Abstract

Introduction

The 1978 Alma-Ata Conference championed the key role of Primary Health Care (PHC) in guaranteeing rights and reducing inequalities, declaring the responsibility of all governments to formulate policies and strategies to launch and sustain primary health care in coordination with other sectors¹1 Organização Mundial da Saúde. Declaração de Alma-Ata. Conferência Internacional sobre Cuidados Primários de Saúde. Alma-Ata, URSS; 6–12 de setembro de 1978. Alma-Ata: OMS; 1978.. However, Brazil’s public health has historically experienced a shortage of doctors in PHC, leading to the creation of the More Doctors Program (PMM) in 2013²2 Lei nº 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013. as a response to medical supply.

In the “Legal Amazon”, a legally defined region, often cared for by campaign and emergency models³3 Souza ABL. Construção de uma rede de serviços no interior do Amazonas: a experiência do SESP e da FSESP. In: Schweickard TJC, Ferla AA, Lima RTS, Kadri MR, organizadores. História e política pública de saúde na Amazônia. Porto Alegre: Rede UNIDA; 2017. p. 43-70., the PMM has enabled a significant increase in the number of doctors and consequent improvement in access to medical care in the Special Indigenous Health Districts (DSEI)⁴4 Fontão MAB, Pereira EL. Projeto Mais Médicos na saúde indígena: reflexões a partir de uma pesquisa de opinião. Interface (Botucatu). 2017; 21(1):1169-80.. These physicians were to receive periodic visits from academic supervisors from local supervisory institutions, but the difficulty of accessing part of the territories, such as several indigenous areas, resulted in the absence of supervision in the first year of the PMM⁵5 Luna WF, Ávila BT, Brazão CFF, Freitas FPP, Cajado LCS, Bastos LOA. Projeto Mais Médicos para o Brasil em áreas remotas de Roraima, Brasil: relações entre médicos e Grupo Especial de Supervisão. Interface (Botucatu). 2019; 23(1):1-14.. Therefore, in 2015, the Ministry of Education created the Special Group of Supervision (GES) for the pedagogical monitoring of these doctors⁶6 Portaria Normativa nº 28, de 14 de Julho de 2015. Dispõe sobre a criação e organização do Grupo Especial de Supervisão para áreas de difícil cobertura de supervisão, no âmbito do Projeto Mais Médicos para o Brasil, e dá outras providências. Diário Oficial da União. 14 Jul 2015.. In Roraima, the authors of this article were part of the GES as supervisors and/or tutors, with a focus on ongoing education related to the work process and skills for action in indigenous health in the DSEI East and DSEI Yanomami and Ye’kuana (DSEIY)⁵5 Luna WF, Ávila BT, Brazão CFF, Freitas FPP, Cajado LCS, Bastos LOA. Projeto Mais Médicos para o Brasil em áreas remotas de Roraima, Brasil: relações entre médicos e Grupo Especial de Supervisão. Interface (Botucatu). 2019; 23(1):1-14.. One of the authors was also a physician linked to PMM at DSEIY.

Starfield⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002. classically described the principles of PHC in four essential attributes (first contact access, completeness, longitudinality and coordination), plus three derivatives (family, community, and cultural competence). In Brazil, public policies on PHC have been gradually developed from the Alma-Ata Conference up to the current Family Health Strategy, deploying several devices.

In the case of public policies for indigenous peoples, progress was also slow and gradual, culminating with the creation of the Indigenous Health Care Subsystem (SASI-SUS) in 1999, through the Arouca Law (nº 9.836/99)⁸8 Lei nº 9.836, de 23 de Setembro de 1999. Acrescenta dispositivos à Lei nº 8.080, de 19 de Setembro de 1990, que “dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências”, instituindo o Subsistema de Atenção à Saúde Indígena. Diário Oficial da União. 23 Set 1999.. Through these initiatives, the DSEI was proposed to provide PHC care, with multidisciplinary indigenous health teams (EMSI) linked to the base poles and with the support of professionals from the Indigenous Health Support Center. The states and municipalities must guarantee the levels of secondary and tertiary care.

