In 2001, I interviewed Emma, a 43 year old woman I had met two years earlier during a relief operation we conducted after a mountain of garbage in a landfill came tumbling down onto the shanties where they lived. She was the mother of three children, worked as a rag sewer and belonged to Kadamay, an urban poor community group organized by the leftist movement. It was one of my earlier writing tasks as an activist. In the course of our conversation, she revealed that there was a time when she felt she was ‘going crazy’, and told her kids she would rather kill them and herself than continue to watch them live in desolation. Her children simply hugged her and she regained her composure. I remember being dumbfounded by the ease and calmness with which she shared that story. She said reason overruled her and recollections of how she resolutely took care of her siblings when they were orphaned at an early age fueled her determination to prevail. According to her, being part of Kadamay helped her enormously to cope, giving her a new-found understanding of the genuine roots of destitution and the will to be part of the struggle.
I should have not forgotten her story. The following year, I attempted to take my own life, overdosing on medications prescribed to me six months after I was diagnosed as ‘mentally ill’. Unlike her, the bio-medical mental health system got hold of me and I fell victim to the adverse effects of psychiatric drugs which induced suicidality. Whereas her madness was clear to her as a result of trauma from enduring extreme economic hardship and the consequent sense of helplessness, mine was explained to me using the ‘defective brain’ argument which I, tragically, bought into. Over a decade later, I have never been happier to be proven wrong.
Inadequate institutions – a blessing?
The Philippines, as I have learned from my exposure to international advocacy, is no deviation from the general picture of the world as being prevailed upon by the biomedical model. Mental health problems are considered diseases despite lack of evidence. Primary care is pharmacological. Responses to crisis often result in human rights violations including coercion, torture, degrading treatment and forced hospitalization. Persons with mental health issues and psychosocial disabilities are highly stigmatized. Unsurprisingly, discussions and actual efforts on addressing mental health issues are confined to the framework of treatment and divorced from the development paradigm which includes housing, employment, social services and the justice system. Counter consciousness to the mental illness narrative, though slowly gaining traction, remains low.
Being a ‘Third World’ country, the Philippines does not have the capacity to operate hundreds of mental or ‘social care’ institutions given the meager budget allocated for health in general. Also, it does not have a legal system that provides for compulsory treatment orders mostly found in rich and western countries where there is an overrepresentation of involuntarily treated persons with psychosocial disabilities. We only have over 600 psychiatrists and roughly 15 State-run psychiatric facilities nationwide with a little over 6,000 in-patient beds. These are mostly integrated in general hospitals except for three standalone mental institutions, around 50 drug rehabilitation centers, of which 21 are public, which can accommodate 17,000 people, and one halfway house . There are 58 private psychiatric facilities with 32 of them located in the capital and the rest sparsely distributed in five out of the 17 regions. These fortunate limitations meaningfully reduce what could otherwise have been a skyrocketing number of medical incarcerations. In 2014, government health officials admitted that the mental health information system is inadequate and fragmented. There is no suicide registry. No comprehensive epidemiological study has been done. To make matters worse, the last census in 2015 excluded disability. Though alternative non-medical healing modalities are available, these are very limited as they are unpopular, costly, and largely concentrated in the capital. I only know of two peer-run services operating beyond social media.
A lot of mental health advocates, oblivious to the human rights and disability perspective, lament this infrastructure situation which prompted the proliferation of mental health bills and the subsequent passage of the country’s first Mental Health Act. During congressional deliberations, we have passionately objected to their contents which contravene the UN Convention on the Rights of Persons with Disabilities (CRPD) the Philippines is a State party to. Legislation was largely designed by mental health professionals who see the issue as a medical problem. Though it provides a long list of rights, the law violates the critical right to consent by laying down exceptions to legal capacity and accessing one’s medical records. The focus is also limited to accessibility of treatment that is primarily psychiatric and neurologic. The CRPD mandates ensuring independent living, social inclusion and elimination of barriers that cause disability but these were absent in the hearings and the law. Their concept of prevention does not include addressing socio-economic reasons for mental health problems.
