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Conteúdo (article):

Vítimas indiretas da violência: um olhar sobre os impactos na saúde
Indirect victims of violence: a look at health impacts

Full name: Bruno Costa Poltronieri
Institution: Instituto Federal de Eduação, Ciência e Tecnologia do Rio de Janeiro (Federal Institute of Education, Science and Technology of Rio de Janeiro)
Email: bruno.poltronieri@ifrj.edu.br
ORCID: 0000-0002-2127-0574

Full name: Edinilsa Ramos de Souza
Institution: Fundação Oswaldo Cruz (Oswaldo Cruz Foundation)
Email: edinilsaramos@gmail.com
ORCID: 0000-0003-0903-4525

Full name: Rayana Tavares de Oliveira Bueno
Institution: Fundação Oswaldo Cruz/Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (Oswaldo Cruz Foundation/Fernandes Figueira Institute)
Email: buenorayana@gmail.com
ORCID: 0000-0003-1440-560X

Abstract.
We sought to investigate the perceptions of indirect victims or family members of homicide victims, about the repercussions of these deaths on their health. A qualitative, exploratory, descriptive study was carried out, based on eight semi-structured individual interviews with two groups: family members of police officers victimized by lethal violence, and family members of people killed as a result of police intervention, designated here as homicide. Both groups reported the perception that their health deteriorated after the homicide, and mentioned problems such as depression, panic disorder, insomnia, heart conditions and eating disorders. They also highlighted the acquisition of habits that are harmful to health, such as the consumption of alcoholic beverages, tobacco and self-medication, and the worsening of pre-existing health issues. It was observed that the homicide committed and suffered by police agents affects various aspects of the lives of indirect victims that are inseparable from health issues in a broader sense. These people are also victims of this violence, although their suffering is often made invisible. Studying this topic helps to give space to the suffering and mourning of these people and to subsidize the best performance of the institutions and services involved in the attention, care and reception of these family members.
Key words: Violence; Homicide; Victimization; Impacts on Health;

INTRODUCTION
Violence has been the subject of public health studies in Brazil since the mid-1970s and 1980s, due to the growth of epidemiological indicators of external causes (accidents and violence). These events represented the second leading cause of death in the country, and young people were the main victims. At the time, the economic, social, political and family impacts of violence were already highlighted1.
Homicide, the ultimate expression of violence, is a lethal event in which the life of another is intentionally taken. It is a problem of interest to the areas of Public Security, Justice and Health. In the last-mentioned area, it constitutes the subgroup Aggression, in the large group of deaths from External Causes, according to the International Classification of Diseases (ICD-10 revision). In Public Security, it has been analyzed as Intentional Violent Death (MVI), a category consisting of intentional homicide, robbery (robbery followed by death), intentional bodily injury followed by death, and death resulting from police action (legal intervention). In Brazil, the homicide death rate peaked in 2017, followed by a decrease in 2018 and 2019. However, the downward trend did not continue in 2020, when 50,033 homicides were recorded, with a rate of 23.6/100,000 inhabitants2, which demonstrates the magnitude and relevance of the issue.
Among the alarming numbers of homicides in the country, deaths involving police officers, either as victims or perpetrators of violence, stand out. In 2020, the country had 6,416 fatalities from police interventions, the highest number since 20133, when this indicator began to be monitored by the Brazilian Forum on Public Security. The other side of this reality is police victimization. In 2020, 194 police officers were killed by Intentional Lethal Violent Crimes (CVLI) across the country, showing an increase of 12.8% over the previous year. Among the victimized police officers, 51 were killed on duty and 131 killed off-duty4. These data show that the number of homicides caused by the police is 33 times greater than the number of police officers killed5.
The profile of lethal victims of police action and victimized police officers is very similar. Most of them are men, black, young, and poor3, demonstrating that issues of gender, race, and social class are characteristics that intersect and increase the risk of dying violently6.
Lethal violence generates not only direct victims, those who die, but also the so-called indirect victims, hidden victims, or survivors of homicide7. Indirect victims are generally part of the direct victim\'s social circle, with or without blood ties, and suffer significant effects from the violence perpetrated8.
It is estimated that for every victim of lethal violence, there are at least three people deeply affected by the impacts of homicide on their lives9. These impacts reverberate on health, cause, or worsen illnesses, worsen the quality of life, and well-being of these people. National and international studies point to health effects such as: labyrinthitis, anorexia, obesity, insomnia, increased smoking and alcohol consumption by family members of the deceased person, heart disorders, increased stress and phobias, hypertension, diabetes, and panic attacks10–14.
Actions of care and attention to the damage caused to indirect victims are topics that are rarely addressed or discussed. In many cases, family members and people close to them do not see themselves or are seen as victims of violence7. Therefore, this study focused on investigating how indirect victims perceive the repercussions of lethal violence on their physical and mental health and, to this end, approached the family members and people close to those who lost their lives to violence.
The theoretical foundation was based on the concept of social suffering15, which recognizes that human suffering is influenced by several social, cultural, economic, and political factors, in addition to biological factors. This allows the analysis of social structures impact on the experience of mourning by individuals and communities. Furthermore, Butler\'s16 theories about unrecognized mourning and non-grieving people were incorporated. The author highlights how some lives are considered worthy of mourning, while others are not recognized as worthy of such recognition. This manifests itself through the dehumanization and denial of public mourning for certain groups.

