ABSTRACT

This study aims to analyze indigenous mortality in Brazil in 2000, 2010, and 2018. This is a descriptive study with data from the Mortality Information System (SIM, in Portuguese). Proportional mortality among indigenous people and the remaining Brazilian population was calculated according to age, sex, cause, and regions of Brazil. The proportion of deaths among indigenous people, for individuals younger than one year of age, in 2000, 2010, and 2018 was 15.3%, 17.7%, and 16.2%, respectively. The proportions for the general Brazilian population were 7.2%, 3.5%, and 2.7%, respectively. For indigenous people aged 50 years and over, the proportions in the same years were 47.0%, 48.1%, and 52.0% and in the rest of Brazil, 66.8%, 74.4%, and 79.4%, respectively. In 2018, indigenous children under 1 year of age died more from perinatal disorders (39.4%), infectious and parasitic diseases (10.1%), and external causes (9.8%). In children under 1 year of age, from the non-indigenous Brazilian population, these causes corresponded to 57.8%, 3.8%, and 2.8%, respectively. Indigenous people over 50 years of age died more from circulatory diseases (28.6%), respiratory diseases (15.4%), and neoplasms (14.6%), and in the remaining Brazilian population, these causes represented 31.5%, 13.6%, and 19.0%, respectively. Health inequalities and worse indicators among indigenous peoples in Brazil are evident.

KEYWORDS
Mortality; Health of indigenous populations; Information system; Epidemiology; Brazil

Introduction

Indigenous people in Brazil face unfavorable situations in terms of health, reflected in higher rates of mortality for these individuals in comparison to the rest of the Brazilian population¹1 Ferreira MEV, Matsuo T, Souza RKT. Aspectos demográficos e mortalidade de populações indígenas do Estado do Mato Grosso do Sul, Brasil. Cad. Saúde Pública. 2011; 27(12):2327-39.,²2 Santos RV, Borges GM, Campos MB, et al. Indigenous children and adolescent mortality inequity in Brazil: What can we learn from the 2010 National Demographic Census? SSM - Population Health. 2020; (10):100537..

According to population data in Brazil, the last census done by the Brazilian Institute of Geography and Statistics (IBGE) revealed that the indigenous population corresponds to 896,900 people (0.4% of the Brazilian population) distributed throughout all states of the country³3 Instituto Brasileiro de Geografia e Estatística. Os indígenas no Censo Demográfico 2010: primeiras considerações com base no quesito cor ou raça. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2012.. Although a small contingent of the Brazilian population, indigenous peoples represent an enormous socio-cultural expression. There are 305 different ethnic groups, speaking 275 languages³3 Instituto Brasileiro de Geografia e Estatística. Os indígenas no Censo Demográfico 2010: primeiras considerações com base no quesito cor ou raça. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2012.,⁴4 Mendes AM, Leite MS, Langdon EJ, et al. O desafio da atenção primária na saúde indígena no Brasil. Rev Panam Salud Publica. 2018; (42):e184.. It is important to understand and value their many lifestyles, respect their traditional knowledge, and guarantee that they participate in the management of health care for their own communities.

Among the causes of morbimortality of indigenous people in Brazil, historically, there is a predominance of infectious and parasitic diseases⁵5 Coimbra Júnior CEA, Santos RV, Escobar AL, organizadores. Epidemiologia e saúde dos povos indígenas no Brasil. Rio de Janeiro: Editora Fiocruz; 2003.. Currently, what can be observed is an epidemiological transition taking place in this population, a double burden of diseases which include infectious and parasitic, as well as noncommunicable diseases (NCDs)⁵5 Coimbra Júnior CEA, Santos RV, Escobar AL, organizadores. Epidemiologia e saúde dos povos indígenas no Brasil. Rio de Janeiro: Editora Fiocruz; 2003.,⁶6 Schmidt MI, Duncan BB, Silva GA, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet. 2011; 377(9781):1949-61.. This transition is being caused by intense changes in lifestyle, associated with civilizing patterns which deny plural lifestyles, especially those which value living closer to nature, imposing life in artificial environments⁷7 Krenak A. O amanhã não está à venda. São Paulo: Companhia das Letras; 2020..

