason. The police may hospitalize any person who suffers from mental illness or is a chronic alcoholic or drug addict, so long as they immediately inform a judge and so long as the hospitalization is based on an offi cial medical opinion.276 A judge may also order the hospitalization of such an individual, based on a summary of prior information, even if these persons have not been declared demented, chronic alcoholics, or drug addicts. Family members and “neighbors who feel uncomfortable”277 may petition a judge for an individual’s involuntary commitment.278

However, the Civil Code does not provide for the detainees’ right to a hearing within a reasonable time before an independent and impartial tribunal.279

Law 22.914—that only governs in the city of Buenos Aires280—is somewhat more protective than the Civil Code. The Law requires that the hospital’s director must provide a medical opinion, or confi rm an opinion of another establishment, within 48 hours of a hospitalization.281 Law 22.914 also establishes that, in certain cases, notice of such hospitalization must be communicated to the Public Ministry282 within 72 hours,283 and in general when the hospitalization exceeds 20 days.284

Nonetheless, these limited protections are still inadequate in that they fail to guarantee the right to independent review.

Similarly, the Mental Health Law of the Autonomous City of Buenos Aires, Law 448, contains solid guarantees regarding the rights of persons with mental disabilities, yet it fails to provide adequate protections against arbitrary detention.285 The only procedural protection provided by this Law is that involuntary institutionalizations “must be certifi ed by two professionals, who cannot pertain to the same institution….”286 Law 448 does not provide for the review of detentions by a judicial or other independent and impartial review body.287

2. Lack of representation by counsel

Argentine statutes fail to adequately guarantee detainees the right to representation by counsel of his or her choosing in involuntary commitment proceedings. Under Argentina’s Civil Code, the judge must appoint a special defender whose role is to ensure that the hospitalization is not longer than necessary, or, where possible, to avoid the hospitalization altogether.288 However, the Code does not require that the special counsel represent the interests of the individual, and does not guarantee the individual’s right to present testimony or evidence on his or her behalf. Similarly, in the Autonomous City of Buenos Aires, Law 448 does not provide an express right to counsel for persons involved in involuntary commitment proceedings.

 In practice, according to Dr. Alejandro Molina, the Pubic Defender of Minors and the Incapacitated at the National Civil Appellate Chamber, there is no true legal representation for individuals detained in psychiatric institutions. There is only one offi cial attorney before the Chamber, for all of the cases that are presented, and this attorney is not required to represent the views of the person subject to commitment. Instead, the attorney is charged with coming up with “an adequate synthesis” of the individual’s desires and what the attorney feels is best for the individual.289 Dr. Molina explained that attorneys at the Chamber try to “achieve consensus” among the parties, stating: “We think more about the well being of the group, not about individual rights.”290

The MI Principles provide that during the review of an individual’s detention, the individual is entitled to “choose and appoint a counsel” to represent him or her “including representation in any complaint procedure or appeal.”291 To the extent that the individual lacks the funds to pay for counsel, one shall be provided by the State.292 The individual, his or her personal representative, and counsel are “entitled to attend, participate and be heard personally in any hearing.”293

The Argentine Supreme Court in Tufano determined that the MI Principles provide basic rights and procedural guarantees of persons “presumably affected by mental suffering,” including the right to counsel and to an independent determination of mental illness.294 The Supreme Court also found violations of fundamental procedural guarantees where an immediate hearing with personal or other representation is not provided.295

3. Lack of independent periodic review of admissions

Symptoms of psychiatric distress may vary enormously over a lifetime. Accordingly, systematic and periodic review of admissions by an independent review body is necessary to protect detainees’ right to liberty, and to ensure that they do not remain detained even when they no longer pose an imminent danger to themselves or others.296

Nevertheless, there are no provisions under Argentina’s national statutes providing for periodic review of psychiatric admissions decisions by an independent and impartial review body. In the city of Buenos Aires, Law 22.914 provides that judges297 and Advisors for Minors and the Incapacitated are required to verify the evolution of the patient’s health, the regimen of attention, the living conditions, and the personal and medical care provided.298 But neither Law 22.914 nor Law 448 contains explicit provisions guaranteeing the right to the periodic review of admissions decisions by an independent and impartial review body.299

In all the facilities investigators visited, institutionalized persons and staff remarked that there was no periodic review of involuntary admissions. At Penal Unit 20, staff and detainees informed investigators that there was no system in place to allow for periodic review of detentions, and that the judges assigned to the cases of those on the Unit “almost never come to visit the detainees and do they do not ask about their cases.”300 In the few cases that a judge does manage to visit, staff indicated, such visits are infrequent.301 With respect to Tobar Garcia Hospital, Dr. Molina, the Public Defender, told investigators that, “the judges go very infrequently, perhaps once per year.”302 At Diego Alcorta Hospital, staff also stated that patients receive no periodic reviews of their admissions.303 As testament to the seriousness of the situation, each public defender is in charge of approximately 1,000 cases.304 It is important to note that even regular visits, such as those made to Penal Unit 20, do not fulfi ll the requisites of an independent and impartial periodic review.

V. Insufficient oversight and monitoring of detainees’ rights

Effective oversight and monitoring is essential to ensure the protection of the rights of people detained in institutions. It is well established that people detained in psychiatric institutions and other closed facilities are particularly vulnerable to human rights abuses.305 Individuals detained in long-term institutions are dependent upon these institutions for their basic needs, including food, clothing, shelter, protection from harm, and medical care. These facilities control individuals’ access to communication and their contact with the outside world. As a result, individuals detained in institutions face a variety of difficulties in attempting to report abuses: many do not have the ability to communicate freely, fear reprisals for speaking out, or simply do not know of mechanisms through which they can report abuse. When individuals diagnosed with a mental illness or those with developmental disabilities do speak out, they often find that they are dismissed as lacking credibility, or as being delusional or out of touch with reality. Hence, human rights abuses may go undocumented and unaddressed for years.

