Suffering of homeless people in Salvador, Bahia, Brazil, and care provision in a health service

Abstract

The number of Homeless People in Brazil and worldwide has been increasing in unequal and exclusionary societies, leading to increasing demands on health services from people in extreme suffering. This article aims to reflect on the suffering of the Homeless people, its repercussions on health workers and care, at a Psychosocial Care Center for Alcohol and Other Drugs, in Salvador, Bahia, Brazil. A qualitative approach with cartographic orientation was employed, involving individual, unscheduled encounters with staff members and service users, which were recorded in Cartographic Diaries, and five scheduled meetings with the staff to reflect on health care practices, which were recorded and transcribed. The analysis comprised reading the empirical material in dialogue with authors who provided the epistemological and methodological foundations of the investigation. The findings point to the complexity of the suffering experienced by homeless people, which goes beyond substance use and mental disorders and is marked by exclusion, violence, racism, and social humiliation. The study suggests that recognizing and analyzing the effects of this suffering on health workers and service users can help reduce distance and blindness toward their existences and support the construction of health services with objective conditions that enable health workers to provide care more closely aligned with the needs of these individuals.

Keywords:
Homeless people; Psychosocial Care Centers; Psychological distress.

Resumo

O número de pessoas em situação de rua (PSR) no Brasil e mundialmente vem aumentando, em sociedades desiguais e excludentes, levando a demandas crescentes, em serviços de saúde, de pessoas em extremo sofrimento. Este artigo objetiva refletir sobre o sofrimento das PSR, suas repercussões nos/as trabalhadores/as de saúde e no cuidado, num Centro de Atenção Psicossocial Álcool e Outras Drogas, em Salvador-BA, Brasil. Utilizou-se uma abordagem qualitativa, com orientação cartográfica, realizando encontros individuais, não agendados, com a equipe e usuários do serviço, registradas em Diários Cartográficos, e cinco encontros agendados com a equipe para refletir sobre o cuidado em saúde, que foram gravados e transcritos. A análise envolveu a leitura do material empírico, dialogando com autores que fundamentaram epistemológica e metodologicamente a investigação. Esta aponta para a complexidade do sofrimento das PSR, para além da droga e do transtorno mental, marcado pela exclusão, violências, racismo e humilhação social. Sugere que reconhecer e analisar os efeitos desse sofrimento nos/as trabalhadores/as de saúde e usuários/as contribui para diminuir o distanciamento e cegueira em relação às suas existências, e construir serviços de saúde com condições objetivas de conformar trabalhadores/as de saúde que possam produzir um cuidado mais alinhados às necessidades dessas pessoas.

Palavras-chave:
Pessoas em situação de rua; Centros de Atenção Psicossocial; Angústia psicológica.

Introduction

The number of homeless people has increased progressively worldwide. In Brazil, in 2022, this population grew by 38% compared to 2019 and by 211% compared to 2012; in absolute terms, 281,472 people were living in this situation (IPEA, 2023).

At the genesis of this scenario are unequal societies marked by exclusion, violence, and social fractures, which lead to the weakening or rupture of mechanisms of social belonging for part of the population: precarious housing, employment, and access to income; food insecurity and limited access to quality education and health care. This process shapes the production of desire and restricts life prospects for a growing number of people.

Within this context, material deprivation generates psychological harm, producing what Souza (2012) calls a precarious habitus - a sociopsychological disposition that discourages engagement with environments considered successful, such as the labor market and education within a capitalist context. Thus, life possibilities, including living on the streets, involve personal, family, and social contexts, as well as the absence of the State and of rights in an unequal society (Silva, 2020).

In many territories, health services - especially those that serve more vulnerable populations, such as Psychosocial Care Centers for Alcohol and Other Drugs (CAPSad) and Street Outreach Clinics - are among the few interfaces between these individuals and the State, excluding police or repressive forces.

CAPSad are health services that provide care to people experiencing psychological distress caused by the use of crack, alcohol, and other drugs, across different age groups (Brasil, 2011). They are strategic components of the care network designed by the Ministry of Health as a state policy in response to the increase in crack consumption and the judicialization of policy and life amid prohibitionism. These services are designed to operate with open doors, without requiring abstinence from drugs, and their work demands significant psychological flexibility and affective “athleticism” from their teams (Lancetti, 2015).

These are services in which the contradictions of a predominantly prohibitionist society become evident - one that criminalizes users of illicit drugs. Existential territories intersect and overlap at the heart of the anti-asylum movement (Merhy, 2013), where tensions, conflicts, racism, and violence are produced; yet they are also spaces where potentials, new forms of existence, and productions of health and life are constantly renewed (Oliveira et al., 2022; Cirne et al., 2023; Fraga et al., 2025).

With the growth of homeless people in major Brazilian cities, these services have increasingly addressed the social and health needs brought by this population. Such needs challenge health teams due to their complexity and multidimensionality, calling to produce comprehensive, intersectoral care that considers the multiplicity of lives and analyzes the “phenomenon of homelessness” through contributions from multiple fields of knowledge, including the perspectives of homeless people themselves.

A systematic review published in 2018 indicated that, in Brazil, there is growing interest in studies on homeless people, with a concentration in psychology (26.13%). These studies are categorized as addressing: singularities and diversities; reasons and motivations for living on the streets; different ways of living and surviving in homelessness; the social construction of public images; intersections between health and social assistance; relationships with the city; and processes of leaving the streets (Sicari et al., 2018).

This review discusses different ways of living and surviving on the streets, including studies that approach homelessness as a form of creation, learning, resistance, potential, affective bonds, and the construction of new ways of inhabiting the city (Campos, 2012; Oliveira, 2012; Moura Júnior, 2012; Castiglioni, 2012), as well as studies that emphasize processes of disaffiliation - rupture of social bonds, distancing from the labor market, and violations of rights - along with marginalization and oppression (Silva, 2020; Moura Júnior, 2012).

