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Diplomatura de Políticas Públicas en Salud Mental 2026 — Transcript

by Escuela de Gobierno en Salud "Floreal Ferrara" · 4,479 words · 708 segments · language en · Watch on YouTube

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0:02Good morning, everyone. Uh, well, we
0:05are here to start a new, uh, a new
0:08block within the framework of the
0:10diploma program in public health policy
0:13for mental health. Uh, my name is
0:16Mariano Rey, I am the provincial
0:17director of mental health and
0:19problematic substance use for the
0:21Ministry, and today we will be sharing
0:23this first space of this module
0:25together with Ariel Parajón. I am
0:28currently being recorded because at the
0:31same time that we are which is part of
0:41the method we use to be able to work on
0:43some public policy issues in mental
0:44health and health in general, uh,
0:46closer to the territories. So, that is
0:50a bit of the reason why I am not here
0:52synchronously, but rather recording
0:55this a little bit beforehand so that
0:57you can listen to it later, but I did
1:00not want to miss out or fail to
1:02participate, because we are absolutely
1:04convinced that these training spaces
1:06are not only a working method, but an
1:09indispensable tool to be able to build
1:11what we need to transform the care
1:14model in terms of mental health. Yes,
1:17today we start this module which has to
1:19do with addressing problematic
1:21substance use; uh, with a number of
1:23issues that we will be able to think
1:25about from a historical perspective,
1:26also situating them in a current
1:28context, some issues that have to do
1:30with conceptual definitions, but that
1:32also provide tools to be able to think
1:34about the way in which we relate to a
1:36problem. Yes. Uh, problematic substance
1:40use in the health agenda has had a very
1:42marginal role, I mean, very typical of
1:45mental health policy, uh, which
1:47historically has had a marginal role
1:49within health policies, and even more
1:52so problematic substance use. I mean,
1:56an instance in which it was something
1:58absolutely, uh, uh, that remained on
2:01the sidelines, mainly due to issues of
2:03a double stigma. If people with mental
2:07health conditions are already bearers
2:10of a certain stigma, imagine those
2:12people who, apart from going through a
2:14mental health situation, also have
2:16problematic substance use. Well, this
2:19is something that for health workers
2:22has always been a challenging horizon.
2:25Uh, and I have been working with this
2:27topic for more than 20 years and in
2:29countless situations, and still to this
2:32day, it continues to happen to us. What
2:34comes up is, well, what disciplinary or
2:36interdisciplinary tools do we need to
2:38be able to advance on a problem for
2:40which we do not have all the solutions?
2:42Why? Because, just like mental health
2:47issues, problems with substance abuse
2:50cannot be addressed solely through
2:53healthcare or medical providers; they
2:56generally involve many situations
2:59related to a social context and a
3:02specific territorial setting.
3:06Problematic substance use is not the
3:08same in large urban centers as it is in
3:10situations, for example, that we might
3:12encounter in the interior of our
3:14country or within our own province.
3:16Right? So, for us, it has been very
3:19important from the beginning in terms
3:21of the strategic planning of our
3:23Ministry of Health's healthcare agenda.
