1 2 3 Voluntary collective isolation as a best response to COVID-19 for indigenous 4 populations? A case study and protocol from the Bolivian Amazon 5 6 Prof. Hillard S. Kaplan, PhD1,2,*, Benjamin C. Trumble, PhD2,3, Jonathan Stieglitz, PhD2,4, Roberta Mendez 7 Mamany1,2, Maguin Gutierrez Cayuba5, Leonardina Maito Moye, Lic.6, Sarah Alami, MA2,14, Thomas Kraft, 8 PhD2,14, Raul Quispe Gutierrez, MD2, Juan Copajira Adrian, MD2, Prof. Randall C. Thompson, MD7,8, Prof. 9 Gregory S. Thomas, MD, MPH9,10, David E. Michalik, DO11,14, Daniel Eid Rodriguez, MD, PhD2,13, Prof. 10 Michael D. Gurven, PhD2,14,* 11 12 13 1Economic Science Institute, Chapman University, Orange, CA, USA 14 2Tsimane Health and Life History Project, San Borja, Bolivia 15 3School of Human Evolution and Social Change, Center for Evolution and Medicine, Arizona State 16 University, Tempe, AZ, USA 17 4Institute for Advanced Study in Toulouse, Toulouse, France 18 5Gran Consejo Tsimane, San Borja, Bolivia 19 6Asemblea Legislativa Departamental, Trinidad, Bolivia 20 7Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA 21 8University of Missouri–Kansas City, Kansas City, MO, USA 22 9Memorial Care, Southern California, USA 23 10Division of Cardiology, University of California at Irvine, CA, USA 24 11Miller Women’s and Children’s Hospital Long Beach, CA, USA 25 12Division of Pediatric Infectious Diseases, University of California at Irvine, CA, USA 26 13Department of Medicine, Universidad de San Simón, Cochabamba, Bolivia 27 14Department of Anthropology, University of California, Santa Barbara CA, USA 28 29 * Corresponding authors: [email protected], +1(805)455-7238 30 [email protected], +1(505)228-7309 31 32 Word count (text): 4697 33 34 35

1 36 Abstract 37 Indigenous communities worldwide share common features that make them especially vulnerable to 38 COVID-19 complications and mortality. They also possess resilient attributes that can be leveraged to 39 promote prevention efforts. How can indigenous communities best mitigate potential devastating 40 effects of COVID-19? In Bolivia, where nearly half of all citizens claim indigenous origins, no specific 41 guidelines have been outlined for indigenous communities inhabiting native communal territories. Here, 42 we describe collaborative efforts as anthropologists, physicians, tribal leaders and local officials to 43 develop and implement a COVID-19 prevention and containment plan focused on voluntary collective 44 isolation and contact-tracing among Tsimane horticulturalists in the Bolivian Amazon. Phase I involves 45 education, outreach, and preparation, while Phase II focuses on containment, patient management and 46 quarantine. Features of this plan may be exported and adapted to local circumstances elsewhere to 47 prevent widespread mortality in indigenous communities. 48

49 Introduction 50 The world’s 370+ million indigenous people living in ~90 countries make up ~5% of the global 51 population.1 Their lifeways, language, and culture have long been threatened by the many facets of 52 colonialism and globalization, and their livelihoods and lives are now again at stake amid the coronavirus 53 pandemic. SARS-CoV-2 has caused COVID-19 in >200 countries and territories, with the number of 54 confirmed cases and deaths highest in the United States and Europe.2 Indigenous peoples worldwide 55 share common characteristics that make them especially vulnerable to COVID-19. Indigenous 56 populations suffer higher rates of extreme poverty, morbidity and mortality than their non-indigenous 57 neighbors across the spectrum of low to high-income countries.3 These conditions place indigenous 58 people at higher risk of complications and death from COVID-19. Respiratory infections are already a 59 major source of morbidity and mortality in many indigenous populations in low-income countries. As a 60 stark indicator of what could potentially occur, the H1N1 influenza pandemic of 2009 resulted in 3-6 61 times higher mortality among indigenous versus non-indigenous populations of the Americas and 62 Pacific.4 63 As of April 30, 2020, Bolivia had 1,167 confirmed COVID-19 cases and 62 deaths, largely confined 64 to Santa Cruz and La Paz provinces (https://www.boliviasegura.gob.bo/). The Bolivian national 65 government response to COVID-19 began on March 12, 2020 and included border closure, suspension of 66 interdepartmental and interprovince transport, and nationwide quarantine (Decrees 4196 & 4199). 67 Testing has been limited, and focused primarily in urban centers. The Beni Department, home to over 18 68 indigenous populations, is mostly rural with its first confirmed case of COVID-19 reported on April 20, 69 2020. This lowland forest and savanna region once bore witness to a large and sophisticated civilization, 70 recently identified as one of the five major centers for early plant domestication – the first to 71 domesticate manioc and squash ~10,000 years ago.5 Despite the fact that almost half of Bolivians are 72 considered to be of indigenous origin, no specific guidelines have been outlined for remote indigenous 73 groups inhabiting native communal territories (Tierras Comunitarias de Origen, TCO). 74 In what follows, we first highlight general aspects of indigenous populations relevant to the 75 current COVID-19 pandemic, then review our specific experience in a collaborative effort to develop and 76 implement a COVID-19 prevention plan among Bolivian horticulturalists of the Beni Department.

77 Indigenous populations: vulnerabilities and resilience 78 Excess mortality from infectious disease has a long history among indigenous populations. 79 Smallpox, measles and other virgin-soil epidemics eliminated up to 80% of native populations in the 80 Americas following European contact.6, 7 So far, COVID-19 has already heavily impacted the Navajo

2 81 nation in the U.S., with more deaths in the Navajo nation than in the rest of New Mexico, which has a 13 82 times larger population.8 At the same time, at least seven indigenous individuals in the Brazilian Amazon 83 have tested positive9, and three have died, including a 15-year old boy from the largest semi-isolated 84 tribe in South America, the Yanomami. The latter case illustrates the potential for COVID-19 to have 85 devastating impacts in remote communities: the boy, experiencing flu-like symptoms, traveled to the 86 distant Roraima state capital hospital for medical attention. His diagnosis was delayed, however, and 87 prior respiratory complications common among the Yanomami and other indigenous populations (e.g. 88 pulmonary tuberculosis, acute lower respiratory tract infections)10 can entail increased risk of death for 89 COVID-19 cases. Teenagers in industrialized countries have otherwise exhibited minimal risk of death 90 from COVID-19.11 91 Indigenous populations experience unique vulnerability to COVID-19 for several reasons. In 92 addition to respiratory and other health conditions increasing the risk of COVID-19 mortality, indigenous 93 communities often lack access to clean water, soap, personal protective equipment and public 94 sanitation.12 Local medical services are underfunded for many urban indigenous communities, and 95 limited or non-existent for remote rural communities. Hospitals and clinics already lack capacity to meet 96 high demand for COVID-19 testing and treatment in the general population, let alone for indigenous 97 communities located farther away13, who often experience stigma or discrimination. Long travel to 98 regional hospitals or clinics entails additional risk of virus transmission on crowded public transportation 99 or other commonly used travel routes. An inability to pay for medical services further hinders access 100 when not covered under government insurance plans. 101 Local norms can also promote virus transmission. Collectivity is a core ethos pervading multiple 102 aspects of daily life in many indigenous cultures—from extended family coresidence, communal labor 103 and production, food sharing and other group activities. This collectivity is key for long-term resilience 104 but can hinder compliance with shorter term physical distancing measures, compared to other 105 populations with more individualistic cultures and nucleated households. 106 Many indigenous groups in rural areas have developed important ties to markets and towns, 107 especially where traditional subsistence livelihoods are vanishing. This market access, which is often 108 provided by roads or navigable rivers, can be vital for food security, access to medicine, social security 109 benefits and other government-sponsored cash programs, but can also facilitate rapid viral transmission 110 from more densely populated regions. Also, as various industries and businesses employing indigenous 111 communities shut down during the COVID-19 crisis, food insecurity has become a serious obstacle to 112 maintaining livelihoods.14 113 Tribal elders - many of whom serve as tribal leaders - are at particularly high risk of COVID-19 114 fatality due to their age, certain comorbidities (e.g. hypertension, diabetes), disability and 115 immunosenescence. Elders are vital for maintaining indigenous culture and language amid rapid 116 globalization, and so their potential loss could result in cultural or linguistic extinction. Elders act as 117 “walking libraries”, language, ritual and mythology specialists, role models and teachers, and caretakers 118 in multigenerational households. 119 Lastly, because indigenous people often inhabit protected territories rich in biodiversity and 120 natural resources, intensive resource extraction (e.g. logging, mining) has posed constant threats to 121 indigenous livelihoods and lives. For example, illegal gold mining is believed to be responsible for many 122 Yanomami infection-related deaths in northern Brazil and Venezuela since the 1980’s, including fatal 123 measles and malaria infections as recently as 201915, 16. Yanomami leaders now allege that their first 124 COVID-19 fatality was due to exposure to infected gold miners9. Illegal resource extraction may also be 125 increasing during the pandemic due to less government surveillance and enforcement, resulting in even 126 greater exploitation of indigenous territories and fatal clashes with indigenous communities.13 127 Past tragic history and current vulnerability has heightened the fear of massive devastation from 128 COVID-19 for indigenous communities around the world.13, 14, 17 Given the potential threats and obstacles

