Health in the Amazon

It is 10 PM on a refreshing night, following a scorching September day in the heart of the Brazilian Amazon forest. The chant of howler monkeys is baffled by the sound of music, which the villagers of São Francisco are dancing to. São Francisco is part of the Rio Iriri Extractive Reserve, a federally protected land in the Xingu River basin, and the villagers are celebrating the end of an expedition that brought them COVID-19 vaccines, blood exams, and medical checkups. The crew is a group of researchers from a local university, nurses from the municipality, and doctors hired by a US non-governmental organization (NGO). They chat near the hammocks where they will sleep.

For almost a month, they traveled in two small boats filled with medical supplies, stopping in more than 30 communities in a region called ‘Terra do Meio’ (which roughly translates as ‘midlands’), a mosaic of conservation areas as big as Iceland, where about 5,000 Indigenous and other culturally diverse populations live, including ‘ribeirinhos’ (riverside people) and ‘quilombolas’, residents of quilombo settlements, which were first established by escaped slaves of African origin from the seventeenth century onward.

A nurse talks to villagers in a riverside community.

The nurse explains the vaccination procedure.

Villagers wait for their vaccination and other medical check-ups.

The expedition crew is planning their long return trip to the closest city of Altamira when a villager from a neighboring community calls the doctor in charge. The villager’s face is serious, and his voice is distressed. “We are at least four hours away on a boat from any health center, and the centers are frequently empty,” he tells the doctor. His 2-year-old twin granddaughters had just been sick and were treated by the expedition doctors, but he worries for the health of the community once the crew is gone.

The medical team starts in Altamira, the closest city.

From Altamira, they travel 270 km by car to Maribel, and then more than 1,200 km by boat to the riverside communities.

Emergency evacuations

Although access to healthcare is safeguarded as a free and universal right in the Brazilian constitution, families living in the Terra do Meio do not have any local doctors. There are only five nurse technicians for the whole conservation area, placed in simple health centers, who rely on boat rides from local people to reach patients in need. The closest hospital is hundreds of kilometers away in the city of Altamira. September is the dry season, when the volume of water in the river is low, exposing rocks and logs on the bottom that make it more difficult to sail. In these conditions, a journey to the hospital can take up to 5 days in a motorboat, followed by a 9-hour drive on a dirt road — precious time in the face of an emergency. “People are often bitten by scorpions and snakes here, and in these cases, we have no time to lose,” the villager says.

The villager asks the doctor to help his community secure enough boat fuel and funds to build landing strips and rent airplanes for emergency evacuations. He remembers the days when he had no choice but to work for an infamous cattle farmer in the region. Known for his brutality, the farmer illegally grabbed and deforested an area of about 1.3 million hectares of forest inside the reserve — an area about the size of Puerto Rico. The villager is not proud of his past but points out that in the case of a medical emergency, the farmer would provide evacuation by airplane, even if that meant the worker would have to work for free for years to pay the costs back. “If we had a health problem, he would help us,” he remembers. By airplane, patients could be in the city in hours, a journey that takes days in a boat.

The medical team visit villagers in their homes.

They bring vaccines and other medicines.

The Rio Iriri Extractive Reserve is a publicly owned piece of the forest where the government allows culturally diverse people to live sustainably by fishing, hunting, keeping small crops, and harvesting wild plants. These ribeirinhos are descended from Indigenous peoples and migrants from northeastern Brazil who moved to the Amazon in the 1850s to exploit latex from rubber trees. Today, their economy is based on the manual harvesting of Brazil nuts, a time-consuming and exhausting labor that involves walking long distances into the jungle. The presence of people in these areas helps keep out cattle farmers, land-grabbers, illegal loggers, and gold miners who have driven deforestation in the region.

Fast money needed

The Amazon forest serves an essential role in regulating the global climate. But when the health of the people who live in the Amazon is overlooked, the rainforest’s health is also harmed. When villagers are forced to travel long distances to seek medical care in the city, they leave behind the forest, which makes it vulnerable to land-grabbers, says Erika Pellegrino, the doctor in charge of the vaccine expedition. In addition, people often engage in destructive and illegal activities, such as mining and logging, that give them fast money to pay for transportation and medical costs, she adds.

Pellegrino has heard many stories like this. As a researcher at the Federal University of Pará Medical School, she is conducting a study to understand how access to healthcare (or the lack of it) in the riverside communities of Terra do Meio is linked to environmental protection. “Although not obvious, there is a strong relationship between territorial security and health access,” she says.

Back in March 2021, during the pandemic’s peak in Brazil, Pellegrino and colleagues started promoting community meetings with local people by ham radio, the only method of communication available in most Amazonian villages. During six conversations, which she called “radical listening sessions,” she questioned more than 200 villagers about the main challenges they faced in living their traditional way of life in the forest. Land invasions and difficulties in accessing healthcare were unanimous answers. “They told us that if they had better access to healthcare and education, it would support them to stay on their lands, resisting external pressures, and protecting the forest,” Pellegrino says.

Many adults and some children seated or standing in a large circle in a schoolroom.

Villagers in the Rio Iriri Extractive Reserve talk with the medical team.

Francisco Assis, a 60-year-old Brazilian-nut harvester and community leader in the village of São Francisco, is a living example of this connection between healthcare and deforestation. Just before the pandemic, in 2019, Assis embarked on a 10-hour boat trip to the city looking for treatment for unbearable pain that had been growing in his abdomen for years without medical care. The doctors recommended surgery. What is usually a simple procedure in which the patient spends just a couple of days in the hospital took him 2 months away from home. The extra time was needed to run tests and for recovery in the city after the operation, as it would be too expensive and time-consuming to go back and forth from the hospital to his house.

Francisco Assis traveled 10 hours for medical treatment.

