The Fight to End Neoliberal Madness in Honduras

Madness in Honduras

The figure of the loco (madman) is common in Honduras. Since I began conducting fieldwork in Honduras in 1996, I have observed and written about the ways in which the cultural construction, imagining, and stigmatization of madness compound the vulnerability of already vulnerable populations. In diverse formal and informal settings I have observed poor Hondurans whose behaviors deviate from established norms or who have known diagnoses of mental illness being called “locos/locas” (madmen/madwomen), laughed at, and, more often than not, not taken seriously. ⁴ I have also observed their patterned ostracization, denial of employment, and criminalization. People labeled as “locos” are today particularly likely to be targeted for physical violence and abuse in apparent hate crimes by gang members, police, fellow inmates (if incarcerated in prison or a mental hospital), and even, at times, family members and health care workers (see, e.g., EFE, 2009; Tiempo, September 11, 2009; La Prensa, July 17, 2013; August 8, 2014; January 28, 2016; Valladares, 2014; El Heraldo, February 8, 2018). In general, both through my own ethnographic observations and through extensive reviews of media reports on incidents of targeted violence carried out against these individuals, this danger is markedly increased for people who exhibit dramatic behaviors that might be medicalized as symptoms of psychosis.

Just as poor drunks are labeled, feared, and criminalized as bolos (Pine, 2008a; RP, 2021), poor individuals exhibiting nonnormative behavior are colloquially labeled sicóticos and dementes and are popularly and even often medically understood as violent and dangerous because of their perceived madness or mental illness. The assumption is that anyone diagnosed with or showing signs of mental illness is intrinsically violent. For example, the 15-year 2021 National Health Plan published in December 2005 begins its discussion of mental health with the statement that “the most frequently diagnosed mental health problems in the primary health network are: violence (30%), depressive disorders (27%), epileptic disorders (11%), neurotic disorders (9%), psychological development disorders (6%), [and] infant behavioral disorders (5%)” (Rápalo et al., 2005: 47). It goes on to list homicide and domestic violence statistics before continuing to describe other diagnoses that fall within its definition of “mental illness”—the disturbing implication being that violence is itself necessarily a symptom of mental illness.

Locos are also portrayed in the Honduran media and popular discourse as inherently criminal, with very little critique of this dangerous conflation. Because of these associations, individuals with known diagnoses or visible symptoms of mental illness are unlikely to have the necessary support to risk going to the police in the event that they are attacked. The mentally ill have every reason to fear the police in Honduras, as is evidenced by a video circulated widely on the alternative and social media in 2019 that showed police in San Pedro Sula threatening, punching, kicking, and then throwing from a building a man displaying clear symptoms of mental illness, breaking his arm and wrist in the process (Honduras No Te Rindas, 2019; Primicia Honduras, 2019). Conversely, posts and articles by journalists showing people engaged in criminal activities and/or individuals who have been violently (and triumphantly) arrested by police on charges of violent behavior often refer to such individuals as “locos” or enfermos mentales (mentally ill) without any evidence that that is the case (Tiempo, December 7, 2016; El Heraldo, August 17, 2017; La Prensa, April 29, 2019; C. Funes, July 30, 2020). Gang members and clicas (cliques) also embrace this assumed correlation, often incorporating “loco” and “locos” into their group monikers and individual nicknames as a way of emphasizing their dangerousness (La Prensa, April 3, 2018; El Heraldo, May 27, October 25, 2021).

In a corrupt penal system, the pervasive association of mental illness with criminality often results in the unjust imprisonment of people with known diagnoses or visible symptoms of mental illness for crimes they did not commit. Honduran prisons are notoriously dangerous, a fact that is inseparable from their intentional overcrowding and militarization (Moreno, 2006; Pine, 2012; 2018a; Criterio, July 30, 2020). Mentally ill prisoners—guilty or not of criminal behavior—are always denied necessary psychiatric and other health care treatment and often subjected to torture in prison by fellow inmates or guards (EFE, 2018). In my academic work I am ordinarily loath to cite U.S. State Department country-conditions reports for Honduras because of the way they whitewash human rights abuses committed under allies’ regimes and exaggerate or fabricate human rights abuses of U.S. enemies (see Pine, 2008b). That said, even as the U.S. State Department enthusiastically supported the Hernández narco-dictatorship, its 2019 and 2020 country-conditions reports both commented on the lack of adequate support for cognitively impaired and mentally ill prisoners in the severely overcrowded Honduran prison system (Bureau of Democracy, Human Rights, and Labor, 2019; 2020). They also both asserted that “mental health professionals expressed concern about social stigma by families and communities against persons with mental disabilities and a lack of access to mental health care throughout the country.” ⁵

