3.1 Summary of Contingency Plans for the Cross-Border Regions of the Amazon Basin.

3.1.1 Health Contingency Plan in the Vale do Javari, Brazil - Peru Border

INTRODUCTION TO THE CONTINGENCY PLAN

The contingency plan (CP) is proposed as guidance for preventing adverse events or
mitigating impacts, facilitating rapid responses and identifying those who should respond.
This mechanism is used for adequate and timely health interventions. The intercultural
context is considered in this region, as in the others. The contingency plan also outlines
the guidelines related to safety and the behavior expected of professionals, especially
those working for Public Health Services who participate in addressing an emergency, and
the routines and protocols for monitoring, communication flows and organizing the
responses, as well as the inputs required for action. The objective of the contingency plan
proposed for this region is to plan and support health actions carried out when
establishing epidemiological barriers and/or in contact situations.

Objective of the Contingency Plan for the Region

The purpose of contingency plans is to plan and support the health actions that are carried
out in situations of epidemic outbreaks and/or contact, as well as to guide health
professionals from Indigenous territories and from the Emergency Network in planning,
communication, management and decision-making in the face of a health emergency. In
addition, they must define the strategies for action and the resources needed depending
on the possible epidemiological scenarios. From an administrative point of view,
contingency plans define the flow of communication and incorporate the coordinated
planning, operation, and monitoring of health services, social institutions and the
Indigenous peoples involved.

Prior and adequate planning when addressing epidemic outbreaks and contact processes
is, therefore, a fundamental element for preventing and mitigating the impacts of these
events. In addition to the prior and permanent nature mentioned above, the preparation
of contingency plans must take into account the sociocultural specificities and the context
in which Indigenous peoples live, as well as the required coordination among the different
actors involved in their implementation and their respective spheres of action at different
levels, which poses a challenge for articulation and cooperation among the different
actors to deal with the territorial complexities and limitations, as well as with the
dynamics of Indigenous peoples’ lives. This, in turn, requires development and

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implementation of contingency plans from a cross-border perspective that ensures
coordinated and integrated action among the parties involved.

CONTEXT OF CONTINGENCY PLAN IMPLEMENTATION

The context of the implementation of contingency plans takes special account of the
vulnerabilities of Indigenous peoples in remote areas and especially of peoples in isolation
and in initial contact due to the vulnerable conditions in which their lives unfold, as well as
the conditions and characteristics of their environment, in which pressures and threats are
constantly growing. These populations, as well as those that live near isolated Indigenous
peoples and peoples in initial contact, are characterized by poor health conditions and
epidemiological threats that constitute risk factors.

For this reason, the socio-environmental and geographical context, pressures on the
territories, epidemiological profiles, definition and operation of epidemiological barriers,
as well as the continuous updating of information for event prevention should be
considered when implementing the contingency plan. The information considered
necessary for this region is:

Intensity, profile and reasons for traffic between Indigenous peoples and cities, for each
Indigenous people and river or subregion.

Conditions of access to basic services by the Indigenous population residing and in transit
in the city.

Monitoring of health and socioeconomic indicators in the municipality (identifying,

whenever possible, the specific segment of the Indigenous population).

Systematic communication with Indigenous organizations, government agencies, civil

society organizations and social public policy monitoring institutions that affect Indigenous
peoples.

In short, the establishment of sanitary barriers and cordons in the Javari Valley must
consider these flows and the exchanges with populations from other river basins. This
makes it necessary to map the characteristics of this traffic, as well as the epidemiological
status of the peoples who live nearby. In addition to this mapping and monitoring of
mobility and migratory flows through specific barriers or buffer zones, it should be noted
that the appropriate use of sanitary cordons for the protection of Indigenous peoples in
isolation and initial contact must include a broad set of preventive and epidemiological
and control measures involving the entire population surrounding said territories

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(including the professionals who work in these territories), as well as environmental
control.

COMMUNICATION FLOW AND DECISIONS

Regarding intersectoral actions, it is important to establish communication flows between

the field teams and the local health level; between the local level and the central level;
and between the local level and medium and high complexity health referral centers.
Rapid and supported decision-making is important in consultation protocols for users and
in current clinical protocols, especially if the intervention involves evacuation from the
territory when dealing with populations in recent contact.

These intersectoral relations can ensure that service and permanence in the referral
centers consider the specificities of the diet and traditional way of life of the person(s) or
group(s) in question, mainly those in recent contact. In this sense, regular dialogue with
Indigenous communities and organizations is also fundamental, since their cooperation is
crucial when territories are shared by isolated and contacted peoples, as in the case of
Vale do Javari. Finally, determining the flow of communication with the press and other
media and with national and international society is important.

PREVENTIVE ACTIONS

The contingency plan provides for preparatory actions to ensure a rapid response and
effective implementation of prevention and mitigation measures. Prior and adequate
planning when addressing epidemic outbreaks and contact processes is, therefore, a
crucial element for preventing and mitigating the impacts of these events.

In this sense, in addition to these aspects, the contingency plan should also contemplate
the need to consider issues related to the security and integrity of the Indigenous people
and the teams participating in these events, and preventively consider the scenarios that
might trigger continuous actions. These aspects should all be included in the contingency
plan.

Another crucial aspect in the context of contact and epidemic outbreaks is the spatial
configuration of the relevant systems and Indigenous health care referral networks for the
peoples of the Vale do Javari in Brazil and the Yavarí Valley in Peru. Prior preventive
actions, from the perspective of the contingency plan for this region, include continuously
and systematically updating the following elements:

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• Intensity, profile and reasons for traffic between Indigenous peoples and the city, for
each Indigenous people and river or sub-region.
• Conditions of access to basic services by the Indigenous population residing and in
transit in the city.
• Monitoring of health and socioeconomic indicators in the municipality (identifying,
whenever possible, the specific segment of the Indigenous population).
• Systematic communication with Indigenous organizations, government agencies, civil
society organizations and social public policy monitoring institutions that affect
Indigenous peoples, with special emphasis on the Indigenous Health District Council.

OPERATIONALIZATION OF THE EVENT

 Health Assessment:

 The teams that work on these events, in addition to having been selected and trained
beforehand, must have their immunization status up to date and not show any signs
or symptoms of an active infectious-contagious disease. It is important for a doctor to
carry out a clinical evaluation before a team starts operating in the territory. On the
other hand, they must have up-to-date knowledge of the health and clinical protocols
for acting based on the epidemiological barriers, depending on the characteristics of
the epidemiological outbreak.

 Quarantine:

Another fundamental mechanism to be considered in the contingency plans are

quarantine periods, to be determined according to the updated epidemiological context,
the epidemic outbreak or contact with isolated Indigenous peoples or peoples in initial
contact. Quarantine periods must be established before coming into contact with these
Indigenous people, to avoid the entry of external pathogens. In the case of situations that
especially involve isolated peoples, longer quarantine periods should be observed,
considering the greater vulnerability of these groups to infectious diseases. In an
emergency, it is possible to exceptionally choose not to carry out the quarantine, if it is
unequivocally demonstrated that the quarantine could cause even greater damage to the
health and life of these people, delaying, for example, a service that requires urgent
intervention.

 Field Evacuation and Resolution:

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Given the remoteness and difficult access to the territories when referral is required for
more complex treatments, as well as the sociocultural specificities and socio-
epidemiological vulnerability, which must be taken into special consideration when
dealing with isolated peoples and peoples in initial contact, transfers for hospital
treatment should be avoided whenever possible, and carried out only in special cases and
to previously trained facilities, following a previously agreed flow. Therefore, the choice of
equipment, medicines and supplies should be guided by choosing the best possible
resolution considering the different possible types of field medical and health intervention
-territory-, avoiding unnecessary transfers whenever possible. In this sense, the
intervention must try to use the best equipment available, for example, portable
ultrasound and radiology devices, hemoglobinometers, oximeters, rapid tests for malaria
and sexually transmitted diseases, among other technological means of diagnosis and
intervention to be used in those contexts.

 Security and Codes of Conduct:

The contingency plans should also provide guidance on security and the behavior
expected of the professionals involved in the contact situation, such as the establishment
of rules on the organization of work and responsibilities, food, hygiene, photograph
taking, the carrying of weapons, institutional communication and care of the equipment.
In addition, rules must be established regarding the food offered to Indigenous people
(especially industrialized products), use of personal protective equipment, protection of
the environment and proper disposal of waste, especially infectious waste.

