Mary Petrone • 2019 Issue
From The Editors:
The vulnerability of uncontacted tribes globally to infectious diseases is a pertinent public health concern with few currently-existing effective solutions. Mary Petrone highlights recent political developments in Brazil which may spell disaster for native communities. She notes modern public health officials’ failures in equal incorporation of indigenous input in the design of public health policy and the unfortunate commonality of neo-colonialist approaches to public health. She discusses implementation science’s importance to point out the need to redefine and expand the notion of “public” in the idea and execution of “public health” policy.
Jair Bolsonaro, sometimes called the Donald Trump of Brazil, was elected Brazil’s 38th president last October. Like Trump, Bolsonaro won popularity with his tough-on-crime, anti-corruption rhetoric and political outsider persona. The former army captain turned politician has also faced criticism from social liberals for his controversial statements about women, people of color, and members of the LGBTQ community. Moreover, he has alarmed conservationists by pledging to fuel the country’s faltering economy with agribusiness, an industry that exploits resources found in the Amazon rainforest.
The far-right nationalist’s tumultuous campaign and surprising victory can be attributed to, among other things, Brazil’s political and economic instability. After surviving the global economic downturn that began in 2008, the country plunged into the worst recession in its history six years later. Brazil’s financial crisis officially ended in 2016, but recovery has been slow, and millions of Brazilians remain unemployed. At the same time that many citizens were struggling to regain financial stability, allegations of corruption surfaced against the former president Luiz Inácio Lula da Silva. Last year he was handed a 12-year sentence for money laundering charges, which he is currently serving.
The status quo was corrupt and defunct at the start of the presidential campaign season, and Bolsonaro promised to disrupt it. Although the retired captain began serving in Congress in 1991, it was his unconventional, social media-fueled campaign that brought him national name recognition. He deepened political divisions within the country by pledging to put “Brazil before everything and God above all.” This tension came to a head when a strong showing in the first round of elections was followed by an assassination attempt during one of his campaign rallies. Nevertheless, on October 28, 2018, Bolsonaro defeated Fernando Haddad, former mayor of São Paulo, winning 55% of the popular vote.
While it remains to be seen whether the fledging administration will re-stimulate Brazil’s economy, the impact of Bolsonaro’s pro-business ideology on the world’s largest rainforest and the people who live in it is clear. The plight of the Amazon rainforest due to large-scale deforestation has concerned environmentalists for over two decades (1). Illegal logging practices have expanded with the growing presence of ranchers and speculators in the rainforest because these informal industries are difficult to regulate. In an effort to connect protected territory with what he considers the “true Brazil,” Bolsonaro has promised to turn over land demarcated for conservation to mining and commercial farming companies.
The stand-off that has been generated between advocacy groups and proponents of agribusiness by these promises encompasses the perceived dual ecological and anthropological crises. Not only is the Amazon rainforest one of the most biodiverse biomes in the world, it is home to rich human diversity due to the number of indigenous tribes who live in it. These tribes are regarded as key conservationists of the Amazon because they stave off small-scale deforestation efforts, thereby preserving the high rates of carbon sequestration that make the rainforest an integral part of the global ecosystem (2).
Furthermore, removing these communities from their land would have grave consequences for the Earth’s climate, but the loss of human diversity would be just as irreparable and devastating. Scholars are limited to learning about isolated tribes from a distance. If indigenous communities are not protected, tens of languages and associated cultures will be permanently lost, along with the environments in which these communities exist.
The justification for expanding agribusiness into the Amazon is ostensibly economic; however, the new administration has a clear ulterior motive for usurping claim to protected land. Bolsonaro’s disdain for indigenous people is apparent, having once lamented, “It’s a shame that the Brazilian cavalry wasn’t as efficient as the Americans, who exterminated their Indians” (3). Any legislation that increases the presence of ranchers and loggers in the rainforest will be enacted at the expense of the indigenous tribes and their land, and this is no accident. In his first 10 days in office, Bolsonaro conferred responsibility for the affairs of indigenous people, which was previously under the purview of the National Indian Foundation (FUNAI), to the Department of Agriculture.
