The worsening of people's mental health is among the main concerns about the long lasting impacts of the COVID-19 pandemic (1–3). Given the emergence of a previously unknown virus and the guidelines to protect population from its patterns of fast spreading, people experienced great levels of insecurity, fear and many other types of distress (2, 4), frequently framed as mental health problems. Nonetheless, in various contexts around the world, the pandemic also overlapped economic and social crisis, accelerating processes of marginalization and social exclusion. This interaction of local and global dynamics is of foremost importance to understand how the spread of the coronavirus interacted with biological, cultural and social factors, and shaped the nature of people's distress and anguishes worldwide, often conforming synergistic environments in which health and social conditions mingled in a process that has been referred to as “syndemic” rather than strictly as a “pandemic” (5, 6). This contextual interaction questions the automatic association between the COVID-19 pandemic and its psychological outcomes. To think about this contextual interaction on mental ill health and wellbeing, Rose et al. (7) suggested moving toward an “neuroecosociality” framework that includes a biosocial approach of the immediate social environment of humans, who create and shape the “ecological niches” where they inhabit, being simultaneously shaped by them. The arrival of SARS-CoV-2 must, therefore, be situated in time and space and understood as an interaction of the spreading of the virus with economic and sociocultural dimensions.

Stuckler and Basu's (8) book, “The Body Economic”, brought together several examples on how fiscal austerity policies implemented in the context of the 2008 financial crisis have had effects on the worsening of the living and health conditions in several European countries. With a particular emphasis on mental health, Thomson et al. (9) have also explored the connections between austerity measures and the worsening of various epidemiological indicators. According to these authors, since the implementation of austerity policies in England that followed the financial crisis of 2008, gender and socioeconomic inequalities in poor mental health have increased, drawing attention to the fact that the first to bare the detrimental impacts of such policies are generally those who experience social disadvantages. In fact, very little research has been produced exploring the implications of feeble social policies to mental health in countries of the Global South to date (10, 11). Such countries are marked by greater inequality and face a pervasive gap in the scope of social protection nets, and have frequently been pointed to have an ubiquitous gap between mental health needs and the available service provision to address them (12–15). The fact that the pandemic has reached virtually all countries around the globe and, in one way or another, has had direct and indirect effects on the mental health of the global population, created new challenges especially for the Global South.

To explore the interconnections between the COVID-19 pandemic, its impacts on the mental health of the population, and sociocultural realities, Brazil may offer a relevant case. In fact, the country has made a significant increase in social investment during the 1990's and the first decade of the 2000's, which reflected on an expansion of access to many social policies, that sought to guarantee the rights provided by the 1988 Citizen Constitution (16, 17). Even though a comprehensive consolidation of a Welfare State was never achieved in the country, important attainments in several indicators on health, educational and socio-economic development were accomplished in this period (18). Also, a major mental health reform was also implemented in the country, ensuring greater access to services to poor populations as well as a shift from institutional to community care focusing in reducing the pervasive mental health gap (19, 20). Nevertheless, in recent years, these advances that had contributed to the reduction of many social inequalities have been systematically dismantled (10).

In Brazil, the COVID-19 pandemic broke out in a context of reduced public spending in social and health policies as well as in a process of erosion of social rights, which has been slowly consolidated in recent years, as a new logic of neoliberal government (21–23). Especially since the governments of Michel Temer (2016–2018) and Jair Bolsonaro (2019 – current), there has been a significant reduction in the scope of social policies that would be essential to contain the direct and indirect impacts of the health crisis that unfold from the pandemic. The greatest example of this process was the approval, in 2016, of Constitutional Amendment No. 95 (EC 95), which established a cap for public spending on social policies for the next 20 years, determining that budgetary changes in this sector would be restricted to an adjustment equivalent to the inflation rate. This measure has been pointed out as promoting a worsening in the living conditions of the Brazilian population and a setback in the fight to reduce inequalities, especially in a context of economic crisis such as the one experienced in recent years in the country (24).

Effectively, the pandemic accelerated the social consequences of dismantling social protection services, adding even more vulnerabilities and fostering processes of exclusion, highlighting the association between the reduction of public spending, the increase in poverty and inequalities as well as general health indicators (11, 25). Specifically, there was an increasing concern about the contingencies that this scenario would create to the mental health of the population (26). Several reports of the worsening of mental health conditions were published, with general guidelines for the functioning of mental health services, family caregivers, educators and primary care services (27–29). Thus, the main question that guided our research was which contingencies of the pandemic should be taken into consideration to better understand the psychological sufferings and distresses of marginalized populations living in contexts of poverty and exclusion. To understand local perceptions of emotional distress and suffering experiences, many authors have suggested paying attention to “narratives of distress” (30, 31). Narrative approaches can help to better understand how individuals talk and see their own mental health struggles and seek support (32, 33). Also, exploring first person narratives can help moving beyond a concept of mental health focused on disorders to one that comprehends mental health as a phenomenological experience, that takes place in time and space.

