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Carandiru

2004; Elsevier BV; Volume: 364; Linguagem: Inglês

10.1016/s0140-6736(04)17632-0

1474-547X

Drauzio Varella,

LGBTQ Health, Identity, and Policy

View Large Image Copyright © 2004 André BrandāoIt was dark and cold on First Avenue when I left the hospital and heard my name being yelled from the opposite sidewalk by a strange figure covered in a scarf and long coat. It turned out to be a Brazilian pianist who was living in New York. He took pity on my tropical clothes and invited me to dinner with a group of gay men.It was 1983, and New York was the epicentre of the HIV/AIDS epidemic in the Americas. I was 40 years old, and a visiting oncologist at the Memorial Hospital. While dining with those funny guys, I became convinced that AIDS in Brazil would turn into a tragedy.6 years later I knocked on the iron door of Carandiru, a São Paulo penitentiary housing 7400 inmates, where I decided to make an educational video about how HIV was spreading there. As the door slammed behind me I felt the way I had at Sunday matinees during my childhood, when I watched black-and-white films starring men in uniforms behind bars.My voluntary work in Carandiru started with an inquiry into the frequency of HIV in 1492 prisoners enrolled in the Intimate Visit Programme, which permitted wives and girlfriends to visit the prisoners in their cells for intimate relations.Injectable cocaine was the most fashionable drug in the poorest neighbourhoods and inside the prison. The results showed that 17·3% of the prisoners were HIV-positive and that 58·0% tested positive for hepatitis C virus (HCV). Among 82 transgendered people, positivity was 78·0%. One inmate who reported more than 1200 sexual partners during the previous year, with whom he had had unprotected receptive anal intercourse, was HIV-negative. Intravenous drug abuse, age, number of sexual partners in the last year, and length of imprisonment were the most significant risk factors. All transgendered people imprisoned for more than 6 years were infected with HIV. Tests were done in São Paulo and all the results confirmed by the Cleveland Clinic Foundation.Based on the results, we devised an educational project, which acquired its final form after several modifications imposed by our experience in that aggressive milieu.The jail had seven pavilions, each five stories high, with cells holding from two to more than 20 men. Built in the 1950s as a pre-trial detention centre, it became a permissive house where one could find first offenders as well as criminals sentenced to decades of incarceration. The number of guards in charge was unbelievably low: a pavilion like number 8, which housed 1500 persistent offenders, usually had five or six unarmed guards on each shift. How so few could control such a mass of criminals was, for me, the deepest mystery of Carandiru.Cells were locked at 1900 h and opened the next morning at 0800 h. Prisoners were allowed to move freely around the pavilion and its yard, but prohibited to circulate outside of it, with the exception of convicts involved in work or those who had bribed the gate's guard. Every Friday morning, an experienced guard unlocked the door of the old cinema of Pavilion 6, which had been rebuilt after being burned in a previous riot, for the 300–400 prisoners designated to attend the talks given there. The rest of the doors were opened 20 min later so as to avoid accidents, as prisoners were safe inside their own pavilion, but beyond its limits their lives could be at risk.Friday's sessions with the doctor became very popular, and ran for almost 10 years without a single act of violence. They usually began with videos of popular singers projected onto a large screen. As the men gathered, the doors were closed and a video about AIDS was started. Afterwards, I walked among the prisoners with a wireless microphone to answer questions. I was amazed by their carefully phrased questions, which were more pertinent than those of my colleagues at medical conferences. AIDS and tuberculosis were not merely theoretical issues here, as they saw healthy looking men begin to sicken. People dying before their eyes was an ordinary event.I soon realised that the "just say no" approach would be a fantasy for them, and in the end decided to emphasise three factors:1) Solidarity with the sick. AIDS does not spread by casual contact.2) Without condoms HIV is transmitted from men to women, from women to men, and between same-sex partners.3) Everyone who injects cocaine will get the virus. If you cannot face life clean, sniff it or smoke it, but do not inject it.This last message was delivered after the others, because it generated a wave of applause and whistles that created a festive atmosphere for my exit. It did not take me long to conclude that the warm reception at the end was the first symptom that crack cocaine was becoming a new fashion that would rapidly displace needles.As a result, injectable cocaine completely disappeared from the jail. Shooters were seen by the prisoners as unreliable individuals capable of transmitting the virus within their own communities. Over a period of years, the guards seized no syringes at all. The addictive power of crack cocaine invaded the jail and imposed its implacable laws upon the crowd of users.A study we did in January, 1994, reflected the new tendency: 105 of 780 inmates tested (13·7%) were HIV-positive; 310 (41%) were HCV-positive. Multivariate analysis showed independent risk factors to be: 1) age less than 29 years; 2) previous incarceration in Carandiru; 3) more than one sexual partner in the last year inside the prison; and 4) intravenous drug use before admission.The results identified a trend of slowing HIV dissemination behind bars. The inmates