Filipe Leonel (Ensp) e Julia Dias (CCS)
Researchers from the Oswaldo Cruz Foundation develop a plan to support the fight against Covid-19 among indigenous peoples. One of the goals is to intensify surveillance and improve information about the impacts of the pandemic on these populations, through six lines of action. The initiative mobilized different units and vice-presidencies and was highlighted by the president of Fiocruz, Nísia Trindade Lima. “This is a joint action by the Foundation, present throughout the national territory, to support the confrontation of this serious humanitarian crisis that affects indigenous peoples in Brazil,” he warned.
The advancement of coronavirus in the indigenous population has been accompanied by a series of challenges. Indigenous peoples are a group particularly vulnerable to Covid-19 due to the high prevalence of different diseases and health problems (malnutrition and anemia in children, infectious diseases such as malaria, tuberculosis, hepatitis B, hypertension, diabetes, obesity and kidney diseases) and previous difficulties in accessing the health system, particularly specialized care. In addition, indigenous people suffer from the increase in fires and deforestation, with poor sanitation and, in many situations, face enormous economic fragility, which makes it difficult to maintain social isolation, which is a fundamental measure in facing the pandemic.
“The scenario seen in indigenous populations is dramatic, but there is still a lot that can be done. This is what we are dedicated to. Fiocruz has been working in indigenous health for over 30 years. Now, we are integrating several lines of action to look carefully at the needs of these historically vulnerable populations”, says the president of Fiocruz.
Due to its history of work in indigenous health, Fiocruz was recently convened to form a working group to provide technical support in the development of a plan to confront and monitor Covid-19 in indigenous peoples by the Union, after determination by the Superior Federal Court (STF). Researchers from Fiocruz and the Brazilian Association of Collective Health (Abrasco) have been meeting and are expected to present their recommendations in early August.
Challenges in information production
The disparity in information on the impacts of the pandemic on indigenous populations also reinforces this vulnerability. According to Ana Lúcia Pontes, a central issue is to measure the number of cases and deaths in the indigenous population. This is because, even due to differences in registration procedures and coverage, there is a divergence between the official data provided by the Special Secretariat for Indigenous Health (Sesai) and the figures released by the Articulation of Indigenous Peoples of Brazil (Apib). The Sesai data, for example, refer only to the indigenous population in indigenous territories, and do not, as a rule, include indigenous people living in urban areas or in territories outside demarcated lands.
As of August 1st, Apib had recorded 614 deaths from Covid-19 in the indigenous population, with 21,217 confirmed cases in 145 affected peoples. While the official data from Sesai registered 15,848 confirmed cases, with 285 deaths in the Special Indigenous Sanitary Districts (DSEI). “We are following the progress of Covid-19 in the indigenous population. Suspected cases are very low, and we do not know if this is a problem of active search or lack of access to diagnostic tests. In addition, the data could be broken down, as the distribution of cases is not homogeneous”, explained Pontes, who also coordinates the Abrasco Indigenous Health WG and monitors the activities of the Mixed Parliamentary Front in Defense of Indigenous Peoples (FPMDPI), which introduced bill 1,142 sanctioned with vetoes on July 8.
For the researcher, more than the high incidence rates of the disease and the number of deaths, it is important to look at what this represents. “The older ones are dying and this is an immense loss. They are often leaders who hold unique knowledge, transmitted orally intergenerationally, and have an important role in the social organization and struggle of these peoples”, she explains. The doctor reinforces the need to analyze how different peoples are being affected, as some groups may be at greater risk. Brazil has approximately 300 ethnic groups and 270 languages spoken, which represents one of the highest levels of sociodiversity in the world. “Historically, indigenous peoples have faced epidemics that put them at risk of genocide. We have a responsibility”, warns Ana Lúcia Pontes.
