June 2018 Volume 3 Issue 1

HEALTH IMPACT ASSESSMENT OF THE CONSTRUCTION OF
HYDROELECTRIC DAMS IN BRAZIL

Diego Velloso Veronez, MD; Karina Camasmie Abe. PhD; Simone Georges El Khouri Miraglia, PhD

Abstract:

Background: Brazil´s dam-building plans in Amazonia imply substantial environmental and social impacts.
This study evaluates the relationship between social, environmental, economic aspects, and impacts on the
health status of the population of Rondônia, Brazil, due to the implementation of the Jirau and Santo Antônio
hydroelectric dams.

Methods: A qualitative and retrospective Health Impact Assessment (HIA) is used to focus the study objectives.
The information is arranged in a structured diagram that enables an outside reviewer to assess the aspects/
impacts relationship derived from the construction of the dams. This comes with outline recommendations for
health risk management that can orient national health authorities. We selected a narrative review synthesis as
the most appropriate approach for the study.

Results: The diagram network was built making it possible to analyze the impact changes caused by this enterprise
in the health sector. Additionally, the model will serve in the implementation of a complete HIA approach in an
attempt to quantitatively map the impacts and to propose recommendations.

Conclusion: The diagram pathway has been useful as an important tool for assessing a broader view of direct
and indirect impact categories, serving as a basis for further evaluations and studies. This effort is very important
for highlighting the priorities in the public policy decision-making process, serving as a basis for the Brazilian
Health System.

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

Introduction

Brazil is undergoing a rapid demographic expansion
and intensive development process, supported by the
implementation of major infrastructure projects in the
country to facilitate the development of the national
territory (Brasil 2013; 2014).

To ensure the country’s infrastructure and economic
growth in the face of worldwide economic uncertainties,
the Brazilian government created the Growth
Acceleration Program (Programa de Aceleração do
Crescimento - PAC) in its first phase in 2007, which has
since promoted the planning and execution of major
social, urban, logistical, and energy infrastructure in
the country (Brasil, 2013).

Currently, the PAC is in its second phase, which started
in 2010, in which investments are directed towards
the energy sector with the construction of large dams,
such as the Jirau (9° 15′ S 64° 38′ W) and Santo Antônio
(08° 48′ S 63° 56′ W) dams, both located on the Rio
Madeira in the municipality of Porto Velho in the state
of Rondônia (Brasil 2013).

In the construction of hydropower plants, financial
resources are mobilized from the public and private
sectors through consortia; furthermore, many
inputs, such as labor, machinery, equipment, and
the construction materials needed for the work, are
required. This mobilization often disfigures the region
where the project will be installed, leading to impacts1
with cross-border dimensions (Bortoleto, 2001; Brasil,
2013; Cruz and Silva, 2010; Fearnside, 2014; Rocha,
2014).

In large enterprises, the human and ecological impacts
must be considered. According to World Health
Organization, health is a state of complete physical,
mental, and social well-being and not merely the
absence of disease or infirmity (WHO, 1946).

To demonstrate the relationships arising from works
of large enterprises and the health of the affected
population, the need to compile evidence of health
impacts and to represent them in an interconnected
manner has been identified.

An understanding of the impacts of major projects
requires socioeconomic and environmental studies,
which should be presented according to the relevant
legislation (CONAMA No 001/86) to minimize any
possible negative impacts in the periods prior to the
project, during the construction of the project, and
after its completion. Thus, it is possible to perform
a proper management of the impacts of the project
(CONAMA, 1986; Cruz and Silva, 2010).

To minimize the negative impacts and maximize the
positive impacts, any project in Brazil that will potentially
cause an environmental impact must undergo the
licensing process, according to CONAMA Resolution No.
01/86 and CONAMA Resolution No. 237/97. Resolution
01/86 defines the concept of an environmental impact
assessment, its criteria, its guidelines, and establishes
the mandatory Environmental Impact Assessment (EIA)
and Environmental Impact Report (EIR) to exemplify
the activities subject to the EIA/EIR. These reports
have less formal language and represent key aspects
of the EIA, and they are presented at public hearings
to all stakeholders (Cunha, 2008).

However, the EIA/EIR does not adequately address the
possible impacts on the health of the population and
the health system (increased demand for medical care)
based on the type of project because all constructions
of large enterprises result in positive or negative
impacts that directly reflect the population’s wellbeing
(Brasil, 2014).

Faced with this problem in the conceptual approach of
the EIA/EIR, the World Health Organization (WHO) and
the National Health Service of the United Kingdom (UK-
NHS) consider that numerous activities of the public
and private sectors produce health consequences
(WHO, 2002).

Due to the fact that the health system can be overloaded
by diseases provoked by environmental impacts,
in an attempt to improve the health care approach
in environmental impact studies, a new method of
impact assessment for health has been proposed, the
Health Impact Assessment (HIA). This methodology,
which officially appeared in 1999 in a document called

1 Environmental aspects are a result of activities, products, or services that can interact with the environment, causing or pos-

sibly causing environmental impacts, whether positive or negative. Environmental impacts are any change in the physical, chemical,
and biological properties of the environment resulting from human activities(4).

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

the Gothenburg Consensus, is defined by the WHO as
a set of tools and procedures to judge policies, plans,
or programs by systematically evaluating the potential
effects on public health (WHO, 1999).

The HIA is an established method in countries such as
Canada, the USA, Australia, and the member states of
the European Union. This tool allows one to evaluate
a project and its potential health impacts and propose
mitigation actions for health promotion (Brasil, 2014;
Winkler et al., 2013). In Brazil, the concept was
disseminated in 2014 by the Ministry of Health of
Brazil with the publication of a national guide aimed
at transferring the HIA methodology in the country.
Its application has been encouraged in environmental
licensing, aiming at large enterprises that could cause
health impacts. The challenge faced by the Ministry of
Health is the integration of the HIA and EIA/EIR (Brasil,
2014).