This article presents the results of a research project inspired in participatory action methods implemented through virtual meeting platforms and phone calls that investigated subjective experiences of dwellers of a peripheral region of the city of São Paulo, in Brazil, during the COVID-19 pandemic. Our objective was to explore how local residents experienced the circumstances imposed by the pandemic and to identify the main conditions underlying their anguishes and distresses. Some of the findings of this research have already been published elsewhere discussing the interfaces of mental health outcomes of the pandemic in contexts of urban insecurities (34). This article, more specifically, explores how reduced public spending, socioeconomic vulnerability and social reproduction responsibilities are contributing to widespread emotional distresses during the pandemic. As it will be seen in our results, the effects of the COVID-19 pandemic have had implications for the psychological wellbeing of those who experience social disadvantages and inequalities, specifically, of women living in the outskirts of the city of São Paulo. To contend with this assertion, stories of three women residing in the peripheral territory are presented, for whom the suspension of public social protection services during the COVID-19 pandemic resulted in situations of psychological suffering and feelings of emotional burden, often times so intense that disrupted their ability to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community, all capacities defined under the concept of mental health.

This research was inspired by Participatory Action Research methods (PAR). This approach sought to integrate the experiential dimension of first-person reports, expanding the validity and generalizability of our research findings (35–37).

The district of Sapopemba has a population of 284,524 people, most of them are self-declared black or brown, and a fifth of this population lives below the poverty line. This is equivalent to almost 60,000 people. Located in the south-eastern region of the city, Sapopemba is placed on an important route between central and eastern areas of the city. In addition to the precariousness faced by the local population, Sapopemba faced great difficulty in containing the spread of the COVID-19, being one of the regions of the city with the highest number of cases of contamination and death. The district is also characterized by a long history of social mobilization. This has ensured important achievements over the last 30 years in welfare services, such as day care for children, elementary schools, expansion of the public transport network and the implementation of a wide network of health services of the public health care system (SUS). All these achievements are related with struggles and social mobilization of local organized civil society movements (38).

In fact, most of the residents of the neighborhood live in small houses, often with several people sharing the same rooms of the house, and 21.58% of the houses do not even have running water and sewage. The percentage of informal workers in the region is also high, which led many people to have their income reduced with the closing of shops and slower circulation of people on the streets. These persistent vulnerabilities made the implementation of preventive measures harder and intensified the blockage of economic activities, helping to intensify the contagion and mortality caused by the pandemic in the district.

Members of the Center for Human Rights of Sapopemba (CDHS) and a team of researchers from the Section of Psychiatric Epidemiology of the Institute of Psychiatry, University of São Paulo Medical School (NEP/IPq-HCFMUSP) sought to create a community-based project aimed at strengthening ties of solidarity and emotional support among residents of the district of Sapopemba during the pandemic. Simultaneously, the initiative allowed to collect reports on the ways residents of the peripheral territory of the city of São Paulo frame, conceive and attribute meaning to their experiences of suffering in times of the COVID-19 pandemic.

Community leaders from the territory were appointed by the CDHS and other local social organizations to participate in the project as volunteers, making phone calls providing emotional support to other residents of the territory. The NEP team, together with the members of the CDHS, produced a semi-structured guidebook with general instructions to lead telephone calls that would be made by volunteers. The guidebook was structured as a support instrument to help the volunteers carry on the conversations. Volunteers received training in empathic listening and guidelines on how to conduct semi-structured interviews. To make the calls, each volunteer was sent a kit containing a guidebook, a notepad, a prepaid cell phone SIM card, a headset, and pens.