In the last few years, there has been an increase in the number of surveys about inequalities in health for indigenous people²2 Santos RV, Borges GM, Campos MB, et al. Indigenous children and adolescent mortality inequity in Brazil: What can we learn from the 2010 National Demographic Census? SSM - Population Health. 2020; (10):100537.,⁸8 Machado M, Pagliaro H, Baruzzi RG. Perfil demográfico dos Hupd’äh, povo Maku da região do Alto Rio Negro, Amazonas (2000-2003). Rev Bras Estu Popul. 2009; 26(1):37-50.

9 Souza LCG, Santos RV, Coimbra Júnior CEA. Estrutura etária, natalidade e mortalidade do povo indígena Xavante de Mato Grosso, Amazônia, Brasil. Cienc. Saúde Colet. 2010; 15(supl1):1465-73.-¹⁰10 Pagliaro H. A revolução demográfica dos povos indígenas no Brasil: a experiência dos Kayabí do Parque Indígena do Xingu, Mato Grosso, Brasil, 1970-2007. Cad. Saúde Pública. 2010; 26(3):579-90.. However, recent studies that focus on the mortality of the indigenous population in Brazil are still scarce¹¹11 Campos MB, Borges GM, Queiroz BL, et al. Diferenciais de mortalidade entre indígenas e não indígenas no Brasil com base no Censo Demográfico de 2010. Cad. Saúde Pública. 2017; 33(5):e00015017.. Few surveys have focused on rates of mortality for specific age groups¹1 Ferreira MEV, Matsuo T, Souza RKT. Aspectos demográficos e mortalidade de populações indígenas do Estado do Mato Grosso do Sul, Brasil. Cad. Saúde Pública. 2011; 27(12):2327-39.,²2 Santos RV, Borges GM, Campos MB, et al. Indigenous children and adolescent mortality inequity in Brazil: What can we learn from the 2010 National Demographic Census? SSM - Population Health. 2020; (10):100537.,¹²12 Cardoso AM, Santos RV, Coimbra Júnior CEA. Mortalidade infantil segundo raça/cor no Brasil: o que dizem os sistemas nacionais de informação? Cad. Saúde Pública 2005; 21(5):1602-08.

13 Caldas ADR, Santos RV, Borges GM, et al. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad. Saúde Pública. 2017; 33(7):e00046516.-¹⁴14 Wong LLR, Sánchez JA. Situación de la población afro-descendiente e indígena en América Latina - puntos de reflexión para el debate sobre Cairo + 20 = Situação da população afrodescendente e indígena na América Latina - pontos de reflexão para o debate sobre o Cairo + 20. Belo Horizonte: ALAP; 2014. [acesso em 2020 out 25]. Disponível em: http://www.alapop.org/alap/Serie-E-Investigaciones/N4/FINAL_Alap2015_Serie_eInvestigaciones_14012016.pdf
http://www.alapop.org/alap/Serie-E-Inves... , and the available ones indicate that mortality rates for indigenous people have not diminished at the same pace as the rates for the rest of the Brazilian population¹²12 Cardoso AM, Santos RV, Coimbra Júnior CEA. Mortalidade infantil segundo raça/cor no Brasil: o que dizem os sistemas nacionais de informação? Cad. Saúde Pública 2005; 21(5):1602-08.

13 Caldas ADR, Santos RV, Borges GM, et al. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad. Saúde Pública. 2017; 33(7):e00046516.-¹⁴14 Wong LLR, Sánchez JA. Situación de la población afro-descendiente e indígena en América Latina - puntos de reflexión para el debate sobre Cairo + 20 = Situação da população afrodescendente e indígena na América Latina - pontos de reflexão para o debate sobre o Cairo + 20. Belo Horizonte: ALAP; 2014. [acesso em 2020 out 25]. Disponível em: http://www.alapop.org/alap/Serie-E-Investigaciones/N4/FINAL_Alap2015_Serie_eInvestigaciones_14012016.pdf
http://www.alapop.org/alap/Serie-E-Inves... .

