Abstract

This study analyzes health perception within a quilombola community in the agreste region (scrubland) of Pernambuco based on the social determinants of health. The community comprises approximately 250 families, with agriculture and work in the flour mill as their main sources of subsistence. This action-analytic research was conducted with data collected and analyzed by means of qualitative approaches, through in-depth interviews, culture circle, and participant observation. Data were analyzed using the collective subject discourse technique. The results indicate that a complex context underlies the perception of health within this environment, including diet quality, the work developed, and the relationship with the land. The systemic perspective offered by the social determinants enabled us to understand health in its entirety, whereby territory appears as a central element in the reproduction of the quilombola population’s health and way of life. This is especially relevant when we consider that these groups are in constant struggle for the demarcation and titling of their lands - a fundamental condition for a healthy living in the community.

Keywords:
Health; Social determinants of health; Quilombola community; Environment and Health

Introduction

In a structurally unequal society, the differences present in minority groups are expressed in daily life as experiences of exclusion. The capitalist society is nourished by inequalities, which produce different life conditions and are expressed in the different health, disease, and healthcare profiles. They are generated primordially by power appropriation, i.e., by the private apprehension of the richness originated by the social classes, by the patriarchal monopoly of power - expressed in the different forms of gender discrimination - and by the appropriation of advantages by certain ethnic-racial groups (such as in eurocentrism) - evidenced by the colonial relations produced by racism (Breilh, 2008BREILH, J. Uma perspectiva emancipadora da pesquisa e da ação baseadas na Determinação Social da Saúde. In: Taller Latinoamericano de Determinantes Sociais de la Salud. Cidade do México: Universidade Autônoma do México, 2008.).

This discussion is the basis to comprehend the social determinants of health, which, besides the unhealthy lifestyles, incorporates the ways of life in inequity (Breilh, 2010BREILH, J. Las três ‘S’ de la determinación de la vida: 10 tesis hacia uma visión crítica de la determinación social de la vida y la salud. In: NOGUEIRA, R. P. (Org.). Determinação social da saúde e reforma sanitária. Rio de Janeiro: CEBES, 2010.), which is a tool to rethink the epidemiology and the social organization, the civilization of radical egotism that leads to the destruction of life. This perspective comprehends cosmovision ruptures that permit the overcoming of anthropocentrism, revendicating nature rights and the Eurocentric uniculturalism related to the conventional allopathic medicine, as well as the gender, ethnic, and racial uniculturalism (Breilh, 2017BREILH, J. Matriz de procesos críticos: fundamentos teórico explicativos. Quito: Dirección Nacional de Derechos de Autor y Conexos, 2017.).

The social determinants of health - based on the Latin American social medicine trend - permits the comprehension of health in its complexity and, by means of an integral perspective, breaks with the biomedical hegemony and the logic of liberalism. Besides, it points to the necessity of observing historic laws of production and social organization, emphasizing social health processes.

According to Breilh (2010BREILH, J. Las três ‘S’ de la determinación de la vida: 10 tesis hacia uma visión crítica de la determinación social de la vida y la salud. In: NOGUEIRA, R. P. (Org.). Determinação social da saúde e reforma sanitária. Rio de Janeiro: CEBES, 2010.), health develops as an articulated process between general, particular, and singular spatial dimensions. The general dimension corresponds to State policies, the determination of the system of accumulation and production, as well as the general cultural processes and epistemic determinants. On the other hand, the particular domain is related to groups’ ways of life, with their own models of exposition to health damaging processes and group vulnerabilities. The last component, the singular domain, refers to each individual’s phenotypes and genotypes, and each one’s own lifestyle (Breilh, 2011BREILH, J. Aceleración agroindustrial: peligros de la nueva ruralidade del capital. In: BRASSEL, F.; ZAPATTA, A.; BREILH, J. (Ed.). ¿Agroindustria y soberanía alimentaria?: hacia una nueva Ley de Agroindustria y Empleo Agrícola. Quito: Sipae ediciones, 2011.).

