Communication and Health for the Population in the Brazilian Legal Amazon

Ulysséa Leal D* and Acioly Fernandes PM

Federal University of Vicosa, Brazil

Keywords: Brazilian Amazon Region; Unified Health System; Health; Communication; Health Services; Right to Health

Opinion

The Brazilian Legal Amazon region is home to the largest rainforest on the planet and spreads over a monumental geographical area (5,016,136.3 km2). Such grandeur engenders equally colossal contradictions: it concentrates impressive mineral fortunes, yet has the lowest social indicators; it gathers great biodiversity, but is the scene of the worst land disputes in the country. This region, called the Legal Amazon, is one of the largest ecological and biodiversity reserves on the planet, made up of 9 states and 808 municipalities and has 28.1 million inhabitants. Among the inhabitants are around 1.6 million indigenous people from 250 different ethnic groups and 150 different languages, as well as 426,000 Quilombolas, riverine, urban and peripheral populations [1]. This imposing setting, which is home to a third of the world’s trees and 20% of the world’s fresh water, is also paradoxical when it comes to issues relating to health- disease-healing processes. It is enough to point out that the region is responsible for the highest rates of infectious and parasitic diseases; has an insufficient supply of public services of all kinds, as well as infrastructure difficulties, particularly communication and transportation, and concentrates the worst rates of use of health services in the country, facing low availability of doctors (1/1000 inhabitants), which is 7 times lower than that found in the capitals of southern Brazil. The great geographical distances characteristic of the Brazilian Amazon region, travel difficulties and the limits of road access become obstacles for these populations to access the health system (Figure 1). However, these obstacles are Opinion still poorly considered in the planning of actions and funding to deal with this inherent element of the Amazonian scenario [2].

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Figure 1: Brazilian Legal Amazon [3]. The development process in the region has prioritized capital-intensive and labor-saving ventures, whose dynamics, determined by the foreign market, promote an economically unequal, sectorally heterogeneous and socially excluding model. As a result, Amazonian states have the worst results in terms of social and health indicators at a national level, expressing this exclusion. In the region, only 58.9% of the population has a water supply, 13.1% has access to sewage collection and only 21.4% of the sewage generated is treated and, in areas bordered by rivers, the absence of sewage collection reaches 95.9%. It should be considered that access to water and basic sanitation are the main health conditioning factors for populations living in rural, forest and water areas. In addition, life expectancy in the region is low due to mortality from non-communicable causes and infectious diseases (mainly among children) and accidents and violence (among young adults) [4].

With the aim of improving the level of health of forest, rural and water populations in Brazil, the National Policy for the Integral Health of Rural, Forest and Water Populations (PNSIPCFA) was created and approved at the 14th National Health Conference. The result of a debate with representatives of social movements, such as the Land Group, it was enshrined in Ordinance No. 2,866/2011, which establishes the policy within the Unified Health System (SUS), as a guiding and legitimate instrument for recognizing the health needs of these populations and the conditions and social determinants of the countryside, forest and waters in their health/disease process. The policy, through actions and initiatives that recognize the specificities of gender, generation, race/color, ethnicity and sexual orientation, seeks to promote access to health services; the reduction of health risks arising from work processes and agricultural technological innovations; and the improvement of health indicators and their quality of life [5].

When Brazil’s re-democratization process took place, the right to health became a fundamental part of the process of building “being a citizen”. In this context, communication and health were placed as an important part of social participation, one of the guidelines of the Unified Health System (SUS). In order for a complex health system to function in a country of continental size and diversity, it is necessary to establish the centrality of communication, since it is impossible to articulate principles, which presuppose the active inclusion of various actors and their voices, historically excluded, without the use of communication. The relationships between health, communication and education are interwoven in the concept of citizenship, including access to land, drinking water, housing, work, education, the environment and a way of life free from physical and psychological violence [6]. Only in this context can a fully healthy human being be conceived. For the Amazonian population, especially the riverside population, the term citizenship (cidadania in portuguese) has been adapted due to their deep relationship with the forest and the union of the terms, creating Florestania [7]. Beyond the role of informing society about health or just preventing diseases, the relationship between Communication and Health has been a multidimensional universe in which agents and institutions develop strategies, weave alliances, antagonisms and negotiations (Figure 2).

