Health-interfering streets experiences: homeless people’s perspective

ABSTRACT

Health, understood as a multidetermined attribute, characterizes the political and social organization of a country. From Brazilian 1988’s Federal Constitution onwards, health has been understood as an individual right. Homeless people create important obstacles on the accomplishment of such right. The objective of this study is to understand the difficulties encountered on the streets that impact the perception and health state of adults living on the streets of a municipality in Zona da Mata Region, State of Minas Gerais, Brazil. A qualitative methodological approach was applied through semi-structured interviews and observation recorded on a field diary. The research interviewed 20 people living on the streets. Main difficulties involved climate exposition, as rain and cold; prejudice; vulnerability to physical and sexual abuse; obstacles to access food, drinking water and toilets; difficulties to access certain social spaces and health treatment. By knowing the situations that determine the various levels of health among people living on the streets, it is possible to build strategies and policies so to cope with their actual needs. Inter-sectoriality of public action is still a great challenge, despite necessary to accomplish a right that is fundamental and universal: health.

KEYWORDS
Homeless people; Right to health; Health status disparities

RESUMO

A saúde, compreendida como estado multideterminado, revela a organização política e social de um país. Com a Constituição Federal brasileira de 1988, foi considerada um direito. A população em situação de rua expõe importantes obstáculos à garantia desse direito. O objetivo deste estudo é o de compreender as dificuldades da vida na rua que interferem na percepção e no estado de saúde de adultos em situação de rua em um município da Zona da Mata Mineira, Brasil. Adotou-se a metodologia qualitativa por meio de entrevistas semiestruturadas e observação com registro em diário de campo. Dela participaram vinte pessoas em situação de rua. Destacam-se as dificuldades relacionadas a exposição não protegida às mudanças climáticas, como frio e chuva; vivência de preconceito; vulnerabilidade à violência física e sexual; obstáculos no acesso à alimentação, água potável, banheiros; dificuldades para frequentar alguns espaços sociais e de manter tratamentos de saúde. Reconhecendo as situações que determinam os níveis de saúde das pessoas em situação de rua é possível construir políticas e estratégias que contemplem suas reais necessidades. A intersetorialidade das ações públicas ainda é um desafio ao cumprimento de um direito fundamental de todos: o direito à saúde.

PALAVRAS-CHAVES
Pessoas em situação de rua; Direito à saúde; Disparidades nos níveis de saúde

Introduction

The fundamental right to health was initiated in Brazil in 1988 through the promulgation of the Federal Constitution (CF/88). Far beyond the absence of disease, health is understood as a multidetermined state, which carries an intimate relationship with the living conditions and access to public and social goods of individuals and groups of inhabitants of a given society¹.

Social inequalities portray deep patterns of socio-sanitary realities across the various segments of the population. In this context, important health inequities are produced. The poorest population is put aside, left to a situation of vulnerability². The non-guarantee of housing that provides protection and privacy inflicts this vulnerable situation upon the individual, negatively impacting his state of health.

People who use the streets as housing expose complex vulnerabilities, manifesting heterogeneous needs and demands for their living. In this context, they need social and health services more appropriate to their peculiarities^3-7.

Vulnerability is understood by Carmo and Guizardi⁸ as the overlapping of various factors, in several dimensions, able to make an individual or group of persons more susceptible to the risks and unpredictability of life. The conditions of social vulnerability are possibly connected also to the opportunities experienced by the individual as to the social, economic, cultural and political characteristics of the place.

Knowing the difficulties that affect the health-disease-care process of that group of inhabitants is a fundamental condition for contributing to the formulation and implementation of public policies and services that effectively respond to their needs⁸.

This paper is part of the Master degree dissertation presented before the Graduate Program in Collective Health at the Federal University of Juiz de Fora. It aimed to understand the difficulties of life on the streets that affect health according to the perception of adults living in the streets of a municipality pertaining to Zona da Mata Mineira, southeast region of Minas Gerais State.

Methodology

A qualitative approach was adopted by means of semi-structured interviews and field diary records of daily observation of conviviality in the streets and in the institutions researched.

The research was carried out in a municipality of Zona da Mata Mineira. Its population is composed of 559,636 inhabitants, from which 880 are homeless⁹. The research field involved the two municipal temporary shelter services that offer overnight beds, being one for women and the other for men. It lasted from March 2016 to February 2018.

Subjects with cognitive impairment or presenting behavioral changes due to the use of alcohol or other psychoactive substances were excluded from the study.

