Abstract

The article presents the results of qualitative action research on armed violence with health and education professionals and territorial community services in Manguinhos, Rio de Janeiro, Brazil. It is justified by the urgent nature of this violence in the territory and aims to identify its impacts on their health and work, coping, protection, and care strategies. The effects of armed violence on health and education professionals and the territory are discussed through interviews and focus groups with participant observation, identifying some of its transversalities, such as the Brazilian State racist public security policy based on a warlike logic of confrontation with groups with armed control of the territory, which makes life precarious by exposing residents and workers to constant risks, weakening the community fabric and preventing full access to health and education.

Key words:
Armed violence; Health; Politics; Protection

Introduction

This article is about armed violence (AV) and its effects on the health and work of health and education professionals. The empirical support stems from research in Manguinhos/Rio de Janeiro, which aims to produce scientific evidence on these impacts on workers’ health, services, and the community fabric.

On the Brazilian scene, specifically in Rio de Janeiro, we see rhetoric and practice anchored in armed combat against what has come to be called organized crime located in favelas, reified as the locus of crime and other social ills. In practice, how public security is conducted varies with the targeted territories. We have followed the normalization of rights violations, deaths, and morbidities in favelas, where the population tends (not by chance) to be primarily Black.

State institutional violence operated through AV is closely linked to racial and class issues. It is expressed through racist police selectivity that mainly targets young Black bodies and causes deaths, fear, emotional wounds, and dehumanization. While the suburbs are invaded in police operations, the same is not the case in areas inhabited by middle and upper-class families and, not by chance, mostly white¹1 Bento C. O pacto da branquitude. São Paulo: Companhia das Letras; 2022..

Rio’s favelas are the target of management and control policies grounded in the history of Brazilian social upbringing, colonization, Black and Indigenous dehumanization, the whitening policy, and the unequal spatial distribution of living and housing places¹1 Bento C. O pacto da branquitude. São Paulo: Companhia das Letras; 2022.^,22 Gonzales L. Por um feminismo afro-latino-americano: ensaios, intervenções e diálogos. Rio de Janeiro: Zahar; 2020.. The violent occupation of favelas by armed groups - such as factions and militias - has been recorded since the 1980s, as has the failure of security policies, which resulted in a vast number of deaths³3 Ramos S. Trajetórias no tráfico: jovens e violência armada em favelas cariocas. Trivium 2011; 3(2):41-57.. Even the Pacifying Police (UPP) project, created in the late 2000s, also failed in the following decade, mainly due to the maintenance of the structures that sustain public security⁴4 Ramos S. UPP: a falência de um programa para mudar a polícia [Internet]. 2022. [acessado 2023 jun 11]. Disponível em: https://wikifavelas.com.br/index.php/UPP:_a_fal%C3%AAncia_de_um_programa_para_mudar_a_pol%C3%ADcia
https://wikifavelas.com.br/index.php/UPP... ^,55 Franco M. UPP, a redução da favela a três letras. Uma análise da política de segurança pública do estado do Rio de Janeiro. São Paulo: n-1 edições; 2018..

Hamann-Nielebock and Carvalho⁶6 Hamann-Nielebock E, Carvalho IS. A violência armada e seus impactos sobre a população civil: um fardo necessário? Rev Bras Segur Publica 2012; 2(1):104-118. argue that violence between armed groups operating in the retail drug trade and Brazilian public security forces should be conceptualized as armed violence, a concept that includes the intentional use of force “with firearms or explosives by organized or semi-organized groups against individuals, groups, or the State, in such a way as to inhibit sustainable development” (p. 105).

The dynamics of armed violence in Manguinhos, underpinned by the War on Drugs policy, include constant police operations to curb trafficking and seize drugs, weapons, and people from the so-called criminal faction. This heavily armed group dominates the territory through warfare until it is eliminated and, in theory, a “drug-free” society⁷7 Boiteux L. El antimodelo brasileño. Prohibicionismo, encarcelamiento y selectividad penal frente al tráfico de drogas. Nueva Sociedad 2015; 225:132-144.

8 Valois LC. O direito penal da guerra às drogas. Belo Horizonte: D'Plácido Editora; 2016.

9 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Sumário executivo: violência armada e saúde: investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2020.^-1010 Silva MM, Ribeiro FML, Frossard VC, Souza R, Schenker M, Minayo MCS. "No meio do fogo cruzado": reflexões sobre os impactos da violência armada na Atenção Primária em Saúde no município do Rio de Janeiro. Cien Saude Colet 2021; 26(6):2109-2118..

