ABSTRACT

This study adopted a theoretical-methodological perspective anchored in the Ecosystem Approach to Health, the Social Reproduction of Health, and the Social Determinants of Health to analyze the socioenvironmental vulnerability and health of populations exposed to crude oil during the COVID-19 pandemic and present pathways for comprehensive community reparation. We employed action research as a strategy for dialogic interaction with the subjects of the territories and the construction of emancipatory experiences in the struggle for health, the environment, and sustainable development. We presented a general outlook on the social determination of the health of small-scale fishing communities and the promotion of community-institutional dialogues. The results reinforce the need for environmental health studies that combine academic knowledge with the wisdom of water peoples in the pursuit of truth, justice, and reparation. To do so, it is necessary to unveil environmental injustice, racism, and conflicts, engaging in dialogue about the development model and neo-extractivism in society as essential challenges and opportunities for promoting Healthy and Sustainable Territories.

KEYWORDS
Vulnerability to disasters; Health surveillance; Occupational health; Oil spill; COVID-19

Introduction

The relationship between the environment and human development is at the heart of the Global Agenda for confronting the environmental crisis, particularly the climate crisis, given the consequences imposed by the extractive neoliberal model. Promoting the development of Healthy and Sustainable Territories (HST) depends on understanding territorialized action based on identity and community. Therefore, HSTs are spaces where healthy living is facilitated through community actions promoting social participation and strengthening Black identities and public policies that interact with each other and converge in the territory^{11 Machado JMH, Martins WJ, Souza MS, et al. Territórios saudáveis e sustentáveis: contribuição para saúde coletiva, desenvolvimento sustentável e governança territorial. Com Ciências Saúde. 2017;28(2):243-249.,22 Brito TCS, Peixinho BC, Pirró JCF, et al. Territórios Saudáveis e Sustentáveis: estratégias de cuidado para a saúde da população negra do campo em Caruaru/Pernambuco. Saúde debate. 2022;45(131):1017-1032. DOI: https://doi.org/10.1590/0103-1104202113106I
https://doi.org/10.1590/0103-11042021131...} .

In recent decades, summits, conferences, and forums have discussed strategies for promoting HSTs and sustainable development to establish global planning^{33 Barbieri JC. Desenvolvimento sustentável: das origens à Agenda 2030. Petrópolis: Vozes; 2020.}. The 2030 Agenda for Sustainable Development was approved in 2015 and comprises 17 global Sustainable Development Goals (SDGs) with implementation plans until 2030. SDG 14 is related to water life, stressing the need to preserve and sustainably use oceans, seas, and marine resources^{33 Barbieri JC. Desenvolvimento sustentável: das origens à Agenda 2030. Petrópolis: Vozes; 2020.,44 Machado GCXMP, Vitali M, Brandão ACB, et al., organizadores. Territórios sustentáveis e saudáveis: experiências de saúde ambiental territorializadas. 2. ed. Brasília, DF: Funasa; 2021.}.

However, the SDGs’ goals are challenging to achieve even for economically developed countries, as they do not adequately consider the different characteristics and response capacities of each territory^{55 Veiga JE. A furtiva saga dos ODM aos ODS. In: Frey K, Torres PHC, Jacobi PR, et al., organizadores. Objetivos do desenvolvimento sustentável: desafios para o planejamento e a governança ambiental na Macrometrópole Paulista. Santo André: EdUFABC; 2020. p. 20-31.}, which can result in a limited focus on managing complex issues, depending on actions in the social, economic, political, and environmental dimensions, resulting in a reductionist view of the health-disease process.

Some challenges threaten the conservation of common goods, such as the oceans, due to the harmful effects of accelerated economic growth. They affect the most vulnerable populations, especially in Global South countries^{66 Schutz GE, Tambellini AMT, Asmus CIRF, et al. A agenda da sustentabilidade global e sua pauta oficial: uma análise crítica na perspectiva da Saúde Coletiva. Ciênc saúde coletiva. 2012;17(6):1407-1418. DOI: https://doi.org/10.1590/S1413-81232012000600005
https://doi.org/10.1590/S1413-8123201200...} . Production processes linked to agricultural and mineral exploration are predominant in these territories, emphasizing oil-related energy matrices, one of the leading causes of these threats^{77 El-Sayed A, Kamel M. Climatic changes and their role in emergence and re-emergence of diseases. Environ Sci Pollut Res Int. 2020;27(18):22336-22352. DOI: https://doi.org/10.1007%2Fs11356-020-08896-w
https://doi.org/10.1007%2Fs11356-020-088...} .

Over ten major ocean oil disasters have been reported worldwide since the 1970s, making marine ecosystems and fishing populations in these territories materially and symbolically vulnerable.^{88 Santos RC, Gurgel AM, Silva LIM, et al. Desastres com petróleo e ações governamentais ante os impactos socioambientais e na saúde: scoping review. Saúde debate. 2022;46(8):201-220. DOI: https://doi.org/10.1590/0103-11042022E815
https://doi.org/10.1590/0103-11042022E81...} This model’s adverse effects directly impact traditional communities’ way of life, generating conflicts and reinforcing social injustice^{99 Rede Brasileira de Injustiça Ambiental. Crise conjuntural e expropriação permanente: petróleo e injustiças ambientais no Brasil. In: Santos MOS, Gurgel AM, Gurgel IGD, organizadoras. Conflitos e injustiças na instalação de refinarias: os caminhos sinuosos de Suape, Pernambuco. Recife: Editora UFPE; 2019. p. 105-117.,1010 Santos MOS, Nepomuceno M, Erivaldo J, et al. Oil Spill in Brazil-Analysis of Vulnerabilities and Socio-Environmental Conflicts. BioChem. 2022;2(4):260-268. DOI: https://doi.org/10.3390/biochem2040018
https://doi.org/10.3390/biochem2040018...} .

The oil disaster-crime that affected the Northeast in 2019 engendered new injustice and environmental racism, expanding the contexts of vulnerability historically experienced by the fishing population in these territories<sup>1010 Santos MOS, Nepomuceno M, Erivaldo J, et al. Oil Spill in Brazil-Analysis of Vulnerabilities and Socio-Environmental Conflicts. BioChem. 2022;2(4):260-268. DOI: https://doi.org/10.3390/biochem2040018
https://doi.org/10.3390/biochem2040018...

