GEN-CARE ANDEAN-AMAZONIAN

A new Epidemiological scenario of Neglected Tropical Diseases has been revealed by the Pandemic (Fig. 1): different levels of underreporting of diseases caused by the disruption of morbidity management have occurred accompanied by increased infection rates by Plasmodium vivax, reintroduction of P. falciparum, increased cases of American Cutaneous Leishmaniasis, spread of visceral Leishmaniasis and Chagas disease, increased number of cases of leptospirosis and tuberculosis, in addition to showing that the traditional strategies of community education and promotion of health are repetitive (not very sustainable and less inclusive, with fleeting and limited impact, with reduced community participation in proposed actions), which is why there is an urgent need to redirect Information, Education and Training strategies for Behavioral Change (04 Learned Lessons), which initially allow progressive empowerment of the population with an emphasis on women, to accompany and strengthen the other changes in state programs as well as stimulate the ability of communities to detect diseases. Particular attention should be given to the rural population (the most disadvantaged and with the greatest impact of NTDs), working as chestnut harvesters every year. 

Formative research objectives for both short-term (first year) and medium-term (subsequent years), intend to start with a change of behaviours, practices and lifestyles of the community, allowing the project to cement and promote the development required for a true "tropical health system",

which begins with the study of strengths and weaknesses of health
information to integrate marketing concepts with different approaches,
in order to influence behaviors that benefit individuals and communities
for greater social good and continue with different development
processes that optimize the current tasks that allow a greater impact in
the control of NTDs. The proposed solutions of Primary Health Care
(EPS) are aligned with the public policies of the Ministry of Health and
Sports, applying the policy of Community and Intercultural Family
Health (SAFCI), which stimulates attitudes and reflective thinking about
the realities identified in the rural communities in particular and the
surrounding socio-institutional factors, which are based on life,
assuming the challenge of social responsibility established in the
Political Constitution of the State, as a natural aspiration of the
human being and of society, with an intersectoral, integral approach,
integrated and iterative.

The population of the Bolivian Amazon (hot-pops), are demographically grouped into sub-populations that share social, behavioral and geographic risk characteristics, so the solution proposes a continuous intervention to mitigate inequality and inequity in access to health, precarious surveillance systems, collection and capture of data on NTD cases that the 13 original peoples that inhabit the Bolivian Amazon currently have. The first stage proposes to evaluate local knowledge, perceptions of diseases and clinical signs, to identify opportunities that allow us to correct the disparity of knowledge, communication and access to information, using the main native languages, to consolidate a "Community Network to exchange  health information" that supports the PHC. As of the second year, promote a migration process from traditional notification systems to electronic notification, storage, processing and analysis of data (big data); monitoring and prediction of the appearance of epidemic outbreaks and their severity (machine learning); exploration of data (data mining), which allows technical answers with scientific support, generating evidence for informed decision-making in a health system that requires transformation.

A crucial step then is to induce, train, monitor and evaluate more than 700 people, establishing solid and participatory links in the Promotion and Prevention of NTDs (Information, Education and Training for Behavioral Change), applying social marketing tools and ICTs, developing messages that will be extended to predominantly rural municipalities, due to their lack of communication infrastructures; construction of relevant health indicators and a feedback mechanism for service providers regarding the timely distribution of health and prevention products, to achieve a change in the state of lethargy of the traditional health system and its authorities. Our next step is to introduce digital information systems which will allow us to codify records of diagnoses, interventions, and results, systematically, chronologically, and promoting the development of a true "tropical health system" by strengthening qualified, timely diagnosis structures which are not present in the area yet.

The traditional surveillance system is slow and needs support to identify common disease outbreaks and new NTDs early to generate timely responses. After identifying the existing communication modalities, IEC/CC tools will be designed, validated and applied for the target population, through a range of materials and activities that optimize Promotion and Prevention interventions through the development of applications for smartphones and social networks (sending information through apps, video-chats, podcasts and digital health, web-based fact sheets, model stories, videos, commentaries, infographics, questions - answers and intranet content for health personnel) in order to inform, educate, reflect and empower the population. By having an informed and trained population, we will propose the migration of health processes to the digital system (stage II), with electronic notification, storage, processing and analysis of data, a situation that will progressively require the different authorities to participate, support and process sustainability.

