ABSTRACT

This paper contributes to the dialogue between the social sciences and social medicine in Latin America by exploring therapeutic pluralism in indigenous health policies and services in Brazil. It reviews recent anthropological research, concepts and current debates to critically examine Brazilian indigenous health policy and its concept of “differentiated care,” which proposes articulation between official health practices and indigenous therapies. A number of contradictions and tensions are present in the structural organizational of the indigenous health subsystem at the national level and in the daily practices of health teams at the local level. Guided by the hegemonic ideology of biomedicine, health professionals fail to recognize the dynamics and agency expressed in indigenous health practices.

KEY WORDS:
Health of Indigenous Peoples; Health Policy; Traditional Medicine; Anthropology; Brazil

INTRODUCTION

Since the Alma-Ata Declaration, a number of international documents have proclaimed the value of traditional knowledge in primary health services. Concomitantly, social medicine - called collective health in Brazil - has emerged in Latin America as a field differentiated from that of the public health characteristic of countries of the global north, going beyond the biological dimension of the disease process to focus on social conditions in the production of health. This health movement has been receptive to the contribution of the social sciences in understanding the health-disease process and in the organization of health services. In Brazil, many social scientists have been incorporated into collective health programs and conduct research that aims to contribute to the development and evaluation of health policies and services. This paper seeks to contribute to the dialogue between the social sciences and social medicine in Latin America by exploring therapeutic pluralism in indigenous health policies and services in Brazil, reviewing recent publications and current debates.

Most Latin American countries recognize the pluri-ethnic nature of the State and have established policies aimed at providing services in intercultural contexts that call for respect of and articulation with the traditional health practices that are present throughout the continent.¹1. Langdon EJ, Cardoso MD. (org.). Saúde indígena: políticas comparadas de saúde indígena na América Latina. Florianópolis: Editora EDUFSC/IBP; 2015. Brazilian indigenous health policy has been constructed under the concept of “differentiated care” and guided by the principles of universal access, community participation and articulation with the cultural traditions of the collectivities, respecting their practices and incorporating them, when possible, in the routine services offered by health centers.²2. Brasil, Fundação Nacional de Saúde, Política Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 2002. Although indigenous people comprise a relatively small proportion of the total Brazilian population (between 0.02% and 0.04%), their presence is prominent in the social imaginary as well as in public policies³3. Ramos AR. Indigenism: Ethnic politics in Brazil. Madison: University of Wisconsin Press; 1998. based on the constitutional guarantee of land, health and culture.

The First National Conference on the Protection of Indigenous Health, held in 1986, was part of a larger political process that culminated in the Constitution of 1988 with ample guarantees of citizen rights. In the health field, this process converged with the health reform that had as one of its principal results the creation of the Unified Health System (SUS) [Sistema Único de Saúde], in 1988. The SUS was conceived of and implemented as a social welfare policy with universal health coverage for the entire Brazilian population.⁴4. Garnelo L. O SUS e a saúde indígena: matrizes políticas e institucionais do subsistema de saúde indígena. In: Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva: explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. p. 107-144. After almost a decade of debates and various legal measures attempting to establish norms specifically for indigenous peoples, the Subsystem of Indigenous Health (SASI) [Subsistema de Atenção à Saúde Indígena] was instituted by Law 9836/99 and subsequently regulated by the National Policy for Health Care for Indigenous Peoples (PNASPI) [Política Nacional de Atenção à Saúde dos Povos Indígena] in 2002.

It is important to contextualize historically and politically the creation of the SASI, given that its proponent, Sérgio Arouca, who is a well-known advocate of the health reform, recognized the limitations of the universal policy of the SUS with respect to the particularities and necessities of indigenous minorities. Such recognition called for the institution of a specific policy and system that would not deprive indigenous peoples of the universal right to health, mandating the provision of a number initiatives in indigenous territories and promoting an extension of primary care without precedent in the history of interethnic relations in Brazil. It sought not only to guarantee the right to universal access to health services, putting indigenous peoples on equal footing with the rest of Brazil’s citizens, but also to provide culturally specific care sensitive to the local necessities of the numerous ethnic groups attended by the SASI.

The constitutional recognition that the violent history of interethnic contact generated social, economic, political and geographic marginalization of indigenous peoples, resulting in situations of vulnerability, justified one of the most inclusive social programs in Latin America in terms of coverage of services and allocation of an important amount of resources dedicated to the betterment of indigenous peoples’ health.¹1. Langdon EJ, Cardoso MD. (org.). Saúde indígena: políticas comparadas de saúde indígena na América Latina. Florianópolis: Editora EDUFSC/IBP; 2015. In addition to the charge of carrying out primary care in indigenous reserves, the SASI was given its own budget and a number of differentiated administrative and management strategies not established for other ethnic or racial minorities. It is important to point out this singularity of the subsystem management, given that in Brazil, federal levels of government are granted only regulatory and coordinating functions of health policy and not that of overseeing directly the provision of services, as occurs in the case of indigenous communities.⁴4. Garnelo L. O SUS e a saúde indígena: matrizes políticas e institucionais do subsistema de saúde indígena. In: Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva: explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. p. 107-144.

As is common in other social policies in Brazil, there is a gap between the legal-political guarantee of a right and the results in the daily life of the country’s citizens. Thus, for indigenous peoples, the existence of a special policy and subsystem of services has had little apparent impact on the improvement of health conditions.⁵5. Santos RV, Cardoso AM, Garnelo L, Coimbra Jr CEA, Chaves MBG. Saúde dos povos indígenas e políticas públicas no Brasil. In: Giovanella L. (org.). Políticas e sistema de saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2008. p. 1035-1056. Their situation continues to be precarious, marked by the persistence of parasitic and infectious diseases that coexist with an accelerated nutritional and epidemiological transition in which new diseases emerge, including chronic syndromes, overweight and obesity, mental and behavioral disorders and external causes of illness and death.⁶6. Basta PC, Orellana JDY, Arantes R. Perfil epidemiológico dos povos indígenas no Brasil: notas sobre agravos selecionados. In: Saúde Indígena: uma introdução ao tema. Brasília: Ministério da Educação, SECADI, UNESCO; 2012. p. 60-107 Historically high rates of malnutrition and infant mortality coexist with substance abuse, violent death and suicide, particularly among youth, and reflect structural violence, political subordination, economic exploitation, social discrimination, marginality and inadequate health care.⁶6. Basta PC, Orellana JDY, Arantes R. Perfil epidemiológico dos povos indígenas no Brasil: notas sobre agravos selecionados. In: Saúde Indígena: uma introdução ao tema. Brasília: Ministério da Educação, SECADI, UNESCO; 2012. p. 60-107

Anthropologists have accompanied the construction of the indigenous health policy since the First National Conference in 1986, through political participation, collaboration with indigenous and ethnic organizations and research at the national and local levels.⁷7. Langdon EJ, Garnelo L. (org.). Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Editora ContraCapa, ABA; 2004. They have an important presence in local and national forums, councils, commissions and committees charged with the construction, administration and evaluation of services, even though their opinions, criticisms and suggestions often receive little consideration by governmental authorities.

