text:
Leandro David Wenceslau and Francisco Ortega
Urban mental health and the moral economies of sufferingin a 'broken city'
Reinventing depression among Rio de Janeiro urban dwellers
in Urban transformations and public health in the emergent city
Recent epidemiological surveys have shown an important prevalence of depressive and anxious symptoms in the Brazilian population, especially in its urban metropolises. In the past two decades, primary health care in Brazil has increased its coverage, becoming the main reference in public mental health care. Social determinants of mental suffering represent a challenge for patients and professionals in search of more comprehensive approaches to mental health. This chapter presents an ethnographic study conducted in the city of Rio de Janeiro with twenty-two patients who presented depressive symptoms and were treated in primary health care. Primary care physicians used the native categories of 'hill' and 'asphalt' to typify the patients´ depressive presentations. This categorisation has important consequences for the diagnosis and treatment of these symptoms. 'Hill' and 'asphalt' are analysed as 'moral economies' (Didier Fassin), and their meanings are contrasted with the individual therapeutic experiences of two patients. The singularities of these experiences evince that even approaches based on a broader understanding of these problems may hinder a comprehensive approach to the patients' suffering experiences in those expanding therapeutic scenarios.
Urban living is frequently regarded as a source of both benefits (e.g. access to public services and labour market) and risks (e.g. violence and pollution) to its inhabitants. The so-called urban paradox (Iossifova, Doll and Gasparatos, 2018) has engaged researchers from different disciplines interested in how urban dwellers cope with life in cities and whether, and in what conditions, the benefits outweigh the risks. In urban health research it is no different. While city living is associated with health hazards resulting from risk factors in the urban social or physical environments (Grant, 2018; Grant et al., 2009; Kjellstrom et al., 2007), it is also associated with better access to health care, education and employment (Gruebner et al., 2017).
Several studies show a negative correlation between mental health and urban living. Mood and anxiety disorders are more prevalent among city dwellers (who have a 40 per cent increased risk of depression and more than 20 per cent for anxiety) than among residents of rural areas, and there is a higher risk of schizophrenia for people who grew up in cities in comparison to rural areas (Peen et al., 2010; Krabbendam and van Os, 2005; van Os, Pedersen and Mortensen, 2004). In Brazil, a nation-wide study of depression shows a 50 per cent higher prevalence among individuals living in urban areas (Munhoz et al., 2016).
While city–rural comparison constitutes one area of study in urban health research (the other two being comparisons between cities and within cities: see Galea and Vlahov, 2005), in this chapter we are more interested in differences within cities, and more specifically we explore the care offered to people with depressive symptoms in primary health care facilities in the city of Rio de Janeiro.
Among the risk factors for mental health originating from the urban social environment, the concentration of low socio-economic status is the most important and shows the most consistent association. Poverty and deprivation are associated with greater risk of depression and schizophrenia (Galea et al., 2007; Rapp et al., 2015). Moreover, urban inequity is related to levels of insecurity and violence in cities, factors that directly influence mental wellbeing (Stephens, Carrizo and Ostadtaghizaddeh, 2016).
Brazilian cities exhibit high levels of urban inequity, and results from the São Paulo Megacity Mental Health Survey statistically associate those living in areas with medium and high levels of income inequality with increased risk of depression relative to those living in areas with low levels of income inequality (Chiavegatto Filho et al., 2013). Moreover, according to the Brazilian National Health Survey, in 2013, the proportion of Brazilians who did not receive any treatment for depression was 78.8 per cent, while 14.1 per cent received only pharmacological treatments. Access to care is scarce and above all unequal, with poor people and those living in low-resource areas having less access to mental health care than other people (Lopes et al., 2016). Beyond the problem of access, there are several reasons for the limited engagement with mental health care among low-income populations. These include the failure to acknowledge that one has a significant problem, the belief that the disorder will resolve itself spontaneously, a desire to deal with the problem by oneself or not knowing where to search for help, a perception that the treatments available are not efficient or are deleterious, and stigma-related barriers (Silva et al., 2013: 288; Van Beljouw et al., 2010; Thornicroft, 2007; Corrigan, 2004).
Understanding these disparities is an important aspect of developing effective mental health interventions, but so is rejecting 'one-size-fits-all' approaches. Global Mental Health initiatives recognise alternative, community-based and culturally sensitive approaches from low- to middle-income countries, and reject standardised approaches to treating depression and other conditions (Patel and Saxena, 2014). And yet there is an important tension between the need for locally appropriate and participatory approaches on the one hand, and on the other the dismissal of those approaches and interventions when they fail to match the standards of evidence-based practices and interventions, particularly efforts to 'scale up' and generalise those interventions (Ortega, 2018).
Conditions like depression, with which we deal specifically in this chapter, have socio-economic and environmental determinants for wealthy city dwellers which differ from those for people living in low-income neighbourhoods or urban refugees. Depression can have different manifestations for these individuals, and therefore approaches by mental health professionals have to be differentiated (Stephens, Carrizo and Ostadtaghizaddeh, 2016). These differences call for socially attuned interventions and policies that address the specific cultural and mental health needs of urban dwellers (Caracci, 2006).
Brazil can be considered the country with the highest prevalence of common mental disorders in the world, with the second-highest prevalence of depressive disorders in Latin America (5.8 per cent) and the highest prevalence in the world of anxiety disorders (9.3 per cent) (World Health Organization (WHO), 2017). The São Paulo Megacity Mental Health Survey has shown that this scenario is even more serious in the larger Brazilian urban centres, with a prevalence of 19.9 per cent for anxiety disorders and 11 per cent for mood disorders (9.4 per cent for major depressive disorders) in the Metropolitan Region of São Paulo (Andrade et al., 2012).1 In addition to the global controversies surrounding the diagnostic criteria of mental disorders and the epidemiological instruments used to measure them, these data point to the significant levels of moral, emotional and social suffering among residents of the Brazilian metropolises. This suffering is associated both with difficulties in their social life and with a lack of capacity to manage other health conditions, especially chronic conditions such as diabetes, obesity, hypertension and chronic respiratory diseases. This chapter focuses on the sociocultural processes and social determinants involved in engendering this urban landscape of suffering, and the local responses to these difficulties within public health services.
'Hill' and 'asphalt' in Rio de Janeiro
Rio de Janeiro is the second largest city in Brazil, with more than 6 million inhabitants. The city has experienced varying fortunes in recent years, from hosting international mega-events such as the 2014 FIFA World Cup and the 2016 Olympics to being one of the main victims of the political disputes that since 2014 have created a serious economic crisis in Brazil. Paradoxes and social divisions permeate the social organisation of the Rio de Janeiro population, which has been studied in the last few decades mainly through the lens of the divide between 'hill' and 'asphalt'.2 Comparing the reactions of different social strata of the city to an arrastão – a series of simultaneous assaults carried out on a beach in Rio de Janeiro – the Brazilian journalist Zuenir Ventura described Rio de Janeiro in 1994 as a 'broken city' (Ventura, 1994). The spatial and housing division is associated with differences in income and access to social rights. In Rio de Janeiro, this division takes on a particular character, because of its peculiar territorial overlap – given the geographical proximity between the 'hills' and the more urbanised areas of 'asphalt' below – and the intense social conflicts resulting from the structural violence produced by social inequality and armed violence catalysed by illegal drug trafficking.
While other cities, such as São Paulo, could be viewed as 'surrounded cities' because of the peripheralisation of poverty, in Rio de Janeiro luxury buildings are situated within a few blocks, or even metres, of hills lacking even basic sanitation, with low income and educational levels. Between 1996 and 2008 the Gini coefficient for social inequality remained stable in Rio de Janeiro and poverty levels actually increased, in contrast to the picture at the national level, where both poverty and inequality rates reduced during this period (Neri, 2010).
This chapter analyses recent transformations in public mental health care in Rio de Janeiro from an ethnographic perspective. At the heart of these transformations was the significant expansion of the Family Health Strategy (FHS) – the primary health care model within the Brazilian universal public health system (SUS in Portuguese) – within the city (Paim et al., 2011; Macinko and Harris, 2015). In 2009 less than 7 per cent of the population in Rio de Janeiro City was assisted by a family health team. In December 2017 the proportion had risen to around 70.6 per cent. In absolute numbers, this means that, over eight years, approximately 4 million additional residents were absorbed into the FHS system (Ministério da Saúde, 2016; Prado Junior, 2015; Harzeim, 2013). This care includes mental health approaches and initial therapeutics offered by a general practitioner, especially for the most prevalent disorders: depression, anxiety and/or use and abuse of alcohol, tobacco and other drugs. Alongside the expansion of primary care coverage, the municipal health secretary instituted Family Medicine as the largest Brazilian programme of medical residency (currently with 150 positions), in addition to supporting the expansion of programmes in other institutions. In 2010 Rio de Janeiro had sixteen yearly residency positions for Family Medicine. By 2016 that number had increased to 202 (Soranz, 2014).
One of the authors of this chapter (Wenceslau) worked as a family physician in Rio de Janeiro City in 2013 and identified, through informal conversations and in his daily work routine, the presence of discourses and practices among FHS professionals that sought to integrate social and cultural influences into their diagnosis and proposed treatment of individuals dealing with mental illness. To the health care professionals, there were differences both in how mental issues were presented (that is, the narratives and behaviour of patients and family members) and in their causes between those living in the 'hill' and those in the 'asphalt'. Thus we developed an exploratory ethnographic study in order to evaluate how this division was used to both understand and address mental suffering among the Rio de Janeiro population.
In order to carry out the study, we selected a family health unit in the north zone of Rio de Janeiro responsible for the care of approximately 25,000 people, comprising eight teams and covering areas both in the 'hill' and in the 'asphalt'. The unit was located in a middle-class neighbourhood, whose social development index ranked between the tenth and twentieth highest of the 158 neighbourhoods in Rio de Janeiro (Cavallieri and Peres Lopes, 2008). We interviewed thirteen Family Medicine physicians and, of these, selected six to be followed for three months, through participant observation of their activities during consultations, home visits and work meetings. During this period, we also interviewed and closely followed the assessment and treatment of twenty-two patients, twelve of whom lived in the 'hill' and ten in the 'asphalt'.
