Abstract

Introduction

Violence is a complex, intersectional and historically determined social problem that represents a violation of human rights. The high number of homicides in Brazil¹1 Cerqueira D, Bueno S, coordenadores. Atlas da violência 2023. Brasília: Ipea, FBSP; 2023. demonstrate its centrality in producing illnesses and deaths that cause great suffering and have economic and social impacts. Gun violence is responsible for most homicides in the country, with a percentage growth of those perpetrated by firearms (FA) from 40% to 71% between 1980 and 2016²2 Cerqueira D, coordenador. Atlas da violência 2018. São Paulo: FBSP; 2018., which remained practically stable until 2021¹1 Cerqueira D, Bueno S, coordenadores. Atlas da violência 2023. Brasília: Ipea, FBSP; 2023.. In addition to the deaths, there are important consequences for the morbidity that affects survivors of gun violence, their relatives and neighbors, such as disabilities and often invisible marks that show up in mental suffering³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.

4 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.^-55 Araujo VS, Souza ER, Silva VLM. “Eles vão certeiros nos nossos filhos”: adoecimentos e resistências de mães de vítimas de ação policial no Rio de Janeiro, Brasil. Cienc Saude Colet. 2022; 27:1327-36..

However, this striking feature of our culture does not reach the population homogeneously, but affects, above all, vulnerable groups due to social inequalities, composed, to a large extent, of young, black, and poor men¹1 Cerqueira D, Bueno S, coordenadores. Atlas da violência 2023. Brasília: Ipea, FBSP; 2023.^,66 Flauzina ALP. Corpo negro caído no chão: o sistema penal e o projeto genocida do Estado brasileiro. Rio de Janeiro: Contraponto; 2022.. The percentage of homicides in the country is concentrated in the black population, which has represented on average 70% of victimization, reaching 77% in 2021. Although we have observed a reduction in homicides between 2018 and 2021, this phenomenon is concentrated at the non-black population. The risk of death from this cause – 2.9 times higher for the black population – shows the racial inequality of violence¹1 Cerqueira D, Bueno S, coordenadores. Atlas da violência 2023. Brasília: Ipea, FBSP; 2023.. The prevalence of gun violence affecting this population expresses the perpetuation of a colonial power dynamic whose hallmarks are violence and expropriation⁷7 Santos BS. Para além do pensamento abissal: das linhas globais a uma ecologia de saberes. In: Santos BS, Meneses MPG, organizadores. Epistemologias do Sul. Coimbra: Almedina; 2014, p. 23-71.. We believe that the concept of structural racism is fundamental in this context since more than ¾ of the country’s history is marked by the enslavement of Africans who were brought by force, raped, and expropriated of their lives, set free late in life without any kind of access to a reconciliation policy that would promote minimum living conditions. Thus, structural racism is expressed in four main dimensions of social life: economic, which concerns the reproduction of material life; legal, related to the norms that guide the way society works; institutional, related to how social institutions work; and ideological, which touches on the social imaginary⁸8 Almeida SL. O que é racismo estrutural? Belo Horizonte: Letramento; 2018..

Racism legitimizes colonial relations that are perpetuated subjectively and materially, giving basis to the reproduction of hierarchical and unequal power relations that delimit differentiated spaces of socioeconomic, political, and institutional action based on phenotypic characteristics, where the black population is at the base of the pyramid of exploitation and subjugation⁷7 Santos BS. Para além do pensamento abissal: das linhas globais a uma ecologia de saberes. In: Santos BS, Meneses MPG, organizadores. Epistemologias do Sul. Coimbra: Almedina; 2014, p. 23-71.^,99 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. 117-42.. Although there are no “races”¹⁰10 UNESCO. The race question: publication 791 [Internet]. Paris: UNESCO; 1950 [citado 3 Maio 2023]. Disponível em: https://unesdoc.unesco.org/ark:/48223/pf0000128291
https://unesdoc.unesco.org/ark:/48223/pf... from a biological perspective, racism, as a social phenomenon, is extremely present in social relations in Brazil and has profound and perverse consequences of creating spaces of vulnerability, zones of nonbeing¹¹11 Fanon F. Pele negra, máscaras brancas. Salvador: EDUFBA; 2008., where human dignity is not considered and life is reduced to bare life¹²12 Agamben G. Homo sacer: o poder soberano e a vida nua. Belo Horizonte: UFMG; 2002., institutionalizing and legitimizing violence.

The political intentionality of the action of the State of Rio de Janeiro in the favelas has been marked by exclusion and violence. They are scapegoats for social problems, whose dangerous agent is in the figure of the young black man as an enemy to be fought. This is a social production of structural racism that feeds institutional racism updated daily by justice and police institutions. Through the systematic (re)production of ethnic-racial segregation through everyday discriminatory norms, practices, and behaviors, racism reifies disadvantages and discrimination against the black population¹³13 Brasil. Ministério da Saúde. Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: Ministério da Saúde; 2013., particularly regarding the absence of effective citizen public security.