METHOD
It is a qualitative, exploratory, descriptive study that investigated the perceptions of indirect victims about the repercussions that the violent death of a relative or close person has on their health. To this end, family members of people killed by police officers and family members of police officers killed by violence were approached.
The qualitative methodology was used because of the possibility of studying the stories, representations and interpretations that social subjects make about how they live, feel and what they think20. Therefore, investigating the effects of homicide involving police officers on the lives of indirect victims, through their statements, is also a way of giving visibility to those who have lost a loved one, but are invisible in statistics and public policies aimed at reducing the impacts of violence on health.
The study participants were located from associations and groups active in social movements of family members and friends of victims of police lethality, and family members of victimized police officers, in the city of Rio de Janeiro.
In the initial contact with these actors, the "snowball" technique was used21, and they were asked to indicate other people with this experience of loss and interest in participating. This technique is useful for researching hard-to-reach groups, in which the inclusion criteria are not socially explicit. And to study sensitive issues, of a private nature, which require the knowledge of people belonging to the group or who are recognized as informants, in order to locate them21.
The inclusion criteria were: living in the city of Rio de Janeiro, being over 18 years old, having a relative/acquaintance victimized by lethal violence involving police officers, and having occurred at least 2 years ago; due to the need for time for the elaboration of mourning, and the study to analyze this perception regarding the emergence or worsening of health problems in the participants22.
Eight family members met the criteria and agreed to participate. They constituted two groups: relatives/close people of police officers who were victims of lethal violence (group 1), and relatives/close people of people victimized as a result of police intervention (group 2).
Group 1 was composed of three women, two self-declared white, and one black, with ages ranging from 41 to 71 years; all of them had a college degree and were the mother, mother-in-law or sister of a slain police officer. Regarding the agents, two were men, military police officers, and one was a woman, a civil police officer. Two direct victims were described as black, one as white, aged between 24 and 51. The homicides of the military police officers occurred in the course of their professional activity. The civil police officer was killed during his time off-duty for having been identified as a police officer in a robbery; she was pregnant of her first child. The deaths occurred in neighborhoods of the city of Rio de Janeiro or in municipalities in the metropolitan region of the capital.
Two interviewees in this group had other experiences of violence and mourning involving police officers. One of them is married to a military police officer who was shot on his way to work, and another had a military police officer boyfriend murdered.
Group 2 was composed of four mothers and one father, most of whom declared themselves black, aged between 42 and 58 years. Two participants had a college degree. The victims of the lethal violence were described as young, black men, aged between 16 and 29, and a 2-year-old boy. Most of the deaths occurred in police operations carried out in poor neighborhoods and shanty towns in Rio de Janeiro, such as Manguinhos, Alemão, Acari and Maré. One of the deaths occurred in the unit where the victim was serving a socio-educational measure. Most of the perpetrators were military police officers, but in one case they were a prison officer, and in another they were a soldier in the Brazilian army, whose victim survived with severe permanent sequel, which drastically changed his life and that of his mother.
Semi-structured individual interviews were conducted in locations chosen by the participants, respecting their privacy. They focused on various aspects of their lives, such as: their life history, perceptions of the impacts of lethal violence on their lives, and the resources and social support used to deal with what happened. The interviews lasted about an hour and thirty minutes; have been recorded and digitized. All participants signed an informed consent form.
The material was submitted to thematic analysis, which includes reading and interpreting the content of the interviewees\' discourse23. Through this analysis, it is possible to find answers to the questions formulated and, confirm or not, the hypotheses that were previously established. This article focused on the impacts of the death of a relative/close person on the health of indirect victims, among the topics addressed in a parent research. The health category was analyzed through three subcategories or subthemes: physical illness, mental illness, treatments and medications.
The original research was submitted to and approved by the Research Ethics Committee of the Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente (National Institute of Child, Women\'s and Adolescent Health) – Fundação Oswaldo Cruz IFF/FIOCRUZ, under opinion no. 3.420.525, of June 27, 2019.