The processes of these dimensions tend to be reproduced and to conserve their conditions. This occurs hierarchically because, besides having some autonomy that permits the generation of changes, the more specific and local processes are subsumed in the more general processes, i.e., the biological and the social are connected not only by an external bond, but by an essential internal bond, given by the subsumption movement. Thus, the biological is developed under the subsumption of the social, at the same time that it has a relative autonomy (Breilh, 2010BREILH, J. Las três ‘S’ de la determinación de la vida: 10 tesis hacia uma visión crítica de la determinación social de la vida y la salud. In: NOGUEIRA, R. P. (Org.). Determinação social da saúde e reforma sanitária. Rio de Janeiro: CEBES, 2010.).

In this sense, health problems cannot be defined only as individual phenomena because the factors that lead people to sickness potentially affect the whole community, and are produced and extended to the whole society. Thus, health must be comprehended in its complexity.

Therefore, the comprehension of the developing process of the people, the individuals’ life story and their story as a part of a group are required for the analysis of the health conception of a given population in the social determinants of health perspective. These aspects give health meaning in the sense that they are directly related with the inequality experiences in these populations.

The social determination may help us comprehend the ways of life and the organization of the quilombo populations considered in this study, permitting a detailed view of the question in macro and micro spaces. It may also aid the understanding of how health is reproduced in the general, particular, and singular spaces, and how they interact.

Quilombo communities are the fruit of a historical process of resistance against the racist ideology that enslaved, dehumanized, and objectified the black person. This process began with the colonization of Brazil and persists nowadays with the exploration of their territories by multinational companies and local oligarchies. In this space of confrontation, these communities struggle for the recognition of their ways of life, the titling of their lands, and the guarantee of their fundamental rights (Fernandes, 2016FERNANDES, S. L. Itinerários terapêuticos e política pública de saúde em uma comunidade quilombola do Agreste de Alagoas, Brasil. 2016. Tese (Doutorado em Psicologia Social) - Universidade de São Paulo, São Paulo, 2016.).

Such populations have a history of privation, injustice, and invisibility by the rest of society and the public power. Quilombolas [quilombos’ inhabitants] have determinant processes of their health related to their history of exploration, as well as their lives and territory. Thus, they are inserted in an exclusionary system, which does not respect their culture and way of life and also seeks to impose, through a structurally hegemonic white racist logic, another culture and manners of living.

It is important to recognize the quilombos’ practices “considering the historical, social, cultural, ethnic, and political complexity in the construction of their ways of life”³3Our translation. (Rezende, 2015REZENDE, L. C. O cotidiano de uma comunidade quilombola: a (des)construção da integralidade na visão de moradores e equipe de saúde. 2015. Tese (Doutorado em Enfermagem) - Universidade Federal de Minas Gerais, Belo Horizonte, 2015., p. 33). Thus, the comprehension of these communities based on the political and social struggle is needed, inserted in the context of a country that still needs to recognize them as a living and valuable piece of history. Policies and health practices that attend these communities’ demands are required, based on the integral care and the acceptance of their culture and daily practices.

To approach health in quilombo communities, it is necessary to highlight the ethnic-racial disputes and the struggle for land, which are markers of the historical inequalities faced by Brazilian quilombolas. Martins (2009MARTINS, J. S. Exclusão e a nova desigualdade. São Paulo: Paulus, 2009., p. 66) states that the system of land tenure and acquisition during the colonial regime of sesmarias: “Could only become a landlord those who were white and free, and, until a certain period, catholic. There was a racial and religious interdiction to land access”⁴4Our translation.. This statement makes evident the domination logic that historically affected black peoples and their struggle for land and territory. Struggles that converged different dominance markers, including ethnic-racial, gender, class, and religious markers.

Thus, it is necessary to understand these community’s daily life, their resistance practices, and their culture and way of life’s particularities in a structurally exclusionary society (Rezende, 2015REZENDE, L. C. O cotidiano de uma comunidade quilombola: a (des)construção da integralidade na visão de moradores e equipe de saúde. 2015. Tese (Doutorado em Enfermagem) - Universidade Federal de Minas Gerais, Belo Horizonte, 2015.). Thus, health policies that effectively promote affirmative actions for this population health conditions must incorporate the particularities of each context experiences, with the participation of the individuals with more knowledge about such characteristics: the quilombolas.

This article aims to analyze the health perceptions of the inhabitants of a quilombo in the agreste region of the state of Pernambuco, under the perspective of health social determination.

