The Amazonas region of Brazil provides 20 percent of the world's fresh water, contains 60 percent of its tropical forests, and hosts 50 percent of the planet's biodiversity. Yet, poor living conditions make this tropical paradise hazardous to the health of its human inhabitants. Poverty, malnutrition, disease, and population growth lead to imprudent land usage that exhausts natural resources and imperils human survival. But an integrated population-environment program can temper the volatile combination of vulnerable people and threatened ecosystems, by educating health care workers and adolescents about reproductive health, encouraging sustainable resource use, and empowering women through economic opportunities.

Manicoré: Poverty in the Heart of Beauty
The municipality of Manicoré is located in the middle of the Amazon jungle, three days by boat or 90 minutes by white-knuckle flight from the nearest large city, Manaus. Seventeen thousand people live in town, and 23,000 inhabit 225 small villages along seven main rivers. The second largest municipality in the state of Amazonas, Manicoré occupies an area the size of Denmark. People move around the region primarily by boat; seasonal roads reach only 10 percent of the rural population.

Although Brazil is often thought of as a middle-income country, Amazonas is one of its poorest states, and its rural communities are some of Brazil's most impoverished. Official health statistics, which are notoriously underreported, indicate that over 50 percent of Manicoré's pregnant women receive little or no prenatal care, and die in childbirth at the third highest rate in the state. Prostitution is particularly prevalent among young girls, contributing to the high number of adolescent pregnancies: over 30 percent of the region's children are born to women under 18. Sexually transmitted diseases are common, and, although Manicoré lacks testing facilities, HIV/AIDS infection rates are apparently rising.

Poverty, accompanied by poor health and environmental degradation, is pervasive; most families live on less than $3 per day. Manicoré's residents have few economic opportunities, outside of subsistence agriculture, government service, or small-scale extraction of forest products like Brazil nuts, rubber, fruits, and tree oils. The employment outlook for women and adolescents is even bleaker; prostitution and drugs provide money for some, while others seek work outside the region.

Planting the Seeds: An Integrated Approach
Management Sciences for Health (MSH), a non-governmental, non-profit health organization, was invited to Manicoré in 2001 by a green-certified lumber company to provide technical support for a health survey, which was part of the company's stakeholder appraisal of communities in its concession. Not surprisingly, the diagnostic survey deemed access to health care, health training, and infrastructure inadequate. In 2002, MSH launched a successful, small-scale maternal health initiative funded by the World Bank, and in March 2003, MSH expanded upon the work of that initiative by placing me in Manicoré to implement its first population-environment project.

Our innovative pilot program sought to educate adolescents about reproductive health, promote environmental conservation, and strengthen community economic development, especially for women and youth. We strove to: 1) educate community health promoters about reproductive health care for adolescents, and provide them with communication tools to reach adolescents effectively; 2) mobilize a group of rural educators to convey health information using creative activities like theater and music that engage youth and help them communicate effectively with their peers; and 3) establish sustainable, income-generating projects that encourage self-sufficiency, provide satisfaction, and increase financial opportunities. By addressing the community's diverse needs, the program endeavored to reach more people and improve the overall health of the population and the fragile ecosystem in which they live.

Nuts and Bolts: Health Care and Handicrafts
Health workers in Manicoré are hungry to increase their knowledge and improve their skills. Working with the municipal Ministry of Health, I started a training program for community health agents in 84 rural communities. I led interactive and participatory sessions with a small group of Manicoré-based health agents. As most health agents are political appointees, not health professionals, it was challenging to create effective training activities that addressed their varying levels of interest and ability. While some health agents attended state-sponsored health education sessions and had years of rural health experience, other agents were illiterate and had little background in public health.

Therefore, the training sessions encouraged participation by using group activities, such as picture-based dialogue and oral presentations. These monthly courses were the first training sessions that rural agents were required to attend.

I also conducted monthly training sessions on reproductive health for technicians at all three municipal health centers in Manicoré. Participation was high, as these meetings occurred during the normal workday and were supported by the centers' nurses and doctors. At my first session, I used a banana to demonstrate how to put on a condom correctly. My demonstration freed the technicians to express their beliefs and ask questions about contraception.

I worked closely with Projeto Arara, a local non-governmental organization comprised of urban health agents fighting HIV/AIDS. As adequate and accurate information on adolescent health is not available, we drafted a simple survey to assess high school students' health behavior, views on the environment, and reproductive health knowledge. In 2004, members of Projeto Arara will lead interactive sessions on reproductive health at area high schools, including such topics as contraception, postponing sexual debut, HIV/AIDS and other sexually transmitted infections, self-esteem, and possibly environment. To increase these sessions' effectiveness, I offered the agents public speaking training to give them the self-assurance they need to work with adolescents. Recognizing the value of health education, the urban health agents have increased their visits to the high schools from once a semester to once a month.