Most studies addressing the difficulties of homelessness focus on survival (Sicari et al., 2018). Alles (2010), Al Alam (2014), Aguiar (2014), and Abreu (2013) argue that being homeless produces suffering linked to difficulties in physical survival (hunger and cold) and associated with prejudice, stigma, disrespect, and police violence.

Caring for homeless people prompts an analysis of encounters between health workers and lives marked by vulnerability and violence. These marks generate forms of suffering that must be acknowledged and addressed. In a CAPSad that is intensively accessed by homeless people, it is essential to analyze the production of suffering, how it affects health workers, and how it shapes care provision itself.

When searching for the term “Suffering” in the Health Sciences Descriptors (DeCS) on the Virtual Health Library (VHL) website, the following entries appear: “Fetal Distress,” “Physical Suffering,” “Situations of Extreme Suffering,” “Emotional Suffering,” “Moral Suffering,” and “Psychological Suffering.” Among these, those most closely related to the understanding of suffering proposed by the authors cited above are “Emotional Suffering” and “Psychological Suffering.” Upon accessing these terms, the descriptor “Psychological Distress” appears. We thus arrive at a descriptor that seems to conceptualize suffering in a more comprehensive manner, characterized as a “negative emotional state marked by physical and/or emotional discomfort, pain, or anguish” (VHL, 2020, our translation).

Publications addressing the suffering of homeless people from this perspective are limited. Searches conducted in major health databases, such as the VHL and the Scientific Electronic Library Online (SciELO), reveal: (a) publications that address the concept of “ethical-political suffering,” in a manner similar to the discussion in this article, as a social and political production shaping existences (Esmeraldo Filho; Ximenes, 2024); (b) studies that treat suffering as synonymous with mental disorder (Marques et al., 2022; Barros; Peixoto, 2023; Bittencourt, 2021); (c) studies that address suffering at the fold between researcher and research subject, focusing on this relationship (Romanini, 2023); and (d) studies that introduce the notion of “psychosocial suffering,” which dialogues with the object of this article but does not address homeless people (Rocha; Falcão, 2023). Almost all were published in psychology journals, with only one appearing in a public health journal.

Thus, there is a need to expand research on the suffering of homeless people and its repercussions on health care - research that broadens the understanding of suffering beyond substance use and mental disorders, incorporating ethical, social, political, and existential dimensions.

This article aims to analyze the suffering of homeless people followed by a CAPSad located in the Historic Center of Salvador (HCS), Bahia, Brazil, and how this suffering interferes with care relationships. The investigation that gave rise to this article was grounded in encounters with homeless people and with CAPSad health workers, a service accessed daily by many of these individuals. In the following section, we present the territory of the investigation, the HSC.

The Historic Center of Salvador, Bahia, Brazil: the research territory

This study is grounded in a concept of “territory” as living, multiple, and filled with lives, relationships, and meanings, considering geographic space (the used territory) as a “territory that shelters all people, all institutions, and all organizations” (Santos, 2005, p. 252, our translation).

The city of Salvador, founded in 1549 by the Portuguese, is one of the oldest cities in the Americas and was Brazil’s first colonial capital (1549 - 1763). It was there that the first slave market of the “New World” was established, initially to supply sugarcane plantations and later to support gold extraction in Minas Gerais (Portal Educacional, 2024).

For a long time, the Historic Center of Salvador (HCS) served as the city’s economic and cultural core, playing an important role in Bahia and in Brazil. It corresponds to “the founding nucleus of Salvador, where, in the seventeenth century, the city’s main buildings were constructed” (Braga; Santos Júnior, 2009, p. 24, our translation). Today, it contains the largest preserved ensemble of colonial-period architecture in Latin America (IPHAN, 2024; Espinheira, 2009).

In contrast to the architectural, historical, and cultural richness of this territory, moving away from the main streets reveals precarious buildings and drug trafficking. Pelourinho, which attracts Brazilian and international tourists, is deeply marked by the enslavement of Africans who were abducted to work, be tortured, and die in European colonies worldwide. It is a territory where “[...] many Black tears rolled down the unhappy faces of those who were forced to abandon and reconstruct, within an adverse reality, the references of a homeland that had been usurped from them” (Torreão, 2004, p. 154, our translation).

Today, the HCS is one of the areas with the highest concentration of homeless people in Salvador, where they engage in a wide range of informal and precarious work activities (Carvalho, 2016).

The CAPSad, located within the premises of the Bahia School of Medicine (BSM) at the Federal University of Bahia until early 2021, was inaugurated in 2012 and, for 12 years, operated through a partnership between the BSM and the Bahia State Health Department. Since 2024, service management has been transferred to the School of Nursing. The service has a multidisciplinary, territorially oriented team composed of psychologists, a psychiatrist, an occupational therapist, workshop facilitators, a nurse, harm reduction workers, and a physical education professional. It provides outpatient and collective activities (medication groups, alcoholism groups, family support, and various workshops), as well as territorial activities (visits to service users).

It is within this territory - marked by slavery, inequality, and the vulnerability of those who live and work there, but also by a remarkably rich culture and intense production of life, potential, and resistance - that the research field giving rise to this article was constructed.

Methodological pathway

This study considers culture, historical period, territory, relationships, and the experiences of subjects who produce social practices permeate the process - in act - of knowledge production. Methodologically, it posits that such production takes place in encounters, in relation to spaces where life is constructed. Experience is understood here through multiple conceptual lenses (Foucault, 2010; Deleuze, 2017; Abrahão et al., 2013; Pelbart, 2017; Maturana, 2001), and is constructed as the researcher relates to the world, is affected by it, and is transformed - thus building new ways of feeling, thinking, and acting.

