INTRODUCTION large dams in existence around

There are more than 57,000 large dams in existence around the world today

(International Rivers 2018). Many of these dams were built with the purpose of

combating poverty through cost-effective energy production, supplying drinking water,

and improving agricultural production (World Health Organization 2000; World

Commission on Dams 2000; Scudder 2006). Despite these commendable goals, time and

time again researchers have documented that dam construction negatively impacts

surrounding human populations through environmental degradation and adverse health

effects (World Commission on Dams 2000; Scudder 2006). In many cases, the

environmental, health, and associated social costs outweigh the benefits to economic

development, especially for local populations (de Faria et al. 2017; Fearnside 1999, 2016;

Lees et al. 2016; Cochrane et al. 2017).

In terms of the human health impacts, there is considerable literature on the types

and severity of negative effects from dams worldwide (Braun 2010; Cao et al. 2012;

Erlanger et al. 2008; Fearnside 1999, 2016; Goldsmith and Hildyard 1986; Lerer and

Scudder 1999; Scudder 2006; World Commission on Dams 2000; World Health

Organization 2000; Kirchherr et al. 2016). Unfortunately, this information is rarely

integrated into dam planning. Making matters worse, health officials, researchers, and

Non Governmental Organizations (NGOs) who attempt to mitigate the negative impacts

of dam construction rarely possess data organized into cohesive models or frameworks to

account for the complexities of health-environmental-and social interconnections. To

address these problems, this research applies Singer’s (2009) syndemic theory to health

impacts of dams as a way to explain the interrelated and often compounded effects of

environmental changes, social inequality, and multiple diseases that negatively influences

humans.

Syndemic theory offers a unique framework to study the health impact of dam

construction. It postulates that the concurrent presence of two or more ill-health

conditions in a population can lead to a dynamic interaction in which each of the

conditions shapes and aggravates the other, thereby amplifying their separate effects

(Bulled and Singer 2011; Everett and Wieland 2012; Gonzalez-Guarda et al. 2012, 2017;

Halkitis et al. 2012; Himmelgreen et al. 2009, 2013; Kline 2012; Mustanski et al. 2014;

Romero-Daza et al. 2012; Singer and Clair 2003; Singer 1996; Willen et al. 2017; Singer

and Snipes 1992; Tsai and Burns 2015). When Singer first coined the term syndemic (a

combination of the words synergy and epidemic) he emphasized the fact that diseases and

ill-health do not happen in a vacuum. For example, considering the 2017 outbreak of

Cholera in Yemen that involved over 200,000 cases and killed 1,300 people, syndemic

theory shows how this was not a random happenstance. The outbreak was preceded by,

and made much worse by, widespread problems of malnutrition, disrupted sanitation and

a lack of access to clean water all due to civil war (Bruwer 2017). Treating the Cholera

outbreak as an isolated incident ignores the larger socio-political forces at play that both

create and exacerbate the situation.

Applied to the problem of health and dam construction, a framework based on

syndemic theory can tie previous environmental, political, anthropological, public health,

and biological studies together showing how all factors combine and negatively impact

each other, thereby weakening the overall health status of human populations. The

research presented here applies such a framework as it focuses on the massive Belo

Monte Dam being built along the Xingu River in the eastern part of the Brazilian

Amazon. The dam will be the third largest in the world and produce an estimated 11,233

megawatts of energy (Diamond and Poirier 2010; Governo Federal do Brasil 2009; Norte

Energia 2014). The widely reported destruction of rainforest (approximately 400 square

kilometers), the displacement of 20,000 people in the vicinity of Altamira (the urban

center closest to the dam site), and the influx and then departure of an estimated 50,000

workers is only the beginning of problems as the dam will create long-term

socioeconomic, environmental, and public health problems in an extensive area along the

Xingu River (Anderson and Elkaim 2018; Diamond and Poirier 2010; The Guardian

2016; Sullivan 2016; Harris 2015).

To assess local-level health impacts, research focuses on a community located

downstream from the dam as a case study. The municipality of Gurupá is located 188

kilometers downstream from the Belo Monte Dam at the confluence of the Xingu and

Amazon Rivers. The community (town population near 11,000 and the surrounding

Figure 1.1 Location of Gurupá and the Belo Monte Dam (UHBM)

municipality 26,000 – IBGE 2010) is included in the ‘indirect impact’ area for the dam

(Governo Federal do Brasil 2009).

The community is paradigmatic for the research focus in three ways: (1) Gurupá,

as most of the Amazonian “ribeirinho” [river bank dwellers] communities, is dominated

by an agro-extractivist economy with subsistence farmers (growing manioc as the staple),

extractivists (açaí, timber, and palm hearts), and subsistence/commercial

fishers/shrimpers fully dependent on the river for their health and livelihood (Wagley

2014; R. Pace 1998). This dependence makes the population very susceptible to a long

list of changes expected by the creation of the dam. (2) Because it is a downstream

community with the indirect impact designation, government officials and public health

researchers have assumed Gurupá will experience little health impact from the dam,

although this is contrary to global research. As a result, officials have done minimal

preparation for potential health impacts. In general, analysis of downstream communities

like Gurupá, is crucial since over the long run they receive the brunt of

socioenvironmental and health impacts as they are very susceptible to worsening water

quality and disruptions of natural flood regimes and typically lack proper healthcare

resources

(Adams 2009; Scudder 2006; World Commission on Dams 2000; Ligon et. al. 1995). (3)

The community is the best studied ribeirinho/agro-extractivist community in the social

sciences providing an invaluable base-line to understand health impacts in a holistic

fashion (see Wagley 1953 and 2014; Galvão 1955; Oliveira 1991; Pace 1998; Royer

2003; Pace and Hinote 2013).

Already during the fieldwork portion of this research from 2015-2016 the

municipality of Gurupá has experienced impacts associated with the dam—which is still

under construction during the time of this study. For example, there has been a strain on

the local health services as medical personnel are diverted to the dam site in Altamira to

care for the burgeoning numbers of sick and injured construction workers. Regional

hospital beds (for patients too ill for care in local facilities) are in such short supply that

one doctor commented that ill patients in outlying communities like Gurupá have died

waiting for an available bed (C. Pace 2013). In addition, according to the Secretary of

Health in Gurupá, increases in the incidence of dengue fever are attributed to an upsurge

in movement of people to and from Altamira (C. Pace 2013). Water quality issues have

arisen as suspected contaminants from the construction site have travelled downstream.

The rural workers union and health officials have called several emergency meetings to

discuss the problem.

Since the date for completion and full operation of the dam is projected for 2019,

the purpose of this research is to assess the current public health infrastructure of the

community of Gurupá, gathering a wide variety of social, environmental, and health data,

including 60 plus years of ethnographic research in the area (including 10 years of my

personal experience). These data are combined with the worldwide literature on the

health impacts of dams and syndemic theory, creating a likely scenario model. These data

form a cohesive model accounting for the complexities of health-environmental-and

social interconnections. Based on the model, recommendations for mitigation strategies

are articulated and will be given to the public health officials from the region as well as

other interested stakeholders.

Chapter Overview

The following is an overview on the contents of this dissertation. Chapter 2 will

discuss the background information necessary to put this research project into context by

providing a brief overview of previous studies examining the impacts that large

hydroelectric dams have had on communities globally. It will also cover syndemic theory,

which includes the background of the concept as well as examples of how it has been

used in medical anthropology and public health studies. This section will elucidate the

overlapping and interacting factors that create and mutually enhance disease and illness

as well as provide common critiques of the theory. Chapter 3 includes a detailed

description of the research site including its geographical location, demographics,

historical context, and connection to the national and global political economy. Placing

the town of Gurupá in a national/global context illuminates how economic and political

power is asserted in the planning process with little to no regard for the people inhabiting

the region.

Chapter 4 describes the mixed methods used in this study and an overview of the

data collected. Chapter 5 covers a detailed description of the public health system in

Gurupá and in Brazil as a nation. This chapter reveals how resources flow through the

public health system, how they are used, and what health means to the community. In

Chapter 6, quantitative results are presented from the project’s health surveys, food

frequency questionnaires, and anthropometric measurements. These data provide a

holistic overview of the baseline health status of Gurupá.

For Chapter 7, qualitative findings are discussed, highlighting the major themes

that emerged from interviews and ethnographic observations. The discussion of syndemic

theory and how it can be applied to the public health impacts of the Belo Monte Dam

through a heuristic model is found in Chapter 8. Chapter 9 is the conclusion to the

research, which provides recommendations to mitigate potential negative impacts.

Research Questions

Research on the health impacts of the Belo Monte dam in Gurupá was

divided into two phases. The first phase includes the qualitative portion of the

research. I chose to use qualitative methods for the first phase because at the

beginning of the research I was still establishing rapport and getting acquainted with

different members of the community, which lends itself to more in-depth interviews.

The qualitative data collected were then used to formulate parts of the quantitative

phase.

For the first phase I focused on the following set of questions:

(1) What is the structure of the local and regional health care system?

What do the care professionals identify as the strengths and

weaknesses of the system? What changes do they foresee with the

dam completion?

(2) How do community members view their current health status?

(3) What changes to their health or health care do they anticipate within

the coming years and what is the general opinion on, and discourse

about, the Belo Monte Dam?

For the second phase of research I focused on questions such as:

(1) What are the public health impacts of the Belo Monte dam on the

downstream riverine community of Gurupá? Will there be changes in

infectious disease rates, nutritional status/food security, or access to

healthcare? Will there be increases in malaria, dengue fever, and

waterborne illnesses ranging from dysentery to diarrhea due to

environmental changes and problems with water quality?

(2) Do the data collected identify syndemic relations? What is the

relationship between the various health impacts?

(3) How can different stakeholders such as grassroots organizations,

NGOs, and local government agencies use this information to mitigate

the health care problems? How can data on unanticipated syndemic

relationships be used to “fill in” the gaps of public health care?

Background to the Study: Plans and Delays

This dissertation is an anthropological analysis of the public health system of the

small riverine town of Gurupá, which is on the cusp of significant changes created by the

Belo Monte Dam construction. Initially, I designed the research project to assess public

health impacts of a completed dam project, as the initial turbines were to be functional in

2015. Yet as I started the fieldwork (2015-2016) it became abundantly clear that the dam

would not be completed during my time in the field. The Belo Monte Dam, in fact, has

been a focus of controversy, and construction delay, dating all the back to the 1970s. The

dam project has been proposed, reworked, and shelved many times due to economic,

political, and environmental concerns, including a series of work stoppages due to legal

problems after dam construction was well underway in the 2010s.

One of the more famous conflicts over the dam occurred in 1989. At this time the

national electric company, Electrobrás, was planning to construct approximately 297

dams in Brazil with 79 of them being in the Amazon region (Fearnside 2006). As the

plans for the first proposed dam in the vicinity of the Belo Monte site were discussed,

strong opposition spearheaded by Indigenous peoples and their supporters emerged. For

example, the First Encounter of the Indigenous Nations of the Xingu in 1989 held in

Altamira brought together various Indigenous groups, as well as environmentalists,

activists, and international celebrities, to draw attention to the negative impacts these

dams would have on nearby populations and the surrounding environment (Barbosa

2000:112-114).

Two iconic media events occurred during this period of protest that likely had

some impact on delaying construction for years. The first was the very public support of

the British singer Sting who brought the issue to the world stage. In conjunction with

Sting’s support was the dramatic show of force by Tuire Kayapó, a woman leader of the

Kayapó, who waved a machete in the face of Electrobrás’s chief engineer for the dam

during a public forum (Barbosa 2000, Hall and Branford 2012, Perez 2015). The second

media event was the televised testimony of Kayapó caciques (chiefs) protesting the dam

at the World Bank, an agency that was financing much of the project. Whether or not

these events were directly tied to the World Bank’s decision to cancel this first attempt to

build the dam is unclear (there were also political changes occurring in the Bank at the

time resulting in the “greening” of its lending policies and in an economic sense the dam

was very costly and risky making it less desirable—see Barbosa 2000:70-71), but to the

public they represented a clear and defiant statement of opposition.

Nonetheless, in 2005 the project resurfaced, this time financed principally by the

Brazilian government during a period of economic prosperity. The plan for the dam

passed through Congress, but then entered a six-year long legal delay because of

incomplete environmental impact assessments (Fearnside 2006, Perez 2015). It was not

until January of 2011 that Belo Monte’s installation license was finally granted. This

milestone, however, was immediately followed by a court order to suspend the license in

February of 2011 due to more compliance deficiencies and environmental concerns

(Perez 2015). By March the suspension was overturned and construction activities began again.

From that point there have been at least 8 more orders to suspend the Belo Monte project. The

stoppages came from failures to: hold prior consultations with dam-affected populations

(especially Indigenous groups), fulfill the requirement of a mitigation action plan, create

compensation measures for those impacted, and complete infrastructure projects such as building

bridges, fixing the local sewage system, resettling populations and demolishing and removing

structures and vegetation from areas to be flooded (Perez

2015).

Most recently in 2016, the federal court suspended Belo Monte’s installation

license due to failure to provide adequate housing to those impacted by the dam. Norte

Energia (now managing the dam’s construction) had proposed building three different

sized houses out of concrete blocks, but only constructed the smaller size and made them

out of cinder blocks. The resulting problems were that larger families could not fit in one

house and the cinder block structures did not support the traditional sleeping hammocks

that most people use in the Amazon (hammocks are both cooler and less expensive than

beds). Additionally, the houses were not built to local codes, forcing the town of Altamira

to made amendments to their building codes to accommodate the houses. Opponents of

the dam are challenging this change as unconstitutional (Sullivan 2016).

Background to the Study: Personal Experiences

At the time of writing this dissertation, the estimated competition date for a fully

functioning dam is in 2019. For this reason my research has shifted from studying the

health impacts in Gurupá created after the completed construction of the dam to the

analysis of the recent history of Gurupá’s health care system, which will serve as a

baseline study to understand changes coming from the dam. The benefit of having lived

and worked in the area of study off-and-on for over 10 years allows me to have a unique

longitudinal perspective on the dam’s impact on Gurupá.

I first came to know Gurupá in 2005 during an ethnographic field school held in

the community. At this time I had just completed my first year as an undergraduate at

Middle Tennessee State University and decided to spend my summer travelling and

learning anthropological research methods. Armed with one year of Portuguese, a

research project to measure the undernutrition rates of children, and several college-ruled

notebooks, I got my first taste of ethnography. The journey to Gurupá started with an

eight-hour plane ride from the United States to the city of Belém in the state of Pará.

Belém is the last major city before traveling up the Amazon River to the smaller

community of Gurupá. Gurupá is accessible primarily by riverboat, although small planes

can fly in and out on a small runway, usually in the event of a medical emergency. The

riverboat leaves once a week, traveling from Belém all the way to Manaus, which is a

five-day trip. Fortunately, the trip to Gurupá is only 24 to 36 hours depending on tides,

weather, and how much cargo must be loaded or unloaded along the way.

For most of my time in Gurupá I resided in the town (described in Chapter Two),

but critical to my study, I also twice visited the city of Altamira, where the dam is being

built and where the biggest impact has been so far. The trip to Altamira can be by river

boat from Gurupá, a 12 hour trip up the Xingu River with a stop in Victoria and a quick

taxi ride to the city. Alternatively, from Belém the trip is a difficult 20-hour bus ride along

paved and dirt roads full of potholes. Arrival in Altamira is typically chaotic, as the city

has exploded in population and is haphazardly organized. Navigating the city with its

snarling traffic is always problematic. I did manage to find and speak with several of the

most active voices against the dam, members of NGOs who fight social injustice in the

Amazon. For example I met briefly with the Instituto Socioambiental

(Socioenvironmental Institute) or ISA in 2012 to discuss my project when Altamira was

in the throes of protest against the dam. Many activist organizations from across the globe

had traveled to the location as a show of force against the project. Revisiting Altamira in

2015, however, was a vastly different experience. The activist organizations had departed

having failed to stop Belo Monte from happening. They moved on to new proposed dam

sites leaving ISA alone to fight for the people’s rights in the wake of the beginning stages

of construction on Belo Monte.

Back in Gurupá, the inevitability of the dam brings to the surface certain truths. It

is clear that government planners on the regional and national level will (and have) use(d)

any means necessary to complete big development projects with little to no regard for the

ones most affected (Schmink and Wood 1984: 419-438, Silva 2009). The attitudes of

people in Gurupá reflect these understandings with one local health care worker stating,

“the government does not care about the Amazon; we are invisible to them” (C. Pace

2015). Stephen Nugent (1993) has written about this problem of invisibility and how

outsiders have not taken the Amazon populations seriously. He states that Amazonians are

either being subsumed under the rubric of nature which denies them a separate social

existence (particular the indigenous populations), or disappear under a formal invisibility

manufactured by developers who view them as a social pathology that impedes economic

development (Nugent 1993: 6, 35, 39). I personally recorded derogatory discourses about

people from the Amazon while spending time in the South of Brazil. I was told more than

once that the only thing in the North (Amazon) are lazy Indians who just want to steal the

White people’s land and make it a reservation and take everything the White man worked

hard to create (C. Pace 2013).

With the multitude of development projects occurring in the Amazon, many

justified through national discourses on invisibility such as these above, there is constant

struggle in communities like Gurupá to defend resources and livelihoods from outside

interests. In this dissertation I focus on challenges to public health that stem from the

Belo Monte dam, a megaproject that will benefit others while bringing little if any value

to the local community—but assuredly create long-term social and environmental

hardships according to the existing literature on dam impacts world-wide. I include

information about the local health and the public health system in Gurupá, both its

strengths and weaknesses, to address some of the areas that are more vulnerable to dam

impacts. I combine these data into a model using the theory of syndemics to connect

social, political, and environmental impacts with those of particular epidemics. The goal

of the research is to create a model that can be used by those who want to strengthen the

community-led health programs likely impacted by the dam, including using these data to

petition the government for specific resources needed as the short and long-term health

problems manifest in the community.

CHAPTER TWO:

LITERATURE REVIEW

The process of damming rivers is a practice common to humanity that predates the

Neolithic Period (McCully 2001). Throughout time there have been multiple reasons to

construct dams, ranging from the regulation of seasonal flooding, management of water

for irrigation, to the storage of water for arid regions. More recently dams have been built

for recreational purposes and, more importantly, to produce hydroelectric power. Today

large hydroelectric dams are responsible for 19% of the world’s total electricity

production (Perlman 2012). Given the growing energy needs worldwide, the search to

find ways to create greater amounts of electricity from renewable resources like water has

become of mounting global importance. In the haste to fulfill the economic benefits of

renewable energy, however, planners often ignore what happens to the people living near

these large development projects.

Drawing from a list of approximately 50,000 large dams in existence around the

world (large dams are defined by measuring 15 or more meters from the base to the top—

McCully 2001), researchers have documented that dam construction negatively impacts

surrounding human populations, with environmental degradation and adverse health

effects being the two most detrimental failings (World Health Organization 2000).

Concerning the latter, there is considerable literature on the types and severity of health

impacts from dams worldwide (Braun 2010; Cao, et al. 2012; Erlanger, et al. 2008;

Fearnside 1999; Goldsmith and Hildyard 1986; Lerer and Scudder 1999; Scudder 2006;

Sleigh and Jackson 2001; World Commission on Dams 2000; World Health Organization

2000). Some well documented problems include malnutrition due to decreases in the

variety of fish in the river, the spreading of infectious disease due to increased migration

to the area, and reduced access to health services after populations are displaced from

their homes (Erlanger, et al. 2008; Gaur and Patnaik 2011; Sleigh and Jackson 2001). One

of the most menacing issues with dam construction projects, however, is the

contamination of water. This along with changes in water flow and canalization allow

vector-borne diseases to flourish, especially in tropical areas (Lerer and Scudder 1999).

Dam Impacts

The World Health Organization (2000), or WHO, recommends that health impacts

from dams be sorted into six categories: communicable diseases, noncommunicable

diseases, injury, nutrition, psychosocial disorder, and social well-being. The WHO also

suggests that the level of priority given for each category, in terms of migration, be left up

to the local community. Later in this dissertation I will use the theory of syndemics to

disentangle the dynamic interactions occurring on the local level involving the changing

environment, migration of populations into the area, increases of communicable diseases,

forced displacement and resettlement of populations, loss of land and livelihoods,

changing dietary patterns, and the disruption of access to health and public services and

how each category of dam impacts, listed above, may contribute to and exacerbate the

other categories to provide a bleak outlook on population health if not properly addressed.

But first, I will begin by highlighting some of the major health issues that occur globally

in each of these categories.

Non-communicable diseases

Non-communicable diseases that are directly linked to dam construction and

implementation include poisoning by biological toxins, minerals, and pesticides (World

Health Organization 2000). They may also include cardiovascular disease, diabetes, or

cancer as indirect impacts of changing dietary patterns, subsistence strategies, or stress

levels (increased and sustained cortisol levels) caused by lifestyle changes created by the

impacts of dams. These latter effects, however, are discussed in the nutrition and

psychosocial diseases sections that follow. This section will focus on problems of toxin

release caused by the processes of dam construction.

In a very important comparative case from the Brazilian Amazon, the Tucuruí

Hydro Power Complex, located along the Tocantíns River which is to the east of the

Xingu River where the Belo Monte dam is located, chemicals were used to defoliate large

areas to be flooded by the dam reservoir. Over time the chemicals entered the local water

supplies. According to local reports, as a consequence a significant number of dam

construction workers and native people in the surrounding area died from consuming

contaminated water (LaRovere and Mendes 2000).

In other cases worldwide, high levels of mercury have been found in people living

downstream from dams, especially in watersheds located near mines. Bacteria in the

reservoir water convert any mercury in the water from the dam into methylmercury,

which is a central nervous system toxin. These toxins are ingested by various plants and

animals over time and work their way up the food chain where they are concentrated in

fish. When a human population consumes the fish, they are exposed to a high

concentration of methylmercury. This is of great concern to pregnant women because

these chemicals adversely affect the development of the brain and nervous system of

fetuses, causing damage to memory, attention, language and motor skills (Burma Rivers

Network 2012).

Another health impact of poor water quality caused by dams is cyanobacteria,

which is a type of microscopic algae produced from quickly eutrophied (nutrient

enriched) water such as the water found in dams of tropical areas. For example, the

construction of the Three Gorges Dam in China led to an elevation of water temperature

and a reduction in the flow of the Yangtze River, thus creating conditions ideal for the

growth of cyanobacteria (Bartram and Chorus 2002). These cyanobacteria can cause a

range of gastrointestinal and allergenic illnesses in humans. Some cyanobacteria can even

promote liver cancer during chronic low exposure over a long period of time. The worst

known case of cyanobacterial toxin poisoning actually occurred in the Brazilian city of

Curaru in the state of Amazonas. In 1996 patients who were undergoing dialysis used

water from a reservoir. The toxin went straight into their bloodstream and this direct

exposure killed more than 50 people (World Health Organization 2000).

A subset of health problems related to water and dams is the lack of planning in

case of a dam break. Ideally there should be contingency plans to deal with the

devastating environmental damage, possible loss of life, and water contamination.

Contingency plans, however, are infrequently made. This is exactly what happened in

Brazil on November 5, 2015 at the Fundão Dam in the state of Minas Gerais, which

broke and released 60 million cubic meters of mining waste in a massive flood that

resulted in 19 deaths (Breslin 2015; The Guardian 2015). The Brazilian mining industry

is being charged with negligence in regard to operating and maintaining the dam,

suggesting that safety regulations were ignored and that the biggest environmental

disaster in Brazil’s history, as described by the environment minister Izabella Teixeira,

could have been averted (The Guardian 2015). Samarco, one of the companies held

legally responsible for the disaster is reported to have been forewarned of a possible dam

rupture in 2013 yet never came up with a contingency plan (Guardian 2015). This is the

fifth dam break to occur in the state of Minas Gerais in the last decade and brings up

serious questions regarding how safety is assessed. It also leads to questions about the

haste to build dams to fulfill the massive energy needs of the country and whether or not

this will result in more disastrous dam breaks.

According to Scudder (2012), the greatest, immediate risk from dams actually

comes from operational inefficiencies, especially for downstream communities. In

backto-back years (1999 and 2000) the poorly managed Yali Dam in Vietnam released

flood waters that killed and injured villagers in downstream communities as well as

completely destroyed crops and livestock reaching all the way to Cambodia. In China a

series of dam breaks killed an estimate of 230,000 people in 1975 (McCully 2001). In

addition to the mismanagement of dams, Patrick McCully (2001) found that overtopping

is the single major reason for the failings of dams. Engineers build dams to withstand the

maximum flood estimates, however climate change is not a factor in these estimates.

According to the Intergovernmental Panel on Climate Change the planet will warm

considerably by the end of the century causing global rains to increase by 2-4 percent,

thus increasing the likelihood for exceeding spillway capacity (McCully 2001). The panel

has highly recommended that all past, present and future dams take into account the

effects of global warming to mitigate any negative impacts that arise with dam failings

(Khagram 2004). Returning to the case of the Fundão Dam break in Brazil, there

were additional deaths and injuries caused by the sudden flooding and consequential

mudslides. Towns like Bento Rodrigues that were in the direct path of the break have

been destroyed, leaving more than 500 people homeless. As the mining waste from the

iron ore mine moved through the River Doce Watershed many downstream communities

have had their main water source polluted. More than 200 towns, some with as many as

278,000 inhabitants, are struggling with contaminated water and no idea as to when the

water will be safe to drink again (The Guardian 2015, ABC 2015). The waste, which

includes heavy metals and chemicals, has travelled 500 kilometers to reach the Atlantic

Ocean killing fish and aquatic life along the way (ABC 2015). The Royal Society of

Chemistry based in Europe states that in addition to metals such as mercury, arsenic,

chromium and manganese, the dam water also contains harmful bacteria (Massarani

2015). This is a very serious impact specifically to downstream communities who were

once thought of as out of the impact area. Due to this particular dam break’s magnitude,

the long-term effects have not been fully assessed, but the damage to health, society,

livelihoods, and the environment is likely to be immense and last for decades (Massarani

2015).

Nutrition

Nutrition and food insecurity are factors of great concern for communities

displaced by dam construction. Yvonne Braune (2010) writes about the unintended

nutritional consequences of compensation programs in Lesotho, Africa. The Lesotho

Highlands Water Project (LHWP) is a large scale, multi-dam development project, which

began in 1989 and was completed in 2009. It is a joint project between the Lesotho and

South African governments (Keketso 2003). The series of dams were constructed to

supply South Africa with water and to generate power for Lesotho. Around 400 families

in the Maluti Mountains of Lesotho were relocated and 20,500 residents of this area were

affected in some way by the LHWP.

Braun (2010) shows the importance of understanding how several seemingly

unrelated factors of dam construction and relocation can act upon each other to produce a

variety of unintended consequences. For this specific project, planners developed policies

to mitigate the negative impacts felt by the community living in the area where the dam

was to be constructed. In Lesotho however, the policy developers did not understand how

the role of gender within the household would be affected by giving the compensation

money only to the men. Giving money to the men provided them with power over

domains that were traditionally controlled by women, thus creating unequal access to

household resources. Women were more likely to be in poverty and at risk nutritionally in

Lesotho and those who lost land due to the multi-dam project were even more vulnerable

to these risks. With the loss of land women were not only forced to feed their family with

less available and less varieties of food, but they also were deprived of growing food in

their gardens to sell as supplemental income. With the simple act of giving the men the

compensation as heads of the household, women’s rights were diminished and food

insecurity increased.

In addition to reinforcing gender inequalities, the compensation received for lost

land was inadequate (Braun 2010). For fields larger than 1,000 square meters, the

government gave a food package to the family, which was meant to replace what the

household would have produced from its fields. The food packages were to be delivered

once a year and the program was to last for a total of 15 years. The community members

who saw their land as providing them with financial security, however, saw this program

as unfair. What would happen to their families once the food packages stopped? Not

having land to pass down to their children and their children’s children was of major

concern to the population. Braun (2010) concludes that both the material and

psychological impacts on the community must be considered when developing policies

related to population displacement from dams.

In another study Kedia (2004) examines how food production strategies changed

among resettled populations due to the Tehri Dam construction in North India. The

resettlers went from having a diverse, high-protein diet in the mountains of the middle

Himalayas to subsisting on a nutrient-poor, high carbohydrate diet in the plains of the

foothills of the Himalayas. They also went from producing food for consumption to

producing food for cash as they increasingly became involved in a market economy. Not

only did this influence nutrition, but it also affected their entire lifestyle. Being more cash

dependent forced resettlers into urbanized lifestyles and exposed them to consumer

products. Adult male resettlers developed addictions to alcohol and tobacco for which

they spent a considerably greater amount of money than their counterparts still living in

the mountain villages. Poor nutrition, alcohol and tobacco were risk factors for

cardiovascular disease, obesity, diabetes, domestic violence and other health conditions.

From research, Kedia (2004) offered policy suggestions for the government that included

providing more food assistance for the resettlers, as well as teaching them new

subsistence practices that would help them provide for themselves and not be so

dependent on the market economy.

In many cases it is not only displaced populations, but also downstream

communities that suffer from food insecurity and poor nutrition as a result of the building

of large dams, especially for the purposes of regulating river flow for hydropower or

irrigation (Scudder 2012). Hyrdroelectric dams require a constant flow of water through

the turbines to generate electricity. This demand can interfere with the natural flood

regimes of rivers that are important to traditional agricultural systems as well as a means

to replenish ground water and fishing resources (Saarnak 2003). In Brazil, the Tucuruí

Dam has had many negative impacts on fisheries that affect the variety and quantity of

fish available to riverine communities who rely on fish as a dietary staple. Worldwide,

dams are responsible for the endangerment and/or loss of one-fifth of the world’s

freshwater fish population (McCully 2001). The Sobradinho Dam, also in Brazil (the state

of Bahia), has negatively affected 11,000 downstream communities that practice flood

recession agriculture resulting in food shortages and lowered productivity of the region

(Scudder 2012).

Saarnak (2003) discusses the impacts of hydroelectric dams on downstream

communities in the Senegal River Valley. Traditionally the people inhabiting this flood

plain have adapted to live and work with the natural rises and falls of the river. When the

rainy season flooded the river, fishers spanned out throughout to region to work. When

the water receded, the fishers would leave the area and flood recession farmers would

take over the valley. When the Manantali Dam was built for the purpose of hydropower

the flow of the river was subjected to the power demands of the country. To produce more

energy, the dam released water, thereby creating downstream flooding, but without

notifying the farmers. The floodwaters wiped out newly planted crops and resulted in

massive crop failure (Saarnak 2003). In addition, the reservoir decreased the sediments

that the naturally flowing river contained so that when the valley was flooded it no longer

held the same fertilization properties for the fishers and farmers and thereby directly

impacted the food availability for the region.

