Arduous trip through Amazon brings COVID-19 vaccines to vulnerable groups | Science

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A version of this story appeared in Science, Vol 374, Issue 6575.

“Vaccine! Let’s vaccinate everyone!” Shouts go up from the steep and muddy banks of the Iriri River in the heart of the Brazilian Amazon forest. A team of doctors, nurses, and nongovernmental organization (NGO) workers are hauling plastic foam boxes from a small aluminum motorboat. Dozens of residents of this village, Boa Esperança, gather on the balcony of a wooden house to avoid the scorching Sun and await their COVID-19 vaccines.

Medical teams are a rare sight here. This crew has traveled 9 hours in pickup trucks along bumpy roads from the closest city of Altamira, then sailed a few more hours. They are at the start of a 17-day river trip to give shots at settlements in preserved areas of the world’s biggest tropical forest.

Most residents here are riverine people (ribeirinhos in Portuguese)—riverside dwellers who have lived in the Amazon for centuries, relying on artisanal fishing and harvesting. The Brazilian government views them as a traditional group—a category that also includes Indigenous tribes and descendants of runaway enslaved Africans, known as quilombolas. These groups were given priority status to receive the COVID-19 vaccine in a national plan released in December 2020, following pressure from human rights activists and local leaders. Many Indigenous groups, which receive care from a special federally funded health department, have been vaccinated. But riverine peoples depend on local municipalities, which are mostly too poor to do much, for their health care. As a result, whereas city dwellers in Brazil are already getting boosters, many people living on remote riverbanks still wait in isolation for their first or second shots.

“It is a population very difficult to reach that has suffered from neglect from the state for centuries,” says the doctor in charge of the expedition, Erika Pellegrino of the Federal University of Pará, Altamira. The municipal health department of Altamira supplied the COVID-19 shots—two-dose AstraZeneca and single-dose Janssen vaccines—that the team is delivering along with various childhood vaccines. But NGOs, including the local Socio-environmental Institute and the U.S.-based group Health in Harmony, organized and funded the expedition itself, which cost nearly $20,000. Grassroots associations helped with the infrastructure, converting houses into improvised vaccination centers.

Two people stand calf-deep in a river next to a boat filled with supplies; in front, a medical supply box sits on the ground.
Small aluminum boats navigate shallow waters to reach remote Amazon communities.Sofia Moutinho

It has taken four long trips between June and September to vaccinate more than 700 people living on three reserves on the banks of the Iriri, Xingu, and Riozinho do Anfrísio rivers. The number of people vaccinated so far might seem small, but it includes many of the estimated 1700 riverine people living in these reserves, located in the vast mosaic of federally protected lands called Terra do Meio (Middleland)—an area about the size of Iceland that abuts Indigenous reserves. The whole Amazon forest likely contains tens of thousands of riverine people, but they haven’t been formally counted. Also lacking are centralized data on how many have been vaccinated through government campaigns or NGO missions like this one.

“It is a relatively small number of people spread on a gigantic territory,” Pellegrino says of the riverine groups. “And that is our biggest challenge.”

“Hello, hello everyone!” The expedition is coming in 2 days with COVID-19 vaccines and exams. Copy that?” a crew member in Boa Esperança announces into a ham radio transmitter. “Positive! Copy that!” come the crackling responses. As the vaccination team proceeds up the river, it relies on radios like this, the only form of communication available to many riverine people, to spread the word about upcoming visits. That’s how 63-year-old Francisco dos Santos, a nut harvester, fisherman, and local singer known as Chico Preto, learned about the vaccination.

Dos Santos’s 79-year-old wife, Maria Madalena Freire, narrowly survived a severe case of COVID-19 in August 2020. Local organizations and NGOs offered her an emergency air evacuation, which she declined, saying she wished to “die in the forest.” But that experience impelled the couple to sail for 2 hours in a motorized canoe to a vaccination site in the village of Manelito, about 160 kilometers up the river from Boa Esperança. “We wish we could have brought more people with us, but the fuel was not enough,” dos Santos says. The medications, checkups, and basic blood tests offered by the team were an extra draw, he says.