3 129 mentioned above, many indigenous communities have decided the most viable option is to restrict or 130 close their own borders, with action aimed largely at preventing viral transmission. Many groups have 131 already restricted their borders on their own, especially those accustomed to lockdown during prior 132 epidemics.14 For example, in response to COVID-19, Waswanipi Cree of central Quebec sealed off 133 community access to nonresidents, and require 14-day quarantine for any returning residents who left 134 the community.17 Mapoon aborigines of Cape York peninsula, Australia, enacted more severe self- 135 imposed travel restrictions, including the banning of all visitors and denial of return access to residents 136 who leave temporarily.18 Hundreds of indigenous communities in Brazil, Peru, Colombia and Ecuador 137 have similarly blockaded their borders.19 This includes the Shuar horticulturalists of Ecuador, which 138 currently has the highest official per capital infection rates of Latin America.20 Other measures to isolate 139 and protect the most vulnerable individuals are being actively proposed and discussed.21 140 141 Preventing pandemic spread in lowland Bolivia, Beni Department 142 The Tsimane of Bolivia are spread across over 100 villages, many of which are located along the 143 Maniqui or Quiquibey rivers, or nearby interior forested regions. Their population size is ~16,000 144 individuals, with ~4% over the age of 60 years. Tsimane produce nearly all of their own food (>90% 145 calories in the diet)22, and have no access to running water or sanitation. They experience high infectious 146 burden from diverse pathogens.23-25 Much morbidity and mortality is due to infections, particularly 147 respiratory infections. Pulmonary tuberculosis remains widespread and bronchiectasis is very common. 148 Tsimane life expectancy at birth was in the low 40’s until the late 20th century26. Since the 1970’s, roads 149 have increased access of some communities to towns, and increased availability of motorized water and 150 land transport in the last decade has facilitated more frequent travel to towns, particularly San Borja 151 (population ~45,000). Medical facilities are limited for Tsimane: a mission-sponsored clinic located on 152 the outskirts of San Borja provides some care, a hospital in San Borja provides basic attention and 153 routine surgeries by general practitioners, and rudimentary health outposts dispersed throughout 154 Tsimane territory. Medical attention from specialists requires transportation to larger cities, including 155 the Beni capital of Trinidad (∼6–8 hours by road from San Borja). Tsimane thus represent a population 156 that is highly vulnerable to COVID-19 with limited options for treatment. 157 The Tsimane Health and Life History Project (THLHP) has been working with Tsimane 158 communities since 2002, studying health and aging while providing primary healthcare and biomedical 159 surveillance.27, 28 Below we provide an overview of our experience working with the Tsimane 160 government and communities, and with local health and governmental officials in the San Borja 161 municipality to help prevent SARS-CoV-2 from reaching Tsimane communities. 162 In general, our approach in developing a COVID-19 strategy is based on two principles. The first 163 is that preventative measures prior to mass infection can greatly reduce the burden of morbidity and 164 mortality. The second is that any effective plan must be a collaborative effort among all stakeholders, 165 and must involve the indigenous populations in the decision process. We divide the plan into two 166 phases: Phase I, in which SARS-CoV-2 is spreading rapidly in Bolivia but before there were confirmed 167 cases in the Beni Department; and Phase II, the current situation, as the pandemic spreads to the region 168 in which the Tsimane live (see Table 1). 169 170 Phase I: Awareness and Prevention 171 Coordination with tribal leadership representing indigenous populations. The Tsimane population has 172 two governing councils, the Gran Consejo Tsimane and the Consejo Regional de Tsimane y Moseten. 173 Long-standing formal agreements and goodwill between the THLHP and these governing councils to 174 conduct research and provide primary health care to Tsimane villages, help establish trust and facilitate 175 mutual collaboration to plan and execute the prevention response (see Appendix 1).

4 176 177 Information provisioning. Our team includes 10 Tsimane, all bilingual in Tsimane and Spanish languages. 178 The first step was to educate our team and the health secretary for the Gran Consejo about SARS-CoV-2 179 (e.g. its origin, transmission, symptoms), and the obstacles to obtaining effective treatment. Three 180 THLHP physicians and project directors worked with Tsimane team members to translate and adapt US 181 Centers for Disease Control informational posters into the Tsimane language.29 Given that there are 182 currently no known or suspected cases in the Tsimane population, and that transportation was limited 183 by the Bolivian government, the team along with Gran Consejo members—all asymptomatic for any 184 COVID-19 or flu-like symptoms for at least two weeks—travelled by motorcycle to ~60 villages to hold 185 community meetings, starting March 25, 2020 (Figure 1). Those meetings had two goals: to inform 186 community members about COVID-19, and to stimulate discussion of potential preventative responses 187 (Appendices 2 and 3). Presentations included information about how SARS-CoV-2 is spreading 188 worldwide, the incubation period and risks of contagion, the often asymptomatic nature of the virus, 189 unique vulnerabilities of older people and those with other health conditions, the lack of a vaccine and 190 available treatments, and the role of quarantine in preventing virus transmission. The challenges of 191 certain traditional practices, such as communal sharing of shocdye’, or fermented manioc beer, was also 192 discussed. There was also discussion of how SARS-CoV-2 might spread throughout the Tsimane 193 population via market interactions and other encounters with outsiders. 194 195 Collective decision-making. Like most other indigenous populations, the Tsimane have experience with 196 local epidemics of communicable diseases.26 Tsimane in all visited villages were quick to recognize 197 disease risks, and their own unique vulnerabilities. Historically, the traditional Tsimane response to 198 epidemics was to flee and isolate deep in their territories and away from outsiders. As observed in a 199 growing number of indigenous populations17-19, Tsimane population-wide consensus is that collective 200 isolation is the most viable strategy for minimizing COVID-19 exposure until vaccines or treatments 201 become available. 202 Lively two-way discussions during community meetings focused on how to best accomplish 203 collective isolation. One important element was preventing napo (i.e. non-Tsimane outsiders) from 204 entering Tsimane territory and each village. Villages organized groups of volunteers to build and guard 205 physical blockades against entry. Another important element was to regulate interactions of villagers 206 with nonresidents. Most meetings resulted in village-level consensus that no one should leave the 207 territory and go to an area with disease risk unless there was an emergency. There was also agreement 208 regarding the need for a 14-day quarantine in several key entry points to the Tsimane territory for any 209 villager who leaves and then returns to the village. The notion of quarantine was deemed similar to 210 several traditional practices, such as the isolation and protection of postpartum mothers and their 211 newborn infants. Much discussion focused on the need for also quarantining individuals presenting with 212 symptoms and in particular the construction of huts out of local materials for quarantine living quarters. 213 There was also much discussion about how to protect the elderly, especially those with disabilities. In 214 most communities, discussions concluded with a formal meeting act that attendees either signed or 215 fingerprinted, representing the collective agreements made during the meeting. Those acts constitute 216 formal proof for government authorities about the collective decision-making process. 217 Village meetings also resulted in requests by community members for assistance in 218 accomplishing collective isolation. These included: 1) soap and salt to complement the foods that 219 Tsimane produce locally, 2) sufficient medicine for common ailments, so that Tsimane can avoid leaving 220 their territory to seek medical attention, 3) supplies for the quarantine quarters (e.g. mosquito netting, 221 eating utensils), and 4) assistance with barriers (e.g. locks and chains) to secure the physical barricades 222 that were newly created to achieve village isolation. 223 The decisions from these meetings formed the basis of the prevention plan for all villages.

