Fear, concern, challenge, responsibility are words used by community health agents in the Amazon to describe sensations experienced in the face of the covid-19 pandemic. Alongside doctors, nurses and nursing technicians, these workers are an integral part of the multidisciplinary teams in primary care services of the Unified Health System (SUS). In the midst of the health crisis, they became essential in disseminating information and monitoring communities that can only be reached by boat.
This October 4th, as has happened every year, the work performed by these professionals will be honored once again by various health agencies. The National Day of Community Health Agents was instituted by Federal Law 11.585/2007. The date has also been annually remembered by the category to charge better conditions. There are so many demands in the midst of the pandemic that, in May, the Commission on Social Security and Family of the Chamber of Deputies organized a public hearing to debate them.
“I was afraid, but we had to ally ourselves with the front line. And it went with all the security protocols. In the community there were three deaths. It was a big challenge. It was not easy. But we got the quick tests and when we identified the symptoms, we already started the isolation process”, he told Brazil Agency the community health agent Krisiane Brito do Nascimento, 19 years old.
A resident of the rural area of Iranduba (AM), about 40 kilometers from Manaus, she served the riverside community of Tumbira until the beginning of this year. There is no health center there. Twice a week, on Tuesdays and Thursdays, Krisiane took the boat for home visits. Methodically monitored the health of residents, especially hypertensive and diabetic patients, measuring pressure, saturation and glucose. On other days, he was on standby for any emergency and dedicated himself to filling out the forms online that gather data with patient information.
In Brazil, there are currently around 400,000 community health agents. To exercise the function, you must have completed high school or elementary school in specific cases, and complete a specific course accredited by the Ministry of Health. They can act in actions to promote health and prevent diseases, especially with a focus on guidance and in home or collective educational activities. They usually end up being the main link between the team and the communities. In most of these isolated places in the Amazon, for example, there is no doctor or nurse, and visits by these professionals are sporadic. In an emergency, it is often the community health agent who needs to accompany the patient to the nearest city.
These professionals are also usually people known to the population, even before starting their work, which facilitates the opening to enter the homes of residents. It was Krisiane’s case. “When I started acting, I was already very close to a lot of people. But we create more bonds”, he stated.
This reality won the screens in a documentary which is being released today (4) by the non-governmental organization Sustainable Amazon Foundation (FAS). In 42 minutes, the film titled Between banzeiros and canoes: the health agents of the Amazon brings together stories of workers who, like Krisiane, work in communities located within Conservation Units (CUs). The film addresses the difficulties of the profession and the daily lives of professionals who work in the forest. Available 24 hours a day, they are often activated at dawn. On a daily basis, they give tips on hygiene and nutrition, recommend the practice of physical activity, check vaccination cards, give instructions on the importance of prenatal care, among other recommendations.
There are reports of critical cases in which the agent’s work was fundamental, such as a gallstone crisis and labor. In the pandemic, the distribution of masks and gel alcohol, instruction on the procedures that the population should adopt and preparation of the community to receive the teams responsible for the vaccination were added to the routine tasks. They go from house to house, informing the day of receiving the first and second dose.
“It’s a beautiful professional choice. We visit, give guidance, give lectures for children, for women, for men. And we have to do an active search”, says Waldemir da Silva. At 62, he is the indigenous health agent in the Três Unidos community of the Kambeba people, located in rural Manaus.
With four decades of experience in the profession, he says that the pandemic has been the moment in which he felt the greatest responsibility. “It made me very worried, especially with the elderly and adults in the community who are diabetic, hypertensive, anemic. We increased visits. Sometimes, we visited up to ten times a day, because there were patients who got really bad. We had about 40 cases,” he told Brazil Agencyl.