AV is an event that includes several manifestations such as shootings, confrontations, “stray bullets”, sniper action, the ostentatious display of weapons and threats to control territory or robberies, and the use of explosives such as bombs⁹9 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Sumário executivo: violência armada e saúde: investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2020.. It affects people’s physical and mental health and the functioning of community spaces, imposing risks and insecurities that influence the ways of being in the favelas, such as the fear of leaving and returning home, work, and school, and the fear of dying (oneself and family members).

Influences on the work of health professionals include shutting down services, the need to restructure care and develop safety strategies in the face of imminent armed violence, and the concern about their exposure to a daily fear-and-stress routine⁹9 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Sumário executivo: violência armada e saúde: investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2020.^,1111 Barbar AEM. Atenção primária à saúde e territórios latino-americanos marcados pela violência. Rev Panam Salud Publica 2018; 42:e142.. Education is also impacted when teachers care for themselves and their students in a context of fear and silencing¹²12 Bello-Ramírez A, Pereira-Vianna C. Profesoras en medio de la violencia armada: una pedagogía visceral desde las favelas de Rio de Janeiro. CS 2021; 33:11-40..

We are interested in building an overview of AV and its impact on the health and daily lives of health and education professionals working in the Manguinhos territory. We believe that if, on the one hand, the local contexts and their specificities do not allow for generalizing the results, on the other hand, some social, political, and economic markers in the neighborhood are also found in other territories in Rio de Janeiro and Brazil, such as armed groups that dominate the territory, racist, ostentatious, and rights-violating security policies, and precarious State public policies.

Regarding the groups participating in the research, we should underscore that their activities are diverse, as are their working relationships and the space in which they work. We cannot homogenize the experiences of violence - and its impacts - of health and education professionals.

Methods

A qualitative action-research study¹³13 Thiollent M. Metodologia da pesquisa-ação. São Paulo: Cortez: Autores Associados; 1986.^,1414 Minayo MC S. Desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo/Rio de Janeiro: Hucitec/Abrasco; 2014. was conducted from 2019 to 2022, producing information on the occurrence and impacts of AV in Manguinhos and proposing debates with workers and society.

In the first phase, we administered questionnaires to managers (7), held individual interviews (9) and focus groups (3), and AV episodes were recorded on social media. Participants included workers from health facilities - Primary Health Care (PHC) and Psychosocial Care Networks (RAPS) and Urgent/Emergency Care (4); and Education - state schools (2). Participant observation was conducted at all field meetings and during institutional visits. In order to measure the magnitude of the problem, AV episodes were recorded for 90 weeks, based on reports on WhatsApp (2 groups), Facebook (2 groups), and FIOCRUZ institutional e-mail, which signals AV situations in the territory.

Due to COVID-19, the second phase was carried out remotely. In order to increase visibility and mobilization around the AV’s colossal impact and conditionalities, the results were fed back (4) through the production of an Executive Summary and meetings with participants and public debates in partnership with researchers, professionals, and social movements (9). These meetings led to a Summary Document and the production of scientific dissemination materials, all of which were disseminated through the networks of the researchers and partners, available at https://linktr.ee/fernandamlr.

The project was approved by the Ethics Committees of the National School of Public Health, the Municipal Health Secretariat, and the State Education Secretariat of Rio de Janeiro. The participants signed the Informed Consent Form and the institutions provided Letters of Consent. All the principles governing human research were respected. Two CNPq calls for proposals funded the research: Universal and Junior Postdoctoral.

Results

Manguinhos is an impoverished neighborhood in the North Zone of Rio de Janeiro. It has 12 favelas with different socioeconomic conditions and access to public policies, with the fifth worst HDI in the municipality and high urban violence rates¹⁵15 Favela de Manguinhos [Internet]. Wikifavelas 2023. [acessado 2023 jun 11]. Disponível em: https://wikifavelas.com.br/index.php/Favela_de_Manguinhos
https://wikifavelas.com.br/index.php/Fav... ^,1616 Lyra D, organizador. Infância e trânsito em Manguinhos. Rio de Janeiro: CECIP/Criança Pequena em Foco; 2015.. In 2010, the Census counted 36,160 inhabitants, including 23,216 Black people¹⁷17 Instituto Pereira Passos. População residente por cor ou raça, segundo as Áreas de Planejamento (AP), Regiões de Planejamento (RP), Regiões Administrativas (RA) e Bairros no Município do Rio de Janeiro - 2010. Rio de Janeiro: Prefeitura da Cidade do Rio de Janeiro; 2019..