Methodological strategies

This study consists of a research-action of analytic character with a qualitative approach in data collection and analysis. This approach is appropriate to explain complex realities, which, according to Minayo (2014MINAYO, M. C. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec, 2014.), is applicable for the study of history, and the relations, representations, believes, perceptions and opinions, which are products of human interpretations of how they live, feel, and think.

The study was conducted between 2015 and 2018 in a rural quilombo community in the agreste of Pernambuco. Around 250 families reside in this community, and they identify their origins to the destruction of the quilombo de Palmares, a former resistance stronghold in the region, a symbol of resistance and organization, which was situated in the south of Pernambuco and the north of Alagoas. This community’s families live predominantly from the agriculture, cultivating mainly manioc, corn, common beans, and vegetables. Manioc is used to produce flour, dough, “beiju”, and gum; products which are sold in the nearby town.

The data were obtained by participant observation, through in-depth interviews and a group meeting based on Paulo Freire’s dialogical pedagogy of cultural circles.

For the participant observation, the data were obtained by the researcher participation in the life of the observed, within their cultural scenario (Minayo, 2014MINAYO, M. C. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec, 2014.). We identified the future participants through conversations with members of the quilombo association. During the research, we strengthened the bound with the community and participated of their association meetings, funerals, celebrations, walked through their territory, and together with their leaders talked with some residents and their families. In these talks, we learned about important trees and plants in their territories, as well as their social equipment. All observations were registered in a field journal.

Ten in-depth interviews were conducted with community inhabitants, in which we invited the interviewee to speak freely about the subject, making questions only to instigate the interviewee’s reflections (Minayo; Romeu Gomes, 2011MINAYO, M. C. S. (org.); ROMEU GOMES, S. F. D. Pesquisa social: teoria, método e criatividade. 30.ed. Petrópolis: Vozes, 2011.). The interviewees were defined based on the leaders’ indication, which were: members of the association; representants of the group “Guerreiras Quilombolas” - “Quilombo women warriors”, a women’s collective; representants of existing cultural groups; subjects related to the religions present in the territory; subject that uses medicinal herbs; subject related to prayers; subject related with births.

The culture circle (CC) is a methodological tool developed by Paulo Freire “of a dialogical learning and mutual knowledge exchange character, based on the liberating and problematizing pedagogy of the theoretician”⁵5Our translation. (Cavalcante et al., 2016CAVALCANTE, A. S. P. et al. Círculos de cultura como ferramenta de construção de consenso: diálogos sobre avaliação de risco e vulnerabilidade. Revista Brasileira de Pesquisa em Saúde, Vitória, v. 18, n. 4, p. 124-131, 2016.). Within the circle, everyone collaborates in knowledge construction, and the aim is to promote a space for experience and learning exchanges.

The intervention of the researcher promotes the development of ways and contributes to the study of the participants’ reality. It is not only a data collection approach, but a tool for the production of collective knowledges for the critical comprehension of the territory.

This method has a group facilitator, in this case, the researcher responsible for the process conduction. The meeting was conducted in the quilombo’s association, with the participation of nine subjects, which were previously invited.

The first meeting started with the explanation of the study methodology and all members signed the Free and Informed Consent Form (FICF). Then, we started the thematic investigation, when the culture circle’s members suggested central themes and words to be discussed. Such themes are based on the participants’ reality, and are denominated “hinge themes” or “generating words”, which are fundamental for the comprehension of the themes chosen (Freire, 2006FREIRE, P. Ação cultural para a liberdade e outros escritos. 10. ed. São Paulo: Paz e terra, 2006.). In this meeting, we discussed their health perceptions and selected the themes to be discussed in the following meetings. However, in this article, we will discuss only the results of the first meeting, in which were debated the health perception of the participants. In the last meeting, the sixth, the results of the analyses were validated by the participants.

For the analysis of the interviews (individual or in the culture circle), the method used was the Collective Subject Discourse (CSD), following Lefèvre & Lefèvre (2005LEFÈVRE, F; LEFÈVRE, A. M. C. Discurso do Sujeito Coletivo: Um novo enfoque em pesquisa qualitativa (desdobramentos). 2. ed. Caxias do Sul: Educs, p. 256, 2005.), through which we organized and tabulated the verbal data.