The voice that asylum lawyers prefer their country-conditions experts to use, in my experience, is the ethnographic present, which promotes a culturalist interpretation of violence and mental illness and militates against a structural analysis rooted in the violence of capitalist imperialism (e.g., a framing of neoliberal madness). The ethnographic present (e.g., “Mental illness is stigmatized in Honduras,” “Honduran prisons are extremely violent places”) precludes honest analysis of the root causes so frequently and dishonestly evoked in U.S. migration policy debates. But the impacts of neoliberal policy on mental health care and on the ability of Hondurans to enjoy the necessary conditions for mental health (neither of which were good for the poor to begin with) have been devastating.

Honduran health care experts have reported an alarming increase in mental illness diagnoses and suicide attempts since the 2009 coup (Valladares et al., 2018; VTV Somos Todos Honduras, 2017; Proceso Digital, 2018; La Prensa, July 6, October 20, 2019; July 2, 2020; Radio Progreso, February 21, 2019; Ramírez, 2019; Confidencial HN, 2022) in comparison with previously published rates (Reyes Ticas and Espinoza, 1993; Chirinos-Flores et al., 2002). ⁶ My own ethnographic research findings on trauma in Honduras have concurred with those of my Honduran medical colleagues and with those of clinical research by psychologists demonstrating that trauma and its embodied manifestations (medicalized as symptoms) are exacerbated by economic precarity, which in turn corresponds with housing, food, and bodily precarity in individuals with mental health diagnoses. I have written about my fieldwork in the children’s mental health ward of Hospital Escuela in 2014, where an abrupt increase in youth suicides and suicide attempts in the years following the 2009 coup was causing the ward’s chief psychiatrist great concern (Pine, 2016). This was, not coincidentally, the same period when the related “unaccompanied minor” crisis at the U.S. border was being blamed by Republicans and Democrats alike on bad Honduran parenting and gang violence.

Jesús (a pseudonym), an elected official of the psychiatric hospital workers’ union who works at Hospital Mario Mendoza (adjacent to the nation’s premier teaching hospital, Hospital Escuela, in the capital Tegucigalpa) told me in a June 2022 interview about the immediate impact of the coup on his work environment:

Look . . . we saw it here, because the police beat people up—people who went out to protest. And the closest place or the most viable solution was to bring them to Hospital Escuela so that they could do whatever had to be done—people who arrived with their heads split open, their legs broken, internal injuries, even bullet wounds—so Hospital Escuela was the place to go at that moment. But after they got out, they’d end up as patients in the psychiatric hospitals because of the trauma they had suffered. And . . . suicides increased at the time. Usually before the coup we’d get maybe one person a week who had attempted suicide. Sometimes even a month would go by without new suicidal patients. But after the coup it increased. We’d sometimes get two people a day, six in a week, because of the situation. It wasn’t easy. It wasn’t easy.