The project was publicized at the CDHS headquarters, where residents of the neighborhood interested in receiving a supportive call were able to provide their names and phone number. An enrolment list was circulated in social actions such as the distribution of food boxes to those in need. A list with 201 names and phone numbers was collected. We messaged all participants to verify their availability and make detailed information available as well as asking for those interested to sign a consent form. The information from interested parties was passed on to the volunteers, according to each one's availability. The volunteers were divided into two groups, which were followed up in weekly meetings by the research team through online platforms. Held between September and December 2020, these meetings were intended for reporting and discussing about cases heard by the volunteers, about the experiences of suffering that the people contacted by them were facing and how they could be supported. In addition, meetings were also spaces to create bonds between volunteers and researchers, to share questions and difficulties that could arise during the calls and for collectively discussing the experiences of suffering and caring arrangements. In this sense, volunteers played a dual role. On the one hand, they sought to strengthen ties of solidarity and provide emotional support to community counterparts. On the other hand, they reported the experiences heard from their perspectives and local repertoires on how suffering was being understood and experienced, as well as on possible referrals and ways to seek support to overcome the situations encountered. The project followed up a total of 18 people during this timeframe.

Meetings were recorded, transcribed, and analyzed using CAQDAS software (NVIVO 12). After transcription, the material was free-coded. Based on this coding, researchers discussed, in a multidisciplinary team (sociologists, social psychologists and psychiatrists), the main axes identified throughout the coding process, grouping the codes into themes that combine deductive and inductive approaches. Once the team has identified the relevance of the issue associated with the suspension of public services to women's mental health in the region, three ethnographic cases were selected as illustrative of this circumstance. The Research Ethics Committee of the Medical School, Clinics Hospital, University of São Paulo (CAAE: 46272221.2.0000.0068) approved the research protocol. All participants were informed about the purpose and scope of the study and the voluntary nature of their participation. Informed consent was obtained from all participants. As soon as community members signed up to participate in the project and received supportive calls, they received a message via WhatsApp to confirm their interest and a link to fill out an Informed Consent Form in digital format, as there was no in-person contact with any of the research participants and volunteers.

In addition to the lack of an energetic government response to the pandemic, existing social protection services suspended or reduced their activities, greatly impacting those who depend on them. When implementing the project and making available a list where people could enroll to receive emotional support, all entries were made by women. Perhaps one of the possible explanations to this result may be because registrations were carried out at the point where food boxes were delivered to families in need. Women contacted by the project in Sapopemba reported significant suffering resulting from the absence or reduction of assistance from the services and an increase in housework and caregiving activities. In this section we report the stories of three different women that illustrate how their mental lives were troubled by such circumstances.

The social measures to contain the pandemic, such as isolation and social distancing, have led to the suspension of many social welfare services. As presented in the cases above, caring for children or dependent people relied pre-eminently on domestic labor, revealing and also deepening the structural care crisis that was already underway (40). Effectively, several authors have pointed out that those who took over the gap caused by the lack of social protection services during this time were mainly women. This was especially harsh in marginalized communities, namely for those living in urban peripheries and in contexts of poverty and exclusion (25, 44–47). The increase in the domestic burden harmed women not only in economic terms, but also had direct consequences for their structural position, accentuating pre-existing inequalities and also leading to daily uncertainties that affect their mental wellbeing (9), as shown in the cases of I., E. and P.

The discontinuity of public welfare services and the increase in caring responsibilities exacerbated a sense of helplessness experienced by the women contacted by the volunteers. The suffering, anguish and distress reported by them resulted precisely from the weakening of their subsistence arrangements and the consequent siege of their strategies to face precarious circumstances. Simultaneously, the lack of these fragile networks has jeopardized material and emotional dimensions of care. Despite its economic dimension, caring relationships also involve deeper personal and affective attributes.

The association between the mental health outcomes of the COVID-19 and the suffering experiences of women in the urban peripheries is ubiquitous in all cases presented. I., despite being married, performs as a single mother. During the pandemic, she was no longer able to rely on institutional support and family networks. Given that her mother belongs to a risk group, she could not be present in the daily care of her children as she did before. As she had no place or person to leave them with, I. had to leave her job, which further increased the family's material and financial vulnerability and made her feel unable to assure their subsistence and to address her children's needs. Likewise, E. also had to stop exercising paid activities because housework and childcare depended primarily on her own work. In her case, both school activities and the support center for people with mental disorders were suspended indefinitely. In addition, her youngest daughter's day care had also stopped activities. The family's financial situation and her children's wellbeing and health were at the center of her anguish, which caused her feelings of despair. P. was relieved when, months after the start of the pandemic, activities at the Center for Children and Adolescents in vulnerable situations where her daughter was enrolled resumed activities, albeit partially.

