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