3:27First, by placing problematic substance
3:28use within mental health policies, as
3:30our regulatory framework on mental
3:32health has provided since 2010. But
3:35making it a reality also implies
3:37starting to mainstream certain issues
3:40and getting them circulating within a
3:42healthcare agenda that, for a very long
3:45time, as I was saying, overlooked or
3:47brushed aside. Yes, this involved
3:51changes at the training, conceptual,
3:53and epistemological levels, in how we
3:55characterize the problem, and also some
3:57issues that have epidemiologically
3:59transformed our landscape. Right? What
4:03do I mean by this? I mean, today we
4:06don't just have users experiencing
4:08consumption problems, with or without
4:11substances—and we will talk a bit
4:13about that—but there are also various
4:16implications that reach us in different
4:19services that aren't traditionally the
4:21ones closest to mental health. And this
4:25also has to do with some clinical
4:27presentations we are seeing, where
4:29people arrive with very severe
4:30subjective erosion, but also in
4:32conditions of extreme vulnerability. I
4:34mean, they are often very vulnerable
4:36individuals, right? And we find them,
4:39for example, in issues linked to
4:41motherhood and consumption, or pregnant
4:43women. And how that also impacts
4:47neonatal units. I mean, we have some
4:51provincial hospitals where 30%of
4:53newborns test positive for drugs. I
4:58mean, this is a problem that isn't just
5:01the snapshot where we engage with that
5:03pregnant woman or the newborn in the
5:05NICU, but it actually also has to do
5:07with pregnancy check-ups. I mean, with
5:11issues that are more linked to how we
5:13build, uh, either barriers, or
5:15accessibility, or access barriers, or
5:18accessibility. Uh, how do we think
5:20about gender issues in relation to
5:22these matters? Uh, but well, how do we
5:25also engage in dialogue without being
5:27compartmentalized or fragmented within
5:30the hospital framework, and obviously
5:32also regarding the more community-based
5:35approach or primary care level in
5:37problems that are extremely complex? So
5:40, how do we circulate and develop broad
5:42health teams that have different
5:44disciplines, some more linked to the
5:46field of mental health and some not
5:48linked to mental health, but to general
5:51health, articulated with other actors
5:53to be able to generate, as I was
5:54telling you, better conditions of
5:56accessibility on one hand, support and
5:59care processes on the other, and then
6:01the continuity or follow-up of some of
6:03these people's trajectories with the
6:05formal health system? Yes. So, the
6:08importance of being able to think about
6:11the issue of consumption in terms of
6:13the era, in terms of the situation, is
6:15invaluable. If we had to define, for
6:17example, all these issues that I am
6:19sharing with you, a bit behind on that,
6:21we will see them throughout the entire
6:23module. Yes, it is about starting to
6:26share with you some issues that are
6:27indispensable for us, but also
6:29difficulties that we have encountered
6:30along the way. Because it is also true
6:35that when we started our management
6:38process almost 7 years ago, there were
6:42many hospitals, to mention one issue,
6:46that didn't have the habit of working
6:49with drug users. Yes, but I told you a
6:53little while ago that the issue is not
6:55just drugs with drugs; I mean,
6:56problematic consumption is with
6:57substances. So, in terms of the era, we
7:01also find other phenomena that have had
7:03an impact and continue to have it at
7:06different moments or life cycles of
7:08people, such as what has to do with
7:10digital consumption, yes? Which can
7:14also be problematic. Those of us who
7:16have been working on this for a long
7:19time already saw the impact that social
7:21networks, or even before social
7:23networks, online games, had on the
7:25frameworks and ways people connect. Yes
7:27. Or in the ways of forming bonds and
7:30how that also had an impact based on
7:32the psychic structure of each person.
7:35But today, with the massification of
7:37some issues, it is also starting to be
7:39a problem that is beginning to have its
7:41own agenda at the level of districts
7:43and the different municipalities
7:45regarding digital consumption or
7:47digital well-being. I mean, we
7:49shouldn't just think about those who
7:52have problematic consumption or use of
7:54social media, cell phones, or anything
7:57related to screens, but also about how
8:00we build digital well-being. Right? So,
8:03digital consumption is part of a health
8:05agenda. Another issue that came up a
8:10lot, also linked to digital consumption
8:13, is online betting, which is another
8:16phenomenon we've been seeing lately,
8:19especially since the pandemic, much
8:22more so. Yes. And that has also had a
8:26very significant community impact and
8:29an increase in some other problems due
8:31to everything that the dynamics and
8:34logic of gambling imply. I mean, it's
8:37not that the issue of compulsive
8:39gambling is new. Yes, in fact, our
8:42province has 10 centers for the care
8:44and support of people with gambling
8:46problems, but it started to become much
8:48more widespread with the use of
8:50platforms, let's say. Before, when the
8:55issue of gambling was more linked to
8:57going to bingo halls or casinos or
9:00something like that, the physical
9:02barrier or how the mechanisms were for
9:04generating self-exclusion and so on,
9:07implied some dynamics that, with the
9:09emergence of online gambling platforms,
9:12and much more so with the rise of
9:15illegal online gambling platforms, have
9:17made consumption much more massive, and
9:21it doesn't end there. I mean, a very
9:24short time ago we were witnessing a
9:27huge platform, I would say, like a
9:30laboratory in relation to how this
9:33operating dynamic is implemented, which
9:36was the World Cup. I mean, when we
