Abstract

Introduction

Sustainable development reserve (UCs) constitute protected areas in accordance with Law n. 9,985/2000¹1. Brasil. Lei nº 9.985 de 18 de julho de 2000. Regulamenta o art. 225, § 1º, incisos I, II, III e VII da Constituição Federal, institui o Sistema Nacional de Unidades de Conservação da Natureza e dá outras providências. Diário Oficial da União 2000; 19 jul. of the Brazilian System of Protected Areas (SNUC), which aims to sustainably use their natural resources and ensure the conditions and means necessary to improve riverine populations’ living conditions (whose way of life is primarily aimed at subsistence) based on the intensive use of family labor via technologies with low environmental impact derived from orally transmitted knowledge and, usually, sustainable basis ²2. Medeiros R, Araújo FFS. Dez anos do Sistema Nacional de Unidades de Conservação da Natureza: lições do passado, realizações presentes e perspectivas para o futuro. Brasília: Ministério do Meio Ambiente; 2011..

The Mamirauá Sustainable Development Reserve (MSDR) is one of 71 conservation units in the state of Amazonas, Brazil (which make up the State Conservation Unit System - SEUC - promulgated by complementary Law n. 53, of June 5, 2007) and one of the 1,940 making up SNUC. Both policies include criteria and standards to create, recategorize, implement, and (especially) manage protected areas ³3. Tribunal de Contas do Estado do Amazonas. Relatório conclusivo de Auditoria Operacional e Ambiental em Unidades de Conservação Estaduais do Amazonas. https://www.tce.am.gov.br/portal/wp-content/uploads/relatorio_de_auditoria_operacional_e_ambiental_em_ucs.pdf (acessado em 25/Set/2015).
https://www.tce.am.gov.br/portal/wp-cont... ^,44. Ministério do Meio Ambiente. Cadastro Nacional de Unidades de Conservação. https://www.mma.gov.br/cadastro_uc (acessado em 25/Set/2015).
https://www.mma.gov.br/cadastro_uc... .

Becker ⁵5. Becker BK. Geopolítica da Amazônia. Estud Av 2005; 19:71-86. states that the meaning of UCs sustainable use policies in the Amazon changed as they became a strategy for forest peoples’ survival and their maintenance, a common human heritage (especially forests, mega diversity, and water), constituting a vector of endogenous development, unlike other techno-industrial models.

However, the presence of populations within protected natural areas involves controversial, non-consensual issues among subjects who are neglected by municipal, state, and federal legislation ⁶6. Martins A. Conflitos ambientais em Unidades de Conservação: dilemas da gestão territorial no Brasil. Revista Bibliográfica de Geografía y Ciencias Sociales 2012; 17:1-11.^,77. Veríssimo A, Rolla A, Vedoveto M, Futada SM. Áreas protegidas na Amazônia Brasileira: avanços e desafios. Belém: Imazon/São Paulo: Instituto Socioambiental; 2011..

We express the conclusions from a doctoral thesis, conducted from 2013 to 2018, which aimed to expand the knowledge about the interactions between living and health conditions of riveirine communities in UC areas co-managed by non-state institutions. The fragility of the healthcare and information systems in the Brazilian Amazon required that our methodology met the complexity of the socio-environmental reality of UCs. We adopted a theoretical perspective based on Juan Samaja’s Social Reproduction since it includes interactive analyses at different hierarchical levels to assess life in its entirety.

The conceptual basis of Social Reproduction integrated to health themes

Social Reproduction has been the object of wide debate in social theory. It has several definitions and theoretical-methodological aims. Classical Marxism designates it as the creation of social (including time and space) and “spiritual” (immaterial) works, including material production or manufacture (both part of historical development), which imply the reproduction of society itself ⁸8. Lefebvre H. A vida cotidiana no mundo moderno. São Paulo: Ática; 1991..

Constructivist sociology, as per Pierre Bourdieu & Jean Claude Passeron’s La Reproduction. Éléments Pour une Théorie du Système d’Enseignement (1970) ⁹9. Bourdieu P, Passeron J-C. La Reproduction. Éléments pour une théorie du système d'enseignement. Paris: Les Éditions de Minuit; 1970., uses social category to interpret the power relations of educational institutions. Their theoretical proposal is based on the premise that, in capitalist societies, these relations always contain a dimension of symbolic violence, i.e., dominant groups impose an arbitrary set of cultural referents (knowledge, languages, norms, values, representations, etc.) to society as a whole, reinforcing their privileged position ¹⁰10. Abrantes P. Revisitando a teoria da reprodução: debate teórico e aplicações ao caso português. Análise Social 2011; 46:261-81..