Previous experiences and the training of key groups of the population (explaining motorcycle taxi drivers, market vendors, leaders) will allow the dissemination of new information, adapting communicational content to the regional worldview in order to allow us to gain the trust of the community. These tools will be organized within a framework of six principles (Accessible, Actionable, Credible and reliable, relevant, timely and understandable);

Reaching individuals, families and communities; giving children, teenagers, adults and elderly, a more amicable approach to the prevention against NTDs. Part of the strategy is to give institutions and communities a sense of co-responsability, to prevent, promote and surveill; Mainly focusing on Social Councils, Federation of Zafreros, Federation of Social Communicators, Human Rights Ombudsmen, Ministries of Labor, Rural Development, Agriculture, Environment, of Government, Health, Civil Society Organizations, Voluntary Collaborators, other health agents), Non-Governmental Organizations, Technical and Economic Cooperation Agencies, Single Federation of Rural Workers of the Amazon, and others).

The expansion and identification of existing communication modalities will allow designing, validating, applying and optimizing the training of the population using traditional media and new digital health tools, mainly with children and adolescents, motivating and socially committing to personal and family prevention. against NTDs (malaria, arboviruses, leishmaniasis, Chagas, Tuberculosis and others). Currently the control is done once a year and only by people outside the community, finding that more than 50% of the time the data is incomplete.

Traditionally, notifications from rural areas and secondary cities are made through paper records (forms and notebooks), which are in charge of health personnel and community agents called Health Responsibles (RS) and Voluntary Collaborators (CV), who carry out statistics manual sent to capital cities for consolidation and sent to health authorities (National Health Information System - SNIS); This situation will be improved with the implementation of new techniques for data collection, monitoring and agile or timely epidemiological surveillance for immediate decision-making.

The current health vision of the country of the authorities and population in general, is limited to an Andean epidemiological profile where the main economic resources of the country (mining) were found; the interpretation of tropical diseases often has exotic interpretations, these criterias have not allowed much development of the tropical health system in important geographic areas for many generations, specially affecting small population groups, which are in a geographical, cultural and social disadvantage.

The effort to establish innovative and shared strategies will allow the development of new alternatives for similar community settings; the optimization of NTD control following and annexing the knowledge of traditional medicine and studies carried out in other geographical areas, such as: cheap repellents for insects that complement the use of mosquito nets impregnated with long-lasting insecticides (LLINs); increase the useful life of the LLINs strengthening its residuality through washing with native natural products; improve access to effective diagnosis and treatment.

Chestnut (Bertholletia excelsa) harvesting is the main subsistence economic activity of 13 of the 36 native Bolivian Amazonian peoples (Pacahuara, Esse-Ejja, Chacobo, Cavineño, More, Araona, Yaminahua, Machineri, Tacana, Tsimane, Maropa and Leco); Every year (November to April), around 50,000 people move into the forest in the middle of the rainy season to collect chestnuts (zafra); malaria technicians and volunteer collaborators are the only ones who provide any health care to this population called "chestnut farmers or zafreros". Fig.2.

The most frequent pathologies that present in addition to malaria are: leishmaniasis, common cold, acute respiratory infection (ARI), acute diarrheal disease (EDA), enteroparasitosis, dengue, conjunctivitis, dermatomycosis; as well as work accidents: cuts, bruises, sprains, fractures and snake bites.

For decades, our multidisciplinary team has carried out different meetings, interventions and training activities, prevention, supervision, evaluation with health volunteers, community leaders, the general population, in addition to health care providers; This situation has allowed us to follow and know in the field the local and regional characteristics of the health services and particularly those of the cultural groups of the region where even the prioritization of the most vulnerable is still insufficient (absence of detection of asymptomatic infections of the malaria in pregnant women and in the first 1000 days of the child's life, lack of knowledge of parasitic and vector sensitivity and resistance indices, real prevalence of arboviruses, leishmaniasis, Chagas disease and others), as well as the weak response capacity, limited availability of medicines and deficiencies in care due to operational needs; the space and heterogeneity of the scenario of "border malaria" and the reintroduction of P. falciparum due to commercial activities with Brazil, a country with which there is in common the clear upward trend in transmission rates of malaria, have not yet been understood. Plasmodium vivax and P. falciparum (Amazonas state, Acre)

For years various attempts have been made to implement complex interventions to control Malaria, leishmaniasis and arboviruses in this lively population, which enters the forest and after 5 or 6 months leaves for intermediate cities where outbreaks of different diseases arise. This need to contribute to provide real and better solutions has motivated us to live and work in the region and propose an ambitious research-action project with a mobile population, from a country with low to medium income, in a border context, in a scenario of "changing epidemiology" that requires the contribution of new strategies for new challenges. This population that lives in the midst of extreme limitations, have survival skills, demonstrating cognitive qualities of reflection and improvement of their behavior with the learning of new techniques to embark on prevention.