identified the educational programme as the main factor that influenced the observed change in behaviour. Unfortunately, the fundamental reason underlying this change was the substitution of an intravenous route for administering cocaine for an inhaled one. When we commented on the results to the prison director, he said, "See how life in jail is, doctor; even crack has a good side".Frequently, after the cinema session, sick inmates approached me in the corridors, complaining of fever, anorexia, weakness, weight loss, and pain. They had dermatitis, oral candidiasis, herpes zoster, enlarged lymph nodes, and tuberculosis. Impressed by the severity of their suffering in a facility where medical services were provided by fewer than ten unmotivated general practitioners, I decided to spare one afternoon of my private clinic to see patients in Carandiru, voluntary work that lasted 13 years and profoundly affected my personal life and the way I viewed the practice of medicine.The infirmary was a group of regular cells, painted sky blue, on both sides of a gallery. Each cell held a wrecked bed, a sink, a toilet, and a broken glass window with bars. Some patients were there to recover from surgery after shootings and stabbings or had orthopaedic problems, wounds caused by boiling water spilled over them by antagonists, and myriad dermatological problems. Others, debilitated by the endemic tuberculosis, wandered about spreading the Koch bacillus through the gallery. Wrapped up under cheap blankets lay feverish men with cachexia who were in the terminal phase of AIDS, with the resigned look in their eyes that death imposes when it comes at a slow pace.Helped by prisoners serving as nurses, I also started seeing outpatients from other pavilions. From noon until 1900 h or later, I examined from 50 to 70 patients. Trained for the era of technology, I was not prepared for that kind of old-fashioned clinical practice, armed with one stethoscope, a small bunch of medicines, and nothing more.Step by step I learned that incarceration makes men puerile and that treatment of prisoners requires paediatric wisdom. Many times, it was enough just to listen to their complaints or simply agree with the intensity of suffering they claimed to feel. The resentment reflected in their eyes was usually disarmed when I touched their bodies for auscultation.With the experience that repetition confers I gained confidence as a doctor, liberty to walk through the jail, spontaneity of manners to relate with the convicts, and a deeper understanding of the effect of my profession.After 7 years, I decided to write a book about how life was organised in that special environment, a task that took 3 years. Carandiru Station rapidly became a publishing success and inspired director Hector Babenco to make a film that was seen by almost 5 million people in Brazil alone.In November, 2002, all the prisoners were transferred elsewhere and Carandiru was imploded. Four public schools and a park have been built where it stood. It was dark and cold on First Avenue when I left the hospital and heard my name being yelled from the opposite sidewalk by a strange figure covered in a scarf and long coat. It turned out to be a Brazilian pianist who was living in New York. He took pity on my tropical clothes and invited me to dinner with a group of gay men. It was 1983, and New York was the epicentre of the HIV/AIDS epidemic in the Americas. I was 40 years old, and a visiting oncologist at the Memorial Hospital. While dining with those funny guys, I became convinced that AIDS in Brazil would turn into a tragedy. 6 years later I knocked on the iron door of Carandiru, a São Paulo penitentiary housing 7400 inmates, where I decided to make an educational video about how HIV was spreading there. As the door slammed behind me I felt the way I had at Sunday matinees during my childhood, when I watched black-and-white films starring men in uniforms behind bars. My voluntary work in Carandiru started with an inquiry into the frequency of HIV in 1492 prisoners enrolled in the Intimate Visit Programme, which permitted wives and girlfriends to visit the prisoners in their cells for intimate relations. Injectable cocaine was the most fashionable drug in the poorest neighbourhoods and inside the prison. The results showed that 17·3% of the prisoners were HIV-positive and that 58·0% tested positive for hepatitis C virus (HCV). Among 82 transgendered people, positivity was 78·0%. One inmate who reported more than 1200 sexual partners during the previous year, with whom he had had unprotected receptive anal intercourse, was HIV-negative. Intravenous drug abuse, age, number of sexual partners in the last year, and length of imprisonment were the most significant risk factors. All transgendered people imprisoned for more than 6 years were infected with HIV. Tests were done in São Paulo and all the results confirmed by the Cleveland Clinic Foundation. Based on the results, we devised an educational project, which acquired its final form after several modifications imposed by our experience in that aggressive milieu. The jail had seven pavilions, each five stories high, with cells holding from two to more than 20 men. Built in the 1950s as a pre-trial detention centre, it became a permissive house where one could find first offenders as well as criminals sentenced to decades of incarceration. The number of guards in charge was unbelievably low: a pavilion like number 8, which housed 1500 persistent offenders, usually had five or six unarmed guards on each shift. How so few could control such a mass of criminals was, for me, the deepest mystery of Carandiru. Cells were locked at 1900 h and opened the next morning at 0800 h. Prisoners were allowed to move freely around the pavilion and its yard, but