Abstract

Epidemiological surveys by ethnic groups are scarce in Brazil. The health and nutrition conditions of indigenous peoples who face situations of social inequities and inequalities, negatively influence their health indicators. This study is the widest investigation on the subject ever carried out on the Baniwa ethnic group, one of the most numerous in the country. The survey aimed to analyze the living conditions and nutritional profile of children aged under 60 months and women aged 14 to 49 years of the Baniwa ethnic group, residing in the northwest region of the state of Amazonas, in the Indigenous Land of Alto Rio Negro, an area that serves as a border connecting Brazil, Colombia, and Venezuela. The results show a high prevalence of chronic malnutrition in 52.5% (95%CI 48.9-56.1) and anemia in 68.3% (95%CI 64-5-71.8) of children under 60 months, in addition to overweight in 26.3% (95%CI 18.4-27.0) and anemia in 52.3% (95%CI 43.6-53.6) of the women. The situations of food insecurity observed in this study are linked to poor income and sanitation conditions. The magnitude of these injuries expresses the low effectiveness of primary care actions offered by the health system, with a significant percentage of hospitalizations resulting from injuries sensitive to basic care at the primary care level.

Key words:
Health of Indigenous peoples; Nutritional status; Maternal health; Child health; Amazon

Introduction

Surveys aimed at characterizing health and nutritional conditions carried out in the Brazilian population in recent decades have demonstrated a decline in nutritional issues, such as a decrease in malnutrition and anemia, in parallel with an accelerated increase in chronic Noncommunicable Diseases (NCDs), with an emphasis on obesity, cardiovascular diseases (CVDs), and diabetes mellitus¹1 Castro IRR, Anjos LAD, Lacerda EMA, Boccolini CS, Farias DR, Alves-Santos NH, Normando P, Freitas MB, Andrade PG, Bertoni N, Schincaglia RM, Berti TL, Carneiro LBV, Kac G. Nutrition transition in Brazilian children under 5 years old from 2006 to 2019. Cad Saude Publica 2023; 39(2):e00216622.

2 Freitas MB, Castro IRR, Schincaglia RM, Carneiro LBV, Alves-Santos NH, Normando P, Andrade PG, Kac G. Characterization of micronutrient supplements use by Brazilian children 6-59 months of age: Brazilian National Survey on Child Nutrition (ENANI-2019). Cad Saude Publica 2023; 39(2):e00085222.^-33 Instituto Brasileiro de Geografia e Estatística (IBGE). Evolução dos indicadores de qualidade de vida no Brasil com base na Pesquisa de Orçamentos Familiares. Rio de Janeiro: IBGE; 2023..

Compared to what is observed for the Brazilian population in general, the health and nutritional conditions of Indigenous peoples who face social and health inequities and inequalities are less known, which negatively influence their health indicators¹1 Castro IRR, Anjos LAD, Lacerda EMA, Boccolini CS, Farias DR, Alves-Santos NH, Normando P, Freitas MB, Andrade PG, Bertoni N, Schincaglia RM, Berti TL, Carneiro LBV, Kac G. Nutrition transition in Brazilian children under 5 years old from 2006 to 2019. Cad Saude Publica 2023; 39(2):e00216622.^,44 Garnelo LM, Macedo G, Brandão LC. Os povos indígenas e a construção das políticas de saúde no Brasil. Brasília: OPAS; 2003.^,55 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.. Studies conducted with Indigenous peoples in Brazil have pointed to the persistence of a high prevalence of chronic malnutrition and anemia in children⁶6 Santos RV, Welch JR, Pontes AL, Garnelo L, Cardoso AM, Coimbra Jr CEA. Health of Indigenous peoples in Brazil: Inequities and the uneven trajectory of public policies. In: McQueen D, editor. Oxford Research Encyclopedias of Global Public Health. Oxford: Oxford University Press; 2022. p. 1-33., concurrent with the rapid nutritional transition that is reflected in the high prevalence of excess weight, diabetes mellitus, and high blood pressure in adults⁷7 Ferreira AA, Santos RV, Souza JAM, Welch JR, Coimbra CEA. Anemia e níveis de hemoglobina em crianças indígenas Xavante, Brasil Central. Rev Bras Epidemiol 2017; 20(1):102-114.

8 Escobar AL, Santos RV, Coimbra Jr CEA. Avaliação nutricional de crianças indígenas Pakaanóva (Wari'), Rondônia, Brasil. Rev Bras Saude Mater Infant 2003; 3(4):457-461.

9 Pantoja L de N, Orellana JDY, Leite MS, Basta PC. Cobertura do Sistema de Vigilância Alimentar e Nutricional Indígena (SISVAN-I) e prevalência de desvios nutricionais em crianças Yanomami menores de 60 meses, Amazônia, Brasil. Rev Bras Saude Mater Infant 2014; 14(1):53-63.^-1010 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388.. At the same time, infectious and parasitic diseases persist in the epidemiological scenario, with diarrhea and acute respiratory infections standing out as the main causes of illness and death in children under five years of age¹¹11 Cardoso AM, Horta BL, Santos RV, Escobar AL, Welch JR, Coimbra CE Jr. Prevalence of pneumonia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. Int Health 2015; 7(6):412-9.^,1212 Escobar AL, Coimbra CE Jr, Welch JR, Horta BL, Santos RV, Cardoso AM. Diarrhea and health inequity among Indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. BMC Public Health 2015; 15(1):191..