The notion of Social Reproduction, articulated by Ferguson’s Canadian Marxist Feminism ¹¹11. Ferguson S. Feminismos interseccional e da reprodução social: rumo a uma ontologia integrativa. Cadernos Cemarx 2017; (10):13-38., aims to capture this contradictory nature (constituted by many layers of subjectivities and social positions) via a perspective which insists on the dynamic and complex character of the social, i.e., it proposes to take Social Reproduction beyond the narrow concern of gender, class, and economic relations.

Juan Samaja’s Social Reproduction, applied to health, is one of the three theoretical perspectives in critical epidemiology of collective health which aim to assess its social, political, economic, cultural, and environmental processes by considering them as events which mediate health, a part of a network of hierarchically organized determinations ¹²12. Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Salud Pública 2013; 31 Suppl 1:S13-27.^,1313. Helene LMF, Salum MJL. A reprodução social da hanseníase: um estudo do perfil de doentes com hanseníase no Município de São Paulo. Cad Saúde Pública 2002; 18:101-13..

Castellanos ¹⁴14. Castellanos PL. Epidemiologia, saúde pública, situação de saúde e condições de vida: considerações conceituais. In: Barata RB, organizador. Condições de vida e situação de saúde. Rio de Janeiro: ABRASCO; 1997. p. 31-75. claims that human Social Reproduction means meeting biological needs, their ecological, political, and economic relations - mediated by production and work -, and forms of consciousness and conduct. The historically determined circumstances of human groups’ Social Reproduction (which they face throughout their lives) will take place as subordinates or winners ¹⁵15. Castellanos PL. Análises de situación de salud de poblaciones. In: Navarro FM, organizador. Vigilância epidemiológica. Madrid: McGraw-Hill Interamericana; 2004. p. 193-213. due to the interaction of members of different institutions and groups of a given society since it is human beings and their relations which are reproduced, i.e., their conditions of existence or, as Possas ¹⁶16. Possas C. Epidemiologia e sociedade: heterogeneidade estrutural e saúde no Brasil. São Paulo: Hucitec Editora; 1989. reconceptualizes, its living and health conditions.

Juan Samaja’s application of Social Reproduction to health themes has a basis conceived from a historical-dialectical analysis of the function and logic of scientific research in its multiple dimensions and determinations, based on two references: Friedrich Hegel and Karl Marx’s Historical-Dialectical Method in the 19th century and Jean Piaget’s Psychogenesis and Charles Sanders Pierce’s Semiotics in the 20th century, which Samaja called the Dialectical-Genetic Method ¹⁷17. Medeiros MS. Comunidades ribeirinhas na amazônia ocidental: condições de vida e de saúde. Manaus: Editora Reggo; 2019.^,1818. Medeiros MS. Condições de vida e de saúde no contexto de uma Unidade de Conservação Ambiental de uso sustentável na Amazônia Brasileira [Tese de Doutorado]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2018..

He developed this method against mechanistic ones, which he deems as insufficient to assess sociocultural phenomena, including health issues, though they have completely new characteristics since, in addition to their physical-chemical processes and hereditary transmission of traits (typical of organic living systems), they show mechanisms to represent objective and subjective states via written language, other forms of symbolization, and beliefs which enabled the formation of the various types of sociability and culture ¹⁷17. Medeiros MS. Comunidades ribeirinhas na amazônia ocidental: condições de vida e de saúde. Manaus: Editora Reggo; 2019.^,1818. Medeiros MS. Condições de vida e de saúde no contexto de uma Unidade de Conservação Ambiental de uso sustentável na Amazônia Brasileira [Tese de Doutorado]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2018..

Samaja conceived of its heuristic device as belonging to a procedural entity which functions recursively and can be represented as spirals. Herbert Simon’s Architecture of Complexity and Hegel’s Aufhebung constitute essential aspects to assess the proposition of data matrix systems and the interdependence of Samaja’s Social Reproduction dimensions ¹⁹19. Samaja J. A reprodução social e a saúde: elementos metodológicos sobre a questão das relações entre saúde e condições de vida. Salvador: Casa da Qualidade Editora; 2000.^,2020. Samaja J. Epistemología y metodología: elementos para una teoria de la investigación científica. 3ª Ed. Buenos Aires: Eudeba; 2005.^,2121. García R. Interdisciplinariedad y sistemas complejos. Revista Latinoamericana de Metodología de las Ciencias Sociales 2011; 1:66-101..