Building upon the vast body of scholarly work exploring the social production of and the cultural significance of trauma, suffering, and mental illness in relation to structural violence and the state—what Szasz (1997) terms “the manufacture of madness” (see also, e.g., Fanon, 1963; Foucault, 1988; Kupers, 1999; Scheper-Hughes, 2001)—Nancy Scheper-Hughes (2014) advocates for deeper analysis of countless contemporary ethnographic instances of “the militarization and madness of everyday life.” Taking her cue, I have argued that the U.S.-led imposition of neoliberal fascism in Honduras has in certain specific cases directly or indirectly become somatized as psychosis and in many more instances in ways that are medicalized and/or otherwise culturally interpreted as mental illness or madness (Pine, 2018b). This is not to say that psychological distress and/or madness do not occur absent neoliberalism but rather that—as numerous medical and social scientific studies have shown in Latin America and around the world—neoliberalism can be maddening (Acosta and Quiñones, 2016; de la Mata Ruiz, 2017; Davies, 2021; Guinsberg, 2004; Sparke, 2016; Roberts, 2021; Herrawi et al., 2022; Sousa and Marshall, 2017; Esposito and Perez, 2014; Petras and Vieux, 1990; Petras, 2002).

Indeed, Honduran doctors in psychiatric hospitals reported that in the context of the government’s extravagant failure to contain the COVID pandemic (inseparable from its neoliberal restructuring of health care provision) they saw additional increases in the numbers of people presenting signs of mental illness and concomitant populational treatment needs, which further stretched already overextended resources (Criterio, 2020; La Prensa, July 2, 2020; McBoyle, 2021). Jesús confirmed this in our interview, telling me that since COVID became a crisis in Honduras, he has seen four or five patients a day being transferred to Hospital Mario Mendoza from Hospital Escuela following suicide attempts. “The emotional weight has just been too much for the Honduran population,” he told me, “and we don’t have enough psychiatric hospitals to be able to treat them.”

A Brief History of Psychiatric Care in Honduras

Neither mental illness nor psychiatric care in Honduras began, of course, with neoliberalism. The first health care facility designated to treat patients designated as enfermos mentales (mentally ill) or perturbados mentales (mentally disturbed) in Honduras was a special ward, opened in 1926, of Hospital General San Felipe in Tegucigalpa, although a high proportion of patients were epileptic or suffered from other ailments or injuries not categorized today as mental illnesses. In the mid-1940s, the ward’s name was modernized from “Asilo de Indigentes y Alienados” (Poorhouse and Lunatic Asylum) to “Department of Neuropsychiatry.” At that time it was restructured by Dr. Ramón Alcerro Castro—who complained of the ward’s previously having served as a “wastebasket” for the rest of the hospital, where all overflow, uncategorized, extremely poor, or otherwise complicated patients were sent—to treat patients diagnosed with psychiatric illnesses (Alcerro Castro, 1953; Espinoza Murra, 1980; 2008; Reyes Ticas, 1997). The first available statistics from the Department of Neuropsychiatry, from 1951–1952, list a patient population of 186 (98 men, 88 women) (Reyes Ticas, 1997: 90). Following the times, popular treatments pioneered in Honduras by Alcerro included lobotomies and electroshock therapy. He also lobbied for strict nationwide professionalization of psychiatric care, prevention of patient abuse, and the development of standards for forensic psychological exams in criminal cases. By 1957 the ward had a patient population of 400 (with far fewer beds than patients), and in 1960 the Hospital Neuropsiquiátrico was created as a separate entity adjacent to the Hospital General San Felipe. In 1965, responding to a plea posted in the American Psychiatric Association’s journal by a Peace Corps volunteer for support for Honduran psychiatry, Dr. Richard W. Hudgens (1966: 470) wrote after visiting the hospital,

The Neuropsychiatric Hospital is an annex of the National General Hospital of San Felipe and was designated for 200 patients. There is an average daily census of 514, with 214 beds; more than half the patients sleep on the floor. Many of them are inadequately clothed. The structure is dilapidated, unheated. . . , overrun with rats, and widely soiled with human waste despite continual cleaning. During the winter some patients die usually of dysentery as the immediate cause.

He noted optimistically, however, that “[the] current situation, bad as it is, has greatly improved in the past two years,” complimenting his Honduran colleagues on their efforts to improve patient conditions (471). In a follow-up report written for the Pan American Health Organization in 1967 (quoted in Espinoza Murra, 1980: 107–108), however, Hudgens mentioned the 23 2 by 3-meter cement isolation cells and described the common patios:

With overcrowding, a lack of cleanliness, patient inactivity and the shortage of medical and nursing personnel, the patios are terrible sight. Nakedness, filth, and evidence of physical illness are common. On the walls of the patios are numerous sickly-looking vultures and pigeons. Hundreds of these birds daringly descend on the women’s patio #1 at mealtime, sharing their food and soiling the facility.