Indeed, gender and feminist studies have highlighted the central role posed by the moral dilemmas that arise from the responsibility of ensuring that care is adequately provided in the family milieu (48–50). The stories of the three women referred to the material and affective forces that derived from the responsibility of caregiving and the psychological suffering that unfolds from it. Flore et al. (51) considers that the social, intimate and affective experiences of caregiving, and the political contexts in which care labor is materially constituted, emerge as central elements to understand the many kinds of suffering lived by those who undertake these tasks. The emotional labor of care is also pointed by Fullagar and O'Brien (52) as central on women's sufferings. According to their research, sufferings were commonly articulated in relation to the responsibility of caregiving, mobilizing feelings of success/failure as mothers, workers and partners.

The cases here presented lead us to believe that the lack of formal welfare services intensified the sense of isolation, once care is increasingly relegated as an individual responsibility. Power and Hall (53) argue that governments are progressively advocating “personalization,” “choice and control,” and “autonomous and independent living” policies. In this scenario, care provision ends up depending on personal characteristics and individual capabilities. The neoliberal economy weakens and limits the strategies that people have to face their daily lives, falling on individuals' shoulders the responsibility of ensuring social reproduction and survival (41). Although social protection services were already insufficient and under dismantling, the COVID-19 pandemic has thrown the door wide open to the structural care crisis and the weaknesses of social protection systems, intensifying the appeal to individual solutions to deal with it (46). In the cases of the contacted women and their families, the accountability for care reproduces structural inequalities that are crossed by class and racial dynamics, which are remarkable in the Brazilian context (54). This pattern affects the most vulnerable women even in an intergenerational way. Cases like I.'s, for example, who has to leave her oldest daughter to take care of her youngest, generate chains of female care among underage women so that the adult woman can work in the formal labor market, while young girls miss the opportunity to study and play, both as important for personal and intellectual development.

In this scenario, marginalized communities and civil society organizations had to mobilized to face the “social protection gap”, and to ensure that the basic infra-structure to sustain life in times of the pandemic was offered (55). Churches, post offices and local associations were important resources to help people to keep going and to cope with the psychological struggles of daily life. Effectively, the social organization of care in Brazilian urban peripheries during the pandemic depended on networks structured around close social ties (relatives, co-religionaries, neighbors), participation in civil associations (social movement, Human Rights Centers or associations) and associative and religious practices. According to D'Andrea (56), this model was even more important during the pandemic. It was “without any decent state assistance” that “the peripheries fought the spread of the coronavirus, [using] a practice as old as it is fundamental for the survival of the poorest: solidarity” (p. 53). Historically, solving the issues of survival of underserved populations “almost always involves being on the streets mobilizing more extensive family, neighborhood and solidarity networks” (p. 48), which configures structures of opportunities and provides support for individuals to “get by” in order to mitigate material and affective vulnerabilities (41, 42).

Indeed, mutual support in contexts of church goers or the community of co-religionists, appeared as important supportive networks and were commonly mobilized in situations of suffering. Among the cases presented, participant E., an evangelical practitioner, sought emotional support and assistance in the local church in her community. In turn, I. resorted to the social movement of prisoners' friends and family. Through the movement, she was able to receive information about the functioning of prisons during the pandemic period, learn about and participate in political claims about the prisoners' rights, and also receive emotional support from other people who shared similar experiences.

Studies on health-related quality of life in Brazil during the COVID-19 pandemic detected higher prevalence of common mental disorders among females and low income groups, suggesting the improvement of mental health services (57–59). These findings corroborate our own results as they reinforce the association of the quality of life in contexts of vulnerability and poor mental health calling special attention to gender. Our ethnographic approach to understanding the meanings of women's psychological experiences can help in moving further with this suggestion, reinforcing that beyond formal mental health interventions, it is also important to ensure social rights and adequate policies supporting caregiving practices. In this sense, we assert that the State must implement policies in order to ensure that care can be adequately produced by the society. In so forth, practical competence and situated knowledge are fundamental for the development of appropriate public policies that address the needs to be met by care within territories. Thus, the elaboration of programs and public policies should be based on cultural heritage, proposals and understandings coming from social movements, commissions and councils that work at the ground level and are acquainted with specific issues and on locally feasible and suitable practices, and not in a way that overrides them.