This is a qualitative study with a cartographic orientation, derived from the doctoral research of one of the authors, which sought to accompany the construction and deconstruction of existential territories, micropolitically produced and amenable to cartographic mapping (Rolnik, 2016).

The study was guided by the following questions: How is the suffering of homeless people assisted by the CAPSad produced? How does this suffering reverberate among health workers and in care provision? Based on the empirical material and the experience of its production, the analysis dialogued with the literature, seeking to advance a critical-analytical perspective that would enable an attention to care for homeless people as social practices immanent to the researcher affected in these encounters - also products of their experience, and not external to it.

To this end, encounters with homeless service users and with CAPSad workers were taken as devices for producing the research field and data, between 2017 and 2019.

These encounters were divided into two types: (a) encounters with workers and service users between 2017 and 2018, when one of the authors worked as a physician at the service - unscheduled encounters that occurred in the everyday routine of the service and were shaped by the position occupied within the team; and (b) encounters with workers and service users in the first half of 2019, when the researcher was no longer working at the service - weekly visits to the CAPSad were conducted to follow, over one or two previously agreed shifts, various activities such as consultations, intake processes, field visits for active outreach, and spontaneous interactions in the courtyard.

Across both periods, 25 entries were produced in the Cartographic Diaries (CD) (EPS em Movimento, 2019), in which situations experienced by the author that affected them and produced transformations were recorded and elaborated, generating new ways of understanding relationships with homeless people and care provision - new experiences.

In the second half of 2019, five scheduled meetings with team workers took place, one per month, to discuss and reflect on situations recorded in the CDs that were selected for addressing recurring themes in the service. All meetings were scheduled in advance according to team availability, and included the workers present on the day, averaging ten participants per meeting. The discussion of the first meeting was recorded, transcribed, and sent to the team prior to the next meeting; participants were asked to select excerpts to serve as triggers for the subsequent discussion, and so on. All material derived from the CDs and from the discussions in meetings with workers constituted the empirical corpus of the study.

By bringing into the analytical field the experiences produced in encounters with homeless people and their reverberations in care provision, the analysis was permeated by existences produced in connection with the street (Oliveira et al., 2023), contributing to “making visible the processes inherent to an experience in which subject and object are formed and transformed in relation to one another and as a function of one another” (Foucault, 2004, p. 631, our translation).

The analytical process was conducted through intensive and extensive readings of the empirical material, grounded in the authors who provided the epistemological and methodological foundations of the investigation (Foucault, 2010; Deleuze, 2017; Pelbart, 2017; Rolnik, 2017), in dialogue with scholars who study related themes.

This research was approved by the Research Ethics Committee (REC) of the Federal University of São Paulo, under process number 91996918.3.0000.5505 (Certificate of Ethical Review Submission - CAAE), through substantiated opinion number 2,906,748. In constructing the research field, care was taken to ensure confidentiality, preservation of identity, and respect for the participants’ privacy, considering asymmetries in power relations.

Suffering of homeless people and the need to see it beyond drugs and mental disorders

A service user states that the people followed by the CAPSad are not normal. He says that things went through his mind that were not right […], things he could not even put into words. He believes that all the denial of rights he experienced throughout his life caused suffering and illness; that he needed to deal with this by trying to grow, adapting, transforming himself (CD, February 4, 2019, our translation).

This excerpt from the Cartographic Diaries (CD) gives voice to deep and intense form of suffering linked to a lifetime of denied rights. This man - a young Black man, one of the longest-standing users of the service, experiencing homelessness and problematic substance use (alcohol and crack) - has been followed by the CAPSad for years. Although substance use permeates his life and produces sufferin, within a society that stigmatizes and marginalizes “drug users,” it is only one layer of this suffering.

This is a form of suffering that routinely appears as a demand placed on CAPSad teams throughout Brazil, especially when dealing with people in extreme vulnerability. Structural violenc, which underpins contemporary neoliberal society, deepens their exclusion. For many, it is viscerally connected to going to and remaining on the streets, to existence within that territory, to relationships with licit and illicit drugs, and to the actions of public or private actors linked to the production of such violence - generating and intensifying suffering, inequality, and exclusion. This constitutes a way of governing lives through precarity, which destroys and shapes perspectives and dreams (Lorey, 2018).

Another CDs excerpt recounts the story of a young Black man experiencing homelessness:

He had to come to that territory because, where he lived, he would be murdered by one of the dominant drug trafficking factions or by the police; he explained that, after protesting against the killing of a friend by police officers, one of them whispered to him: “You’re going to die!” He said that, in that neighborhood, police officers often kill a person and plant drugs at the scene to justify the murder (CD, January 7, 2019, our translation).

This account expresses suffering produced by the exercise of necropower - “contemporary forms of subjugating life to the power of death” (Mbembe, 2018, p. 71, our translation) - and by governing lives through death policies. In a context where people die for being young, peripheral, and Black, where murders are naturalized and barely felt by segments of the population, a lack of empathy prevails, rooted in the narcissistic identification of whiteness (Müller; Cardoso, 2017; Ribeiro, 2019). In common sense discourse, those who are murdered are precisely the threat: dangerous, marginal, drug users; if they died, it is because they were involved in crime, trafficking, or drug use and therefore “deserved” a fate that had already been sealed for them.

Another excerpt from the CDs describes an episode in which one of the service users, a Black man, assaulted an employee of the School of Medicine:

When questioned (about the assault), he said that he and other service users were standing in front of the school before the doors opened, wanting to go to the CAPSad. Security guards did not allow them in; when the secretary arrived, she was allowed to enter. Moments later, she opened the doors and, without addressing or speaking to them, allowed the dogs to enter. At that moment, he assaulted her […]. The phrase he kept repeating was: “Do dogs have more value than me?!” Anyone who knows him a little knows that this kind of situation often triggers crises; the feeling/perception of being discriminated against produces intense anger and indignation, and he suffers greatly from it. I myself have heard him recount situations in which people crossed the street so as not to have to pass by him, thinking he would rob them; or left a bus stop the moment he arrived. This episode was very significant for me! I have seen him cut himself, pierce himself with shards of glass or needles, saying: “I do this to myself so I don’t have to do it to others.” I have seen him threaten to assault team colleagues and even myself, but I have never seen him actually carry it out (CD, February 14, 2018, our translation).