A history of psychiatric medicine in Honduras by the leading Honduran psychiatrist Dr. Americo Reyes Ticas (1997: 92) noted of the same period that

budget limitations, personnel shortage, a mostly untrained workforce, and a population of 500 psychotic patients interned in a building that itself was in bad shape make it difficult to provide acceptable psychiatric treatment. Although they had access to strong anti-psychotic drugs to control the patients, understaffing and overcrowding meant that [staff] would frequently resort to carceral methods including chains, iron shackles, straitjackets, fixation abscesses, and solitary confinement. ⁷

Following the publication of various scandalous reports and the efforts of a small but growing community of organized Honduran health care workers to improve treatment and working conditions, a new psychiatric acute care facility was inaugurated in 1973 next to Hospital Escuela in Tegucigalpa and named for Dr. Mario Amado Mendoza, who had directed the Hospital Neuropsiquiátrico at San Felipe from 1968 to 1971. Patients and staff (along with their union) moved to the new hospital. The old hospital at San Felipe—still associated in popular memory with prejudicial notions of criminal insanity—has gone through various transformations and functions today as a geriatric care facility. Another facility, the Hospital Neuropsiquiátrico Santa Rosita, was inaugurated with 300 beds in 1976 near the Támara national prison in the Amarateca Valley, 45 kilometers outside of Tegucigalpa, for longer-term treatment with a particular focus on alcoholism and addiction. In 1975, as Santa Rosita was being prepared to open, the Public Health Secretariat created a mental health unit with the stated goal of expanding and decentralizing mental health care with a focus on community mental health approaches so that Hondurans would not have to depend solely on the two psychiatric hospitals for mental health care—a goal that has been reiterated by government and other experts on countless occasions (see, e.g., Departamento de Salud Mental, 2004: 6; Aparicio et al., 2008; Esquivel and Rodríguez, 2019). Since then, however, no new inpatient facilities have been built for psychiatric treatment, and the government has not developed or invested in community mental health initiatives. ⁸

With 214 beds for psychiatric patients in a nation with an approximate population of 2 million in 1960, the overall proportion of beds was approximately 11 per 100,000. While it is not clear—given treatment approaches, methods of patient selection, understaffing, and other variables—that a larger number of beds would necessarily have ameliorated the situation for patients described above—it is worth noting that this is well below the low of 28.1–41.7 psychiatric care beds per 100,000 population recommended by public health researchers today for the United States (Hudson, 2021). ⁹ In 2022, Honduras has approximately 250 inpatient psychiatric beds for a population of nearly 10 million, or around 2.5 per 100,000.

Numerous sources indicate that decades of neoliberal economic policies have exacerbated the underlying structural causes of the deplorable conditions noted by the earliest advocates of psychiatric modernization and professionalization in Honduras—understaffing, insufficient state investment in and upkeep of facilities, and overcrowding. In 2002, the Pan American Health Organization (Vásquez and Leria, 2010: 44) reported

a series of observations regarding conditions at the Santa Rosita Psychiatric Hospital, including persons placed incommunicado in isolation cells, poor sanitation and hygiene with human excrement on the floors where people slept, poor lighting and ventilation, and lack of access to medical care. Other deplorable conditions included female sterilization, psychosurgeries and electroshock without anesthesia, naked women roaming around the institution, lack of bedding and furniture for personal belongings, and unhygienic bathrooms.

A newspaper article published the same year noted that among the more than 100 men and 70 women at Santa Rosita at that time were men and women who had been hospitalized continuously for 40 years, beginning their stay at the “insane ward” (sala de enajenados) of Hospital General San Felipe (Revistazo, 2002). It is clear that among psychiatrists at the hospitals and government officials, good intentions (or at least assertions of them) abounded alongside a clear awareness of the dire situation in the hospitals. For example, the Health Secretariat’s 2004 National Mental Health Policy, and the 2005 National Health Plan 2021, both published during the presidency of the hard-line neoliberal and later coup leader Ricardo Maduro, emphasized a need to move toward community and integral health and away from the near-exclusive focus on pharmacological and institutional solutions to mental illness and other mental health problems (echoing the stated goal of the Health Secretariat’s creation of a mental health department in 1975 noted above).

