Abstract

The collection of recyclable materials is an occupation with an increasing number of workers, who find in it a livelihood in a context of socioeconomic inequalities and unemployment. This article describes resistance strategies of women collectors who are part of an association in Northeast Brazil, in addition to describing how they managed health problems during the COVID-19 pandemic, especially regarding medicines. A quantitative and an ethnographic approach were used by collecting data on sociodemographic and medicines present in the homes of 13 participants and conducting participant observation and in-depth interviews. Amid the health crisis, the participants mentioned problems such as unemployment, gender relations, violence, and work stigmas. If, on the one hand, the pandemic has further increased vulnerability for certain population segments, on the other hand, it has enhanced collective resistance strategies. The collectors of the association organized to obtain various materials and benefits both for their headquarters and their neighborhood. We identified 58 units of medicines, prescribed and obtained mainly at the Basic Health Unit. Of these, 27.6% had action on the nervous system (analgesics, psycholeptics, and psychoanaleptics) and 17.2% on the cardiovascular system and on the alimentary tract and metabolism. The collectors developed self-attention practices with the medicines highlighting their central role in facing health problems.

Keywords:
Solid Waste Collectors; COVID-19; Resistance Strategies; Medicines; Health self-attention

Introduction

In Brazil, collecting recyclable materials became a source of income in large urban centers from the 1950s onwards. The production of waste from the growing Brazilian industrial hub meant that many unemployed people saw waste as a way of earning a living (Rocha; Francischett, 2021ROCHA, D. C.; FRANCISCHETT, M. N. Aspectos históricos e sociais do trabalho do(a) catador(a) de materiais recicláveis. Pesquisa em Educação Ambiental, [s.l.], v. 16, n. 1, p. 33-51, 2021.).

“I collect paper. I’m proving how I live!” is a phrase from the autobiography of Carolina Maria de Jesus (2014JESUS, C. M. Quarto de Despejo: diário de uma favelada. 10. ed. São Paulo: Ática, 2014., p. 20), a Black woman, a favela resident, and collector in São Paulo, who portrays the hard work of these people in terrible socioeconomic conditions, dealing with violence, stigma, and need to work in scavenging.

Excluded populations develop survival strategies to obtain their sustenance, with garbage collection as one of these possibilities. By collecting, separating, and transporting recyclable materials in dumping grounds, landfills, cooperatives, streets, and vacant lots, they begin to occupy new workspaces and build an essential source of income in times of high unemployment rates (Medeiros; Macêdo, 2006MEDEIROS, L. F. R.; MACÊDO, K. B. Catador de material reciclável: uma profissão para além da sobrevivência?. Psicologia & Sociedade, Recife, v. 18, n. 2, p. 62-71, 2006.; Cruz, 2020CRUZ, U. R. X. A relação entre o trabalho dos catadores de materiais recicláveis da rede de reciclagem do estado do Rio de Janeiro e a manutenção da indústria de reciclagem. Revista Tamoios, São Gonçalo, v. 16, n. 2, p. 117-142, 2020.; Rocha, 2020ROCHA, D. C. O contexto histórico-social do trabalho dos sujeitos da Associação de Catadores de Materiais Recicláveis de Dois Vizinhos-PR. 2020. 185 f. Dissertação (Mestrado em Educação) - Universidade Estadual do Oeste do Paraná, Francisco Beltrão, 2020.).