In order to preserve the confidentiality, respondents were identified by the letter E, followed by numbers 1 to 20, i.e., E1 to E20.

Data were interpreted in the light of dialectical hermeneutics, respecting Minayo’s¹⁰ moments of ordering, classification and final report. The information systematizing allowed to identify the material collected in the field by means of the transcription of the interviews and preliminary reading. The classification was carried out based on the floating reading of the interviews with the purpose of recognizing the central ideas, and allowed to find the sense cores under analysis. This paper highlights the core ‘living in the streets and its impact on health’.

After the identification of the sense cores, the fragments of the speeches, or units, related to each core were organized in a chart (chart 1), as proposed by Alencar et al.¹¹.

Chart 1
Analysis of the interviews

Cores of sense	E1	E2	E (...)	E20	Horizontal Summary
Difficulties of living on the street that harm the person's health
Vertical Summary

Source: Own elaboration.

After their organization in chart 1, the units were analyzed as for the horizontal and vertical summaries of each sense core. While the horizontal summary made possible the identification of convergences, divergences and complementarities of each respondent speech, the vertical summary allowed to detect the articulation of each subject’ sense cores.

The research was approved by the Research Ethics Committee of the Federal University of Juiz de Fora, Consent No. 1,913,094/2017. All respondents signed the Free and Informed Consent Form (TCLE).

Results and discussion

Twenty homeless persons over eighteen years of age participated in the research, of which fourteen are men and six are women.

Respondents age ranged between 25 and 68 years old, mostly black with incomplete elementary school. The time they lived in the streets varied from two to 31 years. The longer the length of time living in the streets, the greater the feeling of belonging to that reality, experiencing the instability and precariousness of the streets and building forms of survival. Those are years of uncertain feeding, searching for drinking water, informal work, distancing from families, prejudice and violence that impact physical and mental health¹².

The difficulties of living in the streets reported by the respondents are compiled in chart 2.

Chart 2
Difficulties of being a homeless that impact on health

KINDS OF DIFFICULTIES
Difficulties related to basic needs	- Thirstiness
	- Hunger
	- Bathrooms
	- Personal hygiene
Difficulties related to climate changes	- Coldness
	- Rain
Psychosocial difficulties	- Prejudice, embarrassment, discrimination, lack of compassion
	- Difficulties to make part of some social spaces
	- Physical and sexual violence
Difficulties related to work	- Precarious informal work
Health difficulties	- Living in the streets with stigmatized chronic diseases (epilepsy)
	- Fear of being sick in the streets and not being rescued

Source: Own elaboration.

Drinking water and food are basic needs. Therefore, if these needs are not fulfilled, they cause numerous health impairments, besides being relevant factors of social exclusion. Respondents’ reports strongly reinforced the existence of those deprivations:

To be honest, I already starved. Indeed. It’s the hunger and it’s the desire to eat. It’s the hunger and it’s the desire to eat. Then that’s it... we want to eat something tasty we want to drink a specific thing and cannot. (E9).

To get water to drink is very difficult. I work, so I can still buy a bottle here and there, but those who cannot find a work have much more difficulty. Then you have to drink dirty water anyway. It’s that or it’s being thirsty [...] We eat what we find, what we are given, what we can buy. (E1).

The difficulty in fulfilling the basic needs is one of the main homeless vulnerabilities¹³. The 1948 Universal Declaration of Human Rights states that adequate food, which includes access to drinking water, is one of the essential components to ensure a healthy standard of living for every human being¹⁴. In Brazil, in 2009, the National Policy for Homeless People (PNPSR) contemplated the need to provide permanent access to food for homeless people by means of the implementation of food and nutritional security actions¹⁵. In 2010, food was included in the Constitution as a social right through Constitutional Amendment 64/2010¹⁶. But its implementation is still a challenge.

This research municipality provides a popular restaurant located in its central region, for which users of shelter services receive a meal ticket, distributed by the Reference Center Specialized in Homeless Population (Centro POP). However, some homeless individuals complain about the timing of the offer and do not attend claiming mobility difficulties.

Still about basic needs, respondents claimed absence of facilities to wash clothes and difficulty to bathe:

We live on the street, don’t we? We sit on the floor... and the street is dirty. How are our clothes going to look? Dirty, huh? And do we have a place to wash? There’s nowhere to wash. When we don’t go to the shelter... there’s no way to even bathe. (E1).