This interpretation subsumes physical-chemical phenomena into biological ones or sublate them by the biological, meaning that they have been overcome but are preserved since biological phenomena form new emergencies within the historical process of life. Following this hierarchy of complexity, we find that social phenomena will subsume biological phenomena, regulating and re-signifying them, rather than substituting them ²¹21. García R. Interdisciplinariedad y sistemas complejos. Revista Latinoamericana de Metodología de las Ciencias Sociales 2011; 1:66-101..

Figure 1 shows that culture, cosmology, politics, techno-economic processes, and public policies emerge in Social Reproduction as expressions of the State.

Thus, we can conceive research problems as complex adaptive systems whose hierarchical approximation enable us to decompose problems (complex system) into complex and smaller levels (complex subsystems) to assess the whole. We describe our choice of strata and anchorage unit since these depend on researchers. Each stratum has its own set of terms, concepts, and principles. It is essential to consider an autonomous system with objects and functionalities for each stratum ²²22. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004..

Analyzing the behavior of a stratum/level/dimension will enable us to perceive how their respective systems interact to form upper strata, which leads us to recognize it not as less important (lower stratum) but essentially less complex than superior ones. Thus, complex social systems behave like totalities composed of subsystems. Its analysis fails to fragment the totality and denaturalize the problem or social reality ²²22. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004..

We stress that understanding the dialectics of human phenomena as relational or social totalities implies understanding the particular dialectics of the parties (the subjects) and of the whole as a complex unit ²¹21. García R. Interdisciplinariedad y sistemas complejos. Revista Latinoamericana de Metodología de las Ciencias Sociales 2011; 1:66-101.^,2222. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004.^,2323. Mesarovic MD, Macko D. Fundamentos de una teoría científica de los sistemas jerárquicos. In: Whyte L, editor. Hierarchical structures. Madrid: American Elsevier; 1973; p. 48-68..

From this perspective, we can understand how Social Reproduction and living conditions influence health. This theory attenuates biological and sociological reductionism, which formulates problems anchored only in one perspective ²⁴24. Santos SL, Augusto LGS. Multidimensional model for dengue control: a proposal based on social reproduction and risk situations. Physis (Rio J.) 2011; 21:177-96.. Thus, the social nature of diseases is less visible in singular and isolated cases, becoming clearer only when we examine human collectives’ way of getting sick, caring, and dying and consider the social dimension of the clinical approach ²⁵25. Laurell AC. La salud-enfermedad como proceso social. Cuad Méd Soc 1982; (19):7-25..

Thus, human condition results from interactions between culture, language, values, norms, structure, and social organization, among other processes within a complex hierarchical system ²¹21. García R. Interdisciplinariedad y sistemas complejos. Revista Latinoamericana de Metodología de las Ciencias Sociales 2011; 1:66-101.. Dressler & Willis ²⁶26. Dressler D, Willis WMJ. Sociologia: o estudo da interação humana. Rio de Janeiro: Interciência; 1980. corroborate this assertion by stating that the most important consequences of social interaction are socialization, via which individuals present and adopt standards and norms of behavior which their cultures deem appropriate.

Samaja’s method to analyze the living and health conditions of communities

Analyzing the determination of health via Social Reproduction differs from classical epidemiology (which uses a causality model based on risk factors). The latter fails to respond to problems since their representations and related public policy interventions take place in populations, thus failing to consider their contextual differentiations, vulnerabilities, susceptibilities, and resulting effects ¹³13. Helene LMF, Salum MJL. A reprodução social da hanseníase: um estudo do perfil de doentes com hanseníase no Município de São Paulo. Cad Saúde Pública 2002; 18:101-13.^,2727. Diderichsen F, Evans T, Whitehead M. The social basis of disparities in health. In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, editores. Challenging inequities in health. New York: Oxford University Press; 2001..

Social Epidemiology applies Social Reproduction to analyze living and health conditions determined by production structures, occupation types, working circumstances, and consumption patterns. The form of insertion in the labor market, the capacity of claiming mobilization, choices “of what” and “how” to consume, and the vulnerabilities due to this process influenced social demand and healthcare models ¹²12. Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Salud Pública 2013; 31 Suppl 1:S13-27.^,1616. Possas C. Epidemiologia e sociedade: heterogeneidade estrutural e saúde no Brasil. São Paulo: Hucitec Editora; 1989.^,2828. Almeida-Filho N. Integração metodológica na pesquisa em saúde: nota crítica sobre a dicotomia quantitativo-qualitativo. In: Goldenber GP, Marsiglia RMG, Gomes MHA, organizadores. O clássico e o novo: tendências, objetos e abordagens em ciências sociais e saúde. Rio de Janeiro: Editora Fiocruz; 2003. p. 143-56..

