Written by GHSM undergraduate students Elisabeth Lindvall and Hannah Akki
This August, just before commencing our final year of Global Health and Social Medicine (GHSM) here at King’s College London, we – Elisabeth and Hannah, were given the incredible opportunity to embark on an adventure exploring mental health care provision in Rio de Janeiro, Brazil. The aim of this internship was to observe how primary mental healthcare is organised, delivered and managed in the northern area of Rio de Janeiro, coordinated by GHSM at King’s in partnership with the Institute of Social Medicine (ISM) at Universidade do Estado do Rio de Janeiro (UERJ).
The city earns its reputation of stunning beauty, uniquely situated between rainforest, green mountains and white sand beaches. But beyond Rio’s breath taking views and famous landmarks, hides a complex entanglement of social issues. A delicate political situation of impeachment and corruption, has led to reduced public funding resulting in strikes within the police force, schools and healthcare. Inevitably, this affects hospitals and other healthcare institutions that, with less resources, struggle with their daily activities. In spite of these political issues, Brazil operates the largest universal healthcare system worldwide – Sistema Único de Saúde (SUS). It is based on the principle of health as a citizen’s right, with the aim to provide comprehensive, universal and preventative care through decentralised management and provision of health services, promoting community participation.
Getting a first-hand experience to observe, learn and discuss how SUS operates on the ground was a unique and incredibly rewarding experience. In addition to getting an in depth understanding of innovative mental health care provision in primary settings of SUS, acquired through shadowing physiatrists out in clinics, we also participated in different academic seminars. At UERJ, we spent time at both the ISM and LIPAPs (Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde), an interdisciplinary centre that works with action and research within primary health care with particular focus on mental health. LIPAPs run various projects to improve mental health care particularly in community settings, as well as training healthcare workers according to the WHO with the mental health gap action program (mHGAP).
Dr. Sandra Fortes who is both a professor at UERJ and a leading researcher at LIPAPs, is also a psychiatrist within SUS. She provided us access into the daily practices of primary mental healthcare in Rio where we participated in weekly psychiatric consultations in family clinics. Specific to the matrix system in Brazil, each consultation is with the presence of not only a psychiatrist, but also a family doctor, a nurse, an intern psychiatrist and a psychologist. Through these consultations, we understood that many of the issues patients experience in Rio are often rooted in, or triggered by, social or political structures impairing their mental health and ability to access care. In one case, due to the increased violence in particular parts of Rio, a local resident was not able to visit their local clinic, leaving them without medicine or care for long periods. These consultations gave us useful insight into how the collaborative nature of the Brazilian matrix system is able to tackle issues of access to healthcare by ensuring care and access to medicine, for each individual patient.
Moreover, we attended a mindfulness workshop led by Dr. Fortes which reflected SUSs wider efforts to continually integrate complementary medical practices in their delivery of primary mental healthcare. Additionally, we also participated in different group consultations specific to women, provided as a space for them to share their hardships and victories. These group consultations have become an important way of providing therapy and medicine within the Brazilian model of care. Through this form of consultations, patients share a feeling of collective community in comparison to the individual struggle. Undoubtedly, there is a collective notion present in the Brazilian society that was reflected in its health care practices, and to us, represented the warmth and openhearted mind of the people on Rio.
Our time in Rio de Janeiro, gave us insight in how a universal, financially restricted yet innovative health care system can operate on the ground, and with limited resources succeed to deliver mental health care to a large and diverse population. Most importantly, we learned that equity in access to drugs is a fundamental cornerstone in providing mental health care. This internship was an extraordinary experience that allowed us to apply studied knowledge in a specific context, and we feel extremely grateful to have had this opportunity. Therefore, we want to sincerely thank everyone that made this possible, particularly Dr. Carlo Caduff, Dr. Francisco Ortega and Dr. Sandra Fortes, King’s and UERJ. Last but not least, we are grateful to the KCL Global Engagement program (Latin America) for funding this internship with the provision of two bursaries.