Work-related mental disorders and their inclusion in health policies in the Brazilian Unified Health System ( Sistema Único de Saúde )

Introduction

According to national statistics issued by the Ministry of Social Security (Brasil, Ministério da Previdencia Social, 2012), mental and behavioural disorders are the third main reason why people claim disability and sickness benefits. In a report published in 2010, the International Labour Organization (ILO) emphasised the importance of developing new preventative models for occupational health interventions due to risks in the workplace.

In Brazil, mental disorders have been featured in discussions about occupational health policies for a long time, often approached from the perspective of work-related injury and illness. These usually focussed on the repercussions on the mental health of workers of problems associated with absence from work due to accident and sickness. However, this focus gradually shifted to accepting that mental disorders could be occupational diseases and should feature in the political agenda. The objective of this study is to understand when and why this shift occurred.

Workplace health and safety legislation was first introduced in Brazil in the 19th century, as a result of an increase in the number of work-related accidents, and offered work injury insurance (Chamon, 2005). In European countries, industrial workers went to the streets to demand better pay and working conditions. This prompted a political debate and resulted in the institution of social protection laws around the world and later in Brazil.

According to De Decca (1991), throughout much of the First Brazilian Republic (1889–1930), there were several strikes in cities around the state of Sao Paulo stemming from workers demanding shorter working hours. But there was no social or labour legislation, and factory workers were frequently disciplined and subject to internal rules and punishments such as fines, salary cuts and even physical punishment, which meant Brazilian workers had absolutely no social security.

Health protection was first available to workers in 1919 (Decree n. 3724). After this Decree, the government became gradually more involved in the formulation of new social policies, including health policies. In this period, official health actions were limited to medical care.

The development of public health protection for workers gained momentum with the institution of the Ministry of Health in 1953, resulting in official actions relating to the prevention of diseases and accidents. ‘Medical care expands and evolves within the scope of social security institutions’ (Paulus Júnior and Cordoni Júnior, 2006: 14).

Between the late 1970s and the beginning of the 1980s, workplace health actions were driven by the interest of the employers. The application of the norms issued by the Ministry of Labour were the responsibility of the Occupational Health and Safety Specialist Service (Serviço Especializado em Segurança e em Medicina no Trabalho, SESMET). SESMET professionals, such as occupational health physicians, were employees who received a salary and were broadly guided by the interests of the employers, therefore often failing to register work-related accidents and illnesses (Lacaz, 1996). In this period, public health was limited to the treatment of injuries.

Democracy was restored in Brazil in the 1980s after 20 years of military dictatorship, and health was back on the political agenda, with a focus on workers as actors of their own history, claiming the right to health care, participating in and exerting social control, demanding better working conditions and increasing their involvement with trade unions.

Workers and health professionals, articulated within the health reform movement, tried to transform public institutions in order to bring occupational health discussion into the public health scope, aligned to international proposals debated by the World Health Organization (WHO) regarding primary health care to the working population (Cunha and Cunha, 2001).

Those involved in these discussions participated in open public Health and Occupational Health Conferences, which focussed on health as a universal right and the reformulation of the public health system. These conferences became privileged spaces for the exercise of citizenship to discuss and implement health policies in Brazil, later incorporated in the 1988 Constitution.

The main objective of the First National Occupational Health Conference (Brasil MS, 1986) was to formulate the National Occupational Health Policy, which was later incorporated into the Federal Constitution of 1988 and the Organic Law of Health – Law n.8080/90 (Brasil, Ministério da Saúde (MS), 2001a).

With the approval of the Federal Constitution, Occupational Health was incorporated into the Brazilian Unified Health System (Sistema Único de Saúde, SUS), and health was defined as a social right and a duty of the state (Brasil, 1988). Therefore, occupational health, as well as sanitary and epidemiological services, became the responsibility of SUS (Brasil, 1988).

According to the Ministry of Health (MS), occupational health interacts with different levels of care and management in the SUS, as well as with social security, labour, environment, justice, education and other departments involved in development policies. The MS also advises that occupational health practices are interdisciplinary and require workers to participate in their management (Brasil, Ministéiro da Saúde, 2006: 14).

Within this historical context, the objective of this study is to understand how mental disorders, as occupational diseases, were included in the political agenda of discussions about health policies in Brazil.