5 224 225 Coordination with regional government and public health authorities. A critical element of Phase I has 226 been to coordinate with local police and military authorities enforcing the national government-ordered 227 quarantine (e.g. interprovincial travel ban), the local hospital and the COVID-19 response network, the 228 governor of Beni, and Tsimane representatives in the National Assembly. This enabled our team to 229 receive government-approved permits to (a) rapidly travel to Tsimane communities to hold meetings, 230 and (b) transport physicians, medicines and Personal Protective Equipment (PPE) to the Tsimane 231 territory from La Paz and Santa Cruz. The signed community meeting acts were shared with authorities 232 in seeking food assistance and enforcement of collective isolation. 233 The regional Beni government has donated some food supplies directly to Tsimane villages. Our 234 team is coordinating with the office of the Governor of Beni to augment their food distribution with our 235 purchase of soap and salt for each village, as requested in community meetings. We are also equipping 236 each village that constructs quarantine living quarters with mosquito netting and eating utensils, as 237 requested by villagers, in addition to locks and chains, where necessary. 238 239 Purchase of personal protective equipment (PPE) for local distribution. As in much of the world, there 240 is a shortage of PPE in Bolivia. We are currently purchasing N95 masks, goggles and gloves to donate to 241 the local San Borja hospital, health care professionals, and THLHP personnel. Surgical masks and gloves 242 will also be donated to each village as needed. Unavoidable shortages may require best practice 243 ‘guerrilla’ techniques for safe reuse of PPE. Training on appropriate use of PPE based on WHO guidelines 244 will also be provided. 245 246 Provision of medical care for non-COVID-19 patients within Tsimane territory. One of the most 247 pressing needs for accomplishing collective isolation is the provisioning of medical care for individuals 248 with diseases other than COVID-19. Due to the nature of their environment and lack of public health 249 infrastructure, the Tsimane suffer from myriad infectious diseases, including intestinal parasites, 250 diarrheal diseases, and respiratory diseases. Those infections often require people to seek medical 251 treatment at the San Borja hospital and/or to purchase medicines from San Borja pharmacies. To the 252 extent possible, our goal is for most medical care to be provided at the five government-supported rural 253 health posts with one attending primary care physician in a collaborative effort among team and 254 government-paid physicians, so that villagers will not have to leave the territory and risk infection in 255 town. We are also acquiring medicines in anticipation of Phase II, when travel to and from the territory 256 will likely incur greater risk or be impossible due to inclement weather. 257 258 Summary of Phase I. Prior to engaging in Phase I, most Tsimane had little knowledge regarding COVID- 259 19 risk. Now, they are actively involved in planning to prevent and contain its spread into their 260 communities. We hope that these first steps will help prepare for the much more challenging Phase II. 261 262 Phase II: COVID-19 containment and patient management 263 Phase II began when the first COVID-19 cases were diagnosed and confirmed in the Beni region 264 (April 20, 2020), though as of writing, no cases have yet been confirmed in the San Borja municipality 265 nearest to the Tsimane communities. Given risk of spreading COVID-19 through travel, during Phase II 266 our main team has ceased visiting Tsimane villages. From our THLHP research station in San Borja, 267 THLHP personnel will conduct contact-tracing in communities with suspected and confirmed COVID-19 268 cases, utilizing the Tsimane radio station (capable of reaching most Tsimane villages) and other modes of 269 communication (e.g. shortwave radio, cell phone). We will also establish two base stations within the 270 Tsimane territory for treatment for medical problems other than COVID-19. Our team will also continue

6 271 to provide updated Phase I information, and help coordinate local government and public health 272 responses in Tsimane territory. 273 274 Case reporting to the Tsimane population. Through the Tsimane radio station, we will provide daily 275 briefings and updates on confirmed and suspected COVID-19 cases in each village. We have begun by 276 providing briefings about new cases and deaths within Bolivia. Once COVID-19 is detected in the 277 Tsimane region, these briefings will become more detailed and include suggestions for strategic 278 responses. In addition to the Tsimane radio station, our San Borja office will communicate with distant 279 Tsimane communities by two-way ham radio, and with nearby communities by cell phone. 280 281 Case reporting to local authorities. Tsimane will be able to utilize our office staff for reporting suspected 282 cases in their villages. Tsimane-speaking team members will be available to receive information about 283 suspected cases from villages by telephone, radio or word of mouth. Those cases, which may not be 284 known to local health authorities given their remoteness, will be reported to the Bolivian COVID-19 285 response network authorities for investigation, possible testing, and treatment. 286 287 Link suspected and confirmed COVID-19 cases to geographic information system (GIS)/census 288 database. THLHP has collected household roster and global positioning data for most households in the 289 ~100 Tsimane communities. We will link reports on confirmed and suspected COVID-19 cases to this GIS 290 data to track virus spread and potential centers of infection. This information will be used to coordinate 291 isolation responses among affected and unaffected communities, while being careful not to stigmatize 292 individuals or families impacted by COVID-19; stigmatization hampered Ebola efforts in Sub-Saharan 293 Africa30, 31 as well as HIV treatment in the US.31 To reduce stigmatization of suspect or confirmed COVID- 294 19 cases, we will emphasize inclusion and solidarity with COVID-19 cases in radio messages and other 295 communications. These stress that anyone is capable of being infected, that once an individual has 296 recovered and has been symptom-free for two weeks, contagion risk is very low, and that only with 297 village unity can the community be best protected. Similar appeals by community leaders can reinforce 298 and further legitimize these statements. 299 300 Coordinate isolation responses within affected and unaffected communities. Utilizing GIS data and 301 following up on suspected cases, we will utilize all communication modalities to help communities 302 respond to spread of SARS-CoV-2. 303 Suspicion or confirmation of COVID-19 cases in a community will trigger family-level and 304 individual-level physical distancing and quarantine or isolation measures. Since many Tsimane families 305 have distant horticultural gardens and can efficiently build rudimentary houses with forest materials, it 306 is possible for each family to leave the village and self-isolate from other families. For families lacking 307 suspected or confirmed cases, this self-isolation may be a preferred response to infections in or near 308 residential clusters. During Phase I meetings, we suggested that families prepare for such isolation, 309 particularly if elderly members were present, and we addressed strategies for care and isolation of 310 COVID-19 cases. We will support those families with detailed advice and culturally and linguistically 311 specific print materials and radio on how to use PPE and successfully quarantine family members 312 presenting symptoms.29 313 For villages with no suspected or confirmed cases, it will be important to restrict visitation to 314 and from other villages. Those villages will also be advised to prepare for family-level isolation in 315 secondary houses. 316 317 Testing and contact-tracing. A system for local rapid-test of suspected COVID-19 cases represents a 318 critical tool in containment of viral spread. We are actively pursuing point-of-care molecular testing to

