I apologize in advance for the length of this post, but it´s just about my work in Rio these past few weeks…I´m heading to Porto Alegre tomorrow!
They teased me on the ward today, jokingly introducing me as another little friend of President Lula because of my interests in the social problems in Rio and how they interface with medicine in the emergency department. Behind the smiles, however, was less amusement than resignation to disappointment. When Brazilians discuss the recent election and subsequent administration of their latest president, these are the emotions flavoring their words, touching their faces. As one physician explained to me, “In Lula, we had placed all of our hopes. He was a dream for Brazil, a fantasy. We thought he would help the poor, and there are so many poor. He was our last chance, but he couldn’t do it. It’s not his fault; there’s just no money. He’s trying to pay our debts, and no one is helping.”
Talking about progress in Brazil doesn’t flow easily. It’s not that people have given up believing in it completely; it’s just that they have accepted that in a country where even guaranteeing a basic level of services is a financial struggle, “progress” and “advancement” aren’t necessarily on the radar. The politicians make promises, but as the brasileiros will tell you with a wry smile, once election time is over, all that is left are the billboards stuck in the dusty plots of land, proclaiming the forthcoming new emergency block that there is just no money to construct. The doctors ask me if there is any way for institutions here to get sponsorship from institutions abroad. They do not understand why the countries in better financial positions in the world are not doing more to help out, why the trend is towards investing less in poorer countries, and why people think that the problems here in Brasil that very recently warranted funding are so much less than they once were. “Lula could do more if the rest of the world could just help out,” one doctor said to me.
So, instead, the Brazilians are working with what they’ve got. The hospitals try to make changes as smooth as possible, preparing the hospital for changes that may or may not be approved so that passage will go quickly if funded. They attempt to keep negotiations within the hospital, where approval and implementation are faster. In one hospital, they have decided on having one chief for the in-patient, out-patient and emergency departments so as to stop the fights between them. With medical education, they are attempting to bring students back to emergency medicine as they are being seduced by the sophisticated technologies and procedures of other specialties—a trend that reflects those in countries around the world, but that in Brasil, simply does not match the needs of the patient population. The emergency departments are not poorly funded. “They are the gateway to the hospital and so the care is strong, with well trained doctors,” several of the physicians told me, “Of course, everywhere, we need more staff, more technology, but it’s beyond the basic level of care in the hospital that we really have problems.”
Often times, the solutions are creative. The State Ministry of Public Health in Rio de Janeiro has just begun a pilot program to ease the burdens on the emergency departments here, which are often forced to hold patients for extended periods of time because there just aren’t beds open in the rest of the hospital. The doctor in charge of the program tells me, “In a country where over 90% of the population is poor, the problem is the public health care system. It is overcrowded, and people often go to the emergency department for primary health concerns because they think the care will be much faster. The biggest problem in the emergency departments is that there are too many patients.” They have created a telephone center that people can call if they think they have an emergency. They discuss their symptoms with trained operators who use set algorithms to decide if the patient truly has an emergency, and consult with doctors who are standing by if necessary. If there is reason to think it is a true emergency, an ambulance that is essentially a mini intensive care unit on wheels is taken out to the patient’s house. The idea is to treat the patient at home, so as to never have to bring them into the hospital. Of course, if hospital care is needed, the patients go directly to the intensive care units. Their physicians can call the center and find the closest hospital with beds available instead of just going to any hospital and hoping for an opening.
In Porto Alegre in the southern state of Rio Grande do Sul, the solution for the overcrowding issue in state hospitals has simply been for the government to purchase beds in the private hospitals. It’s cheaper than completely building new hospitals to accommodate the growing number of patients who need to utilize the public health systems because private insurance is a luxury very few in Brazil can afford (and because the public health system is arguably better than the private one, anyway).
The Red Cross (Cruz Vermelha Brasileira) head office in Rio just reopened two years ago, when the new administration decided to recommence funding the organization, which had been closed with the previous administration for the last ten years. The office is a beautiful grey building that stands in its own square, Praca da Cruz Vermelha, ambulances and buses hurtling by the castle-like structure. Inside, the staff, in large part volunteers, works hard in rooms humming with ceiling fans, computers and telephone conversations attempting to unite and support the branches of the organization spread out across Brazil that have all stayed open independently even while the head office was shut down.