Therefore, this study proposes to analyze the following question: what is the evolution in mortality for the indigenous population and how does it compare with the population of Brazil in general, for the years 2000, 2010, and 2018, according to sex, age group, region of Brazil, and causes of death? Thus, the objective of this study was analyze indigenous mortality in Brazil in the years 2000, 2010 and 2018. We hope that the understanding of different aspects of mortality in the indigenous population, its basic causes, its variation in terms of region, sex, and age groups, may provide subsidies to guide public health policies and reduce inequalities.

Material and methods

This is a descriptive study with data from the Mortality Information System (SIM, in Portuguese) from the Brazilian Ministry of Health, related to deaths of indigenous people in Brazil and of the Brazilian population in general, for the years 2000, 2010, and 2018. The data is available at the site of the Computer Department of the Unified Health System (Datasus) (https://datasus.saude.gov.br/)

Proportional mortality (%) was calculated according to age group, sex, underlying cause and region of residence, by means of absolute and relative frequencies. The calculation of proportional mortality for the indigenous population is given by a ratio in which the numerator was the fraction of analyzed deaths among indigenous populations (y) according to sex, age group, region, and underlying cause of death, multiplied by 100; and the denominator was the total number of deaths analyzed, according to the following formula:

The same formula was used to calculate proportional mortality for the general population of Brazil, with the denominator being the total number of deaths in the Brazilian population, not including the deaths of indigenous people. The two groups (indigenous and general Brazilian population) were compared for the curves of proportional mortality (%) of the causes of death, according to the chapters of the ICD-10, by age group. In addition, the analysis of mortality according to sex and age group was performed. The organization and data analysis was carried out using Microsoft Office Excel (Microsoft©, 2016).

Due to the nature of this study, there was no need to submit it to the Research Ethics Committee.

Results

Figure 1 represents the age distribution curves of the deaths of indigenous people and the general Brazilian population for the years 2000, 2010, and 2018. For those three years, the mortality of infants younger than 1 year of age was high, reaching 15.3% (2000), 17.7% (2010), and 16.2% (2018). Meanwhile, for the remaining Brazilian population, the rates were in decline, corresponding to 7.2% (2000), 3.5% (2010), and 27% (2018). The proportions of deaths in the general population, for the age group of 1 to 4 years were 1.1% (2000), dropping to 0.6% in the other two years (2010 and 2018); whereas among the indigenous population, it was approximately 8% (2000 and 2010) and 5.3% (2018). For the age group of 5 to 19 years, mortality was above 6% among indigenous people (2000, 2010, and 2018), and for the rest of the population, 3.3% (2000), 2.5% (2010), and 2.0% (2018). The proportions of deaths for the age group of 20 to 49 years, among the indigenous population, were 22.5% (2000), 18.6% (2010), and 19.6% (2018), while for the Brazilian population in general, the proportions were 21.1% (2000), 18.6% (2010), and 15.3% (2018). Approximately half of the deaths among indigenous populations occurred among adults aged 50 years and older, reaching 47.05% (2000), 48.1% (2010), and 52.03% (2018), whereas for the remaining Brazilian population in the same age group, those proportions increased and reached 79.36% in 2018 (figures 1 A, B, and C).

Figure 2 shows the distribution of deaths among the indigenous population by age group, according to the region of residence. One can observe that mortality for children younger than 1 year of age was greater in the North region (2000: 24.5%; 2010: 25.4%; and 2018: 22.8%) and Midwest region (2000: 25.2%; 2010: 16.5%; 2018: 14.3%). For the age group of 1 to 4 years, it was also higher in the North region (2000: 12.9%; 2010: 9.9%; 2018: 7.3%) and in the Midwest region (2000: 14.1%; 2010: 11.86%; 2018: 5.25%). In the age group of 5 to 19 years, the Midwest region once again stood out (2000: 8.9%; 2010: 10.2%; 2018: 8.6%). For the age group of 20 to 49 years, the Southeast region stands out, with proportions of 31.7% (2000) and above 20% (2010 and 2018). Mortality for the age group of 50 years and older was higher in the Northeast region (68.58%) in 2000, Southeast (above 70%) in 2010, and North (42%) in 2018 (figures 2 A, B, and C).

