According to its constitution, every citizen of Brazil is entitled to free healthcare, both the preventative and the emergency kind. In practice however, services are often rationed by long wait periods and ill-equipped facilities, where patients are known to have died while waiting for much needed treatment. In Sao Paolo however, at a public health care facility called Bompar, there is a health clinic whose staff is dedicated to bringing medical care into the poorest communities both with an open door policy for visitors to their facility and medical teams that make house calls at tents, street corners, and even in crypts at the local cemetery. I followed along with Dr. Alexandre Carvalho on his rounds through the streets of Sao Paolo to see this kind of work first hand.
“Public healthcare is free for everybody but it is hard to reach the more transient communities,” I’m told by Dr. Carvalho as we hurry down the streets on which he makes his house calls. “Many of them are weary of the state given how they have been abused by police in the streets. So we have to make an extra effort in our outreach to provide them with preventive and emergency care.” To do that, each doctor at his clinic is assigned a team of ten social assistants and three assistant nurses. The social assistants, themselves former homeless people who have succeeded in returning to sheltered life, are the clinics eyes and ears on the streets, finding homeless in need of medical care and convincing them to visit the clinic for treatment. On his street call rounds, they also help the doctor locate his patients, as they are familiar with the movement patterns of their clientele. The assistants build trust relationships with the homeless community and help the doctor earn the confidence of his patients.
Illnesses such as tuberculosis and HIV are prevalent among the homeless community, as are side effects of drug and alcohol abuse and sexual exploitation. “Women have an especially hard time in the streets”, the doctor tells me. “After they flee their families from domestic abuse they wind up being suppressed in the streets, getting raped over and over again until they finally numb to it. Brazilian culture is very male dominated and that is no different in the communities that live in the streets. But they wind up in relationships in the street, cooking for their partner and feeling seemingly protected by them. But sometimes these relationships are abusive, too.”
Others of his patients find themselves homeless after a lifetime of hard work and alcohol abuse, when their bodies finally refuse to keep up and make them incapable to work. Many poor, rural Brazilians work under exploitative conditions, for example as truck drivers, being pushed to work impossibly long hours to meet the schedule set forth by their employers. To manage the demands, many drivers resort to the use amphetamines to stay awake and abuse alcohol to unwind during their downtime. At Dr. Carvalho’s clinic we meet one such patient, who after decades of working as a truck driver found himself with a life threatening heart arrhythmia caused most likely by his amphetamine abuse. He can no longer work due to his condition, but being below the retirement age he has no income to rely on and is running out of savings quickly. “Stories like his are very common here unfortunately”, Alexandre tells me. “I can try to get him the specialised care he needs from a cardiologist, which will help to advance his case that he is incapable to work, but while there theoretically is such a thing as disability pay in Brazil, authorities do everything in their power to deny giving such benefits to a worker even if he truly, desperately needs it.”
The clinic facility itself is a bare place, but has mostly what it needs to provide preventative care to its patients. Emergency care has to be provided by a nearby hospital, but ambulances are slow to arrive in truly urgent cases, taking often over an hour to appear. “We have shock paddles to do resuscitation”, the doctor tells me, “but we don’t really have the ability to bring somebody back once they’ve flatlined. In such situations minutes count, but ambulances don’t come here that fast.”
The pharmacy at the clinic is well stocked with many basic medicines Dr. Carvalho’s patients might need, including tuberculosis treatments, insulin for diabetics, anti-depressants and other psychoactive drugs, contraceptives, and even emergency contraceptives. Abortion is illegal in Brazil, but emergency contraceptives can be administered through the public health clinics. A condom dispenser is helpfully placed in the waiting room. Patients visiting the clinic or getting house calls do not have to pay a copay. Any medicine a doctor prescribes is also completely free for the patient. “We can’t give out monthly dosages however to our homeless patients, as they often sell their drugs, or loose them in a police raid, or when they get robbed”, Alexandre explains. “So, we give them medicine for a few days and have them come back for more. This way we can also keep an eye on them to make sure they take their medications properly. But it’s a challenge as many homeless do have drug abuse issues, and sometimes disappear for weeks. Especially with tuberculosis patients that is a problem, as they need to religiously take their medicines for a period of 6 months to be cured completely and avoid a relapse with a drug resistant strain.”
The clinic is open seven days a week and many stories are hard to observe for the doctor. Still, he says “I love what I do. This is important work. These people need serious care and someone has to give it.”