Concerning specifically to women’s personal hygiene, it was possible to identify the difficulty related to the menstrual period:

I think a difficulty for we, women, is the issue of hygiene. Yes, I’m talking about menstruation. Sometimes we can’t buy sanitary pads... (E20).

In another study, it was found that personal hygiene behaviors, such as bathing, clean clothes, and asepsis in general, are almost always associated with shelters and Non-Governmental Organizations (NGOs), because they are places that offer this self-care¹⁷.

There are no public toilets in this research municipality. Bathing spots are only available in the shelters. The difficulty of access to places where to do the personal hygiene causes several damages to health, such as lice infestations, skin diseases, difficulties to treat wounds, among others¹⁸.

Strongly associated with the issue of preserving the personal hygiene are the discrimination and prejudice against the homeless body, physical appearance and the way of dressing. Discrimination against the body that suffers the consequences of living in the streets is a reaction against an unidealized appearance¹⁹. A marginalized, dirty body exuding strong odors does not match the ideal of a clean society:

And when we’re messy, dirty, it feels like the treatment is different. We’re being left out... people only talk to us what is sorely needed. (E20).

Ensuring access to personal hygiene strengthens self-esteem. Prejudice related to hygiene issues also decreases life-changing hope. The appearance emerged in the interviews as a determining factor to enter into the formal labor market:

And getting a normal job is also difficult. I want to work. Sometimes we want to go tidy to hand in the resumé to the company, but we don’t even have clothes for the job interview. Besides, I miss some teeth... and that’s not good for the interview, right? Nobody wants to hire someone who doesn’t look good. (E13).

Personal appearance and body hygiene are among the discrimination factors that hinder access to public policies and to the construction of the possibilities of leaving the streets, including insertion into the labor market²⁰.

It is difficult to access the resources that can provide self-care:

Bathroom... it is the hardest thing here in the municipality. If they could, they’d restrain us from using the bathroom even in the supermarket... but they don’t know who’s homeless and who’s not... so there’s no way to prevent, right? If we are a homeless person... sometimes we want to pee, to go to the bathroom... See the difficulty: we have to keep asking because the person keeps denying. (E4).

As for Maslow²¹, feeding, hydration, breathing, sleep, sex and appropriate place for physiological functions are at the basis of the hierarchical classification of human needs. Allowing access to the bathroom is taking care of a basic, physiological need of every human being. Often, because there is no bathroom available, the person uses the street. Apart from the ‘degradation of public space’, there is the violation of privacy and the feeling of degradation of the very condition of human being.

According to the respondents, the impossibility of insertion in the formal labor market makes the informal activity carried out on the streets an alternative of precarious insertion, because the lack of social protection and appropriate conditions of work causes significant impacts health:

For me difficulty is to load a handcart all day... because I carry things in a handcart, right? Up and down, in the sun and in the rain... all day long. That is the sole difficulty. (E4).

Some of the actions to access the labor market provided for by the National Policy for the Social Inclusion of Homeless People imply the insertion of these people as a priority target for the intermediation of employment by social institutions, their professional training, the encouragement to cooperative forms of work and the guarantee of access to labor rights, including retirement²². In addition, the public sector investment in training and professional qualification for that population, as predicted by the PNPSR, is also one of the behaviors to promote and stimulate movements that improve living conditions¹⁵.

Climate change also appeared as mishaps for living in the streets. Populations under social vulnerability are deeply impacted and seriously weakened, mainly on their health, due to the protection absence of guarantee against temperature changes²³, as, for example:

In the cold season I’ve been cold. I’m cold now, right? And when it rains? How do we hide from the rain? If it’s raining in the cold, then... we get all wet and the clothes look even colder! (E7).

In connection to vulnerabilities, respiratory diseases are mentioned by many respondents:

I had high fever and my body was hurting. It was pneumonia. But, thank God, I’m getting better. (E12).

Every year I have pneumonia. Besides, I have tuberculosis. (E19).

Respiratory diseases can be aggravated due to inequities resulting from the unequal insertion of individuals in society²⁴. In addition to an increased risk for the incidence of tuberculosis, street conditions also lead to an increase in the negative disease outcomes²⁵.

