Social characteristics of participants
Mining is an activity predominantly performed by men. Only one person interviewed was female, who worked as a cook in the mining operation. The average age of the participants was 47 years old and the predominant level of education was elementary school, which all the interviewees had completed. Five participants were illiterate and the average length of service in the mine was 20 years.
The analysis of the 29 interviews and the field notes allowed us to identify the five major themes, which are illustrated in Fig. 3.
Theme 1 - Death in mining
Most of the participants have already witnessed death from diseases in the mine. Hepatitis, tuberculosis and malaria were cited as the main cause of death from infectious diseases. Regarding malaria, 16 participants reported cases of co-workers who had died from the disease. Most died due to lack of medical care or incorrect treatment. However, most reports were from participants who experienced part of the gold rush in the 1970s and 1980s; a time when there was not much infrastructure in the region or the Brazilian National Health Service (SUS), as well as decentralization in the diagnosis and treatment of malaria in the Amazon Region.
“One memory that struck me was seeing my friend die of malaria, where he was not diagnosed and had the wrong treatment, because we thought he was just suffering from a virus, and when he died, the autopsy found that it was malaria, and he died without receiving help and this is very sad” (Gold miner 5).
“...I only remember those in which the miners don’t take all the doses and end up drinking alcohol and sometimes there is no way to cure them when they go seek treatment. They are already very bad and end up dying. They even made a cemetery for the miners. And do you know what happens there? Some people dig up the bodies because some were buried with many gold nuggets” (Gold miner 19).
“When I came here to cook, there were no women working in the mine because the work was heavy and there was a lot of malaria, I was at the brink of death because of malaria” (Gold miner 27).
Regarding the current malaria situation, the miners reported that they have lost their fear of the disease, despite becoming infected, since they know that if they get sick they will have access to diagnosis, doctors and medicines.
“Malaria no longer frightens anyone, nowadays it is no longer frightening, because there is medicine available for everyone and this makes life much easier because if the gold miner gets sick he can go to SUCAM (Superintendence of Public Health Campaigns) and gets medicine” (Gold miner 19).
“In the past I was afraid to go to the mine because of malaria, and I heard stories and saw people with symptoms and that made me afraid, nowadays I am no longer afraid of malaria” (Gold miner 3).
Theme 2. Diagnosis and treatment of malaria
Regarding the thick smear test, despite the great majority expressing confidence in the test, some interviewees reported not fully trusting the test. These interviewees reported that the finger was not the best place to collect blood as it would run the risk of a false negative result. They claimed that they prefer blood collection in the ear lobe because they reported the occurrence of false-negative results in a sample collected from the finger and positive results for collection in the ear lobe.
“...sometimes it doesn’t give a positive result either on the finger exam or on the vein exam, but also if they collect blood from the ear that gives a positive result” (Gold miner 9)
The interviews revealed that workers believe in medicinal plants. Bottles containing infusions of roots and leaves of common plants of the Amazon are very common among miners. They believe that quinine tea, bilberry tea, paca gallbladder tea (Cuniculus paca, a wild rodent that is common in the region) possess medicinal properties. Despite this, some said they did not agree with these practices for treating malaria due to negative experiences in the use of these popular and home remedies.
“I have already heard of boldo* tea for malaria and several other teas made from tree bark. I have already had some, and people say that they have taken them and have been without malaria for over twenty years. These bottles of infusions are very good” (Gold miner 22).
*Peumus boldus.
“I've heard of malaria teas and bottled infusions, one of which is gall tea, but I never got to take these homemade medicines. But I've heard reports from people who took them and never had malaria” (Gold miner 15).
“Some gold miners I knew died because of that, they stopped taking the normal medicine to take the natural ones and ended up not having the desired effect against malaria and they died” (Gold miner 25).
Most participants trust the medicine distributed by the National Health Service in Brazil. However, many respondents reported discomfort with the medication due to the adverse effects of the treatment. Many complained of having to travel from the mine to the city for a diagnosis and for medicines. This displacement, according to the miners, could be avoided if they had the medicine available in the mining area.
“Some people are able to take malaria drugs to the mines, because they ask the doctor and take it in case they start to feel any symptoms. Then, take it to the mine without needing to come here again” (Gold miner 5).
Several gold miners reported resorting to the clandestine antimalarial market when they are in the mines and start to show symptoms of the disease. Reports indicate that Artecom® (dihydroartemisinin-piperaquine), which is unregistered in Brazil, illegally enters the country through the borders with Suriname, Guyana and French Guiana. The miners describe that the drug has the advantage of being a single dose, which relieves symptoms for a few days, but does not cure the disease. The choice of medication by the miner depends on where he is when he becomes symptomatic. Respondents reported that geographical isolation, in addition to the loss of work days if they have to return from a distant area to the city, are major factors in choosing this treatment, regardless of knowing the type of malaria. The miners interviewed were unaware of the importance of different treatments for different types of malaria.