This is a form of symbolic violence that reminds him that, in this society, his life is worth very little - sometimes less than that of a dog; a self-directed violence perceived as necessary, which lays bare the minimal value attributed to this life: a bare life (Agamben, 2002; Pelbart, 2016). These are sufferings that scream out without being heard. This cry for help from a Black man in the CAPSad - who self-harms in order to “speak” of his pain, using a language inscribed on his own body - demands a form of listening that must move beyond what is instituted and beyond racism, which leads to the non-recognition of the Other, of their perspectives and their suffering, even within health services.

Structural, institutional, and individual racism are contemporary strategies for producing exclusion, violence, and death, legitimizing the idea of which bodies may or may not be eliminated, which lives matter and which do not. Institutional racism historically enacted by the Brazilian State constructs this selectivity through the fabrication of the image of Black people as delinquents (Almeida, 2019; Lancetti, 2015; Moço, 2018).

The production of precarity and vulnerability by neoliberalism, combined with the symbolic and physical deaths characteristic of necropower, the objectification and invisibility of Black, poor, and peripheral bodies (or their selective visibility), leads to chronic, intense, and everyday suffering. This diffuse and intense malaise is an expression of social suffering, “a notion politics (...) indispensable to describe all the aspects of contemporary injustice” (Renault, 2010, p. 221).

In this sense,

Neoliberalism is also characterized by a general process of social exclusion where the social and psychological dimensions are again intertwined. For those who are victims of long-term unemployment for example, feelings of shame and depressive affects are consequences of a social situation as well as factors that make their situation worse (Renault, 2010, p. 224).

Encounters such as the one described below affected us deeply, producing shifts in how we understand the suffering received by the team:

While I was talking with a CAPSad patient in the courtyard - a Black man engaged in the homeless people’s movement - he stated indignantly that slavery had not ended; it had only changed its form; that democracy exists to destroy them! That it is for the few! That people place too much blame on drugs, but these issues come before drugs, and drugs only exacerbate what was already there! (CD, January 7, 2019, our translation).

From these encounters, we sought to develop lenses through which to view the suffering of homeless people. Encounters with suffering that is experienced singularly but produced socially, marked by how poverty, exclusion, racism, among other factors, are expressed in these lives and shape existences within certain limits of freedom and choice. These are encounters with people who arrive at the CAPSad often in crisis, agitated, marking their presence through violence; frequently under the influence of substances or with mental disorders also precipitated or exacerbated by use.

However, at the genesis of these crises - and as their consequence - there are forms of sufferings that, under no circumstances, as indicated in the CD accounts, can be understood solely through the lens of substance use and mental disorders. They are composed of deeper layers that traverse both biological bodies and “bodies without organs” (the plane of production and expression of desire), leaving marks, affecting, and producing constant upheavals in these existential territories (Deleuze; Guattari, 2004; Rolnik, 2016).

To construct these lenses, we dialogued with the concept of social suffering (Renault, 2010), articulated with ethical-political suffering (Sawaia, 2002) and social and political humiliation (Gonçalves Filho, 2007). From this perspective, “malaise cannot be observed and explained independently of the social dynamics and political and economic interests that construct, recognize, and name it” (Pussetti; Brazzabeni, 2011, p. 468, our translation), which are embedded in a local context of power relations.

Social suffering entails “deep pains, sometimes unspeakable,” that permeate the lives of many homeless people and is:

[…] the result of harm arising from contexts of social inequality and extreme poverty, from violence and unjust social relations; it is an overwhelming force that strikes the human being and their subjectivity, causing profound pain and bodily marks that refuse to silence what is often unspeakable for the one who suffers. It is an eminently social experience […] resulting from everyday situations of violence experienced by certain social groups that lack the power even to negotiate the conditions of their own existence (Von Flach, 2019, p. 31, our translation).

Social suffering “results from violence committed by the very social structure rather than by an individual or group within it: the concept refers to the harmful effects of unequal power relations that characterize social organization” (Pussetti; Brazzabeni, 2011, p. 469, our translation). Because it is caused by exclusion, mediated by social injustices, and subjected to hunger and oppression, it constitutes an ethical-political suffering that “may not be felt as pain by everyone” (Sawaia, 2002, p. 102, our translation). It is a suffering that screams without being heard and that

[…] encompasses the multiple affections of body and soul that mutilate life in different ways […]. Therefore, […] it portrays the everyday experience of dominant social issues in each historical period, especially the pain that arises from the social condition of being treated as inferior, subordinate, without value, a useless appendage of society. It reveals the ethical tone of the everyday experience of social inequality, of the socially imposed denial of the majority’s possibilities to appropriate the material, cultural, and social production of their time, of moving in the public sphere, and of expressing desire and affection (Sawaia, 2002, pp. 104 - 105, our translation).

From this same perspective, the concept of social and political humiliation broadens the understanding of exclusion beyond an economic lens, indicating that equality implies the dissolution of domination rather than the erasure of cultural or economic differences (Gonçalves Filho, 2007).