Dos Santos, like most riverine people in the region, is a descendant of Indigenous people and “rubber soldiers,” immigrants from northeastern Brazil sent by the government to the forest to harvest latex for the U.S. war effort during World War II. They now support themselves by fishing, hunting, and harvesting Brazil nuts and the coconutlike fruits of the babaçu palm. None has access to running water, and only a few have electricity from solar panels or diesel generators for a few hours a day. Their communities have no doctors and are days away from a hospital. Four nurse technicians, hired by the municipality with support from NGOs during the pandemic, are the only medical support for kilometers. They are supposed to assist all families living in the reserves in Terra do Meio. “God knows how difficult it is to get medical assistance here,” Freire says. “When a health team comes, I am the first to run after them.”

A nurse technician (first photo) fills a syringe with COVID-19 vaccine in Maribel, Brazil. Nut harvester Francisco dos Santos shows his vaccination card at the Manelito vaccination stop. Sofia Moutinho

It’s a dangerous environment for a COVID-19 outbreak. “The vulnerability [of these groups] is socio-epidemiologic,” says Douglas Rodrigues, a physician at the Indigenous clinic at São Paulo State University’s hospital, who has been working with Indigenous and riverine communities for more than 30 years. Along with a lack of proper health care, the riverine people have elevated rates of comorbidities such as diabetes and infectious disease, which raise their risk of severe disease and death from the virus, he says. Their communal lifestyle, in which large families often share a one-room house, also makes it easier for SARS-CoV-2 to spread. Isolating the infected “is just not possible in their way of life,” Rodrigues says.

Riverine and Indigenous communities have restricted visitors to their territories since the start of the pandemic to prevent the disease’s arrival. But illegal activities such as mining, logging, and land grabbing, which have spiked in the past year, continue to bring in outsiders. As a result, COVID-19 has spread with devastating consequences.

Among Indigenous peoples in the region, disease incidence and mortality during the pandemic’s first wave in 2020 were respectively 136% and 110% higher than the national average, according to a study published in April in the journal Frontiers. There are no official numbers for riverine peoples, as they are not tracked separately by the Ministry of Health.

To get to the expedition’s farthest stop, the village of Lajeado in the Riozinho harvesting reserve, the vaccination crew must travel more than 600 kilometers up the narrow Riozionho do Anfrísio. Some parts of the river look like a swamp, with shallow, dark water full of caimans. Others are studded with rocks, rapids, and little waterfalls. Only small boats called rabetas —with a retractable propeller attached to a long shaft—can navigate these shallow waters.

“Hold on!” shouts one of the boats’ captains while lifting the propeller from the water to avoid a fallen tree on the river’s bottom. The co-captain stands on the prow using a machete to chop away overhanging tree limbs. Crew members duck as spiky vegetation along the shore sweeps past the boat.

Aboard are six people and precious cargo: a box containing dozens of vials of the AstraZeneca vaccine and a few single-dose Janssen syringes. They must be kept between 2°C and 8°C, and are carefully stored on ice that is supposed to last 5 days. By then, the team will have returned to less treacherous waters, and can transfer to a larger boat with a solar-powered freezer.

By the time the team has finished the 2-day-long journey from its previous vaccination stop in Morro do Anfrísio to Lajeado, one of the rabetas has broken down three times. Arriving just before sunset, the crew set up their hammocks. Vaccinations will start early in the morning. A nurse technician jokes that she’s having withdrawal symptoms from going so many hours without vaccinating anyone. “My hands are shaking to give these shots!” she says.