7 319 help confirm diagnoses. In the context of collective isolation in which most villagers are not leaving their 320 communities, contact-tracing and testing of household members is viable. A coordinated effort among 321 our team and government health workers responsible for testing, adequate local sample processing, our 322 updated village census, and Tsimane-speaking contact-tracers (located at both our base and within 323 communities, to avoid travel between town and communities), might be able to contain disease 324 outbreaks before they spread to other villages. The development of this plan is still in process. 325 326 Patient management. Unlike many other infectious diseases, evidence-based treatment for SARS- 327 COVID-2 is still under investigation worldwide. Effective supportive measures include supplemental 328 oxygen, hydration, and the ability to intubate and mechanically ventilate, if needed. Use of antibacterial 329 treatment may be needed for possible bacterial superinfection. With a 50-80% mortality for intubated 330 patients in industrialized countries32, intubation is likely futile in this setting without specialist support. 331 The risks of hospitalization include exposure to other COVID-19 patients and potentially infected 332 hospital personnel to an incoming Tsimane patient and accompanying relatives, who have the potential 333 to bring the virus back to their communities on their return. At this time, for all but the most severely 334 symptomatic patients, the disadvantages of being hospitalized to the patient and the community likely 335 outweigh the benefits. 336 As the chief strategy for managing COVID-19 cases with inadequate oxygen saturation (assessed 337 using available pulse oximeters), supplemental oxygen has the potential of being administered outside 338 the hospital at the five health posts noted above. Twenty-four-hour oxygen delivery can be provided by 339 a nasal cannula with oxygen reservoir in conjunction with oxygen concentrators. This would allow 340 effective treatment, short of intubation, to be provided close to the patient’s community in a much less 341 congested space. For patients not requiring oxygen, within-village isolation can be performed. 342 Conversations about treatment strategies will require direct involvement of community leaders and 343 family members to reduce chances that patients refuse treatment. For any refusals, isolation will be 344 critical, combined with symptom relief with analgesics and hypoxia monitoring. 345 In the future, if effective COVID-19 treatments such as intravenous anti-viral and 346 immunomodulatory agents are found to be effective and are available, regional inpatient management 347 may help prevent disease progression and mitigate mortality.

348 Adapting prevention strategies to other indigenous populations 349 The risks, challenges and options for strategic responses faced by indigenous communities share 350 many features with those faced by populations throughout the world, due to characteristics of COVID-19 351 itself. However, there are some common circumstances among many indigenous, aboriginal and tribal 352 peoples that present different risks and opportunities. 353 With respect to risk, severely affected urban areas throughout the world are likely to exhaust 354 medical supplies, laboratory facilities, and hospital beds, leaving little for indigenous populations. Similar 355 issues for minorities and resource-poor have the potential to worsen health disparities33. At the same 356 time, unique sources of resilience can be leveraged to prevent widespread mortality in indigenous 357 communities. The ability to produce subsistence foods daily is vital for collective isolation. Land and use 358 rights by indigenous communities are therefore critical to ensure reliance on subsistence-related 359 activity. Government-recognized tribal sovereignty is also an advantage for many indigenous 360 populations. This can facilitate making community decisions that can be enforced by government and 361 tribal authorities, including restricting movement in and out of the territory. Cultural norms of strong 362 family bonds and community meetings, like the ones that we discussed, are a common venue for 363 collective decision-making. Lastly, low population density facilitates both isolation and contact-tracing.

8 364 These sources of resilience can be applied to the development of strategies for prevention and 365 mitigation of COVID-19 mortality in indigenous populations. 366 Table 1 provides a general framework for the essential elements, implementation strategies, 367 and considerations of local context for prevention and containment plans in other indigenous 368 populations.Phases I and II ideally occur sequentially, but these may need to be advanced 369 simultaneously if COVID-19 is already present locally. Many other details will likely need to be adapted 370 to local circumstances in other tribal settings. Assessing local knowledge and education about COVID-19 371 are fundamental. Another critical element is promoting and respecting active collective decision-making 372 by the communities themselves, involving all relevant stakeholders, including community leaders and 373 members, local government and public health authorities, and any other entities involved in managing 374 pandemic response. If communities decide to isolate collectively, economic, medical and logistical 375 support may be necessary to make isolation feasible. The acquisition and training in the use of PPE is 376 another essential element, as is a plan for treatment of chronic or acute diseases other than COVID-19 377 to ensure that emergent cases are treated, while maintaining the isolation plan. 378 For Phase II, communication strategies should be in place to inform people about where cases 379 have been suspected and/or confirmed, without creating stigma which may prevent individuals from 380 seeking medical attention31 (for Spanish versions of these documents see Appendix 4-6). There should 381 be strategies for preventing the spread of the virus to unaffected areas and families. Physical distancing 382 can be applied at the village, household and individual levels as circumstances change, and adapted for 383 specific rural and cultural contexts. Outside sources can provide assistance with the provisioning of PPE 384 to local health care workers and for assisting in quarantine and isolation of patients. Testing and 385 contact-tracing will greatly facilitate containment of cases, as reliable and portable tests become 386 available. If oxygen support remains the most effective treatment, this may be provided by innovative 387 strategies at local health posts as described above. Telemedicine support from in-country or distant 388 specialists could be provided to assist regional healthcare workers, in particular as more is known about 389 potential therapies and best patient support practices as COVID-19 spreads globally. If intravenous 390 therapies prove effective, such as antiviral and/or immunomodulatory agents, then opportunities for 391 hospitalization will become important. 392 Other aspects of Phase II may also have to adapt to local conditions. The extent to which an 393 indigenous population relies on goods purchased in markets may require changes in the isolation plan. 394 One possible solution for market-reliant indigenous communities is to institute controlled markets near, 395 but outside, villages to avoid town visits or to prevent outside merchants from entering communities. 396 This process is currently being implemented among the Moseten, a more acculturated indigenous group 397 who are culturally and linguistically similar to the Tsimane. This involves making arrangements with 398 trusted merchants regarding those goods that villagers wish to sell and purchase, and about the controls 399 to be put in place. On select days, goods could be transported to designated areas with sellers and 400 buyers maintaining physical distance and using PPE. 401 402 Conclusion: Act now to prevent disaster 403 Our goal for this contribution is to promote general, adaptable strategies for mitigating the effects of the 404 SARS-CoV-2 pandemic on indigenous populations. We surmise that there are many indigenous peoples 405 who have not benefitted from advanced preparation for this pandemic, and whose needs may be 406 excluded from regional plans due to lack of resources, logistical and cultural support. We encourage 407 wider, immediate discussion of mitigation strategies across multiple stakeholders. Websites such as 408 United Nation’s COVID-19 and Indigenous Peoples 409 (https://www.un.org/development/desa/indigenouspeoples/covid-19.html) could act as a hub for

9 410 relevant, up-to-date information on action plans around the world. The time to act is now, before 411 COVID-19 creates devastation in indigenous populations. 412 413 Contributors. 414 DER, JCA, RQG, MGC, RMM and LMM were instrumental in organizing and implementing the COVID-19 415 plan in the Tsimane territory. HSK and MDG conceived the paper. MDG, HSK, JS, DER, GST and DEM 416 drafted the paper. All authors contributed ideas, comments and revised the paper. All authors approved 417 the final version. 418 419 Declaration of interests. All authors declare no competing interests. 420 421 Acknowledgements. THLHP is funded by NIH/NIA (RF1AG054442) and by NSF (1748282). JS also 422 acknowledges IAST funding from the French National Research Agency (ANR) under the Investments for 423 the Future (Investissements d’Avenir) program (ANR-17-EURE-0010). Funders did not influence any 424 aspect of our COVID-19 plan or decision to submit. We thank the THLHP team for their relentless 425 prevention efforts, especially Arnulfo Cari Ista, Bernabe Nate Añez, Bacilio Vie Tayo, Jesus Bani Cuata, 426 Erwin Gutierrez Cayuba, Alberto Vie Tayo, Cristian Alameda Claros, Lorgio Canchi Tayo, Marcos Renard 427 Vasquez and Genaro Roca Moye. We also thank the Horus study team for assistance in protocol 428 development.

429

430

10 431 Table 1. Essential elements, implementation and local considerations for a COVID-19 Prevention and 432 Containment Plan

433

Phase Essential Elements Implementation Local Considerations Is there centralized tribal representation Discussions about existing plans, Assessing or dispersed governing structure? Coordination Tribal leaders local awareness, Requested assistance from Attitudes toward non-indigenous? non-tribal sources Relationship and trust with regional Phase 1 governments, health-related NGOs?