Amidst the pandemic, other illnesses and incidents are also unrelenting. “It’s not that there isn’t drinking water in the community, because there is. But sometimes children or adults bathe in the river and can swallow some water. Then there are cases of diarrhea, nausea. The temperature does that too, because there are days here that are very hot. And there’s malaria. There have not been so many cases, but every case that appears is worrying, because it causes high fever, weakness, vomiting, diarrhea”, says Waldemir. He also brings on the tip of his tongue the number of people he has helped after snake bites. “There were 33 cases, of various types such as jararaca and surucucu-pico-de-jaca”, he said.
Although the indigenous health agent is listed in the Brazilian Classification of Occupations (CBO), it is not yet a regulated profession. Its performance is recognized within the scope of the Indigenous Health Care Subsystem, created in 1999 linked to the Unified Health System. However, there are few parameters for the hiring process, although the right to nominate the community itself is generally preserved. “I carried out a selection process according to the reality of indigenous peoples,” says Waldemir.
To regulate the profession, Bill 3.514/2019, by Congresswoman Joenia Wapishana (Rede-RR), is in process. The proposal seeks to grant indigenous health agents professional prerogatives that community health agents already have. It also reiterates some specificities, including the need to master the language, customs and traditional knowledge of each ethnic group. The project guarantees the participation of the indigenous community in the selection processes. In June, it was approved by the Commission on Human Rights and Minorities and is now awaiting consideration by the Commission on Social Security and Family.
difficulties
With the support of the private sector and agreements with the Government, the FAS acts on four fronts to overcome the difficulties of working in the Amazon: conducting research such as the diagnosis of SUS in the forest, which is currently in progress, the organization of courses in qualification, the financing of ambulanchas and the structuring of the telehealth system. According to Luiz Castro, coordinator of the Health in the Forest Program, developed by the organization, a more immediate demand is the need for more first aid courses, which are not considered mandatory today.
“They have to be prepared for that emergency. And first aid is not defined in its list of attributions. But whoever is living in a community, eight hours or more by boat from the municipality’s headquarters, needs people who are prepared to serve. And this needs to be recognized”, he says in the documentary produced by FAS. According to Luiz Castro, the agents know that the communities depend on them, since most do not have a nursing technician, much less a higher-level health professional living in the area.
According to Waldemir, the close relationship with the residents increases the responsibility. “The health agent is generally a communicative person. It is always informing, lecturing. And it makes friends. Talk with older people, with children. You are the first person to be informed of any problems. When it requires a deeper understanding, I call the nursing technician. But the health agent is the one who passes on the trust of the health system. It is a routine contact that generates respect, dignity”, he observes.
Despite the importance of this work, entities that represent the category demand greater valuation. At the public hearing held in May, the National Confederation of Community Health Agents and Agents for Combating Endemic Diseases (Conacs) showed the lack of specific qualification for combating covid-19. Also according to the organization, in many places it was necessary to provoke the Public Ministry so that community health workers were vaccinated, because they were not considered professionals in the front line of combating the pandemic, such as doctors and nurses.
One of the main demands during the public hearing was the approval of the Constitutional Amendment Proposal (PEC) 14/2021, authored by Mr. Leonardo (Solidariedade-MT). It establishes social protection and valorization of community agents, in addition to guaranteeing special and exclusive retirement and establishing the responsibility of the local SUS manager for the regularity of the employment relationship. For the Commission on the Federalization of Community Health Agents, the way in which hiring currently occurs creates vulnerability, encourages harassment and allows community health agents to be transformed into political marketers.
The lack of regularity in the employment relationship generates instability. Krisiane’s contract ended in February this year. Since then, she has been waiting for a new hiring possibility by the Iranduba city hall. “We miss work. But it depends on the governors”, he says. Structural improvements and availability of inputs are also demanded to allow better performance not only of community health agents, but of all other members of the multidisciplinary teams. Although Waldemir assesses that the situation is much better than it was 20 years ago, he cites some limitations. “Spider and scorpion bites, we can solve it right here, but no charge. There is no antivenin serum for these cases. There it is only in Manaus. We have a speedboat. Give it 1 hour and 20 minutes until then”.
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