In order to improve this aspect, the action line “support for diagnosis” proposes different fronts, such as the strengthening of Fiocruz laboratories to support molecular diagnosis and distribution of serological tests. The first initiative aims to ensure an adequate and agile supply of inputs for the laboratories of the Fiocruz Units and for researchers working in molecular diagnostic networks. The action is conducted by the Fiocruz Regionals in the Amazon, Bahia, Rondônia and Mato Grosso do Sul.
Fiocruz Amazônia researcher, Luiza Garnelo, recalls that underreporting is not a problem exclusive to the indigenous health subsystem, and that these data are important for understanding the dynamics of the pandemic, improving surveillance and primary health care actions, and for reduce mortality.
“We are working on the acquisition of personal protective equipment and tests for health professionals and agents who are in the communities. One of the initiatives is to capillarize this diagnostic resource and work directly with the teams that work in the communities. It is reversing a flow. Once the process is installed and you have the severity of the illness, is when the patient is removed. The attempt is to internalize the actions and reinforce primary care”, commented Garnelo.
Fiocruz will distribute 4 thousand rapid tests for the diagnosis of Covid-19 to the indigenous peoples of the Alto Rio Negro, Alto Solimões and Purus. The tests were donated by the Immunobiological Technology Institute (Biomanguinhos) to Fiocruz Amazonia, which coordinates actions in the region. In June, a Fiocruz team was in São Gabriel da Cachoeira conducting training of multipliers to handle the rapid tests for Covid-19. Garnelo emphasizes: “the idea is that the diagnosis can be capillarized to facilitate monitoring and surveillance in a remote and difficult to access region, with small villages spread over extensive territory, which makes it difficult for teams to face Covid-19”.
Multipliers are moving to implement these tests in the localities. After this phase, the results will be transmitted by radio or public telephones, the only forms of communication available. “With this, we are covering about 18 million hectares in the municipalities of São Gabriel da Cachoeira and Santa Isabel, where approximately 700 communities are located. We have the great challenge of crossing these rivers to reach them with due care, following the protocols “, explains Garnelo.
The proposal is to strengthen the performance of Indigenous Health Agents who work in communities in the Alto Rio Negro region. At the request of the Federation of Indigenous Organizations of the Upper Rio Negro (FOIRN), Fiocruz Amazonia carried out in partnership with the Joaquim Venâncio Polytechnic School of Health (EPSJV / Fiocruz), State Secretariat of Education (SEDUC / AM) and the Special Indian Sanitary District Alto Rio Negro (DSEIARN) the increase in education and technical professionalization of 139 Indigenous Community Health Agents who are now qualified to work in these communities. “They will be the focal point of this network so that higher education professionals can move around with more assertiveness”, explains the researcher.
Other areas of action
In addition to the diagnosis support axis, Fiocruz’s actions include health care, research, education, emergency support and communication and information initiatives. In the areas of education and communication and information, a group of researchers has been working on the dissemination of technical-scientific subsidies and educational materials, through podcasts, for Indigenous Health Agents (AIS). The initiative, conducted by the Joaquim Venâncio Polytechnic School of Health (EPSJV), had a first stage that resulted in ten Policast radio programs on facing Covid-19 in an indigenous context, addressing aspects of prevention, sanitation, health care and AIS activities, which are available in the “Indigenous Health” section of the “SUS in Action: Health workers in times of coronavirus”.
The second stage of the initiative has the central idea of producing information that can be used in reorientation of the agents work process during the pandemic period, according to the researcher of the Laboratory of Professional Education in Health Surveillance at the Polytechnic School of Health Joaquim Venâncio (EPSJV / Fiocruz), Ana Claudia Vasconcellos. “Podcasts address the care that must be taken during home visits, the reception of mild and severe cases of Covid-19, the recommendations to pregnant and puerperal women, on the correct use of masks, signs and symptoms, forms of contagion and various other themes”.
In order for the audios to reach the health agents, a network was created to disseminate information material via Whatsapp and a partnership with the NGO SocioAmbiental Institute (ISA) to transmit the information by radio. Ana Lucia Pontes, who participated in the design and production of podcasts in the first stage, draws attention to the importance of this initiative in order to provide qualified and capillarized information to indigenous communities.
