Abstract

This article aimed to discuss the processes of deter mining the environmental situation in the states that are part of the Brazilian Legal Amazon, based on the analysis of socio-economic, environmental and sanitary indicators. The indicators showed a very dynamic and heterogeneous region, with a growing population mostly concentrated in urban areas, combining economic growth and environ mental degradation associated with a rapid and precarious urbanization process, and with deve lopment projects focused on the exploitation of natural resources. The result is a complex picture of health problems, with the presence of infectious and parasitic diseases related to severe environmental changes and poor conditions of life, caused mainly by inequalities in social and economic indicators that produce vulnerabilities and negative effects on the environmental and sanitary context.

Keywords:
Living Conditions; Environmental Degradation; Environmental Health Indicators; Environmental Health

Introduction

The technical-scientific debate about the relationship between health, environment, and development in the Brazilian Amazon, available in scientific journals, is still very limited, despite the significant amount of articles that discuss the eco logical, biological, and social aspects of the region in question. In general, the articles available in these journals on health in the Amazon relate to clinical or epidemiological endemic diseases (such as malaria, dengue, leishmaniasis, and viral hepatitis). On the other hand, the articles relating to the environment and development are restricted to disciplinary ap proaches on biodiversity, land use, deforestation, and sustainable development (Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.; Confalonieri, 2005CONFALONIERI, U. E. Saúde na Amazônia: um modelo conceitual para a análise de paisagens e doenças. Estudos Avançados, São Paulo, v. 19, n. 53, p. 221-223, 2005.).

The studies that seek to multidisciplinary articu late the themes "health, environment and develop ment" in the Brazilian Amazon are rare. From elec tronic portals such as Pub-Med and SciELO, which cover a significant production of biomedical and public health essays, only three articles have been found on the subject (Briceño-León, 2007BRICEÑO-LEÓN, R. Chagas disease and globalization of the Amazon. Cadernos de Saúde Pública, Rio de Janeiro, v. 23, n. 53, p. 33-40, 2007. Suplemento 1.; Vicentin et al, 2003VICENTIN, G.; MINAYO, C. G. Saúde, ambiente e desenvolvimento econômico na Amazônia. Ciência e Saúde Coletiva, Rio de Janeiro, v. 8, n. 4, p. 1069-1085, 2003.; Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.).

Starting from the hypothesis that the economic model of development adopted in the Brazilian Amazon has produced significant environmental changes and failed to positively impact the social and health indicators, this study aims to discuss the processes of determining the social and envi ronmental situation in the states that make up the Legal Amazon, from their available socioeconomic, environmental, and health indicators. Therefore, the socio-environmental determination corresponds to the processes that, at the level of macropolitics, shape the structures of production (goods and ser vices), and distributions of wealth, simultaneously conforming environmental processes (cycles of cli mate, soil and waters, for example) and the health status of populations (Sobral; Freitas, 2010SOBRAL, A.; FREITAS, C. M. Modelo de organização de indicadores para operacionalização dos determinantes socioambientais da saúde. Saúde e Sociedade, São Paulo, v. 19, n. 1, p. 35-47.).

The choice of this region as the object of analysis is justified for presenting environmental (climate, ecosystems, and biodiversity) and demographic (sociodiversity with low density and population concentrated in the cities) peculiarities that, com bined with economic processes, such as extensive agriculture, livestock, mining, hydroelectric power plants and industries, produce effects on health conditions of populations related to its development model (Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.).

Material and methods

This study is an analysis of processes to deter mine the socio-environmental and health situation (social, economic, cultural and environmental fac tors, among others, that influence health problems in the population), as (Sobral and Freitas, 2010SOBRAL, A.; FREITAS, C. M. Modelo de organização de indicadores para operacionalização dos determinantes socioambientais da saúde. Saúde e Sociedade, São Paulo, v. 19, n. 1, p. 35-47.) stated, with the use of quantifiable variables (indi cators) and literature review.

The delimitation of the study area comprised the total area of the 9 states which make up the Legal Amazon (Acre, Amapá, Amazonas, Mato Grosso, Pará, Rondônia, Roraima, Tocantins, and Mara nhão). After this step, a bibliographical research was performed on SciELO and MEDLINE (PubMed) covering the last 10 years, using the descriptors (search terms) "health, environment and develop ment" and "Amazon". The search made up a review that identified the themes that have been prioritized in the research on the relations between health, environment, and development, to contextualize and discuss the indicators.

Subsequently, socioeconomic, environmental and health data and indicators of the region were collected. The organization of the data and the indi cators aimed to show the possible relationships and interactions between socioeconomic determinants, the environmental changes and their impacts on the exposure and direct effects to the health of the populations (Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.).

Data collection was carried out electronically via websites provided by Brazilian public institu tions. The health indicators were collected at Rede Intergerencial de Informações para o Setor Saúde (Inter-Managerial Information Network for the Health Industry - RIPSA), and the economic and social indicators in the publications of the Instituto Brasileiro de Geografia e Estatística (Brazilian In stitute of Geography and Statistics - IBGE), UNDP (United Nations Development Program), and Insti tuto Nacional de Pesquisas Espaciais (National In stitute for Space Research - INPE). The organization of data and the discussion of the study started off from the central hypothesis of the study presented in the introduction, observing the developments and comparisons of the indicators of the Brazilian Amazon (and its states) with the indicators achieved in the country, as well as the possibilities of crossing the data. The main reference when collecting the in dicators was the year of the last Population Census (2010) held in the country (IBGE, 2010IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Banco de dados agregados: 2010. Disponível em: <Disponível em: http://www.sidra.ibge.gov.br/pesquisas >. Acesso em: 5 dez. 2014.
http://www.sidra.ibge.gov.br/pesquisas... ), aiming at building a frame with separate data on its origin, however close in relation to the collection years.