In Argentina, government institutions generally fail to adequately monitor the conditions and treatment of detainees in psychiatric institutions. In principle, individuals could direct complaints of human rights violations to a variety of officials.306 However, for the reasons described above, it is rare and difficult for persons detained in psychiatric institutions to do so.

In the city of Buenos Aires, under Law 22.914, judges and the Advisors for Minors and the Incapacitated assigned to the cases of institutionalized persons are required to provide oversight and monitoring of the conditions and treatment of detainees in mental health facilities.307 However, staff and institutionalized persons alike told investigators that these procedures are either not followed (as the staff at Penal Unit 20 reported) or that they result in no notable change in the conditions and treatment of those institutionalized.

A few instances of monitoring, however, appear to have been effective. In 2005, Buenos Aires city authorities made four unannounced visits to Alvear Hospital, triggering a lawsuit.308

During these visits, one city official found the hospital so overcrowded that persons hospitalized were sleeping on the floor in the hallways.309 The need for greater oversight and monitoring of conditions in psychiatric institutions is captured in the official’s comments to the press: “The public mental health system in Buenos Aires is in a state of abandonment.”310 Also in 2005, the Commission on Jails of the Public Defender Service and the National Penitentiary Attorney’s Office drafted reports denouncing the deplorable conditions in which persons detained in Penal Unit 20 were housed.311

International human rights standards obligate States to ensure the safety and wellbeing of individuals in detention.312 The CRPD requires States party to prevent “all forms of exploitation, violence and abuse” by ensuring the effective monitoring by independent authorities of all institutions and programs providing services to persons with disabilities.313 Similarly, the MI Principles call for the establishment of mechanisms “for the submission, investigation and resolution of complaints and for the institution of appropriate disciplinary or judicial proceedings for professional misconduct or violation of the rights of a patient.”314

According to the Inter-American Commission, States should monitor the enforcement of the rights of people with mental disabilities in institutions through State human rights ombudsmen’s offices.315 The Commission recommends that States “[s]upport the establishment of organs that supervise compliance with human rights norms in all psychiatric care institutions and services.”316 Such organs should involve consumers, family members, representatives of consumers, and mental health workers.317

According to the Special Rapporteur on the Right to Health, due to the “acute vulnerability of some persons with mental disabilities” it is critical that “effective, transparent and accessible monitoring and accountability arrangements are available.”318 The enhanced monitoring and accountability in psychiatric hospitals is “[o]ne of the most urgent steps which many States need to take to facilitate the realization of the right to health of persons with mental disabilities.”319

VI. Mental health reform 

A. Promising mental health reform initiatives 

1. National sphere

In February 2006, the National Mental Health, Justice and Human Rights Roundtable was created.320 The Roundtable’s objectives are promoting mental health policies that include a human rights perspective and endorsing policy changes toward implementing good mental health praxis. The Roundtable proposes to develop national strategies for the dissemination of programs on mental health and human rights emphasizing stigma and discrimination against people with mental disabilities. The Roundtable also intends to promote an analysis of the situation of human rights and mental health throughout the country.

Toward these goals, regional colloquia have been developed in different parts of the country to promote the strengthening of local organizations and the formation of regional roundtables. Based on direct participation in activities organized by the Roundtable, investigators affi rm that, while the project is still in its initial phase and lacks institutional support,321 the initiative has awakened interest and hope to achieve long-term integral mental health system reform. The Roundtable has also provided a space for the public sector to be heard on these issues.

2. The Autonomous City of Buenos Aires

In 1994, the city of Buenos Aires was granted autonomy through the reform of the National Constitution. Since then, the city has enacted several valuable legal provisions containing language supportive of mental health reform initiatives. The city’s 1996 Constitution establishes a basis for mental health reform, providing that mental health policies should not be instituted for the ends of social control or punishment, but rather, they should be directed toward progressive deinstitutionalization and creating a service network of social protection.322 Article 48 of Basic Health Law 153, enacted in 1999, states that mental health care should avoid segregative institutions and work toward progressive deinstitutionalization.323 The Law calls for the city to implement alternative models of care focused on social integration, such as half-way houses, protected workshops, therapeutic communities and day hospitals.324

In 2000, the city enacted progressive legislation, Law 448, outlining rights and protections for people receiving treatment in the city’s mental health system.325 This law echoes many international human rights standards, including: the right to the respect of one’s dignity, the right to informed consent,326 the right to personalized attention, and the right to rehabilitation and community integration.327 The Law states that treatment should be provided by all means possible on an outpatient basis. The Law also provides that the rights established in the “National Constitution, the Convention on the Rights of the Child, and all other international treaties, the Constitution of the City of Buenos Aires, and article 4 of Law 153” are rights possessed by all persons provided services by the mental health system.328 And Law 448 calls for the creation of a General Council on Mental Health, charged with: “a) the formulation of mental health policies, programs and activities; b) the evaluation and follow-up of the Mental Health Plan; c) aspects linked with ethical considerations; d) the framework for the general policies in with the General Council on Mental Health.”329

Unfortunately, while Law 448 is an important step forward in mental health reform, it has not been implemented in an articulated manner. Law 448 calls for mental health care to be delivered by interdisciplinary teams, eradicating any hierarchical status among mental health professions. Nevertheless, there are professional groups that are opposed to Law 448.330

In 2006, in the City of Buenos Aires, PREASIS was created.331 The policies established through PREASIS support planned discharges toward promoting the autonomy and community reintegration of persons discharged from psychiatric institutions.332 At the time of the writing of this report, PREASIS had implemented two half-way houses for women. Both houses have the capacity to house eight people. The program is planning the creation of a third house for men.

3. The province of Buenos Aires

In 1999, the Ministry of Health of the province of Buenos Aires, established PREA. This initiative is based on the premise that hospitalized individuals suffer from two significant problems: “the deterioration that institutionalization produces, with a consequent loss of autonomy, abilities and skills,” and the loss of “socio-familial” ties.333 To overcome these problems, the program promotes the reintegration of persons who have been hospitalized into the community through social networks to support their reintegration.

