**4.3. Health and globalization in a small town in the Amazon**

**4.2. Eating habits**

20 Current Issues in Global Health

these aspects also had the influence of globalization.

residents and 38% of urban residents.

Source: field study conducted by the authors.

Regarding the eating habits and types of food the interviewees consumed, this study found

Changes in the eating habits of the population in Amazon are associated with strong marketing strategies that large international food companies develop in the region to attract new consumers. In this study, despite the low percentage of interviewees who reported changes in their eating habits, the introduction of processed and ultraprocessed products in their diet was observed, especially among the young population, who consumes a higher variety of processed foods [32]. In addition, the heads of families have the perception that the processed food consumed by young people is not good for health and mentioned their worry about increased number of diabetic and hypertensive people in the municipality. This perception is reinforced by official data about diabetes and hypertension [33]: there were 3 cases of diabetes and 43 cases of hypertension in 2007 at the municipality of Ponta de Pedras. In 2011, 16 cases

of diabetes and 285 cases of hypertension were reported, demonstrating the increase.

Industrialized food products are sold in stores and represent a food transition, which has affected the health standards of the population. Answers on eating habits of the families indicated the consumption of chicken, pork, beef, and sausage, despite the population's preference for fish and flour. The weekly consumption frequency of the inhabitants is as follows: sausage in the rural area, 25 and 15% in the urban area and chicken once a week, 31% of rural

**Table 1** shows the processed foods purchased every month, in proportion to the number of urban and rural interviewees. Some foods, which are not part of the traditional Amazon diet or manufactured with local products, are bought by a high number of families. The lack of a refrigerator could explain the purchase of canned goods and noodles, but yogurt bought by

more than half the rural families, and 66% of urban families, weakens this argument.

**Type of food Urban population in % Rural population in %**

Pasta/noodles 85.9 94.1 Yogurt 65.9 55.9 Soft drinks 58.8 61.8 Canned/conserved food 49.4 60.3 Cereals/grains 44.4 38.2 Candies/sweets 35.6 25.0 Ketchup/mayonnaise/mustard 28.1 10.3 Snacks 24.1 11.8

**Table 1.** Processed and industrialized foods bought monthly by the population.

The North region of Brazil has a history of low health indicators. Health has to be seen today as a global issue, and healthcare globalization is a positive aspect that should be developed in a clear and well-planned manner [34]. At the current stage of globalization, the policies that promote health [28] have not brought considerable improvements for the population of Marajó Island, especially low-income population. Globalization is consistently consolidated as it pulls down the relationship between territory and its natural products and the community. Then, characteristics of the urban way of life, such as diseases, also appear in rural areas, resulting from the consumption of industrialized and globalized products, pressure for increased productivity on workers, and the appeal to the consumption of goods and merchandise.

The dynamics of small cities show limited development due to several factors, such as low educational level, scarce resources, difficult communication and transportation, and lack of sanitation infrastructure, which affect health conditions.

This research used the questionnaires applied to residents to identify health problems. One can observe that their perceptions on their health problems are more focused on new health issues than on diseases that historically are part of their everyday life.

The interviewees did not frequently report diseases, such as diarrhea and malaria, often cited in studies analyzing these riverside environments and registered in official data. Infant mortality in the municipality is very high, 30.2 per 10,000 newborn, placing it in the 4199 place among 5570 Brazilian municipalities. Also, there were a tax of 9.2/1000 hospital admissions due to diarrhea, in 2014 [1]. The Information System on Social Indicators of the State of Pará reported 924 hospital admissions in 2010, in Ponta de Pedras, of those 199 (18.3%) were due to infectious and parasitic diseases. These represent the second cause of internment after baby deliveries (231 hospital admissions).

In the interviews, 17% of people from the urban area and 21% from the rural area reported physician diagnosis of hypertension. High cholesterol levels were reported by 8% of urban interviewees and 7% of rural; and diabetes was reported by 6% of urban interviewees and 4% of rural ones. In fact, Information System from Ministry of Health indicates a large increase in the number of hospital admissions due to diabetes mellitus in Ponta de Pedras, in the last 10 years. There was 1 admission in 2009 due to this disease, 2 admissions in 2011, 5 in 2012, 6 in 2013, 15 in 2014, 22 in 2015, 25 in 2016, and 25 in 2017.

During data collection, some interviewees complained about the lack of physician and medicines for the treatment of diseases such as hypertension, diabetes, and high cholesterol levels, especially in the rural area, where the access to health services is more difficult. They reported that the Family Health Program (FHP) from the government does not always provide medication, and because of their low income, they cannot buy pharmaceutical products.

Regarding sewage discharge, the most common practice is discharge in a watercourse, compromising the water quality of the river and its source. In the urban area, 43% of the residents adopt this practice, and in the rural area, 82.6% justified by the absence of a sewage system, except for the cesspools. Septic tanks are the second option of sewage disposal to 32% of

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23

Sewage discharged in a stream eventually goes to the river, where the residents wash clothes, fish, where children take a bath, and whose water is used in home cleaning and other daily activities. Regarding waste disposal, 21% of urban residents burn the waste, claiming that the city does not collect solid residues as it should. In the rural area, burning residues is conducted by 98% of the respondents, who claim that burning is better than throwing them

This study found that the population of Ponta de Pedras is not satisfied with the services provided by the municipality, including the cleaning and other essential services such as education and health. Health services are top complaints, reported by 67% of the interviewees

In Ponta de Pedras, the problems are perceptive in the landscape. **Figure 3a–d** shows how the environment and health are intrinsically related, affecting the quality of life of the population.