The socio-political context of mental health
In a CRPD-based disability law summer school I attended in Ireland, I remember a young lawyer participant from Peru pointing out a critical fact – capitalism brought upon us these problems in mental health and giant pharmacological industries is just one of the biggest culprits. I could not agree with him more. The semi-feudal, semi-colonial character of Philippine society has been setting its citizens up for failure in many aspects of life, consequently jeopardizing their mental health. Our government is the top breeder of mental distress and psychosocial disability by remaining corrupt and subservient to its foreign imperialist masters led by the US and local bourgeois compradors as well as landlords to the detriment of the Filipino people. Our economy is stuck at being export-oriented and import-dependent instead of self-subsistent. Globalization and neoliberal policies shoved down our throats have eroded social justice and plundered our nation. Our country has massive natural resources but the vast majority of the Filipino people, numbering to around 60 million, are buried in poverty. There is huge inequity between the rich and the toiling masses. Our agriculture remains backward. Millions of peasants are landless while lands are concentrated in the hands of a hundred families. Militarization in the countryside wreaks havoc. Farmers and indigenous peoples are being displaced and brutally forced out of their lands to give way to foreign mining industries and agribusiness. Unfair labor practices are rampant. Salaries are low. Workers’ wages are highly exploitative while big concessions are provided to capitalists. Most social services are expensive because they are privatized. Recently, the administration had the audacity to enact a new law that imposes higher taxes on consumer goods, further penalizing the poor while giving income tax cuts to the affluent.
The absence of national industrialization has forced ten per cent of the population to become overseas workers. On top of the anguish over being separated from their families, many migrants have been subjected to violence, discrimination and, worse, killings in their host countries. The social repercussions of the diaspora have been considerable. The culture of impunity which has become deeply rooted in the country has left so many families of human rights defenders, members of the press and environmental activists bereaved. The ongoing bloody war on drugs waged by the current administration targeting the poor has left thousands dead and hundreds jailed arbitrarily. The justice system is snail paced, ineffective and almost inaccessible, exacerbating the grief of victims. The education system is a failure on so many levels including producing disability-sensitive individuals.
The list of oppression and exploitation experienced by the people is endless. Yet, in most mainstream discussions on mental health, no one attempts to recognize that socio-economic determinants as the root cause of many mental distress, much less in offering corresponding solutions. To make matters worse, multinational pharmaceutical companies, through their medical professionals conduits, ensure that the Philippines remains a significant market for psychotropic drugs by aggressively promoting the idea that recovery is best achieved using medications.
It is still a long way for my people to analyze mental health through this lens and almost impossible for the bureaucracy that thrives on this system to end sufferings. Human rights militants have yet to embrace the interests of persons with disabilities in their cause. However, despite the absence of a mental health rhetoric, progressive social movements are unceasing in their endeavors to transform society that will accord people decent living. Many self-advocates have also risen to mainstream disability rights throughout the decades though there remains no unified or strong cross-disability alliance. Disabled People Organizations (DPO) have only come so far in influencing inclusion reforms and holding the government accountable. Most advocacy groups rely on volunteerism and private partnerships to cater to the needs of their constituents which include raising awareness on CRPD. Though struggles are very pragmatic, one of the biggest contributions of some DPO leaders is the facilitation of our entry into the disability movement which paved way for our engagement with a wider audience. Online communities have been initiated and are the main platform for peer support. Some NGOs are involved in suicide prevention projects. Celebrities have also started coming out to raise mental health awareness. Several of us have begun reclaiming our place in national government policy formation and capacity building in recent years and taking the steps towards slowly ending the invisibility and misrepresentation of our sector. Our efforts have also resulted in the identity change of many individuals from ‘mentally ill’ to ‘persons with psychosocial disabilities’. This marks a meaningful leap from seeing themselves as mere damaged goods or ‘patients’ to rights bearers. The change in perspective has accorded the understanding that they are part of human diversity and that the social injustice they face is not their impairment but part of the disabling environment they live in.
Oftentimes, tales such as Emma’s are easily construed as misery narratives overlooking the crucial fact that, more importantly, they are accounts of resilience and courage to be part of something meaningful and bigger than themselves. I read my article on her again and smiled at her concluding sentence: ‘Changing the situation is an uphill battle but what matters is that we are living fighting back.’