 Immunization In the Event of Contact:

In the event of contact with isolated peoples, immunization is one of the most important
health actions that can be conducted; however, it should not be the first action due to the
side effects or the physical discomfort that it can cause. Since it is not an emergency
medical intervention, to the extent possible it should be planned and agreed upon with
the recently contacted Indigenous people and interpreters; this will also depend on the
context of the contact. It is especially important to have effective communication support,
trained interpreters and experienced people when starting a dialogue that establishes
basic trust, in addition to showing through visible examples what you want to achieve.
Immunization should only be started after obtaining the consent or acceptance of the
Indigenous people contacted.

Health teams should monitor adverse events after immunization, as well as any other
signs and symptoms that appear during the next 48 hours. There are no significant
differences in the immunization scheme of the isolated peoples, but it is important that as

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many immunizations as possible are carried out in a single opportunity to avoid the loss of
immunization opportunity in a group that can potentially stop having contact with the
national society, which can lead to various risks and situations of vulnerability to infectious
diseases that circulate in the environment.

• Agreements to Ensure Traditional Nutritional Security:

Another factor to consider when operationalizing the contingency plan is the possibility of
rapid degradation of the group's economy during an epidemic outbreak or contact
situation, which makes food support and security essential. It must be based on natural
products such as fruits, cassava, cassava flour, starch, animal protein sources (different
game animals and fish) and tubers such as sweet potatoes and yams (always considering
and respecting the food taboos that the group observes during illness). In the case of
contact, offering processed products should be avoided as far as possible, since they may
not be well accepted or cause health problems for the group and/or generate dependency
relationships. It is important to look for traditional foods in the towns near the territory of
the target population of the plan, and to enter into a supply agreement prior to possible
contacts or epidemic outbreaks.

 Situation Room:

The creation of a Situation Room with the effective presence of the actors involved in
implementing the contingency plan is an important factor to promote the exchange of
information, the establishment of agreements and the organized and systematic
distribution of responsibilities among institutions (such as, for example, the Federation),
the Ministry of Justice, the Federal Police, Civil Defense, mayors, Indigenous associations,
hospitals, the Armed Forces and others). In addition to institutional representatives,
persons who have experience in handling outbreaks or contact situations and/or persons
who are directly or indirectly involved in these events should be invited to participate
when necessary.

Another important point regarding the Situation Room is to ensure the participation of the
Local Health Referral Team. The Situation Room should meet every week or more often as
needed.

3.1.2 Triple Border Health Contingency Plan among Brazil, Guyana and Suriname –
Parque de Tumucumaque Indigenous Land in Brazil and Suriname

INTRODUCTION TO THE CONTINGENCY PLAN

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The contingency plan for this region is a planning instrument for the purpose of mitigating
the impacts of health-related events and is designed to guide an adequate and timely
health intervention with rapid responses and identifying those responsible. According to
the Brazilian Ministry of Health, "A Contingency Plan is the document that records the
planning developed based on the study of a certain public health emergency hypothesis."
The Health Surveillance Secretariat (SVS) in Brazil established prioritized Contingency
Plans for public health emergencies related to dengue, yellow fever, influenza, hantavirus,
visceral leishmaniasis and natural disaster management.

A Contingency Plan also provides guidance on the security and behavior expected of the
professionals who participate in the emergency, outlines the routines and protocols of the
health teams, organizes and identifies the need for and availability of supplies, defines the
hierarchy and communication lines among all the actors involved, and establishes a flow
of communication among the parties involved.

In contexts that involve Indigenous populations, in addition to considering these elements,

it takes into account the need to apply intercultural criteria and, therefore, differentiated
care according to the sociocultural and health needs of the Indigenous population. A key
aspect that stands out in this regard is that the construction of contingency plans must be
based on the participation and perspectives of the Indigenous population in its diversity.

Purpose of the Contingency Plan for the Region:

Its purpose is to offer consultative and preparatory information for developing

contingency plans in the cross-border Indigenous region between Brazil and Suriname,
with the inclusion of operational elements and recommendations for their
implementation.

COMMUNICATION AND DECISION FLOWS

The proposed contingency plan provides for the establishment of communication flows
among the field teams, the different bodies and organizations involved at the local level in
the field and at the central level of the two countries.

It also seeks to identify communication flows between referral centers for medium and
high complexity health issues, which would streamline decision-making processes.

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The network and communication channels should be structured using different
technologies adapted to the environment, including good quality internet service in
villages located in strategic places such as Kuxaré and Missão Tiriyós.

It is also essential to define and implement a specific plan for communication and dialogue
with Indigenous communities and organizations, taking into consideration the flow and
levels of communication for coordination. In this sense, the plan specifically recommends
preparing an organizational chart for inter-institutional communication and decision-
making.

Situation Room

A Situation Room should be installed to assist the decision-making and communication

processes in order to hold discussions, share information and agree on the responsibilities
of the institutions involved and invited persons who can directly and indirectly contribute
technically to implementation of the plan. The Local Referral Team must also participate in
the Situation Room. The frequency of the meetings should be determined when they are
implemented. Weekly meetings are suggested, but they can be held more often
necessary.

PREVENTIVE ACTIONS

As in other regions and contingency plans, the importance of prevention is highlighted.

This means that the teams identified for intervention in these health emergencies or
contact events, in addition to being selected and trained ahead of time, must have been
fully immunized, not present any signs or symptoms of active infectious disease, and must
be up to date with the clinical protocols for dealing with a health emergency,
epidemiological outbreak or situations of contact with isolated peoples or peoples in
initial contact. The plan recommends that the members of the intervention team(s)
undergo a complete medical screening prior to the intervention.

OPERATIONALIZATION OF THE EVENT

In addition to the above considerations, the operationalization of contingency events

includes the following aspects:

Given the distance and difficult access to the territories from the referral network for
more complex treatments, as well as the specific sociocultural and socio-epidemiological
vulnerabilities, transfers to a hospital for treatment should be avoided as far as possible

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and only used in exceptional cases. Previously sensitized staff should provide this service
following a previously agreed procedure.

The choice of equipment, medicines and supplies should seek the greatest possible
resolution of problems in the territory itself, avoiding unnecessary transfers. The use of
portable and laboratory devices with appropriate technology for these contexts should be
considered.

The intervention requires the establishment of a cold chain network in towns located in
strategic places, such as the communities of Kuxaré and Missão Tiriyós.

Conduct an in-depth diagnosis of the situation of the health structures in the peoples, to
develop and implement a strategy for their improvement and operation in the territory,
which must include emergency response and coordination in the territories in question,
considering the cross-border characteristics.

The contingency plans must also provide guidance regarding the security and behavior
expected of the intervention teams in the territory, their roles, responsibilities, health
regulations, photograph taking, institutional communication and physical security.

The agreements and codes of conduct in the field during emergency and contingency
actions must be defined beforehand in conjunction with the Indigenous leaders.

Prepare and agree with the Indigenous communities on a health protocol on border
transit for epidemiological monitoring and the adoption of prevention practices.

3.1.3 Health Contingency Plan Bahuaja Sonene National Park – Madidi National Park and
Integrated Management Area

INTRODUCTION TO THE CONTINGENCY PLAN

The contingency plan for the Madidi - Bahuaja Sonene region seeks to outline general
actions to prevent or address adverse events and their consequences to minimize impacts.
The plan is also designed as a means for defining the tools that help generate rapid
responses, identify the actors, their role and the actions planned in an emergency context.

The proposed instrument gives overall guidance for adequate and timely health
interventions in a complex local context, with Indigenous populations in vulnerable
conditions and with isolated Indigenous peoples. This characteristic means taking into
consideration the sociocultural context, the traditions and customs of these peoples and

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their health status, as well as the presence of different actors that are integrated to
different degrees. In this framework, an epidemiological profile of the region was built in
which local populations are emphasized. This analysis highlights the characteristics of
these populations and the main health problems and morbidities present in the region,
where traditional medicine plays an important role.

This information is an element to be considered prior to any contingency intervention

since it must take these elements into account for organizational purposes and to provide
the necessary responses. A relevant aspect is identification of the institutions and their
own intervention designs to articulate the logistics and the way to approach the
contingency. For this reason, the plans must be reviewed frequently to ensure that
interventions are effective.

Objectives of the Contingency Plan for the Region

Develop a contingency plan to safeguard and protect Indigenous peoples and peoples in
isolation and initial contact based on their health situation and address emerging diseases
in Indigenous peoples and epidemiological outbreaks in the Indigenous population and
peoples in initial contact and in the event of contact with Indigenous peoples in isolation
in the Amazon border regions of the Bahuaja Sonene National Park – Tambopata National
Reserve and the Madidi National Park and Integrated Management Natural Area.

