“This is what it is like to live here: you are not meant to see, hear or speak. When there is an outburst of violence, it is ‘each to their own’. It is frightening.”
Elena lives in Complexo do Alemão, a group of slums home to more than 170 000 people in Rio de Janeiro, Brazil. The Alemão landscape is in stark contrast to postcard images of Rio: a labyrinth of steep unpaved alleys flanked by poorly built houses and surrounded by improvised barricades to control vehicles entering the area. Less visible, but more striking, is the uncontrollable violence that dominates the lives of the residents here.
Complexo do Alemão, like hundreds of other slums in Rio de Janeiro, is controlled by heavily armed groups who manage the profitable drug trafficking business in the area. Violent clashes can erupt at any time, anywhere, as a result of police incursions or fighting between rival groups. But even when things appear calm, thousands of people like Elena live under the rule of these gangs and in constant fear of being in the wrong place at the wrong time.
Médecins Sans Frontières (MSF) started a project in Complexo do Alemão in 2007, after a series of brutal clashes between police forces and armed groups. During one police operation in June, 17 people were reportedly killed in one day. Residents caught in the cross-fire have no emergency medical care. Even in peaceful times, ambulances do not enter slums like Complexo do Alemão.
MSF's ambulance, a converted Kombi, is narrow enough to negotiate the roadblocks and steep terrain of Complexo do Alemão
Photo by David Prichard
The MSF project focused on emergency life-saving activities, including rescue, stabilisation of patients and transfer to public hospitals outside Complexo do Alemão. For this purpose, MSF turned a basic van into an ambulance, which had to be narrow enough to drive through the many roadblocks and alleyways.
The project also offered psychological support to people exposed to violence, helping them to cope with their experiences. “Because people here are expected to remain silent about any violent events they may witness, they are often forced to keep all these tragic stories inside. The mental health services offered at the MSF clinic gave people affected by violence the possibility to express their suffering and deal with it better, given that there is little they are able to change in the environment around them,” explained Douglas Khayat, MSF psychologist in Complexo do Alemão.
Psychological care helps residents cope with suffering
MSF psychologist Douglas Khayat with Elena, a 43-year-old who's husband is an alcoholic and who is exposed to episodes of domestic violence
Photo by David Prichard
For Elena, the benefits of psychological services at the MSF clinic came as a surprise. “I found out about the psychologists by chance. I fell ill at home and I was rescued and taken to the MSF clinic. There, I found out that I had high blood pressure. After giving me medication, the doctor asked if there was anything bothering me,” explained Elena. “My husband drinks a lot and this makes me very nervous. I agreed to see a psychologist. It was the first time in my life that I had seen a psychologist and it has helped me a lot. Now I can deal with problems in a way that I was not able to before.”
Like Elena, many patients are referred to the psychologists by the medical doctors, since they come to the MSF clinic seeking medical care for psychosomatic symptoms. “It is crucial that the doctors and psychologists work in collaboration to identify people in need of mental health support. Often, patients arrive at the clinic with a physical complaint that is triggered by a psychological condition, for example recurrent headaches,” said Douglas.
Apart from psychosomatic complaints, depression and anxiety are the most common symptoms found in adults. In children, behavioral problems, aggressiveness and learning difficulties are common. Behind the symptoms, there is usually a tale of violence – half of all the patients seen by MSF’s psychologists had a story to tell. More than one-third of these had been in a conflict situation and one in five had had a family member killed. “Given the horror of the reports, we expected to find more cases of Post Traumatic Stress Disorder (PTSD), which is common when people go through a sudden shock,” explained Douglas. “But we found that cases of PTSD were a minority. This is a sad indication that events that we would normally find extraordinary have already become routine here. Yet people do not emerge from these experiences unscathed.”
Time to leave
After two years, MSF is closing its project in Complexo do Alemão. “The project was an emergency response, designed to last for only a couple of years. People here are still exposed to a lot of pressure from all sides and violence is part of their daily lives. But, the number of armed clashes and injuries inside Complexo do Alemão has decreased, leading to fewer emergency cases – the original focus of our project,” explained Tyler Fainstat, MSF’s Head of Mission in Brazil. “Some health services have also become available to residents, even though they are not right inside the community,” he added.
Between 2007 and 2009, the MSF team provided residents of the Complexo do Alemão with 19,000 medical consultations and 650 emergency rescues using the customised ambulance. The team of psychologists provided over 3,000 consultations to 1300 patients, both adults and children.
For Ana Maria, the psychological support was vital. “My brother was killed in the community when he was 16 years old and ever since I have been depressed. I didn’t want to leave the house, I didn’t want to talk to anybody, I was completely isolated,” said Ana Maria. “Then I lost my daughter in an accident. I just wanted to die. It was during one of these crises that I found out there were psychologists here at the clinic. Here I found the support I needed to carry on living.”
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The names of patients in this article have been changed to maintain their anonymity.