On Monday, I spoke with a nurse who volunteers during the week for the Disasters and Emergency Department at Cruz Vermelha when he is not at his paying job or with his four year old son and pregnant wife. He wishes he could work here as a staff member, but again, the government has enough burdens without funding this organization any more. He patiently answers my questions about how to affect change in health systems here. “You can’t expect fast progress. We make changes and hope that they will affect other parts of the system well, and will attract the notice of those above us. We don’t have enough funding, and until we do, we won’t even be able to buy the supplies we need. The government is always changing and until it stays the same, it won’t be easy.”
A physician at one of the municipal hospitals (there are three types of hospitals here: municipal, state and federal) echoed those sentiments, explaining to me, “in 1998, there were new traffic laws that were passed that improved the rate of accidents. Within 2 years, there were 20% less accidents than before the laws were passed. However, like everything else in Brazil, good or bad, the project was let go and now has returned to the pre-1998 levels. Health can’t work like this; it requires continuity. Work needs to be done one step at a time- it’s better to go slowly than to take one step forward only to go two steps backwards!” Emergency medicine took off here in the early 1980s, but in many ways it faces the same issues it always has. The change from a dictatorship to a democracy allowed people to move across state lines, and as people entered Rio, the need for more staff, equipment and space emerged. She acknowledged that the social problems in Rio are a large aspect of the cases seen in the emergency department, and also within the city. Rio is a violent city, and while there are many programs designed to address this amongst other social problems, associations between the hospitals and public health are new here.
Here in Rio, doctors do get involved with these issues through a variety of NGOs and sometimes in the hospitals. Medicos da Familia, Medicos Sems Fronteiras, and Medicos Solidarios are all working in various sectors of this issue. In particular, Medicos Sem Fronteiras (Doctors Without Borders) focuses on social exclusion and disaster relief in the area. They work in the favelas and those living in the street, attempting to establish health care centers for people who otherwise have difficulty accessing them. They are attempting to change the accepting attitude towards the violence and misery in the city by creating sustainable medico-social initiatives and showing community members how to fight for their own rights. Through these efforts, they also are creating a channel of communication between these socially excluded communities and the government that ought to serve them.
On a national level, the public health issues across the country are vastly different, as the Head of International Affairs at Cruz Vermelha explained to me. First off, there are only 50 regional Cruz Vermelha branches in a country that simply needs more help (there are 200 offices in the much smaller country of Chile, just to give an idea of what the density of offices should be like). Then, there are the issues. In the Southern states, which are much richer, the problems are the high concentration of people in the major cities: Rio de Janeiro, Sao Paulo, Porto Alegre. Drugs and violence here place many of the citizens in dangerous situations, as exemplified by the current drug wars in the favela of Rocinha, which many people are calling the worst moments in its history. Access to clean water, which has been identified as a world-wide public health focus, is also an issue here. Near Niteroi, an area of Rio, there is one community where less than 30 percent of the people have access to adequate clean water. And then, there is the weather. While not a problem here in Rio, in the southern cities, such as Porto Alegre, the cold means tough times for the homeless in the streets. Moving up north, tuberculosis and yellow fever are concerns of the middle regions of Brasil. In the northeast, in the state of Bahia and around, the problems are more of a social nature: poverty, abuse. Machismo is a strong part of the culture and men often take out their misery on their wives. Finally, in the Amazonas, the communities of indigenous peoples are spread out and development is sporadic at best, limiting access to healthcare services. The cultures of these people also have conflicts with Western medicine and the attempts at establishing healthcare systems in the region in the past simply haven’t worked. Then, there are the problems of the country as a whole: the widely publicized spread of HIV/AIDS, the presence of other STDs, and the disastrous effects of the floods that often occur.
Everyone knows that Brasil is a large country with a large population and many problems. Creating collaboration between physicians and public health officials to address these issues is clearly not something new here. However, it seems as if in this era of failed promises, continuing frustration and let down by the one man they had entrusted to deliver Brasil from its social issues, the brasileiros are finding it hard to keep looking forward. The little steps are continuing, but it’s as if many people just don’t know quite where to go from here.
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