Brazil - Colombia - Peru Border

Consultant: Lyli Yaneth Chindoy Luna
Collaborator: Roberta Cerri
2022

The region of the triple border Brazil/Peru/Colombia comprises an extensive cross-border area between the Solimões (Amazon) and Iça (Putumayo) rivers, where the Colombian Amazon Trapezium and its collision zones in Brazil and Peru are located.

In Colombia, the region corresponds to the extreme south of the Amazonas department, and in Brazil it is in the northwest of the Alto Solimões region. In Peru, the area includes the town of Caballococha in the province of Mariscal Ramón Castilla, at the southern end of the Amazon trapezium.

The Amazon Trapezium in Colombia includes the municipalities of Leticia, Puerto Nariño, and the southern part of Tarapacá, a non-municipalized area that makes up the Colombian department of Amazonas. In Brazil, the region comprises the municipalities of Amaturá, Atalaia do Norte, Benjamín Constant, Fonte Boa, Jutaí, Santo Antônio do Içá, São Paulo de Olivença, Tabatinga, and Tonantins. In Peru, the area is located in the northwest of the country, joined by the Maranon and Ucayali rivers, where the main course of the Amazon River originates. The towns or cities located in this region in the province of Mariscal Ramón Castilla of the department of Loreto.

MAPA INTERATIVO

Observe no mapa interativo do Módulo Povos Indígenas, onde se localizam os territórios indígenas na região amazônica e observe as regiões fronteiriças estudadas pelos consultores da OTCA:

TERRITORIES AND INDIGENOUS POPULATION

The indigenous population in the tri-border region delimited by the study is approximately 107,000 individuals, with the Tikuna and the Kokama being the most numerous and with a presence in all three countries. The traditional indigenous areas are recognized differently in each country.

In Colombia, these territories are recognized as indigenous reserves, but part of the population considered indigenous lives outside of the reserves in rural and urban communities, called Parcialidades by the Colombian government.

The indigenous population on the Brazilian side, in the Alto Río Solimões region, totals 70,526 people living in 28 indigenous lands in predominantly rural areas belonging to 07 municipalities in the region (IBGE 2020 estimate). The indigenous people live in 235 communities located along the Solimões River, its tributaries, and streams. The indigenous population of this sub-region is composed of 7 ethnic groups, with the Tikuna being the most populous ethnic group not only in the region, but also in Brazil – approximately 46,000 individuals.

On the Peruvian side, in the region of Loreto, 11 language families (84.6% of the indigenous languages spoken in the country) and 29 ethnic groups are located. In the province of Mariscal Ramón Castilla, the Tikuna are also the most numerous people: about 8,844 inhabitants distributed in native communities, riverside villages and intermediate towns.

The Colombian Amazon Trapezium region and its colliding areas in Brazil and Peru are located between two zones with the presence of isolated peoples: (a) to the south, the Vale do Javari Indigenous Land, site of the largest number of isolated peoples recorded in the Amazon; (b) and to the north, the Río Puré National Park in Colombia, where the Yurí-Passé live. Due to its strategic position – between two locations with the presence of isolated peoples – the region is considered strategic in containing outbreaks and epidemics.

HISTORICAL AND ANTHROPOLOGICAL CONTEXT

Mobility, resistance and sedentarization of the people of the upper Solimões River

The first historical records of the occupation of human groups in the region date back to before 1690, when Spanish and Portuguese missionaries, drug collectors, and troop leaders arrived in the Upper Solimões River. At that time, the indigenous peoples living there were grouped in towns with thousands of inhabitants on the banks of the Solimões River (Amazonas) and its tributaries and on the lower course of the Içá River (Putumayo) and practiced trade based on regional networks. With the arrival of the Spanish Jesuits, many of these indigenous towns gave way to colonized settlements and in this process some ethnic groups, such as the Omaguas, disappeared; others, such as the Kokama and Tikuna settled in new groupings establishing a continuous interethnic relationship with the Spanish explorers and Jesuits.

