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“THE MUD STILL ROLLS”: implications of compensatory reparations for the post-disaster health service in Brumadinho, MG Brazil

Janaína de Souza Aredes: http://orcid.org/0000-0002-4147-2405
E-mail: janainaaredes@gmail.com
Instituições de filiação: Instituto René Rachou - Fundação Oswaldo Cruz (FIOCRUZ Minas). Núcleo de Estudos em Saúde Pública e Envelhecimento (NESPE).
Cidade e País: Belo Horizonte - MG, Brasil.
Titulação: Doutorado em Saúde Coletiva

Sérgio Viana Peixoto: http://orcid.org/0000-0001- 9431-2280
E-mail: sergio.peixoto@fiocruz.br
Instituições de filiação: Instituto René Rachou - Fundação Oswaldo Cruz (FIOCRUZ Minas). Departamento de Gestão em Saúde – Escola de Enfermagem (UFMG).
Cidade e País: Belo Horizonte - MG, Brasil.
Titulação: Doutorado em Saúde Pública

Josélia Oliveira Araújo Firmo: http://orcid.org/0000-0001-5330-476X
E-mail: joselia.firmo@fiocruz.br
Instituições de filiação: Instituto René Rachou - Fundação Oswaldo Cruz (FIOCRUZ Minas). Núcleo de Estudos em Saúde Pública e Envelhecimento (NESPE).
Cidade e País: Belo Horizonte - MG, Brasil.
Titulação: Doutorado em Saúde Pública.

ABSTRACT
The present study aims to analyze the needs of health services after the tailings dam collapse disaster in Brumadinho, MG Brazil from the perspective of managers and professionals. This is a qualitative methodological study, based on 26 interviews guided by a semi-structured script. The data were processed using the content analysis technique, and the interpretation was mediated by the theoretical-methodological framework of hermeneutic anthropology. The study showed that both the process of obtaining compensation and its materialization had a major impact on local health services, both in terms of the emergence of new health demands and the work overload of professionals who had to handle situations beyond their designated jobs, involving porous limits of agreements and negotiations between the population and the company responsible for the disaster. The analysis shows the need to develop and equate strategies that consider the guarantee of rights without compromising the health and quality of life of those affected: those who care and those who are cared for. It is expected that this study’s results may support surveillance actions, health care, and future risk management in similar contexts.

KEYWORDS: Health Effects of Disasters. Mining. Health Services.

INTRODUCTION
The state of Minas Gerais (MG) has seen two of the most serious incidents related to mining dams in the twenty-first century. In 2015, a dam collapse disaster occurred in Mariana, MG, on the premises of the Samarco mining company, resulting in 19 deaths and dispersed waste that reached approximately 36 municipalities across 650 km of the Rio Doce Basin.1 Four years later, in 2019, in the municipality of Brumadinho, MG, the tailings dam at the Córrego do Feijão mine, managed by the mining company Vale S.A., broke. This tragedy resulted in more than 270 deaths and spread approximately 13 million m3 of waste over an area of approximately 18 municipalities in the Paraopeba River basin.2,3
Disasters are occurrences that culminate in a disruption and imbalance in the routine of a community, impacting its daily life with human, material, economic, environmental, and health losses.4,5 In Brumadinho, it was the largest widespread work accident ever to occur in Brazil, in addition to the various implications related to losses and damages that have caused a direct impact on the health of the local population.2,4 Therefore, it is clearly necessary to monitor the health needs of the affected communities so as to aid in the planning of existing health services, especially in cases of an increase in and emergence of new demands.5
Dam collapses and the consequent release of mining waste represent “a potential source of exposure to heavy metals” – by oral, inhalation, and dermal routes.3 It is also important to note that the years following the Brumadinho tailings dam disaster were mediated by the epidemiological scenario of the COVID-19 pandemic. These factors, in a chain reaction, can affect the demand for health services and result in an increase in medical consultations and hospitalizations.5 It is also well-known that the implications of a disaster are also related to an overload on the health service. In the first four months of 2019, there was a 63% increase in the number of services provided in Primary Health Care in Brumadinho, which required the additional hiring of more than 80 professionals.4 International studies6-8 indicate that, worldwide, disasters, whether natural or not, imply health problems. However, according to the literature consulted in this study, it is important to remember that the medium and long-term consequences, as well as the impacts on health, professionals, and services, still remain unclear.
Considering the above, the present study aims to analyze the main needs of health services in Brumadinho, MG after the tailings dam disaster from the perspective of managers and professionals.