Psycho-social disorders, social well-being and injury

Displacement of people is one the most studied social impacts of development.

Many social scientists, especially anthropologists, are dedicated to understanding the

processes that displaced and resettled people must go through to be able to adapt to their

new settings (Cao, et al. 2012; Cernea 2000; Heming, et al. 2001; Oliver-Smith 2009;

Scudder 2012). This process is a delicate one and involves many factors as entire

communities are moved from a place where they have lived, sometimes for generations.

Gaur and Patnaik (2011) discuss in their study how the Korwa, an indigenous group of

Central India, perceive their health since they were removed from their homes located in

the forest tracts. The research focuses on the experiential health, or how people’s

embodied experience of their state of being is formed by a complex relationship between

physical, emotional, environmental, and social factors of living. Within this framework

Gaur and Patnaik examine the concept of liminality and health. Liminality refers to the

state of being betwixt and between, or being out of place due to, in this case, forced

displacement. The article observes that the Korwa are suffering from a loss of experiential

health because they are taken away from their familiar lifestyles (the forest provides for

them) to a new environment where they must work in wage labor. The Korwa feel that

this is not healthy and therefore have mental distress in addition to higher rates of

parasitic- and vector-borne diseases.

Resettlement projects have been highly unsuccessful and have continuously

impoverished communities over the past 50 years. An important theoretical model for

resettlement proposed by Cernea (2000) is the Impoverishment Risks and Reconstruction

model, which seeks to identify risks associated with forced displacement and illuminate

the processes necessary for the reconstruction of livelihoods. The model highlights the

negative effects that populations may incur due to forced displacement such as: bringing

about landlessness, joblessness, homelessness, marginalization, food insecurity, increased

morbidity and mortality, community disarticulation, loss of access to public services, and

loss of civil and human rights. Host populations, groups that will receive people

migrating in from being displaced or to work on the dams, are also considered in this

model.

Displacing populations without proper planning can lead to communities lacking

access to clean water and basic sanitation facilities, such as in the case of the Nam Theun

II hydroelectric project in central Laos (Erlanger, et al. 2008). Approximately threefourths

of the individuals examined for this survey of resettled communities were infected with

an intestinal parasite while about 20% had at least two intestinal parasites. Malnutrition

was a problem for one out of every six children in the community along with moderate

levels of anemia. The resettled community might have serious mental health risks from

loss of land, community, resources and displacement. For the downstream community

there are likely to be many changes in ecology that will affect the social structures and

livelihoods of the population. Factors such as uncertainty, enforced reorganization of

subsistence patterns, and loss of social coherence is associated with psychosocial stress.

These stressors can be perpetuated by drug abuse, depression, and new residents

migrating to the area, causing further tensions and conflict (Erlanger, et al. 2008).

Injury is another factor that is significant when discussing impacts on health.

Workers may suffer from any number of work related injuries in the construction phase of

dam implementation. For example, in one anecdotal case from the Belo Monte Dam, on

May 30, 2015 there were three work related deaths. A large silo holding approximately

500 tons of cement fell off of a truck as workers were unloading it killing three and

injuring another three workers (Harris 2015). This may have been an oversight in health

and safety regulations or just an accident that can occur when working with these large

construction materials, but this type of injury and fatality cannot be ignored in the health

impacts of dams. Workers at the Belo Monte dam site did report that the working

conditions to which they were subject to were atrocious and likened it to being in prison

(Jagger 2013). There are many occupational risks that come with working in construction,

but those risks are amplified when companies neglect employees and their working

conditions.

Communicable Disease

The following section will focus on health impacts that are specific to tropical

regions like the Amazon. The WHO Human Health and Dams report (2000) recognizes

that hot and humid tropical climates suffer from greater rates of communicable diseases

which, when coupled with environmental changes and migration of populations occurring

in relation to dam construction, can lead to devastating effects upon local communities.

Communicable diseases are the most easily quantifiable impacts from hydroelectric dam

projects. Dams create pools of standing water, which allows mosquitos to reproduce at

rapid rates. This not only makes life intolerable—with biting intensity measured at 600

bites per hour on exposed humans for the Tucuruí region of Brazil—but also increases the

possibility that the mosquitos carry malaria or dengue (Fearnside 1999).

There are approximately 18.9 million people living near large dams in tropical

areas worldwide who are at a higher risk of malaria (Yewhalaw, et al. 2013). In addition,

mosquitos can migrate for up to 50 km (approximately 31 miles), or even farther with

prevailing winds or river traversing boats, so the number of people affected by dam

induced increases of malaria is likely to be much higher (World Health Organization

2000). A study conducted in the Narmada Valley, India shows the result of the Bargi Dam,

a multi-purpose irrigation and hydroelectric dam, on rates of malaria. Prior to the

construction of the dam in 1996 malaria epidemics were very rare with an overall

prevalence of malaria at 19%. In 1997 these rates rose to 91% with the only obvious local

change being the Bargi Dam (Singh, et al. 1999).

Another ecological effect of tropical dams is an overabundance of aquatic

marcrophytes, which are plants that live in or near water (a water lily, for example). The

roots of these plants are breeding grounds for animal vectors associated with diseases

such as schistosomiasis, malaria, cholera, gastroenteritis, enterovirosis, arbovirosis and

filariasis (Erlanger, et al. 2008). Schistosomiasis has been a problem in many areas where

dams have been constructed —such as the Aswan Dam in Egypt. This is a parasitic

flatworm found in snails that can bore through the skin of a person who wades or swims

in water contaminated with infected snails. In the case of the Aswan Dam the incidence of

infection with schistosomiasis rose from 21% to 75% and as high as 100% in some

communities (Goldsmith and Hildyard 1986). Many of these areas are rural with very

little access to health services. Leaving an infection like schistosomiasis untreated can not

only damage organs and tissue, but also weaken the body leaving it vulnerable for other

diseases.

Another likely facet contributing to the spread of communicable diseases is the

creation of new jobs and the expansion of infrastructure, which produces a steady stream

of migrant workers to the dam construction sites. Since the jobs created consist mainly of

manual labor, the majority of the migrant workers are male. Sex work is a well-known

consequence of this scenario, which increases the rates of sexually transmitted diseases

such as HIV and hepatitis B (Erlanger, et al. 2008; Lerer and Scudder 1999). Returning to

the example of the Lesotho Highlands Water Project or LHWP, Braun (2010, 2011)

discusses the unequal burdens placed on women due to their exclusion from receiving

development compensation. Given their poverty and the competition for work in an

economy with few opportunities, some women were pushed into sex work. Not

surprisingly, the LHWP work site ranked as the third highest in the prevalence of

HIV/AIDS in a country that already has the third highest HIV/AIDS rate in the world

(Braun and Dreiling 2010; Willemse 2007, Workman and Ureksoy 2017). In 2009, when

the construction of the five major dams was complete, AIDS was reported as the leading

cause of death in all hospital wards, with a total of 14,000 AIDS related deaths overall for

the year (Olowu 2014).

Overcrowding and less than favorable sanitary conditions are known factors for

the spread of disease leading to major epidemics (WHO 2016). A study by La Rovere and

Mendes (2000) showed a major problem with the Tucuruí Dam was the doubling of the

population due to labor immigration. The lack of adequate provisions for housing led to

the emergence of shantytowns (favelas) and the relocation of people to surrounding

islands with little to no infrastructure. Access to schools, medical facilities, and public

services necessary for families was limited. Infant mortality rates for the municipality

were six times greater than the rest of the state once dam implementation had begun.

Increases of malaria, diarrhea, respiratory problems, and even an outbreak of typhoid

fever in 1981 were found to be among the most daunting health consequences.

Finally, a recent threat to public health, specifically in Brazil, is the emerging Zika

virus. The Centers for Disease Control and Prevention cited in their January 2016 edition

of Morbidity and Mortality Weekly Report (Hennessey et al. 2016) that between

440,000–1,300,000 cases of Zika were reported in Brazil in 2015. Zika virus is a vector

borne disease that occurs from mosquito-to-human transmission, but has also been passed

through sexual and blood transmission. Aedes aegypti is the mosquito that carries Zika

virus as well as other endemic diseases such as dengue fever and chikungunya, which

also have similar symptoms. Although 80% of those infected with Zika will be

asymptomatic and those who are symptomatic will not result in fatality, there is a concern

with how this virus infects pregnant woman. According to the Brazilian Health Ministry,

there was an increase in children born with microcephaly in 2015, which causes an

infant’s head to be much smaller than normal and results in stunted brain growth and

development (WHO 2016). The tissue of several infants born with microcephaly did

contain some traces of Zika virus, but further studies must be conducted to give a clear

causal relationship between Zika and microcephaly (Hennessey et al. 2016). Nonetheless,

Zika, as any vector borne disease is likely to be on the rise with the increase in standing

pools of water that are common around dam sites.

Political Economy of Health

All of these health issues that I have discussed in this section can be placed within

a syndemic framework in order to show how they can be interlocked with each other and

with societal and global factors such as economics and politics, resulting in mutually

worsening health effects. It is important to note, however, that syndemics falls under a

larger more widely used theoretical tradition called the political economy of health. This

theory, which I will simply call political economy throughout the rest of the dissertation,

seeks to uncover the underlying factors of poor health by examining macro-level

structures such as policy impacts, the allocation of resources, or the effects of capitalism

(Singer 1995).

The political economy approach was used as early as the 1840s in Friedrich

Engels’s publication about the working class of England (Engels 1845). In his work he

states that the poor health of the working class was due to the social organization of British

capitalism which created poor living conditions, overcrowding, food insecurity, and a lack

of access to physicians (Baer 1982). Farmer et al. (2004) builds on and refines this

approach by using the concept of structural violence—a term originally used by

Johan Galtung (1969) wherein individuals within a society are harmed by institutions

which block them from meeting basic needs. It is a system where elite sectors of society

utilize classism, racism, sexism, ageism, and other forms of oppression to exert power

over the marginalized, keeping them disenfranchised for the elite’s own gain.

Like political economy and its correlate structural violence, syndemic theory

highlights the marco-level factors involved in causing poor health. But syndemic theory

can advance these approaches even further by pointing out how ill-health factors

intermingle to create extreme disease clustering within an already disadvantaged

population. I wish to first examine some of the factors related to political economy and

then later I will discuss how syndemic theory fits within political economy to create a

holistic picture of health and health systems.

As an example of the political economy approach to health, The Guardian (2017)

examined how the Zika virus has been spreading throughout Brazil, highlighting the

inefficiencies in national infrastructure and the role politics. The report begins with the

Brazilian government not meeting the basic sanitation needs of people, with more than

half of the population lacking access to sewage collection and clean drinking water.

Communities are faced with collecting clean water where they can find it and storing it in

their houses. This practice, unfortunately, creates the perfect opportunity for mosquitos to

breed in stagnant water containers maintained in residential areas. The Guardian goes on

to show how the recent corruption scandals in Brazil may have caused the former

president, Dilma Rousseff (who in December of 2016 was impeached for breaking budget

rules, causing the government accounts to appear in much better shape than they were at

the time), to remove a public health doctor from his position in the ministry of health who

may have had more insight into how to fight the communicable disease outbreaks. Instead

Rousseff put a psychiatrist in this position so that she could pass government bills in

order to not face impeachment (Guardian 2017).

There are also political processes behind the ability of municipalities in Brazil to

provide health services to their populations as shown by Mobarak, Rajkumar, and

Cropper (2005). According to the authors, there are three types of decentralization for the

allocation of health care funds that occur at the municipal level: full state management,

basic assistance management, and full county system management. Under the full state

management the state government has complete control of the health system and can

determine the funds and types of provisions allotted to the municipalities. With the basic

assistance management the municipality manages all primary health care, but leaves the

more complex services to the state government. For the full county system management,

complete control of primary care and complex services goes to the municipality.

In order for a municipality to apply for full county system management it must be

deemed fit to handle the decentralized administrative role by a judge at the federal

government level. If a municipality has full management of their healthcare (in 1999

about 8% had full management status while 80% were under basic assistance), then the

transfers required for reimbursement are subject to an annual ceiling, which is decided

upon through political negotiations with the federal government (Mobarak, et al. 2005).

As a result of these systems, municipalities which are more politically favorable to the

party in power, or that have closer political ties to the state, are more likely to be granted

full county system management as well as have a more relaxed budget to use towards

health care. The fact that the more rural and impoverished North has fewer and poorer

public health services may be, in part, due to the lack of political interest that the higher

levels of government have for this region (Bliss 2010). When federal or state

governments provide subsidies for multimillion-dollar projects surrounded by

controversy and possibly even corruption, instead of dispersing more funds for healthcare

or infrastructure to the most impoverished areas, they are further widening the income

gap and creating even more poverty and suffering.

The Broader Political Economy

In the last decade there has been more research on the negative impacts of large

dams than in the last 50 years combined. Given the data on harmful effects, why, then, do

large dam projects continue to receive planning priority and receive copious funding? To

answer this question we must take a look at the larger factors at play. For example, in the

case of Brazil it is clear that factors such as growing national energy demands, the push to

become a successfully developed country in the global economy, and its global spotlight

as the host of both the 2014 FIFA World Cup Soccer games and the 2016 Summer

Olympics drive many of the government’s decisions potentially including the

construction of hydroelectric dam projects. The rate at which Brazil is trying to

accomplish these goals does not seem to allow for slow and deliberate decisions about

what is best for all communities being impacted.

This type of mindset is not limited to Brazil as countries all over the world look to

dam construction as a means to increase energy production and gain a spot in the global

economy. Indeed, since the United States began construction on the many dams that

helped “conquer the Wild West,” large dams are seen as, “potent symbols of both patriotic

pride and the conquest of nature by human ingenuity” (McCully 2001: 24). The notion of

progress seems to envelop these dam projects whether it is progressing from developing

to a developed nation, progressing into a more equal society by distributing water and

resources, or progressing towards the future with dreams of clean renewable energy. The

symbolism and rhetoric around dam projects have even been seen to take a religious tone

as seen in the speech by the first Prime Minister of India when he spoke at the opening of

the Bhakra Dam.

Which place can be greater than this, this Bhakra-Nangral, where thousands and

hundreds of thousands of men have worked, have shed their blood and sweat and laid

down their lives as well? Where can be a greater and holier place than this, which

we can regard as higher?

It seems that when a dam becomes shrouded in symbolism, the men that laid down their

lives become less about poorly managed work environments and more about honor, pride

and a testament to humanity’s conquest over nature.

In the case of the Maheshwar Dam in India, the fact that the government’s top

priority was dedicated to proving that it could attract international investors greatly

hindered the consideration of more beneficial alternatives. This leads to perhaps the most

salient driver of development; the profitable nature of these projects. The World

Commission on Dams (2000) estimates that $2 trillion have been spent on dam projects

throughout the 20th century. This money goes to dam building corporations who then use

part of the funds to create a powerful pro-dam lobby to influence nations. Furthermore,

when there are billions of dollars to be made with little to no transparency required, this

easily lends to the familiar practice of corruption.

From China to Brazil to India, industries that profit from dam construction are

oftentimes tied to governmental agencies (i.e. Department of Agriculture or Energy)

creating a common interest of profitability and an environment for bribery, kick-backs,

and overall indifference to objection (McCully 2001). Aid agencies are also involved in

this culture of corruption by the notion of “tied aid”—a practice that requires borrowers

to only purchase equipment and other necessities for dam construction from the donor

country. This was the case in the UK when, in 1993, the National Audit Office found that

approximately £234 million in subsidized loans were being given to fund the Pergau Dam

in Malaysia despite the conclusion that this project was unnecessary and going to cost the

Malaysian people £100 million more in electricity charges. In addition, the two biggest

construction companies in the UK were awarded contracts for the dam without any regard

to competition from other outside construction companies. Both companies were also big

contributors to the Conservative Party (McCully 2001).

It is clear to see that the lucrative nature of dam building takes precedence over

the numerous negative impacts that have been outlined in this chapter. The global

workings of market economies are a huge factor in a nation’s ability to make decisions

that affect the most vulnerable in any society and as shown above, when the most

vulnerable are ignored, poverty and disease reign. Dams allow the most powerful groups

to encroach upon and lay claim to the previously communal land and resources of the

most politically and economically weak groups of people in the name of progress. As

McCully (2001:24) concluded, “The massive momentum provided by bureaucratic

structures, careers, ideologies and profit has kept the big-dam machine rolling over the

past six decades with few insiders questioning the damage done or evaluating whether the

promised water, food, and prosperity for all have been realized.”

Syndemic Theory

Within the study of global health there has been an increased awareness that

single diseases do not act alone or exist in a vacuum shut away from the outside

environment (Singer and Clair 2003; Singer 1996; Singer, et al. 2012; Singer and Snipes

1992). This approach, however, runs counter to the models used in modern Western

biomedicine, which works within a reductionist framework isolating each illness into

separate pathogens with a distinct set of symptoms (Singer 2009). By contrast, the theory

of syndemics posits that diseases interact with each other causing people with

comorbidities to suffer jointly and mutually aggravating effects. On a community and

population health level this framework allows for a holistic view of all factors that

influence health. It also challenges the practice of blaming poor health on individual

behaviors.

Syndemics illuminates how societal and global decisions impact health options for

the most vulnerable populations, often leaving them with a significant burden of disease

(Singer 2009). Although relatively new, researchers utilizing the concept of syndemics

have expanded the approach to include factors such as nutrition, structural violence,

diabetes, politics, and so forth (Everett and Wieland 2012; Gonzalez-Guarda, et al. 2012,

2017; Himmelgreen, et al. 2013; Kline 2012; Littleton, et al. 2012; Ostrach and Singer

2012; Romero-Daza, et al. 2012; Sattenspiel and Mamelund 2012; Singer 1996;

Singer and Bulled 2012; Singer, et al. 2012; Willen et al. 2017; Mustanski et al. 2014;

Mendenhall et al. 2017; Workman and Ureksoy 2017).

Once a disease becomes endemic in a region with multiple existing health

disparities, it takes little time before a cascading effect to occur which can lead to

multiple epidemics happening simultaneously. Multiple infections pose a unique threat to

healthcare providers who must be aware of how certain pathogens interact with others in

order to mitigate the effects of co-morbidity. A well-documented example of this is the

Human Immunodeficiency Virus (HIV) and tuberculosis (TB). Exposure to TB in

individuals is 800 times more likely to result in an active TB infection in those with HIV

than those without this co-infection (Singer 2009). This is due to the fact that HIV blocks

the immune system thus allowing TB to be more effective in infecting an individual.

Tuberculosis may also activate T cells that are more likely to be susceptible to HIV

infection. In addition, these two infections can accelerate the effects of each other causing

the rapid deterioration of health in a population. Understanding how diseases interact with

each other is crucial to those working in community health. This allows healthcare

professionals to understand the course of disease transmission and identify those most at

risk.

Malnutrition is another factor involved in many syndemic relationships. Much

research has gone into the effects of poor nutrition on the immune system. Singer (2009)

details three ways in which malnutrition can pose a threat to the health of individuals and

leave them open to infection. First, insufficient protein intake can severely hinder the

immune system’s ability to fight off infection as well as increase muscle weakness and

impair cognitive functioning (Jeejeebhoy 2000). Second, nutrients called anti-oxidants are

required to fight off oxidative stress. If these nutrients are absent, then oxidative stress

can enhance viral replication, weaken cell repair activity, and contribute to an overall loss

of immune function. Finally, micronutrient deficiency weakens the body’s ability to

protect itself from infection by impairing epithelial cells, which produce a protective

barrier against pathogens. Deficiencies in vitamins A, D, E and zinc can also affect T-cell

responses (Kau, et al. 2011). In these ways, once the balance of food security is tipped in

a negative way and the local diet changes significantly there is certainty that detrimental

health consequences that will emerge.

Another advantage of using a syndemic perspective is the ability to identify other

factors that contribute to disease and illness in a broad social context. For example,

syndemic theory has shown how factors such as poverty, structural violence, and the

environment create and aggravate health disparities, thus contributing to a greater burden

of disease for certain populations. Medical anthropologists and public health officials

have embraced this framework for its ability to illuminate social and environmental

factors that have a heavy impact on population health. With this knowledge, it is more

likely that proper actions can be taken to really address the cause of certain epidemics.

Case Studies: Syndemic Research

One of the very first syndemic relationships examined in the literature is what is

known as the SAVA (substance abuse, violence and AIDS) syndemic (Singer 2009). This

cluster of risk factors has a profound effect on many different populations from Hispanic

women, MSM (men who have sex with men), to drug users. Once a single disease is

detected in an individual, a working knowledge of syndemic theory can provide a

warning that other factors may be working on this individual to increase the suffering and

burden of disease. For example, in a study conducted by El-Bassel et al. (2011) a random

sample of 416 women who were in methadone treatment programs was surveyed about

the life experiences. Eighty-eight percent of the women in the program had self-reported

personal experiences with physical or sexual abuse in their lifetimes. These women were

also more likely to report no or inconsistent condom use and were less likely to request

partners to use condoms. When physical violence leads to fear of requesting condom use

from partners, the risk of becoming infected with HIV increases. Stress stemming from

intimate partner violence has been shown to trigger relapse in drug using women and it is

well noted that intravenous drug use is also a risk factor for HIV (El-Bassel, et al. 2011).

Stress has been shown to weaken the immune system and increase the likelihood of

multiple infections and dismal health outcomes (Singer and Clair 2003; Singer 1996,

2009). Drug use also interacts directly with AIDS to worsen both conditions (Singer

2009).

To add to this complicated condition, Himmelgreen et al. (1998) show in a study

of 41 drug-using Hispanic women and a control group of 41 non-drug using Hispanic

women that the drug users are more likely to be food insecure and live in extreme poverty

than the control group. Limited access to food, general disinterest in eating, and a focus

on drug needs rather than food preparation all contribute to the increased levels of

malnutrition among these drug-using women. Accounting for malnutrition and poverty in

the SAVA syndemic formation further complicates the burden and susceptibility of

disease within this population.

One of the most critical lessons learned from syndemics research is the necessity

to understand the complicated ways in which the socio-cultural environment impacts

human biology and individual decision-making regarding one’s health and well-being. If

public health programs only take a biomedical approach to HIV and treat all cases the

same, as a disease isolated from the social context, they frequently end up with

unsuccessful interventions. It is also important to understand the specific cultural context

in which communities live in order to determine risk factors for disease.

Paul Farmer is a medical anthropologist and physician whose work exemplifies

how society, culture, and history are factors that affect the most vulnerable populations.

Through his ethnographic studies, Farmer also shows the importance of understanding

health and illness within a cultural context and not through a global or Western lens. One

such example comes from Farmer’s work in a rural village in Haiti. In 1956 Haiti’s

largest hydroelectric dam was built on the Riviére Artibonite which promptly flooded out

the peasants living on the banks of the river. Many fled to the nearby hilltops, receiving

little to no compensation for the land they left behind. Due to this sudden major upheaval

and the fact that everything had to be left behind, the residents of the newly created

community of Do Kay reported feeling dazed and unable to act decisively (Farmer 2006).

Community members lost their crops and their ability to feed their children. Without a

single economic option in sight to make up for this loss, poverty and high levels of

depression began to affect the population. In addition, the community did not have access

to proper sanitation and clean water, thereby incurring high rates of typhoid fever as well

as high infant mortality rates stemming from diarrheal disease. As mentioned previously,

persistent malnutrition and food insecurity worked to aggravate these diseases by

suppressing the immune system. When the river was dammed and the community

displaced this set off a ripple effect of impacts ultimately resulting in widespread poverty.

Weakened immune systems, poor sanitation, and no viable economic options set the stage

for the HIV and TB syndemic to hit this community very hard.

Since the majority of HIV cases that came through the clinic in Do Kay were

women, Farmer (2001) conducted a small study of 50 women to distinguish specific risk

factors for HIV for this population. Twenty-five of these women had symptomatic HIV

infections while the other twenty-five formed the control group of seronegative women.

The most striking result showed that risk factors for women in Do Kay were not linked to

prostitution, high numbers of partners, illicit drug use, or blood transfusions. Instead, the

HIV positive women were all similar in the fact that they had lived in Port-au-Prince,

worked as a servant, and had sexual partners who were transient and more likely to be at

a higher risk for HIV.

The women’s scenarios were similar: they had tried to escape their economic

situations by leaving Do Kay to work as servants in Port-au-Prince, where the likelihood

of contracting HIV is much higher. They were also more likely to form relationships with

men who were soldiers, truck drivers, or construction workers. Men in these professions

had daily salaries and were seen as more economically secure. However, the men in these

professions moved back and forth from rural areas to the city and often had multiple

sexual partners, thus increasing their risk of HIV. It is clear to see from this ethnographic

study that the risk factors of HIV in Do Kay are particular to the community’s culture and

history. They are not the same risk factors found in urban areas of Haiti or in the United

States, places where most of the public health publications and programs are created for

HIV/AIDS prevention.

Workman and Ureksoy (2017) have, more recently, used syndemic theory to

examine the role of water insecurity in a previously explored syndemic relationship

between food insecurity, HIV/AIDS, anxiety, and depression. Approximately 514,000

Basotho, citizens of Lesotho, require humanitarian assistance due to the decades-long

drought causing major disruption in the food supply. The lack of opportunity for farming

has thrown the country into poverty with a 45% unemployment rate. This, in turn,

increases the anxiety and depression felt throughout the country as it suffers through

environmental, economic, and social stresses.

Workman and Ureksoy sought to include water insecurity as a prominent stressor

in the everyday lives of the Basotho. They found that while quantity of water is

important, it was the quality of the water and their perception of its cleanliness that

caused the most stress and anxiety within the sampled population. Increased stress and

anxiety within the community has an increased and additive effect on depression.

HIV/AIDS also increases stress and anxiety due to a family member’s death or having to

take in an orphan whose parents died from AIDS. Losing a family member and taking in

an orphan also led to increased food insecurity. Studies like this are crucial in obtaining a

more complete understanding of syndemic dynamics as the health and well-being of

populations are constantly being impacted by ever-changing factors surrounding them.

Critique of Syndemic Theory

Despite the strengths of syndemic theory, it is still a relatively new theory in

medical anthropology and public health and has not been fully tested in a wide variety of

settings. The theory’s novelty and its lack of critical scholarship pointing out gaps and

flaws is, in and of itself, a weakness. As work in syndemics continues to gain momentum

and more and more syndemic relationships are postulated, it will be important to verify

they met the definition established by Singer and are actually syndemic relationships. For

example, in order for a group of afflictions to be considered syndemic they must be

occurring as simultaneous epidemics within a population, they must be acting upon each

other in a negative way to increase the burden of disease, and they must include

biological agents of disease as well as social determinants. Singer offered this critique

about his theory, “[One problem] stems from the challenge of differentiating two or more

components of a single disease from two or more interacting diseases” (2009, 30). This is

a note of caution that a researcher must be able to show that the health conditions in a

population meet all of the criteria of a syndemic, which may be difficult to prove at times

given the complexity of these interactions. Tsai and Burns (2015) make the same critique

from a quantitative perspective. The article describes the difficulty in obtaining a

quantifiable result that is statistically significant enough to prove that the interaction of

certain diseases are indeed additive and mutually enhance poor health.

One safeguard against misidentifying syndemic relationships is to discuss

potential co-interactions within a broader framework of political economy of health. In

this way if the studied relationships turn out to not be syndemic, the broader theory still

allows detailed analysis of complex health conditions. The research results should enable

a better understanding of problems a population faces and allow better intervention

strategies.

It is also important to separate syndemics from globalization. Although both are

frameworks used to describe the effects and interconnectedness of social, political,

environmental and economic systems, syndemic theory focuses much more heavily on

the social injustices that tend to come with globalized societies and how they interact to

double the burden of disease on populations.

CHAPTER THREE:

RESEARCH SETTING

Located in the North of Brazil along the equator,

the Amazon is Brazil’s largest geographic region, as well

as its poorest. It has a long history of

economic and political marginalization since colonial

occupation by the Portuguese. Because it is not a

productive environment for plantation crops, successive colonial

governments turned to predatory extraction of rainforest

resources using indigenous slaves in the collection of the

scattered commodities (Parker 1985, Wagley 2014). The most

valuable resources were cacao and a varietyof oleaginous

seeds and aromatic barks, which were extracted until depleted.

Only in the last half of the 1800s with the rubber boom

did the region produce much wealth. All of this was

lost with the collapse of the rubber boom (1912) due to

the rise of plantation

rubber in Asia (Weinstein 1983; Barham and Coomes 1996).

It was not until after the end of the second

world war that industrialized nations sought to create projects

aimed at boosting the economies, improving health, and/or

increasing involvement in the globalized economy by the

developing countries (Escobar 1991). The industrialized countries

saw the Amazon as an underdeveloped region within an

underdeveloped country in need of outside assistance

to solve its internal problems (Robock 1963). The

political and economic elite of Brazil largely accepted this

viewpoint as well. All saw the people of the Amazon

(both indigenous and peasant) as poor, ignorant, and

backward. They were unable to cope with the environment and

make it productive, and thereby were a barrier to

development (Nugent 1993). Economic expansion through

development projects directed by outside groups became

the solution to the problem (Robock

1963). These projects, however, continued the past patterns

of predatory extraction. Timber, palm-hearts, and minerals

were extracted with little concern for the impact on

ecosystems or the local people’s lives. Development was

measured in gross profits with little regard to distribution of

resources or rising poverty levels

(Barbosa 2000).

In the 1980s, however, there was a paradigm shift

among social scientists and environmentalists to view the

‘traditional’ life of the rural peoples of the

Amazon as a sustainable adaptation that leads to rain

forest conservation. Discussions arose of “primitive ecological

knowledge” that must be preserved for the well-being of

the tropical ecosystem (Milton 2013; Bodley 1996; Posey 1983).

Indigenous and traditional peoples (e.g. peasants) were labeled

‘guardians of the rain forest’ and all of its resources

(Hall 1997, Barbosa 2000). These proenvironment messages are

now part of the mind-set of many if not most

Amazon peoples. When asked, most will respond with unease

to the notion of deforestation. Yet, as a paradox,

developmentalist discourses are also widespread and are still

a strong force guiding policy in the region.