Communication modalities available, Community-meetings in native language, existing knowledge of COVID-19, Education/Awareness flyers, radio broadcasts, “Whatsapp” & social understanding of disease transmission, media language(s) spoken Community meetings, Consideration of Legal status of tribal territory and collective isolation, formation of committees ability to collectively isolate, cultural Collective Decision Making to enforce decisions, documentation of practices about decision-making, ability collective decisions and use rights to produce own food Is there an existing containment plan? Is Understanding of existing Covid-19 Coordination with regional there a policy directed towards management strategies, Needed assistance government and public health indigenous communities, potential role from non-tribal sources, Communication and authorities of NGOs in plan, structure of decision enforcement of community isolation decisions process Understanding existing supply and shortages, Are there local/national stockpiles? Is Purchase of and training in use of Sourcing supplies, sourcing funds for PPE locally available, are healthcare PPE purchase, distribution to communities, workers trained in its use instructional videos Local medical infrastructure, availability In-territory medical care for non- Health posts, roving medical team, medicine of medication and diagnostic equipment, COVID-19 diseases to prevent support common morbidities and their symptom exposure in hospital environment overlap with COVID-19 Territorial autonomy, subsistence Safe supply chain of medication, tests, and autonomy vs need for markets, Isolation Support Transition: basic necessities, blockades and enforcement transportation and community access, Phase 1 to 2 Supply chains in place? Network of contacts within each village, Availability of communication Case Reporting to Indigenous social media groups, cell phone, ham radio, modalities, nature of within and Population Phase 2 financial support for communication between-community interactions Local infrastructure for case Communication with local Covid response investigation, existing human resources, Case Reporting to Local Authorities team to investigate suspected cases trust between local population and authorities Generate map of cases, affected Availability of census and geographic Mapping of suspected and confirmed households/communities, Adjust containment information, fluidity of communication cases plan to local 'hot spots' with local communities Radio, telephone and in-person All of the above considerations, communication to isolate affected individuals geographical distribution of households Coordinate isolation responses families from other families, and to isolate and communities, obstacles for isolation unaffected communities from affected at individual, family and community communities levels Availability of test kits, human Investigate each case, how it entered resources for case investigation, Testing and contact-tracing community, and test all potentially affected frequency of contacts among families individuals and with outside world Isolation of less sick patients, periodic All of the above considerations, measurement of blood oxygen of symptomatic changing best practices and availability Patient management patients, high-flow oxygen support, proning, of treatment modalities antiviral and other treatments as they become available 434

11 435 Figure 1. (a, b) Tsimane community meetings during Phase I; (c) A blockade aimed at preventing non- 436 Tsimane from entering a Tsimane community; (d) Delivery of salt and soap to be used to aid in 437 quarantining of suspect COVID-19 cases. Photo credit: THLHP team. 438 439

440 441 442 443

12 444 References 445 446 1. https://www.worldbank.org/en/topic/indigenouspeoples. 2020 (accessed April 20, 2020. 447 2. https://www.worldometers.info/coronavirus/countries-where-coronavirus-has-spread/. 448 (accessed April 30, 2020. 449 3. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. The Lancet 450 2009; 374(9683): 65-75. 451 4. La Ruche G, Tarantola A, Barboza P, Vaillant L, Gueguen J, Gastellu-Etchegorry M. The 2009 452 pandemic H1N1 influenza and indigenous populations of the Americas and the Pacific. Eurosurveillance 453 2009; 14(42): 19366. 454 5. Lombardo U, Iriarte J, Hilbert L, Ruiz-Pérez J, Capriles JM, Veit H. Early Holocene crop cultivation 455 and landscape modification in Amazonia. Nature 2020: 1-4. 456 6. Cook ND. Born to die: disease and New World conquest, 1492-1650: Cambridge University 457 Press; 1998. 458 7. Mann CC. 1491: New revelations of the Americas before Columbus: Alfred a Knopf Incorporated; 459 2005. 460 8. Romero S. Checkpoints, curfews, airlifts: virus rips through Navajo nation. New York Times. 2020 461 April 10, 2020. 462 9. Phillips T. Covid-19 fears grow for indigenous South Americans as Yanomami teen tests positive. 463 Guardian. 2020 April 8, 2020. 464 10. Sousa AO, Salem JI, Lee FK, et al. An epidemic of tuberculosis with a high rate of tuberculin 465 anergy among a population previously unexposed to tuberculosis, the Yanomami Indians of the Brazilian 466 Amazon. Proceedings of the National Academy of Sciences 1997; 94(24): 13227-32. 467 11. Team CC-R. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — 468 United States, February 12–March 16, 2020, 2020. 469 12. Ferrante L, Fearnside PM. Protect Indigenous peoples from COVID-19. Science 2020; 368(6488): 470 251. 471 13. Soares J. Brazil: Indigenous people in the Amazon brace for coronavirus. dwcom. 2020 April 6, 472 2020. 473 14. Wight A. Coronavirus ‘could devastate’ indigenous communities. SciDevNet. 2020 April 1, 2020. 474 15. Smith R. Measles outbreak threatens isolated Amazonian tribe. CNN. 2018 July 5, 2018. 475 16. Fraser B. Measles outbreak in the Americas. The Lancet 2018; 392(10145): 373. 476 17. Coletta A, Traiano H. The world’s indigenous peoples, with tragic history of disease, implore 477 outsiders to keep coronavirus away. Washington Post. 2020 March 31, 2020. 478 18. Mounter B. Self-imposed coronavirus lockdown part of Cape York efforts to protect vulnerable 479 communities. ABC Far North. 2020 March 23, 2020. 480 19. Collyns D, Cowie S, Parkin Daniels J, Phillips T. 'Coronavirus could wipe us out': indigenous South 481 Americans blockade villages. Guardian. 2020 March 30, 2020. 482 20. León Cabrera JM, Kurmanaev A. Ecuador Gives Glimpse Into Pandemic’s Impact on Latin 483 America. New York Times. 2020 April 8, 2020. 484 21. Allam L. Indigenous elders ask to be evacuated from remote communities over coronavirus 485 fears. Guardian. 2020 April 3, 2020. 486 22. Kraft TS, Stieglitz J, Trumble BC, Martin M, Kaplan H, Gurven M. Nutrition transition in 2 lowland 487 Bolivian subsistence populations. The American journal of clinical nutrition 2018; 108(6): 1183-95. 488 23. Blackwell AD, Trumble BC, Maldonado Suarez I, et al. Immune Function in Amazonian 489 Horticulturalists. Annals of Human Biology 2016; 43(4): 382-96.

13 490 24. Vasunilashorn S, Finch CE, Crimmins EM, et al. Inflammatory gene variants in the Tsimane, an 491 indigenous Bolivian population with a high infectious load. Biodemography and Social Biology 2011; 492 57(1): 33-52. 493 25. Dinkel KA, Costa ME, Kraft TS, et al. Relationship of sanitation, water boiling, and mosquito nets 494 to health biomarkers in a rural subsistence population. American Journal of Human Biology 2020: 495 e23356. 496 26. Gurven M, Kaplan H, Supa AZ. Mortality experience of Tsimane Amerindians of Bolivia: Regional 497 variation and temporal trends. American Journal of Human Biology 2007; 19(3): 376-98. 498 27. Gurven M, Stieglitz J, Trumble B, et al. The Tsimane Health and Life History Project: Integrating 499 anthropology and biomedicine. Evolutionary Anthropology: Issues, News, and Reviews 2017; 26(2): 54- 500 73. 501 28. Kaplan H, Thompson RC, Trumble BC, et al. Coronary atherosclerosis in indigenous South 502 American Tsimane: a cross-sectional cohort study. Lancet 2017; 389(10080): 1730-9. 503 29. Prevention CfDCa. Coronavirus Disease 2019 (COVID-19) Print Resources. 2020. 504 https://www.cdc.gov/coronavirus/2019-ncov/communication/print-resources.html. 505 30. Barry SH, Richard PA. Cultural Contexts of Ebola in Northern Uganda. Emerging Infectious 506 Disease journal 2003; 9(10): 1242. 507 31. Reluga TC, Smith RA, Hughes DP. Dynamic and game theory of infectious disease stigmas. 508 Journal of Theoretical Biology 2019; 476: 95-107. 509 32. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 510 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet 511 Respiratory Medicine 2020. 512 33. Board NTE. How to Save Black and Hispanic Lives in a Pandemic. New York Times. 2020 April 11, 513 2020. 514 515