PREA has established various forms of assistance to those discharged from the hospital, including financial support to cover housing and related expenses, and assistance in finding jobs for the program’s participants. Before discharge, PREA works with those in the program to regain skills they need to live independently.

During investigators’ visit to Estevez Hospital, one woman who was involved in the program stated that she was relearning skills that years of hospitalization had erased. “[The program staff] spend a year or so teaching you how to deal with money, with living outside [the hospital],” she explained.334

In June 2004, PREA’s Coordinator, Dr. Patricia Esmerado told investigators that there were 45 women from Estevez Hospital alone living in houses in the community as part of the program, and that they were working to incorporate more women into the program.335 By October 2006, the number of persons discharged, living in these communal residences had increased to 50.336

At the time of the writing of this report, Cabred Hospital was planning the Primeras Jornadas Nacionales e Internacionales: Salud Mental y Derechos Humanos. Experiencias de reforma para la inclusión (First National and International Workshop: Mental Health and Human Rights. Reform experiences for inclusion). Topics of discussion included mental health from a human rights perspective, public policy agendas, judicial problems, and the incorporation of persons directly affected by polices in their planning and implementation. This workshop was based on the May 2007 Precoloquio en Salud Mental (Preliminary Discussion on Mental Health), where participants debated many of the same topics and their relation to mental health system reform.

Additionally, the mayor of the city of Moron, Martín Sabbatella, and the Minister of Health of the province of Buenos Aires, Claudio Mate, signed an agreement establishing a community residence project. The project aims to integrate persons discharged from psychiatric institutions into community life, avoid prolonged institutionalization and promote the autonomy of those discharged.337

Together, the Workshop, the Preliminary Discussion and the agreement between the city of Moron and the Ministry of Health of the province of Buenos Aires are part of a therapeutic program that includes agreements between Cabred Hospital and other cities.338 This program proposes to facilitate the social inclusion of institutionalized personas through half-way houses, subsidies, mental health attention in decentralized health centers, and work with Family Courts.339

4. The province of Rio Negro

The province of Rio Negro, in the north of Patagonia, provides another positive model of community care for people with mental disabilities.341 In 1991, the province passed Law 2.440, Promoción Sanitaria y Social de las Personas que Padecen Sufrimiento Mental (Health and Social Promotion of Persons who Experience Mental Suffering). This legislation outlaws public mental hospitals and outlines a system for social reintegration of persons with mental illness.342

Today, the region offers mental health services in 33 general hospitals, 178 health centers, 6 half-way houses, and 6 social enterprises or micro enterprises aimed at the social reintegration of persons discharged from psychiatric hospitals. These services attend to Rio Negro’s population of just over half a million persons.343

The mental health services in the city of El Bolson are a good example of the Rio Negro model. Bolson’s chief psychiatrist participated in the movement leading to the enactment of Law 2.440, and has worked on implementing its reforms ever since.344 In 2005, Bolson’s mental health services consisted of a team of fi ve psychologists, five mental health workers and one psychiatrist. The professionals worked as members of an interdisciplinary team along with families, doctors, psychologists, social workers, educators, the police, lawyers, and employers with the goal of integrating the users of its mental health services into the community. One-third of the therapy sessions with professionals involved at least one member of the person’s family. In addition to traditional therapy, the team also offered artistic workshops, and part-time job opportunities in a snack bar and catering service. Mental health workers played a crucial role in helping users transition between the hospital and the community, often performing home visits or accompanying them as they go about their daily chores.

While Rio Negro provides an encouraging model of mental health reform, it is not without its problems. An independent study on the mental health services in the province concluded that increased funding is needed to fully comply with law 2.440.345 Greater investment is needed particularly with regard to housing alternatives for individuals with chronic mental illness who do not have families that can support them.346 The study also found that users of mental health services are not adequately involved in decision-making concerning the delivery of services.347

5. The province of San Luis

The Hospital Escuela de Salud Mental (Mental Health Teaching Hospital), in the province of San Luis, may be another promising deinstitutionalization model. Since 1993, the psychiatric hospital in San Luis has undergone signifi cant reform, largely under the direction of Dr. Jorge Luis Pellegrini. The hospital has been transformed from a locked institution with more than 100 longterm residents, to a clinic with ten beds for acute care. Dr. Pellegrini told investigators that the current average stay was three to seven days.348 Today the hospital functions more as a community clinic than as an inpatient psychiatric hospital. Apart from mental health care, the Teaching Hospital offers general health services, including immunizations, pregnancy screenings, and alcoholism recovery workshops.349

At the beginning of the reform effort, Dr. Pellegrini said “[the staff] saw the users as children, they didn’t know their names, only their nicknames, and the majority of those hospitalized were punished [by staff].” 350 Describing the conditions in the hospital at the start of the reform, he told investigators, “the walls were covered with fecal matter and urine.”351 To begin the reform, Dr. Pellegrini installed his offi ce in one of the institution’s isolation cells. The Teaching Hospital then unlocked the institution’s doors, bought new clothes for the residents, eliminated the hospital logo from the clothing, and injected a sense of dignity into the care and treatment they provided.352

The hospital pharmacist, Enrique A. Capella, also described serious problems with the improper and excessive use of medication before the reform: “When I arrived I found many medications that were expired or about to expire. It took me three hours each day to prepare the medications for 106 patients . . . there was a chemical straightjacket over the patients, they were like zombies.”353 The fi rst course of action, according to Mr. Capella, was to decrease the amount of medication given to the persons institutionalized. The process began with a reevaluation of the diagnosis of each person and a review of the medications each person took.354

Investigators were unable to confi rm what had happened to all the individuals who had been hospitalized in the Teaching Hospital before the reform. Dr. Pellegrini told investigators that the vast majority of the persons went to live with their families, while Mr. Capella stated that of the 106 persons, 80 went to live in community-based homes.355 Investigators did not have the opportunity to visit these homes and could not confi rm the actual conditions of people who had been discharged from the hospital.