Social humiliation, therefore, is

[…] suffering that is long endured and ruminated. An ancestral and repeated suffering. A suffering that, in the Brazilian case and several generations ago, began with acts of dispossession and servitude […]. Indigenous peoples exposed to land violation and Black people uprooted and exposed to racism. […] Poor citizens exposed to proletarian labor, unemployment, and indigence. […]. The violence that wounds the humiliated is never merely the pain of an individual […]. The pain is always long-lasting, collectively endured. The humiliated person does not quite know why they cry and never cry only for themselves; they cry an enigmatic pain and cry a cumulative pain (Gonçalves Filho, 2007, pp. 194 - 195, our translation).

These are the deep, socially produced pains that reach the CAPSad and that, although they are singular experiences for each homeless person, are not individual; they occur in the present but are ancestral, carrying the history of social and political humiliation that has marked generations of the most oppressed segments of society.

Brazil is an extremely unequal country. Privileges in access to higher education - still highly elitist - deepen social chasms and unequal power relations. This creates fertile ground for medical and psychiatric power/knowledge to produce “abnormals,” including “abnormals of desire,” to stigmatize and exclude (Merhy, 2012).

Considering that this suffering is not necessarily felt as pain by everyone (Sawaia, 2002), we ask: how does the suffering of homeless people affect health workers, given that it is foreign to them and, in general, not part of their (our) experiences or existences? In what ways does it interfere with care?

Effects of the suffering of homeless people on health workers and on care provision

[…] he said that workers do not understand what it means to live on the streets; that they should be prepared to deal with service users’ crises, because those who had problems with drugs and lived on the streets were them, and they were there to be cared for - not us, the workers, who had money and access to food and housing […] (CD, September 28, 2017, our translation).

We begin with this statement-analysis from a patient, which invites us to place ourselves under analysis and to reflect on how we receive homeless people and on the kind of care we are able to produce.

The excerpt below reports an everyday scene in the service and points to this exclusion, to an interdiction produced within relationships, in the details, in the delicacy (or deviation) of a gaze. The failure to recognize any person’s life as potent and deserving of respect is already a form of violence; when this non-recognition appears explicitly as institutional and symbolic violence, it ultimately generates more revolt, hatred, and suffering - feelings that frequently become visible through further violence (Oliveira et al., 2022).

A service user, during an assembly, said […] that some health workers did not connect with service users, walked past without looking, without saying good morning, only speaking to them to ask them not to use drugs; they did not try to find out how the night had been, whether they were well, they did not connect. […] there was a lack of bonding, conversation, coming close - not to monitor drug use and impose rules, but to listen (CD, September 28, 2017, our translation).

Feelings such as those expressed in this account, produced in the relationship between staff and service users, undermine trust, hinder the construction of a strong bond, and diminish the vital potency of the Other who seeks care. This is suffering reactivated in the relationship with health workers within a service whose social function is to care for these individuals and guarantee their citizenship rights. When suffering is not seen beyond substance use - when one perceives oneself as a body that authorizes the health worker to assume a policing stance, of reprimanding drug use and imposing abstinence - social and ethical-political suffering is reactivated in that body, reinforcing a position of inferiority and diminished worth. This scene subtly reveals a facet of necropolitics, which deepens inequities and leads to a “death by a thousand cuts”.

For those who are born with death clinging to their bodies (Von Flach, 2019), reducing inequality goes beyond physical access to health services. Structural racism and the necropolitical State continue to express themselves violently upon the bodies of those deemed “killable” and “dieable.” Death remains attached to their bodies. In primary care, for example, studies show arrangements in which, in order to be assisted, homeless people must “behave appropriately” (Sá Dultra, 2018, our translation). If they do not, access to any right is barred.

Encounters with the CAPSad team enabled health workers to express their anguish regarding the care of homeless people. This is an extremely delicate, artisanal, complex, and difficult form of care, dealing with situations that are extreme and dramatic - lives that, although potent, are increasingly marked by suffering, violence, and illness. These lives bring demands that exceed the health sector, yet are funneled into health services due to the enormous capillarity of Brazil’s Unified Health System (SUS) and its extensive interface with vulnerable populations. The excerpt below prompted reflection on this scenario:

The team tries to take care of all the demands that the patient brings to the service, when we shouldn’t, right? […] Sometimes the anguish that the patient brings is also our anguish! It is the anguish of not being able to solve everything for that person […] Wanting to take care of everything for that person, when we are not all that, we cannot be all that. So, yes, that also becomes a trigger of suffering - for them and for us! For them, because of disappointment and the anguish of not resolving everything here […] (First meeting with the CAPSad team, July 11, 2019, our translation).

These encounters are also permeated by social expectations regarding the service, which are actualized in how health workers understand their roles. This often leads to the construction of a salvationist becoming in care, but also a colonial one (insofar as it brings the perspective of “solving” the Other’s life according to viewpoints external to them): a colonial-salvationist becoming (Oliveira, 2021). This becoming may manifest as institutional and symbolic violence, further revolt, hatred, and suffering, and becoming visible through further violence, in an endless cycle (Oliveira et al., 2022).

This feeling also expresses a form of violence constructed from the position of privilege occupied by health workers, since “the social position of privilege is marked by violence, even when a given subject is not deliberately violent” (Ribeiro, 2019, p. 33, our translation), and by a highly asymmetric power relationship established with homeless people, socially and politically legitimized by universities and demarcated by the social class to which health workers belong (Akotirene, 2019).

The research brought into analysis a mismatch between what homeless people demand from the team and what the team can and/or is able to produce or offer. Recognizing this conflict and perceiving oneself as moved by this colonial-salvationist becoming - along with the difficulty of overcoming it - also generates suffering and anguish in health workers, who then struggle to produce care in other ways.

Deepening the design of strategies that help overcome this challenge requires attention to the suffering that traverses the lives of homeless people - considering the suffering reproduced and intensified in relationships with health teams within each service. It also requires attention to what is constructed as responses to the social health needs expressed in these encounters - an endeavor that goes beyond the individual posture or effort of each health worker.