The 1^st National Health and Nutrition Survey of Indigenous Peoples in Brazil, the only nationwide survey that focused on the Indigenous population in the country, evidenced the marked inequality that separates them from the non-Indigenous contingent of the population⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.. Without denying the relevance of producing nationwide data on the health and nutritional conditions of Indigenous peoples in the country, investigations focusing on local contexts can also potentially deliver information that enables the identification of intra-regional inequalities and ethnic singularities. Furthermore, there are not enough epidemiological studies representative of ethnic groups as a whole. This investigation aimed to analyze the living conditions and nutritional profile of children under 60 months and women aged 14 to 49 years in the Baniwa ethnic group, from the Northwest region of the state of Amazonas. This is the most extensive investigation on the subject ever conducted regarding this specific ethnic group, one of the most numerous in the country.

Population and methods

The Baniwa people live in villages distributed along the Içana River, a tributary of the Rio Negro in the Alto Rio Negro Indigenous Lands (I.L.), municipality of São Gabriel da Cachoeira, state of Amazonas, in a border area connecting Brazil, Colombia, and Venezuela¹³13 Garnelo L, Diniz L, Sampaio S, Silva A. Ambiente, saúde e estratégias de territorialização entre os índios Baniwa do Alto Rio Negro. Tellus 2010; 18:39-63.^,1414 Wright RM. História indígena e do indigenismo no Alto Rio Negro. São Paulo: Instituto Socioambiental; 2005. (Figure 1).

The Baniwa population receives medical care from the Indigenous Health Subsystem through the Alto Rio Negro Special Indigenous Health District (DSEI-ARN), which has five operational units, the base hubs (Camarão, Tunuí, Tucumã, São Joaquim, and Canadá), on the land occupied by the Baniwa. Each base hub provides care to the main village and a group of smaller villages attached to it, forming five health microregions equivalent to the traditional territorial distribution of Baniwa kinship groups.¹³13 Garnelo L, Diniz L, Sampaio S, Silva A. Ambiente, saúde e estratégias de territorialização entre os índios Baniwa do Alto Rio Negro. Tellus 2010; 18:39-63. The reference care system is located in the municipal headquarters of São Gabriel da Cachoeira. It also provides banking and other public institution services, in addition to commercial establishments used by Indigenous people.

The study population was selected based on a list produced by the Indigenous Health Care Information System of the Rio Negro Special Indigenous Health District which, in January 2009, totaled 5,980 individuals. The Camarão microregion, closest to the municipal headquarters, had 21 villages and 1,622 Indigenous residents; Tunuí had 14 villages, and 1,576 residents; Tucumã had 17 villages, and 1,088 Indigenous people; Canadá had 18 villages and 1,694 Indigenous people; and São Joaquim had 19 villages and 1,186 Indigenous people. Women of childbearing age (14-49 years) made up 22.8% of the population (n = 1,366) and children < 60 months represented 15.5% (n = 930)¹⁵15 Fundação Nacional de Saúde (FUNASA). Plano Distrital 2008 a 2010 do Distrito Sanitário Especial Indígena do Alto Rio Negro-2006. Brasília: FUNASA/MS; 2009..

A stratified probabilistic sample was calculated for the set of Baniwa villages and by microregion, estimated based on the size of the target population in each microregion with a prevalence of 50% for all endpoints, a relative precision of 5%, and a 95% confidence level (95% CI). The estimated sample size was increased by 20% to reduce the impact of potential losses.

Villages with less than 2 families (n = 4) and those that did not have children < 60 months or women aged 14 to 49 years (n = 6) were excluded from the sample calculation. The five host villages of the base hubs were left out of the draw and were included in the study population a priori. At the end of this phase, 78 villages remained on the list for sample calculation purposes. The selection followed sequential Poisson sampling criteria. For the selection of women and children, out study estimated the need to include in the sample at least 602 Baniwa women and 450 children, residents of the sampled villages, based on data from the DSEI -RNA Indigenous Health Care Information System (Sistema de Informação da atenção à Saúde Indígena - SIASI).

Data collection was carried out between 2011 and 2013, guided by the procedures used in the 1^st National Survey of Health and Nutrition of Indigenous Peoples in Brazil⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52., seeking to achieve data comparability. The questionnaires contained variables for village, household, women, and children. Living conditions and socioeconomic profiles were investigated, using household sociodemographic variables, such as the total number of residents in the household, sources of income and food consumed, asset rate, and sanitation conditions. The asset rate calculation was also based on the methodology of the 1^st Survey (Coimbra et al.⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.), whose measurement of durable goods available in each household formed a correlation matrix between the numbers of items found. The sum and relative contribution of each durable good supported the formulation of scores that guided the classification of households into tertiles (1^st tertile - lowest sum of goods; 2^nd tertile - intermediate sum; and 3^rd tertile - highest sum of goods), by microregion.