11 Ramalho C, Norberto W. A situação do comércio de pescados em algumas localidades pernambucanas: reflexões preliminares após os vazamentos do petróleo. Recife: Universidade Federal de Pernambuco; 2019.

12 Pena PGL, Northcross AL, Lima MAG, et al. Derramamento de óleo bruto na costa brasileira em 2019: emergência em saúde pública em questão. Cad Saúde Pública. 2020;36(2):e00231019. DOI: https://doi.org/10.1590/0102-311X00231019
https://doi.org/10.1590/0102-311X0023101...

13 Araújo ME, Ramalho CWN, Melo PW. Pescadores artesanais, consumidores e meio ambiente: Consequências imediatas do vazamento de petróleo no Estado de Pernambuco, Nordeste do Brasil. Cad Saúde Pública. 2020;36(1):e00230319. DOI: https://doi.org/10.1590/0102-311X00230319
https://doi.org/10.1590/0102-311X0023031...

14 Conselho Pastoral da Pesca. Manifesto Campanha Mar de Luta: Justiça Social aos Povos das Águas [Internet]. Olinda: CPP; 2020 [acesso em 2023 maio 24]. Disponível em: http://www.cppnacional.org.br/publicacao/manifesto-campanha-mar-de-luta-justi%C3%A7a-social-aos-povos-das-%C3%A1guas
http://www.cppnacional.org.br/publicacao...

15 Soares MO, Teixeira CEP, Bezerra LEA, et al. The most extensive oil spill registered in tropical oceans (Brazil): The balance sheet of a disaster. Environ Sci Pollut Res. 2020;29(1):19869-19877. DOI: doi: https://doi.org/10.1007/s11356-022-18710-4
https://doi.org/10.1007/s11356-022-18710... -1616 Santos MOS, Santos CPS, Alves MJCF, et al. Oil in Northeast Brazil: mapping conflicts and impacts of the largest disaster on the country’s coast. An Acad Bras Cienc. 2022;94(2):e20220014. DOI: https://doi.org/10.1590/0001-3765202220220014
https://doi.org/10.1590/0001-37652022202...</sup> . People’s exposure to oil and its derivatives is a severe public health problem, affecting the environment and the health of those exposed, with socioeconomic repercussions^{1717 Maldonado A. Un indicador para el Sumak Kawsay. México: Clínica Ambiental; 2013.,1818 Euzebio CS, Rangel GS, Marques RC. Derramamento de petróleo e seus impactos no ambiente e na saúde humana. RBCIAMB. 2019;52(1):79-98. DOI: https://doi.org/10.5327/Z2176-947820190472
https://doi.org/10.5327/Z2176-9478201904...} .

Within this scenario, the COVID-19 syndemic has deteriorated the oil disaster-crime’s effects, impacting health, sovereignty, food security, and the guarantee of fundamental rights, aggravating the vulnerability of the affected traditional small-scale fishing communities. These problems were exacerbated by the arrival of people from outside the territories seeking isolation or quarantine, increasing the exposure of small-scale fishermen/fisherwomen to the new coronavirus^{1010 Santos MOS, Nepomuceno M, Erivaldo J, et al. Oil Spill in Brazil-Analysis of Vulnerabilities and Socio-Environmental Conflicts. BioChem. 2022;2(4):260-268. DOI: https://doi.org/10.3390/biochem2040018
https://doi.org/10.3390/biochem2040018... ,1919 Grupo observatório dos impactos do coronavírus nas comunidades pesqueiras. Reivindicações da pesca artesanal do Brasil frente à pandemia do coronavírus [Internet]. [local desconhecido]: Grupo Observatório dos Impactos do Coronavírus nas Comunidades Pesqueiras; 2020 [acesso em 2023 jun 12]. Disponível em: https://drive.google.com/file/d/1jNPUd2rJRYTw5UJCcbKy92o7dzRYjNCJ/view
https://drive.google.com/file/d/1jNPUd2r... ,2020 Trindade AAM, Pena PGL, Lima MAG, et al. Vigilância popular da saúde nas comunidades pesqueiras tradicionais e ecologia dos saberes no enfrentamento à COVID-19. Ciênc saúde coletiva. 2021;26(12):6017-6026.}.

There is a need to think about the social determination of health, as it is integrated into the social arrangements of life in a broad, complex, and profound sense^{2121 Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Sal Pub. 2013;31(1):13-27.}. It is crucial to reflect on strategies to overcome the vulnerability of small-scale fishing communities, planning comprehensive, territorialized reparation actions, understanding the environment, its socio-ecosystem-based interactions, and their reverberations to preserve life^{1717 Maldonado A. Un indicador para el Sumak Kawsay. México: Clínica Ambiental; 2013.}. Building participatory practices integrating communities and social movements is vital for implementing grassroots health surveillance promoting HSTs^{22 Brito TCS, Peixinho BC, Pirró JCF, et al. Territórios Saudáveis e Sustentáveis: estratégias de cuidado para a saúde da população negra do campo em Caruaru/Pernambuco. Saúde debate. 2022;45(131):1017-1032. DOI: https://doi.org/10.1590/0103-1104202113106I
https://doi.org/10.1590/0103-11042021131... ,2222 Rigotto RM, Leão FAF, Melo RD. A pedagogia do território: desobediências epistêmicas e insurgências acadêmicas na práxis do núcleo tramas. In: Rigotto RM, Aguiar ACP, Ribeiro LAD. Tramas para a justiça ambiental: diálogo de saberes e práxis emancipatórias. Fortaleza: Edições UFC; 2018. p. 59-89.,2323 Carneiro FF, Pessoa VM. Iniciativas de organização comunitária e Covid-19: esboços para uma vigilância popular da saúde e do ambiente. Trab Educ Saúde. 2020;18(3):e00298130. DOI: https://doi.org/10.1590/1981-7746-sol00298
https://doi.org/10.1590/1981-7746-sol002...} .

This article presents the research results entitled ‘Promotion of Healthy and Sustainable Territories and Reparation of small-scale Fishing Communities to Overcome Socioenvironmental Vulnerabilities in the Context of COVID-19 in Pernambuco’. Rather than focusing on the details of each objective achieved, we aimed to make a general presentation, showing how action research allows for diagnoses on determining health, the promotion of community-institutional dialogues, and emancipatory experiences in the fight for health, environment, and development. Furthermore, we managed to identify the challenges and opportunities for promoting HSTs.

