Annibal Coelho de Amorim
Fellow Since 1996
Instituto Municipal Nise da Silveira
This description of Annibal Coelho de Amorim's work was prepared when Annibal Coelho de Amorim was elected to the Ashoka Fellowship in 1996.
Brazilian neurologist Annibal do Amorim has successfully demonstrated a way to democratize public human service institutions that (1) break down prevailing health and human services models in which "the expert treats the passive patient;" (2) enable local citizens to initiate new volunteer-based solutions; and (3) stimulate further citizen action.
The New Idea
Annibal do Amorim has seized upon a unique provision in the reformed Brazilian constitution of 1988 that promotes local "social control" of public human services institutionshealth, welfare and education. Annibal believes that this constitutional provision opens the way to "provide a new basis for citizenship through a process of democratizing public services." Since 1992, he has been demonstrating the practicality of his vision at the Pedro II Psychiatric Center of greater Rio de Janeiro. As a senior doctor at the hospital, Annibal instituted a series of reforms that attracted community organizations and citizen volunteers into the hospital premise in ways that produced a free, healthy coexistence with mental patients. As the program has evolved, it has become clear that it is succeeding on three fronts. First, it steadily breaks down the prevailing health and human services model in which "the expert/doctor treats the passive patient/beneficiary" by organically building a new community-based model inside the existing system. Second, it enables local citizens to launch new volunteer-based solutions to the particular human services problem. In the case of Annibal's pilot demonstration project this involved literally scores of new initiatives taken by a range of community organizations, to meet the needs of those suffering from mental illness. In a climate where declining public budgets mean reduced public services, these very low-cost community-based alternatives become strategic imperatives. Third, the Community Center that Annibal set up within the hospital premise has proven to be a powerful incubator of further citizen action beyond the mental health field, becoming an important nodal point in the revitalization of civil society in the surrounding area of some two million persons.Having developed and demonstrated his "model" at the Pedro II Psychiatric Center, Annibal is now focusing on "spreading the news" throughout Brazil. This involves developing a strategy to communicate the model and building the capacity to service those who would apply it.
The provision of basic human services in Brazilpublic health, education and welfare has long been the prerogative and responsibility of the state. Through decades of authoritarian and generally corrupt governments, and a closely related unchecked growth of bureaucracy and inefficiency in human service provision, the noble ideals at the origin of public human service institutions have been badly eroded. Today, most Brazilians view public servants, at best, as leaches on society who do as little actual work as possible.The various fields within the human services have suffered differently under this regime. In the health arena, for example, a model for health care emerged in which the expert-doctor would "treat" a passive patient; knowledge flowed down from the doctor. The logical extreme of this model in the subfield of mental health led to a practice in which those judged mentally ill by reason of antisocial behavior were separated and institutionalized under the "care" of experts. One of the many deficiencies of this model is that it lets society "off the hook" for responding to these social health issues in a very fundamental sense.Certainly in the field of mental health, but also more generally throughout the human services fields, there is a recognition that an alternative democratic and community-based model may be more effective in addressing health and other human service problems. For over a decade around the world, mental hospitals have been shifting to day care and community care approaches. More generally, with public sector funding for human services declining in Brazil and elsewhere, there is no reasonable prospect of providing comprehensive public services using the old model. There is growing recognition of the need for lower-cost, community-based alternatives to, as Annibal puts it, "continue to invent health by offering new opportunities for improving the quality of life and social interaction."
In transforming the Pedro II Psychiatric Center, Annibal employed a lurethe availability of underutilized physical premisesto attract community organizations into the hospital. He initially invited the community to hold meetings and events at the hospital and to establish permanent offices there, on the condition that they make a commitment to fight prejudice against mental illness and adopt a plan to involve mental health patients in their organization in some way. Over the first four years that the Community Center, as they call it, has been evolving at the hospital, 21 groups have established permanent offices there and many others have held events there. Of course, by enticing community groups into the hospital Annibal has deliberately initiated an open-ended experiment in democratization of human services. For example, he instituted a governing council for the Community Center project, made up of three representatives from the citizen organizations and three from the hospital. Its specific mandate is to serve as an intelligent bridge between the hospital and the wider community in dealing with the issues of health, and specifically the need for the community to assert "social control" over the hospital. In this way the Community Center has developed an identity and mission separate from the individual programs of the different groups working in the Community Center. And this mission has captured and spurred the imagination and energies of the individual groups, who serve on activity committees and rotate representatives through the governing council. Groups in the Community Center also experience other benefits. They plan and collaborate far more than they did before moving in. They reach many more people than they used to since the Community Center has become so well known in the area. In a typical two-month period, over 10,000 people will come through the Centerstreet children, pensioners, the unemployed, parents, teachers, youth groups, the elderlysome of whom become regular volunteers. Through this dense weaving of the social fabric runs the colorful thread of the mentally ill, for, as Annibal notes wryly, "It is their home in which all this social activity is happening, after all. The rest of us are guests here."While his pilot at the Community Center utilizes the availability of free physical premises, Annibal insists that this does not limit the replicability of the model. He argues, first, that there is a supply of underutilized space in public buildingsnot only disused mental hospitalsthroughout the country. Second, to quote Annibal, "While having underutilized space to give away is a great way to start, 'social control' is not dependent on it. Once a few people in the community understand that they have the experience, knowledge and common sense required to transform their situation, a building is beside the point." His work at the Community Center suggests that there is a growing realization of this power to transform at the broad popular level and that public servants have a unique opportunity to facilitate the conversion of this realization into action.Having developed and demonstrated his "model" at the Pedro II Psychiatric Center, Annibal is now focusing on communicating it to a wider audience. This necessitates both careful documentation of the work and key principles of the Community Center and building the institutional capacity to support those who would like to adopt the model.
As a young boy, Annibal witnessed the demeaning loss of status that his father endured as a career civil servant at a time when government generally fell into ill repute. Despite the fact that his father exemplified the highest ideals of public service, he could hardly stem the tide of popular opinion against the generally bad, lazy and self-serving government of the military dictatorship years.Annibal has inherited his father's ideals of service and has, since qualifying as a doctor and later as a specialist in neurology, dedicated his life to public health. Unlike virtually all of his professional peers, he has not operated a lucrative private practice alongside his public duties. Instead, he has sought to reform the system that begets such duplicity. He believes that society will only overcome its prejudice against public servants when two things have happened. First, citizens must take the reigns of social control of the human services in their communities. Second, the public servants must become adept at helping them to do so. Through the transformation of the Pedro II Psychiatric Center, Annibal has found a way to do both simultaneously.