“The mud still rolls”: implications of compensatory reparations for the post-disaster health service in Brumadinho-MG, Brazil

Aredes, Janaína de Souza; Peixoto, Sérgio Viana; Firmo, Josélia Oliveira Araújo

doi:10.1590/1413-81232026317.21112024

Abstract

The present study aims to analyze the needs of health services after the tailings dam collapse disaster in Brumadinho-MG Brazil from the perspective of managers and professionals. This is a qualitative methodological study, based on 26 interviews guided by a semi-structured script. The data were processed using the content analysis technique, and the interpretation was mediated by the theoretical-methodological framework of hermeneutic anthropology. The study showed that both the process of obtaining compensation and its materialization had a major impact on local health services, both in terms of the emergence of new health demands and the work overload of professionals who had to handle situations beyond their designated jobs, involving porous limits of agreements and negotiations between the population and the company responsible for the disaster. The analysis shows the need to develop and equate strategies that consider the guarantee of rights without compromising the health and quality of life of those affected: those who care and those who are cared for. It is expected that this study’s results may support surveillance actions, health care, and future risk management in similar contexts.

Key words:
Health Effects of Disasters; Mining; Health Services

Resumo

O objetivo do trabalho consiste em analisar as necessidades do serviço de saúde após o desastre do rompimento da barragem em Brumadinho-MG na perspectiva dos gestores e profissionais. Trata-se de uma pesquisa com abordagem metodológica qualitativa, a partir da realização de 26 entrevistas guiadas por roteiro semiestruturado. Os dados foram tratados a partir da técnica de análise de conteúdo e a interpretação mediada pelo referencial teórico-metodológico da antropologia hermenêutica. O estudo evidenciou que tanto o percurso para a aquisição das indenizações como a sua materialização afetou sobremaneira o serviço de saúde, tanto no que se refere ao surgimento de novas demandas em saúde, como a sobrecarga de trabalho dos profissionais que precisaram mediar situações para além das suas atribuições, envolvendo limites porosos dos acordos e negociações entre população e a empresa responsável pelo desastre. Depreende-se da análise a necessidade de desenvolver e equacionar estratégias que considere a garantia de direitos sem comprometimento à saúde e à qualidade de vida de todos os afetados: quem cuida e quem é cuidado. Espera-se que os resultados apresentados possam subsidiar ações de vigilância, cuidados em saúde e a gestão de riscos futuros em contextos semelhantes.

Palavras-chave:
Efeitos de Desastres na Saúde; Mineração; Serviços de Saúde

Resumen

El objetivo de este estudio se centra en el análisis de las necesidades del servicio de salud tras el desastre del rompimiento de la presa de Brumadinho-MG desde la perspectiva de los gestores y los profesionales. Se trata de un estudio con un enfoque metodológico cualitativo, basado en 26 entrevistas orientadas por un guion semiestructurado. Los datos se procesaron mediante la técnica de análisis de contenido y la interpretación estuvo mediada por el marco teórico-metodológico de la antropología hermenéutica. El estudio demostró que tanto el trámite de adquisición de las indemnizaciones como su materialización tuvieron un gran impacto en el servicio de salud, tanto por la aparición de nuevas demandas en salud como por la sobrecarga de trabajo para los profesionales que tuvieron que mediar en situaciones ajenas a sus competencias, en los porosos límites de los acuerdos y negociaciones entre la población y la empresa responsable por el desastre. El análisis muestra la necesidad de desarrollar y equiparar estrategias que contemplen la garantía de los derechos sin comprometer la salud y la calidad de vida de todos los afectados: los que cuidan y los que son cuidados. Se espera que los resultados presentados puedan apoyar acciones de vigilancia, a la asistencia en salud y a la gestión de futuros riesgos en contextos similares.

Palabras clave:
Efectos de Desastres en la Salud; Minería; Servicios de Salud

Introduction

The state of Minas Gerais (MG) has seen two of the most serious incidents related to mining dams in the twenty-first century. In 2015, a dam collapse disaster occurred in Mariana-MG, on the premises of the Samarco mining company, resulting in 19 deaths and dispersed waste that reached approximately 36 municipalities across 650 km of the Rio Doce Basin¹. Four years later, in 2019, in the municipality of Brumadinho-MG, the tailings dam at the Córrego do Feijão mine, managed by the mining company Vale S.A., broke. This tragedy resulted in more than 270 deaths and spread approximately 13 million m³ of waste over an area of approximately 18 municipalities in the Paraopeba River basin²^,³.

Disasters are occurrences that culminate in a disruption and imbalance in the routine of a community, impacting its daily life with human, material, economic, environmental, and health losses⁴^,⁵. In Brumadinho, it was the largest widespread work accident ever to occur in Brazil, in addition to the various implications related to losses and damages that have caused a direct impact on the health of the local population²^,⁴. Therefore, it is clearly necessary to monitor the health needs of the affected communities so as to aid in the planning of existing health services, especially in cases of an increase in and emergence of new demands⁵.

Dam collapses and the consequent release of mining waste represent “a potential source of exposure to heavy metals”-by oral, inhalation, and dermal routes³. It is also important to note that the years following the Brumadinho tailings dam disaster were mediated by the epidemiological scenario of the COVID-19 pandemic. These factors, in a chain reaction, can affect the demand for health services and result in an increase in medical consultations and hospitalizations⁵. It is also well-known that the implications of a disaster are also related to an overload on the health service. In the first four months of 2019, there was a 63% increase in the number of services provided in Primary Health Care in Brumadinho, which required the additional hiring of more than 80 professionals⁴. International studies⁶^-⁸ indicate that, worldwide, disasters, whether natural or not, imply health problems. However, according to the literature consulted in this study, it is important to remember that the medium and long-term consequences, as well as the impacts on health, professionals, and services, still remain unclear.

Considering the above, the present study aims to analyze the main needs of health services in Brumadinho-MG after the tailings dam disaster from the perspective of managers and professionals.

Methodology

This is an exploratory study with a qualitative methodological approach⁹, which allows us to understand how the services work in order to identify potentialities and possible bottlenecks faced in practice based on the experience lived by the actors themselves in their sociocultural locus. This methodological approach was chosen because it is the most appropriate for addressing complex and multidimensional issues, such as those that permeate the implications of a disaster.

The study was conducted with managers and health professionals in the municipality of Brumadinho-MG, with preference being given to those who worked in the service before the dam collapse. Individual interviews guided by a semi-structured script, were used for data collection. This type of interview aims to explore a given problem in depth based on the interviewee’s perceptions of their experiences and follows a guiding topic that covers the core themes of the study⁹. In summary, the topics covered the following axes: report on professional performance; memories of the day of the disaster from the perspective of the health service; routine of health services before and after the disaster; impacts related to the pandemic; suggestion of mitigating measures for the impacts of the disaster on health services; among others.