The regressive attitudes towards rainforest inhabitants that have been popularized by Bolsonaro and the “ruralistas” who support Amazonian agribusiness are demoralizing but not unprecedented. In a shocking revelation in 2013, a 50-year-old report was uncovered that details atrocities committed by the ironically named Indian Protection Service (SPI) between the 1940s and the 1980s. The SPI was created to promote the welfare of indigenous people, but, according to the eponymous Figueiredo report, ultimately contributed to a large-scale genocide of tribal people through the intentional use of weapons, poison, and the spread of disease, specifically smallpox (4). Of the 134 government officials accused of malfeasance none have faced legal repercussions.
Other government efforts to preserve human diversity have mostly paid lip service to this mission. Long before Bolsonaro’s election, the Brazilian government was providing only a fraction of the funding that FUNAI, which replaced SPI, had requested for protecting isolated tribes. In 2015, Sydney Possuelo, the former head of the agency’s Isolated Indians Unit, proclaimed, “FUNAI is dead. But nobody told it, and nobody held a funeral” (5). At the same time, Dilma Rousseff’s administration, which served from 2011-2016, was accused of favoring the interests of business over the protection of indigenous people by reducing the amount of officially demarcated protected land (5).
This political hypocrisy alludes to a larger cultural conundrum. Brazil is home to a significant indigenous population. According to FUNAI’s most recent census, more than 800,000 people identify as indigenous. Although this group comprises just 0.4% of the total population, it is richly diverse, containing 305 ethnic groups and 274 languages (6). Of course, these numbers reflect merely a fraction of the size and diversity that existed before the arrival of European explorers in the 1500s. Some historical accounts estimate 90% of the Amerindian population had been decimated by 1650 due to a combination of disease, war, and enslavement (7). The tribes who managed to escape forced assimilation sought refuge in isolation. Today, there are an estimated 60 to 100 uncontacted tribes living in the Brazilian Amazon rainforest, the most numerous of any country in the world (7).
Preserving the isolated status of these tribes has proven to be a monumental task for government officials. The Brazilian government passed legislation in 1988 recognizing tribal lands and prohibiting contact with the remaining tribes unless they are facing extinction. However, efforts to enforce this law have ranged from ineffective to nonexistent due lack of political will and the sheer magnitude of the goal. Accounts of violent clashes between tribes and ranchers as a result of contact events have recently been reported (8). Drug trafficking routes have become entrenched in the dense landscape, increasing the presence of hostile trespassers within tribal territories. In fact, some tribes have already initiated contact with government after evading illegal invaders for years (8). Others have used their intimate knowledge of the forest and weapons to protect themselves.
More concerning than violence, however, is the threat of infectious diseases that can infiltrate tribal communities along with outsiders, against which many indigenous people are defenseless. Pathogens pose the greatest threat to the safety of uncontacted tribes because of the rapid pace with which they can annihilate a vulnerable population—one person infected with measles may transmit the virus to as many as 27 other individuals (9). In a population where everyone is susceptible to the pathogen, such as in an isolated tribe, the number of infected individuals will increase exponentially by a factor of 27 until the entire community is either immune or dead. It is therefore unsurprising that contagious pathogens feature prominently in the history of the Americas. Scholars have argued that the introduction of smallpox and influenza to Native American tribes played a key role in Columbus’ conquest of the New World (10). The climate historian John McNeill cites immunity (and lack thereof) to yellow fever as a key driver in the colonization of the Caribbean (10).
But the dangers of exposing isolated tribes to infectious diseases are not confined to history books. A measles outbreak presumably introduced by illegal loggers near the Venezuela-Brazil border is currently threatening the existence of the isolated Amazonian Yanomami tribe, members of which were never exposed to the virus before (11). In late 2018, Indian authorities opted to not recover the body of John Allen Chau, a US missionary killed by the uncontacted Sentinelese tribe from the Andaman Islands, out of concern for the tribe’s health and safety. Since then, an American who made contact with the Amazonian He-Merimã tribe in January has been accused by FUNAI of spreading disease to these immunologically vulnerable people, as even the common cold could prove devastating (12).
Despite these recurring events, the public health field has failed to establish ethical mechanisms for treating disease in newly contacted tribes because the application of Western medicinal practices has historically been confounded with acting in the best interests of a vulnerable group. That is, conventional methods for improving health outcomes may be inappropriate or ineffective in indigenous populations and, even worse, could impose a neo-colonialist agenda on Brazil’s tribes (13). Neo-colonialism, or the imposition of Western ideology on former imperial subjects such that colonial power dynamics are maintained, is manifest when local populations are viewed as vehicles for implementing a new technology instead of as humans (14). These situations are borne out of the implicit imbalance of power established during the colonial era, which has been perpetuated through political and economic disparity.
