The complexities of life in Complexo do Alemão

06 August 2008

“It is actually an area completely cut off from the rest of Rio, there are barriers that isolate it – the police cannot come in, the ambulances cannot fit through the narrow streets.”

© MSF

Daniel Fiandero works as Medical Focal Point, or team leader, in Complexo do Alemão, Rio de Janeiro, Brazil. This is his first mission with MSF and this interview was conducted in June, six weeks after he arrived at the project, where the MSF unit provides primary health care to a community struggling to access health services. The health facility is open seven days a week.

What led MSF to open a project in Rio de Janeiro?

The project came in response to outbreaks of violence in May/June 2007 within this community called Complexo do Alemão, in Rio de Janeiro. During these episodes of heavy violence, there was a great deal of shooting, which led to little access to health care, schools or any other services. Everything shut down. The unit was set up to provide health care to people directly affected by this violence, for example, people hit by stray bullets and those who have regular health needs not seen to as a result of the violence. So we are based within the community. Now, as things are a little more quiet, we are providing for the more general needs.

What services do the project provide to the population of Complexo do Alemão?

Our focus is primarily the emergencies, especially the heavy trauma emergencies. In these cases, we stabilise the patients at the MSF unit and refer them to where they can receive specialised care, or our medical team will treat them if we cannot refer them. We are not dealing with the more chronic problems, such as controlling diabetes or hypertension, as there already is a system in place within the government structures to help them control these chronic problems; therefore they have access to health care for those conditions. The same is true for HIV and TB. We have a protocol to screen for acute problems that need to be treated on the day and the more chronic cases are orientated, educated and sent to the appropriate places.

As this community is under tremendous stress – there is daily violence – psychosocial services are therefore as important as the medical services. The MSF unit has local psychologists seeing patients on a daily basis with appointments, providing counselling on many problems they might be having. From a medical point of view, it really helps to have psychological services at hand, and that you can call upon them when you need to, for example, in helping to explain a condition to a family. We also have patients coming in with medical complaints that might primarily be psychological stress, and we can refer these cases to the psychologists. The psychological service is doing a lot for the community.

Are there other health structures in that area?

The MSF unit is the only medical unit within the boundaries of the community. It is actually an area completely cut off from the rest of Rio, there are barriers that isolate it – the police cannot come in, the ambulances cannot fit through the narrow streets; it is literally cut off. On the outside there are health care facilities, there are hospitals and ambulatory services, but inside there is nothing. Our first aim is to stabilise patients and to then send them to the appropriate services. We treat what we can, trying to alleviate the heavy load on the government services, but we do need to refer patients.

What is your role in the project?

I am the medical focal point. The mission comprises of Brazilian doctors; they actually see the patients. My role is to coordinate the doctors, monitor their work, make sure they are working according to MSF standards and in a professional manner. I also help with setting up protocols and organising referral systems, and I help with whatever the team needs from a medical point of view, for example with cases that are more difficult.

What are the main challenges that MSF faces in the project?

There are quite a few challenges in this project, which have to do mostly with where we are situated and that the community is largely isolated. Within the community we are very much accepted; everyone is very grateful that we are there, they welcome us, they want us to do even more within the community. In that way it is very easy for us to be there. But it is a tough base because we are cut off from the outside, nobody else can come in, so we feel quite alone.

How did MSF establish itself in the community?

That happened mostly before I arrived in the project but of course it is an ongoing process. The team now has a very good relationship with the community, they have made connections with community leaders and have been working really hard to establish these good relationships. It is important to explain what we are doing, why we are there, and the way MSF works. The community really appreciates the MSF ethos and the way we do things. We have also hired staff from the community, such as community health workers, who are very good and, of course, they know the community very well. They do talks among the community on a daily basis, they organise get-togethers, and they do health education work, including explaining our services.

Did your previous experience in South Africa help you do the work you are doing now in Rio?

It helped a lot. Where I worked in South Africa, I got exposed to all the specialties. To give you an idea: for three months I was the paediatrician – any case in paediatrics came to me and I had to deal with it; then, for the next three months I was the maternity doctor; then surgery, and so on. Now any kind of general emergency can come to me, from an obstetric emergency to a trauma emergency. Also, here we don’t have a lab or X-ray facility, so without a lot of testing equipment it really comes down to the patient’s history and clinical examination, and I am used to that. Where I was working in South Africa it used to take me two days to get a blood result back, so I am used to not having one; by the time it came back I would have discharged the patient.

Also, I have never had an English-speaking patient since I started practising medicine, so from that perspective it’s normal for me to interact with the non-English-speaking patients here. Just as an anecdote, when I arrived here, and wanted a patient to breathe in order to listen to the chest, I would speak isiZulu or isiXhosa. It took me two weeks to realise what I was doing! I just thought it was bad pronunciation, but I was obviously speaking the wrong language.

After working with MSF for six weeks now, would you say it is what you expected it would be when you applied?

There are many similarities and a few differences. In terms of the people I am working with, it is really what I hoped for, and expected to some extent. The team is very professional, very active, and interested in helping those who are in need; in doing everything they can to improve whatever they can in the lives of those around. There is also a high priority in organisation, in making sure things are running smoothly and professionally, and the systems are very well monitored. That has been really good.

But the fact that I am in Brazil, in a very urban area, does not seem, for me, like a “typical” MSF project. Even though it is very urban, and there are structures outside that function very well, again, there is a general feeling of isolation in the community we work in. It has been strange, as I believe most people coming to work with MSF expect “Africa”, and being in Brazil is very different from what I expected. It is strange to be working in this community, which is completely cut off from the outside world – you see guns, grenades, etc – and then you go home to Rio City where it normal life again. From that point of view it has been really interesting.

What strikes you as different or similar comparing Brazil and South Africa?

There many similarities in the people. There is a openness and friendliness, which I recognise from South Africa. I really feel at home; this spirit of sharing and caring for everyone that you can. In terms of the needs, the problems are very different. Although there is the same problem of violence, the violence is very different and the stresses are therefore very different, for example, it is not the same kind of stress in terms of HIV. However, the level of violence and the organisation of violence, I’ve only recognised in movies. The level of control these people are subjected to places the community under an incredible amount of stress, but they stay in high spirits.

Are you enjoying this experience?

I am enjoying it, it is an amazing experience to come across so many people with such different views of life. The MSF view of life is quite amazing, the idea that you are there to really help the community around you: You give your time to people in places where most people wouldn’t choose to go. When I told people where I was going they were surprised and shocked at the same time. So it is a truly amazing experience.