In December 2006, the legislature of the province of San Luis ratifi ed a Ley de Desinstitucionalización (Deinstitutionalization Law), which contains progressive provisions regarding mental health treatment and the rights of persons with mental disabilities.356 The Law prohibits the institutionalization of persons with mental disabilities in public and private institutions anywhere in the province.357 It also endorses the fundamental rights to life, liberty and security of the person and the presumption that persons with mental disabilities are capable of making decisions, save evidence to the contrary—although the Law does not defi ne what evidence is necessary, who determines incompetence, or how this determination is to be made.358 The Law does specify that a determination of incapacity in one circumstance does not indicate that a person is incapable of exercising self-determination in other contexts.359

B. Deinstitutionalization movement

Many consumer and ex-patient groups, professional organizations, disability rights activists and human rights groups are actively engaged in a movement for the deinstitutionalization of mental health services in Argentina. Some of these groups and organizations are highlighted below.

1. Consumer and ex-patient groups

Investigators met with a number of consumer and ex-patient organizations supportive of deinstitutionalization.

For example, members of Radio Colifata, a radio program founded in 1993 on the grounds of Borda Hospital to give voice to patients and ex-patients, described to investigators how their experiences with the radio had impacted their lives and helped them organize in support of deinstitutionalization.

[This is] how the radio helped us. We found a family. Alfredo’s [Olivera] idea for the radio arose when he was a psychology student. Thanks to him we could see the other side of the world. That those outside could hear we who were hospitalized. The good thing about the radio is that it shows us that we can do professional things, demonstrate to society that we can do them.360

Hugo, an ex-patient who belongs to Radio Colifata, said:

The government is paying almost 3,000 pesos [a month] per [hospitalized] patient. If they pay me 1,000 pesos to live in an apartment, I can live very well, and the government saves 2,000 pesos.361

Another member commented, “in the Colifata I felt that it was not only about combating the [model of the] psychiatric hospital but of proposing alternatives.”362

Members of these organizations are acutely aware of the stigma and prejudice they encounter as a result of having received mental health services. In talking about the discrimination that he has faced, Fernando, a member of Radio Colifata related:

In ’97-’98 I got a job in a delivery pizzeria. I started to work, kept to myself, and I started to recover. On Radio Colifata they interviewed us and the interview was shown on television and a woman who worked the register saw it. She told the owners and the next week they asked for the uniform back and they never call me again. 363

Another member of Radio Colifata commented,

A year ago I submitted the paperwork for my disability pension. I don’t know what else to do. We are unprotected from all sides. We are discriminated against. We can’t get work anywhere. For the past four years I’ve been looking for work. Society also creates obstacles for us.364

In May 2007, Radio Colifata, together with Tea Imagen Escuela Integral de Televisión (Tea Image Integral School of Television) and the Deputy Secretary of Human Rights of the city of Buenos Aires, organized the Primer Encuentro Mundial de “Colifatas” o Radios Realizadas por Usuarios de Salud Mental (First Worldwide Encounter of “Colifatas” or Radios run by Mental Health Consumers).365 The encounter was a worldwide forum of radio transmitters that operate in psychiatric institutions with the objective of sharing experiences between the participants. During the encounter there were debates, artistic presentations, and a poster display refl ecting diverse social perceptions on madness.

2. Active professional organizations

A number of professional organizations support mental health reform efforts. The FORO is one example. The FORO is comprised of 20 institutions that work in the mental health sector and represents approximately 9,000 professionals. The group was formed in 1997 with the objective of preserving the right to mental health. The government of the city of Buenos Aires called on this organization to participate as advisors in the drafting of Law 448, and its members have been integrated into the Consejo General de Salud Mental (General Council on Mental Health) established in Article 5(k) of Law 448.366

The FORO maintains what its members described as a “sociopolitical” concept of mental health, and is engaged in examining the non-medical effects of mental illness. Members of the organization are proponents of deinstitutionalization, the prevention of illness and the promotion of mental health. Members stated that Tobar Garcia, Borda and Moyano Hospitals account for 80 percent of the mental health budget for the city of Buenos Aires. FORO members told investigators that the expenditures for mental health care in an institution were approximately 2,500 pesos (US$833) per person institutionalized per month. This money, they argue, could be better invested in community services and providing housing alternatives to those institutionalized.367

The Asociación de Psiquiatras Argentinos(APSA—Argentine Association of Psychiatrists), an association with 2,400 members, including psychologists, anthropologists, and lawyers, has also been supportive of mental health reform. APSA coordinates a forum on mental health policy, including training in mental health services administration and policy implementation. APSA has been instrumental in bringing the government’s attention to human rights abuses taking place in psychiatric hospitals and has been involved in the deinstitutionalization process at the Mental Health Teaching Hospital in the province of San Luis.368

In 2004, Dr. Graciela Lucatelli, APSA’s president, estimated that with the national mental health budget of approximately 1.5 million pesos (US$500,000) per year there could be attention for acute patients, half-way houses, and ambulatory teams for attention in the home “and we would have money to spare.”369 Dr. Lucatelli noted the importance of establishing alliances with other non-governmental organizations and scientifi c societies to press for mental health reform. “Workers think that if the hospitals are closed they will be without a job,” she said, adding, “the leaders have the unions as a good excuse not to advance with these changes.”370

The Asociación en Defensa de los Derechos en Salud Mental (ADESAM—Association for the Defense of Rights in Mental Health), is another organization that supports a transformation in mental health services. ADESAM’s members are psychologists, psychiatrists, and lawyers dedicated to the promotion and defense of the rights of persons with mental illness.371 In December 2005, investigators participated in the fi rst encounter of the Movimiento de Desmanicomialización y Transformación Institucional (Movement for Deinstitutionalization and Institutional Transformation) in which organizations from different sectors and with different work experiences came together to discuss deinstitutionalization efforts.