One brief history published by a Honduran psychiatrist (echoing Hudgens’s polite optimism) in 2008 extolled the progress in Honduran psychiatric care over the decades (Espinoza Murra, 2008), but while most forms of shock therapy had been phased out by that time none of the other conditions that Hudgens and others deplored in the 1960s had improved over the decades, and some things had gotten worse. There is a clear causal relationship between the implementation of neoliberal policies and the continued decline of never-adequate-to-begin-with psychiatric health care available to individuals in Honduras suffering from trauma, malaise, or psychosis and other forms of mental illness. Also in 2008, nearly two decades into the implementation of neoliberal structural reforms in the Honduran health sector, the World Health Organization (WHO) issued a report on the Honduran mental health system. In its executive summary, Aparicio et al. (2008: 6) noted:

All aspects of patients’ human rights are . . . neglected, including legal protections, labor standards, quality of care, etc. Training and refresher courses in mental health, including in psychosocial care, is not adequately provided to general and mental health staff. Furthermore, the participation of users and family members in mental health schemes is not promoted.

The resource and budget problem of the public health care sector in Honduras is even worse in psychiatric hospitals and clinics, which, in keeping with the broader societal prejudice against people with mental illness, are further deprioritized. The same WHO report highlighted the fact that in 2006 only 1.75 percent of the funding designated for health care went to mental health, and of that, 88 percent went to psychiatric hospitals (Aparicio et al., 2008: 7). The proportion of the national budget allocated to mental health care has not increased since then (Vargas Elvir, 2021). When I asked Jesús about funding cuts, he pointed out that psychiatric hospitals today run on more or less the same budget as 20 years ago, but between inflation, crumbling infrastructure, population increases, and a heightened need for psychiatric services resulting from collective trauma, “they don’t even need to cut funding” to produce the same effect.

Since the 2009 coup, human rights conditions in all public health care facilities have worsened. The postcoup regimes of Roberto Micheletti, Pepe Lobo, and Juan Orlando Hernández reduced health care funding further through budget cuts and graft, with qualified and unionized medical staff being denied pay and/or laid off, to be replaced (in many cases) by unqualified but politically loyal workers (Carmenate Milian et al., 2016; Fiallos and Mendoza, 2019a; 2019b). I have previously written about the harmful impacts of budget shortages on mental health care provision in Hospital Escuela, where I conducted fieldwork in 2014 (Pine, 2016). Hospital Escuela operates at a severe deficit, as do all Honduran public hospitals. Because of its crumbling infrastructure, like the Hospital Mario Mendoza next door it has frequent shutoffs of water and electricity (only 3 of Honduras’s 31 hospitals were built or remodeled after 1980) (Fiallos and Mendoza, 2019a; Barahona, 2022).

In Honduran public hospitals, there are few or no medical supplies available for patients, and medication supplies also often run dry or are faulty or expired (see, e.g., Tiempo, August 7, 2020; E. Funes, 2021; Proceso Digital, 2021). This means that if family members are not purchasing and delivering drugs, food, clothing, and other necessary supplies, patients simply go without. Multiple interviewees told me that, as in previous decades, naked patients abandoned by their families roam the halls and sleep two, three, or four to a single cot in fetid wards—a claim confirmed by photographs in journalistic exposés depicting exactly those conditions (CLACSO, 2010: 29; El Heraldo, November 25, 2019). These unhygienic conditions and the government’s refusal to provide additional necessary personal protective equipment to staff and patients predictably produced disastrous outcomes when the pandemic hit, with the psychiatric hospitals becoming sites of mass contagion even as the need for mental health services increased in relation to the crisis (Hondudiario, 2021; Barahona, 2021; Criterio, 2020; La Prensa, October 29, 2020).