Finally, it is important to consider that, if on the one hand, the systematization and analysis of secondary data and the construction of indica tors have been widely used for global analyses (of countries or even regions), allowing for a broader view about certain topics, on the other geographic spaces and public policies present limitations. The first limitation is that each piece of data used was collected and built from different patterns of quality, validity, reliability, coverage, sensitivity, and specificity, resulting from a context of great local variability in the ability to collect data, which interferes in the quality of the data. The second one is that, even though the limits indicated previously did not exist, each indicator is, by nature, a reduc tion of the complexity to a single one-dimensional value (Van Bellen, 2005VAN BELLEN, H. M. Indicadores de sustentabilidade: uma análise comparativa. 2. ed. Rio de Janeiro: FGV, 2005.).

This reality reduction feature, however, is the synthesis capability represented by the indicators, which contribute fundamentally to make studies between magnified scales possible and enable multidisciplinary analyses (Van Bellen, 2005VAN BELLEN, H. M. Indicadores de sustentabilidade: uma análise comparativa. 2. ed. Rio de Janeiro: FGV, 2005.; Corvalán et al., 2000CORVALÁN, C.; BRIGGS, D.; KJELLSTRÖM, T. The need for information: environmental health indicators. In: CORVALÁN, C.; BRIGGS, D.; ZIELHUIS, G. (Org.). Linkage methods for environment and health analysis: general guidelines. Geneva: United Nations Environmental Programme, United States Environmental Protection Agency, Office of Global and Integrated Environmental Health of the World Health Organization, 2000. p. 25-51.). In Brazil, there is a wide tradition in the production of socio-economic and demographic indicators, as well as health indica tors. Some environmental indicators, such as those that require environmental quality monitoring, are newer and have more limitations. However, in this study, even some environmental indicators, such as those related to access to water and sanita tion, are produced based in the census, therefore having better quality, periodicity and nationwide reach (IBGE, 2012IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Indicadores de Desenvolvimento Sustentável. Estudos e Pesquisas Informações Geográficas 9. Rio de Janeiro, RJ, 2012.; Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.; Corvalán et al., 2000CORVALÁN, C.; BRIGGS, D.; KJELLSTRÖM, T. The need for information: environmental health indicators. In: CORVALÁN, C.; BRIGGS, D.; ZIELHUIS, G. (Org.). Linkage methods for environment and health analysis: general guidelines. Geneva: United Nations Environmental Programme, United States Environmental Protection Agency, Office of Global and Integrated Environmental Health of the World Health Organization, 2000. p. 25-51.).

Results

Socioeconomic indicators

In the period of 2002 to 2011, with the exception of the state of Amazonas, the states of the Legal Amazon presented more than 200% increment in GDP (Gross Domestic Product). In the same period, the states of the Amazon increased their contribu tion to the national GDP, rising from 7% (2002) to 13% (2011).

In 2011, the state of Mato Grosso remained with the highest GDP per capita of the Amazon. For that indicator, the negative highlight was the state of Maranhão, which obtained the lowest GDP per capita, with the worst performance of the Country, despite being the 15^th largest GDP and having the tenth largest Brazilian population. The other states showed GDP per capita below the national average (Table 1). It is important to add that the consider able amounts of GDP affected by the Amazonian states reflect the significant growth of the Brazilian economy between the years, even in the face of the global economic crisis intensified during the period (IBGE, 2013IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Contas nacionais: 2011. Rio de Janeiro, RJ, 2013.).

Between 2000 and 2010, extreme poverty (percentage of the population with average home income per capita up to 25% of the monthly mini mum wage) of the Legal Amazon performed above the national average, despite showing a decrease of 37.4% below the national average. In the year of 2010, the state of Mato Grosso reached the low est percentage in that indicator. Now, the state of Maranhão remained with the highest rate of extreme poverty in the Amazon and the country (Table 1).

In the same period, the HDI (Human Develop ment Index) of the Legal Amazon had an increase of 0.143 points, surpassing the growth of Brazil's HDI (Table 2). It is worth pointing out that the states of the Amazon remained among the worst performances in the country. For example, the state of Maranhão presented the second worst HDI among the Brazilian states in 2010, even though it had an increase of 0.163 points in that indicator in the period studied (UNDP, 2013PNUD - PROGRAMA DAS NAÇÕES UNIDAS PARA O DESENVOLVIMENTO. Atlas do desenvolvimento humano no Brasil: 2013. Disponível em: <Disponível em: http://atlasbrasil.org/2013/consulta >. Acesso em: 15 dez. 2014.
http://atlasbrasil.org/2013/consulta... ).