This form of occupation of large indigenous groups along the banks of large rivers meant that smaller groups that sought not to establish contact with the local colonization process became internalized in firm lands, living atomized in family nuclei with few external exchange relationships. By the end of the 19th century, when the cauceros arrived in the region, the Tikuna were already settled, especially along the banks of the Solimões River (Amazonas) where they became known for their fishing and canoe-building skills.

The exploitation of rubber led to an expansion of the relations between settlers and indigenous people. The Tikuna left their large malocas and began to live in family groups scattered around rubber plantations, serving as key laborers in rubber extraction. The Kokama, who until then had lived in Peru, began to migrate to the Alto Solimões and joined the Tikuna in rubber tapping. Historical and anthropological records indicate that during this period the indigenous population was intensely exposed to violence and disease, the consequences of which are still observable today.

With the end of the rubber cycle, the indigenous peoples of the region began to organize themselves autonomously and live from a subsistence economy. In Brazil, it was during this period that indigenous agencies began to operate in the region, as is the case of the Indigenous Protection Service (SPI), today FUNAI, thus forming a new cycle of relations with external agents, in this case governmental agents.

Today, fishing is one of the most important productive activities for the Tikuna and other people of the region, with fish being the main source of protein. The basis of their diet is fish with manioc flour, which is complemented with other products from family farming, such as bananas, fruits harvested and food purchased in the city, such as rice, coffee, pasta and cookies. Like other indigenous people, there is little monetary movement among them; however, they trade and exchange some products such as manioc flour and bananas. Many indigenous people are employed in public functions such as health and education, and receive some financial benefits from social security policies, such as retirement.

The Tikuna language is widely spoken by tens of thousands of inhabitants whose communities are distributed in three countries: Brazil, Peru, and Colombia. In the villages on the Brazilian side, the intensive use of the Tikuna language is not threatened by the proximity of the cities or by coexistence with speakers of other languages within their own area. The Kokama language, of Tupi origin, has been replaced mainly by Portuguese in Brazil or Spanish in Peru and Colombia.

As far as inter- and intra-ethnic political relations are concerned, the indigenous peoples in Colombia are organized more autonomously than in neighboring countries. Each indigenous people in Colombian territory is traditionally represented from their own structures that were inherited thousands of years ago by their ancestors, however under the recognition of the government in the legal figure of partialities or Cabildos (administrative authority representative of the indigenous community).

SOCIO-ECONOMIC PROCESSES

Transboundary flows and intense presence of illegal activities

The geographic position of the triple Amazonian border, in the middle of large rivers, without roads and poor means of communication, propitiates the distancing of local municipalities from their national political centers. However, the presence of two international airports, one in Leticia and the other in Tabatinga, makes the region an important point of displacement between countries, which has propitiated the development of tourism in Leticia and an easier displacement of public agents to the region.

The border situation combined with the intense migratory flow has caused municipalities to build their own socio-economic relations over the years, as is the case of the municipality of Leticia (Colombia) and the city of Tabatinga (Brazil), or the municipality of Puerto Nariño (Colombia) and the city of Caballo Cocha (Peru). However, the region’s economic and social development indicators are very low compared to the national and even state/departmental averages.

The low social and economic development of the region has favored the intense presence of illegal activities. Constant reports from indigenous leaders and public officials indicate that many indigenous communities in the region have been atomized or displaced due to the presence of armed conflicts, drug trafficking, and other illegal activities. This context exposes the indigenous population to situations of extreme vulnerability and violence, and weakens their traditional socio-cultural practices.

In Brazil, the abundance of fish resources in the Alto Solimões region and the cultural traits of the Amazonian populations place fishing in a prominent position in terms of local income and employment generation, besides being the main source of protein for the population. Most of the fish comes from the Brazilian rivers and goes to Leticia, where a small portion is for local consumption, and most of it is transported to Bogotá by plane in order to supply the Colombian domestic market, but also for export to several countries. In this way, in many municipalities of Alto Solimões, fish farming has been emerging as an economic alternative, appearing as a strong potential for economic income for the region; however, on the other hand, the lack of presence of public agencies for regulation and inspection of fishing has propitiated its illegal practice within indigenous territories.