Worldwide, it is estimated that around 15 million people work in scavenging (Coelho et al., 2018COELHO, A. P. F. et al. Cargas de trabalho de catadoras de materiais recicláveis: proposta para o cuidado de enfermagem. Revista Gaúcha de Enfermagem, Porto Alegre v. 39, e2018-0006, 2018.). This activity has been recognized since 2002 in Brazil, appearing in the Brazilian Classification of Occupations as “Workers collecting and selecting recyclable material” (MTE, 2017MTE - MINISTÉRIO DO TRABALHO E EMPREGO; CBO - CLASSIFICAÇÃO BRASILEIRA DE OCUPAÇÕES. 5192-Trabalhadores da coleta e seleção de material reciclável. 2017. Disponível em: <Disponível em: http://www.mtecbo.gov.br/cbosite/pages/pesquisas/BuscaPorTituloResultado.jsf >. Acesso em: 30 jun. 2022.
http://www.mtecbo.gov.br/cbosite/pages/p... ). According to a 2012 study, 400,000 to 600,000 people worked collecting recyclables in the country at the time, 68.9% men and 31.1% women, with an average age of 39.4 years. Other relevant data from this study are that 66.1% were Black, 38.6% had some contractual employment relationship, and 93.3% lived in urban areas (Ipea, 2013IPEA - INSTITUTO DE PESQUISA ECONÔMICA APLICADA. Situação social das catadoras e dos catadores de material reciclável e reutilizável. Brasília, DF: IPEA , 2013. Disponível em: <Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/9979/1/situacao_social_mat_reciclavel_brasil.pdf >. Acesso em: 28 ago. 2022.
http://repositorio.ipea.gov.br/bitstream... ). Furthermore, it is estimated that 75% of professionals who work in solid waste sorting cooperatives are women, mostly Black, excluded from the formal job market, which tends to absorb male labor (Cherfem, 2016CHERFEM, C. O. Relações de Gênero e Raça em uma Cooperativa de Resíduos Sólidos: desafios de um setor. In: PEREIRA, B.C.J; GOES, F.L. (Org.). Catadores de Materiais Recicláveis: um encontro nacional. Brasília, DF: IPEA, 2016. p. 47-74.; Coelho et al., 2018COELHO, A. P. F. et al. Cargas de trabalho de catadoras de materiais recicláveis: proposta para o cuidado de enfermagem. Revista Gaúcha de Enfermagem, Porto Alegre v. 39, e2018-0006, 2018.). It is worth mentioning that female collectors have a lower average income than male in the same role (Ipea, 2013IPEA - INSTITUTO DE PESQUISA ECONÔMICA APLICADA. Situação social das catadoras e dos catadores de material reciclável e reutilizável. Brasília, DF: IPEA , 2013. Disponível em: <Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/9979/1/situacao_social_mat_reciclavel_brasil.pdf >. Acesso em: 28 ago. 2022.
http://repositorio.ipea.gov.br/bitstream... ).

Most of the time, direct work with solid waste occurs in places without structures. Their very disposal can compromise and degrade water resources and soil, triggering diverse and complex problems, affecting physical health, producing psychological and psychiatric disorders and social disintegration of those who work with scavenging (Coelho et al., 2016COELHO, A. P. F. et al. Risco de adoecimento relacionado ao trabalho e estratégias defensivas de mulheres catadoras de materiais recicláveis. Escola Anna Nery, Rio de Janeiro, v. 20, n. 3, e20160075, 2016., ²⁰¹⁸COELHO, A. P. F. et al. Cargas de trabalho de catadoras de materiais recicláveis: proposta para o cuidado de enfermagem. Revista Gaúcha de Enfermagem, Porto Alegre v. 39, e2018-0006, 2018.; Filipak et al., 2020FILIPAK, A.; STEFANELLO, S.; OKADA, J. M.; HUNZICKER, M. H. “O motor é a gente mesmo”: cuidado em saúde dos trabalhadores da reciclagem. Interface, Botucatu, v. 24, n. supl. 1, e190472, 2020.). Thus, health problems such as infectious, degenerative, and cardiovascular diseases, anxiety and depression crises, panic syndrome, chemical dependency, and increased violence, among others, are components of the same phenomenon (Siqueira; Moraes, 2009SIQUEIRA, M. M.; MORAES, M. S. Saúde coletiva, resíduos sólidos urbanos e os catadores de lixo. Ciência & Saúde Coletiva , Rio de Janeiro, v. 14, n. 6, p. 2115-2122, 2009.; Santos; Silva, 2011SANTOS, G. O.; SILVA, L. F. F. Os significados do lixo para garis e catadores de Fortaleza (CE, Brasil). Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 8, p. 3413-3419, 2011.). Furthermore, there are the occupational effects of scavenging, mainly problems related to work accidents (cuts, punctures, burns, etc.), with a high incidence of food poisoning and parasitic diseases (Siqueira; Moraes, 2009SIQUEIRA, M. M.; MORAES, M. S. Saúde coletiva, resíduos sólidos urbanos e os catadores de lixo. Ciência & Saúde Coletiva , Rio de Janeiro, v. 14, n. 6, p. 2115-2122, 2009.).

