ABSTRACT

Health, understood as a multidetermined attribute, characterizes the political and social organization of a country. From Brazilian 1988’s Federal Constitution onwards, health has been understood as an individual right. Homeless people create important obstacles on the accomplishment of such right. The objective of this study is to understand the difficulties encountered on the streets that impact the perception and health state of adults living on the streets of a municipality in Zona da Mata Region, State of Minas Gerais, Brazil. A qualitative methodological approach was applied through semi-structured interviews and observation recorded on a field diary. The research interviewed 20 people living on the streets. Main difficulties involved climate exposition, as rain and cold; prejudice; vulnerability to physical and sexual abuse; obstacles to access food, drinking water and toilets; difficulties to access certain social spaces and health treatment. By knowing the situations that determine the various levels of health among people living on the streets, it is possible to build strategies and policies so to cope with their actual needs. Inter-sectoriality of public action is still a great challenge, despite necessary to accomplish a right that is fundamental and universal: health.

KEYWORDS
Homeless people; Right to health; Health status disparities

Introduction

The fundamental right to health was initiated in Brazil in 1988 through the promulgation of the Federal Constitution (CF/88). Far beyond the absence of disease, health is understood as a multidetermined state, which carries an intimate relationship with the living conditions and access to public and social goods of individuals and groups of inhabitants of a given society¹1 Brasil. Lei nº 12.864 de 24 de setembro de 2013. Altera o caput do art. 3º da Lei nº 8.080, de 19 de setembro de 1990, incluindo a atividade física como fator determinante e condicionante da saúde. Diário Oficial da União. 25 Set 2013..

Social inequalities portray deep patterns of socio-sanitary realities across the various segments of the population. In this context, important health inequities are produced. The poorest population is put aside, left to a situation of vulnerability²2 Casallas AL. La medicina social-salud colectiva latinoamericanas: una visión integradora frente a la salud publica tradicional. Rev. Cienc. Salud. 2017; 15:397-408.. The non-guarantee of housing that provides protection and privacy inflicts this vulnerable situation upon the individual, negatively impacting his state of health.

People who use the streets as housing expose complex vulnerabilities, manifesting heterogeneous needs and demands for their living. In this context, they need social and health services more appropriate to their peculiarities³3 Argintaru N, Chambers C, Gogosis E, et al. A cross-sectional observational study ofunmet health needs among homeless and vulnerably housed adults in three Canadian cities. BMC Public Health. 2013; 13(577):1-9.

4 Barata RB, Carneiro Junior N, Ribeiro MCSA, et al. Desigualdade social em saúde na população em situação de rua na cidade de São Paulo. Saúde Soc. 2015; 24(1):219-232.

5 Borysow IC, Furtado JP. Acesso, equidade e coesão social: avaliação de estratégias intersetoriais para a população em situação de rua. Rev. Esc. Enferm. USP. 2014; 48(6):1069-1076.

6 Farias DCS, Rodrigues ILA, Marinho IC, et al. Saberes sobre saúde entre pessoas vivendo em situação de rua. Psicol. saber soc. 2014; 3:70-82.^-77 Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad. Saúde Pública. 2015; 31(7):1497-1504..

Vulnerability is understood by Carmo and Guizardi⁸8 Carmo ME, Guizardi FL. O conceito de vulnerabilidade e seus sentidos para as políticas públicas de saúde e assistência social. Cad. Saúde Pública. 2018; 34(3):1-14. as the overlapping of various factors, in several dimensions, able to make an individual or group of persons more susceptible to the risks and unpredictability of life. The conditions of social vulnerability are possibly connected also to the opportunities experienced by the individual as to the social, economic, cultural and political characteristics of the place.

Knowing the difficulties that affect the health-disease-care process of that group of inhabitants is a fundamental condition for contributing to the formulation and implementation of public policies and services that effectively respond to their needs⁸8 Carmo ME, Guizardi FL. O conceito de vulnerabilidade e seus sentidos para as políticas públicas de saúde e assistência social. Cad. Saúde Pública. 2018; 34(3):1-14..

This paper is part of the Master degree dissertation presented before the Graduate Program in Collective Health at the Federal University of Juiz de Fora. It aimed to understand the difficulties of life on the streets that affect health according to the perception of adults living in the streets of a municipality pertaining to Zona da Mata Mineira, southeast region of Minas Gerais State.

Methodology

A qualitative approach was adopted by means of semi-structured interviews and field diary records of daily observation of conviviality in the streets and in the institutions researched.