There has been an increasing amount of research carried out regarding indigenous health. Recent reviews⁸8. Langdon EJ. Os diálogos da antropologia com a saúde: contribuições para as políticas públicas em saúde indígena. In Langdon EJ, Grisotti M. (org.). Políticas públicas: reflexões antropológicas. Florianópolis: Editora UFSC; 2016. p. 17-42.^,99. Teixeira C, Dias da Silva CS. Antropologia da saúde indígena: mapeando marcos de reflexão e interfaces de ação. Anuário Antropológico. 2013;I:35-67. have demonstrated a substantial growth in research groups within collective health and social science graduate programs along with an increase in research and publications that address epidemiological, socio-cultural and political aspects of the topic. This extensive research is demonstrated by the annotated bibliography compiled by Buchillet.¹⁰10. Buchillet D. Bibliografia critica de saúde indígena no Brasil (1844-2006). Quito: ABYA-YALA; 2007. Important academic publishers, such as the Editora Fiocruz, Editora UFSC, EDUSP and others, publish specific books on the theme. In particular, Fiocruz’s collection on Indigenous Peoples has increased the visibility of these works.¹¹11. Santos RV, Coimbra Jr CEA. Saúde e povos indígenas. Rio de Janeiro: Editora Fiocruz; 1994.^,1212. Garnelo L. Poder, hierarquia e reciprocidade: Saúde e harmonia entre os Baniwa do Alto Rio Negro. Rio de Janeiro: Editora Fiocruz; 2003.^,1313. Pagliaro H, Azevedo MM, Ventura Santos R. (org.). Demografia dos povos indígenas no Brasil. Rio de Janeiro: Editora Fiocruz, ABEP; 2005.^,1414. Leite MS. Transformação e persistência: Antropologia da alimentação e nutrição em uma sociedade indígena amazônica. Rio de Janeiro: Editora Fiocruz; 2007.^,1515. Ferreira LO. Medicinas indígenas e as políticas da tradição: entre os discursos oficiais e as vozes indígenas. Rio de Janeiro: Editora Fiocruz; 2013.^,1616. Souza MPS. (org.). Processos de alcoolização indígena no Brasil: perspectivas plurais. Rio de Janeiro: Editora Fiocruz; 2013.^,1717. Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. The vitality of the field is also represented in the increasing number of authors and published articles in collective health, anthropological and social science journals in general.

THEMES AND CONCEPTS IN INDIGENOUS HEALTH POLICY

“Differentiated care” is central to Brazilian indigenous health policy. The discussion of “differentiation” refers to the foundations of public policy marked by a permanent tension between the abstraction of equality through universalized, standardized rights regulated by the State and the diversity of demands, desires and necessities voiced by individuals and social groups hoping that their singularities will be heard and respected and whose agency operates on the concrete level.¹⁸18. Habermas J. A nova in-transparência. Novos Estudos CEBRAP. 1987;(18):103-114. It is within this sphere that Habermas places social movements, including those of ethnic minorities, which rise as central subjects and creators of citizenships that are manifested in daily life and not only as a legal abstraction.

The National Policy on Heath Care for Indigenous Peoples does not precisely define the meaning of indigenous health, but correlates it with care that is respectful of indigenous knowledge and practices and that seeks an “articulation” capable of improving the health of these peoples.²2. Brasil, Fundação Nacional de Saúde, Política Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 2002. It recognizes that all indigenous societies “have their own systems of interpretation, prevention and treatment of illness”²2. Brasil, Fundação Nacional de Saúde, Política Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 2002.; it also underscores the importance of traditional medicine for community health care and recommends articulation with these systems of knowledge, “incorporating them, when possible, in the routines of work in health.”²2. Brasil, Fundação Nacional de Saúde, Política Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 2002. The same document also affirms that primary care should be seen as a complement to and not a substitute for traditional practices.²2. Brasil, Fundação Nacional de Saúde, Política Nacional de Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 2002. In other words, Brazilian legislation and regulatory documents call for articulation between official health practices and the diverse indigenous therapies in existence. This commitment to articulation between indigenous and official practices was reaffirmed in 2004 in Ordinance No. 70 “Directives for the Administrative Model of Indigenous Health” and in the VIGISUS II Project (2004-2008) regarding traditional medicine that sought to validate traditional knowledge and develop strategies for articulation between official and indigenous health systems.¹⁹19. Ministério da Saúde, Fundação Nacional de Saúde. Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007. Despite their dialogic and participatory nature, these projects had little impact upon the actions of the larger subsystem. In addition, efforts to create regulatory legislation of alternative therapeutic practices and traditional medicine contradict the validation of traditional knowledge as legitimate.²⁰20. Ferreira LO. A emergência da medicina tradicional indígena no campo das políticas públicas. História, ciências, saúde - Manguinhos. 2013;20(1):203-219. In the case of the SASI, legislation is not clear regarding what constitutes “articulation” and how it could be carried out in the daily actions of primary care. In the terms of Habermas¹⁸18. Habermas J. A nova in-transparência. Novos Estudos CEBRAP. 1987;(18):103-114. cited above, there is still little congruency between the abstract right guaranteed in the legislation and the therapeutic practices of the multi-professional teams that provide primary care in indigenous villages.

Although the recommendation to articulate different health traditions appears to suggest a greater concern for and fostering of the diversity of societies and indigenous cultures, a careful reading of the norms referring to “differentiation” evidences their vague character and the impossibility of putting them into practice as well as the lack of any contribution to advancement or innovation in the biomedical logic that organizes primary health care. It is important to underscore the absence in the SASI’s principal documents of the term “interculturality,” one of the pillars of policies directed at ethnic minorities in a great part of the world. In spite of the polysemy of word in different contexts, it has operated as a directive for more horizontal interaction in mediations between the state and indigenous leaders.²¹21. Hansen Narvaez FN. Interculturalidad en salud: competencias en prácticas de salud con población indígena. Ciencia y Enfermería. 2012;18(3):17-24. However, Brazilian health policy has passed over this relevant discussion present in the rest of the Latin American continent.