The interviewees were selected using the chain or snowball technique, in which one interviewee suggests another because they consider that the latter can offer important testimony to the study¹⁰. To identify the interviewees, the first step was to approach the highest-level managers through a visit and initial contact directly with the Municipal Health Department of Brumadinho, the department responsible for organizing all services and professionals in the municipality. This was an initial mapping exercise to understand the study area, which defined the developments and identification of subsequent interviewees⁹.

The final number of participants was determined by the empirical data saturation criterion. In this method, the interruption of data collection is defined based on successive analyses that occur simultaneously with data collection, one of the basic premises of qualitative studies⁹. The interviewees were recruited by formal invitation via direct approach by the study researchers. All interviews were recorded, and, at a later moment, the audios were transcribed verbatim.

The textual excerpts were categorized and coded, enabling the identification of themes and subjects of greater relevance in accordance with the content analysis technique in the thematic modality⁹. Based on this categorization, the following occurred: organization of the empirical data; critical reading and definition of the categories of analysis; and treatment of the results mediated by reflective analysis, inference, and interpretation. To ensure the validation of the analysis, the coding of the data was analyzed independently by different members of the research team in order to reach a consensus on the final categories.

The entire data analysis process was guided by the theoretical-methodological framework of hermeneutic anthropology¹¹. In this approach, the analysis is anchored in the interpretation of the meaning that social groups attribute to certain events, taking into account the sociocultural context of action, as well as the different factors that influence it¹¹.

To ensure the anonymity of the interviewees, captions were used for the excerpts with the following information, respectively: order of interview, professional training, gender (F for female and M for male), and age. Since the municipality is characterized as an inland city, it was decided not to mention the work sector and hierarchical level of activity in the caption to avoid identifying the professionals. All of the participants read and signed the informed consent form. The study was approved by the Research Ethics Committee of the René Rachou Institute, Fiocruz-MG, CAAE: 74082223.1.0000.5091 and is in accordance with Resolution 466/2012 of the National Health Council.

Results and discussion

Between January and March 2024, 26 interviews, guided by a semi-structured script, were conducted, with 19 women and 7 men, aged between 29 and 65. Only three professionals joined the service after the disaster. First, according to the snowball technique¹⁰, contact was made with three initial seeds that unfolded into subsequent contacts, as summarized in Figure 1.

Figure 1
Methodological approach to selecting interviewees - Snowball technique

For the study participants, the needs of the health service resulting from the disaster were related to a common axis: investment in the city, which included the expansion of services, infrastructure, compensation processes, and income transfer to the population. From this main axis, two final categories emerged to be addressed in this article, namely: The process of acquiring money: the impact of declarations for the health services, and “It buffered, but did not solve”: the challenges of care in the face of the impacts resulting from money.

The process of acquiring money: the impact of declarations for the health services

The municipal health service was called upon to issue documents confirming its use by the population. Basically, two statements were requested at different times by the company responsible for the disaster: the first concerns emergency aid and the second concerns the compensation process. The emergency aid referred to the benefit granted by the company to all residents who proved that they had a permanent residence in Brumadinho and had used the health service before the tailings dam collapsed¹². Two professionals gave the following explanations:

We had to start making declarations of address and registration so that people could receive the money. It was a demand that came in, an order, and we had to comply. [...] We had to stay inside the health center, abandon our obligations of promoting health and prevention, and had to keep making declarations. (E09, ACS - Agente Comunitário de Saúde in Portuguese, F, 56 years old)

Everything was out of balance, the entire service was disorganized, because the patient really wanted the declaration. All of this was the responsibility of Primary Health Care. The nurse had to stop the demand, or he would set aside a period of his schedule just to make these declarations, because it wasn’t just a matter of signing. We had to confirm that the patient really lived there and used the PSF [Programa Saúde da Família in Portuguese]. (E03, nurse, F, 34 years old)

Later, in a second stage, there was the individual compensation process, in the amount of R$ 100,000.00 (one hundred thousand reais), which also had an impact on the health service, especially with mental health teams:

When the company launched this in 2019 through a TAC [Termo de Ajustamento de Conduta in Portuguese], it included this signifier, “emotional/psychological shock” which, in theory, means that you don’t necessarily need to have a mental disorder or a diagnosis, you just need to be shaken, to have suffered something due to the dam break. So, everyone started coming here to the CAPS [Centro de Atenção Psicossocial in Portuguese], to the PSF where the psychologists were inserted: “I’m feeling this and it’s because of the dam break”, and they demanded a report from the professionals supporting something that had to be related to mental health. Many private psychologists worked in a somewhat unethical way during this period, because the compensation was actually being paid, a report was enough. [...] So, before it was too open, so the company began to limit this diagnosis thing [CID F43.1 - Classificação Internacional de Doenças/Estresse Pós-tramático in Portuguese], it limited it a little, but not enough, because the psychologists, doctors in private practices, did everything, then the company understood what the logic was: if there’s money, there will be someone to do it, so it closed for good. The company stopped making out-of-court settlements, closed the deal, and said, “Now everything will be done through the courts, through the public prosecutor’s office.” (E22, psychology, M, 38 years old)

According to the report, individual compensation went through distinct phases mediated by absence, uncertainty, and porosity regarding the criteria to receive it. Chart 1 summarizes the implications of both benefits in various spheres of health care. The first axis Weakness in the criteria (Chart 1) corresponds to the limitations on the rules that supported the justification of the declarations that would be issued by the health service. This gap showed the difficulty for professionals to ratify documentation, and, at the same time, it brought some problems in the health service routine, such as a loss of nurses’ stamps, cases of false signatures, and, consequently, pressure on the health service professionals. This scenario led to the Breaking of bonds and line of care (Chart 1), which concerns conflicts between professionals and users, mediated by threats, harassment, and team reassignment.

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Chart 1
The compensation process and its implications for health care.