METHODOLOGY
This is an exploratory study with a qualitative methodological approach9, which allows us to understand how the services work in order to identify potentialities and possible bottlenecks faced in practice based on the experience lived by the actors themselves in their sociocultural locus. This methodological approach was chosen because it is the most appropriate for addressing complex and multidimensional issues, such as those that permeate the implications of a disaster.
The study was conducted with managers and health professionals in the municipality of Brumadinho, MG, with preference being given to those who worked in the service before the dam collapse. Individual interviews guided by a semi-structured script, were used for data collection. This type of interview aims to explore a given problem in depth based on the interviewee\'s perceptions of their experiences and follows a guiding topic that covers the core themes of the study.9 In summary, the topics covered the following axes: report on professional performance; memories of the day of the disaster from the perspective of the health service; routine of health services before and after the disaster; impacts related to the pandemic; suggestion of mitigating measures for the impacts of the disaster on health services; among others.
The interviewees were selected using the chain or snowball technique, in which one interviewee suggests another because they consider that the latter can offer important testimony to the study.10 To identify the interviewees, the first step was to approach the highest-level managers through a visit and initial contact directly with the Municipal Health Department of Brumadinho, the department responsible for organizing all services and professionals in the municipality. This was an initial mapping exercise to understand the study area, which defined the developments and identification of subsequent interviewees.9
The final number of participants was determined by the empirical data saturation criterion. In this method, the interruption of data collection is defined based on successive analyses that occur simultaneously with data collection, one of the basic premises of qualitative studies.9 The interviewees were recruited by formal invitation via direct approach by the study researchers. All interviews were recorded, and, at a later moment, the audios were transcribed verbatim.
The textual excerpts were categorized and coded, enabling the identification of themes and subjects of greater relevance in accordance with the content analysis technique in the thematic modality.9 Based on this categorization, the following occurred: organization of the empirical data; critical reading and definition of the categories of analysis; and treatment of the results mediated by reflective analysis, inference, and interpretation. To ensure the validation of the analysis, the coding of the data was analyzed independently by different members of the research team in order to reach a consensus on the final categories.
The entire data analysis process was guided by the theoretical-methodological framework of hermeneutic anthropology.11 In this approach, the analysis is anchored in the interpretation of the meaning that social groups attribute to certain events, taking into account the sociocultural context of action, as well as the different factors that influence it.11
To ensure the anonymity of the interviewees, captions were used for the excerpts with the following information, respectively: order of interview, professional training, gender (F for female and M for male), and age. Since the municipality is characterized as an inland city, it was decided not to mention the work sector and hierarchical level of activity in the caption to avoid identifying the professionals. All of the participants read and signed the informed consent form. The study was approved by the Research Ethics Committee of the René Rachou Institute, FIOCRUZ-MG, CAAE: 74082223.1.0000.5091 and is in accordance with Resolution 466/2012 of the National Health Council.

RESULTS AND DISCUSSION
Between January and March 2024, 26 interviews, guided by a semi-structured script, were conducted, with 19 women and 7 men, aged between 29 and 65. Only three professionals joined the service after the disaster. First, according to the snowball technique10, contact was made with three initial seeds that unfolded into subsequent contacts, as summarized in Figure 1.
For the study participants, the needs of the health service resulting from the disaster were related to a common axis: investment in the city, which included the expansion of services, infrastructure, compensation processes, and income transfer to the population. From this main axis, two final categories emerged to be addressed in this article, namely: The process of acquiring money: the impact of declarations for the health services, and “It buffered, but did not solve”: the challenges of care in the face of the impacts resulting from money.