The year 2020 is marked in world history as the beginning of the SARS-CoV-2/COVID-19 virus pandemic, which generated deserted streets, chaos in public health, and negative consequences for the economy and public policies. Due to the suspension of several economic activities during the lockdown period, there was an impact on the sustainability of many companies and services, which led to the dismissal of many workers, in addition to a decrease in income, an increase in hunger, and the reconfiguration of work in throughout Latin America (Malaver-Fonseca; Serrano Cárdenas; Castro Silva, 2021MALAVER-FONSECA, L.F.; SERRANO CÁRDENAS, L.F.; CASTRO-SILVA, H.F. La pandemia COVID-19 y el rol de las mujeres en la economía del cuidado en América Latina: una revisión sistemática de literatura. Estudios Gerenciales, Cali, v. 37, n. 158, p. 153-163, 2021.). For socially vulnerable populations, the consequences were even more significant. Faced with this new reality, many of the unemployed saw collecting recyclable materials as an alternative, given the economic and social difficulties faced during the period. Many groups, collectives, non-governmental organizations (NGOs), and social movements sought mutual support strategies in the first two years of the pandemic. The Juventude na Luta collective, which emerged during the health restrictions due to COVID-19, was made up of young residents of Bons Ares (a peripheral region of one capital in the Brazilian Northeast), who built social actions together with waste collectors from the Bons Ares Waste Collectors Association (ASCABOA). In this article, we describe the local context where they live, their resistance strategies, and how they dealt with their health problems during the pandemic, with a focus on medicines. Research related to waste collectors, such as Galon (2015GALON, T. Do lixo à mercadoria, do trabalho ao desgaste: estudo do processo de trabalho e suas implicações na saúde de catadores de materiais recicláveis. 2015. Tese (Doutorado em Enfermagem) - Universidade de São Paulo, Ribeirão Preto, 2015.) and Coelho et al. (2018COELHO, A. P. F. et al. Cargas de trabalho de catadoras de materiais recicláveis: proposta para o cuidado de enfermagem. Revista Gaúcha de Enfermagem, Porto Alegre v. 39, e2018-0006, 2018.), investigated these workers’ healthcare and how social, work, and environmental issues influence their life contexts. However, few studies from the perspective of the investigation proposed here, which seeks to understand the use and perceptions of medications from subjects organized in an association.

Methodology

Data collection and analysis

The field research occurred in the context of ASCABOA, located in Grande Bons Ares (GBA), in a northeastern capital, from May to October 2021. Female workers affiliated with the Association, aged between 18 and 59, were included. (we excluded women aged 60 or over as they are considered a risk group for COVID-19) Furthermore, their source of income was only collecting recyclable materials (other sources cited were working as a cleaner and a delivery person). During the research, this scenario changed, with men working exclusively at the Association due to unemployment, but the inclusion criterion above remained.

We opted for a mixed method, using a quantitative approach mixed with a qualitative ethnographic one to understand the use and perceptions of medicines by ASCABOA collectors.

For the first approach, the participants’ sociodemographic data were collected (number of residents in the house, date of birth, affiliation, education, race/color, religion, and household characteristics), and the medications found in their homes were identified (name, dosage, pharmaceutical form, who prescribed it, where they were purchased, among others). Medication data were organized in an Excel® spreadsheet and analyzed according to frequency and percentage. The ATC/WHO (Anatomical Therapeutic Chemical/World Health Organization International Working Group for Drug Statistics Methodology) classification system was used, with each medicine identified according to its drug, whose ATC/WHO code (fifth level) was obtained from the National List of Essential Medicines (Rename) from 2022 and only then categorized by Anatomical/Pharmacological Group (first ATC/WHO level) and by Therapeutic/Pharmacological Group (second ATC/WHO level).

For the other methodological approach, we chose the ethnographic method, as it allowed us to understand what meanings were attributed to the condition of waste collectors and what impact this work had on their lives and their relationships with medicines. In participant observation, the field diary was used. In-depth interviews were also carried out on a day, time, and place defined by the participants and with a script to facilitate the dialogues (the average time was 60 minutes). The interviews were always recorded when authorized, with subsequent transcription in full.

The research complied with CNS Resolution No. 510/2016, receiving a favorable opinion for its execution by the Human Research Ethics Committee. The names of the locations, institutions, and collectors have been changed to ensure anonymity. All participants were informed about the research and signed the Informed Consent Form.

