Building the barricades: Three interdisciplinary studies on Mental and Substance Use Disorders in the context of armed violence in Brazil

This research aims to understand the impact of armed conflict on the mental health and wellbeing of people living in the context of violence in the Complex of Maré - a conglomeration of 16 peripheral communities in Rio de Janeiro with a population of over 140,000 people*. By focusing on Brazil - a LMIC in which the state pursues a military-style intervention into peripheral urban territories (favelas) regulated by armed gangs trading drugs - the research seeks to locate an understanding of MNS disorders within the intensity of armed conflicts in peripheral territories that characterise many of the world's poorest and least developed countries. The research will seek to bring new understanding about the mental health and wellbeing of people living within a community subject to multiple stress factors (socio-economic exclusion, high levels of violence, limited access to cultural networks and institutions, etc) where daily lives are circumscribed by multi-faceted armed regulation and combat resulting from the so-called 'war on drugs'.

While the situation of MNS disorders is acute in fragile territories on the peripheries of many major cities in LMICs, the favelas of Rio de Janeiro are characterized by a narcotic narrative of sale, consumption, conflict and abuse that makes the territorially-specific analysis at the heart of this research an appropriate means to open up new avenues for future research. In the absence of funding or state structures that can develop, evaluate and maintain complex mental health interventions in LMICs, civil society organizations that utilize existing personal and social resources that can be provided through trained lay people, volunteers, peers, and families. This proposal will learn from, and develop low-cost approaches that are found to be effective within the context of the urban battlefields of the war on drugs in Rio de Janeiro.

Locating the research in Maré is significant since it allows the contextualization of the research questions in a territory where there are 15 areas used for the open dealing of crack, known locally as 'cracolandias'** [http://bit.ly/2moGPC4]; a lethality rate due to police actions in Maré in 2016 (12.8:100,000 inhabitants) eight times higher than that of Brazil (1.6:) and three times that of Rio de Janeiro state (3.9:) in 2015], as well as informal care networks for people living with MNS disorders. Maré is of the scale of a small city and has an organization, Redes da Maré, which has a long experience in the field of studies on violence and public safety and in the field of care for people who use crack, alcohol and other drugs.

The research proposes 3 studies: Study 1 on 200 crack-cocaine users living on or at risk of living on streets within and on the borders of the Maré communities, investigating existing mental health of the respondents, their knowledge and perception about MNS disorders, possibilities of self- and community-based care, existence of informal care networks. Study 2: an investigation of the mental health and wellbeing of people affected by high levels of violence and insecurity, with a focus on their mental health, patterns of drug use (legal and illegal), family and educational background, income generation and access to social, health and drug treatment programmes. It will include a survey of 1,200 residents of Maré with respondents from each of the 16 communities and 20 semi-structured interviews with respondents from the survey who are living with mental disorders and/or substance abuse Study 3: Arts-based practices to produce narratives and images that challenge stigma and exclusion associated with MNS disorders, resulting in of life stories and a public photographic installation.

* Population data source: IBGE - Brazilian Institute of Geography and Statistics' Profile of Brazilian Municipalities 2011 http://bit.ly/2mgzu6M
** RUI, Taniele. Usage of "Luz" and "cracolandia": fieldwork of spatial practices"

This proposal aims to enable local communities to collaborate with HEIs to create strategic means of resistance to MNS disorders and produce learning that can inform and shape public policy in support of UN Sustainable Development Goal 3, ensuring healthy lives and promoting well-being for all at all ages. The impacts of the project lie across intersecting arenas that will improve understanding of MNS disorders within peripheral communities affected by fragility and conflict, raise awareness, inform state and civil society practitioners, and influence public policymakers in Brazil and beyond.

Its main beneficiaries will be:

1) community members in the community of the Complex of Maré, Rio de Janeiro, Brazil, with particular attention to those living at with MNS disorders on or in proximity to the street, who will benefit from improved healthcare interventions and impacts that improve public policy;

2) civil society organisations delivering health and social care initiatives for mental health care in vulnerable communities, who will benefit from capacity building support to strengthen their delivery, cost effectiveness and structures;

3) Municipal and national government agencies and policy makers with responsibility for health and public security, as well as international researchers on these areas, whose knowledge will be extended by the way the project investigates the complex interrelationship of urban violence and MNS disorders;

4) International multilateral organisations and further international communities in developing countries, particularly within Latin America, that face similar challenges and may benefit from these insights in the planning and delivery of effective interventions and in the formulation of public policy around mental health and public security;

5) individual participants in the research, including both substance users and their families and friends, who will benefit from improvements to interventions in their care, from being signposted to services, and from changes in public perception of substance users that are the aim of the photographic, drama and narrative outputs of the research. Participants include 1,200 community members surveyed, 200 substance users surveyed and 20 who participate in in-depth interviews, and attendees to 8 focus groups convened by Redes da Mare.

The project will provide new empirical data to understand the challenges of living with and treating MNS disorders in Brazilian urban communities severely affected by fragility and conflict in territories subject to multiple stress factors such as socio-economic exclusion, high levels of violence, limited access to cultural networks and institutions, etc. The research moves beyond data collection to use innovative methodologies to identify social and human capital within the specific territory of Maré. The aim is to create mechanisms that lead to managing and preventing MNS disorders and associated health inequalities more effectively in the short- and long-term and to ensure coproduction and reciprocal exchange of knowledge which can shape public policy (municipal, national and regional). The impact will be maximised through the participatory, collaborative design of the three studies and through a variety of narrative outputs that will be disseminated as print and e-publications and through social media and door to door campaigns.