Abstract

This article aims to describe the views of health and disease held by the Teréna people of the Buriti Indigenous Land, in the state of Mato Grosso do Sul, Brazil, devoting closer attention to the iden tification and diagnostic interpretation of chronic disease and related therapeutic practices. Con ducted from March to August 2010, this qualitative study employed semi-structured interviews with 24 Teréna members and was complemented with field notes (participant observation). The understanding of health and disease held by the Teréna are integral to daily life issues such as diminishing land avail ability, climate change, influences of urban life, and rule-breaking. Observations regarding therapeutic processes revealed an interest in counseling, as well as in family and religious care, concurrently with the biomedical care obtained at the local health cen ter - resources that are seen as complementary. The interpretive schemes reported by the participants for the causality of hypertension bear relation with living conditions, environmental contamination, dietary changes, spell-casting, and disobedience to older adults. Understanding disease and seeking cure are experienced by the Teréna as processes stemming from local knowledge, involvement of various participants, and available resources and technologies, each of them part of a dynamic cul tural and social context.

Keywords:
Health of Indigenous Peoples; South American Indians; Therapeutic Itineraries

Introduction

From the contact with the non-indigenous soci ety and between interethnic relations, indigenous peoples go through changes in their ways of life, social, and economic transformations that invari ably affect, over time, their livelihood and way of understanding health and dealing with diseases.

According to Concone (2003)CONCONE, M. H. V. B. Cura e visão de mundo. Revista Kairós-Gerontologia, São Paulo, v. 6, p. 45-60, dez. 2003., to deal with the disease, all cultures (any culture) produce health knowledge. Thus, the disease is part of symbolic processes and is not considered an entity that is universally perceived and experienced in the same way (Langdon, 1994LANGDON, E. J. M. A negociação do oculto: xamanismo, família e medicina entre os Siona no contexto pluri-étnico. Florianópolis: Universidade Federal de Santa Catarina, 1994.). In addition, the dis ease is perceived not as a static state, but as a process that requires interpretation and action in the sociocultural environment, which implies negotiation of meanings in the search for a cure (Staiano, 1981STAIANO, K. V. Alternative therapeutic systems in Belize: a semiotic framework. Social Science and Medicine, London, v. 15, n. 3, p. 317-332, 1981.).

Reinforcing this idea, Souza (1998)SOUZA, I. M. A. Um retrato de Rose: considerações sobre processos interpretativos e elaboração de história de vida. In: DUARTE, L. F. D.; LEAL, O. F. (Org.). Doença, sofrimento, perturbação: perspectivas etnográficas. Rio de Janeiro: Fiocruz, 1998. p. 151-168. points out that defining and explaining an experience of dis tress and endowing it with meaning involves acts of interpretation, which are not reducible to a mere projection of subjective meanings, or a reproduction of the already given meanings in culture, in which trying to put some order to the threat of disorder that accompanies the illness is a process that devel ops in a world shared with other people, composed of a plurality of voices with which you dialogue, negotiate, and debate to produce definitions and ways to manage the disease.

From these considerations, and aiming to score the theoretical positioning in this study, the culture follows the concept presented by Geertz (1989)GEERTZ, C. A interpretação das culturas. Rio de Janeiro: LTC, 1989., which conceives it as a symbol system providing a model from and a model to reality, in which culture means human action, people's everyday life experience, dif ferent interpretations formulating, day after day, the ways in which they are reproduced, according to the meanings of life, death, and the universe.

Thus, the reflections in this article aim to de scribe the visions on health and disease, emphasiz ing the identification, the diagnostic interpreta tions, and therapeutic practices related to chronic disease among Teréna Indians living on Buriti indigenous lands, Mato Grosso do Sul, Brazil.