The fate of the Botswana Basarwa (previously referred to as “Bushmen”) who were forced into mainstream education and medical care systems through the Remote Area Development Program (RADP) illustrates the consequences of ill-applied Western ideology (15). Access to schools and healthcare is considered a universal good, but the results of the “development” program have been devastating for the Basarwa. The transition from an active, rural lifestyle to a sedentary, urban one replete with processed food has led to skyrocketing rates of obesity and diabetes (16). Today, the Basarwa live in poverty, suffer from substance abuse, and die of HIV/AIDS at shocking rates.
As a historically marginalized group, indigenous people in Brazil lack the social currency to stand up to the government and are therefore at risk of following a similar trajectory. Worse, the cruel irony enveloped in protecting Brazil’s tribal people from foreign pathogens is that all of the requisite medical tools already exist. The majority of deaths in newly contacted tribes are caused by diseases that are preventable, detectable, and curable with Western medicine. Brazil provides universal health coverage to its citizens through the publicly funded Sistema Unico de Saude (SUS), and its constitution includes a right to health for all citizens.
Not only is the Amazon rainforest one of the most biodiverse biomes in the world, it is home to rich human diversity due to the number of indigenous tribes who live in it.
But the myopic lenses of medicine and finance ignore not only the cultural and racial themes that shape the relationship between indigenous peoples and the mainstream culture living around them, they overlook the sheer complexity of connecting people with medical care. In medicine, the phrase “bench to bedside” sums up the goal of translational research: using findings from the laboratory (bench) to develop strategies for clinicians treating patients (bedside). This is an important first step in medical innovation; however, the controlled hospital environment should not be the end of the pipeline for research because it is a poor proxy for the chaos of everyday life.
Public health professionals take on this chaos by stepping out of the hospital and into the community, but it was not until recently that a formalized approach for addressing the obstacles that arise during this transition was codified. Implementation science is a new field that “assesses the extent to which efficacious health interventions can be effectively integrated within real-world public health and clinical service systems” (17). Implementation research involves evaluating the cost-effectiveness, scalability, and feasibility of an intervention and should be developed in conjunction with the target community.
This final aspect, recognizing communities as equal stakeholders in the implementation process, is the most important, and its absence has stymied numerous disease control efforts. The acclaimed doctor and social justice advocate Paul Farmer described what he called “the Ebola suspect’s dilemma” during the 2014-2016 Ebola outbreak in West Africa. While the outbreak was unfolding, anyone experiencing Ebola-like symptoms such as vomiting, fever, and muscle pain was instructed to go to the hospital for treatment. Interestingly, Farmer and his team found that many people were choosing to stay home instead, potentially exposing their family members to the deadly virus (18). These decisions were not borne out of ignorance but were logical calculations. In the initial stages of infection, symptoms of Ebola and malaria are indistinguishable. Individuals experiencing these symptoms realized that if they had malaria but went to the hospital, they would be placed in the Ebola ward and almost certainly contract Ebola. If they did have Ebola, their risk of dying was only slightly lower if they went to the hospital instead of staying at home (18).
This kind of calculation is rarely made by the upper middle-class Westerners who are typically involved in handling an outbreak response or in managing a development program as evidenced by the RADP. Clearly, a corollary to Western ideological dominance in global health is the persistence of socio-cultural blind spots that can lead to unexpected outcomes in the implementation of health initiatives. If disease control efforts are to be improved, advocates and researchers must break out of a purely Western mindset and work in collaboration with local communities to shape interventions.
Brazil’s uncontacted tribes present another challenge to this already complex problem because there is no way to engage with this population without destroying their isolated status. Public health practitioners are therefore limited to understanding health outcomes among indigenous people who are in contact with mainstream society, but who continue to live in extremely rural communities. Fortunately, avenues to establishing such communication channels already exist. For example, there are Portuguese-speaking, contacted members of the Awá tribe living in eastern part of the rainforest who work with FUNAI to help the agency track the vitality of the tribe’s uncontacted brethren, with whom they also maintain a relationship (18).