Theoretical and methodological framework

This research is based on a constructivist perspective, which considers language fundamental for producing social meaning. As such, it is assumed that knowledge is a collective undertaking, a social practice. Social events, therefore, must be understood as a product of social processes historically constructed and socially contextualised.

We analyse discursive practices in order to study the dynamic aspects of the use of language and to understand its consequences, which are not always intentional (Spink and Medrado, 1999). Language, as a discursive practice, is determined by dynamic exchanges between people and between materialisms present in the dialogical processes that take place in the world around us.

According to Bakhtin (2003), different speech genres may be found in everyday conversations as well as in several literary genres. Speech genres may be understood as ‘the relatively constant and characteristic manners in which we speak that form the shared essence that enables communication’ (Spink, 2004: 44).

The contents of discursive practices are called interpretative repertoires and are defined as

building blocks of discursive practice – a group of terms, descriptions, common places and figures of speech – that determine the range of possibilities of discursive constructions, using the context in which these practices are produced, as well as the specific grammatical styles and speech genres as a benchmark. (Spink and Medrado, 1999: 47)

The analysis of interpretative repertoires enabled us to understand how mental disorders, as occupational diseases, have come to form part of documents relating to occupational health care. It also allowed us to identify the dynamics and variability of the interpretative repertoires in order to understand the multiplicity of meanings that circulate in the discourses thus produced.

We assume that the documents analysed were discursive productions, derived from a mosaic of meanings intertwined by several voices, as postulated by Bakhtin (2003). We argue that all manners of texts are above all dialogical. To understand mental disorders as discursive productions, we had to consider the contexts in which discourses about the construction of mental disorders as occupational health were produced. We were interested in evaluating the ‘background against which discourses were produced, both as social and interactional contexts, as in the Foucauldian sense of historical constructions’ (Spink and Medrado, 1999: 43).

Within this framework, the inclusion of mental disorders as occupational diseases is seen as the result of negotiations with different participants in the process: researchers, legislators, employers, unions, professionals, public institutions and workers. Therefore, the documents produced are seen as a specific type of social language.

The corpus used for analysis is a collection of writings considered to be of public domain because they are public products of social institutions. The way in which they were made available to the public allows for accountability to be assigned. As social products ‘they may reflect the gradual changes in institutional attitudes and positions assumed by the symbolic instruments that permeate our everyday lives’ (Spink, 1999: 136).

The public domain documents considered in this study cover occupational health legislations and the reports issued by the MS following three National Occupational Health Conferences (Conferência Nacional de Saúde do Trabalhor, CNST).

Regarding the legislation, nine legal documents, published between 1919 and 1999, were analysed as part of this study. They referred to welfare regulation, whereby 12 diagnostic categories for mental and behavioural disorder as occupational diseases were identified. Besides these nine documents, we analysed the Welfare Technical Epidemiological Nexus (Nexo Técnico Epidemiológico Previdenciário, NTEP) legislation (Law n.11430, of 2006) which came into effect in April 2007. This was a new methodology in social security used to identify work-related diseases.

The three National Conferences took place in 1986, 1994 and 2005. The reports are available in the occupational health section of the MS official website (Brasil, MS, 1986, 2001b, 2005).

The documents selected for analysis helped us to understand the position of a diversity of participants involved in including this group of diseases in occupational health policies. They also enabled us to understand the discursive practices that regulate action on mental health as occupational disease in the field of social security.

Methodology

The analysis of the selected documents (the legal ones and the conference reports) consisted in identifying the interpretative repertoires that were associated with mental disorders, searching for words such as mental, psychic, disorder and suffering so as to analyse how these repertoires were used in the different legal documents.

A similar analytical strategy was applied to identify repertoires related to the causal nexus between work conditions and mental health, using the nexus as a key word. The objective of this procedure was to identify the issues associated with the introduction of mental disorders as a category of occupational disease in the political discussion agenda, as well as to understand the reasons for recognising mental disorders as occupational diseases.

The discourse analysis performed on this collection of documents enabled us to describe how mental disorders as occupational diseases were included in public workplace health policies.

Workplace health policies

The discussions about health care and the broadening of the notion of health that happened in the 1980s significantly influenced the inclusion of mental disorders as occupational diseases in the 1990s as these events substantially changed policies in the healthcare model in Brazil.