According to the records, at least one episode of armed violence was recorded in 46 weeks (51%), and transportation changed, people were injured, and health and education facilities were closed in 24 weeks (52%). Police raids include the presence of various segments, especially in the morning. Twenty-seven of 37 weeks in the pre-pandemic period (July 2019 to February 2020) recorded incidents, or 0.7 per week.

During the pandemic (March 2020 to February 2021), 19 occurrences were recorded in 53 weeks, or 0.3 occurrences/week. Considering records as of June 2020, the month in which the Constitutional Challenge (ADPF) N°365 - ADPF of the Favelas - was enacted, a legal instrument of the Supreme Court to protect a fundamental public precept, we have 13 episodes in 40 weeks or 0.3 per week. The figures show the ADPF’s positive impact in reducing police incursions since this instrument aims to regulate and reduce their incidence.

As far as the organization and work process are concerned, AV resulting from clashes between security forces and the local armed group commonly occurs close to homes, shops, public facilities, squares, and transport stops, in other words, amid daily life and often without giving any apparent signs of a new event. The research team has even suspended institutional visits due to the risk of police operations altering the functioning of local facilities, which confirms the daily challenges professionals and residents face. From meetings with professionals, we identified the production of an environment of insecurity and fear that weakens bonds, generates psychological suffering, and inhibits the quality of services. AV has direct and indirect individual and collective psychosocial impacts: deaths and injuries, disrupted services, restricted movement, loss of material goods, violence trivialization, and death. We also have illnesses, deteriorated health conditions, psychosocial trauma, chronic pain, difficulty sleeping, hypertension, headaches and stomach aches, tachycardia, uncontrolled diabetes, high stress-related skin bruises, excessive consumption of substances and medicalization, vulnerability and insecurity, anguish, fear, tension, stress, discouragement, a constant state of alertness and calculation of “risks”, despair, emotional instability, depression, anxiety, insomnia, panic episodes, lethargy and paralysis, generalized malaise, bouts of crying, sensitivity to sounds reminiscent of gunshots, Post-Traumatic Stress Disorder (PTSD), feelings of powerlessness, emotional burnout, exhaustion, and excessive tiredness.

Health managers reported an overload of responsibility, fear for themselves, professionals, and users, and uninterrupted attention to guidance and communication. Education professionals reported great tension and stress in dealing with the agitation of students and the school community, including families. Besides the impact on professional performance, there are consequences for personal, family, and community life, the social fabric, and the functioning of services. This disruption has enormous costs and violates the right to universal, equitable, comprehensive, and quality access to social policies.

The severe cases of violence affecting service users emotionally shake the teams and require a variety of coordinated actions, which sometimes leaves other health needs uncovered. Illnesses, leaves of absence, and layoffs lead to staff shortages and, consequently, more significant work intensification. The total or partial closure of services influences their dynamics on the days following those with AV episodes.

On more than one field visit, the team heard reports about how the equipment is used as a “shield” in situations of confrontation between security forces and the local armed group - in this case, professionals find themselves “in the middle of the crossfire”¹⁰10 Silva MM, Ribeiro FML, Frossard VC, Souza R, Schenker M, Minayo MCS. "No meio do fogo cruzado": reflexões sobre os impactos da violência armada na Atenção Primária em Saúde no município do Rio de Janeiro. Cien Saude Colet 2021; 26(6):2109-2118. and fear being seen as conniving by the police as if they were collaborating with and covering up for “bandits”, and by the latter as if they were “snitches”. The feeling of powerlessness, vulnerability, and risk is even greater for Community Health Workers (ACS). Because they are workers and residents of the area, they are on the streets often and have a close relationship with many of the users of the local clinics.

During our fieldwork, we identified the precarious structure of the facilities, which are made of containers and drywall and have open internal courtyards. It was expected to spot bullet holes in walls and air conditioners, and changes in the location of activities - the school secretary changed rooms to be less exposed; in the health service canteen, there is no sitting in the place marked by a bullet hole.

Another issue is the traffic at the start of working hours and when people return home. As identified in social media records and reports from those who live and work in Manguinhos, police operations are commonly conducted in the early hours of the morning, precisely when there is a large circulation of people, forcing professionals to follow the territory’s movement pari passu through social networks and define safe points between their homes and workplaces.

In their daily lives, professionals prepare some individual and collective actions to deal with, protect, and care for people. There is a constant calculation of risks based on an assessment of signs - not opening shops, not letting motorcycle cabs circulate, and police operations - searching for clues that could foreshadow a new AV episode.

Communication about risks occurs through WhatsApp groups that alert the teams and inform them about changes in the routine of the units. The Manguinhos PHC participates in the Safer Access Protocol (AMS), which establishes protection measures in the event of violence based on a classification of risks built locally and collectively, changing the routine of facilities that can suspend external activities or even close altogether. This protocol also works in other clinics in the city and some municipal schools.