The study location

The GBA is a region comprising five neighborhoods, and the municipality’s official data records a population of approximately 225,000 inhabitants in 2021-2022, representing 8.33% of the capital’s population. The residents who formed the Juventude na Luta collective and the associates reported that the Association’s location was the “vixe do vixe” within the GBA, that is, an even more violent space than the rest of the region, already known for the interjection of amazement and fear “vixe,” which was pronounced by people when they heard someone say they lived there.

As in many more populous Brazilian capitals and cities, the GBA has its origins in the region’s disorderly growth, building a social stigma around its inhabitants and producing situations of significant vulnerability and accumulation of social problems, such as violence and structural problems (precarious sanitation, pavement, and lighting conditions, presence of garbage in the streets, among others). It is also worth mentioning the spatial division due to conflicting interests within the locality itself, which is reflected in the movement of residents from one community to another, impacting differentiated access to public facilities, such as healthcare units.

The collectors mentioned a Basic Health Unit (UBS) and two private pharmacies close to ASCABOA (about 1 km), the leading health equipment.

Results and discussion

Women collectors, stigmas, and resistance strategies

During 2021, there was an increase in the number of members: from 24 (20 women and four men) to 36 members (30 women and six men). Thirteen women, aged between 23 and 59, participated in the study, six of whom were Black, five were mixed race, one was Indigenous, and one was White. Just over half were married (seven), and the rest were divided between single (five) and divorced (one). The number of children was between one and five, with two saying they did not have children. The level of education varied between not reading/not writing (two), incomplete (four) and complete (two) primary education, incomplete (three) and complete (two) secondary education. Most professed the Christian faith (five evangelicals and four Catholics), one identified herself as an Umbanda follower, and three did not want to declare their religion. All 13 residences had electricity and running water. During the research period, six houses received access to the public sewage network, achieved via sanitation works from the Association’s articulation with other social movements; the others had septic tanks (five) or open sewers (two). Most (nine) of the collectors lived in their own homes, coming from urban occupations regulated by the state; three were in a borrowed house, and one was renting.

Amid the health crisis caused by the pandemic, participants pointed to issues and problems that had a direct impact on their lives, such as unemployment, gender relations, local violence, and the stigmas of scavenging work.

In family relationships, the central role of these women was evident, being a point of convergence in their stories. Maintaining the family’s subsistence and raising their children and grandchildren were their shared needs. These women, especially those who lived in a single-parent situation, emphasized the relevance of scavenging in their lives, even more so in times of unemployment and the absence of a father figure:

Vanessa spoke of her troubled relationship with her husband, at times citing issues related to psychological violence when he belittled her situation as an unemployed woman. She portrayed with great hurt the fact that her husband required earning and, at the same time, boycotted her when collecting:

All participants, except one, stated that they had worked as domestic workers at some point in their lives. Iara reported that scavenging was a salvation amid unemployment caused by the insecurity of her job as a domestic worker, which she left when she had psychological problems after her son’s death.

Conflicts between “parallel powers” (an expression used by the community) were intense during the research period, generating a territorial division that prevented free movement between neighborhoods, which limited both the scavenging work in different regions and participation in the Association. In some reports, the impacts of urban violence were mentioned by women who lived in places outside the perimeter of the ASCABOA headquarters, speaking primarily of the difficulty in accessing health services and medicines:

The fact that they work with recyclable materials and live in a place historically known as violent and with structural problems highlighted social stigmas:

Some women spoke about the expectation that scavenging would open doors and be another source of income, becoming a new possibility for the reinvention of the poorest segments and social emancipation (Velloso, 2005VELLOSO, M. P. Os catadores de lixo e o processo de emancipação social. Ciência & Saúde Coletiva , Rio de Janeiro, v. 10, n. supl., p. 49-61, 2005.):

The organization, via the Association, was a central point in the union and articulation of these women’s resistance. Cooperative/associated collectors have more possibilities to negotiate their sales and guarantee continuity of supply, adequate physical space, and better working conditions (Grimberg; Blauth, 1998GRIMBERG, E.; BLAUTH, P. Coleta seletiva: reciclando materiais, reciclando valores. São Paulo: Instituto Pólis, 1998.). In addition to improving productivity and participation in social movements and forums, their selective collection service consolidates their participation within institutions (Siqueira; Moraes, 2009SIQUEIRA, M. M.; MORAES, M. S. Saúde coletiva, resíduos sólidos urbanos e os catadores de lixo. Ciência & Saúde Coletiva , Rio de Janeiro, v. 14, n. 6, p. 2115-2122, 2009.).