The health service then had to deal with Nuances of the (dis)association between illness and the guarantee of rights (Chart 1), covering sensitive issues, such as secondary interests, and seeking health services only for the purpose of proving its use. On the one hand, emergency aid required the use of health services; on the other, compensation depended on the need to verify an illness, as this mental health professional explains:

It distorted all of our work, because people were suffering; we could see that they needed care, but they wanted the report to guarantee their rights. Since these compensations have been dragging on to this day, many people have not been able to get them and are undergoing expert assessments with psychiatrists. So, the psychiatrist asks for the entire CAPS medical record, for example, to assess whether the person is still affected, but it’s been five years! Because he associated the guarantee of rights with a mental illness. For your rights to be guaranteed, because you were shaken by the situation you experienced, you had to have an CID, and the shock does not mean an illness in itself. For example, there were people who said “look, I had to leave my house, the civil defense came here and took something away from me, but I need to have a report with CID F43.1, because otherwise I won’t get the R$ 100,000.00 compensation”. (E13, psychology, F, 32 years old)

The demand for reports relevant to compensation covered complex situations, such as the request for documents by people with and without previous mental disorders, or disorders not necessarily linked to post-traumatic stress (criterion), factors manifested in the daily routine of professional practice:

Then you create another feeling, which is anxiety, and then it seems to freeze the other mental health condition again, it doesn’t flow [...]. When we go to the region, to the matrix support, we see increased anguish: “oh, because my neighbor bought a new car, his son has a cool cell phone. Because they received the money, I didn’t, because the health department didn’t want to give me the report”. It seems like the person stops and that life will only get back on track when this is resolved for them in the judicial sphere. We identify this very well, sometimes it’s a patient with a circumstantial demand, with a very demanding attitude, a feeling of hostility, who is never good, the service isn’t good, nothing in the network is good, nobody helps me, but you see that it’s a citizen who is stuck in this process, while he doesn’t have an answer for himself. (E23, medicine, M, 32 years old)

The interviewee’s speech reveals a feedback in the patient’s health conditions, which in some cases leads to the worsening of another previous condition for which the patient was already being monitored at the unit. In line with these aspects, the professionals report the specific context of Brumadinho, in which compensation processes permeated the routine of the health service:

It’s a boring job, because you have to deal with things that are a bit outside of your clinic’s scope. I have to make a diagnosis, but there’s no diagnosis! There’s none. And then there’s that thing about the patient wanting it, this wear and tear, old patients, with whom you’ve established ties, asking for a transfer to another professional, because you don’t give them what they want, as if we’re the ones who are harming them, it’s no longer the company, it’s us who are harming them. (E23, doctor, M, 32 years old)

The data reveal a myriad of factors that affected the health service. This sector was called upon to go beyond its role in promoting health care, and professionals had to mediate situations that were outside their scope of responsibility, especially when it came to taking responsibility for bottlenecks in the compensation process. As a result, care delivery was compromised, conflicts were created, and workers were overworked¹².

Based on the above, both emergency aid and compensation had direct implications upon the routine of the service at different levels of care. However, other impacts emerged after obtaining financial resources, as will be explained in the next analytical category.

“It buffered, but did not solve”: the challenges of care in the face of the impacts resulting from money

This category presents the various implications arising from the completion of compensation processes, especially in mental health claims:

For example, we soon had emergency aid, which guarantees rights, but it was retroactive, so five months after the incident, people received around R$ 5,000.00 (five thousand reais). Suddenly, boom: R$ 5,000.00 in your account! In a city in the countryside. So, there was euphoria, confusion in this city, people buying a lot of things, and it was a mess to get this benefit. This gave a boost to the situations that are more like mania [...]. These values entering people’s lives, this duplicity: I am suffering the loss, but I have the possibility of starting my life over in a different way, but I am still very involved with the tragedy. (E13, psychology, F, 32 years old)

The post-disaster context highlights the reparation in the municipality, manifested in works, agreements, reparations, compensation, aid, among others¹³. However, at the same time, professionals identified an important gap in terms of planning these actions, which has resulted in the emergence of new social demands with direct repercussions on health, as shown in the following excerpts:

This tragedy that we see after the dam break related to this benefit today is alcohol and drugs. In the past, when someone in the family group started to abuse drugs and couldn’t maintain the habit, the person would start taking things out of the house, selling a television, and then the family would be alerted to seek help. But today that doesn’t happen, today people have addictions, they don’t have debts, because they can support themselves. The same thing with alcohol, before, people had to work during the day, do any job to be able to drink, which would even reduce the damage. Today, they can’t reduce the damage because they don’t work. Today, they can maintain their addiction, so these diseases and more serious syndromes are arriving in younger patients, drug users with heart problems, having heart attacks before the age of 30. It was a tragedy for us to hear things like: “the mud still rolls”. It’s a tragedy that has been slowly coming, it’s still silent even after the dam break. (E05, nurse, M, 43 years old)

It seems that because there was a lot of money circulating and involved in the whole story, the person’s mental health was not normal. The person thinks “I can do anything. I can buy alcohol, drugs. I have the money”, because it was a very needy community and suddenly the issue of money arises. (E14, nurse, F, 50 years old)

For the interlocutors, investment dissociated from financial education for the population is the root cause of these social problems. The characterizations of this demand presented by the professionals (Chart 2) include:

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Chart 2
Factors associated with the change in the profile of mental health demands: “Today there is addiction, there is no debt”.

(Lack of) money as a protective factor: refers to the increased demand for alcohol and other drugs due to the money circulating in the city due to the compensation and income transfer processes promoted after the tragedy. Professionals report that this demand was rare and/or non-existent before 2019. Based on their practice, they observe an absence of this patient profile in the first business days of the month and the fact that they seek health services around the 10^th and 15^th of the month, associating this scenario with the monetary value credited on the first business day of the month. In turn, they relate the lack of money as a protective factor in the use of substances and, as a consequence, a characteristic that would favor early intervention and greater chances of successful care (Chart 2).
Changes in the consumption profile and clinical cases resulting from use: after the tragedy, consumption of more expensive substances, cocaine, and beer. As a consequence, withdrawal crises give way to intoxication and serious conditions, which have required hospitalizations and made early intervention difficult (Chart 2).
Social vulnerabilities: factors related to substance use are reported, such as drug trafficking and its implications for the use of health services. At the same time, there is the fact that people stop working because of money. In this second point, the interviewees attribute factors related to the guarantee of a fixed income, which in turn has favored idleness and the lack of search for work, as well as the situation of the tragedy itself in which people seek the use of substances as a treatment resource (Chart 2).

International studies indicate that, worldwide, disasters, whether natural or not, lead to the onset of mental disorders, increased alcoholism, smoking, consumption of other drugs, among other similar events⁶^,⁷. In addition, vulnerabilities that already exist in the community are further exacerbated, as they are added to new risk scenarios related to environmental and health implications¹⁴. However, no studies were found that made a direct association between the acquisition of financial resources after a disaster and the increase in the consumption of alcohol and other drugs, as elucidated in the empirical data.