Among the protection strategies professionals use are taking shelter in the places considered safest inside the units, such as central corridors; removing professionals, users, and students from the riskiest spaces, such as courtyards; avoiding leaving the facilities late and alone and seeking alternative, less risky routes. In education, many professionals said they refused to work at night. In the health sector, attempts were made to talk to the security forces and the local armed groups to limit the unit’s exposure.

Health professionals are often mobile, on home visits, or in community spaces. On these occasions, vests, coats, and badges have been referred to as protective because it identifies them. When they are in situations of risk, they are received by residents and shopkeepers; when they enter and leave the territory, they protect themselves at safer points, such as a prominent local supermarket.

Another set of strategies aims to promote health and prevent illnesses related to daily life with AV, such as leisure, art, cultural activities, psychotherapy, and the use/abuse of medication. Not sharing AV episodes with family and friends aims to avoid excessive concern and consequent pressure on oneself.

When asked what could be done to change the AV situation, the professionals pointed to macro and micro-political actions: reviewing security and education policies to include violence reduction strategies; investing in educational actions; valuing professionals, with improved salaries; incidence on arms policy; improving housing infrastructure; proposing public civil action to reduce the impacts of violence; improving dialogue between health units and public security agencies; changing the times of police raids; enforcing public services to curb deviations; reinforcing the units’ infrastructure; improving the AMS; developing preventive care and receptive/listening actions for professionals and creating spaces for qualified discussion on armed violence and drawing up coping strategies; valuing and encouraging social movements to broaden the future prospects of children and young people, creating protective spaces; and encouraging the creation and strengthening of community solidarity networks. Reflecting on this problematizing question shows how the professionals have a complex view of public safety, which is not restricted to policing or controlling drugs and weapons.

Discussion

As this is a complex problem, we do not propose here to restrict the approach to armed violence to a simple description of the factors involved in its constitution. We consider it to be related to the War on Drugs policy waged in the principal Brazilian cities and especially in the state of Rio de Janeiro. It is an event that drastically erupts in everyday life, throwing us into a virtual space of risk, reproducing vulnerabilities that particularly affect Black and suburban people who live in impoverished spaces and those who work there. AV is most dramatically present precisely in these spaces, led by civilian or paramilitary groups with armed control of the territory, who exercise force beyond the rule of law and where the repressive arm of security policy is directed par excellence, feeding a cycle of escalating violence revealed in the daily production of deaths, morbidities, and incarceration⁹9 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Sumário executivo: violência armada e saúde: investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2020.^,1010 Silva MM, Ribeiro FML, Frossard VC, Souza R, Schenker M, Minayo MCS. "No meio do fogo cruzado": reflexões sobre os impactos da violência armada na Atenção Primária em Saúde no município do Rio de Janeiro. Cien Saude Colet 2021; 26(6):2109-2118.^,1818 Muniz JO, Almeida RR. Respondendo às balas: segurança pública sob intervenção das palavras entrevista com Jacqueline Muniz. Trab Linguist Apl 2018; 57(2):993-1014.^,1919 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Lives Violência armada e saúde: documento síntese. Pesquisa Conflitos armados e saúde - investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2021..

Latin America is one of the most significant armed violence settings. Social inequality, poverty, low economic growth, unemployment, disorderly urban growth, inefficient public services, the growing availability of small arms, the illicit drug trade, the presence of armed groups that dominate territory, a culture of violence, and corrupt or ineffective state security forces underpin an outlook where, in some city areas with a specific population profile, AV numbers are close to or even exceed those of countries at war²⁰20 Moura T. Novíssimas guerras, novíssimas pazes. Desafios conceptuais e políticos [Internet]. 2004. [acessado 2023 jun 11]. https://www.ces.uc.pt/publicacoes/oficina/214/214.pdf
https://www.ces.uc.pt/publicacoes/oficin... . The concept of violent sociability²¹21 Silva LAM. Sociabilidade violenta: por uma interpretação da criminalidade contemporânea no Brasil urbano. Soc Estado 2004; 19(1):53-84. adds a qualitative dimension to the analysis by highlighting the radical transformation of common social relationships based on everyday violent practices, in which physical force is detached from any morality and calculation regarding the adequacy of means and ends. In the Brazilian case, we should add the colonial historical process, whose interactions were marked by physical coercion and exploitation of the labor and resources²²22 Quijano A. Colonialidade do poder, eurocentrismo e América Latina. In: Lander E, organizador. A colonialidade do saber: eurocentrismo e ciências sociais - perspectivas latino-americanas. Buenos Aires: Clacso; 2005. p. 107-132. of Black and Indigenous peoples. The legacy of slavery, which marginalized bodies that represent the “other”, and the political-ideological project of racial democracy conceal the structural inequalities and racism that prevent the social ascension of the Black and suburban population and keep them in slum areas, naturalizing their punishment as a justification for keeping a supposed order¹1 Bento C. O pacto da branquitude. São Paulo: Companhia das Letras; 2022.^,22 Gonzales L. Por um feminismo afro-latino-americano: ensaios, intervenções e diálogos. Rio de Janeiro: Zahar; 2020..