The simultaneous acceptance of conflicting discourses on

pro-development and pro-environment is exactly what is going

on in areas being impacted by the Belo Monte Dam. For

example, in the municipality of Gurupa , just downstream

from the proposed Belo Monte dam project, the paradox

of pro-development and proenvironment sentiments was

captured in a survey conducted between 2007-2009 by

Richard Pace and Brian Hinote (2013) concerning people’s

attitudes toward the Belo Monte Dam, still in its

planning stages. When asked, 63.4 percent of respondents said

they were in favor of the Belo Monte Dam, citing the

anticipated economic and development benefits. However, when

asked about environmental issues of deforestation and if

conserving the biodiversity of the rainforest is of great

value, the majority of respondents agreed to this as well.

In fact, 99 percent of the respondents replied

positively to the question, “Should the rain forest be

conserved to ensure future biodiversity?” What many in the survey

were missing was the connection between the construction

of the Belo Monte Dam and the wide-spread

environmental destruction this would cause.

The connection between dam construction and public health

is even more obscure in the minds of many in

Gurupa . In part, this is understandable since even with

a thorough review of information released in official

government documents, NGO reports, or coverage by the

media, a person will find little discussion of potential health

problems, particularly for downstream communities like Gurupa .

Elsewhere in the world there is an abundance of

literature assessing health implications of dam projects, but

this information is not readily available to the communities

that need it now. For this reason it will be integral

for this project to take the health factors associated with

the creation of large hydroelectric dams and relate them to

the daily life and health structure of Gurupa . In order

to do this, however, one must have a clear

understanding of how things work in Gurupa . The

following sections will provide historical and cultural

background on Gurupa , which will provide cultural

context to understand the health care systemand the

changes it is undergoing.

Getting to Gurupá – Some Personal Notes on Entrance into the Field

I remember clearly my arrival by boat in January of 2015 as I began my

dissertation research. The first quarter moon hung above the distant city lights of Gurupá

as we rounded the last delta island. As the boat got closer to the landmass illuminated by

streetlights, the captain slowed the engines. From the deck I could see the letters of the

hand painted sign above the dock growing larger. My travel companion/research assistant

and soon to be fiancé—Cesar Cisneros—and I stood eagerly at the front of the boat, him

in Brazil for only the second time and myself feeling like a seasoned veteran having

traveled to Brazil multiple times. It was after midnight when the boatmen threw the big

braided rope over a tree-sized pole sunk deep into the bottom of the river in the port of

Gurupá. Once securely tied up, we disembarked, uneasily guiding our oversized luggage

down an aluminum ramp to shore, barely wide enough to walk comfortably.

Figure 3.1 View of the dock from the boat. Source: Author

Figure 3.2 Ramp to boat. Source: Author

The walk from the dock to our pre-arranged accommodations was roughly a

quarter-mile over cobbled and aged roads. The graffiti I spotted on the side of buildings

and walls was striking to me, as it was something new, although the stray dogs wandering

the town were not. Even though this was one of several times that I had been in Gurupá,

arriving in the middle of the night makes for a sleepy and disorienting reentry. The walk

seemed longer than expected. In each hand I carried a fully packed suitcase that weighed

what I would later learn to be the same as a bushel of açaí seeds—that is roughly between

15 and 22 kilograms.

I still felt the same exhilaration upon arriving as I did the first time in 2005, and

actually every time since. Some twelve years ago I stepped off of the same boat onto the

same road and up to the same house where I would live. This time, however, my trip was

not limited to a summer. I would spend the next year working and living among people

that have become lifelong friends. As daunting a task as it was to spend such a long time

away from my family and friends, excepting Cesar, the warm welcome I received as I

entered my research home calmed my nerves. It was as if I had just seen them yesterday

and we picked right back up as if no time had passed at all. It is easy to feel this level of

comfort with the people of Gurupá, whether you have known them for years or just met

them. The openness and hospitality of the community to researchers and my family in

particular are some of the attributes that make this town unique.

The municipality of Gurupá, with its estimated population of 30,727 (IBGE 2010), is

located at the confluence of the Xingu and Amazon Rivers (see figure 3.3 below). The

population is largely ribeirinho—literally meaning riverbank peoples. They are

subsistence farmers (manioc being the staple), extractors of forest commodities (rubber,

timber, oleaginous seeds, açaí, Brazil nuts), and subsistence fishers who are often referred

to as “agro-extractivists,” or by the pejorative term “caboclo” (Harris 1998; R. Pace

1998; Wagley 1953). In the beginning of the 2010s nearly 70 percent of the population

lived in the countryside and approximately 30 percent in town (IBGE 2010). As will be

discussed later, this pattern is changing rapidly.

Gurupá is a poor place by Brazilian standards. The state of Pará, where it is located,

has an overall rural poverty rate of 58.4 percent, with 44 percent living in extreme

poverty (Pace and Hinote 2013). The municipality of Gurupá does not have many natural

resources or infrastructure with which to generate great amounts of economic wealth. For

the rural dwellers the main economic activity is agro-extractivism. In terms of farming,

the staple crop is manioc produced in small slash-and-burn plots (roças). Manioc is

consumed as farinha (toasted manioc flour), beiju (manioc “bread”), mingau (manioc

porridge), and tapioca (prepared as a spongy bread). Rice, beans, corn, squash, and a

number of fruit trees compliment manioc production. In terms of extraction, the main

resources are timber, açaí, and heart of palm. Within recent years, açaí production has

greatly increased, stimulated by growing regional, national, and global interest in the

fruit. Gurupá is now experiencing a modest economic boom due to the fruit export.

Figure

Map

Gurupá,

Pará

Subsistence and commercial fishing and shrimping are also an option, but in Gurupá not

much money is made from this.

In town the largest employer is the municipal government. Occupations include civil

servants, health and education professionals, health care and educational assistants, as

well as transportation and custodial services. In the private sector most jobs are in sales in

small-scale retail stores, service jobs in restaurant/bars, and innumerable part-time or

temporary jobs involving manual labor. There are a few businesses specializing in

furniture production and mechanical repair, but they are all small-scale enterprises.

In the social science literature much has been written about the municipality of

Gurupá. Charles Wagley, for example, wrote his classic ethnography, Amazon Town,

about the community following research in the 1940s. Amazon Town has become the

base-line reference for nearly all studies focusing on the traditional rural populations of

the Amazon and is still widely cited today. Following in Wagley’s footsteps and

continuing the tradition of research in Gurupá are his students Eduardo Galvão (Santos e

Visagens – Saints and Spirits), Arlene Kelly (Family, Church and Crown: A Social and

Demographic History of the Lower Xingu Valley and the Municipality of Gurupá, 1623-

1889 in 1984) and Richard Pace (The Struggle for Amazon Town: Gurupá Revisited in

1998, Amazon Town TV in 2013, and an updated version of Wagley’s Amazon Town in

2014). These and additional researchers who spent substantial time in the community and

produced significant publications are found in Table 1. Collectively, these works provide

valuable longitudinal data to contextualize recent changes in the region.

Table 1. Gurupá Researchers and Principal Works. Source: Hendrickson, Pace, Miller,

and Hurst-Dodd 2013.

1953

Charles Wagely. Amazon Town. New York: Macmillan.

1955

Eduardo Galvão. Santos e Visagens. São Paulo, Companhia Editôra Nacional.

1957

Charles Wagely. Uma Communidade Amazônica. São Paulo: Brasiliana.

1964

Charles Wagley: revisit (1961) and new preface to Amazon Town. New York:

Oxford University Press.

1974

Darrell Miller. Amazon Town in 1974. MA Thesis. Gainesville: University of

Florida.

1976

Charles Wagley. Amazon Town, second edition with chapter by Darrell Miller

“Itá in 1974”. New York: Oxford University Press.

1984

Arlene Kelly. Family, Church, and Crown: A Social and Demographic History of

the Lower Xingu River Valley and the Municipality of Gurupá. PhD

Dissertation, Gainesville: University of Florida

1986

Penny Magee. Plants, Medicine, and Health Care in Amazônia: A Case study of

Itá. MA Thesis. Gainesville: University of Florida.

1987

Richard Pace. Economic and Political Changes in the Amazonian Community of

Itá. PhD dissertation. Gainesville: University of Florida.

1991

Paulo H. B. Oliveira. Ribeirinhos e Roçeiros: Subordinação de Resistência

Camponesa em Gurupá, Pará. MA Thesis. University of São Paulo, Campinas.

1997-

FASE. Boletim Projecto FASE Gurupá. Belém: FASE.

1998

Richard Pace. The Struggle for Amazon Town: Gurupá Revisted. Boulder,

Colorado: Lynne Reinner Publishers.

Table 1 Continued

1999

Fabío Poelhekke and Paulo H.B. de Oliveira Junior. Projeto Gurupá: Sustainable

Tropical Forest Exploitation through Community Ownership, A Brazilian Initiative.

Development 42:2:53-56.

2001

Girolamo Domenico Treccani. Violência e Grilagem: Instrumentos de aquisição da

propriedade no Pará, Belém: UFPA-ITERPA.

2002

FASE. Projecto Gurupá internet site (www.fase.org.br). Accessed 12/2002.

2003

Jean-Marie Royer. Logiques sociales et extractivisme. Etude anthropologique d'une

collectivité de la forêt amazonienne, Etat du Pará, Brésil. PhD dissertation.

Université Paris III-Sorbonne nouvelle, Institut des Hautes Etudes d'Amérique

Latine.

2004

Neila Soares da Silva. Like a Mururé: Social Change in a Terra-Firme Community

on the Amazon Estuary. MA Thesis. Gainesville: University of Florida.

2006

Monte Hendrickson. Child Labor in the Brazilian Amazon: An Ethnographic

Approach. MA Thesis. Murfreesboro, TN: Middle Tennessee State University.

2006

Mônica Barroso. Waves in the Forest. PhD Dissertation, London School of

Economics.

2006

Girolamo Domenico Treccani. Regularizar a Terra: Um Desafio para as Populações

Tradicionais de Gurupá. PhD dissertation. Belém: Universidade Federal do Pará,

NAEA.

2008

Émina Márcoa Nery dos Santos. A Construção de Espaços Públicos na Política

Educational em Gurupá. PhD Dissertation. Belém: Universidade Federal do Pará,

NAEA.

2009

Richard Pace. Television’s Interpellation: Heeding, Missing, Ignoring, and

Resisting the Call for Pan-National Identity in the Brazilian Amazon. American

Anthropologist 111(4):407-419.

2009

Benedita Alcidema Coelho dos Santos Magalhã. Educação do Campo, Poder e

Políticas Públicas: A Casa Familiar Rural de Gurupá-Pa., Uma Construção

Permanente. Master’s Thesis. Belém: Programa de Pos-Graduação em Educação:

UFPa.

2013

Richard Pace and Brian Hinote. Amazon Town TV: An Audience Ethnography in

Gurupá. Austin: University of Texas Press.

A Brief History of Gurupá

In the early 1600s Dutch traders were among the first Europeans to document their

arrival in Gurupá. At the time they encountered numerous Indigenous groups in the Xingu

and Lower Amazon region with whom they traded through a series of trading posts. In

1609 the Dutch constructed a fort in Gurupá named Mariocaí, the native Tupí word for

the area and population living there at the time (Wagley 2014, Kelly 1986). Groups of

Irish and English settlers also founded settlements in the region, trying to establish

tobacco plantations (Kelly 1986). All groups remained in the area until the Portuguese,

who claimed the area, decided to dispel the foreigners. Through a series of military

engagements, the Dutch lost their fort at Mariocaí and they, along with the

English and Irish colonists were killed, imprisoned, or fled (Kelly 1986). In 1623 the

Portuguese rebuilt the fort and named it Saint Anthony of Gurupá. There were several

additional military conflicts with the English, Dutch and a group of 22 Irish families who

moved to the area in 1621, and later the French, but the Portuguese remained in control

and persevered (Kelly 1986).

The Portuguese, unlike the Dutch, were not in the Amazon to set up trading posts.

Instead they set out to colonize the region and claim the indigenous peoples for the

Catholic Church and the Portuguese crown. The Portuguese enslaved the indigenous

populations, who were used for labor in transportation (paddling canoes) and to collect

forest resources to export back to Europe. Gurupá’s fort became the staging grounds for

brutal slaving raids throughout the region. The Church, most notably the Jesuits,

accompanied the raids and always claimed a portion of the captives for their missions.

Slaves forced into labor for the colonists died in large numbers, so the majority of the

surviving indigenous populations were found in the missions. This became a point of

contention between colonists wanting more slave labor and the mission system, which

developed a near monopoly on indigenous labor for transportation and collection of forest

goods (Kelly 1986).

By 1639 the population of Gurupá had grown large enough to be classified as a town

(Kelly 1986). Its success can be attributed to the favorable position of the fort upon a

bluff making it advantageous for the Portuguese soldiers to keep an eye on who was

coming and going along the river (Wagley 2014). Boats passing by were required to stop

and pay taxes at Gurupá, making it a well-known stopping point along the Amazon River.

In 1757 the Jesuits were expelled from Brazil and their mission system secularized.

During this period, known as the Directorate (1754-1799), the Portuguese state sought to

increase the economic output of the Amazonian colonies to make up for the Portuguese

loss of Asian lands to the Dutch (Kelly 1986). The new law gave equal rights to

indigenous people, although far from a humanitarian policy; the real reason was to allow

the Portuguese to force the population into the labor force for state projects. Eliminating

the protections previously set forth for the indigenous groups through the mission system

was detrimental to the surviving Native American cultures. By disbanding the indigenous

groups and putting them into small, supposedly more efficient European-style family

units, the Portuguese colonies deprived them of their social capital and ability to pool

resources to aid one another (R. Pace 1998). The Directorate, however, was largely

ineffective in increasing any economic profit from the colonies and was finally abandoned

in 1799, leaving in its wake a newly created impoverished class of formerly indigenous

peoples mixed with various European and African peoples (R. Pace 1998; Kelly 1986).

After the Directorate, Gurupá suffered a deep economic depression triggered by

overextraction of forest resources, loss of labor (due to the decimation of the Native

Americans), and a decline in the international market for tropical products (R. Pace

1998). Unrest was brewing from the rural underclass as they continued being exploited

by an evolving debt-peonage system, eventually known as aviamento. Unrest culminated

in the Cabanagem Revolt between 1822 and 1836. The rebellion was by cabanos, a newly

emerging peasantry in the Amazon, against the Brazilian Imperial Government.

The revolt was one of the bloodiest uprisings of all Brazilian history (Anderson 1985; R.

Pace 1998; Cleary 1998; Simmons et al. 2007; Harris 2010). Fifteen to twenty percent of

the population was lost during this time as the Portuguese reasserted control over the

region (Kelly 1986).

In 1839, following the Cabanagem, a new law went into effect forcing men who did

not own land or were unemployed to serve in state sponsored projects—called the

Workers’ Corps. Gurupá became one of the nine military posts that were centers for the

Workers’ Corps (Kelly 1984). Military commanders abused workers in the corps by

forcing them to work on private pursuits for their own personal benefit, eventually

resembling a type of pseudo-slavery (R. Pace 1998).

By 1842 the town of Gurupá had two streets and two town squares for its

residents to gather. The areas of town were divided into a city (cidade) where the

Europeans lived closest to the river, and the village (aldeia), where the remnants of

indigenous peoples and mixed residents lived. These times were difficult for Gurupá as

money and resources were almost non-existent. Boats no longer stopped in Gurupá,

having found an alternate route to the North, which bypassed the town. The fort was

abandoned and the town was in shambles (Wagley 2014, Kelly 1986). A new system had

come into play during this time, built from the lack of currency and resources available.

This system, called aviamento, consisted of a chain of debt, from the lowly

agroextractivist, through the landowner or trading post merchant, called the patrão

(boss), and upwards through various levels until it reached the international financial

institutions of Europe (R. Pace 1998).

The system operated as a classical “siphon economy” where raw materials and wealth

left the region, keeping the local population in a constant state of poverty and

vulnerability (Ciccantell 1999; Pace 1998; Wagley 1953). Although the aviamento system

allowed traders to maintain economic ties to the local inhabitants, or ribeirinhos, who

could then purchase goods and medicine, the system produced perpetual indebtedness, or

debt-peonage. In many ways aviamento was more akin to slavery than a market system.

Prices were frequently manipulated since the traders held a monopoly on imported goods

(R. Pace 1998). Without much to offer the outside world, the Amazon remained a poverty

stricken region.

However, opportunity and prosperity were just around the corner for Gurupá, sparked

by foreign interest in the region’s wild rubber. From the 1870s-1910s Gurupá and the

Amazon region enjoyed a surge in export known as the rubber boom. The population in

Gurupá is thought to have doubled at this point with 20 general stores opening, a weekly

newspaper being circulated, and goods and imports coming in constant flows to the city.

There were even extravagant balls with live orchestras held in the mansions of the rubber barons

(Wagley 2014). The city had gotten the economic boost it so desperately needed to build up and

grow. In 1912 plans to build the town hall were drawn up and an Italian engineer was brought in

to supervise the project. It was to be the grand two-story center of pride in the town. Unfortunately,

before the building was completed the rubber bust hit. The building was not completed for many

decades.

As high as the lavish lifestyle was during the rubber boom, it was just as low for

the bust. After the British took seeds from rubber trees out of Brazil and modified the

trees though grafting to produce more latex, the seedlings were transplanted to Malaysia

to establish plantations. The mass production of easily accessible trees, plus the cheap

labor of Malaysia, led to a decline in the world price of rubber. Rubber production was no

longer as profitable in the Amazon since the creation of plantations was largely

impossible due to the particularities of the ecosystem (Robuck 1963). This devastated the

regional economy, leaving it to contend with five decades of economic depression.

Gurupá was now a site where pessimism, isolation, and poverty were endemic.

Agricultural production was minimal, there was little revenue from extraction, and health

care was at its lowest point due to the paucity of riverboats stopping in town with food

and medical supplies (Wagley 2014). Life was difficult and the poverty of the era would

have a profound and lasting impact on the health of the future generations of Gurupá. By

1920 the population of Gurupá had decreased to just 300 inhabitants and communication

with the outside world was nearly nonexistent (Wagley 2014).

The remaining population of Gurupá, although ravaged by nutritional decline, out

migration of the men to find work, and the decimating impact of disease (e.g. malaria,

dysentery, small pox, typhoid), carried on into the next couple of decades until

circumstances created by World War II ironically brought good fortune to the town. In

1942 as the Malaysian rubber fields were taken over by the Japanese, the allied forces

turned to the Amazon for rubber. Brazil and the United States signed the Washington

Accords and new programs were established to increase rubber production (Wagley

2014).

It was under the Washington Accords program that Charles Wagley first came to

Gurupá in 1942. He was part of the public health initiative to combat poor health of the

rubber tappers, particularly high incidences of malaria (Wagley 2014). Wagley worked

with the newly formed Serviçio Especial de Saúde Pública (Special Service for Public

Health), or SESP. He was sent to Gurupá during this time to set up health posts and

increase access to medical care. Wagley and his teams also implemented aggressive

prevention measures to reduce the breeding grounds of mosquitos to reduce vector-borne

diseases (Wagley 2014). Many people of Gurupá today look back on this time as a period

when the community was strengthened and given an opportunity to get back on its feet. In

fact, many of the mosquito-control practices and the strong emphasis on

communitycentered healthcare continue in present day Gurupá (Chapter 5 will provide an

in-depth analysis on the history of public health in the Amazon and Gurupá).

Once the war was over the United States withdrew funding and the municipality

slipped back into economic depression. The town continued without industry, which

meant few jobs and little hope for growth (R. Pace 1998). Education was substandard.

The illiteracy rate in the town was at about 40 percent, while a very high 80 percent in the

rural areas (R. Pace 1998). There were about seven one-room primary schools with

limited supplies for a municipality of 7,000 people at the time. Although conditions in the

schools were challenging and teachers very often taught without receiving payment for

months at a time, many people in Gurupá identify the addition of the schools as a huge

improvement allowing their children to receive at least the basics of education (R. Pace

1998).

The 1970s brought about more turmoil in the history of Gurupá (see R. Pace 1998).

Under the military dictatorship (1964-1985), the state embarked upon a major push to

develop the Amazon’s resources to fuel the industrialization of the South and, by the

1980s, pay mounting international debt. Conflict over land ownership increased as large

companies, often subsidized by the state, sought to extract timber and heart of palm from

the region. Due to a lack of land demarcation, poor administrative records, and the

historical practice of communal land ownership, most people in Gurupá never had land

titles. As the large business interests began appropriating land, legally, and more often

than not, illegally, resistance grew from displaced farmers. With the guidance of the

Catholic Church, following the tenets of Liberation Theology, the local priest worked

with the rural workers union to protest land expropriation. Paralleling the strategies of

other social movements in the Amazon (e.g., the rubber tappers of Acre under the

leadership of Chico Mendes – Allegretti 2008), the Church-Rural Union coalition used

Brazilian land law (posse or homestead rights) to claim public land with no legal title.

The technique proved successful. Interviews with the participants of this campaign by R.

Pace (1998) reveal that the successes of this movement in gaining land titles led to a

powerful sense of empowerment and social cohesion as well as providing newly founded

community-wide organization through the rural union local groupings and especially the

ecclesiastical base communities (comunidades eclesiastical de base) or CEBs of the

Catholic Church. Both of these organizations later became important bases for health care

initiatives, which is described in Chapter Five.

Quotidian Life in Gurupá Today

By the 2000s, life in Gurupá had changed considerably from its history of

isolation and oppression. Today there is greatly increased mobility within and beyond the

municipality by motorized boat, increased connections to the outside world from access

to Western medicine in the hospital to even the Internet, and greater freedom for previous

forced labor/debt peonage relations. To get a feel for daily life today in Gurupá, and to

provide cultural context to the changes occurring within the public health system, what

follows is a description of quotidian life in the community.

A typical day in Gurupá has many variations depending on the time of year and

the commitments individuals may have to work, family, and friends. Yet, the cadence of

the day is generally the same. The morning starts just after sunrise for your average

Gurupaense. Living just two degrees south of the equator, sunrise and sunset vary little

throughout the year. In both the town and the countryside it is still common to wake to

the sound of roosters crowing, sometimes long before sunrise. In town, just before sunrise

there is the sound of motorbikes rushing a few earlier risers to their jobs. Intermingled

with the noise of motors are the cries of bread vendors walking the streets and offering

their goods. By eight o’clock the streets start to fill up with people walking (or riding

motorcycles) to work. Without fail, by nine o’clock there will have been at least one car

passing by blasting announcements through giant subwoofers extruding from the trunk of

the car. The cars bring news of the day's activities, meetings, local advertisement, and

also announcements such as birthdays.

Places to eat breakfast in town keep strict hours if you need your morning coffee

and tapioca (basic breakfast meal). All service is between 6:00 and 8:30 am, and if you

happen to wonder in at 9:00 am you will be turned away. However, if one knows how

things work in Gurupá, you can time visits to friends knowing that the encounter will not

be complete until cafezinho (expresso coffee) or suco (fruit juice) is offered.

After a full morning of work Gurupaenses usually head home around 11:30 or

noon to have their lunch. Midday is the hottest time of the day with the sun directly

overhead. It is not safe to be out in direct sunlight and the heat reflected off all the

concrete and asphalt, which can cause serious problems of overheating. People stay

indoors or in the shade from noon to about 4:00 pm. Many shops will close for the

afternoon as well. The ability to ride around in the midday sun on a fast moving

motorcycle, however, has made this behavior less mandatory. Getting from one side of

town to the other can take only a minute or two on a motorcycle instead of 15-20 minutes

needed to walk.

After resting indoors and napping after lunch, the community members head back

out around 4:00 pm and work until 7:00 pm. The streets fill up first with motorcycles,

then with pedestrians. A complicated pattern of navigation ensues as pedestrians and

motorcycles compete for space on the streets due to the paucity of sidewalks in town. As

per Brazilian law, pedestrians yield to all motorized traffic. There are sections of streets

still dominated by pedestrians, and kids still play in the streets (soccer, dodge ball, even

an interesting version of cricket), but these spaces are now confined to less traversed

streets, many of which are located in the back part of town away from the river.

Figure 3.4 One of the main praças where the town gathers on weekends. Source: Author

Figure 3.5 Teenagers play pick-up soccer game after lunch. Source: Author

Figure 3.6 Hanging clothes out to dry. Source: Author

The evenings are much cooler for people to be outside and socialize. There are

two plazas where people can meet for a beer, to watch TV in public or, depending on the

time of year, practice for the local dance competitions. Weekends are reserved for various

church services and the promenade, or tradition of walking up and down First Street

(cruising on foot along the street closest to the river) between the Catholic Church and the

plazas. Although there are motorcycles milling in and out on First Street, it is common

knowledge that pedestrians own the street on weekend evenings.

Walking around town, except in midday, you can witness a wealth of activity.

There are children playing in the streets or walking home from school dressed in their

uniforms (classes are held in morning, afternoon, and then evening sessions so children

are coming and going throughout the day). Most elementary school students will attend

school in the morning or afternoon while the older high school students attend in the

evening.

Passing by the houses and glancing through open windows and doorways, one can

see people hand washing and hanging out their laundry to dry. Some people own their

own washing machine, but everyone uses the tropical sun to dry their clothes. Shop

owners are either busy attending to clients or bored sitting behind desks and playing with

their phones. Cell phone reception is limited in the town with only one mobile company,

TIM, having mediocre service. Every now and then cell reception will just stop working

for days or even a week. When this occurs most cell phones become substitute cameras,

iPods, or Gameboys. The younger generations pass music and videos along to each other

using Bluetooth and have successfully built up this system of connectivity despite the

lack of service.

The town is set up in a grid system, as has been described in the literature since

Walgey’s Amazon Town. There have been some important expansions as the town has

grown from a population of 3000 in the 1980s, to 10,000 in the 2010s, and now, by some

local estimates, approaching 20,000. Yet, the streets still run numerically from the river.

First Street is closest to the river with Second Street coming next all the way to the

farthest regions—about 10 streets altogether. The side streets are known as travessas, but

not many people know the actual names given to the streets.

Figure 3.7 View of First Street from the river. Source: Author

There are several neighborhoods that have arisen over the last 10 years – Xingu,

Fortaleza, and Horto being the largest. The Xingu neighborhood is the oldest of these and

is located to the west of the Gurupá on the outskirts of the town. Although people have

lived here for a decade, there are still houses being built, often in any space available. To

navigate through this area there are systems of wooden platforms that connect the houses

and are raised above the standing water below. Since parts of the Xingu neighborhood are

a 15 to 20 minute walk from the town center small shops selling essential items and foods

are spread throughout. There are also soccer fields where neighborhood families can

engage in friendly tournaments.

Fortaleza and Horto are younger neighborhoods than the Xingu. The Fortaleza area

(located just below Gurupá’s fort, hence the name) is built up more commercially than the

other neighborhoods. They have markets to buy fish and fresh produce, a place to sell

timber extracted from the forest, and even their own dock.

Figure 3.8 (top) and Figure 3.9 (bottom) Second Street is mostly commercial.

Source: Author

Figure 3.10 Walking down the street in Xingu. Source: Author

Horto on the other hand is the newest and fastest growing neighborhood. It is located

straight back from the river behind the historic Jewish Cemetery. Horto is the least

developed with myriad of houses backed up against one another. Most of the houses have

an outhouse located very close to the house (approximately 20 feet) that empties into the

standing water below.

Figure 3.11 Standing water in Horto. Source: Author

Streetlights are not common in these areas making night travel more dangerous.

Rafael, a man in his 30s who has worked for the rural workers union for some time, told

me that families living in the interior who want a place to stay in town during festival

time build these houses. He mentioned that most of the time they seemed to be

unoccupied, especially since the new municipal government has taken away the free rides

in their trucks into town from the countryside because of budget cuts. Yet, taking a quick

tour through the area shows that there are, in fact, many families living in the

neighborhood. People living here are generally more impoverished and their houses have

poor sanitation. A conversation with one of the local nurses revealed that it is from this

neighborhood that most of the cases of childhood diarrhea arise. These are also the sites

where the houses are built above standing water and have the most issues with

mosquitoes. There is a clear class divide the farther one ventures away from the river or

the farther one builds into a swampy area. There are also few stores and no markets for

consumer items. In fact, besides the impromptu soccer field by the airport, there are no

commercial or public commons, nor signs of community cohesion like the other

neighborhoods.

For the older, established areas of Gurupá, a sense of community is most prominent in

the day-to-day. Starting with the morning announcements there is always something

going on for the community to celebrate or commemorate. I have sat while eating

breakfast many mornings when the announcement car would drive by with the times for

the local soccer matches or church festivals. The soccer games, in particular, were part of

the local entertainment and sparked friendly rivalries. Attending these big community

events and being able to join in on the joking that happened the next morning over

breakfast made it possible to feel like a part of the community.

I was also able to participate in community life by offering tangible services. Using

Cesar’s considerable photography/videography skills, we began to record events for

people in Gurupá. This, in turn led to invitations to weddings, religious ceremonies, and

even being asked to make a short film for real estate purposes. We used USB drives to

pass along the footage for free and became known as the unofficial documentarians of the

town. People whom we had never met or even seen around town approached us and

promptly pointed out which of their friends and family members needed their picture

taken at the moment. Watching the people’s faces light up as they viewed the images

made it all worthwhile.

Enjoying celebrations and special occasions like Carnival or saint’s festivals are

another way in which the community unites. Each neighborhood block is responsible for

a team to enter a dance competition or a parade or a specific task for the Church. Again,

friendly competition and fun drives these community activities and gives Gurupaenses

something to look forward to and practice for every month of the year.

The festival of the most beloved saint of Gurupá, Saint Benedict, is such an important

event that most people celebrate it first and then Christmas, which occurs at the same

time, as a secondary celebration if they celebrate it at all. Families from the interior and

those that have moved away to bigger cities will flock back to Gurupá in droves to be

able to participate in the festivities. Masses held at the Catholic Church are filled to the

brim with parishioners who come together to pray. The much loved Bishop Erwin

Krautler who was in charge of the entire Xingu region until his retirement in 2016 makes

a special trip to Gurupá every year for the São Benedito celebration. The Bishop will also

travel every other year to celebrate confirmations in Gurupá. About 70 percent of the

town is Catholic with Protestants such as Evangelicals, Jehovah Witnesses, and

Pentecostals making up the remaining 30 percent. However, since religion has been so

tied to the culture of Gurupá, you will find most community members, Catholic or not,

out at saint festivals enjoying time with friends and families.