ASCABOA was organized in 2012, bringing together collectors from different neighborhoods in the GBA. In 2015, with the support of some institutions and in conjunction with community movements in the region, a place was provided that served as a warehouse and headquarters. Even though it only had a warehouse of around 24 m² and only one bathroom, this improved the quality of the work, valuing the construction of trade networks for recyclable materials in the region itself. However, workers did not have manual transport vehicles, making it impossible to carry materials over long distances. At first, there were just six collectors, as Alessandra reported. This number increased over the years after the construction of the first headquarters and intensified during the COVID-19 pandemic, as mentioned above. As highlighted, the consequences of the pandemic were reflected in several sectors beyond public health, directly impacting less favored populations and increasing unemployment and hunger numbers (Malaver-Fonseca; Serrano Cárdenas; Castro Silva, 2021MALAVER-FONSECA, L.F.; SERRANO CÁRDENAS, L.F.; CASTRO-SILVA, H.F. La pandemia COVID-19 y el rol de las mujeres en la economía del cuidado en América Latina: una revisión sistemática de literatura. Estudios Gerenciales, Cali, v. 37, n. 158, p. 153-163, 2021.). However, the political organization of these women during the pandemic period was fundamental for the construction of collective strategies, including the physical change of the headquarters. The territorial dispute between the “parallel powers” led to the end of the concession of the site provided by the Residents Association, and ASCABOA was transferred to a region with better access for the majority of members. Despite the rental cost, the property brought advantages such as a larger plot of land, a terrace where materials were separated and weighed, an administrative room (consisting of a bathroom, a living room, and a kitchen), and a shed where a machine press was installed. In addition, two houses were provided to female collectors who did not have their residences.

Throughout the study, the importance of organizing these women around the Association was perceived. Alessandra was the oldest collector among the participants and was present from the first political articulations for the cooperative’s emergence. Renata, in turn, joined in 2021. It was clear that the feeling of belonging that emerged builds a bond of identity and resistance in the face of adversities in the local context.

Women occupied a prominent position in ASCABOA, coordinating the organizational aspects, political articulations, the construction of support networks, and the mobilization of members. The few associated men performed manual duties, repairing equipment and maintaining infrastructure.

Operationally, the Association was organized by distributing the material collected and the items received through donations. Sorting and weighing were carried out at headquarters by the collectors themselves, with part of this process being the responsibility of those who had young children and could not leave them alone at home.

During the pandemic, ASCABOA joined other waste collector associations in articulating the achievement of Auxílio Catador²2The Auxílio Catador Program, approved in 2020 by state law, transferred a financial amount directly to collectors through a personalized bank card, seeking, in return for this support, an increase in activities related to reuse, recycling, and treatment of waste solids. and basic sanitation in the neighborhoods where the members lived. It also collaborated with other social movements, such as the Juventude na Luta collective mentioned above, aiming to participate in projects and obtain basic food baskets, personal hygiene materials, personal protective equipment (PPE), and health education about COVID-19, among others.

“So the easiest thing I think is to self-medicate”: home pharmacies and self-attention practices

A total of 58 medicines were observed in 12 of the 13 residences, with a minimum of one in one home and a maximum of 11 in another. Regarding the pharmaceutical form, 63.8% (n=37) were tablets, 15.5% (n=9) were liquids for oral use, 12.1% (n=7) were capsules, 3.4% (n=2) were dragees, 3.4% (n=2) were ointments, and 1.7% (n=1) were ophthalmic solutions. Storage took place in the bedroom (four homes), kitchen (three homes), and living room (three homes). In one of them, the medicines were in the bathroom, and one of the participants reported that she carried them in the bag she used daily. For seven medications, it was impossible to identify the expiration date, and two expired. It is worth mentioning that in the house with the largest number of medications, one was expired, and six had no expiration date.

When asked who recommended the medicines, 60.3% (n=35) of the items were prescribed by the neighborhood UBS physician (28 prescriptions) or by a psychiatrist (seven prescriptions). Indications made by pharmacists were reported for 19% (n=11) of the medications, by UBS nurses for 8.6% (n=5), and for information found on Google, 5.2% (n=3). The other medications were recommended by family members (sister recommended it once, mother recommended it twice, and the collector herself self-medicated in one case).