Considering the case of the state of Rio de Janeiro, it can be stated that the favelas and peripheries of the cities have the configuration of a state quite different from the idea of a modern social contract, in which the state has the power to control violence¹⁴14 Weber M. Ciência e política: duas vocações. São Paulo: Cultrix; 2011.. Usually, these territories, mostly occupied by black people, are target of daily violent approaches by security forces and by armed groups that control the territory¹⁵15 Zaluar A, Barcellos C. Mortes prematuras e conflito armado pelo domínio das favelas no Rio de Janeiro. Rev Bras Cienc Soc. 2013; 28(81):17-31.. The alleged power of the State is porous and is exercised through negotiations between public actors – mainly members of the police forces, but not only – and actors belonging to armed groups – such drug dealers and militias, which configuring a violent sociability¹⁶16 Silva LAM. Sociabilidade violenta: por uma interpretação da criminalidade contemporânea no Brasil urbano. Soc Estado. 2004; 19(1):53-84. marked by the omnipresence of gun violence. In these spaces, a vicious cycle of gun violence is reproduced, and it affects generations of residents and, to a lesser extent, local workers/ services³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020..

Gun violence is an issue in many societies, and it has economic and social tolls. Conflicts involving economic and political interests, territorial disputes, religion, among other factors, are carried out and sometimes articulated by governments, organized groups, drug trafficking, militias, and public security forces. In such situations, FA, weapons with an enormous diversity of destructive power, are used to dominate or exterminate those considered enemies. In 2017, there were over one billion FA worldwide, the vast majority in the hands of civilians (85%). In Brazil, there were 17.510.000, or 8,3 guns per 100 people, less than half of which were registered (n=8.080.295)¹⁷17 Small Arms Survey. Global firearms holdings [Internet]. Geneva: Small Arms Survey; 2020 [citado 18 Out 2023]. Disponível em: https://www.smallarmssurvey.org/database/global-firearms-holdings
https://www.smallarmssurvey.org/database... . According to estimates, in the country, there are 7,5 times more FA in civilian hands, compared with security forces, which followed increased access to ammunition¹⁸18 Pellanda A, Santos CA, Dadico CM, Cara D, Madi FR, Orsati FT, et al. Relatório ao governo de transição: o ultraconservadorismo e extremismo de direita entre adolescentes e jovens no Brasil, ataques às instituições de ensino e alternativas para a ação governamental [Internet]. São Paulo: Campanha Nacional pelo direito à educação; 2022 [citado 18 Out 2023]. Disponível em: https://campanha.org.br/acervo/relatorio-ao-governo-de-transicao-o-ultraconservadorismo-e-extremismo-de-direita-entre-adolescentes-e-jovens-no-brasil-ataques-as-instituicoes-de-ensino-e-alternativas-para-a-acao-governamental/
https://campanha.org.br/acervo/relatorio... , especially after the legislative changes that occurred during the Bolsonaro administration (2019-2022).

Regarding attention to the impacts of gun violence on the health of vulnerable populations, the international literature is still incipient, focusing on the problems of public security and urban violence from a macro-politics perspective, in which we point out the relevance of this contribution. In addition, much of the international scientific and political production focuses on situations characterized as “armed conflicts”, whose norms are established and exclude allegedly minor forms of violence such as civil disturbances, riots, isolated acts of terrorism and sporadic violence that occur in contexts of peace¹⁹19 Comitê Internacional da Cruz Vermelha. Como o Direito Internacional Humanitário define “conflitos armados”? [Internet]. Brasília: CICV; 2008 [citado 20 Abr 2022]. Disponível em: https://www.icrc.org/sites/default/files/external/doc/pt/assets/files/other/rev-definicao-de-conflitos-armados.pdf
https://www.icrc.org/sites/default/files... ^,2020 Hamann-Nielebock E, Carvalho IS. A violência armada e seus impactos sobre a população civil: um fardo necessário? Rev Bras Seg Publica. 2012; 2(1):104-18..

In this context, which Moura²¹21 Moura T. Novíssimas guerras, novíssimas pazes. Desafios conceptuais e políticos. Rev Crit Cienc Soc. 2005; 71:77-96. calls “newest wars”, a new type of organized gun violence is developed, and although it occurs locally, it manifests itself globally in “undefined zones, where war and peace are blurred”²¹21 Moura T. Novíssimas guerras, novíssimas pazes. Desafios conceptuais e políticos. Rev Crit Cienc Soc. 2005; 71:77-96. (p. 81). Thus, forms of urban violence are intensified in circumscribed territories, but in a context of institutionalized peace. Latin America is one of the most expressive scenarios of this type of violence. Social inequality, poverty, low economic growth, unemployment, disorderly urban growth, the inefficiency of public services, growing availability of light weapons, illicit drug trafficking, presence of armed groups controlling territories, culture of violence, and corrupt or ineffective state security forces construct a scenario where, in certain spaces of the city, for a given population profile, the rates of violence are close to or even exceed those of countries at war.