This setting produces and reproduces social exclusion related to the unequal distribution of social goods such as housing, food, sanitation, employment, and leisure. It leaves specific populations at the mercy of forced coexistence with armed groups that expose them to daily AV situations. In such contexts, barriers to access services such as health and education occur directly and indirectly through their precariousness and the lack of professionals¹¹11 Barbar AEM. Atenção primária à saúde e territórios latino-americanos marcados pela violência. Rev Panam Salud Publica 2018; 42:e142..

Some of its many impacts are the number of deaths and injuries (mainly young Black men), family breakdown, diseases and psychosocial trauma caused by the loss of people and prolonged contact with violence, restricted fundamental rights, loss of material goods, and economic harm, such as the closure of businesses. Intermittently, schools and health services have to close down wholly or partially, and community activities such as home visits - a crucial part of PHC’s proposed care - are suspended because of shootings and police raids that pose a risk to life. Operations by public security forces in search of people linked to armed groups, drugs, and weapons do not always mean protection measures due to their recurrent violence. It is not uncommon for the police to arrive in the favela and fire guns, leaving the local population extremely vulnerable and resulting in injuries and deaths - among “criminals” and “ordinary people”. Feelings of insecurity grow on such occasions, generating fear among everyone in the area⁹9 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Sumário executivo: violência armada e saúde: investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2020.^,1010 Silva MM, Ribeiro FML, Frossard VC, Souza R, Schenker M, Minayo MCS. "No meio do fogo cruzado": reflexões sobre os impactos da violência armada na Atenção Primária em Saúde no município do Rio de Janeiro. Cien Saude Colet 2021; 26(6):2109-2118.^,1919 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Lives Violência armada e saúde: documento síntese. Pesquisa Conflitos armados e saúde - investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2021..

Some studies conducted in recent years on the impact of armed violence on PHC and education have highlighted how it is a barrier to accessing services and point to public security forces and local armed groups as the primary agents of violence. The presence of both prevents professionals from moving around the territory, leaving it “unstable”, generating fear, and changing daily activities²³23 Santos LC. Viole^ncia armada e escola pu´blica: desafios a` atuac¸a~o do professor em favelas do Rio de Janeiro [dissertac¸a~o]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2022.^,3434 Cavalcanti M. Tiroteios, legibilidade e espaço urbano: Notas etnográficas de uma favela carioca. Dilemas Rev Estud Conflito Contr Soc 2008; 1(1):35-59.. Nevertheless, Barbar¹¹11 Barbar AEM. Atenção primária à saúde e territórios latino-americanos marcados pela violência. Rev Panam Salud Publica 2018; 42:e142. highlights PHC’s potential in implementing coordination, citizenship, and care” (p. 3), given its guiding principles of comprehensiveness, longitudinality, and participation. AV adversely affects the teams’ work process, interferes with the care and learning produced in meetings between the population and health and education professionals, and impacts mental health. The routine of risks and the feeling of vulnerability imply fear, frustration, anxiety, depression, apathy, a sense of powerlessness, and challenges to the functioning of services and the work of professionals.