COMMUNICATION AND DECISION FLOWS

Communication, based on daily reports by radio, internet and cell phone/telephone or any
other available means three times a day. The implementation of preventive measures
requires river and terrestrial monitoring, as well as an emergency early warning system to
ensure that the organization responsible for the emergency alert is immediately notified,
to organize the entire community and the relevant actors, including health and education
personnel, those responsible for protecting natural areas, local organizations, and others.

This communication requires a direct relationship among the institutional actors and the
social and Indigenous organizations involved, which must make decisions in an organized,
efficient and timely manner.

PREVENTIVE ACTIONS

The binational area of the Amazon region between Bolivia and Peru should be zoned, and
gradually also the communities. Zoning helps minimize risks in health contingency actions

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with isolated Indigenous peoples, peoples in initial contact and vulnerable Indigenous
peoples.

Risk areas

The risks and threats posed by the transit of outside people, the significant presence of
Indigenous peoples in isolation (the Toromona in Bolivia and unidentified groups in Peru)
should be identified in forests, lands and inhabited areas in the communities, the
adjoining concessions, the areas where the families of the community carry out economic
subsistence and market activities, and nearby communities. Sensitivity levels should be
assessed in relation to the risk of unwanted encounters when there are sightings and
indications of the presence of isolated peoples.

Safe zones

Safe areas must be identified in communities for health emergencies and events involving
PIACI. The safe zones that are present in the communities are usually the following:

The community Health Post, which, despite its physical limitations, has trained nursing
staff. It is important to note that this community space has various limitations, one of
which is that it is not equipped with medicines and means of communication are limited.

The community educational center of the, which in most cases has teaching staff. These
teachers are important because they have extensive knowledge of the strengths and
weaknesses of the population, which is why this is a key actor.

The Surveillance and Control Post of Natural Areas. This is a space that houses park
rangers but, despite its importance, it has operational limitations. However, its personnel
have the best training and ability to react in an adverse situation. Communication with
these actors is key since they interact with one or more communities, have access to
different places and understand the problems.

For the three strategic spaces for the contingency plan in this region to be used for
addressing emergencies and shelter, they must have:
 A supply of non-perishable food and water for a week.
 A water tank and a water pumping system.
 Warm clothing for the children.
 A first-aid kit with basic medicines
 The shelter must have five gas cylinders.

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  A gas stove, dishes, pots and everything necessary to prepare and serve food to the
community.
 The entire community is a safe place for families, and for that reason these areas
need some improvements and maintenance.
 The area adjacent to the farms should be cleared of grass and bushes.
• The families, in coordination with the different local actors, should organize
surveillance shifts in the most sensitive areas of the community.
• A community member should be responsible for communication (before, during and
after the emergency), and a support group should coordinate information inside and
outside the community.
• A community health agent should be responsible for surveillance and coordination
with health personnel from the community or nearby Health Post, to support the
health workers.
• Detailed health communications should be organized and reported to the nearest
Health Post. Health workers will communicate with other state entities such as the
Surveillance and Control Post for protected natural areas (Madre de Dios in Peru and
Hospital de San Buenaventura in Bolivia.)

Identify in the communities the areas of greatest risk for unwanted encounters with
Indigenous peoples in isolation.

The community health workers in Peru and the Communal Health Leader or Secretary in
Bolivia, the park rangers, the health personnel with the assistance of the Ministry of
Culture, have identified the risk areas in which there might be an accidental meeting with
Indigenous people in isolation, which include adjacent areas and places of displacement of
Indigenous peoples in isolation (rivers, streams, roads, forest areas -chestnut and timber-,
fishing areas and farms near the communities.

OPERATIONALIZATION OF THE EVENT

The duration of an emergency can be subdivided into three phases or general stages:

Health protection barriers or cordons are elements that ensure the health of peoples in
isolation and prevent them from suffering the consequences of epidemics and diseases in
the neighboring peoples. A plan should also be in place for following up and monitoring
activities.

Preventive actions: the ex-ante time when the indicators of a PIACI emergency must be
identified early, and preventive activities, preparation and early warning must be carried
out, because an emergency with peoples in isolation cannot be predicted far in advance.

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The period of the emergency is the most critical moment and the epicenter of the
emergency, when activities, actions and decision-making must be rapid, quick
assessments must be made of what is available and whether to evacuate or not.
Communication and an immediate community response are key. The community board,
health personnel, community health promoters and those responsible for the sectors
involved should work together to overcome the emergency quickly, with less human and
economic risk for communities and peoples in isolation.

Decline and conclusion of the emergency. This phase is still part of the emergency;
although the community and people are no longer in danger, they are still vulnerable. If an
evacuation is carried out, food, overnight accommodation and shelter for the families and
medical care for the evacuees must be ensured.

If the families were evacuated, the necessary logistics must be put in place for their return
to the community. A community monitoring team should be appointed to indicate when it
is possible to return to the community.

The plan must include the following emergency response and containment measures:

Health workers organize the response and containment of the health emergency,
supported by park rangers and the community support group.

The health workers, park rangers and community members in charge organize the
response to the health emergency or with the PIACI.

Health workers are primarily responsible for responding to the emergency.

The community health promoters coordinate the health personnel.

The community member in charge of photographic and video recording must coordinate
with those responsible for managing the emergency.

The community leaders coordinate with health workers to respond to the emergency.

Supply groups of traditional foods are formed, as well as a group for the protection of
children and the elderly (older adults).

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The organization for the eventual need for river, land or air evacuation in the Lower
Madre de Dios River is activated depending on the emergency conditions and the
availability of means for the different types of evacuation.

For several years, the administrations of the protected areas in Peru and Bolivia have
established a basic agreement whereby conservation activities are coordinated and joint
patrols and field visits are frequently conducted.

Understanding that this instrument was already being implemented in the region, the
need to monitor and coordinate health actions with emphasis on Indigenous Peoples and
PIACI was added. Therefore, in the understanding that these actions have been
operational, they must be further formalized with the participation of the Ministries of
Foreign Affairs, Ministries of the Environment and Ministries of Health, in addition to the
participation of the Ministry of Culture in the case of Peru.

3.1.4 Health Contingency Plan for the Acre - Madre de Dios Region on the Border
between Brazil and Peru, Focusing on the Middle Basin of the Las Piedras River and the
Madre de Dios Territorial Reserve in Peru.

INTRODUCTION TO THE CONTINGENCY PLAN

The contingency plan for the Las Piedras River basin was developed based on the
"Territorial Study and the Mamoadate – Madre de Dios Territorial Reserve Indigenous
Health Situational Diagnosis" carried out in 2021.

The contingency plan developed for a community level contains information and a set of
recommendations, mechanisms, measures and protocols for timely response and action
by families in the community, by the responsible state entities at the national, regional,
and local levels, and by the various civil institutions and actors present in the Las Piedras
River basin. It also describes how these actors should act during emergencies, when there
is accidental contact or the presence of Indigenous peoples in isolation in the area close to
homes, farms, hunting and fishing areas and camps of the Native Communities of Monte
Salvado, Puerto Nuevo and Mirador Santa Alicia.

The purpose of this document is to prevent and reduce risks in health emergency
situations. This instrument provides for the participation of various state entities and civil
society that have responsibilities and conduct activities in the Monte Salvado community
area of the Las Piedras River basin.

Objective of the contingency plan for the region:

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Design a health contingency plan for emergency events with peoples in isolation, to
develop preventive and response actions during the event and its mitigation.

The following activities are contemplated based on this objective for the contingency plan:

Demarcate the general aspects that describe the purposes, the conceptual, normative and
methodological corpus of the health contingency plan.

Carry out a diagnosis of the health situation of the communities, the coexistence of
Indigenous peoples in isolation with the communities in the communal sphere and
sensitive areas, risk factors and the presence of state and civil institutions.

Propose post-emergency health, remediation and health monitoring actions and the
preparedness of communities and institutions.

Develop an early warning procedure.

Institute specific actions in case of unwanted or accidental encounters and their possible
consequences for PIAs.

Propose measures during emergency events that consider the presence, sighting and
indications of the presence of Indigenous people in isolation.

Institute, strengthen and activate the special local trans-sectoral scheme to support the
local population and protect the health of Indigenous peoples in isolation.