We consider it necessary to break down the bureaucratic and social barriers of the traditional financial organizations of my country, which opt for foreign consultants who are unaware of our reality and offer theoretical solutions, in addition to allowing us to consolidate technically and scientifically trained national human teams with the capacity for "real response" to build a new national roadmap for Bolivian Amazon Health-2030.

The challenge will allow us to carry out some priority tasks:

1) Implement updated social marketing and ICT tools, which replace repetitive community education and promotion strategies that are unsustainable and less inclusive with limited impact.

2) Widespread use of webinars and other virtual platforms and “hybrid Promotion and Prevention” programmatic approaches, Malaria/Covid-19; Malaria/Maternal and Child Health; Arbovirosis/leishmaniasis and others.

3) Suggest solutions to the reduced and slow capacity of the supply chain (drugs, supplies, basic biosafety elements).

4) Propose new and innovative formal approaches that allow municipalities and governorates to understand and absorb the co-financing obligation before a final round of financing from the Global Fund.

Carrying out these tasks will allow us to carry out research that provides technical answers with scientific support, generating evidence for informed decision-making, as well as consolidating the multidisciplinary technical and scientific team that provides "real answers" to regional needs and builds a new national roadmap for Bolivian Amazon Health-2030.

The proposed participatory activities will incorporate from the very beginning the population's responsibility and bring empowerment to the community the care and development of its local and regional health system, also proposing alternatives for health care in the jungle to Zafreros and their families.

It will allow the creation of a team of qualified professionals in social marketing and ICTs with experience, who carry out new processes of promotion, prevention and updating.

Development of applications for smartphones to send and receive surveillance and patient monitoring information, mini-videos, video-chats, podcasts, and digital health, in order to insist on information, education, reflection, and training for the population.

Experience in the field with community participation: motivational songs in native rhythms and languages; motorcycle taxi drivers explaining local health endemics; consolidate active community participation with a new team of professionals who change the old health care processes.

First year:

Increased by 30% attendance and participation of the population in health promotion and prevention events.

The sub-registration of NTD cases, in particular Malaria, has decreased.
Consolidated as the main means of Information, Education and training in health to the digital tools developed, 70% of follow-up in peripheral populations.

90% improved information and surveillance systems with patient monitoring through whatsapp.

100% consolidated social marketing interventions focused on disease prevention and control.

Five years:

Reduction between 10 and 30% of the morbidity of Vector-Borne Diseases (ETVs); Rash diseases of childhood; maternal child health.

Consolidated at 80% the social marketing interventions for the prevention and promotion, diagnosis and treatment of NTDs, based on the adaptation of the tools and processes used to the intervened contexts and the understanding and monitoring of the native peoples.

Reduced between 10 to 30% the incidence of NTDs, reduction in mortality in the mother-child binomial and the resurgence of malaria (Plasmodium falciparum) due to lack of foresight and epidemiological surveillance.

The Ministry of Health has the National Malaria Control Program (PNCM) as a leading program that has five “Strategic Goals”:

1. Guarantee universal access to immediate and quality malaria diagnosis, treatment and follow-up.
2. Promote, strengthen and optimize the mechanisms and tools for vector control.
3. Strengthen the health system to prevent severe malaria.
4. Foster an environment conducive to sustainability through health system and community engagement.
5. Monitoring and evaluation.

NTDs pose a challenge for the health, social and economic development of countries, so our activity will contribute to Goal 4 (SDG: Obj. 3, 4, 10,); through "relationship building" and a new "focus on the health of sugarcane harvesters / control of NTDs", seeking the participation of multiple sectors in the construction of new common objectives, where social marketing interventions for prevention and control of NTDs are based on understanding the population and adaptation to the geographical, social and economic context.
Our indicators to follow:
-Number of schools, teachers and students who received IEC
-Number of mini videos and video-chats, podcasts edited / broadcast on the network and that have followers (number of members).
-Number of medical consultations, orientations and explanations made through safe and reliable digital health (App) that meet privacy, security and content standards.
-Number of patients with treatment follow-up that reduces treatment abandonment.
-Improve patient adherence through accompanied treatment
-Number of services provided by health personnel (SAFCI) outside the establishment.
-Number of establishments that implemented the new project techniques (Marketing and ICTs)
-Registration of the N° of new variables, Marketing and ICTs incorporated into the SNIS.
-Number of local health committees formed

The progressive use and development of preventive, monitoring and control cyber-health strategies. Implementing processes to combat and eliminate the barriers of late diagnosis, insufficient or no diagnosis (Fig.3).