Figure 3 displays the distribution of deaths according to sex - male and female - among indigenous populations. The curves are similar in the distribution by sex and by period. A high proportion of deaths can be observed among indigenous children younger than 1 year of age, between 1 and 4 years of age, and between 5 to 19 years of age. The differences between males and females occur among adults aged 20 to 49 years, predominantly males, and among adults above 50 years of age, especially females (above 50%) in the three years (2000, 2010, and 2018) (figures 3 A, B, and C).

Figure 4 shows the proportion (%) of indigenous mortality according to the chapters of ICD-10. In terms of the underlying causes of death among indigenous people, it is noticeable that in the year 2000, the ill-defined and unknown causes of mortality predominated (22%), followed by circulatory system diseases (17%), infectious and parasitic diseases (12%), and external causes (12%). In 2010, the most frequent causes of death were circulatory system diseases (18%). There was also a reduction of ill-defined and unknown causes (14%) and of external causes (14%), infectious and parasitic diseases (11%), and respiratory system diseases (11%). In 2018, external causes were predominant (17%) and circulatory system diseases as well (17%), followed by respiratory system diseases (12%), neoplasms (10%), ill-defined and unknown causes (9%) and infectious and parasitic diseases (8%). The results show a reduction in infectious and parasitic diseases (from 12% in 2000 to 8% in 2018), as well as ill-defined and unknown causes of mortality (from 22% in 2000 to 13% in 2018). On the other hand, neoplasms, respiratory system diseases, and external causes of mortality increased in the period. The circulatory system diseases remained stable during the studied period (figures 4 A, B, and C).

Figure 5 shows the causes of death among indigenous people and among the remaining Brazilian population according to the chapters of ICD-10 and for age groups. In 2000, the main causes of death among indigenous people were: for the age group of younger than 1 year, perinatal affections (29.7%), ill-defined and unknown causes (20%), and infectious and parasitic diseases (17.4%); for the age group of 1 to 4 years, infectious and parasitic diseases (32.6%) and endocrine, nutritional, and metabolic diseases (18.5%,). In the age group of 5 to 19 years and in the age group of 20 to 49 years, the main causes were death by external causes (46.5% and 28.8%, respectively), while for those above 50 years of age, the main causes were circulatory system diseases (30.0%) and ill-defined and unknown causes (28.3%). In the remaining Brazilian population: for the age group of younger than 1 year, perinatal affections (53.8%); for those between 1 and 4 years of age, external causes (19.25%) and respiratory system diseases (18.5%); for age groups of 5 to 19 years and 20 to 49 years, death by external causes (60.1% and 36.0% respectively); and for the age group of 50 years and over, circulatory system diseases (36%) (figures 5 A and B). In 2018, the main causes of death among the indigenous population were: for the age group of younger than 1 year, perinatal affections (39.3%), infectious and parasitic diseases (10.3%), and external causes (9.3%); for the age group of 1 to 4 years, infectious and parasitic diseases (28.4%) and respiratory system diseases (20%); for the age groups of 5 to 19 years and 20 to 49 years, external causes (53.5% and 37.4%, respectively); for the age group of 50 years and over, circulatory system diseases (28.6%), respiratory system diseases (15.4%), and neoplasms (14.6%). For the remaining Brazilian population, in 2018, the following causes stood out: for the age group of younger than 1 year, perinatal affections (57.8%); for the age groups of 1 to 4 years, 5 to 19 years, and 20 to 49 years, deaths by external causes (20.5%, 63.3% and 40.5%, respectively). For the age group of 50 years and over, the main causes were circulatory system diseases (31.5%), respiratory diseases (13.6%), and neoplasms (19.0%) (figures 5 C and D).

Discussion

The present study showed worse health indicators in the indigenous population in comparison to the rest of the Brazilian population, evidenced by the high proportion of mortality during childhood and by the expressive proportion of premature deaths among young adults - less than half of all indigenous individuals are able to live beyond 50 years of age. Among indigenous people, there is a higher proportion of ill-defined causes of death and of death by infectious and parasitic diseases, indicating a worse quality of health care and information, as well as worse living conditions.