The process of acquiring money: the impact of declarations for the health services
The municipal health service was called upon to issue documents confirming its use by the population. Basically, two statements were requested at different times by the company responsible for the disaster: the first concerns emergency aid and the second concerns the compensation process. The emergency aid referred to the benefit granted by the company to all residents who proved that they had a permanent residence in Brumadinho and had used the health service before the tailings dam collapsed.12 Two professionals gave the following explanations:

We had to start making declarations of address and registration so that people could receive the money. It was a demand that came in, an order, and we had to comply. (...) We had to stay inside the health center, abandon our obligations of promoting health and prevention, and had to keep making declarations. (E09, ACS - Agente Comunitário de Saúde in Portuguese -, F, 56 years old)

Everything was out of balance, the entire service was disorganized, because the patient really wanted the declaration. All of this was the responsibility of Primary Health Care. The nurse had to stop the demand, or he would set aside a period of his schedule just to make these declarations, because it wasn\'t just a matter of signing. We had to confirm that the patient really lived there and used the PSF [Programa Saúde da Família in Portuguese]. (E03, nurse, F, 34 years old)


Later, in a second stage, there was the individual compensation process, in the amount of R$100,000.00 (one hundred thousand reais), which also had an impact on the health service, especially with mental health teams:

When the company launched this in 2019 through a TAC [Termo de Ajustamento de Conduta in Portuguese], it included this signifier, “emotional/psychological shock” which, in theory, means that you don’t necessarily need to have a mental disorder or a diagnosis, you just need to be shaken, to have suffered something due to the dam break. So, everyone started coming here to the CAPS [Centro de Atenção Psicossocial in Portuguese], to the PSF where the psychologists were inserted: “I’m feeling this and it’s because of the dam break”, and they demanded a report from the professionals supporting something that had to be related to mental health. Many private psychologists worked in a somewhat unethical way during this period, because the compensation was actually being paid, a report was enough. (...) So, before it was too open, so the company began to limit this diagnosis thing [CID F43.1 - Classificação Internacional de Doenças / Estresse Pós-tramático in Portuguese], it limited it a little, but not enough, because the psychologists, doctors in private practices, did everything, then the company understood what the logic was: if there’s money, there will be someone to do it, so it closed for good. The company stopped making out-of-court settlements, closed the deal, and said, “Now everything will be done through the courts, through the public prosecutor’s office.” (E22, psychology, M, 38 years old)

According to the report, individual compensation went through distinct phases mediated by absence, uncertainty, and porosity regarding the criteria to receive it. Chart 1 summarizes the implications of both benefits in various spheres of health care. The first axis Weakness in the criteria (Chart 1) corresponds to the limitations on the rules that supported the justification of the declarations that would be issued by the health service. This gap showed the difficulty for professionals to ratify documentation, and, at the same time, it brought some problems in the health service routine, such as a loss of nurses\' stamps, cases of false signatures, and, consequently, pressure on the health service professionals. This scenario led to the Breaking of bonds and line of care (Chart 1), which concerns conflicts between professionals and users, mediated by threats, harassment, and team reassignment.
The health service then had to deal with Nuances of the (dis)association between illness and the guarantee of rights (Chart 1), covering sensitive issues, such as secondary interests, and seeking health services only for the purpose of proving its use. On the one hand, emergency aid required the use of health services; on the other, compensation depended on the need to verify an illness, as this mental health professional explains:

It distorted all of our work, because people were suffering; we could see that they needed care, but they wanted the report to guarantee their rights. Since these compensations have been dragging on to this day, many people have not been able to get them and are undergoing expert assessments with psychiatrists. So, the psychiatrist asks for the entire CAPS medical record, for example, to assess whether the person is still affected, but it\'s been five years! Because he associated the guarantee of rights with a mental illness. For your rights to be guaranteed, because you were shaken by the situation you experienced, you had to have an CID, and the shock does not mean an illness in itself. For example, there were people who said “look, I had to leave my house, the civil defense came here and took something away from me, but I need to have a report with CID F43.1, because otherwise I won\'t get the R$100,000.00 compensation”. (E13, psychology, F, 32 years old)

The demand for reports relevant to compensation covered complex situations, such as the request for documents by people with and without previous mental disorders, or disorders not necessarily linked to post-traumatic stress (criterion), factors manifested in the daily routine of professional practice:

Then you create another feeling, which is anxiety, and then it seems to freeze the other mental health condition again, it doesn\'t flow (...). When we go to the region, to the matrix support, we see increased anguish: “oh, because my neighbor bought a new car, his son has a cool cell phone. Because they received the money, I didn\'t, because the health department didn\'t want to give me the report”. It seems like the person stops and that life will only get back on track when this is resolved for them in the judicial sphere. We identify this very well, sometimes it\'s a patient with a circumstantial demand, with a very demanding attitude, a feeling of hostility, who is never good, the service isn\'t good, nothing in the network is good, nobody helps me, but you see that it\'s a citizen who is stuck in this process, while he doesn\'t have an answer for himself. (E23, medicine, M, 32 years old)

The interviewee\'s speech reveals a feedback in the patient\'s health conditions, which in some cases leads to the worsening of another previous condition for which the patient was already being monitored at the unit. In line with these aspects, the professionals report the specific context of Brumadinho, in which compensation processes permeated the routine of the health service:

It\'s a boring job, because you have to deal with things that are a bit outside of your clinic\'s scope. I have to make a diagnosis, but there\'s no diagnosis! There\'s none. And then there\'s that thing about the patient wanting it, this wear and tear, old patients, with whom you\'ve established ties, asking for a transfer to another professional, because you don\'t give them what they want, as if we\'re the ones who are harming them, it\'s no longer the company, it\'s us who are harming them. (E23, doctor, M, 32 years old)

The data reveal a myriad of factors that affected the health service. This sector was called upon to go beyond its role in promoting health care, and professionals had to mediate situations that were outside their scope of responsibility, especially when it came to taking responsibility for bottlenecks in the compensation process. As a result, care delivery was compromised, conflicts were created, and workers were overworked.12
Based on the above, both emergency aid and compensation had direct implications upon the routine of the service at different levels of care. However, other impacts emerged after obtaining financial resources, as will be explained in the next analytical category.

“It buffered, but did not solve”: the challenges of care in the face of the impacts resulting from money
This category presents the various implications arising from the completion of compensation processes, especially in mental health claims:

For example, we soon had emergency aid, which guarantees rights, but it was retroactive, so five months after the incident, people received around R$5,000.00 (five thousand reais). Suddenly, boom: R$5,000.00 in your account! In a city in the countryside. So, there was euphoria, confusion in this city, people buying a lot of things, and it was a mess to get this benefit. This gave a boost to the situations that are more like mania (...). These values entering people\'s lives, this duplicity: I am suffering the loss, but I have the possibility of starting my life over in a different way, but I am still very involved with the tragedy. (E13, psychology, F, 32 years old)

The post-disaster context highlights the reparation in the municipality, manifested in works, agreements, reparations, compensation, aid, among others.13 However, at the same time, professionals identified an important gap in terms of planning these actions, which has resulted in the emergence of new social demands with direct repercussions on health, as shown in the following excerpts:

This tragedy that we see after the dam break related to this benefit today is alcohol and drugs. In the past, when someone in the family group started to abuse drugs and couldn\'t maintain the habit, the person would start taking things out of the house, selling a television, and then the family would be alerted to seek help. But today that doesn\'t happen, today people have addictions, they don\'t have debts, because they can support themselves. The same thing with alcohol, before, people had to work during the day, do any job to be able to drink, which would even reduce the damage. Today, they can\'t reduce the damage because they don\'t work. Today, they can maintain their addiction, so these diseases and more serious syndromes are arriving in younger patients, drug users with heart problems, having heart attacks before the age of 30. It was a tragedy for us to hear things like: “the mud still rolls”. It\'s a tragedy that has been slowly coming, it\'s still silent even after the dam break. (E05, nurse, M, 43 years old)

It seems that because there was a lot of money circulating and involved in the whole story, the person\'s mental health was not normal. The person thinks "I can do anything. I can buy alcohol, drugs. I have the money", because it was a very needy community and suddenly the issue of money arises. (E14, nurse, F, 50 years old)