14 516 Appendix 1. Organizational structure for local collaborations for Tsimane COVID-19 prevention efforts

517 INSTRUCTIONS FOR STRUCTURE AND FUNCTIONS OF THE TSIMANE LOCAL SURVEILLANCE COMMITTEE 518 FOR THE CORONAVIRUS EPIDEMIC 519 520 PARTNERS OF THE CORONAVIRUS CONTROL SURVEILLANCE PLAN IN TSIMANE COMMUNITIES 521  GRAN CONSEJO TSIMANE, represented by Mr. Maguin Gutierrez Cayuba. 522  TSIMANE HEALTH AND LIFE HISTORY PROJECT, represented by Drs. Hillard Kaplan, 523 Michael Gurven, Jonathan Stieglitz, and Benjamin Trumble. 524  BIOLOGICAL STATION OF BENI, represented by Ms. Carola Vaca 525  MEDICAL SOLIDARITY FOUNDATION (CANARY ISLANDS), represented by Dr. Sergio 526 Bejarano 527 528 COMPOSITION OF THE SURVEILLANCE TEAM 529 a) Village chief. 530 b) Representative of the elderly. 531 c) Representative of women. 532 d) Representative of the Tsimane Health and Life History Project. 533 e) Representative of the Gran Consejo Tsimane. 534 535 FUNCTIONS OF THE SURVEILLANCE TEAM 536 a) Implement internal regulations of the community for handling suspicious cases. 537 b) Direct the construction of the quarantine environment for probable contacts and 538 suspicious cases. 539 c) Define the conditions of contact with a suspected case and probable contacts. 540 d) Coordinate with any local health centers and the mobile medical team of the Tsimane 541 project to report cases and contacts. 542 e) Hold meetings with the community to report and coordinate activities during the 543 epidemic. 544 545 OPERATIONAL DEFINITIONS 546 Definition of a suspected case. 547  Once the epidemic has started, a person with a cough and fever with or without 548 breathing problems and who is coming from an area that has already reported 549 confirmed cases of COVID- 19 will be considered a suspected case. 550 551 Definition of probable contact. 552  Anyone from an active COVID-19 epidemic zone. 553 554 QUARANTINE 555 Who will enter quarantine? 556  Individuals who meet the definition of a suspected case and probable contact. 557 558 What will quarantine consist of? 559  Quarantine will consist of separating suspected cases and probable contacts from the 560 rest of the community. For this, they will be provided with an environment to rest as 561 well as giving them utensils (for example, a plate, spoon, cup) so that their family

15 562 members can deliver their food while they are separated. They will also be given 563 detergent to wash hands, clothes, and kitchen utensils. 564 565 Quarantine duration time 566  Potential contacts should be quarantined for observation for twelve days to see if they 567 have symptoms; if they do not have symptoms they can join their family and 568 community. Suspicious cases should receive medical attention (from the nearest health 569 center) and should be quarantined until their symptoms subside. They will be provided 570 with the necessary food and medication during their illness, as well as daily evaluations 571 to see the progression of the illness and the need for transfer to more specialized health 572 centers. 573 574 SUPPLIES FOR EACH SURVEILLANCE COMMITTEE 575 a) Detergent, plate, spoon and cup for suspected cases. 576 b) First aid kit for the community. 577 c) Supplies needed for coordinating with local health centers, to prevent patients with first-level 578 treatable diseases from going to San Borja. 579 580

16 581 Appendix 2. Sample script from Tsimane community meeting during Phase I (English). 582 583 Introduction. 584 We are in a special situation, since we have a disease called COVID-19. This disease started in China in 585 December 2019. It then spread to several countries and continents, and currently this disease is killing 586 hundreds of people per day in many countries. More than 170,000 people have died worldwide from 587 COVID-19. The most important thing to mention is that the disease is already in Bolivia; we have 588 hundreds of cases in Bolivia, which is precisely why we are having this meeting. 589 590 What is COVID-19 and coronavirus? 591 COVID-19 is a respiratory disease that can be contagious, just like a cold. COVID-19 is caused by a virus 592 called coronavirus. Currently, there is no vaccine or medication to prevent or cure COVID-19. 593 594 There is greater risk in contracting the disease for people over 50 years of age, people with diabetes- 595 based diseases, hypertension, kidney disease, heart disease, and those who are immunosuppressed, 596 anemic and malnourished. 597 598 How is coronavirus spread? 599 The virus likely started in an animal other than humans, but it is now spreading from person to person. 600 The virus is believed to spread mainly between people who are in close contact with each other (within 601 one meter distance), through droplets that are produced when an infected person coughs or sneezes. It 602 could also be possible for a person to contract COVID-19 by touching a surface or object that has the 603 virus and then touching their mouth, nose, or possibly their eyes, as it has been shown that a person 604 may touch their face more than 100 times a day. These droplets can fall on plates, glasses, or other 605 plastic, metal or wooden things; in them the virus can live for at least a day, and maybe more. A healthy 606 person can thus become infected with the virus by touching those infected things and putting their 607 hands to their mouths. 608 It is important to wash your hands with soap before eating or before putting your hand to your mouth or 609 eyes. 610 611 What are the symptoms of COVID-19? 612 COVID-19 patients have had mild to severe respiratory disease with the following symptoms: 613 • fever greater than 38°C 614 • dry cough 615 • difficulty breathing 616  In the event that a case is complicated it can present: pneumonia (infection) in both lungs, failure of 617 one or multiple organs, or death. 618 619 What can I do to avoid this disease? 620 • Avoid close contact with sick people. 621 • Avoid touching your eyes, nose, and mouth with your unwashed hands. 622 • Wash your hands frequently with soap and water for at least 20 seconds. If possible you can also use a 623 hand sanitizer that contains at least 60% alcohol (if soap and water are unavailable). 624 625 What should I do if I feel sick? 626 • Stay at home so as not to infect others. 627 • Cover your nose and mouth with your elbow crease or disposable tissue when you cough or sneeze 628 and then throw it away.

17 629 • Clean and disinfect frequently touched objects and surfaces. 630 What is quarantine? 631 Quarantine is a measure of social isolation that serves to prevent the spread of coronavirus infection. 632 633 How can quarantine prevent transmission? 634 When a person comes from an area where the epidemic has been confirmed, he or she can then 635 develop the disease within 6-10 days. It is asked that this person be isolated for 14 days, to see if he/she 636 has the infection or not. If you have the infection, you must remain under treatment and isolated for up 637 to 30 days. If you don't have the infection then you can rejoin the community again. In this way we 638 prevent an infected person from entering the community and spreading it to others. 639 640 Why is isolation important? 641  Because there is still no vaccine to prevent coronavirus. 642  Because a person infected at the beginning (in the first 6-10 days) may not show any 643 disease symptoms, but is highly contagious. 644 645 646 647 648 649