9:40watched the World Cup and saw how
9:43online gambling platforms were
9:45sponsoring it, it was something that
9:47became very widespread. Even the
9:51hydration break itself has little to do
9:53with hydrating people and a lot to do
9:55with the fact that these are the
9:57dynamics or moments in which bets on
9:59games increase exponentially. So, how
10:03our capitalist system and platform
10:06capitalism begin to acquire a very
10:08profound dimension that, although we
10:11historically associated it and thought
10:14that the issue of problematic
10:16consumption—those of us who worked a
10:19long time ago on the issue of legal or
10:22illegal drug use—also placed, uh, the
10:26impact that neoliberalism or capitalism
10:29has in its different forms of
10:30connection and production of
10:32subjectivity. Here it also becomes very
10:36clear with other modes of consumption
10:38that are substance-free, right? but
10:41they also generate, uh, horizons for
10:44constructing subjectivity, uh, and also
10:46have a very strong impact on
10:48communities. So, notice how
10:51consumptions are appearing that have
10:53historically been minimized and that
10:56have a very large presence today, which
10:59has to do with substance-free
11:01consumption. In that sense, uh, the
11:05Provincial State has generated a series
11:07of inter-ministerial policies, uh, that
11:09maybe Ariel can share a little bit more
11:12about now, uh, the plan that we put
11:14together at the provincial level to
11:16address gambling in adolescents. Yes,
11:19because we understand that, in reality,
11:21you cannot prohibit gambling, but you
11:23do have to generate very strong and
11:25very clear regulatory instances,
11:26especially to protect those who are
11:28most vulnerable. And in that case,
11:30minors are also a very important focus
11:32for being able to care for, uh, and
11:34generate strategies for care and
11:36accompaniment in these cases. So we
11:39have, uh, problematic substance-free
11:40consumption and problematic
11:42substance-based consumption. Those
11:44problematic substance-based
11:46consumptions continue to be, in all
11:47studies conducted at the provincial,
11:49national, and international levels. Uh,
11:52by far, uh, the ones that generate the
11:55most health problems are the
11:56consumption of legal substances. Yes.
12:00Uh, and illegal substance consumption
12:02often comes with a lot of other layers,
12:05uh, especially certain consumptions
12:07that we accompany in the health system
12:10for people who, in reality, uh, are
12:12completely disconnected. So, how can we
12:15go about building life projects? Uh, it
12:19cannot just be about healthcare and
12:21support; it has to be within the
12:23framework of an integral public policy,
12:25as we call it, which is different areas
12:27of government working simultaneously to
12:29be able to think about how processes of
12:32citizenship building are generated.
12:35Right? So, notice how the debates are
12:37very broad. The formal health system
12:40often does not reach those people who
12:42need it most and, in that sense, there
12:45are other instances that are
12:47indispensable for being able to
12:48articulate and generate, uh, an
12:50accompaniment and care flowchart, or a
12:53network, uh, of accompaniment and care
12:55that exceeds the formal system, within
12:59which the indispensable role of social
13:02organizations must be incorporated due
13:04to their proximity in some territories
13:06and the impact of their work at the
13:08community level, we would say, in
13:10general terms, but also in what has to
13:13do with the accompaniment processes, uh
13:15, at the territorial level, uh, which
13:17have far fewer, uh, access barriers, uh
13:20, when we talk about consumption issues
13:22. Thinking about certain public health
13:27criteria, such as availability and
13:30equity, is very, very important. I mean
13:35, people with problematic substance use
13:37usually don't come on a scheduled basis
13:40; if we set up a health system that
13:43primarily operates in the morning, and
13:45they are sleeping in the morning after
13:48long periods of consumption, it is very
13:51difficult for them to meet certain
13:53structures. Yes. How do we rethink the
13:57logic of the health system's entry
13:59points? As well as the admission
14:02criteria that institutions often create
14:05, which act as a high barrier for us to
14:09be able to support those who need us in
14:13the way that they can. Yes, because
14:16people arrive with what they have and
14:18as best they can. That is why many
14:21times social organizations, which have
14:24a much lower threshold of requirements
14:26than the traditional health system,
14:28have a better reach in some aspects
14:31than the health system itself. That is
14:35why it is important that we work
14:38together, not only to learn other ways
14:42to be more flexible, so that those who
14:46need us most can enter the formal
14:49health system, but also to build codes
14:52and forms of communication and
14:55operation that prevent fragmented work
14:59and ensure continuity of care, whether
15:04in our provincial care centers, our
15:07community mental health and problematic
15:11consumption centers, our residential
15:14units, or hospitals. And in that link
15:19with social organizations, as I
15:22mentioned, or other non-governmental
15:26organizations—the "third sector"—or
15:29even private institutions, we must form
15:33a network; otherwise, everything
15:37remains fragmented, which only harms
15:40the person who needs support. Right? So
15:45, we have to keep transforming, uh, our
15:48characterization to have a common
15:50language regarding problematic
15:52substance use and, with that, generate,
15:55uh, working links and operational
15:57dynamics that help ensure the few or
16:00many resources we have in each
16:02territory can function as articulately
16:05as possible, so that it doesn't come at
16:07the expense of our communities 'health.
