Homicides and territorial struggles in Rio de Janeiro favelas

OBJECTIVE

To evaluate the risk of homicide in Rio de Janeiro’s favelas, taking into account the territorial disputes taking place in the city.

METHODS

The study is based on data on mortality from homicide in the city of Rio de Janeiro between 2006 and 2009. Risks in favelas and in surrounding areas were evaluated, as was the domination of armed groups and drug dealing. Geographic and ethnographic concepts and methods were employed, using participant observation, interviews and analysis of secondary data on health.

RESULTS

Within the favelas, mortality rates from homicide were equivalent to, or lower than, the rest of the city, although they were considerably higher in areas surrounding the favelas, especially in areas where there was conflict between armed rival gangs.

CONCLUSIONS

The presence of trafficking crews and turf war in strategic areas of the city increases homicide rates and promotes the “ecology of danger” in these areas.     

Obstetric nursing in prenatal consultation

This study consists of a report about a research project which started in August, 1997. The project involved teachers from the maternal-paediatrics department with Faculdade de Enfermagem--UERJ (Nursing Faculty with State University of Rio de Janeiro) and professionals from the municipal health center in Rio de Janeiro--SMS/RJ. The introduction of prenatal nursing consultation as a new subject in the nursing graduation course, as well as its formation, and implementation in the referred municipal health center is reported in this paper. This study also proposes a review of the current biomedical consultation model, in order to motivate reflection, break paradigms, and increase the prenatal consultation process in Rio de Janeiro.     

A survey of demand for medical care in three public health clinics in Rio de Janeiro, Brazil

A sample survey was conducted in three public ambulatory medical care units in Rio de Janeiro in order to show the demographic and nosological aspects of the clientele as well as to evaluate the quality of clinic records. The sample included 2,029 patients registered in the health clinics and 3,980 consultants from October 1, 1990 to September 30, 1991. The diagnoses were coded according to the 9th revision of the International Classification of Dieases. Females accounted for about 60% of the sample, and more than a half were between 15 and 49 years of age. Children under 10 years old made up 28% of the total. About 38% of the patients came from the poor areas of the city: the "favelas". The case files were poorly filled out, frequently lacking useful information. The most frequent cause was classified in the XVIo chapter of the ICD - ill-defined causes, followed by respiratory, infectious, genitourinary and circulatory diseases. External causes predominated in one of the health clinics, which is an emergency service. There was a great demand for preventive measures, such as prenatal care and child care, even at the clinic that was traditionally devoted only to curative medicine. The most frequent specific diagnoses were upper respiratory tract infection, hypertension, gynecological problems, prenatal care, and skin diseases. There were no records for referrals to other health services. The poor quality of the medical records causes problems in terms of quality of health care. Use of such record-keeping systems, even while criticizing them, is essential to improve them.     

Culture and empowerment: health promotion and AIDS prevention among prostitutes in Rio de Janeiro

This paper discusses the difficulties that can arise when health promotion projects are developed within marginalized groups. This could be documented using the example of AIDS prevention among prostitutes. We applied questionnaires and focus group interviews were performed with prostitutes in Mangue, Rio de Janeiro in 1989. Later, during the decade of 1990, we accomplished open interviews with prostitutes who frequented S?o Jo?o Square in Niterói and with the leaders of the prostitutes' movement of Rio de Janeiro. During the analysis of the interviews we observed that although, from a public health point of view, prostitutes are considered as a group, they seldomly represent themselves in this way. In other words, while the goal of health promotion agencies and the prostitute movement is to build a prostitutes' grassroots movement able to organize and fight for prostitutes' rights and citizenship, most of the subjects studied believed that prostitution was an evil activity and consequently created narratives which denied their belonging to the prostitutes' community.     

Quality assessment of the public water supply in Nova Iguaçu, Rio de Janeiro

This study proposes to develop methodologies for public water supply quality control by implementing evaluation and control mechanisms and enhancing environmental health surveillance decision-making. These objectives were based on data for waterborne diseases recorded at the Rio de Janeiro State Health Department. We selected the following neighborhoods: Posse (1st Township) and Caioaba (5th Township), with dissimilar situations, allowing us to produce a model of water supply coverage in the Municipality of Nova Igua?u, Rio de Janeiro State. The study underscored the poor quality of the water supply in the two townships, since 61% of the samples were positive on bacteriological examination, showing the undesirable effects of differential sanitation, especially in developing countries.     