Material and methods

This study was structured using social movements of water peoples and representations of health management, assuming a theoretical-methodological perspective anchored in the Ecosystem Approach to Health (EAH)^{2424 Webb JC, Mergler D, Parkes MW, et al. Tools for thoughtful action: the role of ecosystem approaches to health in enhancing public health. Can J Public Health. 2010;101(6):439-441. DOI: https://doi.org/10.1007/BF03403959
https://doi.org/10.1007/BF03403959... ,2525 Augusto LGS, Mertens F. Abordagens ecossistêmicas em saúde, ambiente e sustentabilidade: avanços e perspectivas. SiD. 2018;9(1):16-22. DOI: http://dx.doi.org/10.18472/SustDeb.v9n1.2018.29743
http://dx.doi.org/10.18472/SustDeb.v9n1....} , the Social Reproduction of Health ²⁶, and the perspective of the Social Determination of Health^{2121 Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Sal Pub. 2013;31(1):13-27.} raised by Latin American critical epidemiology. Action research was used as a strategy for dialogic interaction with the territories’ subjects and constructing emancipatory experiences in the fight for HSTs based on a mixed approach, with triangulation of quantitative and qualitative methods^{2727 Minayo MCS, Sanches O. Quantitative and qualitative methods: opposition or complementarity? Cad Saúde Pública. 1993;9(3):239-262. DOI: https://doi.org/10.1590/S0102-311X1993000300002
https://doi.org/10.1590/S0102-311X199300...} . This methodological perspective enables more complete studies and participatory interventions for the resolution/intervention of socioenvironmental problems.

The research was conducted with 21 researchers from February 2021 to May 2023. At the contextual level of observation, the study area comprised 16 municipalities on the coast of Pernambuco (Cabo de Santo Agostinho, Tamandaré, Ipojuca, Sirinhaém, São José da Coroa Grande, Barreiros, Rio Formoso, Ilha de Itamaracá, Goiana, Itapissuma, Paulista, Jaboatão dos Guararapes, Recife, Olinda, Igarassu, and Abreu e Lima). At the anchoring level, it consisted of the communities of municipalities that received the most significant amount of oil from Cabo de Santo Agostinho, Tamandaré, Ipojuca, Sirinhaém, and São José da Coroa Grande, with a significant representation of fishermen who suffered intense vulnerability resulting from both the crude oil spill and, subsequently, the repercussions on livelihoods caused by the COVID-19 syndemic.

Initially, we performed reconnaissance visits to the territory, participant observation, and meetings to discuss and define actions with local social movements. The study subjects were fishermen, representatives of social movements, and health managers (state and municipal level). The project was implemented considering seven specific objectives with methodological strategies developed during the action research (table 1).

Concerning the quantitative approach, an epidemiological survey was conducted in 27 colonies/associations in the 16 municipalities, with the application of a questionnaire structured in 14 blocks related to oil exposure, health, income, quality of life, COVID-19, and mental health aspects, in a sample of 1,259 fishermen registered in the spreadsheet of the Environment and Sustainability Secretariat^{2828 Secretaria de Meio Ambiente e Sustentabilidade e de Fernando de Noronha (PE). Cadastro de Pescadores e Pescadoras Artesanais de Pernambuco. Recife: SEMAS; 2020.}. Afterward, 102 blood samples were collected from a subsample of the survey participants to assess environmental and occupational exposure to oil, following the criteria of longer exposure time in the territories with the most considerable amount of oil collected (Cabo de Santo Agostinho, Ipojuca, Sirinhaém, and Tamandaré) to assess early exposure and effect indicators.

Participatory techniques, such as mapping, culture circles, focus groups, workshops, ethnographic experiences, rapid participatory diagnosis, individual interviews, and field diaries, were used in the qualitative approach. Literature review and documentary research in different databases were employed as secondary data. Communication/intervention-training-action strategies were produced in a procedural and participatory way through workshops, documentaries, booklets, opinions, dialogue circles, seminars, and training.

A matrix was structured to systematize the objectives, the respective methods, and the results from the reading of all the results and products of the action research, which were analyzed according to the following categories: popular-institutional dialogues; emancipatory experiences in the fight for health; environment and sustainable development; sustainable development objectives; challenges and opportunities for promoting HSTs.

This study was approved by the Research Ethics Committee of the Aggeu Magalhães Institute of the Oswaldo Cruz Foundation under the Certificate of Presentation of Ethical Appreciation - CAAE nº 25398119.9.0000.5190 and Opinion Nº 5.037.340.

Results and discussion

The 2019 oil disaster-crime profoundly affected small-scale fishing communities in the social, environmental, economic, biological and cultural dimensions, with a knock-on effect on the lives of the communities, which suffered from the COVID-19 syndemic impact associated with the several barriers to access to the Unified Health System (SUS). The different aspects of vulnerability suffered are shown in table 2.

Overview with main action research results

Crude oil hit the entire coastline of the Northeast region, devastating the lives of thousands of small-scale fishermen and causing negative impacts on fauna and flora, and triggering several vulnerability events, which significantly affected the living conditions, health, the environment, the economy, and the social reproduction of this population. Oil has resurged in several locations after all these years^{1212 Pena PGL, Northcross AL, Lima MAG, et al. Derramamento de óleo bruto na costa brasileira em 2019: emergência em saúde pública em questão. Cad Saúde Pública. 2020;36(2):e00231019. DOI: https://doi.org/10.1590/0102-311X00231019
https://doi.org/10.1590/0102-311X0023101... ,1616 Santos MOS, Santos CPS, Alves MJCF, et al. Oil in Northeast Brazil: mapping conflicts and impacts of the largest disaster on the country’s coast. An Acad Bras Cienc. 2022;94(2):e20220014. DOI: https://doi.org/10.1590/0001-3765202220220014
https://doi.org/10.1590/0001-37652022202...} . Fishermen reported environmental damage due to oil permeating vegetation, mangrove mud, marine animals, and coral reefs. Given the magnitude of the event and the difficulties experienced, they believed that another disaster was imminent. Socioeconomic repercussions and interrupted fishing activities^{1313 Araújo ME, Ramalho CWN, Melo PW. Pescadores artesanais, consumidores e meio ambiente: Consequências imediatas do vazamento de petróleo no Estado de Pernambuco, Nordeste do Brasil. Cad Saúde Pública. 2020;36(1):e00230319. DOI: https://doi.org/10.1590/0102-311X00230319
https://doi.org/10.1590/0102-311X0023031... ,2929 Ramalho CWN. A situação do comércio de pescados em algumas localidades pernambucanas: reflexões preliminares após os vazamentos do petróleo [Internet]. Recife: Núcleo de Estudos Humanidades, Mares e Rios, Universidade Federal de Pernambuco; 2019 [acesso em 2023 jun 13]. Disponível em: https://www.researchgate.net/publication/337006000_a_situacao_do_comercio_de_pescados_em_algumas_localidades_pernambucanas_reflexoes_preliminares_apos_os_vazamentos_do_petroleo
https://www.researchgate.net/publication...} occurred even in municipalities with few or no oil sightings.