**Figure 3.** Urban area that represents an environmental and sanitary risk to the residents. (a) Stilt houses and precarious wooden bridge to access the houses, (b) residence with wooden bridge, (c) and d) precarious access to water and environmental and health vulnerability. Source: collection of the Laboratory for Studies of Cities—UNIVAP [10].

urban residents, especially for those living in floodless areas.

in the river.

as an unsatisfactory service.

Chronic noncommunicable diseases (CNCDs) account for 58.5% of all deaths worldwide and 45.9% of the global burden of disease [28]. In Brazil, these figures have increased more than three times since the 1990s. Chronic diseases have played an important role in the epidemiological profile of populations, especially those living in urban areas; the study also reports different determinants in this type of anthropic space organization [35].

Despite the large water supply in the Legal Amazon, official data show that the worst regionally evaluated indicators belongs to this region: 56% of the households do not have water supply from the public system; of the total water volume distributed by the public system, 32.5% had no treatment, and 92% of the municipalities in the region had no sewage collection system [1]. In Ponta de Pedras, many residents, because they need these essential services, had to improvise water access and storage systems.

Most interviewees from the urban area (75%) reported access to water supplied by the Pará State Sanitation Company (COSANPA), but that the water is not treated. Less than 10% of the interviewees reported access to water from a neighbor or an artisanal well. The situation is different in the rural area, where 90% use river water and 10% store in gallons, water that comes from the urban area. In the interviews, residents complained about the constant lack of water, for up to 3 or 4 days a week, which explains using the neighbor's water. Many residents store water inadequately at home, often creating an environment that favors the proliferation of vectors such as *Aedes aegypti*, the mosquito that transmits dengue virus. The environment presents precarious conditions reported by the interviewees, with stagnant water and garbage. The perception of water quality by the population is ambiguous; although they find impurity and recognize the scarcity of water and sanitation, they see the river and the forest as natural resources essential for them.

In spite of the belief that water is of good quality, 76% report water treatment before consumption, as they do not trust its origin. In the rural area, 67% treat it before cooking and drinking. However, rural residents have the perception that the "river is clean," as they eat fishes and shrimps from this environment. Before using the water, some urban residents reported that they "boil" it (3%), filter it (16%), or use sodium hypochlorite (43%); in the rural area, 72% answered they use sodium hypochlorite distributed by the Municipal Health Department. Considering the above, their low reference to waterborne diseases and diseases transmitted by vectors is not consistent with this unhealthy situation. More than 45% of urban respondents and 65% of rural respondents did not know the predisposing factors to their diseases.

When asked about disease concerns, rural residents answered they had symptoms of a viral disease due to poor water quality. However, only two families were submitted to laboratory exams and found a parasitic disease (the resident did not know how to describe the disease). In Ponta de Pedras, waterborne diseases, most reported by residents, were viral (12% in rural and urban areas) and diarrhea (5% in the urban area and 3% in the rural area). This study in Ponta de Pedras highlighted the lack of infrastructure, such as piped water and sewage system, and that its availability does not cover all sections of urban and rural areas. In the urban area, the neighborhoods were occupied in diverse periods, while public investments in infrastructure were made in different stages and paces.

Regarding sewage discharge, the most common practice is discharge in a watercourse, compromising the water quality of the river and its source. In the urban area, 43% of the residents adopt this practice, and in the rural area, 82.6% justified by the absence of a sewage system, except for the cesspools. Septic tanks are the second option of sewage disposal to 32% of urban residents, especially for those living in floodless areas.

that the Family Health Program (FHP) from the government does not always provide medica-

Chronic noncommunicable diseases (CNCDs) account for 58.5% of all deaths worldwide and 45.9% of the global burden of disease [28]. In Brazil, these figures have increased more than three times since the 1990s. Chronic diseases have played an important role in the epidemiological profile of populations, especially those living in urban areas; the study also reports

Despite the large water supply in the Legal Amazon, official data show that the worst regionally evaluated indicators belongs to this region: 56% of the households do not have water supply from the public system; of the total water volume distributed by the public system, 32.5% had no treatment, and 92% of the municipalities in the region had no sewage collection system [1]. In Ponta de Pedras, many residents, because they need these essential services,

Most interviewees from the urban area (75%) reported access to water supplied by the Pará State Sanitation Company (COSANPA), but that the water is not treated. Less than 10% of the interviewees reported access to water from a neighbor or an artisanal well. The situation is different in the rural area, where 90% use river water and 10% store in gallons, water that comes from the urban area. In the interviews, residents complained about the constant lack of water, for up to 3 or 4 days a week, which explains using the neighbor's water. Many residents store water inadequately at home, often creating an environment that favors the proliferation of vectors such as *Aedes aegypti*, the mosquito that transmits dengue virus. The environment presents precarious conditions reported by the interviewees, with stagnant water and garbage. The perception of water quality by the population is ambiguous; although they find impurity and recognize the scarcity of water and sanitation, they see the river and the forest