In indigenous contexts, PHC has guidelines described in the National Health Policy for Indigenous Peoples (PNSPI)⁹9 Fundação Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, FUNASA; 2002., focused on interculturality and the concept of differentiated attention, through the adaptation of technologies and professionals to local specificities¹⁰10 Pontes ALM, Rego S, Garnelo L. O modelo de atenção diferenciada nos Distritos Sanitários Especiais Indígenas: reflexões a partir do Alto Rio Negro/AM, Brasil. Cienc Saude Colet. 2015; 20(10):3119-210.. It also contemplates diversity and the overcoming of factors that make this population more vulnerable to health hazards, recognizing the efficacy of their medicine and the right to their culture⁴4 Fontão MAB, Pereira EL. Projeto Mais Médicos na saúde indígena: reflexões a partir de uma pesquisa de opinião. Interface (Botucatu). 2017; 21(1):1169-80., although in practice it still presents several challenges and contradictory aspects to be understood and overcome¹¹11 Ferreira LO. Interculturalidade e saúde indígena no contexto das políticas públicas brasileiras. In: Langdon EJ, Cardoso MD, organizadores. Saúde Indígena: políticas comparadas na América Latina. Florianópolis: UFSC; 2015. p. 217-46..

However, the DSEIY had already been created in 1991, coinciding with the demarcation of the Yanomami Indigenous Territory (TY) and the overwhelming epidemic of malaria in the region, largely as a result of the massive entry of miners into the territory in the late 1980s¹²12 Pithan OA. O modelo Hekura para interromper a transmissão da malária: uma experiência de ações integradas de controle com os indígenas yanomami na virada do século XX [dissertação]. Roraima: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2005.. By 2017, the population served by the DSEIY was over 25,000 people in the TY, Yanomami and Ye’kuana ethnic groups, in some 320 communities in the states of Roraima and Amazonas (Figure 1). In that year, there were 67 EMSI responsible for PHC in the villages, encompassing 460 professionals hired by a non-profit organization and 14 doctors linked to PMM(^e(e)Data provided by the DSEIY Epidemiology team).

Until November 2018, all the PMM doctors who worked at DSEIY were Cuban. With the end of the international cooperation Brazil-Pan American Health Organization - Cuba, all vacancies were occupied by Brazilians, bringing to the debate new relationships and challenges. This research aimed to understand the experiences of Brazilian doctors in their first months of work in PHC within the DSEIY, analyzing challenges and potential in this context.

Methods

An exploratory research was carried out, with a qualitative approach, seeking to work with an understanding of reality focused on meanings and subjectivities, in the sense of the discovery of its social codes from the speech, in a field marked by specificity and differentiation¹³13 Minayo MCS. Pesquisa social – Teoria, método e criatividade. 33a ed. Rio de Janeiro: Vozes; 2013. p. 9-29.. Such choice aimed to exercise the attentive look and the deconstruction of the idea of neutrality, since all researchers involved in the process had some function in the indigenous health related to the DSEIY.

In order to build the data, individual interviews were conducted with 18 of the 20 doctors linked to the PMM who worked in the DSEIY in 2019. We opted for the use of semi-structured interviews to allow the interviewees to discuss the subject, without being restricted to the inquiry formulated¹³13 Minayo MCS. Pesquisa social – Teoria, método e criatividade. 33a ed. Rio de Janeiro: Vozes; 2013. p. 9-29.. The questions were about the experience of acting in indigenous health, using the concept of experience as “what crosses us by, what happens to us, what touches us”¹⁴14 Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; 19:20-8. (p. 21). It is not what happens, but what generates transformation in the subject who lives it, according to Larrosa Bondía¹⁴14 Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; 19:20-8..