Methodology

The study was a qualitative approach developed in the Teréna villages belonging to Buriti Indig enous Land (TI), with 2613 people (IBGE, 2010IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Censo demográfico 2010: características gerais dos indígenas - resultados do universo. Rio de Janeiro, 2010.). Buriti TI has 2,090 ha and is divided into nine vil lages - Buriti, Água Azul, Recanto, Oliveiras, Olho D'Água, Barreirinho, and Nova Buriti belonging to the municipality of Dois Irmãos do Buriti, and Córrego do Meio e Lagoinha belonging to the mu nicipality of Sidrolândia.

Data collection was carried out between March and August 2010, when semi-structured interviews were conducted with twenty-four people (i.e., adults who received the diagnosis of having a chronic ill ness and with families who experienced the illness, in order to get to know the individual and collective experiences of the illness, regardless of whether or not going through treatment) and religious lead ers with significant presence in situations of ill ness - combined with the participant observation method and record in field logbook. Interviews were conducted in households to search for proximity and privacy of information, being recorded when al lowed; the participants of the study were introduced by Arabic numerals, and the logbook records and transcripts were written in italics.

The research project was submitted to the Re search Ethics Committee of the Federal University of Mato Grosso do Sul, receiving favorable opinion and forwarded to the National Commission on Ethics in Research, with the request for approval and authorization of the Regional and National Executive Board of the National Indian Foundation (Funai) to initiate contact with the leaders of local councils and family leaders when the goals, meth ods, and study procedures were presented.

Teréna People: social, political, and economic organization

The Teréna people are identified as members of the Arawakan linguistic branch, living in small areas in the states of Mato Grosso do Sul, Mato Grosso, Sao Paulo, and Parana, with a long history of contact with the non-indigenous society.

It is the second indigenous group of Mato Grosso do Sul, divided into ten indigenous lands and in two other areas, together with Kadiweu people, in the municipality of Porto Murtinho, and among the Guarani/Kaiowa in Dourados, in addition to Teréna people who migrated to urban areas, especially to Campo Grande, the state capital.

When describing elements of the Teréna culture, Azanha (2005)AZANHA, G. As terras indígenas Teréna no Mato Grosso do Sul. Revista de Estudos e Pesquisas, Brasília, DF, v. 2, n. 1, p. 61-111, 2005. highlights the patrilineal social structure, in which the male and female roles are well defined. Each village is formed by a group of family branches establishing a network of marital, economic, political, and religious alliances. For each village there is a leader (cacique) and a board (coun cil of men), which work directly in the community's political and economic issues.

In general, the cacique (chief) is expected to follow up the various events of the community, the ability to fundraise, exert positive influence on conflict mediation, the distribution of strategic information and material goods, especially those obtained in negotiations with external institutions. His performance is constantly evaluated under socially valued behavior parameters in the Teréna culture such as serenity, reciprocity, and balance in the exercise of power. For this reason, nowadays, the choice of the cacique is performed by the com munity of each village, which chooses their leaders by voting, unlike the imposition or influence of the Government agency in previous years.

In addition to these political representatives, Funai has the chief of Indian Station in Buriti Vil lage (Buriti PNI), who is currently an indigenous representative. There are still the family leaderships (branch leaders), religious leaderships (Protestant, Pentecostal-Evangelical, Catholic, Spiritualist Churches, and Shamanism), professional leader ships (groups of indigenous workers in the areas of education and health), and associations (indigenous organizations) within each village.

Regarding productive activities, most are farm ers, enhancing the traditional way of life that con nects them directly to the land and production of the family farms of permanent crop intended for household consumption and in case of surplus, for commercialization, in addition to providing seeds for the next harvest, food for pets, and enabling intra- and interfamily exchanges. They use mecha nization (tractor) and traditional techniques of preparation and land use (slash and burn farming, planting, and harvesting according to the moon's phases and nature signs) (Ribas, 2011RIBAS, D. L. B. Doenças e práticas terapêuticas entre os Teréna. 2011. Relatório (Pós-Doutorado em Ciências Humanas) - Pontifícia Universidade Católica de São Paulo, São Paulo, 2011.).

The life of these families is subject to the pos sibility of its set productive capacity in the avail able area (family farms), satisfying the subsistence needs of its members, the renewal of the means of production and consumer goods, and the exercise of social and political activities.