3. Institution directors

Investigators also found tremendous support for reform among individual mental health professionals, including many institution directors. At Colonia Montes de Oca, Director Jorge Rossetto is actively engaged in changing the paradigm of mental health attention. “The people who entered the institution, died here,” Rossetto noted. Now work is being done to discharge institutionalized persons. At the time of investigators’ visit in 2004, one house on the grounds of Colonia Montes de Oca had been renovated and housed three individuals in the discharge process. Two of these individuals attended school in the nearby town of Torres, and one worked for the city. Colonia Montes de Oca was working to discharge all three and place them in the community. “We want patients to return to the community,” Rossetto commented, “we want to demonstrate that everyone is able to be rehabilitated.”372 By July 2007, two of the three persons who had been living in the house had been discharged.373

Toward implementing his vision, Rossetto established an agreement with the Mental Health Teaching Hospital in San Luis that provides training for staff at the Colonia in how to implement mental health reform. As part of this reform plan, fi ve day treatment centers and a half-way house have been created, and a second half-way house is planned. “Regreso a casa,” (“I return home”) is another component of the plan. “Regreso a casa” will provide stipends of 360 pesos (US$120) per month to persons being discharged who have families, yet whose families would not be able to help in their discharge without economic support. As of the writing of this report, 41 persons were involved in this program.374

In 2002, a reform program was launched at Cabred Hospital. Until that time, there were no therapy programs, and those institutionalized short-term and long-term were housed in the same wards. Dr. Leo Zavattaro, the Director of Cabred Hospital, said that the hospital’s current strategic plan includes reform and deinstitutionalization processes, through agreements between the Hospital and nearby cities to create group housing for individuals being discharged. By 2005, the Hospital had already signed such an agreement with the cities of Moreno and Pilar, and was about to sign another with the city of Morón. Cabred Hospital’s draft strategic plan goes through the year 2010, by which time the plan proposes that the Hospital’s capacity be reduced from 1,320 to 500 beds, 200 of which will be designated to provide geriatric care. Dr. Zavattaro reported that a subsidy from the Ministry of Human Development of the province of Buenos Aires will permit the discharge of 300 individuals with economic difficulties. He estimated that another 200 persons could be discharged due to the agreements reached with the cities. By 2007, Dr. Zavattaro said that more than 250 persons were discharged and that agreements had been signed with five additional cities.375

At Borda Hospital, Director Dr. Miguel Angel Materazzi reported that in 1998 there were 1,250 people institutionalized there; at the time of investigators’ 2004 visit the number had dropped to 1,050. During the fi rst half of 2007, the average number of persons hospitalized had been reduced to 853.376 “My emphasis is attention in the home,” Dr. Materazzi stated.377 Dr. Materazzi also expressed support for the city’s legislation on mental health reform, saying, “we are applying Law 448. I’m in complete agreement with [Law] 448.”378

VII. The right to self advocacy

While Argentina has a vibrant consumer and ex-patient movement, groups that comprise this movement are not consulted by the government in service planning or development. Although administrators at Cabred Hospital stated that the family-run group Asociación Argentina de Ayuda a la Persona que Padece de Esquizofrenia y a su Familia (APEF—Argentine Association to Help those with Schizophrenia and their Families) had an advisory relationship at the hospital, investigators could not confirm that any user organizations had a substantive role in policy formulation at a hospital or government level.

According to international standards, people with disabilities have a right to be involved in the planning and execution of services that affect them. The Inter-American Convention on Disability establishes unequivocally the right of people with disabilities to participate in the “development, execution, and evaluation of measures and policies” to implement the Convention.379 The Convention further affi rms that governments shall promote the participation of people with disabilities in this policy planning and implementation.380

The UN Standard Rules also make clear that people with disabilities themselves have a right to participate in public policy-making, and appeal to governments to “encourage and support economically and in other ways the formation and strengthening of organizations of persons with disabilities, family members and/or advocates.”381 Mere token representation without actual participation in policy planning by persons with disabilities is insuffi cient.382 Throughout the Standard Rules, the importance of self-advocacy for persons with disabilities in local, national, and international arenas is emphasized. The Standard Rules also characterize as being of “utmost importance,”383 the participation of persons with disabilities in the development of government programs that affect them. This participation should include an active role in policy-making and planning, the elaboration of economic policies, information gathering, personnel training, and the monitoring and evaluation of disability programs.

The Pan American Health Organization (PAHO) also acknowledges that mental health services users play an essential role in formulating policy. While family members, mental health workers, and the community in general have a role in shaping policy, PAHO recognizes that, “In fi rst place are the people (patient, client, user) around whom all policy should be structured.”384

VIII. Conclusion

Argentina’s mental health and social service system for people with psychiatric and intellectual disabilities is out-of-step with changes that have taken place around the world over the last 30 years. Largely due to the lack of community-based mental health services, people with mental disabilities are segregated from society in psychiatric institutions. This segregation constitutes a form of discrimination against people with mental disabilities as well as people improperly labeled with a psychiatric diagnosis, a practice prohibited under international human rights law.385

By warehousing thousands of individuals in large institutions, instead of providing alternatives to institutionalization—including housing and community-based mental health services and supports—Argentina is doing incalculable damage to people who could, with the proper services and supports, live productive and healthy lives. The segregation of these people from their families, opportunities, and their communities furthers their isolation, contributes to their disabilities, and makes the likelihood of their ever returning to independent life all the more remote.

This massive institutionalization is the result, fundamentally, of misguided policy decisions that translate into the misallocation of significant government resources, and the failure to develop specific policies directed toward community-based mental health care.

Argentina’s laws regulating involuntary commitments to psychiatric hospitals do not provide adequate protections against arbitrary detention. Substantive provisions allowing for detention are overly broad and ill-defi ned. Procedural provisions in force do not guarantee the right to review of a detention decision by an independent authority, do not provide for the right to representation, and do not provide the right to periodic review of commitment decisions by a judicial or other independent authority.