The nutritional profile was obtained through anthropometric measurements taken by two trained evaluators (Lohman et al.¹⁶16 Lohman TG, Roche A, Martorell R. Anthropometric Standartization Reference Manual. Champaign: Human Kinetics Books; 1988.). Height was measured using a portable anthropometer AlturaExata (Belo Horizonte, Brazil), with an accuracy of 0.1 cm. The same anthropometer was used to measure the length of children < 24 months of age. Weight was measured with a portable digital scale (Seca 872, Hamburg, Germany), with a capacity of 150 kg and precision of 100 g., The mother/child function of the same scale was used for children < 2 years of age.

Hemoglobin concentration in children (ages ≥ 6 months and < 5 years of age) and women (aged 14-49 years) was measured by drawing a drop of capillary blood with finger sticks, using disposable lancets and an Accu-Chek Softclix lancing device (Roche, Mannheim, Germany) and portable hemoglobinometers (HemoCue Hb 201+, Ängelholm, Sweden). Children with hemoglobin levels < 11.0 g/dL were considered anemic and levels < 9.5 g/dL were considered indicative of moderate/severe anemia; women were considered to have anemia with hemoglobin levels < 12.0 g/dL for those over 14.0 years of age and < 11.0 g/dL for pregnant women¹⁷17 World Health Organization (WHO). Iron deficiency anaemia: assessment, prevention and control. Vol. 1. Geneva: WHO/NHD; 2001..

The Anthro software was used to calculate anthropometric indicators, using data on children’s height, weight, and age to estimate height-for-age (H/A), weight-for-age (W/A), and body mass index-for-age (BMI/A), according to the cutoff points proposed by the World Health Organization (WHO) for diagnosing malnutrition¹⁸18 World Health Organization (WHO). WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva: WHO; 2006.. Women’s BMI was calculated and the WHO¹⁹19 World Health Organization (WHO). Physical status:the use of and interpretation of anthropometry. Geneva: WHO; 1995. cutoff points were used for diagnosing underweight, overweight, and obesity.

The population characteristics were described by absolute and relative frequencies, with statistical weighting. Their respective 95% CIs were estimated considering the effect of the stratified probabilistic sample study design. Calculations were performed in IBM SPSS Statistics 22.0 (IBM Corp, Armonk, NY, USA).

The research was approved by the Research Ethics Committee of the Federal University of Amazonas and by the National Research Ethics Committee (CAAE-0337.0.115.115-10). All legal procedures for obtaining consent were followed.

Results

The final sample of the study consisted of 26 villages: 6 in the Camarão microregion, 4 in Tunuí, 5 in Canadá, 4 in Tucumã, and 7 in São Joaquim. Among the sample of households, 361 participated (86.8% of what was planned), and none refused. The inclusion of 602 women, aged 14 to 49 years, and 450 children, aged < 60 months, was planned, with data being obtained for 577 (95.8%) and 376 (83.6%), respectively. The stratified calculations for women and children, according to the planned and actual sample microregions, are shown in Table 1.

The highest percentage of losses occurred in São Joaquim (24.8% losses for the child population), due to the impossibility of geographic access to one of the selected villages. Camarão had 23.6% losses, due to the absence of residents during the collection period.

The median number of residents per household was 6 people. The Canadá microregion had the highest density of people per household (median = 8 and mean = 7.71). For the set of women, the median was one woman per household, with a maximum number of five women per household, except in the Canadá microregion (median = 2). As for the children, in all microregions, the median was one per household, with a maximum of four children per household in Camarão.

The socioeconomic profile of the households (Table 2) showed that the majority had dirt floors (75.3%), with slightly lower percentages being recorded in the two microregions closest to the municipal headquarters (namely, Camarão - 62.2% and Tunuí - 67.2%). The majority of houses had wattle and daub/adobe walls (64.7%) and thatched roofs (61.4%), with lower percentages in Canadá (32.0% of wattle and daub/adobe walls) and Tunuí (47.5% of thatched roofs).

In the distribution of the household goods rate, 36.3% of households were found in the 1^st tertile of the sum of goods. The proportion of households with social security beneficiaries was 20.5% for all microregions. This percentage was lower in Tunuí (9.5% of retirees) and higher in Canadá (27.0%) (Table 2). In approximately half of the sampled households (55.8%), their residents were enrolled in a government social benefit program. In two of the five microregions in the study, this percentage exceeded 65.0% (Camarão with 66.1% and Canadá with 65.7%). For this variable, geographic distance was irrelevant, since the percentage reached by residents in São Joaquim, the furthest microregion from the municipal headquarters, was slightly higher (48.3%) than that achieved in other microregions comparatively closer to the city, such as Tunuí (42.6%) and Tucumã (46.1%).

Respondents pointed out the production of food resources in the territory itself as significant: 98.2% of households cultivate or raise animals and in around 97% hunting, fishing, and food collection activities are carried out (data not tabulated). The number of households (95.2%) reporting the consumption of processed foods was high, while the proportion of respondents (7.0%) who reported receiving donated food was low.

