23-05-2025
The floating clinics bringing healthcare to the banks of the Amazon
In a village on the bank of the Arapiuns river, deep in the Amazon rainforest, simple houses are clustered around a church, a primary school and a football pitch. But there is no doctor's surgery.
Access to healthcare here is precarious – there is no phone signal and only the handful of homes equipped with solar panels have a regular internet connection.
To find the nearest medical centre, you have to travel four hours downstream. Santarém, the closest city with hospitals, is eight hours away.
'People have already died because of the distance,' said Rosinilda dos Santos, 59, who lives in the village of São Francisco. She has spent her whole life on the banks of the Arapiuns, a winding river with dark waters lapping sandy beaches where locals live on subsistence agriculture, fishing and hunting.
Like many in her community, the grandmother-of-12 began working on manioc plantations as a child and now suffers from related back and eye problems.
With healthcare facilities so far away and costly to reach, São Francisco residents usually only seek medical assistance in the case of an emergency.
Occasionally though, medical assistance comes to them.
The Telegraph accompanied a team of doctors who travelled along the river in a pair of converted boats, crewed by volunteer doctors and packed to the gunwales with consultation rooms, dental clinics, and crucial supplies.
Over four days, the bulky vessels called at seven different communities in the Lower Arapiuns region of Santarém, a municipality of 330,000 spanning an area nearly the size of Wales.
In São Francisco, Ms dos Santos was keen to see a gynaecologist about the uterine polyp that has been bothering her for the past five years.
A polyp is a benign growth but can cause bleeding and discomfort. Improvising with the equipment available on the Ailton Barros boat, a groaning two-storey metallic structure painted white with yellow and blue lines, a volunteer gynaecologist wearing a camping head torch swiftly performs the procedure to remove the polyp.
'It's a weight off my mind,' said Ms dos Santos as she stepped back onto dry land, where fellow villagers were queuing for triage, clutching plastic bags containing their medical records.
With the boats' focus being primary healthcare, the team of doctors and nurses predominantly distribute vaccines, STI tests and medication for common complaints like musculoskeletal pain and gastrointestinal problems.
But 'we always get emergencies,' said Maria Rita Brasil, a 29-year-old nurse and the manager of the Abaré II.
She ran around cleaning wounds and administering intravenous saline solutions to patients in between filling out vaccination cards at an impromptu immunisation station under the shade of a tree, all while telling stories of her work in the region's most remote communities, some 32 hours away from the nearest city.
'On our last trip, we had a child who had been wounded by a rifle shot,' she said matter-of-factly.
She was unfazed by the appearance of one patient with a severely infected tooth abscess, and another with a suspected ectopic pregnancy.
As well as the unexpected, doctors aboard the boats have to contend with changes to the climate.
The Brazilian Amazon has experienced two successive years of severe drought, which scientists have attributed to man-made climate change, while last year was one of the worst on record for forest fires.
Local health professionals say that the changing climate is exacerbating health problems in the region, as well as leaving distant communities isolated for longer periods.
'In the last three years I've seen the appearance of a lot of skin problems and respiratory diseases that are caused by smoke and by high temperatures during the drought,' said Everson dos Santos, 46, a community health officer in the indigenous village of Tucumã-Açu.
Community health officers provide guidance and prevention on the ground, as well as serving as a vital liaison between the local population and the authorities.
The most frequent problems continue to be outbreaks of vomiting and diarrhoea, particularly during the transition from dry to rainy seasons.
In the village of Anã, Leandro Godinho's whole family ended up in hospital with diarrhoea in December last year. The 35-year-old schoolteacher's eldest son was so ill he had to be evacuated to Santarém by seaplane.
'[He had symptoms] for nearly a week. He was vomiting and had diarrhoea so was really dehydrated, he could barely stand,' recalled Mr Godinho, who feels like his own insides haven't completely recovered from the ordeal two months later.
A GP on board the boats prescribed him some painkillers, while the paediatrician recommended blood tests for his two sons. They were advised to go to Santarém for that, a journey that costs 60 reais (£8) per person each way – a cost that weighs on Mr Godinho's 1,400 reais (£185) salary.
Still, he was grateful for the appointments his family were able to get on their doorstep.
The boats are an integral part of Santarém's public healthcare infrastructure – and a unique feature of Brazil's NHS-inspired public health system, the SUS.
The SUS is centred on the principles of universal and equitable access to free healthcare for the entire population.
'Under this concept, healthcare comes to the river dwellers, it's not for river dwellers to go after the healthcare,' said Marcela Pinheiro, health technical advisor at Projeto Saúde & Alegria (PSA), an NGO that pioneered the model of floating healthcare centres in Brazil.
The concept of riverboats that travel up and down waterways to deliver regular medical assistance to remote communities was included in Brazil's national policy for providing primary care to river-dwelling populations in 2013. There are now 96 such boats serving 83 municipalities across the Brazilian Amazon and Pantanal.
'Our work is about prevention, health promotion, and care,' said Tângara Sansil, the city of Santarém's coordinator for river healthcare. She oversees 32 permanent basic health centres scattered around riverside communities as well as the city's three floating healthcare centres, which are known as UBSF.
Per national guidelines, these boats must visit their designated coverage area at least six times a year to provide vaccines and cervical screenings, routine check-ups, and urgent care if needed. But they can also team up with universities or NGOs to offer extra services.
'The floating healthcare centres provide GP services, so partnerships with NGOs allow us to bring specialist doctors,' said Ms Sansil.
A non-profit called Abarcar supplied the staff for the expedition The Telegraph joined in February. Among them were gynaecologists, paediatricians, GPs, dentists, and medical students. They also brought donations of much-needed medicines.
The state of Pará, where Santarém is located, there are only 1.18 doctors for every 1,000 people – well below the national average of 2.41, according to a 2023 study by the University of São Paulo.
Providing specialist consultations to the riverside communities directly helps reduce the number of people on waitlists in the city.
But the UBSF system has its limitations, even for communities within the boat's regular catchment area which does not include the Lower Arapiuns region.
While locals up and down the river were thrilled at being able to access healthcare on their doorsteps, they also lamented that the doctors come so infrequently and leave so quickly.
The Abaré II, for example, has only recently started up its regular visits again, after renovation works that lasted over two years.
'Out of [nearly] 100 boats, only 23 function regularly,' said Ms Pinheiro from PSA.
The NGO is working with the Oswaldo Cruz foundation, a public research institution, on a two-year 'diagnosis' of Brazil's floating healthcare centres, to identify shortcomings and possible improvements. Preliminary findings will be presented at the COP30 UN climate conference hosted by Brazil later this year.
'The challenge is to make the policy more efficient … to ensure it doesn't just get lost over the years,' she said.