COMMUNICATION FLOWS AND DECISIONS

There are five teams and health facilities that must act and respond during emergencies
and contacts of any kind (5 operational levels). They must respond during health
emergencies and contingencies in the event of accidental contact or for another reason.

First level:
- Ministry of Health (MINSA), Lima headquarters
- Directorate of Indigenous or Native Peoples

Second level:
- Madre de Dios DIRESA.
- Indigenous Health Strategy
- Santa Rosa Hospital in Puerto Maldonado (III Level).

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 Third level:
- Health micro network of the Las Piedras district, Planchón Health
Center
- Tambopata Health micro network, Millennium Health Center

Fourth level:
- The Monte Salvado community Health Post is operational and
serves Puerto Nuevo and Mirador Santa Alicia.
- The Puerto Nuevo community health post is very irregular; it usually
does not have staff and the infrastructure is very inadequate.

Fifth level:
- Community health promoters in the communities of Monte Salvado,
Puerto Nuevo and Mirador Santa Alicia.
- Specialists (men and women) in Indigenous and natural oral health
in the communities of Monte Salvado, Puerto Nuevo and Mirador
Santa Alicia.

The levels that make decisions during a health emergency or accidental contact or others
are the first and second levels, specifically the MINSA Directorate of Indigenous Peoples
and the Madre de Dios Health Strategy Coordination of DIRESA. This team will implement
the actions provided for in the contingency plan, select the team(s), the roles of each level
and agency or establishment, according to the responsibilities of each level.

Situation Room

The response to an emergency event requires the establishment of a situation room or

Unified Command Post (PMU) of the native communities in the upper part of the middle
basin of the Las Piedras River.

The governing state entities, representatives of the communities, their Indigenous

organizations and allied civil organizations should establish a Situation Room or PMU for
decision-making, dialogue, information sharing and agreements regarding responsibilities
with institutions of each actor, for example Civil Defense, municipalities, community
directors, Indigenous organizations, health officials, hospitals, other related institutions
and specialists from the communities and technicians directly and indirectly involved in
protection and during accidental or other contact with PIA.

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The situation room will be coordinated by a representative of the Ministry of Health and
representatives of national, regional and local state entities, communities, Indigenous
organizations and civil society. Regular and special meetings will be held based on a
schedule specifying times and places. Situation room agreements will define the
institutional tasks and responsibilities (based on Albertoni and Chindoy 2023).

PREVENTIVE ACTIONS

Preventive measures are contingency plan activities that are carried ahead of time in
preparation for a possible contingency or health emergency in the event of epidemic
outbreaks or contacts with PIAs. These actions involve various actors and require prior
preparation and close articulation. For this contingency plan, preventive measures include
the following:

The families of the communities participate in the sanitary cordon.

- Immunize the families of the communities
- Develop and implement health protocols for communities

Activate the community organization for emergency situations.

- Select a community member responsible for communication and a
support group (before, during and after the emergency) to coordinate
the information that is communicated inside and outside the
community.

- Organize families when few people and families remain in the

community and most are absent because they traveled to Puerto
Maldonado, are working in the Brazil chestnut camps or are doing
other activities that force them to leave the community for some time:

Identify the areas in the community posing the greatest risk for unwanted encounters.

- When families from the community go fishing

- When families and mitayeros (hunters) go hunting and gathering in the forest
- When families go to the farms
- When families navigate the rivers
- When other activities are carried out in an area of the community where
hunting, fishing, gathering, farming and the presence of any evidence or the
presence of brothers in isolation is found, heard of or suspected, the agents and
the leaders will recommend:

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 - That community members do not approach the risk area where evidence was
identified, or the presence of Indigenous peoples in isolation was found.

Carry out drills with the community.

- The DACI and FENAMAD specialists and protection agents must

organize two (02) emergency drills each year, because of the presence
of Indigenous people in isolation in front of the community of Monte
Salvado
- The community should be trained to respond in emergency health
situations and in case of contact
- Choose a responsible community member and group to support the
drill

Patrols in the community:

- River patrols:
- Land patrols:

Evacuation Routes

Identify the river and air evacuation routes used in the communities during
emergencies due to the presence of Indigenous people in isolation in front of
the Monte Salvado community.

- River evacuation route

- Air evacuation route

Safe areas
- In the identified communities, there should always be two or more safe
areas. A safe area is the shelter at the surveillance checkpoint (PCV) and
another safe area is the entire community.
- The old control post is the one most often used as a shelter, and later the
expansion of the PCV. This expansion of the PCV was built by the MINCU to
be used as a shelter during emergencies; it must be provided with the
necessary reserves:

 A supply of non-perishable food and water for a week.

 A water tank and a water pumping system.
 Basic clothing for the children
 Warm clothing for the children.

18
  A first-aid kit with basic medicines
 The shelter must have five gas cylinders.
 A gas stove, crockery, pots and everything necessary to prepare and
serve food to the community.
 The entire community is a safe place for families, and for that reason
these areas need some improvements and maintenance.

- The entire community is a safe place for families, and for that reason these areas
need improvements and maintenance.

 Clear the area adjacent to the farms of grass and shrubs.

 As much as possible, avoid leaving few people in the community.
 If the presence of families is unavoidable, the community members
who stay must pretend to be more numerous than they are and play
loud music.
 The families, in coordination with the agents, must organize
surveillance shifts in the most sensitive areas of the community.

Training for the Implementation of Contingency Plans

Training for implementation of the contingency plan will go hand in hand with training in
other skills that are of vital importance in emergency situations.

The training and internships must focus on the health personnel of the Health Centers in
this area, on the culture protection agents and FENAMAD and on the members of the
three communities.

Training and internships for health workers, protection agents and community members.

OPERATIONALIZATION OF THE EVENT

Actions Implemented during Contingencies with PIAs:

Emergency alert: the organization responsible for managing the emergency alert is
immediately notified with the aim of organizing the entire community.

The protection agents of the Ministry of Culture and FENAMAD must be the first to be
informed when a community member or agent sees traces, evidence, or brethren in
isolation in high-risk areas identified by the community:

19
  When a community member or agent sees a brother or sister in isolation
near the community (left bank of the Las Piedras River).
 When a community member or agent sees footprints or isolated brethren
on the farms.
 When they see footprints, traces or the brethren on the beaches of the Las
Piedras, Curiaco, Lidia Chica, Lidia Grande, San Francisco, Quebrada and
Mashco rivers, the well and the lake.
 When they see footprints, traces or the brothers/sisters on the road or in
the chestnut groves and logging camps.
 When community members see footprints, traces or brethren in a risk area
close to the houses in the community, they must immediately give notice
so that the protection agents can give early and timely warning.

Alert communication: alert of a possible emergency. Immediately notify the organization

responsible for the emergency alert, to organize the entire community.

Activation of communication: The CCNN health workers, the protection agents of the
Ministry of Culture and FENAMAD must organize communication during the emergency.

 The agents and community members responsible for handling

communications should:
 send and receive information by radio.
 send and receive information by phone.
 send and receive information online.

 Communicate with the Madre de Dios DIRESA (regional health

governing entity), state institutions and FENAMAD:
 Communicate with MINSA, the Puerto Lucerna and Planchón EESS
and DIRESA.
 Notify the MINCU and the DACI of the emergency.
 Notify the Puerto Nuevo and Santa Alicia CNs of the emergency.
 Notify FENAMAD of the emergency.
 Notify the Nomole, Yushi and Megiri Posts of the emergency.
 The wavelengths of the radio stations of the Ministry of Culture.

Discussion and Emergency Containment Measures

• Protection agents organize a DIALOGUE with brethren in isolation, when they

approach or are found in other areas of the communities:

20
 i) The agents and community members in charge organize the dialogue
with the isolated brethren.
ii) The agents are primarily responsible for the dialogue with the isolated
brethren.
iii) The most experienced community members coordinate the dialogue with
protection agents.
iv) The agent and community member responsible for keeping a photo and
video record must coordinate with those responsible for managing the
emergency.
v) Most of the men in the community coordinate with the agents for
interaction with the isolated peoples; they must speak the native
language, that in this case is Yine).

- Group responsible for TRANSFERRING PRODUCTS from the family farms.

- Group for the PROTECTION OF CHILDREN, WOMEN AND THE ELDERLY.

Measures for Evacuation:

Activate the organization for the EVACUATION of families.