In the legislation that was analysed, mental disorders are present as a collection of very diverse terms (mental alienation, mental disorders, mental suffering) that are remnants of past difficulties in identifying and conceptualising them. Additionally, occupational diseases tend to develop over time and may consequently be diagnosed late, making it more difficult to establish a causal nexus with work-related conditions.

When health and safety policies concerning occupational diseases were initially developed, it involved understanding the causes responsible for becoming ill. In other words, occupational diseases were not considered to be work-related; instead, illnesses were attributed to individual aetiology and employers were rarely penalised for them (Almeida, 2006).

Disputes regarding the causal relation between occupational diseases and work conditions were associated with the exercise of power by authority figures that were responsible for legally establishing and endorsing the connection between disease and work. These authority figures were most of the time SESMET occupational health physicians, who carried this responsibility until the promulgation of Decree n. 3048/99. There was a lot of criticism about the practices of these professionals, regarding their autonomy and their bias towards employers (Brasil, MS, 2001a). After the Decree came to force, establishing the causal nexus between disease and work conditions and the legal responsibility for defining occupational diseases were no longer restricted to occupational health physicians. A new authority figure had emerged: the medical expert from the National Social Security Institute (Instituto Nacional do Seguro Social, INSS).

With the change in legislation, an important procedural instrument to identify work-related diseases was introduced: the Work Accident Communication (Comunicação de Acidente de Trabalho, CAT). A CAT was issued by employers and allowed workers to receive social security benefits relating to occupational diseases. Furthermore, CAT was pivotal to defining what constituted an occupational disease until the implementation of Welfare Technical Epidemiological Nexus, NTEP in 2007.

By issuing a CAT, the employer recognised and accepted that workers had been subject to working conditions that were responsible for their injuries or sickness. Employers had to issue a notification against themselves, thus admitting responsibility for accidents and illnesses that happened at work. This led to a widespread practice of CAT underreporting, as highlighted by professionals during the National Occupational Health Conference, CNST. Furthermore, CAT was an internal procedure and was not subject to external audits. The National Social Security Institute (INSS) was only able to consider occupational injuries and sickness that had been reported via CAT by employers.

Currently, CAT can be issued by other actors, such as professionals who provide public occupational healthcare services, and are no longer exclusive to occupational health physicians who act in the workplace.

The underreporting of sickness cases was one of the arguments used by Oliveira (CNST, 3ª. CNST, 2005, 2008) for the implementation of the NTEP methodology. Underreporting was confirmed by the low number of registered cases of work-related accidents and illnesses reported in official government statistics in 2007, year in which the new methodology was implemented by the INSS.

The NTEP methodology established a new process for identifying occupational diseases, now based on epidemiological criteria, which enabled establishing the causal nexus between work and diseases more effectively. This led to disputes and debates between government bodies and employers who have contrasting financial, political and social interests.

It can be argued that public policies are associated with state actions directed to the public and to the wider society. However, the process of formulating public policies includes collective actions from various social actors, in an orchestrated game of interests in a manner such that government practices are built in collaboration with other sectors of society, as well as social actors who come together to address common interests, establishing negotiations and formulating policies – in the case of this study, occupational health policies.

Therefore, it can be argued the inclusion of mental disorders as a work-related hazard is a topic of interest and dispute about who determines the causal nexus between work and diseases in the CNST texts.

Mental disorders

A significant factor influencing the recognition of the links between mental disorders and work was the positive shift in public perception regarding preconceived judgements relating to mental disorders. This shift prompted mental health discussions in the Second Conference (CNST) and led to the formulation of legislation that included mental disorders as occupational diseases.

Mental disorders due to work were first reported in national statistics after the publication of Decree n. 3048/99. According to Codo (1988) and Barbosa-Branco et al. (2013), official statistics about mental disorders were few and limited. The implementation of NTEP in 2007 meant that CAT was no longer compulsory, and causal relations were mandatorily established by the new methodology, which considered accidents and illnesses from an epidemiological perspective associated with the National Classification of Economic Activities (Classificação Nacional de Atividades Econômicas, CNAE) of the employer. As a result, work-related mental disorders gained visibility amid the 50 most diagnosed conditions in the Anuário Estatístico da Previdência Social (2005, 2013), particularly depression and acute stress incidents.