RESULTS
IMPACTS OF HOMICIDES ON THE PHYSICAL HEALTH OF INDIRECT VICTIMS
I\'ve had numerous diseases ending with "itis": gastritis, sinusitis, labyrinthitis
(Mother of civil police officer killed while returning home)
Physical health problems are the most easily recognized and cited by indirect victims. Among these, the most reported refer to the cardiovascular system, such as: uncontrolled blood pressure, hypertension, tachycardia and feeling of infarction, even among people who did not have any of these problems previously. Two participants reported severe occurrences, such as Cerebral Vascular Accident (CVA) and cerebral aneurysm, with sequel.
Gastritis, lack of appetite, change in eating habits, and weight loss or gain also appeared frequently in the reports. Other changes such as hair loss and weak nails, contractions in the abdomen, muscle spasms, cold sweat with cold skin and migraine were mentioned. There were also reports of the emergence of chronic diseases with a major impact on the lives of participants, such as diabetes and labyrinthitis.
All those interviewed realized that their health worsened after the incident. Some reported the worsening of pre-existing problems after the homicide. The explanations for the illness were diverse: some pointed out that the feelings of hatred and injustice arising from this death contributed to it; others reported that, although they appeared to be well, they felt sick inside; They also mentioned changes in eating and sleeping habits, which also affected their health.

My health went from bad to worse, right? Everything acquired later. We get sick. We don\'t see justice for what happened, we end up getting sick (Mother of young man killed by UPP police officers in Manguinhos).
I had gastritis. I reached almost 90kg. I ate, ate, ate, ate desperately (Mother of a civil police officer killed while returning home).
Some reported having acquired habits that were harmful to their health, such as drinking alcohol and tobacco. One interviewee reported that, after her son was killed by a police officer, she started smoking again after 15 years of abstinence. However, this return was not described as something harmful to your health, but rather as something that distracts you, helps pass the time and fills the void.

I stopped smoking when my youngest was born. Then, after he passed away, I started smoking again. It was the only thing I managed to get through the night. Sometimes I stay at the window smoking, looking at nothing, at silence (Mother of young man killed by police officers in Complexo do Alemão).

The indirect homicide victims expressed suffering when talking about the health problems that affected them, mainly because they understood that they were consequences of the death of their loved one and all the changes that occurred in their lives after this episode. Many interviewees stated that the grieving process, the change in their view of the world, the focus on fighting for justice or on caring for other children and family members, caused them to neglect their own health, which may have contributed to the emergence/worsening of diseases.

IMPACTS OF HOMICIDES ON THE MENTAL HEALTH OF INDIRECT VICTIMS

In the first year of my son\'s death, I thought about dying every day (Mother of a young man killed by police officers in Complexo do Alemão).


The impacts on mental health are more difficult to verify and measure, but they were also reported by the interviewees, whose main complaints were suffering after the death of a loved one, the difficulties experienced in the grieving process, the difficulty of feeling good or happy, and changes in the way of living.
Feelings of sadness, depression and disorientation were reported, with mourning constantly updated, no matter how much time has passed since death, as they relive the event frequently. They also mentioned a huge feeling of emptiness, darkness, loneliness, and death in life. They all said it was not possible to return to the "state of happiness," or to have the same outlook they had on life before their loved one\'s death.
I really thought that way I would reach the level of madness with the death of my daughter (Mother of a civil police officer killed while returning home).

Today I remember a lot of what happened every day, every night. I still cry every night (Mother of a young man killed by police officers in Complexo do Alemão).