River evacuation
Land – river evacuation
Air evacuation

Health Surveillance Organization

Heath Establishment of the Response and Monitoring Room with the participation of
Surveillance the Yine communities of the Las Piedras River basin, supported by their
Organization for organizations for the preparation and dissemination of epidemiological bulletins
response for the three countries.
Development of an early detection and community control strategy with
community health agents.
Genomic investigation of confirmed cases. The Madre de Dios region has
considerable human mobility due to mining and forestry activities and is
therefore more susceptible to new variants.
Design a community public health surveillance process that articulates all levels
of political and administrative divisions; municipalities, departments, districts,
capitals, populated centers and dispersed rural areas, non-municipalized areas,
communities, Indigenous settlements and lands. Consider communication
mechanisms and the intercultural perspective. Specific or cultural health
conditions that are part of the worldview of Indigenous peoples must be taken
into consideration for the epidemiological surveillance of Indigenous
communities in the upper part of the upper Las Piedras river basin, based on
the integration of intercultural variables in the epidemiological profiles (bad air,

21
 evil eye, discouragement, etc.) that allow the analyst to determine the actual
health situation of this specific population and thus conduct intercultural
surveillance of Indigenous health.
Prior availability of an internet network or communication mechanisms that are
appropriate for the environmental and territorial conditions with adequate power
to ensure uninterrupted communication between the most remote areas of the
Las Piedras River basin and the local, regional and departmental health posts.
Establish “Cordons Sanitaires” (Sanitary Barriers or Cordons) by consensus
between the health authorities and Indigenous communities. Intercultural
actions for health promotion and disease prevention in Indigenous peoples and
communities adjacent to the PIACI, as a factor to protect the good living of this
population. These are part of the sanitary cordons.
Source: based on Albertoni and Chindoy 2023: 27

Accidental Contact

Contact situations, which may be fortuitous, casual, or other, require a specific response.
In case of contact, the situation room or MPU must have established the procedure to be followed
in case of an event as follows:
a. Field team members.
b. Health protocols for entering the contact area.
c. Contact methodology (extreme situation or specific request by the PIAs).
d. Recognition of the main etiological agents responsible for in epidemics present in
neighboring communities similar to the epidemiological profile of the PIAs and common
diseases and injuries.
e. Health care actions.
f. Quarantine based on an intercultural approach.
g. Determination of the immunization profile.
h. Profile of serological field tests.
i. In accordance with the principle of problem-solving capacity, procedures within the
Indigenous territory should be prioritized, avoiding the transfer of persons whenever
possible. Only in serious cases that cannot be addressed at the local level of care offered by
the health teams should patients be transferred to the medium or high complexity
treatment network. The evacuation must be conducted after consulting and receiving the
consent of the Indigenous people involved.
j. Define risk criteria and assess risks.
k. Contact monitoring (monitoring protocol).
l. Flow of information and communication for monitoring between countries and with the
media.
m. Define the security behaviors of the Indigenous people and the teams that enter. The
contact situation is a crucial time for establishing the relationship between the Indigenous
contacts and non-Indigenous contacts. Many actions can be interpreted in ways other than
the initial intent. Therefore, certain rules must be strictly followed to avoid exposure to
certain risks.

(Albertoni and Chindoy 2023: 30 – 31)

Immunization in Contact Situations

22
In the event of accidental, unwanted or other contact, the care teams and support teams
will implement a strict immunization protocol. In this case, Albertoni and Chindoy (2023)
recommend immunization as one of the fundamental actions to be considered, but using
a strategy that considers its secondary effects, because of the reactions it can cause and
because the immunization schemes should be completed as fully as possible so as not to
miss the opportunity, since the PIACI can move again to other places.

Early Warning Action

• There will be daily communication with the Puerto Nuevo Yushi and Nomole,
Megiri, Yopri and FENAMAD posts. The first contact will be on frequency 7020 and
culture frequency 8185 or 4650 will be used next. The person responsible for radio
communication is the agent designated during the days of the emergency.

• In an emergency, after communication by radio and internet, the Alto Madre de

Dios and Pariamanu posts will communicate or call by phone or internet, in the
following order: the Ministry of Culture (DACI specialists and agents for MDD,
DDCMDD), FENAMAD, PNAP, DIRESA and GOREMAD. The Ministry of Culture will
communicate directly by radio or internet or other means, to coordinate and
support the agents or specialists who are in the community to implement the
planned actions.

• If communication cannot be established with the Yushi and Alto Madre de Dios
checkpoints, they will communicate with the Puerto Nuevo checkpoint. They will
notify the Ministry of Culture of the emergency.

• In cases where the above actions are not applicable, they will contact SERNANP
(Parque Alto Purús), 5390. Upon receiving the SERNANP alert, they should contact
the Ministry of Culture or FENAMAD.

• Another option is to use the radio transmitter of the Regional Emergency

Operations Center (COER), to notify of the emergency.

• The FENAMAD radio should be used in the city of Puerto Maldonado. The Ministry
of Culture should contact specialists Maximiliano Mamani, Romel Ponciano and
Flavia Aguilar.

23
Communication with the MINSA Directorate for Indigenous or Native Peoples (DPIO), the
DIRESA Madre de Dios, and if necessary with the headquarters of the Ministry of Culture
will be by radio.

3.1.5 Health Contingency Plan in the Tri-Border Region of Peru, Brazil and Colombia

INTRODUCTION TO THE CONTINGENCY PLAN

The health contingency plan for the region of the Triple Border of Peru, Brazil and
Colombia is a navigation chart that outlines the actions for preventing adverse health
events or mitigating their impacts. This instrument is used as a rapid response guide that
includes the agreed actions and social actors. Its implementation is important for
adequate and timely health interventions.

The contingency plan for Indigenous populations should consider the sociocultural
epidemiological profile, the social determinants of health and health care using a
differentiated ethnic and intercultural approach, since it should be appropriate for the
context in which these populations live.

The situation of isolated Indigenous peoples who come into initial or permanent contact
with Indigenous or non-Indigenous communities adjacent to their ancestral territories can
trigger epidemiological processes with high morbidity and mortality, which in the past
have led to the extermination of peoples in Brazil, Peru and Colombia. Therefore, efficient
and effective health actions should be coordinated and implemented by health service
providers and the actors involved in the care of the PIACI from the beginning of contact
for health protection and disease prevention in the groups or communities that come into
contact in the regions in which these peoples are known to live, as is the case of the Triple
Border among Brazil, Peru and Colombia in the Amazon. The proposed contingency plan
takes this situation into account and highlights the need for intervention with intercultural
relevance considering the situation on the Triple Border.

Objective of the Contingency Plan for the Region:

The objective of the plan is to outline intersectoral health actions for the implementation
of intercultural technical and operational strategies for preventing and mitigating negative
impacts on the health of highly vulnerable Indigenous peoples and peoples in initial
contact in case of epidemic outbreaks and/or contact situations. It also spells out the
action strategies and the necessary resources for likely epidemiological and social
scenarios in health emergency situations in the geographic area of the Triple Border.

CONTEXT OF CONTINGENCY PLAN IMPLEMENTATION

24
For the implementation of this contingency plan, five reference teams are established
with different levels of activities determined by the teams of the health authorities, their
service networks, neighboring communities and the institutions involved, taking into
consideration the principle of intersectoral action.

Definition of Teams, Roles and Responsibilities:

First, the central reference team should be created to make up the International Unified
Command Post of the Triple Border region. This includes the participation of specific
actors, contacts, media, communication flow and the operational, administrative and care
articulation process in the event of contact or a health emergency in the communities
adjacent to the isolated Indigenous peoples, which include the three States. The teams’
responsibilities, contacts and references must be registered and shared through
mechanisms established by the respective competent bodies:
• The reference team for each region of Brazil, Peru and Colombia is established
based on relevant specific actors, contacts, media, communication flow and
roadmaps for operational, administrative and care coordination in case of contact
and/or of a health emergency in the communities adjacent to the isolated
Indigenous peoples in each region.
• The local reference team of each State and each region is established through the
designated local committees.
• The field reference team related to the health service provision network is
established in each of the regions according to each State’s system.
• An intercultural reference team (adjacent Indigenous communities) is established
in each region and locality, taking Indigenous organizations into consideration.

Second: Terms or codes of conduct in the event of contact must be established for the
teams of each reference level. Protocols to ensure the health, environmental, cultural and
social protection of Indigenous peoples in isolation and initial contact should be
developed at the same time.

Third: Auxiliary and support teams must be created, since their stay with the Indigenous
peoples can be prolonged depending on the situation.

Fourth: The field teams must include at least one (1) woman, one (1) Indigenous
“knower”1 or health leader from the neighboring communities trained in Western
biosafety actions in accordance with the established protocol.