16:11Yes. Uh, to do this, to try to approach
16:15and reach some point of agreement in
16:17terms of language, we built a, yes, a
16:20provincial guide for the comprehensive
16:23approach to problematic substance use,
16:26in which we placed and proposed, yes, a
16:29definition of problematic substance use
16:32to keep in mind, yes, so we can start
16:36thinking about levels of intervention
16:38at the different stages people might go
16:41through in a situation of problematic
16:43use, yes? Whether it's the initial
16:47intake, addressing an emergency, or
16:50regarding the continuity of care, some
16:53concrete tools to help us work along
16:56those lines. Always keeping in mind
17:00that, from the perspective of the
17:01provincial government, we position
17:03ourselves from a risk and harm
17:05reduction model; this does not mean,
17:07this risk and harm reduction model,
17:09that abstinence cannot be achieved in
17:11some cases, but rather it is about
17:13tailoring strategies where people are
17:15active participants in making decisions
17:17about their own health. In other words,
17:20nothing different from what we mean
17:22when we talk about informed consent, in
17:25a way, in action. Yes. And with the
17:27dynamism that this entails. Yes. Uh,
17:29and now I will return to this point
17:31because I think it is very important.
17:33Yes. Uh, and from there to go about
17:36building those forms of care, those
17:39care flowcharts, those equations that
17:41are indispensable. Why do I say this
17:44about informed consent? Because there
17:49are also many issues linked to
17:51criticisms of our regulatory framework
17:53regarding mental health which, by the
17:56way, we are experiencing a historic
17:58moment in which, (which also happened
18:01to us during the Macri administration,
18:03but it's happening again now) there is
18:06a desire to push for a rollback in
18:08regulatory terms of policy regarding
18:10mental health, of the regulatory
18:12framework in mental health and,
18:14fundamentally, the two groups that in
18:19some way raise questions regarding how
18:21potent the implementation of the
18:23regulatory framework in mental health
18:25has been or not. One of them has to do
18:28with schizophrenic family members,
18:30another has to do with problematic
18:31substance use. And why? Because it
18:34keeps persisting. And in this sense, I
18:36mean, there is a characterization that
18:38is real, but then the conclusion
18:40reached is not good. Yes. The real
18:43characterization is that there are
18:45still many barriers to access for those
18:47people who have problematic substance
18:49use, and that, in reality, you have to
18:52navigate the health system through its
18:54different components to find that, if
18:56you have a consumption problem, it is
18:58difficult to manage to build, uh, a
19:00space where they can feel, uh, at ease,
19:03comfortable, and supported. Not because
19:05they don't exist, they do. Yes, but
19:08there are many who choose not to work
19:09with substance use. So, that naturally
19:12turns into a barrier, accompanied by
19:15the perception of confinement as a cure
19:17. Right? Why do I say this? Because
19:21many times it is true that in some
19:24situations the issue of the
19:25voluntariness of the processes in a
19:28person whose life is organized around
19:30consumption, right?,but in reality the
19:33person truly has their will affected,
19:35which is not 100%of cases. That is
19:38where the dilemma lies. In which cases
19:42can an involuntary decision be made, or
19:44to make it involuntary, which is within
19:46the powers and possibilities of a
19:48healthcare team, and which ones? You
19:52can work with the person's will in
19:55building, uh, a work process that can
19:58gradually incorporate them in order to
20:02be able to start a care process. Not
20:05all people want to quit all substance
20:07use. Not all people have problematic
20:09substance use. I mean, of the universe
20:12globally, of the universe of people who
20:15consume, between 8 and 13%have
20:17problematic substance use. And those
20:20problematic uses also require, uh, a
20:24very common effort, as I was telling
20:29you, which are not just sanitary, but
20:31are, uh, from a comprehensive public
20:33policy. Yes. Regarding the definition
20:36of problematic substance use, which Ari
20:38can also continue to advance on now, uh
20:40, in a little bit, nothing for us.