The omissions in the conception and administrative structure of the SASI have led various anthropologists to reflect critically on the concepts that orient it and the practices through which it is manifested. Among these, the works of several authors²²22. Garnelo L, Macedo G, Brandão LC. Os povos indígenas e a construção das políticas de saúde no Brasil. Brasília: Organização Pan-americana de Saúde; 2003.^,2323. Langdon EJ. The notion of inclusion in Brazilian Indian health policy: services and cultural practices. Revista Anales - Nueva Época. 2010;13:153-181.^,2424. Langdon EJ, Diehl EE, Dias-Scopel RP. O papel e a formação dos Agentes Indígenas de Saúde na atenção diferenciada à saúde aos povos indígenas brasileiros. In: Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva: explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. p. 213-240.^,2525. Diehl EE, Langdon EJ. Transformações na atenção à saúde indígena: Tensões e negociações em um contexto indígena brasileiro. Revista Universitas Humanística. 2015;80:213-236.^,2626. Ferreira LO. Limites e possibilidades da articulação entre as medicinas tradicionais indígenas e o sistema oficial de saúde. In: Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007. p. 166-174.^,2727. Langdon EJ. Problematizando os projetos de medicina tradicional indígena. In: Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007. p. 110-122.^,2828. Ferreira LO. Interculturalidade e saúde indígena no contexto das políticas públicas brasileiras. In: Langdon EJ, Cardoso MD. (org.). Saúde indígena: Políticas comparadas na América Latina. Florianópolis: Editora UFSC; 2015. p. 217-247.^,2929. Garnelo L, Pontes AL. (org.). Saúde indígena: uma introdução ao tema. Brasília: SECADI, Ministério da Educação; 2012.^,3030. Cardoso MD. Saúde e povos indígenas: equívocos na política atual. Cadernos de Saúde Pública. 2014;30(4):860-866.^,3131. Cardoso MD. Políticas de saúde indígena no Brasil: do modelo assistencial à representação política. In: Langdon EJ, Cardoso MD, (org.). Saúde indígena: Políticas comparadas na América Latina. Florianópolis: UFSC; 2015. p. 61-82.^,3232. Garnelo L. Fórum saúde e povos indígenas no Brasil: Posfácio. Cadernos de Saúde Pública. 2014;30(4):875-877. have questioned the meaning of indigenous health policy, its administrative practices and the quality of its primary care.

Many of these publications underscore the essentialist view of health authorities, one that promotes an understanding of culture as a fixed set of beliefs that determine action.²³23. Langdon EJ. The notion of inclusion in Brazilian Indian health policy: services and cultural practices. Revista Anales - Nueva Época. 2010;13:153-181. Such a rigid ideation has as its consequences the incapacity to recognize inter-societal differences, indigenous agency, the vitality of ethnopolitics and the capacity to recreate and reinvent traditions. Cardoso³⁰30. Cardoso MD. Saúde e povos indígenas: equívocos na política atual. Cadernos de Saúde Pública. 2014;30(4):860-866. calls this static view “inclusive normatization,” promoted by the subsystem that homogenizes administrative processes and the rendering of health services, refusing to recognize the inequalities to which indigenous people are submitted as well as the diversity of their ways of life.³²32. Garnelo L. Fórum saúde e povos indígenas no Brasil: Posfácio. Cadernos de Saúde Pública. 2014;30(4):875-877.

Langdon³³33. Langdon EJ. Medicina tradicional: reflexões antropológicas sobre atenção diferenciada. In: Haverroth M. (org.). Etnobiologia e saúde dos povos indígenas. Recife: NUPEEA; 2013. p.15-36. also criticizes the narrow view that the official system recognizes as traditional medicine, limiting it to a generic shamanism and/or the use of medicinal plants without taking into account the extreme variety of indigenous systems of care and healing.

Within this context, to proclaim differentiation, Brazilian health policy does not dialogue with the expectations and views of indigenous peoples; they are, in the end, negated or ignored by an official health system that limits itself to a vague ordering of administrative health routines. It is marked by a high degree of standardization of rigid prescriptive technical norms, whose strictly biomedical character makes them impervious to local contexts and singularities.³⁰30. Cardoso MD. Saúde e povos indígenas: equívocos na política atual. Cadernos de Saúde Pública. 2014;30(4):860-866.^,3434. Welch JR. Fórum saúde e povos indígenas no Brasil: Introdução. Cadernos de Saúde Pública. 2014;30(4):851-854.^,3535. Novo MP. Política e intermedicalidade no Alto Xingu: do modelo à prática de atenção à saúde indígena. Cadernos de Saúde Pública. 2011;27(7):1362-1370.

The asymmetry of these relations is congruent with that which Pontes, Garnelo and Rego³⁶36. Pontes AL, Garnelo L, Rego S. Reflexões sobre questões morais na relação de indígenas com os serviços de saúde. Revista Bioética. 2014;22(2):337-346. call interaction between “moral strangers.” Based on the propositions of Engelhardt Jr.,³⁷37. Engelhardt Jr HT. Fundamentos da bioética. São Paulo: Loyola; 1998. the authors characterize the relations between indigenous people and health professionals as a situation in which the subjects do not share common values or moral authority. In the face of moral estrangement between subjects in interaction, the establishment of a consensus promoting the viability of adequate action would require true dialogue involving the participation of indigenous leaders and others in order to constitute a community of argumentation and communication. This in fact does not occur.³⁶36. Pontes AL, Garnelo L, Rego S. Reflexões sobre questões morais na relação de indígenas com os serviços de saúde. Revista Bioética. 2014;22(2):337-346. Thus, the action of the Brazilian State, as expressed in indigenous health policy and its regulatory documents, translates not into a discursive community, but into postcolonial asymmetry and the legal and moral subalternization of indigenous peoples. This asymmetry also finds translation at the technical level in the hegemony of the primary health care model developed in a mechanical and standardized form on indigenous reserves.