Considering this scenario, this study aims to identify
and organize the direct and indirect health impacts and
their determinants due to the environmental alteration
caused by the construction of the hydroelectric dams
on the Madeira River in the state of Rondônia, Brazil,
considering national and international available data
and references. We provide a review of various health
effects associated with environmental, social, and
economic aspects to provide a systematic, integrated,
and clear overview of both the aspects and impacts
with regard to the scope of the problem detailed in
a network schematic diagram. Recommendations
are proposed for the health authorities to pursue
the constructors to seek means to protect the public
health associated with the construction’s impacts in
the region and to obtain bases for health policy makers.

Methods

A qualitative and retrospective HIA was used to focus
the study objectives. Rapid assessment was performed
because of shortages of time and money as well as due
to the difficulties of accessing data on projects and their
construction. The HIA steps conducted in this study
were Screening, Scoping and Appraisal (partial). The
HIA relied on secondary data and expert informants
and interviews to obtain essential qualitative data. The

information was arranged in a structured diagram that
enables an outside reviewer to assess the aspects/
impacts relationship derived from the construction of
the dams and to identify gaps that require further study
and intervention. The product is a diagram network
that enables one to easily visualize the relationships
among the aspects and impacts associated with the
environmental, social, and economic consequences
of the dams’ construction resulting in public health
effects. This comes with outline recommendations for
health risk management that can orient national health
authorities towards indicating the steps required
to formulate specific management plans through
negotiation with local stakeholders.

We selected a narrative review synthesis as the
most appropriate approach for the study because
studies regarding health impacts derived from
hydroelectric dams have been conducted in diverse
types of traditional research, with widely different
methodologies and often varied but nevertheless
related research questions. This heterogeneity makes
it difficult to apply a more traditional systematic review
approach.

The main search engines used to source the literature
were PubMed, Scientific Electronic Library Online,
Latin American and Caribbean Health Sciences (Lilacs),
and Google. The search was conducted using the
terms “hydroelectric” or “power plants” and “Brazil”
in combination with the terms “impact” or “effect”, in
English, Portuguese, or Spanish, without time limits.
Moreover, the date of the last search was August
2016. The references of all of the retrieved original
articles and reviews were assessed for additional
relevant articles. International guidelines, government
sites, grey literature, and expert opinions were also
consulted for data and additional references. The
articles’ languages considered in this search were
English, Portuguese, and Spanish.

The reading of the documents and articles was
performed to refine the selection, leaving only those
that addressed the issue related to the research
objectives. The main articles and retrieved documents
were reviewed with the focus on the diagram network
impacts of the construction.

After collecting the information, a diagram network

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

linking the environmental, social, and economic
aspects and impacts was built using the CMAP software
(developed by the Florida Institute for Human &
Machine Cognition).

Study Area

The state of Rondônia (RO) is located in the northwest
of Brazil and covers an area of 237,590.543 km2 with 52
municipalities, and it is bordered by the states of Amazonas
to the north, Mato Grosso to the east, Acre to the west,
and the Republic of Bolivia to the west and south (Figure 1)
(IBGE, 2015).

Fig 1 Location of the state Rondônia in Brazil. Source:
Prepared by the authors with the ArcGIS Online software

Both hydropower plants are located in the state of
Rondônia on the Madeira River, in the municipality of
Porto Velho. The first is the Santo Antônio hydroelectric
dam, which has a reservoir with a flooded area of 421.5
km2 at its maximum level and an installed capacity of
3,568 MW, located at a distance of 8 to 10 km from
the urban area of the municipality of Porto Velho (IBGE
2015; SANTO ANTONIO ENERGIA, 2016).

The second hydroelectric dam is the Jirau dam, which
has a reservoir with a flooded area at its maximum
level of 361.6 km2 and an installed capacity of 3,750
MW. This plant is on the Madeira River 120 km from

the urban area of Porto Velho. The work of the Santo
Antônio plant began in the second half of 2008,
whereas the construction of the Jirau plant began in
mid-2009. Both began partial power generation from
2012 (IBGE, 2015; ESB, 2016).

Results

Baseline Assessment
The state of Rondônia, whose capital is Porto Velho, is
located in the north of Brazil, bordering Bolivia. This
state represents 2.8% of the country, with an area of
237,765 km2, and contains approximately 0.8% of
the Brazilian population, with 1,562,409 inhabitants
in 2010 (Hacon and others 2014). Porto Velho is a
municipality that has an area of 34,090 km2 and a
population of 428,527 inhabitants (Cruz 2010).

The state of Rondônia has a predominantly young
population and has also recently seen an increase in its
population over the past 60 years. Between years 2000
to 2010, Rondônia saw an increase in the number of
people who self-identified as colored or black, brown,
and Asian; maintained its indigenous population; and
saw a decrease in the share of people who self-declared
as white in 2010 compared to the data from 2000.
In 2010, the black or brown population in Rondônia
represented 62.5% of the total population, whereas
in Brazil, this ratio was 50.7%. A relevant piece of
information is a 717% increase in the number of Asian
people in Rondônia between 2000 and 2010, increasing
from 0.2% to 1.4% in the population distribution and
suggesting an intense migratory movement of this
portion of the population.

The per capita household income of Rondônia
increased by slightly more than 31% from 2000 to
2010, going from 78.8% of the national income to
84.3%, supported by an approximately 50% drop in the
unemployment rate (from 9.88% in 2000 to 5.31% in
2010). In both census years, the unemployment rate in
the state of Rondônia has remained below the national
rate in Brazil, whereas the literary rate has remained
very close. The Rondônia vehicle fleet grew by 330%,
from 0.6% of the Brazilian fleet by 0.8%.