As for sanitary conditions (Table 3), water from the river was referred to as the main source for domestic consumption (76.7%), and, in the microregions furthest from the municipal headquarters, this reached 100%. Almost all of the interviewees (97.6%) declared that they defecate in the open. Electricity is discontinuous in most households (59.3%), and 40.7% did not have electricity. In the Tucumã microregion, this percentage rose to 73.1% of the participants without electricity in their homes. Charcoal or firewood burned outside the home (58.4%) were the main fuels used in cooking food among the Baniwa.

Table 4 highlights the main nutritional problems found among Baniwa women and children. Overweight and obesity were identified in 26.3% and 4.6% of women, respectively. Canadá and Camarão stood out for the highest overweight frequencies (36.0% and 32.1%). The microregions closest to the municipal headquarters, Camarão and Tunuí, had higher obesity rates, 7.5% and 7%, respectively. The proportion of women with anemia was 52.3% and varied little between microregions, except for Canadá (71.5%).

More than half of the children < 60 months (52.5%) had low height-for-age, with reduced variation between microregions, and 11.2% had low weight-for-age. No cases of overweight or obesity were found in children (data not tabulated). The frequency of anemia in children was 68.3%, with emphasis on Tunuí, where 75.3% of children were anemic. The main self-reported causes of hospitalization among hospitalized children were diarrhea (45.1%) and acute respiratory infections (35.0%).

Discussion

In addition to providing a detailed overview of the living and health conditions of the Baniwa, based on a statistically representative sample, the findings provided comparisons with previous research that focused on Indigenous peoples on a national scale, as occurred in the 1^st National Health and Nutrition Survey of Indigenous Peoples.

The Alto do Rio Negro region has been the focus of important investigations over the last few decades¹⁴14 Wright RM. História indígena e do indigenismo no Alto Rio Negro. São Paulo: Instituto Socioambiental; 2005., both from an anthropological and an ecological-human point of view. Studies indicate that the forest is well preserved, but the soils are described as acidic and lacking in micronutrients essential for agriculture, conditions that also result in limited availability of game and fish²⁰20 Pimenta NC, Gonçalves ALS, Shepard GH, Macedo VW, Barnett APA. The return of giant otter to the Baniwa Landscape: a multi-scale approach to species recovery in the middle Içana River, Northwest Amazonia, Brazil. Biol Conserv 2018; 224:318-326.

21 Chernela J. Indigenous forest and fish management in the Uaupes Basin of Brazil. Cult Surviv Q 1982; 6(2):17-18.^-2222 Moran EF. Human adaptive strategies in Amazonian Blackwater Ecosystems. Am Anthropol 1991; 93(2):361-382.. The traditional Baniwa settlement pattern is characterized by low population density and spacing of villages, characteristics that contribute to reducing the depletion of land and food sources around homes¹³13 Garnelo L, Diniz L, Sampaio S, Silva A. Ambiente, saúde e estratégias de territorialização entre os índios Baniwa do Alto Rio Negro. Tellus 2010; 18:39-63.. However, changes in settlement patterns, demographic growth in villages, and recent changes in families’ economic activities have had a negative impact on production and access to traditional foods. These changes promote the consumption of processed foods and the consequent impoverishment of the diet²³23 Garnelo L, Baré GB. Comidas tradicionais indígenas do Alto Rio Negro. Manaus: EDUA; 2009.. In this context of change, the results of the present study need to be contextualized and interpreted.

This study’s results showed that the Baniwa face unfavorable income conditions, with 36.3% of households falling into the lowest tertile of the asset rate. One can question the use of consumer goods to classify the socioeconomic profile of Indigenous families. However, maintaining the same methodology used in the 1^st Survey provided a comparison of the Baniwa findings with the group of Indigenous population living in the national territory, of which 33.4% of households fall into the same tertile. This problem is exacerbated in other Indigenous populations living in the Amazon, since, according to the 1^st Survey, 50.8% of Indigenous households in the North region fall into the lower tertile⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52., putting the Baniwa in a slightly more favorable situation than their counterparts in the North.

The physical conditions of the dwellings exhibit significant differences when comparing the Baniwa with the global profile of the Indigenous population investigated by the 1^st Survey, in which 30.9% of the houses had dirt floors and 25.4% had thatched or wooden roofs⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.. The frequencies for these two characteristics were more than double in Baniwa households (75.3% and 61.4%, respectively). However, in the case of Amazonian Indigenous peoples, this characterization needs to be relativized, as the scenario found indicates that members of the group continue to use natural resources available in their territory to build homes. This condition guarantees autonomy in the management of livelihoods and allows families to channel financial resources towards other subsistence needs²³23 Garnelo L, Baré GB. Comidas tradicionais indígenas do Alto Rio Negro. Manaus: EDUA; 2009..

This reasoning does not extend to the lack of sanitation that favors the transmission of infectious and parasitic diseases associated with open defecation and consuming water of dubious drinkability. The preponderance (97.6%) of those who declared that they defecate in the open contrasts with the 30.0% of respondents to the 1^st Survey who answered affirmatively to the same question⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.. A similar proportion was obtained for the origin of water consumed in households, with 76.7% of respondents reporting that they obtain it from rivers and other watercourses, as compared to 11.6% of Indigenous households interviewed in the 1^st Survey. In this regard, 97.8% of respondents from Canadá stated that they consume water from rivers and streams; from São Joaquim, 73.3%, and from Tunuí, 67.8%, showing that exposure to waterborne diseases worsens in certain locations. In at least two of these microregions, São Joaquim and Tunuí, diarrhea was the most frequent cause of child hospitalizations (64.3% and 65.0%, respectively).