18 650 Appendix 3. Sample scripts for radio messages during Phase I (English). 651 652 Script 1 653 URGENT: Coronavirus and COVID-19 have arrived to Bolivia. 654 655 Coronavirus disease has reached Bolivia. The disease originally came from China, and has now spread to 656 countries all over the world. The disease can decimate the lungs, and no treatment has come out yet. 657 This disease is very dangerous and contagious. Many have already died of this disease. 658 659 It starts with fever, dry cough, and sore throat. Your throat and chest feel squeezed, and you can't 660 breathe. It is dangerous for all people: for children, young and old, but it is more dangerous for those 661 over 60 years old. 662 663 This disease is more dangerous for those who already have other diseases such as tuberculosis, 664 diabetes, high blood pressure, anemia, malnutrition and other diseases of the lungs. Therefore, our 665 Tsimane population is at high risk. 666 667 Although our Tsimane population has suffered from infectious diseases in the past, this disease is very 668 contagious, moreso than other diseases you may have experienced or heard of, and more lethal once 669 infected. You can catch it when you are near a sick person. The disease lives in saliva. When you talk, 670 cough or sneeze, you emit this saliva. In that saliva, there are very small droplets that cannot be seen 671 and the virus lives there. If a droplet reaches your eyes, nose or mouth, you can get the virus and the 672 disease. 673 674 In the same way, if that sick person grabs a plate, cup, or anything else, the disease stays in those things. 675 So, healthy people -- when they greet the sick person, or when they touch those things of the sick 676 person that have been contaminated with those tiny droplets -- they themselves can catch the disease. 677 678 In the first 6-10 days, the coronavirus enters your body and you can be sick for up to three weeks, if you 679 do not die sooner. 680 681 You should seek help: contact the community chief, so that they contact a Tsimane Health and Life 682 History Project member (for example, by phone or radio) to receive help. 683 684 Script 2 685 What can be done to avoid having a coronavirus infection? 686 If you know of someone who has come from a place where there is an epidemic such as Santa Cruz, 687 Cochabamba or La Paz and is with a cough, cold or sore throat: 688 • Avoid approaching them (that is, stay >3 meters away) while talking to that person. 689 • Wash your hands for 20 seconds before touching your mouth, nose and eyes. 690 691 If you are sick with a cough, cold or sore throat and have come from a place where there is an epidemic 692 such as Santa Cruz, Cochabamba or La Paz, then you should: 693 • Stay separated from your family and the rest of the community for two weeks until disease symptoms 694 disappear. 695 • Cover your nose and mouth when you cough or sneeze with a cloth or your arm. 696 • Clean any objects that you grasp. 697

19 698 699 What can my community do to prevent the infection from coming? 700 Do not let people who come from other places where the epidemic already exists into your community, 701 regardless of whether they are family members, friends or acquaintances. 702 703 What happens if those people enter? 704 • A separate house should be built where they stay for two weeks; if they do not develop signs of 705 the illness, then they can enter the community. 706 707 What if there is a person with coronavirus in my community? 708 • Another separate house must also be built, as there must be two weeks until the disease 709 subsides. 710 • The patient must have their own plate, cup and spoon, mosquito net and clothes, place to go to 711 the bathroom, and soap for washing their body, dishes and clothes. If they can cook for themselves 712 than they can be provided with food to cook; if they cannot cook for themselves, then they must be 713 served on their plate. The caregiver must be careful not to contract the disease, for example, by always 714 washing their hands after providing food for the patient. 715 • Finally, if for some reason the disease reaches the community, then those residents who are 716 healthy - especially the elderly - should leave the community until the disease is gone. 717 718 719

20 720 Appendix 4 (Appendix 1 in Spanish). Organizational structure for local collaborations for Tsimane 721 COVID-19 prevention efforts 722

723 INSTRUCTIVO DE ESTRUCTURACIÓN Y FUNCIONES DEL COMITÉ DE VIGILANCIA LOCAL TSIMANE PARA LA 724 EPIDEMIA DE CORONAVIRUS 725 726 ALIADOS DEL PLAN DE VIGILANCIA DE CONTROL DE CORONAVIRUS EN ETNIA TSIMANE 727 COMUNIDADES 728 GRAN CONCEJO TSIMANE representado por el Sr Maguin Gutierrez 729 PROYECTO SALUD Y ANTROPOLOGIA TSIMANE representado por el Prof. Hillard Kaplan, Michael 730 Gurven, Jonathan Stieglitz, y Ben Trumble 731 ESTACION BIOLOGICA DEL BENI representado por la Sra. Carola Vaca 732 FUNDACION SOLIDARIDAD MEDICA CANARIA a nombre del responsable Dr. Sergio Bejarano 733 734 CONFORMACIÓN DEL EQUIPO DE VIGILANCIA 735 Quienes forman parte del comité de vigilancia 736 f) Corregidor 737 g) Representante de ancianos 738 h) Representante de mujeres 739 i) Representante de Proyecto Antropología 740 j) Representante del Gran Concejo Tsimane 741 742 FUNCIONES DEL COMITÉ DE VIGILANCIA 743 f) Implementar normas internas de la comunidad para manejo de casos sospechosos 744 g) Dirigir la construcción de ambientes de cuarentena para contactos probables y casos 745 sospechosos 746 h) Definir las condiciones de contacto con caso sospechoso y contactos probables 747 i) Coordinar con centros de salud y con equipo de epidemiologia del proyecto Tsimane 748 para reporte de casos y contactos. 749 j) Reuniones con la comunidad para dar informes y coordinar actividades durante la 750 epidemia 751 752 DEFINICIONES OPERATIVAS 753 Definición de caso sospechoso 754 Una vez que se haya iniciado la epidemia, se considerara como caso sospechoso a toda persona 755 que presente tos y fiebre con o sin problemas para respirar y que este viniendo de una zona que 756 ya se haya notificado casos confirmados de COVID 19. 757 758 Definición de probables contactos 759 Cualquier persona que provenga de una zona de epidemia de COVID 19 activa 760 761 CUARENTENA 762 Quienes entraran a la cuarentena? 763 Los individuos que cumplan con la definición de caso sospechoso y contacto probable 764 En que consistirá la cuarentena? 765 La cuarentena consistirá en la separación de los casos sospechosos y los contactos probables 766 del resto de la comunidad. Para esto se les brindará un ambiente para alojarse además de darles

21 767 de plato, cuchara y vaso para que sus familiares les hagan llegar sus alimentos mientras se 768 encuentra separado. También se le dará detergente para que laven sus manos, ropa y utensilios 769 de cocina. 770 771 Tiempo de duración de la cuarentena 772 Los posibles contactos deben estar en cuarentena para su observación durante 12 días para ver 773 si presentan síntomas, de no presentar síntomas pueden integrarse a su familia y comunidad. 774 Los casos sospechosos deben asistir a la atención médica (Centro de salud más cercano) y deben 775 estar separados en la cuarentena hasta que remitan sus síntomas. Se les proveerá la 776 alimentación y la medicación necesaria durante su enfermedad, así como evaluaciones diarias 777 para ver la progresión de la enfermedad y la necesidad de transferencia a centros de salud más 778 especializados. 779 780 INSUMOS PARA CADA COMITÉ DE VIGILANCIA 781 d) Comprar detergente, plato, cuchara y vaso para los comités para que usen los contactos cuando 782 interactúen con los casos sospechosos. 783 e) Botiquín para IRAS de comunidad 784 f) Coordinar con centros de salud para evitar que los pacientes con enfermedades tratables en 785 primer nivel vayan a SB 786 787