We also chose to work with a 'mental health problem' lens, a native category, used by Family Medicine physicians in order to group together the most common accounts and manifestations of suffering that they designated as 'mental'. In view of the setting, a public primary health care facility, we focused our investigation on how 'depressive symptoms' were addressed. Among the most common mental disorders, depression and anxiety are considered the most prevalent in the general population and in primary care (Lim et al., 2018; Steel et al., 2014), with depression being the single largest contributor to non-fatal health loss (WHO, 2017). Studies and documents that guide the integration of mental health into primary health care establish that its professionals may and must be capable of identifying and offering resolutive care to patients with mild and moderate depression and also of recognising and following, with specialised mental health care, more severe cases (WHO and World Organization of Family Doctors (WONCA), 2008; WONCA, 2018; WHO, 2016; Wahlbeck, 2015).
In the FHS, professionals are distributed in teams that are each responsible, on average, for 3,500 to 4,000 people (Ministério da Saúde, 2012; Ministério da Saúde, 2017). The six physicians we followed were members of four different teams. We were able to identify an initial repercussion of the division between 'hill' and 'asphalt', as defined by these teams. Among the four teams we followed, one was dedicated exclusively to the poorer community in the region, while the other three were responsible for the middle-class population. The professionals themselves referred to the poorer community as the 'hill' and to the middle-class population as the 'asphalt'.
To these professionals, there were important differences between the depressive symptoms of these two populations. In the interviews, they stated that the 'hill' population was unlikely to present isolated cases of depression, rather presenting mixed experiences of depressive and anxious symptoms and important bodily manifestations (such as diffuse pains, dizziness and fatigue). Patients from the 'asphalt', on the other hand, in the view of the physicians, presented more typical cases of depression, characterised by symptoms of profound sadness and withdrawal from social interaction.
Health care professionals also acknowledged the importance of social determinants in the production of depressive symptoms and in their evolution. According to them, in the 'hill' people lived more 'within networks', and, as a result, the sorrows and suffering they experienced received greater care from the community, leading those individuals to present manifestations and accounts viewed as 'depressive' less frequently. These 'networks', which worked as mechanisms for social protection and care, were made up of the close supportive relations between neighbours and by the social interaction within different community institutions, such as Evangelical churches, centres of Afro-Brazilian culture and religion, and artistic-cultural associations, such as the community's samba school. On the other hand, the 'asphalt' population had little in the way of networks, with few relationships between neighbours, distance from family members and low participation in other spaces of social interaction.
In the professionals' perception, the depressive symptoms experienced by 'asphalt' inhabitants manifested the social isolation and financial decline that frequently affected them and that recurred among the older segment of this population. The fact that, over the course of their lives, this population was less exposed to social stressors, such as poverty and violence, had, according to the health professionals, rendered the inhabitants 'less resilient' and more susceptible to the development of depressive symptoms when faced with difficulties that, on the other hand, were part of the 'hill' population's everyday lives (for example, unexpected deaths of relatives or friends, lack of food, inadequate housing). However, despite being 'more resilient', when presenting depressive symptoms the 'hill' population did so more intensely, with many bodily manifestations, including frequent incidences of 'syncope' (fainting), as a result of the disruption of nearly all of their social bonds.
To the physicians, 'somatisation' in cases of depression was more common among 'hill' inhabitants than among 'asphalt' inhabitants. This perception is connected with an intense and protracted debate within anthropological studies which, directly or indirectly, has analysed the expansion of public mental health care, including the field's most recent iteration, Global Mental Health (Patel and Prince, 2010). Since the publication of a number of important transcultural psychiatry works such as 'Depression, somatization and the "new cross-cultural psychiatry"' (Kleinman, 1977) and a number of seminal ethnographic studies in various countries – including work on 'nerves' and 'nervousness' in Brazil (Duarte, 1986; Duarte, 1997) – there has been a discussion surrounding the hypothesis that depressive symptoms, especially among lower-income groups or less industrialised populations, could present themselves predominantly as physical or bodily grievances, as local idioms of distress or even as certain culture-bound syndromes (Kleinman and Good, 1985; Jenkins, Kleinman and Good, 1991). This hypothesis was strongly disputed by authors such as Abas et al. (1994) and Patel (2001; Patel et al., 2001), who pointed both to the importance of the presentation of depression through physical symptoms among more elite and industrialised populations and to the identification of psychological manifestations through 'culturally adapted' questionnaires in less Westernised groups. However, controversies remain with regard to the existence of a set of symptoms, however varied in their composition, that can be seen to globally represent a case of depression: critics point to the risk of incurring a categorical fallacy, that is, a selective recognition of manifestations and phenomena produced by the interest in identifying a certain category within a certain social and cultural universe (Haroz et al., 2017; Kirmayer, Gomez-Carrillo and Veissière, 2017). The different perceptions of depressive symptoms among doctors and patients from the 'hill' and those from the 'asphalt' observed in this research are an example of the difficulties in establishing such a pattern.
Therapeutic approaches: 'social networks' and 'patient-centred' consultations
The perceived differences between manifestations of depressive suffering among people from the 'asphalt' and among people from the 'hill' were also translated into distinct emphases in proposed treatments and care, especially through non-pharmacological interventions. The acknowledgement of a 'lack of networks' as one of the main causes of depression in the 'asphalt' led professionals to insist strongly on offering 'unit groups' to those patients. 'Unit groups' were social activities led by health professionals for the purpose of offering spaces for social interaction and learning, such as the 'dance group', 'crafts group', 'wellbeing group' and other, more psychotherapeutic groups, such as the 'cuca fresca' (cool head) group and the 'mental health group', conducted by psychologists. Members of the 'asphalt' population were also more frequently referred for individual psychological assessment and more likely to 'join the queue' for medium- and long-term psychotherapeutic care.
Evaluation by a psychiatrist from the 'matrix support team' was also commonly suggested to the 'asphalt' dwellers by physicians.3 Many of these patients had at one point had better financial circumstances and had not previously used the public health system, but rather private insurance that does not, generally speaking, include primary care services. However, because of crises and changes in their financial situations, they found themselves forced to migrate from private insurance to the public system. Thus the 'asphalt' dwellers, accustomed to the specialised services of private insurance companies, would often come to their appointments with the aim of being referred to a psychiatrist or psychologist, without expecting or desiring that a family physician evaluate or in any way attempt to treat their 'mental' needs. Among these patients, there were doubts concerning the capacity of a doctor who is not a psychiatrist to diagnose and treat mental health conditions.
For the 'hill' population, we observed that the Family Medicine physicians would more frequently use a series of consultations that they described as following a 'person-centred clinical method' (Stewart et al., 2014). These were encounters consisting of dialogues with a therapeutic goal in which the family physician would first encourage the patient to freely describe their experiences. Next, through open questions, they sought to help the patient to promote changes in their practices and behaviour that might reduce their suffering and deliver lasting improvements to their wellbeing.
The use of antidepressant medication was a common therapeutic resource among both populations, but for different reasons. According to the professionals, 'asphalt' patients demanded pharmacological treatments more frequently for two reasons. As previously stated, these patients would often seek public services because of financial downturns and, in many cases, had already begun medication treatments that had been previously prescribed by private doctors and that could not be interrupted. Additionally, in the view of the doctors, because of their 'low resilience', these patients had difficulties in overcoming depressive symptoms, even low-intensity ones, without medication. Among the 'hill' dwellers, those who sought a health service because of mental suffering did so only in severe cases, making cases of depression in the 'hill' less frequent but more severe and in greater need of pharmacological treatment.
Contact with health professionals strengthened the hypothesis that differences could be drawn between 'hill' and 'asphalt'. These involved different causes, presentations and approaches to depressive symptoms among the two populations. In order to describe these phenomena from diverse local perspectives, in addition to using the professionals' accounts, we also investigated the experiences and behaviours of the patients themselves, exploring their perceptions of their own suffering through interviews and visits to the 'hill' and 'asphalt' territories, and by following consultations. However, when studying these experiences through the perspectives of the patients, we identified limits and problems, which are described below, derived from the use of the 'hill'/'asphalt' categorisation as a way of interpreting depressive suffering of people living in a 'broken' metropolis such as Rio de Janeiro. These difficulties are illustrated by the cases of 'Raquel' and 'Pedro' (fictitious names).
'Raquel'
Raquel was a short twenty-seven-year-old black patient with close-cropped dark hair. She lived in the 'hill' and worked as a groomer at a pet store. In the first consultation we followed, she described having constant thoughts of killing herself and hearing 'voices' whose contents she was unable to identify. She lived in a small house that had two bedrooms, one for herself, the other shared by her nine-year-old daughter and sixteen-year-old son. According to Raquel herself, she had depression 'once again'. She had no desire to leave her room, where she spent most of her time alone, lying down and crying a great deal. In addition to her suicidal thoughts, Raquel recounted the need to make small cuts on her arms in order to reduce her unease when it became more intense. Among the thoughts that troubled her were her many concerns regarding her sixteen-year-old son, 'Diego', diagnosed with schizophrenia when he was ten years old, in addition to memories from a period when she lived through an aggressive marriage and the fact that she greatly missed her mother, who had passed away six months previously. She did not usually cry during consultations. Reacting to the questions posed by her physician, she alternated between looking at him and looking straight ahead while she narrated what she was feeling and thinking:
I know I have depression and I want to get better. I know I have two children and they need me, I don't have relatives, I know I have this disease, I'm aware and I want treatment. I heard there's no cure, but there is a treatment. Depression is this sadness, like, I can't control myself when I have to cry. I just have to cry. Things don't have a solution for me. When the depression is strong, it makes you want to kill yourself. Because, like, I think death is rest. Since I lost my mother, maybe I'm like 'am I going to meet her? Or not?' But then my children are the reason for me to stay. I think if I didn't have them I would have already killed myself.