For the illiteracy rate of the population with 18 years old or older, the Amazonian states showed significant declines, with amounts above 20% (Table 2). The most unfavorable performances in the national ranking were achieved by the states of Maranhão (4^th position) and Acre (7^th position). The states also showed adverse results above the national and Legal Amazon averages (Table 2) (UNDP, 2013PNUD - PROGRAMA DAS NAÇÕES UNIDAS PARA O DESENVOLVIMENTO. Atlas do desenvolvimento humano no Brasil: 2013. Disponível em: <Disponível em: http://atlasbrasil.org/2013/consulta >. Acesso em: 15 dez. 2014.
http://atlasbrasil.org/2013/consulta... ).

Environmental and sanitary indicators

In the space that surrounds the Southern and Eastern Amazon (the states of Rondônia, Mato Grosso, Tocantins, Maranhão, and Pará) the fire outbreaks, the accumulated deforestation, and the construction of highways are expanded, as well as the expansion of crop acreage and the intensifica tion of the consumption of pesticides (INPE, 2013INPE - INSTITUTO NACIONAL DE PESQUISAS ESPACIAIS. Monitoramento da floresta amazônica brasileira por satélite: 1988/2011. 2013. Disponível em: <Disponível em: http://www.obt.inpe.br/prodes/prodes_1988_2011.htm >. Acesso em: 27 dez. 2014.
http://www.obt.inpe.br/prodes/prodes_198... ; IBGE, 2012IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Indicadores de Desenvolvimento Sustentável. Estudos e Pesquisas Informações Geográficas 9. Rio de Janeiro, RJ, 2012.). For these characteristics, (Becker, 2009BECKER, B. K. Geopolítica da Amazônia. Estudos Avançados, São Paulo, v. 19, n. 53, p. 71-76,2009.) named the space as the "arc of fire". Regarding the consumption of pesticides, the indexes reached using these substances in the region were expres sive, corresponding to 18% of the national total. According to the latest figures released by the IBGE (year 2009), the state of Mato Grosso achieved the highest national index of consumption of pesticides per hectare of acreage in the Legal Amazon (IBGE, 2012IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Indicadores de Desenvolvimento Sustentável. Estudos e Pesquisas Informações Geográficas 9. Rio de Janeiro, RJ, 2012.) (Table 3).

According to the indicators, the growth data for the crop and pasture areas over the natural areas, the hotspots, and the accumulated deforestation in the Amazon have reached the highest indicators in the same "arc of fire", with a clear coincidence between the expansion of extensive farming and the defores tation with burning events and the use of pesticides (Table 3). When crossing environmental indicators (rate of deforestation and use of pesticides) with so cial indicators (extreme poverty and evolution of HDI) we observed the following discrepancies between the indicators in the periods studied: 1) The state of Mato Grosso, which reached the third largest GDP and the higher HDI of the Amazon at the end of the studied period, achieved the second highest rate of deforesta tion and use of pesticides, in addition to the second smaller development of the HDI; 2) The state of Pará, which reached the highest GDP, was the third state in the region with the highest percentage of extremely poor population, and presented the second worst HDI and the fourth lower development in this indicator, even getting the third highest rate of deforestation (Tables 1, 2, and 3).

Concerning access to basic sanitation services (water supply, sanitary sewage systems, and solid waste disposal, collection, and treatment), the Amazonian states followed the national trend, with positive increments in the period from 2000 to 2010. In 2010, the states of Rondônia, Acre and Pará reached the lowest indicators of access to water supply through the main water network (Table 3). It is worth highlighting that, although there has been an increase in access to sanitation services, the percentage of coverage of the Amazon is well below the national average (IBGE, 2010IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Banco de dados agregados: 2010. Disponível em: <Disponível em: http://www.sidra.ibge.gov.br/pesquisas >. Acesso em: 5 dez. 2014.
http://www.sidra.ibge.gov.br/pesquisas... ).

The access of households to sanitation through the general mains is still restricted in the region, with only 14% of the total number of households served. For solid waste collection, the coverage percentage was 71% of the served households. With the exception of the state of Maranhão, in all other states of the Legal Amazon the percentage was above 70% (Table 3).

Advances in access indicators related to sanita tion actions in the Amazon are expressive, especial ly regarding access to water supply services. How ever, when comparing these indicators with those of other regions, states and cities of the country and the quality of the services provided, it is observed that the region still maintains a persistent adverse situation. According to the last Pesquisa Nacional de Saneamento Básico (Basic Sanitation National Survey - PNSB) (2008), among the cities that distrib uted water without any type of treatment, the ones located in the North region (20.8% of the cities) were in evidence, where 7 states of the Legal Amazon are located. On that item, the states of Pará (40.0%) and Amazonas (38.7%) presented the most unfavorable percentages (IBGE, 2008IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa nacional de saneamento básico: 2008. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/pnsb2008/ . Acesso em: 27 dez. 2014.
http://www.ibge.gov.br/home/estatistica/... ).

The same states were those in which more than 40% of the cities pointed out instances of ration ing supplies. The most frequent reasons cited by the cities for rationing were: problems related to drought/dry weather (50.5%); insufficient water at spring (39.7%); deficiency in production (34.5%); and insufficient distribution (29.2%) (IBGE, 2008IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa nacional de saneamento básico: 2008. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/pnsb2008/ . Acesso em: 27 dez. 2014.
http://www.ibge.gov.br/home/estatistica/... ).