CSD consists in the analysis of the verbal material collected, extracting from each one their central ideas or anchor words for their key-expressions. “With the key-expressions of the central ideas or similar anchors, one or more synthesis-discourses are composed in the first person singular”⁶6Our translation. (Lefèvre; Lefèvre, p. 16, 2005LEFÈVRE, F; LEFÈVRE, A. M. C. Discurso do Sujeito Coletivo: Um novo enfoque em pesquisa qualitativa (desdobramentos). 2. ed. Caxias do Sul: Educs, p. 256, 2005.).

Results and Discussion

Health perception by quilombolas is directly related to central elements of their daily life: eating, work, and land. These are building elements of their way of life and essential for the discussion of quilombola’s health.

Quilombola’s health conception

During the study, we asked the participants in two moments about what they understood by health: during the first dialogue in the culture circle and the individual interviews. In the first dialogue, each one spoke about what they understood about collective health, and each participant complemented each other’s speeches. The speeches were analyzed using the CSD and presented in the last dialogue of the culture circle, in which the meaning of health for the community members was collectively validated:

The conception presented refers to a wide understanding about health, i.e., to a widened health conception, which is present in the report of the VIII Conferência Nacional de Saúde [VIII National Health Conference]. This conference treats health as the result of life conditions related to “diet, housing, education, income, environment, work, transport, employment, leisure, freedom, access and possession of land, and access to health services”⁸8Our translation. (Brasil,1986BRASIL. Ministério da Saúde. Relatório final da 8ª Conferência Nacional de Saúde. Brasília, DF, 1986., p. 4). Moreover, according to the report, the health conception is determined by each society historical context. Thus, the conception aforementioned refers to a set of attributes shared by the subjects/participants in their life contexts.

The health conception built during the culture circle takes into consideration not only factors related to the biological dimension, but includes social, psychical, political, and contextual factors. Health is related to the way of life, access to public policies, proximity with nature, and experiences within the territory. In addition, it is also related with the diet quality, such as the avoidance of pesticides that affects humans’ health and the nature. Such health perception found in the culture circle’s discussions is confirmed in the interviews, as appears in CSD 2:

Quilombolas’ understanding of health is related to the concept of integral health, considering the totality of the elements that are related and modify people’s health conditions. It is clear in CSD 3: “Health is related to your inner well-being, your spiritual peace. Thus, health is a set with many factors involved, it is not only the health of my body, it is the health of all that is around, they are also a part of my health”.

This will to live of the quilombolas is reflected in their health perceptions because, even though they become conscious about having some disease, the disease is smaller than their overall health. The disease is only an unbalance in one of the health aspects, the biological/physiological, and not of the whole. As aforementioned, health is here conceived in its complexity. Therefore, it is not the opposite of disease, it is a part of a wider world view, a world in which quilombolas are connected with, which they recognize and relate. Health is crossed by forms of collective coexistence, the guarantee of rights, the relation with nature, and spirituality. An example is CSD 4: “I consider myself, despite all the diseases I have, I consider myself healthy. I take controlled medication and thanks God I’m healthy, I cannot say I’m sick”. (CSD 4)

Health results from the society and the subjects’ experience, relating to the way of life, the social organization, the affectivity, and subjectivity, as well as culture, leisure and relations with nature (Silva Junior, 2006SILVA JUNIOR, A. G. Modelos tecnoassistenciais em saúde: o debate no campo da saúde coletiva. São Paulo: Hucitec , 2006.). This health conception ruptures with pathologizing logics and produces an ethics of the healthy that is not antagonistic to disease. On the contrary, it conducts to a health comprehension that overcomes dichotomies so marked in medical sciences between the normal and the pathological. According to Canguilhem (2009CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense Universitária, 2009.), overcoming normality conceptions beyond the pathological criteria is a possibility to build a health based on ethical productions of living.

Health is seen by quilombolas integrally, in its wholeness, in accordance with what the theory of the social determinants of health calls principles for a healthy society or a society of life. Such principles, according to Breilh (2017BREILH, J. Matriz de procesos críticos: fundamentos teórico explicativos. Quito: Dirección Nacional de Derechos de Autor y Conexos, 2017.), are the “4S”, sustainability, sovereignty, solidarity, and being healthy/biosecurity - essential elements to build a society committed with life and its people’s health.