Life expectancy at birth for both men and women and
for the total population in Rondônia remained below

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

the Brazilian average and showed a small increase in
the period, rising from 69.1 years in 2000 to 72.1 years
in 2010 (IBGE census C).

With regard to the existing health establishments in
the state and in the capital of Porto Velho, there was an
increase in the number of health facilities, particularly
after 2010. However, the number of establishments
has not grown in proportion to population growth,
and greater attention is required when taking into
consideration access to health services and the
conditions of service and assistance.

The Madeira River, which passes through the state of
Rondônia, belongs to the Madeira River basin, which
is the most important basin in the state and extends
far beyond its limits within the lands of Brazil and the
Republic of Bolivia, occupying an area of 1,244,500
km2.

The hydroelectric dams of Santo Antônio and Jirau on
the Madeira river, both in the municipality of Porto
Velho, have a total installed capacity of 7,318 MW.
The two projects cost an estimated R$ 18.4 billion. The
Madeira River, due to its importance has tributaries in
Bolivia, Peru, Acre and Rondônia. This river is the main
tributary of the Amazon (downstream), both in volume
of water and sediments (de Souza Moret and Guerra,
2009). Several irregularities were verified during the
dams’ construction, such as the change of dam axis
of the Jirau unit without the preparation of specific
studies required by the Environmental Legislation, no
study was presented on the impacts in the communities
downstream of the plant. Moreover, there was no
mitigation measures regarding the restructuring of the
fish spawning area, compromising local and traditional
feeding based on fishing, due to decrease of fishing
areas (FURNAS et al., 2005).

In addition, the EIA/EIR states that there would

be no impact on indigenous lands (FURNAS et al.,
2005), which is false, since the Kaxarari indigenous
communities in the extreme region of Katawixi, on the
upper Candeias River, on the Karipuninha River, in Alto
Jaci and Jacareuba on the Mucuinnão river (who live
less than 20km from the hydroelectric construction)
were not reported in the EIA/EIR and consequently
does not present any assessment data or monitoring
of the effects affected by the construction (Moret and
Guerra, 2009).

Besides that, during the construction only 1,500
workers would stay as permanent workers. Between
the first and third year would be around 15,000
contracted workers and, at the peak of the work, there
will be the hiring of up to 20 thousand workers for only
3 months (Moret and Guerra, 2009). Unemployment
itself is detrimental to health and has an impact on
health outcomes, for example, increasing mortality
rates, causing physical and mental ill-health, and
greater use of health services (Mathers and Schofield,
1998). This shows the importance of exposing and
gathering the health determinants, sometimes even
unanticipated during the construction of the plants, in
order to make it possible to mitigate negative impacts
on future infrastructure works.

Network of aspects and impacts
To begin a systemic analysis of the aspects and
impacts caused by the Jirau and Santo Antonio
hydroelectric dams in Rondônia, this paper notes
some of the positive and negative impacts related to
all phases of the design and construction, showing
the relationship between an aspect and an impact
through a macro-systemic view. Table 1 shows the
main potential aspects and impacts observed during
the construction of hydroelectric plants.

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

Processes that induce
impacts

Resulting actions Impacts/aspects Reference

Construction site
installation

Occupation of land and
changes in land use,

deforestation, slash-and-
burn, and floods

Elimination of flora
and fauna; micro- and
macro-climate change;
proliferation of human

infectious parasitic diseases.

Guerra and Carvalho 1995.
Cunha 2008.

Sanches and Fisch 2005.
Alves and Justo 2011.

Mobilizing communities
(riparian, indigenous, and

others) and changes in
fishing activity

Guerra and Carvalho 1995.
Alves and Justo 2011.

Rocha 2014.

Human exposure to
mercury and heavy metals

Lacerda and Malm 2008.
Almeida et al. 2005.

Luca, 2012.

Cross-border impacts Marengo 2008.

Recruitment of labor

Rapid population growth
and urban development

Unplanned territorial
occupation, volatility
of real estate values,

loss of cultural heritage,
restructuring of pre-

existing economic
activities, disorderly
population growth,

unemployment, slums,
social marginalization.

Cruz and Silva 2010.
Rocha 2014.

Need for expansion of
health, transportation, and

education infrastructure

Cruz and Silva 2010.
Franco and Feitosa 2013

Increased vehicle
fleet and air pollution,
increased incidence of

cardiorespiratory diseases
on urban population,
increased stress and
greenhouse gases.

Queiroz and Motta-Veiga
2012.

Fearnside, 2005a

Increased noise and number
of traffic accidents on urban

population
Expert analysis

Table 1. Processes that induce impacts and actions and impacts/aspects resulting from the construction of
hydroelectric dams in Brazil

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

Increase of Population
(local and migrant)

Increased income

Greater access to the
consumption of alcohol,
drugs, and prostitution,
leading to violence and

social exclusion

Queiroz and Motta-Veiga
2012.

Increased tax collection Expert analysis
Population lifestyle change
due to the purchase power

increase

Queiroz and Motta-Veiga
2012.

Change in eating habits,
increase in unhealthy food
outlets, increasing obesity

Queiroz and Motta-Veiga,
2012

Increase in prostitution
Increase in sexually

transmitted diseases
Expert analysis

Increase in communities
and social conflicts

Inequalities and social
conflicts, increased drug use

Expert analysis

Increase in neuropsychiatric
disorders

Expert analysis

Delay in work completion Elevated cost of the work
Worker turnover, fluctuation

in workers’ incomes
Expert analysis

Start of plant operation

Reduced supply of unskilled
jobs and increase in skilled

labor

Decrease in income and
unemployment; increased

social conflicts, Health
impacts of unemployment

Expert analysis

Increase in national
electricity supply

Socioeconomic
development, increased
affordability of energy

Expert analysis

Global Impacts

Population increase
Increased costs in the

health system
Expert analysis

Change in the population’s
quality of life

Improved regional and
national infrastructure

Expert analysis

Territorial development Expert analysis

In Figure 2, one can observe the link between environmental areas (highlighted in green), health areas (red),
social areas (white), and economic areas (gray). This figure is divided into quadrants to facilitate viewing and
understanding during the explanation.