CHAPTER FOUR:

METHODS AND DATA COLLECTION

The Brazilian Case: Site Justification

Brazil is considered a middle-income country and is in the process of an

accelerated transition in demographics (rapid urbanization over the last six decades) and

nutrition and epidemiologic profiles, while continuing to face overwhelming social and

economic inequalities (Aquino, et al. 2012; Victora, et al. 2011). Brazil struggles with

incredibly high rates of income inequality. Beginning in the 1980s, for example, Brazil

has repeatedly ranked in the top percentile of the planet’s most unequal countries in terms

of income disparity—including on more than one occasion being ranked as the worst in

the world (UNDP 1993; 17). This gap is clearly reflected in the health sector where the

burden of infectious disease and inadequate access to health care has affected the poor,

rural regions (the rural North and Northeast of Brazil) at much higher rates.

This trend continues today. For example, child mortality rates are twice as high in the

North and Northeast of Brazil, with the indigenous populations, found mostly in these

areas, lagging even farther behind in health indicators (Victora, et al. 2011). Deaths from

HIV/AIDS and respiratory infections have increased and the high rates of tuberculosis

and Chagas diseases have remained unchanged since the 1980s (Barreto, et al. 2011;

Victora, et al. 2011). In addition, infectious diseases such as dengue fever are completely

unaffected by control efforts and have continued to wreak havoc through continual

epidemics.

In fact, one year after the construction of Belo Monte began, the town of Altamira had

an average of 30 suspected cases of dengue fever coming into the hospital on a daily basis

from the construction sites—a number much higher than in the previous year

(Peduzzi 2012). Nationally, between the years 2000 and 2009 there were approximately

3.5 million reported cases of dengue fever, of which 845 were fatal. Efforts to control the

abundance of the mosquito responsible for dengue fever, Aedes aegypti, have been

challenging due to the limited access to proper infrastructure and sanitation (Barreto, et

al. 2011; Teixeira, et al. 2013).

Chronic, or non-communicable diseases (NCD) are also distressing the poorest

regions of Brazil. Although the NCD mortality rate has decreased between 1996 and

2007, the highest rates of mortality are still found in the North and Northeast regions,

which also includes the largest increase in diabetes mortality (Victora, et al. 2011). The

rates of overweight/obesity, diabetes, hypertension, and cancer (breast, lung, prostate and

colon) have been increasing since 1996 with cardiovascular diseases, diabetes, cancer and

chronic respiratory disease accounting for 58 percent of all deaths (Schmidt, et al. 2011).

Type 2 diabetes has been on the rise as a public health problem in Brazil, as throughout

much of the world. According to a national registry for diabetes and hypertension 1.6

million people in Brazil are living with diabetes. Of these cases 4.3 percent have had a

diabetic foot disorder, 2.2 percent an amputation, 7.8 percent renal disease, 7.8 percent

myocardial infarction and 8 percent a stroke (Schmidt, et al. 2011).

In a study by Garcia Rosa et al. (2013) researchers identified connections between

some of Brazil’s staple foods and the incident rate of diabetes. The researchers used

biochemical, anthropometrical, and blood pressure measurements to test for diabetes.

They also used medical records as a baseline, reviewing them once again after 5 years

(2006-2011). To assess food consumption, a semi-quantitative food frequency

questionnaire for Brazilian staple foods of rice, beans and manioc flour were given. Daily

food intake in grams was measured for these foods to be able to compare them to diabetes

outcome status. The results found that individuals who developed type-2 diabetes had

higher frequencies of red meat consumption and less consumption of manioc flour.

Surprisingly, manioc flour consumption had an inverse association with developing

diabetes and may be an example of a food with protective qualities against type 2

diabetes (Garcia Rosa, et al. 2013). White rice and beans, on the other hand, showed an

increased risk for the disease.

Another rising non-communicable disease is cardiovascular disease, which has

become the leading cause of death in Brazil, with hypertensive heart disease rising from

11 percent to 13 percent in 2007, ischemic heart disease remaining at 30 percent, and

cerebrovascular disease at 32 percent of all mortalities. The increases in some of the

nutrition related NCDs (cardiovascular, diabetes, cancer) are attributable to what is

known as the nutrition transition. This concept was proposed by Barry Popkin (1993) to

describe a shift in dietary consumption of traditional diets to a more Westernized diet high

in sugars, fats, and industrialized products. Along with changing levels of energy

expenditure these shifts are usually a result of economic, demographic, environmental,

and cultural transitions within a society. Although these rapid changes in diet and activity

are influencing the amount of nutrition related non-communicable diseases globally, they

seem to have the greatest effect on low- and middle-income countries.

Popkin (2004), for example, looked at nutrition transition in rural China in the 1970s.

At the time there was a prevalence of widespread food insecurity, limited access to

transportation, no television, and minimal processed food, and most occupations were

extremely labor intensive. In a matter of 30 years this population experienced great

changes in nutritional status—shifting from an undernourished population to high rates of

obesity. During an 8-year study examining the BMI of adults (age 20-45), Popkin (2004)

and colleagues found that prevalence of overweight and obese men doubled from 6.4

percent to 14.5 percent and increased by 50 percent from 11.5 percent to 16.2 percent for

women. These increases correlate with China’s rural population’s transition to modern

technology to lessen the amount of labor-intensive work, consumption of soft drinks and

processed foods, uses of mass transit, increases in watching television (now found in

nearly all homes), and a reduction in riding bicycles (especially for children). The trend

of increased sedentary lifestyles and poor diets is creating an unequal burden of disease

on the poor who continue to suffer from lingering communicable diseases and limited

health care access.

Several studies in Brazil have shown the nutrition transition by looking at

population-based surveys with women between 1975 and 1997. At the beginning of the

study in 1975, Monteiro et. al. (2004) found the number of underweight women was

twice as many as overweight women. However, by 1997 this shifted to more than two

cases of obesity to one case of underweight. Pereira et al. (2012) takes this information

one step further to examine the saturated fat, trans fat, and sugar consumption in the

Brazilian diet through individual dietary intake surveys and non-consecutive food

records. Changes in the diet came from income growth and changes in the overall food

system of Brazil, particularly the increase in use of modern supermarkets and the

promotion of processed foods and beverages with low nutrient density. The ease of access

and the convenience of these products have led to a high intake of saturated fat and sugar

in the Brazilian diet. In addition to processed foods this study found a higher

consumption of red meats, which has been associated with cardiovascular disease

(Pereira, et al. 2012). Overall the surveys found a decrease in household food availability,

except for bakery products, sweets, soft drinks and ready-to-eat processed meals, and

very high levels of sugar, saturated and trans fats in the daily consumption habits of the

Brazilian population.

The shift in dietary patterns and physical activity in Brazil has been noted in all

regions. Data from the Amazon, however, are more limited. One example is the study of

ribeirinhos by Silva and Padez (2010). This study examined 304 adults living in the

Amazon basin by taking anthropometric measurements to determine rates of overweight

and obesity. Evidence of a high prevalence of overweight/obesity was found in the adults

of this region as a result of Western influences and the nutrition and epidemiologic

transition. As access to healthcare, vaccinations, and better incomes increase the

population is less strained by preventable disease and therefore can spend more money on

processed foods eventually leading to higher body mass. Other consumer goods are also

more available to the people of this region like cigarettes. The ability to purchase

cigarettes is a sign of high social status, thus contributing to the cardiovascular problems

seen in overweight/obese populations.

Another study done by Piperata (2007) used anthropometric measurements along with

structured interviews to understand the factors relating to health and nutrition for this

population. Piperata found a high degree of stunting, which signifies nutritional stress or

poor health during growth and development. In fact, children aged one to six had a high

prevalence of parasitic infection along with illness such as diarrhea and respiratory

infections. This is due to limited access to healthcare and the poor sanitary conditions of

these communities—most people drink, bathe, wash clothes, and dump trash and human

waste directly into the river.

However, when short-term nutritional status was measured (the degree of wasting

among all age groups in a population) the study found normal rates except in some adult

males. Men who were directly employed by wage labor jobs showed higher rates of

overweight and obesity. Through the structured interviews the researchers discovered that

men who worked in wage labor were often fed at least three times a day while at work.

Meals were usually buffet style allowing them to eat as much as they wanted and the

foods served were energy dense foods. Wage labor jobs included grounds keeper, cook,

motorboat drivers, and other less physically demanding jobs.

This study allows for a unique look into the nutrition transition. Since the men were

showing the highest amounts of body fat percentage and higher BMIs, it is easy to see the

effect of a more sedentary profession and higher consumption of processed foods. Women

continued to work in subsistence labor in order to be able to feed themselves and their

children and thus maintained high levels of physical activity (Piperata 2007). Dufour and

Piperata (2014) have refined the concept of the nutrition transition to look more closely at

the nuances involved in joining a market economy. Instead of a linear transition from

under nutrition to over nutrition with the onset of more processed foods in the diet, there

are more complex issues at play between differing populations. Even within the same

population there are still differences in age, sex and income when it comes to nutritional

health. The data collected work to bridge the gaps in the literature about overall health

and nutrition of people living in the Amazon Basin as well as daily life activities and

behaviors that impact health changes.

Beyond a handful of health studies such as Silva and Piperata’s, little is known

about the health of rural inhabitants of the Amazon. Most of the health statistics

concerning the North of Brazil are measures of health for those living in the urban

capitals and the indigenous tribes throughout the area (NAEA 2006; Piperata, et al. 2011).

The information that is known paints a bleak picture for the Amazon. Although important

strides have been made to improve health indicators such as infant mortality, life

expectancy, vaccinations, and nutritional status, the rate of change is slow, unevenally

distributed among urban centers of the region, and greatly lags behind the rest of the

country (IBGE 2010). The few studies that venture out to the rural regions of the state of

Pará have noted that only 6.5 percent of households are connected to a sewage system

(NAEA 2006; Piperata 2007). This means that many households are dependent on the

river for domestic consumption and it is not surprising to see populations with high rates

of intestinal parasites (Piperata 2007; Silva 2001, 2006; Silva 2003). Other serious health

concerns show high rates of food insecurity, violence, slave labor, teenage pregnancies,

and child malnutrition (NAEA 2006).

Infectious diseases are serious issues in this area with the highest concerns over

malaria, viral hepatitis leprosy, tuberculosis, leishmaniasis, dengue fever, and AIDS.

Very little is known about HIV infection and local perceptions or behaviors in the rural

Amazon. But due to limited education and health access, the potential for significant

casualties from this and other diseases is daunting. Infectious diseases, hunger, poor

sanitation, limited access to healthcare, and the emergence of chronic diseases such as

diabetes, cancer, and hypertension are contributing to what is known as the double burden

of disease (Marshall 2004).

The importance of gathering relevant health data that accurately depict life in the

Amazon basin cannot be overstated. The complexities of a vulnerable population who are

integrated into and affected by the environment must be understood so that when issues

arrive, such as the construction of the Belo Monte Dam, health will not be ignored. In

order to conduct this research project, the methods utilized build upon previous research

in the area in an effort to provide a consistent and comparative source of information and

a means to monitor change.

Research Design

As explained in the Introduction, the specific aim of this research is to explore the

potential health impacts of the Belo Monte Dam on the downstream community of

Gurupá through a syndemic framework. The research was divided into two phases.

Throughout the first phase I examined the follow research questions:

(1) What is the structure of the local and regional health care system?

What do the care professionals identify as the strengths and

weaknesses of the system? What changes do they foresee with the

dam completion?

(2) How do community members view their current health status?

(3) What changes to their health or health care do they anticipate within

the coming years and what is the general opinion on, and discourse

about, the Belo Monte Dam?

For this phase I took a close look at public health organization in the local

community and region. Through interviews with key personnel and

participantobservation I examined challenges to the public health system, specifically

focused on the community level (hospital, health posts, and public health offices). In

addition, I investigated local perceptions of health and the environment in Gurupá and

how community members have or have not incorporated the Belo Monte dam into their

health discourse. Through participation-observation and informal and structured

interviews, data were collected on the structure and functioning of the health care system,

perceptions of problems/gaps in policy and policy administration, as well as local

understanding of changes occurring in a holistic context (environmental, economic,

demographic, familykinship, politics, religion, and world view). Data were also collected

from a wide array of healthcare professionals, NGOs, and community members in

Gurupá as well as in

Altamira—headquarters of many agencies and organizations involved with the Belo

Monte Dam project. The interviews with health professionals helped me to increase the

knowledge on specific viewpoints held by each stakeholder.

For the second phase of research I focused on questions that explored the most

probable health impacts affecting downstream communities, such as:

(1) What are the public health impacts of the Belo Monte dam on the

downstream riverine community of Gurupá? Will there be changes in

infectious disease rates, nutritional status/food security, or access to

healthcare? Will there be increases in malaria, dengue fever, and

waterborne illnesses ranging from dysentery to diarrhea due to

environmental changes and problems with water quality?

(2) Do the data collected identify syndemic relations? What is the

relationship between the various health impacts?

(3) How can different stakeholders such as grassroots organizations,

NGOs, and local government agencies use this information to mitigate the

health care problems? How can data on unanticipated syndemic relationships

be used to “fill in” the gaps of public health care?

Current and historical data were collected from all local health sources (public health and

the local hospital archives), from the existing global literature, and from data obtained

from phase I research in Gurupá. As far as the quantitative data is concerned, I utilized a

version of the Short Form- 36 Health Survey, which is one of the most common

instruments used in health research (D’Souza, et al. 2013; Laguardia, et al. 2011; Liang,

et al. 2006; Pheley, et al. 2002; Sabbah, et al. 2003; Zhu, et al. 2012). This survey aims to

identify changes in health status over time using a standardized set of multi-dimensional

health concepts (Laguardia, et al. 2011). Data are collected on certain health status

indicators with thirty-six questions regarding physical functioning, physical role

limitations, bodily pain, general health, social functioning, emotional role limitations, and

the mental health of the respondent. This survey has been translated into Portuguese and

validated with Brazilian populations showing its ability to be culturally appropriate

(Pheley, et al. 2002). The short version of this survey is 10 percent to 20 percent less

accurate than the longer forms; however, the levels of reliability and validity are above

the recommended minimum and it only takes approximately 5 to 10 minutes to complete

(Laguardia, et al. 2011). Therefore it is an ideal tool to use in combination with other

surveys and will not result in respondent fatigue. Although many researchers have

administered the SF-36 Health Survey in health care facilities, the survey is versatile

enough to be administered throughout a rural population. By capturing information from

people who do not have access to health clinics or hospitals, the survey can create a

broader view of overall health status by filling in the gaps of the rural people (Darko, et

al. 2012).

The SF-36 Health Survey also gathers perceived health status. These data provide

a more accurate picture of population health by allowing the researcher to interpret the

nuances related to quality of life and general well-being, rather than solely analyzing the

number of deaths reported for a population. Darko et al. (2012) have shown this

advantage in a study focusing on the health of adult women in Accra, Ghana. The study

found women reported over 30 worsening health conditions. This is important to note

since some diseases may not be counted by the hospital data because they are in early

stages and asymptomatic. In addition, the health survey can be interpreted to hint at

possible risk factors for disease through responses.

A second research instrument I used is a food frequency questionnaire or FFQ.

This instrument provides data to evaluate dietary intake patterns, which can add to the

health profile of small, rural communities by showing variations in diet and access to

certain foods. FFQs are commonly used to assess long-term dietary intake by listing a

variety of foods and asking the frequency of consumption over the period of a week,

month, or even year (Gibson 2005). Specific categories of foods can be used during

analysis to predict the intake for certain nutrients or non-nutrients in an individual. Fresh

fruits and juices are examples of food items that can be used as predictors for vitamin C

intake. Fats and cholesterol intake can be evaluated by measuring the prevalence of

alcohol, artificial sweeteners and certain condiments (Gibson 2005). FFQs should list out

pre-determined lists of foods native to the area and can be administered as a standard

interview lasting 15 to 30 minutes. This technique is not very burdensome or invasive for

the respondent and can be used with other surveys to collect information.

A study performed on preschool-aged children in the United States (Perez,

Himmelgreen and Ferris 1997) exemplifies how an FFQ can provide a culturally

appropriate snapshot of a group’s food intake. Researchers gave caretakers of the children

a food frequency questionnaire with a list of 198 foods, which also included 30 Puerto

Rican traditional dishes since the study sample was taken from a Latinx population. Data

on cooking methods used in food preparation were collected as well. In order to better

assess nutritional status, foods on the FFQ were grouped into categories important to

child nutrition. The researchers also grouped food into the five categories used by the

USDA Food Guide Pyramid (bread and cereals, meat and alternates, milk and dairy

products, vegetables, and fruits) to facilitate comparisons among populations.

The results of the FFQ showed that preschool-aged children had a high frequency

of artificially flavored beverages, whole milk, sweets and desserts, breakfast cereals, and

foods high in fat. Vegetable consumption was below the minimal recommended level and

55 percent of the total daily fruit servings were coming from fruit juices. In terms of food

preparation, caretakers most frequently used frying, stewing, and boiling. The researchers

concluded from the FFQ that preschool-aged children had poor dietary patterns lacking in

vegetable intake and high in fruit juices, sweets, and high fat foods. The researchers

suggested that the consumption of high fat foods could be reduced and the intake of

nutritious foods be increased. If open-ended qualitative questions are added during the

administration of the FFQ in communities, this could successfully fill in gaps about

access to certain foods or possible explanations of food variety.

When the goal of the FFQ is to study associations between dietary habits and disease,

then questionnaires should be able to rank respondents based on the frequency of

consumption so that low intakes can be separated from high intakes. The analysis at this

level involve an odds ratio or relative risk of disease (Gibson 2005). Most

epidemiological studies use FFQs as the primary dietary assessment method (Masson, et

al. 2003). This method was used to assess the consumption of carotenoids and the risk of

lung cancer in a study in southwestern Finland (Holick, et al. 2002). Relative risks were

computed by dividing the rates of the highest consumption rate quintiles by the lowest

consumption rate quintiles. The study found that the consumption of foods rich in

carotenoids was inversely related to the lung cancer risk (Holick, et al. 2002).

Sampling

For this study, the SF-36 Health Survey short form adapted to Brazil and a FFQ

specific to the Amazon were combined into an interview schedule (given the low literacy

rates of many in Gurupá). This instrument was administered to a clustered sample of

households within the community to capture varying socioeconomic statuses and

subsistence patterns. The interview schedules were administered to one adult female and

one adult male per family (the self-identified heads of household if available). Piperata

(2007) used this technique in her study to administer household characteristic surveys and

semi-structured interviews. This combination of surveys captures critical information

about illnesses and ill-health conditions that have occurred during the previous year in the

community as well as illnesses/ill-health/socioeconomic status. I use random sampling

within each designated strata for a total of 100 surveys. The interviewer randomly chose

houses in each by approaching every third house spanning the geographical region until

the desired number of houses was visited.

Data Collection

To help complete the surveys I hired two research assistants. Both of the research

assistants were natives of Gurupá, although one had just recently moved back from

Altamira while the other lived there her whole life. The research assistant who had lived

in Gurupá her whole life helped with most of the survey distribution. She had gone to the

Federal University of Pará to study anthropology and has an interest in research methods

and data collection. Her family is well established in Gurupá and she was able to conduct

surveys in all neighborhoods with ease. The second research assistant did fewer surveys,

but is a data analyst for the Secretary of Health and helped me pilot the surveys. Within

the past two years he had moved back to Gurupá to take care of family members. He

states that he is a native of Gurupá, but spent his school age years growing up in

Altamira. He is currently taking online classes to become a computer programmer.

Both of the assistants were paid 10 reis per survey completed, which translates to

about $5 per survey. They were compensated in cash once the surveys were returned to

me. Altogether, the research assistants and I completed 101 health surveys and food

frequency questionnaires. We spent from May until July disseminating the surveys,

during the rainy season. Unfortunately, we were unable to distribute the surveys again to

the same households during the dry season and some of the results may be affected by

seasonality.

Limitations

Any anthropologist who has done fieldwork can attest to the truth of Murphy’s

Law, “Whatever can go wrong, will go wrong.” The nature of our research is built on

human cultural and societal interactions, which we know to be in a constant state of flux.

The idea for my research project came along in 2011 when the government granted Norte

Energia a permit to begin construction on the Belo Monte Dam on the Xingu. This

seemed timely since I was just beginning my doctorate program and by the time I would

be able to conduct field research the dam would be complete. Thus, my dissertation was

focused on studying the public health impacts that would affect Gurupá. Belo Monte has

been shrouded in controversy since the 1970’s when it was first proposed to the public.

Throughout the years human rights activists and environmentalists alongside indigenous

groups and community members around Belo Monte worked hard to stop the dam from

being built. Judges would halt construction based on several injunctions including Norte

Energia’s failure to consult the indigenous people whose land and livelihoods would be

impacted, failure to fully complete the environmental impact assessments, human rights

violations, and most recently its involvement in the corruption scandal of the Brazilian

government. Each time the dam was halted there would be a higher court somewhere that

would grant permission to build again and again because the Brazilian government would

not have this multimillion-dollar project canceled. The constant delays meant that in 2015

when I began my fieldwork, the dam was still not complete. Studying the public health

impacts of a dam that had not started working was not going to suffice for a dissertation.

Therefore, with the help of my committee, we were able to come up with a better plan

and arrive at the current research project involving Gurupá as a case study to create a

heuristic model of public health impacts of dams. In the end, I believe that this iteration

of the project will be more beneficial to the town of Gurupá as a model to help in

identifying most salient impacts and how they are syndemically related to others.

A second limitation of this study occurred when bureaucratic delays of the

Brazilian government prevented me from being able to return to Brazil and complete the

anthropometric measurements of children that I had originally planned to do. Although

this would have provided an updated snapshot of nutritional health when added to the

anthropometric measurements taken in Gurupá in 2005 and 1986, this portion of the

research was only adding to the baseline health survey for the dissertation and not

absolutely vital to the findings of this study. The data from health records, interviews,

food frequency questionnaires, observations and the health survey have provided the

wealth of information necessary to create the syndemic model which will be discussed in

the following chapters.

Broader Impacts and Ethical Considerations

Through gathering data on health trends from Gurupá into the syndemic

framework, the research will contribute not only to the theoretical understanding of dams’

health impacts on a downstream community, it will also provide valuable data and models

for stakeholders to use in order to improve future planning. These data will allow local

community leaders and NGOs to better plan for the full range of health issues likely to

come from large hydroelectric projects in the Amazon Basin.

The research project adheres to the Institutional Review Board guidelines for

ethics for the University of South Florida (IRB Pro00017815). Informed consent has been

gathered from all participants with the right to refuse to participate or stop participation at

any point during the process. Access to the raw data is limited to the researcher and

research assistants. No identifying personal information was used in data collection to

ensure privacy and confidentiality of those participating in the study. Data are kept on my

computer under password protection. The findings of the study will be disseminated to

the community, but will not contain any information that will cause members of a small

community to identify each other. Written and oral reports will be made available to the

community members and results will be left with the Secretary of Health, director of the

hospital and the Mayor. The data are also accessible to the Institutional Review Board at

the University of South Florida upon their request in accordance with their Human

Research Protection Program Policy 701 Section 5.1.17.

CHAPTER FIVE:

RESULTS: PUBLIC HEALTH IN GURUPÁ

During the late 1980s Brazil underwent a major shift in the way healthcare was

managed and provided nationwide. This reform created the Sistema Único de Saúde

(Unified Health System) or SUS. The new system focused on providing comprehensive

universal healthcare to all citizens of Brazil. In order to understand how the Belo Monte

Dam will affect Amazonian populations, and particularly the community of Gurupá, it is

necessary to first review the history of SUS within the overall historical context of

Brazilian public health. I will follow with an overview of how SUS functions in the rural

states of the Amazon. Finally, I will provide a review of the literature associated with

health behaviors and access to healthcare in the Amazon.

History of Public Health in Brazil

The Portuguese colonization of Brazil began in the 16th century and the main

forms of institutional health care at this time were a handful of hospitals in São Paulo,

Salvador, Belém, and Olinda. By the late 1820s, institutions for sanitary control of ports

and epidemics were established (Paim et al. 2011). The first steps toward the formation of

the current health care system, however, began in 1923 with the Eloy Chaves Law. This

law created retirement and pension funds for certain occupations, initiating the first

Brazilian social security model. Also during this time health professionals formed a dual

health system, one for preventative public health services and one for curative social

security services (Canut 2012; Paim et al. 2011). During the presidency of Getúlio Vargas

(1930-1945) the government created different ministries, which sought to institutionalize

public health, social security, and occupational health. These ministries, however, were

sorely underfunded. Health coverage at this time was only available to those in the urban

workforce, excluding rural workers and the unemployed from receiving health care

services.

It was during World War II that Brazil, in partnership with the USA, developed its

first national health care system (Wagley 2014). Called the Serviçio Especial de Saúde

Pública (the Special Service for Public Health) or SESP, the agency oversaw the nation’s

public health planning and implementation. After the war ended, and international funds

were withdrawn, the agency suffered. For about a decade, however, SESP had success in

dealing with some critical health problems in the Amazon, which I will cover in greater

detail later in this chapter.

During the military dictatorship of 1964-1985 the health care system was again

reorganized through centralization and was administered by a large bureaucracy with a

directive to expand and reach a greater portion of the population. For the first time in

Brazilian history, large numbers of rural workers were included in the system. With this

increase in demand, the military government increasingly turned to the private sector to

build hospitals and expand capabilities. Eventually the restrictions of the growing

privatized system, coupled with the inability of the government to meet the demands of

an overextended healthcare system, led to an unequal and fragmented health care system.

Due to these problems, a large portion of the Brazilian population was once again

excluded from the predominantly private health services located in urban areas.

The next phase of health care development occurred during the recession of the

mid 1980s with serious talk about healthcare reform (Paim, et al. 2011; USA 2013). An

ideological shift in the country mandated that as a fundamental social and political right,

health care should be provided free of charge by the government to every citizen. In other

words, health was seen as an irrefutable human right and the government was responsible

for delivering it.

The Unified Health System came into existence through the constitution of 1988

during the 8th Annual Conference of Health. In addition to universal healthcare coverage,

the Brazilian Constitution also outlined the duties of the state to guarantee this through

economic and social policies required to promote curative services as well as monitoring

of health and providing preventative services to reduce the risk of disease (USA 2013).

The organizational principles behind SUS, or Unified System of Health, declared that it

function as a regionalized and hierarchal network and would be both administratively and

politically decentralized to allow for the participation of all stakeholders, including

community members, for the improvement of provision of healthcare services (Sistema

Único de Saúde n.d.).

At the municipality level local governments were charged with providing primary

health care services and were responsible for the management and allocation of funds and

resources. This policy assumed that community members would vote on issues important

to them and that local governments would have a more in depth understanding of what is

most needed in their area. In this way policy planners figured that the decentralized

nature of SUS would allow each municipality to flourish. It was the duty of the state to

assist the municipality to set policy goals as well as provide 18% of the funding to the

Municipal Health Fund (Mobarak et al. 2005). The federal government provided 54% of

the funding to the National Health Fund, which distributed money to the municipalities

through 78 different programs (Joint Learning Network 2014).

The federal government was also responsible for national regulation of health

care, developing national policies, and managing the private sector activity. The private

health sector stepped in to provide insurance coverage to many of the middle and upper

class citizens of Brazil through the Supplementary Health Program (SHS). Those who

could afford private health care could also utilize the SUS resources for more complex

procedures, which might not be covered under the private sector.

In addition to providing hospitals and clinics to the public, the government took

an active approach to health with the creation of the Family Health Program, Programa

Saúde da Família (PSF), and the Community Health Agents Program (PACS) in 1994.

Community outreach and preventive family health care were achieved through teams of

health care professionals and trained community health workers who delivered care to

households and communities (Joint Learning Network 2014). The outreach teams were

initially responsible for approximately 800 to 1,000 families, but have increased these

numbers exponentially since their creation in 1994 to 32,000 units available to the public

in 2008 (Joint Learning Network 2014).

Evaluations of PSF and PACS have shown the programs produce positive results

due to their ability to follow families through time on a regular basis, thus allowing health

care workers to have intimate knowledge of the community. With greater knowledge

comes the ability to better educate about diseases endemic to the area and specific health

practices and beliefs. This familiarity also enables the PSF to detect any differences in

health that may lead to an early detection of disease that may require specific attention.

The already established organization of these units increases the ease with which

interventions and programs can be implemented (Rocha and Soares 2010). As Rocha and

Soares (2010) concluded in their studies, PSF has been highly effective in reducing

mortality, especially among infants in the poorest regions of Brazil.

After eight years of program implementation, researchers estimated the reduction

of infant mortality of the Northern region of Brazil to a low of 15 per 1,000 as opposed to

the national average of 27 per 1,000 (Rocha and Soares 2010). When comparing Brazil to

other Latin American countries, Brazil rose from 26th out of 33 for infant mortality rates

in 1990 to 19th out of 33 in 2006 (Joint Learning Network 2014; Macinko, et al. 2006).

Hospital admissions declined by 24% on a national level between 1999 and 2007, and at

the state level, those that had greater PSF coverage also reported lower hospital

admissions (Dourado, et al. 2011). As these evaluation studies have shown, the SUS and

its outreach programs successfully improved health and well-being of the population.

Despite these gains, the amount of coverage that the municipalities can offer

varies from location to location and in some cases inhibits this success. Mobarak,

Rajkumar, and Cropper (2005) explain the political processes behind the ability of

municipalities to provide health services to their populations. There are three variations of

decentralization that occur at the municipal level: full state management, basic assistance

management, and full county system management. Under the full state management the

state government has complete control of the health system and can determine the amount

of funds and types of provisions allotted to the municipalities. The basic assistance

management level allows the municipality to manage all primary health care, but leaves

the more complex services to the state government. In the last version, full county system

management gives complete control of primary care and complex services to the

municipality. In order for a municipality to apply for full county system management, a

judge at the federal government level must deem it fit to handle the decentralized

administrative role.

If a municipality has full management of their healthcare (in 1999 about eight

percent had full management status while 80 percent were under basic assistance and two

percent under full state control), then the transfers required for reimbursement are subject

to an annual ceiling which is decided through political negotiations with the federal

government (Mobarak, et al. 2005). Municipalities which are politically aligned with state

and national political parties in power are more likely to be granted full county system

management as well as have a more relaxed budget to use towards health care.

Municipalities not aligned with parties in power, in contrast, typically have less control

over the management of resources and often have fewer resources allotted to them as

well. Additionally, the overall lack of political interest in the rural and impoverished

northern region of Brazil due to the lack of its political capital to influence decision

makers on the national level more than likely results in fewer and lower quality public

health services than in the industrial South (Bliss 2010).