Raquel stated that she had had 'depression' crises since she was eight years old. The first episode was associated with her father's death, when she attempted suicide by taking multiple diazepam tablets. Since then, she had had similar episodes associated with specific circumstances in her life. She was divorced, but for eight years she had been trapped in a marriage in which there had been many infidelities and she had been assaulted by her husband. It took her years to leave her husband because of conflicts with her religious practices: at the time, Raquel was an Evangelical Christian. Two years previously, she had managed to leave that relationship, had stopped being an Evangelical Christian and had begun to care for her children in the house she shared with her mother.
The crisis period we followed had been triggered by her mother's death, which had taken place six months before we met her. Though some time had passed, Raquel's feelings of mourning for her mother were now intensifying. Her medical practitioner began treatment with antidepressants, in addition to an anxiolytic, clonazepam, in order to stimulate sleep until the antidepressants began to have an effect. Over the course of that same week, there were two follow-up consultations, in which the physicians was particularly concerned with evaluating the suicidal thoughts and the continued presence (or lack thereof) of the 'voices'. He also sought to promote therapeutic conversations based on a 'person-centred' approach, trying to encourage Raquel to return to activities that were good for her, such as practising jiu-jitsu.
The following week, Raquel returned for an unscheduled consultation. During the weekend, Diego had attempted sexual contact with his younger sister. Raquel became anxious and upset and did not know how to deal with this situation. She communicated the situation to Diego's father, who repeated what he had done in other situations when their son had exhibited violent behaviour: Diego was beaten as punishment for what he had done. According to Raquel, his father was the only person Diego respected, and physical aggression was the most efficient way to calm him down and make him change his behaviour. Diego was also followed by the same medical practitioner, in partnership with the 'matrix support' psychiatrist. He was medicated, but in light of this new fact, it was decided that Diego should again be referred to a Centre for Psychosocial Care (CAPS in Portuguese).4 Though anxious and upset with Diego's situation, in that second week, Raquel reported that her depressive symptoms had already improved and that she had returned to work.
Over the course of the next three months, Raquel's 'depressive crises' occurred every three to four weeks. Taking care of Diego became harder, and she had to deal with the realisation that schizophrenia is incurable and can become more severe. Raquel was living through a confusing period, torn between whether or not she desired to have a child in her new relationship. Finally, she had been able to begin individual, biweekly psychotherapeutic sessions. The frequent consultations with the family physicians and the use of medication also continued. Of the three types of medication, she stated that clonazepam was the most helpful, both because it helped her sleep and because, according to her, it reduced her 'tensions' and 'nervousness'. She evaluated the medical care she received as very good and stated that both her physician and the 'matrix support' psychiatrist always welcomed her, talked to her at length and gave advice and guidance for Diego's care, which was sometimes better than what she received at the CAPS. In our last contact, she told us that, for the first time, Diego's father had gone to talk with the CAPS psychologist, something she believed was important because she felt that the father needed to understand Diego's problem better and to be more involved in his treatment.
'Pedro'
Pedro was a tall seventy-three-year-old white man. Born in Chile, he had lived in Brazil for over forty years. He lived in an apartment in a middle-class building in one of the main streets of the 'asphalt'. It was not a luxury building: it did not have a doorman, and the façade was old and worn. We were welcomed by Pedro and his wife, 'Laura', who was seventy years old and also Chilean. The couple were the only two residents of their apartment. When we asked what their biggest health complaints were, Pedro answered:
What worries me most is the debts that come every month and that I can't pay entirely. My son helps me to pay them. This even affects food. Sometimes there's not enough food in our home. The standard of living we used to have is totally different from the standard of living we have now. We could go out to eat every week, we could buy new clothes, gifts for our granddaughters on their birthdays, but we can't now. All of this affects us, hurts us. Before, our granddaughters would come over on the weekend and the fridge would be full. Now, they don't come any more, because the fridge is empty. It gives me anguish, sadness, anger, and it makes me upset. I get up in the morning and to this day I'll go take a shower thinking I'm going to work. But then it hits me.
Pedro was a retired engineer, but his income was not enough even to pay the rent. Until three years before our meeting, he had done freelance work for an important Brazilian state company. With the financial crisis that hit the state of Rio de Janeiro, these work opportunities disappeared and, even though he was retired, he found himself 'unemployed'.
One of the effects of the financial crisis that caused most suffering for Pedro and his wife was the loss of contact with their granddaughters. Their only son was in a better financial situation and frequently helped them with their expenses. However, they had problems with their daughter-in-law, who ever since they had gone into debt had, according to them, distanced herself from them and made it difficult for them to contact their two granddaughters, aged five and seven.
Pedro attributed his sadness and anger to the fact that he was unable to get work. He then stated that he was even looking for 'menial' work. However, in addition to the difficulty caused by his age, he was unable to find employment opportunities because of the serious political and economic crisis that has affected the state of Rio de Janeiro and Brazil as a whole since 2014. He also complained of weight loss. He lifted his shirt and showed us his thin body, visible bones and caved-in abdomen, stating that he had never seen himself in this condition before. He stated that he slept well but, upon waking, remembered all of his problems. He did not believe he ate poorly and claimed his appetite was normal. Because of this, he did not agree that his 'emotional state' had produced the weight loss. He was worried about his wife because he believed she was more intensely affected by their family problems than he was. He was dedicated to caring for her, even bringing her breakfast in bed every day.
Pedro had started treatment at the family health facility around two years before we interviewed him and was satisfied with the care he received from his medical practitioner. In particular, he mentioned the free examinations he had been undergoing in order to monitor his diabetes, his hypertension and a benign polyp he had in his gallbladder, in addition to the medication distributed free of charge. He wished to have an endoscopy in order to rule out a stomach ailment as a cause of his weight loss. He did not establish a clear connection between his weight loss and his 'emotional state'. To him, the 'emotional state' was connected to his 'finances'.
He was a chronic user of some other types of medication, in addition to those he used for his hypertension and diabetes. When he was 'nervous' and anguished, especially in the morning, he remembered his financial problems and took bromazepam, an anxiolytic tranquiliser, to calm down. He had always viewed himself as willing and happy to work, and he continued to feel this way. When asked whether he saw himself as having 'depression' or being depressed, he answered:
Depression is not wanting to do anything. I was reading on the Internet, it's the person who doesn't want to do anything, doesn't want to shower, sleeps too much and has other symptoms. I don't think I have depression. My emotional state is that of unemployment, I can't pay what I owe.
In addition to his home visits, we followed two of Pedro's consultations with his medical practitioner. After checking the results of his diabetes tests, which were stable, the physician would again ask Pedro how he was feeling and he would again state his sadness, his anger at his financial situation, his concern for his wife and his thoughts of 'feeling like a nobody', especially in the mornings. The Family Medicine physician explained that depression could present itself in ways other than a desire for isolation and a lack of interest in doing anything, and that antidepressants could relieve some of those symptoms, and could perhaps even make him feel more disposed to exercise and more inclined to eat a better diet, thus helping with his weight loss. Pedro had a routine check-up, which revealed that he had no issues besides the weight loss. During this appointment, Pedro agreed to begin taking the antidepressant fluoxetine. The physician then reinforced the suggestion that he take part in some of the 'unit groups' with his wife, and he answered that it was 'a possibility'. He said he would try, but that the schedule offered was not very convenient.
Over the following months, Pedro continued to fail to gain weight, and he did not participate in any of the 'unit groups', but, after some resistance, started taking fluoxetine. However, he complained that he still saw no improvement with regard to his weight loss. He was still unhappy with his 'unemployment' and was worried about his wife. He kept regular appointments with his medical practitioner, who, in turn, insisted that he participate in the groups.
'Hill' and 'asphalt' as moral economies
Raquel and Pedro were patients considered to have depression by their Family Medicine physicians. However, the ethnographic snippets we have presented, except for the shared mentions of sadness, point to so many singularities that stating that these two people suffered from the same 'mental disorder' becomes, as Goldberg (2011: 226) noted, a form of 'magical thinking'. Even sadness, mentioned by both, was experienced differently, and these differences could not be reduced to a variation in intensity. While for Raquel it was accompanied by suicidal impulses, for Pedro it was associated with anger and motivated him to want to keep on working. The bodily manifestations – the self-mutilation in Raquel's case, and Pedro's weight loss – were also different, pointing to distinct conceptions of corporeality. In both cases, the role of micro- and macro-social determination was so evident that it is difficult to frame the situation of these individuals in terms of mental illness alone or to regard their response to these circumstances as abnormal.
Some elements of their experiences corresponded in part to the illness profiles of the 'hill' and the 'asphalt' described by health professionals. In Raquel's case, the violent interactions with her former partner, her mother's unexpected death and her difficulties in accessing adequate care in the public health system for a son with a severe mental disorder caused her suffering. In Pedro's case, social isolation, financial crisis and family problems accounted for his wife's distress. However, certain important elements did not fit this categorisation.
Raquel experienced a certain degree of isolation within her community. She had expressed a desire to move because, living in the 'hill', she still interacted with people and places that reminded her of her previous relationship, which was marked by violent situations. In the three months during which we followed her, she would again have crises marked by suicidal thoughts, isolation and self-mutilation every three to four weeks, despite a care plan that involved continuous antidepressant use, frequent consultations with her Family Medicine physician and maintaining her jiu-jitsu practice and leisure activities with her family. At the end of the observation period, Raquel attributed an experienced improvement to starting individual psychotherapy.
Pedro did not match the profile of a 'non-resilient' man that was expected from an 'asphalt' resident. He was determined to work again, if it were possible. Although experiencing low self-esteem, he reported that he was anxious to solve his financial difficulties, and did not feel sick or depressed. For this reason, he did not expect the 'unit groups' to help him with his problems, but he missed having a closer relationship with his daughter-in-law and granddaughters.