Poliomyelitis, philanthropy and physiotherapy: the birth of the career of physiotherapist in Rio de Janeiro in the 1950s

The polio epidemics in the country and especially in Rio de Janeiro left hundreds of children with sequels in the 1950s. The public outcry over the polio epidemic, the reports in the press and the association of experienced physicians with businessmen, bankers and relatives of victims created the conditions for the emergence of a philanthropic entity to combat infantile paralysis. The Brazilian Beneficent Association of Rehabilitation (BBAR) was founded in 1954, and two years later the association created the School of Rehabilitation of Rio de Janeiro (SRRJ), the first institution to graduate physiotherapists in the country. This article presents a socio-historical analysis of the establishment of physiotherapy as a profession in Rio de Janeiro in the course of the creation and accreditation of the School of Rehabilitation. It is concluded that the polio epidemics played a central role in the creation of the School of Rehabilitation and that conversely this institution had a strong influence in the recognition of physiotherapy as a health profession in the country.     

Community health centers: an alternative for the health system

Reflecting on the current reorganization of the relationship between the state and civil society, the health care field is involved in an intense debate over the organization and use of government and private health services. The authors propose an alternative, consisting of the implementation of primary health care clinics, managed by local institutions and funded by the Unified Health System. To support this proposition, they report on the current experience at the Rocinha slum in Rio de Janeiro, where a community health center was built by the neighborhood association 12 years ago and has been managed by the community since then. The hospital referral rate at the clinic, requests for laboratory tests, and use of precriptions have been considerably limited, although these services are available. These low rates are attributed to the possibility of closer social control by the community, as well as to the geographical features of the center, favoring a broader perception of both health problems and treatment. In order to provide more substantial support to the proposed centers, some suggestions are presented, like the implementation of direct agreements between the government and neighborhood associations (not allowed under current legislation) and expanding potential sources of funding for the health centers, currently restricted to government programs.     

A framework for developing evaluation tools used in Washington State's Healthy Communities projects

Washington State's Healthy Communities pilot projects were developed to test approaches and recommendations of the Washington State Nutrition and Physical Activity Plan and to provide a statewide model for implementation. The Healthy Communities program included plans for ongoing process evaluation to ensure implementation. Two years into the first project, however, the evaluation team recognized that data for evaluation were inadequate to explain the experiences of the pilot community partnership. The team sought a framework through which to better understand how the community partnership functioned, including what worked well and how guidance and technical assistance could best be provided. The evaluation team identified the community health governance model of Lasker and Weiss through a literature search and applied this model to existing Healthy Communities project evaluation data. The team also designed a new survey tool based on the model and used it in the second pilot community. The new tool provides feedback to community partners to help guide project implementation and tests the applicability of a theoretical model to public health practice.     

Reliability of birth certificate data in Rio de Janeiro, Brazil, 1999-2001

The objective of this article is to assess coverage and reliability of data from the Information System on Live Births in the City of Rio de Janeiro, based on an analysis of live birth certificates issued by the various hospitals and compared to information from the "Study on Neonatal and Perinatal Morbidity and Mortality and Care in the City of Rio de Janeiro". A total of 9,608 interviews with post-partum women were paired case-by-case with the respective birth certificates. The statistical analysis consisted of calculating the Kappa index adjusted to the prevalence of categorical variables and the intra-class correlation coefficient for continuous variables, with a 95% significance level. The study showed excellent coverage (96.5%) for hospital births in the City of Rio de Janeiro during the period studied. The variables presenting the highest concordance levels (over 0.90) were the infant's sex, birth weight, mother's age, type of delivery, and type of pregnancy. The variables marital status, mother's schooling, and number of prenatal visits showed lower reliability indices (Kappa < 0.70). The article discusses the importance of data quality in the Information System on Live Births (SINASC) and the system's use as a tool to help define maternal and child health policies.     

Induced abortion among low income women: dimensions of the problem

This paper examines the practice of abortion, especially induced abortion among low income women. The discussion is based on survey data collected between 1984 and 1985 in seven slum communities (favelas) situated in the metropolitan area of Rio de Janeiro, Brazil. Despite restrictive law, induced abortion is extremely frequent. Among married women 21.4 per cent reported experience of induced abortion. Most abortions were performed by physicians, however the quality of care of these procedures can be questioned since almost all induced abortions are illegal there is no possible supervision by health authorities. The incidence of post-abortion complication is very high, especially for those performed by traditional midwifes or by the woman herself. More than 60 per cent of the women were not using contraception at the time of pregnancy. About, 21 per cent reported that they were using the pill. Such a high pill failure rate is inacceptable, and probably was related to incorrect use. This points to the need for a better access to family planning care within the health services. The consequences of the restrictive abortion laws in Brazil are also discussed. Restrictions that in practice prove to have little impact on the practice of induced abortion, appear to be very effective in brooding even more the social-economic inequalities.     