EPIDEMIOLOGICAL PROFILE AND ASSISTANCE

Persistence of infectious diseases and social conditions of the population

Regarding the indigenous population on the Brazilian side, it was observed that the most common health problems are related to infectious and parasitic diseases – evidence of a historical process that so far has not been overcome by the health interventions adopted. Within this group of diseases, respiratory infections are the most frequent and were identified in all age groups throughout the life cycle, however with a much greater repetition in the group from 1 to 4 years, especially in those under 1 year old.

Despite advances in clinical interventions, the persistence of infectious diseases is associated with the social conditions of the population, especially external factors that impact the socioeconomic models of subsistence, such as the type and use of housing (climate protection, collective housing, domestic overcrowding, etc.), the consumption and sanitation of water – usually contaminated – in addition to other environmental impacts such as deforestation.

Acute respiratory diseases are also among the main causes of death in the three countries. These pathologies have an important component of association with health determinants related to the population’s living conditions. Most cases occur during the Amazonian “winter”, a time when heavy rains and flooding occur in the region. Similarly, the humidity increases and a slight cold comes, which affects mainly the most vulnerable groups (children under 5, the elderly, the chronically ill, etc.). Therefore, respiratory diseases are the main cause of infant mortality both in the Department of Loreto and in Leticia, Puerto Nariño, and for the indigenous population of Alto Solimoes.

Considerable records of tuberculosis have also been observed in the region. In Peru, the Department of Loreto concentrates one of the largest cases of tuberculosis in the country. In Brazil, the state of Amazonas has the third highest mortality rate from the disease in the national territory, and in Leticia, tuberculosis appears in third place among the causes of mortality from communicable diseases.

Among protozoan infections, the most important corresponds to the diagnosis of Malaria. However, the indicators are positive regarding this endemic disease in the region. The population of the analyzed municipalities of the upper Solimões River, as well as the region of Loreto, in Peru, have shown a significant tendency to decrease the number of malaria cases.

Neoplasms are also among the main causes of death in Leticia, Puerto Nariño, Loreto Department, and Amazonas State, Brazil, where the disease is configured as the main cause of death in the 30 to 69 age group, especially malignant tumors of the cervix.

HEALTH SYSTEMS

Health infrastructure in the region

In Alto Solimões, Brazil, the health facilities that provide outpatient and inpatient care to the general population are the health posts, basic health units, the Emergency Care Unit (UPA), general hospitals, and some outpatient clinics, the first two being establishments exclusively for primary care. Most facilities are under municipal management. The only facility with higher resolution is the Hospital de Guarnição de Tabatinga (HGUT) linked to the Brazilian Army that has 05 beds for low complexity treatment and no ICU beds. The hospital does not provide elective surgeries, only emergencies. Therefore, patients who need ICU beds and/or elective surgeries are referred to Manaus.

Health care for indigenous peoples is operationalized in the context of the Indigenous Health Care Subsystem (SASISUS), constituted, in the region, by the Special Indigenous Health District Alto Rio Solimões (DSEI ARS) – a structured network of operational and administrative units coordinated by the Ministry of Health. The strong presence of Community Health Agents (ACS) and Indigenous Health Agents (AIS) in communities throughout the region is also noteworthy.

Colombia has a health system based on a management model that combines public funding and private insurers. The insurers take care of individual services, such as outpatient consultations and family care, while the municipalities and departments are responsible for collective services, such as health surveillance. As for the provision of services in the region, the public network of the Amazonas Department has two hospitals: Hospital San Rafael de Letícia, which is the only institution that offers second level care in the department, and another hospital located in the municipality of Puerto Nariño that provides first level services and emergency care. Highly complex demands are resolved in the large urban centers of Bogotá, Neiva, and Villavicencio. The health centers offer basic care services and depend financially and administratively on the departmental government to serve the population, including the indigenous population. Some health centers cover the rural area, but the non-municipal indigenous areas are not covered by the service.