Experiences such as Raquel's and Pedro's illustrate an observation that was repeated, in different levels of intensity, with the twenty-two patients we followed more closely in the field. The classification of 'hill' and 'asphalt' that was incorporated into health professionals' discourses and practices, as well as the interpretations and clinical approaches that derive from it, did not correspond to people's experiences, and sometimes even diverved from them. On the Family Medicine physicians' side, these divergent visions of suffering have repercussions, for example, in the evaluation of many 'difficult' cases in the 'asphalt' and in the recurring statement that patients in this area do not adhere to proposed treatments, especially those in the 'unit groups'. On the patients' side, there were accounts from 'hill' patients who felt that there was a lack of specialised mental health care; this was more frequently offered to 'asphalt' dwellers, who were sometimes regarded as 'health insurance migrants' and who at times did not establish good therapeutic bonds with Family Medicine physicians.
The moral dimension of the use of social categories such as 'hill' and 'asphalt' emerged as a fundamental question for an understanding of these different diagnostic and therapeutic approaches to depressive symptoms in these settings of public integral health care. For this analysis, we turn to Didier Fassin's proposal of a critical moral anthropology as a perspective for analysing contemporary health policies (Fassin, 2008; Fassin, 2012a; Fassin, 2012b; Fassin and Rechtman, 2009), in other words, analysing how 'hill' and 'asphalt' work as 'moral economies', defined as 'norms and values, sensibilities, and emotions' that may be 'rephrased as moral', although they are not, in their usual sense, perceived to be ethical or moral (Fassin, 2012a: 4, 10).
Addressing the relationship between morals and politics, Fassin proposes that moral issues may not be understood in isolation from political, religious, economic and social spheres of human activity. One of the great enigmas in the social sciences is precisely that of the articulation between the macro-social (the different politics) and the micro-social (beliefs and practices), that is, understanding 'how public discourses and public policies influence institutional and professional practices – and are in return consolidated or sometimes reformulated through the latter' (Fassin, 2012b).
In our field of study, the explanatory model of 'lacking networks' and lacking the capacity for 'resilience' in the face of social adversities produced moral and affective approximation or distancing between physicians and patients, depending on the different population profiles. The Family Medicine physicians presented discourses and practices that were aligned with the principles of the Brazilian public health system, especially equity and the interest in offering more medical care to neglected populations, such as the 'hill' inhabitants. Some of the professionals referenced the need to overcome the 'inverse care law'. This concept was proposed in 1971 by the family physician Julian Tudor Hart, who, when analysing primary care access and therapeutic supply in south Wales, noted that the populations that least need care are the ones that have most access to health services, while the populations that most need care access these services the least (Tudor Hart, 1971; Chew-Graham et al., 2002).
The 'hill' represented a poorer population than that of the 'asphalt', less protected by social rights and policies. Nonetheless, these people were considered more resistant, with a greater sense of community and of the collective, values in tune physicians' critical views of society. On the other hand, the 'asphalt' comprised a population with better social and economic starting points, but it was more individualistic, with few community practices and values, which made it more fragile, less resistant and less willing to accept care from family physicians. Thus family physicians' social postures produced moral bonds with 'hill' patients – to whom they more frequently offered the psychosocial tools specific to their specialty, such as the 'person-centred clinical method' – and, on the other hand, a distancing from the 'asphalt' patients.
In this ethnographic research, the use of the 'hill' and 'asphalt' categories as 'moral economies' has repercussions for physicians' clinical practices and patients' therapeutic experiences. The anthropological recognition and analysis of these practices provides new ways of looking at the complex social interactions that constitute the expansion of public mental health care in a Latin American metropolis such as Rio de Janeiro. It is not only 'native' medical categories, but also standardised diagnoses, protocols and treatments that produce divergences between patients and health professionals in how depressive suffering is addressed.
The acknowledgement and use of social determinants in the interpretation of, and approach to, these experiences, exemplified in this research by the categories 'hill' and 'asphalt', may also produce these dissonances, especially when we analyse their repercussions in the affections that form the terrain of therapeutic social interactions. They may also create categories that encourage 'one-size-fits-all' approaches, the focus of concerns and debate in the Global Mental Health field, as we noted at the beginning of the chapter. Sociocultural categorisations may become obstacles to more singularised evaluations of suffering, even though they are often created with the intention of producing an integral, 'bio-psychosocial' approach, as in this case study.
Therefore in this scenario, a relevant social research task is to show the role that social procedures such as the 'hill'/'asphalt' categorisation and its moral dimension have in the recognition and treatment of emotional suffering. The offer of, and justification for, biomedical resources such as psychiatric diagnoses and pharmacological treatments, and also psychosocial interventions such as 'groups' and 'person-centred consultations', were moulded by this categorisation. In this ethnographic study, we understand that making the adoption of these categories and their repercussions visible may be a useful resource for reducing barriers to understanding between health care users and professionals regarding the former's experiences of mental suffering and the latter's therapeutic practices. An important challenge for urban mental health is exploring how our experiences of the city and the environment are an important component of the construction of subjectivity, in its reflexive and emotional aspects. In a territorially 'broken' city such as Rio de Janeiro, ethnographic health research may point out paths to deconstructing often invisible social, health and moral barriers, unravelling their production processes and thus signalling the possibility of critical (re)constructions and moral proposals that, at least, reduce the weight and rigidity of social division mechanisms and the categories that derive from them.
1 There is no dataset for Rio de Janeiro comparable to the São Paulo Megacity Mental Health Survey, a population-based survey funded by WHO. The existing studies in Rio are not population-based but composed of smaller samples, mostly from primary care services (Fortes., Villano and Lopes, 2008; Fortes et al., 2011; Gonçalves et al., 2014).
2 Over the years, part of Rio's low-income population has settled on the city's hills, forming the favelas. The city's high-income citizens usually live by the sea and in elegant planned neighbourhoods and gated communities – referred to locally as the 'asphalt' – in contrast to the hills, where urban development has little in the way of formal planning and often lacks proper infrastructure.
3 The 'matrix support' team is the Brazilian model of collaborative care in mental health within the primary care system. It involves multiprofessional teams that may include psychiatrists and psychologists. They offer 'matrix support' – a concept of work process integration in health care, developed and used in the Brazilian FHS – to assist primary care teams (Wenceslau and Ortega, 2015; Athié et al., 2016). In practice, psychiatrists consult together with the Family Medicine residents, when required by the latter. They also discuss diagnostic and treatment options with the residents.
4 CAPS are community mental health care centres that replaced psychiatric asylums following the Brazilian psychiatric reform.
Abas, M., Broadhead, J.C., Mbape, P., and Khumalo-Sakatukwa, G. (1994). Defeating depression in the developing world: A Zimbabwean model. British Journal of Psychiatry, 164(3): 293–6.
Andrade, L.H., Wang, Y.-P., Andreoni, S., Silveira, C.M., Alexandrino-Silva, C., Siu, E.R., Nishimura, R., Anthony, J.C., Gattaz, W.F., Kessler, R.C., and Viana, M.C. (2012). Mental disorders in megacities: Findings from the São Paulo Megacity Mental Health Survey, Brazil. PLoS ONE 7(2): e31879.
Athié, K., Lopes do Amaral Menezes, A., Machado da Silva, A., Campos, M., Delgado, P.G., Fortes, S., and Dowrick, C. (2016). Perceptions of health managers and professionals about mental health and primary care integration in Rio de Janeiro: A mixed methods study. BMC Health Services Research, 16, art. 532.
Caracci, G. (2006). Culture and urban mental health. Psychiatric Times, 23(14): 40–2.
Cavallieri, F., and Peres Lopes, G. (2008). Índice de desenvolvimento social: Comparando as realidades micro urbanas da cidade do Rio de Janeiro. Coleção Estudos Cariocas. Rio de Janeiro: Instituto Municipal de Urbanismo Pereira Passos.
Chew-Graham, C., Mullin, S., May, C.R., Hedley, S., and Cole, H. (2002). Managing depression in primary care: Another example of the inverse care law? Family Practice, 19(6): 632–7.
Chiavegatto Filho, A.D.P., Kawachi, I., Wang, Y.P., Viana, M.C., and Andrade, L.H. (2013). Does income inequality get under the skin? A multilevel analysis of depression, anxiety and mental disorders in São Paulo, Brazil. Journal of Epidemiology & Community Health, 67: 966–72.
Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7): 614–25.
Duarte, L.F.D. (1986). Da vida nervosa nas classes trabalhadoras urbanas. Rio de Janeiro: Jorge Zahar Editor/CNPq.
Duarte, L.F.D. (1997). Nerves and nervousness in Brazilian urban culture. Curare – Journal for Ethnomedicine, 12: 21–38.
Fassin, D. (2008). The elementary forms of care: An empirical approach to ethics in a South African hospital. Social Science and Medicine, J67(2): 262–70.
Fassin, D. (2012a). Introduction: toward a critical moral anthropology. In D. Fassin (ed.), A companion to moral anthropology, 1–18. Malden: Wiley Blackwell.
Fassin, D. (2012b). Towards a critical moral anthropology: A European Research Council programme. Échos de la recherche. La lettre de l´EHESS, 49, http://lettre.ehess.fr/3323 (last accessed 1 November 2019).
Fassin, D., and Rechtman, R. (2009). The empire of trauma: An inquiry into the condition of victimhood. Princeton: Princeton University Press.
Fortes, S., Lopes, C.S., Villano, L.A.B., Campos, M.R., Gonçalves, D.A., and Mari, J. (2011). Common mental disorders in Petrópolis-RJ: A challenge to integrate mental health into primary care strategies. Brazilian Journal of Psychiatry, 33(2): 150–6.
Fortes, S., Villano, L.A.B. and Lopes, C.S. (2008). Nosological profile and prevalence of common mental disorders of patients seen at the Family Health Program (FHP) units in Petrópolis, Rio de Janeiro. Brazilian Journal of Psychiatry, 30(1): 32–7.
Galea, S., Ahern, J., Nandi, A., Tracy, M., Beard, J., and Vlahov, D. (2007). Urban neighborhood poverty and the incidence of depression in a population-based cohort study. Annals of Epidemiology, 17: 171–9.
Galea, S., and Vlahov, D. (2005). Urban health: evidence, challenges, and directions. Annual Review of Public Health, 26: 341–65.
Goldberg, D. (2011). The heterogeneity of 'major depression'. World Psychiatry, 10(3): 226–8.
Gonçalves, D.A., Mari, J., Bower, P., Gask, L., Dowrick, C., Tófoli, L.F., Campos, M., Portugal, F.B., Ballester, D., and Fortes, S. (2014). Brazilian multicentre study of common mental disorders in primary care: Rates and related social and demographic factors. Cadernos de Saúde Pública, 30(3): 623–32.
Grant, M. (2018). Planning for healthy cities. In M. Nieuwenhuijsen and H. Khreis (eds), Integrating human health into urban and transport planning, 221–50. Cham: Springer.
Grant, M., Coghill, N., Barton, H., and Bird, C. (2009). Evidence review on environmental health challenges and risks in urban settings. WHO European Centre for Environment and Health, Technical Report. WHO Collaborating Centre for Healthy Cities and Urban Policy, University of the West of England (UWE), Bristol.
Gruebner, O., Rapp, M.A., Adli, M., Kluge, U., Galea, S., and Heinz, A. (2017). Cities and mental health. Deutsches Ärzteblatt International, 114: 121–7.