Final considerations

It is not simple for health workers to “see” the suffering of homeless people through lenses different from the hegemonic ones so deeply rooted in the knowledge/power instituted within health practices - namely, the framing through substance use and mental disorder/illness. It is challenging for them to recognize their role in the production and reproduction of the suffering and violence that permeate these lives.

The critical-analytical exercise grounded in the frameworks of social suffering, ethical-political suffering, and social and political humiliation sought, simultaneously, to analyze and reflect on the production of suffering among homeless people assisted in a CAPSad and on how this suffering reverberates among health workers and in care provision.

Recognizing and analyzing the effects of these crossings on the (our) bodies of health workers and on service users helped make visible how they are produced in encounters and contributed to reducing distance and “blindness” regarding the suffering of homeless people, enabling progress in the production of an “in-between.”

This movement makes it possible not to approach the needs of homeless people in health services from perspectives alien to their existences and to the violence and oppression they experience daily; not to analyze them through a representational, aseptic, and moral lens; and to produce other becomings, different from the colonial-salvationist one. It helps us to build a “common” in a fold between “the suffering of homeless people and the effects of this suffering on the bodies (also ours) of health workers,” by exercising the act of throwing our bodies into the world and allowing ourselves to be traversed by these Others (Merhy, 2004).

It invites us to produce other lenses and perspectives; to foster encounters that allow us to be affected by the Other and, in a kind of boomerang effect, to come to inhabit that Other differently as well (Pelbart, 2014). It is an invitation to build health services with objective conditions capable of shaping health workers who are affected by the inequities, violence, and differences that traverse the people with whom they relate, within a register of potency and creativity in the production of health care as the production of more life.

Acknowledgments

We thank all homeless people in the Historic Center of Salvador and the workers of the services who participate daily in the provision of care and in the production of more life with these individuals within this territory.

• Reviewers:
  Ana Machado and Beatriz Brandão
• All research data are available in this text.