1
The “knower” is a person from the same or a similar ethnic group who has knowledge of the culture of the
people in the contact situation and is recognized as such in their own or other communities. This actor may
also have knowledge of traditional medicine.

25
Fifth: The contact community must follow the established flowchart and Contingency Plan
guidelines. The Contingency Plan should be designed in intersectoral and intercultural
discussion groups.

COMMUNICATION AND DECISION FLOWS

Regarding intersectoral actions, the contingency plan states the importance of mapping
out the communication flows between teams at the local, regional, and central levels,
including medium- and high-complexity health care centers. This is important for rapid
decision-making and must be supported by the applicable health protocols and medical or
clinical interventions; this is especially important when the intervention requires the
transfer of populations in recent contact for treatment outside the territory. Intersectoral
relations can ensure that, in exceptional cases and when the situation warrants, there are
spaces available for care and accommodation in health facilities, which must comply with
parameters for differentiated and intercultural care that consider, for example, Indigenous
peoples’ own diet and respect for the customs and spirituality of peoples or groups,
especially those in initial contact. Systematic dialogue with the communities, related
Indigenous organizations, institutional actors and experts in different disciplines with
knowledge on the subject is considered essential for the preparation of the contingency
plan. The cooperation of this group of actors is decisive for territorial exchanges and for
the protection of Indigenous peoples in isolation.

Triple Border Situation Room or Unified Command Post (PMU).

When developing the contingency plan in this region, the Situation Room or Unified
Command Post must be set up for dialogue, information sharing and agreements on
responsibilities with institutions of each of the States where they are present, for
example: Civil Defense, municipalities, Indigenous associations, hospitals and other invited
actors that are directly and indirectly involved with the situation of isolated Indigenous
peoples and peoples in initial contact. This must be coordinated by the delegates of the
three countries, who must enter into agreements to act jointly and make the contingency
plan operational in accordance with the objectives and needs that arise due to health
emergencies or contact situations. The terms for intervention will be defined in the
Situation Room or Unified Command Post. They must include at least the following:

• Coordinated and systematic health actions among the agents and actors of the
Triple Border among Peru, Brazil, Colombia in accordance with the health systems
of each country.

26
 • Territorial health planning with the participation of the neighboring Indigenous
communities involved.
• Culturally appropriate healthcare protocols for neighboring populations.
• Determination of the disease burden of neighboring Indigenous peoples.
• Intercultural Care Guide.
• Instruments and tools for collecting interculturally relevant health information.
• Design of Health Care Schemes that establish the procedures for articulation of the
countries’ health systems with the Indigenous health systems within each
country’s legal framework.

OPERATIONALIZATION OF THE EVENT

STAGE Intercultural strategies.

(1) Organization (1.1) Identification of Indigenous authorities and leaders who can
of the response participate in the response to an emergency event. In the case of
localities where there are peoples in isolation, the leaders of the
surrounding communities must be identified and invited to participate
in the planning.
(1.2) Identification of the specific responsibilities of Indigenous and civil
society entities that can collaborate with complementary health
response actions such as, for example, supply of the necessary
elements for subsistence (fuel, food, tools, etc.), protection against
possible victimization due to the absence of public institutions and
other options available within the framework of humanitarian
assistance in emergencies at the local level.
(1.3) Development of specific action protocols – the contingency plan with
the participation of Indigenous authorities and local institutions -. The
mechanisms established in the protocols must involve the various
governmental and non-governmental sectors, for example, regional
police, migration control, national parks, representative Indigenous
structures, NGOs, health departments and directorates, etc.
(1.8) Establishment of a contact list (institutional data).
(1.9) Identification of Indigenous and non-Indigenous specialists and
preparation of a contact list with information on the professionals who can
provide specific advice.
(1.10) Maintenance of an updated inventory of the human, physical, and
financial resources considered essential for the response plan and
available in Indigenous areas or in areas surrounding the PIAs,
specifying their location, as well as how to activate and transfer them
to the emergency or location.
(1.11) Conducting an analysis of the local health situation, the needs of the
health systems, and the shortcomings of the actual or potential

27
 response capacity.
(1.12) Training the professionals involved in the contingency plan, to ensure
that they have specific training on the general characteristics of
peoples in voluntary isolation, as well as on the specificities that make
Amazonian Indigenous peoples highly vulnerable to epidemics.
(1.13) Conducting periodic and regular exercises and drills of varying
complexity to assess the existing capacities in Indigenous territories. At
the end of a drill or exercise, the group should be able to answer two
basic questions: i) what went well? and ii) what should be improved?
(2) Heath (2.1) Establishment of the Binational Response and Monitoring Room
Surveillance with the participation of Indigenous institutions for the
Organization for preparation and dissemination of epidemiological bulletins
Response involving the three countries.
(2.2) Development of an early detection and community control
strategy with community health workers.
(2.3) Genomic investigation of confirmed cases since there is
considerable human mobility among the inhabitants of the
border region and they are therefore more susceptible to new
variants.
(2.4) Designing a community public health surveillance process that articulates
political and administrative divisions at all levels: municipalities,
departments, districts, capitals, populated centers and dispersed rural
areas, non-municipalized areas, reservations, settlements and
Indigenous lands. Take communication mechanisms and the
intercultural perspective into account. For the epidemiological
surveillance of the Indigenous communities of the triple border, specific
or cultural health conditions that are part of the worldview of
Indigenous peoples must be taken into consideration based on the
integration of intercultural variables in the epidemiological profiles (bad
air, evil eye, discouragement, etc.) that allow the analyst to determine
the actual health situation of this specific population and thus conduct
intercultural surveillance of Indigenous health.
(2.5) Prior availability of an internet network or communication mechanisms
suitable for the environmental and territorial conditions with the
necessary and adequate strength to ensure constant communication
between the most remote areas of the triple border departments
(Loreto/Peru – Tabatinga /Brazil – Amazonas/Colombia) with local,
regional and departmental health posts.
(2.6) Establishment of sanitary cordons by agreement between the health
authorities and the Indigenous communities. Intercultural health actions
for the promotion of health and the prevention of diseases of Indigenous
peoples and communities adjacent to the PIACI as a protective factor of

28
 the good living of this population. These are part of the sanitary cordons.
(3) Protocols, (3.1) Definition of common and/or shared procedures among the three
procedures and neighboring countries that will guide actions, tasks and communication. A
formats procedure must specify the expected result; describe the sequential and
logical process to be followed (actions and tasks); establish the necessary
equipment and materials; set safety standards or guidelines; and define
the forms of registration and disclosure of data and information.
(3.2) Standardization of forms to consolidate strategic information to support
country monitoring services and community surveillance services.
(4) (4.1) Establish a situation analysis room with participants designated by the
Operationalization countries and Indigenous authorities for coordination and
of the response communication among the sectors that may be involved in the public
health emergency. Structuring a cross-border situation room makes it
possible to optimize the available resources and ensures that information
is shared among all the areas involved. It also allows the unification of the
various groups that should take part in the response. The situation room
should be structured into thematic groups to facilitate the
operationalization of the response.
(4.2) Creation of a Special Advisory Group made up of different specialists. In
addition to the interdisciplinary and intercultural specialists selected
according to the nature of the event and the identified needs, such as an
epidemiologist, a specialist in infectious diseases, etc. The group must
also have Indigenous specialists and/or anthropologists to provide
support in decision-making.
(5) Levels of 5.1. Alert:
measurement 5.1.1. Health surveillance:
and response (a) Review the protocols or develop them with the reference team.
(b) Activate the situation room.
(c) Stress the importance of immediate communication and notification of
suspected cases in Indigenous and surrounding communities
(d) Monitor the behavior of influenza syndrome (IS) and severe acute
respiratory syndrome (SARS) cases in the local Indigenous population
for risk assessment and support in decision-making.
(e) Prepare and disseminate specific Epidemiological Bulletins for the
Indigenous population, which include intercultural indicators.
(f) Raise awareness among health professionals and the population
regarding the vulnerability of Indigenous peoples, especially those in
isolation.
(g) Develop and promote the training of human resources to work in an
intercultural context and provide permanent guidance to community
agents.
(h) Develop and disseminate intercultural health education materials for
health workers and the community in the language they speak.
(i) Notification of suspected cases must include the identification of the

29
 Indigenous community and ethnic group.
(j) Definition of the responsibilities and competences of the Indigenous
entities in addressing the epidemic situation.