By extension, those who have already received all the compensation processes return to the health service, as this professional explains:

It is interesting that, after some people received the R$ 100,000.00 in compensation, they return for treatment, distressed, now able to talk about what they experienced. Because, even unconsciously, in the subjective field, there was hope for that, for those life projects that come from the money, they thought that it would help with the anguish of this tragedy, to give them a buffer to deal with the loss. “It buffered, but did not solve” [...]. We have alcohol and other drugs that we understand, which are also for remediation, we’ve studied this a lot, and then we have research that says that patients who do not take care of themselves, or do not take care of their mental health, sometimes use alcohol and other drugs as a treatment resource. (E13, psychology, F, 32 years old)

In addition to these issues, the impact of the disaster may, in a cascading effect, increase the incidence of chronic diseases, as well as increase mental disorders, such as depression and anxiety⁸, resulting from feelings of discouragement and uncertainty beyond the dam break itself, but also from the implications of the event, such as the company’s liability and punishment for the damage caused to the population, the environment, and the city¹⁵. In addition, studies²^,¹³ indicate that the agreements regarding the municipality’s reparations, as well as individual compensations, were not made harmoniously, reinforcing other interests to the detriment of the needs of the affected communities.

All of these factors and contexts had a direct impact on the health service and demanded a delicate and porous performance from the worker. One professional points out the following:

It’s pressure from managers, from employees, the way they talk, it’s coercion, like: “Where’s the money? Aren’t you working well?” It’s harassment. [...] It’s created anxiety in the population that the [company] gave a lot of money, so everything has to work 100%. So, this has also created a crisis for people who work in health, because it’s pressure all the time. We can’t say no to anyone. (E18, nursing, F, 40 years old)

In turn, professionals recognize that post-disaster needs go beyond financial investment in the health sector and consider another perspective concerning the emerging demands:

A serious problem that I see and realize is that they have directed the actions of improvements to a health structure. For example, there are medicines, there are exams, there are professionals, there is a structure if the person gets sick. But, the way things are going, the focus is on health, people want health, mental health and so on, and it spills over into the service, because then the idea is created that the solution lies with the health service, for problems that go far beyond that. So, if the teenager started using a substance because he is a little loose, without much to do, there is no offer of anything, the family will understand that the one who has to solve the problem is the doctor or the psychologist, and sometimes even the professional also falls into this illusion that the patient’s problem can be solved with some type of medication. [...] So, what is the suffering? Is it the suffering of someone who needs to be stimulated, needs to leave the house, go to some activity, or is it in fact a disorder, a pathology that requires medication? You will see that most of it is suffering and this turns into a demand for PSF, etc. [...] In some ways, it’s almost as if the health professional is the last place the patient turns to, so when he does, things that are not related to health fall on the health professional. (E22, psychology, M, 38 years old)

It is important here to consider the concept of social suffering, which goes beyond biomedical analysis, encompassing sociocultural aspects that permeate the daily lives of the population affected by the event: “Such aspects are related to the intersection between physical events and the way in which affected groups react to them, to the forms of dialogue required of them, on the one hand; and, on the other, to the way in which corporate and public agencies respond institutionally to their demands”¹⁶ (p.38).

At the same time, it is important to emphasize that the agreement for reparations in the municipality was considered the largest ever made in Latin America and one of the largest in the world¹³. By extension, the disaster itself favored the organization of the municipality’s health services, as well as care strategies¹². However, at the same time, this investment in health brought about an accountability of this sector and of the professionals who work in it beyond their objectives and attributions.

Within the restructuring of the health service, one area of care stands out in the municipality: mental health. It was fully expanded, at the different levels of care, as summarized in Figure 2. Before the disaster that occurred in the city, all demand related to mental health was absorbed only by the Psychosocial Care Center (CAPS Centro de Atenção Psicossocial - in Portuguese), in mode I, intended for municipalities or health regions with a population of over 15,000 inhabitants¹². After the disaster, CAPS was restructured to level II. Although this mode is indicated for municipalities or health regions with a population of over 70,000 inhabitants¹², in Brumadinho, its inclusion was authorized outside the criterion due to the context of the tragedy. In addition, other expansions were made at the different levels of care, including pre-hospital and per-hospital care (Figure 2).

Figure 2
Mental health expansions.

It is important to consider that there was a forecast of an increase in demand for mental health after an event of this magnitude. The restructuring aimed to provide greater agility and precision in terms of identifying demands within the affected population.¹² At the same time, the emphasis on this sector also brought other implications and, therefore, must be analyzed with caution, as two mental health professionals explain:

After the dam break, what was the most stimulated field? It was the field of mental health. There are psychologists everywhere, there are psychiatrists everywhere, so the population also bought into this idea. So, this links all their problems, all their suffering to the service. The idea that was sold, and the population bought into this idea, is that I have to be treated and my suffering is treated by a doctor, a psychologist, and psychotropic drugs. Suffering is not necessarily diagnosable. If not, the service will always work at maximum capacity, because the population will always be suffering, but the population does not understand that this suffering is not a mental health suffering, of depression, anxiety, schizophrenia. It is like you go out the door of your house, there is a truck, then you go get in your car, a journey that used to take 15 minutes now takes 50 minutes. And you do not associate your emotional and mental state with your daily life. And then you go to the PSF, they don’t solve it, then you go to the CAPS, you go to the doctor to get a medicine to improve your life and then it becomes chronic. The suffering is not treated, it becomes chronic. So, it’s almost like high blood pressure, he will always be a patient of that service, he will always be irritable, from time to time he will be anxious. He doesn’t progress, what could perhaps improve, the health service can’t solve, such as where he lives, how he gets to school with his son, how he gets to Belo Horizonte, because he works there. And people can’t make these associations, that we don’t treat all suffering with a psychiatrist, with a psychologist. We treat it in other ways, so if there isn’t this different perspective, it won’t get out of this: a city of mining only. (E22, psychology, M, 38 years old)

I imagine it would have been much more beneficial if all the things that were implemented after the collapse had been discussed and explained to the population. Because the population was not heard. It was more interpretative, not to say imposing: “it seems like they need this.” Without asking, without bringing it up for a more in-depth dialogue about what they really need. The issue of vehicle flow in the neighborhood itself, the interruption of roads that allowed easier access to other parts of the city or to other communities that no longer exist. If the flow of vehicles is diverted to another point that does not pass through the community, or if these roads are reopened that allow this access that once allowed better contact between one community and another, all of this, in my opinion, contributes to an improvement in the population’s experience of well-being with the region, with space, and, at the same time, there is an improvement in people’s mental health. (E12, psychology, M, 38 years old)

Another consequence of the disaster is deterritorialization, as it brings substantial changes to the community-material and symbolic losses and health problems-changes in living conditions and increases in existing vulnerabilities¹⁷. Although the reparation process involved the community and the health service¹⁵, professionals point out that there was no effective listening and participation that considered the demands of those who live and work in the territory. In this sense, they emphasize the need to think of reparation strategies as part of a project for the community, which includes actions to promote health and physical activities, encourage events for socialization in the community, among others. Above all, actions that consider the territory beyond a geographic delimitation: as an intersubjective space of belonging and meaning¹⁷. This would imply favorable impacts on health conditions, which would also minimize the emergence of other social demands after the event.