The examination of the concept of differentiated care and public policy has led to new orientations in research on race and ethnicity.³⁸38. Coimbra Jr CAI, Santos RV. Saúde, minorias e desigualdade: algumas teias de interrelações, com ênfase nos povos indígenas no Brasil. Ciência e Saúde Coletiva. 2000;5(1):125-132. Others focus on specific questions of health service organization, such as the actions and training of professionals, including indigenous health agents,³⁹39. Diehl EE, Pellegrini MA. Saúde e povos indígenas no Brasil: o desafio da formação e educação permanente de trabalhadores para atuação em contextos interculturais. Cadernos de Saúde Pública. 2014;30(4):867-874.^,4040. Diehl EE, Follmann HBC. Indígenas como trabalhadores de enfermagem: a participação de técnicos e auxiliares nos serviços de atenção à saúde indígena. Texto & Contexto Enfermagem. 2014;23(2):451-459,^,4141. Langdon EJ, Diehl EE, Dias-Scopel RP. O papel e a formação dos agentes indígenas de saúde na atenção diferenciada à saúde aos povos indígenas brasileiros. In: Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva: explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. p. 213-240.^,4242. Pontes AL, Stauffer A, Garnelo L. Profissionalização indígena no campo da saúde: desafios para a formação técnica de agentes indígenas de saúde. In: Garnelo L, Pontes AL. (org.). Saúde indígena: uma introdução ao tema. Brasília: SECADI, Ministério da Educação; 2012. p. 264-288.^,4343. Scopel D, Dias-Scopel RP, Langdon EE. Intermedicalidade e protagonismo: A atuação dos agentes indígenas de saúde Munduruku da terra indígena Kwatá Laranjal, Amazonas, Brasil. Cadernos de Saúde Pública. 2015;31(12):2559-2568.^,4444. Cardoso MD. Políticas de saúde indígena e relações organizacionais de poder: reflexões decorrentes do caso do Alto Xingu. In: Langdon EJ, Garnelo L. (org.). Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Contracapa Editora; 2004. p. 195-215. indigenous participation in councils for public accountability⁴⁵45. Garnelo L, Sampaio S. Bases socioculturais do controle social em saúde indígena. Cadernos de Saúde Pública. 2003;19(1):311-318.^,4646. Garnelo L, Sampaio S. Organizações indígenas e distritalização sanitária: os riscos de “fazer ver” e “fazer crer” nas políticas de Saúde. Cadernos de Saúde Pública. 2005;21(4):1217-1223.^,4747. Langdon EJ, Diehl EE. Participação e autonomia nos espaços interculturais de saúde indígena: Reflexões a partir do sul do Brasil. Saúde e Sociedade. 2007;16(2):19-36.^,4848. Ghiggi Jr A, Langdon EJ. Controle social como autoatençáo: Estratégias Kaingang diante os abusos das Bebidas Alcoólicas. In: Souza MLP (org.). Processos de alcoolização indígena no Brasil: perspectivas plurais. Rio de Janeiro: Editora Fiocruz; 2013. p. 159-178. and the models of health care that are carried out in indigenous villages.³⁶36. Pontes AL, Garnelo L, Rego S. Reflexões sobre questões morais na relação de indígenas com os serviços de saúde. Revista Bioética. 2014;22(2):337-346.^,4343. Scopel D, Dias-Scopel RP, Langdon EE. Intermedicalidade e protagonismo: A atuação dos agentes indígenas de saúde Munduruku da terra indígena Kwatá Laranjal, Amazonas, Brasil. Cadernos de Saúde Pública. 2015;31(12):2559-2568.^,4949. Diehl EE, Langdon EJ. Transformações na atenção á saúde indígena: Tensões e negociações em um contexto indígena brasileiro. Revista Universitas Humanística. 2015;(80):213-236.^,5050. Novo MP. Os agentes indígenas de saúde do Alto Xingú. Brasília: ABA, Paralelo 15; 2010.^,5151. Dias da Silva C. Improvisos e cuidados: a saúde indígena e o campo da enfermagem. In: Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva: explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. p. 181-212.

In this set of initiatives, special note should be given to the VIGISUS II Project mentioned above and associated with the area of traditional medicine.¹⁵15. Ferreira LO. Medicinas indígenas e as políticas da tradição: entre os discursos oficiais e as vozes indígenas. Rio de Janeiro: Editora Fiocruz; 2013.^,1919. Ministério da Saúde, Fundação Nacional de Saúde. Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007.^,2020. Ferreira LO. A emergência da medicina tradicional indígena no campo das políticas públicas. História, ciências, saúde - Manguinhos. 2013;20(1):203-219. It supported a number of academic studies along with community action that stimulated, recorded and systematized experiences of validation and revitalization of traditional health practices. This experience represented the closest approximation to the concept of “articulation” between official and native practices since the implantation of the SASI.¹⁵15. Ferreira LO. Medicinas indígenas e as políticas da tradição: entre os discursos oficiais e as vozes indígenas. Rio de Janeiro: Editora Fiocruz; 2013.^,1919. Ministério da Saúde, Fundação Nacional de Saúde. Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007.^,5252. Ferreira LO. As “boas palavras” dos Xondaro Marãogatu como alternativa para a redução do consumo de bebidas alcoólicas entre os Mbyá-Guarani-RS. Tellus. 2004;7(2):121-136.^,5353. Perez Gil L. Possibilidades de articulação entre sistemas de parto tradicionais indígenas e o sistema oficial de saúde do alto Juruá. In: Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007. p. 23-36.

The production of ethnographies on the organization and daily provision of health care for indigenous communities has been a rich field for anthropological research in Brazil. As can be seen from the above discussion, this broad gamut of research, through local focus on villages, ethnic groups, specific diseases, biomedical practices, native systems of health practices and healing, among others, has provided a range of information on the functioning of the SASI and its organization in special indigenous health districts. These studies employ anthropological paradigms for the comprehension of health models and practices as well as the perspective of the actors in local contexts, seeking to understand how people organize and orient their practices with respect to the health problems they perceive, including those that do not correspond to biomedical nosology.

Dynamics and emergence of forms of self-care

Another set of studies focused more strictly on “ethnomedicine” or indigenous medicine, points out the dynamic and processual character of practices related to health care. Such studies are based on classical ethnographic methods, characterized by long periods of fieldwork and close relations with the subjects studied, and seek to understand the meanings and dynamics of self-care understood as the relation between action and structures of meaning that are involved in the production of health, following Menendez’s⁵⁴54. Menéndez EL. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Ciência & Saúde Coletiva. 2003;8(Supl 1):S185-S208. conception of self-care practices in its more ample sense. They describe and analyze the singularities, interactions, negotiations and existing conflicts in social processes, as well as the social construction of the body, personhood, identities and cosmopolitical dimensions that are directly related to the processes of biological and social reproduction of the group.