Another factor that influenced the definition of work-related mental disorders was the challenge posed by the social history of mental disorders. For a long time, mental health sufferers were excluded from productive activities, confined in asylums, while in the workplace, mental illnesses were mostly considered individual predispositions. According to Codo (1988: 21), when the National Constituent Assembly debates took place in the 1980s, the issues around the inclusion of mental disorders as occupational diseases related to a ‘silence collusion’ in society. Preconceived judgements by society were also suggested by Rebouças (1989: 40), when describing the subtle development of work-related illnesses:

… the discrimination against these manifestations is an aggravating factor, justified by society on the belief that mental disorders are a product of problems limited to the context of the individual and his family, thus assigning culpability to the worker regarding the origins of his illness, while excusing working conditions and practices as responsible for the development of illnesses.

Despite discussions by some social movement sectors in the 1980s, about the various factors involved in the process of developing mental illnesses, Codo (1988) stated that such discussions were insufficient to secure labour welfare, as ‘the act of concealing mental illnesses respond (responded) to financial and political pressures’ (p. 21). In other words, mental suffering was marginalised and described by the author as something shameful. In order for mental disorders to be recognised as occupational diseases, social prejudice had to be challenged. Therefore, for this to happen, mental health problems would have to be discussed publicly. Hence, to discuss mental illness in the prevailing economic, political and social context was a complex subject given its diagnostic characteristics and social constraints.

The lack of visibility of mental disorders as occupational diseases in the national statistics before the publication of Decree n. 3048/99 was due to the disputes around establishing a causal nexus initially by the occupational health physician, and then by the INSS medical expert, who used the CAT to determine entitlement to social security benefits. Without the CAT, workers had to gather evidence and file legal action against the employer in order to declare they had become ill due to working conditions. This was generally a lengthy process that often resulted in financial difficulties for the workers, as well as in psychosocial issues raised by having to prove that the ailment, a mental disorder, was derived from productive activities and working conditions and not exclusively a produce of individual troubles.

Including mental disorders in discussions about occupational health

The first Conference (CNST), held in 1986, discussed the right to occupational health, although it did not address mental disorders and other associated repertoires. The document reports on the discussion and evaluation of the then existing occupational health model, suggesting its reformulation, in order to be incorporated into the new Constitution in 1988 (Brasil MS, 1986). The key proposals of the first CNST envisaged the recognition of diseases and their relation with working practices, and the need to prevent the underreporting of accidents and sickness. The recognition of mental disorders as occupational diseases was only addressed in the second CNST in 1994.

The subject of mental disorders was addressed in the second CNST via an activity entitled Specific Panel, under the heading Mental Health and Labour. The Interunions Department for Workplace and Health Research and Studies (Departamento Intersindical de Estudos e Pesquisas de Saúde e dos Ambientes de Trabalho, DIESAT) enabled this activity, which comprised three presentations about work and its impact on workers’ health. Presenters implied that mental health had been discussed in the first CNST, although the outcome had not been significant to feature in the conference’s final report, nor it had an impact on the sectors of society.

The Panel explored the reasons why establishing causal nexus between mental disorders and work, which was described as a ‘subjective’ issue, was considered challenging given the lack of mental health qualification by syndicalists. One of the panel presenters, Pérsio Dutra, who was a trade union member, said he believed that syndicalists were better equipped to evaluate and to facilitate discussions with workers of various business organisations about accidents at work, which were considered an objective issue. The presenter suggested that one of the obstacles for recognising work-related mental illnesses was the need to transform preconceived views about mental health in society, in order to establish their links with work and not exclusively with the individual.

The presenter also believed that in the 1980s and 1990s, the medical experts and occupational health physicians involved in determining work-related illnesses did not establish a causal nexus between mental disorders and work due to the nature of the diseases and also because the entitlement to social security benefits involved a game of financial and political interests. It meant that companies would have to pay higher national insurance contributions and workers would have greater job security when returning to work. For the government, represented by the INSS, the inclusion of diseases meant funding the welfare costs associated with retirement. Therefore, the focus was on how the financial aspects of the welfare system permeated the discussions about establishing the causal nexus between diseases and work, and among the mental disorders.

The panel suggested that the organisation of labour and working conditions were responsible for causing work-related diseases. The term mental disorder was used for the first time in the second CNST conference.

The second CNST incorporated mental disorders as a category of diseases in the political discussions centred on occupational health, under different headings. The term often used to refer to occupational mental health problems was suffering. Focusing on the interpretive repertoires relating to mental health enabled us to identify conceptual formulations made about occupational diseases in general and the use of the terminologies associated with mental suffering, distress, fatigue and stress, and their impact on the mental health of workers.