Regarding the disposal of solid urban waste, the access to the appropriate destination in Legal Amazon was also restricted, for in more than 70% of the cities in the disposal of households and/or public solid waste was accomplished by means of open sewers (landfill) (IBGE, 2008IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa nacional de saneamento básico: 2008. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/pnsb2008/ . Acesso em: 27 dez. 2014.
http://www.ibge.gov.br/home/estatistica/... ).

Health indicators

(Freitas and Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.) pointed out that the health status of the states of the Amazon is very heterogeneous, with expressive number of deaths by infectious and parasitic diseases. For these dis eases, the states of Acre, Amazonas, Roraima, Pará, and Maranhão reached the highest instances of the Country. However, it is possible to observe the significant occurrence of deaths by circulatory sys tem diseases, values that match the ones achieved nationally. Another important issue is the advances in notifications of external causes (injuries by accidents and violence), first cause of the deaths observed in the states of Roraima and Amapá.

For infant mortality rate, a consistent decline since the 1970s was observed in the country, and the Legal Amazon related to the expansion of mother and child health programs, especially those aimed at pre-natal, childbirth, and puerperium; to the exten sion of medical services in quite lacking areas of the Country; to basic sanitation actions and the large changes in reproductive patterns that showed sharp declines in fertility levels (RIPSA, 2013RIPSA. Biblioteca virtual em saúde: 2013. Disponível em: <Disponível em: http://www.ripsa.org.br/fichasIDB/ >. Acesso em: 15 dez. 2014.
http://www.ripsa.org.br/fichasIDB/... ).

Between the years of 1980 and 2010, for example, the infant mortality rate was 69.1 to 15.97 deaths for every 1,000 children born alive (RIPSA, 2013RIPSA. Biblioteca virtual em saúde: 2013. Disponível em: <Disponível em: http://www.ripsa.org.br/fichasIDB/ >. Acesso em: 15 dez. 2014.
http://www.ripsa.org.br/fichasIDB/... ). In 2010, the states of the Legal Amazon reached rates between 18 (Roraima) and 25.41 deaths for every 1,000 children born alive (Amapá) (Table 4). The states of Amapá and Maranhão recorded adverse results in the country. Even with the positive devel opments over the decades, the state of Maranhão has maintained the lowest percentage drop in this indicator (50%) (RIPSA, 2013RIPSA. Biblioteca virtual em saúde: 2013. Disponível em: <Disponível em: http://www.ripsa.org.br/fichasIDB/ >. Acesso em: 15 dez. 2014.
http://www.ripsa.org.br/fichasIDB/... ).

For diseases related to adverse conditions of sanitation, acute diarrheal disease (ADD) in chil dren under five years old. In the period from 1998 to 2007, the rates of hospitalization per 1,000 inhabitants for ADD in children under 5 years old have shown that there is a tendency of decrease in these hospitalizations in the Legal Amazon (PAHO, 2010OPAS - ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE. Ministério da Saúde. Secretaria de Vigilância em Saúde. Sustentabilidade ambiental e de saúde na Amazônia Legal, Brasil: uma análise através de indicadores. Brasília, DF, 2010. Série Saúde Ambiental, n. 4.).

However, according to data from 2010, the states of the Legal Amazon still have worrying indicators of such events, representing 30% of total hospital admissions in the country. The highest occurrences were found in the states of Amapá and Maranhão. It is worth pointing out that, for diseases related to inadequate sanitation (DRISA), the states of the Legal Amazon also reached the highest instances of the country. In 2010, the states of Pará, Rondônia and Maranhão reached the highest rates of hospi talization in SUS of children younger than 5 years old per 1,000 inhabitants of DRISA at the national level (Table 4), with the same positions observed from 1998 to 2009 (RIPSA, 2013RIPSA. Biblioteca virtual em saúde: 2013. Disponível em: <Disponível em: http://www.ripsa.org.br/fichasIDB/ >. Acesso em: 15 dez. 2014.
http://www.ripsa.org.br/fichasIDB/... ).

At the intersection of social indicators (extreme poverty, illiteracy rate, and HDI) in the year of 2010, with the rates of hospitalization for ADD and DRISA, we observed that the state of Maranhão (which showed the worst performance in the HDI, illiteracy and extreme poverty rate indicators) obtained the third highest rate of hospitalization of the DRISA and the fourth highest rate for the ADD. The state of Pará, which had the second worst performance for the HDI, was fourth for illiteracy rate, achieved the second highest rate of hospitalization for ADD and the highest rate for DRISA (Tables 2 and 3).

As for hospitalizations due to acute respiratory infection (ARI) in children younger than 5 years old, from 1998 to 2010, the data of the Legal Amazon did not show many variations in relation to the national average, only highlighting Mato Grosso and Pará (PAHO, 2010OPAS - ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE. Ministério da Saúde. Secretaria de Vigilância em Saúde. Sustentabilidade ambiental e de saúde na Amazônia Legal, Brasil: uma análise através de indicadores. Brasília, DF, 2010. Série Saúde Ambiental, n. 4.). In 2010, the same profile observed over the years was observed in incidence rate by ARI in children younger than 5 years old in the states of the Amazon, which have achieved rates that ranged between 60.65 and 28.34 hospitalizations per 1,000 inhabitants (Table 4).