Such studies analyze “other” forms of knowledge that are revealed through the ethnographic method and recognize the plurality of knowledge and rights as well as the right to such plurality,⁵⁵55. Portela Guarin H. La epidemiología intercultural: argumentaciones, requerimientos y propuestas. Popayán: Editorial Universidad del Cauca; 2008. raising questions related to indigenous cosmologies, shamanisms, relations with nature, practices of commensality, conviviality and sociality of daily life and reproductive processes that are crucial elements in the social and biological reproduction of any group. Of these numerous studies, the more recent include Pereira⁵⁶56. Pereira LM. Imagens Kaiowá do sistema social e seu entorno. [Tese Doutorado em Antropologia]. São Paulo: Universidade de São Paulo; 2004.; Guimarães⁵⁷57. Guimarães S. Cosmologia Sunamá: O Xamã e a constituição do ser. [Tese de Doutorado em Antropologia]. Brasília: Universidade de Brasília; 2005.; Garnelo¹²12. Garnelo L. Poder, hierarquia e reciprocidade: Saúde e harmonia entre os Baniwa do Alto Rio Negro. Rio de Janeiro: Editora Fiocruz; 2003.^,5858. Garnelo L. Mito, história e representação social de doença sexualmente transmissível entre os Baniwa-Noroeste Amazônico. In: Nascimento DR, Carvalho DM, Marques RC. (org.). Uma história brasileira das doenças. Rio de Janeiro: Mauad Editora; 2006. p. 15-31.; Biserra⁵⁹59. Bissera RS. Ainda estamos vivos: Uma etnografia da saúde Sanumá. [Tese de Doutorado em Antropologia]. Brasília: Universidade Federal de Brasília; 2006.; Mendes dos Santos⁶⁰60. Mendes dos Santos G. Esboço sobre cosmologia, doença, cura e cuidados nos Enawene-Nawe. In: Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007. p. 78-90.; Oliveira⁶¹61. Oliveira ACM. Ritos, corpos e intermedicalidade: Analise das práticas de resguardo entre os Ramokokamekra/Canela. [Dissertação de Mestrado]. Recife: Universidade Federal de Pernambuco; 2008.; Silveira⁶²62. Silveira NH. Imagens de abundância e escassez: comida guarani e transformações na contemporaneidade. [Tese de Doutorado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2011.; Oliveira⁶³63. Oliveira D. Arandu nhembo’ea: cosmologia, agricultura e xamanismo entre os Guarani-Chiripá no litoral de Santa Catarina. [Dissertação de Mestrado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2011.; Oliveira⁶⁴64. Oliveira JC. Entre plantas e palavras: Modos de constituições de saberes entre os Wajãpi. [Tese de Doutorado em Antropologia]. São Paulo: Universidade de São Paulo; 2012.; Ávila⁶⁵65. Ávila T. Cultura, sexualidade e saúde indígena. In: Teixeira C, Garnelo L. (org.). Saúde indígena em perspectiva: explorando suas matrizes históricas e ideológicas. Rio de Janeiro: Editora Fiocruz; 2014. p. 241-261.; Scopel⁶⁶66. Scopel D. Uma etnografia sobre a pluralidade de modelos de atenção à saúde entre os índios Munduruku na Terra Indígena Kwatá Laranjal, Borba, Amazonas: práticas de autoatenção, xamanismo e biomedicina. [Tese de Doutorado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2013.; Dias-Scopel⁶⁷67. Dias-Scopel RP. A cosmopolítica da gestação, do parto e do pós-parto: práticas de autoatenção e processo de medicalização entre os índios Munduruku. Brasília: Paralelo 15; 2015.; Scopel, Dias-Scopel and Wiik⁶⁸68. Scopel D, Dias-Scopel RP, Wiik FB. Cosmologia e intermedicalidade: o campo religioso e a autoatençào às enfermidades entre os índios Munduruku do Amazonas, Brasil. Tempus - Actas de Saúde Coletiva. 2012;6(1):173-190.; and Pérez Gil⁶⁹69. Pérez Gil L. Cuerpos en transformación: Sobre la noción de persona y el control alimentar entre los Yaminawa. Tellus. 2010;10:53-82..

Shamanism, a classic theme in anthropology, persists as a theme of interest, but with focus on the transformations of shamanic practices and their role in the affirmation of indigenous and cultural revitalization stimulated, at least in part, by the rise of public policies reaffirming cultural diversity. In addition to its role in relation to cosmopolitics and health, shamanism as an expression of traditional medicine constitutes a form of symbolic capital that expresses the affirmation of identity before the surrounding society.⁷⁰70. Langdon EJ, Rose IS. (Neo)Shamanic dialogues: encounters between the Guarani and ayahuasca. Nova Religio. 2012;15(4):36-59.^,7171. Langdon EJ, Rose IS. Contemporary Guarani Shamanisms: Traditional medicine and discourses of native identity in Brazil. Health, Culture and Society. 2013;3(1):30-48.^,7272. Pérez Gil L. Políticas de saúde, pluralidade terapêutica e identidade na Amazônia. Saúde e Sociedade. 2007;16(2):48-60.^,7373. Rose IS, Langdon EJ. Chamanismos guaraní contemporáneos en Brasil: un estudio de transfiguración cultural. Revista Colombiana de Antropología. 2013;49(1):105-127. Langdon⁷⁴74. Langdon EJ. New perspectives of Shamanism in Brazil: Shamanisms and Neo-Shamanisms as dialogical categories. Civilizations: Revue Internationale d’Anthropologie et de Sciences Humaines, 2013;61(2):19-35. argues that contemporary shamanisms must be understood as dialogic practices that emerge from the articulation with non-indigenous groups as well as with public policies, resulting in the appropriation of knowledge and objects from the hegemonic society, as seen in the case of the Guarani in Southern Brazil who adopted ayahuasca (Banisteriopsis caapi) in their ritual practices. With governmental resources and the health team’s participation, a project was developed to reduce violence and alcohol abuse in the community. Incorporation of this Amazonian substance in their ritual practices resulted in the strengthening of the political and religious authority of the community’s traditional leadership (karaikuery).⁷⁵75. Rose IS, Langdon EJ. Diálogos (neo)xamânicos: encontros entre os Guarani e a ayahuasca. Tellus. 2010;10(18):83-113. This is far from an isolated case, as recent studies have shown for the Huni Kuin (Cashinahua)⁷⁶76. Haibara de Oliveira A. Já me transformou - modos de circulação e transformação de pessoas saberes entre os Huni Kuin (Kaxinawá). [Dissertação de Mestrado em Antropologia]. São Paulo: Universidade de São Paulo; 2016. and other groups in Acre.

Studies of therapeutic pluralism have increasingly drawn from Menéndez’s⁷⁷77. Menéndez EL. Metodología cualitativa: Varios problemas y reiteradas omisiones. Index de Enfermería. 2012;21(1-2):62-68. approach, in particular the concept of self-care practices⁵⁴54. Menéndez EL. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Ciência & Saúde Coletiva. 2003;8(Supl 1):S185-S208. in its more strict sense, in order to research the variety of strategies used by patients and their families to prevent, treat, control, alleviate and or cure illnesses and other afflictions. The use of practices of self-care in the strict sense focuses on both representations of illness and practices. The studies recognize the autonomous character of these practices and their articulation with models of care, scientific or not. In addition, they show that experience with biomedical practices, particularly since the implantation of the SASI, has led to incorporation of these therapies and medications in indigenous therapeutic itineraries and self-care practices.