Shelters are equipment of the social assistance for welcome and protection. They usually work for the overnight staying. The municipality in which this research was conducted, there are two shelters able to accommodate 150 homeless adults per night. As for the PNPSR, the reception services must meet the municipality demand, taking into account data obtained by municipal surveys on homeless population¹⁵. Research provided for the Municipal Secretariat of Social Development estimated that there are 884 people living in the streets of the municipality⁹. Therefore, only 17% of them succeed in sleeping in shelters. However, it is noteworthy that adherence to this type of service is contradictory and tense among homeless, due to the idleness of available vacancies. The interviews report that the ‘lack of freedom’ and the imposition of ‘rules’ are factors of non-adherence to the service:

Look... here I have no freedom. It’s good to sleep here... but, for example: I want to go to a June party... I haven’t seen that in how many years? To see it, I have to sleep in the streets, just like in my past. As I’m older and the streets are very dangerous, I don’t want to sleep in the streets anymore. That’s it. There is not that freedom. That’s the little life I’m living. (E10).

We get food, bath, protection in the shelter. Only when we are inside the shelter there are rules, and people don’t want to follow rules... they want to have freedom, after all... a shelter is not a prison. (E16).

Current shelter management follows a taming policy, whose objective is to control the behavior of individuals so that they do not bother during their overnight stay, curtailing freedom by means of strict rules²⁶. To expand and qualify access to these institutions, it is important to promote participatory management mechanisms, encouraging meetings between the coordination and users or their representatives so to enable a democratic room for the discussion of their demands.

Also very present in the respondents’ speeches was the experience of prejudice:

But the worst difficulty is prejudice. We know that people look at us as if we were garbage, as if we wanted to be in this situation or as if it were a punishment. I wonder: if it’s punishment, whose punishment is it? From God? I’ve never seen God. No one has ever seen God. Do the mistakes we’ve made in life deserve such a severe punishment? That can even lead to depression. There is a lot of people who live in the streets carrying that depression. (E1).

Prejudice and discrimination are connected to the various myths surrounding the homeless, because there is a common understanding that those people are dangerous, slutty, drugged. Such views serve only to strengthen the scenario of social exclusion. In addition, they harm the mental health of those people, who, treated as a nuisance, develop feelings of non-social belonging²⁷, what cause isolation, and even generate depression and anxiety, as reported in E1 speech.

Some authors affirm that homeless population feels shame, low self-esteem and uselessness²⁸. This is noted in E1 above speech when he reports being treated as ‘garbage’, that is, as a discarded object, without utility²⁹. PNPSR determines the development of educational actions that contribute to the formation of a culture towards respect, ethics and solidarity, so to safeguard compliance with human rights¹⁵. Raising society’s awareness for the difficulties faced by homeless every day would help to demystify several issues connected to prejudice. It is an activity that requires determination and commitment of the public authorities and all social sectors.

Another worrying aspect in this scenario is vulnerability to violence. In the streets, violence appears in several ways: psychic, which is expressed by prejudice; social, which happens through non-access to social goods; and physics, which is life-threatening.

Once I was beaten by the police... and I had not done anything to the police... I really got beat up a lot. (E2).

One of PNPSR objectives is to implement human rights centers and channels to receive reports of violence¹⁵. However, Arbex³⁰ reports police and public agents’ violence against the homeless people as significant. Among the cases, he relates physical and verbal aggressions and destruction of personal objects.

All female respondents revealed fear of sexual violence, and some of them tell stories of rape:

So, difficulty is the fear of being a victim, of being another body found in the Paraibuna River or floundering on the sidewalk. And we, women, have to be more afraid because of the violence caused by sex too. (E17).

Here on the street, I was also abused. I don’t even remember the man’s face. I don’t want to remember. All I remember is it was disgusting. And that’s how my last son came into the world. (E15).

I’ve been abused a lot, see? First, was at home by my husband. I have nine children and eight have the same father. We got together very young... in love. But soon he got involved with drugs, started to beat me, forcing the encounter... sexual, right? (E15).

I ended up getting to know the drugs because of the end of a relationship and now I’m like this... in the streets and in addiction. I was beaten up by him every day, but I was afraid of leaving him. Then he left me. But I really came to the streets because of the drugs. (E17).

But soon he got involved with drugs, started beating me, forcing a relation... sexual, right? And after a lot of getting beaten up, I decided to leave home. And that’s what I told you before... to find an empty apartment, to invade... that you already know. Here in the streets I was also abused. (E15).