Haroz, E.E., Ritchey, M., Bass, J., Kohrt, B., Augustinavicius, J., Michalopoulos, L., Burkey, M., and Bolton, P. (2017). How is depression experienced around the world? A systematic review of qualitative literature. Social Science and Medicine, 183: 151–62.
Harzeim, E. (ed.) (2013). Reforma da atenção primária à saúde na cidade do Rio de Janeiro – Avaliação dos três anos de Clínicas da Família. Pesquisa avaliativa sobre aspectos de implantação, estrutura, processo e resultados das Clínicas da Família na cidade do Rio de Janeiro. Porto Alegre: OPAS.
Iossifova, D., Doll, C.N.H., and Gasparatos, A. (2018). Defining the urban: Why do we need definitions? In D. Iossifova, C.N.H. Doll and A. Gasparatos, Defining the urban: Interdisciplinary and professional perspectives, 1–7. Abingdon and New York: Routledge.
Jenkins, J.H., Kleinman, A., and Good, B. (1991). Cross-cultural studies of depression. In J. Becker and A. Kleinman (eds), Psychosocial aspects of depression, 67–99. Hillsdale, NJ: Lawrence Erlbaum Associates.
Kirmayer, L.J., Gomez-Carrillo, A., and Veissière, S. (2017). Culture and depression in Global Mental Health: An ecosocial approach to the phenomenology of psychiatric disorders. Social Science and Medicine, 183: 163–8.
Kjellstrom, T., Friel, S., Dixon, J., Corvalan, C., Rehfuess, E., Campbell-Lendrum, D., Gore, F., and Bartram, J. (2007). Urban environmental health hazards and health equity. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 84(3, Supplement): i186–97.
Kleinman, A. (1977). Depression, somatization and the 'new cross-cultural psychiatry'. Social Science and Medicine, 11(1): 3–10.
Kleinman, A., and Good, B. (eds) (1985). Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder. Los Angeles: University of California Press.
Krabbendam, L., and van Os, J. (2005). Schizophrenia and urbanicity: A major environmental influence – conditional on genetic risk. Schizophrenia Bulletin, 31: 795–9.
Lim, G.Y., Tam, W.W., Lu, Y., Ho, C.S., Zhang, M.W., and Ho, R.C. (2018). Prevalence of depression in the community from 30 countries between 1994 and 2014. Scientific Reports, 8(1), art. 2861.
Lopes, C.S., Hellwig, N., de Azevedo e Silva, G., and Menezes, P.R. (2016). Inequities in access to depression treatment: Results of the Brazilian National Health Survey – PNS. International Journal for Equity in Health, 15, art. 154.
Macinko, J., and Harris, M.J. (2015). Brazil's family health strategy – Delivering community-based primary care in a universal health system. New England Journal of Medicine, 372(23): 2177–81.
Ministério da Saúde, Brazil (2012). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política nacional de atenção básica. Brasília: Ministério da Saúde.
Ministério da Saúde, Brazil (2016). Departamento de Atenção Básica. Histórico de cobertura da Saúde da Família. http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php (last accessed 10 May 2016).
Ministério da Saúde, Brazil (2017). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS).
Munhoz, T.N., Nunes, B.P., Wehrmeister, F.C., Santos, I.S., and Matijasevich, A. (2016). A nationwide population-based study of depression in Brazil. Journal of Affective Disorders, 192: 226–33.
Neri, M.C. (ed.) (2010). Desigualdades e favelas cariocas: A cidade partida está se integrando? Rio de Janeiro: Fundação Getulio Vargas and Centro de Políticas Sociais.
Ortega, F. (2018). 'Why not both?' Negotiating ideas about autism in Italy, Brazil, and the US. In E. Fein and C. Rios (eds), Autism in translation: An intercultural conversation on autism spectrum conditions, 89–106. London: Palgrave Macmillan.
Paim, J., Travassos, C., Almeida, C., Bahia, L., and Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. Lancet, 37(9779): 1778–97.
Patel, V. (2001). Cultural factors and international epidemiology: Depression and public health. British Medical Bulletin, 57(1): 33–45.
Patel, V., Abas, M., Broadhead, J., Todd, C., and Reeler, A. (2001). Depression in developing countries: Lessons from Zimbabwe. British Medical Journal, 322(7284): 482–4.
Patel, V., and Prince, M. (2010). Global Mental Health: A new global health field comes of age. Journal of the American Medical Association, 303(19): 1976–7.
Patel, V., and Saxena, S. (2014). Transforming lives, enhancing communities – Innovations in Global Mental Health. New England Journal of Medicine, 370(6): 498–501.
Peen, J., Schoevers, R.A., Beekman, T.A., and Dekker, J. (2010). The current status of urban–rural differences in psychiatric disorders. Acta Psychiatrica Scandinavica, 121: 84–93.
Prado Junior, J.C. (2015). Desafios para a expansão de programas de residência em Medicina de Família e Comunidade: A experiência carioca. Revista Brasileira de Medicina de Família e Comunidade, 10(34): 1–9.
Rapp, M.A., Kluge, U., Penka, S., Vardar, A., Aichberger, M.C., Mundt, A.P., Schouler-Ocak, M., Mösko, M., Butler, J., Meyer-Lindenberg, A., and Heinz, A. (2015). When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry, 14: 249–50.
Silva, L., Ramalho da Silva, P.F., Gadelha, A., Clement, S., Thornicroft, G., Mari, J., and Brietzke, E. (2013). Adaptation of the Barriers to Access to Care Evaluation (BACE) scale to the Brazilian social and cultural context. Trends in Psychiatry and Psychotherapy, 35(4): 287–91.
Soranz, D.R. (2014). O programa de residência em medicina de família e comunidade do município do Rio de Janeiro. Revista Brasileira de Medicina de Família e Comunidade, 9(30): 67–71.
Steel, Z., Marnane, C., Iranpour, C., Chey, T., Jackson, J.W., Patel, V., and Silove, D. (2014). The global prevalence of common mental disorders: A systematic review and meta-analysis 1980–2013. International Journal of Epidemiology, 43(2): 476–93.
Stephens, C., Carrizo, A.G., and Ostadtaghizaddeh, A. (2016). Revisiting the virtuous city: Learning from the past to improve modern urban mental health. In N. Okkels, C. Blanner Kristiansen and P. Munk-Jorgensen (eds), Mental health and illness in the city, 465–80. Singapore: Springer.
Stewart, M., Brown, J.B., Weston, W., McWhinney, I.R., McWilliam, C.L., and Freeman, T. (2014). Patient-centered medicine: Transforming the clinical method. 3rd ed. New York: Radcliffe Publishing.
Thornicroft, G. (2007). Most people with mental illness are not treated. Lancet, 370(9590): 807–8.
Tudor Hart, J. (1971). The inverse care law. Lancet, 297(7696): 405–12.
Van Beljouw, I., Verhaak, P., Prins, M., Cuijpers, P., Pennix, B., and Bensing, J. (2010). Reasons and determinants for not receiving treatment for common mental disorders. Psychiatric Services, 61: 250–7.
van Os, J., Pedersen, C.B., and Mortensen, P.B. (2004). Confirmation of synergy between urbanicity and familial liability in the causation of psychosis. American Journal of Psychiatry, 161: 2312–14.
Ventura, Z. (1994). Cidade partida. São Paulo: Companhia das Letras.
Wahlbeck, K. (2015). Public mental health: The time is ripe for translation of evidence into practice. World Psychiatry, 14: 36–42.
Wenceslau, L.D., and Ortega, F. (2015). Mental health within primary health care and Global Mental Health: International perspectives and Brazilian context. Interface – Comunicação, Saúde, Educação, 19(55): 1121–32.
WHO (2016). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Mental health Gap Action Programme (mhGAP) – version 2.0. Geneva: WHO.
WHO (2017). Depression and other common mental disorders: Global health estimates. Geneva: WHO.
WHO and WONCA (2008). Integrating mental health in primary care: A global perspective. Geneva: WHO.
WONCA (2018). Core competencies of family doctors in primary mental health care. www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/Groups/Mental%20Health/Core%20competencies%20January%202018.pdf (last accessed 1 November 2019).
Urban transformations and public health in the emergent city
Editors: Michael Keith and Andreza Aruska de Souza Santos
urban transformation; mental health; violence against women and girls (VAWG); mobility; sanitation; food; racism
Series editors' foreword
Chapter 2: Mental health, stress and the contemporary metropolis
Chapter 3: Feminised urban futures, healthy cities and violence against women and girls
Chapter 4: Understanding the relationships between wellbeing and mobility in the unequal city
Chapter 5: Urban (sanitation) transformation in China
Chapter 6: The food environment and health in African cities
Chapter 7: Urban mental health and the moral economies of sufferingin a 'broken city'
Chapter 8: Violence as a language of construction and deconstruction in Rio de Janeiro and Brazil
Urban transformations and public health in the emergent city examines how urban health and wellbeing are shaped by migration, mobility, racism, sanitation and gender. Adopting a global focus, spanning Africa, Asia, Europe and Latin America, the essays in this volume bring together a wide selection of voices that explore the interface between social, medical and natural sciences. This interdisciplinary approach, moving beyond traditional approaches to urban research, offers a unique perspective on today's cities and the challenges they face. Edited by Professor Michael Keith and Dr Andreza Aruska de Souza Santos, this volume also features contributions from leading thinkers on cities in Brazil, China, South Africa and the United Kingdom. This geographic diversity is matched by the breadth of their different fields, from mental health and gendered violence to sanitation and food systems. Together, they present a complex yet connected vision of a 'new biopolitics' in today's metropolis, one that requires an innovative approach to urban scholarship regardless of geography or discipline. This volume, featuring chapters from a number of renowned authors including the former deputy mayor of Rio de Janeiro Luiz Eduardo Soares, is an important resource for anyone seeking to better understand the dynamics of urban change. With its focus on the everyday realities of urban living, from health services to public transport, it contains valuable lessons for academics, policy makers and practitioners alike.
Time for mapping
Cartographic temporalities
Editors: Sybille Lammes, Chris Perkins, Alex Gekker, Sam Hind, Clancy Wilmott, and Daniel Evans
The digital era has brought about huge transformations in the map itself, which to date have been largely conceptualised in spatial terms. The emergence of novel objects, forms, processes and approaches in the digital era has, however, posed a swathe of new, pressing questions about the temporality of digital maps and contemporary mapping practices, and in spite of its implicit spatiality, digital mapping is strongly grounded in time. In this peer-reviewed collection we bring time back into the map, taking up Doreen Massey's critical concern for 'ongoing stories' in the world, but asking how mapping continues to wrestle with the difficulty of enrolling time into these narratives, often seeking to 'freeze' and 'fix' the world, in lieu of being able to, in some way, represent, document or capture dynamic phenomena. This collection examines how these processes are impacted by digital cartographic technologies that, arguably, have disrupted our understanding of time as much as they have provided coherence. The book consists of twelve chapters that address different kinds of digital mapping practice and analyse these in relation to temporality. Cases discussed range from locative art projects, OpenStreetMap mapping parties, sensory mapping, Google Street View, visual mapping, smart city dashboards and crisis mapping. Authors from different disciplinary positions consider how a temporal lens might focus attention on different aspects of digital mapping. This kaleidoscopic approach generates a rich plethora for understanding the temporal modes of digital mapping. The interdisciplinary background of the authors allows multiple positions to be developed.
Globalisation contested
An international political economy of work
Author: Louise Amoore
Bringing fresh insights to the contemporary globalization debate, this text reveals the social and political contests that give 'global' its meaning, by examining the contested nature of globalization as it is expressed in the restructuring of work. The book rejects conventional explanations of globalization as a process that automatically leads to transformations in working lives, or as a project that is strategically designed to bring about lean and flexible forms of production, and advances an understanding of the social practices that constitute global change. Through case studies that span from the labour flexibility debates in Britain and Germany to the strategies and tactics of corporations and workers, it examines how globalization is interpreted and experienced in everyday life and argues that contestation has become a central feature of the practices that enable or confound global restructuring.


