The recent police raids unleashed by the São Paulo City Government, Brazil, in the areas known as cracolândias, or “cracklands” (a derogatory term, but widely used by the population and the mass media) deserve to be denounced immediately, as in the challenges to their legality and legitimacy in the courts, and analyzed in the medium and long term. The latter are essential, although usually overlooked, with serious consequences, precisely because the customary immediacy of such issues in Brazil means that the measures taken are invariably inconsistent with psychological and social processes that take longer and are more complex.

A now-classic article by McLellan et al. ¹1. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284:1689-95. highlights the profound mismatch between understanding and managing different chronic medical conditions (e.g. diabetes and hypertension) and the approach to serious addiction to alcohol and other drugs, legal and illegal, which obviously transcend the biomedical dimension, while sharing the slow evolution of chronic illnesses, frequently subject to relapses and even progressive worsening in certain individuals and contexts. It would be entirely unthinkable to demand that patients and health professionals “immediately” solve the diabetes “problem” in a given community or geographic region. Due to the striking interface with moral categories (such as a purported “lack of willpower”/victim-blaming) and psychosocial categories (including heavy stigmatization and marginalization), a substantial share of the population, from politicians to opinion-makers, view the pursuit of immediate and radically “effective” “solutions” as not only acceptable, but also desirable (to the point of posting their magic “solutions” via social networks).

Critics may exaggerate somewhat when they see “urban and ethnic cleansing” in Brazil, a complex, multiracial society marked by profound social inequalities, including and even mainly in the country’s megalopolises (although black men are overrepresented in various relevant Brazilian studies). Yet the urgent demand for measures to “eliminate” (some even say “eradicate”) the crack “problem” and “crackheads” evidently resonates with heinous concepts used to describe conflicts with a racist and sectarian basis, for example the Civil War currently waging in Syria.

There is also a clear juxtaposition in São Paulo, as elsewhere in the world, of interventions aimed at excluding undesirable groups from certain urban areas and “gentrification”, a form of urban renewal that inflates real estate values in certain neighborhoods by excluding the resident population, whether by forced eviction, mass expropriation, or substantial hikes in housing and local business costs. The neighborhood thus gains in sophistication (real or perceived) what it loses in affordability. Brazil’s history is ripe with such processes that bear no relationship whatsoever to drug use. Hence the simplistic logic of necessarily associating one issue with the other. A sad but well-documented example is the systematic destruction of Brazil’s historical heritage in favor of a presumed modernization of urban spaces (a particularly illustrative case was the demolition of the Church of São Pedro dos Clérigos, a symbol of baroque architecture in Rio de Janeiro) ²2. Prefeitura do Rio de Janeiro. Memória da destruição. Rio: uma História que se perdeu. Rio de Janeiro: Prefeitura do Rio de Janeiro; 2002..

It is quite common worldwide to simplistically equate the eviction of drug users and other marginalized population groups with a purported urban modernization. Precisely for this reason, programs for drug users that include shelters, building or renovation of housing units, and even subsidized rent have provided the basis for initiatives normally grouped under the heading of “housing first”, which have now been assessed by hundreds of studies worldwide. The vast majority of these assessments have been favorable, although the severity of various situations (such as advanced mental illness) hinders keeping these groups stably housed, even in high-income countries with exemplary social programs ³3. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet 2014; 384:1541-7..

The prioritization of abstinence as a condition for entering the program, rather than as desirable outcome (although not always feasible), goes against the very simple concept, but it is widely viewed as a quick solution by broad segments of public opinion. The contention is that a severely ill individual can, by some touch of magic, engage in treatment programs full of schedules, required attendance, and even complex short-term targets.

Heavy and regular crack users frequently experience serious respiratory and oral health problems, besides problems with short-term memory and coordination, since the substance is absorbed quickly and leads to intense effects in minutes or even seconds. But this does not make them “zombies”, since calling them such names violates their most fundamental rights as human beings. It labels them as social pariahs, as the object of scorn and discrimination, when they deserve solidarity and compassion. It is not difficult to draw parallels with various serious medical conditions, both historic (as in Hansen’s disease, formerly leprosy), or contemporary, such as degenerative neurological diseases, chronic pulmonary diseases etc.

