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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.

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

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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

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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

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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

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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

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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

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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

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Fig 2. Network of Aspects and Impacts. 



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

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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. 



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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 



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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 



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22

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

23

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

24

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

25

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

26

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

27

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.



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28

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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


