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The Challenge of Mental Health in Rio’s Favelas

Terezinha de Jesus, mother of boy Eduardo, killed by police in Alemão in 2015. Photo by Antonio Scorza / Agência O Globo

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Psychological problems, when untreated, can have severe impacts that go beyond basic mental health. Even minimal anxiety can lead to an accumulation of a stress hormone known as cortisol, which can lead to a deteriorating physical state. In disadvantaged areas, like some favelas, for example, the amount of stress faced by residents on a daily basis can be extremely high. An elevated measure of this stress, called allostatic load, is related to decreases in capacity to self-regulate, make plans, and working memory. According to Martha J. Farah, who studied the psychophysiological effects of living in poverty in the U.S., there is a strong negative correlation between years living in poverty and cognitive brain functioning.

In Rio de Janeiro, a city known for its harsh inequalities, mental health is often set aside on the list of priorities. Professionals and residents alike, however, agree that it is a problem that needs to be urgently addressed.

The Brazilian government has developed a system of Family Health Clinics focused on prevention and promotion of health and part of the broader SUS (Unified Health System). Since 2008, the system has widely expanded, and family health outposts are now spread throughout the city of Rio, covering 56,8% of the city’s communities, up from 3.5% in January of 2009. The system also accounts for emergency health care in its UPA (Emergency Care Units) outposts. Although the preventive care in the family units accounts for mental health, there also exist additional health posts dedicated to severe mental disorders, known as CAPS (Community Psychosocial Centers). Despite this, assistance to those needing basic mental health prevention or treatment remains deeply insufficient.

Joana Thiesen is one of the psychiatrists based at a Family Health Clinic in Rocinha, the largest favela in Brazil. She also works at the health unit in another South Zone favela, Pavão-Pavãozinho, and has just started at the Catete unit, where the health system is used by favela residents as well as those from the formal city. She facilitates group therapy sessions with an aim at harm reduction–in Rocinha, she deals with a lot of alcoholism and other drug addictions. An advantage of these group therapy sessions, she says, is that they allow for an exchange of coping mechanisms that an individual, professional therapist could not come up with. Health professionals often live different day-to-days than many favela residents, among which “many have already developed abilities to deal with this.”

Natalia Helou Fazzioni, a researcher in health anthropology at the Rio de Janeiro Federal University (UFRJ), speaks differently of group therapy after her experiences in Complexo do Alemão, a complex of favelas in Rio’s North Zone. For her, this model is inadequate for a community like Alemão, where those seeking mental health support could be relatives of policemen or of drug traffickers, or otherwise find themselves in conflict with one another, making group therapy unproductive. Even in situations where the existing problem is unrelated to violence, mental health is an intimate thing that may be hard to open up about. Incidentally, opening up is a lot of what mental health treatment is about. Fazzioni says individual psychological treatment needs to be made available to those who might, some day, need it: “Psychological assistance isn’t always necessary, many of these people solve their problems through individual means, through religion, other things. But the option of treatment through psychology, psychoanalysis, has to be available.”

Doctors Without Borders (MSF) attempted to call attention to this when, from 2007 to 2010, they ran an emergency health clinic in Complexo do Alemão. In addition to basic emergency health care, MSF deployed psychologists to their outpost, located in the middle of the complex. Douglas Khayat, one of these psychologists, lamented the lack of mental health support but praised the limited success that the MSF project had on residents of Alemão. “People started to talk about things that they never talked about. This has an immediate effect in terms of relieving tension, and of course when you relieve tension, with directed view, you have a gain in terms of quality of life,” he says.

According to Douglas, psychologists in Brazil prefer the private sector where they can charge high amounts. This contributes to a widespread preconception that “mental health problems are problems of the rich, the poor don’t have time to be sad, because they have to make a living, raise their children, build a house…,” as Natalia Fazzioni points out. Irenaldo Honório da Silva, a physical therapist and president of the neighborhood association of Pica-Pau, a favela in the North Zone, says people in favelas still believe that mental health problems are taboo. According to him, the lack of health infrastructure in the community contributes to this problem: “There are many people here affected by depression. And they don’t succeed in getting better because there is no adequate care.”

Irenaldo in Pica-Pau

Unfortunately, adequate mental health treatment is often replaced by quick-and-easy medication practices. Rivotril, a calming prescription drug, is sold at low prices and in extreme quantities in Brazil. In the U.S., the prescription drug is known as Klonopin (medical name clonazepam), and is considered one of the most dangerous on the market today. Fazzioni denounces the medicalization of Brazil’s mental health problems, explaining the difficult situation faced by doctors who are not specifically trained in psychology and often face a long line of patients, most of whom are looking for the quickest (efficiency aside) remedy out there. In favelas, the cheap price of Rivotril makes this remedy attractive. For those who don’t get access to such prescription drugs, alcohol and other street drugs are accessible and can become the patient’s escape from day-to-day challenges.

These challenges are of a wide scope in Rio’s favelas, and often differ from those of middle- and upper-class Brazilians living in the formal city. On top of economic and family stress, favela residents often have to deal with the stress of violent outbursts and at times excruciating forced evictions from their communities. The constant worry that shootings may erupt close by or that one’s home and community are otherwise insecure have severe effects on stress levels and, subsequently, on mental health. Douglas Khayat argues that this was made worse by the implementation of the Pacifying Police Units (UPPs), which made violent altercations between police and drug traffickers more frequent in Alemão. With the resulting unpredictability, he said, favela residents have to be on constant alert. This was amplified by constant police operations in various favelas during the recent Rio 2016 Olympic Games. Impacts of violence on residents’ mental health are all the more serious when family clinics have to suddenly close down in times of violence. Joana, who has experienced such situations in Rocinha, says residents often complain that the clinic closes at times when residents are in most dire need of its support.

Marize Bastos da Cunha, a health researcher at Fiocruz, says she has seen an increase in diabetes and hypertension in recent years, a problem she believes is directly tied to increases in chronic depression and anxiety. “The government is investing in weapons more than health and people’s living conditions.” Echoing Irenaldo, she says that depression is still an invisible problem, particularly among favela youth. “Youth are only an object of health politics to talk about pregnancy and drugs. So this young person is living an extremely dramatic day-to-day, he is suffering from stomach problems, mental health problems, lack of perspective in life, hypertension, obesity…. And this young person has no specific care program designed for him or her.”

Living conditions can also be a barrier to a healthy mind. Favela residents may have limited living space, streets can be crowded and dirty, sewage may run freely due to the lack of an adequate sewerage system. These conditions are the precursor to a number of health problems, such as tuberculosis. Irenaldo, of Pica-Pau, has been demanding that Rio’s city government set up better infrastructure in his community for years. He believes that the lack of an adequate sewerage or trash removal system has severe impacts on his community’s well-being, and that mental health problems are more frequent within his favela due to poor living conditions.

Government neglect is thus a major contributor to mental health problems. A good example is the City’s Morar Carioca program, which since 2010 had promised to bring missing services into hundreds of favelas. Instead, the program has left communities like Pica-Pau waiting, and then reliving abandonment, over and over again. The abandonment of favelas by the government not only leaves them in a precarious state that contributes to mental health challenges, but can create a sense of desperation for residents, and thus causes increased depression and anxiety for those who are forced to live with the consequences. Stigmatization of favela populations can also have similar impacts, as those living in favelas feel marginalized in the city and, sometimes, end up feeling a sense of shame towards where they come from.

This stigmatization is of course unfounded, and favelas have come to increasingly represent values of creativity and community. In fact, the resilience residents have found to deal with mental health is thanks mainly to the self-built assets of favelas, such as collective action, creativity and community.