key: cord-319900-16osnnga
authors: Arcadepani, Felipe B.; Tardelli, Vitor S.; Fidalgo, Thiago M.
title: The SARS-Cov-2 threat in Cracolândia, an open-air drug use scene in Brazil
date: 2020-07-02
journal: Int J Drug Policy
DOI: 10.1016/j.drugpo.2020.102835
sha: 
doc_id: 319900
cord_uid: 16osnnga

nan

The coronavirus SARS-Cov-2 has recently emerged as a global emergency, with fast worldwide dissemination. It is transmitted by respiratory droplets and contact route in the asymptomatic and symptomatic phases (2) . Due to this transmission dynamic, gatherings of people contribute to the spread of the virus and are strongly discouraged by health policy agencies.

Substance use disorders have historically posed a heavy societal burden, endangering individual and family health and well-being, spreading through communities, and using resources of the health care system. These disorders are common in the general population and are a public health concern (1). Furthermore, this population is especially vulnerable to infectious diseases and deserves closer attention in the current pandemic (3). Open-air drug scenes raise an additional challenge as they bring together a large amount of people in poor sanitary conditions, maintaining or even expanding the current pandemic.

In Brazil, there is "Cracolândia", a place in the central region of São Paulo. It is the oldest and most densely populated open-air drug scene in Brazil, with 500 residents and more than 2000 regular visitors (4) . Other metropolitan areas of the country also present their Cracolândias, which makes them a national problem. They are characterized by crowded gatherings of people in highly vulnerability situations; a scenario with great potential for the spread of SARS-Cov-2. To make matters worse, people in Cracolândia live with deplorable hygiene conditions, some with restricted access to water and soap or other forms of decontamination.

Furthermore, drug use occurs in places such as tenements and hotels in the area with poor ventilation and sometimes no proper sewage treatment, in a setting with several people close together in small spaces. A reflection of that is the high prevalence of tuberculosis among this population (5) . Individuals also share straws and pipes to use cocaine and crack cocaine, possibly promoting the spread of infectious diseases such as viral hepatitis. Many of them also engage in sexual risk behaviors such as exchanging sex for money, which increases the risk of sexually transmitted infections including syphilis and HIV (5) . All these issues make these individuals a high-risk group for infected by SARS-Cov-2 as they present several clinical (including pulmonary) comorbidities and social conditions that, besides posing difficulties for disease prevention, may play a role in hampering their immunological responses and general health. The population living or frequenting outdoor scenes lack adequate support from the Brazilian Public Health System, and the current pandemic adds more urgency to specific policies to address their susceptibility to this and other diseases. Actions that enable primary hygienic care for this population must be implemented. Encouraging people to seek public shelters is one of these measures. It is essential, however, that these places offer adequate sanitary conditions, which has been reported as a problem in some public shelters in Brazil. Many of the people living in the cracolândias may not be aware of the magnitude of the pandemic and may not be familiar with the risks to which they are exposed, as well as the simple measures that they could put into practice to protect themselves and to minimize the spread of the virus.

Providing this information in a manner specifically designed for this population might be a simple cost-effective intervention that could yield fruitful health impacts if combined with housing policies. Brazil has needed a comprehensive housing-first policy based on solid harm-reduction principles for a long time. A pandemic that requires social isolation, especially for high-risk populations, turns this existing necessity into an emergency measure, taking into account basic public health principles and human rights.

Finally, another vital front of action is providing health care for this population, especially for people with any respiratory symptoms and those willing to quit or control their substance use. Health care facilities must provide treatment for their clinical comorbidities, focusing particularly on primary conditions such as hypertension and diabetes, which may be highly underdiagnosed among people who frequently use crackcocaine and are highly vulnerable to severe cases of COVID-19. Respiratory and pulmonary conditions such as tuberculosis should also be a priority in this period.

Vaccination against influenza is another simple measure that can be used to protect individual and public health. Along with clinical care, it is essential to offer mental health treatment, focusing on substance use disorders and psychiatric comorbidities.

Other harm reduction strategies should be used for those individuals who refuse to go to a healthcare facility and decide to stay in the cracolândias. Providing hand sanitizer and soap, taking vaccines to the drug use scenes and proceeding with vaccination there, providing disposable individual-use pipes and needles, and explaining the importance of not sharing pipes, straws, and needles are just some examples of simple but highly cost-effective initiatives.

Perceiving the risk and making resources available to a marginalized population such as Cracolândia's is in line with the harm reduction approach, which can be controversial and challenge society and politicians' ideas and beliefs. Times of exception like wars and pandemics have the potential to precipitate the development of technologies and solutions that accelerate social progress. This already vulnerable population is now at an even higher risk than ever and may suffer severely from the consequences of SARS-Cov-2 if not given the attention they deserve during this pandemic. This is not just about health; this is about humanity.

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