Therefore, Social Reproduction transcends the economic infrastructure. It crosses the entire social apparatus, which implies recognizing state actions to meet social demands, such as health, education, sanitation, nutrition, safety, and leisure ¹⁴14. Castellanos PL. Epidemiologia, saúde pública, situação de saúde e condições de vida: considerações conceituais. In: Barata RB, organizador. Condições de vida e situação de saúde. Rio de Janeiro: ABRASCO; 1997. p. 31-75.^,2929. Lana FCF. Saúde, doença e condições de vida. REME Rev Min Enferm 2006; 10:105..

Samaja ¹⁹19. Samaja J. A reprodução social e a saúde: elementos metodológicos sobre a questão das relações entre saúde e condições de vida. Salvador: Casa da Qualidade Editora; 2000.^,2222. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004. claims that this dialectical-genetic paradigm, applied especially to health, enables us to think about complexity by contextually differentiating organic (individual) and social relations without reducing one to another, such as, for example, the social to the individual. Samaja proposes a data matrix to understand more descriptively and efficiently each level comprising the totality of the studied phenomenon.

The matrixing of the observed elements is arranged horizontally and vertically, the former called “units of analysis” (which scientific anchoring represents, i.e., context, anchorage, and subtext), whereas the latter, arranged vertically, is called “observation units” or “variables”, representing the matrix by analysis categories or dimensions which relate to our theoretical objects ²²22. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004.^,2828. Almeida-Filho N. Integração metodológica na pesquisa em saúde: nota crítica sobre a dicotomia quantitativo-qualitativo. In: Goldenber GP, Marsiglia RMG, Gomes MHA, organizadores. O clássico e o novo: tendências, objetos e abordagens em ciências sociais e saúde. Rio de Janeiro: Editora Fiocruz; 2003. p. 143-56..

In summary, variables are the attributes or subjects of observable interest within the unit of analysis, which have dimensions established based on theoretical criteria. Their dimensions are one of their partial aspects (or predicates) which are relatively independent of others and which, together, constitute the social totality ¹⁷17. Medeiros MS. Comunidades ribeirinhas na amazônia ocidental: condições de vida e de saúde. Manaus: Editora Reggo; 2019.^,2222. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004.^,2828. Almeida-Filho N. Integração metodológica na pesquisa em saúde: nota crítica sobre a dicotomia quantitativo-qualitativo. In: Goldenber GP, Marsiglia RMG, Gomes MHA, organizadores. O clássico e o novo: tendências, objetos e abordagens em ciências sociais e saúde. Rio de Janeiro: Editora Fiocruz; 2003. p. 143-56..

The methodological path of the comprehensive approach of Social Reproduction to analyze living and health conditions

Municipalities, the Uarini and Fonte Boa/Maraã areas in the MSDR, communities, and households were defined as units of context, anchorage, and subtext analysis in this study, respectively. MSDR covers the Alvarães, Fonte Boa, Japurá, Jutaí, Maraã, Tonantins, and Uarini municipalities, comprising the Triângulo and Upper Solimões health regions in Amazonas State, Brazil, which are only accessible by boat. They house about 11,000 people in 200 communities and 1,873 households ³⁰30. Medeiros MS, Augusto LGS, Barca S, Sacramento DS, Santiago Neta IS, Gonçalves IC, et al. A saúde no contexto de uma reserva de desenvolvimento sustentável: o caso de Mamirauá, na Amazônia Brasileira. Saúde Soc 2018; 27:128-48..

Note that the MSDR is the only conservation unit with a research institute, the Mamirauá Institute for Sustainable Development (IDSM), linked to the Brazilian Ministry of Science, Technology and Innovation, motivating our research ³⁰30. Medeiros MS, Augusto LGS, Barca S, Sacramento DS, Santiago Neta IS, Gonçalves IC, et al. A saúde no contexto de uma reserva de desenvolvimento sustentável: o caso de Mamirauá, na Amazônia Brasileira. Saúde Soc 2018; 27:128-48..