Amazonian Public Health in Context

Brazil’s northern region is typically idealized by most outsiders as an endless

expanse of lush green forests, diverse and exotic plant and animal life, and groups of

indigenous people living in harmony with their environment, untouched by the modern

world: a type of preserved Garden of Eden (Slater 2001). These images of the Amazon, of

course, are far from reality. Most inhabitants of this region, by contrast, live in urban

spaces of 20,000 or more people (IBGE 2010). Some of these towns and cities, like

Marabá and Altamira, are located along relatively recently constructed highways that

dissect the region. Others live in the more traditional river towns and cities like Belém,

Manaus, and Santarém.

A third group, referred to as ribeirinhos (river bank peoples), live in rural areas

reachable only by small motorboat or canoe through what seems, to the untrained eye,

miles of deceptively identical tributaries. In these expansive areas, infrastructure is next

to non-existent, education is limited, and access to health care is minimal. Described as an

invisible population due to their traditional lifestyle and loose politico-social organization

(Nugent 1993), this group has received little attention from the government or individual

politicians (Silva 2004a, 2004b, 2009). Even development projects in the region, such as

the Transamazon highway and large hydroelectric dams which were purportedly designed

to relieve poverty by improving the economy and bringing people into the region, more

often than not actually brought environmental degradation, population displacement, and

the marginalization of populations (Cummings 1995; de

Sousa Júnior and Reid 2010; Diamond and Poirier 2010; Fearnside 1999; Fearnside 2006;

Hall and Branford 2012; LaRovere and Mendes 2000). In terms of public health, the

Amazon’s lack of political power results in a general lack of medical resources. Due to

this pattern, critics of the Belo Monte Dam believe that the project will follow in the

footsteps of other development projects and result in impoverishment and abandonment

for the local population. This, however, does not have to be the case.

The Case of SESP

In the name of development, in July of 1942 the Brazilian Ministry of Health and

the Institute of Inter-American Affairs (IIAA) of the United States created a rural

comprehensive health service program in the Brazilian Amazon. SESP, as the program

was called, was created during World War II to improve health conditions of the regional

population in order to facilitate the flow of raw materials critical for the war—in

particular rubber since the Japanese had overrun the rubber fields of Malaysia (Mayberry

and Baker 2011). At this time the underdeveloped Amazon region was suffering greatly

from the prevalence of malaria and other infectious diseases. Over the next seven years

SESP endeavored to improve public health in the region. Among the most successful of

its programs was the establishment of health posts in more than 30 rural Amazon towns

that had no previous access to Western medical care. In addition, SESP installed water

supply systems, and sanitary privies, and implemented an aggressive anti-malaria

campaign, which included regular sprayings of DDT throughout the communities. As part

of the plan to bring migrant workers from other regions of Brazil into the Amazon basin

to tap rubber, SESP worked tirelessly to screen and immunize some 50,000 workers,

thereby mitigating the spread of disease via transient populations (Mayberry and Baker

2011). This initial public health effort was critical to improving the overall health of the

ribeirinho population and laid the foundation for future development of clinics and

hospitals in the region.

Even after the end of the war in 1945, SESP continued to provide and promote

basic health service to small rural populations. Health services included maternal and

child health, improvements in sanitation and water systems, vaccinations,

epidemiological monitoring, and the collection of statistical information (Mayberry and

Baker 2011). Much of the success that SESP achieved can be attributed to its policy of

integrating community participation into its projects. For example, SESP created the

visitadora (visitors) program to train first aid specialists. Vistadoras were members of the

local community trained to go out into the towns or villages and direct people in need of

healthcare services to the health posts. American and Brazilian registered nurses working

for SESP trained more than 100 visitadoras each year, which also included midwives who

were instructed in the fundamentals of Western obstetrics. The visitadoras were also

trained to provide immunizations, educate the public about nutrition, and collect

information on growth and disease monitoring. The success of this program was rooted in

the recognition that planned home visits were much more effective in reaching the rural

population for primary care than relying on patients to seek out the few and often distant

health post. Visitadoras spent half their time visiting homes and the other half at the

health post providing curative services.

One particular case study of a successful SESP program was in Gurupá.

Anthropologist Charles Wagley was instrumental in bringing SESP to Gurupá (Wagley

1953). Wagley was head of the Health Education Division of the SESP and later the

Assistant Superintendent of SESP. From 1942 to 1945 he worked as the director of a

program focused on the health of migrant workers recruited from the Northeast of Brazil

to work the rubber trails of the Amazon – the so-called Soldados da Borracha (rubber

soldiers). He first visited Gurupá in 1942 when his team began distributing anti-malaria

medicine, developing educational materials describing how tropical diseases were spread

and how they could be prevented, building latrines, and establishing the health post. Once

these initial tasks were completed, Wagley worked with the medical staff to create

policies that would successfully implement the goals of SESP in Gurupá.

In Gurupá the benefits of the SESP were first felt in 1943 when the community’s

health post was established. The next year, Gurupá was able to construct a more

substantial building for the health post, install sanitary privies in 90 percent of the

dwellings in the town, and vaccinate 100 percent of the population against small-pox.

Within a two-year time span (1944-1945) 6,329 people were treated in Gurupá’s health

post (R. Pace 1998). The visitadoras of Gurupá were utilized to make home health visits

and educate rural families on the benefits of public health. SESP also involved the

community schools in teaching children good health habits through the introduction of a

health club. Finally, every three months a team of SESP workers would come and spray

DDT in the community, reducing mosquito breeding and diminishing the incidence of

malaria.

In each of these activities, Wagley was instrumental in adapting public health

needs to local realities, as well as attempting to integrate folk views into public health

education (Sá and Sá 1990). Beyond the aid brought by SESP during the 1940s, Wagley’s

presence in the community and resulting publication of Amazon Town provided the

community with notoriety among policy makers. This notoriety provided dividends, as

the community was one of few that later managed to obtain funding for a hospital.

Post SESP Gurupá

Unfortunately, the success of the SESP did not last long. After 1960 the US

handed complete control of SESP to the Brazilian Ministry of Health and it became

known as the FSESP (SESP Foundation). Throughout the 1960s FSESP began to decline

as the government looked to the states to finance the health services. The states, however,

did not contribute, which led to a precipitous decline in many services (Moitta et al.

1985). When Wagley revisited Gurupá in 1962, FSESP, facing bankruptcy nationally, had

withdrawn much of its funding for the region. Wagley noted that employees were not

being paid for their services and the health posts were in disarray and in desperate need of

repair. Amoebic dysentery was widespread and malaria was once again wreaking havoc

throughout the Amazon.

When a student of Wagley, Darrel Miller, visited Gurupá in 1974, he observed that

the town population had doubled since Wagley’s first visit, to 1,300 residents (Miller

1975). Roads were beginning to be paved, bicycles were in use, electricity ran from dusk

until about 11:00 pm, and most houses had running water which greatly decreased the

occurrence of dysentery. Since SESP was no longer functioning as a source of healthcare,

a new governmental organization named Funrural (Rural Workers Assistance Fund)

together with Assistência Adventisita (Adventist Assistance) had taken over and was in

the process of building a new hospital where the old SESP health post had been. FSESP

had not been able to secure a permanent physician since 1960 and according to Miller,

FUNRURAL brought new hope to the people of Gurupá, offering to provide two or three

new doctors for the hospital they were constructing. The hospital was finally inaugurated

1976 and opened its doors to the public.

By the 1980s, near the end of the military dictatorship, Gurupá was a much

different place. The town, once again, received very little support from state and federal

governments and since Gurupá was not seen as important to the national economy, or by

this point, national security, the amount of funding going into health care was nonexistent

(Magee 1987). Although the fairly new hospital was complete and staffed, inadequate

medical supplies and technical support, along with low salaries created a high turnover

rate among employees. Most doctors, dentists and other professionals left Gurupá after

one or two years in search of higher paying jobs with better infrastructure.

The high rate of personnel turnover created serious healthcare discontinuities in the town.

The turnover left the remaining staff at a severe disadvantage to make much of a dent in

the common illness at this time: intestinal parasites, venereal diseases, hepatitis B,

infectious diarrhea, and whooping cough (Magee 1987).

Other problems created health care difficulties such as, for example, the X-ray

machine in the hospital had not been used in three years in 1984 because it was missing a

part that the state would not replace. At one point the dentist drill blew a fuse and

remained useless because the dentist could not convince anyone from the state to come

out to Gurupá and fix it (Magee 1987). Reliance on pharmaceutical medicine for

treatment of illness was not an option for many since medicines were always hard to find

in town. Therefore, many in the community had to rely on folk medicine and the

medicinal plants that they planted in their backyards. It would have been difficult in

Gurupá not to feel the utter sense of invisibility from the state and federal governments

when it came to health care. Even the town’s biochemist stated in 1985 that he did not

believe in public health. He told researchers that public health is a myth that the

government talks about, yet no money ever comes for it (R. Pace 1998).

To add to this, the attitudes of the health professionals did little to gain the trust of

the community. Oftentimes these professionals came from low rated medical schools and

were not competitive enough in terms of training and competence to make a good living

by practicing medicine in the larger urban centers. Doctors, dentists and other

professionals came to Gurupá as a last resort. For example, Pennie Magee (1987) notes

during her time in Gurupá the poor attitude of the town’s doctor towards her patients. At

one point the doctor warns Magee to be careful because all of the people of Gurupá lie

and she has learned to ignore everything they tell her about their illness. The doctor

ignored all community participation utilized during the time of SESP. She refused to meet

with community health midwives to train them, instead preferring to spend that training

time with the hospital aids. The doctor had no interest in the local people and no interest

in remaining in Gurupá any longer than necessary. As a result, her ethnocentric and

condescending views and actions caused a rift in the way the population viewed Western

medicine and the hospital for some time.

By 2005, when I first visited Gurupá, there were glimmers of hope that a link

could once again be made between the folk views maintained by the community and the

views of the hospital staff. I learned about, and came to know, several well-liked workers

in the hospital who had gained good reputations in the community by incorporating their

regional knowledge of folk medicine into Western medicine. A very well-liked physician

by the name of Dr. Julia gained high praise from the community when she took an

interest in the medicinal plants that community members were using and growing in their

back gardens for everyday aches and pains. She lamented that the community knowledge

of plant uses was diminishing and strongly encouraged people to begin to teach and pass

down the local knowledge. Community members were excited to share and felt more like

participants in their own healthcare. Eva, a housewife in her 70s with an impressive back

garden stated, “Our knowledge is important and Dr. Julia understood that.” (C. Pace

2013). The doctor had even gone so far as to choose some community leaders with

expertise to help build up a laboratory specific for medicinal plants. All this ended,

however, when the local government changed and the new mayor saw no benefit in these

actions. According to Eva, the new mayor was so opposed to the doctor’s work that she

eventually left Gurupá for a bigger city, unable to complete her laboratory (C. Pace

2013).

Several health care workers and local pharmacists were also very beneficial in

bridging the gap between the jargon spoken by the doctors and others at the hospital and

the local dialect. For example, I observed Antonio who ran one of the town’s pharmacies

interact with customers. He would spend the extra time to explain in common terms what

the medicine being prescribed was, what it did, and what to expect from it. Another factor

that helped build rapport between the healthcare workers and the community was the

municipality-wide vaccination campaigns. These national campaigns occurred twice a

year and required much community participation. Local businesses would donate ice to

keep the vaccinations cool, boats for transportation would be donated so that workers and

volunteers could reach the most remote places, and volunteers from all professions would

attend training sessions and then set out with vaccines for polio, measles, and DPT. The

success of the vaccination campaigns is very much a function of widespread community

support and participation in the program, according to the regional public health officers

(C. Pace 2015).

By the mid-2000s the healthcare system in Gurupá was once again functioning

fairly well for a small Amazonian town. As initially established by Wagley and SESP, the

hospital and health posts once again worked very closely with the community. Workers

for the Posto de Saúde das Famílias (Family Health Post) or PSF would make house calls

in town and the surrounding rural hamlets to make sure there are no health problems

needing attention. The Secretary of Health still runs the highly successful vaccination

campaigns twice a year to make sure that all the children are up to date on their

inoculations. These campaigns have significantly reduced chronic childhood diseases. In

addition, the aggressive treatment of malaria outbreaks (isolation of those infected,

medication, and selective spraying of DDT) has all but eliminated the parasite from the

municipality. Currently, the only occurrences of malaria are brought in from other locales.

In 2005, I began to conduct research assessing the level of undernutrition among

the town’s children and to compare these data to similar data gathered in 1984. The

nutritional research was carried out in each of the schools in the town. The research team

took anthropometric measurements from children who assented with permission from the

school, and then recorded and analyzed the data. Our team consisted of undergraduate

anthropology students and employees of the hospital. The hospital also donated the use of

their scales. In 2007 and 2009 I returned to Gurupá to update my findings. The

results of the nutritional research between 1986 and 2005 showed improvements made in

child nutrition. Gurupá’s rate of stunting (as measured in the sample population) fell from

32.2% to 15.9%. Stunting is usually associated with chronic nutritional deficiencies and

chronic disease, resulting in a low height-for-age. Since Gurupá’s rates had decreased by

half, the data suggest an improvement in living conditions. Factors that might have

contributed to this decrease include the expansion of riverboat transportation (from twice

a week to daily service) resulting in an increased supply of food and other products.

Table 2. Rates of Stunting, 1986 and 2005.

N Z H A

Sample in 1986 (N = 472)*

Sample in 2005 (N

= 572)*

- 5 = 2

- 4 = 3

4 = 3

3 = 10

3 = 29

2 = 78

−2 = 118

152 or 32.2% of total

91 or 15.9% of total

Source: Roe-Fehrman and C. Pace 2007. *Ages 5-15 years old

Another potential reason for the decrease in the prevalence of low height-for-age

children is that more food may be locally grown and distributed in the town’s farmers

markets. Additionally, there is the on-going economic boom in açai and heart of palm

production. This boom generates a consistent income for growers and harvesters at the

household level, which in turn stimulates other sectors of the economy. As a result, there

is more money circulating in town. With the increase, families are able to purchase more

and a better variety of food, thus decreasing the chronic undernutrition children were

facing.

The implementation of the Conditional Cash Transfer Program, Bolsa

Alimentação (Food Grant), in 2001 may have also been a contributing factor to the

decreasing undernutrition rates in Gurupá. The program required 85% school attendance

and families also had to complete prenatal exams and maintain all vaccinations current

for children from birth to the age of 6. If all requirements were met the families would

receive an allotment of money to purchase food for the children (Soares 2012). So in

addition to more money flowing into the community there were also safeguards put in

place to ensure the reduction of inequality among its most vulnerable populations.

In Table 3 I present a collection of disease rates in Gurupá from research conducted by R.

Pace (1998) between the years 1981 and 1985 as well as data collected from my recent

study in 2015 and 2017. Using this information allows for a comparative snapshot of the

baseline health of Gurupá over a 34 year period of time. The data collected in the 1980s

show cases of infectious diseases that have since been eradicated from Gurupá. Better

sanitation practices and increased vaccinations have led to the disappearance of measles,

cholera, and tetanus, while the campaign to spray DDT and enforce strict monitoring

policies have curbed the existence of malaria. We see that tuberculosis and leprosy were

problems back in the 80s and continue to persist, although there have been some

significant decreases in the recent years, most likely due to the access to healthcare and

the increased presence of doctors in the area.

The 2012-2014 portion of data is a limited list of illnesses the hospital had

recorded and a list of the incidence of reportable diseases. The numbers on these data

sheets are most likely low estimates of disease rates since not all people in Gurupá who

become sick seek professional health care. Many prefer to self-medicate.

Table 3. Individuals with Reportable Diseases 1981-2014

Disease

Cases

between

1981-1985

Number of

(new) cases

2012

Number of

(new) cases

2013

Number of

(new) cases

2014

AIDS

Cholera

Dengue

Hanson’s

Disease

(Leprosy)

Hepatitis

Malaria

189

Measles

Tetanus

Tuberculosis

Vaginal

Discharge

Syndrome

114

Venomous

Animal Bites

Interviews with the public health workers in 2015 revealed that at this point in

time tuberculosis and leprosy were the main concerns as they have not been able to break

the chain of infection for these diseases. There have not been any significant increases,

yet the steady rate of infection is of utmost concern to the municipality. The rate of AIDS

has also risen, which spurred the nurse João to plead with the government for better

testing measures so that health providers do not have to wait for the patient to go to

Belém to get tested. As of yet, these expedited local tests have not made it into the

healthcare budget. In addition, venomous animal bites have been on the rise throughout

the past couple of years, which could pose a further problem if Belo Monte impacts the

habitat of snakes and other animals and creates more contact with people. In terms of

other changes, the Secretary of Health in collaboration with the Catholic Church conducts

monthly workshops on women’s health. During the workshop free exams are offered.

Also, throughout the year one of the clinics on the outskirts of town is opened specifically

for women’s health appointments on Wednesdays.

Overall, in comparison to neighboring communities, Gurupá is faring relatively

well in terms of healthcare. Figure 5.1 shows the rates of malaria from 2008 through 2014

for Gurupá as well as the cities and towns that surround it. This provides some insight

into how endemic the rates of malaria are in this area as well as the success

Gurupá has had with staving off large numbers of infections.

Rates of Malaria

120

100

Altami

80 Brasil Novo

60 Gurupa

Porto de

Moz

Senador

Jose Porfí rio

20 Vito ria do Xingu

2008 2009 2010 2011 2012 2013 2014

*Source: DATASUS

Figure 5.1 Rates of Malaria in Pará

The general decline in malaria from 2008 to 2014 can be seen in Figure 5.1, but

with a spike in 2011 when construction on the Belo Monte Dam began. This is the same

information that was reported from several sources during this time and seems to have

disproportionately affected the closest downstream towns from Altamira and Vitória do

Xingu where the dam is located. Gurupá, on the other hand is one downstream

community that has kept malaria rates so low that it is barely visible on the graph. Porto

de Moz in particular is only a couple of hours trip from Gurupá by speedboat, yet has had

significantly higher rates of infection than Gurupá. This lends to the hypothesis that

Gurupá heath care workers have been working much closer with the local community to

control the rates of disease, especially when it comes to malaria.

I have also spoken with many health professionals who offer anecdotal evidence

of Gurupá’s health status. For example, when a Navy medical ship was visiting Gurupá in

2009, I was able to talk with a gynecologist about the healthcare of nearby communities

the boat visits. The physician made it clear that out of the three municipalities, Gurupá

had the best public health system. The local government, health posts, and hospital do a

good job with the health demands of the population. The physician reported that she only

saw coisas bobas (silly, trivial, common health problems) here. Overall she had good

things to say about Gurupá’s public health system even though it is not perfect. She

mentioned that the Navy would not visit Gurupá as frequently since they are not needed

as much.

When I asked her about the biggest health problem in Gurupá, she spoke from the

viewpoint of her specialty and indicated that family planning is a major issue. The doctor

stated that the minds and beliefs of the people are hard to conquer. She has tried to

educate her patients about contraceptives, but men do not want to use condoms and

women must have the money for birth control. The form of birth control she referred to is

a monthly injection that is offered for free at health posts or hospitals. However, the

supplies usually run out and patients must obtain the injections from a pharmacy at about

10 reis per shot (about $5 US dollars at the time), which is very expensive for the average

rural dweller. Another barrier to birth control is gossip or folk beliefs. The doctor said she

hears women say they do not want birth control because a neighbor told her that it made

her sick or a cousin said it gave her ulcers. These types of beliefs are hard to overcome

when the doctor is only here for three days.

The Navy physician’s comments were instructive and offered an excellent

negative contrast to the practice of public health in Gurupá. The Navy practiced topdown,

minimal interaction medicine. There was little attempt to understand the local culture and

the local folk view was simply seen as irrational and problematic. In other words, a

cultural approach to public health was not utilized. If the Navy physician had interacted

with the town’s public health officials (which she and the rest of the crew oddly did not),

then maybe she might have realized that the cultural and communitycentric approach to

public health, pioneered by Charles Wagley and SESP in Gurupá, is a major reason for

the overall health status of the community. Yet, in the mid-2000s health care resources

and professionals are unevenly distributed in the region with only about 17,000 doctors

for over 14 million inhabitants. This is seven times lower than the ratio of doctors to

inhabitants in other areas of Brazil, such as the city of São Paulo (Paixão, et al. 2009). As

I discuss in Chapter 6, at the end of its construction, the Belo Monte Dam poses a threat

of unleashing floods of unemployed migrants into towns like Gurupá. The hospitals in the

city of Altamira have already been overrun by the influx of people migrating to work on

the dam (Leite, et al. 2013). If care is not taken to tend to the health needs of the migrant

population as well as the host communities where they will end up, as it was in the time

of SESP with the rubber tapper population, then the population health and the already

strained hospital resources will be severely impacted.

A valuable comparative study in the region conducted by Schmink and Wood

(1992) offers insight into how populations deal with large-scale projects, in this case the

construction of the PA-279 state highway. Schmink and Wood focused in part on the

small rural town of São Felix do Xingu. As a result of highway construction, rapid

urbanization occurred when rural to urban migrants sought new opportunities away from

the traditional extractive activities and the aviamento system (an exploitative system of

debt-credit). With the influx of migrants into the town came increases in crime, violence,

and prostitution. The local fishing based economy was also experiencing changes due to

pollutants from nearby mining projects which drastically decreased fish stocks. In

addition to pollution, São Felix also felt the pressures from other fishing towns and

tourists fishing for sport, which further decreased the fish population. Food variety and

consumption also decreased during this time. Schmink and Wood showed a drop of 68

percent of the total number of foods, especially fruits and vegetables, consumed within a

2-year span. Families experienced hunger due to their lack of income and the increased

commercialization of food. The main health problems at this time included malnutrition

and malaria, the latter tied to increased breeding grounds for mosquitoes due to the

mining projects. Health services did improve during this time, but the quality of life

declined.

Those working in the public health sector in Gurupá are overwhelmed by the task

at hand, trying to keep a politically ignored, economically weak, and impoverished (by

Southern Brazil’s standards) community healthy. Now even more uncertainty has entered

the arena with the political mayhem following the impeachment of President Dilma

Rousseff in 2016 and the certain reductions in important programs like the Bolsa Familía.

Although Dilma is also responsible for pushing the Belo Monte Dam project through

without proper environmental and social impact analyses, the community fears that with

her gone much needed financial assistance will disappear as well. Bolsa Familía is a

conditional cash transfer program run by the Social Development Ministry that was

implemented in October of 2003 in order to help condense all of the previous conditional

cash transfer programs into one entity (Soares 2012). The total household income and the

number of children in the family determine the benefits that each family receives in

addition to the available government budget. According to the Social Development

Ministry’s website (Desenvolvimento Social e Agrário 2015), in September of 2015 there

were over 13 million families receiving the Bolsa Familia. In Gurupá the majority of the

population is receiving some sort of aid from the Bolsa and they would take a large

economic hit if the program disappeared.

This political-economic change, when combined with many other potential

changes stemming from the Belo Monte Dam, is just the beginning of a complex chain of

events with multiple facets and outcomes. Each impact that reaches Gurupá will have its

own ripple effect throughout the public health system, likely triggering, and worsening

other impacts.

CHAPTER SIX:

QUANTITATIVE RESULTS

As summarized in Chapter Four (methods), quantitative data for this project come

from official Brazilian census and local health databases as well as two surveys (n=100)

administered simultaneously in the community of Gurupá. The surveys include one on

perceptions of local public and personal health and a second on food consumption

frequencies. In the paragraphs that follow I will discuss the survey demographics and

compare the data we collected to the census data in terms of representativeness, then

proceed on to discuss some of the findings of the surveys.

Survey Data: Basic Demographics

The sampled population for the health surveys and food frequencies

questionnaires include community members from 17 years old to 74 years old. The mean

age for the sample is 33 years old, which is slightly older than the 15-19 year old age that

is the average for the municipality according to the Brazilian census (See Fig. 6.1).

However, when children younger than 15 are excluded to match my sampling criteria

then the average age from the census falls into the 30-34 years old (IBGE 2016). Figure

6.2 is the information taken from the Brazilian Census of 2010 (IBGE 2016).

Figure 6.1 Age Pyramid for the study sample (n=100)

Figure 6.2 Age Pyramid for entire population of Gurupá. Source: IBGE 2010.

The next question on the survey dealt with gender distribution. It was our

intention to get an equal distribution of women and men to answer the survey. However,

we found that women were more often home and more willing to answer the survey

questions as you can see in Figure 6.3. The population count in Gurupá for the 2010

census according to IBGE (2016) consisted of 4,789 males (49.9 percent) to 4,791

females (50.1 percent). The sample size for this study consisted of 41 male and 59 female

heads of households. The head of the household was self-identified as such and was a

way for the study to identify one adult male and female who would know the most about

the family including the questions about the children living in the household.

Figure 6.3 Gender Distribution for Sample (n=100)

As shown in Figure 6.4 below, over 50 percent of the people whom we surveyed

declare that they live with their partner, but are not married. There are several reasons for

this. One, according to key consultants, is the rather extensive preparation called

PreCana, required to get married through the Catholic Church. This process is strictly

enforced by the resident priest and involves a substantial time commitment to church

activities in the year preceding the ceremony (during a mass in the

interior I attended the priest remarked, “Getting the young

people into the church to get married should be one of the top priorities for the

community”). For those living in the rural countryside, the infrequent visitation by the

priest (sometimes only once a year) can also delay or negate the possibility of an official

wedding. In addition, there are the typical costs associated with getting married (wedding

and reception) which many in Gurupá cannot, or do not, want to pay. A final factor is that

Male

Female

Gender

an official marriage is just not considered that important for many people (see Wagley

2014:168-178 for similar observations in the 1940s).

Figure 6.4 Civil Status of Sample (n=100)

One example demonstrating these problems occurred during my time in the field.

We were invited to a group wedding in the interior of Gurupá. The location was a small

community of houses off of a tributary of the Amazon River. Before the ceremony I

spoke with one of the young couples about their upcoming nuptials. One groom reported,

“Well we are already married in our eyes. We have a daughter and a son together, but

since the priest doesn’t come very often to our community we might as well get married

in the church [meaning the group ceremony].” That day three different couples were

married and a handful of baptisms were performed since the next time the priest would be

back that far into the rural interior was unknown.

The next two figures (6.5 and 6.6) show the birthplace of the survey respondent as

well as their parents’ birthplace. The responses to these questions indicate some families’

longevity in the community, as well as the migration patterns from big cities or small

Single

Live Together

Married

Separated

Widowed

Answe

Civil Status

interior towns to Gurupá. As one resident stated about migration, “The town of Gurupá is

where you come when you live in the interior and want access to city conveniences like

electricity and a wider variety of food. I heard once that one young lady was tired of fish

and wanted to move to the city to have more access to meat.” Another newly immigrated

man 23 years old stated that, “My family wanted to give me better access to schools and

job opportunities. I now work in the Department of Education.”

Figure 6.5 Place of Birth for Sample (n=87)

Gurupa

Interior of

Gurupa

Town of

Breves

City of

Belem

Town of

Porto

Birth Place

Figure 6.6 Parents’ Birth Place for Sample (n=100)

Over half of the survey sample was born in Gurupá with most others born in

interior rural areas near Gurupá, but within the municipality. Fewer were born in Belém,

Breves, and other big cities. As per the inclusion criteria, all of the participants in the

survey had lived in Gurupá for over 1 year. Figure 6.6 is the distribution of their parents’

birthplace, which indicates how long families have been in the area. As shown above,

over half of the parents were born in Gurupá or the rural areas surrounding Gurupá in the

same municipality. The respondents not only have lived in Gurupá for many years, but

also have family roots in the area. Very few were from other big cities and no mothers

were born in Belém. This shows that rural and urban Gurupá have had a stable population

over the past few generations. José, an elder man in his 70s from town, for example,

reported he could trace Gurupá’s history back to colonization. He told me, “When the

Portuguese came to colonize Gurupá they killed most of the indigenous men and married

the women. Most people in Gurupá have Portuguese and indigenous blood. In fact, my

great grandfather was Portuguese and my great grandmother was indigenous.”

Gurupa

Belem

Breves

Interior

Porto

Father's Birth

Place

Gurupa

Breves

Interior

Porto

Mother's Birth

Place

We also asked if families owned an additional house—a question designed to solicit

information on seasonal or repeated migration patterns between the rural interior of

Gurupá and the city. Only four percent of the survey sample answered that they own

another residence in the interior. For example, Igor age 23, stated, “My family has a farm

in the interior, but they wanted me to move to the city so I can build a little store to sell

items and make a little bit more money on the side. I go back and forth often.” Fifty

seven percent of the survey sample reported having only one residence, while thirty nine

percent declined to answer.

Despite the low numbers in the survey, observations made on the outskirts of

town showed many homes in various stages of completion. When asking key consultants

about the houses, they reported that people from the interior build them to stay in town

during festival time; otherwise they are left vacant. For example, Rafael age 50

commented, “Usually around the festival time (São Benedito Festival in December) we

have so many people coming from out of town and so many family members coming in

from the interior that all of the hotels are booked up and there is nowhere to stay! People

have even started to build houses to stay in when they come for the festival.” The

survey sample did not capture this pattern, largely due to the fact that no one was at home

in these “festival homes” during the survey visit which was conducted at a non-festival

time.

Table 4. Percentage of Sample who have another Residence (n=61)

Response

Percentage

57 percent

Yes

4 percent

To understand the socioeconomic lifestyle of the survey respondents, questions

about their principal occupation, monthly income, and perceived class status are included

(see table 5 and figures 6.7 – 6.8). This information helps indicate what types of jobs are

offered in Gurupá as well as what the typical earning power is for the population. The

Brazilian Statistical Public Opinion Research Institute has a set of criteria to determine a

family or person’s social class. It is based upon the level of disposable income retained

after one’s basic needs are met. Based on this assessment Gurupá’s population is

comprised of 95 percent of the population in either the higher or lower working class,

with about 26 percent in the lower working class in abject poverty (R. Pace and Hinote

2014).

Table 5. Principal Occupation for Sample (n=100)

Occupation

Percentage

Administrative & Clerical

Domestic Work/ Vocational

Housewife

Government

Healthcare

No Work

Small Business Owner/Employee

Education

Taxi Driver

Agriculture

Retired

Guard

Community Radio

No Answer

Total Monthly Income

In Brazilian Real

60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00%

R$ 0 - 500

R$ 501 - 1000

>R$ 1000

*The exchange rate for the time of research was R$2.64 for US$1

Figure 6.7 Total Monthly Income for Sample (n=92)

Poor

Middle

Class

Figure 6.8 Class Distribution for Sample (n=96)

As shown in Figure 6.7, the people of Gurupá on average earn $678 reais

(SD=511.93) per month (approximately $217.52 at the current exchange rate of R$3.12 to

the US$1). Looking at Table 6, those working in administration along with vocational

jobs, such as carpentry, make up nearly 40 percent of the study sample. The third most

common occupation in the sample is a housewife. When combined with the six percent of

the sample who replied “no work” that leaves over 20 percent of the sample with no

income, meaning that they work in the home. This may influence the fact that even

though the cost of living is not very high in town, most people self-identified as “poor”

on the survey (approximately 70 percent) shown by the class distribution in Figure 6.8.