Inside many Argentine institutions, people are subjected to serious human rights violations, including violations of the right to life, the right to health, and the right to humane treatment. Perpetrators are rarely, if ever, caught or sanctioned. Insufficient monitoring and oversight in institutional facilities contributes to a climate of lawlessness, both with respect to the abuses inflicted on institutionalized persons, as well as malfeasance in the administration of the institutions.

Yet, while there are significant obstacles to overcome, Argentina has the resources to engage in a dramatic shift in the way it approaches public mental health services. The country has a large base of mental health professionals; renowned models of mental health reform; and progressive laws endorsing the promotion of mental health attention in primary care, the formation of community-based services, and deinstitutionalization. In the city and province of Buenos Aires, where 75 percent of the largest psychiatric institutions exist, authorities are generally supportive of mental health reform, and several are taking proactive steps toward transforming their mental health services. Numerous professional, human rights, family member, and consumer/ex-patient organizations are actively engaged in actions to support this paradigm shift. In the words of one Buenos Aires city official, “There is money [to implement reform], we have to make the changes, we have to do it now.”386

Recommendations

The following recommendations list concrete steps that federal, provincial, and city governments, directors of psychiatric institutions, and international fi nancial institutions should take to reform Argentina’s mental health system to make it one that is respectful of human rights and prevents future abuses:

TO THE EXECUTIVE BRANCH OF THE FEDERAL GOVERNMENT, AND SPECIFICALLY THE NATIONAL MINISTRY OF HEALTH:

• Create a high level National Commission to plan for mental health service system reform

The federal government should create a high level National Commission to plan for mental health service system reform, in coordination with the Mental Health and Healthy Behavior Executing Coordinating Unit of the National Ministry of Health. The government will only resolve the problem of custodial institutionalization and the improper detention of individuals when it commits itself to creating community-based support systems that assist people with mental disabilities to live integrated in the community. The National Commission should include the broad participation of professionals, human rights organizations, provider organizations, lawyers, families, users and advocates consistent with the UN Standard Rules.387 In turn, the National Commission should develop a national policy for the provision of services to people with mental disabilities in the least restrictive environment. The plan should, at a minimum, provide for:

i. the development of community residential and day program services for people who are currently institutionalized; 

ii. the development of vocational rehabilitation programs, job opportunities and active participation of users in their treatment and rehabilitation; 

iii. the development of support services to enable families to continue their care-giving roles for family members with mental disabilities; iv. the opening of short-term acute care psychiatric beds in general hospitals or community based clinics; 

v. a schedule of planned discharges, policy of no new admissions to long-term care, and phase down of long-term care institutions in collaboration with directors of psychiatric institutions; and 

vi. a national public education campaign to combat stigmatization of and discrimination against people with mental disabilities, including human rights and disability awareness training for health care professionals, teachers, and others serving persons with mental disabilities.

• Review all psychiatric commitments

This National Commission should conduct a review of all residents in intermediate and long-term care beds in institutions to identify their needs for community services and priority for discharge in collaboration with directors of psychiatric hospitals. The Mental Health Law of the City of Buenos Aires, Law 448, calls for such a review of psychiatric hospital admissions. Such a review should be implemented, not only in the federal capital, but throughout the country.

• Implement a national program to develop community-based mental health services 

The National Commission should also implement a nationwide program to develop community based mental health services and services ensuring the social reinsertion of people with mental disabilities.

• Shift funding to community-based services 

The National Commission should develop and implement a policy requiring the reinvestment of the savings in the management of institutional services that will result from to the discharge of persons who have been institutionalized long-term. Such resources should instead be directed toward the development of community residential and other support services.

• Provide greater resources to the Mental Health and Healthy Behavior Executing Coordinating Unit within the federal Ministry of Health 

The federal government should provide the necessary resources to the Coordinating Unit to gather and centralize mental health data from the provinces, which is essential to ensure effective planning and implementation of sound mental health policies throughout the country.

• Support the development of consumer-directed advocacy 

The federal government should provide financial and logistical support to groups of mental health consumers, ex-patients and family members to enable them to develop as self-directed advocates. The government should open opportunities for such groups to actively participate in the development and implementation of polices, programs, and services affecting them.

• Develop a program for training staff 

The federal government should implement a training program for mental health workers, from professionals to technicians, to implement rehabilitative programs for residents of psychiatric institutions. This program should include training in basic principles of human rights and nondiscrimination.388

• Ensure safe, clean and humane living environments in all psychiatric institutions 

The federal government should establish enforceable standards for the eradication of dangerous, fi lthy, and unhygienic conditions in institutions throughout the country. All institutions should be held strictly accountable for compliance with these standards, including: 

i. the immediate repair of non-functioning toilets, sinks, and showers; 

ii. the daily cleaning of living spaces and bathing areas with disinfectant products; 

iii. the access of each detained individual to a bed with a clean mattress, sheets and blankets; iv. clothing and shoes that are clean and in good condition; 

v. immediate access to soap, towels, toilet paper, and personal hygiene products for each detained individual;

vi. sufficient food with a nutritional balance adapted to the particular needs of each individual; and 

vii. immediate and regular fumigation to rid institutions of cockroaches and other insects

• Provide appropriate medical and psychiatric care 

The federal government should order the provision of medical and psychiatric care to ensure the safety and health of all people hospitalized in psychiatric institutions.

TO THE LEGISLATIVE BRANCH OF THE FEDERAL GOVERNMENT:

• Enact a national mental health law

The legislative branch of the federal government should enact a national mental health law in compliance with international human rights standards. At minimum, this law should provide: 

i. due process guarantees in involuntary civil commitments, including: 

1. the right to judicial review of all involuntary admissions before an independent authority within 72 hours of admission; 
2. the right to periodic review of involuntary admissions by an independent and impartial entity at reasonable intervals; 
3. the right to client-centered legal representation in initial commitment hearings and all subsequent review hearings. The State should provide an attorney if the individual cannot afford one. 

ii. principles guaranteeing mental health attention, including adequate community-based treatment and rehabilitation focused around the needs and desires of the individual receiving the services, along with guarantees that all services be provided only after obtaining the informed consent of the person receiving the services; and 

iii. the other rights recognized in international standards pertaining to people with mental disabilities.389

TO THE NATIONAL MINISTRY OF JUSTICE AND THE MINISTRIES OF JUSTICE OF THE PROVINCES:

• Investigate recent deaths in institutions and establish protocol to ensure full investigations of any future deaths

Independent authorities should investigate all deaths of individuals in institutions. Investigators documented four unexplained deaths at Diego Alcorta Hospital and a death rate four times higher during the winter months than during the summer at Cabred Hospital. Prosecutors, under the corresponding jurisdictions, should investigate these and other deaths and establish a protocol to ensure the full and independent investigation of any future deaths in institutions.

