A Toilet as a Symbol of a Comprehensive Approach to Harm Reduction

5 October 2016

“Building a toilet in a favela inhabited by people who use drugs has become a symbol of reduced violence in the area, a symbol of negotiations with criminal leaders, the state’s recognition of the PWUD right to housing and their acceptance as neighbors by other favela residents,” says Maira Gabriel about the harm reduction work done by her organization Associação Redes de Desenvolvimento da Maré (Association of Networks of Mare District Development).

These words marked a turning point in my understanding of the work of this organization. As I was headed to a meeting to exchange experiences with the Brazilian Harm Reduction program, I expected to hear about syringes, HIV prevention and informational materials. But what I heard was a story about deep immersion in the traditions and rules of life of people who use drugs; how they built their contact with the outside world and how these relationships affected the life of the community.

Imagine Rio De Janeiro. You immediately see the carnival, celebration and happy people enjoying life. It is true, but it is only a part of the story, only a part of the city and its inhabitants. In Rio, as in other large cities in Brazil, there are slums - favelas, there is no infrastructure and the real power is in the hands of criminal gangs that set the rules.

The organization Associação Redes de Desenvolvimento da Maré works to improve access to health care and the quality of services provided to favela residents. Until 2012, they had not been engaged in drug policy or supporting PWUDs, but the situation changed in 2008 when the government began a policy of "pacification" and police squads appeared in each favela. As usual, from the outset, the police have been paying close attention to people who use drugs. Stigma expressed by other favela residents, criminal violence and the police forced people who use drugs out of their favelas seeking other places of residence. A large group of people who use drugs settled in favela Maré. Maira and her team realized that this new community in the favela had special needs and that these people needed help to build a decent life.

While residents of favelas have access to public services (hospitals, social services, etc.), only those who have a residence registration can use these services. Most people who use drugs who moved to Maré do not have a registration and cannot receive services from the state. So Maira and her colleagues advocate for issuing certificates of residence to those new residents and for increasing the availability of public assistance.

The drugs mainly used in Brazil are stimulants, cocaine and crack, and therefore harm reduction programs differ from CEECA countries where the drug scene is quite different. For example, in Brazil, OST is not provided as there is no need for it. Drug treatment most often occurs in religious rehabilitation centers that are funded by the state. From the viewpoint of people who use drugs, the more treatment and rehabilitation options are available the better. Most often they use rehabilitation in faith-based centers to rest from street life for a couple of months. Programs aimed at improving the quality of life for people who use drugs focus more on mental health, providing sleeping pills or antidepressants to people who are now suffering. I immediately asked if they distributed any drug paraphernalia. Maira told me that they gave out tubes for sniffing, but people usually used their own that they made themselves.

Following 2006 amendments to the drug law, drug use was partially decriminalized in Brazil, and instead of prison PWUDs were referred for treatment or community service. Up to that point the use and sale of drugs had been part of the same section of the criminal law. However, the amended law did not spell out exactly what amounts were considered as personal use. This uncertainty has given police an opportunity to decide arbitrarily whom to detain and convict and who could be released. This demonstrates a high level of police racism against darker-skinned PWUDs. At the state level, racial discrimination is prohibited, but in real life it exists at all levels. Discrimination of PWUD based on their economic status is another problem. If a detained person has not been previously convicted of drug related crimes, he/she will await trial at liberty, provided that he/she is registered. But if the detainee lives on the street, it will be a long wait for the court in a detention center.

This explains why, despite the decriminalization, many people are locked up in prisons for possessing small amounts of drugs for personal use. Unfortunately, the number of women in prisons has increased. Most often these are women who brought drugs in small doses to their husbands or boyfriends. Released from prisons, women frequently become homeless and live on the streets. Most of them have someone in jail – a husband, a son, or a brother. Women cannot visit them in jail because they have no identification papers, no registration. Without a personal identification document, a person has no chance even to be buried under his or her own name.

"Thirty two women who use drugs live in our district. We have been working with them for the past year and a half. Most of these women have a child or two. There are special services where they can access contraception, and this is particularly important, because in Brazil, abortion is prohibited. Of course, it is possible to make an illegal abortion, but it is very expensive and extremely painful. Sometimes women themselves terminate their pregnancies. Illegal abortions are a cause of high mortality among women," says Maira as she describes the life of women in favela Maré.