The production of mortality indicators provides information on the social development of a society and its economic and political aspects¹⁹19 Freemantle J, Ring I, Solomon TG, et al. Indigenous mortality (revealed): the invisible illuminated. Am J Public Health. 2015; 105(4):644-53.. Identifying that there is inequality in mortality among vulnerable groups, such as indigenous peoples, reiterates the importance of understanding this information and applying it into policies and programs of public health that are more efficient. Therefore, it is important to improve the quality of information regarding the indigenous population of Brazil, according to their racial, ethnic, and regional characteristics, in order to overcome social-regional inequalities which impact health indicators¹²12 Cardoso AM, Santos RV, Coimbra Júnior CEA. Mortalidade infantil segundo raça/cor no Brasil: o que dizem os sistemas nacionais de informação? Cad. Saúde Pública 2005; 21(5):1602-08.,¹⁷17 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília, DF: Ministério da Saúde; 2017.,²⁰20 Chor D. Desigualdades em saúde no Brasil: é preciso ter raça. Cad. Saúde Pública. 2013; 29(7):1272-75.,²¹21 Marinho GL, Borges GM, Paz EPA, et al. Infant mortality among indigenous and non-indigenous people in the Brazilian microregions. Rev Bras Enferm. 2019; 72(1):57-63..

The results in this study are in line with a survey conducted in 2012 in Brazil, which indicated higher mortality among the indigenous population, in comparison with the rest of the Brazilian population¹⁷17 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília, DF: Ministério da Saúde; 2017.. In that study, proportional mortality in children younger than 1 year of age was 25.84%, and only 37.56% among adults 50 years of age and over. The study also found that there were more deaths of indigenous children and young adults¹⁷17 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília, DF: Ministério da Saúde; 2017..

In the present study, it is alarming that there is such a high number of deaths among indigenous children younger than 1 year of age, since this is one of the most important health indicators, reflecting the living conditions of a given population and the quality and effectiveness of the health care provided to that population²²22 United Nations International Children’s Emergency Fund, World Health Organization, The World Bank, UN Population Division. Levels and Trends in Child Mortality Report 2015. Genebra: WHO; 2015.,²³23 Lansky S, Friche AAL, Silva AAM, et al. Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care. Cad. Saúde Pública. 2014; 30(supl1):s192-s207.. In Brazil, in recent decades, there has been an expressive decline in infant mortality in every region of the country¹²12 Cardoso AM, Santos RV, Coimbra Júnior CEA. Mortalidade infantil segundo raça/cor no Brasil: o que dizem os sistemas nacionais de informação? Cad. Saúde Pública 2005; 21(5):1602-08.,²⁴24 Coimbra Júnior CEA, Santos RV. Saúde, minorias e desigualdade: algumas teias de inter-relações, com ênfase nos povos indígenas no Brasil. Ciênc. Saúde Colet. 2000; 5(1):125-32.. In the period between 2000 and 2010, the Infant Mortality Rate (IMR) dropped from 29.7 to 15.6 deaths per 1,000 live births in Brazil. However, among indigenous children, the decline was from 74.6 to 41.9 deaths for every 1,000 live births¹³13 Caldas ADR, Santos RV, Borges GM, et al. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad. Saúde Pública. 2017; 33(7):e00046516.. It is important to mention that the results of this study are aligned with the literature, since they confirm that the reduction in the proportion of infant deaths among indigenous people did not occur at the same pace as it did in the general Brazilian population¹²12 Cardoso AM, Santos RV, Coimbra Júnior CEA. Mortalidade infantil segundo raça/cor no Brasil: o que dizem os sistemas nacionais de informação? Cad. Saúde Pública 2005; 21(5):1602-08.