Many families still need the government welfare program, Bolsa Familia, to cover their

day-to-day expenses with 180 Reais per family per month, which is about US $55

(Illingworth 2016).

Those who move into Gurupá from the interior are generally from populations of

low socioeconomic status. In most cases they find or build houses on the freely available

land farthest from the river. Many have poor sanitation since latrines are built upon

stagnant water. The common practice in the interior is to construct a latrine over flowing

water, which disperses the waste. This does not work in town as places available for

construction are typically over stagnant water and waste does not wash away.

In terms of access to education, as Gurupá grows it has added more schools to the

city from kindergarten through 11th grade, since high schools in Brazil end a year earlier

than in the United States. From our survey results, 20 percent of the population completed

elementary school and 50 percent completed high school education. They could

read or write to some degree, although as indicated earlier, many could not comfortably

write out the answers to this survey necessitating the interview schedule format. Each

head of household was asked if they would like to complete the interview schedule. Upon

consent, they were asked if they preferred the questions read aloud. Only two of the 100

participants chose to review the survey questions on their own. Although more time

consuming, this format allowed for more opportunities to have a conversation about the

interview questions and open ended responses.

In addition to the K-11, the Federal University of Pará, located in the city of

Belém, has experimented with offering a couple of undergraduate degrees taught over an

extended period of time in Gurupá. The community now boasts several scores of

residents (four percent of the sample from Table 6) with undergraduate degrees in

pedagogy, computer science, sociology, and fine arts.

Table 6. Education Level (n=96)

Level Completed

Percentage (n=100)

No School

4.1

Elementary

20.8

Middle School

18.8

High School

50.0

University

4.2

Vocational Training

2.1

A majority of the overall sample in Gurupá has been able to complete their studies

through high school and is able to read and write to some degree. The amount of students

going on to the university level is still low as it requires moving away from family in

Gurupá and living in a much bigger city of Belém, where it becomes much more expense

to live. If students do make it out to study at the university it then becomes highly

unlikely that they will return to Gurupá with their expertise because Gurupá cannot offer

competitive wages. This was expressed to me by a student home for winter break.

“I really would love to come back and work as a nutritionist in Gurupá, but there

are no jobs for me here. The only thing I can do is work in a school and they will

not pay me very much. I will have better luck going to a bigger city even though I

love it here.” –Student, age 19.

This seems to be a problem especially in the healthcare field. Not being able to earn

competitive wages causes those few medical students who would want to come back to

practice in Brazil to not be able to do so, which means that foreign doctors with no ties to

the community will have to keep coming in to fill these voids.

Health Status

For a brief look at how the town of Gurupá is faring compared to some of the

other cities in the area refer to the figures below. Figure 6.9 gives a general idea of the

population of the towns surrounding Gurupá. The cities are arranged from left to right

with Senador José Porfirio being the closest town to Belo Monte, Porto de Moz about

mid-point between Belo Monte and Gurupá, and the town of Afuá the farthest away from

the dam. Although their towns differ in size, they have many of the same resources and

environment as Gurupá.

Figure 6.9 Population of Cities in the Amazon Basin. Source: IBGE 2010

The following graph shows the rates of infant mortality along with childhood diarrhea

hospitalizations in the respective cities. Keep in mind this information was collected in

2010, the year before the construction of Belo Monte began. Gurupá is faring much better

than Senador Jose Porfirio and Porto de Moz in infant mortality and about the same with

Afuá. This may be due to the fact that, according to a previous interview I had with a

visiting doctor, Gurupá has better family planning services. Diarrhea hospitalizations are

also low compared to the other cities except for Porto de Moz. This is likely due to the

infrastructure in the towns as shown in the next Figure 6.10.

Figure 6.10 Rates of Infant Mortality and Diarrhea. Source: IBGE 2010

The figure below compares the percentage of the population with access to

adequate sewage. In this respect Senador Jose Porfilio and Porto de Moz both have a

higher percentage of people with proper sanitation, although the highest number is still

only about 11%. This may be one of the indicators as to why Porto de Moz has much

lower rates of diarrhea hospitalizations than Gurupá.

Figure 6.11 Percent of Population with Adequate Sewage. Source: IBGE 2010

Compared to the towns that surround Gurupá it has been doing relatively well in

population health. Although the health statistics in the Amazon are lower than Brazilian

national standards and much lower than global standards, the people of Gurupá are

surviving and gradually even improving throughout the years in certain areas (doctor to

patient ratio, better transportation for medicine and more variety of food, continual focus

on public health campaigns).

To begin the health survey portion of my research I wanted to know what the local

perception of health was for the residents of Gurupá. The survey included a series of

questions about the health status and recent illnesses of the participants. Figure 6.12 lists

the responses to the rating of people’s current health status. On a scale starting with 0

meaning very bad to 4 meaning excellent, we found the following views.

Figure 6.12 Self proclaimed health status for sample (n=100)

When asked about their current health status 82% of respondents were feeling

good, very good, or excellent with 70% in the good range. Only about 18% of

respondents felt that their health was bad or very bad. Those in the bad category were

usually older and had one or more chronic health problems. One man, in particular

answered that his health was bad because, “I work with manioc and acai, working on the

farm and in the forest is hard and my body often hurts because of this.”

The majority of the sample did classify their health as good because at the time of

the survey they were not sick. There might have been times at peak cold and flu season

that might have affected these answers, but for the most part if they are not in the hospital

their health is good.

Very Bad

Bad

Good

Very Good

Excellent

Current Health

Figure 6.13 Health Status Compared to Previous Year (n=98)

Approximately 83 percent of the respondents saw their health as the same, a little

better, or much better than the previous year. This means that although access to

medicines and to healthcare services are, in general, problematic for most (as discussed

earlier), over half of those surveyed felt their health to be equal or better than last year. In

part this may be reflective of preventative health practices that are being utilized in

Gurupá. Less people need to go to the doctor, hospital, or take medicine due to healthy

behaviors. Gurupá has always fared better in community health than those in surrounding

towns of the same size due to a better economy, better diet, and a lack of malaria, to name

a few reasons.

Figures 6.14 and 6.15 below refer to the question on the survey about illnesses the

respondent has had over the previous year and any illnesses children in the household

have during the same time period. These are self-reported and may include some illness

that were not reported by the hospital if survey respondents self-medicated.

Much worse

A little

worse

Same

A little

better

Much better

Health Comparison

*Seventeen percent of the sample population responded that they had not had any illnesses in the past year,.

Figure 6.14 Illnesses in the Past Year (n=46)

Figure 6.15 Child Illnesses in the Past Year (n=23)

Seventy two percent of the survey respondents responded they were not ill or did not

recall any illness. Among the illnesses reported, the most common ones were food

poisoning, colds, and flu. From the conversations with key consultants, it is very likely

that the illness rates are greatly underreported because most people do not view a

Heart problems

Food Poisoning

Asthma

Allergies

Vomit and

Diarrhea

Child Illness in the Past Year

common cold, seasonal flu or even food poisoning as being a reportable illness. These

illnesses are more likely to be treated with home remedies instead of requiring a trip to

the hospital and are therefore more forgettable.

For example, in Gurupá the rainy season (December through May) is the peak

period for “gripe,” or common cold. It is a frequent topic of conversation in town

whenever the days are especially rainy, slightly chillier, or cloudier than normal. The

phrase, “que chuva!” or “what rain!” often precedes an in depth conversation about the

gripe to come. Over breakfast one morning I recorded André (a 60 year old local

merchant) commenting about the weather. He said, “There is so much rain right now.

That means the gripe is coming. I heard the guy up the street got it and it was really bad

this year. It always comes around, but it seems to affect people a lot harder now.”

Food poisoning tends to happen quite frequently as well. A conversation with my

research assistant, a newly hired data analyst at the hospital, revealed that there are much

higher rates of intestinal parasites in the population than there had ever been recorded by

the hospital in previous years. My hypothesis is that this has to do with declining water

quality in Gurupá. In fact, during one of my summer trips to Gurupá in 2012 there was a

community meeting of many of the villages of the interior to discuss why rates of

childhood dysentery seemed to be on the rise. One of the leaders of the meeting stated, “I

believe that the waste from the construction of the Belo Monte Dam (which began the

year earlier in 2011) gets into the river and goes downstream to contaminate our water.

This is why all of our children are getting sick more often. Someone needs to do

something about this.”

The health officials in Gurupá also noticed a difference in the city. João, age 30,

who works as a nurse, stated, “There are people here that just don’t know about

sanitation. Especially the people who move from the interior think that they can live like

they did out there, but being in the city is different and this is what we need to teach them

to reduce the rates of dysentery in children.” João went on to talk about infrastructure and

water sanitation in the city stating that the farther away you live from the town center the

harder it is for you to get resources. There are even some areas that have no electricity

lines because no one has cared to go out there and put more up. The water provided from

the town’s well runs out and people are left without water for a period of time.

The response to the rates of child illnesses for the previous year was very low with

only a handful of responses. Although I have seen many children get sick in Gurupá

during my visits, I have observed that parents usually just let it run its course and chose to

medicate their children with home remedies. The fact that the children did not need to go

to the doctor may have led the survey respondents to exclude these types of illnesses

when asked on the survey. Out of the other 23 percent of respondents, allergies were the

most common illness. This is interesting, as I have not seen a category for allergyinduced

illnesses (besides asthma) in the health data from the Secretary of Health. This may be

due to the fact that allergies are a new diagnosis and have otherwise been classified as a

cold or flu. This would be an interesting area for further inquiry.

The following two figures, Figures 6.16 and 6.17, show the answers to questions

about health behaviors. Smoking and alcohol intake, of course, are clearly linked to heart

disease, lung disease and cancer (Centers for Disease Control and Prevention 2015;

American Heart Association 2016; National Institutes for Health 2017).

Figure 6.16 Percentage of Smokers for Sample and Frequency (n=100, n=14)

The results of the survey indicate that an overwhelming majority of survey takers

(80 percent) answered that they do not smoke. Of the 18 percent that answered yes, 58

percent reported smoking 5 to 10 cigarettes a day. An analysis of the survey data also

revealed that there were twice as many male smokers (12 of the 18) to female smokers (6

of the 18).

Figure 6.17 Percentage of Alcohol Drinkers for Sample and Frequency (n=100, n=39)

Yes

Answer

Smoke

per

day

2-4

per

day

5-10

per

day

>10

per

Frequency

Yes

Answer

Drink Alcohol

per

1-2

month

3-6

per

month

per

>12

month

Frequency

As for drinking alcohol, the population is close to a split down the middle with 44

percent responding that they do drink alcohol and 53 percent responding no. Of the 44

percent that answered yes, 74 percent only have 1 to 2 drinks a month and 5 percent have

12 or more per month (with 3 percent answering that they drink every day). All of the

males responded to this question with 31 out of the 41 total answering yes, whereas 56

(total 59) women responded with 13 of them answering yes. In Gurupá it is much more

acceptable for a male to go out to the bars and drink publically than for women to do so.

Women’s drinking will usually occur during a festival or other event such as a wedding. It

is worth noting that drinking and violence have been areas of concern with the

community. Some worry that there are too many bars and young men are spending too

much time there. However, my sample does not show any alarming trends towards an

epidemic of alcohol abuse. This is not to say, however, that it should not be considered as

a future impact in the public health of the community.

Perceptions of Health Care

Since many of the successful public health campaigns in the past have benefitted

from strong community involvement, it is important to understand the population’s views

on community health and their opinions on the health care system in general. To

understand the view of health from a local, folk, or insider (emic) perspective I include

the following open-ended questions about the health care system in Gurupá. These

questions are designed to answer my research questions from Phase 1 of the study. I

wanted to know how community members view their current health status and what they

identify as the community’s most challenging health problems. I also wanted to know

what they thought of the health care system and collect some of their personal stories

about navigating this system when faced with an illness. Finally, these questions are also

meant to capture the sample’s general opinion on the Belo Monte Dam and how (or if)

they see their health or health care changing in the coming years.

Table 7. What do you think is good about the health system in Gurupá?*

Answer

Percent of Respondents who cited each

item (n=100)

Nothing Good

38.9

Patient Care

18.1

It is good, but needs improvement

19.4

Dentist/Doctors

22.3

X-Ray machine

1.4

It is close by

1.4

Table 8. What do you think is bad about the health system in Gurupá?*

Answer

Percent of Respondents who cited each

item (n=100)

No Medicine

51.3

No Resources

20.7

No Infrastructure

17.1

No Doctors

21.9

Not Clean

9.7

Poor Patient Care

14.6

No Education

1.2

No Transportation

1.2

No investment in SUS (**explain)

1.2

Everything

9.8

No answer

16.8

*The totals in these charts add up to over 100 percent because many people put multiple

answers in this section, as was encouraged by the open-ended format.

Tables 8 and 9 indicate local views on what is good and bad about the local health

care system. In terms of positive views listed on Table 8, a little over 22 percent of the

sample appreciate that the community has doctors and dentists (many surrounding areas

still lack professional health care providers), around 18 percent like the patient care they

receive, and just over 19 percent acknowledged health care is positive, but still needs

improvement. However, nearly 40 percent answered that nothing is good about the

systems. Representative of these negative views are the following comments expressed

during interviews. “Almost nothing is good. The health of the municipality is

horrible.

They don’t have specialists or essential tests for screenings of diseases” –Female, age 33.

“It has been a joke. I don’t think anything has been good. I hope that it gets better in the

future.” – Male, age 21.

Table 9 lists the problems people perceive in the health care system. Over half of

the survey responses declare that the major health issues in Gurupá are a lack of medicine

and resources. It is common knowledge within the community that when the hospital is

low on medicines, it takes a long time to get more shipped in from Belém. This has been

an ongoing issue for Gurupá and one that stems from the amount of state and national

funding that is allocated for these purposes. This creates a difficult situation when it is the

national government that determines the budget for healthcare and is the same entity that

is deciding on development projects that will have adverse health effects for

communities.

The doctors in Gurupá appeared to be seen as both good and bad components of

the healthcare system. It seems that the quantity of doctors is an improvement, four more

doctors as opposed to just the two that had originally practiced there.

“The healthcare system is average. We have doctors and nurses and people who

help us” Female, age 20.

“In terms of patient care the professionals do not let a single patient go without

being seen” –Female, age 33.

However, these doctors still cannot cover the entire municipality, so there may be

times and places that a doctor is unavailable. The quality of doctor-patient interaction is

another issue as noted by the poor patient care responses. As stated in the qualitative

section earlier, there is a sentiment that the doctors patronize or are dismissive of patients,

which seems to be reflective in the views of the survey respondents as well.

“In Gurupá there is no priority for children, pregnant women and the elderly. They

don’t have medicine at the hospital and many times we are treated with ignorance

by the health professionals” – Female, age 24.

“In my opinion we need a hospital that does not have prejudice against the

patients and that have all of the medicine that are necessary for the population” –

Female, age unknown.

“Some of the medical professionals do not know us and treat the patients with like

they are ignorant because of their social status” – Male, age 23.

Each survey respondent was asked what the most serious diseases in Gurupá are

in order to obtain a better understanding of what the community perceives to be important

health issues. Figure 6.18 shows the percentage of community members who mentioned

one of these diseases.

HIV/AIDS

Dengue

Hansen's

Tuberculosis

Yellow Fever

Cancer

Other

Zika

Pnuemonia

Serious Diseases Identified by

Community

Figure 6.18 Serious Disease Identified by the Sample (n=100)

Most people who answered the question did not choose just one disease, but instead

put several that they thought affected the town. Approximately 21 percent of those

surveyed responded specifically with the pairing of AIDS and Dengue as two of the most

serious diseases in Gurupá at the current moment. Below is the information gathered from

the hospital records presented in Chapter 5; it is clear that AIDS has increased from 2012-

2014 going from a prevalence of 3 known cases to 17 cases. Dengue has also been high

with many of the individuals that were being interviewed knowing at least one person

who had suffered from this disease.

Table 9. Individuals with Reportable Diseases 2012-2014

Number of (new)

cases 2012

Number of (new)

cases 2013

Number of (new)

cases 2014

Dengue

N/A

AIDS

Women’s Health Questions

The following questions focus on the women taking the survey. Modeled after

Hilton da Silva’s health survey (see appendix C), the questions take a snapshot of

women’s health in Gurupá, which, according to the Navy Gynecologist I interviewed in

2009 (see Chapter 4), is better than other surrounding communities (C. Pace 2009).

Figure 6.19 Number of Pregnancies for Sample (n=53)

There were 59 women in this sample, 49 of which answered the question on how

many pregnancies they have had. The majority of women (72 percent) had between one

to three pregnancies. From this data it seems that the number of women having large

numbers of children is low. Three of the women who took the survey were currently

pregnant and seven were currently breastfeeding.

It is important to note the method and location of childbirth as this gives some

indication to the resources and trust in the health care system (Otis and Brett 2008;

Kyumuhendo 2003; Bazzano et al. 2008). If women were having their babies at home

more often, even when the hospital is near and available, then that could mean there is a

disconnect between the mother and her trust in the hospital.

Never

Pregnant

Number of Pregnancies

Figure 6.20 Method of Birth and Location (n=49, n=45)

Eighty percent of the women who had had children had a natural birth. As

resources are scarce, C-Sections are usually not the preferred method of childbirth.

During my most recent visit to Gurupá in 2017 one of my good friends had a family

member go to the hospital to begin an induced labor only to be turned away because there

was no running water in the hospital. Women with more complicated pregnancies are

usually sent to Belém or Breves, which can be a very expensive endeavor. Even though

the hospital lacks resources, it is still the preferred place for childbirth. Only 13 percent

of women have had home births.

Another way to determine the level of women’s health available is asking about

prenatal care. Women both need to know it exists and also follow through with

appointments in order to achieve the full health benefits it provides during pregnancy.

Vaginal

C-

Section

Both

Type of

Birth

Home

Hospital

Both

Location of Birth

Figure 6.21 Did you have Prenatal Care and how many times? (n=51, n=33)

Although the percentage of women who had some sort of prenatal care is high (84

percent), about a quarter of them only went 1 to 3 times during pregnancy.

Finally, women must have access to cervical cancer screenings as a priority for

women’s health (Landy et al. 2016). The municipality has made an effort to boost the

number of women who receive screenings by creating an entire day in which the health

posts are dedicated to women’s health issues as well as encouraging free screenings with

workshops held in town.

Yes

Prenatal Care

1-3

times

4-6

times

7-9

times

How Many Times?

Yes

Cervical Cancer

Screening

Less

Than 1

Year

Years

Last Exam

Figure 6.22 Percentage Cervical Cancer Screenings in Sample and Frequency (n=53,

n=34)

Cancer came up in about 4 percent of the survey responses as a serious illness that

Gurupá faces. Conversations with those working as technicians for the hospital revealed

that cancer screenings are difficult to provide due to the lack of resources. There are

times, however, when Navy medical ships or other traveling physicians make it to Gurupá

to perform these exams, or during women’s health conferences for the entire municipality.

This could be a contributing factor to the 70 percent of women who have had a screening.

Views on Health and the Belo Monte Dam

Those on the forefront of public health in Gurupá whom I interviewed were honest in

reporting that they just did not know what the impacts of the Belo Monte Dam would be.

The purpose of this research was to expand the knowledge base of the public health

impacts of dams to better prepare the community for future implications of Belo Monte.

The question below helped me to gauge what people’s existing knowledge and views are

on the Belo Monte Dam.

When asked about the Belo Monte Dam, responses to this question seemed to

downplay potential health impacts in Gurupá. About 60 percent said there will be no

impacts and 40 percent said there will be impacts. The community members either

follow the rhetoric that the government releases and believe the dam to be a good

thing in the name of progress and development, or they are swayed by the non-profits

and Catholic Church that Gurupá will see negative consequences such as

environmental destruction and population displacement. From the survey data, those

who believe there will be an impact overwhelmingly mention the impacts on the

water quality and flow of the river, which in turn will affect the amount of fish

available. Among the comments collected are the following.

“With the contamination of the river it will hurt the water quality, which will hurt

our health” – Female, age 24.

“It is going to affect us directly through the ecosystem and diminishing our source

of food for the rural and urban communities” – Female, age 26.

“The dam will have an impact on Gurupá because we are going to have a river

without fish, shrimp, etcetera.” –Male, age 23.

Figure

Will there be Impacts from Belo Monte in

Gurupa ?

(n=80)

Yes

Will Belo Monte have an impact on

Gurupá

Food Frequency Questionnaire

In Gurupá, the purpose of administering the food frequency questionnaire is to

gauge what foods are currently available to the community and how much is available.

Not only does this food snapshot allow future researchers to have a baseline record of

foods available prior to the completion of the dam, but it will also allow for an analysis of

where the nutrition trend is leading and provide information for further action. We

administered a Food Frequency Questionnaire or FFQ to the same sample as the health

survey. Below are lists of foods that we asked respondents to note how frequently they

were consumed. The choices for frequency of consumption are: never, monthly, weekly,

or daily. The tables that follow lists the responses that are one or more times a day, never,

or on a weekly basis.

Table 10. Foods Consumed 1 or more times a Day

Food

Percentage of people who responded “one

or more times a day” (n=100)

Sugar

91.6

Coffee

90.7

Farinha (manioc flour)

86.0

Garlic

66.8

Table 10 Continued

Onion

60.5

Bread

60.3

Rice

56.6

Açai

49.5

Tomato

49.4

Beans

32.3

Table 11. Foods Never Consumed

Food

Percentage of people who responded

“Never” (n=100)

Peanuts

92.6

Broccoli

89.9

Peaches

83.5

Tucumã (a local fruit)

77.9

Strawberries

76.5

Sugar Cane

72.4

Honey

68.2

Pears

65.1

Heart of Palm

61.4

Melon

55.3

Table 12. Foods Consumed on a Weekly Basis

Food

Percentage of people who responded “1 or

more times a week” (n=100)

Table 12 Continued

Beef

76.5

Chicken

64.2

Fish

63.9

Spaghetti noodles

55.8

Potatoes

51.1

Eggs

50.0

Crackers

43.7

Banana

42.7

Cabbage

38.1

Tapioca

32.1

Using the tables above one could construct an average food consumption pattern

for the survey sample. Foods like rice, farinha (manioc), sugar, and coffee are consumed

by over half of the sample one or more times a day—making these foods the base of the

diet. Coffee is consumed in the morning for breakfast, often in the afternoon, and may

also be offered as a cafezinho, translating as “little coffee,” when going to visit friends

and family. The cafezinho is offered in the form of a shot of espresso with nothing in it

but sugar. In an interesting twist from this pattern, four out of the six key consultant

family homes that I routinely visited served carbonated soft drinks instead of cafezinhos.

The meats and other proteins in this FFQ are consumed at least once a week when

available. When meat is not consumed there might be pasta available or sometimes the

meal may just consist of açai, farinha, and rice. In town, the most available meats are beef

followed by chicken. Fish is not sold commercially. There are small markets around town

where local fishers sell their daily catch. There were times during my research in Gurupá

when I could not order fish in the local restaurants because there had been very little sold

at the market that day. The changing eco-system and the potential reduction of some fish

species is something to be aware of when thinking of environmental impacts of the Belo

Monte Dam and how they will affect the nutritional status of downstream communities.

A number of fruits, vegetables, and nuts are among the foods listed as never consumed.

Native fruit consumption is lower than I anticipated. In part this may have been a factor

of the seasonality of the fruits and timing of survey. But from observations over the years

in various town markets, local fruits, beyond bananas and a few pineapples, are rarely

sold. If households have fruit trees in their backyards, then consumption may increase.

But it appears that for most people in the town, fruit is simply not a major part of the diet.

The amount of vegetables and nuts consumed is also low. In large part this pattern is a

result of the relatively high costs of these items since they are mostly imported from other

regions.

Conclusion

The health and food frequency surveys provide this research project with baseline

information about health care status in Gurupá as well as local views of the healthcare

system between the years 2015 and 2017. Although the majority (70 percent) of people

ranked themselves as poor and had serious criticisms of the healthcare system in Gurupá,

most (again 70 percent) also rated their current health status as good. Therefore, although

things could always be better, from the perspective of the local population as represented

in the survey sample, the community of Gurupá seems to be fairly stable in terms of

health status without extreme suffering. That being said, very few (12 percent) rated their

health as “very good” or “excellent” making the likelihood of a decline to “bad” or “very

bad” health status a likely scenario in the event of a major change. This is a key concern

surrounding the health impacts of the Belo Monte Dam.

In terms of women’s health, there are a number of campaigns by the hospital and

the Catholic Church that are working hard to promote women’s health. There are

workshops every month that bring women from all over Gurupá and the interior to talk

about issues and get advice from the doctors. The abundance of doctors from Cuba,

especially female doctors, means that once a week they are able to dedicate the entire day

specifically to women and women’s health issues. The success is showing given that the

majority of women are keeping up with their appointments to be screened for cervical

cancer, are making regular appointments for prenatal care, and having their babies at the

hospital. There still needs to be some work done on the rates of STIs, however, as the

numbers of hepatitis and vaginal discharge syndrome are still pretty high in the

community.

Table 13. Individuals with Reportable Diseases 2012-2014

Number of (new)

cases 2012

Number of (new)

cases 2013

Number of (new)

cases 2014

Vaginal discharge

syndrome

114

Hepatitis virus

N/A

Finally, the food frequency questionnaire is a baseline look at the types and

varieties of foods community members are eating every day. Although this is just a mere

snapshot of a sample of Gurupá, it is nevertheless helpful to have a standard from which

to judge change in the future. Future research will be needed to assess the nutritional

status of the community once the dam has been functioning for a considerable amount of

time. It is also important to look at certain items that are being consumed multiple times a

day, such as sugar, cookies, and cake. Epidemic rates of obesity are not an issue in

Gurupá at the present time. The data gathered by R. Pace (1986) and Roe-Fehrman and C.

Pace (2006) show the percentage of school-aged children with z-scores for weight for

height as being +2 and above as 3.4 percent and 3.49 percent respectively. Having a

zscore of +2 signifies that the child is overweight/obese and in 2006 there were very few

(although more than in 1986) cases. Yet, for 2014 alone the hospital recorded 287 new

cases of hypertension and approximately 74 new cases of diabetes among adults, which

indicates that chronic diseases related to nutrition, and eating habits are likely on the rise

for this area (SIAB 2014). For the entire results of the FFQ, please refer to Appendix B.

The next chapter will discuss the qualitative portion of this research in order to

produce a holistic picture of life and health care in the town of Gurupá. The qualitative

data collected gives thick descriptions of what it is like to live in Gurupá, what the belief

systems are and how this is used to communicate with one another and create health

narratives. The interviews give the community members, health officials and hospital

employees a voice to put all of this data into context and will aid greatly in determining

best practices moving forward from the impacts predicted from Belo Monte.

CHAPTER SEVEN:

QUALITATIVE RESULTS

This chapter describes the results of participant observation and informal

interviews I conducted during fieldwork from 2015-2017. I was fortunate to rent a room

from the Secretary of Health, on the second floor of his family home, which allowed me

to interact with all types of health care workers who came to visit informally, or who

rented rooms there as well. Despite the proximity, there were still challenges to

interactions since most health care workers were constantly traveling throughout the

municipality to deal with one health issue after another. This meant that the time for

interactions, let alone questions, was always limited. Notwithstanding this, over the

prolonged research stay I was able to piece together enough discourse and observations to

examine the key health issues for the community, particularly the ones foremost on the

minds of the health care workers. The main themes I encountered were: benefits of

community cohesion; healthcare and outsiders; lack of structure and organization of the

public health system; migration from the interior; and drugs and violence.

Community Cohesion

Reading through the anthropological literature on Gurupá, a prominent pattern

emerges of long-term active community participation in the sharing of tasks and risks.

Whether it is through communal work parties (mutirão or convite), adoption of needy

children (filhos de criação), creation of fictive kin networks (compradesco), or even

supporting a local soccer club, a support network tying the community together is readily

available (Wagley 2014; R Pace 1998). This interconnection is noticeable when you

spend time in the town and realize that nearly everyone knows everyone else and carries

out some sort of social interaction, often on a daily bases.

These social interactions create a high measure of community cohesion. Kearns

and Forrest (2000) comment, “A Community’s social cohesion results from the positive

effect that a strong sense of belonging, or attachment to a place and residents’ identities

intertwining with that of the place, has on notions such as adherence to common values

and norms, the salience of past experiences and common ideas and culture.” When a

community is invested in itself as collective, initiatives for health programs, or other

types of community based projects, will typically lead to more successful results. This has

been the case time and again in Gurupá when the community has banded together to

overcome adversity.

According to my consultants, the decade of the 1980s was a critical period

shaping the current form of community cohesion.

I studied theology in school and became a community leader for the Catholic

Church. I fought for the social movement with the church to make sure that

people didn’t have patrãoes (land owners who kept the community members

under a system of debt peonage) anymore and that they had the rights to the land

that they worked and lived on. I consider myself a revolutionary. Myself and other

community members worked together to kick out corrupt leaders. It was a great

time for the community. We all worked together. –Antonio, age 70

The anthropological literature supports this as well (Oliveira 1991; R. Pace 1998).

During the period at the end of the military dictatorship that brutally ruled Brazil from

1965-1985, a social movement to protest social and economic inequalities emerged under

the auspices of the Catholic Church. Using Liberation Theology as a theological base, the

town’s Italian priest worked with the local rural workers union to secure small farmers

and resource extractors’ legal claims to land title. The local landowning elite resisted the

movement through threat and intimidation, ultimately resorting to voter fraud to halt

elections in the rural union. Following discovery of the fraud, members of the opposition

occupied the union building until state legal authorities were called to the town. In the

end the social movement was successful in obtaining legal title to land for thousands of

ribeirinhos, and from this base launched a successful political party (Partido do

Trabalhodores or Workers Party) that governed Gurupá until 2016.

The Church/Rural Union social movement organization has contributed greatly to

the community’s cohesion. Public health workers have repeatedly used its structure and

social networks to successfully implement programs. In fact, all of the health education

meetings and health fairs that I attended during my stay in Gurupá were hosted at the

church. These have included children’s rights groups and women’s health groups, which

hold workshops every month to discuss poignant health issues within the municipality.