The diseases considered endemic in the Ama zon region, such as malaria and American cutane ous leishmaniasis have direct relation with the anthropic processes that promote environmental change (such as deforestation, migration flows, construction of roads, agriculture,extensive cattle farming, and urban occupation on native forest areas), the seasonal variations, and the susceptibility of the population (Martins et al., 2004). This direct relation explains the variabil ity of the morbidity of diseases. For malaria, the states which have achieved the highest values for the Parasitic Annual Index (PAI) for the period from 1990 to 2010, were Acre, Roraima, Rondô nia, Amazonas and Amapá (PAHO, 2010OPAS - ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE. Ministério da Saúde. Secretaria de Vigilância em Saúde. Sustentabilidade ambiental e de saúde na Amazônia Legal, Brasil: uma análise através de indicadores. Brasília, DF, 2010. Série Saúde Ambiental, n. 4.; Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.) (Table 5).

According to data from 2010, the incidence rate of American cutaneous leishmaniasis in the Amazon was of 70.26 cases confirmed for every 100,000 inhabitants. The states of Acre, Amapá, Mato Grosso, Roraima, and Rondonia recorded the greatest coefficients in the same year (Table 5).

Visceral leishmaniasis is expanding in Legal Amazon states. Until the late 1990s, the states of the Northeast region reached 90% of the cases in the country, but the states of Tocantins, Maranhão, and Pará are progressively showing significant rates over the years, which corroborates the spread of visceral leishmaniasis in the Amazon region (Silva et al., 2008SILVA, A. R. et al. Situação epidemiológica da leishmaniose visceral, na ilha de São Luís, Estado do Maranhão. Revista da Sociedade Brasileira de Medicina Tropical, Uberaba, v. 41, n. 4, p. 358-364, 2008.). For example, in 2010, these states presented the highest incidence rates in the Legal Amazon (Table 5).

Among the diseases directly linked to living conditions and nutritional deficiencies, leprosy and tuberculosis are worth mentioning due to the indica tors achieved in the region. According to the leprosy detection coefficient per 100,000 inhabitants for 2010, the states of Mato Grosso, Tocantins, Mara nhão, and Rondônia presented the greatest results in the Country. The rates confirmed these states as hyper-endemic (Table 5). In studies in several cities of the Amazon, leprosy reached a hyper-endemic character, reaching, in the 21^st century, prevalence rates in over 20 cases per 10,000 inhabitants. From 2001, cities of Maranhão have presented rates over 60 per 100,000 inhabitants - the highest municipal taxes in the Amazon (Aquino et al., 2003AQUINO, D. M. C. et al. Perfil dos pacientes com hanseníase em área hiperendêmica da Amazônia do Maranhão, Brasil. Revista da Sociedade Brasileira de Medicina Tropical, Uberaba, v. 36, n. 1, p. 57-64, 2003.; Figueiredo; Moura da Silva, 2003FIGUEIREDO, I. A.; SILVA, A. A. M. Aumento na detecção de casos de hanseníase em São Luís, Maranhão, Brasil, de 1993 a 1998. A endemia está em expansão? Cadernos de Saúde Pública, Rio de Janeiro, v. 19, n. 2, p. 439-445, 2003.).

In 2010, the highest incidence rates of tubercu losis per 100,000 inhabitants in the Legal Amazon states were in the Amazonas, Pará, Acre, Mato Grosso, and Maranhão (Table 5). At the national level, the states of Amazonas, and Pará presented, respectively, the second and fourth highest indica tors (RIPSA, 2013RIPSA. Biblioteca virtual em saúde: 2013. Disponível em: <Disponível em: http://www.ripsa.org.br/fichasIDB/ >. Acesso em: 15 dez. 2014.
http://www.ripsa.org.br/fichasIDB/... ).

Discussion

The insertion of the Amazon in national eco nomic development projects reoccurred in different moments of its history, as in the case of the exploita tion of the "drugs of the sertão " (spices, fruit, seeds, roots, among other typical products of the region) and the "cycle of rubber" (1879/1912 and 1942/1945). Since the late 1970s to the present, mineral explora tion, agribusiness, mining, prospecting, and large ventures (such as dams) can be mentioned as fronts for economic expansion in the region, in addition to the Free-Trade Zone and the Industrial Center of Manaus (Monteiro, 2005MONTEIRO, M. A. Mineração industrial na Amazônia e suas implicações para o desenvolvimento regional. Novos Cadernos do Núcleo de Altos Estudos Amazônicos, Belém, v. 8, n. 1, p. 141-187, 2005.).

This development model promoted deep changes in the dynamics of the region and altered the old secular pattern of occupation, based on low demo graphic density, subsistence gathering and the river flow (Castro, 2012CASTRO, E. Amazônia: sociedade, fronteiras e políticas. Caderno de Recursos Humanos, Salvador, v. 25, n. 64, p. 9-16, 2012. Dossiê.; Becker, 2009BECKER, B. K. Geopolítica da Amazônia. Estudos Avançados, São Paulo, v. 19, n. 53, p. 71-76,2009.; Sathler et al., 2009SATHLER, D.; MONTE-MÓR, R. L.; CARVALHO, J. A. M. As redes para além dos rios: urbanização e desequilíbrios na Amazônia brasileira. Nova Economia, Belo Horizonte, v. 19, n. 1, p. 11-39, 2009.).