Thus, the availability of food to share always had great importance and strengthens the principle of reciprocity, therefore, it is intrinsically related to Teréna social identity.

Besides the cultivation of plantations, some families raise cattle on a small scale, in the exten sive system in grazing regime, with low productivity in light of the few viable resources and the limited availability of fields and pastures for raising cattle. They also work as cowboys, string trimmer men, sugarcane cutters in the sugar mills of the region, tractor drivers, tractor mechanics, horse tamers, pole pullers, fence makers, lasso knot and imple ment makers, butchers, and other occupations in rural areas.

In the TI, there are still occupations in public services in the education (school principal, teach ers, and secretary) and health (nursing technician, dental hygiene technician, nursing assistant, In digenous health agent, and Indigenous sanitation agent) fields requiring schooling and that are very valued and disputed.

According to Teréna leaderships, the territorial extension of Buriti TI is insufficient to meet the need of reproduction of the existing population due to the reduced territorial extension allocated to family farms (0.87 hectare/per capita), the impov erishment of the soil, the few forest reserves, and the population growth of Teréna.

Analyzing the situation of indigenous lands in the State of Mato Grosso do Sul, due to the population growth, degradation, and impoverish ment of areas, the average size of family farms has decreased with a tendency to downgrade the territorial standards originally established by the Indian Protection Service (SPI), which are far from the standards of the National Indian Foundation (Funai) to the northern region of the country (Fer reira, 2007FERREIRA, A. C. Tutela e resistência indígena: etnografia e história das relações de poder entre os Teréna e o estado brasileiro. 2007. Tese (Doutorado em Antropologia Social) - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 2007.).

Explanations for diseases

In every society, interpretative models of health and disease are daily built, theorized, and rewritten by different cultures (Kleinman, 1980KLEINMAN, A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Los Angeles: University of California Press, 1980.; Menéndez, 2003MENÉNDEZ, E. L. Modelos de atención de los padecimentos: de exclusiones teóricas y articulaciones práticas. Ciência & Saúde Coletiva, Rio de Janeiro, v. 8, n. 1, p. 185-208, 2003.).

In general terms, an episode of the disease is characterized by the recognition of symptoms, diagnosis, treatment, and evaluation. In severe or prolonged cases, episodes often become crises threatening lives and defying the meaning of exis tence (Langdon, 1994LANGDON, E. J. M. A negociação do oculto: xamanismo, família e medicina entre os Siona no contexto pluri-étnico. Florianópolis: Universidade Federal de Santa Catarina, 1994.).

According to the collected narratives, in the design of the health-disease process, biological, sociocultural, and psychological aspects are present in the context in which they are inserted.

Although unique for those expressing them, the meanings of health and illness for Teréna indicated possibility of combination of different recurring factors that, somehow, compose questions of their everyday life and which, at other times, did not exist in the community: reduction in the availability of land, climate change, changes in lifestyle, breach of rules, influences of the urban environment, and the presence of processed foods.

The understanding of health and disease and its causality described in the aforementioned ac counts suggest a complex interaction between the elements of territorial, environmental, and social order that are experienced on a daily basis from the perspective of culture itself and its own individual ity. According to Geertz (1989)GEERTZ, C. A interpretação das culturas. Rio de Janeiro: LTC, 1989., understanding the culture of a people exposes their normality without reducing their particularity. Thus, suffering and becoming ill, although afflicting people in a similar way, are not always perceived in the same way by people of the same culture or people of the same gender, age, and social role they occupy.

It should be emphasized also that these meanings depend on the time dimension, because the knowledge of a person is continuously reworked and reshaped due to specific interactive processes (Alves, 1993ALVES, P. C. A experiência da enfermidade: considerações teóricas. Cadernos de Saúde Pública, Rio de Janeiro, v. 9, n. 3, p. 263-271, 1993.).