A recent literature review on Latin American production regarding the relationship between gun violence and health²²22 Ribeiro FML, Andrade CB, Dias CAO, Almeida BC. Violência armada e saúde na América Latina: revisão de literatura. Rev CS. 2023; 40:141-79. identified studies that sought to map and record the impacts of gun violence on vulnerable populations. It is noteworthy that in the region, young people, especially black people and residents of the peripheries, were identified as an extremely exposed group, which accounts for illnesses and deaths, also showing the structural and institutional racism already mentioned.

Methodology

The article shows the accumulation of empirical research by the authors in the area of Violence and Health, in an interdisciplinary dialogue with the fields of Public Health and Psychology and with the national and international literature. From these various experiences, we seek to weave a critical analysis of a problem recurrently identified in our research praxis, bringing as a contribution the post-colonial approach that helps to reflect on the relationship between racism and gun violence in the context of Brazil and Rio de Janeiro and its effects on the mental health of those who live and work in favela territories highly impacted by this violence. Therefore, the investigation conducted by us³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.^,2323 Silva MM. Controle de substâncias ilícitas e seus impactos em violência e saúde: estudo de caso no Rio de Janeiro (Brasil) e Lisboa (Portugal) [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2023.

24 Silva M, Gonçalves LF, Freitas H. Padrões de violência urbana e determinação social no município do Rio De Janeiro [Internet]. In: Anais do 14o Congresso Internacional da Rede Unida. Saúde em Redes; 2020; Rio de Janeiro. Rio de Janeiro: 2020 [citado 29 Maio 2021]. Disponível em: https://www.redeunida.org.br/pt-br/evento/8/standalone/anais/?title=10372
https://www.redeunida.org.br/pt-br/event...

25 Ribeiro FML, Silva MM, Andrade C, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. Lives violência armada e saúde. Catálogo pesquisa violência armada e saúde. Rio de Janeiro: Fiocruz; 2021.

26 Serpelon F, Radtke K, Assis S, Henning F, Nätt D, Elbert T. Grandmaternal stress during pregnancy and DNA methylation of the third generation: an epigenome-wide association study. Transl Psychiatry. 2017; 7(8):e1202.

27 Serpeloni F, Radtke KM, Hecker T, Sill J, Vukojevic V, Assis SG, et al. Does prenatal stress shape postnatal resilience? An epigenome-wide study on violence and mental health in humans. Front Genet. 2019; 10:269.

28 Avanci J, Serpeloni F, Oliveira TP, Assis SG. Posttraumatic stress disorder among adolescents in Brazil: a cross-sectional study. BMC Psychiatry. 2021; 21(1):75.

29 Serpeloni F, Narrog JA, Assis SG, Avanci JQ, Carleial S, Köbach A. Narrative exposure therapy versus treatment as usual in a sample of trauma survivors who live under ongoing threat of violence in Rio de Janeiro, Brazil: study protocol for a randomised controlled trial. Trials. 2021; 22(165):1-10.^-3030 Serpeloni F, Narrog JA, Pickler B, Avanci JQ, Assis S, Koebach A. Terapia de exposição narrativa para o tratamento do transtorno de estresse pós-traumático com pessoas que passaram por violência doméstica e comunitária: estudo de série de casos em dois centros de saúde no Rio de Janeiro, Brasil. Cienc Saude Colet. 2023; 28:1619-30. are the basis of the analysis, seeking to make racism visible as a central element in engendering violence and its impacts on health. The objectives, methodologies, and main results, as well as compliance with ethical principles, such as the approval by Research Ethics Committees, can be checked in the referred material.

Gun violence in Rio de Janeiro

Gun violence includes various manifestations such as shootings, clashes, “stray bullets”, sniper action, the ostensibility of FA exposure, threats with FA to control the territory or robberies, and use of explosives, among others³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020., which, in the state of Rio de Janeiro (RJ), is related to clashes between armed groups with control of territories, especially the so-called criminal groups that operate in the retail drug trade, militias, and public security forces¹⁵15 Zaluar A, Barcellos C. Mortes prematuras e conflito armado pelo domínio das favelas no Rio de Janeiro. Rev Bras Cienc Soc. 2013; 28(81):17-31.^,31.31 Silva J, Fernandes L-F, Willadino R. Grupos criminosos armados com domínio de território. In: Justiça Global, organizador. Segurança, tráfico e milícias no Rio de Janeiro. Rio de Janeiro: Justiça Global; 2008. p. 16-24..