(Confalonieri, 2005CONFALONIERI, U. E. Saúde na Amazônia: um modelo conceitual para a análise de paisagens e doenças. Estudos Avançados, São Paulo, v. 19, n. 53, p. 221-223, 2005.) and (Netto et al., 2010NETTO, G. F. et al. Impactos socioambientais na situação de saúde da população brasileira: estudo de indicadores relacionados ao saneamento ambiental inadequado. Tempus - Actas em Saúde Coletiva, Brasília, DF, v. 4, n. 4, p. 53-71, 2009.) warned that the development process undertaken in the Amazon region generated environmental transformations with risks to human health. In this regard, we can mention: the pollution of water bodies by mercury from the gold fields; microbial contamination by sanitation deficiencies in the cities; respiratory diseases caused by the smoke of burning after deforestation; the local changes of hydrological cycles that provide potential breeding grounds for mosquitoes, etc.

According to (Rojas and Toledo, 1998ROJAS, L. B. I.; TOLEDO, L. M. Espaço e doença: um olhar sobre o Amazonas. Rio de Janeiro: Fundação Oswaldo Cruz, 1998.), the historicity of the diseases considered endemic in the Amazon region, such as malaria, leprosy and tuberculosis, maintains a close relationship with demographic, ecological, socioeconomic and cultural changes in the region, which determines a continuous reorganization of its geographical space, and changes the processes of reproduction of these endemics.

In turn, the dynamics of occupation and exploita tion of the region promoted changes in the dynam ics of natural ecosystems, anthropization of the landscape, and urbanization, allowing the invasion of natural habitats of these animals, in addition to greater risks of occurrence and reoccurrence of infectious process (Paraná et al, 2008PARANÁ, R.; VITVITSKI, L.; PEREIRA, J. E. Hepatotropic viruses in the Brazilian Amazon: a health threat. Brazilian Journal of Infectious Diseases, Salvador, v. 12, n. 3, p. 253-256, 2008.; Vasconcelos, 2006VASCONCELOS, C. H.; NOVO, E. M. L. M.; DONALISIO, M. R. Use of remote sensing to study the influence of environmental changes on malaria distribution in the Brazilian Amazon. Cadernos de Saúde Pública, Rio de Janeiro, v. 22, n. 3, p. 517-526, 2006.; Confalonieri, 2005CONFALONIERI, U. E. Saúde na Amazônia: um modelo conceitual para a análise de paisagens e doenças. Estudos Avançados, São Paulo, v. 19, n. 53, p. 221-223, 2005.).

Given this complex scenario and from the vari ous indicators analyzed, it is possible to produce some thoughts on what might be called a socio-environmental and sanitary scenario in the Amazon region, identifying its vulnerabilities. In general, following a national trend, all the states of the Amazon have undergone increments and advances in economic, social, and quality of life indicators in the last two decades.

It is worth pointing out that, in spite of the increments achieved in economic indicators, that reach did not provide the states with a performance compatible with social indicators in comparison to the other states of the country. In the meantime, the state of Maranhão in the Northeast region presented the most adverse social indicators of the country, reaching the worst poverty index, the second worst HDI, and the fourth highest rate of illiteracy.

As for the environmental indicators, there is a clear tendency of the states that make up the "arc of fire" to have presented the most unfavorable indexes, resulting from the advances of deforesta tion, the agribusiness (mainly soybeans), extensive cattle farming, and burnings that accompany such economic fronts (Waichman, 2008WAICHMAN, A. V. Uma proposta de avaliação integrada de risco do uso de agrotóxicos no estado do Amazonas, Brasil. Acta Amazonica, Manaus, v. 38, n. 1, p. 45-50, 2008.). The highest rates of deforestation and hotspots in the country were recorded in states like Mato Grosso, Pará, and Maranhão.

This situation is of great concern, by the pros pect that the economic development in the region, which promoted fast and profound changes in the dynamics of ecosystems (mainly by deforestation), be characterized as unsustainable by enabling elevation of social indicators during the rise of the occupation and, later, fall of the results at the end of the process of deforestation in the Amazon loca tions (Rodrigues et al, 2009RODRIGUES, A. S. L. et al. Boom-and-bust development patterns across the amazon deforestation frontier. Science, New York, v. 12, p. 1435-1437, 2009.).

According to the crossings of indicators, devel opments in economic indicators (GDP and GDP per capita) were not observed in environmental indica tors (rate of deforestation and use of pesticides). The state of Mato Grosso, for example, obtained the second largest GDP in the Amazon and the most unfavorable results in deforestation and use of pes ticides, in addition to the lower development in the HDI. The state of Pará, which reached the highest GDP, presented 22.89% situation of extreme poverty and the high rate of deforestation (Tables 1, 2 and 3).

Thus, despite the considerable increase of wealth produced in the Amazon region in recent decades, such performance will not be observed in sanitation indicators for the region under the same dynamics. It is a public policy that is essential to the health of populations that, nonetheless, still have limited access to sanitation actions. According to the data reviewed herein, the states of the Amazon had the the most unfavorable water supply access indicators in the country, even with its water potential.