Susan Sontag ⁴4. Sontag S. Illness as metaphor. In: Reiff D, editor. Essays of the 1960s and 1970s. Nova York: Library of America; 2015. p. 675-732.^,55. Sontag S. AIDS and its metaphors. In: Reiff D, editor. Later essays. Nova York: Library of America; 2017. p. 143-206. showed brilliantly in her essays on different diseases like tuberculosis, cancer, and AIDS that metaphors can be at least as lethal as the diseases themselves. But such metaphors can prove convenient for those hoping to impose measures on these groups against their own will. Such impositions deprive human beings of their properly human dimension, manipulating them acritically as things, scraps to be discarded.

Another dimension that often completely escapes analysts of Brazil’s long urban history is that marginalized populations using a wide variety of substances in public places have included children and adolescents sniffing glue and other solvents (a situation dating several years back and still persisting in some places). This drug habit is equally serious, associated with various harms and risks, especially in young people that are still growing and developing, in situations that are already adverse, such as serving time in juvenile detention centers ⁶6. Howard MO, Balster RL, Cottler LB, Wu LT, Vaughn MG. Inhalant use among incarcerated adolescents in the United States: prevalence, characteristics, and correlates of use. Drug Alcohol Depend 2008; 93:197-209..

Brazil’s current economic crisis jeopardizes the basic subsistence of a vast population contingent, including both drug users and non-users, hindering access to housing and food security and creating clusters in certain public spaces and a huge contingent of excluded Brazilians. Not by coincidence, when police raids are launched to round up homeless people, the latter show up in clinics supposedly specialized in persons with a wide variety of conditions, as chronical mental patients, as street vendors, or as families in search of their children or other missing relatives. I add here an anecdotal report of a case that occurred in a field survey I was coordinating several years ago, when an interviewer was arrested in a state in the North of Brazil and only released several days later. When I was finally contacted, I confirmed to the authorities that this colleague belonged to our team of interviewers. Curiously, our interviewer was complying faithfully with the established study protocol, wearing a t-shirt with the research institution’s logo, plus an ID badge. The police officer that took him to the precinct told him, “It’s better to arrest first and ask questions later, because it’s a lame excuse that the person works for some institution that supposedly has legitimate business in such places”.

Indiscriminate mass round-ups of individuals in these scenes have been followed by their compulsory detention or hospitalization, a counterproductive measure explicitly condemned by United Nations agencies ⁷7. Joint United Nations Programme on HIV/AIDS. Joint UN Statement calls for the closure of compulsory drug detention and rehabilitation centers. http://www.unaids.org/en/resources/presscentre/featurestories/2012/march/20120308adetentioncenters (acessado em 06/Jun/2017).
http://www.unaids.org/en/resources/press... and assessed as both ineffective and potentially associated with various human rights violations and harms, as shown in a recent systematic review ⁸8. Werb D, Kamarulzaman A, Meacham MC, Rafful C, Fischer B, Strathdee SA, et al. The effectiveness of compulsory drug treatment: a systematic review. Int J Drug Policy 2016; 28:1-9..

Intervention programs based on solid epidemiological and clinical evidence unfortunately fail to attract public attention, since they have shown not only some successes but also the inevitable failures of any measure aimed at controlling or mitigating serious and large-scale health conditions, as exemplified by the successive initiatives to control dengue or malaria, or at the individual patient level, treatments for cancer or chronic heart or kidney conditions. In such cases, the occasional failures or setbacks are never used to justify interventions like the recent spectacle in São Paulo, where the rallying cry is human degradation and demonstration of force.

Readers and policymakers (who will rarely expend their time and effort on the kind of reading that forces them to think, since they are always saturated with certainties) would benefit greatly from the sincere report by Gabor Maté ⁹9. Maté G. In the realm of the hungry ghosts: close encounters with addictions. Berkeley: North Atlantic Books; 2010., a Hungarian physician, naturalized Canadian. Gabor Maté offers a rare combination of reporting on his daily work with heavy users in Downtown Eastside Vancouver, Canada, permeated by small but relevant triumphs, but also devastating disappointments, and state-of-the-art science and a sincere and moving description of his own limitations and personal and professional weaknesses, as well as his biography as the son of prisoners of a Nazi concentration camp. Unfortunately, Brazil appears to lack people with the courage to expose their failures and limitations, since it is so much easier and profitable to flaunt quick fixes, even if they are fallacious.

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