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

Fig 2. Network of Aspects and Impacts.

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

The first stage in the construction of a hydroelectric dam
is the installation of the construction site, which, in our
study, started in the second half of 2008 and provided
changes in the installed location. These changes can be
observed in quadrants 1 and 2 in Figure 2. In quadrant
1, it appears that the occupation of the land can lead
to a change in land use due to deforestation and slash-
and-burn practices. This can cause the elimination of
the diversity of flora and fauna. Due to slash-and-burn
practices, an increase in the incidence of respiratory
diseases may occur in the population caused by the
emissions of the generated pollutants (Dominici et al.,
2006).

By analyzing quadrant 2 in Figure 2, the flooding of
areas for water storage purposes by the plant as well as
other potential regional flooding due to the change in
land use (observed in quadrant 1) and the installation
of the construction site can be observed. This impact
can cause the expropriation of areas by relocating the
local riparian population, which is mainly composed of
fishermen, indigenous people, and other population
groups, to other locations. This way of displacement
deprives people of their means of production and
shifts them from their traditional ways of life.

Flooding in the riverbed can significantly change
fishing activity and the life of the riparian community,
which is often completely dependent on fishing for its
subsistence. Other likely impacts are the proliferation
of infectious parasitic diseases and community
exposure to heavy metals. For example, mercury,
released by erosion and ingested through water use
and fish consumption, can trigger diseases linked to
bioaccumulation, including neurotoxicity and loss of
motor control and other health problems (Passos and
Mergler, 2008).

In quadrant 3 of Figure 2, a probable population
increase is observed due to the need for labor to
start the project, which can generate an exacerbated
migration of human resources to the construction site
installation. The vast majority of this migrant population

consists of direct and indirect workers (contractors) of
projects that contribute to unplanned land occupation,
with an urban growth beyond that tolerated by the city
(Moret and Guerra, 2009)

Thus, there may be the expansion of poor communities
with inadequate housing conditions due to the housing
demand generated by migration. In many cases, these
are areas that lack basic sanitation and with social
conflicts, including indigenous lands, leading to the
social exclusion of the population or the individuals
who live in the community. Another fact is that this
change in the place brings a loss of cultural identity,
leading to a decrease in tourism in the region and,
consequently, lost revenue. This scenario causes a
change in the price of real estate or the appreciation of
some areas over others (FURNAS et al., 2005).

Another change in the population's life is the increase
in income provided by the supply of employment. This
increase in income boosts the purchasing power of the
local population, allowing access to goods and services
that improve the quality of life. However, possible
negative aspects consist of a higher consumption
of alcohol and drugs, which also leads to increased
prostitution and violence, producing direct effects
on the population's health and wellbeing, such as
psychological diseases, sexually transmitted diseases,
fractures, and trauma caused by violence.

Traumas are also accentuated due to traffic accidents,
as noted in quadrant 4. The increase in population
attracted to the region affects the morbidity and
mortality rates of non-communicable diseases,
especially those of external causes, such as accidents
and violence (Silveira, 2016). This effect can have
several reasons, among them comes from the change
in behavior in the population because the increased
income begins to consume a greater number of goods
and services, notably the acquisition of cars and
motorcycles, in addition to the expansion of industrial
production to meet the need for transportation.

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

This increased demand can cause environmental
consequences, such as a greater generation of solid
waste and atmospheric emissions. Atmospheric
emissions are the result of the increased vehicle fleet
and the increase in industrial production because
the burning of fossil fuels releases gases into the
atmosphere that are harmful to health. Consequently,
there may be an increase in the incidence of respiratory
diseases in the population, such as pneumonia,
bronchitis, emphysema, asthma, cardiovascular
ischaemic diseases, and cancer, which are diseases
commonly associated with air pollution (Kampa and
Castanas, 2008; Abe and Miraglia, 2016). In addition
to these diseases, it is also possible to trigger stress
and obesity due to decreased physical activity, and
pollution exposure (Madrigano et al., 2010).

Additionally, in Quadrant 4 in Figure 2, one can observe
the need for infrastructure in the state of Rondônia,
such as roads, avenues, streets, bus terminals, basic
sanitation, and others to bring an improvement in
people's quality of life.

Another impact in the increase in the fleet, according
to expert analysis, is the generation of noise for
residents who live in the vicinity of roads, increasing
the morbidity associated with stress.

A transversal fact that typically occurs is the delay in the
completion of the work (quadrants 3 and 4 in Figure
2), which occurs due to factors such as the lack of raw
materials, strikes and absenteeism by employees,
financial resources, and environmental conditions. All
of these factors increase the cost of the work and may
lead to dismissal.

By analyzing quadrant 5 of the network of aspects
and impacts, one can verify the global results of the
operation of the hydroelectric plant, which can be
positive or negative. The positive results are the
increase in quality of life in the country due to higher
energy availability and increased purchasing power.
The negative results include an accelerated migration,

increased health demand in both the public and private
network, and increased demand for education, which
served a certain number of people prior to the project
installation and must meet an increased demand from
people but with the same infrastructure after the
installation.