Thus, the concept of quilombola’s health presents elements that point to these principles. Health is seen as a series of articulated elements that are necessary for a good life in the interviewees’ conception. In the middle of the complexity of health, we highlight some elements that often appear in the discourses and are related to well-being perception, such as the healthy diet, and the relations between health, work and nature.

Healthy is a safe and quality diet

For the quilombolas, food is an element constantly mentioned when approaching health. Eating is a daily practice related to community and family bonds, to memories, to the land and the daily life cooking practices. To understand the meaning of food in quilombola’s culture and tradition, it is necessary to consider that these communities are built in an ethnic-cultural territory in which they not only reside, work and socialize, but also where they have most moments of leisure. It is their ancestral land in which they reproduce their culture and way of life, as well as new forms of knowledge and existence. This land is where they cultivate, create, and produce most of their food (Silva; Baptista, 2016SILVA, R. P.; BAPTISTA, S. R. A comida em comunidades quilombolas: reflexões sobre saberes e mercados solidários. Ágora. Santa Cruz do Sul, v. 18, n. 1, p 68-77, 2016.).

The care with the diet is often mentioned in the subjects/participants discourses about health, as in CSD 5:

This CSD shows the importance of a balanced food for health, regarding the amount of food consumed, and the origin of the food, valuing quality food and its direct influence on health. An important element is the food belonging to the territory to not be “restricted to fruits from the fair”. The care with the diet is also a health care, as shows the next CSD:

The CSD 6 shows the care with the food origin to not eat unsafe food and the care with a regular and moderate diet. For this, it is necessary to debate sustainability, one of the “4S” presented by Breilh (2017BREILH, J. Matriz de procesos críticos: fundamentos teórico explicativos. Quito: Dirección Nacional de Derechos de Autor y Conexos, 2017.), which refers to an harmonious relationship between the human being and the nature, maintaining the balance of the metabolism society-nature (S-N) in a relation of respect and protection.

According to the report of IPES-FOOD (2017)IPES food. Unravelling the food-health nexus: addressing practices, political economy, and power relations to build healthier food systems. Brussels: The Global Alliance for the Future of Food; IPES Food, 2017., the current food systems have been damaging health in different manners, affecting the population and the nature. Such damages and health risks are present when people eat unsafe or contaminated food, containing many pathogenic agents, or even with their composition altered, such as genetically modified plants. Another form that it affects negatively health is through unhealthy eating habits, which occur through the use of specific or a group of health-damaging food.

The dominant societal model goes on the opposite direction of sustainability and destroys the balance of the metabolism S-N, which is necessary for the reproduction of life and the production of health. This anthropocentric model treats nature as something exterior to human life and of lower importance. Mother Earth lost its sacred character and was reduced by modern science to a commodity. This logic is the opposite of the relation between the quilombolas and the nature, which is intimately articulated with their culture, generating communitarian lifestyles

Health is related with work

Another crucial element present in the subjects-participants’ discourses is the relation between health and work. Work is present in quilombolas’ life from a young age, either on agriculture, on the flour mill, or selling their products in the city’s fair. Work structures quilombola’s lifestyle, and being able to work is synonymous with health, as presented in the CSD above:

Labor for Marx (2013MARX, K. O capital: crítica da economia política (livro 1). São Paulo: Boitempo, 2013., p. 283) “is, first of all, a process between man and nature. (…) Through this movement he acts upon external nature and changes it, and in this way he simultaneously changes his own nature”. Following the author, we can state that the quilombola transforms nature through his work and, doing it, transforms himself, as work is an important part for their physical, social, economic, and cultural reproduction, thus acting as a promoter of the quilombola’s existence conditions, connecting their body and mind, as well as nature with their culture (Sousa; Santos, 2019SOUSA, M. S. R.; Santos, J. J. F. Territorialidade quilombola e trabalho: relação não dicotômica cultura e natureza. Katálysis. Florianópolis, v. 22, n. 1, p. 201-209, 2019.).

Also, according to Marx (2013MARX, K. O capital: crítica da economia política (livro 1). São Paulo: Boitempo, 2013.), work is a condition for men’s existence and permits the human beings to be constructed as such, since a reflection about the action is needed, which leads to the reflection about themselves. The non-alienated work permits the recognition of themselves and the life produced, as well as the reality that one lives and transforms.