Communities that were socioeconomically dependent on the marine ecosystem struggled to adapt to the reality imposed by the disaster, as they had fewer tools to react to the changes and lower physical, financial, and human capital^{3030 Silva LIM, Antunes MBC, Albuquerque MSV, et al. O derramamento de petróleo no litoral pernambucano a partir das narrativas do Jornal do Commercio. Rev Eletron Comun Inf Inov Saúde. 2022;16(4):913-25. DOI: https://doi.org/10.29397/reciis.v16i4.3279
https://doi.org/10.29397/reciis.v16i4.32... ,3131 Mesquita B, Quinamo T. Impactos socioeconômicos e ambientais da contaminação por petróleo nas praias do litoral da região nordeste do Brasil: Justiça azul e pesca artesanal no centro do debate do derramamento de petróleo no Brasil. Recife: Fundação Joaquim Nabuco; 2020.}.

Many fishermen were away from work for more than 30 days. They faced hardships in receiving financial assistance and staple food baskets, which directly affected the income of these communities, compromising food sovereignty and security. The disaster-crime damaged a traditional structure of community economic organization around small-scale fishing^{1010 Santos MOS, Nepomuceno M, Erivaldo J, et al. Oil Spill in Brazil-Analysis of Vulnerabilities and Socio-Environmental Conflicts. BioChem. 2022;2(4):260-268. DOI: https://doi.org/10.3390/biochem2040018
https://doi.org/10.3390/biochem2040018... ,1212 Pena PGL, Northcross AL, Lima MAG, et al. Derramamento de óleo bruto na costa brasileira em 2019: emergência em saúde pública em questão. Cad Saúde Pública. 2020;36(2):e00231019. DOI: https://doi.org/10.1590/0102-311X00231019
https://doi.org/10.1590/0102-311X0023101... ,1313 Araújo ME, Ramalho CWN, Melo PW. Pescadores artesanais, consumidores e meio ambiente: Consequências imediatas do vazamento de petróleo no Estado de Pernambuco, Nordeste do Brasil. Cad Saúde Pública. 2020;36(1):e00230319. DOI: https://doi.org/10.1590/0102-311X00230319
https://doi.org/10.1590/0102-311X0023031... ,1515 Soares MO, Teixeira CEP, Bezerra LEA, et al. The most extensive oil spill registered in tropical oceans (Brazil): The balance sheet of a disaster. Environ Sci Pollut Res. 2020;29(1):19869-19877. DOI: doi: https://doi.org/10.1007/s11356-022-18710-4
https://doi.org/10.1007/s11356-022-18710... ,2929 Ramalho CWN. A situação do comércio de pescados em algumas localidades pernambucanas: reflexões preliminares após os vazamentos do petróleo [Internet]. Recife: Núcleo de Estudos Humanidades, Mares e Rios, Universidade Federal de Pernambuco; 2019 [acesso em 2023 jun 13]. Disponível em: https://www.researchgate.net/publication/337006000_a_situacao_do_comercio_de_pescados_em_algumas_localidades_pernambucanas_reflexoes_preliminares_apos_os_vazamentos_do_petroleo
https://www.researchgate.net/publication... ,3232 Ramalho CWN. Os possíveis impactos dos vazamentos de óleo nas comunidades pesqueiras artesanais em Pernambuco: um breve e provisório balanço. Recife: Núcleo de Estudos Humanidades, Mares e Rios, Universidade Federal de Pernambuco; 2019.}. During the disaster-crime, fishermen were exposed to oil while fishing, collecting the produce, handling contaminated instruments and animals, and consuming the fish retained due to the difficulty in selling it.

Concerning health, many fishermen were unaware of the oil impacts, leading to exposure and poisoning. Personal Protective Equipment (PPE) was not used initially, was inadequate, or was even inappropriately used. Most of those who participated in the cleanup of oil residues did so without training.

The ocular and inhalation mucosa were exposed and there was dermal contact with the oil, generating irritation, redness, burning in the eyes, insomnia, headaches, joint pain, and Post-Traumatic Stress Disorder (PTSD), as mentioned in other studies^{1010 Santos MOS, Nepomuceno M, Erivaldo J, et al. Oil Spill in Brazil-Analysis of Vulnerabilities and Socio-Environmental Conflicts. BioChem. 2022;2(4):260-268. DOI: https://doi.org/10.3390/biochem2040018
https://doi.org/10.3390/biochem2040018... ,1818 Euzebio CS, Rangel GS, Marques RC. Derramamento de petróleo e seus impactos no ambiente e na saúde humana. RBCIAMB. 2019;52(1):79-98. DOI: https://doi.org/10.5327/Z2176-947820190472
https://doi.org/10.5327/Z2176-9478201904...} .