5.1.2. Assistance:
(a) Establishment of procedures for the transfer of Indigenous patients to
receive specialized care.
(b) Establishment of the action protocol in case of contact with an isolated
Indigenous group.
(c) Establishment of service, communication and notification procedures
with the participation of community agents and local leaders.
(d) Establishment of quarantine protocols.

5.1.3. Environmental Surveillance

(a) Monitor water quality in communities.
(b) Monitor the presence of environmental impacts close to the community.

5.2. Imminent Danger

(a) All the elements of a level and alert

(b) Adoption of preventive health measures directed at the population
surrounding the PII, especially Indigenous people but also non-Indigenous
people, and intensification of the entry barrier for strangers and health
surveillance of those who enter the territory with the aim of creating a
sanitary cordon in the environment to prevent the transmission of the
virus and the spread of other diseases. It is important to implement
sanitary cordons in coordination with the Indigenous communities’
mechanisms.
(e) Promotion of awareness actions in the surrounding communities regarding
the presence of PIIs.
(d) Establishment of a reference team in case of contact with a PII group.

5.3. Public Health Emergency

5.3.1. Mitigation
(a) Regarding the care of Indigenous patients in hospitals: (i) provide an
accompanying person and an interpreter, when necessary, respecting the
clinical conditions of the patient; (ii) adapt clinical protocols, as well as
special access and reception criteria, considering sociocultural
vulnerability; (iii) prioritize differential access to newly contacted
Indigenous peoples, including the provision of separate accommodation
for hospitalized patients, and (iv) ensure that diagnoses and health
conditions are communicated in a way that Indigenous patients can
understand;
(b) Ensure the logistics of control, distribution and provision of inputs to

30
 Indigenous territories.
(c) Adopt heath surveillance measures at points of access to Indigenous
territories and communities.
(d) Strengthen primary care at the local level through the adoption of
measures established in the protocols for respiratory diseases.
(e) Adopt hospital care measures for serious cases and individual restrictive
home isolation measures for mild cases.
(f) Implement support points for the diagnosis and care of mild cases within or
near the communities and to support the permanent active search, rapid
tests and treatment in Indigenous and surrounding communities.
(g) In the event that an isolated Indigenous person must be transferred to a
hospital, the transfer must be carried out after consulting with and
obtaining the consent of the Indigenous people involved.
h) Maintenance of high immunization coverage in Indigenous and isolated
communities in the three countries of the triple border.
(i) Monitor the availability of vaccines shared among countries.

5.3.2. Containment
(a) Prepare the health system: inputs, human resources and medicines.
(b) Establish an external health care mechanism to reach dispersed rural
areas of the three countries with State funding. Install primary health care
centers that work in coordination with traditional practices and
Indigenous health promoters.

In case of contact, the Situation Room or MPU must operationalize by defining the
following:

a. Field team members.

b. Health protocols for entering the contact area.
c. Contact methodology.
d. Recognition of the main etiological agents responsible for epidemics among
neighboring communities that approximate the epidemiological profile of PIAs and
common diseases and injuries.
e. Health care actions.
f. Quarantine with an intercultural approach.
g. Immunization profile adopted.
h. Profile of field serological tests.
i. In accordance with the problem-solving capacity principle, treatment within the
Indigenous territory should be prioritized, avoiding the transfer of patients
whenever possible. Only in serious cases that go beyond the local level of care
offered by the health teams should the patient be transferred to the medium or

31
 high complexity service network. The evacuation must be carried out after
consulting with and receiving the consent of the Indigenous peoples involved.
j. Define the risk criteria and assessment.
k. Contact monitoring (monitoring protocol).
l. Flow of information and communication between countries for monitoring.

m. Define security procedures for incoming teams. The contact situation is a crucial moment
for establishing the relationship between the Indigenous and the non-Indigenous contacts.
Many actions can be interpreted in ways other than the initial intent. Therefore, it is
necessary to strictly follow certain rules to avoid exposure to certain risks.

Immunization in the Event of Contact

In the case of contact with isolated Indigenous peoples or peoples in initial contact,
immunization must be carefully planned considering the secondary effects and the
likelihood of conducting complete immunization schemes.

This requires communication support with interpreters and persons with experience in the
matter to establish a relationship of basic trust in order to carry out this health procedure.
The teams on the ground must strictly monitor the health of the immunized population in
view of the effects it can produce.

For this reason, it is recommended that countries prioritize vaccines such as those
exemplified in these regions and monitor coverage, which should always be high,
especially in regions surrounding Indigenous groups in voluntary isolation, considering
that these populations are very immunologically vulnerable.

The basic technical, logistical and operational structure for efficient immunization in these
areas must be established. This entails the procurement of cold rooms, freezers and
equipment for immunization units, especially in municipalities with an unsatisfactory cold
network, as well as the rental of refrigerated containers for immunobiological storage to
deal with the COVID-19 pandemic or other pandemics, according to the specifications for
each type of vaccine, each country’s and the World Health Organization’s regulations or
specific guidelines. For this, the competent local entities of the three countries of the
triple Amazonian border must identify the areas and necessary elements to supply them
with these elements.

Common tools must be developed by the countries to monitor and triangulate the
information on people immunized at the border, since many are immunized in the

32
neighboring country, which makes epidemiological control by local health authorities
difficult.

3.1.6 Napo, Curaray and Río Tigre Region Health Contingency Plan on the Border
between Ecuador and Peru

INTRODUCTION TO THE CONTINGENCY PLAN

The contingency plan is an instrument to prevent adverse events or mitigate their impacts,
such as frequent epidemiological outbreaks among the Indigenous population and
peoples in initial contact and in cases of contact with isolated Indigenous peoples. It aims
to facilitate rapid responses by the actors involved. In the case of Indigenous populations,
it is necessary to consider factors such as the epidemiological profile, differentiated health
care in intercultural contexts, considering different practices, sociocultural dynamics,
traditional medicine, Indigenous health systems and food traditions, among others. The
contingency plan, as a dynamic instrument, must be reviewed continuously and
systematically with the participation of the competent institutions and Indigenous
organizations, civil society and the relevant stakeholders involved.

These elements are essential to ensure a speedy response and the effectiveness of the
intervention, and that of the prevention and mitigation measures provided for in the
contingency plans in relation to the provision of health services.

Objective of the Contingency Plan for the Region:

The purpose of the Contingency Plan is to establish the health procedures and actions that
must be considered at the inter-institutional level to deal with possible epidemic
outbreaks and/or contact with PIAs, as well as to guide the health professionals who
provide their services in Indigenous territories and are part of the public health emergency
network, to improve planning, execution, communication, management and decision-
making in the event of a health emergency.

In addition, they must establish prevention and action strategies and ensure that the
necessary resources are available according to the likely epidemiological scenarios and in
the event of contact with Indigenous populations in isolation and initial contact.

33
From the administrative point of view, the purpose is to define the flow of communication
and incorporate the prevention, planning, operation and monitoring of health services
and the associated institutions involved in a coordinated manner.

In the event of contact with an Indigenous population in isolation, the contingency plan
seeks to reduce or mitigate the risks, for instance through immunization through vaccines
as needed and possible and, if applicable, addressing emergencies resulting from this
scenario.

CONTEXT OF CONTINGENCY PLAN IMPLEMENTATION

The contingency plan contemplates a communication and information system that
ensures adequate monitoring and considers ethnic disaggregation by peoples and
nationalities, in addition to proposing indicators to determine the immunization coverage
of peoples and nationalities. In addition, the plan recommends that a qualified community
health team care for the health of the peoples in initial contact or in the event of contact
with Indigenous peoples in isolation.

COMMUNICATION AND DECISION FLOWS

Regarding intersectoral actions, the proposed CP establishes the need to generate

centralized communication flows between the field teams and the local health level,
between the local and central levels, and between the local level and medium and high
complexity health referral centers by creating a "Situation Room". This makes rapid
decision-making possible, with the support of consultation protocols with users and
current clinical protocols, especially when it is necessary to evacuate patients from
populations in recent contact from the territory for treatment. These intersectoral
relationships can ensure that the spaces for care and accommodation in the referral sites
comply with food requirements and the traditional way of life, especially for those in
recent contact. In this sense, regular dialogue with Indigenous communities and
organizations is also crucial, and their cooperation is decisive in contexts of territorial
movements between isolated and contacted individuals.

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Situation Room

Upon receiving confirmation of contact with Indigenous peoples in isolation, the District
Health Director, in coordination with the Directorate for the Protection of Indigenous
Peoples in Voluntary Isolation of the Ministry of Justice, which is the governing body for
the protection of Indigenous peoples in isolation and initial contact, will activate the
response through the (i) District Risk Management Committee -of which the Intercultural
Health Analyst will be a part- and (ii) the Special Early Response Team.