In Rio de Janeiro, favelas and other vulnerable territories accumulate precariousness related to ineffectiveness in providing basic social rights. Even though they are heterogeneous spaces, they are generally marked by low health coverage, poor access to urban mobility, the presence of unhealthy housing and non-universal coverage of urban equipment such as health and education. On the other hand, the experience of episodes of gun violence is often recurrent, which increases the risk of being targeted by FA and implies changes in the operation of health services, education, and public transport, representing a violation of rights that impacts mental health³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.

4 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.^-55 Araujo VS, Souza ER, Silva VLM. “Eles vão certeiros nos nossos filhos”: adoecimentos e resistências de mães de vítimas de ação policial no Rio de Janeiro, Brasil. Cienc Saude Colet. 2022; 27:1327-36.^,3232 Fazzioni NH. Tiro que mata, tiro que “cura”, tiro que fere: notas etnográficas sobre violência armada e direito à saúde. Antropolítica. 2020; 47:168-90..

Since the 1980s, in Brazil and Rio de Janeiro, we have observed the consolidation of a fundamental element in this field: the drug trafficking³³33 Zaluar A, Noronha JC, Albuquerque C. Violência: pobreza ou fraqueza institucional? Cad Saude Publica. 1994; 10 Supl 1:213-7., whose confrontation has occurred through a militarized strategy based on the idea of the War on Drugs. In Rio de Janeiro, the police concentrate their operations in areas where drug trafficking is present¹⁵15 Zaluar A, Barcellos C. Mortes prematuras e conflito armado pelo domínio das favelas no Rio de Janeiro. Rev Bras Cienc Soc. 2013; 28(81):17-31., with the justification of combating the armed groups responsible for this trade³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.^,2323 Silva MM. Controle de substâncias ilícitas e seus impactos em violência e saúde: estudo de caso no Rio de Janeiro (Brasil) e Lisboa (Portugal) [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2023.. The repressive action focused on small dealers of illicit substances and not on large drug dealers and money launderers is criticized, which evidences the perverse way in which vulnerable youth are entangled in the plots of violence and penalized both by disputes between armed criminal groups and police violence²³23 Silva MM. Controle de substâncias ilícitas e seus impactos em violência e saúde: estudo de caso no Rio de Janeiro (Brasil) e Lisboa (Portugal) [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2023.. Even after four decades of investment, this security policy has not managed to achieve the reduction of violence or the end of drug trafficking; however, the impacts on generations of favela residents are perpetuated.

The scenario of extreme and permanent violence is one of the factors that led to the strengthening of militias, groups that grew from the “provision” of “protection” services to the population in precarious territories in the face of the ineffectiveness of their guarantee by the State. This “offer”, however, comes with FA threats, imposing the obligation to pay fees to have access to protection and basic services¹⁵15 Zaluar A, Barcellos C. Mortes prematuras e conflito armado pelo domínio das favelas no Rio de Janeiro. Rev Bras Cienc Soc. 2013; 28(81):17-31.. A recent map shows a significant presence of these groups in the territorial geography of the state³⁴34 GENI. Grupo de Estudos dos Novos Ilegalismos. Mapa dos Grupos Armados do Rio de Janeiro. Rio de Janeiro: Universidade Federal Fluminense; 2020 [citado 20 Maio 2024]. Disponível em https://geni.uff.br/2022/09/13/mapa-historico-dos-grupos-armados-no-rio-de-janeiro/
https://geni.uff.br/2022/09/13/mapa-hist... .

The presence of armed groups with control of territory and the violent action of the police against them¹⁵15 Zaluar A, Barcellos C. Mortes prematuras e conflito armado pelo domínio das favelas no Rio de Janeiro. Rev Bras Cienc Soc. 2013; 28(81):17-31. establishes a regime of unequal power relations, in addition to the statutes of democratic legality, which grants the strongest party the power of the veto over the life of the weakest party, called social fascism⁷7 Santos BS. Para além do pensamento abissal: das linhas globais a uma ecologia de saberes. In: Santos BS, Meneses MPG, organizadores. Epistemologias do Sul. Coimbra: Almedina; 2014, p. 23-71..

The favela has historically been targeted with classist and racist stereotypes that criminalize its population. Such stereotypes, repeated and naturalized to exhaustion, create a kind of social permissiveness with public opinion, which sees violence as “something common”, and “part of daily life”, which ends up legitimizing the way security policy is operated. The trivialization of discourses such as “good thieves are the ones who are dead” and “human rights for correct humans” illustrates the population’s intolerance of everyday criminality and its agents and shows traces of authoritarianism, as well as partial and reductionist understanding of the problem. The political insistence on selective, unequal, and violent public security materializes the social representation that insists to recursively affirm the favela as a place of danger and dangerous people.