Fazzioni²⁸28 Fazzioni NH. Tiro que mata, tiro que "cura", tiro que fere: notas etnográficas sobre violência armada e direito à saúde. R Contemp Ant 2020; 47:167-190. observes that health professionals, on the one hand, suffer from the demand for work and, on the other, lack more assertive intervention tools. Turnover of professionals, discontinued work processes, and weakened links with users are highlighted by Almeida, Peres, and Fonseca²⁹29 Almeida JF, Peres MFT, Fonseca TL. O território e as implicações da violência urbana no processo de trabalho dos agentes comunitários de saúde em uma unidade básica. Saude Soc 2019; 28(1):207-221. and Gonçalves, Queiroz, and Delgado³⁰30 Gonçalves HCB, Queiroz MR, Delgado PGG. Violência urbana e saúde mental: desafios de uma nova agenda? Fractal Rev Psicol 2017; 29(1):17-23., especially regarding ACS. Fazzioni²⁸28 Fazzioni NH. Tiro que mata, tiro que "cura", tiro que fere: notas etnográficas sobre violência armada e direito à saúde. R Contemp Ant 2020; 47:167-190., Flórido et al.²⁷27 Flórido HG, Duarte SCM, Floresta WMC, Marins AM F, Broca PV, Moraes JRMM. Gerenciamento das situações de violência no trabalho na estratégia de saúde da família pelo enfermeiro. Texto Contexto Enferm 2020; 29:e20180432., Almeida, Peres, and Fonseca²⁹29 Almeida JF, Peres MFT, Fonseca TL. O território e as implicações da violência urbana no processo de trabalho dos agentes comunitários de saúde em uma unidade básica. Saude Soc 2019; 28(1):207-221. and Machado et al.³²32 Machado CB, Daher DV, Teixeira ER, Acioli S. Violência urbana e repercussão nas práticas de cuidado no território da saúde da família. Rev Enferm UERJ 2016; 24(5):254-258. highlight the AV interference in conducting home visits, leaving uncovered needs which, in many cases, such as bedridden older adults, represent a lack of access to healthcare.

Constant AV episodes and the necessary “climate” reading mark the daily lives of residents³⁴34 Cavalcanti M. Tiroteios, legibilidade e espaço urbano: Notas etnográficas de uma favela carioca. Dilemas Rev Estud Conflito Contr Soc 2008; 1(1):35-59. and professionals who, in their work, need to enter, move around, and leave the territory and, to do so, “internalize” risk assessment and avoidance strategies in their routines. WhatsApp intensive use to get news of possible danger signs is a constant and necessary exercise, part of individual and collective protection strategies, also identified by Fazzioni²⁸28 Fazzioni NH. Tiro que mata, tiro que "cura", tiro que fere: notas etnográficas sobre violência armada e direito à saúde. R Contemp Ant 2020; 47:167-190. and Flórido et al.²⁷27 Flórido HG, Duarte SCM, Floresta WMC, Marins AM F, Broca PV, Moraes JRMM. Gerenciamento das situações de violência no trabalho na estratégia de saúde da família pelo enfermeiro. Texto Contexto Enferm 2020; 29:e20180432. in their research.

Based on the record of AV incidents in Manguinhos, the concern about the “climate” and the possibility of new episodes is justified since more than half of the weeks (n = 90) had some occurrence. Santos and Silva²⁶26 Santos LC, Silva CAF. Conseque^ncias da viole^ncia armada carioca para as aulas de Educac¸a~o Fi´sica. Movimento 2020; 26:e26036., based on data from the Fogo Cruzado platform, state that 46% of the municipality’s schools recorded at least one firearm shot within 300 meters of their location in 2019. From 2017 to early 2019, five people were shot on school grounds. In the research in Manguinhos, although we did not collect reports of deaths, there were many accounts of professional illness and equipment damage.

On more than one occasion during the research, we heard references to people’s AV “trivialization” or “naturalization”. Based on a study with PHC unit professionals in Rio de Janeiro, Santos et al.²⁵25 Santos RSD, Mourão LC, Almeida ACV, Daher DV, Santos KMD, Brazolino LD. Nuances entre o Acesso Mais Seguro e o conflito armado no contexto da atenção básica. Cad Saude Publica 2020; 36(10):e00139519. stated that they noticed some “trivialization” of violence in the reports due to the recurring AV in the area. Fazzioni²⁸28 Fazzioni NH. Tiro que mata, tiro que "cura", tiro que fere: notas etnográficas sobre violência armada e direito à saúde. R Contemp Ant 2020; 47:167-190., in turn, problematizes the common sense idea that favela residents trivialize violence due to its high occurrence, to which we agree, extending the strangeness of such a narrative to health and education professionals. We ask here: Wouldn’t these be survival and protection strategies in the face of a daily life traversed by AV?

This question can be answered by Dejours³⁵35 Dejours C. A loucura do trabalho: estudo de psicopatologia do trabalho. São Paulo: Cortez Oboré; 1992. when he states that, in the face of adversity and challenges imposed by working conditions, individual and collective defensive strategies are developed so that suffering can be controlled and relieved³⁵35 Dejours C. A loucura do trabalho: estudo de psicopatologia do trabalho. São Paulo: Cortez Oboré; 1992.. This fact is corroborated by Morais²⁴24 Morais KB. Trabalho e sau´de de professores(as) de escola pu´blica em territo´rio de viole^ncia armada: sobre cenas da vive^ncia docente [dissertac¸a~o]. Rio de Janeiro: Fiocruz/Ensp; 2021., who points to the “naturalized” armed violence as a defensive strategy used by teachers to protect themselves from suffering and continue their work routines.