The dynamics of self-care practices are reflected in studies that focus on religious practices and conversion. Ghiggi Jr.⁷⁸78. Ghiggi Jr A. Uma abordagem relacional da atenção à saúde a partir da terra indígena Xapecó. Florianópolis. [Tese de Doutorado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2015. identified emergent healing practices in the evangelic churches on a Kaingang reserve and a network of native healers involving alliances with non-indigenous people that live outside it. On this same reserve, Oliveira⁷⁹79. Oliveira MC. Os especialistas Kaingáng e os seres da natureza: Curadores da aldeia Xapecó. Florianópolis: Fundação Catarinense de Cultura; 1997. accompanied the Church of Health in the 1990s and its hybrid practices that represented “tradition” for the Kaingang leaders, despite the marked presence of biomedicine, popular Catholicism and spiritist practices. Other research⁸⁰80. Oliveira PHA. Comida forte e comida fraca-fabricação dos corpos e nutrição entre os Kaingang da TI Xapecó. [Dissertação de Mestrado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2009.⁾ has registered significant interchange between the Kaingang and non-indigenous people with respect to alimentary habits and festive activities.

Analyses of therapeutic pluralism have been the object of diverse publications exploring self-care practices in contexts of “intermedicality,”³⁵35. Novo MP. Política e intermedicalidade no Alto Xingu: do modelo à prática de atenção à saúde indígena. Cadernos de Saúde Pública. 2011;27(7):1362-1370.^,8181. Greene S. The shaman’s needle: development, shamanic agency, and intermedicality in Aguaruna Lands, Peru. American Ethnologist. 1998;25(Supl 4):S634-S658.^,8282. Follér ML. Intermedicalidade: a zona de contato criada por povos indígenas e profissionais de saúde. In: Langdon EJ, Garnelo L. (org.). Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Editora ContraCapa, ABA; 2004. a concept that considers the articulation and appropriation of different knowledge traditions as marked by negotiations and relations of power that favor the development of new models of health care. Drawing from the concepts of intermedicality and self-care practices, Scopel⁶⁶66. Scopel D. Uma etnografia sobre a pluralidade de modelos de atenção à saúde entre os índios Munduruku na Terra Indígena Kwatá Laranjal, Borba, Amazonas: práticas de autoatenção, xamanismo e biomedicina. [Tese de Doutorado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2013. and Dias-Scopel⁶⁷67. Dias-Scopel RP. A cosmopolítica da gestação, do parto e do pós-parto: práticas de autoatenção e processo de medicalização entre os índios Munduruku. Brasília: Paralelo 15; 2015. explore the coexistence of diverse health care models among the Munduruku people, as well as the political, economic and ideological aspects and strategies of power involved in health and illness knowledge and practices, independent of their origin. These concepts aid in the recognition of the mutual influence of contextual factors, the dynamics of Munduruku choices, and the various models and practices, hybrid and syncretic, that are present in daily life and in the processes of social and biological reproduction of the group.

The above studies demonstrate that it is necessary to go beyond the notion that different therapeutic traditions represent discrete systems with clear-cut frontiers between biomedical and indigenous practices. Research shows that there is a strong intertwining between diverse medical traditions in the daily practices of the patients and their families. This is contrary to the common sense opinion of many health professionals working with indigenous groups who perceive “culture,” “beliefs” and “tradition” as static realities and thus interpret them as obstacles for the acceptance of biomedical services.⁸³83. Kelly JA. State healthcare and Yanomami transformations: A symmetrical ethnography. Tucson: University of Arizona Press; 2011.^,8484. Kelly JA. Uma etnografia de ponta a ponta: O Ministério de Saúde e os Yanomami da Amazonas, Venezuela. In: Saúde Indígena: Politicas comparadas na América Latina. Florianópolis: Editora EDUFSC/IBP; 2015.^,8585. Silva CDC. Cotidiano, saúde e política: uma etnografia dos profissionais da saúde indígena. [Tese de Doutorado em Antropologia Social]. Brasília: Universidade de Brasília; 2010.

The hybrid medical practices documented in many of the above studies are evidence that contact zones between indigenous groups and biomedical practitioners⁸¹81. Greene S. The shaman’s needle: development, shamanic agency, and intermedicality in Aguaruna Lands, Peru. American Ethnologist. 1998;25(Supl 4):S634-S658.^,8282. Follér ML. Intermedicalidade: a zona de contato criada por povos indígenas e profissionais de saúde. In: Langdon EJ, Garnelo L. (org.). Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Editora ContraCapa, ABA; 2004. are spaces of intermedicality permeated by negotiations between political subjects endowed with social agency who, drawing from their experiences and necessities, adopt, appropriate, and articulate with all of the therapeutic options that are available. Pontes, Rego and Garnelo⁸⁶86. Pontes AL, Rego S, Garnelo L. O modelo de atenção diferenciada nos distritos sanitários especiais indígenas: reflexões a partir do Alto Rio Negro/AM, Brasil. Ciência & Saúde Coletiva. 2015;20(10):3199-3210.⁾ reached a similar conclusion through research in the Alto Rio Negro region of Brazil, where the indigenous health agents are the central protagonists in articulation between native and biomedical therapeutic models, although such articulation is ignored, negated or refused by the non-indigenous health professionals whose strong adherence to biomedical principles impedes them from perceiving the breadth and fecundity of the self-care practices present in the villages.

A similar refusal to recognize self-care practices by health professionals is documented in research on indigenous patients with diabetes and hypertension or other conditions that are subjects of specific health programs. Portela Garcia⁸⁷87. Portela Garcia SC. Diabetes e hipertensão arterial entre os indígenas Kaingang da Aldeia Sede, Terra Indígena de Xapecó: Praticas de autoatenção em um contexto de intermedicalidade. [Dissertação de Mestrado em Antropologia]. Florianólopolis: Universidade Federal de Santa Catarina; 2010. observed a great disparity between the perception of health professionals and Kaingang patients, who appropriated the programmatic care directed at them while simultaneously adopting other forms of self-care according to their necessities and desires for autonomy.

