Dedé Outpatient Clinic - creation, management, and closing

Author: Dorlene Meireles Mendonça

Translated by: Lidiele Nogueira

Review: André Rezende Broseghini and Junia Zaidan

Introduction

According to Brazil’s 1988 Federal Constitution, healthcare is a right for everyone and it’s the government´s duty to provide it.  Guaranteed as a social right by the Constitution, healthcare must be provided to the Santa Marta favela residents, in the city of Rio de Janeiro. Under the management of Chapa Azul (or the Blue Ticket), the residents' association drew up a project to enhance healthcare in the favela. Therefore,   Dedé Outpatient Clinic, was developed in the higher part  of the favela with the goal to assist resident´s in health-related  demands . Its building is part of the resident’s association and was named after José Manoel Machado, a resident known as Dedé, who died in an electrocution accident while helping another resident.

Interview with one of the doctors in charge of the outpatient clinic

I talked to the doctor in charge - Dr. José Luis Magalhães Rios - who spoke to me about the idea of building an outpatient clinic inside the favela:

“One of the main problems of the favela’s residents was the difficulty to access healthcare services due to, on one hand, their low income and, most importantly, due to the precarious healthcare provision. Although the South Zone was well served by the State with healthcare facilities, the quality of the services have always been low, and, mostly, there were no health preventive actions. Not even to prevent diseases nor to treat chronic diseases such as hypertension, and to avoid complications related to it such as strokes, heart attacks, and deaths. Back then, I was graduating as a doctor and I was aware of these problems, and in the favela I was already participating in the ECO Group (a NGO that promotes culture and education in Santa Marta). We had then the idea of creating a place to give medical care inside the favela, but one that was not only for attending or treating sick people. It needed to be focused on  preventive action, referred to as primary attention: vaccinating children from all possible diseases,  treating hypertensive and diabetic people etc. Because of all of that, since the beginning, we were concerned with  training health agents from the favela, since we consider they play the most important role in prevention and education. Halfway through, we found out many people with tuberculosis, which was transmitted from within the favela, and so we started a project focused on the detection of cases and awareness of patients to go through the whole treatment.”

As a result, there appeared  some partnerships involving  the health project for Favela Santa Marta.

“The first big partnership was with Santo Inácio school, through the Alumni Association - ASIA, that financed the purchase and renovation of the building as well as its equipment. And also the payment of our team: at the beginning for one doctor (me) and two Health Agents named Almira and Lourdes (if I'm not mistaken). The team also had a psychologist, Gisele, who provided care to residents, therapeutic groups, and performed other actions related to mental health. We had decided that the clinic should be on the higher part of the favela, where residents had most difficulty to go and come back from the hospitals outside the favela, especially when sick. An old, large shack appeared, that belonged to a traditional resident who had died and whose family was selling it (I don't remember his name), right at the top of the hill. It was where our first headquarter was established. The shack was made of stucco, including the slab. And it was renovated just to get us started. Years later, when the City Hall started urbanization, we got an agreement with the Social Development Department, which designed a new project and built the headquarters of the clinic, which is still there , under the “Maicon Jackson slab”, which is made from concrete. The partnership with the City Hall also made it possible for us to create a system for referring residents to the Municipal Health Center of the IV R.A. (Administrative Region 4), in Silveira Martins street, which was “in charge” of the Santa Marta area. As a result, the referred residents had priority care in the specialties of the center, such as dermatology, gynecology, and pulmonology, in addition to being able to order some tests, such as blood count, feces, and urine, which were carried out there. It was a big step forward. From this partnership vaccination campaigns “inside” the Favela as well as the tuberculosis prevention project also came up After some time, we managed to formalize an agreement, via the City Mall (when Marcelo Alencar was the mayor of Rio de Janeiro), through which the Municipal Healthcare Center (CMS) started to supply medicine – the same ones they had in their pharmacy – for the clinic. Then, the results of our work increased a lot: before, we depended exclusively on free samples and/or the resident having the money to buy the medicine and so being able to treat himself. We also established a partnership with Lagoa Hospital, which became the main Hospital to treat emergencies for Santa Marta residents. This was also a big win. After this, we got a partnership with the  the National Social Security Institute (INSS) which allowed us to add more people to our team. We managed to get the INSS to sign an agreement with the ASIA, through which it would pay for the clinic services, in accordance with the SUS’s (Brazil’s free Healthcare System) table. Therewith, we were able to hire more doctors (we got to be 5 or 6) and more health agents (who got to be 7 or 8). And then the work “boomed”, both in terms of quality, quantity, and conditions of care, as well as in terms of preventive actions and health control of the residents, besides additional activities, such as rehabilitation. It was the “golden” era of Dédé’s outpatient clinic.”