Francisco Assis traveled 10 hours for medical treatment.

“I got healthy after the surgery,” Assis says. “But I lost all the money I had, and I couldn’t harvest or work on my crops.” Although his surgery was free through the public health system, Assis spent more than 20,000 reais (almost double the annual national minimum wage) on transportation and accommodation. Time away from the Amazon also affected his community work. Assis is part of a group called ‘Xingu Mais’, which reports illegal activities in the forest, such as land invasions by gold miners and loggers, to the government.

Riverside people who live in the forest are often the first to spot and denounce illegal deforestation, says Marcelo Salazar, an environmental and social-justice activist: “They are the ones who speak out first, but often they are not heard.” Salazar has been working with riverside communities for more than 20 years and recently joined the US-based NGO Health in Harmony in its new branch in Brazil, and is partnering with Pellegrino. “To be heard, [riverside peoples] need political strength and governance, and access to health helps to strengthen their social fabric that is now torn,” he says.

Community leaders

A man wearng green T-shirt and baseball cap seated at table with CB radio set.

Raimundo Francisco Belmiro has seen many villagers struggle with health expenses.

Raimundo Francisco Belmiro, resident of the Riozinho do Anfrísio Extractive Reserve, also in Terra do Meio, is a 56-year-old rubber tapper. He has lost track of how often he has seen people involved in destructive activities to cover health expenses. “It is not because they are bad, it is just that they need it,” he says. Born and reared in the environs of the Riozinho do Anfrísio river, Belmiro also worked in illegal mines when he was young. But about 20 years ago, he changed sides and led the process to transform the region into federally protected lands. Since then, Belmiro has become an admired community leader to many, but he has also received death threats for denouncing land grabbers and deforestation. He says that now, with COVID-19, the situation is worse.

Belmiro has received death threats for denouncing deforestation.

With less government oversight during the pandemic, illegal mining in the Brazilian Amazon has grown, especially in protected lands. According to data from the Brazilian National Institute for Space Research, 72% of the illegal mining in Brazil in 2020 was inside protected lands.

For Pellegrino, providing long-term access to healthcare for the communities of the Amazon will reduce deforestation and safeguard the forest. "If we offer quality healthcare to these people, they will be stronger to protect their territories and less willing to engage in illegal and destructive activities,” she says. “Where there are healthy traditional populations, there is a forest standing.”

A man wearng green T-shirt and baseball cap standing in front of a table with a CB radio set.

Belmiro has received death threats for denouncing deforestation.

Planetary health

A female nurse with face mask holding two blood samples.

Villagers provide blood samples as part of their health check-ups. Credit: Isadora Brant.

A small but growing number of studies have examined links between human health and conservation, as part of a new field known as ‘planetary health’, which considers a population’s health within its surrounding ecosystem.

Most studies of planetary health examine the effects of the environment on human health — for example, by exploring how environmental degradation exacerbates certain infectious diseases. But some researchers are turning this idea on its head by studying the effects that people who lack healthcare can have on natural resources, says ecologist Skylar Hopkins at North Carolina State University. Hopkins uses the example of a study of fishing villages around Lake Victoria, Kenya, where the population has a high prevalence of infection with human immunodeficiency virus. The researchers showed that fishers who were sick used easier fishing practices, which were more destructive and often illegal.

Only a few studies have assessed the impact of health interventions on environmental protection. “There is evidence that improving health improves some aspects of conservation,” Hopkins says. “But a lot of times there are programs working hard to do these interventions, but without academic partners or the necessary budgets to do the proper monitoring and evaluation to show there's really environmental impact.”

A recent study on improving rural health care showed that deforestation caused by illegal logging decreased by 70% in a national park in Indonesian Borneo 10 years after an affordable health clinic opened in the area. The researchers looked at more than 80,000 patient records, socioeconomic surveys, and satellite data on deforestation to quantify the conservation and health outcomes of expanding healthcare access in the region. “We objectively showed that delivering healthcare might have a significant impact on the rate at which deforestation was happening there,” says an author on the study, disease ecologist Susanne Sokolow at Stanford University.

Reliance on NGOs

A small motorboat with canopy carrying six people and equipment up river. Forest in background.

The medical team travel by boat along the Riozinho do Anfisio river.

Pellegrino knows that in the Amazonian villages, she must be rigorous in her research. Beyond the qualitative surveys she has conducted, she plans to collect quantitative data from health records, together with satellite images of deforestation. Then, she will organize community meetings to discuss possible interventions that could improve community access to healthcare. “To take care of these people’s health is to take care of the forest and of the whole planet,” she says.

An Amazonian village visited by the medical team.

NGOs continue to have an important role. Health in Harmony financed the delivery of COVID-19 vaccines to Terra do Meio, as well as financing other health expeditions in the riverside villages. Health in Harmony will also help cover the costs of implementing the interventions planned by Pellegrino.

The NGO has also promised to donate nine emergency evacuations annually to Altamira, as the local health department does not guarantee these life-saving flights. But the role of community leaders is essential — in this case, to construct a landing strip for the airplanes. Assis, the community leader, has led the construction of a landing strip for emergency evacuation in the village of São Francisco on the Iriri riverbank. Together with his wife and teenage sons, Assis has spent hours working with hoes and grubbers to open a strip of land that will allow local flights. “When we saw people dying of COVID-19 elsewhere, we were very afraid that someone in the community would need to be taken to the hospital,” he says. Assis is happy with the support from NGOs, but he still resents the lack of health assistance given by the government to him and his fellow ‘forest protectors’, as they like to call themselves. “We are here left alone and dying slowly,” he says, “while the forest we preserve is giving oxygen to people all over the world.”

Fransisco Assis and his wife work to clear a landing strip for life-saving flights.