Just as general hospitals in Honduras are places of nosocomial disease contagion, Honduran psychiatric patients and family members I interviewed described Mario Mendoza and Santa Rosita as places that drove people mad, which, given the well-documented human rights violations and violence that frequently occur in these settings, is not surprising (see also Flamenco Arvaiza, Nickels, and Hunter-Nickels, 2020). Even regime-friendly sources have acknowledged that conditions have failed to improve over the years (e.g., Sharma, 2020: 6). The 2015 U.S. Department of State Human Rights Report for Honduras, for example, noted that “patterns of abuse reported in mental health facilities included degrading treatment, arbitrary commitment, inappropriate use of physical restraints, unhygienic conditions, inadequate or dangerous medical care, and sexual or other violence” (Bureau of Democracy, Human Rights, and Labor, 2015: 29).

Of even greater concern to the patients and workers with whom I have spoken, however, has been the carceralization of the two institutions over the course of the past decade. While both hospitals and their predecessor (as noted above) have employed carceral practices such as shackling and isolation cells throughout their existence and while the psychiatrists running the institutions have also spent a great deal of time and energy professionalizing forensic psychological evaluations for criminal trials, prisoners convicted of violent crimes and psychiatric patients had mostly occupied separate physical spaces through the first decade of this century. With the increased militarization of Honduran society and the vastly increased criminalization of poverty and resistance that followed the 2009 coup (restarting and intensifying policies that had been implemented earlier in the decade [see Pine, 2008b]), prisons became ever more crowded and dangerous for their inmates, and judges allied with the dictatorship began sentencing people convicted of violent crimes to lengthy stays in Mario Mendoza or Santa Rosita instead, without consulting the attending psychiatrists (Proceso Digital, 2019; Flamenco Arvaiza, Nickels, and Hunter-Nickels, 2020). This shift occurred despite recommendations from some members of the Honduran judiciary and by the government in its 2013 National Human Rights Action Plan (as well as by the psychiatric hospital workers’ union) that patients awaiting trial or convicted of crimes be housed in separate mental health facilities from other patients (Secretaría de Estado en los Despachos de Justicia y Derechos Humanos, 2013: 212–213; El Heraldo, November 25, 2019; Varela, 2019). According to several hospital workers with whom I spoke independently, at least one psychiatrist at Mario Mendoza was himself threatened with jail time if he did not comply with the order to accept a prisoner sentenced to an extensive stay in the hospital when his and his colleagues’ shared professional opinion was that the prisoner did not belong there.

Vocational nurses and internal hospital security staff reported feeling much more afraid than before of being attacked by their patients because of the increased carceral population, and patients I spoke with told me that hospital staff members have been even quicker to shackle patients (carceral or not) than before. Patients and staff alike told me of numerous specific incidents of violence, ranging from rape to murder, against staff and fellow patients by members of the carceral patient population (see also, e.g., El País, February 9, 2018; El Heraldo, November 25, 2019).

The influx in the past decade of criminally convicted patients has profoundly changed the character of the institutions for the worse. According to all of my interviewees, in recent years at any given point carceral patients have made up at least half the patient population. With security concerns as a rationale, both institutions have been occupied by police, who patrol the grounds and at times outnumber the patients. The claim that the occupation of the facilities by police improves security for patients and staff in the wake of large increases in the number of patients with violent criminal convictions is dubious at best. Though hospital policy prohibits weapons on the premises, these security forces are generally armed, and my interviewees reported numerous instances of firearms’ being used by police to threaten staff and patients, fired (both on purpose and by mistake, leaving bullet holes in the walls), and even stolen by patients from police busy texting on their cell phones. Patients and workers described being constantly harassed, intimidated, and threatened by security forces, whom they also accused of smoking and drinking daily on the premises (where alcohol and tobacco use are strictly prohibited) and of smuggling illegal substances to carceral patients in the hospitals.