Other chronic problems identified as critical and urgent by officials and for which the anthropological approach has revealed a different perspective are “alcoholism” and mental illness, including suicide. Rejecting the label of alcoholism promoted by health officials, researchers have used the concept of “alcoholization” suggested by Menéndez⁸⁸88. Menéndez EL. El proceso de alcoholización: revisión crítica de la producción socioantropológica, histórica y biomédica en América Latina. México DF: Cuaderno de la Casa Chata; 1982. to analyze situations of alcohol consumption from the collective perspective, one that directs attention not only to the pathological but to the positive and ritual dimensions. The concept moves beyond individual and a-historical bodies and examines historical contexts and relations of the group with the larger society. Such studies do not lose sight of conflictive situations related to abuse of alcohol, but seek to understand how indigenous people perceive such risks and the strategies they develop to resolve them.¹⁶16. Souza MPS. (org.). Processos de alcoolização indígena no Brasil: perspectivas plurais. Rio de Janeiro: Editora Fiocruz; 2013.^,7878. Ghiggi Jr A. Uma abordagem relacional da atenção à saúde a partir da terra indígena Xapecó. Florianópolis. [Tese de Doutorado em Antropologia Social]. Florianópolis: Universidade Federal de Santa Catarina; 2015.^,8989. Ferreira LO. O “fazer antropológico” em ações voltadas para a redução do uso abusivo de bebidas alcoólicas entre os Mbyá-Guarani, no Rio Grande do Sul. In: Langdon EJ, Garnelo L. (org.). Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Editora Contra Capa/ABA; 2004. p. 89-110.^,9090. Ghiggi Jr A, Langdon EJ. Reflections on intervention strategies with respect to the process of alcoholization and self-care practices among Kaingang indigenous people in Santa Catarina State, Brazil. Cadernos de Saúde Pública. 2014;30(6):1250-1258.^,9191. Pereira PPS, Cemin AB, Cedaro JJ, Ott AMT. Política de Atenção integral à saúde mental das populações indígenas de Porto Velho/RO: a voz das lideranças. Tempus - Actas da Saúde Coletiva. 2013;7(4):131-145.^,9292. Souza MLP, Schweichardt JS, Garnelo L. O processo de alcoolização em populações indígenas no Alto Rio Negro: Limitações do CAGE como instrumento de screening para dependência ao álcool. Revista Psiquiatria Clinica. 2007;34(2):90-96.

Other problems in mental health have been studied among indigenous peoples and, like alcohol abuse, demand complex explanations requiring a much more ample understanding than that which is found in biomedical manuals of diagnosis and treatment. Researchers point to the need for adequate knowledge of the social, economic and political relations behind the emergence of mental perturbations in indigenous communities and to the participatory character need to construct collective solutions and strategies to deal with them.¹⁹19. Ministério da Saúde, Fundação Nacional de Saúde. Medicina tradicional indígena em contextos: Anais da primeira reunião de monitoramento. Brasília: Ministério da Saúde, FUNASA; 2007.^,9191. Pereira PPS, Cemin AB, Cedaro JJ, Ott AMT. Política de Atenção integral à saúde mental das populações indígenas de Porto Velho/RO: a voz das lideranças. Tempus - Actas da Saúde Coletiva. 2013;7(4):131-145.^,9393. Ferreira LO. Jurupari ou visagens: reflexões sobre os descompassos interpretativos existentes entre os pontos de vista psiquiátrico e indígenas. Mediações - Revista de Ciências Sociais. 2012;16(2):228-248.^,9494. Silva AC, Langdon EJ, Ribas DLB. Fatores estruturais e as práticas de autoatenção das famílias com parentes com transtornos mentais: contexto Kaiowá e Guarani do Mato Grosso do Sul. Brasil. Tempus - Actas de Saúde Coletiva. 2013;7(4):149-168.^,9595. Silva AC, Langdon EJ, Ribas DLB. Percepção e cuidados com as pessoas diagnosticadas com psicopatologia crônica nas Comunidades Kaiowá e Guarani de Mato Grosso do Sul. Ciências Humanas e Sociais em Revista. 2014;36(1):7-25.

Other themes, such as research on nutritional status and food habits⁹⁶96. Coimbra Jr CEA, Flowers NM, Salzano FM, Santos RV. The Xavánte in transition: health, ecology, and bioanthropology in Central Brazil. Michigan: University of Michigan Press; 2004.^,9797. Leite MS, Santos RV, Coimbra Jr CEA. Seasonality and nutritional status of indigenous peoples: the case of Wari’ in Rondônia State, Brazil. Cadernos de Saúde Pública; 2007;23(11):2631-2642.^,9898. Garnelo L. Cosmologia, ambiente e saúde: mitos e ritos alimentares Baniwa. História, Ciências, Saúde-Manguinhos. 2007;14(Supl):191-212. and the distribution and use of medications in indigenous reserves⁹⁹99. Diehl E, Rech N. Subsídios para uma assistência farmacêutica no contexto da atenção à saúde indígena: contribuições da antropologia. In: Langdon EJ, Garnelo L. (org.). Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: ABA, Editora Contra Capa; 2004. p. 149-170.^,100100. Diehl E, Grassi F. Uso de medicamentos em uma aldeia do literal de Santa Catarina. Cadernos de Saúde Pública. 2010;26(8):1549-1560.^,101101. Diehl EE, Almeida LK. Medicamentos em contexto local indígena: A “farmácia caseira” Xokleng, Santa Catarina. Revista de Antropologia Social dos Alunos do PPGAS-UFSCar. 2012;3(2):189-206. have a greater affinity with the field of collective health. However, they reflect the anthropological perspective and methodology in order to analyze indigenous agency and communication and relational asymmetries between health professionals and the indigenous communities, demonstrating the heterogeneity of perspectives and forces.

All of these studies point to the creative dynamics found in self-care practices, be they considered traditional or emergent forms. They challenge the dichotomy generally established between indigenous and official models of care and make biomedical services also objects of ethnographic research on the local level, as is demonstrated in some of the aforementioned studies that examine how primary care is articulated with local knowledge and practices by the community members in situations of intermedicality. These study results converge to demonstrate that despite its hegemony and State support,¹⁰²102. Dias da Silva C, Teixeira CC. The construction of citizenship and the field of indigenous health: A critical analysis of the relationship between bio-power and bio-identity. Vibrant: Virtual Brazilian Anthropology. 2015;12(1):351-384. biomedicine does not supplant other forms of therapeutic practices. On the contrary, the continuing expansion of its services and medications coexists with the flourishing of popular and alternative healthcare models in Latin America and other parts of the world.