When Maira’s organization began working with women, the most frequent request the organization received was to help find a way to communicate with their children, who most often lived with their relatives. Often the family and relatives of a drug dependent mother do not want her to meet with her children. The second reason why communication with their children is impossible is when women who use drugs are deprived of parental rights. This can happen quite quickly if the child is ill and the mother seeks help in a public hospital, and then they will know that the mother uses drugs. Usually this triggers the process of deprivation of parental rights.

"The only way for a woman to survive on the street is to obtain physical and financial protection,” Maira says. “All women have to live with men - they control all aspects of life in the favelas. And if there is a quarrel in the household, the woman is forced to leave home. Because of this dependence, women suffer from violence constantly. The government is trying to change the situation, recently police opened gender centers, but our women do not go to public services, and all problems remain within the community. For example, out of 85 cases of violence, only two cases have been made known outside the community. Only in one case, following a quarrel, the man left and the woman stayed in the house. And the woman, living alone and not being subjected to violence, regained her mental and physical health."


To help women become more independent and have their own housing, Maira’s team is trying to figure out how and with whom to discuss an agreement on the construction of community housing in the favelas. A lot of effort is dedicated to changing the attitudes of other favela residents toward the community of people who use drugs. In fact, communicating with their neighbors can help women experiencing violence and make them more independent in their relationships with men.

Most people who use drugs and live in Maré dropped out of school at an early age, most often because of racial discrimination. Getting an education is not a priority for them, but getting a job is. Therefore, integrating the PWUD community in the local economy is also a very important issue for Maira and her colleagues.

HIV and hepatitis are currently not a priority for Maira’s non-profit. "What we are now working on, in the first place, is the problem of tuberculosis. We try to help build housing so that each tenant has more space and that the rooms are ventilated. There is not affordable accommodation and we have a long wait list – there are 80 people in our PWUD community and only 16 houses," Maira explains.

The new project, which our Brazilian colleagues launched this year, is about building a toilet. I was perplexed when I heard this was the objective of the project. In our countries, because of the focus on HIV, harm reduction projects often narrow their activities down to preventing infections. Addressing the basic needs of people whose self-esteem and sense of security are affected often remains beyond the scope of many projects. But why toilets? How did they figure out this was the most important need? Maira said that when her organization began working with people who use drugs, first they were talking to these people one on one, and it was difficult to understand what needs these community members had in common. They were looking for an opportunity to hear a collective request. Finally, the first such experience was a discussion of the need to build a toilet.

At first glance, it may seem that the construction of a toilet is a mundane task that can be completed in a couple of days; it is simply a matter of gaining access to the sanitation system and getting construction tools and materials. However, in the reality of Maré this task turned out to be a sequence of complex negotiations. At first there were lots of discussions and concerns within the PWUD community: some wanted the toilet, others feared that it would contribute to violence and toughen rules within the community. Our next steps included obtaining permission from criminal groups as well as coordinating this issue with government agencies and consulting with local residents.

The construction of the toilet thus became an example of an integrated approach to harm reduction programs. Request for a toilet came from people who use drugs. Together with the community, Maira’s organization worked out the details of its construction based on the principle of "we do this for you and with you, and then you assume responsibility for running the project and set your rules." This approach seems different from the conditions in many projects working with communities in our region. In our region we have some examples of drop-in centers for communities, but those who open these centers continue to control the operations and set their own rules. And then they wonder why their tenants do not care about this space and do not treat this drop-in center as their own.

I was listening to Maira’s story with bated breath. Their attention to, and respect for, the traditions and boundaries of the PWUD community and their careful planning of every step thrilled me to the core. At the end of the conversation, I asked if people who use drugs worked in the organization as employees. Maira said, "We have just come closer to knowing and understanding each other. For a long time they have been sizing us up. Now our relations have evolved, so this year we and members of the community of people who use drugs are willing to work together in our organization."

The meeting with Maira Gabriel and EHRN’s mission to AWID Forum in Brazil was organized with the support and help from OSF. We would like extend our special thanks to Olga Rychkova from OSF’s International Harm Reduction Development/Public Health Program for all her insights, advice and assistance.

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