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3. New sociopolitical governance models are needed to tackle health challenges in the Amazon

Opinion BMJ 2025; 391 doi: https://doi.org/10.1136/bmj.r2010 (Published 06 November 2025) Cite this as: BMJ 2025;391:r2010

1. Nathália Nascimento, professor1,

2. Raquel Tupinambá, PhD candidate2

3. 1University of São Paulo, Brazil

4. 2University of Brasília, Brazil

Promoting health in the Amazon can be achieved only by protecting ecosystems and natural territories and by recognising traditional care practices and indigenous medicine, argue Nathália Nascimento and Raquel Tupinambá

Indigenous peoples have inhabited the Amazon for more than 12 000 years, playing a fundamental role in safeguarding and managing the forest. At the onset of colonisation in the 16th century, the indigenous population was estimated at roughly 10 million.12 Today, their population has declined by approximately 90% as a result of the colonisation process, which included slavery, extermination campaigns, deforestation, and the devastating impact of diseases brought from other continents.3 In Brazil, traditional peoples are legally recognised as socioeconomically and culturally distinct groups, with their own forms of social organisation and strong ties to territory and nature.4 As well as indigenous peoples, this designation includes Quilombolas (Afro-descendant Maroon communities), Ribeirinhos (river dwelling communities), extractivists, and other groups who share a view of the Amazon as a living health system in which the health of the ecosystem is inseparable from human health.

The Amazon is home to approximately 45% of Brazil’s indigenous population, as well as hundreds of Quilombola, Ribeirinho*,* and extractivist communities.5 These communities are mostly distributed along the rivers, in regions inaccessible by roads or railways. In this context, villages and communities guide their healing practices based on ancestral knowledge of natural resources and the interconnections between bodies, landscapes, and spiritualities.67

Indigenous medicine, grounded in distinct cosmologies, understands illness as an imbalance that goes beyond the physical body, encompassing spiritual and environmental dimensions.8 The strength of these practices, combined with logistical constraints, means that many communities turn to the official healthcare system only when traditional methods have proved insufficient. Recently, the intensification of environmental degradation has threatened the interdependent system that involves physical, spiritual, and environmental dimensions. Studies have linked changes in land use to an increase in vectorborne epidemics, such as malaria.910 Mercury contamination from gold mining and hydropower plants is affecting human health. Estimates suggest that populations in the region are consuming up to six times more mercury than internationally recognised limits.11 The impact of climate change effects, such as increasingly severe and prolonged droughts, have resulted in water and food insecurity and have worsened access to healthcare, owing to the poor navigability of the rivers that prevented travel to healthcare centres and access to medicines.12

Healthcare systems in the Amazon face numerous challenges, such as geographic isolation, a lack of financial resources, limited medical specialties, insufficient coverage of health centres, and a lack of respect for interculturality.1314 These challenges are reflected in the region’s status as the most precarious in health in the country.15 These systems also fail to recognise traditional care practices and indigenous medicine, in which the illness and healing are interpreted through cosmologies specific to each culture and connected to the relationships with territory and nature. In this context, indigenous populations face a dual health crisis, characterised firstly by the worsening of emerging and neglected diseases driven by environmental degradation; and secondly by the inadequacy of the official healthcare system to acknowledge their cultural and logistical realities.

Importance of ancestral knowledge for health in the Amazon

Healthcare systems need to adapt to meet the needs of the Amazon’s culturally diverse community. There are several successful examples of initiatives, such as boat hospitals and boat ambulances (floating medical units), which periodically bring healthcare to remote areas to complement indigenous medicine. Indigenous Health Agents (AIS, in Portuguese) play a key role in translating and adapting guidelines from the Unified Health System (SUS, in Portuguese) to local realities. Nevertheless, despite ongoing progress, substantial cultural barriers remain when traditional populations access the official healthcare system, because the understanding of illness and emergency care often diverge.

Existing assistance efforts remain insufficient in the face of the demand and the speed of environmental disturbances. In 2023, the humanitarian crisis experienced by the Yanomami people, triggered by illegal gold mining, led to the deaths of over 420 indigenous people, most due to malaria, respiratory infections, and malnutrition.1516 Of those, 65% were children under the age of one.16 That same year, a severe drought drastically affected access to water, fishing, agriculture, and the mobility of Ribeirinho communities, further worsening health conditions and access to basic healthcare.

A new ecological and intercultural Amazonian health system

In this context, it is vital to understand that the complexity of the Amazon demands solutions that cannot be based solely on replicating the prevailing biomedical model. It is essential to build a new sociopolitical governance system that recognises the inseparability of human health and environmental health. This shift must be guided by principles such as interculturality and respect for the worldviews of traditional peoples, placing value in care practices that are based on local knowledge and equity in access to culturally appropriate healthcare.

This new system requires integrated public policies, designed through active listening to Amazonian peoples, and the effective participation of their leadership in decision making processes. It also requires strengthening community care networks, investing in primary healthcare strategies that consider the geographic and sociocultural specificities of the territories, and intersectoral actions aimed at protecting ecosystems as structural determinants of health.

Finally, promoting health in the Amazon will not be achieved solely by building more hospitals, but through preserved ecosystems, protected territories, and dialogue to connect knowledge of indigenous and local peoples with academic knowledge. Rethinking Amazonian health demands that we recognise that caring for nature is the first and most fundamental act of caring for life.

Footnotes

Competing interests: None declared.

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

References

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Barreto, JPL. Kumuã na kahtiroti-ukuse: uma “teoria” sobre o corpo e o conhecimento-prático dos especialistas indígenas do Alto Rio Negro [Thesis] [Portuguese]. Universidade Federal do Amazonas, 2021. https://tede.ufam.edu.br/handle/tede/8289

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