Anti-Neoliberal Health Movements

In 1965, 11 years after massive banana strikes forever changed labor relations in Honduras, 2 years after the violent coup that ousted President Ramón Villeda Morales (a physician who had attempted to democratize Honduras) and installed the dictator Oswaldo Lopez Arellano as president, and 8 years before the founding of Hospital Mario Mendoza, the workers of the Hospital Neuropsiquiátrico adjacent to Hospital General San Felipe organized to form the Sindicato de Empleados del Hospital Neuropsiquiátrico (Union of Neuropsychiatric Hospital Workers—SIEMHON). The union received legal status in 1967 (Rodríguez, 2010: 38) and, as mentioned above, formally changed its name to SIETMHOPSYS in line with its goal of broadening its membership to include mental health care workers at other public and private institutions. Its members are demonized in the antiworker mainstream press for their political militancy but also (in some cases accurately) accused of human rights abuses at the bedside.

As a continuously existing organization identified with (and against) an institution characterized primarily by its dramatic failure to achieve the stated goals of management and the Honduran government over the decades, the psychiatric hospital workers’ union presents an interesting case study of Honduran social justice movement strategies over time. Its primary stated workplace goal (improvement of the quality of mental health care available to Hondurans) aligns with the stated goals of the authorities, but its political economic analysis of the problems underlying the lack of quality mental health care in Honduras has placed it in direct conflict with those authorities. And conflict—rather than conciliation with interests of the capitalist state—has been the defining quality of the union’s approach to social justice struggle over time.

Unlike some Honduran unions, which have allied themselves with neoliberal governments (including dictatorships) to achieve their goals, the psychiatric hospital workers’ union has maintained a militant anti-neoliberal, anti-imperialist stance. Unionized workers at Mario Mendoza and Santa Rosita foresaw the impacts of neoliberal restructuring in the early 1990s as President Rafael Leonardo Callejas Romero (1990–1994) implemented IMF-led reforms that severely cut public spending, including on health care. In 1992, the psychiatric hospital workers’ union broke from the AFL-CIO-allied, anticommunist Confederación de Trabajadores de Honduras (Honduran Workers’ Confederation—CTH) to join the newly formed and much more combative anti-imperialist, anticapitalist Confederación Unitaria de Trabajadores de Honduras (Single Confederation of Workers of Honduras—CUTH) (see Armbruster-Sandoval, 2005: 184 n. 34; Tendencia Marxista Militante, 2010). In the years that followed, it fought alongside the other members of the CUTH against neoliberal structural adjustments (see, e.g., Equipo de PT, 1999: 12), and its members consistently held leadership positions within the federation, speaking out against the coup, neoliberalism, dictatorship, and imperialism despite the associated risks to their lives and safety ¹⁰ (Trucchi, 2010; El Heraldo, August 11, 2013). The psychiatric hospital workers’ union’s struggles against IMF reforms in the 1990s and 2000s presaged its anti-IMF leadership following the coup, in particular in the massive (and brutally repressed) Spring 2019 protests following the Hernández administration’s agreement with the IMF. If implemented, this agreement would have resulted in the privatization of education and health care sectors, including massive worker layoffs (IMF Communications Department, 2019; El Heraldo, April 24, 2019; Suazo, 2019; Sosa and Pino, 2019; SOA Watch, 2019).

Indeed, in line with its members’ understanding that the neoliberal coup state was both increasing the incidence and severity of mental illness by traumatizing the population and reducing its ability to address the needs of patients, the union was at the forefront of resistance to the coup from the start (see, e.g., Emanuelsson and Emanuelsson, 2012; UEAH, 2009; 2010a; 2010b). Its members have taken to the streets and loudly denounced every major attack on health care since the coup, including in the 2010–2011 protests in defense of the public sector led by teachers’ unions also affiliated with the CUTH (Trucchi, 2011), the 2015 indignados protests following the pilfering of US$300 million from the Honduran Institute for Social Security (Palencia, 2015; Pine, 2015; Meyer, 2017), the 2019 anti-IMF protests, and the Where’s the Money? protests demanding accountability for the theft by government contractors of nearly US$48 million spent on seven mobile hospitals for COVID care that never materialized (Cárcamo et al., 2022).

