BMJ 2025; 391 doi: https://doi.org/10.1136/bmj.r1925 (Published 06 November 2025)Cite this as: BMJ 2025;391:r1925
Gabriela Di Giulio, associate professor – School of Public Health, University of São Paulo, São Paulo, Brazil
Carla Morsello, associate professor – School of Arts, Science and Humanities, University of São Paulo, São Paulo, Brazil
Leandro Giatti, associate professor – School of Public Health, University of São Paulo, São Paulo, Brazil
Michele Rocha El Kadri, public health researcher – Leonidas and Maria Deane Institute, Fiocruz Amazônia, Manaus, Brazil
Tiago Jacaúna, associate professor – Department of Social Sciences, Federal University of Amazonas, Manaus, Brazil
Sandra Hacon, professor – National School of Public Health Sergio Arouca, Rio de Janeiro, Brazil
Historically, public policy has treated the Brazilian Amazon as a vast natural resource for economic exploitation1 and an “empty demographic space” ripe for occupation.2 Based on this framing, development projects have had profound social-environmental and cultural impacts on Amazonian ecosystems. They have overwhelmed the age-old interactions between traditional peoples and managed nature,3 pushed indigenous and traditional communities to the fringes of urban centres,4 and imposed systemic violence.
This has led to a loss of biodiversity and socio-diversity and undermined “buen vivir” principles, which conceptualise wellbeing through community based autonomy, the rights of nature, and social justice, while challenging dominant principles of development and individualism.5 Amazonian indigenous peoples hold a holistic and interconnected view of health and illness. They value the balance between society and nature.67 They believe that diseases like malaria and covid-19 are not only biological phenomena, but also the outcome of imbalances—rooted in the actions and power of the “white man” intertwined with spells, spiritual disturbances, and protective factors linked to shamanic practices.89
Ecological degradation, loss of biodiversity, and climate change in the Amazon have driven the emergence and re-emergence of infectious diseases.101112 In this context, the metaphor of microbial insurgencies, in which microbes disrupt human systems and challenge human control, becomes plausible,13 aligning with indigenous interpretations of the Amazon as a more-than-human entity.
Additionally, in areas affected by environmental degradation and climate change, food insecurity is more likely, as wildlife harvest rates decline14 and the natural environment becomes increasingly unsuitable for crop cultivation.15 Sacred sites for traditional communities—such as forests, mountains, caves, and rivers—have been destroyed by companies and individuals which are driven by market forces that prioritise profit over environmental and cultural preservation.416 These environmental and cultural losses have contributed to increased physical and mental illnesses among Amazonian communities and reduced quality of life and opportunities. Globally, they represent the loss not only of vital ecological resources and climate-regulating systems, but also of ancestral knowledge and potential solutions to the climate crisis.4
Current global health discussions, particularly those shaped by the climate emergency, are beginning to recognise not only the critical importance of ancestral knowledge, but also the need to stop focusing only on human factors, and instead move towards a multispecies, more-than-human approach to health governance, as well including physical and mental wellbeing.17 This shift in attitudes recognises the intrinsic value and interconnectedness of all beings, and increasingly acknowledges that existing health systems and strategies fail to tackle the illness and suffering caused by the climate crisis.