When analyzing the government’s actions to manage the disaster-related damages, it became clear that the government was inactive or inert, neglecting the impact on the lives of fishermen/fisherwomen. The government’s actions focused strictly on financial compensation, which was insufficient because it limited the benefit to those who had the General Fishing Registry, the issuance of which had been interrupted for years, and because it historically excluded women. It was also limited to the presence of oil for the eligibility of municipalities. Community support actions were conducted mainly by volunteers and organizations from the communities^{1919 Grupo observatório dos impactos do coronavírus nas comunidades pesqueiras. Reivindicações da pesca artesanal do Brasil frente à pandemia do coronavírus [Internet]. [local desconhecido]: Grupo Observatório dos Impactos do Coronavírus nas Comunidades Pesqueiras; 2020 [acesso em 2023 jun 12]. Disponível em: https://drive.google.com/file/d/1jNPUd2rJRYTw5UJCcbKy92o7dzRYjNCJ/view
https://drive.google.com/file/d/1jNPUd2r... ,3333 Peixinho BC. Reparação comunitária integral das comunidades pesqueiras artesanais no enfrentamento ao derramamento de petróleo no litoral de Pernambuco [dissertação]. Recife: Instituto Aggeu Magalhães; 2023.,3434 Florêncio JPW. Transtorno de estresse pós-traumático entre os pescadores artesanais do litoral de Pernambuco, pós-derramamento de petróleo de 2019 [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2023.}. There was little visibility in the media, with a failure to listen to the affected people and traditional communities^{1010 Santos MOS, Nepomuceno M, Erivaldo J, et al. Oil Spill in Brazil-Analysis of Vulnerabilities and Socio-Environmental Conflicts. BioChem. 2022;2(4):260-268. DOI: https://doi.org/10.3390/biochem2040018
https://doi.org/10.3390/biochem2040018... ,3030 Silva LIM, Antunes MBC, Albuquerque MSV, et al. O derramamento de petróleo no litoral pernambucano a partir das narrativas do Jornal do Commercio. Rev Eletron Comun Inf Inov Saúde. 2022;16(4):913-25. DOI: https://doi.org/10.29397/reciis.v16i4.3279
https://doi.org/10.29397/reciis.v16i4.32...} .

The research highlighted the lack of action in most municipalities in health activities, with failures in the coordination of care and surveillance, revealing a lack of preparation of professionals to act in disaster situations and public health emergencies^{3535 Peres MCM, Freitas CM. Relatório Técnico. O desastre tecnológico envolvendo derramamento de petróleo no Brasil - Diagnóstico preliminar sobre lições aprendidas e perspectivas futuras para o setor saúde [Internet]. Rio de Janeiro: Centro de Estudos e Pesquisas em Emergências e Desastres em Saúde; 2021 [acesso em 2023 jun 13]. Disponível em: https://www.arca.fiocruz.br/handle/icict/56099
https://www.arca.fiocruz.br/handle/icict...} . Furthermore, we observed scattered initiatives of care, surveillance, and healthcare, most of which were taken up belatedly by state and municipal managers and occurred in other countries with oil spills^{88 Santos RC, Gurgel AM, Silva LIM, et al. Desastres com petróleo e ações governamentais ante os impactos socioambientais e na saúde: scoping review. Saúde debate. 2022;46(8):201-220. DOI: https://doi.org/10.1590/0103-11042022E815
https://doi.org/10.1590/0103-11042022E81...} . In this context, only one of the municipalities created an advance action plan despite the lack of support from the federal sphere.

We also observed pre-existing vulnerability in the territories, permeated by gender, class, and race issues^{3636 Pena PGL, Gomez CM. Saúde dos pescadores artesanais e desafios para a Vigilância em Saúde do trabalhador. Ciênc saúde coletiva. 2014;19(12):4689-98. DOI: https://doi.org/10.1590/1413-812320141912.13162014
https://doi.org/10.1590/1413-81232014191...} . Working conditions are precarious, with rudimentary work tools and equipment, long working hours, and overload due to the fish’s low added value<sup>3636 Pena PGL, Gomez CM. Saúde dos pescadores artesanais e desafios para a Vigilância em Saúde do trabalhador. Ciênc saúde coletiva. 2014;19(12):4689-98. DOI: https://doi.org/10.1590/1413-812320141912.13162014
https://doi.org/10.1590/1413-81232014191...

37 Pena PGL, Freitas MCS. Condições de trabalho da pesca artesanal de mariscos e riscos para LER/DORT em uma comunidade pesqueira da Ilha de Maré, BA. In: Pena PGL, Martins VLA, organizadores. Sofrimento negligenciado doenças do trabalho em marisqueiras e pescadores artesanais. Salvador: EDUFBA; 2014. p. 53-92.-3838 Flores MG. Vulnerabilidade socioambiental e saúde da mulher em comunidades de pesca artesanal do Cabo de Santo Agostinho e Ipojuca, Pernambuco [dissertação]. Recife: Instituto Aggeu Magalhães; 2022.</sup>. Several fishermen reported that their health was worse or much worse than the previous year, with cardiovascular, respiratory, endocrine, and arbovirus diseases.

In 2020, subsuming these processes, they were revictimized in the face of late and disjointed government action, besides the global public health emergency from the COVID-19 syndemic. A state ban on marine animal capture sites was even adopted as a preventive measure against contamination by the virus during social distancing, prolonging losses and economic harm^{1919 Grupo observatório dos impactos do coronavírus nas comunidades pesqueiras. Reivindicações da pesca artesanal do Brasil frente à pandemia do coronavírus [Internet]. [local desconhecido]: Grupo Observatório dos Impactos do Coronavírus nas Comunidades Pesqueiras; 2020 [acesso em 2023 jun 12]. Disponível em: https://drive.google.com/file/d/1jNPUd2rJRYTw5UJCcbKy92o7dzRYjNCJ/view
https://drive.google.com/file/d/1jNPUd2r... ,2020 Trindade AAM, Pena PGL, Lima MAG, et al. Vigilância popular da saúde nas comunidades pesqueiras tradicionais e ecologia dos saberes no enfrentamento à COVID-19. Ciênc saúde coletiva. 2021;26(12):6017-6026.}. We see a outlook with different health problems, which are compounded and increase the burden of diseases and are exacerbated by socioenvironmental vulnerabilities, aggravating problems in the territory and configuring a syndemic^{2020 Trindade AAM, Pena PGL, Lima MAG, et al. Vigilância popular da saúde nas comunidades pesqueiras tradicionais e ecologia dos saberes no enfrentamento à COVID-19. Ciênc saúde coletiva. 2021;26(12):6017-6026.,3939 Bispo JJP, Santos DB. COVID-19 como sindemia: modelo teórico e fundamentos para a abordagem abrangente em saúde. Cad Saúde Pública. 2021;37(10):e00119021. DOI: https://doi.org/10.1590/0102-311X00119021
https://doi.org/10.1590/0102-311X0011902... ,4040 Santos MOS, Peixinho BC, Cavalcanti AMC, et al. Estratégias de comunicação adotadas pela gestão do Sistema Único de Saúde durante a pandemia de Covid-19 - Brasil. Interface Comun Saúde Educ. 2021;25(supl1):e200785. DOI: https://doi.org/10.1590/interface.200785
https://doi.org/10.1590/interface.200785...} .