Such uneven distribution of sanitation services at the national level may be due to the profound social inequalities that still exist in the Country, supported by data from access to basic sanitation services of the 2010 Census and the 2008 PNSB. Ac cording to the data, these services were available to 77.50% users who had household income up to two minimum wages. The households had total income of up to half the minimum wage were served by only 41.3% of the sanitation services (IBGE, 2010IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Banco de dados agregados: 2010. Disponível em: <Disponível em: http://www.sidra.ibge.gov.br/pesquisas >. Acesso em: 5 dez. 2014.
http://www.sidra.ibge.gov.br/pesquisas... ).

Thus, the states of the Amazon have reached the most unfavorable results in social and health indica tors at the national level, expressing the population marginalization in some way. This inequality of access to sanitation services is also observed when comparing the cities in the region with the rest of the Country. It should be noted that the adverse data regarding accessibility to inadequate sanitation services is compatible with the adverse indicators of prevalence and incidence of inadequate sanitation-related diseases and acute diarrheal diseases.

By crossing the data, it even indicated antagonis tic performance situations between economic and social indicators and the rates of hospitalization. The state of Pará, for example, which showed the highest GDP of the Legal Amazon, had unfavorable results in the HDI, poverty, and illiteracy rates indicators of hospitalization for acute diarrheal and sanitation related diseases. Now, the state of Maranhão presented a development in the economic indicators, but could not overcome the adverse data of extreme poverty, HDI and education (illiteracy rate), that were compatible with the hospitalization rates for DRISA and ADD (Tables 1, 2, and 4).

The infant mortality rate for the Amazonian states followed the trend of increasing reduction observed at the national level, however still remains among the largest ones in the country. Regarding that issue, (Szwarcwald et al., 2002SZWARCWALD, C. L.; LEAL, M. C.; ANDRADE, C. L. T.; SOUZA JR., P. R. B. Estimação da mortalidade infantil no Brasil: o que dizem as informações sobre óbitos e nascimentos do Ministério da Saúde? Cadernos de Saúde Pública, Rio de Janeiro, v. 18, n. 6, p. 1725-1736, 2002.) found that 35% of the population of the northern region has the largest occurrences of under-registration of deaths. According to the authors, such events are related to the burials in clandestine cemeteries without the requirement of the death certificate, associated with poverty in the rural area.

Concerning leprosy and tuberculosis, illnesses directly related to precarious conditions of life of the population, the indicators presented cor roborate existing research on these diseases in the region (Campos et al., 2014CAMPOS, G. S.; MENEZES, C. B.; MARTINEZ-ESPINOSA, F. E. Exposição à malária por plasmodium vivax em gestantes de área endêmica de Manaus/AM: características ambientais que as tornam suscetíveis à infecção e vulneráveis à doença. In: OLIVEIRA, J. A. (Org.). Espaço, Saúde e Ambiente na Amazônia: ensaios de Geografia da Saúde. São Paulo: Outras Expressões, 2014. p. 69-79.). Thus, the areas considered endemic for leprosy comprise from the state of Rondônia, North and Central Mato Grosso, South Pará, Northwest Tocantins to the far West of the state of Maranhão. This area corresponds to the "arc of fire" of the Legal Amazon. The state of Maranhão stands out by presenting rates consider ably higher than the other states (Silva et al., 2010SILVA, D. R. X. et al. Hanseníase, condições sociais e desmatamento na Amazônia brasileira. Revista Panamericana de Salud Publica, Washington, DC, v. 27, n. 4, p. 268-275, 2010.).

The Amazonian states also showed high rates of incidence of tuberculosis, which can be attributed to the long history of endemicity in the region and the persistence of poverty, precarious access to sanita tion actions and negative indicators of quality of life in general. Surveys carried out among indigenous peoples of the Amazon showed that the incidence rates of TB in these populations can be up to ten times greater than in the Brazilian population in general, with significantly high risk of illness and death (Levino; Oliveira, 2008LEVINO, A.; OLIVEIRA, R. M. Tuberculose na população indígena de São Gabriel da Cachoeira, Amazonas, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 23, n. 7, p. 1728-1732, 2007.).

Such findings provide subsidies to understand the dynamics of the disease in the Amazon region. It should be noted that, historically, the rates of incidence and prevalence of tuberculosis at mu nicipal level are higher in the Legal Amazon. Since 2003, this condition led the Northern region to be considered as a priority in the National Tuberculosis Control Program due to persistent incidence and prevalence rates achieved over the decades, that can be attributed, among other determinants, to the pre cariousness of living conditions, the shortcomings of the organization and the lack of accessibility of the population to the Unified Health System (SUS) (Levino; Oliveira, 2008LEVINO, A.; OLIVEIRA, R. M. Tuberculose na população indígena de São Gabriel da Cachoeira, Amazonas, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 23, n. 7, p. 1728-1732, 2007.).

