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 João
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 Promoção da Saúde), 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 Frontières 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 João 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. João 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.
João 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", João 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.