A grid of enlarged pages from the artist's high school yearbook showing the 2005 senior class forms Class of 2005 (A Vision Becomes a Reality...In Cap and Gown). The first several pages shows students in everyday clothing, not smiling, almost like mug shots. These are the non-graduating seniors of the high school. We see Bradley among them, looking younger than his age, eyes closed head tilted downward. Then come the graduates, with gowns and caps with tassel falling over their left shoulder, bright smiles. The school seems shaming the non-graduates and dropouts, picturing them as a gallery of failures, a foil to their show the graduates' success.


text:
Amphilius lentiginosus és una espècie de peix de la família dels amfílids i de l'ordre dels siluriformes.

Morfologia
Els mascles poden assolir els 11,8 cm de llargària total.

Distribució geogràfica
Es troba a Àfrica: conques del riu Cuvo (Angola) i del riu Congo.

Referències

Bibliografia
  .

 Helfman, G., B. Collette i D. Facey: The Diversity of Fishes. Blackwell Science, Malden, Massachusetts (Estats Units), 1997. .

 Skelton, P.H. i G.G. Teugels, 1986. Amphiliidae. p. 54-65. A J. Daget, J.-P. Gosse i D.F.E. Thys van den Audenaerde (eds.) Check-list of the freshwater fishes of Africa (CLOFFA). ISNB, Brussel·les, Bèlgica; MRAC, Tervuren; i ORSTOM, París, França. Vol. 2.
 Skelton, P.H., 1992. Amphiliidae. p. 450-467. A C. Levêque, D. Paugy, i G.G. Teugels (eds.) Faune des poissons d'eaux douces et saumâtres d'Afrique de l'Ouest. Vol. 2. Coll. Faune Tropicale núm. 28. Musée Royal de l'Afrique Centrale, Tervuren, Bèlgica i O.R.S.T.O.M., París, França. PDF
 Trewavas, E. 1936. Dr. Karl Jordan's expedition to South-West Africa and Angola: The fresh-water fishes. Novit. Zool. (Tring) v. 40: 63-74, Pls. 1-2.
  .

lentiginosus

redpajama_set_name: RedPajamaWikipedia


Bring those cute smiles to school. It's Picture Day!!!
On September 12th we will have Fall pictures taken, and the next day on September 13th we will take the Winter pictures.
Wednesday, September 20th FDLRS will be presenting a parenting class on "Structure and Behavior". Dinner will be served and door prizes given out.
The meeting is from 6:00pm to 7:00pm.
1. Childcare providers are babysitters: Childcare is a profession and a very invaluable career. There is not just a quick course that someone takes to become qualified. Many childcare providers have dedicated their lives to this profession and have poured their heart and soul into their classes or programs. They are dedicated to raising up the next generation and are required to take continuing education units yearly.
2. The price of tuition is going directly into someone's pocketbook: The truth is that tuition covers so many costs: supplies, food, furniture, curriculum, replacement, licensing fees, insurance, marketing costs, learning activities, dishes, paper products, safety supplies, office supplies, and more.
3. You get what you pay for: You have to look past dollar signs and look into the heart of a program! Some of the best teachers work in the most affordable programs, and that's a great thing!
4. Men shouldn't be working with young children: Some of the most noteworthy ECE figures who I love reading advice from are men: Tim from Taught by Finland, Teacher Tom, and Scott from Brick by Brick. And honestly, I think my husband rocks! He does a great job with fathering our own children, and all of my classes looked forward to the times he would pop in and say hello.


text:
NGC 1365: Majestic Island Universe
Image Credit & Copyright: Martin Pugh
Explanation: Barred spiral galaxy NGC 1365 is truly a majestic island universe some 200,000 light-years across. Located a mere 60 million light-years away toward the chemical constellation Fornax, NGC 1365 is a dominant member of the well-studied Fornax galaxy cluster. This impressively sharp color image shows intense star forming regions at the ends of the bar and along the spiral arms, and details of dust lanes cutting across the galaxy's bright core. At the core lies a supermassive black hole. Astronomers think NGC 1365's prominent bar plays a crucial role in the galaxy's evolution, drawing gas and dust into a star-forming maelstrom and ultimately feeding material into the central black hole.
Tomorrow's picture: beyond the known world

redpajama_set_name: RedPajamaCommonCrawl


Backflow protection devices are essentially the parts of an industrial plumbing system designed to make sure that, should there be any flooding, the water from the flooding is not able flow back into the plumbing system. Industries that rely on clean water, such as hospitals, swimming pools, medical clinics, or spas, all need to be equipped with enough backflow protection devices to ensure that the water is never contaminated. If you are involved with one of these industries, here are some possible backflow devices that you can install in order to make sure that your water remains pure.
An air gap is one of the simplest types of backflow protection measures, because it is simply the separation of the water that is used for cleaning or drinking and all other fluids. For example, any used water will be kept strictly separate from clean water in order to make sure that the two don't mix. If you have the clean water in a basin or other storage area, there will be little chance that contaminated flood water will be able to flow back into it.
Double check valve assembly is when there are two valves are located in the plumbing system both upstream and downstream. These are the check valves that ensure that water does not flow in the wrong direction. These reduce the chances of any flood water backflowing into the main system because the check valves only allow water to flow from one direction to the other.
This type of protection device is a single check valve that closes automatically if it senses that water has begun to flow in the wrong direction. Once the flooding has subsided, an industrial plumber will be able to release this valve by applying pressure in order to restore the normal flow of water and make sure that everything continues to work correctly.
This is a device that has two check valves with an area of low pressure between them. This is essentially a buffer zone that will maintain control of the water in order to make sure that there is no backflow. This reduced pressure zone is used whenever the water starts to flow in a direction that is not anticipated.
For more information about backflow protection and keeping your water clean, talk to a professional industrial plumber.


The stay of execution on joint UK-Pakistani national, Mirza Tahir Hussain, expired yesterday (Sunday 1 October), meaning that he could expect to receive a 'death warrant' with his execution date at any time.
On the same day President Musharraf of Pakistan gave an interview to ITV's Sunday Edition programme in the UK where he said that the law does not permit him to intervene to stop the death sentence being carried out.
36 year old Mirza Tahir Hussain was sentenced to death in Pakistan in 1989 for the murder of a local taxi driver. He alleges the driver attempted to assault him and that he killed the man in self-defence. Mirza Tahir has been tried several times in both the religious and secular courts in Pakistan and twice acquitted of the crime. Amnesty International is seriously concerned that his trials were unfair.
"My family is now desperate. My brother, who has spent all his adult like in a Pakistan jail, could receive notice of his execution any time. It is not true that President Musharraf cannot stop the execution of an innocent man in the country where he is President. It is clear that the constitution does permit him to do so.
"My brother did not commit the crime of murder that he has been convicted of. His trial was unfair and his detention in Pakistan for the last 18 years has destroyed all our lives. I implore President Musharraf to end our agony and commute the sentence immediately.
A broad coalition of organisations are campaigning on Mirza Tahir Hussain's behalf. They include Amnesty International, the Islamic Human Rights Commission, the Muslim Parliament of Britain, Reprieve, Fair Trials Abroad, and the Bar Human Rights Committee. The campaign is also supported by MPs and MEPs of all political parties including John Battle MP, Hilary Been MP, Greg Mulholland MP, Sajjad Karim MEP and Edward Macmillan-Scott MEP.


text:
#ifndef BOOST_ATOMIC_DETAIL_GCC_ARMV6PLUS_HPP
#define BOOST_ATOMIC_DETAIL_GCC_ARMV6PLUS_HPP

//  Distributed under the Boost Software License, Version 1.0.
//  See accompanying file LICENSE_1_0.txt or copy at
//  http://www.boost.org/LICENSE_1_0.txt)
//
//  Copyright (c) 2009 Helge Bahmann
//  Copyright (c) 2009 Phil Endecott
//  ARM Code by Phil Endecott, based on other architectures.

