Brazil is experiencing corruption scandals, political turmoil, and its worst recession in decades. Yet for all the chaos in centres of political and financial power, the country’s challenges are perhaps most acute in remote corners of the Amazon.
There, a swathe of newly-elected local leaders, empowered by Brazil’s decentralised governance, are struggling to safeguard the health of their citizens as long-term problems are exacerbated by recent drastic public spending cuts.
The “deep” Amazon is now surprisingly urbanised yet its cities are largely invisible in academic and political debates. In the 21st century, it is generally taken for granted that towns and cities are connected by roads. However, in the Brazilian state of Amazonas almost a million people live in dozens of roadless cities of 3,000 to 70,000 residents. These settlements are wholly reliant on rivers.
As an extreme example, take Ipixuna, one of the most remote towns in Brazil. Located on a major Amazonian tributary, Ipixuna is an incredible 2,820km by boat from the state capital, Manaus. During the dry season barges transporting fuels and non-perishable foods from Manaus can take more than a month to arrive. Like most Amazonian cities without roads, Ipixuna is extremely poor, socially unequal and has a very limited urban infrastructure.
These cities are increasingly vulnerable due to a combination of under-development and climate change. In Amazonia, people are being hit by increasingly frequent and severe floods and droughts. For instance, residents of Caapiranga, a roadless town much closer to Manaus, told us that river levels reached both record highs and lows in 2015. Much of the town was flooded in May yet by October Caapiranga was cut-off by low water levels.
Remote Amazonas cities are guardians of almost one million square kilometers of rainforest. Yet despite global interest in developing the green economy, tourism is still unheard of even in a place like Ipixuna with 98% of its surrounding forest intact and a rich indigenous culture. That Ipixuna lags behind wealthier parts of Brazil is unsurprising, but it’s more of a shock to discover that its Human Development Index (HDI) is equivalent to that of Uganda.
Healthcare crisis deep in the Amazon
All Brazilians are guaranteed healthcare as a constitutional right, delivered through a universal and free health system. However, preventable problems like diarrhoea or malnutrition mean Amazonas’s life expectancy and infant mortality are among Brazil’s worst. Chronic staff shortages are exacerbated in roadless areas as health teams often travel days by boat to reach rural communities.
Tackling these problems requires investment in basic sanitation. Access to clean water is essential for preventing waterborne diseases, yet in the majority of municipalities in Amazonas, household water is untreated. In Ipixuna, for example, only 3% of urban households have adequate sanitation.
Environmental health is often not taken seriously by local government: “The neighbour built his pit-toilet at the side of my kitchen,” said one Ipixuna resident we interviewed. “When it rains a lot, it overflows. My small children play outside so I have complained many times to the council, but nothing was done.”
Improving health and health-care
These places and people are invisible to policy-makers. After all the Amazonas state government in Manaus can be days away, never mind the national capital in Brasilia.
The local political elite are often the descendants of former rubber barons or similar. Many health bureaucrats are nepotistic or political appointments, and rarely have any specialist healthcare background. Most roadless municipalities lack a team of permanent doctors and instead rely on short-term hires that may spread their time between multiple places.
As the remoteness of these cities makes public auditing and financial scrutiny more complicated, the region breeds a sense of impunity. Three mayors were recently arrested on corruption charges, while 30 municipalities are being investigated for embezzlement. For example, $R15 million (US$4.7m) was recently stolen from the health and education budgets in Pauini, a roadless municipality of 19,000 people ten days by boat from Manaus.
To improve healthcare in these places, authorities could start by investing time and energy in primary care through Brazil’s existing Family Health Strategy, which promotes prevention, recovery and rehabilitation. This can prevent more serious conditions requiring costly air-evacuation for hospital treatment, which is already under threat. Mayors should also engage with changing health threats, including emerging chronic diseases such as hypertension and diabetes, and the “old” diseases like malaria, viral hepatitis and tuberculosis.
Where is the outcry about ill-health and neglect in Amazonia’s forgotten cities? Until now, interest in Amazonian governance – nationally or internationally – has been dominated by environmental debates. There have been rural investments in sustainable development reserves but a shortage of new ideas to solve urban problems. Each new mayor has the opportunity to create a political and institutional environment conducive to improving the living conditions of citizens, ensuring the basic right to health. These long-neglected cities in the Amazon rainforest, however charming, deserve better.