But the myopic lenses of medicine and finance ignore not only the cultural and racial themes that shape the relationship between indigenous peoples and the mainstream culture living around them, they overlook the sheer complexity of connecting people with medical care.
Expanding and incentivizing academic efforts to understand health outcomes in Brazil’s indigenous population is also essential because the limited body of work that currently exists on this topic is in its infancy. Research addressing the health and well-being of this diverse population has been primarily exploratory, either characterizing the epidemiology of commonly studied pathogens such as HIV and tuberculosis, or cataloguing challenges to implementing treatment and prevention strategies in remote populations (19-21).
As a result, the situation for uncontacted tribes is extremely precarious. Once a contact event occurs, public health officials must act immediately to preserve the health of the affected tribe. Without a contingency plan in place or any guidance from the literature, the cycle of marginalization and impoverishment of indigenous people will continue, either through the extinction of entire tribes or through the imposition of strict disease-control measures that will drive indigenous people off their land ostensibly in the name of public health.
Given the new Brazilian administration’s anti-indigenous people stance, preservation efforts must look to other institutions for support. Scholars and non-profit organizations who are equipped to manage contact events may be the most promising alternative. An important first step in preparing for contact events is establishing collaborations between public health experts, anthropologists, linguists, and advocates. Preparing for the breadth of languages spoken among uncontacted tribes will be essential for communicating with members once contact occurs and, hopefully, establishing a trust and a dialogue between parties. Anthropologists should work in conjunction with advocacy groups who have ties to contacted tribes to find interpreters who can mediate stressful situations.
Scholars who study tribes in South America can also help public health professionals understand the non-Western medicine and medical practices tribal members use. It is hubristic to assume that Western medicine is the only solution for medical ailments. The rich plant-based medical traditions of indigenous people, which may prove preferable to some tribal members, should be explored. These traditions should not be dismissed as herbal quackery as they have led to significant medical advances. For example, the 2015 Nobel Prize in Medicine and Physiology was awarded to Youyou Tu for her discovery of Artemisinin, a plant-based extract that is still used today to treat malaria (22).
The public health community must establish a stable infrastructure to address the health needs of contacted indigenous people as they transition into mainstream society. Obesity, suicide, and addiction afflict indigenous communities at higher rates than the rest of the population (22). It is critical that the medical community is prepared to manage these chronic diseases once the danger of infectious disease transmission has subsided.
Finally, economic stability is vital for preventing indigenous communities from falling into poverty. Contact forces tribes into the mainstream economy, creating a dependent relationship with Western society. In Colombia, where the government has made a considerable effort to protect its uncontacted tribes, those who have been contacted have turned to tourism to support themselves when agriculture did not suffice. The consequences of this demoralizing dependence on outsiders was alluded to by one Ticuna woman who explained, “You have to sell yourself, make an exhibition of yourself. It’s not good” (23).
As of now, there is no acceptable roadmap for accomplishing the above goals because indigenous people have not been included in the discussion. This group must first and foremost become equal stakeholders in the efforts to preserve the precious human diversity living in the Amazon. Western public health practitioners may contribute political influence and access to financial resources when planning for and facilitating safe contact events, but they should not be omnipotent decision makers. Instead, they should serve as allies to indigenous communities and embrace the interdisciplinary challenges that are implicit in cross-cultural work.
The aggressive anti-indigenous rhetoric and policies of Brazil’s new administration accelerates the urgency with which concerned parties must act to prevent the demise of the country’s most vulnerable inhabitants. There is a strong political will to “integrate these citizens,” as Bolsonaro recently tweeted, signaling a rapid increase in contact events, both intentional and accidental. With such sentiments guiding legislation, mainstream culture will surely conquer Brazil’s final frontier. This sad reality precipitates the need for a new level of public health preparedness that will hinge on innovative implementation solutions to familiar problems. Implementation research has already begun to become embedded in public health ideology and practice. What remains to be seen is whether the people who have access to these tools are willing to relinquish them and empower communities whose agency and land have systematically been taken from them.
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Please see the print issue PDF at http://tinyurl.com/distilled2019 for headshot, affiliation, and email address.
Please see the print issue PDF at http://tinyurl.com/distilled2019 for headshots, affiliations, and email addresses.