Long and winding route

A vaccine expedition set out from the city of Altamira, Brazil, to remote riverine communities within the federally protected territory known as Terra do Meio (Middleland). The team traversed roughly 1200 kilometers, following rough dirt roads to Maribel and continuing by river to vaccinate hundreds of residents. It took 11 days to reach their farthest stop, Lajeado, and another 6 days to return.

Starting point

Vaccination stops

A vaccine expedition traveled about 1200 km, first over dirt roads and then by river, with 15 stops along the way.
K. Franklin/Science

People on the neighboring Indigenous lands of Xipaya and Kuruaya have been vaccinated for months, thanks to the federally funded health department that serves them. But many of the municipalities responsible for riverine peoples have neglected vaccinations. Altamira started to make the vaccine available to these groups in May, but only after the federal public attorney’s office started to ask municipalities to enforce their priority in the national rollout.

Such disparities are nothing new, says anthropologist Roberta Cerri at the Oswaldo Cruz Foundation, who is researching health access in these communities. She believes Brazil should have a separate health strategy for all traditional people living in the Amazon forest. “Neither COVID-19 nor any other infectious disease differentiates if a person is from an Indigenous tribe or a riverine community,” she says.

Consistent vaccination across both Indigenous and riverine communities is also key to safeguarding uncontacted tribes in their vicinity. There are about 100 of these groups in the forest, according to the Brazilian government’s National Indian Foundation, and they are especially vulnerable to many infectious diseases. “For isolated groups, a flu virus is already a pandemic, to say nothing of the coronavirus,” Rodrigues says. In keeping with Brazil’s long-standing no-contact policy, they won’t be vaccinated. But inoculating their neighbors creates a safety barrier, reducing the chances of the disease reaching them.

In Lajeado, the crew improvises a vaccination post with school chairs and a table under the bright yellow flowers of an ipê-amerelo tree. After a full day of vaccinations, only one woman is left in line. But opening a vaccine vial just for her would mean wasting four of its five doses, which expire 6 hours after opening. Samya Mauad, a nurse technician, quickly finds three more villagers willing to get shots. Still missing one person, she tries to recruit a man who came to vaccinate his toddler against childhood diseases. But he refuses.

“Did you ever get vaccinated?” she asks. He nods. “So why don’t you take this one? The more people get vaccinated, the more protected we get.” Villagers watching the scene jump in with words of encouragement. But the pressure irritates the man, and he walks away, carrying his daughter.

It’s not the first time Mauad has encountered hesitancy. Most often, people are afraid of side effects, and she manages to convince them, she says. But even in an area without cellphone reception and with only a few internet hubs, fake news spreads. People have told Mauad that the injection contains a “devil’s chip” to control minds, that it turns people into homosexuals, or that it makes them develop AIDS.

Some of the misinformation may come from certain evangelical missionaries active in the region, who are currently under scrutiny by a parliamentary commission investigating antivaccine propaganda and human rights violations during the pandemic. Other falsehoods come from the highest levels of the Brazilian government: President Jair Bolsonaro, who regularly criticizes COVID-19 vaccines, said on a Facebook live broadcast in October that citizens were developing AIDS after receiving the shot. Few officials have countered his message. “The Brazilian federal government has made no effort to instruct people about the importance of vaccinating,” Rodrigues says.

Still, the crew estimates that fewer than 1% of the people approached on this trip have refused shots. The team is now planning trips to bring dentists and doctors to the region and has started to organize an expedition to vaccinate teenagers, who have been eligible for vaccination since August.

Despite their isolation, many riverine people know the pandemic is causing global waves of illness and want to keep COVID-19 at bay. Antonio Silva Matos, a gold miner in the city of Novo Progresso traveled about 300 kilometers back to Lajeado, near his home, to get his shot. (Health authorities in Novo Progresso would only vaccinate residents, not migrant laborers, he says.) The trip required a pickup truck, a bus, a motorbike, and a motorboat—and cost him 3000 reais (about $600). He didn’t regret it. “So many people have the vaccine at their doors and don’t want it,” he says. “I just don’t get it.”