Tanto em educação como em saúde alguns programas localizados no Brasil tem dado bons resultados. Veja esse artigo publicado no Lancet
Access to health care in Brazil's favelas is poor, but several innovative projects in Rio de Janeiro are starting to improve the situation. Sharmila Devi reports.
Nanko van Buuren rushed back to the head office of the Brazilian Institute for Innovations in Social Healthcare, the non-profit group he started in 1989 that is best known by its Portuguese acronym of Ibiss. But his waiting colleagues are long-used to the erratic time-keeping of this tall Dutchman, whom the street children of Rio de Janeiro's favelas or slums call Paitrao, which combines the Portuguese words for father and boss. On this warm afternoon in mid-April, he was delayed because he had been touring some Ibiss projects with a delegation from Success for Kids, an educational charity backed by Madonna, the latest high-profile celebrity who wanted to tackle the entrenched poverty in the favelas. “Madonna called me personally last week to talk about how they can adapt Success for Kids to our own situation”, said van Burren. “They will have to adapt it because a lot of kids here are running around with guns because of organised crime and the drugs trade.”
Ibiss has grown into one of Rio de Janeiro's best-known non-governmental organisations through its many projects aimed at helping the city's most economically and socially excluded people. Since the beginning, its model has been to go into the favelas and ask the residents themselves not just what they need, but how they would organise it. If the programme is successful, Ibiss then lobbies the government to adopt it on a wider scale. Successful initiatives include leprosy-awareness programmes, helping children to leave or to avoid the drug gangs using football and music, and training favela residents to become community health-care workers. Ibiss has grown from just van Buuren and a handful of Brazilian staff to some 600 employees, mostly locally trained Brazilians, who work on about 62 projects.
Brazil will host the soccer World Cup in 2014 and the Olympic Games in 2016 and the government has promised to spend billions of dollars on infrastructure and security to ensure safety and enjoyment for the influx of international visitors. In Rio de Janeiro, a city of about 6 million people, the 1 million residents of some 1000 favelas hope they will benefit from the largesse too. Long neglected by government agencies, they have relied on their own efforts and the help of groups such as Ibiss to ensure access to basic health care and other services, such as electricity or waste collection.
The death toll from gun battles in the favelas between drug gangs, security forces and unofficial police militias is huge considering there is no actual insurgency or civil war. The UN has estimated the police murder three people a day on average in Rio de Janeiro, making them responsible for one in five killings in the city. Populated mostly by economic migrants from the north-east of Brazil, and caught between the drug gangs and the police, the favelas lack systematic access to the health-care system. There are high rates of tuberculosis and maternal and child mortality. Children are particularly vulnerable to diseases that spread in unsanitary conditions. Meanwhile, many Brazilian doctors and nurses are lured by higher salaries to the private sector.
Brazil accounts for about 17% of worldwide cases of leprosy, second only to India, which has about 54% of cases. The spread of leprosy is for the most part a consequence of migration to the favelas, since patients from rural areas often interrupt their 12—18 month course of treatment when they move to Rio's favelas, said Nancy Torres, an Ibiss health worker who helps to organise self-treatment groups. Ibiss also worked with the producers of a popular telenovela, or TV soap opera, to introduce a character with leprosy to help erode its social stigma.
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Incursions by heavily armed police are a regular feature of life in the favelas
Brazil does have one of the developing world's best programmes to combat HIV/AIDS, thanks in part to legislation guaranteeing universal access to antiretroviral treatments and the government's authorisation to local companies to produce the drugs without the consent of the patent-holder. But Joseph Amon, director of health and human rights at Human Rights Watch, said issues such as the treatment of drug dependency and the deinstitutionalisation of psychiatric care are still in need of urgent reform. Brazil is one of at least 115 countries that recognises a constitutional right to health. “We're just starting to see the start of advocacy efforts by the government, which needs to give meaning to the constitutional right to healthcare”, he said.
Some favelas have achieved progress in basic sanitation, education and roads. But many others are no-go areas for outsiders, including health workers and local journalists. Heavily armed police making a raid on drug gangs are often the only visitors. Even the more developed favelas provide a stark contrast to rich areas of Rio de Janeiro, such as Ipanema and Copacabana. The wealthiest 10% in Brazil are thought to control about 50% of the country's wealth.
van Buuren, a former WHO psychiatrist, first ventured into the favelas more than 20 years ago, building up trust with the heavily armed drug lords who rule by fear. “It's now very easy for us to do our work because we are very well-known in the slums, especially by the bosses of organised crime,” he said. “It took years of building up confidence. One of the main reasons is that I can't look at people as just criminals or murderers. I ask how are the kids and the man thinks not as a drugs boss but as the father of his children and he's proud to explain. If you are afraid when you talk to the boss, he smells that you're afraid and you're treated in that way.”
van Buuren now speaks better Portuguese than English, having fallen in love with Brazil and its people. Before moving to Brazil, he developed programmes to deliver psychiatric care to the homeless, immigrants, and other hard-to-reach populations in his native Netherlands. For WHO, he helped to train health professionals to cope with disaster and conflict situations. He said Brazilians thought he was crazy when he started Ibiss, with its ethos of enlisting people in the favelas to help to formulate solutions to their problems. “What is funny about Brazil is that people are very open. They looked at us and said you're crazy but go ahead if you want to do it”, he said. “In Holland, they've already created so many obstacles that you can't even start to experiment.”
Ibiss ran into strong opposition when it began distributing condoms, including among street children, but condom distribution is now routine in Brazil. “The church and other groups wanted to think that children had no sexuality and I don't know how they combined that thinking with young girls getting pregnant”, he said. One of Ibiss's biggest successes is its community health-care training programme, which has since been adopted by the Brazilian Government following strong advocacy by Ibiss. There are now more than 3000 health posts all over Brazil.
“In the early 1990s, we saw how the public health system didn't enter the slums”, he said. “So we took people, mostly women, from the slums and gave them training, one-and-a-half days a week for nine months, in the early detection of diseases, how to seek treatment and how to get a prescription.” He said the women felt greatly empowered. “Many would ask after they had referred someone to a medical post about the final diagnosis and they would feel incredibly proud when they found out they were right in their initial diagnosis.”
Brazil is also a source country for the international trafficking of people. The government is being urged, like that of South Africa before it hosted this summer's soccer World Cup, to adopt stricter measures so that offenders are brought to justice. According to the UN, over 75 000 Brazilian women are being sexually exploited in Europe. Rio de Janeiro is seen as one of the principal points of departure for these women to leave the country. Ibiss works on the streets with male and female prostitutes and transvestites and tries to map where and how people are gathered in the better-known areas of prostitution in Rio de Janeiro.
Security remains of paramount concern. The Brazilian Government has now embarked on a pacification programme in which police enter and stay in a favela to enforce law and order. Seven favelas have been occupied so far and dozens more occupations are planned in the run-up to the World Cup and Olympics.
Van Buuren fears the programme could become a victim of its own success, with favela residents selling their homes for a quick profit but unable to survive for long in new shantytowns further out of town. “Pacification has to include incentives for companies to settle in these areas and create jobs or else poor people will lose out.”