It should be noted that the cost of Artecom® in the mines, according to respondents can be as much as 300 Reais ($55 − 08/11/2020), with a significant economic impact, representing approximately 60% of the miners' average monthly income as well as their health.
“...people take single dose medicines without even knowing what type of malaria they have, without having an exam, without anything.” (Gold miner 11).
“I've already taken Artecom, but I think that these remedies1 here in Brazil are even better than what Artecom is. Even some miners prefer these remedies here in Brazil, despite being a bad medicine, but they provide security for the patient. With these drugs, the patient takes a complete treatment.” (Gold miner 22).
“But there is a medicine that is a single dose that comes from another country. It was strong, but the good thing is that it was a single dose.” (Gold miner 18).
Respondents reported that the number of pills and the length of the treatment were two disadvantages of the medication distributed by the government in Brazil. Treatment abandonment, mentioned by the miners, is very frequent, caused mainly by the ingestion of alcoholic drinks. Alcoholism in mining was mentioned as a common problem, associated with a hard working life and isolation. Many cited the use of brandy as the main drink due to its affordable price and the lack of need for refrigeration.
“Here many people abandon treatment because of alcoholic drinks. Because people take a few doses of the medicine and they already feel well and this causes the miners to abandon the treatment because they are feeling good already, and they will start toconsume alcohol again” (Gold miner 1).
“Practically every month I had malaria, but this was due to my carelessness. Even though I had the disease, I only took the medicine until Friday, because on Saturday I stopped taking it to drink alcohol” (Gold miner 17).
Some miners perceived the medication as a contributing factor to the death of some patients. According to them, depending on the person’s clinical condition, their bodies could not handle the treatment.
“I’ve seen people die of malaria. They arrive very weak because the disease is very strong and when they took the dose of the medicine, which is very strong, they ended up not being able to handle it and that was fatal.” (Gold miner 21).
“The medicine is very strong, you cure malaria and get sick in the liver due to the medicine and this is very bad...” (Gold miner 03).
MDA is a tool used in several countries as a strategy to combat malaria. During the interviews, the researchers asked about a possible MDA intervention in the mine. The miners showed resistance to the implementation of a program like this and, with the main refusal reason being a need to be symptomatic to take the medication. According to them it is necessary to perform the malaria test. In addition, they reported the negligence of the miner regarding his own health as an important factor for refusing an MDA program.
“They wouldn’t take the medicine if they didn’t feel anything, the miner is stubborn and without feeling anything he wouldn’t consider himself sick” (Gold miner 5).
“I think it would not make sense to give medication without the person feeling anything wrong with him, and without having a positive test. If I tested positive for malaria, and I don’t have symptoms I wouldn’t take anything, because this is a cultural thing for the miner, he only takes medicine when he feels the symptoms and it’s already bad” (Gold miner 4).
“Here in the gold mine, it is difficult for people to accept mass medication, because here people only take it when they are really feeling the disease, without an exam they wouldn’t take it” (Gold miner 1).
Theme 3. Malaria transmission and prevention in mining
The transmission of malaria by mosquito bites was reported by most respondents. However, the statements given on this topic evidenced doubts, and were always accompanied by "I think", "because people say". As such, they seem to be based on popular beliefs.
“Some say you get malaria from the mosquito, but I'm not sure about that, because it can also be caught from water or some other virus” (Gold miner 13).
Doubts about the transmission of the disease led to many theories regarding the source of infection. People believe that they could be infected through contaminated water, viruses, environments such as ponds, and poor diet.
“You get malaria by drinking dirty water, water from rivers, the malaria I got was like that, when I was in the forest drinking water directly from rivers.” (Gold miner 5)
“Some say you get malaria from the mosquito, but I'm not sure about that, because it can also be caught from water or some other virus” (Gold miner 13)
Among the 29 workers interviewed, only one participant showed confidence in his statement regarding how malaria transmission occurs. About half of the interviewees did not believe that people could be asymptomatic for malaria and reported that cases of malaria increased during the rainy season.
“I think you only have malaria if you have symptoms, otherwise there is no way you have malaria” (Gold miner 2).
“Malaria in the rainy season here is cruel, we already had a record level of malaria in the municipality and, in the neighboring community, all the residents had malaria.” (Gold miner 29)
The insecticide-impregnated mosquito net was cited by most miners as an effective measure and used for fear of malaria or other animals such as bats, since the mosquito net becomes a physical barrier during the worker’s sleep. The washing of the mosquito net in order to remove the strong odor it exhales was reported by the interviewees.