Discussion

The socio-environmental impacts from the installation
of hydroelectric power plants have received increasing
attention from researchers and the media in both the
national and international conjunctures. The problems
arising from the implementation of these works,
both social and environmental, are broader than
imagined. In this sense, this is the first time, through
an extensive bibliographical survey, that the direct
and indirect health impacts of the population, derived
from hydroelectric projects, have been gathered in
Brazil. These effects were addressed in a systemic
and networked way, showing the interconnections
between environmental effects and people's health.

The diagram network impacts elaboration is an
efficient and structured method to begin an HIA and
facilitates the reading of the various impacts and their
correlations, allowing the implementation of mitigation
actions (policies and actions) at the source, preventing
a collapse in the health system. In this case, the effects
were analyzed retrospectively, and the experience
gained from these analyses will serve as a substrate for
future projects on the same topic (Harris, 2007; Harris
et al. 2007).

To build the diagram network impacts (Figure 2), from
the starting point, there were premises that facilitated
the understanding of the correlation of the wide range
of existing variables, their causes, and the ultimate
effects on public health (Bortoleto, 2001; Guerra and
Carvalho, 1995; Queiroz and Motta-Veiga, 2012).

The objective of this study was to demonstrate the
possible consequences of the hydropower project

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

by creating a matrix of interconnected aspects and
impacts, called the network of aspects and impacts.
The target study population was the riparian, urban
and indigenous population. Nothing in the literature,
in which there is a broad view and the dynamics of
changes caused by the implementation of a project of
this size, similar to this network, has been found. This
view is pioneering and allows both a global and a specific
analysis of existing problems or potential damage due
to the changes stemming from an intervention.

The importance of creating a holistic view is noted
by Wehnham (2011), who describes the importance
of a multi-sectorial vision, including sectors such as
transportation, energy, and the environment, aiming
to understand the health consequences (Wernham
2011).

The network of aspects and impacts presents a multi-
sectorial vision. This is noted from the installation of
the construction site, which causes initial impacts such
as the occupation of land and changes in land use
through deforestation and slash-and-burn, thereby
eliminating the flora and fauna (Lerer and Scudder,
1999). Studies in Australia, which has more than 446
hydroelectric dams, show that dams and weirs affect
the fluvial fauna and flora (Teodoro, 1995, Kingsford,
2000, Thoms and Walker, 1993) and that the ecological
impacts on lowland flooded areas are still poorly
understood because habitat loss may have widespread
impacts on native fish and waterfowl. Associated with
road construction and the urbanization of the area, one
can observe that there is the loss of native habitats,
causing deleterious effects on the population of bees,
birds, animals, and riparian populations as well as
a significant change in eating habits, with most food
being purchased in nearby cities rather than produced
locally or collected (Schmidt 2011). It results in the
loss of access to traditional means of life, including
agriculture, fishing, livestock, and plant extraction
(Cruz and Silva, 2010).

This leads to micro- and macro-climate change, which,
combined with previous environmental changes,
exacerbates the proliferation of infectious parasitic
diseases for humans (Alves and Souza 2011; Cunha
2008; Guerra and Carvalho 1995; Sanches and Fisch
2005). In addition, silting and sedimentation in the soil
due to the construction of the dams have affected the
water quality of the region of the enterprise, increasing
the eutrophication phenomenon, damaging the fauna
and the aquatic flora of the reservoir and, with this,
the quality of the water of this region, which may
constitute not only an environmental and economic
problem but also a public health one (Carneiro and
Rubin, 2007).

The increase in vector-borne diseases due to the
construction of hydroelectric dams is a recurring
problem and was also reported during the construction
of the dam in Turkwel Gorge, a semi-arid region in
Kenya, which was completed in 1994 (Renshaw et al.
1998). Since then, concerns about the environmental
and health impacts have been reported, and authors
have noted the proliferation of the main vector of
malaria, Plasmodium falciparum, near the reservoir
of the hydroelectric plant (Pantoja and de Andrade,
2012). Schistosomiasis was also an endemic disease in
Kenya, but authors suggest that there may be a high
risk of an increase in cases of schistosomiasis due to
the population migration to the construction site.
This risk has also been identified for leishmaniasis.
Nomadic herdsmen, fishermen, and farmers have
been identified as high-risk groups for these diseases
(Renshaw et al, 1998). In our study, the threat of the
proliferation of vector-borne diseases during the
construction of large hydroelectric projects in tropical
regions is also a reality and impacts the local riparian
population, including the indigenous population of
Rondônia. During the construction of the Rosal Dam,
in south eastern Brazil, authors have revealed the
potential in the area for the transmission of malaria,
schistosomiasis, and cutaneous leishmaniasis (Rezende
et al, 2009). Among the infectious parasitic diseases,
the researchers involved in data collection in the

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

hydroelectric dam in Kenya also identified a risk of an
outbreak of the disease known as "Rift Valley Fever",
a viral disease transmitted by mosquitoes, because
the construction site of the hydroelectric dam has a
combination of people, water, animals, and mosquitoes
that facilitate a virus outbreak (Renshaw et al, 1998). In
Brazil, there is also the risk of outbreaks of mosquito-
borne diseases, specifically dengue, yellow fever, and
malaria, which are endemic in the Amazon region,
where hydroelectric plants on the Madeira River are
installed (Britto, 2007).