The research was carried out in a municipality of Zona da Mata Mineira. Its population is composed of 559,636 inhabitants, from which 880 are homeless⁹9 Juiz de Fora. Prefeitura, Secretaria de Desenvolvimento Social. Diagnóstico da População em Situação de Rua de Juiz de Fora. Juiz de Fora: Secretaria de Desenvolvimento Social; 2016. [acesso em 2019 fev 20]. Disponível em: https://www.pjf.mg.gov.br/secretarias/sds.
https://www.pjf.mg.gov.br/secretarias/sd... . The research field involved the two municipal temporary shelter services that offer overnight beds, being one for women and the other for men. It lasted from March 2016 to February 2018.

Subjects with cognitive impairment or presenting behavioral changes due to the use of alcohol or other psychoactive substances were excluded from the study.

In order to preserve the confidentiality, respondents were identified by the letter E, followed by numbers 1 to 20, i.e., E1 to E20.

Data were interpreted in the light of dialectical hermeneutics, respecting Minayo’s¹⁰10 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2014. moments of ordering, classification and final report. The information systematizing allowed to identify the material collected in the field by means of the transcription of the interviews and preliminary reading. The classification was carried out based on the floating reading of the interviews with the purpose of recognizing the central ideas, and allowed to find the sense cores under analysis. This paper highlights the core ‘living in the streets and its impact on health’.

After the identification of the sense cores, the fragments of the speeches, or units, related to each core were organized in a chart (chart 1), as proposed by Alencar et al.¹¹11 Alencar TOS, Nascimento MAA, Alencar BR. Hermenêutica dialética: uma experiência enquanto método de análise na pesquisa sobre o acesso do usuário à assistência farmacêutica. Rev Bras Promoç Saúde. 2012; 25(2):243-250..

After their organization in chart 1, the units were analyzed as for the horizontal and vertical summaries of each sense core. While the horizontal summary made possible the identification of convergences, divergences and complementarities of each respondent speech, the vertical summary allowed to detect the articulation of each subject’ sense cores.

The research was approved by the Research Ethics Committee of the Federal University of Juiz de Fora, Consent No. 1,913,094/2017. All respondents signed the Free and Informed Consent Form (TCLE).

Results and discussion

Twenty homeless persons over eighteen years of age participated in the research, of which fourteen are men and six are women.

Respondents age ranged between 25 and 68 years old, mostly black with incomplete elementary school. The time they lived in the streets varied from two to 31 years. The longer the length of time living in the streets, the greater the feeling of belonging to that reality, experiencing the instability and precariousness of the streets and building forms of survival. Those are years of uncertain feeding, searching for drinking water, informal work, distancing from families, prejudice and violence that impact physical and mental health¹²12 Alcantara SC, Abreu DP, Farias AA. Pessoas em situação de rua: das trajetórias de exclusão social aos processos emancipatórios de formação de consciência, identidade e sentimento de pertença. Rev. colomb. psicología. 2015; 24(1):129-143..

The difficulties of living in the streets reported by the respondents are compiled in chart 2.

Drinking water and food are basic needs. Therefore, if these needs are not fulfilled, they cause numerous health impairments, besides being relevant factors of social exclusion. Respondents’ reports strongly reinforced the existence of those deprivations:

The difficulty in fulfilling the basic needs is one of the main homeless vulnerabilities¹³13 Aguiar MM, Iriart JAB. Significados e práticas de saúde e doença entre a população em situação de rua em Salvador, Bahia, Brasil. Cad. Saúde Pública. 2012; 28(1):115-124.. The 1948 Universal Declaration of Human Rights states that adequate food, which includes access to drinking water, is one of the essential components to ensure a healthy standard of living for every human being¹⁴14 Organização das Nações Unidas. Assembleia Geral da ONU. Declaração Universal dos Direitos Humanos. [internet]. Brasília, DF: ONU; 1948. [acesso em 2019 fev 20]. Disponível em: http://unesdoc.unesco.org/images/0013/001394/139423por.pdf.
http://unesdoc.unesco.org/images/0013/00... . In Brazil, in 2009, the National Policy for Homeless People (PNPSR) contemplated the need to provide permanent access to food for homeless people by means of the implementation of food and nutritional security actions¹⁵15 Brasil. Congresso Nacional. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 Dez 2009.. In 2010, food was included in the Constitution as a social right through Constitutional Amendment 64/2010¹⁶16 Brasil. Congresso Nacional. Emenda Constitucional nº 64, de 4 de fevereiro de 2010. Altera o art. 6º da Constituição Federal, para introduzir a alimentação como direito social. Diário Oficial da União. 5 Fev 2010.. But its implementation is still a challenge.