Other aspects of the health of the Amazonian populations were indicated by (Alencar et al., 2007ALENCAR, F. H. et al. Determinantes e consequências da insegurança alimentar no Amazonas: a influência dos ecossistemas. Acta Amazônica, Manaus, v. 37, n. 3, p. 413-418, 2007.), who warn about the exclusion of the rural Northern region from the national epidemiological scenario, with a vast emptiness of scientific information on the health, nutrition and survival conditions in na tionwide surveys carried out by official government bodies. Observing such information gaps, the authors based their analysis on the evolutionary analysis of the surveys conducted in the state of Amazonas in recent decades, suggesting the persistence of a food insecurity situation evidenced by the high prevalence of children malnutrition, iron deficiency anemia, and hypovitaminosis A, compounded by the high frequency of gastrointestinal parasitic infections.

Thus, it is worth mentioning that, in this com plex health framework, 98% of the cases of malaria and 35% of the cases of leprosy in the Country occur in the Amazon population, with areas considered hyper-endemic for fulminant viral hepatitis. In the mid-1990s, diseases such as cholera and dengue fever have resurfaced in the Amazon. However, the chronic degenerative diseases presented a very simi lar profile to the rest of the country (Confalonieri, 2005CONFALONIERI, U. E. Saúde na Amazônia: um modelo conceitual para a análise de paisagens e doenças. Estudos Avançados, São Paulo, v. 19, n. 53, p. 221-223, 2005.; Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.).

It is from this reflection that we seek to under stand the indicators and studies here singled out as revealing the vulnerability of the population that makes up the Brazilian Amazon, facing a develop ment model designed for the region that produced social inequalities and negative effects on its health and environmental framework.

Conclusion

The development model implemented in the Amazon promoted deep changes in the dynamics of the region and altered the old secular pattern of occupation (Becker, 2005BECKER, B. K. Geopolítica da Amazônia. Estudos Avançados, São Paulo, v. 19, n. 53, p. 71-76,2009.; Sathler et al., 2009SATHLER, D.; MONTE-MÓR, R. L.; CARVALHO, J. A. M. As redes para além dos rios: urbanização e desequilíbrios na Amazônia brasileira. Nova Economia, Belo Horizonte, v. 19, n. 1, p. 11-39, 2009.). If, on the one hand, we can consider that some of the economic and social indicators have improved, on the other, huge inequalities persist as well as negative effects on the health and environmental framework, making certain sections of the population more vul nerable (the poorest people) as well as certain areas (the agricultural expansion, logging and mineral extraction, in addition to the areas of urbanization and industrialization).

(Rodrigues et al., 2009RODRIGUES, A. S. L. et al. Boom-and-bust development patterns across the amazon deforestation frontier. Science, New York, v. 12, p. 1435-1437, 2009.), when comparing the HDI with the deforestation indicators from 286 cities of the Brazilian Amazon, they noted that in the initial stage of the economic expansion fronts (extensive agriculture, livestock and mineral exploitation, among others), there is a relative increase in the HDI and increased deforestation. After this stage, the HDI started a process of decline and its evolu tion remained at lower levels, the stage at which the expansion fronts have settled in the cities. This research points to the unsustainability of this de velopment model, which produces social gains that decline when the natural resources are exhausted.

In relation to the population health aspects, whereas the analysis and discussion held in this article, the results revealed that the main social and environmental changes that have been taking place in the Amazon region contribute to the emergence of a very complex health framework, overlapping the risks of illnesses and diseases. This chart shows the expressiveness of infectious and parasitic diseases, with the emergence and re-emergence of some dis eases caused by profound changes in vectors and cycles of etiological agents (Freitas; Giatti, 2009FREITAS, C. M.; GIATTI, L. L. Indicadores de sustentabilidade ambiental e de saúde na Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 6, p. 1251-1266, 2009.).

Thus, such health situation is combined with: precarious conditions of sanitation; respiratory diseases caused by burnings; chronic degenerative diseases caused by both chemical contamination resulting from the intensive use of pesticides and mercury, as well as by changes in living standards; traffic accidents resulting from a precarious pro cess of urbanization; violence in the cities and in the countryside in a structurally unequal Amazon characterized by conflict situations.

Thus, the important current debate on the Ama zon Rain Forest, models of economic development and their environmental costs cannot be disassoci ated from the discussions and analyses of the living conditions of the population of the region, which are increasingly urbanized and living daily with the overlapping of environmental and health risks.

This article built a broad mosaic of indicators on development, environment and health in a large and diverse region of the country, which is a chal lenge in this type of study. However, one can't help but point out the existing limits in this paper when considering the breadth and diversity of the Amazon which require considering different patterns of geo graphical and health-related situations, resulting in different modes of use and occupation of space and their stories. In this process of tensions, media tions and combinations between the general and the particular items, it is worth remembering important efforts towards that, in the form of books, such as those organized by (Rojas and Toledo, 1998ROJAS, L. B. I.; TOLEDO, L. M. Espaço e doença: um olhar sobre o Amazonas. Rio de Janeiro: Fundação Oswaldo Cruz, 1998.), as well as the latest one organized by Oliveira (2014), or even in the form of articles, like (Viana et al., 2007VIANA, A. L. D. et al. Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal. Cadernos de Saúde Pública, Rio de Janeiro, v. 23, p. S117-S131, 2007. Suplemento 2.). With this article, we hope to contribute to the debate on these tensions and mediations, without losing sight of the more general debate on the model of development and its impacts on the environment and health in the Amazon.

References

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