At the same time, the union’s leadership continued to organize specific protests around patient care and workers’ rights at its two hospitals. As with its leadership in the Resistance (the term is capitalized in Honduras when it refers to the unprecedented broad-based movement against the coup), its tactics in these more localized struggles have been militant, including frequent work stoppages, strikes, and sit-ins at the Public Health Ministry involving hundreds of workers (CLACSO, 2010: 29; 2011: 6; Tiempo, April 20, 2018; August 2, 2019; VTV Somos Todos Honduras, 2019; vanessa, 2021; Proceso Digital, 2021). The union is frequently portrayed in the corporate media as harming patients with its labor stoppages, though it of course maintains that its actions are always aimed at helping patients (e.g., Tiempo, October 9, 2021; Proceso Digital, 2021; Aguilar, 2022; Martínez, 2022).

In a long-term broad-based struggle against multifaceted expressions of neoliberal fascism and empire like this one, it is complicated to pinpoint and attribute credit to particular organizations and/or tactics for major victories. In the case of Honduran institutional psychiatric care in particular, identifying victories is an exercise in estimating the degree to which worker struggles may have mitigated even greater harms, but union members are enthusiastic about their vision for a much better mental health care system even though the two hospitals they work for have been in slow decay (accelerated by neoliberal policies) since their establishment in the 1970s. Leaders of the psychiatric hospital workers’ union with whom I have spoken are confident that their organized coalitional struggle has been central to the end of the nearly 13 years of U.S.-supported postcoup dictatorship and to many major national-level victories (such as the repeal of the IMF reforms in 2019) along the way. When I asked them about their motivations for solidarity actions they have taken that went well beyond their hospital walls or even specifically health-care-focused issues (see, e.g., Consejo Nacional Anticorrupción et al., 2019; Melean, 2020), they insisted (as did the organized Honduran nurses I have written about over the years [see, e.g., Pine, 2010; 2013]) that the struggle to protect their patients was inseparable from the fight for sovereignty and against neoliberal capitalism. Jaime, a union leader, told me:

Solidarity has been very important for both [the CUTH] and our union. We have always condemned imperialist attacks. We have stood in solidarity with the Venezuelan people when the Yankees invaded. Even as Hondurans who ourselves have suffered so much, we have participated in Mesoamerican forums against the blockade of Cuba and against the arrest and imprisonment of the Cuban 5 by the Yankee government. We have always spoken out against these situations, just as we have denounced outrages at the national level. Our federation managed to get Honduras included in the short list of violators of workers’ human rights in the [International Labor Organization] in Geneva, as a result of [neoliberal imperialism]. Imperialism has basically destroyed the achievements won by labor unions in the workplace [and has resulted in] huge unemployment and deterioration of worker benefits, salary reductions, . . . and human rights violations. . . . And with the restrictions they’ve placed [on labor organizing rights] in private companies and transnational companies, unions have been disappearing. So this situation has basically ended up replacing the rights that workers had with “bonuses” that are like lollipops in hell [confites en el infierno] because they don’t have permanent jobs and instead end up getting piecework pay, empire-style—a brutal imperialism against workers, an imperialism that has sabotaged workers’ rights. Workers don’t have the benefits they had before. Our federation has denounced these attacks happening in Honduras internationally. Our federation has spotlighted these issues.

I visited with members of the psychiatric hospital workers’ union in person on January 26, 2022, the day before the inauguration of Xiomara Castro Zelaya, the first woman president and the first democratically elected president since the 2009 coup. They spoke with excitement, pride, and guarded optimism about the change in administration, emphasizing the depth of the damage done over the previous 12 years and the serious challenges ahead at their workplaces and for the country as a whole. They also made clear that they remained steadfast in considering their role as in opposition to management. Indeed, while union representatives were telling me that they had faith in the new government, their members were striking and occupying the Health Ministry as frequently as ever, demanding better conditions for themselves as workers, for their patients, and for all Hondurans (Confidencial HN, 2022; Flores, 2022; Aguilar, 2022; Martínez, 2022).