This research municipality provides a popular restaurant located in its central region, for which users of shelter services receive a meal ticket, distributed by the Reference Center Specialized in Homeless Population (Centro POP). However, some homeless individuals complain about the timing of the offer and do not attend claiming mobility difficulties.

Still about basic needs, respondents claimed absence of facilities to wash clothes and difficulty to bathe:

There are no public toilets in this research municipality. Bathing spots are only available in the shelters. The difficulty of access to places where to do the personal hygiene causes several damages to health, such as lice infestations, skin diseases, difficulties to treat wounds, among others¹⁸18 Brasil. Ministério da Saúde. Manual sobre o cuidado à saúde junto a população em situação de rua. Brasília, DF: Ministério da Saúde; 2012. [acesso em 2019 fev 20]. Disponível em: http://dab.saude.gov.br/portaldab/biblioteca.php?conteudo=publicacoes/manual_saude_populacao_rua.
http://dab.saude.gov.br/portaldab/biblio... .

Strongly associated with the issue of preserving the personal hygiene are the discrimination and prejudice against the homeless body, physical appearance and the way of dressing. Discrimination against the body that suffers the consequences of living in the streets is a reaction against an unidealized appearance¹⁹19 Reis MS, Rizzotti MLA. População de rua, território e gestão de políticas sociais: para além de um retrato social. Serv. Soc. rev. 2013; 16(1):43-65.. A marginalized, dirty body exuding strong odors does not match the ideal of a clean society:

Personal appearance and body hygiene are among the discrimination factors that hinder access to public policies and to the construction of the possibilities of leaving the streets, including insertion into the labor market²⁰20 Conselho Nacional do Ministério Público. Guia de Atuação Ministerial: defesa dos direitos das pessoas em situação de rua. [internet]. Brasília, DF: CNMP; 2015. [acesso em 2019 fev 20]. Disponível em: http://www.cnmp.mp.br/portal/images/Publicacoes/documentos/Guia_Ministerial_CNMP_WEB_2015.pdf.
http://www.cnmp.mp.br/portal/images/Publ... .

It is difficult to access the resources that can provide self-care:

As for Maslow²¹21 Maslow AH. Motivación y personalidad. Barcelona: Sagitário; 1954., feeding, hydration, breathing, sleep, sex and appropriate place for physiological functions are at the basis of the hierarchical classification of human needs. Allowing access to the bathroom is taking care of a basic, physiological need of every human being. Often, because there is no bathroom available, the person uses the street. Apart from the ‘degradation of public space’, there is the violation of privacy and the feeling of degradation of the very condition of human being.

According to the respondents, the impossibility of insertion in the formal labor market makes the informal activity carried out on the streets an alternative of precarious insertion, because the lack of social protection and appropriate conditions of work causes significant impacts health:

Some of the actions to access the labor market provided for by the National Policy for the Social Inclusion of Homeless People imply the insertion of these people as a priority target for the intermediation of employment by social institutions, their professional training, the encouragement to cooperative forms of work and the guarantee of access to labor rights, including retirement²²22 Brasil. Ministério do Desenvolvimento Social e do Combate à Fome. Política Nacional para Inclusão Social da População em Situação de Rua. [internet]. Brasília, DF: Ministério do Desenvolvimento Social e do Combate à Fome; 2008. [acesso em 2019 fev 20]. Disponível em: http://www.justica.pr.gov.br/sites/default/arquivos_restritos/files/documento/2019-08/pol.nacional-morad.rua_.pdf.
http://www.justica.pr.gov.br/sites/defau... . In addition, the public sector investment in training and professional qualification for that population, as predicted by the PNPSR, is also one of the behaviors to promote and stimulate movements that improve living conditions¹⁵15 Brasil. Congresso Nacional. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 Dez 2009..

Climate change also appeared as mishaps for living in the streets. Populations under social vulnerability are deeply impacted and seriously weakened, mainly on their health, due to the protection absence of guarantee against temperature changes²³23 Valverde MC. A interdependência entre vulnerabilidade climática e socioeconômica na região do ABC paulista. Ambient. soc. 2017; 20(3):39-60., as, for example:

In connection to vulnerabilities, respiratory diseases are mentioned by many respondents:

Respiratory diseases can be aggravated due to inequities resulting from the unequal insertion of individuals in society²⁴24 Chiesa AM, Westphal MF, Akerman M. Doenças respiratórias agudas: um estudo das desigualdades em saúde. Cad. Saúde Pública. 2008; 24(1):55-69.. In addition to an increased risk for the incidence of tuberculosis, street conditions also lead to an increase in the negative disease outcomes²⁵25 Figueroa-Munoz, JL, Ramon-Pardo P. Tuberculosis control in vulnerable groups. Bull World Health Organ. 2008; 86(9):733-735..