The subjects were 7 women and 11 men; they were between 25 and 53 years of age; 9 declared themselves white, 7 brown, and 2 black; 9 graduated in medicine in Brazil and 9 abroad, with completion of the course between 2014 and 2018; and worked at DSEIY for 2 to 9 months.

The materials from the interviews were submitted to exhaustive reading, with the construction of conceptual maps¹⁵15 Moreira MA. Aprendizagem significativa. Brasília: UnB; 1998. to visualize the contents brought by the subjects, with the emergence of pre-categories of analysis.

A thematic analysis of content was carried out using Gomes’s perspective as its basis¹⁶16 Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In: Minayo MCS, organizador. Pesquisa social – Teoria, método e criatividade. 33a ed. Rio de Janeiro: Vozes; 2013. p. 79-108.. The documents were ordered, the materials decomposed identifying those nuclei of meaning crosscutting the scenarios of indigenous health care experienced by doctors. It was concluded with the elaboration of an interpretative synthesis, allowing the dialogue of the axes identified with the experiences of the doctors, the objectives and the initial questions of the research. All through this process, procedures were fundamental to give value, understand, interpret the empirical data and articulate them with the theory, to allow the emergence of more consistent reflections on the reality in question¹³13 Minayo MCS. Pesquisa social – Teoria, método e criatividade. 33a ed. Rio de Janeiro: Vozes; 2013. p. 9-29..

The thematic categories were constructed and discussed using the Principles of PHC⁹9 Fundação Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, FUNASA; 2002. as a guide and, complementarily, theoretical references on the knowledge of the experience¹⁴14 Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; 19:20-8. and indigenous health policies.

The Research Ethics Committee of the Federal University of São Carlos under CAAE 17995819.9.0000.5504 approved this research. In this text, all the original names were replaced to ensure the confidentiality of the information.

Results and discussion

Three thematic categories related to health care emerged from the analysis: Work process; Meeting between different cultures; Educational process for and in indigenous health.

Category 1 - Work process

This first category brings the experiences of doctors in the midst of the work process in the care of indigenous people. The nuclei of meaning developed were: relations between PHC and Emergency and Urgency (EU); logistics and infrastructure issues; and interpersonal relations.

In the process of physicians’ work, conflicts arose regarding the identity of the care practices developed, raising questions about the role of PHC:

According to the SASI-SUS guidelines, the DSEI develop actions within the scope of PHC, and should be dedicated to essential health care, especially in the most frequent problems presented by people, especially in its initial phases, and in the prevention and promotion of health⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002.,⁹9 Fundação Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, FUNASA; 2002.. For Carlos, there is some confusion about the role of the teams in indigenous health, since emergency actions are separated from PHC, which would require care at other levels of attention. However, in indigenous communities, the demands often include EU care, something that creates confusions as professionals transpose urban models of health care to that scenario:

According to the principles of APS and the PNSPI, EMSI should ensure first contact access, i.e., to be identified as the first resource to be sought, also called the gateway to the health system⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002., which includes the EU for EMSI. However, relations with other levels of attention have been weak in Yanomami TI, and it is difficult to guarantee referral to another level of attention due to difficulties in radio communication, distance from reference centers, and transportation. For this reason, the limitations encountered for the realization of care in this territory generated insecurity and fear:

This complexity of situations brought the need to reorganize the health environment as highlighted by Vânia, bringing an example of hospitalization in the PHC environment:

Some doctors argued that the materials provided should be compatible with the EU admissions and services they performed, which was often not the case:

Daniela and other interviewees also mentioned difficulties for universal assistance due to limitations in the availability of medications and inputs:

Some conditions were decisive in the supply chain, highlighting the restriction of items in the List of Basic Care Medications for Indigenous Health; the logistics of distribution and insufficient supply; and an abusive and unrestricted use of some medications, especially antibiotics and anti-inflammatories:

This use, besides depleting the stock, could generate risks to the indigenous people, such as induction of bacterial resistance and undesirable adverse effects, as questioned by Barbara:

Sometimes the professionals justified this irrational use by the difficulty of continuity of care, which they related to the diffuse location of communities, the high turnover of professionals and the scales of teams, alternating periods of work and time off. This fact, combined with the focus on emergency actions, hinders the improvement of indicators in indigenous health¹⁷17 Mendes AM, Leite MS, Langdon EJ, Grisotti M. O desafio da atenção primária na saúde indígena no Brasil. Rev Panam Salud Publica. 2018; 42(184):1-6.. Thus, considering the longitudinality as an attribute of PHC, which implies the existence of a regular source of attention and its use over time, regardless of the presence of specific health-related problems, establishing a bond and trust⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002., it is perceived that it needs other contours in indigenous health, as Gustavo brought out:

In this dynamic, the professionals lived in the area for several days, which made the interpersonal relations intense. Some interviewees contested the excessive autonomy of the nurses in making decisions in an indigenous area, justified by the fact that, historically, they were used to working in teams without a doctor. This expectation of being team leader is called by Starfield the “delegated model”, when the legal responsibility is clearly the doctor⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002.. In indigenous health, this model is not necessarily the most common, nor the most effective. Other professionals tend to have more experience than doctors in the cared for territories, less rotation between the base poles, greater workload, and generally more experience in indigenous areas.

Indigenous health professionals should receive adequate training for interdisciplinary work according to local reality⁹9 Fundação Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, FUNASA; 2002.. However, non-indigenous professionals are usually non-qualified to work in very heterogeneous inter-ethnic contexts¹⁸18 Diehl EE, Pellegrini MA. Saúde e povos indígenas no Brasil: o desafio da formação e educação permanente de trabalhadores para atuação em contextos interculturais. Cad Saude Publica. 2014; 30(4):867-74., as Sandro pointed out:

Working conditions, food, housing, sanitation and maintenance of boats and airplanes were structural problems related to health care, which were pointed out as capable of causing risks to the workers’ health:

The isolation generated by scarce access to the Internet and to other doctors for case discussions were described as generators of insecurity. The only external means of communication in most of the base poles was radio, which presented communication and privacy flaws.

One of the precipitators of interpersonal conflicts were the “Medevac removals”, characterized by the air transport of patients to a reference service in the city, whenever there are no adequate conditions of care in the base poles. In these cases, a negotiation between health professional, management, community, and patient happened, in a situation where health care and available resources were in shock because the costs of removal were high, as Flávia put it:

Interpersonal relationships in the work process were also pointed out as favoring the care processes, such as: interdisciplinary integration, realization of conversation wheels with the community and “love” in the care relationship. According to Mário, the organization of shifts among professionals for the division of tasks related to work and domestic responsibilities was a very positive aspect:

The good receptivity of the teams and the indigenous people was also highlighted in several reports, which favored the commitment of the doctors who were arriving at these places of work.

Category 2 - Meeting between different cultures

This category presents the care experiences of doctors with a focus on relations with indigenous culture. Three nuclei of meaning were highlighted: approximation with the different; hierarchy in professional-indigenous relations; and respect for diversity.

In the meeting between cultures, the experience of what is different was highlighted, as described by Daniela, demonstrating enchantment:

TY is home to five languages from the Yanomami and Ye’kuana peoples, Karib linguistic trunk, being characteristically scarcely fluent in Portuguese. Therefore, the difficulty with the unknown language was recurrent, demanding that the relationship be frequently mediated by the translation of an Indigenous Health Agent and demanding an effort to observe non-verbal language. Therefore, doctor-patient interaction and proper identification of people’s health problems was difficult, making the quest for comprehensiveness challenging. According to Starfield, comprehensiveness requires that PHC adequately recognize the full range of needs related to the patient’s health and provide the resources to address them⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002.. In this context, the different languages and languages made comprehensive care more challenging, as reported by Alice:

The differences in language and culture also influenced the way people observed time and space, as Leandro pointed out:

In this universe of the different, some local words were being incorporated by doctors, who used them when talking about their experiences, like: Hoximi (being bad, ugly), Totihi (being good, beautiful) Tuxaua (leadership, chieftain) and Nabè (non-Yanomami, outsider).