Data were collected from the following secondary sources: (i) a bibliographic review to identify the characteristics, facts, and historical events of the MSDR creation and management process; (ii) IDSM management reports to find the number and type of community interventions in the area; (iii) open interviews to review subjects’ discursive representations of local health competencies and responsibilities; and (iv) observation of participants via local immersion to understand the riverine population’s way of life. From these activities, data on the context and anchorage observations units were extracted. They refer to the support to communities from social forces within the Church and the organization of riverine populations, the State (environmental, science, technology, and health policies), and non-state public organizations since they are responsible for implementing environmental policies in these territories ³⁰30. Medeiros MS, Augusto LGS, Barca S, Sacramento DS, Santiago Neta IS, Gonçalves IC, et al. A saúde no contexto de uma reserva de desenvolvimento sustentável: o caso de Mamirauá, na Amazônia Brasileira. Saúde Soc 2018; 27:128-48.^,3131. Medeiros MS, Sacramento DS, Santiago Neta IS, Queiroz RSB, Barca S, Augusto LGS, et al. Health care in environmental conservation units in Amazonas: conflict of competency or responsibility issue? Revista Geonorte 2020; 11:35-51..

Primary and secondary quantitative data were collected, including sociodemographic, environmental, morbidity, and mortality ones from information systems; and a questionnaire with 64 questions on living and health conditions was used to characterize the observation, anchorage, and (especially) subtext context units. It was answered by 239 community members, our study subjects ³⁰30. Medeiros MS, Augusto LGS, Barca S, Sacramento DS, Santiago Neta IS, Gonçalves IC, et al. A saúde no contexto de uma reserva de desenvolvimento sustentável: o caso de Mamirauá, na Amazônia Brasileira. Saúde Soc 2018; 27:128-48..

The total MSDR population and a 18.5% prevalence of individuals who sought health services and were rejected - as per the 2013 Escuta Itinerante do SUS (SUS Itinerant Listening) national survey, organized by the SUS General Ombudsman Office and the Brazilian National Confederation of Agricultural Workers ³⁰30. Medeiros MS, Augusto LGS, Barca S, Sacramento DS, Santiago Neta IS, Gonçalves IC, et al. A saúde no contexto de uma reserva de desenvolvimento sustentável: o caso de Mamirauá, na Amazônia Brasileira. Saúde Soc 2018; 27:128-48.^,3232. Ministério da Saúde. Relatório da "Escuta Itinerante: acesso dos povos do Campo e da Floresta ao SUS". http://www.contag.org.br/arquivos/portal/Relatorio-final-CONTAG.pdf (acessado em 22/Set/2015).
http://www.contag.org.br/arquivos/portal... - were considered in our statistical sampling.

Our analysis plan was based on an array of data. All three units of analysis (subtext, anchorage, and context), variables (attributes of observable interest in the analysis unit), and their respective reproduction dimensions were considered to assess the dialectic of what social interaction they promote due to the interdependence of the parts and the whole. In our analysis, types of social interaction, grouped by Dressler & Willis’ Sociology ²⁶26. Dressler D, Willis WMJ. Sociologia: o estudo da interação humana. Rio de Janeiro: Interciência; 1980. as those which contribute to bringing social agents closer (cooperation, accommodation, and assimilation) or further apart (competition and conflict) were considered. An aspect of interest is to evaluate the nature of social change due to the interaction between riverine populations, protected areas, and health care systems in the Brazilian Amazon.

By adapting Samaja’s original proposal (as other authors have), Ecological-Political Reproduction unfolded into two other dimensions (ecological and political) to highlight the phenomena of the social space of the Amazon ecosystem ²⁸28. Almeida-Filho N. Integração metodológica na pesquisa em saúde: nota crítica sobre a dicotomia quantitativo-qualitativo. In: Goldenber GP, Marsiglia RMG, Gomes MHA, organizadores. O clássico e o novo: tendências, objetos e abordagens em ciências sociais e saúde. Rio de Janeiro: Editora Fiocruz; 2003. p. 143-56.^,3030. Medeiros MS, Augusto LGS, Barca S, Sacramento DS, Santiago Neta IS, Gonçalves IC, et al. A saúde no contexto de uma reserva de desenvolvimento sustentável: o caso de Mamirauá, na Amazônia Brasileira. Saúde Soc 2018; 27:128-48.^,3333. Costa AM. A determinação social da microcefalia/zika no Brasil. Waterlat-Gobacit Network Working Papers 2016; 3:44-61.^,3434. Augusto LGS. Complexidade e processo saúde doença. In: Augusto LGS, Beltrão AB, organizadores. Atenção primária à saúde: ambiente, território e integralidade. Recife: Editora Universitária da UFPE; 2008. p. 50-2.:

(i) In Ecological Reproduction, the social space can express itself negatively in biocommunal life if action strategies provided by Political, Economic, and Cultural Reproductions fail to value the riverine way of life, constituting, in this example, social distancing.

(ii) The resulting healthcare social determination due to Political Reproduction is expressed in the care (or not) of social needs.