By way of summary, a schematic diagram (Figure 3) is proposed that aims to combine the various aspects involved in the relationship between compensation processes and health services. From a socio-anthropological perspective, the concept of sociotechnical disaster¹⁸ helps to understand the repercussions beyond the dam break itself. In this concept, the disaster is not reduced to its purely technological nature, but rather encompasses factors of a social, economic, territorial, and political nature. This diversity of factors that had a confluence in health reveals the multidimensional nature of the event.

Figure 3
Repercussions of compensation processes in the health service.

It is clear that the health service is involved in a process with complex boundaries, in which the guarantee of compensation is directly linked to an illness and the use of the health service. The professionals were in constant contact with insurmountable situations that needed to be nuanced in the daily routine of the service. In turn, the same compensation process, after acquisition, implied the change of a specific demand in the use of the health service, reported by all interviewees: an increase in the consumption of alcohol and other drugs⁶^,⁷. In the context of Brumadinho, the reports show a dissociation between this guarantee and the proper financial education within the community, which resonates in the living conditions of the population and in the health service itself.

All of the factors involved in the compensation process had repercussions as a source of direct and indirect illness for all of the actors involved, both users and health professionals. The data reinforce the need for planning in light of the macro-social impacts of the event and, above all, the definition of the roles of each sector in terms of compensation processes and other programs aimed at compensating damages resulting from the event. It is clear that reparations are crucial,⁴ however, the financial axis dissociated from planning and identification of local needs implies more problems than solutions. The reports show that the repercussions on health are just the tip of the iceberg given the diversity of intertwined factors.

It is also important to note that, on a global scale, there has been an increase in disasters, both natural and technological, which constitute a serious public health problem. Due to the impacts they cause-short, medium, and long term-which reinforces the need for risk management of these events together with governments, the health sector, and a raised awareness of the affected population³. By extension, due to the complex context, it is necessary to consider the various actors and fields of knowledge in order to identify demands. Based on this diagnosis, reparation actions and priorities in the allocation of resources must be developed, considering the meeting of demands applicable to another sector¹^,¹⁹.

Health needs include sociocultural factors, deficiencies, and vulnerabilities beyond the biomedical perspective-diseases, risks, and health problems. In this sense, the analysis of these aspects enables the formulation of protocols and guidelines for health services based on a more coherent approach to the therapeutic process¹. It is important to note that health professionals and managers are identified as key actors in risk management, as well as in the recovery of the living and health conditions of victims. However, structural issues require detailed analyses to support the actions of these actors in reducing damage resulting from disasters. The impacts mentioned are multifactorial and reflect the need to review legal frameworks and strengthen the responsible public bodies⁴^,¹⁴.

For the health service, there are still other challenges and demands that were not explored in this article due to the limitations of its scope, among which are the (re)organization of services in view of surveillance actions regarding heavy metals, impacts on worker health, changes in the dynamics of the city with implications for health demands, among others.

Final considerations

A disaster is not limited to deaths, destruction of property and the environment, illnesses, and immediate injuries. In addition to the more obvious implications, the event will result in changes in the daily lives of a community and, by extension, will have impacts on living conditions with short, medium, and long-term effects on various spheres of society, including the health sector.

This study showed that both the process of obtaining compensation and its materialization had a major impact on the health service, a sector that was at the intersection of a process surrounded by porous boundaries involving agreements and negotiations between the population and the company responsible for the disaster. Professionals were responsible for mediating situations beyond their duties in the health field, which resulted in, among other factors, an overload of work.

The analysis shows that it is necessary to identify the causes related to the impacts resulting from a disaster so that mitigating measures can be implemented effectively for all those involved, in other words, to develop and consider strategies that consider the guarantee of rights without compromising the health and quality of life of those affected.

It is expected that the results presented in this study can support surveillance actions, health care, and future risk management in similar contexts.

Acknowledgements

We would like to thank the Department of Science and Technology of the Department of Science, Technology, Innovation, and Strategic Health Inputs of the Ministério da Saúde for their funding and the Municipal Health Department of Brumadinho for all their support throughout the data collection process. SV Peixoto and JOA Firmo are CNPq productivity fellows.