The debate "Indigenous people and Covid-19 in Latin America: vulnerabilities and resistance" is avaible with Spanish subtitles.
Information for action
The Covid-19 Fiocruz Observatory aims to develop integrated analyzes, technologies, proposals and solutions for facing the Covid-19 pandemic by the Brazilian Health System and the society. The Sergio Arouca National School of Public Health (Ensp/Fiocruz), through the articulation of researchers from the Samuel Pessoa Endemic Department and in partnership with the Abrasco Indigenous Health WG, has been contributing to the Covid-19 Observatory with subsidies such as studies, technical notes and webinars, on the indigenous health theme.
In addition, a group of researchers from Ensp/Fiocruz has participated in a technical note pointing out that Covid-19 is not the only threat to indigenous health, point out environmental and territorial vulnerabilities in the Amazon. “The document warns of problems of food insecurity, which threaten the nutritional status of children, cases of malaria, trachoma, outbreaks and epidemics of acute diarrheal disease, tuberculosis, respiratory infections, sexually transmitted diseases, among others,” said ther researcher Paulo Basta.
The Center for Ecologies, Epistemologies and Emancipatory Health Promotion (Neepes), from Ensp/Fiocruz, develops an interdisciplinary work and an intercultural dialogue with the Munduruku people, in the Tapajós Region, involving not only the theme of mercury and mining, but environmental conflicts and resistance to preserve the identities and territorial rights of this population. At that moment, the initiatives, coordinated by the researcher Marcelo Firpo, were directed to support indigenous peoples in facing Covid-19.
Researchers from the Research Group “Health, Epidemiology and Anthropology of Indigenous Peoples”, that brings together experts from Ensp/Fiocruz, Fiocruz’s Scientific Computing Program (PROCC) and the School of Applied Mathematics of Getúlio Vargas Foundation (EMAP-FGV), produced two editions of the report “Risk of spreading Covid-19 among indigenous populations”, focusing on issues of geographic and sociodemographic vulnerability. In the various public presentations made on these documents, researchers Andrey Cardoso, from Ensp, and Claudia Codeço, from PROCC, highlighted the importance of producing updated analyzes about the spread of Covid-19 in indigenous populations.
According to them, by integrating different databases, the report seeked to identify the segments of indigenous populations with higher vulnerability, according to different population groups, represented by indigenous residing in towns and in urban and rural areas, in towns covered by Special Indigenous Public Health Districts (DSEIs) and in Indigenous Lands (TIs) officially recognized.
The analyzes are based on geographic exposure in municipalities classified according to levels of probability of epidemic, defined for the Brazilian population in general. These reports have been widely circulated not only in the community of collective health specialists but also in civil society in general, including indigenous organizations and their partners. To make these and other contributions visible, the Virtual Health Library of Indigenous Peoples is raising and making available documents, teaching materials and webinars on the theme of Covid-19 and indigenous peoples.
In a scenario of extreme need for intercultural dialogues, researchers Ana Lúcia Pontes, Ricardo Ventura Santos and Felipe Machado, in partnership with a collective of indigenous researchers from different regions of the country, are developing the initiative “Indigenous Voices in the Production of Knowledge". The proposal involves an editorial committee formed by indigenous researchers who formulated two public calls, focusing on indigenous authorship, which aim to capture contributions that give visibility to the multiple specificities inherent to the socio-territorial realities of each people, with an emphasis on complex socio-cultural and political interrelationships with health aspects of indigenous peoples, including the Covid-19 issue.
At the public launch of these calls, which took place during the webinar “Indigenous Peoples in the Production of Knowledge: For a Non-Silenced Health”, on June 26, Inara do Nascimento Tavares, of the Satere-Maué indigenous people and a professor at the Ins Insikiran Institute of Indigenous Higher Education, at the Federal University of Roraima, emphasized: “Institutional partnerships that place themselves in a symmetrical way, in a dialogue proposal, are very important”.