Regarding Safer Access, Santos et al.²⁵25 Santos RSD, Mourão LC, Almeida ACV, Daher DV, Santos KMD, Brazolino LD. Nuances entre o Acesso Mais Seguro e o conflito armado no contexto da atenção básica. Cad Saude Publica 2020; 36(10):e00139519. and Flórido et al.²⁷27 Flórido HG, Duarte SCM, Floresta WMC, Marins AM F, Broca PV, Moraes JRMM. Gerenciamento das situações de violência no trabalho na estratégia de saúde da família pelo enfermeiro. Texto Contexto Enferm 2020; 29:e20180432. highlight its importance in risk management and preventing or reducing incidents involving workers, giving health units greater safety at work and autonomy in evaluating and making decisions. Another important task of the AMS is to justify to management any failure to meet the targets set for the clinics, which also appears to be a concern in the Manguinhos study. According to Santos et al.²⁵25 Santos RSD, Mourão LC, Almeida ACV, Daher DV, Santos KMD, Brazolino LD. Nuances entre o Acesso Mais Seguro e o conflito armado no contexto da atenção básica. Cad Saude Publica 2020; 36(10):e00139519., this methodology also helps to avoid trivializing AV in the community where the service is located since it legitimizes the disrupted activities.

Education professionals also suffer from the AV impacts on their health and work processes: teachers who monitor its occurrence via WhatsApp communication manage risky situations by identifying safer places to protect themselves and their students, and schools that change their operations and close down. Santos and Silva²⁶26 Santos LC, Silva CAF. Conseque^ncias da viole^ncia armada carioca para as aulas de Educac¸a~o Fi´sica. Movimento 2020; 26:e26036. identify “subtle reflexes” such as changes in student behavior, teachers’ laments, the symbolic presence of weapons in classes, and the “ghost effect” - a very low quorum of students.

This scenario includes enormous harm to the learning of children and adolescents and the functioning of families, whose members need their children to be at school to work. Santos²³23 Santos LC. Viole^ncia armada e escola pu´blica: desafios a` atuac¸a~o do professor em favelas do Rio de Janeiro [dissertac¸a~o]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2022. and Santos and Silva²⁶26 Santos LC, Silva CAF. Conseque^ncias da viole^ncia armada carioca para as aulas de Educac¸a~o Fi´sica. Movimento 2020; 26:e26036. also identified fear, tiredness, anxiety, and depression in a study of female teachers in Rio de Janeiro. In a study with teachers at a school in Manguinhos, Morais²⁴24 Morais KB. Trabalho e sau´de de professores(as) de escola pu´blica em territo´rio de viole^ncia armada: sobre cenas da vive^ncia docente [dissertac¸a~o]. Rio de Janeiro: Fiocruz/Ensp; 2021. reports how they feel in a “war scenario”, always at risk, which causes distress, illness, sick leave, and absence from work.

Santos²³23 Santos LC. Viole^ncia armada e escola pu´blica: desafios a` atuac¸a~o do professor em favelas do Rio de Janeiro [dissertac¸a~o]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2022. identified the existence of the AMS protocol in some schools and the use of the “Emergency Pedagogy”, “which aims to prioritize the school environment as a receptive place for young people who frequently witness urban violence” (p. 59). Despite not applying the protocol, as with the research participants in Manguinhos, other schools have contingency plans and other strategies based on communication and collective action²⁴24 Morais KB. Trabalho e sau´de de professores(as) de escola pu´blica em territo´rio de viole^ncia armada: sobre cenas da vive^ncia docente [dissertac¸a~o]. Rio de Janeiro: Fiocruz/Ensp; 2021..

We should emphasize that the AV impacts cannot be decontextualized from the permanence of structural violence and racism that permeate Brazilian society and keep inequalities dramatically exposed in the living spaces of the most impoverished population in large cities - where schools and health services are allowed to close or change their functioning constantly. We see illnesses and layoffs of health professionals and teachers, preventing the population’s full access to social rights⁹9 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Sumário executivo: violência armada e saúde: investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2020.^,1010 Silva MM, Ribeiro FML, Frossard VC, Souza R, Schenker M, Minayo MCS. "No meio do fogo cruzado": reflexões sobre os impactos da violência armada na Atenção Primária em Saúde no município do Rio de Janeiro. Cien Saude Colet 2021; 26(6):2109-2118.^,1818 Muniz JO, Almeida RR. Respondendo às balas: segurança pública sob intervenção das palavras entrevista com Jacqueline Muniz. Trab Linguist Apl 2018; 57(2):993-1014.^,1919 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, Almeida BC. Lives Violência armada e saúde: documento síntese. Pesquisa Conflitos armados e saúde - investigando os sentidos e os impactos da violência entre moradores e trabalhadores da saúde e da educação em Manguinhos/Rio de Janeiro/RJ - estudo de caso. Rio de Janeiro: Fiocruz/Ensp/Claves; 2021..