We observed a fragile bond and belonging to the primary health units, resulting in the low demand for health services during and after the oil disaster crime. This was primarily due to the distance between the professionals and the social reality of the population^{4141 Lopes IBS, Bezerra MGV, Silva LRC, et al. Saúde das trabalhadoras da pesca artesanal: cenários desconhecidos do Sistema Único de Saúde (SUS). Rev Bas Saúde Ocup. 2021;46:e5. DOI: https://doi.org/10.1590/2317-6369000028719
https://doi.org/10.1590/2317-63690000287...} , which harmed the notifications of poisoning cases and the understanding of issues associated with the disaster crime.

Popular-institutional dialogue and emancipatory experiences in the fight for health, environment, and sustainable development: potential for HSTs

Activities were developed in the context of social, health, and environmental issues, implying constructing a fieldwork plan that considers the overlapping of vulnerabilities and socioenvironmental injustice associated with the oil spill and the COVID-19 syndemic. In these circumstances, collective constructions and knowledge exchanges between the work team and interagency workers were fundamental to understanding the social reality and the collective search for emancipatory alternatives targeting community reparation.

Several spaces for sharing knowledge about the affected territory were considered while developing the project, valuing the participation of social fishing movements, non-governmental organizations, educational and research and SUS institutions, management, and professionals of the Health Care Network (RAS), mainly Primary Health Care and health surveillance, given the importance of working in the territories. The popular institutional coordination generated is crucial in strengthening and expanding the struggles to construct HSTs and strengthen the SUS.

These discussions highlight the importance of exchanging and valuing the knowledge of those involved, giving voice and visibility to small-scale fishermen/fisherwomen, and enabling broader debates on the intersections of gender, class, and race. This action corresponds to a participatory research perspective that seeks to generate changes in the territories, an essential characteristic of action research^{2222 Rigotto RM, Leão FAF, Melo RD. A pedagogia do território: desobediências epistêmicas e insurgências acadêmicas na práxis do núcleo tramas. In: Rigotto RM, Aguiar ACP, Ribeiro LAD. Tramas para a justiça ambiental: diálogo de saberes e práxis emancipatórias. Fortaleza: Edições UFC; 2018. p. 59-89.}.

The production and use of audiovisual languages within the project - such as the booklet ‘Water Women’s Health’, the documentary ‘The Sea that Lives in Me’, the activities of the course ‘Free Community Communication for Healthy and Sustainable Territories’, and virtual platforms, such as the ‘Atlas of Environmental Justice’ (EJAtlas) - broadened the discussion, in an accessible way to different audiences, which renewed knowledge production methodologies targeting social transformation through interdisciplinary and intercultural coordination actions and dialogues, in a logic of resistance to the oppression of capitalism, colonialism, and patriarchy^{4242 Fasanello MT, Porto MF. Luz, câmera, cocriação: o cinema documentário como inspiração para descolonizar a produção de conhecimentos. Saúde debate. 2022;46(esp6):70-82. DOI: https://doi.org/10.1590/0103-11042022E607
https://doi.org/10.1590/0103-11042022E60...} .

Participatory strategies, such as creating and implementing the ‘health card for small-scale fishing workers’, were developed with social movements and small-scale fishermen. They reinforced the need for care, greater knowledge about their health conditions, and exchange with regional health teams. Other strategies developed in some Municipal Health Secretariats (SMS) involving the RAS, SUS managers and workers, were healthcare and education actions and the ‘Water Health Intervention Project’, which enabled dialogues and care offers, besides strengthening management performance with the creation of continuing education plan based on the health needs of fishermen and community training. These practices are highly relevant to raising the awareness of service professionals regarding the needs of the territories of small-scale fishing communities^{4141 Lopes IBS, Bezerra MGV, Silva LRC, et al. Saúde das trabalhadoras da pesca artesanal: cenários desconhecidos do Sistema Único de Saúde (SUS). Rev Bas Saúde Ocup. 2021;46:e5. DOI: https://doi.org/10.1590/2317-6369000028719
https://doi.org/10.1590/2317-63690000287...} and reinforce the importance of responsibility, especially of PHC, as the care organizer.

The presence of an interdisciplinary research group enabled the development of differentiated care practices, such as the use of Integrative and Complementary Health Practices (PICS), underscoring the relevance of research using this approach. Academic practices in health and SUS management must contribute to understanding the particularities of communities, the effects on the environment, and the life reproduction conditions of traditional peoples and groups. Thus, it is possible to address the problems associated with capitalism, racist colonialism, and heteropatriarchy, which mainly affect the Global South^{4343 Netto GF, Silva MA, Gurgel AM. Saúde, ecologias e emancipação: conhecimentos alternativos em tempos de crise(s). Saúde debate. 2022;46(esp2):558-560. DOI: https://doi.org/10.1590/0103-11042022E238
https://doi.org/10.1590/0103-11042022E23...} .

Coordination also expanded knowledge and exchange with other research and teaching institutions, enhanced by the participation of social movements and health teams, with experience and reflection based on the territories and reality of these traditional communities.

In this sense, the ‘International course on the oil spill impacts in Brazil: intersectoral coping strategies in the community context’, the continuing education activities with Family Health teams (eSF) from some municipalities participating in the research, the documentary’s film debate, the workshops for methodological organization and presentation of the results, the ‘Seminar on the Oil Disaster-Crime on the Pernambuco Coast and Water People’s Health’, the production of diagnoses and technical opinions on collective health at the request of social movements, the participation of representatives of the movements and health management in defense panels for academic works linked to the project, and the use of differentiated methodologies were crucial strategies, enabling reality-based actions^{4444 Fenner ALD, Knierim GS, Silveira M, et al. Formação-ação: Uma contribuição para promoção de Territórios Saudáveis e Sustentáveis (TSS). In: Machado GCXMP, Vitali M, Brandão ACB, et al, organizadores. Territórios Sustentáveis e Saudáveis: Experiências de Saúde Ambiental Territorializadas. Brasília, DF: Funasa; 2021. p. 136-173.}.