Therefore, work for the quilombola is an essential part of life, besides providing for their family, something that is seen as pleasurable, that permits the forgetting if problems and generates well-being. Thus, it is related with their health perception, i.e., even with a wider understanding of health, as can be perceived in their speeches, when asked if they considered themselves healthy, the subjects-participants almost unanimously gave an affirmative answer. Only two interviewees answered negatively because they could not work anymore, which again is related to the strong association between health and work in this community. Thus, the ability to work brings the feeling of health, as can be seen in the following CSD.

It is not only the work to provide for the family that gives the perception of health and well-being, it is also the work performed for the community benefit, whether on the association or other small actions developed for its benefit. Thus, work is here related with the concept of solidarity proposed by Breilh (2017BREILH, J. Matriz de procesos críticos: fundamentos teórico explicativos. Quito: Dirección Nacional de Derechos de Autor y Conexos, 2017.), which seeks for cultural, gender, ethnic, and racial justice.

Work is a part of quilombolas’ way of life, and being active, in movement, leads to the feeling of being healthy, as shows the CSD 9: “I consider myself healthy because I have a damn will to live, I like living... I am a very active person”.

It is essential to highlight that work is not restricted to its economic sense, and besides being indispensable for its comprehension, it refers to a society and its subjects’ mode of being (Paulo Netto; Braz, 2012PAULO NETTO, J.; BRAZ, M. Economia política: uma introdução crítica. São Paulo: Cortez, 2012.). That means, it is through work that the human being builds and presents himself in a society. Thus, for the quilombola, the work - generally developed in cultivation, animal husbandry, flour mill - is related to their quilombola identity, strengthening their bonds with nature, promoting their ancestral practices, and transforming them while subjects.

Work for the quilombola people is a collective good, which promotes health and strengthens their bond with nature, and consequently reinforces the quilombola identity in the subjects and their families. In this perspective, work is related to the concept of sovereignty, and this is present when there is an empowered people with decision-taking powers, having a territory fit for the common good (Breilh, 2019).

The fact of not being able to work anymore due to old age generates the feeling of inanition and health loss because, as seen before, is through work that the quilombolas and their ways of life are reproduced, besides being a pleasurable space fit for encounters.

The land is our health

Another fundamental element for quilombolas’ health is the relationship with nature and the territory. In many speeches, we found the importance of the care with nature and the direct contact with it for health and life, as can be seen in the following CSD:

Nature is present in the daily life of the subjects-participants, and the importance of trees and the air for health is reported. Sitting below a tree, breathing the fresh air present in the community and receiving the wind are forms of health care. Moreover, the care with nature is care with the community’s health. The territory, according to Silva (2017SILVA, A. P. S. Pesquisa e atuação da psicologia na cidade e no campo: apontamentos e deslocamentos produzidos desde a categoria espaço. In: RASERA, E. F.; PEREIRA, M. S.; GALINDO, D. (Org.). Democracia participativa, estado e laicidade: psicologia social e enfrentamentos em tempos de exceção. Porto Alegre: Abrapso, 2017.), is a space transformed by several ecological, economic, and political relationships that compose a web of experiences that relates the subject to the community productions, to the land and the nature. There is a way of life among traditional peoples, as stated by Santos & Chauí (2014SANTOS, B. S. S.; CHAUÍ, M. Direitos humanos, democracia e desenvolvimento. São Paulo: Cortez , 2014. ), a relation with nature that goes beyond the colonial/modern project of an ontological human necessity as antagonistic or distinct from nature. In contrast, the ontological construction of the subject in these territories is in the cohabitation relation between the human and the nature, which is another element that constitutes this living territory.

The importance of “land” for the quilombola - this land in which they cultivate their food and herbs, where the territory’s trees are nourished, and where they raise their animals - is the quilombola’s territory, a space of residence, work, leisure, and belonging. As stated by Milton Santos and Maria Laura Silveira (2003SANTOS, M.; SILVEIRA, M. L. O Brasil: território e sociedade no século XXI. 5. ed. Rio de Janeiro: Record, 2003.), territoriality is comprehended in the sense of belonging to that to which one belongs, that means, the quilombola’s territory belongs to the quilombola’s people and they belong to their territory; one does not exist without the other. Therefore, without the territory, without a land to plant, to raise animals, and reproduce the ways of life, there is no sustainability, there is no quilombola’s sovereignty and solidarity. Thus, there is no quilombola’s health.