References

• ABRAHÃO, A. L. et al O pesquisador in-mundo e o processo de produção de outras formas de investigação em saúde. Lugar Comum, v. 39, p. 133-144, 2013.
• ABREU, D. de. Pessoas em situação de rua, uso de drogas e o consultório de rua 2013. 180 f. Dissertação (Mestrado Profissional em Saúde Mental e Atenção Psicossocial) - Centro de Ciências da Saúde, Universidade Federal de Santa Catarina, Florianópolis, 2013.
• AKOTIRENE, C. Interseccionalidade São Paulo: Sueli Carneiro; Pólen, 2019.
• AGAMBEN, G. Homo sacer: o poder soberano e a vida nua. In: AGAMBEN, G. Vida besta, vida nua, uma vida Belo Horizonte: Editora UFMG, 2002. p. 25-34.
• AGUIAR, M. J. G. de. Moradores de rua na cidade do Guarujá-SP: condições de vida, saúde, emoções e riscos 2014. 180 f. Dissertação (Mestrado em Saúde Coletiva) - Centro de Ciências Sociais Aplicadas e Saúde, Universidade Católica de Santos, São Paulo, 2014.
• ALMEIDA, S. Racismo estrutural São Paulo: Pólen, 2019.
• ALLES, N. L. Boca de rua: representações sociais sobre população de rua em um jornal comunitário 2010. 228f. Dissertação (Mestrado em Comunicação e Informação) - Faculdade de Biblioteconomia e Comunicação, Universidade Federal do Rio Grande do Sul, Porto Alegre, 2010.
• AL ALAM, M. C. L. População em situação de rua: território como lugar de trabalho em saúde 2014. 88f. Dissertação (Mestrado em Enfermagem) - Faculdade de Enfermagem, Universidade Federal de Pelotas, Pelotas, 2014.
• BARROS, R. N.; PEIXOTO, A. L. A. Saúde mental e cotas: um estudo comparativo entre estudantes universitários no Brasil. Psicologia: Ciência e Profissão, v. 43, p. 1-16, 2023.
• BIBLIOTECA VIRTUAL DE SAÚDE. Descritores em Ciências da Saúde Angústia psicológica. 2020. Disponível em: https://bvsalud.org/ Acesso em: 01 mar. 2025.
  » https://bvsalud.org/
• BITTENCOURT, C. L. Do abandono à criação: o atendimento interdisciplinar de uma adolescente no CAPSIJ. Vínculo, v.1 8, n. 3, p. 586-593, set.-dez. 2021.
• BRAGA, P. M.; SANTOS JÚNIOR, W. R. dos. Programa de recuperação do centro histórico de Salvador: políticas públicas e participação social. Risco: Revista de Pesquisa em Arquitetura e Urbanismo (Online), São Carlos, n.10, p.23-34, 2009. Disponível em: https://revistas.usp.br/risco/article/view/44777 Acesso em: 23 jun. 2025.
  » https://revistas.usp.br/risco/article/view/44777
• BRASIL. Ministério da Saúde. Portaria nº 3.088, de 23 de dezembro de 2011 Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental, incluindo aquelas com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do SUS. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt3088_23_12_2011_rep.html
  » https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt3088_23_12_2011_rep.html
• CAMPOS, M. A. R. Sob o céu da cidade: representações sociais da população em situação de rua no município de Araguari 2012. 151f. Dissertação (Mestrado em História) - Instituto de História, Universidade Federal de Uberlândia, Uberlândia, 2012.
• CARVALHO, S. M. C. de. População adulta em situação de rua e o acesso à saúde Rio de Janeiro: Autografia, 2016.
• CASTIGLIONI, M. do C. Poesia concreta em prosa no asfalto: limites da deficiência no espaço urbano. Interface (Botucatu), v.16, n.43, p.1087-1093, 2012.
• CIRNE, M. C. et al Situação-limite: por outro olhar sobre a violência em um CAPS AD. Psicologia: Ciência e Profissão, v. 43, p. 1-15, 2023.
• DELEUZE, G. Os intercessores. In: PELBART, P. P. (Org.). Conversações 3.ed. São Paulo: Editora 34, 2017. p.155-172.
• DELEUZE, G.; GUATTARI, F. 28 de novembro de 1974 - como criar para si um corpo sem órgãos. In: DELEUZE, G.; GUATTARI, F. Mil platôs: capitalismo e esquizofrenia v.3. Tradução: NETO, A. G. et al Rio de Janeiro: Editora 34, 2004. p.9-29.
• EPS EM MOVIMENTO. Entrada apresentação - diário cartográfico 2014b. Disponível em: http://eps.otics.org/material/entrada-apresentacao/apresentacao-diario-cartografico Acesso em: 02 jan. 2023.
  » http://eps.otics.org/material/entrada-apresentacao/apresentacao-diario-cartografico
• ESMERALDO FILHO, C. E.; XIMENES, V. M. Dimensão subjetiva da pobreza: que dizem as pessoas em situação de rua. Psicologia: Ciência e Profissão, v. 44, e267483, p. 1-14, 2024.
• ESPINHEIRA, G. Projeto de reabilitação sustentável do Centro Histórico de Salvador: a dimensão social e o quadro de vulnerabilidades do Centro Antigo: relatório final Salvador: ONG MOVBAHIA, 2009.
• FOUCAULT, M. Conversa com Michel Foucault. In: MOTTA, M. B. da (Org.). Ditos e escritos VI: repensar a política Rio de Janeiro: Forense Universitária, 2010. p. 289-347.
• FOUCAULT, M. Foucault In: MOTTA, M. B. da (Org.). Ditos e escritos V: ética, sexualidade, política Rio de Janeiro: Forense Universitária, 2004.
• FRAGA, P. V. R. F. et al Entre as ruas e a RAPS: revisão integrativa sobre acesso das pessoas em situação de rua aos serviços de saúde mental. Ciência & Saúde Coletiva, v.30, n.1, e07752024, 2025. Disponível em: https://doi.org/10.1590/1413-81232025301.07752024.2025 Acesso em: 5 set. 2025.
  » https://doi.org/10.1590/1413-81232025301.07752024.2025
• GONÇALVES FILHO, J. M. Humilhação social: humilhação política. In: GONÇALVES FILHO, J. M. Orientação à queixa escolar São Paulo: Casa do Psicólogo, 2007.
• INSTITUTO DE PESQUISAS ECONÔMICAS APLICADAS. Nota técnica: estimativa da população em situação de rua no Brasil (2012-2022) Brasília: IPEA, 2023. Disponível em: https://repositorio.ipea.gov.br/bitstream/11058/11604/4/NT_103_Disoc_Estimativa_da_Populacao.pdf Acesso em: 30 dez. 2024.
  » https://repositorio.ipea.gov.br/bitstream/11058/11604/4/NT_103_Disoc_Estimativa_da_Populacao.pdf
• INSTITUTO DO PATRIMÔNIO HISTÓRICO E ARTÍSTICO NACIONAL. Centro Histórico de Salvador (BA) Disponível em: http://portal.iphan.gov.br/pagina/detalhes/35/ Acesso em: 30 dez. 2024.
  » http://portal.iphan.gov.br/pagina/detalhes/35/
• LANCETTI, A. Contrafissura e plasticidade psíquica São Paulo: Hucitec, 2015.
• LOREY, I. Estado de inseguridad: gobernar la precaridad Madrid: Mapas, 2018.
• MARQUES, F. C. et al Pessoas com sofrimento mental em recovery: trajetórias de vida. Interface (Botucatu), v. 26, e200456, 2022.
• MATURANA, H. R. Cognição, ciência e vida cotidiana Tradução e organização: MAGRO, C.; PAREDES, V. Belo Horizonte: UFMG, 2001. 221p.