Thus, the enterprise of “war” aimed at armed drug trafficking groups is legitimized, but it affects the entire population that lives and works there. The metaphor of “war” is fruitful for analysis: in a war, civil rights are suspended, and a state of exception is installed³⁵35 Agamben G. Estado de exceção. São Paulo: Boitempo; 2004., where deaths are “side effects” that, even unwanted, are accepted. We live in a “war” (officially “against drugs”) that has been perpetuated for 40 years, feeding a vicious cycle of violence where the rates of death, health issues, and precarious life are higher in a population already more socially vulnerable.

Impacts of gun violence on health

Morbidity and mortality related to gun violence have enormous impacts on territories in conflict. This category refers to spaces with frequent confrontations and overrepresentations of firearm injuries. Although violence is spread throughout the city, posing a risk to the entire population, the “measure” of this risk is extremely unequal, chronically affecting such territories and black male bodies. Data from the Mortality Information System of the Brazilian Ministry of Health show that in the different health areas in the municipality of RJ, the areas whose population has the highest purchasing power and is mostly white are those that suffer the lowest impacts of gun violence²⁴24 Silva M, Gonçalves LF, Freitas H. Padrões de violência urbana e determinação social no município do Rio De Janeiro [Internet]. In: Anais do 14o Congresso Internacional da Rede Unida. Saúde em Redes; 2020; Rio de Janeiro. Rio de Janeiro: 2020 [citado 29 Maio 2021]. Disponível em: https://www.redeunida.org.br/pt-br/evento/8/standalone/anais/?title=10372
https://www.redeunida.org.br/pt-br/event... . It is worth remembering that when gun violence eventually happens in these territories and affects a white body, it causes commotion and revolt, which does not happen in favelas and peripheries, where its occurrence and effects are trivialized and made invisible.

Regarding mental health, in this article, we work with a conception not focused only on individual suffering. Rather, individual issues are overdetermined by the relationship of people with society and the contradictions that cross it and that are related to the various social, economic, and political determinations that, in societies marked by colonization, have a common inflection point in racism³⁶36 Passos RG. “Crimes da paz”: as expressões do racismo na saúde mental da população negra. In: Magno PC, Passos RG, organizadores. Direitos humanos, saúde mental e racismo: diálogos à luz do pensamento de Frantz Fanon. Rio de Janeiro: Defensoria Pública do Estado do Rio de Janeiro; 2020. p. 72-83. – especially when mental suffering is related to violence. Racism, in addition to determining inequalities in the form of social insertion of racially oppressed groups, is inscribed in the collective unconsciousness and reproduces situations of physical and symbolic violence whose impacts on psychic dynamics are perverse¹¹11 Fanon F. Pele negra, máscaras brancas. Salvador: EDUFBA; 2008.^,3636 Passos RG. “Crimes da paz”: as expressões do racismo na saúde mental da população negra. In: Magno PC, Passos RG, organizadores. Direitos humanos, saúde mental e racismo: diálogos à luz do pensamento de Frantz Fanon. Rio de Janeiro: Defensoria Pública do Estado do Rio de Janeiro; 2020. p. 72-83.. It should be noted that studies on the impacts of racism on mental health (MH) are still an incipient academic field³⁷37 Damasceno MG, Zanello VML. Saúde mental e racismo contra negros: produção bibliográfica brasileira dos últimos quinze anos. Psicol Cienc. 2018; 38(3):450-64., which has been growing little by little.

Gun violence affects how individuals perceive the world and themselves, as well as how they raise their hopes or express exasperation regarding the future. Its direct consequences include deaths, serious injuries, suffering, and physical and mental illness; the indirect ones imply daily challenges of living in unsafe environments, losing family members, and having unstructured health, education, and social support services³⁸38 Kadir A, Shenoda S, Goldhagen J, Pitterman S. The effects of armed conflict on children. Pediatrics. 2018; 142(6):e20182585..

Research carried out in Manguinhos³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020. and Complexo do Alemão³²32 Fazzioni NH. Tiro que mata, tiro que “cura”, tiro que fere: notas etnográficas sobre violência armada e direito à saúde. Antropolítica. 2020; 47:168-90., both favela complexes in Rio de Janeiro, identified situations of risk and impacts on the MH of managers and workers of health services, education, and civil society organizations, and among the residents. Manifestations of mental suffering include feelings of vulnerability, anguish, fear, stress, discouragement, despair, emotional instability, insomnia, anxiety disorders, panic episodes, depression, lethargy, paralysis, crying, sensitivity to sounds that resemble shots, Post Traumatic Stress Disorder (PTSD), feeling of impotence, emotional exhaustion and burnout, excessive tiredness, use/abuse of medications, worsening of health conditions, headaches and stomachaches, tachycardia, onset or uncontrolled blood pressure and diabetes and skin bruises at times of high stress³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.. The way security forces act play an important role in the illnesses, as illustrated by the speech of a young man:

The recurrence of the criminalization of black youth from the favela brings up inferiority complex and low self-esteem, leading to the feeling of not belonging and being less important. However, state security forces are a relevant social actor together with other armed groups. It is noteworthy that “both expressions of violence are silenced for fear of reprisals, especially those related to the local factions, since reporting it may pose a risk to life”⁴4 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020. (p. 11).