Problems of anxiety, stress, constant fear in daily life, and fear of going crazy, of not being able to bear the suffering were mentioned; a diffuse fear that something may happen to them or to other family members, promoting a state of alert and a sense of constant risk.
One of the interviewees reported having been diagnosed with Panic Disorder the year after the homicide, and still had the same symptoms at the time of the interview, four years later. She described symptoms of tachycardia, chest pressure, sweating, chills, shivering all over her body, and fainting spells that progressively affect her. Another participant, whose son survived the attempted murder by an army soldier, said she developed Obsessive Compulsive Disorder after the incident. Everyday activities, such as riding the bus or going on family outings, became tense moments.
Tension, unfortunately. It\'s strange... Even on the bus, the other day, a guy came in that I felt was going, I saw the bulge on his waist, I got off. I knew he was at risk of robbing the bus (Father of a child killed by military police during an operation in Acari).
Five participants reported sleep-related problems, including interruption, constant insomnia, and hypersomnia. They also began to have exacerbated emotional reactions, with feelings of deep anger and constant revolt, aggressiveness when dealing with people, willingness to become criminals and ally themselves with illicit activities, desire to buy weapons, desire to kill the perpetrator of the homicide, feeling that there is nothing left to lose, in addition to the immense desire for revenge as the only motivation in their lives.
Instead of sleeping eight hours, I slept twelve hours! I didn\'t even wake up. People even thought I was dead (Mother of a civil police officer killed while returning home).

It\'s gotten into my brain, I can\'t sleep more than two or three hours only. I hear fireworks inside the favela, gunshots, I get up. I\'m already scared (Father of a child killed by military police in a police operation in Acari).


Participants in both groups reported that they feel constant fear that something will happen to them. However, the relatives of the victims of the police interventions speak as if they have nothing to lose, since the worst has already happened: the murder of their loved one. The interviewees in this group, committed to activism for the memory of their children and justice for what happened to them, show that they have broken the barrier of fear, speaking out about the issue and fighting for the direct and indirect victims of this violence.
In the group of family members of victimized police officers, participants showed resistance and fear when talking about the subject. They reported the feeling of being watched, themselves and their families, and fear of becoming the target of the perpetrators of the murder of their loved one, creating a state of tension and constant alert, even when they are inside their homes.
This is my life, this is my routine, this is too normal. Sometimes, I avoid being alone. That\'s a fact, I\'ve always had that, since then. I\'m here alone, then I think there\'s someone watching me, I come to see and it\'s no one (Mother-in-law of a military police officer killed in an operation in Jacaré).

USE OF MEDICATIONS AND TREATMENTS AS RESOURCES TO ALLEVIATE SUFFERING AND DISEASE

I think I\'m overloading my liver with so much medicine (Mother-in-law of military police officer killed in operation in Jacaré).

Participants reported that they started using medication for heart problems and blood pressure. They also mentioned the use of tranquilizers, migraine medications, and sleeping pills. Self-medication is frequent in their statements.
Several indirect victims have become drug addicted due to the suffering and illness after the homicide, and bear the adverse effects that medicalization can bring, including the worsening of health problems.
I\'m the migraine medicine freak. My husband says he can\'t stand buying Naramig anymore. It was a colleague from my work who informed me. (Mother-in-law of a military police officer killed in an operation in Jacaré).

Regarding tranquilizers and psychiatric drugs, two distinct views were reported.
On the one hand, the idea that the drug was the main help in dealing with depression, being seen as essential in the treatment to overcome the pain and suffering of the loss, even if it was not prescribed by a health professional. On the other hand, there seems to be some resistance from some interviewees in relation to the use of this resource.
On the day my son was murdered, after they took me out of the UPA [Emergency Care Unit] and took me to my sister\'s house, people wanted to give me tranquilizers, but I locked my mouth. I wanted to be clear-headed. I was afraid of getting drugged (Mother of a young woman killed by UPP police officers in Manguinhos).