Shelters are equipment of the social assistance for welcome and protection. They usually work for the overnight staying. The municipality in which this research was conducted, there are two shelters able to accommodate 150 homeless adults per night. As for the PNPSR, the reception services must meet the municipality demand, taking into account data obtained by municipal surveys on homeless population¹⁵15 Brasil. Congresso Nacional. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 Dez 2009.. Research provided for the Municipal Secretariat of Social Development estimated that there are 884 people living in the streets of the municipality⁹9 Juiz de Fora. Prefeitura, Secretaria de Desenvolvimento Social. Diagnóstico da População em Situação de Rua de Juiz de Fora. Juiz de Fora: Secretaria de Desenvolvimento Social; 2016. [acesso em 2019 fev 20]. Disponível em: https://www.pjf.mg.gov.br/secretarias/sds.
https://www.pjf.mg.gov.br/secretarias/sd... . Therefore, only 17% of them succeed in sleeping in shelters. However, it is noteworthy that adherence to this type of service is contradictory and tense among homeless, due to the idleness of available vacancies. The interviews report that the ‘lack of freedom’ and the imposition of ‘rules’ are factors of non-adherence to the service:

Current shelter management follows a taming policy, whose objective is to control the behavior of individuals so that they do not bother during their overnight stay, curtailing freedom by means of strict rules²⁶26 Rodrigues IS. A construção social do morador de rua: o controle simbólico da identidade. [dissertação]. Juiz de Fora: Universidade Federal de Juiz de Fora; 2015.. To expand and qualify access to these institutions, it is important to promote participatory management mechanisms, encouraging meetings between the coordination and users or their representatives so to enable a democratic room for the discussion of their demands.

Also very present in the respondents’ speeches was the experience of prejudice:

Prejudice and discrimination are connected to the various myths surrounding the homeless, because there is a common understanding that those people are dangerous, slutty, drugged. Such views serve only to strengthen the scenario of social exclusion. In addition, they harm the mental health of those people, who, treated as a nuisance, develop feelings of non-social belonging²⁷7 Rodrigues IS. A construção social do morador de rua: derrubando mitos. Curitiba: CRV; 2016., what cause isolation, and even generate depression and anxiety, as reported in E1 speech.

Some authors affirm that homeless population feels shame, low self-esteem and uselessness²⁸28 Campbell DJT, O'Neill BG, Gibson K, et al. Primary healthcare needs and barriers to care among Calgary's homeless populations. BMC Fam Pract. 2015; 13(16):1-10.. This is noted in E1 above speech when he reports being treated as ‘garbage’, that is, as a discarded object, without utility²⁹29 Varanda W, Adorno CF. Descartáveis urbanos: discutindo a complexidade da população de rua e o desafio para políticas de saúde. Saude soc. 2004; 13(1):56-69.. PNPSR determines the development of educational actions that contribute to the formation of a culture towards respect, ethics and solidarity, so to safeguard compliance with human rights¹⁵15 Brasil. Congresso Nacional. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 Dez 2009.. Raising society’s awareness for the difficulties faced by homeless every day would help to demystify several issues connected to prejudice. It is an activity that requires determination and commitment of the public authorities and all social sectors.

Another worrying aspect in this scenario is vulnerability to violence. In the streets, violence appears in several ways: psychic, which is expressed by prejudice; social, which happens through non-access to social goods; and physics, which is life-threatening.

One of PNPSR objectives is to implement human rights centers and channels to receive reports of violence¹⁵15 Brasil. Congresso Nacional. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 Dez 2009.. However, Arbex³⁰30 Arbex D. PMs denunciados por violência. [internet]. Juiz de Fora: Tribuna de Minas; 2015. [acesso em 2019 fev 20]. Disponível em: http://www.tribunademinas.com.br/pms-denunciados-por-violencia.
http://www.tribunademinas.com.br/pms-den... reports police and public agents’ violence against the homeless people as significant. Among the cases, he relates physical and verbal aggressions and destruction of personal objects.

All female respondents revealed fear of sexual violence, and some of them tell stories of rape:

The violence suffered by women cannot be seen as a result of frailty. In fact, it is strongly linked to a patriarchal model of society that classifies the woman as an object, demoting her. Patriarchalism is a structure characterized by a social organization that enables men to have authority over women and children. Such organization permeates the whole society, including also relations of production and consumption as political structures. Violence against women and its approval from the society are therefore connected to the hierarchical power relations between men and women, enforced by that organization³¹31 Barreto MPSL. Patriarcalismo e o feminismo: uma retrospectiva histórica. Rev. Ártemis. 2014; 1:1-10..