The change in land use is also a by-product of floods
that occur due to the plant, which has resulted in
the mobilization of riparian communities, changing
people's way of life (Guerra and Carvalho, 1995; Rocha,
2014). The population flows that are configured from
the construction of the hydroelectric plants usually
occur through two processes in the Amazon: the search
for territories of contingents looking for work that come
to occupy this area and that of lands’ desocuppation,
marked by the expropriation of the population of
the areas of influence of the reservoir. This results
in a behavior of migratory flows and refluxes, with
no sustainable convergence of public policies and
investments (Cavalcante et al. 2011). In Canada, the
construction of the La Grande Hydroelectric Complex,
known as the James Bay Project, in Quebec spurred
rapid population growth and the need for housing and
infrastructure, which contributed to the expansion of
the construction industry in nearby villages and the
growth of public services, driving business activity
(Senécal and Égré 1999). However, as with other
projects involving the displacement of people, there
are always positive and negative aspects because,
despite a marked improvement in the quality of life in
the new location, several dozen people refuse to leave
the premises and move, especially senior citizens who
are forced to move due to the construction of the dam
where they live. These people seem to experience a
sense of loss, which may result in health problems or
depression (Senécal and Égré 1999).

Another affected community in the Amazon region
is the indigenous population, which, in addition to
removal, undergoes the process of loss of indigenous
culture. During the construction of the Lajeado
hydroelectric plant in the state of Tocantins in northern
Brazil from 1996 to 2001, there was an indigenous
environmental compensation program to mitigate the
social and environmental impacts of construction on
the 3,000 indigenous people from the Xerente tribe,
who were located a few kilometres downstream of
the dam. Although there was a mitigation program,
the history of indigenous people with so-called "non-
indigenous" people has repeatedly been marked by
violence and the struggle for land since the time of
missionaries, prospectors, and settlers, causing great
concern among the heads of tribes who were led to
believe in the government programs which announced
the advantage of the hydroelectric for getting progress
and they had to accept it. In this sense, it caused a great
migration of indigenous peoples (Hanna et al. 2016;
de Paula 2000). This clearly shows the importance of
analyzing cultural and social aspects when addressing
any project. Moreover, it is reported in a recent study,
that the indigenous chief knew the undesirable side
effects that the proximity of the dam construction
would bring to his people, for example, the increase
in prostitution, alcoholism, the arrival of new diseases,
the invasion of Xerente land due to the proximity to
the construction site, and urban expansion, bringing
associated impacts such as roads and noise (Hanna et
al. 2016).

Other impacts can be noted in the urban population
due to the rapid progress of the city and the increase in
the population over a short period of time. According
to Rocha (2014) and Cruz (2010), rapid population
growth causes unplanned land occupation, which
results in the volatility of real estate values and the
loss of cultural heritage, with the degradation of local
history in contrast to development (Cruz and Silva,
2010; Rocha, 2014).

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

Urban development creates a need for the State and
municipalities to expand infrastructure to meet the
burden on health, transportation, education, and
sanitation systems generated by the population growth
(Cruz and Silva 2010; Franco and Feitosa 2013). Due
to the large inflow of workers to the construction site,
it is common for the basic sanitation infrastructure to
be absent or poor, particularly in developing countries,
hindering personal hygiene actions and contributing
to outbreaks of diseases that are transmitted by poor
sanitation, such as diarrhea and cholera (Renshaw et
al. 1998). The inflow of workers is one of the factors
that is felt the most by the local population and was
also found in a study on the hydroelectric plant of
Lajeado in the state of Tocantins in northern Brazil. The
city of Lajeado was full of "people from the outside";
according to anecdotal reports at the time, the city had
doubled in population (Araújo 2003). Next to this plant,
the city of Porto Nacional was also affected by the
construction of the dam, starting with the flooding of
an old and famous beach and sections of a traditional
avenue that had mansions owned by old families in
the city. Due to submersion by the dam, more than 50
of these mansions had to be demolished. The natural
beach was often visited by tourists from various
regions of the country and generated a significant
income for the city (Araújo 2003). The year after the
construction of the dam, there was the inauguration of
a tourist complex on the banks of the dam, including a
new avenue, sports courts, a go-kart racetrack, and an
artificial beach, to reduce the impact generated by the
loss of tourism and to boost new tourism (Araújo 2003).
Unfortunately, it was reported that, a few months after
the opening of the tourist complex, the water from the
dam was of poor quality and the beach needed to be
interdicted to take appropriate action (Araújo 2003);
thus, there was a decrease in tourism, which was an
important source of income, in the region due to poor
infrastructure and sanitation.

During the construction of the Jirau and Santo Antônio
hydroelectric dams, there was also an STD increase
among the regional population, which is very worrying

due to the proximity of the plants to the urban area of
the state capital. Prevention and awareness campaigns
about STDs are an alternative suggested by several
authors (Renshaw et al. 1998) because these cases
overwhelm the local health service and reduce the
population's quality of life.

The change in the population's lifestyle caused by
urbanization and the increase in population is also
a reflection of increased income. On one hand,
increased income may allow access to better health
services, however, on the other hand, it may have
permitted greater access to the consumption of
alcohol, drugs, and prostitution, leading to violence
and social exclusion and resulting in direct health
effects among the population (Queiroz and Motta-
Veiga 2012). Construction workers are a vulnerable
community because they often live apart from their
sexual partners, but they have a sufficient income
to pay for sex workers. In this study, there was an
increased rate of STDs in areas where construction
sites are installed, and this event was also observed
in the study by Renshaw et al (1998), who identified
a gonorrhea outbreak during the construction of the
Turkwel Gorge hydroelectric plant in Kenya.

The construction of a dam has the effect of submerging
both wetlands and dry areas and may include
rivers, lakes, and nearby towns. In a study after the
construction of the Rosal plant in Brazil, it was reported
that the most significant impact during the construction
phase was the increase in temporary residents due
to the influx of workers. The increased population
involved the risk of introducing infectious agents, in
addition to resulting in increased disturbances in the
environment, waste production, and wastewater.
In the operational phase of the plant, the authors
suggest that the greatest impact was the formation of
the lake and the departure of residents and workers
from the area (Rezende 2009). The migration of large
numbers of workers into the region, the displacement
of local residents, and the change in flora and fauna
are the main factors for the loss of local culture and

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

identity, which may result in a wide range of social and
environmental impacts on communities, such as intra-
group conflicts and changes in agricultural practices
and diets (Hanna et al 2016).