The World Health Organization defines electronic health (e-Health) as “the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health care services. health, health surveillance, health literature, health education, knowledge and research.

Telehealth (already existing in the Amazon region) and social marketing in NTD care is still in its early stages in Latin America we intend to explore what has worked in other environments with similar characteristics; the need to build and develop innovative processes of health promotion and education through social marketing and cyber-health, they intend to solve these deficiencies through the initial multidisciplinary work that has a participatory reality for the project and a vision of future self-sustainability, rescuing successes and failures from previous experiences and from established programs that have similar situations.

The First Level of attention is in charge of the Departmental Health Service (SEDES) whose competencies are highlighted by the Ministry of Health

* Diversity:

With our exploratory studies and experience in the area, we have established that an inclusive approach to diversity arouses greater interest in the population, facilitates the implemented learning strategies and motivates teamwork.

* Equity: Traditionally, the greater opportunities that men have in relation to women and the different roles that are socially assigned to them in their socioeconomic activities in the forest, is one of the main challenges that we will have to promote equal opportunities in the promotion health, education, protection and well-being, particularly of women.
 
* Inclusion: We included as a target population 794 people who belong to the 13 indigenous peoples of the Amazon and work in Primary Health Care, with whom we will build future tasks for the control of NTDs in the region in a participatory manner.

"Fundación La Paz", is a non-governmental, non-profit organization, with
more than 40 years of experience in the development of social programs
in Bolivia, which has an inter-institutional agreement with the
Health and Environment Institute "ISMA". It is a non-profit organization with 25 years of experience; with mission and vision of scientific and operational research of morbid processes that occur in Bolivia. Services that are demanded by the Ministry of Health or other agencies. where half of the technical-scientific staff of the Project work.

Our business model proposal is one of formative research, which within the ecological, socioeconomic and demographic processes intertwined with the health of the native peoples, aims to recognize the value of their ancestral knowledge of those key beneficiaries (13 Amazonian ethnic groups), allowing the state and society to get involved to provide real access to Primary Health Care services (promotion, prevention, care, diagnosis, treatment and rehabilitation), in high-transmission tropical environments so that the impact of epidemics is less serious, there are fewer hospitalizations and deaths and the population can reduce socio-economic losses caused (as a side effect) by diseases.

Outbreaks of zoonotic diseases are occurring in these areas and several authors describe it as a potential incubator for the next pandemic, so it is necessary to correct the ancestral under-diagnosis, under-notification, precarious health care and minimal research, to in order to avoid the spread of diseases as well as to solve them using medicines that the jungle provides, as is the case of Cinchona (quinine) that facilitated malaria control for centuries.

Destructive environmental policies, mining on indigenous lands and protected areas, public forest concessions, incentives for oil exploitation. and gas extraction, changes in the implementation of the constitutional rights of indigenous peoples represent a wall that the authorities are not always willing to promote or finance, so our work aims to provide these services and products.

The continuous formulation of innovative projects with a comprehensive or specific approach emerge as an alternative to solve health needs.

Support from international organizations to consolidate the commercialization of cheap insect repellents to complement the use of impregnated mosquito nets; Traditionally used plant-based insecticides are an interesting alternative to develop.

The COVID-19 pandemic has broken the possibilities of building or having sustainability and financial sustainability processes to meet health requirements, in addition to the fact that the central government, governorates (II political level) and municipalities (III level), do not they have the technical and financial capacity to meet these needs.

Political changes have not allowed us to conclude our project as a team called "Fight against the Great Endemics" between the National Laboratory of Parasitology (National Institute of Health Laboratories) and the French Cooperation (Institut Pasteur, Institut de Recherche pour le Developpement), having built and equipped the National Laboratory of Parasitology and Entomology, a Level II Hospital and not being able to specify the Institute of Tropical Medicine in the Amazon (an institution that supports public health initiatives and strengthens regional and local health capacities in the Amazon that respond to disease threats through operations research).

Promotion and Prevention will allow us to recommend to the population and its local, municipal and departmental authorities the need for their co-participation (new rates for the exploitation of natural resources), as well as to consolidate innovative alternatives for the use of natural products that were carried out: antiparasitic ( Fournet A. 1994, Fournet A. 1996, Bourdy G. 2009); or insecticides and repellents (Moore S. 2002, Hill N. 2007, Colina N. 2007, Urquidi M. 2007) and potential against other diseases(https://www.google.com/url?sa=... ).