The majority of medications were obtained in public health establishments: 48.3% (n=28) at the UBS and 6.9% (n=4) at the Psychosocial Care Center (CAPS). One of the private pharmacies in the neighborhood played an essential role in this acquisition, having been observed in 37.9% (n=22) of the items, which demonstrates that even though a physician from UBS or CAPS prescribed the majority of these medicines, some of them were obtained in the private sector. The remaining medications were received through donations (n=2), as a free sample provided by the physician (n=1), or even by the mother (n=1).

In the home pharmacies, a majority percentage of medicines related, according to the first ATC/WHO level (Anatomical/Pharmacological Group), to the nervous system (n=16; 27.6%), followed by drugs acting on the cardiovascular system (n =10; 17.2%), in the alimentary tract and metabolism (n=10; 17.2%), in the blood and blood-forming organs and antiinfectives for systemic use (for each group n=4; 6, 9%), among others (Table 1). The medicines identified as “not included” (n=4; 6.9%) were items that did not have an ATC/WHO code, as they were combinations of drugs such as the compound Dipyrone + Orphenadrine + Caffeine.

The most frequently identified therapeutic/pharmacological groups (ATC/WHO, second level) were: analgesics (n=8; 13.8%), agents acting on the renin-angiotensin system (n=4; 6.9%), antibacterials for systemic use (n=4; 6.9%), psycholeptics (n=4; 6.9%), and psychoanaleptics (n=3; 5.2%), as shown in Table 1. As stated previously, four (6.9%) medicines were not classified because they were not on the ATC/WHO list.

The drugs most frequently present in residences were the analgesics dipyrone and paracetamol, with four units of each (6.9%), followed by omeprazole (treatment of gastric or duodenal ulcers) and losartan (antihypertensive), both with three units (5.2%). One or two units represented the frequency of other medications. It is essential to highlight medications with psychoactive action, classified in the nervous system together with analgesics: antipsychotics (haloperidol; lithium; risperidone), antidepressants (venlafaxine; escitalopram; nortriptyline), anxiolytics (diazepam), and antiepileptics (clonazepam).

It is worth mentioning that we did not identify medicines from the so-called “early treatment” of COVID-19 (or “COVID kit”) in the residences, such as ivermectin, chloroquine, and hydroxychloroquine, nor were they mentioned by the participants, which is a paradox compared to what was observed in the country (Melo et al., 2021MELO, J. R. R. et al. Automedicação e uso indiscriminado de medicamentos durante a pandemia da covid-19. Cadernos de Saúde Pública , Rio de Janeiro, v. 7, n. 4, e00053221, 2021.; Hentschke-Lopes et al., 2022HENTSCHKE-LOPES, M. et al. Sales of “COVID kit” drugs and adverse drug reactions reported by the Brazilian Health Regulatory Agency. Cadernos de Saúde Pública, Rio de Janeiro, v. 38, n. 7, e00001022, 2022.).

Collectors of recyclable materials reported varied situations that can be understood under self-attention, both in its broad and strict sense (Menéndez, 2005MENÉNDEZ, E. L. Intencionalidad, experiencia y función: la articulación de los saberes médicos. Revista de Antropología Social, Madrid, n. 14, p. 33-69, 2005.). In the broadest sense, they involve “[…] all forms of self-attention used to ensure the biosocial reproduction of subjects and groups at the level of microgroups and, especially, of the domestic group” (Menéndez, 2005MENÉNDEZ, E. L. Intencionalidad, experiencia y función: la articulación de los saberes médicos. Revista de Antropología Social, Madrid, n. 14, p. 33-69, 2005., p. 55). Thus, the strategies for coping with the pandemic (described in the previous topic), going to the forró to drink beer and dance, and the children’s day party promoted by the Association, among other activities, are part of this self-attention perspective. In the strict sense, it also occurs within the scope of the family and social groups, i.e., it is based on the collective. It is characterized by intentionality in the health-disease-care process without the direct intervention of specialists, whether from biomedicine or other forms of health care. In the processes of illness, subjects seek solutions with health-restoring-oriented praxis. This search does not imply excluding or privileging a form of health care but often occurs in the articulation between different practices. Furthermore, according to Menéndez (2005MENÉNDEZ, E. L. Intencionalidad, experiencia y función: la articulación de los saberes médicos. Revista de Antropología Social, Madrid, n. 14, p. 33-69, 2005.), praxis is centered on the subject and their social group, which synthesize, articulate, mix, or juxtapose the different forms of attention, reconstituting and organizing part of them in self-attention activities.