Although there are no representative studies on the frequency of intestinal parasitism in the Baniwa population as a whole, the investigation of 270 people in two Baniwa villages showed that 100% of them were infected with protozoa or helminths, with a predominance of Giardia intestinalis and Entamoeba spp. in children aged 0-12 years, confirming the need to ensure adequate sanitation²⁴24 Oliveira RA, Gurgel-Gonçalves R, Machado ER. Intestinal parasites in two indigenous ethnic groups in northwestern Amazonia. Acta Amaz 2016; 46(3):241-246..

The geographic barriers faced by Indigenous populations in the Amazon have been identified as factors limiting access to health care, as they restrict the provision of care infrastructure and allocation of healthcare professionals, limiting the quality and effectiveness necessary for health care²⁵25 Garnelo L, Sousa ABL, Silva CO. Regionalização em saúde no Amazonas: avanços e desafios. Cien Saude Colet 2017; 22(4):1225-1234.. In Baniwa lands, the large geographic extension and 14 large waterfalls make travel more expensive, making it difficult to internalize public policies and provide regular assistance. These conditions also affected data collection for this research, due to difficulties in accessing more distant villages. Such conditions contribute to an increase in hospitalizations for conditions sensitive to primary care, such as diarrhea, having a negative impact on the nutritional status of children.

The percentage of overweight (26.3%) and obesity (4.6%) among Baniwa women was lower than the levels usually reported in the national literature for Indigenous populations in this age bracket²⁶26 Welch JR, Ferreira AA, Santos RV, Gugelmin SA, Werneck G, Coimbra Jr CEA. Nutrition transition, socioeconomic differentiation, and gender among adult Xavante Indians, Brazilian Amazon. Hum Ecol 2009; 37(1):13-26.

27 Lourenço AEP, Santos RV, Orellana JDY, Coimbra Jr CEA. Nutrition transition in Amazonia: Obesity and socioeconomic change in the Suruí Indians from Brazil. Am J Hum Biol 2008; 20(5):564-571.

28 Fávaro TR, Santos RV, Cunha GM, Leite IC, Coimbra Jr CEA. Obesidade e excesso de peso em adultos indígenas Xukuru do Ororubá, Pernambuco, Brasil: magnitude, fatores socioeconômicos e demográficos associados. Cad Saude Publica 2015; 31(8):1685-1697.

29 Gimeno SGA, Rodrigues D, Canó EN, Lima EES, Schaper M, Pagliaro H, Lafer MM, Baruzzi RG. Cardiovascular risk factors among Brazilian Karib indigenous peoples: upper Xingu, Central Brazil, 2000-3. J Epidemiol Community Health 2009; 63(4):299-304.^-3030 Coimbra Jr CEA, Tavares FG, Ferreira AA, Welch JR, Horta BL, Cardoso AM, Santos RV. Socioeconomic determinants of excess weight and obesity among Indigenous women: findings from the First National Survey of Indigenous People's Health and Nutrition in Brazil. Public Health Nutr 2021; 24(7):1941-1951.. However, the percentage values ​​for overweight and obesity are similar to the numbers found in the 1^st Survey for Indigenous women in the North region of Brazil⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52..

Conversely, anemia affected more than half of Baniwa women (52.3%), confirming the findings of high prevalence of this condition among Indigenous women in the North region of Brazil.³¹31 Borges MC, Buffarini R, Santos RV, Cardoso AM, Welch JR, Garnelo L, Coimbra Jr CEA, Horta BL. Anemia among indigenous women in Brazil: findings from the First National Survey of Indigenous People's Health and Nutrition. BMC Womens Health 2016; 16:7. The values ​​found in the present study are almost double the prevalence of anemia in non-Indigenous women in the country³²32 Brasil. Ministério da Saúde (MS). Pesquisa nacional de demografia e saúde da criança e da mulher: PNDS 2006, dimensões do processo reprodutivo e da saúde da criança. 1. ed. Brasília: MS; 2009..