20:43Actually, problematic substance use is
20:45not only compulsive use that organizes
20:48people's lives in relation to
20:50consumption, but that includes those
20:52types of use, but there is also, uh,
20:54use that due to a lack of information,
20:57yes, uh, ends up being problematic in
20:59just a single instance. Yes. Uh, for
21:03example, there are certain injectable
21:05substances where the method of
21:07administration becomes a problem, or
21:10the quantities consumed just once can
21:12already be problematic or even fatal at
21:14some point, and some other forms of
21:16consumption that are also, uh,
21:18problematic due to the context in which
21:21they occur. Example: episodic,
21:24excessive alcohol consumption or
21:27consuming alcohol and, uh, driving. Yes
21:31. Uh, what also makes it problematic is
21:33the behavior that goes along with it.
21:34Right? So, for us, problematic
21:37consumption would basically be any
21:39consumption that threatens people's
21:42health, right? And affects the
21:45realization of individual and
21:46collective projects. Why individual and
21:49collective? Because in reality, we
21:50cannot think of ourselves outside of
21:52the community in which we live. So, our
21:55life project is a project that is also
21:58a collective project, which also seeks
22:00ways to build it with others and from
22:03there return to what is important for
22:05each person within the framework of
22:07their life. So it is important that
22:10these forms of consumption must be
22:12thought of in a situational key, that
22:13these forms of consumption must be
22:15thought of in a contextual key. There
22:18are many care models that have been
22:20thought of in terms of problematic
22:22consumption and, in all those that
22:25seriously complicate, uh, the issue,
22:27they do not focus only on the substance
22:30, or only on the context, or only on
22:32the person, but rather they are
22:34interdependent variables that must be
22:37brought into play with each other to be
22:40able to think in terms of complexity.
22:42So, notice how in the characterization
22:44of the phenomenon there is already a
22:45complex definition. In, in, in the way
22:49of approaching the phenomenon, it also
22:51requires, uh, the value of a
22:54transversal policy, right? Which is not
22:57just a mental health policy, but
22:59necessarily not a security policy. Yes,
23:02that is the shift or the value that
23:03incorporating problematic consumption
23:05into the regulatory framework for
23:07mental health has had, it was to move
23:09it away from the logic of security. Yes
23:11. Uh, and when I say the logic of
23:13security, it doesn't just have to do
23:15with the criminalization it has.
23:18Because our regulatory framework, uh,
23:20in mental health, uh, is one of the
23:22most, uh, interesting in terms of legal
23:25definitions and legal framework in the
23:27region, but then, at the same time, we
23:30still have a drug law in force that
23:32criminalizes consumption. Uh, actually
23:36it doesn't criminalize consumption, but
23:37possession for consumption, simple
23:39possession for consumption. So, clearly
23:42, and I might be getting a bit ahead of
23:45myself here, but regarding the
23:47dimension of drug policy, if drug
23:50policies—and in that sense,
23:52prohibitionism, which is, if you will,
23:54the drug policy most prevalent since
23:57the war on drugs started in the United
24:00States, five decades of the war on
24:02drugs—have achieved that
24:04prohibitionism as a policy has
24:06abstinence, which is what I usually
24:10find most accurate to call the "
24:12sanitary arm" of prohibitionism. Yes.