prohibited to circulate outside of it, with the exception of convicts involved in work or those who had bribed the gate's guard. Every Friday morning, an experienced guard unlocked the door of the old cinema of Pavilion 6, which had been rebuilt after being burned in a previous riot, for the 300–400 prisoners designated to attend the talks given there. The rest of the doors were opened 20 min later so as to avoid accidents, as prisoners were safe inside their own pavilion, but beyond its limits their lives could be at risk. Friday's sessions with the doctor became very popular, and ran for almost 10 years without a single act of violence. They usually began with videos of popular singers projected onto a large screen. As the men gathered, the doors were closed and a video about AIDS was started. Afterwards, I walked among the prisoners with a wireless microphone to answer questions. I was amazed by their carefully phrased questions, which were more pertinent than those of my colleagues at medical conferences. AIDS and tuberculosis were not merely theoretical issues here, as they saw healthy looking men begin to sicken. People dying before their eyes was an ordinary event. I soon realised that the "just say no" approach would be a fantasy for them, and in the end decided to emphasise three factors: 1) Solidarity with the sick. AIDS does not spread by casual contact. 2) Without condoms HIV is transmitted from men to women, from women to men, and between same-sex partners. 3) Everyone who injects cocaine will get the virus. If you cannot face life clean, sniff it or smoke it, but do not inject it. This last message was delivered after the others, because it generated a wave of applause and whistles that created a festive atmosphere for my exit. It did not take me long to conclude that the warm reception at the end was the first symptom that crack cocaine was becoming a new fashion that would rapidly displace needles. As a result, injectable cocaine completely disappeared from the jail. Shooters were seen by the prisoners as unreliable individuals capable of transmitting the virus within their own communities. Over a period of years, the guards seized no syringes at all. The addictive power of crack cocaine invaded the jail and imposed its implacable laws upon the crowd of users. A study we did in January, 1994, reflected the new tendency: 105 of 780 inmates tested (13·7%) were HIV-positive; 310 (41%) were HCV-positive. Multivariate analysis showed independent risk factors to be: 1) age less than 29 years; 2) previous incarceration in Carandiru; 3) more than one sexual partner in the last year inside the prison; and 4) intravenous drug use before admission. The results identified a trend of slowing HIV dissemination behind bars. The inmates identified the educational programme as the main factor that influenced the observed change in behaviour. Unfortunately, the fundamental reason underlying this change was the substitution of an intravenous route for administering cocaine for an inhaled one. When we commented on the results to the prison director, he said, "See how life in jail is, doctor; even crack has a good side". Frequently, after the cinema session, sick inmates approached me in the corridors, complaining of fever, anorexia, weakness, weight loss, and pain. They had dermatitis, oral candidiasis, herpes zoster, enlarged lymph nodes, and tuberculosis. Impressed by the severity of their suffering in a facility where medical services were provided by fewer than ten unmotivated general practitioners, I decided to spare one afternoon of my private clinic to see patients in Carandiru, voluntary work that lasted 13 years and profoundly affected my personal life and the way I viewed the practice of medicine. The infirmary was a group of regular cells, painted sky blue, on both sides of a gallery. Each cell held a wrecked bed, a sink, a toilet, and a broken glass window with bars. Some patients were there to recover from surgery after shootings and stabbings or had orthopaedic problems, wounds caused by boiling water spilled over them by antagonists, and myriad dermatological problems. Others, debilitated by the endemic tuberculosis, wandered about spreading the Koch bacillus through the gallery. Wrapped up under cheap blankets lay feverish men with cachexia who were in the terminal phase of AIDS, with the resigned look in their eyes that death imposes when it comes at a slow pace. Helped by prisoners serving as nurses, I also started seeing outpatients from other pavilions. From noon until 1900 h or later, I examined from 50 to 70 patients. Trained for the era of technology, I was not prepared for that kind of old-fashioned clinical practice, armed with one stethoscope, a small bunch of medicines, and nothing more. Step by step I learned that incarceration makes men puerile and that treatment of prisoners requires paediatric wisdom. Many times, it was enough just to listen to their complaints or simply agree with the intensity of suffering they claimed to feel. The resentment reflected in their eyes was usually disarmed when I touched their bodies for auscultation. With the experience that repetition confers I gained confidence as a doctor, liberty to walk through the jail, spontaneity of manners to relate with the convicts, and a deeper understanding of the effect of my profession. After 7 years, I decided to write a book about how life was organised in that special environment, a task that took 3 years. Carandiru Station rapidly became a publishing success and inspired director Hector Babenco to make a film that was seen by almost 5 million people in Brazil alone. In November, 2002, all the prisoners were transferred elsewhere and Carandiru was imploded. Four public schools and a park have been built where it stood.