In spite of the belief that water is of good quality, 76% report water treatment before consumption, as they do not trust its origin. In the rural area, 67% treat it before cooking and drinking. However, rural residents have the perception that the "river is clean," as they eat fishes and shrimps from this environment. Before using the water, some urban residents reported that they "boil" it (3%), filter it (16%), or use sodium hypochlorite (43%); in the rural area, 72% answered they use sodium hypochlorite distributed by the Municipal Health Department. Considering the above, their low reference to waterborne diseases and diseases transmitted by vectors is not consistent with this unhealthy situation. More than 45% of urban respondents and 65% of rural respondents did not know the predisposing factors to their diseases. When asked about disease concerns, rural residents answered they had symptoms of a viral disease due to poor water quality. However, only two families were submitted to laboratory exams and found a parasitic disease (the resident did not know how to describe the disease). In Ponta de Pedras, waterborne diseases, most reported by residents, were viral (12% in rural and urban areas) and diarrhea (5% in the urban area and 3% in the rural area). This study in Ponta de Pedras highlighted the lack of infrastructure, such as piped water and sewage system, and that its availability does not cover all sections of urban and rural areas. In the urban area, the neighborhoods were occupied in diverse periods, while public investments in

tion, and because of their low income, they cannot buy pharmaceutical products.

different determinants in this type of anthropic space organization [35].

had to improvise water access and storage systems.

22 Current Issues in Global Health

as natural resources essential for them.

infrastructure were made in different stages and paces.

Sewage discharged in a stream eventually goes to the river, where the residents wash clothes, fish, where children take a bath, and whose water is used in home cleaning and other daily activities. Regarding waste disposal, 21% of urban residents burn the waste, claiming that the city does not collect solid residues as it should. In the rural area, burning residues is conducted by 98% of the respondents, who claim that burning is better than throwing them in the river.

This study found that the population of Ponta de Pedras is not satisfied with the services provided by the municipality, including the cleaning and other essential services such as education and health. Health services are top complaints, reported by 67% of the interviewees as an unsatisfactory service.

In Ponta de Pedras, the problems are perceptive in the landscape. **Figure 3a–d** shows how the environment and health are intrinsically related, affecting the quality of life of the population.

**Figure 3.** Urban area that represents an environmental and sanitary risk to the residents. (a) Stilt houses and precarious wooden bridge to access the houses, (b) residence with wooden bridge, (c) and d) precarious access to water and environmental and health vulnerability. Source: collection of the Laboratory for Studies of Cities—UNIVAP [10].

The environment plays a fundamental role associated with health conditions, as environmental factors can cause ecological imbalance and, consequently, the proliferation of pests, which can be vectors of diseases [34]. Wooden houses are characteristic in the Amazon and are mostly built on stilts to avoid river flooding, for being economically viable, and to provide some thermal comfort to residents in local climatic conditions. Based on data collected, the epidemiological profiles of the region and the municipality are marked by overlapping of diseases resulting from local living conditions and low access to prevention and control measures, in addition to poor health services.

Public policies must consider this ongoing process in order to extend the social benefits to the vast Amazon region. Health policies could also act to balance the effects of globalization on

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25

The authors are thankful to São Paulo Research Foundation (FAPESP), Brazilian National Council for Scientific and Technological Development (CNPq), and Coordination for the Improvement of Higher Education Personnel (CAPES) for the financial support to this research, as well as to the University of São Paulo, Department of Environmental Health and University of Vale do Paraiba (UNIVAP), Laboratory for Studies of Cities, São José dos

and Helena Ribeiro3

1 Department of Environmental Health, School of Public Health, University of São Paulo,

2 Laboratory for Studies of Cities, University of Vale do Paraiba, São José dos Campos, SP,

3 Department of Environmental Health, Faculty of Public Health, University of São Paulo,

[1] Instituto Brasileiro De Geografia e Estatística (IBGE). Cidades@contagem populacional 2010. Available from: <http://www.censo2010.ibge.gov.br/sinopse/index.php?uf=

[3] Lemos ALF, Silva JA. Desmatamento na Amazônia Legal: Evolução, Causas, Monitoramento e Possibilidades de Mitigação Através Do Fundo Amazônia. Rio de Janeiro:

[2] Ianni O. A Sociedade Global. Rio de Janeiro: Civilização Brasileira; 2014

health.

**Acknowledgements**

Campos, SP, Brazil.

**Author details**

Viviana Mendes Lima<sup>1</sup>

São Paulo, SP, Brazil

São Paulo, SP, Brazil

**References**

Brazil

**Conflict of interest**

The authors have no conflict of interests to declare.

\*Address all correspondence to: geomendes@usp.br

15&dados=0>. [Accessed: 20 August 2016]

\*, Sandra M.F. Costa2