Biomedicine considers self-attention only to be self-medication with medicines. However, for Menéndez (2005MENÉNDEZ, E. L. Intencionalidad, experiencia y función: la articulación de los saberes médicos. Revista de Antropología Social, Madrid, n. 14, p. 33-69, 2005.), it is only part of it: self-medication is using medicines and all other substances, such as herbs, alcohol, marijuana, etc., as well as activities of many types, such as cupping, massages, and poultices. According to him, it is given by the intention of using any substance, treatment, or carrying out activities that, according to its users, enable better performance at work, in sport, in sexual life, etc.

Among the women collectors, self-attention practices involved using medicines and other preparations. Luzia was a reference in the neighborhood and for the Association’s collectors in recommending medicinal plants and teas. Other preparations mentioned were home-made syrups and home-bottled medicinal preparations bought from the “sisters” of the church they attended. These solutions were not only practices based on African religions or Indigenous medicine, as Luzia explained in one of the conversations, but they also constituted alternatives to the difficulty in accessing health services.

The use of medications, whether through self-medication or prescription, was reported in these women’s routines. There was a common practice, for example, of using anti-inflammatories for pain caused by work. Vitória described that for these purposes, she used teas recommended by Luzia, paracetamol, and Dorflex®, which were recommended by other associates: “I drink this [tea] to relieve back pain. There are days when we carry much weight, and as I am in the screening area, sometimes it is too much. The girls give me paracetamol and Dorflex when it doesn’t go away. Most always have it in their pocket” (Vitória).

Meire spoke about her health condition, relating it to the medicines she used and medical diagnoses. She presented herself as a very sick woman: “I can’t live without my medicine. I’m all messed up, you know?”. These problems portrayed by Meire were high blood pressure, fatigue attacks (related to shortness of breath), varicose veins, and profound anemia. All of them had, at some point in her life, a medical diagnosis, but her understanding of treatments went beyond the physician-patient relationship.

Since going to the UBS with severe headaches and a blood pressure reading of around 16/10 mmHg, when the physician diagnosed her with high blood pressure, Meire understood herself as having hypertension. Another physician from the same UBS recommended non-pharmacological treatment practices and removed the antihypertensive medication. However, the collector contradicted the medical discharge and other recommendations, questioning the contradictory conduct and the relationship with the healthcare team. When asked about the captopril present in her home pharmacy, she said:

According to Conrad (1985CONRAD, P. The meaning of medications: another look at compliance. Social Science & Medicine, Oxford, v. 20, n. 1, p. 29-37, 1985.), individuals develop strategies based on perceptions about diagnosis and treatment, adapting them to their realities. The author called this mechanism self-regulation, which can involve adjusting doses or abandoning treatment, for example, by not complying with medical instructions.

The change of physician at the healthcare unit and the possible guidance on doing physical exercises to take care of excess weight were not effective from a biomedical point of view. Meire created ways to deal with her hypertensive condition, measuring her blood pressure, understanding the characteristic symptoms when her blood pressure was altered, and seeking advice from family members with experience of hypertension:

Like Meire, four other collectors, aged between 28 and 59, were diagnosed with high blood pressure, giving different accounts of the origin of the problem. In the same local context, paradoxically, the physician-patient relationship had other implications for the practice of self-attention by these women. Alessandra and Patrícia lived around 20 m from the UBS. The other two collectors who lived with hypertension were Sara and Fernanda. Both, like Meire, had in common that they lived close to each other and further away from the UBS.

The lesser or greater proximity to the healthcare unit reflected in the way these women dealt with their hypertension. Alessandra and Patrícia reported no problems acquiring the medicines. They stated that they strictly followed the instructions given for use, praising the good service and how well they were treated at the UBS.