Living with AV, on the other hand, has led the population and services to attempt to self-organize into a network in order to determine how to act in times of violent episodes to guarantee the survival of all and the functioning of health and education actions. In our research, we came across the ADPF of the Favelas, filed in November 2019 and which came into force in June 2020, restricting police operations in Rio de Janeiro during the pandemic.

Built collectively by several favela movements and public and private institutions, it aimed to denounce the violations of constitutional rights resulting from the security policy pursued by the State and demand answers that would curb this escalation. Given the reduction in AV incidents in Manguinhos during its time in force, we can say that it positively affected and effectively curbed the expressed violence.

During our fieldwork, we could record the impact of a double tragedy - armed violence and the pandemic - and its effects on health and education professionals who attempted to survive both. The words of a family and community doctor, who at the time worked in one of the PHC services in Manguinhos, are highly illustrative of the rule of being “absolutely hypervigilant”:

At one point, around 5 pm, we heard gunshots... we looked at each other. It wasn’t possible. This difficulty was no longer possible. A police operation in the middle of quarantine wasn’t possible. It wasn’t possible that our COVID-themed day would take on such contours. I thought the universe wanted to remind us that we’re not Italy. That we are more Ecuador, we are South, in a slum, and that the genocidal policy that kills the poor and Black people is not in quarantine. On the contrary. [...] Roberta’s (patient) impulse was to throw herself off a high stretcher. She looked in the window and saw the shots very close up. The men with guns were running. Yes, remember that I’ve already said that our biosecurity depends on the few windows in the unit, and this room had one window³⁶36 Esteves J. Colapso [Internet]. 2020. [acessado 2023 jun 11]. Disponível em: https://causosclinicos.wordpress.com/2020/04/29/colapso/
https://causosclinicos.wordpress.com/202... (s/p).

Social participation in formulating individual and collective coping, protection, and care strategies is a tool of resistance and care for oneself and the population for the joint construction and the possibility of being and circulating in the territory. However, participating professionals expressed how macro-political changes are required for a structural modification of the conditionalities intricate in the production of AV that affects community services and the health of professionals and residents.

Final considerations

Armed violence is strongly present in Manguinhos, as in so many other territories where the guarantees of the democratic rule of law and the respect for human rights are exceptions. We should underscore that its expressions and impacts on people, services, and territory cannot be decontextualized from the structural violence and racism that preserve social and racial inequalities linked to poverty and health inequalities.

The structural and institutional racism maintained by the whiteness culture is reflected in the indicators with material and subjective impacts on the population, territories, and services. The AV-related morbimortality rates in Brazil show the consequences of this violence, especially on the favela population and their services. Other expressions are mass incarceration, trivialized executions of young Black men, police violence, the deadliness of massacres, and firearm-related deaths and injuries among children.

As illustrated by the results of the survey, the health system is hugely impacted by the effects of AV, which affects individual and collective health, causes deaths, injuries, physical and mental trauma, reduces the quality of life of people and communities, generates new issues for medical care and services, and highlights the need for interdisciplinary, multi-professional, intersectoral and socially engaged prevention and treatment³⁷37 Minayo MCS, Souza ER, Silva MMA, Assis SG. Institucionalização do tema da violência no SUS: avanços e desafios. Cien Saude Colet 2018; 23(6):200720-16..

Workers from several sectors, social movements, and civil society have constantly denounced the rampant recurrence of AV in favela territories, tirelessly publicizing the abusive public security policy. Some tools to control police action have shown results in reducing AV-associated deaths and morbidities, such as the ADPF.

It is essential to shed light on the AV impacts on the State public security policy and the urgency of reviewing it, besides the need to invest in formulating preventive and protective public policies based on the defense of constitutionally guaranteed rights. Some of the limitations of the research point to prospects that would give rise to further study of the subject, such as the inclusion of groups of professionals from other territories and sectors, such as social assistance. Furthermore, we believe that analyses that look more closely at the impact of violence on subjects and territories based on social markers of race/skin color and gender are essential for a better understanding of the issue in all its complexity.

References

Publication Dates

History