Together with Manicoré's agricultural cooperative, I initiated a handicraft project that promotes women's economic empowerment and the sustainable use of natural resources and, by requiring all of the participants to attend reproductive health classes, also encourages sustainable fertility. A core group of 20 women uses natural and recycled materials to weave baskets, carve Brazil nut shells into owls and napkin holders, and recycle thick metal cans into inventive animal designs. However, developing products that are both sustainable and marketable was not easy: early attempts produced dolls made from plastic ribbon, recycled-paper hats, and sequin-covered nuts—sustainable, yes, but hard to sell. A $5,000 start-up grant allowed us to seek technical assistance with designing handicrafts, producing honey, and marketing these products.1 Now, some of the new products are both environmentally friendly and economically viable. In January 2004, the handicraft association finalized its first sales agreement with an upscale store in Manaus, which will offer for sale the cooperative's brightly-painted mobiles of Amazonian animals, candleholders made from native nut shells, and imaginative, recycled-metal magnets.

Family Tree: Private and Public Partners
One of our key partners, regional plywood manufacturer Gethal Amazonas, is certified by the Forest Stewardship Council, which assures that Gethal's products are made from timber harvested in an environmentally responsible, socially beneficial, and economically viable way. Gethal provided transportation and communication services for MSH, and collaborated with us to develop activities in 12 communities bordering Gethal's lumber concession. MSH enhanced the benefits for Gethal's employees and other residents by training local health agents and midwives. This public-private partnership, MSH's first, was a new approach for community development in Manicoré.

Our key environmental partner, the National Council of Rubber Tappers (Conselho Nacional dos Seringueiros, known as CNS), has organized local cooperatives of extractivists (workers that sustainably harvest non-timber forest products) in over 20 rural communities. Founded by the Amazonian environmental activist Chico Mendes, CNS works to improve the economic situation of its rural constituents by expanding their harvest to include collecting Brazil nuts, honey, and fruits. In Manicoré, CNS is responsible for organizing the honey cooperative, orchestrating technical workshops to improve quality, and seeking access to markets. CNS also houses the handicraft cooperative and provides administrative and communication support for its daily activities.

I also involved local and regional governmental agencies in the design and implementation of these projects, including a local branch of the national environment agency (IBAMA), the regional agricultural and fisheries agency (IDAM), and Manicoré's municipal government and its secretariats of health, sanitation, and agriculture. Maintaining these partnerships could be stressful. For example, to reach consensus in Manicoré I needed the backing of both the mayor and the Catholic Church—ancient adversaries that compete for the loyalty of Manicoré's residents with old-fashioned bullying and flamboyant festivals. I lobbied, persuaded, and flattered Manicoré's religious and political elites to gain their acceptance, carefully targeting my approach: with the mayor, I spoke about family planning, adolescent reproductive health programs, and sex education in the schools. With the priest, I emphasized maternal health, hygiene, and income-generating projects. Maintaining the support of these key players was a constant challenge but was absolutely necessary to make progress in Manicoré.

Knock on Wood: Goals and Challenges
We sought to improve adolescents' knowledge of reproductive health, increase access to health information in rural communities, and develop a sustainable business producing and selling local handicrafts and non-timber forest resources. Although we were able to make small changes and begin working towards our goals, MSH was unable to obtain sufficient funding, and the project ended in early January 2004. In the short time I worked in Manicoré, the urban and rural health agents received training on reproductive health, childhood illness, first aid, prenatal care, and nutrition, and also took home individual copies of educational guides to STIs/HIV/AIDS. In addition, the handicraft project is off to a successful start, and the participants are dedicated to producing sustainable and profitable goods.

As the first year of my fellowship ended, I learned some important lessons about working in remote regions. Reaching rural communities is far more costly and time-consuming than working in urban areas, and it is difficult to convince donors that small populations are worthy of large investments of time and money. I still believe that improving the health and economic status of the stewards of the Amazon would not only benefit them, but would also help conserve one of the world's natural wonders and richest ecosystems. Although I do not know if I will ever return, my partners, such as Gethal Amazonas and the municipality of Manicoré, will continue building on this foundation to improve the health of the environment and the people of the Amazon.

Click here for the entire Spring 2004 issue of PECS.

Caryl Feldacker, a University of Michigan Population Fellow, worked with Management Sciences for Health in Manicoré, Brazil, from March 2003 to January 2004. She was responsible for increasing community buy-in, strengthening partnerships, and building capacity within the human and environmental health sectors. She has an undergraduate degree from the University of Pennsylvania and a master's degree from Tulane University School of Public Health and Tropical Medicine. Caryl is now working with the Population Council in Corumba, Brazil.