Many families in territories affected by gun violence have lived for generations with adversity related to violence. A study carried out in the city of São Gonçalo, in the state of RJ, revealed that three generations reported having seen or heard shots being fired, people killed on the streets in the neighborhood, and drug trafficking²⁶26 Serpelon F, Radtke K, Assis S, Henning F, Nätt D, Elbert T. Grandmaternal stress during pregnancy and DNA methylation of the third generation: an epigenome-wide association study. Transl Psychiatry. 2017; 7(8):e1202.. It is noteworthy the high exposure to violence during pregnancy, a sensitive period for women and children²⁷27 Serpeloni F, Radtke KM, Hecker T, Sill J, Vukojevic V, Assis SG, et al. Does prenatal stress shape postnatal resilience? An epigenome-wide study on violence and mental health in humans. Front Genet. 2019; 10:269., and the co-occurrence of different types of violence, such as gun violence, intimate partner violence, domestic violence, and sexual violence²⁸28 Avanci J, Serpeloni F, Oliveira TP, Assis SG. Posttraumatic stress disorder among adolescents in Brazil: a cross-sectional study. BMC Psychiatry. 2021; 21(1):75..

The impacts of violence on mental health vary for each person and its effects depend on a complex articulation between several factors such as type and proximity to the event, frequency of exposure, life history, social support, race/ethnicity, gender, age, biological and cultural factors. Not all people who experience violence develop reactions associated with trauma. In Brazil, an epidemiological study in the capitals of Rio de Janeiro and São Paulo showed a conditional risk of 11% for the development of PTSD in adults; however, this rate is expected to be even higher in regions with higher rates of violence³⁹39 Luz MP, Coutinho ESF, Berger W, Mendlowicz MV, Vilete VMP, Mello MF, et al. Conditional risk for posttraumatic stress disorder in an epidemiological study of a Brazilian urban population. J Psychiatr Res. 2016; 72:51-57.. An important factor of struggle associated with trauma refers to the cumulative effect of events experienced, called building block⁴⁰40 Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T. Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry. 2004; 4(1):1-7., that is, the greater the number of exposures to violence, the greater the probability of developing post-traumatic stress. It is important to highlight the prevalence of co-occurrence of armed violence, police violence, and racial discrimination, leading to the development of racially based traumatic stress⁴¹41 Carter RT, Kirkinis K, Johnson VE. Relationships between trauma symptoms and race-based traumatic stress. Traumatology. 2020; 26(1):11-8..

Most people who go through situations of violence are struggling and often unable to share their stories. There is a conflict between not thinking about what happened and the need to express the extent of atrocities experienced⁴²42 Schauer M, Neuner F, Elbert T. Narrative exposure therapy: a short-term treatment for traumatic stress disorders. 2a ed. Göttingen: Hogrefe Publishing; 2011.. In addition to mental health, talking about experiences of violence also has social and political dimensions. However, the environment can often be little conducive to experiencing mourning and expressing the suffering and revolt caused by gun violence, with silencing, as is the case of territories marked by the overt and violent action of both security forces and armed groups³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020..

Although strongly present, gun violence often appears as a kind of “backdrop” in health care in favela territories, sometimes considered by some as “naturalized” by the population, sometimes made invisible by professionals, who question how to provide care due to the enormous complexity of situations³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.. Clinical action on the symptoms resulting from gun violence is fundamental to take care of people and reduce damage associated with violence, but it is insufficient as an isolated action, as the driving cause of illness is social and collective.

Often, people with symptoms of trauma-associated disorders are not identified in health services, mainly due to existing somatization. On the one hand, a high prevalence of traumatic stress is reported in health services. On the other hand, there is a clinical under-recognition of the phenomenon⁴³43 Silva HC, Rosa MM, Berger W, Luz MP, Mendlowicz M, Coutinho ES, et al. PTSD in mental health outpatient settings: highly prevalent and under-recognized. Braz J Psychiatry. 2019; 41(3):213-7.. Many people end up engaging in psychopharmacological treatments aimed at alleviating symptoms or comorbidities such as depression, anxiety, chronic pain, difficulty in sleeping, and hypertension, without considering their origins, and violence is again made invisible.