On the other hand, Sara, Fernanda, and Meire discussed different situations involving compliance with treatment. In these cases, difficulty accessing medicines led them to construct other narratives. Fernanda, talking about the use of captopril: “I prefer to buy it right away at the pharmacy. There are many things that are not available at the healthcare unit, and I buy it right there” (Fernanda). Sara built her relationship with the medication based on her neighborhood and the way her fellow members of the Association took their medication for high blood pressure:

Iara reported having a chronic problem, which she called “phobia,” which she described as sadness, difficulty sleeping, agitation, fear of leaving the house, rapid heartbeat, and, sometimes, even fainting. She was cared for by CAPS and received all her medication through the Unified Health System (SUS). According to her, the physician prescribed diazepam 10 mg to help her sleep, venlafaxine 75 mg, lithium carbonate³3While lithium is classified by ATC/WHO and Rename as an antipsychotic when associated with an antidepressant, it receives another code from ATC/WHO. The lithium leaflet indicates its use together with an antidepressant in the case of severe recurrent depression. 300 mg to “stop feeling sad” (Iara), and liquid haloperidol to stop “jumping like a cricket” (Iara) due to her agitation and fear of leaving home. At the beginning of the conversation, her report of stronger crises seemed to link her problems to the death of her teenage son, as mentioned above. However, when asked how the “phobia” started, she said that it was not caused by the event above but instead due to sexual violence suffered in her childhood, building a process of chronic illness that affected her mental health:

This suffering, which lasted for more than 40 years, had a history of mental illness that began with physical violence, which impacted her life, causing her to develop a stigma for having chronic psychiatric problems:

Iara also expressed a relationship of dependence on the psychotropic drugs she used: “They are the source that calms me down. By taking them, I don’t go around jumping around like cricket, I can sleep, I don’t feel a strange presence watching me, and I can even leave the house. When I’m in crisis, I can’t go out to collect” (Iara).

Renata narrated her story of mental illness, attributing the factor that triggered a panic attack to the COVID-19 pandemic, leading her to seek psychiatric help:

For Renata, Rivotril® (clonazepam⁴4While clonazepam is considered an antiepileptic/anticonvulsant in the ATC/WHO and Rename classification, it has indications for treating anxiety and mood disorders in adults, which appears to be the case with Renata.) and Lexapro® (escitalopram) improved her sleep, describing them as her “buckets of happiness.” The life story of these two women highlights the psychoactive medicines’ central role that has been addressed in other studies (Silveira, 2000SILVEIRA, M. L. O nervo cala, o nervo fala: a linguagem da doença. Rio de Janeiro: Fiocruz, 2000.; Whyte; Van Der Geest; Hardon, 2002WHYTE, S. R.; VAN DER GEEST, S.; HARDON, A. Woman in distress: medicines for control. In: WHYTE, S. R.; VAN DER GEEST, S.; HARDON, A. (Ed.). Social lives of medicines. Cambridge: Cambridge University Press, 2002. p. 50-63.; Maluf; Tornquist, 2010MALUF, S. W.; TORNQUIST, C. S. (Org.). Gênero, saúde e aflição: abordagens antropológicas. Florianópolis: Letras Contemporâneas, 2010.), revealing a clear relationship between gender, mental health, and suffering.

Final considerations

The growth in the number of recyclable material collectors follows the increase in unemployment rates, which causes these socially excluded populations to develop survival strategies to obtain their livelihood and to deal with their illnesses, especially during the COVID-19 pandemic. This study identified that the gender perspective was very relevant in the Association, which mainly comprised female workers responsible for administration and organization and acted politically.

The literature records the collection of materials as a work activity with a risk of physical and mental illness, subjecting workers to unhealthy situations and exposure to harmful materials. However, the socioeconomic conditions they face are also factors that influence their health.

Identifying where each participant lived, observing their routines, describing their contexts and perceptions about health and illness, and listening to their stories allowed us to understand that stigmatization due to the territory where they live and their work and gender relations impact their illnesses and treatments.

As they lived in the capital region with the worst human development indices, being part of a territory with conflicts between “parallel powers,” building a more significant link with public healthcare services was difficult. Reports of illnesses linked to gender-based violence were identified in the research, as well as difficulties in maintaining a single-parent family.

The relationship between these women and medicines showed that self-attention through self-medication has become an essential strategy for dealing with adverse situations present in their daily lives. Even though physicians prescribed most of the medicines found in the homes, each of the participants manipulated their use according to their knowledge and previous experiences. The use of psychoactive medicines stood out, showing a process of medicalization of life and psychological and emotional suffering.

To face many difficulties, active participation in the Association began to provide more possibilities for improving working and housing conditions, in addition to building a bond of identity and resistance in the face of adversities in the local context, directly reverberating in improvements in living conditions observed during the COVID-19 pandemic.

References

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