The expressions used in the second CNST, in particular mental suffering, indicate that the different names, and consequently different definitions, of occupational mental disease may have contributed to the difficulties in recognising mental disorders and work-related illnesses.

The analysis of the second CNST report indicates that to successfully incorporate mental illnesses into public health policies, it was necessary (a) to discuss the implications on the mental health of workers of technological innovation in the production processes; (b) to consider the studies performed by trade unions in partnership with DIESAT, which included the perspective of workers in its results; and (c) to build a new social and political context in Brazil that conceived health not only as the absence of sickness but that also recognised the possible relations between mental health and the workplace. This combination of elements contributed to the inclusion of mental disorders in the agenda of the second CNST.

The NTEP methodology

Against this backdrop of challenges in establishing the causal nexus between diseases and work, the discursive analysis of the third CNST report did not reveal interpretive repertoires associated with mental disorders. The theme of the third conference was the formulation of the NTEP methodology, a new strategy to evaluate social security benefit entitlement for work-related injuries and sickness.

The proposal of a new methodology to assess and determine what would be considered a work-related illness prompted new debates about the process for defining accident benefits, which no longer relied on the internal rules established by employers. The causal nexus was no longer determined by the compulsory issuing of a CAT by employers. The recognition of the epidemiological nexus would be derived from a statistical database, correlating the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes with the National Classification of Economic Activities (CNAE) codes of employers, in order to establish an occupational diseases framework.

The implementation of NTEP by the INSS in April 2007 enabled the identification of accidents and diseases to be established by epidemiological correlation or, rather, presumed cases. Presumed cases were derived by crossing data from the most frequent diagnosed conditions per business activity and were associated with the information provided by INSS workers. The NTEP tool determined whether the disease was work-related, irrespective of there being a CAT. As a result, a statistical increase in the number of injuries and sickness was seen in the INSS following the introduction of this new methodology.

A few social actors contested the use of the new methodology, manifesting themselves via technical reports and legal action claiming statistical inconsistencies. The legislation that supported the implementation of NTEP also determined that employers who had a high number of occupational health incidents would have to make higher social security contributions to cover Occupational Accident Insurance (Seguro de Acidente de Trabalho, SAT).

We conclude that the integration of mental disorders as a diagnostic category of occupational diseases is the result of historical processes that attempted to establish a causal nexus between diseases and work and the consequent inclusion of occupational diseases in the National Statistics. It is an example of a field of negotiations in which financial costs that need to be administered by biopower are applied (Foucault, 2008a, 2008b) and that also involve power disputes between specialists who determine what constitutes an occupational disease.

Consequently, mental disorders were first incorporated into occupational health policies in the 1990s following discussions during the second CNST in 1994, and later via new legislation in 1999 (Decree n. 3048), as a result of discussions between the social actors involved, transforming preconceived ideas and recognising that labour may be responsible for originating mental illnesses.

The aim of this study was to demonstrate that the discussions around occupational health policies, especially the challenges in establishing the causal nexus between mental disorders and work and the incorporation of mental disorders as occupational diseases, are both a result of disputes over power between different social actors who are involved in a complex interchange and actors who interfered and influenced decision-making regarding the formulation and implementation of occupational health policies.

Discussion

The argument made in this article is that it only became possible to establish causal nexus between mental disorders and work via three key elements: (a) that mental disorders were incorporated as occupational diseases due to a broader notion of the right to health triggered in the 1980s via discussions that took place during National Occupational Health Conferences; (b) that preconceived judgements about mental disorders in society and at work have undergone transformation since the 1980s, although issues still remain to a lesser degree, recognising that mental disorders may be caused by workplace conditions and not only by the individual’s circumstances; and (c) that the improvement in the process of assessing and evaluating causal relations between disease and work gave more visibility to occupational diseases.

Recent developments in work-related conditions have most likely provided new manifestations of work-related mental illnesses, for example, flexible working conditions that lessen employers’ costs and responsibilities concerning work-related injuries and sickness; work commitments that exceed normal working hours, enabled by available technologies; and an increase in moral abuse at work. All these have promoted significant transformations on the ways workers relate to their work and, consequently, their relation to life, with repercussions in mental health.