In this account, we observe the past/present di chotomy when highlighting the diseases that they did not know, but now they are frequent because of changes in life with which they have to deal and seek to understand, from their own understanding of the world.

Therapeutic itinerary

The idea of therapeutic itinerary involves the recognition of the disease, its stages - generally composed initially by evaluation in the family or in the community, during which the focus is directed to the relief of symptoms and subsequently, if ap plicable, the search for the last cause of disturbance -, and the different interpretations that emerged during the process (Buchillet,1991BUCHILLET, D. A antropologia da doença e os sistemas oficiais de saúde. In: BUCHILLET, D. (Org.). Medicinas tradicionais e medicina ocidental na Amazônia. Belém: MPEG; CEJUP; UEP, 1991. p. 21-44.).

Under this logic, the therapeutic itinerary must be understood as a result of negotiations between various persons and groups with inter pretations that diverge or not about the identifi cation of the disease and the choice of appropri ate therapy (Langdon, 1994LANGDON, E. J. M. A negociação do oculto: xamanismo, família e medicina entre os Siona no contexto pluri-étnico. Florianópolis: Universidade Federal de Santa Catarina, 1994.). These negotiations guide the decisions to be taken by these people and their groups.

Such accounts lead us to the existence of con comitant practices of their cultural health care system and their biomedical system. The use of medicine has always been present and with great importance, but accompanied by other resources.

It is noteworthy that the understanding of the cure of the disease has been linked to the prepara tion of the root medicine, i.e., the use of the plant as a medicinal remedy can be explained not only by therapeutic properties assigned to it, but also by an order of elements more complex and inherent in the health system that incorporates it (Laplantine, 2004LAPLANTINE, F. Antropologia da doença. São Paulo: Martins, 2004.).

In many narratives, we observe the search for counseling, family and religious care coupled with the biomedical service obtained from the health center, seen as a complementary practice.

The reinterpretation of religious practices, as well as its application in the life of the Teréna, is a result of the interethnic contact, which opens changes in shamanic practices. The traditional shaman, known as koixomuneti, ceases to exist and the incorporation of new religious practices is rec ognized, as in the case of Catholicism, Evangelical churches, and Spiritism.

If, on one hand, we see the absence of a koixo muneti, on the other hand it is recognized that the shamanism is present in different practices. We observe a reinterpretation of these practices, such as the adoption of shamanic activities, which are widely referred to by women (such as blessings, chants, baths, and herbal preparation, both in the taking of infusions and in baths or massage), being recommended according to the initial diagnosis of the disease and modified throughout the treatment in view of the responses obtained.

In general, such practices are transmitted within the family circle, especially among women in the family who directly take care of the choice of the therapeutic resource that will be used for them selves and their relatives.

In addition to women, the indigenous pastors of Evangelical churches are important figures in the rec ommendations for appropriate treatment. According to the informants, they know they will be supported at the Evangelical churches, since there are groups with links set out in search for the cause of the disease and its cure.

Next, the health experiences here described refer us to the importance of controlling feelings for a healthy mind and for the maintenance of a balanced body.

There is an explanation for the production of health and disease that qualifies, in a distinguished manner, the way by which the Teréna determines its therapeutic process. Therefore, the specific and peculiar way by which a health problem is explained and experienced by this people should not be ne glected by health services.

On the other hand, it is important to note that the use of other practices, especially shamanic, is omit ted in the areas of biomedicine. Long conversations with interviewees have enabled us to realize that such practices are mentioned only to indigenous health agents, and not to other professionals of the team (doctors, dentists, and nurses), for fear of reprisals. Such behavior may be related to the process of in crease and appreciation of biomedicine to the detri ment of the knowledge and experience of this people, very common in the health services that serve them.

In the villages, there are health centers with mul tidisciplinary team of indigenous health. Services are offered by the spontaneous demand from patients, and the presence of health staff in each village var ies from one to three days a week, depending on the village. This enables a constant high demand for consultations at the health facility, leading profes sionals to prioritize the service at curative model.