On the Peruvian side, in Mariscal Ramón Castilla, most of the health facilities have only nursing technicians and health agents. In the province there are 20 Health Posts and 05 outpatient Health Centers, all focused on the first and second level of care. There is no hospital in Ramón Castilla, and the closest one is in Iquitos, approximately 330 km from the river. The Community Health Agents are part of the Primary Care policy in Peru and are present in the indigenous and non-indigenous communities of Ramón Castilla performing voluntary health promotion and disease prevention actions. Due to the lack of established human resources in difficult-to-access regions of the Amazon, as well as the scarcity of health equipment, the Peruvian state has developed the so-called Itinerant Platforms of Social Action (PIAS), which are Ships of the Peruvian Navy intended to offer social services intermittently, including health, to communities far from the main centers. However, specialized outpatient consultations and emergency care are non-existent in the region.

Current Situation

In terms of national policies, all three countries recognize health as a fundamental right from the social security perspective. The centrality of the concept of Primary Health Care appears as the organizer of the systems. Thus, the formulation of health policies values, in different degrees, the family and community component, from the territorial, multidisciplinary team, with the incorporation of community health agents and social participation, besides the formal recognition, in all countries, of the practices and knowledge of their native peoples. However, in the field of health policy implementation, the practices adopted are heterogeneous.

In terms of coverage, the Peruvian and Colombian systems are segmented, depending on insurance affiliation, which ends up being restricted to segments of the population or to a restricted package of services. In addition, it is noteworthy that, in these countries, the public sector is focused on the perspective of promotion and prevention, and the private sector is focused on individual care. It happens that, because it is a region with low economic indicators and low consumption, the private sector has no interest in expanding its services to these remote regions, and neither have the governments specialized in individual or family care, thus generating assistance gaps.

None of the three countries has shown progress in implementing intercultural practices and policies. In Colombia a possible model of an indigenous health care system has been the subject of consultation tables between indigenous organizations and government. In Brazil, there have been significant advances in the provision of services and access to health care for the indigenous population, but no innovations have been observed regarding the implementation of intercultural health approaches and models. Peru has advanced in terms of legislation with the approval and publication of the Intercultural Health Sector Policy in 2016, but the results of its implementation have yet to be observed.

Regarding the workforce, the availability, training, and engagement of professionals in the public health system represent one of the major challenges for all countries. The lack of doctors is observed throughout the region, especially in remote or disadvantaged areas. The most available senior level professional is the nurse. Countries also adopt community health workers as a link to the community, however, only in Brazil are they paid for their work.

COVID-19

The Triple Frontier has accumulated high incidence and mortality rates for COVID-19. It is noteworthy that the region presents high receptivity and vulnerability to the spread of SARS-CoV-2, due to low socioeconomic conditions, high concentration of indigenous population and other vulnerable groups, a situation that is further aggravated in view of the difficulties of access to more complex health care. In addition, the triple border region is important for the containment of pandemics within indigenous areas. Associated factors that can lead to rapid spread of the disease include:

  • Main waterway: The continuous flow of people along the Putumayo and Amazon rivers;
  • High-flow airports: international and daily movement of people at the Leticia/CO and Tabatinga/BR airports.
  • Concentration of problems common to border areas: high population mobility, disorderly occupation, and difficulty of access to health care by foreigners;
  • Institutional isolation: lack of roads and means of transportation and communication;
  • Lack of specialized health centers: lack of medical infrastructure and ICU beds;
  • Large, diverse, and dispersed indigenous population: an important part of the regional population is indigenous, belonging to several linguistic families with their own cultural patterns; and
  • Twin cities: the cities of Tabatinga/BR and Leticia/CO have an integrated territorial area, but with different public policies and protocols.

Also, considering that the triple border area is close to areas with the presence of isolated peoples, the region must be considered as an important area for epidemiological surveillance for the protection of the health of these peoples.

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