#include <cstddef>
#include <boost/cstdint.hpp>
#include <boost/atomic/detail/config.hpp>

#ifdef BOOST_ATOMIC_HAS_PRAGMA_ONCE
#pragma once
#endif

// From the ARM Architecture Reference Manual for architecture v6:
//
// LDREX{<cond>} <Rd>, [<Rn>]
// <Rd> Specifies the destination register for the memory word addressed by <Rd>
// <Rn> Specifies the register containing the address.
//
// STREX{<cond>} <Rd>, <Rm>, [<Rn>]
// <Rd> Specifies the destination register for the returned status value.
//      0  if the operation updates memory
//      1  if the operation fails to update memory
// <Rm> Specifies the register containing the word to be stored to memory.
// <Rn> Specifies the register containing the address.
// Rd must not be the same register as Rm or Rn.
//
// ARM v7 is like ARM v6 plus:
// There are half-word and byte versions of the LDREX and STREX instructions,
// LDREXH, LDREXB, STREXH and STREXB.
// There are also double-word versions, LDREXD and STREXD.
// (Actually it looks like these are available from version 6k onwards.)
// FIXME these are not yet used; should be mostly a matter of copy-and-paste.
// I think you can supply an immediate offset to the address.
//
// A memory barrier is effected using a "co-processor 15" instruction,
// though a separate assembler mnemonic is available for it in v7.

namespace boost {
namespace atomics {
namespace detail {

// "Thumb 1" is a subset of the ARM instruction set that uses a 16-bit encoding.  It
// doesn't include all instructions and in particular it doesn't include the co-processor
// instruction used for the memory barrier or the load-locked/store-conditional
// instructions.  So, if we're compiling in "Thumb 1" mode, we need to wrap all of our
// asm blocks with code to temporarily change to ARM mode.
//
// You can only change between ARM and Thumb modes when branching using the bx instruction.
// bx takes an address specified in a register.  The least significant bit of the address
// indicates the mode, so 1 is added to indicate that the destination code is Thumb.
// A temporary register is needed for the address and is passed as an argument to these
// macros.  It must be one of the "low" registers accessible to Thumb code, specified
// using the "l" attribute in the asm statement.
//
// Architecture v7 introduces "Thumb 2", which does include (almost?) all of the ARM
// instruction set.  So in v7 we don't need to change to ARM mode; we can write "universal
// assembler" which will assemble to Thumb 2 or ARM code as appropriate.  The only thing
// we need to do to make this "universal" assembler mode work is to insert "IT" instructions
// to annotate the conditional instructions.  These are ignored in other modes (e.g. v6),
// so they can always be present.

#if defined(__thumb__) && !defined(__ARM_ARCH_7A__)
// FIXME also other v7 variants.
#define BOOST_ATOMIC_ARM_ASM_START(TMPREG) "adr " #TMPREG ", 1f\n" "bx " #TMPREG "\n" ".arm\n" ".align 4\n" "1: "
#define BOOST_ATOMIC_ARM_ASM_END(TMPREG)   "adr " #TMPREG ", 1f + 1\n" "bx " #TMPREG "\n" ".thumb\n" ".align 2\n" "1: "

#else
// The tmpreg is wasted in this case, which is non-optimal.
#define BOOST_ATOMIC_ARM_ASM_START(TMPREG)
#define BOOST_ATOMIC_ARM_ASM_END(TMPREG)
#endif

#if defined(__ARM_ARCH_7A__)
// FIXME ditto.
#define BOOST_ATOMIC_ARM_DMB "dmb\n"
#else
#define BOOST_ATOMIC_ARM_DMB "mcr\tp15, 0, r0, c7, c10, 5\n"
#endif

inline void
arm_barrier(void)
{
    int brtmp;
    __asm__ __volatile__ (
        BOOST_ATOMIC_ARM_ASM_START(%0)
        BOOST_ATOMIC_ARM_DMB
        BOOST_ATOMIC_ARM_ASM_END(%0)
        : "=&l" (brtmp) :: "memory"
    );
}

inline void
platform_fence_before(memory_order order)
{
    switch(order) {
        case memory_order_release:
        case memory_order_acq_rel:
        case memory_order_seq_cst:
            arm_barrier();
        case memory_order_consume:
        default:;
    }
}

inline void
platform_fence_after(memory_order order)
{
    switch(order) {
        case memory_order_acquire:
        case memory_order_acq_rel:
        case memory_order_seq_cst:
            arm_barrier();
        default:;
    }
}

inline void
platform_fence_before_store(memory_order order)
{
    platform_fence_before(order);
}

inline void
platform_fence_after_store(memory_order order)
{
    if (order == memory_order_seq_cst)
        arm_barrier();
}

inline void
platform_fence_after_load(memory_order order)
{
    platform_fence_after(order);
}

template<typename T>
inline bool
platform_cmpxchg32(T & expected, T desired, volatile T * ptr)
{
    int success;
    int tmp;
    __asm__ (
        BOOST_ATOMIC_ARM_ASM_START(%2)
        "mov     %1, #0\n"        // success = 0
        "ldrex   %0, %3\n"      // expected' = *(&i)
        "teq     %0, %4\n"        // flags = expected'==expected
        "ittt    eq\n"
        "strexeq %2, %5, %3\n"  // if (flags.equal) *(&i) = desired, tmp = !OK
        "teqeq   %2, #0\n"        // if (flags.equal) flags = tmp==0
        "moveq   %1, #1\n"        // if (flags.equal) success = 1
        BOOST_ATOMIC_ARM_ASM_END(%2)
            : "=&r" (expected),  // %0
            "=&r" (success),   // %1
            "=&l" (tmp),       // %2
            "+Q" (*ptr)          // %3
            : "r" (expected),    // %4
            "r" (desired) // %5
            : "cc"
        );
    return success;
}

}
}

#define BOOST_ATOMIC_THREAD_FENCE 2
inline void
atomic_thread_fence(memory_order order)
{
    switch(order) {
        case memory_order_acquire:
        case memory_order_release:
        case memory_order_acq_rel:
        case memory_order_seq_cst:
            atomics::detail::arm_barrier();
        default:;
    }
}

#define BOOST_ATOMIC_SIGNAL_FENCE 2
inline void
atomic_signal_fence(memory_order)
{
    __asm__ __volatile__ ("" ::: "memory");
}

class atomic_flag {
private:
    atomic_flag(const atomic_flag &) /* = delete */ ;
    atomic_flag & operator=(const atomic_flag &) /* = delete */ ;
    uint32_t v_;
public:
    atomic_flag(void) : v_(false) {}

    void
    clear(memory_order order = memory_order_seq_cst) volatile
    {
        atomics::detail::platform_fence_before_store(order);
        const_cast<volatile uint32_t &>(v_) = 0;
        atomics::detail::platform_fence_after_store(order);
    }

    bool
    test_and_set(memory_order order = memory_order_seq_cst) volatile
    {
        atomics::detail::platform_fence_before(order);
        uint32_t expected = v_;
        do {
            if (expected == 1)
                break;
        } while (!atomics::detail::platform_cmpxchg32(expected, (uint32_t)1, &v_));
        atomics::detail::platform_fence_after(order);
        return expected;
    }
};
#define BOOST_ATOMIC_FLAG_LOCK_FREE 2

}

#undef BOOST_ATOMIC_ARM_ASM_START
#undef BOOST_ATOMIC_ARM_ASM_END

#include <boost/atomic/detail/base.hpp>

#if !defined(BOOST_ATOMIC_FORCE_FALLBACK)

#define BOOST_ATOMIC_CHAR_LOCK_FREE 2
#define BOOST_ATOMIC_CHAR16_T_LOCK_FREE 2
#define BOOST_ATOMIC_CHAR32_T_LOCK_FREE 2
#define BOOST_ATOMIC_WCHAR_T_LOCK_FREE 2
#define BOOST_ATOMIC_SHORT_LOCK_FREE 2
#define BOOST_ATOMIC_INT_LOCK_FREE 2
#define BOOST_ATOMIC_LONG_LOCK_FREE 2
#define BOOST_ATOMIC_LLONG_LOCK_FREE 0
#define BOOST_ATOMIC_POINTER_LOCK_FREE 2
#define BOOST_ATOMIC_BOOL_LOCK_FREE 2

#include <boost/atomic/detail/cas32weak.hpp>

#endif /* !defined(BOOST_ATOMIC_FORCE_FALLBACK) */

#endif

redpajama_set_name: RedPajamaGithub


text:
Welcome to the American Dad! Wiki, an encyclopedia of all things presented in the television show American Dad! created by Seth MacFarlane. This site uses MediaWiki software, which allows any user to edit or create pages. This was started March 12, 2007, and currently contains 4,692 articles.
The main page has undergone a massive change! Please post feedback.
The American Dad! Wiki Editing Guide
See a general discussion to improve this wiki at American Dad Wikia:CIA.
List of music used in American Dad - A nearly complete listing of every song used in American Dad!. Add ones that we have missed now!
Roger's Disguises New page with info and pictures on all of the intro's disguises.
Guest Voice Credits by Season - Who was in that episode?
Comic Con News! "Weird Al" Yankovic to perform an original song for American Dad!
Yet another American Dad! mobile game coming.
American Dad! renewed for two more years.
Hulu strikes deal to carry all episodes of American Dad!, other FOX animated shows
CIA Headquarters
Help the American Dad Wikia Community by visiting the CIA Headquarters and seeing what needs assistance.
Never been here before? Want to stick around? That's fantastic, because we'd love to have you here. Check out the New Members page for a bit of information on how to get started here at American Dad Wikia. We have made our own member list for your convenience. Please come on over and add your name to our list of contributors.
We'd be delighted for you to help contribute to this project. Editing American Dad Wikia is extremely easy, and requires very little html code. Instead, we use a simpler system supported by WikiMedia. The Sandbox is a place for you to go and practice editing and creating pages. Drop in and see how easy it is to use American Dad Wikia.
Recent episodes [edit]
Yule. Tide. Repeat. aired December 21st, 2020 at 10:00/9:00C on TBS
After Stan's plan for the perfect Christmas goes terribly, tragically wrong, he's given a magical opportunity to make things right.
300 aired September 14th, 2020 at 10:00/9:00C on TBS
Roger's past comes back to haunt him.
Watch the latest episodes here.
American Dad!'s official Facebook page
Random Opening Gags
Krispy Kreme McDonald from "American Dream Factory"
See another
May 2021 be better than the past year.
Upcoming Episodes [edit]
TBA airs TBAst, 2021 at 10:00/9:00C on TBS
New season begins later this spring.
Animated (adult) Shows
Go to these sites for info or for help with your own wiki!
American Dad! • Archer • Beavis and Butt-head • Bless the Harts • Bob's Burgers • Camp Camp • Central Park • Disenchantment • Duncanville • Family Guy • Futurama • Happy Tree Friends • King of the Hill • RWBY • Rick and Morty • The Simpsons • Solar Opposites • South Park
Retrieved from "https://americandad.fandom.com/wiki/Main_Page?oldid=91911"
American Dad Wikia


Except early Mk.XIIs of course!
The bulged cowling was caused to the IX by the XVI's Merlin 266; when the decision was taken to move the filler point, for the 266's intercooler-mounted header tank, it was found that the hinge mechanism caught the pipe which led from the IX's Rolls-Royce intercooler to the firewall-mounted header tank. Rather than have separate cowlings for the two Marks, it was decided to bulge the cowling up, slightly, and fit the same item to both Marks. Modification 1398 "To modify the cowling structure to give greater clearance for coolant pipe," which went into production on 9-8-44, refers.
Very interesting the bulged cowling. I was quite involved with the South African Air Force Museum flights Spitfire Mk IX. However it was a low back bubble top variant which are mostly XVI's. However we were told it was Merlin engined so was a Mk IX? The interesting thing was at the time, the exGuy Black Spitfire MkIX TE566 was hangered at the Museum. What I found interesting was when you sat in the aircraft, the SAAF Museum spitfire's cowling seemed more squared off, but towards the front of the cowling, whereas TE566 seemed definately rounder, to my eye at least? Interestingly enough, the very top section of the propellor spinner is visable, a great reference point in flight. The exhaust stubbs are not however visable, a good thing at night, as they were bright enough without being in your face I would have thought. In the day, not a problem.
I've now discovered that the Malta Mk.IX does not have its original wings, but is the recipient of a second-hand set, which probably explains the presence of the teardrop bulges over the wells; however, it looks as though, on some XVIs at least, the bulge did make its appearance in 1945, maybe because the aircraft were to be delivered to the continent, where metalled runways (and P.S.P., perhaps?) would be encountered more often.
All those curves!! More curvey than what you read about in Curve Monthly! How did they make that top cowling and to a constant spec"? It wasn't stamped out, or was it done on a shaping wheel? Probably built by the same guy who did Park Ward Coachworks Rolls Royce fenders!