“There are people who are not used to using it and are very uncomfortable with the use of mosquito nets. Now those who have had a lot of malaria like me use the mosquito net out of fear.” (Gold miner 7).
One of the reasons reported by the participants for not using the mosquito net was the distance between the city and the mining area, because according to them, if the distance is short, there is no need to sleep in the forest. In addition, in the city, due to the availability of electricity, they can use a fan, as they believe that this measure keeps mosquitoes away.
“I don’t use the mosquito net much because I don’t sleep in the woods” (Gold miner 11).
“I don’t use it so much because I use the fan and the fan on its own is enough to keep the mosquito away” (Gold miner 15).
Theme 4. Impact of malaria on work and income
The biggest problem with infectious diseases such as cutaneous leishmaniasis and malaria in mining is that they limit the productivity of the worker. Some type of economic loss caused by the disease was cited by all respondents. Respondents reported having a fragile and informal employment relationship, where a worker can be replaced by another due to their health status. Most prefer to return to work as soon as the main symptoms disappear, around the third day of treatment.
“...because if he gets sick and doesn’t work he doesn’t get paid and I think that this is also a factor for treatment abandonment, with three days of treatment the person already has to go back to work, where many times they will have to fight for a place with the person that has already replaced him. This return to mining after getting sick is very complicated, because if he cannot return, he will have to seek other camps to be able to work. This has happened to me a lot.” (Gold miner 6).
“I have seen people missing work due to malaria, but I still haven't had malaria and, if I did get it, I would wait between three and four days and then go back to the job” (Gold miner 23).
“When I got malaria, I had to leave the team of miners I was part of, sometimes they even accept you back when you get better, but most often have to look for another team to work with.” (Gold miner 7).
“...when you work for the machinery owners and the miner gets sick with malaria, the owner hires someone else to work because the miner has no support from anyone” (Gold miner 29).
Theme 5. Prejudice and marginalized life
The miners reported that their job was not a life choice, but a life chosen for them, due to the few opportunities they had in childhood. Most of them started mining as a child or teenager and reported luck and hope as the main factors that motivate them to take risks every day in search of gold. Interviewees reported that they do not feel welcomed by society because of the work they do, since there is an association between crime and mining, a fact that, according to them, has no basis in reality. They also cite the environmental conflict they experience as a result of mining activity that, according to the interviewees, lacks efforts from authorities to teach the correct forms of mine management in order to minimize the environmental impact.
“Mining is luck, I was lucky once in my life, but I think about having another source of income. Here is what we have at the moment as a job, because it was where we grew up doing it and we ended up enjoying it, but if I had the opportunity to change I would change.” (Gold miner 8).
“The life of the miner is very hard, and society sees us as invisible people, as outcasts and bad people, and there is a lot of prejudice against people who work in mining. Gold mining is about luck. It’s hard to get a spot, and it’s much harder to find the gold.” (Gold miner 9).
“Society sees us with evil eyes, especially the environmentalists who say that we only degrade the environment. They just point fingers and come to inspect, but no one comes to teach us how to do it correctly.” (Gold miner 20)
“People think the miners are wild, that they end up with everything they go through, but it just isn’t like that. There are a lot of good people here, and we are only fighting for survival because the government does not provide good working conditions.” (Gold miner 27)
Interviewees also reported prejudice regarding the health status of the miners. Since there is a higher incidence of some diseases among miners, when these workers return to the cities they end up being victims of this stigma.
“They end up suffering a certain prejudice, especially when it comes to malaria. This is because when we go to the city they say that if malaria infects many people it is the fault of the miner who brought malaria from the mine.” (Gold miner 16).
In spite of the challenging experiences of the miners such as death caused by the disease, poverty, prejudice, poor living conditions and addictions such as alcoholism, workers showed optimism regarding the reduction of malaria cases and they even believe in elimination. However, they stated that it would require a large investment from the government, commitment and scientific research, in addition to the collaboration and participation of the population affected by malaria.
“I think there is a way to end malaria in Brazil, but it would be a lot of work and, in order to end, the work would have to be continuous, and more constant, to use this smoke with poison more often, not only where people live, but also where they don’t live” (Gold miner 10).
“It is very complicated to put an end to malaria, but it can be reduced, because there is no way to eliminate all the mosquitoes from this huge forest. But that the government can intervene and invest well in the whole of Brazil to end malaria.” (Gold miner 18).
“The Brazilian government has to set a goal. It needs to be more committed to the people, to know the geography of the locations affected by malaria and to invest money so that it is eradicated.” (Gold miner 27).
1The respondent refers to chloroquine and primaquine or Coartem® distributed free in Brazil upon specific diagnosis of the disease