By Gary Duffy
BBC News, Rio de Janeiro
Complexo do Alemao has been the focus of major police operations
Providing physical and mental healthcare to tens of thousands of people in a shanty town in Brazil would be a challenge in itself.
But when the area is controlled by heavily armed drug traffickers and there are violent confrontations with the police, the problems can multiply.
Despite this, international medical charity Medecins Sans Frontieres (MSF) has been offering assistance to people living in one of the most troubled groups of favelas or shanty towns in Rio de Janeiro, after reaching an agreement with local health officials in February last year.
The German's Complex, or Complexo do Alemao, has been the scene of many violent clashes - on one day alone in 2007, 19 people died during a controversial police operation.
Just driving in and out of the area, you soon get the idea that while this sprawling collection of shanty towns has been quieter recently, life here is far from being routine.
Standing near a road leading into the district is a young man in a blue jacket wearing a baseball cap, with a large gun casually hanging on his shoulder.
Tyler Fainstat, head of mission for MSF in Brazil, says: "Because the conflict has been going on for so long and you have a complete absence of the state, at a certain point things which are shocking become normal."
MSF offers emergency medical and psychological assistance at a small community health centre right in the heart of Complexo do Alemao.
"You see young boys with enormous weapons which you would normally expect to see in the war in Iraq," Mr Fainstat says.
"You see people selling drugs out in the open and you see a situation where the system of governance is one which is what they call the parallel power, meaning not the state but basically run by the drug gangs.
"The interesting thing for me is not that people are ever able to cope with it, but that it becomes normal, it becomes the reality there and people are no longer shocked by what they see."
The conflict between drug gangs and police often puts Complexo do Alemao in the headlines here.
Vivianni - not her real name - has been receiving counselling for depression. She is one of many residents who can tell of terrifying experiences as a result of the continuing conflict.
"I have seen and been present during many things," she says.
"There was one time with my son, my flip-flops got caught and I had to shout to him run, run - get out of here - because I couldn't get away and there were bullets flying everywhere."
While many of Vivianni's problems are related to her personal situation, she says living in a conflict zone does make things worse.
"If you ask anyone here they all have a similar story, not just me," she says.
"For good or bad everyone needs help, regardless of whether they have depression as serious as mine or just a slight case. It is normal for people to get sad from time to time, but I think everyone, especially when they have seen this type of conflict, everyone should look for help, psychological help."
The MSF team has stepped in to fill a gap left by the state.
Psychologist Douglas Khayat says one area where they try to help is dealing with people afraid to talk about relatives killed by drug traffickers, or what he calls the "army group".
"They can't denounce this to the police; they can't access justice - that is a real problem. They can come to us and they can talk, they feel confident because we have our presence in there, we put ourselves in the same conditions as them."
Dr Khayat says the continuing threat of violence has a real impact on the mental health of the community.
"People start to develop a kind of permanent tension, anxiety disorders, depression. The kids, you can see learning problems, and aggressiveness. You have a whole range of symptoms which you can really connect to the social situation."
Vivianni says the counselling she receives has helped rebuild her self-respect, despite her emotional problems and the challenges of living in such a troubled neighbourhood.
"Depression is a delicate disease and not very well understood," she says.
"I have developed confidence, which was one of the key issues for me. Because of this I can talk about my problems and I feel I have improved considerably.
"I used to demand too much from myself. People didn't need to put pressure on me, I would do it myself. I learned to see myself as a friend because I used to be my own worst enemy. I learned to respect my limits. I learnt all this here."
Given the scale of the problems in Complexo do Alemao, there seems a limit to what a small team of doctors and psychologists can do.
However, for those they have been able to help, the work here appears to have made a real difference to people who thought no-one was interested in their problems or their lives.