Looking for a late 70's Washburn D62SW Prairie Song acoustic six string. Spruce top with rosewood back and sides with the Martin-style headstock and gold Washburn decal. Thanks!
Fender Stratocaster American Vintage 1957 Reissue.
Fender Jazz Bass American Vintage 1962 Reissue.
Hi there! I assume you mean you were looking for one for sale? Did you ever find one? I've got one and can't imagine selling it.
I've never seen one but that sounds awesome! WNelWeb I'm envious.
I'm having to make some space and have a 197? Washburn Prairie Song D62S Dreadnought, hand made, solid Spruce top, SOLID Indian Rosewood back & sides!! with maple scratchplate and binding. It's a good 9.5 out of 10 and fitted with a Fishman passive under saddle & Washburn hardshell case.
Plays/sounds great. Just had a set up and it cuts through against my Rosewood Martin (but you probably knew that anyway).
I'm in the UK but have shipped guitars to the US before.


The Register has a point, but to be fair to Fujitsu, at least they have acknowledged that IT outsourcing is a very different business to how it functioned just a few years ago. Fujitsu says that they are transforming their business because security, artificial intelligence, the cloud, and the Internet of Things are reshaping how modern IT infrastructure works.
All of this usurps the traditional role of the IT outsourcer or internal IT development team. In more traditional environments there would be a business customer that needs a solution for their area of the company. The CIO would offer analysis and development for those business customers, sometimes performed in-house and sometimes with an external partner through an outsourced arrangement. Sometimes a solution would be designed and built from scratch and sometimes an existing system could be purchased and customised.
This is enormously important. Delivering cloud-based services is not just about storage or processing power on demand; business solutions can also be delivered and charged as they are used removing the need for local software administration and development. For example, a marketing team that previously might have needed some internal tools developed can now find almost all the support tools they need on a subscription basis in the cloud - look at tools like Hootsuite for an example.
The app store has revolutionised how people use applications. Apps are easy to find, install, delete, and are regularly updated seamlessly. End users don't need IT expertise to find an app that helps with their area of the business because they can find and install it themselves in contrast to the tight management of apps that used to be common.
3. Both the above mean that the customer has changed.
IT companies don't necessarily need to be talking to the CIO for business solutions if the CIO is just ensuring that the right infrastructure is in place for business users to use cloud-based apps. It is the business users who are buying IT solutions and they don't want multi-year contracts, they want to pay by the users and only for what is used.
Even if you are a traditional IT supplier with some fat government contracts, how secure are they in an environment where even the public sector has been exploring cloud-based solutions for several years?
Some IT outsourcing will remain in the traditional format of a long-term contract from a client to supplier, but it is likely that these deals will be much more around infrastructure - ensuring that the business can keep the apps up and running. Deciding on the IT that will support business processes is already being devolved to business heads and both the development and charging models are being transformed.
IT outsourcing is no longer about how many developers you can bill from a remote offshore location. It's about offering solutions in a format that customers can easily download and use and with easy options to pay for the value that the app creates.
What do you think when you hear about transformation plans inside big IT companies? Do they really understand how business heads want to purchase IT services today? Leave a comment here or tweet me on @markhillary.


text:
Williamsburg Tasting Trail
By Arielle Patterson
Sip and Sample along the Williamsburg Tasting Trail
There's a new way to experience Greater Williamsburg, but one could say that it's as old as this historic region. While early settlers were building forts and establishing their presence in the area, they also brewed their first beers and planted their first vines. They believed that alcohol had many beneficial purposes. Besides being a clean source of water, they believed it had healing properties and provided energy to the body....
Visit Williamsburg
Website Coupons
Come experience history in the making. It's revolutionary fun with something for everyone. Enjoy everything from luxurious spas, world-class golf and award-winning restaurants to living-history museums, surprising thrills, biking...
Williamsburg Map it Call
Colonial Williamsburg, the world's largest living history museum! This 18th-century city boasts over forty sites and trades, four historic taverns, and two world-class art museums. Forget the textbooks. Forget what you...
Fresh, authentic Mexican cuisine and refreshing margaritas—now open for lunch and dinner daily in historic Williamsburg! WINNER OF BEST MEXICAN RESTAURANT 2015, 2017 and 2018 Open Seven Days Full Bar Available $6.99...


text:
Peri's driven to a desperate act!
By Victoria Wilson
With her world spiralling out of control, Peri decides to take action in spectacular style and when Leela brings the fire truck to school for careers day, Peri locks herself in and threatens to drive it into the school building. John Paul arrives and stands in front of the fire engine to try and stop Peri.
Patrick is impressed with John Paul and promises to put in a good word so that he can be reinstated at Hollyoaks High. John Paul is elated... until he gets a phone call from Finn and later receives a visiting order from his attacker.
Later, Patrick takes Minnie into his care and Maxine is stunned when he suggests they make another go of their relationship. Will she agree for the sake of their daughter?
Victoria Wilson
Feature Writer for What's on TV, TV Times, TV & Satellite Week and WhatToWatch.com
With over 20 years' experience writing about TV and film, Vicky currently writes features for What's on TV, TV Times, TV & Satellite Week magazines plus news and watching guides for WhatToWatch.com, a job which involves chatting to a whole host of famous faces. Our Vicky LOVES light entertainment, with Strictly Come Dancing, Britain's Got Talent and The Voice UK among her fave shows. Basically, if it's got a shiny floor, she's all over it! When she's not watching TV, you might find Vicky in therapy… retail therapy that is!
Natasha Lyonne: seven things you didn't know about the Poker Face star
Party Down season 3: release date, trailer, cast and everything we know about the comedy
Best TV shows on Tubi
EastEnders reveals heartbreaking baby storyline for Whitney and Zack
Magazine Dreams: cast, reviews and everything we know about the Jonathan Majors movie


Our club was founded in 1860 and recently celebrated its 150th Anniversary. The club originally played its matches on the curling pond within the Gosford Estate, located between Aberlady and Longniddry. We last played at this historic site in 2011.
All our league games are played in a friendly atmosphere.
We have members of all ages ranging currently from 20 – 70 but welcome curlers of any age (younger or older!).
Although titled Aberlady, the club is not geographically based, with several members living outwith East Lothian.
The most important thing to our members is to enjoy their curling and to have fun – although the skips would also say that winning is important too!
New Membership New members of all ages and abilities are welcome.
Our three qualified coaches are always available for help and advice.
Full and reserve memberships are available to all new members.
Social Events In addition to our usual club games, we also run some fun competitions with the Christmas fancy dress bonspiel always being popular. We have several supper nights during the season and our annual dinner/prize giving.
Membership Information We cater for all ages, abilities, and genders. We particularly welcome members and graduates of New Stones and 'returning' curlers.


For the last few days we've been clearing out our loft before moving to a new bungalow. This morning, squeezed behind a tottering pile of boxes, Ali found a shopping bag full of negatives and prints that I thought were long-lost. They are mostly snappy snaps from a back packing trip to The Gambia fifteen years ago and I've just spent a happy hour looking at pictures on paper rather than a screen – so much easier to stay mindful when you have something physical in your hand.
The experience has rekindled my love of film photography and I now want to create a darkroom at the new place we are moving to (as well as the gallery and still life studio, on my to do list) – just have to persuade my wife Ali that it's a good idea!
Here are some scans from the hoard of photos. Most are snaps from our travels – a few are early forerunners of the Lomography movement I think!
They were all shot on 35mm neg. If you enjoyed these, you can find more in the 35mm film page of the blog here along with information about where and when they were taken (just underneath the Israel / Palestine pictures).
I felt very nostalgic sliding my hand into each envelope of prints with a feeling of anticipation about what would be inside.
Amazingly, the Canon T70 that took most of these is still in working condition and had charge in the battery when it was also saved from the loft a few months ago!
Sadly missed though, is a personally precious box of black and white prints from a 1992 trip through Eastern Europe. I'm hoping to find them and when I do, I'll be sharing them here on Mindful Photos.
Don't forget to check out the 35mm page.
Is anyone still making film? Do you think it will make a comeback….like vinyl LP's? I loved the darkroom work I did in college in 1977.
Lovely photos. I should do a post with some of my Kenya/Tanzania shots…also 35 mm.
Thanks Michelle, glad that you like them. You can buy film on Ebay these days. A lot of it is out of date. I think there has been a bit of a film comeback with a trend called Lomography where people use plastic cameras and out of date film etc to see what the end results look like. Thanks for your comment. Always appreciated 🙂 I'd enjoy seeing your African pictures. Miles.
Hmm, need to do a post on my blog with the Africa pics which have already been scanned into my computer (from prints)….I didn't scan all of them, my safari in 2005 I shot 35 rolls of film. It took six months to afford to finally get them all processed….even at a "cheap" place.
I'll work on it. Of course it is mostly animals and landscapes.
Yes, digital is a lot less expensive, once you have bought the kit isn't it.
Indeed! It's that initial outlay that kept me from getting everything I needed before the 2005 trip. That and the fact that the safari lodges turn off the generators overnight while people are sleeping so no way to charge batteries!
I have a negative scanner if you want to borrow it?