The violence suffered by women cannot be seen as a result of frailty. In fact, it is strongly linked to a patriarchal model of society that classifies the woman as an object, demoting her. Patriarchalism is a structure characterized by a social organization that enables men to have authority over women and children. Such organization permeates the whole society, including also relations of production and consumption as political structures. Violence against women and its approval from the society are therefore connected to the hierarchical power relations between men and women, enforced by that organization³¹.

Rosa and Brêtas³² draw attention to gender as explanation to differences in the violence that provoke the movement of insertion in the streets. They affirm that ‘the street pertains to men’ is the result of rupture situations due to the wear and tear of relations. But, for some women, the street is a way out for the violence suffered during the domestic conviviality.

E16 speech unveils a plot of violence that began even when she was living in her home. But living in the streets, she shows the fear of being a victim of violence from the power related to social status:

People really like to beat us. They push us out, kick us. And I have that fear of being killed, of being lynched, murdered... raped. And that’s not just fear of other people living in the streets but mainly of those who do not live in the streets. Sometimes an important person does that. There’s no way to tell the police... because they think it’s our fault. And even the police use their authority to beat. That’s too dangerous. I know that sometimes, in our very home, violence happens... as I was beaten in my own house. Imagine in the streets! (E16).

Regarding the protection of battered women, women’s police stations, which should be specialized and trained to care for victims, are still criticized for their work. Moreover, women do not feel properly understood, protected and supported. Thus, the decision to break the silence and denounce situations of violence becomes a burdensome movement³³.

Difficulties were still related as to the need for wandering during the day:

Sleeping in the shelter is still good, but we have to leave very early in the morning, what makes us to wander in the streets. We keep on wandering in the streets since there’s nowhere else to stay. (E9).

The need for homeless people to wander across the urban space has been identified as a tactic to survive or to face daily life, that is, to move around the city in search of protection, food, clothing and others³⁴.

Foot injuries are among the most relevant homeless health problems. Many of them move a lot throughout the city without protection and on the heat of the pavement, resulting in burns, cuts and wounds³⁵.

Failure to pay attention to these situations weakens and determines important illness processes in those individuals, which, apparently not relevant to their way of living, make them reach the health services in acute conditions that hinder their locomotion³⁶.

Many were the difficulties related to the experience of living in the streets reported by this research’ participants. Considering health as composed of multi determined reasons, one can note that, in those cases, it suffers direct impact from the raw reality offered by the streets to those who make it their shelter.

Final remarks

Researching the difficulties of living in the streets that impact on the homeless health was an experience with inevitable regard concerning how much the municipality of the study still has to improve as for intersectoral policies and in the construction of equipment to implement them. Giving voice to homeless people to understand their needs can be the starting point for the recognition of priorities in the planning of municipal actions. We hope that the research can be useful to design actions and strategies enabling a specific municipal policy for that population.

The timing for discussions on access to health services as for the homeless perception is favorable, since the municipality began the design of a policy for those people in 2016. The policy should prioritize the actions of intersectoral nature, in order to provide the coverage of the most diverse homeless health needs. The municipality public authorities should expedite the progress of the policy and enable strategies and equipment for its implementation.

There is need to expand the number of vacancies in shelters so to better meet the homeless. And, in order to provide demand for the shelters, it is suggested that a space be built for listening and debates about the demands of users.

Also relevant are the reports on the absence of public toilets with showers as on public drinking premises and places for washing clothes. Thus, the construction of places that meet the needs of personal hygiene and excretion are fundamental to fulfill the basic needs, as well as to contribute to self-care and to easy health conditions.

The research allowed the understanding of the various aspects related to the experience of living in the streets that impact on health, emphasizing the fear of suffering physical and sexual violence reported by virtually all respondents. Those speeches reveal the need of public authorities to apply a more sensible look over the homeless women reality and their particular demands. There are few researches focusing on those women. Encouraging the development of such research would contribute to meeting their demands.

This research carries some limitations. Because it is a qualitative research, the understanding of the occurrences took place during the period in which data collection was being carried out in the municipality, what may have undergone positive or negative changes as a result of changes in the country political and social context.

Health access may only be effectively contemplated if its determining factors be considered. It is expected that the difficulties presented here, among others, be followed up by the public authorities, with intersectoral intervention, so that transformation actually come about in the daily life of people who face the harshness of the streets.

• Financial support: non-existent

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Publication Dates

• Publication in this collection
  08 May 2020
• Date of issue
  Jan-Mar 2020

History

• Received
  25 June 2019
• Accepted
  16 Oct 2019