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Figure 2: Basic River Health Unit [8]. In line with this approach, Article 3 of the PNSIPCFA sets out the specific objective of: “X - promoting information and communication mechanisms, in accordance with diversity and socio-cultural specificities” [5]. Only by taking into account the cultural logics of individuals and their territories is it possible to move forward with powerful communication for health promotion. This perspective, which takes social markers into account, needs to consider the structural and dynamic consequences of the interaction between these multiple axes of subordination, since disadvantages interact with pre-existing vulnerabilities, producing a different dimension of disempowerment. The diversity of groups and peoples living in the region, such as indigenous peoples, quilombolas, riverside dwellers and urban populations living on the outskirts of large cities, require different strategies. In addition, the seasonal dynamics of the waters are a determining factor in the lives of these populations and make the state’s duty to promote health care in these territories even more complex [9].

The PNSIPCFA expresses the importance of supporting processes of permanent and popular education in health and communication for these populations. In order to be effective, these actions must take place in the territories, involving the communities and through active processes. The policy also proposes to contribute to mobilization, articulation, participation and social control, such as expanding the representation of rural, forest and water populations in state and municipal health councils. At this point we can see that there is a bottleneck in this issue, when we consider that social participation is linked to river transportation, or to excessive workloads at home or in the countryside, or the difficulty of accessing technologies, for example. Communication cannot be detached from an ethical project for society, in which material and symbolic powers are (or should be) distributed equitably. Analysis and surveillance and the availability of information in information and statistics systems are also fundamental for social control and participation and should be used as indicators in health policy planning. Including the provision of data disaggregated by color and race [10].

This right to health and communication includes the right to hear and be heard; to inform and be informed [6], which becomes even more relevant when associated with health uncertainties and crises, as we have experienced in the COVID-19 pandemic. As in many parts of the world, the pandemic has further weakened access to healthcare in the Amazon region. The region’s largest capital, Manaus, with 2,063,689 inhabitants, has suffered from the lack of control of the pandemic by the Jair Bolsonaro government (2019-2022), feeling the impact on mortality rates of a major outbreak when it is not mitigated, where even with an estimated 76% of the population being infected, herd immunity has not been achieved [11]. The discourse of herd immunity holds that a virus cannot spread because it finds a population that has a high level of immunity, reducing the number of individuals susceptible to infection. The region has suffered from low vaccination coverage, especially against SARS-Cov-2, due to the difficulty in accessing riverside and indigenous communities, transportation logistics and supplies, as well as the lack of adequate communication material for these populations. The situation is aggravated by the process of disinformation, which circulates information and discursive practices that compete with the official ones Sridhar D, et al. [12], undermining the social consensus on vaccination. It is therefore essential to train health professionals to use popular and health education strategies to communicate more closely with the reality of these populations. Given the current scenario of infodemic and disinformation that has plagued us, it is necessary to seek resources to facilitate access to knowledge so that different populations and various communication channels can maintain a dynamic and collaborative dialog between science and society. In this way, assertive communication provides people with advantages, as they will have the opportunity to consult informative and simplified materials that are easy to understand in order to promote health and prevent diseases and illnesses.

The lack of cell phone signal, internet and even electricity, makes access to communication complex, including health communication. Thus, although access to cell phones is practically universal, data from the PNAD Continuous indicates that only a quarter of rural residents in the Legal Amazon have access to 3G or 4G mobile internet. In addition, 49% of UBS in the Legal Amazon not located in capital cities have an internet connection, while the proportion of units outside the region with internet is 76%; only 19% of units in the region have refrigerators exclusively for medicines in conditions of use, and the average linear distance from a municipal headquarters to the nearest establishment with urgent and emergency services available through the SUS in the region is 15 km [13].

As such, the right to communication, which is so important for promoting health, publicizing prevention campaigns, disseminating information and combating fake news, is limited for the populations of the Legal Amazon. This right depends on the decentralization of health services and the search for public policies that take into account the social determinants of the health of indigenous people, quilombolas and riverside dwellers in their strategies. The diversity of groups and peoples living in the region requires differentiated and particular strategies. Understanding how information reaches individuals and communities, how it circulates and is interpreted and appropriated, becomes a fundamental aspect in building health promotion and prevention strategies. Despite considerable advances in health conditions in the Legal Amazon in recent decades, in the context of the organization of the SUS, it can be seen that obstacles persist to guaranteeing the full right to health, with similarities in relation to the national challenges for the public health system and an intrinsic relationship with the development model adopted in the territory until then [14].