• Investigate and report on particularly abusive facilities 

Prosecutors should investigate allegations of abuse at psychiatric institutions—investigators identified particularly abusive conditions at Diego Alcorta Hospital, Moyano Hospital and at Penal Unit 20—and hold accountable those responsible for such abuse, including through criminal prosecutions where necessary. Prosecutors, under their corresponding jurisdictions, should analyze patterns of violations and evaluate the possibility of releasing public reports of their findings toward ending abusive conditions in psychiatric institutions.

TO THE NATIONAL AND PROVINCIAL PUBLIC DEFENDER SERVICES ™ 

• Guarantee free and effective counsel for people hospitalized in institutions 

The National General Ministry of Public Defense should guarantee that all persons deprived of their liberty in psychiatric institutions have access to counsel who are responsible for making periodic visits to the institutions, assisting those hospitalized and their families in the fi ling and resolution of complaints, and investigating complaints of abuse, neglect, or suspicious deaths. Similar measures should be taken in each of the provinces that have psychiatric institutions. Public defenders, under their corresponding jurisdictions, should analyze patterns of violations and evaluate the possibility of releasing public reports of their findings toward ending abusive conditions in psychiatric institutions.

TO THE NATIONAL HUMAN RIGHTS OMBUDSMAN’S OFFICE: ™ 

• Create a program to protect against further abuses in psychiatric institutions 

The Human Rights Ombudsman should actively monitor conditions in all facilities serving persons with psychiatric or intellectual disabilities and evaluate the possibility of providing assistance and free legal counsel for those institutionalized and their families. In addition, the ombudsman should be authorized to perform unannounced on-site inspections day or night on a regular basis at all institutions; similar to the function of the Prosecutor in charge of Prisons regarding psychiatric penal units. Reports of findings should be made public.

TO THE GOVERNMENT OF THE CITY OF BUENOS AIRES: ™ 

• Enforce article 48 of Basic Health Law No. 153 

The government of the city of Buenos Aires should enforce article 48 of Basic Health Law No. 153, which mandates that the government work toward progressive deinstitutionalization. The Law further calls on the government to implement alternative models of attention focused on social integration, such as half-way houses, protected workshops, therapeutic communities and day hospitals.

• Take all steps necessary to effectively enforce Law 448 

The government of the city of Buenos Aires should implement Law 448 and take proactive steps toward its implementation, creating a program of community mental health services and community reintegration of persons with mental disabilities.390 Law 448 calls for progressive deinstitutionalization and guarantees the human rights of people receiving treatment in the city’s mental health system, including the right to the respect of one’s dignity; the right to informed consent; the right to personalized attention; and the right to rehabilitation and community integration.

• Comply with the temporary dispositions of Law 448 

The government of the city of Buenos Aires should comply with the temporary dispositions of Law 448. In particular, it should implement the second temporary disposition, which calls for an inventory of the total number of persons hospitalized in psychiatric institutions, with the goal of determining the causes and duration of each person’s hospitalization, and the necessity of continued hospitalization.

• Inform the public regarding the implementation of Law 448 

The government of the city of Buenos Aires should make public information regarding the implementation of Law 448. In particular: i. the budget assigned to different mental health programs; ii. the creation of the commission to follow-up on Law 448; iii. the status of the professional bids for teams providing public mental health services; iv. the programs and activities undertaken toward deinstitutionalization and the community reintegration of persons hospitalized; and v. the steps taken to prevent human rights violations in the provision of mental health services.

• Implement article 21 of the Constitution of the city of Buenos Aires 

The government of the city of Buenos Aires should implement article 21, paragraph twelve of the Constitution of the city of Buenos Aires that refers to mental health policies. This provision states that mental health policies will recognize those receiving mental health services as holders of rights; guarantees the provision of mental health services in government facilities; states that the goals of such facilities are not social control and that they will eradicate punishment; and endorses progressive deinstitutionalization and the creation of a network of mental health services and supports.

TO THE PROVINCIAL GOVERNMENTS: ™ 

• Adopt and enforce laws promoting human rights in the context of mental health 

The governments of the provinces should adopt and enforce mental health laws that respect the human rights of persons with mental disabilities. These laws should endorse progressive deinstitutionalization and guarantee the human rights of people receiving mental health treatment in the provinces. Provincial governments should also guarantee compliance with these laws.

TO DIRECTORS OF PSYCHIATRIC INSTITUTIONS: ™ 

• Eliminate the use of long-term isolation 

Directors of psychiatric institutions should eliminate the use of long-term isolation and ensure safe and humane conditions of confinement. Any use of isolation cells must comply strictly with the internationally accepted procedures to protect against the dangers of inhumane isolation, and should only be used “to prevent immediate or imminent harm to the patient or others.”391 Alternative means of protection must be attempted fi rst, and seclusion may be used solely “when it is the only means available” to protect against such harm.392 Isolation should “not be prolonged beyond the period strictly necessary for this purpose.”393 Under no circumstances should isolation be used for periods of days or weeks. Seclusion and restraint should never be used as a form of discipline or coercion, for staff convenience, or as a substitute for adequate staffing or active treatment.394 Directors should implement the procedural protections in the MI Principles to ensure that people held in isolation are kept under “humane conditions.”