In Brazil, there are few investigations into the concomitant occurrence of maternal and child anemia, making it impossible to outline a general scenario on the topic. However, the long-term consequences of anemia for maternal and child health are well established.³³33 Perez EM, Hendricks MK, Beard JL, Murray-Kolb LE, Berg A, Tomlinson M, Irlam J, Isaacs W, Njengele T, Sive A, Vernon-Feagans L. Mother-infant interactions and infant development are altered by maternal iron deficiency anemia. J Nutr 2005; 135(4):850-855. The few available data point to the importance of this association, as occurs among Suruí women with more than one anemic child. aged 6 to 35 months, who are three times more likely to be anemic than those without anemic children³⁴34 Orellana JDY, Cunha GM, Santos RV, Coimbra Jr CEA, Leite MS. Prevalência e fatores associados à anemia em mulheres indígenas Suruí com idade entre 15 e 49 anos, Amazônia, Brasil. Rev Bras Saude Mater Infant 2011; 11(2):153-161.. A nationwide study, derived from the 1^st Survey, also found concomitant anemia in 29.4% of women of childbearing age and their children³¹31 Borges MC, Buffarini R, Santos RV, Cardoso AM, Welch JR, Garnelo L, Coimbra Jr CEA, Horta BL. Anemia among indigenous women in Brazil: findings from the First National Survey of Indigenous People's Health and Nutrition. BMC Womens Health 2016; 16:7.. In Acre³⁵35 Oliveira CSM, Cardoso MA, Araújo TS, Muniz PT. Anemia em crianças de 6 a 59 meses e fatores associados no Município de Jordão, Estado do Acre, Brasil. Cad Saude Publica 2011; 27(5):1008-1020., a higher prevalence of anemia was found among children whose mothers were anemic. There is also no information on a national scale among non-Indigenous families, but a study carried out in Pernambuco indicated the coexistence of 16.4% of anemic mothers and a prevalence of anemia of 34.4% among their children, with a positive association also being observed with low-income conditions, a large number of residents, and precarious conditions in the households studied³⁶36 Miglioli TC, Brito AM, Lira PIC, Figueroa JN, Batista Filho M. Anemia no binômio mãe-filho no Estado de Pernambuco, Brasil. Cad Saude Publica 2010; 26(9):1807-1820..

Among the Baniwa, the distribution of anemia in women, according to microregions, was highest in Canadá, where mothers and children have anemia percentages of 71.5% and 72.1%, respectively. This microregion has the highest number of residents (median of 8) per household and almost half of the households analyzed (44.4%) fall into the worst tertile of the asset rate. The socio-sanitary indicators of the Canadá microregion appear to be more compromised overall when compared to the others. The variables selected for the study did not allow for more detailed reasons to explain such findings.

For Baniwa children < 60 months, the weight-for-age deficit, with a prevalence of 11.2%, is double the percentage of 5.9% found in the 1^st Survey for the entire Indigenous child population of the country⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.. However, it is a value close to that reported for Indigenous children in the North region (11.4%).³⁷37 Horta BL, Santos RV, Welch JR, Cardoso AM, Santos JV, Assis AMO, Lira PC, Coimbra Jr CE. Nutritional status of indigenous children: findings from the First National Survey of Indigenous People's Health and Nutrition in Brazil. Int J Equity Health 2013; 12:23. On the other hand, Baniwa children have a prevalence of underweight up to 4-fold higher than non-Indigenous children¹1 Castro IRR, Anjos LAD, Lacerda EMA, Boccolini CS, Farias DR, Alves-Santos NH, Normando P, Freitas MB, Andrade PG, Bertoni N, Schincaglia RM, Berti TL, Carneiro LBV, Kac G. Nutrition transition in Brazilian children under 5 years old from 2006 to 2019. Cad Saude Publica 2023; 39(2):e00216622.. This percentage value among the Baniwa exceeds the findings among Indigenous children in the Midwest, South, and Northeast regions³⁸38 Ferreira AA, Welch JR, Santos RV, Gugelmin SA, Coimbra Jr CEA. Nutritional status and growth of indigenous Xavante children, Central Brazil. Nutr J 2012; 11(1):3.

39 Kühl AM, Corso ACT, Leite MS, Bastos JL. Perfil nutricional e fatores associados à ocorrência de desnutrição entre crianças indígenas Kaingáng da Terra Indígena de Mangueirinha, Paraná, Brasil. Cad Saude Publica 2009; 25(2):409-420.^-4040 Campos SBG, Menezes RCE, Oliveira MAA, Silva DAV, Longo-Silva G, Oliveira JS, Asakura L, Costa EC, Leal VS. Short stature in children of Karapotó ethnic background, São Sebastião, Alagoas, Brazil. Rev Paul Pediatr 2016; 34(2):197-203.; among Kaingang children in the South region (with 9.2%)³⁹39 Kühl AM, Corso ACT, Leite MS, Bastos JL. Perfil nutricional e fatores associados à ocorrência de desnutrição entre crianças indígenas Kaingáng da Terra Indígena de Mangueirinha, Paraná, Brasil. Cad Saude Publica 2009; 25(2):409-420.; and among Suruí children (8.5%) in Rondônia¹⁰10 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388.. The weight deficit of Baniwa children is almost four times greater than that found in the Brazilian child population (2.9%) and the non-Indigenous child population of the North region, considering an equivalent age (2.6%), according to the national ENANI-2019 survey¹1 Castro IRR, Anjos LAD, Lacerda EMA, Boccolini CS, Farias DR, Alves-Santos NH, Normando P, Freitas MB, Andrade PG, Bertoni N, Schincaglia RM, Berti TL, Carneiro LBV, Kac G. Nutrition transition in Brazilian children under 5 years old from 2006 to 2019. Cad Saude Publica 2023; 39(2):e00216622..

