A síndrome da exclusão social: As origens, os fatores de risco, os múltiplos sintomas biopsicosociais ao longo dos períodos do ciclo de vida e os fatores perpetuadores

Abstract

Introduction: This project started when I was still a medical student, and began to observe that underprivileged children got sick in a diffuse way, that is, various systems of their organism were affected simultaneously, including mental health. These observations continued in residence and in the practice of pediatrics, and later, in a child psychiatric outpatient clinic, where I found that, besides the diffuse sicknesses, the children were referred to the clinic mainly because of school difficulties. I decided that this thing should be dealt with in primary care, therefore, in the community and not in secondary care, as in the case of child psychiatry outpatient departments. Since then, I have been working in primary care where I did my first masters research in an underprivileged community. The objective was to describe the biopsychosocial profile of children who were in first grade, since, at the time (1990), many of them failed the school year and often dropped out of school at this grade. In this research I used the Case Study method and 39 children of the first grade in a public school were examined, chosen randomly out of 465 students in this grade. The findings showed that, before joining school, most of the children in the sample were exposed to multiple risk factors; on entry into first grade, most of them had been impacted in multiple aspects, thatis, in their physical, psychic and social health, and their families had many problems; three years later, in 1993, the children from the sample had been affected in their schooling. This study, therefore, contributed to the understanding of the causes of failure and school dropout from the point of view of child medicine. Justification: After the research above, which was the basis for intervention projects, I continued to work in the community. However, as I learned more of the local reality, I found that the school problems in general were no more than the symptoms of thephenomenon of social exclusion, a historical process which involved the people from the community. These observations reached into the first year of this decade when I decided to revisit my masters degree work and to check the participants in the 1990 survey who are adults today.Objectives: The objectives of this new research were to study the bio-psychosocial impacts of the social exclusion process on a group of people at different stages of their life cycles. Methods: The method chosen was Case Study and had two parts. The first part was reworking the masters dissertation and reinterpreting it from the point of view of pediatric psychiatry and child development theories, using the backdrop of social exclusion. In part two (2008), 26 interviews were held with 39 of the participants of the 1990 survey. This second part used open interviews, followed by a semi-structured interview to survey their life history. Only a few topics of the history of each one were surveyed: their school trajectory, their work and health problems during the 18 years between the two surveys. Results and Discussion: The analysis and interpretation of the reworking of the masters dissertation showed how the social exclusion process may have produced the multiple impacts found in the 1990 survey. The current survey showed that the exclusion process continued to adversely affect the subjects of the sample, since negative impacts were identified on the school trajectory, the work trajectory and the various psychic reactions to stress situations experienced throughout the life of the participants, resulting in enormouslosses in social inclusion of the individuals of the sample. Besides this, it is probable that this history of defeats also damaged the psychic structure of these people. However, during the interviews, other relevant factors stood out, according to spontaneous reports of the participants. For example, a significant number of people in the communityinvolved with drugs and/or drug trafficking were murdered or imprisoned. It became clear that a critical period in the life cycle, adolescence, provided a background which opened up the community for the multiplication of the use of drugs. In the first place, it was a real opportunity to increase income for people who faced difficulties for social inclusion; secondly, for people who had been impacted psychically, resulting in frustration, anxiety, depression, anguish, anger, drugs could be a way of relieving the symptoms and emboldening the users.If, on the one hand, drug trafficking led to struggles for opportunities to increase sales, on the other, drug dependence made individuals steel, rob, sell family belongings to buy drugs. Both brought violence into the community, which ended up in deaths and imprisonment on a significant scale. The arrival of drugs in a community which was the victim of socialexclusion brought about self-extermination to a significant part of the community made up of young people. In other words, social exclusion prepared a scenario of adversity for the entrance of drugs, which accelerated the exclusion process by ending the life of a large number of young people from the community. Conclusions: With this study, it was possible to identify possible origins of social exclusion and its association to many risk factors which may have produced the multiple biopsychosocial impacts on the population studied in the various periods of the life cycle. The discovery of a process that evolves and is articulated justified the name Social Exclusion Syndrome for the situation described. This name fills a gap in the literature for the definition of this frequent clinical situation, which is still treated with a lot of indifference.This definition gives greater consistency and visibility to the phenomenon by showing how social determinants can produce devastating impacts on health and between generations. At the same time the name can also attract the attention of various areas of knowledge for a better understanding and a better approach. Final considerations: this study indicates paths for intervention, prevention and health promotion. By describing the evolution of the effects of social exclusion of the subjects at different stages in their life cycle, the phenomenon became better understood and, therefore, more open to transformation.