Dealing with high blood pressure

The interpretive schemes causing hypertension mentioned by the Teréna indicate different repre sentations for its origin and may be related to living conditions, climate change, environmental contami nation, changes in diet, breach of rules, spells, and disobedience to older adults, whose logic is grounded in collective knowledge and individual experiences.

In the explanations of the causes of hyperten sion described earlier, we realize that the person maintains a relationship of exteriority regarding the cause of the disease, that is, for reasons beyond its will. It is important to emphasize that individu als produce more than one kind of explanation for their disease, since their knowledge is procedural (Young, 1982YOUNG, A. The anthropologies of illness and sickness. Annual Review of Anthropology, Palo Alto, v. 11, p. 257-285, dez. 1982.).

Another explanation for the cause of the disease was correlated to spells and when people become the target of envy for accumulating goods and refusing to share them with others.

Thus, each individual understands the disease in different and variable ways. To prepare their assump tions, they rely on a multiplicity of elements available in their sociocultural context, but which will be suitable differently due to the uneven distribution and singular ities of the personal trajectory (Adam; Herzlich, 2001ADAM, P.; HERZLICH, C. Saúde, doença e suas interpretações culturais e sociais. In: ADAM, P.; HERZLICH, C. (Org.). Sociologia da doença e da medicina. Bauru: EDUSC, 2001. p. 69-86.).

In the accounts of older people diagnosed with hyper tension, we have identified another way of understand ing the causal factors of the disease itself and aging. They refer to the children's imbalances and the non-compliance of rules by not "listening to older adults".

It is possible to recognize, in the reports, the dis sonance between the behavior of older and younger people, especially because the youngers do not give importance to the advice of their family members.

Regarding the restrictions on the use of salt and fat in the diet, they recognize the need for control, but claim to be impossible to comply with the medi cal recommendations received, for they contradict the very "nature", that is, their way of being. The fat is still considered as a food with symbolic value for what it represents when providing strength to the daily work in the plantations, essential in the economy of Teréna.

If in everyday life, with the usual food, the re strictive recommendations contradict what they understand as adequate and essential food to have strength in carrying out the work, at parties of the Teréna the recommendations jeopardize the par ticipation and sociability, because the main shared food is the salted meat in the form of blankets with a thick layer of fat. While the guests wait for roast beef blankets and boiled cassava, they serve puchero bowls (broth with marrow, fat trimmings, cassava, and salt) that are prepared in large pots and shared through with all those present, a reason of great joy and prestige for the party organizer. Thus, those who are perhaps following some diet with salt and fat restriction would not have enough to eat during the festivities.

Women who received guidance on the need to restrict salt and fat in their diet, with foods that could not be consumed (coffee, fatty meat, and salted food) reported that, although understanding what was requested, they have difficulties to comply with it, because it is difficult to prepare two types of foods (foods with salt and no salt), even by the lack of utensils (pots) and because the food shown as banned were the most desired in the diet, citing the example of the meat, predominantly fatty and salty. In addition, the fact of having fatty meat and coffee at home means wealth and power, by the pres tige given to families when consuming such foods.

In the accounts, the Teréna question the con sumption of foods that have always represented health and strength and that today are presented as disease-causing. It is necessary to remember the importance of the empirical experience and the symbolic value of these foods to interviewees before new concepts and recommendations.

In addition, the timing of meals is always re ported as a meeting with all the family in the "circle" (circular balcony where they have meals) to eat the same food. Thus, having a different food was as if it was not part of that meal for being excluded from the family sharing. Getting things off their chest, they said that "it was better not to eat salt-free and fat-free food, because the food is no longer food".

In this case, it is necessary to consider that the food prepared with salt and fat is inserted in a cultural context, in which the symbolic and social elements have a strong expression for the Teréna.

Another issue, which emerged in the stories of women having high blood pressure, refers to the medicalization of care in health centers, focusing on the measurement of blood pressure and prescription of anti-hypertensive drugs, and without reference to or interest in the living conditions of these same women and their interpretations about the disease.