References

¹ Freitas GC, Flores JA, Camargo Junior KR. "Necessidades de saúde": reflexões acerca da (in) definição de um conceito. Saude Soc 2022; 31(1):e200983.
² Oliveira MP. O preço de um crime socioambiental: os bastidores do processo de reparação do rompimento da Barragem da Vale em Brumadinho, o maior desastre humanitário do Brasil. São Paulo: Dialética; 2023.
³ Peixoto SV, Asmus CRF. O desastre de Brumadinho e os possíveis impactos na saúde. Cien Cult 2020; 72(2):43-46.
⁴ Freitas CM, Silva MA. Work accidents which become disasters: Mine tailing dam failures in Brazil. Rev Bras Med Trab 2019; 17(1):21-29.
⁵ Macinko J, Firmo JOA, Nascimento-Souza MA, Mambrini JVM, Peixoto SV. Acesso, utilização e qualidade dos serviços de saúde após um desastre: resultados do Projeto Saúde Brumadinho. Rev Bras Epidemiol 2022; 25(Supl. 2):e220005.
⁶ Geng F, Zhou Y, Liang Y, Fan F. A longitudinal study of recurrent experience of earthquake and mental health problems among Chinese adolescents. Front Psychol 2018; 9:1259.
⁷ Vlahov D, Galea S, Ahern J, Resnick H, Boscarino J, Gold J, Bucuvalas M, Kilpatrick D. Consumption of cigarettes, alcohol, and marijuana among New York City residents six months after the September 11 terrorist attacks. Am J Drug Alcohol Abuse 2004; 30(2):385-407.
⁸ Barcellos C, organizador. Avaliação dos impactos do desastre de Brumadinho sobre a saúde. Nota Técnica. Rio de Janeiro: Fiocruz; 2019.
⁹ Bauer MW, Gaskell G. Pesquisa Qualitativa com Texto Imagem e Som. Petrópolis: Vozes; 2002.
¹⁰ Patton MQ. Qualitative research and evaluation methods. Londres: Sage Publications; 2002.
¹¹ Geertz C. A Interpretação das Culturas. Rio de Janeiro: LTC; 1989.
¹² Noal DDS, Braga VMR, Leal MB, Vargas AR, Eliazar P. Desastre da Vale: o desafio do cuidado em Saúde Mental e Atenção Psicossocial no SUS. Saude Debate 2021; 44:353-363.
¹³ Quintão FDM, Teodósio ASS, Dias ALF. Doce fel da minero-dependência nas cidades mineiras: Brumadinho e Itabira em perspectiva. Cad Metrop 2022; 24(54):647-668.
¹⁴ Silva MA, Freitas CM, Xavier DR, Romão AR. Sobreposição de riscos e impactos no desastre da Vale em Brumadinho. Cien Cult 2020; 72(2):21-28.
¹⁵ Melo TL, Guimarães LO. Vale tudo: As estratégias de atuação da Vale após o desastre-crime da barragem de Córrego do Feijão. Rev Adm Mackenzie 2023; 24(6):1-27.
¹⁶ Zhouri A, Valencio N, Oliveira R, Zucarelli M, Laschefski K, Santos AF. O desastre da Samarco e a política das afetações: classificações e ações que produzem o sofrimento social. Cien Cult 2016; 68(3):36-40.
¹⁷ Santos MADL, Sol NAA, Modena CM. Território e desterritorialização: o sofrimento social por desastre ambiental decorrente do rompimento de barragens de mineração. Saude Debate 2020; 44(n. esp. 2):262-271.
¹⁸ Zhouri A. Produção do Conhecimento em um 'Campo Minado'. In: Zhouri A, organizador. Mineração, violências e resistências: um campo aberto à produção de conhecimento no Brasil. Marabá: Editorial iGuana, ABA; 2018.
¹⁹ Carvalho MM, Oliveira SS. Configurações psicossociais do rejeito: apontamentos sobre o rompimento da barragem de Fundão em Mariana/MG. In: Duarte DA, Sbardelotto DK, organizadores. Barragens e seus impactos psicossociais. 1ª ed. Paranavaí: EduFatecie; 2021. p. 90-110.

Data availability statement
The data sources adopted in the research are indicated in the article’s body.

Chief editors:
Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

Publication in this collection
03 Aug 2026
Date of issue
2026

History

Received
29 Jan 2025
Accepted
22 Apr 2025
Published
24 Apr 2025

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹ Freitas GC, Flores JA, Camargo Junior KR. "Necessidades de saúde": reflexões acerca da (in) definição de um conceito. Saude Soc 2022; 31(1):e200983.

[2] ² Oliveira MP. O preço de um crime socioambiental: os bastidores do processo de reparação do rompimento da Barragem da Vale em Brumadinho, o maior desastre humanitário do Brasil. São Paulo: Dialética; 2023.

[3] ³ Peixoto SV, Asmus CRF. O desastre de Brumadinho e os possíveis impactos na saúde. Cien Cult 2020; 72(2):43-46.

[4] ⁴ Freitas CM, Silva MA. Work accidents which become disasters: Mine tailing dam failures in Brazil. Rev Bras Med Trab 2019; 17(1):21-29.

[5] ⁵ Macinko J, Firmo JOA, Nascimento-Souza MA, Mambrini JVM, Peixoto SV. Acesso, utilização e qualidade dos serviços de saúde após um desastre: resultados do Projeto Saúde Brumadinho. Rev Bras Epidemiol 2022; 25(Supl. 2):e220005.

[6] ⁶ Geng F, Zhou Y, Liang Y, Fan F. A longitudinal study of recurrent experience of earthquake and mental health problems among Chinese adolescents. Front Psychol 2018; 9:1259.

[7] ⁷ Vlahov D, Galea S, Ahern J, Resnick H, Boscarino J, Gold J, Bucuvalas M, Kilpatrick D. Consumption of cigarettes, alcohol, and marijuana among New York City residents six months after the September 11 terrorist attacks. Am J Drug Alcohol Abuse 2004; 30(2):385-407.

[8] ⁸ Barcellos C, organizador. Avaliação dos impactos do desastre de Brumadinho sobre a saúde. Nota Técnica. Rio de Janeiro: Fiocruz; 2019.

[9] ⁹ Bauer MW, Gaskell G. Pesquisa Qualitativa com Texto Imagem e Som. Petrópolis: Vozes; 2002.

[10] ¹⁰ Patton MQ. Qualitative research and evaluation methods. Londres: Sage Publications; 2002.

[11] ¹¹ Geertz C. A Interpretação das Culturas. Rio de Janeiro: LTC; 1989.

[12] ¹² Noal DDS, Braga VMR, Leal MB, Vargas AR, Eliazar P. Desastre da Vale: o desafio do cuidado em Saúde Mental e Atenção Psicossocial no SUS. Saude Debate 2021; 44:353-363.

[13] ¹³ Quintão FDM, Teodósio ASS, Dias ALF. Doce fel da minero-dependência nas cidades mineiras: Brumadinho e Itabira em perspectiva. Cad Metrop 2022; 24(54):647-668.

[14] ¹⁴ Silva MA, Freitas CM, Xavier DR, Romão AR. Sobreposição de riscos e impactos no desastre da Vale em Brumadinho. Cien Cult 2020; 72(2):21-28.

[15] ¹⁵ Melo TL, Guimarães LO. Vale tudo: As estratégias de atuação da Vale após o desastre-crime da barragem de Córrego do Feijão. Rev Adm Mackenzie 2023; 24(6):1-27.

[16] ¹⁶ Zhouri A, Valencio N, Oliveira R, Zucarelli M, Laschefski K, Santos AF. O desastre da Samarco e a política das afetações: classificações e ações que produzem o sofrimento social. Cien Cult 2016; 68(3):36-40.

[17] ¹⁷ Santos MADL, Sol NAA, Modena CM. Território e desterritorialização: o sofrimento social por desastre ambiental decorrente do rompimento de barragens de mineração. Saude Debate 2020; 44(n. esp. 2):262-271.

[18] ¹⁸ Zhouri A. Produção do Conhecimento em um 'Campo Minado'. In: Zhouri A, organizador. Mineração, violências e resistências: um campo aberto à produção de conhecimento no Brasil. Marabá: Editorial iGuana, ABA; 2018.

