FORTALEZA, Brazil — A man in a white overcoat looks down at the book in his oversized hands with a peaceful expression. Sitting at his desk, he doesn’t appear much older than 30. Behind him stand books on a row of shelves. The scene is captured in a black and white painting framed by a thin, dark-blue frame. A sole plastic fan mounted on the wall beside it represented a futile attempt to cool the waiting room in which it hung, filled with plastic chairs, one of which accommodated me.
In a moment of boredom, I got up to fill my water bottle, but the room’s metal faucet was covered in rust and not even remotely close to functioning. The Maresia—as locals call the strong wind mixed with drops of seawater that blows year-round in this part of Brazil’s northeast—rusts metal within a few years. I wondered distractedly if any economist has investigated the destructive wind’s impact on the local economy. Back in my green chair, I looked back at the man in the painting. He must be a doctor, I thought.
That would make sense because I was in a health clinic on the southern tip of Praia do Futuro, an 8-kilometer stretch of beach on the eastern shore of this northern coastal city. Moments earlier, I had checked in at the reception desk, where a friendly attendant took down my information. It did not matter that I was a foreign citizen; he accepted my identification and in the span of 15 minutes registered me into Brazil’s national health care service registry.
In the hope of traveling to the Amazon rainforest next spring to investigate access to health care in remote settings, I was here to get a yellow fever vaccine. While the health clinic— locally known as a posto de saude—was not the closest to my apartment, it happened to be the only one providing that specific vaccine on Fridays. Once registered, I retrieved my documents from under a glass window and was left to ponder the system in the waiting room with the man looking calmly down at his book.
I had shown up without an appointment. I hadn’t paid anything, as vaccines and many other preventative health care services for all citizens and non-citizens are fully covered by Brazil’s national health service, the Sistema Único de Saude—or simply SUS to close friends and family. How could that be?
I came to Brazil to understand how this vast and diverse country cares for people who use or abuse psychoactive substances. So far, every partial answer has only generated more questions.
Roughly the same size as the United States yet often overlooked by its large northern neighbor, Brazil makes up 47 percent of South America’s landmass, as well as around a third of the population and a third of the continent’s economy south of the US border. Yet it seems that the only cultural export to have pierced the American consciousness is the city of Rio de Janeiro with its outlandish annual carnival, the sound of samba and daydreams of sandy beaches with a choice of a fresh coconut or cold caipirinha cocktail.
In many ways, Brazil and the United States are alike. With 212 million people, this is the world’s 7th-most populous country. Like the United States, it was the forced destination of African slaves during the transatlantic slave trade from the 1500s through the mid-1860s—5.5 million, the largest number brought to any one country. Additional voluntary waves of migration from Europe and Asia helped Brazil become one of the most diverse societies, with 45 percent of citizens identifying themselves as mixed-race in a 2022 census, which saw those identifying as mixed-race overtake the percentage of those identifying as white for the first time.
Like its northern neighbor, Brazil also has huge economic inequality, with the richest 10 percent earning more than 13 times what the poorest 40 percent bring in. Brazil’s Gini coefficient—a global standard for measuring wealth inequality—is 51.6, ten points higher than the US 41.8 and double the Netherlands’ at 25.7. On average, it is a much poorer country, with a GDP per capita of around $10,280 compared to America’s $85,810.
Another similarity with the US is Brazil’s proportion of people in rural areas, with about 18 percent living outside cities. Like the United States, it is an extremely religious country, with 49 percent of citizens affiliated with the Catholic Church and 26 percent identifying as evangelicals—making the total Christian population 75 percent. In the United States, 62 percent identify as Christian, with 23 percent of all US adults identifying as evangelical and 20 percent as Catholic.
To begin understanding the history of drug policy in this gargantuan country, I called Dr. Fabio Mesquita at his home in the city of Santos near São Paulo, home to Brazil’s largest port, which saw a surge in injectable cocaine use in the 1980s. Now a professor at the Federal University of São Paulo and a consultant for the World Health Organization, at the time he was a municipal public health official who rose to national prominence combating the rising impact of cocaine use. He was also the chairman of the Harm Reduction International Conference hosted in Brazil in 1998.
