Brazil
An encouraging example
Anne-Lise Schmitt
Journalist specialised in Brazil
Barely ten years ago, the HIV/AIDS epidemic
was accelerating in Brazil at a comparable rate to that occurring in African
countries.
Thanks to the effective policy designed to inform the population at large and to
reduce the harm done to injecting drug users (which account for one quarter of
the HIV positive population in this country), the rate of contamination has been
slowing down considerably since 1999. Brazil has become an example to the other
Latin American countries.
In 2000, Brazil had 164 million
inhabitants, 500,000 of whom were HIV positive. This is the fourth largest
country in the world, the eighth in terms of economic power and one of the most
densely populated States on the planet: Brazil is a giant. It is also
characterized by extremes of social inequality: 20% of the population are
illiterate, suffer from malnutrition and live under unhealthy conditions, with
little access to information. The risk of HIV contamination is high, due to both
sexual exposure (which was responsible for 52% of all the present cases) and
drug injection practices (25%) (1).
Injecting drug users accounted for only 2.7% of all the cases of contamination
in 1982, but the figure went up to 18.2% in 1998 and reached 25% in 2000. In
view of the epidemiological upsurge, the public authorities decided during the
1990s to back harm reduction projects, which numbered 40 by the year 2000. Most
of these projects involved heightening awareness or handing out sterile
syringes, condoms and alcohol. In a study carried out by the Ministry of Health
in 1999, the following information was obtained about the injecting drug users
taking part in these programmes: 70% of them were males between 18 and 30 years
of age, who were taking drugs in groups and sharing their syringes. 52% of them
were sero-positive and 80% had hepatitis C.
In spite of this alarming situation, there were stillobstacles, particularly
legal ones, to setting up programmes. Uner the present narcotics law (Law 6368
of 1976), anyone who encourages drug use, is liable to prosecution and this, if
interpreted too narrowly, can also be taken to mean anyone who hands out
syringes (cf. insert).
Three federated States located in areas with the highest risks have eluded the
law by drawing up their own harm reduction* legislation based on the
constitution, which states that in a national emergency involving risks to
public health, every individual has the right to health and medical treatment.
In a country where 90% of the population are Catholics, the position adopted by
the Church has caused rifts of opinion.
But behavioural changes are occurring, and injecting drug users themselves are
increasingly taking part in harm reduction programmes and changing their
practices.
The city of Porto Alegre has set up a system of local management with a view to developing a harm reduction policy based on mutual support and social integration.
SHARING EXPERIENCE
Participative democracy was established in
Porto Alegre in 1989 by the Workers' Party, which includes extreme left
movements, social democrats, progressive Christians and trade unionists. Local
inhabitants form neighbourhood Committees presided by a city councillor, who
acts simply as an observer, to decide on investment priorities. Budgetary
allowances are divided up during the assembly of all the neighbourhoods,
depending on the number of inhabitants they contain and their level of
development. The budget is drawn up, signed by the mayor with no amendments, and
then submitted to the city council for approval. The city has sixteen
neighbourhood Committees of this kind, each involving about three hundred people
(this amounts to 10% of the city's population). The members of these Committees
are mostly members of the city's working and middle classes.
The first budgets approved by the Committees focused mainly on city
infrastructure (streets, transport, ecology), violence and security, and were
then gradually extended to include items such as education and access to health
care for all citizens.
Recent activities include the efforts made to decrease the risk of
contamination, for example. For the last four years, under the impetus of a
recent law in the State of Rio Grande del Sul, many programmes have been
developed in which drug addicts themselves participate.
Prevention specialists speak to associations, in schools, social centres,
athletic clubs and clinics in order to get the prevention message across. They
also distribute syringes and condoms. At public health centres, which are rather
reluctant to admit drug addicts, they explain how to clean syringes and carry
out HIV and Hepatitis C and B screening tests: these diseases are actually
responsible for larger epidemics than HIV in the city. The teams also reach out
to high-risk members of the population living on the streets, the prison inmates
at the Porto Alegre central prison and other socially vulnerable communities.
"We always start with what the subjects themselves have gone through, Mirtha
Sendic explains, so that the IVD users can share their experience with their
peers. We call it educating equals."