[19] ¹⁹ Carvalho MM, Oliveira SS. Configurações psicossociais do rejeito: apontamentos sobre o rompimento da barragem de Fundão em Mariana/MG. In: Duarte DA, Sbardelotto DK, organizadores. Barragens e seus impactos psicossociais. 1ª ed. Paranavaí: EduFatecie; 2021. p. 90-110.

Subthemes/Excerpts	Emergency aid	Compensation
Weakness in the criteria	People from outside came here, they didn't even live here, but they had houses here, like rented houses. So you had to find out if it was or wasn't... it was very difficult. Sometimes, you denied it to someone who was entitled to it. Someone else who had a house and didn't even live here, but rented it to someone, received it, because the things were in the person's name. Nowadays, not everyone who has health insurance likes to use the health system. So, they don't have a registration with a UBS [Unidade Básica de Saúde in Portuguese], because they don't use that service. But at that time, they wanted to. How do you prove it? (E10, human resources, F, 54 years old) At the time, it was left up to the health sector. [...] There were lines at the UBS in the beginning to get the declaration. And, at the time, since there was not much control, many people issued declarations that were not truthful, that's when they checked and cut them. And now they are doing this review, they are cutting off many people and asking people to go back to the unit to get the declarations. (E11, nursing, F, 44 years old)	The company said it would pay compensation, but it didn't establish the criteria, it left everything open and didn't negotiate. This thing of providing for one person and not providing for another, that inflamed people's feelings. (E22, psychology, M, 38 years old) There was discrimination on the part of [the company] at first, because it didn't have any criteria, so this led to something like "why does he, my neighbor, receive compensation and I, who suffer the same thing that he has to prove?" (E13, psychology, F, 32 years old) The so-called emotional distress, which is the 100,000 (one hundred thousand reais), is now within a judicial expert assessment, because before the [company] did it in “agreements” that were made extrajudicially, where they accepted the medical report, talking about the person’s treatment and already included that in the compensation amount, already accepting the emotional distress. But they stopped doing that and started going through the judicial branch, if you have distress you have to go through an expert assessment and if the expert says you have it, you will be paid. (E23, doctor, M, 32 years old)
Breaking of bonds and line of care	We had lost stamps from the nurse, false signatures. COREN [Conselho Regional de Enfermagem in Portuguese] was called in for some cases, because the nurses, in addition to the community agent's signature, the nurse, as he was responsible for the unit, was the one who stamped them. They suffered threats, harassment. There were patients who went to their homes, took their personal phone numbers, so, really, it was a very turbulent period. And it had ups and downs. At the beginning, it was worse. Then, it seems that the company stopped the process and then resumed it. So, it turns out that these users went back to the PSF [Programa Saúde da Família in Portuguese] again to request these statements. (E03, nursing, F, 34 years old) It was a difficult time for healthcare as a whole, too. Because when you said no to people, they knew you were denying them the opportunity to have that money. They ended up very stressed, very upset, because there were people who were actually from the city, but had never used the healthcare service. There was a lot of harassment against workers. (E10, human resources, F, 54 years old)	This bonding issue was weakened, because you had a good relationship and then you don't anymore, because I didn't prepare the report with CID F43.1 [Classificação Internacional de Doenças/Estresse Pós-tramático in Portuguese] for him. And then to manage the case in other situations, for example, a case of psychosis, the patient comes, and people say: "oh, so-and-so's patient, you've been with him for a while, you have a good bond". Then the patient comes and says: "do it for me, because I had an emotional shock and so on". But you don't have CID F43.1! I understand your suffering, but you don't have this diagnosis. Then you lose the treatment for the other clinical condition and you lose the patient. As a professional, you get frustrated. This is exhausting. (E23, medicine, M, 32 years old) The most serious thing in my opinion was that it generated a lot of hostility from the population towards the professionals, because at some point the [company] started to require a diagnosis of post-traumatic stress disorder. So, in addition to seeking out a health professional, you had to leave with a report, which is every user's right, but the professional had to put F43.1 so that they could have access to it and most of them did not have this diagnosis. (E22, psychology, M, 38 years old)
Nuances of the (dis)association between illness and the guarantee of rights	What really caught on was when, for example, you lived in Brumadinho and your sister lived in Belo Horizonte, but then you wanted to deceive and wanted to use her name. Your mother lived somewhere and you came and said that she also lived with you. So you think about what happened. The ones who signed were the ACS [Agente Comunitário de Saúde in Portuguese] and the PSF nurse responsible for the unit. So, for example, the ACS who works properly, he knows the whole territory and the people, but those who don't work, they would sign the declaration without analyzing it. (E09, ACS, F, 56 years old) The farmers think that because they have a farm here they have the right to everything. We say that there are “water patients” because they can’t drink the tap water after the dam bursts. So every Monday the company comes and leaves the water, and there has to be someone, a resident in the house to receive it. There are a lot of people who don’t even come here, but they come on the weekend and stay on Monday to get the water, say that it’s there, get the water and leave. Sometimes they come here and say “I have a headache”, just take some dipyrone and leave. Just to say that they consulted here at the unit, that the registry is here. That’s what happens most. And they demand to consult with the nurse to have a record, to say that they had a respiratory problem, and then go there and get a copy of the medical record, because the medical record is also their document for the legal issue. (E11, nurse, F, 44 years old)	And with this issue of benefits, many people became “sick”, some wanted to take advantage of their illness to get a benefit. It’s like this: I hate everything that happened, but I love it for the benefit it brings. In some situations, not everyone, those who suffered direct losses, I think they really did get sick. [...] There are some nuances that are difficult, because there are those who are sick, but there is also this other side. (E05, nursing, M, 43 years old) There is the issue of secondary gains from the disease. Each person, with their own personal desire, will have that gain. For example, whether it is time off work or extra financial resources. I think the population is very dependent on this “what will I gain from this?” Health care is responsible for issuing a report, issuing a certificate. So, I think the pressure for these human desires is very much linked to this. Because health care has the power to do this. If you have a medical report saying that you are sick, there is no one to argue with it. This ends up overloading the professionals. (E18, nursing, F, 40 years old) And, besides that, we have this issue of mental health [for compensation], which is very much linked to suicides. And these are young people who attempt suicide, and then when you look at the history, they never sought anything from the PSF... they never had any follow-up. The person was apparently fine. So, there are situations that are confusing for us. It is difficult to discern to what extent it is really a health issue. (E04, physiotherapy, F, 36 years old)