The District Health Directorate will order the relevant health response actions. The
response action will be taken in close coordination with the Provincial Risk Management
Committee led by the Provincial Governor/Secretary of Rights/Ministry of Culture.

The district health office will indicate the means of communication available for the
coordination of health response actions, specifying the radio frequencies for
communication by radio and the numbers for telephone communication. The staff of the
nearby health center must gather the relevant and necessary information on the
circumstances of the contact so that the special team can activate the intervention plan to
respond to the emergency in the event of contact. During the critical period, all relevant
information related to contact with Indigenous peoples in isolation will be communicated
daily to the health district and through it to the relevant institutions.

35
Dialogues, information sharing and responsibilities will be established with institutions
such as the Army, the Attorney General's Office, Indigenous organizations and other actors
that are directly and indirectly involved in the contact process.

PREVENTIVE ACTIONS
It is important to develop education and communication campaigns with the participation
of community leaders and non-governmental organizations with culturally adapted
messages as a crosscutting theme to raise awareness about the importance of prevention
and contingency measures in the event of epidemiological outbreaks and contacts.

Health strategies with intercultural relevance must also be implemented to prevent

contact with Indigenous Peoples in Isolation and be prepared to address it in the best way
possible in case it happens2.

Considering the following aspects is recommended:

• Define the target population (Napo Curaray Río Tigre Region) and identify
provinces, cantons and parishes of prioritized Peoples and Nationalities for
immunization.
• Consider that geographical access is difficult in these areas or there is high
mobility between communities and there are even communities and
organizations close to roads between rural and urban areas.
• Identify external actors, Indigenous and local organizations.
• Develop culturally adapted informed consent processes with the participation of
the communities to provide care in the event of epidemiological outbreaks and
immunization.
• Jointly disseminate, give training and adapt the Contingency Plan against
epidemiological outbreaks in Indigenous peoples and nationalities for community
leaders, Indigenous organizations and local parish governments (in the Study
Region) for subsequent planning of joint activities.
• Consider the logistical, human talent, medical and budgetary requirements
(disposal of the waste produced must be included) for each territory.
• Determine the appropriate vaccine transport logistics for the selected vaccine
and provide the necessary equipment and devices to ensure its conservation.

2
Norma Técnica de Salud PIACI, MSP, 2017 (Ecuador).
PIACI Technical Health Standard, MSP, 2017 (Ecuador).

36
 • Choose immunization point(s) that meet biosafety requirements and provide the
necessary environment and ensure cultural respect, in addition to being easily
accessible to most of the population.
• Ensure the adequate flow of persons in the process (admission, waiting room,
immunization room, observation and discharge).
• Consider the resources needed to manage possible serious events attributable to
immunization or other conditions that require emergency care. A vehicle, an
emergency care area and transportation (land, river, or air ambulance) are
essential.
• Determine the procedures for data verification, to ensure confidentiality and the
subsequent follow-up of immunized persons.

• Organize logistics with inter-institutional support, local governments, the

Ecuadorian Armed Forces, Indigenous Organizations, Non-Governmental
Organizations and others.
• Conduct training and care and immunization drills in case of epidemiological
outbreaks at least once a year.

OPERATIONALIZATION OF THE EVENT

Health Assessment

The teams that work during these events, in addition to having been previously selected
and trained, must have their immunization up to date, not present any signs or symptoms
of active infectious disease and meet the requirements of the clinical protocols for
addressing the epidemiological outbreak in question. A physician should perform a clinical
checkup prior to the start of each team's intervention.

Contingency Care and/or Intervention

Arrival of the team (which must have their immunization up to date or remain in
quarantine for a predetermined period) at the site of the epidemiological outbreak or
immunization area in the community.
Implementation of the planning in coordination with community leaders and Indigenous
and non-governmental organizations.

37
Installation of the agreed care and/or immunization site and deployment of the workers in
accordance with their duties established prior to entering the community.

Monitoring to ensure cultural respect and proper use of protective equipment and
compliance with biosafety measures.

Monitoring the actions of each team member to ensure that they perform their duties in
the immunization process.

Ensuring the appropriate conservation of the cold chain of the vaccines.

Monitoring and Care of Emerging ESAVIs.

Departure of the immunization team at least 12 to 24 hours after the immunization is

completed, and subsequent community surveillance.

Deployment in the territory should be used for the immunization of children and other
essential activities, if possible.

Participation and audit processes must be ensured by civil society and Indigenous
organizations.

Community Surveillance

Surveillance and control of serious events that may be attributable to immunization or

other conditions in coordination with community leaders.

Coordination with health personnel from the Waorani people or other Indigenous peoples
(Kichwa, Secoya, Arabela) in the Napo - Curaray - Río Tigre Region

Planning of the brigade for the administration of booster doses of the vaccine if necessary
(except if a single-dose vaccine is used), with all the actors involved in the administration
of the first dose.

Responsible Institutions

The Ministries of Public Health of Ecuador and Peru, the Human Rights Secretariat
(Ecuador) and the Ministry of Culture (Peru).

38
Quarantine
Another fundamental mechanism consists of quarantine periods, which must be of the
appropriate duration for the updated epidemiological context, the epidemic outbreak or
the contact process in question. Quarantine periods must take place before coming into
contact with these Indigenous peoples, to prevent the entry of external pathogens. In the
case of situations involving isolated persons or persons in recent contact, longer
quarantine periods should be observed, due to the greater vulnerability of these groups to
infectious diseases. In an emergency, one can exceptionally choose not to implement the
quarantine, as long as it can be unequivocally shown that the quarantine can cause even
greater damage to the health and life of these peoples.

Field Evacuation and Medical and Health Resolution

Considering the difficult access to the territories and the distance from the referral
network for more complex treatments, as well as the sociocultural and socio-
epidemiological specificities (especially in the case of isolated peoples and peoples in
recent contact), evacuation for treatment should be avoided whenever possible, and
conducted only in special cases and to a previously sensitized service, following a
preestablished procedure. Therefore, the choice of equipment, infrastructure, medicines
and supplies should be based on the highest possible resolution of injuries in the field (i.e.,
in the territory), avoiding unnecessary transfers. Portable ultrasound and radiology
devices, hemoglobinometers, oximeters and rapid tests for malaria and sexually
transmitted diseases are examples of appropriate technologies to be used in these
contexts.

Safety and Conduct Codes

It is important to mention that health officials must evaluate the safety conditions in the
contact and/or epidemiological situation. This process will be conducted jointly with
personnel from the National Police, the Army and the institutions in charge of the
protection of Indigenous Peoples in Voluntary Isolation.

The purpose is to consider the relevance of the presence of personnel armed with non-
lethal weapons so they can avoid any situation of violence.

The security support teams must have been thoroughly trained on protocols for contact
with Indigenous Peoples in Voluntary Isolation and Contingency Plans.

39
The health and security support teams should avoid sharing food, clothing or any object
without the supervision of the medical teams. This should be determined in advance and
bringing highly processed products should be avoided.

Personal and site hygiene should always be a priority.

The security teams must assess the advisability of wearing uniforms or an emblem that
might lead to violent reactions on the part of the Indigenous population.

The teams should have internal (shortwave radios) and external (satellite telephones)
communication systems to inform and report on the evolution of the mission.

All waste should be collected and removed from the site where care is being provided.

The treatment of and relations with the Indigenous populations must always be
conducted in an environment of absolute respect and responsibility.

Immunization in the Event of Contact

In situations of contact with people in isolation, immunization is one of the most

important health actions to be carried out, but it should not be the first action, due to its
potential for causing discomfort (invasive measure). As it is not an emergency activity, it
must be planned and previously organized with the interpreters and Indigenous people in
recent contact and will depend on the context of the contact.

It is extremely important to support communication with the participation of interpreters

and experienced persons, to create a dialogue for the establishment of basic trust, in
addition to demonstration through visible examples of what should be done.
Immunization should only start after receiving the consent of the contacted Indigenous
peoples.

Health teams must report adverse events after the immunization, as well as other signs
and symptoms that appear in the next 48 hours. There are no significant differences in the
immunization schedule for isolated peoples, but it is important to give as many
inoculations as possible in a single opportunity; to avoid missing the opportunity to
immunize a group that may lose contact with the national society and therefore remain
vulnerable to infectious diseases circulating in the surrounding area.

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