Rivers, rainforest, and distance stand in the way of care in the Amazon

An MSF project in Portel, Brazil aims to overcome obstacles so Amazonian communities can access health care.

MSF teams travel by boat to reach Amazonian riverside communities in Brazil.

Brazil 2023 © Diego Klein/MSF

Distance is a relative concept to the people of Portel, a district of the Marajó Island region in the northern Brazilian state of Pará. Simple questions have no obvious answer—such as how long it takes to get from town to riverside communities in the heart of the Amazon.

Along the waterways, travel times can change based on the type of boat used, the weather, and the tides. To get to Portel from the state capital, Belém, it generally takes at least 15 hours by catamaran, despite being less than 170 miles apart. From Portel, it can take up to 18 hours to reach the Ribeirinhos (riverside communities), depending on the type of boat taken. 

Criss-crossed by four rivers, Portel has a population of around 62,000. Half of its people live in rural areas, in riverside and Quilombolas communities (communities formed by the descendants of formerly enslaved people). The area paints a typical Amazonian tableau: vast rivers, sticky heat, and stilt houses surrounded by tall açaí palm trees. What’s harder to see are the major barriers to accessing health care that the people of Portel face.

Doctors Without Borders/Médecins Sans Frontières (MSF) was able to observe local needs and difficulties in primary and secondary health care in the municipality in 2021 while working on COVID-19 response. During that intervention, it became clear that there was a need to improve the provision of health care for local communities. The experience also helped our team understand how to work with local authorities to improve access to health care, and led the launch of a new project in the Marajó Island region in April 2023. 

“Our aim is to improve access to health care services for people in rural areas, focusing on women and children, who are the most vulnerable groups,” says Anne Gilon, the head of MSF’s project in Portel. “We work in collaboration with the Municipal Health Department to strengthen the provision of primary health care services, reproductive and sexual health, and health care for survivors of sexual violence.” The project also includes mental health care, family planning, and health promotion, and aims to reduce mortality in the municipality.

Long distances and high costs complicate care 

The people of Portel face many challenges when it comes to accessing health care. Basic health care services are limited and the quality of primary care is poor due to the scarcity of professionals and a lack of financial resources. 

The situation is exacerbated by the area’s remoteness and reliance on river-based transport, a logistical hurdle resulting in higher costs and systemic impact on health care, from the supply of medicines to accessing specialists such as gynecologists, pediatricians, or anesthetists located in towns and cities in the region. 

Health care services that would be simple in other contexts, like following a vaccination schedule or providing routine treatment, can be challenging here. Long distances and high transport costs complicate patients’ journeys to medical facilities and health professionals’ own access to communities.

MSF’s work in the Marajó Island region

To minimize the impact of these challenges, MSF currently operates out of four basic health care units (Unidades Básicas de Saúde or UBS): Portelinha and Rural, in the urban zone; and Acutipereira and Acangatá, in the rural zone. Our teams also work at the medical center in the community of Santo Amaro.

Between September and December last year, MSF teams carried out more than 1,100 medical consultations and around 2,500 people took part in health promotion activities. We have also been supporting local authorities in the creation of systems and protocols, for example in medicine storage. In addition, MSF is also providing training for local professionals.

"We really need this service in the community because it takes us 10, 12 hours to get from here to Portel. Instead of going to the city and spending a lot of time there, the MSF team treats us here."

Maria da Conceição Raposo, a resident of the riverside community of Santo Amaro

"We really need this service in the community because it takes us 10, 12 hours to get from here to Portel,” says Maria da Conceição Raposo, a resident of the riverside community of Santo Amaro. “Instead of going to the city and spending a lot of time there, the MSF team treats us here at the health center in our community, and there are always lots of people there. This is the second time I've been, but I have a brother who's been more often. He has eight children and it's very expensive to go to the city. For people who live far from the city, it's been very good. It's good for our health. It helps a lot."  

To undertake our work in the Marajó Island region, MSF relies on a multidisciplinary team in Portel comprised of 40 professionals from diverse fields including nursing, medical science, psychology, gynecology, pediatrics, health promotion, social care, and logistics, among other fields.

Health workers arrive at the Basic Health Unit of Acutipereira, in the rural zone of Portel, in the Brazilian northern state of Pará.
Portel has dealt historically with a lack of health professionals and facilities, particularly in hard-to-reach remote areas that are home to vulnerable riverside communities. Brazil 2023 © Diego Klein/MSF

Respecting communities’ traditional practices

Traditional practices and knowledge play a key role in riverside and Quilombola communities, which often find themselves in vulnerable situations. One example is the work of midwives, like Maria Dinalva do Nascimento Andrade, from the Quilombola community of São Tomé de Tauçu, located on the Acutipereira River. 

“I’ve already ‘saved’ more than 60 children,” says Dinalva as she watches children play football in the corridor of a school in the quilombo where she was born, raised, and now serves as leader. “The first time I delivered [a child], I was 15 and it was when my mother had one of my sisters.” 

Exchanges with community members like Dinalva allow MSF teams to better understand the reality of life in the Marajó Island region, which helps us to better respond to people’s health needs. 

MSF health promotion manager Felipe Euzébio talks to members of the São Tomé de Tauçu community, in the rural area of the town of Portel, in the Brazilian northern state of Pará.
MSF health promotion manager Felipe Euzébio talks to members of the São Tomé de Tauçu community in a rural area of Portel. Brazil 2023 © Diego Klein/MSF

Information is key to saving lives

Through health promotion, MSF has been working to improve local communities’ knowledge of services related to sexual and reproductive health, and the importance of consuming safe, clean drinking water. 

The ingestion of untreated water is common in the region, sourced from the world’s biggest drainage basin: the Amazon. “The water issue is very complex here,” says community health worker Rosenildo de Almeida. “A lot of people drink unsafe water that’s not for consumption, and this ends up causing a lot of avoidable problems.”

Bringing health care to Brazil's Yanomami Indigenous community

Read more

Felipe Euzébio, head of health promotion and community engagement at MSF in Portel, highlights the importance of working alongside communities and tapping into their knowledge: “It’s a two-way street: we better understand the reality of people here and therefore, we are able to deliver information which impacts and improves their health and well-being.” 

In addition to the Portel project, MSF has a project in the Yanomami Indigenous Land (Terra Indígena Yanomami), also in the Amazon region. Our professionals are working to prevent the spread of malaria and carrying out primary health care assistance in the area, which is located in the Auaris region of the Brazilian state of Roraima. The project was developed in partnership with the indigenous health division of the Brazilian Ministry of Health.