Subthemes	Interview excerpts
(Lack of) money as a protective factor	Today we have a problem with alcohol and other drugs. Why are we only thinking about this now? Because the benefits of reparation have come, money is a protective factor against substance use. Why? Because there is a lack of it. To maintain this, users often create a social problem before causing any physical problem, any organic issue. So, if the person seeks your help, you can intervene. But that wasn't a problem here, because today everyone has their own reparation, so you often don't create a problem, for example, within the family. We are dealing with people who have been using drugs “hard”, as we say, for a long time, supported by money that always comes in, so it never runs out. You can have it every month. So you lose this protective factor, both social and financial. Patients come here with a very important clinical issue, and then it becomes difficult for you to work with this patient, and you can't give the person functionality. The family or the patient comes to us and it is no longer because of the substance use, but because of a clinical weakness, dysfunctionality. So, it's already serious. And alcohol withdrawal is scary. So when a guy gets sick and has convulsions, that's why I say: it's the protective factor, because it's scary. So sometimes he seeks treatment before he becomes so debilitated. But today he doesn't have withdrawal crises, because the addiction is sustained. (E23, doctor, M, 32 years old) The income transfer program that the company runs, it always credits on the first business day of the month. So it's a monetary amount that is credited on the first business day. And there was an interesting trend, which was that these young adults who were already undergoing treatment were absent during the first business days of the month and then returned around the 10th or 15th, and in a more severe acute condition. This was a trend that we were able to observe that seems to be associated with money. People who sometimes didn't have this regular income and now do, and when they receive it, in those first few days, they use it very heavily, leave work and then come back. It's very possible to have this income transfer program and be able to sustain the use of alcohol for 30 days of the month. Something that might not have been possible before because there was a lack of money. So there was a period when the person didn't drink, which to some extent counterbalanced their health. So, possibly, many of those who arrived later have been drinking for a long time and without stopping [...] we understand that it has a lot to do with the compensation benefits that the company established in the municipality, but it did not know how to provide financial education. So, this money somehow entered the daily lives of some people who perhaps even had a problem with alcohol or some other drug and made these people dysfunctional. (E22, psychology, M, 38 years old) Nowadays, alcoholism and drugs are a problem. The other day I found out that there is a guy here who drinks a lot. Every month, when the money comes out, he goes there and buys and puts 50 liters of drinks, alcohol, in his house. Like today, for example, it is very quiet here [UBS], after the 2nd, you can see that the movement in the area increases, drugs, alcohol, because the money came out, always on the first day. (E11, nursing, F, 44 years old)
Changes in the consumption profile and clinical cases resulting from use	The problem here is cocaine and alcohol, which means you can afford a more expensive addiction. Cocaine, let's say, is a higher quality drug, better made than crack, so it keeps the user going for longer and they can financially afford this pattern of addiction. Because if you look at the big cities, the most common thing is this: cachaça and crack. Not here, it's beer and cocaine. Now more people are arriving who are 45 or older, older adults, I think it's because they can't physically handle it. I think young people are still holding out for this long, let's say since 2019, almost 5 years of "heavy" use, their bodies are still working, they're still physically preserved, so for you to deteriorate that, you have to spend more time, let's say, using it. We see people who are 55 years old with dementia associated with drug use. Early dementia, not elderly people. Associated with this, with many neuropathies, people have difficulty walking, other clinical conditions accelerate or worsen, diabetes accelerates, becomes uncontrolled. There is also the onset of these comorbidities associated with use, so it becomes a real hodgepodge, there is a rapid worsening of these people in this age group. There is a very rapid decline that the family members themselves say: “wow, not long ago he was functional and, suddenly, he is not able to take a shower by himself”. (E23, medicine, M, 32 years old) Cocaine is prevalent here, but it does not leave the subject in a critical state, this incapacity. It brings other challenges, perhaps this subject who uses cocaine, or this young adult, is in the territory, he is not here. Those who are here are those who have already suffered losses, men and women of 40, 45 years old who you look at, you do an evaluation and it seems that they are 60, 70 years old, which is not normal for their age group, the disorder they present, a dementia condition, for example, is not something that should appear at 45 years old. So, this is a use that has been going on since 2019, and it is as if we are reaping the results now. These are people who, possibly, have been abusing for a few years, since 2019, I speak of this segment, because before it was not a demand. I, for example, have been here since 2016 and this public did not exist. (E22, psychology, M, 38 years old) With the compensation and with this monthly amount, we see the seriousness of the cases that often come to the CAPS [Centro de Atenção Psicossocial in Portuguese], because today we no longer have so many withdrawal crises where people can no longer use drugs and have that crisis, because sometimes they don't have the financial resources to pay for drugs or alcohol. Today we see intoxication, because people can maintain very heavy use. So, we are even scared about cases of dementia due to very early alcohol use, with people under 60 years old, not even elderly and already suffering from dementia due to alcohol use. (E13, psychology, F, 32 years old)
Social vulnerabilities	We had a patient here whose [compensation] card was with the drug dealer. So, at least he had the money, and when he didn't have it anymore? What will happen? Will he become a homeless person? A thief? Attempt suicide? And people are used to this money, it's way above this money, this compensation. I say it's a very cursed money. In this case, for example, the patient who used drugs, he threatened his father and mother, so his brother went to the judge and asked for a protective measure, and then he managed to have him hospitalized here. This man stayed here for more than two months, even though he had nothing, he was a drug user, but the judge allowed him to stay here, we are offering a hospital bed, for a person who has nothing to demand from the hospital, but since we have CAPS beds, it fit, so when we went to see, the brother wanted to show that this patient was unable to continue taking care of his compensation money. He wanted guardianship. So, that's something that comes in, imagine what doesn't come in? (E04, physiotherapy, F, 36 years old) Mental health as a disease, an illness, which sometimes arises due to social issues. Because today, mental health in Brumadinho is the consequence of social, collective experiences, of violations of rights. Today, mental health in Brumadinho is greatly impacted by the experiences we have had, there are many social aspects at stake. So, for example, if there is a person who uses more alcohol or drugs, they are probably in a situation of greater vulnerability as well. We have reports from relatives, for example, who say that the bank card of their son who receives this income transfer today, which is a minimum wage, is already in the [drug] den. And what about this person? And what about eating? And living? (E13, psychology, F, 32 years old) We see the issue of increased consumption of alcohol and other drugs, and then you can think about the population's illness, but also about purchasing power. You can't find some professions. For example, the city is rural, before you could find someone to do weeding, now you can't find someone, it's harder. Because people receive a certain amount every month. So you no longer have that need, because people used to do odd jobs, because they needed to supplement their income, so you found someone to weed your lot, do some cleaning. There are many people who no longer do these services because they say "what for? If I get this extra money?!" (E24, psychology, F, 55 years old)