According to Alves and Justo (2011), the change in
the water flow rate and riverbed flooding significantly
alter fishing activity and the life of the riparian
community, who are often completely dependent
on this activity (Alves and Justo 2011). Changes in
the physical environment trigger a higher exposure
to heavy metals, especially mercury. This element
has high natural concentrations in the soil, which are
absorbed by the population when using the water and
fishing resources for their needs (Lacerda and Malm
2008, Almeida et al. 2005). According to the WHO,
the maximum allowed concentration of mercury is 50
parts per million (ppm) in water, and in the Amazon
region, the riparian population has a concentration of
70 ppm in their urine, creating a health risk of mercury
poisoning (Luca, 2012).

The fear of intoxication can cause changes in the diet,
passing to the consumption of industrialized products,
related to the indices of diabetes and obesity. This
change in eating habits has had an economic and
cultural impact, as well as not providing a connection
with culture and a connection with the land. In addition,
the indigenous population presents less life expectancy
and face risks of obesity and chronic diseases (Queiroz
and Motta-Veiga, 2012).

With urban development, there is also an increase
in the vehicle fleet to meet the population's needs.
However, this increase contributes to air pollution,
with an increase in cardiorespiratory diseases in the
population, which are commonly associated with
air pollution (Abe and Miraglia 2016; Saldiva et al.
1995; Veronez et al. 2012). Dwellings near roads or
highways may also cause health problems related to air
pollution. A recent study in Beijing suggests that long-
term exposure to air pollution related to vehicle traffic
on major roads in Beijing is associated with lower lung

function, airway acidification, and a higher prevalence
of chronic cough (Hu et al., 2016).

Other illnesses are also identified, such as the increase
in obesity caused by the change in eating habits due to
the increased consumption of processed foods and the
reduction of physical activity, which alters the previous
nutritional behaviour. Another factor that causes
correlated diseases is the stress caused by vehicular
traffic (Ferreira et al., 2013).

The changes not only impact the riparian population
but also reach the entire population of the city of Porto
Velho in the state of Rondônia and in other states in
the Amazon region; that is, they have cross-boundary
impacts (Marengo, 2008)

For example, in the case of air pollution, the
contamination plume can be carried by the wind to
other areas beyond the site where it was generated,
damaging health with diseases associated with air
pollution or causing acid rain that deteriorates property.
Another negative impact caused by air pollution is
the emission of greenhouse gases, which result in
the destruction of the earth’s ozone layer, raising the
planet’s temperature and contributing to drought in
places such as the Amazon basin, the melting of the
polar ice caps, and even the destruction of the planet’s
biodiversity (Ehrmann and Stinson, 1994; IPCC, 2014).

The diagram network impacts elaboration at the
national or international level will be of great value
to enable preventive or mitigating actions to be
taken before a change in public health resulting
from an environmental impact. The actors engaged
in the environmental licensing process in Brazil have
the perception that health is simply the absence
of disease, and the treatment of health in the EIA/
RIMA is sometimes limited to an inventory of the
health services infrastructure in the enterprise’s
area of influence (Brasil, 2014). In spite of the
institutionalization and obligatory nature of the EIA-EIR
to have meant a milestone in the evolution of Brazilian

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

environmentalism (Silveira and Neto, 2014), it is a fact
that the inclusion of the evaluation of health effects in
the environmental licensing process is lacking. There is
no regulation of any specific health impact assessment
tool for the environmental licensing process in
Brazil (Silveira and Neto, 2014).Negligence with the
health effects of the population occurs relatively
frequently, since the only legalized mechanisms of
health participation in the environmental licensing
process is the assessment of malarious potential in
malaria endemic regions (mainly the Amazon region)
(Barbosa et al., 2012, CONAMA, 2001, Katsuragawaet
al., 2009, Silveiraet al., 2012, SVS/MS, 2006). For other
health determinants, there are no specific legislation
or directives articulated with Brazilian environmental
licensing, as opposed to evaluations in developed
countries that consider various social and health
aspects in large enterprises.

Stinson (1994) expresses concern over the potential
impacts of environmental degradation on human
health, indicating the need to increase environmental
awareness and unify various parts and sectors of
society that analyze environmental risks differently and
therefore observe differences regarding the effects on
human health (Ehrmann and Stinson 1994). Thus, it
is considered that the applicability of this model will
be a key point for Brazilian public health, which lacks
information or studies that show the influence of
actions, projects, or programs in the area of health.
This model will serve as a basis for the Unified Health
System (Sistema Único de Saúde - SUS) in its actions
and improve the decision-making process of the
managers of regional health systems.

Motta-Veiga (2012) states that the effects of the
implementation of hydroelectric plants in Brazil
have been the focus of many discussions due to the
size of their impacts. The large scale of the Jirau and
Santo Antônio hydroelectric projects provokes the
displacement of workers from other localities. However,
because this intensive use of labor is temporary, it does
not provide permanent employability, that is, as soon

as the work get concluded, there will be a vertiginous
growth of unemployment and definitive interference
in the local social, environmental and economic
dynamics (de Souza Moret and Guerra, 2009).
However, the approaches found in the literature show
an isolated view, such as only environmental or social
impacts, without appropriately including the health
issue. Therefore, we can appreciate and understand
the importance of creating the network of aspects
and impacts to analyze the interaction of sectors and
stakeholders (Queiroz and Motta-Veiga 2012).

The proposed model supports the creation of mitigation
actions and even remediation actions in health so
that an increase in morbidity and mortality resulting
from the development of the state of Rondônia can
be avoided. This promotes the movement of a state’s
economy with positive impacts regarding sustainable
development and negative impacts with regard to
health, which has been estimated to date.