One such workshop I attended was the Women’s Health Group. Women who

represented most of the communities from the rural interior and many women from the

town attended the workshop. There were presentations given by the Cuban doctors, local

physical therapists, and nurses on topics ranging from breast cancer, and HIV prevention,

to how to raise a healthy child. After a full morning of presentations the women gathered

into small groups to discuss other pressing issues and how to effectively use the

knowledge they had just gained in their communities. Next door in another church

building the town’s medical professionals were holding a small health fair for the

participants to get examined for women’s health issues. During the exams women

received much-needed healthcare and information on sexually transmitted infections.

According to the local health officials I talked with, these types of workshops are well

attended and the information learned is then disseminated throughout the municipality.

The health officials insisted that this system is the principal reason that Gurupá is faring

relatively well in terms of healthcare overall, in comparison to neighboring

municipalities.

The workshops are created to address health issues deemed relevant by the

community members. The most impressive part of this system is the fact that it is the

community members, not the health professionals, who propose the topics. Taking a look

at the topics covered during my research time has provided me a perspective into what the

perceived health issues were for the community. For example, during the women’s health

workshop one of the topics that the women in the area wanted to know more about was

breast cancer. The incidence and prevalence of breast cancer is very small in Gurupá, but

the women were concerned that they did not know enough. Through the workshop they

were given an opportunity to speak with the local doctors to have specific questions

answered.

The workshop lasted a full weekend and covered many health questions that the

doctors do not have time to answer during typical office consultations. For example,

during the meeting an elderly woman seated in front of me, who had travelled

far from another region of the municipality, raised her voice to ask whether it is

better in terms of warding off breast cancer if women breast-feed a lot or a little. The

doctor responded, saying that breastfeeding a lot helps to ward off breast cancer, even

though there are other factors involved as well. The woman seemed happy with this

answer. I overheard her daughter ask if she understood the doctor and she said “of

course.”

The question and answer portion went on for a little bit longer with women asking

additional questions about how they could prevent breast cancer. Some women asked

questions on behalf of the few men attending the workshop as well. Although the

questions were serious in tone the women still found humor in the very public discussion.

The doctor ended the question and answer portion with the statement…

Women should take care not to get breast cancer because these parts are very

useful to babies to feed them and to your husband as well.

The room erupted in laughter with the men nodding in agreement while the women

clapped their hands and giggled.

There were over 100 women and about a dozen men who came to the workshop.

The volunteers for the workshop made nametags for each participant. There was a

concession area for refreshments and a little stand to sell T-shirts printed with Encontro

de Mulher de Gurupá 2015 (Women’s Encounter of Gurupá 2015). The workshop

coordinators paid particular attention to those living in the rural interior with limited

access to healthcare. The church hall was decorated with banners from each of these

communities to show support for those who made the long trip to learn more about health

for themselves and for their families. During the first day roll call the women were asked

to sing songs about their communities and communicate specifics about their

communities’ health care challenges.

Among the speakers at the workshops was a government representative who

spoke about the need for women to be more involved in politics. Following this, one of

the doctors from the hospital announced the type of consultations they would be doing

across the street that day. Next a psychologist from another city spoke on how to raise

children effectively. Her first question to the audience was, “Is there a right way and a

wrong way to raise a child?” The crowd answered that there was, but the psychologist

replied that in reality there were no wrong ways to raise a child. She continued, everyone

just does what he or she can with what they have.

The psychologists made several points during her talk. First, she said that parents

must be attentive to their children and what is going on in their lives. For example, if João

really hates school, gets low grades, and doesn’t want to go to school, then you can’t just

tell him to go no matter what. Instead, she maintained, you should try and find out what is

going on to make him feel this way. She told the women that the best resources they have

in Gurupá are CRAS and CREAS (Social Assistance Reference Center and Specialized

Reference Center for Social Assistance, respectively) if their children need assistance

with mental and behavioral health. Otherwise the children will have to go to Belém to see

a professional.

The psychologist covered more topics such as whether or not you should hit your

children as a punishment. Her viewpoint was that the children only learn about violence

when they grow up with spanking as their punishment. She said that violence does not

solve anything and that violence only propagates more violence. Punishments have to be

a learning tool and children cannot just be told that they did something wrong; they have

to learn from their mistakes so that they understand and do not make the mistake again.

This comment stimulated discussion, with a definite generational difference. Many of the

elderly community members with whom I spoke throughout my research cited the very

lack of corporal punishment as part of the problem with the youth’s behavior.

The youth in Gurupá do not obey their parents anymore. They watch these

telenovelas and they see how the children talk to their parents on the TV and they

try to mimic this behavior. And now the parents cannot even hit their children to

discipline them because they will go tell the Consultario Tutelar (equivalent of

child protective services) and the parents get in trouble! Imagine that! – Eva,

housewife, age 70

Another aspect of the women’s health encounter involved the women breaking up

into small groups to discuss common health issues in their communities. They were

encouraged to come up with viable solutions to these issues through community

involvement. The women seemed to really enjoy this portion of the day and spoke at

length about specific issues they were facing. Health representatives were going around

to the groups so that they would be better able to understand the health issues that women

faced in their respective community.

In addition to providing a space for the doctors and health professionals to offer

presentations to the community, the Catholic Church also provided the space for the clinic

to be held during this time. Women attended the presentations that they chose and then

walked across the street to see one of the doctors for any problem or for a checkup. This

was especially helpful for the many women coming from the rural interior who were

unlikely to get these health services in their local health post. The mobile dentist van was

parked across the street in front of where the Cuban doctors were doing consultations so

women were able to get their oral health checked as well. Some of the technicians from

the hospital and health posts were doing the triage portion of the clinic, which included

blood pressure, height, and weight measurements. When asked about the talks that had

been going on at the workshop all the women in the waiting room agreed that the topics

were very good this year.

The fact that these types of workshops exist for the community will be extremely

beneficial for mitigating health impacts from the Belo Monte Dam. The community

building that occurs during these workshops and the number of people that attend allows

health officials to have a great platform from which to pass along important health

information that will reach even the most rural parts of the municipality. It is also a great

way to keep track of what kinds of health issues the communities are currently facing.

In another example of community cohesion, senior citizens in the town have an

active social organization that has its principal activity once a week. The local physical

therapist, which works extensively with the seniors, described the group.

About 40 or so of them have come together on their own to form a senior

citizen group. Since they are so organized I was able to work with them

very easily and plan group hikes out to Jacupí [nearby creek] to encourage

physical activity. They all had lunch together afterwards and were able to

get out and about for the day to remain active. Not to mention it was a lot

of fun! – Beatrice, physical therapist, age 30

The group also holds weekly dances at 10:30 in the morning to encourage physical

activity. They gather in the town’s event space and play the music loud as they

dance and reminisce on times long passed. Sometimes there will even be a local

band that will play for the group. Leaders of the group like to hold a raffle and

give away little gifts to encourage participation as well. Strong community ties

have been an advantage for a town like Gurupá throughout the years. However,

there are changes that may come into play that could disintegrate the communal

bonds, which I discuss in the following sections.

Health and Outsiders

The issue of health and outsiders came up in two different contexts in Gurupá.

The first was the presence of foreign doctors and problems of cultural fit. The second,

with greater long-term consequences, was the influx of migrants from other communities

to Gurupá. Each case is discussed below.

Foreign Physicians

One morning as I was making my daily rounds to visit people, I decided to stop

into the health post down at the end of 5th street. The health post is located farther inland

from the river and hospital to ensure access to the poor communities. When I arrived,

Fatima, the wife of the Secretary of Health who works at this post, invited me to come in

and tour the facilities. Although quite sparse in terms of equipment and even furniture, the

health post offers essential services to community members since the hospital had

changed its system. Now, all appointments are made through the health posts with

primary care and smaller issues being dealt with by the doctors and techs at the post. I

met with the doctor who had been placed in Gurupá as part of an international agreement

between the Cuban and Brazilian governments to provide 400 doctors to rural areas of

Brazil. Gurupá currently has four of those doctors working in several posts as well as the

two Peruvian doctors that work in the hospital. The Cuban doctors’ contracts are a

mandatory allotment of three years with a couple of breaks to return home for visits.

Sometimes the doctors have a harder time adjusting to life in Gurupá especially if they

are used to working in urban vs. rural areas. Many health issues seemed to be so trivial

that is was difficult for them to understand why they kept occurring.

I observed the doctors interacting with patients on a couple of occasions. One by

one they would come in with an issue and I would hear responses like, “Can you believe

this woman still does something so silly as smoke?” or “This woman is so obese and she

wonders why she has all of these health problems!” I watched the faces of the patients as

recommendations were given in Portañol (Portuguese mixed with Spanish) like, “Well if

your back is hurting then you don’t need to sleep in a hammock” and “You should always

wear shoes in your house.” Some patients protested the recommendations with statements

such as, “I work in the várzea [floodplain] all day and I can’t wear my muddy shoes

inside my house” to which a reply was simply, “Well buy inside shoes.” The patients that

I witnessed were often confused by what was trying to be communicated, but would

usually nod their heads and agree because doctors are held in a position of authority with

which you do not argue. On several occasions doctors would complete the diagnosis and

ask if the patient had understood, to which the patient responded no. The doctors would

then question why the patient did not ask questions earlier to which they responded; “You

did not ask me earlier.” During conversations with community members about the foreign

doctors in Gurupá I usually heard a lot of trepidation. Most times people laughed it off

saying, “They speak funny and gave advice that does not really make sense.” – Lucia, age

38.

Not all of the doctors are problematic, however. Some are more accustomed to

working in rural settings. The differences between these two types of physicians can be

summed up with statements from doctors that I heard during my time in Gurupá.

I really want to make sure that people can understand my Portuguese. I know I

have some pronunciation errors and I like to try and ask local community

members how to correctly say things so I can remember for next time. – Doctor 1

On the other hand,

I don’t understand why people in Gurupá don’t speak Spanish. More people speak

it in the world than do Portuguese. It should be a mandatory language to learn. I

will probably never use Portuguese again when I am finished here. – Doctor 2

I heard many stories involving misunderstandings of the language and culture

with the prospectus of a willingness to learn and improve from one doctor and a complete

inability to step outside their own cultural views from another. One story involved a trip

out to the interior when a doctor was recommending that a patient put “uma gota” or “one

drop” of medicine in her eye. The patient did not understand what she was saying until

finally with a lot of pantomime and the help from one of the patient’s daughters she

finally figured it out using the colloquial term “pinga” or a drip.

I get so frustrated sometimes because I will be saying something perfectly fine in

Portuguese and the older patients just cannot understand. Then all of a sudden

their children repeat the exact same thing I said and that is when the patients

understand! I am using the same words and they still do not understand. –Doctor

This view of the local community by outsiders is unfortunately common in the Brazilian

Amazon, especially within the healthcare field. This was clear even in some of the

healthcare professional’s interviews. An officer for child services spoke with me about

both his professional and personal experiences with non-local doctors.

A man came to the office for help speaking with the hospital staff about the recent

passing of his wife and baby during delivery. The man was being told two

different stories from the nurse and from the doctor about what had happened with

his wife. I went over to the hospital to speak directly with the doctor who seemed

very inconvenienced by my questions. He spoke very harshly to me and said that

it was not my business to which I replied, ‘It’s my job!’ The doctors here are

always from somewhere else and they only stay for a certain amount of days and

then leave. They don’t know the community. – César

The municipality of Gurupá does not receive much money from the state and

national level to pay for their doctors. By urban Brazilian standards, the pay a doctor

receives in a place like Gurupá is miniscule. The base paid is only about 40 thousand reis

a year, or about US $13,000, although housing is included. For most Brazilian physicians

the idea of working in a place so far away from family and for such low play is

prohibitive. In the case for the few Brazilian physicians who do take the job, they often

negotiate a work schedule of 15 days in Gurupá followed by 15 days away (they usually

return to Belém in their off time). The doctors become itinerant, which greatly affects the

long-term sustainable health care for the town. The people of Gurupá understand that

without a permanent presence the doctors have a falta de interes. The temporary nature of

their employment creates a separation between doctor and patient.

As noted above, the doctors (particularly the foreign, but also the urban

Brazilians) often do not understand the local or folk health views and behaviors of the

community. Lacking this perspective, they frequently misunderstand patients’ responses.

Adding in the definite social class differences between physician and patient, the result is

that many physicians act in condescending ways to patients. This is a common theme I

heard from the people of Gurupá when talking about the health care system. João, the

former director of the hospital and one of the few certified nurses in Gurupá,

acknowledges this, but has his own explanation for the cause.

The people do not want to listen to the doctors and they get angry with them

because they try and tell them things to prevent illness. They [the patients] have

the mindset of going to the doctor to get medicine and not a lesson on how to live

a healthy life. I can also imagine the way some of the doctors are speaking to

them that they are probably less inclined to listen as well.

The most common complaints coming from the local population stem from

linguistic and cultural barriers. Views about foreign doctors and their poor fit have not

changed much since the 1990s. However, according to my key consultants, there were a

few doctors who were different and seemed genuinely interesting in learning about the

community and working with the local population to improve community health

problems. One of these doctors came to Gurupá from Cuba in in the early 2000s and

stayed for three years. When I asked several people around town about her they always

had something positive to say. It seems she tried to interact with the community as much

as possible and enjoyed being a part of community events. For example, Eva, an 80-

yearold housewife that I interviewed remembered her fondly as she was very active in

trying to teach the local community about the medicinal properties of the plants that grow

in their backyards. Eva is from the interior and grew up knowing the local plants and how

they are most commonly used for different ailments. She thought this was a great idea

because it centered on community knowledge as a way to increase access to health

resources that were already in people’s backyard, saving time and money. In many

conversations I had I found the people of town spoke highly of this initiative not only

because community members were treated as experts in the field, but also because they

were called upon to pass the knowledge down to others and have an active role in the

healthcare system.

Unfortunately, during her time in Gurupá the leadership changed and with a new

mayor came a different outlook on healthcare. The government no longer supported the

doctor’s take on the importance of local plants and preferred to focus on other initiatives.

Eventually the doctor was met with so much governmental opposition that her superiors

decided that it would be better for her to move to another city. This caused some discord

within the community. Whether or not linked directly to this event, the mayor at the time

was not reelected for another term.

Migrant Influx

The Belo Monte Dam has already, and will continue to displace large numbers of

people from their homes in Altamira. Gurupá’s Secretary of Health and the director of the

hospital both pointed out to me that Gurupá is already a main stopping point for boats

heading to and from bigger cities like Manaus, Belem, Santarém, Altamira, Breves and

many more. They maintain that this could make the community an appealing place for the

displaced to try and find a new home. They both emphasized that the city of Altamira is

only about a 6-hour boat ride from Gurupá.

I made two trips to Altamira, once in 2012 when the dam construction was just

under way and again during in 2015. In 2012 the attitude in the city among protestors of

the dam seemed determinately defiant and optimistic. There were international

organizations working with the indigenous groups and local communities to fight the

construction of the dam every step of the way. International Rivers, Amazon Watch, and

Instituto Socioambiental (ISA), to name a few, were all working together to organize

protests in the community of Santo Antonio, the first community to be displaced. Over

the next year these groups continued fighting hard to end the dam construction, but when

I returned in 2015 all had given up save ISA. An employee explained that once it was

apparent that the dam was going to be built all of the other organizations went on to

protest dam projects in other places. ISA was left alone to mitigate the impacts of the dam

on the local community. Currently, the employee stated, ISA is fighting to force the

construction consortium to fulfill its promises to the affected populations. He lamented

that 70% of the dam had been completed and barely 30% of the promises to the

communities had been fulfilled. In particular, housing that was supposed to be provided

for relocating populations has yet to be provided. Coupled with the lack of basic

sanitation and loss of jobs as the dam construction finishes, the potential for a large

exodus of people from Altamira to places like Gurupá is high. The government

organizations holding the energy consortium accountable say that they have yet to

compensate the local community for the damages and losses incurred. An amount due of

US$1 billion has barely been touched, and according to ISA, only 15% of the amount

promised to protect indigenous lands has been spent. The results are great increases in

illegal loggers invading indigenous lands (Sullivan 2016).

It is also plausible that people from Gurupá who go to work on the dam in

Altamira will come back to Gurupá when they are sick. João put forth this hypothesis as

he had already seen a couple of similar cases. He posits people return when sick probably

due to the overcrowded hospitals in Altamira, as well as the desire to be with family in

times of sickness. The movement of people back and forth to the dam construction site

also leads to the possibility of disease transmission. One example is malaria, which does

not occur in the municipality any more, but can be brought in from affected areas like

Belo Monte.

The case of malaria is a key problem related to migration. The history of malaria

prevention and the role of community cohesion in combating the disease goes back to the

1940s as described by Charles Wagley (2014) during his World War II efforts to boost

rubber production by combating the disease. For more recent times, I spoke with an older

hospital technician about healthcare over the last three decades. She recounted that well

into the 1990s many people were still contracting malaria. To once and for all deal with

the problem, the Secretary of Health and the hospital created a surveillance system that

extended through the different neighborhoods in both the town and rural interior.

Grouping by neighborhoods was already a familiar concept since the Catholic Church

and Rural Union had already organized most of them during the last days of the military

regime. These neighborhoods went on to sponsor neighborhood religious festivals for

their community’s patron saint and even perform in quadrilhas (square dance)

competitions and create floats for Carnival celebrations.

Building upon this structure, each neighborhood chose a community leader who

would serve as a community health worker. This person received training from the

hospital and Secretary of Health office. One of the tasks of the community health care

worker was to find out if any members of the community had fallen ill from malaria. If

so, the community health worker would alert the Secretary of Health who would then

lead a team to spray the area to kill off the mosquito population as well as quarantine the

infected individuals. In this way Gurupá relied heavily on support from the local

community to encourage Public Health programs. Community health care workers were

not only knowledgeable of their own neighborhoods, but they were able to disseminate

information with ease. This created a sense of ownership in public health programs,

which worked exceedingly well for malaria prevention. The hospital technician

reminisced about this case and how successful it was when all members of the

community felt involved in taking responsibility for their own care as well as care for the

neighborhood.

The community health worker program is still in place today, but the numbers of

workers have decreased due to budget cuts. As a result, it is safe to assume that any

increase in population due to migration will only create a wider gap for community

participation in health programs. This, in fact, was a major concern expressed by regional

public health officers who spoke at a health pre-conference held in Gurupá. The

preconference was designed to determine the agenda for the general health meetings that

would be open to the public the next month. The regional public health officers as well as

the director of the hospital noted that Gurupá had been very successful with their public

health campaigns, praising the child vaccination campaign, the eradication of endemic

malaria for the past 9 years, and a much higher community health status than the

surrounding towns. The official was empathic that community health workers were

essential to maintaining this high level of access to healthcare resources, but now the

program was suffering from a lack of funding and training. The hospital employees added

that now community health workers just go house to house completing questionnaires

without knowing how to answer specific questions people have, identify potential health

risks, or provide sound health advice. One hospital employee told me…

There will be times that I speak with the community worker about her

visits. She will show me the completed survey and I will see that a

pregnant woman responded that she has not had any pre-natal visits to the

hospital. When I ask the community worker why she had not gone and if

she gave her information about it she just replies that all she did was mark

the answer and move on to the next house. – Teresa, hospital employee,

mid-30s

The need for foreign doctors in Gurupá in recent years is largely due to an

increasing population. Of the new Cuban doctors, some have been placed in the rural

areas whereas the remainder, work in the town. The town, now over 10,000 people, has

seen a slow but steady growth mainly from rural to urban migration from within the

municipality. Lacking any industry, tourism, or commerce, Gurupá has developed

infrastructure that is only slightly more complex than the average rural community. Yet,

people continue to move to the town from smaller interior hamlets. I asked a couple that

have lived in Gurupá for over 10 years why they thought people continue to leave the

interior to seek town life.

I think that being in the interior is so isolated with limited amounts of

electricity, nothing to do, no parties to attend, so they come to Gurupá

looking for more things to do. If you ask them why they left the interior,

however, they would tell you that they wanted their kids to get a better

education. I’m not so sure about this though because most of the time

these kids aren’t even in school but are out trying to make money for the

family who moved here with nothing. – Henry, retired, Male, Age 70

This sentiment was echoed by César, an officer for child services, when asked about

the most common issues he faces with adolescents in Gurupá.

There has been an increase of children moving from the interior to Gurupá

trying to make money to send back to their families. Most of the time

these children do not have any place to live or anyone looking after them.

They end up on the street having to fend for themselves. – César

The hope of moving to Gurupá to make money for one’s family in the interior is

the reason 22-year-old Igor ended up in town. We met at a town gathering after the arrival

of the Bishop to Gurupá. Igor and his family came in from a small village so they could

attend the rite of confirmation officiated by the Bishop, who was able to make this trip

only once a year. As we spoke I found out that he intended to move in with a family

member on the outskirts of town, work as an office assistant for the Department of

Education, and build a store so that his parents will have extra income. Igor’s family were

cattle ranchers and did not feel that this livelihood would be lucrative enough to support

everyone in the future, so they sent their son to Gurupá to work.

During my research I found this type of residential flexibility common. For

example, during outings to the interior I would meet families whom I would then see

back in the town of Gurupá quite often. They were always in town to visit family and

attend events and to feel connected. The travel between interior tributaries and the town

was so frequent in some cases that many people seemed to have just moved into their

relatives’ houses. From the public health perspective, this type of mobility creates

logistical problems since the official population count for a neighborhood, community, or

the town may be one number, but the number of people actually seeking medical attention

at the location is often much higher.

Life on the outskirts of town brought about other public health issues. For those

living in the rural areas, one nurse said, sanitation means building a latrine downstream

from the house so waste gets swept away by the river. When they move to the city,

however, the land available for house construction is usually in swampy areas where

water flow is limited. The migrants build their houses and latrines thinking of the rural

pattern, but instead end up building latrines on water that is not free flowing. They wind

up living above stagnant, polluted water. The nurse continued that this is a major health

issue that the town has not yet addressed.

There is just not much education about how to stay healthy so people who

live out in the outskirts of Gurupá continue to have uncovered water

basins and do not properly dispose of waste. There are actually more cases

of childhood diarrhea in the city than in the interior. In the interior waste

mostly flows with the river, but in the city it is stagnant. Even things like

washing your hands and putting chlorine tablets in the water are things

that people don’t know about. – João, Certified Nurse, male, age 30

The population growth that Gurupá has experienced over the years has led to the

construction of several new neighborhoods. The municipal government has struggled to

provide these areas with roads, which are often in swampy areas and require considerable

landfill so the roads are not inundated during the rainy season. The city is also responsible

for providing electricity to all homes within the city limits.

While most of the newcomers build their own houses, in a few cases, using federal

grants, the municipality has constructed government housing. The purpose of such

housing is to contend with the migrant influx, although it is extremely uncommon to see

any person living on the street in Gurupá. The housing units follow blueprints from other

parts of Brazil and are not particularly well designed for the Amazon. While on a walk

through the government-housing sector one day I spoke with a woman who had been

living there for a couple of months. She explained what it was like to reside in one of

these houses. Her major complaint was the distance from the town center. She

commented that she had come from the interior and enjoyed living in Gurupá, but the

houses were so far away from the grocery stores and town center. She, like most people

coming from the interior does not have any means of transportation, besides a boat, and

Gurupá has no public transportation. Walking 20 minutes to walk to get groceries or get

to the health post creates considerable difficulty.

She continued with her concerns…

I live here with my sons and I am very grateful that these houses exist

because I have just been staying with friends before I moved in to this

house. I don’t like that there are no streetlights back here. All we have are

the lights in the houses and it is not enough to be able to see at night. It can

be very scary back here away from the town. – 60-year old woman

I asked her why there were not any streetlights and she shrugged her shoulders and said it

is probably due to lack of interest (falta de interes). She said they have asked the local

government many times about getting lights put in, but so far nothing has happened.

Although the city of Gurupá does see many people coming back and forth from

rural areas to the town, it is not prepared to have an increase in people moving from the

interior and building houses. One of the impacts from the Belo Monte Dam includes

changes to the environment, which could have devastating impacts on the rural

community. The families that are dependent on fishing or flood plain farming will be

impacted by the decrease in number of fish and the change in water flow caused by the

dam. If the environmental impacts affect the livelihoods of those in the interior they will

have little left to sustain them and be forced to move into the city to try and make a

living. If provisions are not made to accommodate this increase in population there will

be more inadequate housing and the potential for crowded areas to turn into public health

disasters.

Drugs and Violence

Many Gurupenses believe that there has been an increase in drug use and violence in

recent years. Although there has been no research to document the view, it seems

everyone in town has an anecdotal case to give as proof. Those who are to blame for the

increase, in nearly all cases, are people not originally from Gurupá. Many are said to be

individuals migrating in from the interior. The common view in town is that these people

are unknowns to the local folk and thus possibly dangerous, as they have no friends or

family to hold them accountable for their behavior. The perceived threat to safety is very

high and something that community members have been worried about for some time.

An officer of child services told me in an interview that he was concerned about the

amount of drugs that have begun to come into the town within the last 2 years.

Gurupá is a very strategic place and I think this is how the drugs have

been getting here. Most of the boats on the river going to Breves, Belém,

Santarém, Altamira or Manaus make a stop in Gurupá, which means

people and drugs can get in and out of Gurupá relatively easy. Drug

traffickers come here to sell drugs and the teenagers get access to them. –

César

He also lamented that there were no programs or activities for the youth in Gurupá to

keep them off the streets and out of trouble.

In another interview I asked Julia, a local schoolteacher in her early 40s, what she

thought about the view that there is a lot more violence in Gurupá than in the past. She

stated that she agreed with this view. She teaches philosophy at the local schools and she

went on to tell me that she thinks that the kids in Gurupá are acting out and spending too

much time on the streets doing bad things. Eva, a local hospital tech, informed me that

she went to a workshop earlier in the year to learn about how to detect if your child is

using drugs. She said that this information was very important because drug use has

become such a big problem and she wants to gather all the information to bring back to

Gurupá and educate the parents. Unfortunately, there have been no attempts to monitor

drug use in any capacity so reports of increased use remain circumstantial. Nevertheless,

the perceived threat of increased drug use in adolescents could continue on to create a

breakdown in community cohesion and trust.

Most of the cases of violence in Gurupá I collected were reported to me through

the typical platform for community news dispersion—town gossip. Every morning while

eating breakfast at a local restaurant, the owner would sit down and talk with us about the

stories he had heard around town. Many times these stories involved bar fights with

knives and once even a gun. He said that most of these bars are located on the outskirts of

town where there are less police and less people. Linda, the restaurant owner’s wife and

main cook also informed us of many local stories. She even believed she had a close

encounter with bank robbers from the neighboring town that had made national news.

Linda commented….

I was just watching the news the other night and I saw that the bank in

Porto de Moz had been robbed. There were five or more suspects that

went in and took all the money by gunpoint. Well do you know that there

was a group of five that came into one of the hotels where I work

sometimes as a housekeeper and they looked like the group who robbed

the bank! So, I went up to them to ask where they were from and where

they were going. They seemed to be very vague on the details so I was

extremely suspicious. I told them to come to the restaurant and eat and I

could clean their room while they did so that I could look around some

more, but they didn’t even want to eat! They only stayed one night and

then left. I am sure that those were the bank robbers! Can you believe it?

Here in Gurupá! I tried to use the computer to find their names, but I

couldn’t find anything. Things like this can be so dangerous for Gurupá. –

Linda, female, age 70s

Since the beginning of the construction of the dam there have been more news

stories involving violence in the Amazon. One serious concern has been the increase in

river piracy. Since boat travel is by far the most common means of transportation

throughout the Amazon, the rise of piracy has the potential to impact nearly everyone.

From Gurupá there are daily boats to Altamira, nearly daily boats to Belém, and when

there is a soccer tournament going on in the interior, there are smaller boats constantly

shuttling people back and forth. Most stories of piracy involved armed bands that raid

cargo barges. On a few occasions there is a report of bandits robbing passengers on

smaller boats. The usually take cell phones, watches, and money. The general consensus

in the press and locally in Gurupá is that piracy has increased because of the increase in

cargo runs to Altamira due to the dam construction. Commerce has increased, but

policing of the river by the coast guard has not, so the pirates are left with easy prey.

Closer to home, but still related to the Belo Monte Dam construction, the irector

of CRAS, Roberta, told me that she very worried about the social impacts that the dam

will have on the community. She explained that CRAS is an agency that works

preventatively to pick out vulnerable families who may have some sort of issue or

disability where they require extra help from the government. Once the families are

identified and once the specific issues are ascertained, CRES functions as a cover agency

to find resources in whatever area is needed for the family. She stated that although she

already sees domestic abuse and mistreatment of the elderly population in Gurupá, she

thinks that these things will become much worse following the influx of migrants once

the Belo Monte Dam is complete. She added…

I have already heard of teenage girls leaving Gurupá to work as prostitutes

in Altamira at the construction site of Belo Monte. I don’t think this is very

common, but it is something to be aware of as we continue our work. –

Roberta, CRAS Director, female, age 50s

The fear of increases in crime and violence are not new among Gurupaenses. A

study done by Pace and Hinote (2013), shows that the perception of danger in Gurupá has

jumped from 76.8% of the population maintaining that Gurupá is not at all dangerous in

1986 to 80.2% believing that Gurupá is “more or less dangerous” in 2009 compared to a

meager 17.8% stating that it is not dangerous at all. Pace and Hinote posit that the

increase in perceived fear of crime and violence come from an increase in media

consumption. The nightly news is filled with stories of shootings, robberies and other

crimes and although the stories tend to come out of big cities such as Rio or Belém

people feel as though the world around them is also getting more dangerous. Indeed any

mention of petty crime in Gurupá leads to a conversation on how dangerous Gurupá has

gotten throughout the years. Yet, fear of increased crime and violence, still has an impact

on stress levels and on community cohesion, which could break down due to lack of trust

in the community as a safe place.

Lack of structure and Organization

If there is one thing Gurupaenses have no trouble agreeing on, it is the fact that

there are not enough resources to take care of the health needs of the community. The

hospital often runs out of medication, despite persistent requests from suppliers, and is

forced to wait until the next riverboat is able transport a new shipment. Those times in

between shipments can really stress the resilience of the healthcare community.

Community members blame the health care officials and the overall system for not

securing resources; health care officials blame the local government for falta de interes, at

the same time the local government is blaming the national government for the same

thing.

In Gurupá it is the responsibility of the Secretary of Health to manage resources.

At the head of this operation is Hector, the Secretary of Health appointed by the ruling

municipal political party. If there is any money allocated through the government for

health he is the one who makes the decisions on where to use it. He is the most informed

member of the community about health trends and he is always working on ways to

improve the situation of his community. Hector knows exactly where the deficiencies are

in resource allocation and continuously works to positively shift that balance.