For the interlocutors, investment dissociated from financial education for the population is the root cause of these social problems. The characterizations of this demand presented by the professionals (Chart 2) include:
• (Lack of) money as a protective factor: refers to the increased demand for alcohol and other drugs due to the money circulating in the city due to the compensation and income transfer processes promoted after the tragedy. Professionals report that this demand was rare and/or non-existent before 2019. Based on their practice, they observe an absence of this patient profile in the first business days of the month and the fact that they seek health services around the 10th and 15th of the month, associating this scenario with the monetary value credited on the first business day of the month. In turn, they relate the lack of money as a protective factor in the use of substances and, as a consequence, a characteristic that would favor early intervention and greater chances of successful care (Chart 2).
• Changes in the consumption profile and clinical cases resulting from use: after the tragedy, consumption of more expensive substances, cocaine, and beer. As a consequence, withdrawal crises give way to intoxication and serious conditions, which have required hospitalizations and made early intervention difficult (Chart 2).
• Social vulnerabilities: factors related to substance use are reported, such as drug trafficking and its implications for the use of health services. At the same time, there is the fact that people stop working because of money. In this second point, the interviewees attribute factors related to the guarantee of a fixed income, which in turn has favored idleness and the lack of search for work, as well as the situation of the tragedy itself in which people seek the use of substances as a treatment resource (Chart 2).
International studies indicate that, worldwide, disasters, whether natural or not, lead to the onset of mental disorders, increased alcoholism, smoking, consumption of other drugs, among other similar events.6,7 In addition, vulnerabilities that already exist in the community are further exacerbated, as they are added to new risk scenarios related to environmental and health implications.14 However, no studies were found that made a direct association between the acquisition of financial resources after a disaster and the increase in the consumption of alcohol and other drugs, as elucidated in the empirical data.
By extension, those who have already received all the compensation processes return to the health service, as this professional explains:
It is interesting that, after some people received the R$100,000.00 in compensation, they return for treatment, distressed, now able to talk about what they experienced. Because, even unconsciously, in the subjective field, there was hope for that, for those life projects that come from the money, they thought that it would help with the anguish of this tragedy, to give them a buffer to deal with the loss. “It buffered, but did not solve” (...). We have alcohol and other drugs that we understand, which are also for remediation, we’ve studied this a lot, and then we have research that says that patients who do not take care of themselves, or do not take care of their mental health, sometimes use alcohol and other drugs as a treatment resource. (E13, psychology, F, 32 years old)

In addition to these issues, the impact of the disaster may, in a cascading effect, increase the incidence of chronic diseases, as well as increase mental disorders, such as depression and anxiety,8 resulting from feelings of discouragement and uncertainty beyond the dam break itself, but also from the implications of the event, such as the company\'s liability and punishment for the damage caused to the population, the environment, and the city.15 In addition, studies2,13 indicate that the agreements regarding the municipality\'s reparations, as well as individual compensations, were not made harmoniously, reinforcing other interests to the detriment of the needs of the affected communities.
All of these factors and contexts had a direct impact on the health service and demanded a delicate and porous performance from the worker. One professional points out the following:

It\'s pressure from managers, from employees, the way they talk, it\'s coercion, like: "Where\'s the money? Aren\'t you working well?" It\'s harassment. (...) It\'s created anxiety in the population that the [company] gave a lot of money, so everything has to work 100%. So, this has also created a crisis for people who work in health, because it\'s pressure all the time. We can\'t say no to anyone. (E18, nursing, F, 40 years old)

In turn, professionals recognize that post-disaster needs go beyond financial investment in the health sector and consider another perspective concerning the emerging demands:

A serious problem that I see and realize is that they have directed the actions of improvements to a health structure. For example, there are medicines, there are exams, there are professionals, there is a structure if the person gets sick. But, the way things are going, the focus is on health, people want health, mental health and so on, and it spills over into the service, because then the idea is created that the solution lies with the health service, for problems that go far beyond that. So, if the teenager started using a substance because he is a little loose, without much to do, there is no offer of anything, the family will understand that the one who has to solve the problem is the doctor or the psychologist, and sometimes even the professional also falls into this illusion that the patient\'s problem can be solved with some type of medication. (...) So, what is the suffering? Is it the suffering of someone who needs to be stimulated, needs to leave the house, go to some activity, or is it in fact a disorder, a pathology that requires medication? You will see that most of it is suffering and this turns into a demand for PSF, etc. (...) In some ways, it\'s almost as if the health professional is the last place the patient turns to, so when he does, things that are not related to health fall on the health professional. (E22, psychology, M, 38 years old)

