Samuel Lowenberg - Independent Journalist biography articles articles

Tackling the causes of ill health in Rio's slums

The Lancet   March 12, 2005


Poverty is the root cause of ill health in the sprawling slums of Rio de Janeiro, where mortality rates are up to 10 times those in rich areas. But, reports Samuel Loewenberg, these communities are being targeted by a group of health workers with a new approach to health promotion.

An open sewer runs through the centre of Nova Marilia, a small community on the edge of the mega-urban sprawl of Rio de Janeiro. It is summer in the southern hemisphere, and the open-air waste attracts rats and is a breeding ground for pestilence and disease. When it rains, the sewage overflows, making its way into people's homes. This is one of the poorest municipalities in the state of Rio, and nearly every person in the community is without a job.

In one sense, the residents of Nova Marilia are lucky: the village has not yet been taken over by the drug gangs that during the past 15 years have spread like a plague through Brazil's poor communities. Still, drugs and violence are already making themselves felt. A few weeks ago, two teenagers were gunned down on one of the village's main roads, which, like the others in town, is unpaved.

In a hot concrete room 20 m from the sewage pit, a group of teenagers are laughing. Their teacher, a smiling, open-faced man named Joćo Luiz Vieira, leads them in a cheer: "Vida, quiero vida!" (Life, I want life). This is one of hundreds of unusual health clinics in Brazil, where treatment of disease begins at the most rudimentary stage: how to get through the day. "We believe we have to intervene before health is lost", says Daniel Becker, who founded the clinic programme in 1993. The Nova Marilia project is one of 800 that Becker's Center for Health Promotion runs in Brazil. The Rio-based programme, which has the Brazilian acronym CEDAPS (Centro de Promoēćo da Saśde), takes an innovative approach to public health, seeking to confront disease at its root causes. CEDAPS believes health care should include combating poverty, nutrition, education, environment, and violence. It currently serves some 250 000 people.

Becker, a second-generation Brazilian whose grandparents were Jewish refugees from Eastern Europe, initially trained as a paediatrician. After graduating from the Federal University of Rio, and doing post-graduate work at the International Children's Center in Paris, Becker went to work for Médecins Sans Frontičres in a Cambodian refugee camp. It was there, in 1988, that he realised that many of the conditions plaguing Cambodia's refugees had now arisen in his hometown of Rio de Janeiro.

In 1989, he returned to Rio and set up community health clinics in the city's poorest neighbourhoods. The programme grew so successful that 5 years later he was recruited by the Brazilian Ministry of Health to help craft a nationwide community health strategy covering 65 million people.

Even as he was expanding his clinics, Becker realised that treating disease was not enough. Since the 1960s the slums of Brazil, known as favelas, had expanded astronomically and brought with them their own special problems.

Becker viewed the favelas' high mortality rates as the result of social and economic inequality, stemming from urbanisation, a lack of land, and Brazil's widening income gap. The health disparities are now stark. Figures from the UN Development Programme show that infant mortality in Favela Alemao, one of Rio's poorest areas, is 54·8/1000 livebirths--more than 10 times the rate in the wealthy suburb of Lagoa, which has a rate of 4·3/1000.

In Rio, more than 1·2 million people live in the favelas on less than £1 per day. The residents lack access to the most basic public services, such as health care, education, and space for recreation. The results, Becker explains, are high incidences of malnutrition, diarrhoea, pneumonia, leptospirosis, skin diseases, rotavirus, hepatitis, gastroenteritis, hypertension, heart disease, and strokes.

AIDS is still a relatively small problem in Brazil, and Becker is working to keep it that way. HIV currently infects some 600 000 of the country's 184 million population. What concerns Becker, however, is that the growth is occurring among the poor, and specifically poor women. It is here that Becker's CEDAPS programme offers an innovative approach. CEDAPS works with local community groups--usually women's organisations--helping them to design and set up tailored HIV-prevention programmes.

In one favela, for instance, local women decided that the best place set up their AIDS prevention centre was amongst the kiosks where community members buy their fruits and vegetables. The women, not CEDAPS professionals, are the ones who talk to their neighbours about HIV infection and hand out information flyers and condoms. "They decide what they have to do", says Becker. "The beneficiaries become the problem solvers."

This community-based approach is replicated in CEDAPS programmes for children, elderly people, and general public health. The CEDAPS staff is small--only thirty professionals--and is made up of social workers, educators, psychologists, urban planners, and economists. The fact that local people administer the schemes themselves means that the CEDAPS workers can cover lots of ground, with three staff and two supervisors overseeing projects in three neighbourhoods at a time. The programme operates on a remarkably small budget, less than US$100 000 a year, which it receives from the Dreyfus Health Foundation, based in New York. They also partner with universities, NGOs, and local government agencies.

Becker's programme allows the poor of the favelas "to get help where normally they wouldn't get it", says Len Duhl, a professor of public health and urban planning at the University of California at Berkeley, who has surveyed the CEDAPS projects several times. Because of the lack of general health services in the favelas, "active participation of the community members is really important", he says.

In Brazil, public health is not only a question of disease, but also of bullets. In the 1970s, the favelas went from being simply poor neighbourhoods to centres of organised crime and drug trafficking. Children are indoctrinated into gangs before they hit puberty, and those who escape are still in danger of being caught in the crossfire between gangs and police squads.

4000 teenagers died from gunshot wounds in Rio's favelas last year, which, according to Becker, is ten times the number of children killed in the Israel-Palestine conflict. The massive violence is part of the reason the favelas have no public-health services. "Nobody wants to go there, not teachers, not doctors", says Becker.

So far, his staff members have been lucky; none has been caught in crossfire. Locals usually warn them if something is coming up, he says. Still, he adds, "it's a risk we take all the time".

Perhaps the most vital part of Becker's work is with children, helping them before they fall ill. 25% of the Brazilian population is under the age of 15, and for the poor there are few opportunities. Children only go to school for 3-5 hours, and many never see a day of high school. And for kids growing up in favelas, it is difficult to see a life beyond drugs and violence.

CEDAPS programmes for children, like that in Nova Marilia, try to give the kids alternatives. Poor children receive so few hours of school that is essential to fill their time, says Becker. The children here meet three times a week for 4 hours at a time.

As any teacher knows, getting kids to pay attention on summer days is next to impossible, but Joćo Luis seemed to be doing it. He asks for a volunteer for a role-playing game. Selma, a 14-year-old girl, raises her hand. Her mission is to cross to the other side of the room. The other kids are told they represent Selma's obstacles in life: poverty, discrimination, gangs, and drugs. They are to block her from crossing. Selma makes several tries to get past her laughing and shoving classmates, but they are too many and too strong. Joćo Luis stops the class. Okay, he says, so alone she cannot make it. What should she do? One student suggests asking a friend for help. Selma confers with a friend, who suggests going out the front door and entering through the back. She has found a way around her obstacles.

Joćo Luis calls the class to together to analyse the game. Selma faced difficulties and she asked a friend for help, he says. Together the two came up with a strategy. "A strategy doesn't mean you are running away from a problem", Joćo Luis says. "It means you are being intelligent."

Afterwards, the kids take their seats and, one at a time, stand up and present ideas for projects researching an issue in their community. This activity is far more than just filling time. Paulo Roberto, 16, is going to research how people who use drugs become alienated from their families and neighbourhoods. His plan is to talk to 10 families on three streets over a period of 3 months. "I picked the project because I have a friend who uses drugs and I think they are excluded from the community", he says.

Paulo says that he did not pay much attention in school, but now he is trying harder. "I want to help people who are not listened to", he says.

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