In the Brazilian Amazon, the Unified Health System (SUS, in Portuguese) has still failed to adapt to the rapid changes driven by the climate emergency, biodiversity loss, and pollution. The result is a health system that not only need to enhance the provision of adequate care,18 but also needs to develop diagnostic and health indicators that are more sensitive to the specific needs of Amazonian territories. Preventable conditions, such as perinatal, infectious, and parasitic diseases, remain a critical public health challenge and require the expansion and strengthening of primary healthcare services, both in terms of scope and quality.19 But new health issues have also begun to affect indigenous populations. These health issues include climate anxiety and fear related to the changing climate. The severe drought experienced in the Amazon basin during 2023 and 2024, which was reported as the most intense in recent history, has exacerbated these anxieties.20 Some communities are increasingly concerned about their ability to resist extreme climatic events and survive. They are worried about food insecurity and the disruption of cultural practices. Such anxieties compound other pressing issues linked to territorial pressures.21
Amazonian adaptation strategies
The Amazon rainforest can be understood as a subject with agency and rights. Rivers, in particular, determine and restrict access to health services across vast regions. It is essential to think of it as a liquid territory. It is a fluid and dynamic space shaped by the ebb and flow of rivers. This environment influences not only the way of life of indigenous and riverside populations, but also their approaches to healthcare. They require dynamic, context specific, and adaptive care models.22 This was acutely illustrated during the record droughts in 2023 and 2024, which brought mobility and aid in many areas to a standstill as boats were unable to deliver healthcare and supplies via rivers.
The Amazon river basin covers about 45% of Brazil’s national territory. Along its banks, riverine populations organise their lives according to seasonal flooding (November to June) and drought (July to October). Water levels determine optimal planting and harvesting periods, which is critical for local food security and urban food supply chains. Rivers also dictate where and how to build homes, balancing proximity to waterways for transportation with protection from strong currents. As rivers are the main arteries for the movement of people and goods, travel distances fluctuate considerably. During the dry season, journeys take longer, leaving communities more isolated. During the flood season, travel is faster via improved navigability. In this watery Amazon, time—rather than geographical distance—is the most accurate measure of access, including to healthcare.23
Amazonian communities have developed sophisticated, place based, adaptation strategies grounded in deep ecological knowledge and seasonal observation.212425 These practices—such as the use of seasonal calendars for planning, growing flood-tolerant crop selection to maintain food security, and adaptive shifts between farming, gathering, fishing, and hunting—illustrate a form of climate resilience (and resistance) that could inform broader adaptation strategies. These practices could also inform how to integrate climate adaptation to ecological solidarity, by recognising human and more-than-human interdependencies.
Reimagining health and sustainability through hybrid knowledge systems
Reimagining health and sustainability in the Amazon requires hybrid strategies that integrate traditional, scientific, and political knowledge. Potential pathways should include community based health surveillance grounded in indigenous epistemologies.26 It is vital that traditional food knowledge and dietary practices are valued in order to counter the spread of ultra-processed foods.27 In some regions, the public health system already adopts this hybrid approach. A key example is the work of midwives who combine biomedical and ancestral practices to provide care across vast, harder-to-reach territories. Currently, experiences combining traditional knowledge, research, and public policies have enabled direct cooperation between midwives and the formal healthcare system.2829
Integrating knowledge systems in the Amazon requires more than dialogue, it demands a radical shift in governance, one that decouples health from an exclusively western anthropocentric focus and advances a multispecies, more-than-human model of care, grounded in ecological justice and indigenous world views.
As the 30th United Nations climate summit (COP30) convenes in the Amazon for the first time, and Brazil’s Ministry of Health—with support from the Pan American Health Organization—develops a national climate and health action plan, this moment must prioritise efforts to reimagine health systems through locally grounded, ecologically attuned, and institutionally integrated approaches, particularly within the Unified Health System.
Footnotes
Funding: LG acknowledges funding from FAPESP (2021/06897-9), CNPq (309533/2025-2), and FAPEAM (call 002/2025). TJ acknowledges funding for a postdoctoral fellowship from the State University of Amazonas (PPGSC/UEA) (Call 02/2025-GR/UEA) and the Amazonas Research Foundation (Fapeam) (00296/2021). GDG acknowledges the support from the Global Health and Sustainability PhD Program and Center for Sustainable Amazon Studies (CEAS) at University of São Paulo. SH acknowledges funding from FAPEAM (TACT 005/2024).
Competing interests: We declare no competing interests.
Provenance and peer review: commissioned, not externally peer reviewed.
