Intended for healthcare professionals


Legacy of covid-19 for indigenous health in the Brazilian Amazon

BMJ 2023; 380 doi: (Published 05 January 2023) Cite this as: BMJ 2023;380:o3005
  1. Christine Ro, freelance journalist
  1. London, UK
  1. christineannro{at}

Pre-existing vulnerabilities meant that covid-19 hit indigenous people particularly hard, but as Christine Ro reports, it also kickstarted initiatives to improve health

“I don’t want privileges. I just want the healthcare system to understand,” says Marinete Tukano, treasurer coordinator of Makira E’ta, a network of indigenous women in the Brazilian state of Amazonas.

In Brazil, as in many parts of the world, indigenous groups have poorer health than the rest of the population. Indigenous people in Brazil live mainly in the Amazon region, where the populations are diverse but face several common health problems. They are particularly affected by links between environmental degradation and health. For example, deforestation and illegal mining are associated with malaria, while forest fires worsen respiratory diseases.1

“The government healthcare system for indigenous people has always been precarious, but has become even more precarious since the pandemic,” Tukano says.

Pre-existing social vulnerabilities

In the Amazonian state of Amapá, indigenous people often lack income, sanitation, and medical services.2 Elsewhere in northern Brazil, Warao people face the dual vulnerabilities of being indigenous and refugees from Venezuela. Displacement itself increases the risks of infectious diseases. Malnutrition, diabetes, and obesity are also common in this group.3

Poor living conditions are also visible in Manaus, the capital of Amazonas. Parque das Tribos, a neighbourhood home to over 2000 indigenous people on the outskirts of Manaus, has rubbish strewn along clay paths, with septic tanks in some residents’ gardens. Public sanitation doesn’t extend here.

Even obtaining water here was a fight, says Vanda Witoto, a nursing technician and a leader of the Witoto people. It’s a huge irony given the proximity to the Amazon river. “We have one of the major sources of freshwater in the area,” Witoto says. “However, it’s not always easy for indigenous and riverine people to have wells.”

As a result, residents were not only drinking muddy water but finding it hard to comply with handwashing guidance during the height of the covid-19 pandemic. After much protest the neighbourhood now has piped water, and a basic clinic is being constructed. But food insecurity and poverty persist.

Brazil’s government has resources dedicated to indigenous health, including the indigenous healthcare subsystem (SasiSUS). Specifically trained health workers travel to or live in remote communities, helping to increase trust and acting as a bridge between biomedical professionals and indigenous communities.4

But these have been hampered by politicisation and under-resourcing, including unequal legal status between community health agents and indigenous health agents.1 Indigenous groups have also not had sufficient input into their own health services.5

The presidency of Jair Bolsonaro caused serious damage to public healthcare for indigenous populations, according to Fabio Biolchini, a Médecins Sans Frontières (MSF) adviser for Latin America and the Caribbean. He says that the indigenous health department has been “pretty much dismantled” during the past four years, while many indigenous health promoters stopped receiving salaries.

Bolsonaro also expelled thousands of Cuban doctors, many of whom worked in indigenous villages,6 hollowing out the service to remote areas that were already difficult to access.

Delays and neglect during the pandemic

These factors led to “a true indigenous emergency” during the pandemic, say Arthur Arantes da Cunha and Emerson Augusto Castilho-Martins, epidemiology researchers at the Federal University of Amapá.

Some of the most shocking scenes from the first year of the pandemic were in the Brazilian Amazon, where hospitals were overwhelmed during multiple waves. When MSF arrived in Manaus in April 2020, the first Brazilian city where mass graves were dug,7 gravediggers were already working overtime8 and intensive care units had death rates of 80%.9 Oxygen was in short supply throughout the country, but remote, largely indigenous areas faced particular challenges.

Diagnosis in indigenous communities was badly delayed.10 Certain demographic aspects also came into play. For instance, social distancing was challenging for the multifamily households of the Xikrin people.11 Yet Biolchini says that in rural areas indigenous people, with previous experience of devastating infectious diseases,12 were the first to isolate themselves.

However, continued conflicts on indigenous lands blocked access for some indigenous health workers. Bitate Uru-Eu-Wau-Wau, a journalism student and a youth leader of the Uru- Eu-Wau-Wau people in the state of Rondônia, tells The BMJ that the pandemic reduced the already limited enforcement of indigenous land rights. Cattle ranchers took the opportunity to invade land, and the ensuing conflict meant that health workers sometimes couldn’t visit isolated areas in his people’s territory. In other indigenous territories, illegal miners and loggers continued their activities during the pandemic.2

By January 2021 in the state of Amapá, the death rate from covid-19 was around 2.9/1000 indigenous people compared with 1.1/1000 in non-indigenous people.10 And between 20 March 2020 and 29 April 2021, the incidence of covid-19 in indigenous people in Amapá was about 5.6 times higher than among non-indigenous people.2

Varied coping responses

Although the pandemic continues, government action did eventually help to stem the tide. The indigenous health special district of Amapá and Northern Pará provided personal protective equipment and helped indigenous people to return safely from urban areas to villages, while many primary healthcare facilities on indigenous lands were bolstered during the pandemic.10

Some organisations found ways to integrate understanding of indigenous circumstances into emergency care. Biolchini says that to work in São Gabriel da Cachoeira, a majority indigenous municipality, MSF had 40 translators because of the diversity of indigenous languages spoken by the residents. “For many of them, that was the first time they were hearing about the pandemic.”

Telemedicine became even more of a lifeline for remote rural areas such as Tumbira, a riverine community with some indigenous residents. There, the Foundation for Amazon Sustainability (FAS) and other non-profit organisations are working to expand solar powered electricity sources. Among other benefits, this would allow a continuous link to external health information.

But importantly, many indigenous communities had to provide their own care. For example, Witoto led the creation of an indigenous field hospital in Manaus13 as well as making house calls herself. The pandemic also saw a resurgence in the use of indigenous medicines, which tend to be little understood outside indigenous communities.14

Witoto says that the residents of Parque das Tribos now feel more secure because they have some services. But she warns of the continued burden of mental ill health, with suicide disproportionately affecting indigenous people in Brazil.15 Biolchini concurs, “The second epidemic after covid-19 is the mental health issues epidemic that we are seeing.”

For Tukano, the main challenge now is to improve the quality of care for indigenous people in cities, where there’s less recognition of indigenous identity.

Whether they’re living in or visiting urban areas, indigenous people might not have documents attesting to this identity. Their ethnicity might therefore be classified incorrectly in hospitals, Tukano says.

“I prefer to be treated in a hospital as an indigenous woman,” she explains. This could extend to recognition of specific cultural needs, like hammocks rather than beds or space for spiritual practices. Or it could involve understanding the multiple types of violence to which indigenous women are particularly subject.16

The toppling of Bolsonaro in the recent Brazilian elections has offered a ray of hope. Luiz Inácio Lula da Silva, the new president, had a mixed record on indigenous environmental protection in his previous presidency but unlike Bolsonaro wasn’t openly hostile to indigenous rights. Since his re-election, Lula has talked of reversing some decisions made under the Bolsonaro administration that undermined indigenous rights, including the right to health.

“It’s not going to be an easy task,” says Biolchini, “but [tomorrow is] going to be much better than today, that’s for sure.”


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare I received travel support through a grant from the United Nations Foundation.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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