The height-for-age deficit (52.5%) among Baniwa children is twice as high as the value reported for Indigenous children in Brazil (25.7%), in addition to exceeding the frequency reported for the sample from the North region, according to the 1^st Survey (40.8%)³⁷37 Horta BL, Santos RV, Welch JR, Cardoso AM, Santos JV, Assis AMO, Lira PC, Coimbra Jr CE. Nutritional status of indigenous children: findings from the First National Survey of Indigenous People's Health and Nutrition in Brazil. Int J Equity Health 2013; 12:23.. The prevalence of chronic malnutrition in Baniwa children exceeds the percentage values ​​in Indigenous communities in the North and Midwest regions, such as the Suruí (38.6%)¹⁰10 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388., the Xavante (29.9%)³⁸38 Ferreira AA, Welch JR, Santos RV, Gugelmin SA, Coimbra Jr CEA. Nutritional status and growth of indigenous Xavante children, Central Brazil. Nutr J 2012; 11(1):3., and the Wari’ (45.8%)⁸8 Escobar AL, Santos RV, Coimbra Jr CEA. Avaliação nutricional de crianças indígenas Pakaanóva (Wari'), Rondônia, Brasil. Rev Bras Saude Mater Infant 2003; 3(4):457-461.. In non-Indigenous children in Brazil, the prevalence of short height-for-age is 7.0%¹1 Castro IRR, Anjos LAD, Lacerda EMA, Boccolini CS, Farias DR, Alves-Santos NH, Normando P, Freitas MB, Andrade PG, Bertoni N, Schincaglia RM, Berti TL, Carneiro LBV, Kac G. Nutrition transition in Brazilian children under 5 years old from 2006 to 2019. Cad Saude Publica 2023; 39(2):e00216622..

The high prevalence of anemia does not differ from that indicated by other studies with Indigenous children⁷7 Ferreira AA, Santos RV, Souza JAM, Welch JR, Coimbra CEA. Anemia e níveis de hemoglobina em crianças indígenas Xavante, Brasil Central. Rev Bras Epidemiol 2017; 20(1):102-114.^,1010 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388.^,4141 Leite MS, Cardoso AM, Coimbra CE, Welch JR, Gugelmin SA, Lira PCI, Horta BL, Santos RV, Escobar AL. Prevalence of anemia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. Nutr J 2013; 12:69.. These are children who live in a region with high population mobility and suffer the environmental impacts of predatory mining, disorderly occupation of space, insufficient access to health services, and limited economic conditions⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.^,1010 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388.^,1212 Escobar AL, Coimbra CE Jr, Welch JR, Horta BL, Santos RV, Cardoso AM. Diarrhea and health inequity among Indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. BMC Public Health 2015; 15(1):191.^,4242 Barreto CTG, Cardoso AM, Coimbra Jr CEA. Estado nutricional de crianças indígenas Guarani nos estados do Rio de Janeiro e São Paulo, Brasil. Cad Saude Publica 2014; 30(3):657-662..

One of the latest national surveys that assessed the nutritional status of non-Indigenous children in Brazil indicated a frequency of 10.1% of anemia among children < 60 months in Brazil and 17.0% in the North region, for the same age group²2 Freitas MB, Castro IRR, Schincaglia RM, Carneiro LBV, Alves-Santos NH, Normando P, Andrade PG, Kac G. Characterization of micronutrient supplements use by Brazilian children 6-59 months of age: Brazilian National Survey on Child Nutrition (ENANI-2019). Cad Saude Publica 2023; 39(2):e00085222.. These results suggest an overall improvement in this health indicator in the country, despite the findings among poorer communities in the Amazon³⁵35 Oliveira CSM, Cardoso MA, Araújo TS, Muniz PT. Anemia em crianças de 6 a 59 meses e fatores associados no Município de Jordão, Estado do Acre, Brasil. Cad Saude Publica 2011; 27(5):1008-1020., indicating a high prevalence of anemia, suggesting the persistence of intra-regional and inter-ethnic inequalities, since the data available for the Indigenous population show an even higher prevalence of this condition.

In the Baniwa Indigenous lands, more than half of children, aged < 60 months, have anemia (68.3%). In the distribution by micro-regions, it is clear that in two of them (Tunuí and Canadá) the percentage of affected children exceeds 70%. These values ​​are much higher than the 51.2% of anemic children found in the Indigenous child population as a whole in Brazil and are close to the prevalence of anemia in the Indigenous population of the North region (66.4%)⁴¹41 Leite MS, Cardoso AM, Coimbra CE, Welch JR, Gugelmin SA, Lira PCI, Horta BL, Santos RV, Escobar AL. Prevalence of anemia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. Nutr J 2013; 12:69.. The Baniwa findings are similar to the results of other research in specific Indigenous communities, with prevalence rates exceeding 60% of children in the same age group in the North macro-region, as in the case of the Suruí peoples¹⁰10 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388.. They also match findings among Indigenous people from the Midwest (Kamaiurá⁴³43 Mondini L, Canó EN, Fagundes U, Lima EES, Rodrigues D, Baruzzi RG. Condições de nutrição em crianças Kamaiurá: povo indígena do Alto Xingu, Brasil Central. Rev Bras Epidemiol 2007; 10(1):39-47. and Terena⁴⁴44 Morais MB, Alves GMS, Fagundes Neto U. Nutritional status of Terena Indian children from Mato Grosso do Sul, Brazil: follow up of weight and height and current prevalence of anemia. J Pediatr (Rio J) 2005; 81(5):383-389.) and Northeast⁷7 Ferreira AA, Santos RV, Souza JAM, Welch JR, Coimbra CEA. Anemia e níveis de hemoglobina em crianças indígenas Xavante, Brasil Central. Rev Bras Epidemiol 2017; 20(1):102-114.^,4545 Pereira JF, Oliveira MAA, Oliveira JS. Anemia em crianças indígenas da etnia Karapotó. Rev Bras Saude Mater Infant 2012; 12(4):375-382.. These rates are much higher than the 40% that, according to international criteria adopted by the WHO¹⁹19 World Health Organization (WHO). Physical status:the use of and interpretation of anthropometry. Geneva: WHO; 1995., allow such findings to be classified as a serious public health problem.