It is important here to consider the concept of social suffering, which goes beyond biomedical analysis, encompassing sociocultural aspects that permeate the daily lives of the population affected by the event: “Such aspects are related to the intersection between physical events and the way in which affected groups react to them, to the forms of dialogue required of them, on the one hand; and, on the other, to the way in which corporate and public agencies respond institutionally to their demands”16 (p. 38).
At the same time, it is important to emphasize that the agreement for reparations in the municipality was considered the largest ever made in Latin America and one of the largest in the world.13 By extension, the disaster itself favored the organization of the municipality\'s health services, as well as care strategies.12 However, at the same time, this investment in health brought about an accountability of this sector and of the professionals who work in it beyond their objectives and attributions.
Within the restructuring of the health service, one area of care stands out in the municipality: mental health. It was fully expanded, at the different levels of care, as summarized in Figure 2. Before the disaster that occurred in the city, all demand related to mental health was absorbed only by the Psychosocial Care Center (CAPS Centro de Atenção Psicossocial - in Portuguese), in mode I, intended for municipalities or health regions with a population of over 15,000 inhabitants.12 After the disaster, CAPS was restructured to level II. Although this mode is indicated for municipalities or health regions with a population of over 70,000 inhabitants,12 in Brumadinho, its inclusion was authorized outside the criterion due to the context of the tragedy. In addition, other expansions were made at the different levels of care, including pre-hospital and per-hospital care (Figure 2).
It is important to consider that there was a forecast of an increase in demand for mental health after an event of this magnitude. The restructuring aimed to provide greater agility and precision in terms of identifying demands within the affected population.12 At the same time, the emphasis on this sector also brought other implications and, therefore, must be analyzed with caution, as two mental health professionals explain:

After the dam break, what was the most stimulated field? It was the field of mental health. There are psychologists everywhere, there are psychiatrists everywhere, so the population also bought into this idea. So, this links all their problems, all their suffering to the service. The idea that was sold, and the population bought into this idea, is that I have to be treated and my suffering is treated by a doctor, a psychologist, and psychotropic drugs. Suffering is not necessarily diagnosable. If not, the service will always work at maximum capacity, because the population will always be suffering, but the population does not understand that this suffering is not a mental health suffering, of depression, anxiety, schizophrenia. It is like you go out the door of your house, there is a truck, then you go get in your car, a journey that used to take 15 minutes now takes 50 minutes. And you do not associate your emotional and mental state with your daily life. And then you go to the PSF, they don\'t solve it, then you go to the CAPS, you go to the doctor to get a medicine to improve your life and then it becomes chronic. The suffering is not treated, it becomes chronic. So, it\'s almost like high blood pressure, he will always be a patient of that service, he will always be irritable, from time to time he will be anxious. He doesn\'t progress, what could perhaps improve, the health service can\'t solve, such as where he lives, how he gets to school with his son, how he gets to Belo Horizonte, because he works there. And people can\'t make these associations, that we don\'t treat all suffering with a psychiatrist, with a psychologist. We treat it in other ways, so if there isn\'t this different perspective, it won\'t get out of this: a city of mining only. (E22, psychology, M, 38 years old)

I imagine it would have been much more beneficial if all the things that were implemented after the collapse had been discussed and explained to the population. Because the population was not heard. It was more interpretative, not to say imposing: “it seems like they need this.” Without asking, without bringing it up for a more in-depth dialogue about what they really need. The issue of vehicle flow in the neighborhood itself, the interruption of roads that allowed easier access to other parts of the city or to other communities that no longer exist. If the flow of vehicles is diverted to another point that does not pass through the community, or if these roads are reopened that allow this access that once allowed better contact between one community and another, all of this, in my opinion, contributes to an improvement in the population’s experience of well-being with the region, with space, and, at the same time, there is an improvement in people’s mental health. (E12, psychology, M, 38 years old)