The perspective of popular health surveillance materialized from the encouragement of fishermen’s participation in order to strengthen the popular organization and the incidence of subjects to overcome socioenvironmental and health vulnerabilities^{2020 Trindade AAM, Pena PGL, Lima MAG, et al. Vigilância popular da saúde nas comunidades pesqueiras tradicionais e ecologia dos saberes no enfrentamento à COVID-19. Ciênc saúde coletiva. 2021;26(12):6017-6026.}. Other emancipatory practices were developed, such as free courses for popular water health workers and community communication for HSTs, the creation of ‘Between us: popular network communicators’, the contribution to holding the Free Conference on the Health of Water Peoples and the production of the ‘Pernambuco Charter’, which resulted from collective construction and shares recommendations to be implemented in government agendas based on the vulnerability of small-scale fishing territories in Pernambuco, in order to promote, protect, and care for the health and lives of these people and prevent future associated events.

Challenges for achieving HSTs in small-scale fishing communities

The material and symbolic losses resulting from the vulnerability, exacerbated by the oil disaster-crime and the COVID-19 syndemic, bring about the need for investments and organization of the different government sectors in effective reparation actions^{3333 Peixinho BC. Reparação comunitária integral das comunidades pesqueiras artesanais no enfrentamento ao derramamento de petróleo no litoral de Pernambuco [dissertação]. Recife: Instituto Aggeu Magalhães; 2023.,3939 Bispo JJP, Santos DB. COVID-19 como sindemia: modelo teórico e fundamentos para a abordagem abrangente em saúde. Cad Saúde Pública. 2021;37(10):e00119021. DOI: https://doi.org/10.1590/0102-311X00119021
https://doi.org/10.1590/0102-311X0011902... ,4040 Santos MOS, Peixinho BC, Cavalcanti AMC, et al. Estratégias de comunicação adotadas pela gestão do Sistema Único de Saúde durante a pandemia de Covid-19 - Brasil. Interface Comun Saúde Educ. 2021;25(supl1):e200785. DOI: https://doi.org/10.1590/interface.200785
https://doi.org/10.1590/interface.200785...} . Coordinated actions between the State and the affected communities are required to strengthen territorial sovereignty and preservation, ensuring sustainability for individuals and the environment for an inclusive, safe, healthy, and sustainable territory^{2121 Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Sal Pub. 2013;31(1):13-27.,4545 Maldonado CA. Una propuesta de reparación socio-ecosistémica a los impactos del metabolismo de la actividad petrolera para la Amazonía ecuatoriana [tese]. Quito: Universidad Andina Simón Bolívar; 2018.}. The implementation and strengthening of reparation strategies that focus on the dimensions of compensation, rehabilitation of damages, satisfaction measures, and promotion of guarantees of non-repetition of violations are essential in these contexts of inequalities and socioenvironmental vulnerabilities^{3333 Peixinho BC. Reparação comunitária integral das comunidades pesqueiras artesanais no enfrentamento ao derramamento de petróleo no litoral de Pernambuco [dissertação]. Recife: Instituto Aggeu Magalhães; 2023.,3434 Florêncio JPW. Transtorno de estresse pós-traumático entre os pescadores artesanais do litoral de Pernambuco, pós-derramamento de petróleo de 2019 [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2023.,4646 Beristain CM. Diálogos sobre la reparación. Que reparar en los casos de violaciones de derechos humanos. Quito: V & M gráficas; 2009.}.

Risk management involving the oil disaster-crime is insufficiently structured in the Brazilian context, with insufficient investment in risk and capacity assessments, territorial surveillance, planning of prior and immediate actions, preparation of different emergency teams for response and health services, and health sector representation in disaster risk management^{88 Santos RC, Gurgel AM, Silva LIM, et al. Desastres com petróleo e ações governamentais ante os impactos socioambientais e na saúde: scoping review. Saúde debate. 2022;46(8):201-220. DOI: https://doi.org/10.1590/0103-11042022E815
https://doi.org/10.1590/0103-11042022E81... ,3434 Florêncio JPW. Transtorno de estresse pós-traumático entre os pescadores artesanais do litoral de Pernambuco, pós-derramamento de petróleo de 2019 [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2023.,3535 Peres MCM, Freitas CM. Relatório Técnico. O desastre tecnológico envolvendo derramamento de petróleo no Brasil - Diagnóstico preliminar sobre lições aprendidas e perspectivas futuras para o setor saúde [Internet]. Rio de Janeiro: Centro de Estudos e Pesquisas em Emergências e Desastres em Saúde; 2021 [acesso em 2023 jun 13]. Disponível em: https://www.arca.fiocruz.br/handle/icict/56099
https://www.arca.fiocruz.br/handle/icict... ,4747 Freitas CM, Mazoto ML, Rocha V. Guia de preparação e respostas do setor saúde aos desastres [Internet]. Rio de Janeiro: Fundação Oswaldo Cruz; 2018 [acesso em 2023 jun 13]. Disponível em: https://www.arca.fiocruz.br/handle/icict/40925
https://www.arca.fiocruz.br/handle/icict...} .

There is a need for a health system capable of operating in these territories, with a vision close to the reality of these communities, understanding social reproduction and social determination of health and their vulnerability. Ensuring the right to health of these populations is a challenge for public health, especially when considering the occupational health surveillance^{3636 Pena PGL, Gomez CM. Saúde dos pescadores artesanais e desafios para a Vigilância em Saúde do trabalhador. Ciênc saúde coletiva. 2014;19(12):4689-98. DOI: https://doi.org/10.1590/1413-812320141912.13162014
https://doi.org/10.1590/1413-81232014191...} . Therefore, we underscore the relevance of implementing training processes such as continuing education in health, in which the reality of the territory in which professionals work is considered, in order to interfere in the change of work processes, broaden understanding of health, facilitate the overcoming of the challenges of quality in the healthcare provided, and qualify professionals to act based on their working context^{4444 Fenner ALD, Knierim GS, Silveira M, et al. Formação-ação: Uma contribuição para promoção de Territórios Saudáveis e Sustentáveis (TSS). In: Machado GCXMP, Vitali M, Brandão ACB, et al, organizadores. Territórios Sustentáveis e Saudáveis: Experiências de Saúde Ambiental Territorializadas. Brasília, DF: Funasa; 2021. p. 136-173.}.

