By Maria Fernanda Ziegler | Agência FAPESP – Brazil’s existing socio-economic inequalities and vulnerabilities have only worsened during the COVID-19 pandemic. In the Amazon, age and other known risk factors for the disease have influenced mortality less than scant health service coverage and lack of access to intensive care units (ICUs). In addition, no measures have been taken to provide care for historically marginalized groups living far from the major cities, especially indigenous and riverine communities.
These were the conclusions of the experts who took part in the first two events of the series “Health and Environment in the Amazon in the Context of COVID-19”, hosted by FAPESP on August 5 and August 12.
The series of webinars was proposed by researchers involved in the project “After hydropower dams: social and environmental processes occurring since the construction of Belo Monte, Jirau and Santo Antônio in the Brazilian Amazon”, supported by FAPESP under the auspices of the São Paulo Excellence Chair program (SPEC).
According to the participants, the most evident example of the disparity between the impact of COVID-19 on the North region and the rest of Brazil was the humanitarian crisis that occurred in Manaus in January 2021, when health services in the capital of Amazonas state were overwhelmed and patients died for lack of oxygen (not all of them had COVID-19).
The tragedy was not confined to Manaus. Studies show that the mortality rate per 100,000 inhabitants was far higher in the North region as a whole than in any other Brazilian region or state. The North also saw the highest proportion of avoidable deaths from COVID-19, not just among over-60s but in all age groups.
“All this translates into an unprecedented loss in terms of life expectancy. Some states, such as Amazonas, have returned to levels of mortality not seen since 2004. There has been a massive reversal. Our research shows that the North has been much harder hit than the rest of the country,” said Márcia Castro, an epidemiologist and professor at Harvard University.
Castro led a study, published in Nature Medicine, on the fall in life expectancy due to excess deaths from COVID-19. In Amazonas, life expectancy fell 4.42 years from 75.41 to 70.99. The second-largest fall occurred in Rondônia state, where life expectancy slid 3.92 years from 76.41 to 72.49.
“We continue to forget the basics. Economic development is associated with infrastructure, meaning roads and dams. This is a mistake that’s never been questioned. If you ask anyone living near these massive projects in the North to tell you what they need, the answer will be health and education. You can build whatever infrastructure you like and make a thousand promises of compensation, but neither health nor education improves,” said Emilio Moran, principal investigator for the SPEC-FAPESP project.
According to Moran, Brazil suffers from internal colonialism. “Through these enormous infrastructure projects, the Southeast uses internal exploitation to supply its consumers and industry. The Belo Monte dam, for example, has a huge local impact but no local benefits at all,” he said.
According to Castro, the impact of COVID-19 in Brazil and especially in the North region could be called a “syndemic” – two or more concurrent diseases acting synergistically, with far worse effects on the population than the mere sum of the harm done by each one separately. Social, economic, political and environmental factors also contribute to the gravity of the situation.
“It’s worth noting that in some countries, despite the socio-economic context and vulnerabilities, political decisions have mitigated this synergistic effect. In Brazil, political decisions – or the lack of them – have made the vulnerabilities even worse,” Castro said.
“To understand what’s happening with COVID-19, we have to look back to the cycles of exploitation undergone by the Amazon since the rubber boom, and the highly emblematic slogan coined by the military dictatorship [that ruled Brazil from 1964 to 1985] for the supposed development of the Amazon: ‘Enough with the legends already, let’s make money!’”
More recently, a lot of the progress achieved following the return to democracy has been rolled back, she added. “This cycle of exploitation constantly ignores the local population. All that matters is profit, not improving the conditions for the local communities or protecting the forest. Hence the persistence of these factors that undermine health and the invisibility of these people, who only appear when an election is held,” Castro said.
Besides lack of healthcare and other basic services, the history of the North region includes several epidemics and outbreaks of dengue, malaria and yellow fever, diseases directly associated with deforestation, another persistent problem in the region. “A recent study shows that there are 27 new cases of malaria for every square kilometer of forest cleared,” Castro said.
The participants also stressed the strong likelihood that zoonotic diseases will continue to emerge in the Amazon, given its history and present-day problems. “We don’t know much about the Amazonian virome [sum of all viruses] – only 0.025%, according to some estimates. Destruction of the forest could facilitate the emergence of novel pathogens. In addition to climate and ecological changes, deforestation is also a potential trigger for the appearance of novel viruses,” said Pedro Vasconcelos, a researcher at the State University of Pará (UEPA) and Evandro Chagas Institute in Belém.
The most vulnerable
The tragedy caused by COVID-19 in the North region looks even worse when analyzed from the standpoint of Indigenous and riverine communities. EPICOVID-19 BR, a serological survey conducted by the Federal University of Pelotas (UFPel), showed that members of Indigenous communities were 80% more likely to be infected by SARS-CoV-2 than white people living in the same city.