Fabio explained that Brazil has never been a final destination country for cocaine because of the low local purchasing power. However, it is often the transit country of choice for drug cartels producing cocaine in Colombia, Peru and Bolivia to reach the profitable European and North American markets through Brazil’s Atlantic Ocean ports. Preparing his PhD dissertation on the topic, Fabio calculated that around 80 percent of cocaine arriving in Santos was for export, 10 percent confiscated by the authorities, and 10 percent pushed onto the local market by cartels seeking to create a buffer demand to help make up for obstacles reaching foreign markets.
The 1980s saw the arrival of HIV/AIDS, which began spreading at record rates partly because cocaine was primarily injected at the time. The toxic combination made Santos home to the largest population of HIV-positive people in the country, with 50 percent of infections due to shared needles. In response, the city opened the country’s first needle exchange in 1989 but it was soon shut down by the state of São Paulo, where Santos is located. Needle exchanges were launched elsewhere in the 1990s but the beginning was slow partly due to laws from Brazil’s dictatorship (1964-1985) that inflicted harsh penalties, usually against drug traffickers, to anyone who helped a person consuming drugs. In the end, needle exchanges were officially legalized in 1998 thanks to pressure by civil society and federal universities such as one in the northeastern state of Bahia that skirted the law to offer such services with support from the local governor.
In a push to reduce injection use and the spread of HIV/AIDS, public health officials ran campaigns urging people using drugs to desist from injecting. Drug traffickers reacted by selling smokable cocaine, known locally as basuco, as a “safer” option. That led to its own Pandora’s box of problems still felt today. Since smokable cocaine has a smaller chance of transmitting HIV/AIDS, Fabio said, it became much harder to find public health funds to help people using cocaine because most harm reduction funding is tied to anti-HIV/AIDS grants focused on needle exchange-based programing.
Throughout the early 2000s, crack cocaine spread through Brazil’s major cities. However, while Cracolândia—the world’s largest open-air crack cocaine market, located in São Paulo, which I described in my last dispatch—grabbed headlines, the drug use never reached the status of an epidemic like the opioid crises in America today.
Among the laws that kept coming up in my conversations with doctors and harm reductionists was the country’s psychiatric reform of 2001, Law 10.216, which established greater protections for people with mental and behavioral disorders. To better understand the law, the ensuing regulations, their precedents and legacy, I contacted Marcio Camatta, a nurse by training with a doctorate in nursing and experience in both research and clinical care for those struggling with mental health and substance use disorder. He is currently an associate professor at the Federal University of Rio Grande do Sol, on Brazil’s southern tip.
“To understand the Brazilian model for treating people with serious mental illness and substance use disorder, you must look at what was happening in England and France in the 19th century,” he explained. As subjects of a European colony until 1822, the Brazilian elite often looked to Europe—France in particular—for domestic policy ideas. Prior to the “scientification” of mental health in that period, popular belief held that illnesses like bi-polar disorder and schizophrenia were caused by demons and witchcraft.
While the 1800s saw greater medical care given to patients with serious mental health issues, the pressures of the industrial revolution and its capitalist mindset also meant that many were now labelled “unproductive,” meaning they should be changed to become “full members” of society, otherwise sidelined, Marcio told me. The development heralded the golden age of asylums, with France opening its first in 1793. A few decades later, in 1852, Brazilian Emperor Don Pedro II inaugurated the “Lunatic Palace” in Rio De Janeiro, the first institution in South America focused solely on treating patients with mental disabilities.
The award for most infamous asylum would likely go to the Hospital Psiquiátrico do Juqueri, opened in 1898 in the state of São Paulo and presented as an agricultural colony. In its 118 years of existence, it recorded over 120,000 admissions. During the dictatorship in the 1960s and 1970s, the hospital was filled with over 15,000 forced internments. While many had diagnosed mental and substance use disorders, the dictatorship also threw in people who were undiagnosed but considered “anti-social” as a tool for social control. That included people living on the streets, single mothers, members of the LGBTQ+ community and occasional political prisoners.
Public momentum for deinstitutionalization grew as the horrors of life inside the asylums, some of which were akin to prisons or concentration camps, became widely known through personal testimonies and public investigations. It was only in the mid-1980s that successful grassroots, community-based health care initiatives began to emerge, inspired by the contemporary Italian psychiatrist and social reformer Franco Basaglia, Marcio said.