(iii) The social interaction derived from Techno-Economic Reproduction, whose outcome socially determines health, can express itself negatively in riverine populations’ lives if the legal and institutional framework of exchange relations are unequal and unfair, harming those subjected to occupational or environmental risk, for example.

(iv) Self-awareness and Conduct Reproductions may mean the social assimilation of environmental policies if social assistance or health care are contextualized within the riverine cosmology, which was not the case.

(v) Living conditions express Biocommunal Reproduction since they portray individuals’ material bases, in which access to social goods and services from Political and Techno-Economic Reproductions are essential for greater resilience to forest adversities, which will determine the form and frequency with which populations become ill, interfering in the daily activities necessary to reproduce their conditions as living social organisms.

Data were collected between August and September 2016, after consent obtained from environmental agencies and approval by the Ethics Research Committee of the Aggeu Magalhães Institute, Oswaldo Cruz Foundation (opinion n. 1,667,857).

Results

The Amazonian ecosystem marks riverine Social Reproduction. Its flood dynamics and full, ebb, and dry season regulate communities’ rhythm of life. Annually, from May to June, lowland lands are subject to flooding, such as that in 2015, upsetting social systems.

Aquatic fauna plays an important role in the Ecological Reproduction of floodplains and in other reproductions, whether in the dispersion of seeds, the basis of the population’s food diet, source of income, community organization and trade unions around fishing, or as a symbol in the popular imagination.

The abundance of water resources hides the lack of drinking water during dry months, which riverine interviewees claim is their third greatest issue. Both the three government levels and the IDSM failed to solve the geographical, economic, organizational, and cultural barriers to health access which mark forest life. On the other hand, the floodplain-appropriate IDSM technologies to improve sanitation enabled a type of social assimilation of lowland ecology. However, these pilot projects served only 17 of 200 communities.

Thus, Ecological Reproduction expresses itself negatively in biocommunal life, characterizing social distancing due to political, economic, and Cultural Reproductions which neither protected individuals nor valued the riverine way of life, constituting, in this example, social distancing.

The UCs Political Reproduction emerges amidst an epistemic field of conservation biology within a framework which questions neoliberal state models and sustainable development.

The Amazon State policy manages the UCs via social organizations, of which the IDSM is the most important. Their strategies consist of a rich action and product portfolio, ranging from research, inspections, and infrastructure interventions to payment for environmental services. Still, the actions show discontinuity and almost always receive no support from municipalities.

Regarding municipalities meeting healthcare demands, for at least 12 months (between 2015 and 2016) community care has limited itself to the community health agent, whose evaluation varies between communities, rated worst at Fonte Boa/Maraã. The territory shows a departure from the social interactions within the policy, especially due to discontinuity and lack of dialogue between municipalities and the IDSM.

Riverine populations’ Technological Reproduction is based on family work as a domestic production and consumption unit and on market articulation. Proportionally, riverine populations’ income came, at the time of this study, from programs of income distribution and support for family agriculture, fishing, and environmental conservation (Brazilian Income Transfer Program - Bolsa Família, Forest Assistance Program - Bolsa Floresta, and Green Grant Program - Bolsa Verde), ranging from BRL 32.00 to BRL 372.00 for Brazilian Income Transfer Program and BRL 50.00 for Forest Assistance Program. These join intermittent yields resulting from the sale of Uarini flour and specially pirarucu fishing, the latter concentrated in September and October, during its open season and the restart of marketing activities. Most people (60.6%) in Mamirauá claimed that rents generally stay below minimum wage (at the time = BRL 880.00). Regarding the three salaries of Seguro Defeso (a program to aid fishermen during close season), the riverine population claimed not having received them.

The IDSM induction toward diverse economic activities positively impacted the local economy, approximating techno-economy and politics. On the other hand, IDSM strategies have failed to produce a legal and institutional framework regarding unequal and unfair exchanges in the pirarucu trade, which shows great variation between values to fishermen and those for final consumers, which may be associated with over-exploitation and the increase in work accidents, whose coefficient averaged, in 2015, 403.9 in Uarini and 411.7 in Alvarães per 100,000 inhabitants, respectively, much higher than the national 84.16 per 100,000 one. Thus, we attest the distancing among IDSM Techno-Economic, Ecological, and Political Reproductions.

Regarding riverine populations’ self-awareness and conduct reproduction, we found their low involvement in social control and community support, which the IDSM organized to solve everyday life problems or to demand better living and health conditions. We found that 87.9% fail to participate in social control and 69%, in courses or training, even in spaces which require attendance for the receipt of Brazilian Income Transfer Program and Forest Assistance Program. Those who show some interest in participating in social control or community support have great interest in religion (52.8%); community of the fishing manegement lake (51.8%); and soccer (56%).