Most participants reported doing individual psychotherapy. Some attend therapeutic groups. One does group psychotherapy, mediated by psychologists, and aimed at family members who have had children murdered by state agents.
Those who mentioned serious health problems, such as stroke, stated that they attend appointments and receive regular medical treatment. Others reported that they often see at least one doctor.
The data show that the impacts of homicide on indirect victims, in some way, end up reaching the Health System, even if there is no clear and direct relationship between the death of the family member and the search for the service.
I say that my treatment is together with the mothers. Because I was being treated by a psychologist. He worked at the Clínica da Família, but he left. What I do with mothers is my therapy (Mother of a young man who became paraplegic in an attempted murder, perpetrated by soldiers of the Brazilian Army, in an operation in Maré).
It is interesting to note that the indirect victims mentioned as therapeutic actions the struggle for justice, for the recognition of their rights, for the memory of their loved one, as well as the support of activist groups for these rights.
DISCUSSION
The findings of this research showed that indirect victims of lethal violence perceive several physical and mental health problems that may have been triggered or intensified by the death of their loved one, and which remain years after experiencing this violence.
Studies with indirect homicide victims also point to the emergence of health problems such as hypertension, insomnia, memory loss, gastric and cardiac changes, and diabetes7,10, with serious consequences for these people\'s quality of life. Many of these problems, in addition to other cases of severe illness, were reported in this study, which indicates a pattern in illness perceived by indirect victims.
Most health studies on indirect homicide victims seek to investigate the psychological distress caused by violent death and its consequences on the mental health of family members7. The context of emotional disorganization favors the intensification of habits that are harmful to the health of family members. They tend to increase the intake of alcohol and other substances, due to everyday situations of great stress, which can induce dependence and its undesirable effects. Various emotions and great suffering have been reported here as having arisen or intensified after the homicide, with damage to mental health.
People who have lost a family member or friend to homicide have up to twice as many people
of chances of developing Post-Traumatic Stress Disorder (PTSD)7,9,10,24,25, compared to those who did not go through a similar situation. Often, their mourning is closer to a PTSD than to a natural grieving process26. However, during the interviews, PTSD, specifically, was not investigated, and none of the participants reported having received such a diagnosis.
The indirect victims of this study also reported feelings such as sadness, aggressiveness, anxiety, and somatization. Vieira et al14 stated that: "When human beings internalize negative and controversial feelings, their health is compromised, because they begin to somatize their guilt, their fears, their anguish, and their secrets (p.1777).”
Emotions have a social and cultural character and are manifested and expressed in the body. In this sense, the concept of Social Suffering18 (p.99) is used, which "results from what political, economic and institutional power produces in people and, conversely, from how these forms of power influence responses to social problems". Suffering and pain in situations of violence are intertwined in the body, in the form of illnesses, and cannot be understood only from a biomedical perspective, as they are permeated by social and cultural meanings19. The interviewees reported symptoms and diseases that express the mourning materialized in their bodies, through palpitations, tremors, depression, anxiety, among other health problems described.
Social suffering can be understood as a result of systematic and structural violence in society, in which homicide represents one of its most extreme manifestations. It is observed in the reports that the suffering is not only related to the loss of the loved one, but also to the social and emotional consequences that derive from this loss, in addition to the physical and mental health problems caused or aggravated by the social context of the homicide and the changes in their lives after the event. Therefore, it can be understood that the suffering of mourning narrated by the indirect victims is also social, as they not only experience it in their subjectivities, but also represent the social and cultural experience of a certain historical moment in which they are inserted, being a social process embodied in the subjects15.
It is noteworthy that the mourning process of indirect victims has particularities when compared to that experienced in losses due to natural deaths12. The circumstance and unpredictability of a violent death can have a great traumatic effect on family members, making it difficult to elaborate. The interviewees reported feeling their mourning constantly updated, no matter how much time has elapsed since the death, as they frequently relive the fact.
Indirect victims of homicides perceive that their suffering is not recognized, and that the lives of their lost loved ones seem to be unimportant, denoting that they are not mournable16. They complain about the little or no sensitivity with which they are treated by professionals in health, justice, education and other areas. Added to this is the indifference of companies/employers towards workers who have gone through this process and become ill, and the insensitive, disrespectful, stereotyped and prejudiced way in which media professionals report these deaths27.
Silenced suffering and indignation at seeing the memory of your loved one vilified are forms of revictimization. Added to this is the long duration of legal proceedings, which contributes to prolonging the mourning and suffering of family members7. Relatives of police officers who were killed also reported that their pain was not recognized by the institution to which the victim belonged, or by the State.
According to Butler16, the dehumanization that follows the denial of public mourning for the lost life of a non-bereaved person requires the reversal of a process of dehumanization, that is, it makes it necessary to be familiar with the subject, the ability to identify with him. Discourses that dehumanize the victims of homicides, especially those committed by police officers, contribute to the non-authorization and contestation of the suffering of their relatives. And not having their suffering recognized can contribute to a difficult, long, and disease-causing mourning process.
None of the family members in either group reported having received treatment or health care after the incident. On the contrary, they did not feel welcomed by the institutions of Health, Public Security or Justice.
Regarding medicalization, it is known that many indirect victims of lethal violence become drug addicts14. However, the reports on the use of medications differ: some interviewees reported resistance to the use of psychiatric medications, for fear of becoming dependent, because they did not want to feel "anesthetized" in the face of the pain of loss; others consume them only in moments of anxiety crisis, at the insistence of the doctor; and there are those who use them frequently and claim that they exaggerate their consumption, which can cause or aggravate health problems. Here, it is appropriate to reflect on the medicalization of life, in which problems (of life and mourning) can be represented as illness and, supposedly, become treatable with the use of medications or medical procedures29. It is understood that the fact that some family members resort to the use of medications and treatments to alleviate suffering can be understood as a search for relief based on what the sociocultural structures and conditions provide.
When investigating the effects of the violent death of a loved one on the health of family members, it was noticed that not only the health, but also many aspects of the lives of family members were affected. In the speech of the indirect victims, there were also reports of economic and financial impacts, changes in the organization and family relationship, and impacts on the way of seeing and relating socially.
While the relationship with some institutions appeared as something that aggravated the suffering of the indirect victims, those who reported actively participating in the family associations created after the tragedy were able to reorganize their lives29. When a number of people gather in the public space around some demand, space, time and bodies configure a performative power that composes the political action17. Social mobilization appeared as one of the main forms of support and protection for the health of these people. The way they dealt with the loss, and the actions they sought to mitigate its impacts, also have a social character.
Access to an organized support network and activism groups was one of the biggest differences perceived between the two groups surveyed. The group of relatives of those killed by police officers was more united and organized in support networks, while the relatives of the dead police officers barely mentioned the experience of social activism in their lives. Lonely suffering seems to contribute to the latter group feeling disoriented and in need of support.
The practice of activism was also mentioned as something that can generate illness, because the frequency with which they talk about what happened makes the theme always present in their lives. However, what could be perceived as part of the "social cost" of activism, is seen as a lower price to be paid. Mobilization and speech, in particular, represent the means by which the victims\' families were able to move on with their lives, starting to feel that something was being done on behalf of their loved ones30. The body and the discourse in the collective space elaborate the feeling of "justice", in a way that is not confused with revenge, because it is a response, it is a representation of the "injustice" that the family members feel, and against which they protest31.
From the social mobilization, the indirect victims found space to express their pain, give meaning to their lives and seek moral reparation in the face of public opinion, since they are often stigmatized as "mothers of criminals"32. Many of these mothers are compelled to deal with the daily suffering, with the need to rebuild their own lives and those of the people around them. Day-to-day suffering and updated violence appear as a crucial difference between the two groups of family members studied, and impact the way they experience mourning and illness31.
The difficulties experienced in the grieving process and illness of indirect victims can also be understood as consequences of the cultural norms that involve mourning. The concept of social distress and Butler\'s theories consider that mourning is shaped by cultural and social norms and that society can limit the way people experience and express mourning. Medicalization and the search for individual or group therapies can be seen as coping strategies in a social context where mourning and suffering are not understood or recognized. In this sense, the social or non-social recognition of the violence suffered plays a crucial role in mitigating or exacerbating the impacts of homicide on the health and lives of family members.