And the doctor talks about the people committed to the construction of the clinic.

"The first headquarters was built in a joint effort, in which ECO members and other residents participated. One of the most active volunteers was Polegar, the husband of Lady Sebastiana, Almira's mother. The work just didn't go faster because, at the same time, the construction of the headquarters of the Residents' Association was still taking place, a task  which ECO members had to juggle with their position as directors of the organization. The second headquarters was built in the same place when the original house was demolished (it was almost collapsing...) by the Department of Public Works, which sent engineers, but hired residents to do the work. It’s impossible to remember their names. I remember Seu Fiinho (I think that's the name) who was a professional in breaking the stones that had to be removed from the land. He was a specialist in this. I remember that Frango, Suely's husband, also participated a lot. Not to forget, of course, Itamar, Josafá, Gilson, Fatinha, and others from the Association's board, who were always there leading the work. And me too, of course."

Did you receive any support?

“All kinds of support: voluntary work by many people, involved or not in other activities in the favela. Support from daycare centers, especially Casa Santa Marta, which had our backs. Full support from the board of the Resident’s Association, the ECO Group, Santo Inácio, and other institutions mentioned before. Resources from institutions, such as the City Hall and its secretariats, the Lagoa Hospital, the INSS, and other smaller ones."

How was the process of choosing the name of the clinic?

"Dedé was a very active resident and was one of the Association's directors at the time. Among the improvements that were taking place in the community at that time, there was the electrification of the favela. Or rather: a change of the electric network, to bring light directly from LIGHT (Rio’s electric company)  to every house in the favela. There was a problem with the high-voltage wires and Dedé, along with Itamar, tried to solve it, while LIGHT didn't arrive. Unfortunately, there was an accident, and Dedé was electrocuted in the high-voltage wires, He got caught in the wire and was rescued by Itamar, but he had already had a heart attack. They  immediately called me and we tried to resuscitate Dedé with CPR for almost half an hour until the ambulance and the doctors arrived up there, but it was too late. He was taken to the hospital already dead. For all that he represented and for being a resident who died working for the good of the favela, we decided to honor him, by naming the clinic after him. Well, actually, the name as he was known by everybody in the favela: Dedé."

When was the clinic founded?

"I don't remember. Maybe 1983 or 84. It must have a registry in the ECO ‘archives’.”

Where was it located?

"Together with ECO, we decided that the clinic should be in the upper part of the hill, where residents had more difficulty getting to and from hospitals, especially when they were sick. It ran where today is the ‘Maicon Jackson slab’. It was the roof of the clinic.”

How was the clinic welcomed by the residents?

“Always pretty well! Everyone was very sweet and respectful about our work. All residents always noticed that our job was to improve the health of the residents of Santa Marta and they knew that they could count on us. Grateful, many would send snacks to the team, participate as volunteers in various activities we developed. I remember Dona Alda, in a lab coat, spending some afternoons at the clinic to “help”... she always wanted to be “hired” as part of the team, but it wasn't possible."

Who were the team members?

"I won't remember the names of all the doctors. Some changed over time. And the agents too. The ones I remember are Gisele, a psychologist; doctors Telma, Stella, Paulo,... agents Almira, Lourdes, Dolores (Loia), Regina, Ivana,... nurse Cristina"

And what were the challenges you faced?

"Many! From ‘starting from scratch’, then creating a project, getting sponsorship, thinking about how to do the preventive work, organizing the team... Also ‘learning to become a doctor’ and serving the locals. Saving lives in a critical situation and respecting death, when inevitable. Sharing the anguish and pain of residents who could not find a solution. Getting residents to treat chronic diseases and adopt preventive measures as well. Then expanding the work, getting agreements, expanding the team neither losing focus nor compromising the objectives, and so on... Forming a team that is dedicated and committed to the work was perhaps the biggest ‘medical’ challenge. Other challenges were always decided as a team with ECO, which made them less difficult."