The impact of the pandemic has also been brutal in rural areas. According to a study published in Frontiers in Psychiatry by researchers affiliated with Oswaldo Cruz Foundation (Fiocruz), the incidence of the disease in Indigenous areas is 136% higher than the national average, while the mortality rate is 110% higher.
The most critical Special Indigenous Health Districts (DSEIs) in terms of mortality were Alto Rio Solimões, Cuiabá, Xavante, Vilhena, and Kaiapó do Pará. The data also showed a direct correlation between COVID-19 incidence in indigenous communities and deforestation, land theft (grilagem), and mining.
“Outbreaks of COVID-19 in recently contacted communities have also caused concern. Kwatinemo Indigenous Territory in the Altamira DSEI alone reported 30 cases,” said Luiz Penha, a Tukano who has an MSc in public health and is a member of COIAB, the Coordinating Committee for Indigenous Organizations of the Brazilian Amazon.
Vaccination of Indigenous people, a priority group according to Brazil’s national immunization program (PNI), is also below the average for the total population. Data for August from the Ministry of Health shows coverage below 50% in some DSEIs. The most critical in this regard are Kaiapó, Pará, with 32.4%; Rio Tapajós, Pará, with 38%; Alto Rio Juruá, Acre, with 39.7%; Kaiapó, Mato Grosso, with 42%; and Araguaia, Mato Grosso, with 49.7%.
“These areas all have a lot of land disputes because of encroachment by illegal miners and ranchers. There are also problems with fake news and logistical difficulties. Vaccine rollout hasn’t reached desirable levels as a result,” Penha said.
According to Érika Pellegrino, a researcher at the Federal University of Pará (UFPA) in Altamira, many local people distrust the government. “One person asked me, ‘The government does everything to kill us. Why would they give us the vaccine first?’ It’s a logical argument and hard to refute. But we need to tell people the vaccines can be trusted. We’ve been engaged in a major project to listen to the community. Problems have been caused by religious organizations that have sown many doubts about vaccines in the minds of Indigenous people. Social media are a great help with telemedicine, but unfortunately they also contribute to the spreading of fake news,” she said.
According to the researchers, Indigenous people were considered more vulnerable to COVID-19 at the start of the pandemic because of inequality. “We knew respiratory diseases spread quickly through Indigenous communities. We knew social distancing and isolation were more appropriate to urban areas. We also knew Indigenous people had less access to highly complex healthcare,” said Ana Lúcia Pontes, a researcher at the Oswaldo Cruz Foundation (FIOCRUZ) in Rio de Janeiro.
For Pontes, the COVID-19 crisis in Indigenous communities is compounded by the government’s encouragement of encroachment on their lands, which is an additional risk to their health. “The government’s response to COVID-19 has been mainly informed by denialism and making light of so highly complex a problem as the pandemic,” she said. “Its stance has prevented the organization of an adequate response. In the case of the Indigenous population, the problem has been aggravated by pre-existing vulnerabilities, an anti-Indigenous attitude, and a rolling back of pro-Indigenous policy and the state’s relationship with Indigenous peoples. As a result, the impact of COVID-19 on these groups has unfortunately been even worse.”
Distribution of personal protective equipment (PPE) is a case in point. “The availability of PPE on the front line was insufficient to meet initial demand,” she said. “The same was true of test kits, and this resulted in a major under-reporting problem, made even worse by the publicity given by the authorities to treatment with drugs like chloroquine that have been shown to be ineffective for COVID-19.”
Attitudes to Indigenous people and the applicable legislation have changed radically in Brazil, Pontes added. Until the 1960s, epidemics, violent land disputes and resettlement programs informed by an ideal of integration led to depopulation and profound pessimism about the future of Indigenous people. This process was reversed by domestic and international mobilization to support Indigenous peoples’ struggle for self-determination and the state’s obligation to protect and respect them.
“The Union of Indigenous Nations [UNI], founded in 1980, organized a sit-in at Brazil’s National Congress during the Constituent Assembly to defend the chapter on the rights of Indigenous peoples,” she said.
The Federal Constitution promulgated in 1988 guarantees the rights of Indigenous peoples to their own social organizations, customs, languages and beliefs, and to demarcated lands for their exclusive use. It has also had an impact on health policy. “The same period also saw the creation of a unified national health system [SUS], and indigenists worked closely with leaders of Indigenous communities to create an Indigenous healthcare subsystem. Set up in 1999, it recognizes the social and cultural diversity of the Indigenous peoples, which also affects wellness, sickness, and the therapeutic process,” Pontes said.
The series of webinars on “Health and Environment in the Amazônia in the Context of COVID-19” is an initiative of the University of Campinas (UNICAMP), the University of São Paulo (USP), the Federal University of Pará (UFPA), the National Space Research Institute (INPE), the Federal University of Rondônia (UNIR), the Federal University of Santa Catarina (UFSC), and Michigan State University (MSU) in the United States.
Recordings of the first and second webinars can be watched at www.youtube.com/watch?v=kd13uoLoUCY and www.youtube.com/watch?v=RKqXys_V3RY&feature=youtu.be.