The impacts of the installation of the hydroelectric
dam can be positive with regard to local and national
development in terms of energy availability and
a consequent change in the quality of life of this
population. However, the development can introduce
increased costs in the health system (primary,
secondary, and tertiary, included social and mental
costs). Thus, one can observe the impact on health,
which, despite being a sector that is highly affected,
is often overlooked in projects of large enterprises.
The construction of the hydroelectric dams on the
Madeira River will add new social and economic plots
in the Rondônia territory. The implementation of
transport and electric energy infrastructures in the
Brazilian Amazon has been marked by major impacts
due to the environment and have assigned new
functions and forms of organization in the territory. In
this way, hydroelectric plants constitute a structural
element, generating new arrangements, revealing the
political character and the power use in the territory,
considering that its construction is to meet a demand
external to the Amazon region (Cavalcanteet al., 2011).

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

The balancing of ecological needs with demands
of industries and urban centers can be helped with
certain technical expertise, but it is largely a contest
between powerful political forces and the mute but
fundamental needs for sustaining life on our planet
(Jobin, 1999). It is necessary to consider the health
opportunities, managing and mitigating the social
conflicts. The cost of a dam is usually stated in terms of
the money spent to build the infrastructure and carry
out necessary preparatory tasks such as viability studies
and resettlement. However, the opportunity cost of
sacrificing the land use that would have occupied the
site had it not been used for a reservoir should also
be part of the decision when a dam-building project
is initiated (Fearnside, 2005). This study demonstrates
the importance of a qualitative diagram that serves as
a basis for more efficient quantitative analysis to assist
the start of conducting a prospective and quantitative
HIA. The evidence generated from studies such as
this can support the analysis of likely impacts and
can predict and mitigate future impacts. The diagram
begins to articulate some of the non-environmental
outcomes and impacts of dam-building that are
important to consider. The Brazilian government
needs to develop and adopt a credible institutional
framework (Fearnside, 2006).

We are aware of the limitations of our methodological
approach in terms of the coverage of impacts and a
complete analysis of each different situation and
location. The lack of national high quality studies
to cover a detailed range of determinants of health
on affected population lead us to offer an extensive
bibliographic search to summarize the hydroelectric
dams impacts and to highlight its relevance.
Nevertheless, we are confident that we provide an
adequate basis for enlarging the overview aspects/
impacts influencing a case study that can be replicated
in other situations. We adopt this methodological
approach to the evaluation of an environmental policy
and its associated health effects and we are finding
interesting and significant results. Moreover, this tool
is promising with regard to both retrospective and
prospective HIA studies.

Recommendations

Some recommendations derived from this qualitative
HIA retrospective study should be addressed to
stakeholders and decision-makers.. We summarize
them as follows:

1. Dams have to be weighed against alternative
energy projects in terms of environmental, so-
cial and health costs, sustainability and climate
effects;

2. Perform a prospective and quantitative HIA study
to predict and minimize the health impacts;

3. Obtain evidence from previous studies to serve as
the basis for the probable impacts analysis;

4. Develop a monitoring program to be performed
along with the construction, enabling interven-
tions with focus on minimizing health impacts;

5. Consult stakeholders frequently, searching for
changes in habits and in the health status that ap-
pear before the increase in demand for the health
service;

6. Create a communication system with health
authorities, the construction company and policy
makers to emphasize all of the occurrences of al-
terations in the project and construction process.

Conclusion

The diagram network impacts elaboration has been
useful as an important tool for assessing a broader view
of direct and indirect impacts categories, serving as a
basis for further evaluations and studies. International
data are limited to adapt in a national scenario,
however, bring together national and international
data and evidences can possibility cover a range of
effects, collaborating for the network construction
of evidences and country´s environmental licensing
system.
Brazil´s dam-building plans in Amazonia imply
substantial environmental and social impacts and pose
a challenge to the country´s environmental licensing
system (Fearnside, 2006). We recommend a strategic

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

planning in health impacts to avoid externalities, to
prevent and reduce costs in the health system, and
to obtain continuous improvement with investments
lower than that planned.

Therefore, one can conclude that the implementation
of hydroelectric dams has significant regional effects
in social, environmental, and economic aspects and
especially in the health sector. We suggest a more
comprehensive analysis in all of these sectors in order
to improve the national knowledge and the adoption
of HIA model to mitigate the negative impacts and

maximize the positive aspects on the environment and
the population.

Ethical approval: This article does not contain any
studies with human participants performed by any of
the authors.

Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

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Health Impact Assessment of the Construction of Hydroelectric Dams in Brazil Veronez; Abe; Miraglia

CORRESPONDING AUTHOR
Simone Georges El Khouri Miraglia, PhD
Department: Institute of Environmental Sciences, Chemical and Pharmaceutical,
Economics, Laboratory, Environmental Health and Pollution,
Universidade Federal de São Paulo - UNIFESP, São Paulo - Brazil
Rua São Nicolau 210 - 4° andar, Cep 09913-030 - Diadema - SP
Phone: (+055) 11 3385-4137 #3592
miraglia@terra.com.br

CHIA Staff:

Editor-in-Chief
Cynthia Stone, DrPH, RN, Professor, Richard M. Fairbanks School of Public Health, Indiana University-Purdue
University Indianapolis

Journal Manager
Angela Evertsen, BA, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University
Indianapolis

Chronicles of Health Impact Assessment Vol. 3 Issue 1 (2018) DOI: 10.18060/21777
© 2018 Author(s): Veronez, D.; Abe, KC; Miraglia, S. G. E. K.
This work is licensed under a Creative Commons Attribution 4.0 International License