Health practices must encourage social participation and consider the voice of those involved in the health-disease-care complex, incorporating popular knowledge in gathering technical knowledge from academia and the State’s demands with popular needs in a contextualized and participatory fashion. In this context, they need to involve the stakeholders and authors in their decisive processes of preserving life and confronting the vicissitudes that arise from environmental, social and health injustice subsidized by capital and advances in the small-scale fishing territories.

Furthermore, its most significant incidence is at the societal level, affecting other dimensions of life and overdetermining political and health actions that reflect and imply the power of transformation in communities. The free conference on water peoples’ health was an example of coordination and reinforcement of struggles involving federal, state, and municipal government entities, with the participation of social movements and individuals in educational and research institutions and other non-governmental organizations^{4848 Gonçalves GMS, Santos MOS, Gurgel AM, et al. Experiências pedagógicas para a construção da interdisciplinaridade em saúde coletiva. Saúde debate. 2022;46(135):1238-1248. DOI: https://doi.org/10.1590/0103-1104202213520
https://doi.org/10.1590/0103-11042022135...} .

Small-scale fishermen should participate more in class organizations and social movements and strengthen the dialogue between social movements and the fight for healthier and more sustainable territories. This would reinforce the guarantee of rights established in the National Rural, Forest, and Waters Comprehensive Health Policy (PNSICFA)^{4949 Ministério da Saúde (BR). Política Nacional de Saúde Integral das Populações do Campo e da Floresta. Brasília, DF: Editora do Ministério da Saúde; 2013.} and enable the protection of small-scale fishing territories^{3636 Pena PGL, Gomez CM. Saúde dos pescadores artesanais e desafios para a Vigilância em Saúde do trabalhador. Ciênc saúde coletiva. 2014;19(12):4689-98. DOI: https://doi.org/10.1590/1413-812320141912.13162014
https://doi.org/10.1590/1413-81232014191...} .

Other diagnoses should be structured to promote actions to care for and promote the health of small-scale fishing communities, associating the most visible communication practices, especially in disasters and public health emergencies. The media should consider the voices of the territory’s subjects, confronting the model that predominantly considers institutional voices, characterized by a communication practice limited to the transfer of information, belittling the population’s knowledge and skills^{5050 Araújo I, Cardoso J. Comunicação e Saúde. Rio de Janeiro: Fiocruz; 2007.}.

By understanding communication as an instrument of denunciation in the face of inequalities and constant violations of rights experienced by small-scale fishing communities, the research revealed the need to develop strategies using emancipatory theoretical-methodological perspectives, such as popular education, the pedagogy of alternation^{5151 Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra; 2011.}, and popular and community communication^{5252 Peruzzo CMK. Direito à comunicação comunitária, participação popular e cidadania. Lumina. 2007;1(1). DOI: https://doi.org/10.34019/1981-4070.2007.v1.20989
https://doi.org/10.34019/1981-4070.2007....} , promoting diverse voices and enabling the story of the disaster-crime to be told by the people who first witnessed the arrival of the oil, and who also took to the sea to clean up and protect this ecosystem: the small-scale fishermen, as seen in the photos of the photography competition ‘I who inhabit the sea’, held to make visible the fishermen’s perspective on the disaster-crime.

The aim is to expand dialogue and access to all audiences and give greater visibility to these communities, which creates a virtual platform to act as a repository of information on studies carried out in fishing territories and their respective developments. All these strategies can inspire innovative co-presence, co-creation, and co-production practices, which seek to renew knowledge production methodologies aimed at social transformation, providing new ways of circulating information^{4242 Fasanello MT, Porto MF. Luz, câmera, cocriação: o cinema documentário como inspiração para descolonizar a produção de conhecimentos. Saúde debate. 2022;46(esp6):70-82. DOI: https://doi.org/10.1590/0103-11042022E607
https://doi.org/10.1590/0103-11042022E60...} .

Final considerations

The activities developed facilitated the establishment of a bond with the territory, familiarizing with the subjects and promoting healthcare movements focusing on quality of life and community empowerment to foster sustainable development among small-scale fishing workers. Despite the challenges to their implementation, we showed the importance of establishing popular institutional coordination, whether with social movements, non-governmental organizations, SUS, or teaching and research institutions.

The oil disaster-crime caused distress, impunity, and fear of a repeat of the incident among those most affected. This fear reinforces the desire to strengthen the social organization of the water peoples in search of justice and implement public policies targeting these communities, combining academic knowledge with the wisdom of the water peoples in the search for truth, justice, and reparation. It is crucial to strengthen the PNSICFA and establish it as a management priority, considering the relevance of traditional communities for the country’s food sovereignty and respecting their ways of life.

Furthermore, it is necessary to develop more studies that make socio-environmental injustices and racism visible to discuss the development model and extractivism/neo-extractivism, using participatory methodologies, to promote HSTs. To this end, it is necessary to develop actions within the scope of strengthening, deepening, and qualifying the political influence of these communities with the formation of new leaders, particularly young people.

Promoting, valuing, and qualifying managers and professionals in the health sector is also necessary. Strengthening PHC and health surveillance and respecting social participation in the SUS is also essential. It is vital to have popular, community, and equitable communication that encompasses all the accents, colors, and stories expressed in Brazilian diversity to ensure participation.

Acknowledgments

We are grateful to André Monteiro Costa, Glaciene Mary da Silva Gonçalves, Mariana Maciel Nepomuceno, Rosely Fabrícia de Melo Arantes, Ana Marília Correia Cavalcanti, Augusto Fernando Santos de Lima, Bianca Cardoso Peixinho, Jefferson Phellippe Wanderley Florencio, Maria José Cremilda Ferreira Alves, Mariana Gurbindo Flores, Priscylla Alves Nascimento de Freitas, Ruth Carolina Leão Costa, and Romário Correia dos Santos; the State and Municipal Health Secretariats of Pernambuco; Suape Forum socioenvironmental space; Cabo Women’s Center; Pastoral Council for Fishing; Coordination of Fisherwomen; and all the Colonies and Associations of small-scale fishermen and fisherwomen of the coast of Pernambuco, for all the collaborative processes shared during the research and, above all, for the emotional bonds cultivated in these years of intense work.

References

Publication Dates

History