Differences were identified in the way the indigenous people perceived their own bodies and experienced the disease; and the objectivity of biomedicine was not enough in that context, being necessary to relativize the knowledge:

In Flávia’s account, this other form of experience of illness and pain also arose when reporting the care of a child:

These differences favored personal reflections from doctors who recognized the health/illness process from other points of view. In this sense, there seemed to overcome the disease-based model, reaching an understanding of the experience of illness, emphasizing that the productions of meaning about illness refer to worldviews that, expressed by the individuals, are conformed by the culture of which they are part¹⁹19 Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978; 88(2):251-8..

In this change of viewpoint, it was possible to recognize a new understanding about the local and family culture and how that community experienced health practices and the processes of illness, or even the family and community orientation - an attribute derived from PHC. Therefore, for an adequate analysis of people’s health needs, knowledge about the social and family context where they occur is required⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002..

Recognizing the different ways of seeing health and illness favors an adequate positioning in the face of the tensions produced by the encounter between doctors and patients¹⁹19 Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978; 88(2):251-8.. Hélio said:

This reflection relativized the hierarchy of knowledge, biomedical power, and Eurocentrism, placing the knowledge of indigenous people in equal importance, reflecting the development of another attribute derived from PHC, cultural competence, which involves the recognition of the special needs of subpopulations that may not be in evidence due to ethnic, racial or other special cultural characteristics⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002..

However, the relationship between doctors and indigenous people did not always happen this way. Some questioned the way the indigenous people demanded their rights, interpreting it as excessive, which again brought non-horizontality to the relationship:

The questioning between identity and rights brings with it a static view of culture, as well as the remnants of guardianship, faced by the indigenous until the 1988 Constitution. In other words, in Jorge’s understanding, the indigenous peoples would have more rights the closer they are to the primitive, in an evolutionist vision of culture, disregarding its dynamism²⁰20 Laraia RB. Cultura, um conceito antropológico. 14a ed. Rio de Janeiro: Jorge Zahar; 2004.. The history of contact with the “white” (non-indigenous), the situation of isolation or settlement, the fact of frequenting the city and the use of non-indigenous products and goods interfere with this identity, generating cultural prejudice²¹21 Dalmonego C. “Paeterepë: quem são esses napëpë?” Elementos para o estudo da construção Yanomami da alteridade dos missionários [dissertação]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2015.. According to the doctors’ report, some contacts with the health teams also affected this relationship with the indigenous, as they reproduced relations of domination:

In this report, it is noted that the products taken from the city to the village would be tools that maintain the relationship of domination and perpetuation of the tutelage perspective within the indigenous people, centralizing the inputs and decision making in the non-indigenous, which made difficult the horizontal relationship between health professionals and the population.

In the attempt to achieve respect for different cultures, empathy seems to be one of the paths to dialogue between cultures, as Bárbara expressed:

Thus, after the initial strangeness, attempts to respect and tolerate diversity can be a first step in the shared construction of care in these territories, being a challenge pointed out in various realities²²22 Luna WF, Bastos LOA, Freitas FPP, Ávila BT. Conflito, respeito e construção intercultural: o encontro entre diferentes culturas na atuação dos médicos com os Yanomami. In: Heufemann NEC, Ferla AA, Lima KMS, Martins FM, Lemos SM, organizadores. Saúde Indígena: educação, gestão e trabalho. Porto Alegre: Rede UNIDA; 2020. p. 147-66.:

Interculturality is a possible path for this non-colonizing construction, with recognition of practices and representations of subjects and groups, including the intentional use of therapeutic itineraries different from biomedicine²³23 Menéndez E. Intencionalidad, experiencia y función: la articulación de los saberes médicos. Rev Antropol Soc. 2006; 14:33-69..