The emerge of the pandemic demonstrated the extent of how we are “dependent upon and embedded within social relationships and institutions throughout the life course” (60), either to solve objective problems but also in subjective personal experiences in the everyday world. In addition to shedding light on our shared vulnerability in the social order, the pandemic has also exacerbated inequalities in access to social protection, demonstrating that the COVID-19 pandemic was, by no means, experienced in the same way across society. On the contrary, the way this period was experienced greatly depended on the individual's access to a range of social, relational, and material resources. In this sense, the strategies and means to face the harms, vulnerabilities and setbacks posed by the response to the virus dissemination should not be associated exclusively to personal characteristics, emotional tendencies or people's resilience capacities. Neither should these experiences be reduced to symptomatologic treatments. The cases here presented showed that the strategies to face many of the deprivations and precarious circumstances often rely on solid and strengthened (formal and informal) social support networks (61). In this sense, creating locally rooted institutional networks that allow thinking about the social organization of care for the sustainability of life can offer new possibilities for facing daily deprivations and precariousness, fighting inequalities and developing coping strategies for suffering and anguishes.

Participatory Action Research Methods (PAR) have been valued as a powerful tool to access the subjects' experiences and avoiding scientific paternalism (62, 63). By recognizing practices, discourses and positions as points of view about daily experiences, PAR methodologies allow the recognition of specific subjectivities in the localities where they are configured and developed facilitating a situated inquiry. The present study was based on an innovative research design that can benefit from these methodologies. Nonetheless, the pandemic and the adoption of security health protocols impeded a closer approach to important issues, such as the experiences of men on the peripheral areas of large cities and to explore in greater detail experiences related to race and ethnicity. These topics were only superficially touch by our inquiry and future studies would be able to explore that in greater depth.

Also due to social distancing protocols, we have relied in virtual technologies and online communication tools, either to exchange conversations with volunteers or for them to communicate with the people who received the phone calls. In addition to connectivity hurdles, there were also difficulties with hardware and adequate equipment to guarantee virtual communication. Also, the distancing protocols that imposed digital mediation, limited the possibilities of contact with people who do not have access to cell phones or internet connection, evidencing a pervasive dynamic of digital exclusion in contexts of poverty and deprivation.

There is currently a broad international debate arguing that there is a pervasive gap in the provision of mental health services in different regions around the world, especially in low and middle-income countries, where there is an incipient investment in mental health policies. Several advocates of the so-called “Global Mental Health Movement” have pointed to the need for mental health services and a feeble availability of facilities (64). To repair this gap, it is often argued that countries need to expand the implementation of specialized services in the area (12, 65, 66).

The cases reported above point out, however, to an intertwined network of structural problems and experiences of suffering for which mental health services would have little to offer. Such circumstances can be rich reports to problematize the concept of gap itself, that has been mobilized over the last few decades. The cases allow us to reflect on two main questions. Firstly, we verify that what is often lacking to address the circumstances in which suffering is produced are not psychiatric and mental health services, but broader social protection policies that guarantee basic living conditions for marginalized groups, such as poor women living on the outskirts of São Paulo. The suspension of such services mainly affected already marginalized groups and characterizes in a particular way the sufferings experienced by these groups during the pandemic. This contingency challenges the universalistic association between COVID-19 and mental health outcomes. In so forth, it is necessary to consider the gap in a wider way, not only as a “mental health services gap”, but as a “social protection gap”. It is often due to the lack of social protection services, which ensure that basic social rights are met, that emotional distresses were created by the pandemic. In neoliberal contexts of the Global South, such as the Brazilian one, it is necessary to acknowledge barriers of access to social protection especially in terms of class, race and gender. The findings presented in this paper can bring some suggestions for Global Mental Health and its goals to target marginalized communities. The measures and guidance from international experts often represent a by-pass in this complex and rich network in which mental health is produced and cared for that goes far beyond specialized services. International guidance for mental health policy frequently relies on pre-formatted models for mental health care, often underestimating local support networks, that precede the development of more severe cases that will need formal mental health services. In this sense, nurturing models that increase social participation and social accountability can provide instrumental means to support policy formulation and to ensure that policies adhere to local forms of producing care and to address the concrete needs of the population.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by Research Ethics Committee of the Med School, Clinics Hospital, University of São Paulo (CAAE: 46272221.2.0000.0068). The patients/participants provided their written informed consent to participate in this study.

LB, CA, and FS wrote the initial draft of the article. LB, CA, FS, DR, EM, and LA collected data and performed the analysis. LB, CA, FS, and DR conceived and designed the analysis. All authors were involved in reviewing the manuscripts, contributing to the interpretation of the results, and read and approved the submitted version.

The research project Mental health in adversity: an ethnographic study of the experience of poor mental health in the favelas of São Paulo was funded by the State of São Paulo Research Foundation (FAPESP Grant number: 2019/17397-7). The Brazilian Council for Scientific and Technological Development supports LA (CNPq Grant 307933/2019-9).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.