The biomedical resources are widely and signifi cantly used by interviewees, but without evidence that other practices and other agents are not trig gered.

Another aspect to be highlighted refers to the way in which the healthcare professional makes its guidelines, most of the time, regardless of the context of a person's life.

In her speech, she claims especially the recog nition by the healthcare professional that in her everyday activities she already carries out numer ous activities that move her body, and even so she has high blood pressure. Thus, the recommendation of physical activity practice as a positive action in reducing the level of blood pressure may seem con tradictory for those who believe to remain active in their daily routines.

On this subject, Rozemberg and Minayo (2001)ROZEMBERG, B.; MINAYO, M. C. S. A experiência complexa e os olhares reducionistas. Ciência & Saúde Coletiva, Rio de Janeiro, v. 6, n. 11, p. 115-123, 2001. highlight that in health services, medical recom mendations for people's behavior changes are treated regardless of the environment in which they live. We perceive, therefore, that the ignorance of the everyday life of the people and the nonaccep tance of their afflictions hinders the approach and the results of the treatment proposed.

In spite of the difficulties referred to on the understanding of the treatment received, most in terviewees reported the regular use of medication and resources they judged important, and not con tradictory, to the treatments offered by the doctor.

Therefore, it is possible to affirm that the Teréna perform numerous arrangements and negotiations between its health system and biomedical system in conducting the therapeutic process. In other words, they make a reading of the biomedical apparatus according to their perspective and use it for their own benefit.

As an example of this negotiation, we highlight the use by Teréna of yerba mate with certain roots and leaves added to the mate water (chimarrão) as a resource to lower the level of blood pressure. Although the medical recommendation was for the restriction of the consumption of yerba mate, its use is understood as a therapeutic representation similar to certain therapeutic drugs recommended in the blood pressure control.

Gallois (1991)GALLOIS, D. T. A. Categoria "doença de branco": ruptura ou adaptação de um modelo etiológico indígena? In: BUCHILLET, D. (Org.). Medicinas tradicionais e medicina ocidental na Amazônia. Belém: MPEG; CNPq; SCT; CEJUP; UEP, 1991. p. 175-206. defends the assumption that the disease should be analyzed placing it in a broader level, which is interrelated to the social and cultural reality of certain people.

Final remarks

Despite changes and new ideologies, the sha manism remains present and important in the daily routine of the Teréna. The belief in the need for harmony between the environment, the spirits that inhabit it, and the people's body is identified in the narratives gathered.

We understand that the experiments experienced by the Teréna in understanding their diseases and in the search for the cure are proceedings resulting from local knowledge, the participation of the diverse ac tors involved, resources, and technologies available, all enrolled in a cultural and social dynamic context.

The guidelines received by health profes sionals are part of a parallel and hierarchical knowledge, for they reflect a recognition of the legitimacy of prescriptions of the doctors, who studied and have the authority due to their knowledge. However, the instructions are not always followed, because the doctors are often unaware of the daily life and do not take into ac count particularities and risks to those who live there, who are the only ones subjected to them. Somehow, this defines the gap between biomedi cal knowledge and local wisdom.

Approaches and reinterpretations of the recom mendations received by the medical staff were ob served, as in the case of restriction of the consump tion of yerba mate (chimarrão), which continues to be used by Teréna with hypertension.

If, in the current configuration of the Indigenous health care system, the biomedical knowledge is im posed without considering the effective conditions for the implementation of the recommendations (restric tion of food, physical activity, and use of medicines at fixed times), other actors constitute important alternatives in health care, based on each person's and each family's experiences, being used simultane ously without causing major conflicts. Thus, the use of various resources available is guided by the pursuit of the understanding and the solution of the suffering experienced, extrapolating the physical and showing a complex and broader view of the disease.

To recognize the ways in which the Teréna seek the balance of the body and to consider the non-passivity of reinterpretations before adverse condi tions and recommendations that they experience is the challenge of those aiming to prevent and to treat diseases in different social groups.

References

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