The research network in indigenous health

Collaboration between anthropologists and other researchers in the field of collective health is expressed in academic production as well as in engagement of researchers in favor of indigenous rights and the development of health policy. These researchers have a marked presence in forums, councils, commissions and local and national committees that are charged with public oversight, training of indigenous and non-indigenous health professionals, and monitoring and evaluating health services, in addition to serving as consultants for indigenous communities and associations. They have had an important role in the Intersectorial Commission on Indigenous Health that advises the National Health Council, on committees of the Department of Science and Technology of the Ministry of Health, and also in councils for the development of research in health that identifies priorities for financial support.¹⁰³103. Associação Brasileira em Saúde Coletiva. GT saúde indígena da ABRASCO [Internet]. c2016 [citado 10 may 2016]. Disponible en: https://goo.gl/24G3TE.

One manifestation of the relation between research and political engagement in defense of indigenous rights is the Indigenous Health Workgroup of the Brazilian Association in Collective Health (ABRASCO) [Associação Brasileira de Saúde Coletiva]. Founded in 2000 and composed of anthropologists and health professionals, including the authors of this article, the workgroup maintains alliances with the Brazilian Association of Anthropology and the Brazilian Association of Population Studies in the form of academic events and publications. Members of the workgroup conducted the First National Survey on the Health and Nutrition of Indigenous Peoples, the broadest study on indigenous health that has been conducted in the country.¹⁰⁴104. Associação Brasileira em Saúde Coletiva. Inquérito Nacional de Saúde e Nutrição dos Povos Indígenas: Relatório Final. Rio de Janeiro: ABRASCO; 2009.^,105105. Coimbra Jr CE, Santos RV, Welch JR, Cardoso AM, Souza MC, Garnelo L, Rassi E, Follér ML, Horta BL. The First National Survey of Indigenous People’s Health and Nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health. 2013;13:52.

The National Council of Scientific and Technological Development (CNPq) [Conselho Nacional de Desenvolvimento Científico e Tecnológico] maintains a website where all active research groups in the country are registered. The consultation of this directory using the key word “indigenous health” identified 48 groups. Almost half (23) are associated with collective health institutions; anthropology follows in second place with six groups. An examination of the lines of research developed by these groups shows an interdisciplinary tendency, with the participation of researchers from different areas of health and the social sciences. These groups are also linked in research networks that often extend beyond Brazil. For instance, the National Institute of Science and Technology - Plural Brazil Institute (INCT-IBP) [Instituto Nacional de Ciência e Tecnologia - Instituto Brasil Plural] sponsors an important network linking researchers in anthropology, sociology and the health fields. Initially made up of the Social Anthropology graduate programs at the Universidade Federal de Santa Catarina and the Instituto Leônidas & Maria Deane, Fiocruz Amazônia, it has extended to other universities in Brazil and countries in the Americas, including Mexico, Colombia, Chile, Argentina, Venezuela and the United States. Researchers of this network study a number of different topics, one of the most important being that of indigenous health. In addition to collaboration in research, the network has hosted several colloquiums, round tables and panels at national and international conferences, two of which gave rise to published collections on indigenous health policies in Latin America¹1. Langdon EJ, Cardoso MD. (org.). Saúde indígena: políticas comparadas de saúde indígena na América Latina. Florianópolis: Editora EDUFSC/IBP; 2015. and on anthropology’s contribution to public policy.¹⁰⁶106. Langdon EJ, Grisotti M. (org.). Políticas públicas: reflexões antropológicas. Florianópolis: Editora UFSC/IBP; 2016.

It is crucial to underscore the importance of multidisciplinary research networks in indigenous health for the identification, critical analysis and dissemination of theoretical frameworks and key concepts that guide the studies referenced throughout this article. Researchers are seeking the innovation and incorporation of analytical concepts appropriate to the Latin American context, such as “ethnoepidemiology,”⁵⁵55. Portela Guarin H. La epidemiología intercultural: argumentaciones, requerimientos y propuestas. Popayán: Editorial Universidad del Cauca; 2008. “socio-cultural epidemiology,”¹⁰⁷107. Haro JA. (org.). Epidemiología sociocultural: Un diálogo en torno a su sentido, métodos y alcances. Sonora: Lugar Editorial, El Colegio de Sonora; 2010. and “self-care practices”⁵⁴54. Menéndez EL. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Ciência & Saúde Coletiva. 2003;8(Supl 1):S185-S208.^,108108. Osório RMC. La antropología médica en México. AM: Rivista della Societá Italiana di Antropologia Medica. 2010-2011;(29-30; 31-32):29-58., that stimulate fruitful collaboration and dialogue within the anthropology of health in Latin America and its contributions to public policies from a comparative perspective.

FINAL CONSIDERATIONS

Through qualitative research strategies and with focus on the actors and their interactions, research studies in anthropology contribute to effectively fulfilling and putting into practice the principles of the SUS that aim to respect and articulate with the diversity of knowledge and practices. Focusing on the dynamics of therapeutic practices and the agency of actors makes it clear that therapeutic pluralism cannot be understood by referencing the generalizing dichotomies that put professionals in opposition with their patients or biomedical practices in opposition with traditional, indigenous or popular ones.

Local interactions and practices reflect more global contexts, revealing power relations in matters of life and death and in those that threaten the social fabric. Critical ethnographic analyses point out intersections and articulations between factors of the macrostructural order and the forms through which health and illness are dealt with locally. In this way, the analyses produced by the anthropological approach explore the specificities of particular medical systems as regional, national and global processes that transcend the local context, contributing also to public policy and to the collectivities that are attended by health services.

Brazilian legislation proclaims respect for its indigenous peoples and validation of their knowledge and health practices. However, the exercise of respect for the indigenous people in health interventions does not imply simply “tolerance” for the other, but demands the establishment of a true dialogue among the multidisciplinary health team, the patients and the indigenous community as a whole. The presuppositions associated with such a dialogue are not favorable, given that medical encounters occur in social contexts marked by inequalities and economic and social hierarchies. The debate undertaken by the network of researchers in indigenous health on the integration or articulation of traditional medical practices in primary care points to even greater complexity and difficulty. Any dialogue between such diverse systems of knowledge and practices involves communication between markedly different epistemologies and requires a disposition for placing one’s own point of view in perspective. In other words, the re-dimensioning of the premises and practices of primary health care in indigenous villages in coexistence with traditional knowledge would require that health professionals, scientists and indigenous people take seriously the perspective of the other, in order to recognize that there are various ways to know the nature of the world.¹⁰⁹109. Garnelo L, Mendes dos Santos G. A ciência contemporânea e o conhecimento indígena. In: Val AL, Santos GM. (org.). Grupo de Estudos Estratégicos Amazônicos: Caderno de Debates, Tomo 2. Manaus: INPA; 2009. p. 67-114.

References

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