There is considerable medicalization of stress in the working classes, which ends up generating a cover-up and individualization of the causes of illness⁴⁴44 Valla VV. Pobreza, emoção e saúde: uma discussão sobre pentecostalismo e saúde no Brasil. Rev Bras Educ. 2002; (19):63-75.. Consequently, at the individual level, there is chronic struggle, greater dependence on health services, and high cost of drug treatment that affects both the user and the Brazilian National Health System (SUS) itself. Collectively, the costs that fall on the health care of users and professionals and on the operation of health units and services (and of education, social assistance, and organized civil society) that keep on being partially and completely closed due to episodes of gun violence are high. Activities are suspended, physical structures are damaged, and, consequently, there is a series of economic and social losses³3 Silva MM, Ribeiro FML, Frossard VC, Souza RM, 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. Cienc Saude Colet. 2021; 26(6):2109-18.^,44 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.. Losses from violence are estimated to reach 6% of the Brazilian Gross Domestic Product (GDP), an amount that corresponds to investment in education, with the “intangible costs” of homicides, which reach 2.5%, standing out as the greatest impacts⁴⁵45 Cerqueira D, coordenador. Atlas da violência 2019. São Paulo: IPEA, FBSP; 2019..

Coping actions

Despite having several implications for the mental health of the population, gun violence as a generator of struggle is not a direct object of public policies. Since 2001, the country has had a National Policy to Reduce Morbidity and Mortality from Accidents and Violence⁴⁶46 Brasil. Ministério da Saúde. Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Brasília: Ministério da Saúde; 2005., but in recent years the SUS has lost budget and the guarantee of programs and policies, which impacts the possibility of innovations in the area, especially in the mental health network, whose demand is much greater and more complex than the services offered can handle.

Some health units have mental health services that serve the population or have a multiprofessional team and, for more severe cases, SUS recommends care in Psychosocial Care Centers (CAPs). However, healthcare providers and the population point out the insufficiency of care actions in the face of the enormous demand and the need to expand and develop other strategies⁴4 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.. The retrograde and asylum-based movement that has gained strength in Brazil stands out, especially since 2018, when asylum care units and religious therapeutic communities began to receive a large part of the funding, to the detriment of SUS care structures, such as CAPs⁴⁷47 Ribeiro FML, Minayo MC. As mudanças na política brasileira de drogas: o avanço da lógica da justiça sobre a saúde. Cult Droga. 2020; 25(29):17-39.. This type of public funding has been criticized due to reports of violations of rights such as freedom of thought and religion⁴⁸48 Napolião P, Castro G. Imposição da fé como política pública: comunidades terapêuticas no Rio de Janeiro [Internet]. Rio de Janeiro: CESeC; 2022 [citado 5 Out 2023]. Disponível em: https://cesecseguranca.com.br/livro/imposicao-da-fe-como-politica-publica-comunidades-terapeuticas-no-rio-de-janeiro/
https://cesecseguranca.com.br/livro/impo... .

However, Rio de Janeiro’s society has been resisting and seeking to develop actions to combat gun violence, including the clinical perspective, the production of information by civil society and academic institutions, and the creation of broader resistance fronts, resulting from the struggle of social movements.

The NET-Narrative Exposure Therapy project was developed in Rio de Janeiro, and focused on training Primary Care professionals to identify, welcome, and offer clinical treatment to people who had experienced situations of violence and had post-traumatic stress²⁹29 Serpeloni F, Narrog JA, Assis SG, Avanci JQ, Carleial S, Köbach A. Narrative exposure therapy versus treatment as usual in a sample of trauma survivors who live under ongoing threat of violence in Rio de Janeiro, Brazil: study protocol for a randomised controlled trial. Trials. 2021; 22(165):1-10.. NET is a brief, evidence-based therapy developed for people who have experienced multiple trauma⁴²42 Schauer M, Neuner F, Elbert T. Narrative exposure therapy: a short-term treatment for traumatic stress disorders. 2a ed. Göttingen: Hogrefe Publishing; 2011.. As a result, reduction in post-traumatic stress was observed even six months after therapy was terminated³⁰30 Serpeloni F, Narrog JA, Pickler B, Avanci JQ, Assis S, Koebach A. Terapia de exposição narrativa para o tratamento do transtorno de estresse pós-traumático com pessoas que passaram por violência doméstica e comunitária: estudo de série de casos em dois centros de saúde no Rio de Janeiro, Brasil. Cienc Saude Colet. 2023; 28:1619-30.. NET was well received by health professionals, being viable in this context and with a high potential for dissemination. However, the instability of the political context, and lack of investment in training and human resources are obstacles to its sustainability in services in the long-term⁴⁹49 Catarino FC. Terapia de exposição narrativa: estudo de avaliabilidade em dois serviços de saúde no município do Rio de Janeiro [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2020..

Another important experience in the context of Rio de Janeiro is the proposal by the International Committee of the Red Cross, aimed at protecting health and education professionals located in areas at high risk of gun violence, in partnership with the Municipal Departments of Health and Education. Safer Access works based on a protection protocol, developed collectively with workers, aiming to reduce risks and damages related to armed violence⁴4 Ribeiro FML, Silva MM, Andrade CB, Nascimento MMS, Oliveira CA, Barbosa ICL, et al. 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; 2020.^,5050 Comitê Internacional da Cruz Vermelha. Manual orientador para gestores acesso mais seguro. Brasília: CICV; 2021 [citado 5 Out 2023]. Disponível em: https://www.icrc.org/pt/publication/manual-orientador-para-gestores-sobre-acesso-mais-seguro
https://www.icrc.org/pt/publication/manu... . This protocol provides for the change of operation of the services, ranging from the suspension of some activities to total closure.