Category 3 - Training for and in Indigenous Health

The first experiences of doctors, and the challenges encountered questioned their own training, by putting into practice the knowledge learned. In this Category Three nucleus of meaning emerged: relationships with biomedical formation; outstanding previous experiences; and permanent education in indigenous health.

The graduation in Medicine has a strong biomedical character and, at the same time that this training seems to have generated safety conditions for clinical decision-making in EU situations, it was perceived the need to review precepts that seemed unique to them before.

For her, the biomedical knowledge seemed to contribute to decision-making but, for Gustavo, it would help more “to know better the way of taking more empirical behaviors, which is something that we end up doing, but without training for it”, evidencing that training focused on protocols was not enough for the work in the face of specificities or lack of resources. Besides not being enough, it would need to be reviewed, recreated, as Flavia says: “I had to act several times the way I was told not to do in medical school”.

Although the indigenous peoples themselves recognize resolutiveness in biomedicine, they identify boundaries as to its effectiveness in certain contexts²⁴24 Pereira PPG. Limites, traduções e afetos: profissionais de saúde em contextos indígenas. Mana. 2012; 18(1):511-38.. In this context, the study of Social Sciences, especially Anthropology, was reported as important for action in the context of indigenous health.

The National Curricular Guidelines of Medicine courses (DCN) point to critical and reflective humanistic education, increasingly earlier insertion in the most diverse public health scenarios, especially in PHC, and to the importance of considering human and cultural diversity in its several contexts from the dialogue with other disciplines²⁵25 Brasil. Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Diretrizes Curriculares Nacionais do Curso de Graduação de Medicina. Brasília: Ministério da Educação; 2014..

This process seems to have positively influenced the educational process of interviewees who graduated in Brazil from previous contact with public health in several scenarios, as stated by Bárbara: “I think that the institution helped a lot in understanding public health, it was something that helped me a lot in making this decision”.

In this sense, learning in the PHC services can favor the performance of these professionals because they recognize themselves as the coordination of care, described as an adequate and efficient exchange of information so that people can receive the care in health, including in cases of reference and counter-reference⁷7 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002..

The DCN recognized the need for discussions involving the universe of ethnic-racial differences during graduation²⁵25 Brasil. Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Diretrizes Curriculares Nacionais do Curso de Graduação de Medicina. Brasília: Ministério da Educação; 2014., but they do not exactly address the indigenous issue. Therefore, they have not yet been able to reflect changes in the courses, generating fragility or often lack of specific training for indigenous health, as Tatiana reported:

Experiences in graduate courses, with approaches to the indigenous universe through immersion in local culture, can favor students in the area of health to overcome the romantic imaginary, comprising historical processes of exclusion from public policies, in addition to the development of respect and appreciation of traditional knowledge²⁶26 Luna WF, Nordi ABA, Rached KS, Carvalho ARV. Projeto de Extensão Iandé Guatá: vivências de estudantes de Medicina com indígenas Potiguara. Interface (Botucatu); 2019; 23:e180576.. However, this training hardly happens, as pointed out by the speakers, even for those trained outside Brazil, including countries with a strong presence of the indigenous population, such as Bolivia. It is also important to consider the great diversity of indigenous peoples and their territories. Alice said that she graduated in Paraguay and, even with little contact with the indigenous people in that place whose majority of the population was Guarani, what was lacking was clinical preparation for the endemic:

The previous contact with traditional populations, even if not indigenous²⁷27 Martins AC, Schlosser AR, Arruda RA, Klein WW, Andrade BWB, Labat ALB, et al. Ensino médico e extensão em áreas ribeirinhas da Amazônia. Rev Bras Educ Med. 2013; 37(4):566-72., as well as out-of-town experiences and lack of resources were favorable to the work of doctors in the indigenous context:

Others pondered that the experience in rural areas was not enough, since they are different realities, despite some approaches reported by Leandro:

The Fourth National Conference on Indigenous Health recommended the inclusion of the contents on Indigenous Health in the curricula for technical and higher education in health, but this was not carried out in the great majority of the courses, which generates invisibility about the health of this people²⁸28 Fundação Nacional de Saúde. Relatório final da 4a Conferência Nacional de Saúde Indígena. Brasília: Fundação Nacional de Saúde; 2007.. Thus, the training of professionals working in indigenous health is really completed only after they enter the service, and it is important to create forms of continuing education that address this scenario, which was also recommended by the Conference¹⁸18 Diehl EE, Pellegrini MA. Saúde e povos indígenas no Brasil: o desafio da formação e educação permanente de trabalhadores para atuação em contextos interculturais. Cad Saude Publica. 2014; 30(4):867-74..

An introductory course on Anthropology, promoted by local management to all professionals, as provided in the PNSPI, brought a contact with the culture of the people of TY, as reported by Daniela: “The only thing I did was the course on Anthropology. It helped me a lot”.

However, the training was seen as pinpointed and insufficient, especially given the complexity of the work and the absence of previous contact with these topics during graduation, as Jorge said:

In the encounter with the different and the limits of biomedicine, dialogue with other sciences becomes necessary. However, training for indigenous health professionals has been discontinued and guided by the programs of the Ministry of Health, and not by the local reality¹⁸18 Diehl EE, Pellegrini MA. Saúde e povos indígenas no Brasil: o desafio da formação e educação permanente de trabalhadores para atuação em contextos interculturais. Cad Saude Publica. 2014; 30(4):867-74..

The learning experience over time has been brought up by doctors, developing their safety in the daily health practices in the villages, which demonstrates the construction of the knowledge of the experience, in the relationship between knowledge and human life¹⁴14 Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; 19:20-8.. In this way, daily and specific learning in continuing education should fill the gaps left during graduation. That is, since specificities are very unique, they become unpredictable and the process of action-reflection-action must arise for the problems encountered in practical life²⁹29 Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília: Ministério da Saúde; 2018., building new tools for differentiated attention and according to the principles of PHC.

Final considerations

The experience of Brazilian doctors in the first months of work at DSEIY proved to be complex and heterogeneous, despite the demonstration of satisfaction and learning.

The professionals faced a diversity of challenges related to the work process, highlighting the high turnover of doctors, identity conflicts between PHC and the EU, infrastructure and logistics weaknesses, and strengthening professional performance from interpersonal relations.

The encounter between these professionals and the indigenous people brought enchantment and learning to the performance in the local health context. It also touched on different understandings about the health process and illness. The participation of the indigenous people in health decision-making was presented as important, questioning the power relations between health professional and patient.

They highlighted the absence of content regarding indigenous health in the medical undergraduate program, the importance of personal construction of learning from experience and permanent education processes.

It was concluded that health care in indigenous areas requires an attentive look at the principles of PHC and to this end, it is important to consider the guidelines of differentiated care processes, since it is not just a matter of transposing the work carried out in urban areas, or in the usual rural areas, to the indigenous context. Nor is it a question of simply applying what is taught in medical degrees, since indigenous health is not part of the curriculum. It is a question of building competencies for action in the indigenous context from the practice and to achieve the right to health of these populations.

Acknowledgements

We thank the people interviewed, who shared their anxieties and uncertainties with us; the other professionals of EMSI, especially indigenous health agents and technicians and nursing techniques, for the stories, foods and shared work; finally, the Yanomami and Ye’kuana people, for their traditional doctors who keep on struggling, teaching and working together with non-indigenous health professionals.

References

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