Rosa and Brêtas³²32 Rosa AS, Brêtas ACP. A violência na vida de mulheres em situação de rua na cidade de São Paulo, Brasil. Interface comun. saúde educ. 2015; 19(25):275-285. draw attention to gender as explanation to differences in the violence that provoke the movement of insertion in the streets. They affirm that ‘the street pertains to men’ is the result of rupture situations due to the wear and tear of relations. But, for some women, the street is a way out for the violence suffered during the domestic conviviality.

E16 speech unveils a plot of violence that began even when she was living in her home. But living in the streets, she shows the fear of being a victim of violence from the power related to social status:

Regarding the protection of battered women, women’s police stations, which should be specialized and trained to care for victims, are still criticized for their work. Moreover, women do not feel properly understood, protected and supported. Thus, the decision to break the silence and denounce situations of violence becomes a burdensome movement³³33 Bandeira LM. Violência de gênero: a construção de um campo teórico e de investigação. Soc. estado. 2014; 29(2):449-470..

Difficulties were still related as to the need for wandering during the day:

The need for homeless people to wander across the urban space has been identified as a tactic to survive or to face daily life, that is, to move around the city in search of protection, food, clothing and others³⁴34 Kunzi GS, Heckert AL, Carvalho SV. Modos de vida da população em situação de rua: inventando táticas nas ruas de Vitória/ES. Fractal, Rev. Psicol. [online]. 2014; 26(3):919-942..

Foot injuries are among the most relevant homeless health problems. Many of them move a lot throughout the city without protection and on the heat of the pavement, resulting in burns, cuts and wounds³⁵35 Rodrigues LRS, Callero JR. O direito fundamental à saúde para a população em situação de rua de Salvador. Rev. Juris Poiesis. 2015; 18(18):194-211..

Failure to pay attention to these situations weakens and determines important illness processes in those individuals, which, apparently not relevant to their way of living, make them reach the health services in acute conditions that hinder their locomotion³⁶36 Carneiro Júnior N, Nogueira EA, Lanferini GM, et al. Serviços de saúde e população de rua: contribuição para um debate. Saude soc. 1998; 7(2):47-62..

Many were the difficulties related to the experience of living in the streets reported by this research’ participants. Considering health as composed of multi determined reasons, one can note that, in those cases, it suffers direct impact from the raw reality offered by the streets to those who make it their shelter.

Final remarks

Researching the difficulties of living in the streets that impact on the homeless health was an experience with inevitable regard concerning how much the municipality of the study still has to improve as for intersectoral policies and in the construction of equipment to implement them. Giving voice to homeless people to understand their needs can be the starting point for the recognition of priorities in the planning of municipal actions. We hope that the research can be useful to design actions and strategies enabling a specific municipal policy for that population.

The timing for discussions on access to health services as for the homeless perception is favorable, since the municipality began the design of a policy for those people in 2016. The policy should prioritize the actions of intersectoral nature, in order to provide the coverage of the most diverse homeless health needs. The municipality public authorities should expedite the progress of the policy and enable strategies and equipment for its implementation.

There is need to expand the number of vacancies in shelters so to better meet the homeless. And, in order to provide demand for the shelters, it is suggested that a space be built for listening and debates about the demands of users.

Also relevant are the reports on the absence of public toilets with showers as on public drinking premises and places for washing clothes. Thus, the construction of places that meet the needs of personal hygiene and excretion are fundamental to fulfill the basic needs, as well as to contribute to self-care and to easy health conditions.

The research allowed the understanding of the various aspects related to the experience of living in the streets that impact on health, emphasizing the fear of suffering physical and sexual violence reported by virtually all respondents. Those speeches reveal the need of public authorities to apply a more sensible look over the homeless women reality and their particular demands. There are few researches focusing on those women. Encouraging the development of such research would contribute to meeting their demands.

This research carries some limitations. Because it is a qualitative research, the understanding of the occurrences took place during the period in which data collection was being carried out in the municipality, what may have undergone positive or negative changes as a result of changes in the country political and social context.

Health access may only be effectively contemplated if its determining factors be considered. It is expected that the difficulties presented here, among others, be followed up by the public authorities, with intersectoral intervention, so that transformation actually come about in the daily life of people who face the harshness of the streets.

References

Publication Dates

History