Hospitalizations due to respiratory infections are also considered indicative of low effectiveness of primary care actions¹¹11 Cardoso AM, Horta BL, Santos RV, Escobar AL, Welch JR, Coimbra CE Jr. Prevalence of pneumonia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. Int Health 2015; 7(6):412-9.. Among Indigenous children in the North, the proportion of hospitalizations due to this condition was 54.4%, while 47.6% of hospitalizations of Indigenous children in Brazil as a whole had the same cause¹¹11 Cardoso AM, Horta BL, Santos RV, Escobar AL, Welch JR, Coimbra CE Jr. Prevalence of pneumonia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. Int Health 2015; 7(6):412-9.. These values ​​exceed the percentage of Baniwa children hospitalized due to respiratory infections (35.2%), and it is not possible to distinguish whether this difference is due to a lower frequency of these illnesses in Baniwa children or to less access to hospitalization in this Indigenous territory.

Hospitalization of children due to diarrhea was around 45.1%. Diarrhea is recognized as being associated with poor sanitation conditions⁴⁶46 Caldas ADR, Nobre AA, Brickley E, Alexander N, Werneck GL, Farias YN, Garcia Barreto Ferrão CT, Tavares FG, Pantoja LDN, Duarte MCDL, Cardoso AM. How, what, and why: housing, water & sanitation and wealth patterns in a cross-sectional study of the Guarani Birth Cohort, the first Indigenous birth cohort in Brazil. Lancet Reg Health Am 2023; 21:100496. and is considered a condition that is susceptible to primary care interventions⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.^,1212 Escobar AL, Coimbra CE Jr, Welch JR, Horta BL, Santos RV, Cardoso AM. Diarrhea and health inequity among Indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. BMC Public Health 2015; 15(1):191.^,4747 Paiva RFPS, Souza MFP. Association between socioeconomic, health, and primary care conditions and hospital morbidity due to waterborne diseases in Brazil. Cad Saude Publica 2018; 34(1):e00017316.. This is a higher percentage than hospitalizations for the same cause found for all Indigenous children in the national territory (37.1%) and slightly lower than the percentage found among Indigenous people in the North region (48.4%), according to the 1^st Survey⁵5 Coimbra Jr CEA, Santos RV, Welch JR, Cardoso AM, de Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health 2013; 13(1):52.^,1010 Orellana JDY, Coimbra Jr CEA, Lourenço AEP, Santos RV. Estado nutricional e anemia em crianças Suruí, Amazônia, Brasil. J Pediatr 2006; 82(5):383-388.^,1111 Cardoso AM, Horta BL, Santos RV, Escobar AL, Welch JR, Coimbra CE Jr. Prevalence of pneumonia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition. Int Health 2015; 7(6):412-9..

Final considerations

The present study shows analyses that are representative of an ethnic group as a whole, highlighting situations of economic, food, and health vulnerability that express a compromise in Indigenous living conditions in the Amazon context and point to the lack of internalization of public policies, limited opportunities, and profound inequality when compared to the non-Indigenous population.

The high prevalence of chronic malnutrition and anemia in children under 60 months of age, associated with food insecurity, lack of sanitation, insufficient income, and ineffective primary care, is evidenced by the significant percentage of hospitalizations resulting from conditions sensitive to primary care.

Deficiency diseases such as anemia and malnutrition should not be viewed solely from a biological point of view, as they express social and health inequalities that have a profound impact on the Baniwa population, although they are not limited to them. On the contrary, these are widespread events among Indigenous and non-Indigenous Amazonian populations.

This study’s results point to an alarming situation that demands the recognition of nutritional disorders as a health problem to be prioritized by families and the Indigenous healthcare subsystem. Overcoming this challenge requires the development of actions at different levels, not restricted to health services, as environmental sustainability, food security, and access to income are intersectoral elements.

Additionally, it should be remembered that this study was conducted before the influence of global climate change on river flooding and, consequently, on food supply was acutely perceived. Recent events related to droughts in the Amazon require the intensification of actions to mitigate the vulnerabilities described here.

Acknowledgments

We wish to thank CEA Coimbra Jr and MS Leite who contributed to the process of formulating the study proposal and the preliminary versions of the manuscript. Thanks also go to FOIRN; DSEI-ARN; FAPEAM, and CNPq.

References

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History