• MBEMBE, A. Necropolítica: biopoder, soberania, estado de exceção, política da morte Tradução: SANTINI, R. 3.ed. São Paulo: n-1 edições, 2018. 80p.
• MERHY, E. E. Anormais do desejo: os novos não humanos? Os sinais que vêm da vida cotidiana e da rua. In: CONSELHO FEDERAL DE PSICOLOGIA. Drogas e cidadania: em debate Brasília, DF: CFP, 2012. p. 9-18.
• MERHY, E. E. O conhecer militante do sujeito implicado: o desafio de reconhecê-lo como saber válido. In: FRANCO, T. B. et al (Org.). Acolher Chapecó: uma experiência de mudança com base no processo de trabalho São Paulo: Hucitec, 2004. p.21-45.
• MERHY, E. E. Os CAPS e seus trabalhadores: no olho do furacão antimanicomial. Alegria e alívio como dispositivos analisadores. In: MERHY, E. E.; FRANCO, T. B. (Orgs.). Trabalho, produção de cuidado e subjetividade: textos reunidos São Paulo: Hucitec, 2013. p. 213-225.
• MOÇO, V. R. Das execuções sumárias cometidas por agentes públicos: um estudo da violência policial e seletividade no Brasil. Revice - Revista de Ciências do Estado, v. 3, n.2, p. 96-116, jun.-dez. 2018.
• MOURA JUNIOR, J. F. Reflexões sobre a pobreza a partir da identidade de pessoas em situação de rua de Fortaleza 2012. 159f. Dissertação (Mestrado em Psicologia) - Universidade Federal do Ceará, Fortaleza, 2012.
• MÜLLER, T. M. P.; CARDOSO, L. (Orgs.). Branquitude: estudos sobre identidade branca no Brasil Curitiba: Appris, 2017. 335p.
• OLIVEIRA, J. A. S. de. Encontros entre trabalhadores de saúde e pessoas em situação de rua no Centro Histórico de Salvador, Bahia: violências, potências e insurgências 2021. 290f. Tese (Doutorado em Saúde Coletiva) - Universidade Federal de São Paulo, São Paulo, 2021.
• OLIVEIRA, J. A. S. de et al (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu), v. 26, 2022.
• OLIVEIRA, J. A. S. de et al Cuidado domiciliar a pessoas em situação de rua. In: SAVASSI, L. C. M. et al (Org.). Tratado de atenção domiciliar Santana de Parnaíba: Manole, 2023. p. 1177-1181.
• OLIVEIRA, L. M. F. de. Circulação e fixação: o dispositivo de gerenciamento dos moradores de rua em São Carlos e a emergência de uma população 2012. 147f. Dissertação (Mestrado em Sociologia) - Universidade Federal de São Carlos, São Carlos, 2012.
• PELBART, P. P. O avesso do niilismo: cartografias do esgotamento 2.ed. São Paulo: n-1 edições, 2017.
• PELBART, P. P. Por uma arte de instaurar modos de existência que “não existem”. In: Como (…) coisas que não existem: 31ª Bienal de São Paulo São Paulo: Fundação Bienal, 2014. p.250-265.
• PELBART, P. P. Vida capital: ensaios de biopolítica São Paulo: Iluminuras, 2016.
• PORTAL EDUCACIONAL. Centro Histórico de Salvador Disponível em: http://www.educacional.com.br/reportagens/patrimonio/salvador.asp Acesso em: 30 dez. 2024.
  » http://www.educacional.com.br/reportagens/patrimonio/salvador.asp
• PUSSETTI, C.; BRAZZABENI, M. Sofrimento social: idiomas da exclusão e políticas do assistencialismo. Etnográfica, v. 15, n. 3, 2011. Disponível em: http://journals.openedition.org/etnografica/1036 Acesso em: 30 dez. 2024.
  » http://journals.openedition.org/etnografica/1036
• RENAULT, E. A critical theory of social suffering. Critical Horizons (online), v. 11, n. 2, p. 221-241, 2010. Disponível em: http://mastor.cl/blog/wp-content/uploads/2016/10/Renault-A-Critical-Theory-of-Social-Suffering-.pdf Acesso em: 23 jun. 2025.
  » http://mastor.cl/blog/wp-content/uploads/2016/10/Renault-A-Critical-Theory-of-Social-Suffering-.pdf
• RIBEIRO, D. Pequeno manual antirracista São Paulo: Companhia das Letras, 2019. 136p.
• ROCHA, M. L. B. da et al Psicologia, Conselho Federal de Psicologia e Covid-19: enfrentamento às desigualdades psicossociais no Brasil. Psicologia: Ciência e Profissão, v.43, e243766, p. 1-14, 2023.
• ROLNIK, S. Cartografia sentimental: transformações contemporâneas do desejo 2.ed. Porto Alegre: Sulina; UFRGS, 2016. 248p.
• ROLNIK, S. Esferas da insurreição: para além da cafetinagem da vida. In: SANTIAGO, H.; TIBLE, J.; TELLES, V. (Orgs.). Negri no Trópico São Paulo: n-1 edições, 2017. p. 101-121.
• ROMANINI, M. Sobre dias em que me senti sem ar: desassossegos do pesquisar. Psicologia: Ciência e Profissão, v. 43, e247962, p. 1-13, 2023.
• SAWAIA, B. B. O sofrimento ético-político como categoria de análise da dialética exclusão/inclusão. In: SAWAIA, B. B. et al (Org.). Artimanhas da exclusão: análise psicossocial e ética da desigualdade social 2.ed. Petrópolis: Vozes, 2002. p. 97-118.
• SANTOS, M. O retorno do território. In: OSAL: Observatorio Social de América Latina (online), Buenos Aires: CLACSO, 2005. Año 6, n. 16 (jun. 2005). Disponível em: https://www.clacso.org.ar/ Acesso em: [data de acesso recomendada].
  » https://www.clacso.org.ar/
• SÁ DULTRA, L. Acesso da população em situação de rua na atenção básica: uma análise das práticas instituídas pela Saúde da Família no Centro Histórico de Salvador 2018. 242f. Dissertação (Mestrado em Saúde Coletiva) - Universidade Federal da Bahia, Salvador, 2018.
• SICARI, A. A.; ZANELLA, A. V. Pessoas em situação de rua no Brasil: revisão sistemática. Psicologia: Ciência e Profissão, v. 38, n. 4, 2018.
• SILVA, P. M. F. Entre calles y trabajos: trabalho de pessoas em situação de rua em Recife-Brasil. Revista Colombiana de Sociología, v. 43, n. 2, p. 67-90, 2020.
• SOUZA, J. Construção social da subcidadania: para uma sociologia política da modernidade periférica 2.ed. Belo Horizonte: Editora UFMG, 2012.
• TORREÃO, T. R. S. B. Centro Histórico de Salvador-Bahia: a “mística” do lugar e a (des)concentração de sua espacialidade. In: PINHEIRO, D. J.; SILVA, M. A. (Orgs.). Visões imaginárias da cidade da Bahia: diálogos entre a geografia e a literatura Salvador: SciELO-EDUFBA, 2004.
• VON FLACH, P. M. Experiências de sofrimento social e movimentos de resistência entre trabalhadores e gente de rua (usuários de álcool e outras drogas), na Praça das Duas Mãos - Salvador-Bahia 2019. 327f. Tese (Doutorado em Saúde Coletiva) - Universidade Federal da Bahia, Salvador, 2019.

• Editor:
  Martinho Silva

Data availability

All research data are available in this text.

Publication Dates

• Publication in this collection
  24 July 2026
• Date of issue
  2026

History

• Received
  07 Jan 2025
• Reviewed
  28 Sept 2025
• Accepted
  11 Nov 2025