Municipal Health Councils: activity and representation of grassroots communities

This article was based on the results of research concerning health policy in municipalities that achieved the most extensive development of decentralization and innovation in the State of Rio de Janeiro, Brazil. The study applied a questionnaire for health system users' representatives in Municipal Health Councils. The central issues were: the Councils' political role; social control by the Councils, viewed as surveillance by organized society over government actions; the nature of social representation exercised by the Council members; and the type of mandate they serve. Community representatives in the Councils reinforce aspects pertaining to the exercise of representation in unequal societies. There is a predominance of a differentiated elite consisting of older males with more schooling and higher income than the community average. The notion of "social control" as the basis for the Councils is difficult for the members to grasp. Exercise of representation is diffuse, occurring by way of designation by community associations, election in assemblies, or designation by institutional health policy agencies.     

Healthy Communities and civil discourse: a leadership opportunity for public health professionals

The author argues that the Healthy Communities movement provides public health professionals with an opportunity to become not just community leaders but also agents of change in a broad political sense. Extending the work of Kohlberg and other developmental psychologists, the author describes five levels of civil discourse. Professionals who practice the inclusive, consensus-oriented level of discourse, which is consistent with the philosophy of Healthy Communities, can help reinvigorate civil society and democracy as a part of making their communities healthier.     

Intersections of race,gender and the drug economy: Placing drugs in HIV discussions in Brazil

While much research now demonstrates how social inequalities can drive HIV transmission, relatively little attention is given to the spatialized ‘intersections’ of race, class, and gender. Using this approach, this article considers an understudied phenomenon in Brazilian HIV discussions, the importance of the drug economy in shaping intimacy in favelas. Drawing on interviews with young women in Rio de Janeiro, it documents the intimate relations between young women and male drug workers to situate HIV vulnerability at the juncture of three social-spatial changes: (1) the rise of a drug economy that provides some racialized men, marginalized from mainstream society, with opportunities for work; (2) the precarious economic position of racialized women; and (3) the gendered dynamics including violence that can shape intimate relations. The paper shows how these relationships are contested by women who can cast their partners as living a ‘wrong life.’     

Organizing a project with community-based health agents recruited from prostitutes in Rio de Janeiro.

In Brazil, the Prostitution and Civil Rights Program works to fight against stigma and violence against sex workers and to foster self-esteem, self-determination, and greater access to civil rights. It sponsors the Brazilian Prostitutes' Network. In 1988, the Ministry of Health asked the program to join the Ministry to produce sexually transmitted disease/AIDS prevention materials. The materials were ready for distribution in early 1991 when the program began recruiting prostitutes and transvestites for its Health Education Project. The aforementioned groups and the Brazilian chapter of International Planned Parenthood Federation are working together on this project. By mid-1992, the project recruited 17 community-based health agents (15 female and 2 male prostitutes) from different prostitution areas and through a network of contacts from these areas of Rio de Janeiro. After informal training in April or June 1991, they went into their communities to inform people of their health agent role, distributed free condoms and AIDS education material, and promoted the project. Health agents maintain a weekly report of condom and education material distribution. This allows them to monitor their progress. Health agents now meet with their peers to discuss sex and health issues. The communities have opened their doors to the groups. The project is also geographically mapping the sex trade to target health care and other resources in each area. It is pursuing a reference/counterreference relationship within the existing public health system in Rio de Janeiro. Involvement of sex workers in all phases contributes to the success of the project so far. Future research is needed to determine whether the project is reducing risk of HIV transmission, however.     

Mortality from cardiovascular diseases in three Brazilian states from 1980 through 2002]

OBJECTIVE: To evaluate and compare adult mortality from diseases of the circulatory system (CDs), especially ischemic heart disease (IHD) and cerebrovascular disease (CVD), from 1980 through 2002 in the Brazilian states of Rio de Janeiro, Rio Grande do Sul, and S?o Paulo and their capital cities (respectively Rio de Janeiro, Porto Alegre, and S?o Paulo), taking into account the impact of deaths due to ill-defined causes on mortality rates. METHOD: We estimated mortality rates (crude and adjusted by age and sex) from CDs overall and from IHD and CVD among individuals aged 20 years or older. These rates were weighted with a portion of the deaths from ill-defined or unknown causes, in the same proportion as deaths from CDs, IHD, and CVD in relation to deaths overall, excluding deaths from ill-defined causes. Using linear regression models, we also estimated the mean values of and annual differences in the weighted adjusted mortality rates. The reference population was that of the state of Rio de Janeiro in 2000. RESULTS: The annual decline in the weighted adjusted mortality rates from CDs ranged from -13.1 per 100,000 individuals in the state of Rio de Janeiro to -8.7 per 100,000 in the city of S?o Paulo. For IHD, the annual declines were greatest in the city of Rio de Janeiro (-5.0 per 100,000) and the state of Rio de Janeiro (-4.5 per 100,000), and smallest in the state of Rio Grande do Sul (-2.8 per 100,000) and the city of S?o Paulo (-2.7 per 100,000). With CVD, the range that was found extended from -6.5 per 100,000 in the state of Rio de Janeiro to -2.9 per 100,000 in the city of Porto Alegre. CONCLUSION: The decreases in weighted adjusted mortality rates from CDs, IHD, and CVD occurred after 1980, so it is unlikely that the declines resulted from controlling risk factors or from the practice of myocardial revascularization. The decreases might be related to a period of strong economic development preceding the declines, which translated into improved living conditions and reduced exposure to infections in the perinatal period and childhood.     