Analyzing riverine populations’ material basis showed what is sustainable within environmental policy actions for the reserve since they especially express themselves in biocommunal life. The precarious living and health conditions for the riverine population at Médio Solimões reflect their income and schooling, indicators which have the most negative impact on the local Human Development Index. Its value in 2010 ranged from 0.498 (Maraã) to 0.548 (Tonantins), lower than the Amazonas (0.674) and national (0.727) averages.

Regarding income, 60.6% of the community reported living on less than one minimum wage per month.

Precarious education means, for example, that only 30.5% of those over 18 years of age (who comprise half of the population) in Alvarães have elementary education, corroborating our anchorage findings, which found that 32.5% of subjects were illiterate, could only sign their name, or attended less than two years of school.

Improving riverine populations’ material basis is essential for their greater resilience to forest adversities, which will determine how and how often they get sick. In the case of RDSM, high frequencies of diseases are recorded: (i) infectious gastroenteritis and other attention-sensitive hospitalizations, which account for more than a 1/3 of local hospital admissions, an incidence of 3.2/100,000 inhabitants (higher than the Amazonas average, around 1.3/100,000 inhabitants); (ii) of 28.9 new cases of tuberculosis in 2015 in Fonte Boa, and of 7/100,000 inhabitants in Uarini. The average recorded in Brazil, Amazonas, and Manaus in 2015 was, respectively: 39.9, 70.1, and 98.3/100,000 inhabitants; (iii) new cases of leprosy in 2015, hyperendemic in Fonte Boa (43.4/100,000 inhabitants) and average in Uarini (7/100,000 inhabitants).

Tefé is the only municipality in the region with a laboratory to diagnose tuberculosis and reference center for workers’ health.

Discussion

Samaja ²²22. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004. claims that, according to historical-dialectical materialism, Social Reproduction regulates or determines Biological Reproduction. We find a hierarchy of organization in the history of life, from biological to social. Social Reproduction describes culture, cosmology, politics, techno-economic processes, and public policies as expressions of the State.

In this architecture of complexity, the social is a context of the biological since these dimensions have hierarchically determined ordered relations which are central to how living conditions produce biological processes as social ones. Reductionism, then, occurs when we formulate problems anchored only in one dimension or another ³³33. Costa AM. A determinação social da microcefalia/zika no Brasil. Waterlat-Gobacit Network Working Papers 2016; 3:44-61..

We should refrain from thinking of riverine populations’ way of life without analyzing their system of social representations since, as we have seen, Ecological Reproduction intrinsically depends on natural floodplain cycles, which will especially influence technological, self-awareness of conduct, and Biocommunal reproductions ¹⁷17. Medeiros MS. Comunidades ribeirinhas na amazônia ocidental: condições de vida e de saúde. Manaus: Editora Reggo; 2019.^,2222. Samaja J. Epistemología de la salud: reproduccioón social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004..

In neoliberalism, non-state organizations indirectly decentralizing the responsibility of providing public services also reached natural resources ³⁵35. Godoy AMG. A sugestão sustentável e a concessão das florestas públicas. Revista de Economia Contemporânea 2006; 10:631-54., which measured the Political Reproductions in our study since the social determination of health is expressed in the care of social demands.

Note that analyzing the management model of Amazon protection areas was the theme which most required research time since State policies operate via social organizations. The state manages the MSDR but, in practice, non-state public organizations (IDSM and, more recently, the Sustainable Amazon Foundation) implement action strategies.

Calegare ³⁶36. Calegare MGA. Estratégias de mudança identitária para acesso a bens e serviços sociais na Amazônia. Rev Psicol Polít 2014; 14:151-69. found the use of ethnicity to ensure access to health and education services in two Amazonas UCs, a situation resembling that in São Francisco de Aiucá, a community in Uarini.

In socio-environmentalists’ discourse, environmental policies are unaccountable for the health of the population. On the other hand, they admit that the problem is unclear in the work agenda of the environmental institutions in which they work in Mamirauá ³¹31. Medeiros MS, Sacramento DS, Santiago Neta IS, Queiroz RSB, Barca S, Augusto LGS, et al. Health care in environmental conservation units in Amazonas: conflict of competency or responsibility issue? Revista Geonorte 2020; 11:35-51..