What were the achievements?

"Many! We say that the ‘Family Doctor’  official program that exists today was inspired by our work... Almost 20 years before it was implemented by the State, we used to do that. And better! And with much fewer resources. We had a huge vaccination coverage for children, good prenatal care for pregnant women, the growth of babies monitored by health agents, reduction of strokes among residents, better monitoring of hypertensive patients, etc, etc. I no longer have the numbers, but  when the clinic was over, it gave the dimension of how important these achievements were for the community."

How was the process of closing down the clinic?

I always loved this job! It was like a child to me, who I helped raise and took part in its growth. But life is demanding and, with the birth of my  second child, I had to look for better-paid jobs in order to give more security to my family. So, I had to leave the clinic. I prepared my succession, choosing a new coordinator from among the team's doctors and I became an adviser, taking part in discussions about the progress of the work without coordinating it. But, as I stopped attending and being present there on a daily basis, some tensions began to arise between the ECO Group and the clinic team on how to continue the work. In addition, the issue of INSS remuneration (now SUS) began to be questioned. When I was in charg of managing  these resources, ASIA felt safe from a possible fraud. When I was replaced by another doctor, ASIA felt the need to control these resources more closelyand demand more details about their use, including the team’s payment and the quantity/billing of services provided. ECO, in turn, also felt unsure about validating the management of SUS resources by the clinic team in front of the ASIA, which was the one who legally in charge  before INSS in case of mismanagement. Without ECO's guarantee, ASIA decided to terminate the agreement with INSS, ending the transfer of funds that kept the work running. This was the end of the work and  of the team. To my deep sadness, I tried until the last moment, with all my strength, to convince ECO not to let ASIA put an end to the work. But I was no longer the favela’s doctor... and I was not successful in this battle. Lost, frustrated, resentful, all that remained for me was to get away from ECO and take care of my life in another place."

At the end of the interview, doctor José Luis Magalhães Rios left a message to the residents of the Santa Marta favela:

"Everything is worth it when the soul is not small" – a quote by poet Fernando PessoaAll the work that we have developed and dedicated time to in these years has left many roots. I am happy when I go to the favela and meet my old patients, or their children who heard from their parents that I took care of them when they were little. And I see they are  healthy today... Everything I dedicated to this work enriched me and made me a different doctor, better than most, through the teachings of humanity that Santa Marta gave to me. Today's reality is another but the challenges are no smaller. They are just different. If the community remains united, led by the ECO Group or by new leaders, in search of achievements that benefit the majority of residents, everything will be much easier to achieve - everyone will be happier and will have a “richer” life, full of feelings and satisfaction. However, if each one looks only at themselves and their personal growth in life, without caring for others and getting involved with the community, very little will be achieved, least of all happiness."

Concluding remarks

As we saw, the history of the outpatient clinic was told through a number of questions to and answers from the founding doctor. It is worth remembering that the service included medical appointments; nursing and small services , as well as preventive groups of people with hypertension and diabetes; childcare; vaccination; and a project for the prevention and treatment of tuberculosis. At the time, several challenges came up and were overcome, as it was a struggle to build a public policy that could serve residents.

Dedé Outpatient Clinic closed down and, in 1996, the building's slab was named Michael Jackson Slab (the singer Michael Jackson recorded part of a video clip in there). Currently, the Casa de Cultura Dedé (Dedé House of Culture) - run by the Atitude Social NGO - is in operation there.

After many years without any type of health-related service, now the residents of Santa Marta rely on the services of the Santa Marta Family Clinic, which provides assistance at São Clemente street, 312, Botafogo/Rio de Janeiro. According to the Rio de Janeiro City Hall’s website, the Family Clinics are a part of a project created in 2009 which allowed for the expansion of the Family Health Strategy in the city. However, the services offered by the Family Clinic will be discussed in a next article.

May the right to health become, in fact, a right for everyone, as establishe by Brazil’s 1988 Federal Constitution.

I would like to thank José Luis Magalhães Rios (founder of the Dedé Outpatient Clinic), Maria Dolores Meireles (health agent for the Dedé Clinic) and Itamar Silva (president of the   ECO Group).

With them, it was possible to produce this article, which was not only due to my affective memory.

Thank you!