Living in the same house as Hector afforded me a unique opportunity to

understand the process of managing health issues in Gurupá that requires around the

clock work. As someone who must be informed of any health issues in town he is

constantly being called on his cell phone and rushing off to deal with new situations. I

remember one evening I was invited to join him and his wife as they enjoyed a few beers

with co-workers in their living room. The conversation soon focused on all of the

hardships healthcare workers must face. I had already heard some of the issues that the

Cuban doctors faced, but this was an in-depth look at how public health officials who had

been born and raised in Gurupá viewed their work and the health of their community. The

particular day had been busy with unexpected health issues. They mentioned a case of

yellow fever that popped up in Gurupá. Hector said that it was a child who went to

Amapá from Gurupá and was diagnosed there. Reports then came in from the

municipality about a dead monkey in the forest so they sent a team out to investigate and

confirm whether it was yellow fever. If so, they would have to isolate the area and

monitor for yellow fever from now on. This does not happen frequently so, Hector

emphasized it is important to get everything under control as soon as possible. They

continued on speaking about tuberculosis and leprosy, which had both increased in the

municipality within the last couple of years. Mary, who is an employee of the Secretary of

Health, commented…

Tuberculosis is a big problem here. People do not respect that they have to

cover their mouths a certain way so as not to infect their families. I once

saw a mother with tuberculosis with her daughter who was extremely

anemic and already had a poor immune system. I tried to explain that she

had to protect herself and her daughter especially since she could get TB

very easily, but I don’t know if she will listen. Cases like this are common

here. There was another man who did not take care of himself and ended

up infecting his grandson who lived in the same house. – Mary, age 55

I asked if Gurupá had a big problem with multi-drug resistant TB because people

do not take their medicine. All agreed that they did. They told me that one of the jobs of

the community health workers is to visit individuals with TB to ensure that they are

taking their medication every day. At this point Hector got a phone call about a bad

motorcycle accident and he had to leave to coordinate the flight to the hospital in Belém

since the local hospital could not handle the trauma. It was 9:00 at night, but Hector was

always on call as the Secretary of Health. As Hector left, one of his fellow co-workers

mentioned how stressful the job must be and that sometimes they just have to get together

and drink some beers to relax. He also lamented that the health staff do not get much

vacation time because there are not enough resources or personnel to take over if they

leave.

This type of on-the-go attitude was apparent any time I ran into Hector in town.

He was always on his way to another meeting to discuss a pressing health issue. When he

did travel it was usually with a particular health team into the interior to provide services

for people in needed. His wife Fatima accompanies him on most of these trips, as they are

both in the health care field. She works hard to continue educating herself by going to

trainings and workshops and then bringing back information in order to inform the

community on important health issues. The commitment to health care even extends to

their three children. Their eldest just finished her studies to become a nutritionist. The

second born has begun his first semester at a university in Belém to become a physical

therapist and their youngest son aspires to become a medical doctor.

Hector’s eldest and only daughter spoke with me while she was home on vacation

about wanting to work in Gurupá, but that there were no positions available for a

nutritionist. The only venue for her to work is at the local public schools. In this position

she would have to fight against great odds to provide children with healthy meals. She

laments that it would just be a constant struggle because the government does not care

about providing healthy foods in the schools of the Amazon. She continued…

If any kid in Gurupá has a food allergy or some sort of special need in

nutrition they will not get any support from the school and their parents

will have to make them food to bring. The government only supplies kids

with about 30 centavos [9 cents] per kid to buy a snack during school.

Sometimes the state will provide the other 70 to make 1 real [31 cents],

but even this only gets kids crappy processed snacks that are not very

nutritious. – Hector’s daughter, age 23

In the health survey I administered in the town (see previous chapter), there was

not a single respondent who concluded that all of the community’s health care needs were

met. When asked about what is good about Gurupá’s health care system 40.3% of

respondents stated “nothing.” When asked what is bad about the system 81.2% of all

respondents had at least one critique. Sixty one percent had more than one critique of

health care in Gurupá. The Director of Child Services mentioned that a major problem in

Gurupá is the lack of structure and organization. This is a common theme among the

community members of Gurupá as well. It is well noted that the hospital often runs out of

medication as well as working with run down equipment—that is if they even have the

equipment at all for even the most routine procedures. That the medicine runs out and

equipment is inadequate comes from a lack of coordination between the federal, state, and

local health care workers according to the Child Services Director. Without better

organization and structure the entire community feels the impact of a system that does not

get adequate funding from the state and national levels.

Every now and then I would spot a health care employee out and about in town

and engage in informal conversation about their everyday experiences in the health field.

This was the case one afternoon when I saw the physical therapist out at a restaurant. She

was born and raised in Gurupá, but got her degree elsewhere. I spoke with her for a while

and she told me that it is hard to be a physical therapist here because there are not many

resources for her to use. Beatrice stated…

I am the only physical therapist in town. I have a very small room in one

of the health posts where I can see my patients, but I have to share it with

others. I try and do the best I can with what I have. – Beatrice, Physical

Therapist, age 30

She continued complaining how difficult it is to want to try and help, but not have enough

resources to do so.

Another example of the lack of organization occurred during the Women’s Health

Workshop. The health professionals emphasized the importance of screening for breast

cancer. The women were told that yearly mammograms were essential for women over

40. Later on, I interviewed Benedita, a 60-year-old technician at the hospital, and asked

what she thought about the talks at the workshop. She commented…

The workshop is always very good for people to learn information about

health issues. The problem is that when the women are told that how

important it is to get screened for breast cancer once a year they find

themselves in a tough situation as Gurupá does not have a mammography

machine. Women have to go to Breves or Belém where the wait time is so

long that they have to make an appointment at least 6 months in advance.

Not many women are going to do all this work, especially if they feel healthy.

According to João, the local certified nurse, Gurupá is in desperate need of an

epidemiological system of monitoring disease trends. There is little money put towards

the prevention and maintenance portion of healthcare and this, according to João, is the

fault of the local government for not prioritizing these things, or a falta de interes once

again. This topic of conversation came up during the regional health pre-meeting. All of

the disease reports must go to a central location in the town of Breves where they are

analyzed for the entire region of Marajó. Only after this can the information be dispersed

to the municipalities so that each location can design a plan of action. This poses a

problem if a quick moving epidemic occurs since the communication between the central

location and each town is slow.

Problems with organization and personnel had also led to a reduction in the

vaccination rate for children in recent years, according to the nurse. There was a time

when I first visited Gurupá that the public health workers boasted a near 100%

vaccination rate in the municipality. When I asked about that vaccination program in

2015-2017 I was told that it had greatly declined. The principal reason is the lack of

training of health care workers to head up these campaigns. Mary, one of the participants

in the vaccination campaigns commented about logistical problems with transportation.

She told me,

Last time we went out to vaccinate children we got so many complaints

because the boat had left by 11am and many people missed their

opportunity to get their children vaccinated. We tried to talk to the boat

driver about this, but he did not feel like he needed to stay longer. We used

to go door to door in addition to being in one central location out in the

tributaries to make sure that all children were covered, but now we cannot

find a boat driver to take all that time.

Another Health Department employee named Judith, age 35, noted that the

growing population of Gurupá, and particularly the potential growth it faces in the

upcoming decade would only exacerbate the need for more health professionals. Judith

stated,

There are 103 communities in the municipality of Gurupá and in order to get to all

of them we will need more health professionals. We also need to include the

community as active agents of the health programs. If you do not include the

population and make them excited about health and give them responsibilities in

this you will not have a successful program because no one will care enough to

make it their own.

The following chapter will put together the quantitative and qualitative data

collected through fieldwork and literature reviews to produce a predictive model of

possible syndemic interactions stemming from the Belo Monte Dam that could impede

the health and well-being of the people of Gurupá. The main purpose of the model is to

elucidate the complicated manner in which disease interact with each other and with the

environment and to help community members, law and policy makers, and health

officials determine how to create interventions that will address all the illnesses

interacting with each other to create an unequal burden on the most vulnerable

populations.

CHAPTER EIGHT:

SYNDEMIC MODEL OF POTENTIAL DAM IMPACTS FOR GURUPÁ

The construction and implementation of the Belo Monte Dam has and will

continue to have wide-spread effects. The dam is tied into Brazil’s engagement with

globalization, the energy demands of a growing population, and the desire to continually

raise the GDP of the country. At the same time the immense corruption revealed by the so

called “Lava Jato” (Car Wash) criminal investigation shows that Belo Monte and other

dams have been deeply entwined in big business greed and unethical politics (Amazon

Watch 2016). Within this macro-context of corruption, it is not difficult to see how a

disregard for the dam’s negative impacts on the local populations formed at the highest

levels. This disregard has already created rising health problems in Altamira such as:

violence, sexually transmitted infections, dengue fever, and overcrowding in the

hospitals. These problems are spilling over into neighboring communities, such as the

case of Gurupá.

The dam is what Singer (2013) refers to as a disruptive biosocial process. This is a

process that creates situations and interactions among diseases, which cause an increased

burden of poor health among the most vulnerable populations. In the case of Gurupá, the

health problems already present in the town will be negatively impacted and their

intensity multiplied by a slew of new environmental, social, and health problems

associated with the dam. This combination has the potential to lower the health status of

the whole community and allow opportunistic diseases to develop in a population with

weakened immune systems.

To understand this process, I have created a model to represent the dam’s potential

impact. The model is driven by the data collected from the surveys, interviews, and health

reports for Gurupá. Each health impact in the model was identified by the community as

being salient to protection to the public health of the town.

Creating a Syndemic Model

The ability to visually demonstrate the complexities of syndemics in model form

has been a challenge, to say the least. Mapping the interconnections of every disease,

illness, or ailment that affects a community results in a complex model of intertwined

arrows and boxes. To make sense of these connections ideally would require a more

interactive model than the 2D model that I present here. Nonetheless, as I begin to unpack

the model and all its layers, the interactions will become clear and the predictions I make

will fit nicely into the model. This model is created by combining previous research by

scholars about the public health impacts of dams with my basic, baseline assessment of

health care and health care resources in Gurupá throughout my fieldwork (2015-2017).

The model presented in figure 8.1 has three main layers within concentric circles.

The outermost layer is comprised of the direct impacts of the Belo Monte Dam. These

factors will have powerful and long-term effects that will ripple down to the community

and individual level of health and wellness. They include factors like water quality,

population flow, and river topology. A legitimate environmental impact assessment

conducted at the beginning of the project might have lessened the negative consequences

of these impacts, but there was little pressure from the federal and state level to conduct

such a study. As mentioned previously, the environmental impact assessment did not fully

evaluate many of these factors due to pressing timelines for construction administered by

the government (Fearnside 2014). Therefore, what we are seeing now is a reduction in

water quality, large population increases met with limited resources to accommodate them

and changes in the flow of the river (Barros et al. 2017). Moving toward the center,

the next level contains factors from the community level. By community level I mean the

factors that affect the larger community as a whole and that can interact with individual

health factors to worsen the health status of citizens of Gurupá. In this circle, the model

shows how the community level factors affect each other and how they in turn impact an

individual’s health. This level will be the most important for Gurupá as this is the level

where the community can have the most mitigating power. For example, if public health

campaigns are created to address sanitation issues in houses far away from the center of

town this will help immensely in containing many individual level diseases like malaria,

Zika, or intestinal parasites. I will go into more detail about each syndemic interaction in

the next section.

Finally, the innermost circle contains the individual level factors that contribute to

ill health. These factors include stress, malnutrition, and diabetes that stem from an

increase in violence as well as increases in population flow caused by the dam. Although

these factors directly impact the health of the community members they are usually

indirect impacts from the dam itself. This is why it is important to be able to trace the

syndemic relationships back to the direct impact of the dam itself. The following section

Figure 8.1 Syndemic Model for Dam Impacts will present each syndemic

relationship denoted by the model as well as put it into context from my

qualitative and quantitative data.

Syndemic Relationships

Beginning from the outermost circle are the categories population flow, stagnant

water, water quality and river topology. Each of these is a direct impact of the

construction and maintenance of the dam. Approximately 8,000 male workers have

moved to Altamira to work on the dam and will eventually move out when construction is

complete. If there is a population increase in Gurupá caused by the outmigration of

construction workers in Altamira, then this will put a strain on the community in the areas

of healthcare resources, increased violence, and stress.

Currently, one of the strengths of Gurupá’s public health system, as indicated by

the following comment from the survey, is that “Every patient gets seen because of all the

doctors that are here now.” Ready access to physicians is possible because of the

agreement with Cuba to send doctors to the rural areas of Brazil. The doctors are only

able to attend to the number of people in Gurupá at the moment. If there is an increase in

population this accessibility will be diminished. In addition, the doctors from Cuba are

only contracted for 3-5 years and most will return to their home country or to jobs that

will pay better after their contract is complete. This could leave Gurupá with a severe

medical personnel shortage precisely as the demand for access increases due to the

indirect impact of Belo Monte. The strain on the healthcare system in turn could create

stress within the community and, as a result, any influx of diseases that normally would

be taken care of by the public health system might be beyond its capacity.

Figure 8.2 Population Flow Syndemic 1 – Top image is the screen shot of the animated

Model

Following the colored lines of the model we can see the syndemic relationships

created by each level’s factors. The green line of population flow hits several

community factors in addition to healthcare shortage (as shown by a circle near

the factor) such as crime influx, violence, and wildlife displacement. Not only

does the model portray possible syndemic relationships, but it also shows the

pathways of certain relationships that have already been proposed by Merrill

Singer and others. One such example is known as the SAVA Syndemic, Substance

Abuse, Violence and AIDS. In the model we see that an increase in population

will increase crime rates and violence at the community level. With the amount of

unknown people coming into the community of Gurupá there are bound to be

more avenues for violence and crime. Being that those coming into the

community are mostly male ex-construction workers from the dam, there are

likely to be increases in prostitution and illegal sex trafficking in Gurupá. This has

already occurred in Altamira with the influx of workers. Increased migration to

Gurupá may lead to stress, fear of violence, and substance abuse, which can lead

to the deterioration of community cohesion. Combined with the increased risk of

multiple epidemics acting upon each other in a small community like Gurupá, any

reduction in community cohesion means a loss of one of Gurupá’s greatest

strengths in healthcare.

Figure 8.3 below shows the route in which population flow travels to affect

healthcare shortage and urbanization. The strain on the healthcare system then has

an effect on stress, while urbanization increases the likelihood of violence and

prostitution. Then ultimately these factors have an effect on the individual level

creating added stress, increases in drug (or other substance) abuse and HIV/AIDS.

Figure 8. 3 Population Flow Syndemic 2

In Gurupá these factors are worsened by increased poverty created by the influx of

people, at the same time there is a likely decrease in livelihood, particularly access to

diminishing fish stocks caused by the dam. Ultimately, with prostitution, violence, and

increased crime (including substance abuse) comes the likelihood of contracting

HIV/AIDS. All of these factors have additive power over the others when placed in an

environment of poverty and limited healthcare resources. One of the nurses of Gurupá has

already expressed the need for better HIV/AIDS testing sites.

“Already we have had people here that have to wait a long time to find out

whether they are HIV positive. Since we do not have the resources to test here they must

travel to Belem, get the tests done, travel back to Gurupá and wait for the results to be

send electronically to Gurupá. This can take a while since Gurupá does not regularly have

Internet access.” – João, nurse

In addition, there exists the likelihood of certain diseases becoming comorbid, or

infecting people at the same time given the weakness in their immune system. When

comorbidities hit an epidemic level, they are considered to have a Syndemic

Relationship. One such example is HIV/AIDS and tuberculosis. Both HIV/AIDS and TB

have been on the rise in Gurupá and they both have the ability to affect each other, thus

making their effects on the immune system two-fold. This combined with poor living

conditions, poor nutrition, and poor water quality create extremely vulnerable

populations.

The final community factor that is also influenced by population flow is

deforestation. According to a community member, “When new people move into Gurupá

they do not have much money. This means they will go cut down trees from the forest to

build their houses. They don’t ask permission, they just use our resources here in Gurupá”

– Henry, age 70s. If many people are moving into the vacant areas of Gurupá then the

likelihood of deforestation increases. This has already been a problem in Altamira

(Brodwin 2013). If future migrants to Gurupá are recruited into timber extraction, this

will have an effect on deforestation as well. Environmental destruction will have a very

large impact on the town of Gurupá. It will not only increase violence in the area, as

evidenced by the recent shooting in Altamira of the Secretary of the Environment, but

also affect those that create livelihoods from farming, fishing or extracting acai, heart of

palm and other resources. Without a viable livelihood there may be an economic and

employment void creating a strain on Gurupá’s already strained economic growth. There

may be an outmigration of people moving to Belém, Breves, or Santarem to try and look

for work, which will increase the population of these towns creating more favelas,

shantytowns and susceptibility to disease. Diminished economic opportunities could

create a rise in sex work and risky behaviors as well. This could happen in Gurupá or in

one of the bigger cities and still affect Gurupá given the fluidity of people between towns

and cities.

Figure 8.4 Population Flow Syndemic 3

This is reminiscent of what Farmer (2001) observed in a rural village in Haiti where the

women who contracted HIV/AIDS were bound by the fact that they all had worked as

servants in the city of Port-ou-Prince or had highly transient sexual partners, such as truck

drivers. Even though the rates of transmission had been low in the rural town itself, the

flow of people to and from areas of high transmission resulted in higher rates of

HIV/AIDS.

People are not the only things traveling from town to town. Mosquitos and the

diseases they pass along can travel long distances, allowing vector-borne diseases such as

malaria and dengue to remain an issue in the Amazon. The construction of hydro-electric

dams in the tropics creates standing pools of water which can greatly increase the amount

of mosquitos and the diseases they carry, which now includes the Zika virus in Brazil

(Zika is not included in the model because Gurupá had not had any cases). Combined

with adverse effects on an individual’s immune system from parasites/diarrhea and

malnutrition people are likely to be more prone to these communicable diseases, which

also have deleterious effects on one another if they become co-morbid diseases.

Figure 8.5 Stagnant Water Syndemic

In addition to standing pools of water, Belo Monte has also affected the water

quality of the river. The energy consortium has not completed its promises to the city of

Altamira to upgrade the sanitation system (Barros et al. 2017), thus polluting the areas

around where people live. There may also be substances leaking into the river from the

construction equipment and construction process, which will then travel downstream to

communities like Gurupá. As the Fundão Dam break in Minas Gerais on November of

2015 demonstrates, water that becomes polluted with construction materials and

chemicals can travel far in a short amount of time impacting many communities in its

path. According to local consultants, Gurupá has already had some increases in the cases

of childhood diarrhea thought to be coming from pollution from the Belo Monte

construction site on the Xingu River. This may also be part of the reason for the increase

in intestinal parasites in children as noted by my research assistant at her job as a health

data analyst for the community. The impact of water quality affects childhood diarrhea,

intestinal parasites, and increases the likelihood of malnutrition in children who are

especially vulnerable to poor health.

Figure 8.6 Water Quality Syndemic

River topology will affect the fauna in the area with the possibility of killing off

fish that are integral to the diets of Gurupaenses. From the food survey, 64% of people

responded they eat fish one or more times a week. The decrease in the amount and variety

of fish likely affects nutrition intake as well as those livelihoods that depend on fishing,

which in turn adds to joblessness, stress, and poverty. The changes in the levels of the

Amazon River caused by the holding and releasing of water from the dam on the Xingu

might also affect river transportation decreasing the amount of food, resources, people,

and products that enter Gurupá and reducing the already scarce access to medicine and

other healthcare needs.

Figure 8.7 River Topology Syndemic

Personal stress from breakdowns in social cohesion or increases in violence can

cause negative impacts on the immune system, worsening the vulnerability to heart

disease, anxiety and depression, or worsening the effects of pre-existing diseases like

malaria or tuberculosis, which are in turn worsened by other conditions stemming from

Belo Monte, from malnutrition from the amount of food being imported, to the quantity

and quality of the fish and shrimp being consumed. In addition stress stems from the

systemic corruption the country experiences. President Dilma Rousseff has been

impeached and replaced by a political party little concerned with social programs like the

Bolsa Familia. The residents of Gurupá fear that they will lose this helpful income and

without much of a chance for economic growth in Gurupá, these families will not be able

to obtain the food necessary for their children. There have been several studies of the

nutritional status of ribeirinho populations in the Brazilian Amazon, which provide a

broad outline of the area. A study by Silva and Crews (2006), for example, compared

child nutrition rates among three Amazonian communities in the state of Pará

(Aracampina, Santana, and Caixuanã). Using the six anthropometric measurements of

height, weight, upper arm circumference, triceps, subscapular and suprailiac skinfolds,

the study found that children living in Aracampina and Santana were taller and heavier

than those from Caixuanã. The first two communities are more integrated into a market

economy and have more access to cash, Western goods, and health care, therefore

resulting in a higher z-score for weight-for-height, weight-for-age, and height-for-age.

This dichotomy is seen in other studies in the Amazon where the rural areas that are more

reliant on subsistence farming are associated with greater numbers of undernourished

children (Alencar, Yuyama and Nagahama 2000; Murrieta, Dufour and Siqueiera 1999; R.

Giugliano, LG. Giugliano and Shrimpton 1981). By contrast, communities more involved

in the market economy have greater access to resources, but this also includes greater

access to processed foods. This too is associated with poorly nourished children as well as

adults suffering from chronic diseases (Silva and Begossi 2009; Piperata,

McSweeny and Murrieta 2016).

In another study conducted by Piperata (2007), researchers measured ribeirinhos

ranging in age from birth to 77 years old in a total of 7 communities located in the

Caxiuanã National Forest to determine the influence of subsistence strategies changes on

nutritional status. Using standard anthropometric measurements and household data,

Piperata’s study found the study populations to have a high degree of stunting (low

height-for-age), meaning long-term nutritional stress. However, the incidence rate for

under-weight adults for this population was very low with the majority of adult BMI

measurements in the normal, overweight, and even obese categories. Piperata notes that

men involved in wage labor had the highest propensity of being overweight and obese.

This is due to factors such as less physically demanding work, being fed foods high in fat

and buffet style at work, and having more money to purchase foods rather than rely on

their own subsistence strategies. Similar to the findings in the Silva and Crews (2006)

study above, the inclusion of communities in the market economy has had an impact on

the nutritional status of Amazonian populations.

The results of this research, as indicated in the model, suggest that Gurupá’s

health impacts which are most likely to occur in epidemic proportions and have

deleterious affects on each other are the following: intestinal diseases and malnutrition;

malaria and dengue fever; tuberculosis; sexually transmitted infections; and stress. Each

of the outer boxes indicates a factor that adds to the effect of the likely impacts on the

community. These factors are also affecting each other to increase their risk of becoming

epidemics in the community, and should be watched in the following years. In the

following chapter I will conclude this study as well as provide recommendations for the

community of Gurupá to mitigate the potential impacts of the Belo Monte Dam

CHAPTER NINE:

CONCLUSION

As I finish writing this dissertation, a year after the end of my fieldwork, the

construction of the Belo Monte Dam is nearing completion. Already there are multiple

reports of devastating impacts for the surrounding areas. Violence, crime, underground

prostitution rings, population displacement, and deforestation are just a few of the

problems arising with the dam. For example, in a story published in The Guardian

(2016), deforestation has increased by 24% since the dam began construction. This

increase is mostly due to illegal logging linked to the greater access to the region

following the initiation of dam construction. Associated violence has likewise increased,

highlighted by the murder of a local Secretary of the Environment who was shot on

October 13, 2016 after he tried to stop illegal logging.

The Belo Monte Dam in 2017 was now partially operating on three turbines with

a total energy capacity of 2 GW. The full capacity of Belo Monte is estimated to reach

11.2 GW when all turbines are fully functional sometime around 2019 (Ingram 2016).

Since more hydroelectric dams and power plants are planned for the Amazon region over

the next few decades, it is important to understand the negative health impacts of the Belo

Monte and to model its potential impacts, as well as explore the types of public health

interventions that might be needed.

I started this dissertation by laying out the scope and the purpose of the study—

which is to examine the public health system of the city of Gurupá situated downstream

from Belo Monte dam, and through a syndemic framework create a predictive model of

negative health impacts most likely to affect Gurupá as the Belo Monte dam is

completed. Using the theory of syndemics this study seeks to identify the diseases most

prone to epidemic status in Gurupá and frame them within a context where other diseases,

environments, and behaviors are adding to an overall poor health status. Given the

amount of knowledge that has been gleaned from numerous studies of large dam health

impacts from around the world, it is possible to include the impacts of illness and other

negative health impacts likely to have long-term effects on Gurupá. Chapter Two

reviews the literature on the known health and environmental impacts of dams on

surrounding communities worldwide. The World Commission on Dams (2000) and the

World Health Organization’s (2000) contributions to the study on dam impacts show the

main areas of concern essential to this study. The possible health impacts of dams

worldwide are broken up into six different categories; communicable diseases, non-

communicable diseases, malnutrition, psychosocial diseases and social well-being. From

these categories I pinpoint specific local health data in Gurupá from the hospital records

and ask more in-depth questions in the interviews and on the questionnaires. Linking the

categories together is the basis for the syndemic theory, which was also reviewed in this

chapter. The syndemic theory allows the categories to be viewed as a single, community-

wide process that will inevitably function to increase the adverse effects on the public

health. The literature review of syndemics also shows linkages that have been previously

studied and are known to interact to create even more vulnerable public health situations.

Combining the existing literature on dam impacts with known syndemic relationships, I

formulated the main research questions based on a two-phase mixed method research

design. The research questions are:

Phase I

(1) What is the structure of the local and regional health care system? What do the care

professionals identify as the strengths and weaknesses of the system? What changes

do they foresee with the dam completion?

(2) How do community members view their current health status?

(3) What changes to their health or health care do they anticipate within the coming years

and what is the general opinion on, and discourse about, the Belo Monte Dam?

Phase II

(1) What are the public health impacts of the Belo Monte dam on the downstream

riverine community of Gurupá? Will there be changes in infectious disease rates,

nutritional status/food security, or access to healthcare? Will there be increases in

malaria, dengue fever, and waterborne illnesses ranging from dysentery to diarrhea due to

environmental changes and problems with water quality?

(2) Do the data collected identify syndemic relations? What is the relationship

between the various health impacts?

(3) How can different stakeholders such as grassroots organizations, NGOs, and local

government agencies use this information to mitigate the health care problems? How can

data on unanticipated syndemic relationships be used to “fill in” the gaps of public health

care?

To better contextualize the impacts of Belo Monte, Chapters Three and Four focus on a

brief history of the town of Gurupá, the research that has occurred throughout the years,

and a quick overview of the history of the public health system in Brazil and the Amazon

region. Both of these sections begin with the first colonization of Brazil from Portugal

and detail the most impactful moments in history. It is important to note that the history

of the Amazon in the North of Brazil is different from the history of the entire country,

especially its southern, more populated areas. The policies of the Brazilian government

have not historically been made with the best interests of Amazonian peoples in mind, but

have had lasting impacts on the health and well-being of the populations who inhabit the

area. In fact the planning of all large development projects has occurred with little

consultation with the local populations, especially those in the most precarious and

vulnerable situations.

Yet, the people in Gurupá have continued to work hard to improve their lives in multiple

ways. This work documents community action, from banding together to expel corrupt

members of the rural workers union to going door to door to make sure every child

receives a vaccine, as an important element to maintain some degree of positive public

health. The community members within the town take pride in where they live and strive

to improve conditions and maintain a cohesive social atmosphere. This is one of the main

strengths of Gurupá and may be useful in mediating many of the adverse health effects

stemming from the dam. It might be the critical factor to maintaining a semblance of a

healthy community without the needed level of aid from the government.

Chapter Five discussed the specific methods used in each phase of the research study to

obtain the data collected from 2015 to 2017. Health data were collected from the local

Secretary of Health as well as from the hospital to get a sense of the most serious

illnesses the hospital records on an annual basis. I conducted interviews with local

government employees, NGO representatives, community members, and health

employees to get an understanding of how the health system works in Gurupá, some of

the strengths and challenges of the current system, and what the future might bring with

the knowledge of disease trends in the past couple of years. Some of these issues were

brought up again during the questionnaire phase, which consisted of a health survey and a

food frequency questionnaire. These methods are analyzed and the results and discussions

are explained in Chapter Six as well as summarized in the following section. The

results of the health survey provided insight into how community members viewed their

health and the health system of Gurupá. Along with the health data received from the

hospital and Secretary of Health’s office there is a clear baseline that portrays a picture of

Gurupá’s health status from 2015 and 2017. Although the majority (70 percent) of people

ranked themselves as poor and had serious criticisms of the healthcare system in Gurupá,

most (again 70 percent) also rated their current health status as good. Therefore, although

things could always be better, from the perspective of the local population as represented

in the survey sample, the community of Gurupá seems to be fairly stable in terms of

health status without extreme suffering.

Food frequency questionnaires provide a snapshot of a community’s consumption

patterns. Foods like rice, farinha (manioc), sugar, and coffee are consumed by over half

of the sample one or more times a day—making these foods the base of the diet in

Gurupá. Meats and other proteins are consumed at least once a week when available. In

town, the most available meats are beef followed by chicken. Fish is not sold

commercially. There are small markets around town where local fishers sell their daily

catch. The changing eco-system and the potential reduction of some fish species is

something to be aware of when thinking of environmental impacts of the Belo Monte

Dam and how they will affect the people of Gurupá who eat fish at least once if not more

times a week. Another factor of concern is an increase in the consumption of processed

foods. For 2014 alone the hospital recorded 287 new cases of hypertension and

approximately 74 new cases of diabetes among adults, which indicates that chronic

diseases related to nutrition, and eating habits are likely on the rise for this area. If fish

and other foods native to this area are diminished as a result of a changing environment

due to the dam, the potential for increased intake of processed foods could exacerbate the

cases of hypertension, diabetes, and malnutrition in Gurupá.

The qualitative results are discussed in chapter 7. The information gained through

interviews with community members, non-governmental organization employees, health

care workers and government officials are summarized into several different themes

concerning the health status of Gurupá. The main themes I encountered were: benefits of

community cohesion; healthcare and outsiders; lack of structure and organization of the

public health system; migration from the interior; and drugs and violence. These themes

helped to form the questions for the surveys as well as help to put into context the

quantitative data gathered. This chapter provides valuable information on how

community cohesion is built into the fabric of Gurupá and the willingness to fight for

social justice and take care of the community has worked to elevate Gurupá to a standard

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