The importance of the care with nature and its direct relation with health was another aspect highlighted, when considering the avoidance of pesticides and the attention with soil and people’s health:

According to the dossier Abrasco (2015), one third of the food daily eaten by Brazilians is contaminated by pesticides. Although they are classified as containing medium or low toxicity, considering their acute effects, it is essential to observe the chronic effect that they can cause after decades of exposition, “manifesting many diseases, such as cancers, congenital anomalies, endocrine, neurological, and mental disorders”⁹9Our translation. (Carneiro, 2015CARNEIRO, F. F. et al. (Org.). Dossiê ABRASCO: um alerta sobre os impactos dos agrotóxicos na saúde. Rio de Janeiro: EPSJV; São Paulo: Expressão Popular, 2015., p. 58).

Factors related to the lifestyle were also evidenced as important for well-being and health promotion, as presented in the following CSD:

Thus, the way of life (communitarian) and the lifestyle (personal and familiar) interfere in quilobolas’ health, being linked to power relations that lead to different forms of sickness, and vary depending on the social class, gender, ethnic group or race (Breilh, 2011BREILH, J. Aceleración agroindustrial: peligros de la nueva ruralidade del capital. In: BRASSEL, F.; ZAPATTA, A.; BREILH, J. (Ed.). ¿Agroindustria y soberanía alimentaria?: hacia una nueva Ley de Agroindustria y Empleo Agrícola. Quito: Sipae ediciones, 2011.), as proposed by the theory of social determinants of health.

Final considerations

Quilombo communities keep alive their ancestors’ traditions, such as their agricultural practices, their relation with nature, and the feeling of belonging to the territory, as well as ethnic-racial questions, which are elements that differentiate them from other rural communities. Therefore, further studies about the meaning of health for these communities are needed to develop public policies that attend their needs.

For the quilombolas studied, health goes beyond the absence of disease; disease is just an unbalance in one component (the biological/physiological) of health. Comprehended in its complexity, the guarantee of health is not the responsibility of one sector, it means, of the health sector. It must be provided by the State through integral public policies that articulate different governmental sectors.

Health, in its complexity, has an intimate relationship with the quilombola’s territory and their traditional way of life. It is in this territory that they reproduce their way of life, reside, work, meet, produce their food and medicinal herbs. Thus, the fight for the quilombola’s territory is present in the discourses and the daily life of these subjects because the fight for territory is also a fight for survival (physically, politically, and culturally).

For a traditional group, such as the quilombolas, the territory is the main element for group identity construction. It cannot be understood only as a portion of land because in this space is added all the sociological, geographical, and historical configuration of its members’ life experiences. It is on this territory, physical and symbolical, that its members reproduce physically and socially, being them a part of the whole that is the territory.

Thus, it is from the conquest of the quilombola territory that it is possible to think about sovereignty, sustainability, and solidarity, which are all previous conditions for a healthy life.

As presented in this study, the healthy food, free from pesticides and chemical products, is an important factor in the quilombolas’ conception of health, and the guarantee of their food production is related with the ownership of a territory that provides spaces of cultivation and animal husbandry.

Health, for the quilombolas, refers to present processes in the general, particular and singular dimensions, which are interconnected, and spaces in which protective and destructive health processes are produced. Thus, there is no quilombola’s health without territory, without land to cultivate and raise animals. Work for this people is a health-promoting factor, and brings the feelings of force, movement, and collaboration.

The view of quilombola’s health through the systemic model provided by the perspective of social determinants of health contributes for the comprehension of how protective and damaging health processes develop in the territory, in ways of life and lifestyles, and in how they are integrated in different dimensions through subsumption and relative autonomy movements. Thus, these people’s life history, the culture and the modes of care are considered fundamental elements for the comprehension of quilombola’s health.

Consequently, quilombola’s health care must be based on the guarantee of production and food sovereignty, on the reproduction of their lives, accepting their different knowledges, respecting the individualities, having a systemic view of health, integrating it with life and nature. Thus, a great challenge faced by quilombolas is the demarcation and titling of their lands, which is a daily struggle with farmers, land grabbers, and real estate agents for the ownership of their territories, ways of life, and, consequently, health.

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