Income inequality and homicide rates in Rio de Janeiro, Brazil.

OBJECTIVES: This study determined the effect of income inequality on homicide rates in the state of Rio de Janeiro, Brazil. METHODS: We conducted an ecological study at 2 geographical levels, municipalities in the state of Rio de Janeiro and administrative regions in the municipality of Rio de Janeiro. The association between homicide and income inequality was tested by multiple regression procedures, with adjustment for other socioeconomic indicators. RESULTS: For the municipalities of Rio de Janeiro State, no association between homicide and income concentration was found an outcome that can be explained by the municipalities' different degrees of urbanization. However, for the administrative regions in the city of Rio de Janeiro, the 2 income inequality indicators were strongly correlated with the outcome variable (P < .01). Higher homicide rates were found precisely in the sector of the city that has the greatest concentration of slum residents and the highest degree of income inequality. CONCLUSIONS: The findings suggest that social policies specifically aimed at low-income urban youth, particularly programs to reduce the harmful effects of relative deprivation, may have an important impact on the homicide rate.     

Hemophilia care in the state of Rio de Janeiro, Brazil.

In the developing countries of the world, few people with hemophilia receive adequate care. Nevertheless, Brazil has made significant advances in the treatment of hemophilia over the last decade. The provision of factor concentrates imported by the Government of Brazil is gradually increasing, and patients receive the concentrates for free. A national register was established as well as a coordinated program for comprehensive care. Of the 6 297 persons with hemophilia in Brazil who were registered as of January 2001, 689 of them (11.1%) were registered in the state of Rio de Janeiro. Of those 689, 664 of them were being monitored at the state's coordinating blood transfusion center, which is located in the city of Rio de Janeiro. Among those 664, factor VIII inhibitors were identified in 81 of them (12.2%). Among 653 of the Rio de Janeiro patients who were tested for transfusion-transmitted diseases, the overall prevalence found was 41.5%, with the specific rates being 13.3% for human immunodeficiency virus (HIV), 2.9% for hepatitis B virus (HBV), and 39.4% for hepatitis C virus (HCV). The state of Rio de Janeiro has adopted a comprehensive hemophilia management approach that includes medical, psychological, and social care. As a result, the quality of life of hemophilia patients has improved noticeably. For example, the rate of hospitalization among patients fell by 30% between 1998 and 2001, and there has also been a decline in the school and work activities that they have missed.     

Climate variables, living conditions and the health of the population: leptospirosis in the city of Rio de Janeiro from 1996 to 2009

Extreme climate events have major repercussions on the health of the population, especially when they cause disease or even result in victims due to accidents. The population of Rio de Janeiro is vulnerable to climate variations, mainly due to the socio-economic factors, as the city has a topography and climate that enhance this vulnerability. This article discusses the evolution of leptospirosis in the thirty-two administrative regions of the city of Rio de Janeiro from 1996 through 2009, testing the hypothesis that climate variations lead to an increase in the number of cases of the disease. The meteorological data examined were provided by the National Meteorology Institute and the Brazilian Airport Infrastructure Company. Data on the morbidity and mortality of leptospirosis was collected from Rio de Janeiro's Municipal Health and Civil Defense Department. In this work, it was concluded that there is a direct correlation between the incidence of leptospirosis and rainfall. However, in the final analysis, it must be emphasized that the oscillation of the number of cases is not only determined by rainfall, since other factors influence this dynamic, such as sanitation, in addition to environmental and social factors.     

A comparative analysis of the ambulatory care production register in oncology in the Brazilian Unified Health System

The response of healthcare services to new information systems depends upon, among other factors, their local organization. This study aimed at comparing the chemotherapy and radiotherapy production registers for the cities Rio de Janeiro and Belo Horizonte, Brazil, in the Ambulatory Information System of the Unified Brazilian Health System (in Portuguese, SUS) between November/1998 and February/2003. Both cities showed a pattern of increase for the chemotherapy production series, while the radiotherapy series showed such increase only for Rio de Janeiro. Comparing Box-Jenkins models for each series, Rio de Janeiro showed a delay of three months in recording production, due to public services. In Belo Horizonte, the delay was shorter than in Rio de Janeiro and there was no difference between public and non-public services. The observed differences between the cities seem to be associated with the fact that Belo Horizonte already had a mechanism to control and evaluate production before the introduction of the system in 1998.