• Implement measures to avoid physical and sexual abuse 

Directors of psychiatric institutions should take immediate measures to protect institutionalized persons from physical and sexual abuse. Staff should be trained to identify and protect those persons hospitalized against such abuse.

• Conduct a review of all persons in intermediate and long-term care wards 

Directors of psychiatric institutions should order a review of all institutionalized persons to identify the need for community services and create a plan prioritizing the discharge of persons in intermediate and long-term care beds. Institution directors should enforce a schedule of planned discharges and institute a policy of no new admissions to long-term care wards. ™ 

• Procure the necessary resources for their hospitals 

Directors of psychiatric institutions should procure sufficient staff and the resources necessary to ensure the adequate functioning of their hospitals.

TO THE INTERNATIONAL LENDING INSTITUTIONS, AND SPECIFICALLY THE INTER-AMERICAN DEVELOPMENT BANK (IDB):

• International lending institutions should redirect to community-based services the bulk of the funds currently allocated to rebuilding psychiatric institutions 

Except for essential repairs to infrastructure to existing psychiatric institutions necessary to ensure safety, international fi nancial institutions should, in concert with the Argentinean government, direct loans to the creation and implementation of community-based mental health services. In the particular case of the funds from the IDB loan, Argentinean government offi cials should renegotiate the terms of the loan so that the bulk of the funding can be allocated toward the pressing need for community-based services. The IDB should provide its loans in a manner that promotes respect for international human rights principles, directing funding toward the creation and strengthening of community-based services for people with mental disabilities.

Acknowledgments

This report is a joint endeavor by Mental Disability Rights International (MDRI) and the Center for Legal and Social Studies (CELS). The primary author and researcher of this report was Alison A. Hillman de Velásquez, Director of MDRI’s Programs in the Americas.

The bulk of the research for this report was conducted during six fact-fi nding investigations over a three year span in Argentina, from June 2004 to August 2007. In the many institutions and community-based mental health initiatives investigators visited, administrators, staff and people with mental disabilities were exceedingly generous with their time. Investigators returned to many institutions over the course of the research. Institution administrators, in particular, were gracious and welcoming, even when investigators covered similar ground on return visits. Many government offi cials and organizations of professionals, family members, and ex-patients also agreed to be interviewed for this report. Their candid assessments of mental health services available in Argentina shaped much of the content of this report.

Without the meticulous logistical support coordinated by Roxana Amendolaro, Coordinator of CELS’ Mental Health Team, research for this report would not have been possible. Roxana demonstrated tremendous commitment to this project, participating in fi ve investigations, despite being eight months pregnant with her fi rst child, Carla, during one of these, and spearheading a fi nal round of fact-checking as the report went to press. Alfredo Jorge Kraut, currently Secretary of the Supreme Court of Justice of Argentina, and the country’s principal specialist on the rights of people with mental disabilities, opened numerous doors that offered access to policy makers and mental health professionals alike. Alfredo provided insightful comments from his vast knowledge of the intricacies of Argentina’s legal system and its approach to issues relevant to people with mental disabilities. Had it not been for Alfredo’s energy, enthusiasm, and contacts, the daunting task of compiling information about Argentina’s mental health services system would have seemed a Herculean task.

Eric Rosenthal, Executive Director of MDRI, provided careful guidance and support throughout the report-writing process, reviewing numerous drafts and offering valuable insights to sharpen and polish the fi nal product. Laurie Ahern, MDRI’s Associate Director, also offered expertise from her background as a journalist, emphasizing the need to highlight individual testimonies as part of the research data. Andrea Pochak, Adjunct Director at CELS, lent institutional support to this project and provided meticulous and detailed revisions to the numerous report drafts. Joanne Mariner, former Deputy Director of Human Rights Watch’s Americas Program, offered thoughtful comments, suggesting many improvements in the early stages of the drafting process. Daniel Wilkinson and Maria McFarland of Human Rights Watch also provided important editorial and stylistic recommendations that made the report more cohesive and easier to read.

Authors must thank the numerous individuals who both participated in the investigation and documentation of this report, and who reviewed report drafts and offered their comments and corrections. These individuals include: Ana Laura Aiello, J.D., human rights doctoral candidate, Carlos III University of Madrid; Graciela Guilis, ex-Director of CELS’ Mental Health Team; Mariano Laufer Cabrera, attorney at CELS; Humberto L. Martinez, M.D., Executive Director, South Bronx Mental Health Council; Victoria de Menil, MPH; Clarence Sundram, J.D., President, Board of Directors, MDRI; Willians Valentini, M.D., psychiatrist, consultant to the World Health Organization; and Alicia Ely Yamin, J.D., MPH, MDRI Board member and Instructor, Harvard School of Public Health. Additionally, members of CELS’ Mental Health Team Adelqui del Do, psychologist, and Laura Sobredo, M.D., psychiatrist, and CELS’ legal intern Pablo Alvarez, participated in the investigation of this report.

Marcel Velásquez Landmann, anthropologist, candidate for a Master’s in Public Policy, Georgetown University, participated as an investigator and interpreter, and translated this report from English to Spanish. He displayed undying patience in incorporating what at points seemed like interminable revisions from a variety of reviewers. Without Marcel’s loving support, this report would never have made it past the initial draft.

Freelance photographer Eugene Richards captured several of the compelling images that accompany this report. Weeks of his donated time and his decade-long interest in exposing abuses against people with mental disabilities have been invaluable for lending a human face to the silent suffering of thousands of institutionalized individuals. MDRI is particularly grateful to Gene for his dedication and tireless support of our work. Elizabeth Mallow and Jeremy Robbins also contributed photographs for this report.

Brian Coopper provided careful copy editing of the report. Adrienne Jones, MDRI’s Office Manager helped with formatting and provided valuable technical assistance.

Essential support for the research and writing of this report was provided by a grant from the Overbrook Foundation. In addition, the Morton K. & Jane Blaustein Foundation, and the Merck Fund provided sustaining support without which the completion and dissemination of this report would not have been possible.