FINAL CONSIDERATIONS
The results show that homicide committed and suffered by police officers impacts the physical and mental health of family members and close people, making them victims of this violence as well. The changes in mood, worldview, family relationships, economic and financial issues, and the mishaps involving the struggle for justice are inseparable from health issues in their broad sense. Thus, health policies, the creation of shelter groups, and the provision of psychological treatment, although important to mitigate the impacts, will not account for the complexity of this issue, since it is a matter of living and falling ill strongly marked by structural violence that has socially, economically, and politically excluded portions of the population for centuries in Brazil.
To advance this field of study and gain a more comprehensive understanding of the factors that shape the health consequences of these victims, future investigations should incorporate a more detailed analysis of the intersections between race, class, and gender, expanding knowledge about the complexities of human suffering in contexts marked by violence.
Public health policies are important tools to ensure adequate treatment for the health of indirect victims, inclusion and management of suffering in safe and healthy environments. Health services can become spaces of vocalization for indirect victims, where they receive physical and mental health care, and the recognition of their pain due to the violence experienced. The recognition of social suffering in all its dimensions points to the true demand of family members for a life with rights and dignity.
This study can contribute to a better performance of health services, social movements and institutional apparatuses that care for these family members. And for the academic understanding of the effects of violence on people\'s lives, as well as for the view of emotions and mourning as collective processes and political mobilizers.

ACKNOWLEDGMENTS
The present study was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.
This study was financed in part by the Coordination for the Improvement of Higher Education Personnel - Brazil - Brazil (CAPES) - Finance Code 001.
The present work also had the support of the Vice-Directorate of Research and Innovation, of ENSP/Fiocruz, through the Public Notice of the Program for the Promotion of Scientific and Technological Development Applied to Public Health - ENSP/Fiocruz, for financial support for the translation of scientific articles from Portuguese to English.
 
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