Those alternative pathways to treating people with mental and substance use disorder were part of a greater push within Brazilian society to improve health care for all as the country pursued re-democratization after the fall of the dictatorship in 1985. The constitutional assembly voted for a new constitution in 1988 that included health as a right and created the contours of a government funded health care system, the SUS, which became operational in 1990.
The subsequent 2001 psychiatric reforms and ensuing legislative tweaks created the legal framework that supported non-institutional forms of health care. The goal was to give people maximum freedom while being treated in the communities in which they were living. One of the main policies to come out of the reform was Ordinance 3088/2011, which established the Psychosocial Care Network, known in Portuguese as the Rede de Atençao Psicossocial (RAPS).
A multi-tiered web of RAPS services aims to catch and care for people where they live. The first level involves the training of primary care professionals and emergency department teams, followed by outpatient Psychosocial Care Centers (CAPS), therapeutic residential services and, for the most serious cases, psychiatric beds within general hospitals.
In addition to the medical aspects of treatment, the reforms emphasized psychosocial approaches such as social services, education, employment, income and rehabilitation with the goal of helping people re-integrate into everyday life.
While all appear to be good advances on paper, I look forward to investigating the practical realities of the various efforts in future dispatches. To add further complexity to the issue, drug policy in Brazil is split at the federal level between the ministries of health, justice, and development and social assistance. The last subsidizes therapeutic communities, which unlike the evidence-based examples I’d witnessed in Portugal, are accused by public health officials I spoke with of acting as modern-day asylums run by primarily evangelical organizations operating without medical oversight. Certainly, a topic worth its own dispatch.
To understand the third leg of Brazil’s drug-policy stool, I had the privilege of speaking with Marta Rodriguez de Assis Machado, national secretary for drug policy under the Justice Ministry. We initially met at the United Nations Convention on Narcotic Drugs in Vienna back in April, when she spoke about Brazil’s efforts to curb the ecological damage caused by drug trafficking in the Amazon.
A former professor at the Federal University of São Paulo, she was appointed by President Luiz Inacio Lula da Silva’s administration after he took office in 2022. Our conversation spanned her priorities from prevention to human rights, environmental justice to Brazil’s recent Supreme Court decision to decriminalize the personal use of cannabis up to 40 grams. However, what drew my attention most was her office’s CAIS—Centro de Acesso a Direitos e Inclusão Social (Center for Access to Rights and Social Inclusion)—initiative, modeled after Portugal’s drug commissions, on which I reported last December.
The recently launched CAIS initiative is partnering with local public universities and non-profits to offer centers with psychologists, social workers, harm reduction technicians and lawyers to assist in legal issues. The government’s goal is to fund new or expanding centers in historically disadvantaged communities that have suffered from drug trafficking or repression of drug trafficking. The hope is that the centers will act as hubs to create better access to health care, social services and assistance with the justice system. With an invitation to visit CAIS initiatives across Brazil from my current base in Fortaleza to the Amazon and beyond, I am interested in how they stack up against the Portuguese commissions on which they are based.
Still, while Brazil’s universal health care system, deinstitutionalization efforts and Secretary Machado’s progressive initiatives speak well of the lessons to be learned from this vast country’s public health approaches to people with substance use disorder, or in otherwise vulnerable conditions, I can’t help but think there is an underbelly to this story. Something beyond the strict framework drug policy.
Perhaps I’m simply not used to the level of inequality I am witnessing. Perhaps it’s the weekly news stories of collusion between police and organized crime. Perhaps it’s the ever-present fear of robbery that prevents Brazilians from walking outdoors with their cell phones or jewelry out. Perhaps it’s the evergreen complaints of corruption within SUS and other government services.
After receiving my vaccine, I googled the man depicted in the portrait hanging in Fortazela’s beach clinic. Named Frei Tito, he was not a doctor but a 28-year-old Dominican friar from Fortaleza who allegedly committed suicide in 1973 after being tortured by the dictatorship for participating in a clandestine meeting of the pro-democracy National Students Union. Clearly, there is going to be a lot more to Brazil than sun, beaches and coconuts.
Top photo: Rowland visit to CAIS harm reduction welcome center in Fortaleza