Another consequence of the disaster is deterritorialization, as it brings substantial changes to the community – material and symbolic losses and health problems – changes in living conditions and increases in existing vulnerabilities.17 Although the reparation process involved the community and the health service,15 professionals point out that there was no effective listening and participation that considered the demands of those who live and work in the territory. In this sense, they emphasize the need to think of reparation strategies as part of a project for the community, which includes actions to promote health and physical activities, encourage events for socialization in the community, among others. Above all, actions that consider the territory beyond a geographic delimitation: as an intersubjective space of belonging and meaning.17 This would imply favorable impacts on health conditions, which would also minimize the emergence of other social demands after the event.
By way of summary, a schematic diagram (Figure 3) is proposed that aims to combine the various aspects involved in the relationship between compensation processes and health services. From a socio-anthropological perspective, the concept of sociotechnical disaster18 helps to understand the repercussions beyond the dam break itself. In this concept, the disaster is not reduced to its purely technological nature, but rather encompasses factors of a social, economic, territorial, and political nature. This diversity of factors that had a confluence in health reveals the multidimensional nature of the event.
It is clear that the health service is involved in a process with complex boundaries, in which the guarantee of compensation is directly linked to an illness and the use of the health service. The professionals were in constant contact with insurmountable situations that needed to be nuanced in the daily routine of the service. In turn, the same compensation process, after acquisition, implied the change of a specific demand in the use of the health service, reported by all interviewees: an increase in the consumption of alcohol and other drugs.6,7 In the context of Brumadinho, the reports show a dissociation between this guarantee and the proper financial education within the community, which resonates in the living conditions of the population and in the health service itself.
All of the factors involved in the compensation process had repercussions as a source of direct and indirect illness for all of the actors involved, both users and health professionals. The data reinforce the need for planning in light of the macro-social impacts of the event and, above all, the definition of the roles of each sector in terms of compensation processes and other programs aimed at compensating damages resulting from the event. It is clear that reparations are crucial,4 however, the financial axis dissociated from planning and identification of local needs implies more problems than solutions. The reports show that the repercussions on health are just the tip of the iceberg given the diversity of intertwined factors.
It is also important to note that, on a global scale, there has been an increase in disasters, both natural and technological, which constitute a serious public health problem. Due to the impacts they cause – short, medium, and long term – which reinforces the need for risk management of these events together with governments, the health sector, and a raised awareness of the affected population.3 By extension, due to the complex context, it is necessary to consider the various actors and fields of knowledge in order to identify demands. Based on this diagnosis, reparation actions and priorities in the allocation of resources must be developed, considering the meeting of demands applicable to another sector.1,19
Health needs include sociocultural factors, deficiencies, and vulnerabilities beyond the biomedical perspective – diseases, risks, and health problems. In this sense, the analysis of these aspects enables the formulation of protocols and guidelines for health services based on a more coherent approach to the therapeutic process.1 It is important to note that health professionals and managers are identified as key actors in risk management, as well as in the recovery of the living and health conditions of victims. However, structural issues require detailed analyses to support the actions of these actors in reducing damage resulting from disasters. The impacts mentioned are multifactorial and reflect the need to review legal frameworks and strengthen the responsible public bodies.4,14
For the health service, there are still other challenges and demands that were not explored in this article due to the limitations of its scope, among which are the (re)organization of services in view of surveillance actions regarding heavy metals, impacts on worker health, changes in the dynamics of the city with implications for health demands, among others.

FINAL CONSIDERATIONS
A disaster is not limited to deaths, destruction of property and the environment, illnesses, and immediate injuries. In addition to the more obvious implications, the event will result in changes in the daily lives of a community and, by extension, will have impacts on living conditions with short, medium, and long-term effects on various spheres of society, including the health sector.
This study showed that both the process of obtaining compensation and its materialization had a major impact on the health service, a sector that was at the intersection of a process surrounded by porous boundaries involving agreements and negotiations between the population and the company responsible for the disaster. Professionals were responsible for mediating situations beyond their duties in the health field, which resulted in, among other factors, an overload of work.
The analysis shows that it is necessary to identify the causes related to the impacts resulting from a disaster so that mitigating measures can be implemented effectively for all those involved, in other words, to develop and consider strategies that consider the guarantee of rights without compromising the health and quality of life of those affected.
It is expected that the results presented in this study can support surveillance actions, health care, and future risk management in similar contexts.

ACKNOWLEDGEMENTS
We would like to thank the Department of Science and Technology of the Department of Science, Technology, Innovation, and Strategic Health Inputs of the Ministry of Health for their funding and the Municipal Health Department of Brumadinho for all their support throughout the data collection process. SVP and JOAF are CNPq productivity fellows.



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