A third set of initiatives takes place in the context of producing information on gun violence, such as the collaborative platforms Fogo Cruzado and Onde tem Tiroteio. Both deserve to be highlighted because they are initiatives of the organized civil society that have been denouncing the number of shootings, impacts, and where they occur and because they work as a strategy to protect the general population.

Several social movements have been pointing out the daily violence in vulnerable territories, acting in their confrontation. Movimento Moleque (Kid Movement), Mães de Manguinhos (Mothers from Manguinhos), Mães da Maré (Mothers from Maré), Rede de Comunidades e Movimentos contra a Violência (Community and Movement Networks Against Violence), Café das Fortes (Coffee of Strong Women), Mães Vítimas da Chacina da Baixada (Mothers Victim of the Baixada Massacre), Mães Vítimas de Violência do Estado (Mothers Victim of the State), Vidas Negras Importam (Black Lives Matter), Fórum Grita Baixada (Baixada Shouts Forum) and Parem de nos Matar (Stop Murdering Us) are some important actors who denounce gun violence and demand answers from the authorities. Also noteworthy is the important Policiais Anti-Facismo (Anti-Fascism Police) movement, which questions the state’s own action based on violence.

The work of social movements has sought to produce concrete interventions in public security policy. In November 2019, the Argument for Noncompliance with a Fundamental Precept (ADPF) No. 635, known as ADPF das Favelas, was filed in the Brazilian Federal Supreme Court (STF). Collectively developed by favela movements and public and private institutions, it aims to denounce violations of constitutional rights arising from the public security policy undertaken by the state of RJ and demand responses that contain this escalation⁵¹51 Brasil. Supremo Tribunal Federal. ADPF - Arguição de Descumprimento de Preceito Fundamental 635, de 19 de Novembro de 2019. Brasília: Supremo Tribunal Federal; 2019.. It has a structuring character and proposes to implement broad changes in the operation of public security services, encouraging compliance with the decision of the Inter-American Court of Human Rights in the case of Nova Brasília, regarding the establishment of goals and policies to reduce lethality and police violence, including the use of cameras in the uniforms and vehicles of police forces involved in operations. ADPF 635 has been an important action in confronting police violence and institutional racism, being a historic milestone in the visibility and efforts to control violence in the state’s public security policy.

Final considerations

The situation of gun violence in the state of Rio de Janeiro makes us reflect on the society we have and want. Over decades, the perpetuation of territories dominated by crime through FA and oppression of the population is a pressing issue to which our institutions have failed to provide answers. On the contrary, the security forces have repeatedly acted in an abusive manner; there have been successive reports of violations of rights. For decades, the criminalization of black territories and bodies and the logic of “bad guys” versus “good guys” has provided the basis for an escalation of gun violence, through militarized confrontations that do nothing more than perpetuate the situation and bring suffering and death to residents of favelas and peripheries, as well as to members of the security forces.

We are witnessing a logic of conflict resolution where the democratic rule of law and constitutional guarantees are nothing more than a distant promise. Conflicts are resolved by force by the most armed group that imposes power; rather, they are not resolved, but are perpetuated according to a reasoning where everyone loses. The recurrence of violence on black bodies and territories reifies a history of colonization based on the oppression and subjugation of enslaved people and their descendants.

The effects of these practices are profound, perpetuating themselves in several layers of physical and mental suffering. At the same time, the praise of violence is crystal clear in speeches, actions, and omissions of public authorities, despite the absence of results. There are no easy answers, but certainly more violence, denial of rights, and criminalization of black territories is not the solution. It is undeniable that racism, both structural and institutional, is an essential factor to keep this gear turning. As racism is rooted in the social structure, it is present in practices and also in the popular imagination, perpetuating violence and expropriations that mark the country and affect the black population.

Throughout this article, we sought to show several consequences of gun violence on the health of the population of Rio de Janeiro, present for decades and generations in the city. Its impacts are profound, affecting the health and, above all, the dignity of whole communities, devastated by the imminence of violence and death. Now, perhaps the consequences of this violence are a little more visible thanks to the resistance of social movements and civil society, which continue to work tirelessly to show the contradictions that shape society. These actors are usually advocates of “transforming mourning into battle”, and it is up to us at the academy to support and strengthen this battle. Finally, we end this text with a question by Marielle Franco, a councillor and activist who always fought against violence and became a symbol of this battle when she was a victim of gun violence and was cowardly murdered: “How many more people have to die for this war to end?”

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