BREAKING DOWN THE BARRIERS BETWEEN DRUG USERS AND THE COMMUNITY
Participative democracy, whereby drug
abusers participating in these programmes are eligible for membership of the
neighbourhood Committees, has changed the way people think, and has enabled new
players to become involved. Bars and restaurants have set up used syringe
receptacles and distribute new syringes. On similar lines, companies have been
organised into co-operatives through which drug addicts can find jobs. The aim
of all these initiatives policy is basically to break down the barriers between
drug abusers and the rest of the community. "It's by going to work every day
that drug abusers will come to realise that they are the equals of all the other
citizens, says Myrtha Sendic. IVD users often do not want to stop using drugs,
but, once they have joined the working world, they learn to use them only in the
evening rather than all day long."
The statistics have not yet shown a decrease in the number of cases of
contamination (1), but over 75% of all the contaminated IVD users taking part in
the programme have stopped sharing syringes. Another successful outcome is the
fact that people on the fringes of society are given a hearing by local
inhabitants, which, according to Mirtha Sendic, consolidates and strengthens the
social fabric of the city and the feeling that these people belong to a
community.
1 It has been estimated in one study that
the number of new cases of AIDS among the Porto Alegre IVD users is increasing
by 36% per year. This percentage is attributable to the high rate of drug
consumption in the south and to the geographical position of this part of the
country, which is on the route taken by the drug traffickers.
Contact: mirthasendic@pro.via-rs.com.br
LEARNING TO COMMUNICATE
with high-risk populations and police officials
The first harm reduction project in Brazil
was launched in the port of Santos in the State of Sao Paolo. It was based on
experiments which began in Holland in 1982 and in Australia in 1985. The idea
was to make syringes available at health posts. However, the medical team in
charge, consisting mainly of doctors specialised in STDs, was soon being
questioned by the police. Similar mishaps also occurred to workers involved in
harm reduction early in the epidemic in Europe. Dr Tarcisio de Andrade, who
currently heads CETADE (the Centre for Drug Abuse Study and Therapy) in Salvador
de Bahia, has the honour of having started the first harm reduction project ever
tolerated by the police in Brazil. This was the result of long efforts, where
discussions with police officials were as important as those with the socially
marginalised communities targeted by the programme.
In 1994, Tarcissio de Andrade focused his doctoral dissertation on the risks of
contamination by the HIV virus run by homeless people and the inhabitants of the
favelas, where he discovered that 50% of the IDUs were HIV carriers. He began to
work "using whatever means came to hand". With the help of colleagues and
volunteers, he produced local radio programmes to inform people about the
precautions they should to take to protect themselves from the AIDS epidemic.
The speaker would announce the times at which the mobile teams would be in the
favelas to hand out condoms and syringes. In these broadcasts, the issue of
morality was discussed, people were informed about the epidemiological situation
and above all, they helped to counteract the tendency of locals to reject IDUs.
Making efforts to convince people that this project will not involve selling drugs.
Listeners asked non-stop questions: "the
Church doesn't allow the use of condoms", "handing out syringes means you're
encouraging young people to take drugs", etc. The planners had to explain their
position clearly: "we're neither HIV positive nor representatives of the Church:
the syringe exchange programme is mainly a response to a public health issue.
We're here to give psychological and medical support to people who have the
virus and we want to help both you and your children".
Long talks with the police were still necessary' to convince them that the
permanent' premises were not going to be used to sell drugs. Three years later,
CETADE, thanks to funding from the authorities (the Department of Health in the
State of Bahia, the city of Santos and the Brazilian Federal government);
finally opened a centre providing testing; syringes and condoms.
Nowadays, harm reduction has come to be fully recognised by police officials and
locals'[ alike. According to Dr Tarcisio de Andrade, it is time to take things
farther. He now wants to undertake programmes that will not distinguish between
preventing drug use í and abuse, for "sub-dividing people into! users and
non-users does not give us a very all-round prevention policy". In his opinion,
ways of dealing with everyone have to be found "in order to break down the
imaginary lines between people who use drugs and those who don't, so that the
latter are no I longer looked upon as diabolical and can be brought back into
the fold of the community".
Contact address: tarcisio@ufba.fr