Riverine populations’ highest productive yields derive from trading pirarucu, which the Prelazia de Tefé initially implemented in the 1980s as a way to curb predatory fish trade, a practice which caused its scarcity as food for the local population; at the time, one of the main arguments for creating the proposal for the UCs sustainable typology ³⁷37. Moura EAF. Práticas socioambientais na Reserva de Desenvolvimento Sustentável Mamirauá no Estado do Amazonas, Brasil [Tese de Doutorado]. Belém: Universidade Federal do Pará; 2007..

In Amazonas State, pirarucu production jumped from 60 tons in 2002 (when its management began) to 1,797 tons in 2015. MSDR production comprises 32.4% of the total, thus placing it as the largest sustainable producer of the product in Brazil. However, we find several trade disputes and conflicts with “bosses” and with lake surveillance involving associated professional fishermen and invading fishermen. These have become a police report at the Fonte Boa police station, which refuses to investigate the issue since it claims it is a problem of federal judicial agencies or the Environmental Military Police (the latter fails to employ workers in the region ¹⁷17. Medeiros MS. Comunidades ribeirinhas na amazônia ocidental: condições de vida e de saúde. Manaus: Editora Reggo; 2019.^,1818. Medeiros MS. Condições de vida e de saúde no contexto de uma Unidade de Conservação Ambiental de uso sustentável na Amazônia Brasileira [Tese de Doutorado]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2018.).

The riverine populations’ low involvement in social control and organized community support, especially in IDSM health courses, workshops, training, and lectures, should assume the need for more solidary and horizontal strategies.

This situation may indicate that subjects fail to perceive themselves as protagonists of their Social Reproduction. Another hypothesis relates to low schooling since 42% of individuals either are unable to read, only sign their names or have attend less than two years of school.

Valla ³⁸38. Valla V. A crise de interpretação é nossa: procurando entender a fala das classes subalternas. Brasília: Ministério da Saúde; 2014. (Caderno de Educação Popular em Saúde, 2). finds their preference for religious affairs and soccer as popular classes simultaneously seeking solidarity, the comfort of social support, and relief from their sufferings.

Our analysis of family income, years of studies, and home access to bathrooms, piped water, energy, and communication indicators showed the social, political, economic, and cultural processes arising from state or social groups actions in the MSDR. These have impacted the material basis of riverine populations’ biocommunal life, i.e., how and how often they fall ill, which would enable them to reproduce their conditions (as social living organisms) necessary for human existence.

The interviewed riverine populations failed to report their precarious health conditions and naturalized endemics (such as malaria), which show from medium to high annual parasite indices (average: 10.0 to 49.9; and high: greater than or equal to 50.0). Among the seven municipalities making up the MSDR, the Amazonas State Malaria Control Program only excludes Japurá and Tonantins. The other municipalities, Alvarães, Fonte Boa, Maraã, Jutaí, and Uarini join the other 46 priority cities of the Program ³⁹39. Braz RM, Barcellos C. Análise do processo de eliminação da transmissão da malária na Amazônia brasileira com abordagem espacial da variação da incidência da doença em 2016. Epidemiol Serv Saúde 2018; 27:12.

In general, serious health problems, such as those related to maternal and child health, are solved on a case-by-case basis, which can be expedited by patronage or political indication ⁴⁰40. Fausto MCR, Fonseca HMS. Rotas da atenção básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes Editora; 2013..

Our findings corroborate data from the Amazon Court of Auditors, which evaluated the Amazonas State Conservation Unit System. The report states that other social policies have failed to follow environmental protection, negatively contributing to local populations’ low quality of life ³3. Tribunal de Contas do Estado do Amazonas. Relatório conclusivo de Auditoria Operacional e Ambiental em Unidades de Conservação Estaduais do Amazonas. https://www.tce.am.gov.br/portal/wp-content/uploads/relatorio_de_auditoria_operacional_e_ambiental_em_ucs.pdf (acessado em 25/Set/2015).
https://www.tce.am.gov.br/portal/wp-cont... .

Conclusion

Our use of Juan Samaja’s data matrix evaluated the Social Reproduction processes which integrate the hierarchically organized network of determination, whose interactions shape living and health conditions.

Analyzing such Political and Techno-Economic Reproductions enabled us to reflect on what is sustainable in environmental policy actions organized for the MSDR since they express suffering, illness and death most acutely in “biocommunal” life.

Thus, ensuring access to social goods and services (especially health) and respecting the local way of life is essential for riverine populations’ greater resilience to forest adversities.

Acknowledgments

For funding this research: Graduate Human Resources Training Support Program and the Amazonas State Research Support Foundation (Fapeam).

References

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