24:16Uh, for those who don't have much
24:18information on this, abstinence as a
24:20model, the abstentionist model, is one
24:22that asks the person for abstinence. in
24:27order to achieve abstinence. In other
24:28words, that final goal, which is to
24:30achieve a person's abstinence—which
24:32isn't a bad goal in itself—is asked
24:34of the person in order to start that
24:36process of abstinence. Basically, you
24:38have to stop using to be able to
24:39succeed in stopping your use. And a
24:41huge number of people simply cannot do
24:44that. There are people who can stop
24:47using right off the bat and from there
24:50work on what would be the maintenance
24:53of abstinence. In many other cases,
24:56especially where social issues also
24:58have a direct impact, where, as I was
25:01saying, we aren't just thinking about
25:03consumption, but the concrete variables
25:05and subjective coordinates that cause a
25:08person in a specific context to have
25:10problematic consumption, it often
25:12requires accompaniment and an end point
25:14. So, if in our healthcare facilities
25:18we demand, right? the cessation of
25:21consumption of all substances at the
25:24same time, right? Uh, many times what
25:26we will find is that people won't be
25:28able to sustain it. So, the harm
25:31reduction model allows for the
25:34construction of, if you will,
25:36intermediate goals where abstinence is
25:38a possible goal to reach, but where
25:41some other intermediate goals can be
25:43set, which allows for regulation of the
25:46substance, right? or it also allows for
25:50moving from the most harmful to the
25:52least harmful. The risk and harm
25:54reduction model, as we will also see
25:56throughout this module, is a model that
25:58doesn't just have to do with the
26:00substance, but with all the negative
26:02implications that come with consumption
26:04, many of which are social or legal. Uh
26:08, I mean, today, someone who has, for
26:11example, uh, been caught on the street
26:14with three marijuana cigarettes, right?
26:20And they get a drug-related case filed
26:22against them, the impact that has on
26:24that person when they go out to look
26:26for work is huge. Why? Because one of
26:30the first things they ask us for, right
26:31? And surely, for each of us before
26:33starting, for example, to work in the
26:35health facilities we have, one of the
26:37things they asked for was a criminal
26:38record check. And if automatically what
26:42comes up for a person is that they have
26:43a criminal record for drugs, then
26:44they’re already left out. So, notice
26:48how it has nothing to do with whether
26:50the consumption is exacerbated or a
26:52matter of huge subjective devastation,
26:55but rather that often with much less we
26:58create a very, very harsh mark, right?,
27:00of what later builds a subject of
27:02impossibility. Yes. Uh, and well, so in
27:07that sense we have to make it a bit
27:08more complex, we have to make the
27:10equation a bit more complex and start
27:12thinking in a more thorough and
27:13significant way. Uh, well, I think
27:17you’re going to see a lot of these
27:19issues throughout the modules. I wanted
27:23to do a little back-and-forth on some
27:25issues that I do find important for us.
27:28The issue of problematic substance use
27:30is a central pillar of our first
27:32provincial mental health plan. It will
27:36also be in the second Provincial Mental
27:39Health Plan, which we are starting to
27:41work on now in consultation with the
27:43135 municipalities of our province,
27:46human rights organizations,
27:47non-governmental associations, and
27:49professional associations; and it is
27:52also within the general health planning
27:54of our provincial government. So, for
27:58us, the path is to register it within a
28:01policy that can contain it, that can
28:03provide a response, so they aren't just
28:05the CPAs, as they have historically
28:07been in our province, the places where
28:09people with problematic substance use
28:12were addressed, treated, and
28:13accompanied. It is all the providers in
28:17the Provincial Network for care,
28:18support, and attention that must give
28:19some level of response to consumption
28:21problems. Later we can see who feels
28:24more capable, and based on the capacity
28:28that is being obtained, who can start
28:31taking on a little more. But what we
28:34cannot do is say: "If you have a
28:36substance use situation, you only have
28:38to go to one place," because in reality
28:40it is something that, in terms of
28:42prevalence, in epidemiological terms,
28:44requires us to think about it in each
28:45of the providers, in each of the
28:47components of our health system. So
28:50well, that is somewhat the idea. Surely
28:52we will also be looking at some issues
28:54in historical terms and, and issues
28:57that also have to do with how we build
28:59a future perspective regarding this,
29:01and the dilemmas and and the challenges
29:03we have to be able to build a dynamic,
29:06deep public policy, uh, and that can
29:08put people and communities at the
29:10center. But anyway, uh we are, that is
29:13a bit what the module is for. What I do
29:16ask of you is: let's try to interrupt
29:19at the moments when the teachers are
29:22giving the class, interrupt in the
29:24sense of proposing comments, asking
29:27about concerns, because it is the only
29:30way we are going to go, uh, unwinding
29:33and also getting rid of our own
29:35prejudices; how we also put our own
29:38idiosyncrasy into play or into tension
29:40to be able to approach a better quality
29:43of care, support, and care for, our for
29:47our communities and for each of the
29:49Monarenses who requires any care
29:51process. So well, for the moment we
29:54will leave it here and well, now Ari
29:57will continue with you. Well, thank you
29:59very much.

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