22 788 Appendix 5 (Appendix 2 in Spanish). 789 790 Introducción: 791 Estamos en una situación especial, ya que tenemos una enfermedad llamada COVID 19(nCoV 19) , 792 enfermedad que empezó en China en diciembre del 2019 y se fue diseminando por varios países y 793 continentes, actualmente esta enfermedad está matando entre 500 a 800 personas por día en Países 794 como España, Italia. El último dato que tenemos es que hasta el día de Hoy murieron en todo el mundo 795 más de 15.000 personas; pero lo más importante que debemos mencionar es que la enfermedad ya 796 está en Bolivia, tenemos 27 casos, motivo por el cual damos esta charla. 797 798 Que es la enfermedad por coronavirus 2019 (COVID 19)? 799 Es una enfermedad respiratoria que se puede contagiosa similar a un resfrio, provocado por un virus 800 llamado nuevo coronavirus 2019; Actualmente no existe una vacuna ni medicamento para prevenir o 801 curar la enfermedad por coronavirus 2019 (COVID-19). 802 803 Hay más riesgo en personas mayores de 50 años, personas con enfermedad de base diabetes, 804 Hipertensión, enfermedad renal, enfermedad cardiaca, inmunodeprimidos y hay estudios que refieren 805 que es un riesgo muy alto el hecho de estar con anemia, desnutrición y carecer de servicios básicos. 806 807 ¿Cómo se propaga el COVID-19? 808 Es probable que el virus haya iniciado en una fuente animal, pero ahora se está propagando de persona 809 a persona. Se cree que el virus se propaga principalmente entre las personas que están en contacto 810 cercano unas con otras (dentro 1metro de distancia), a través de las gotitas respiratorias que se 811 producen cuando una persona infectada tose o estornuda. También podría ser posible que una persona 812 contraiga el COVID-19 al tocar una superficie u objeto que tenga el virus y luego se toque la boca, la 813 nariz o posiblemente los ojos, ya que está demostrado que una persona se toca la cara más de 100 814 veces al dia. 815 816 ¿Cuáles son los síntomas del COVID-19? 817 Los pacientes con COVID-19 han tenido enfermedad respiratoria de leve a grave con los siguientes 818 síntomas: 819 • fiebre mas de 38ºC 820 • tos 821 • dificultad para respirar 822 Y en el caso de que se complicara puede llegar a presentar: Neumonía(infección dentro del pulmón) en 823 ambos pulmones, insuficiencia de múltiples órganos o Muerte. 824 825 ¿Qué puedo hacer para no enfermar? 826 • Evite el contacto cercano con personas enfermas. 827 • Evite tocarse los ojos, la nariz y la boca con las manos sin lavar. 828 • Lávese frecuentemente las manos con agua y jabón por almenos 20 segundos. Use un desinfectante 829 de manos que contenga al menos un 60 % de alcohol si no hay agua y jabón. 830 831 Si está enfermo 832 • Quedarse en casa para no contagiar a los demás. 833 • Cubrirse la nariz y la boca con el pliegue del codo o con un pañuelo desechable al toser o estornudar y 834 luego botarlo a la basura. 835 • Limpiar y desinfectar los objetos y las superficies que se tocan frecuentemente.

23 836

24 837 ¿Qué es la cuarentena?: 838 Es una medida de aislamiento social que sirve para prevenir la propagación de la infección por 839 coronavirus. 840 841 ¿De qué manera la cuarentena puede evitar la transmisión? : Cuando una persona viene de una zona 842 donde ha sido confirmada la epidemia esta puede llegar a desarrollar la enfermedad entre 6 y 10 días, 843 por ellos se pide que esa persona sea aislada por 14 días. Para ver si tiene o no la infección. 844 Si tiene la infección deberá permanecer bajo tratamiento y aislado hasta por 30dias. 845 Si no tiene la infección entonces puede volver a reintegrarse a la comunidad. 846 De esta manera evitamos que una persona infectada entre en la comunidad y pueda contagiar a los 847 demás. 848 849 ¿Porque es importante el aislamiento? 850 1ro porque todavía no existe una vacuna para prevenir el coronavirus 851 2do porque una persona infectada al principio (6 o 10 días) no tiene síntomas, pero es altamente 852 contagiosa. 853 3ro la infección se da cuando la persona habla, estornuda o tose expulsando gotitas de saliva donde se 854 encuentra el virus hasta 1 metro de distancia y estas gotitas llegan a la boca, nariz y ojos de la persona 855 sana. 856 También estas gotitas pueden caer en platos, vasos, (cosas de plástico, metal o madera) en ellas el virus 857 vive hasta por días, entonces una persona sana puede infectarse con el virus al tocar esas cosas 858 infectadas y llevarse las manos a la boca. Por eso es importante lavarse las manos con jabón antes de 859 comer y de llevarse la mano a la boca o a los ojos. 860

25 861 Appendix 6 (Appendix 3 in Spanish). 862 863 Script 1 864 El Coronavirus COVID-19, llegó a Bolivia! 865 866 La enfermedad de Cornavirus llego a la comunidad de Bolivia. Esa enfermedad vino originalmente de 867 China, y ahora se ha derramado por todos los países. Esa enfermedad puede fregar los pulmones y no 868 ha salido tratamiento todavía. Esta enfermedad es muy peligrosa y contagiosa. Muchos ya sa ha 869 fallecieron de esta enfermedad. 870 871 Empieza con fiebre, tos seca, dolor de garganta, apreta la garganta y el pecho y no puedes respirar, 872 Es peligroso para todas las personas: para niños, jóvenes y mayores pero es mas más peligroso para los 873 mayores de 60 años. 874 875 Esta enfermedad es mas peligrosa para los que ya tienen otras enfermedades como tuberculosis, 876 diabetes, presión alta, anemia, desnutrición y otras enfermedades de los pulmones. Por eso, nuestra 877 poblacion tiene alta riesgo. 878 879 Aunque nuestra población ha sufrido de enfermedades infecciosas en el pasado, esta enfermedad es 880 muy contagiosa, más que varias otras enfermedades, y más letal una vez infectada. Puedes contágiate 881 cuando estas cerca de una persona enferma. La enfermedad vive en la saliva. Cuando hablas, toses o 882 estornudas votas esta saliva. En esa saliva, hay gotitas muy pequeñas que no se pueden ver y ahí vive el 883 virus. Si llega a tus ojos, nariz o boca puedes contagiarte. 884 885 De igual manera, si esa persona enferma agarra el celular, el plato o la jarra o cualquier otra cosa se 886 queda en esas cosas la enfermedad. Entonces, la gente sana cuando saluda a la persona enferma o 887 cuando toca esas cosas del enfermo que han sido contaminadas con esas gotitas pequeñitas, pueden 888 agarrar la enfermedad. 889 890 A los 6 y 10 días, el coronavirus entra a tu cuerpo y puedes estar hasta 3 semanas enfermo si no muere 891 antes. 892 893 Debes buscar ayuda, comunicarte con el corregido de la comunidad y que el se comunique con el 894 número del proyecto para recibir ayuda. 895 896 Script 2 897 ¿Que se puede hacer para no tener la infección de coronavirus? 898 Si conoces de alguien que hayan llegado de un lugar donde hay la epidemia como ser Santa Cruz, 899 Cochabamba o La Paz y esta con con tos, resfrio o dolor de garganta. 900 • Evita acercarse a él a más de tres metros de distancia para hablar con esa persona. 901 • Lávate las manos por 20 segundos antes de tocarte la boca, nariz y ojos 902 Si usted está enfermo con con tos, resfrio o dolor de garganta y ha llegado de un lugar donde hay la 903 epidemia como ser Santa Cruz, Cochabamba o La Paz, entonces debe: 904 • Mantenerse separado de su familia y el resto de la comunidad por 2 semanas hasta que desaparezcan 905 los síntomas de la enfermedad. 906 • Cúbrase la nariz y la boca cuando tose o estornude con un trapo o con su brazo. 907 • Limpie los objetos que agarra. 908

26 909 Y que se puede mi comunidad para prevenir que la infección llegue? 910 No deje entrar a la comunidad a gente que viene de otros lugares donde ya está la epidemia no importa 911 si son conocidos o familiares. 912 913 ¿Qué pasa si entran esas personas? 914 • Se debe construir una casa aparte donde se queden por dos semanas; si no desarrollan signos 915 de la enfermedad, entonces pueden entrar la comunidad. 916 917 ¿Qué pasa si hay una persona enferma de coronavirus en mi comunidad? 918 • También se debe construir otra casa aparte igual debe quedar dos semans hasta que cure de la 919 enfermedad. 920 • El enfermo debe tener su propio plato y cuchara, su propio mosquitero y ropa, su propio baño, 921 también jabón para que lave su cuerpo, platos y ropa. Si puede cocinarse hay que darle víveres, si no 922 puede entonces hay que servirle en su plato la persona que le cuida debe tener cuidado de no 923 contagiarse, lavándose las manos siempre después de atenderlo. 924 • Finalmente, si por algún motivo la enfermedad llega a la comunidad. Los que están sanos 925 especialmente los mayores deben irse lejos de la comunidad hasta que la enfermedad se vaya. 926 927

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