13 Caldas ADR, Santos RV, Borges GM, et al. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad. Saúde Pública. 2017; 33(7):e00046516.-¹⁴14 Wong LLR, Sánchez JA. Situación de la población afro-descendiente e indígena en América Latina - puntos de reflexión para el debate sobre Cairo + 20 = Situação da população afrodescendente e indígena na América Latina - pontos de reflexão para o debate sobre o Cairo + 20. Belo Horizonte: ALAP; 2014. [acesso em 2020 out 25]. Disponível em: http://www.alapop.org/alap/Serie-E-Investigaciones/N4/FINAL_Alap2015_Serie_eInvestigaciones_14012016.pdf
http://www.alapop.org/alap/Serie-E-Inves... , reinforcing the huge disparities between indigenous children and children of other races/colors in the country.

The continued higher percentage of deaths of indigenous children of 1 to 4 years of age, in comparison to the rest of Brazil, can be explained by the unequal living conditions that those children are exposed to, expressed by the high concentration of deaths among children under 5 years of age. Among those unequal living conditions, we can highlight a lack of public sanitation, no access to basic health care, and precarious access to decent living conditions²¹21 Marinho GL, Borges GM, Paz EPA, et al. Infant mortality among indigenous and non-indigenous people in the Brazilian microregions. Rev Bras Enferm. 2019; 72(1):57-63., resulting in a high prevalence of infant malnutrition and infections¹1 Ferreira MEV, Matsuo T, Souza RKT. Aspectos demográficos e mortalidade de populações indígenas do Estado do Mato Grosso do Sul, Brasil. Cad. Saúde Pública. 2011; 27(12):2327-39.. There is a pressing need for more investments in basic areas, such as health, education, housing, and sanitation²¹21 Marinho GL, Borges GM, Paz EPA, et al. Infant mortality among indigenous and non-indigenous people in the Brazilian microregions. Rev Bras Enferm. 2019; 72(1):57-63., and specifically in obstetric and neonatal care in prenatal care, delivery and birth, and care in the infant’s first year of life²³23 Lansky S, Friche AAL, Silva AAM, et al. Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care. Cad. Saúde Pública. 2014; 30(supl1):s192-s207..

The present study also identifies the higher proportion of mortality among young adults, similar to a survey conducted in the state of Mato Grosso, which showed higher mortality rates among indigenous people up to 19 years of age, as well as between 20 and 39 years of age¹1 Ferreira MEV, Matsuo T, Souza RKT. Aspectos demográficos e mortalidade de populações indígenas do Estado do Mato Grosso do Sul, Brasil. Cad. Saúde Pública. 2011; 27(12):2327-39..

Furthermore, evidence shows that in 2018 only half of the indigenous individuals reached the age of 50 years old, an indication of high premature mortality among that population, which remained consistent in the 20-year period of this study. A similar result was obtained by a research done in the state of Paraná in 2002, which found a proportion of more than 70% of deaths among indigenous people up to 50 years of age, using the same Swaroop-Uemura indicator²⁶26 Rouquayrol MZ, Almeida-Filho N. Epidemiologia & saúde. 7. ed. Rio de Janeiro: MedBook; 2013.. This situation reinforces the restriction to the right to healthy aging among indigenous people, reiterating the inequalities in living conditions and constituting a threat to their way of life, bearing in mind that, for the majority of the indigenous population, the elders are the main keepers of traditional culture.

In Brazil, between 1990 and 2015, a time frame corresponding to most of the existence of the Brazilian Unified Health System (SUS, in Portuguese), many positive changes took place in the health/disease profile of the Brazilian population, with a decline in the inequalities in health indicators in the Brazilian states²⁷27 Souza MFM, Malta DC, França EB, et al. Changes in health and disease in Brazil and its States in the 30 years since the Unified Healthcare System (SUS) was created. Ciênc. Saúde Colet. 2018; 23(6):1737-50.. Inequalities were reduced in terms of mortality by communicable diseases, maternal-infant morbimortality, and avoidable causes of death, resulting in an increase in life expectancy and longevity of the population, with an increase in healthy years of life²⁷27 Souza MFM, Malta DC, França EB, et al. Changes in health and disease in Brazil and its States in the 30 years since the Unified Healthcare System (SUS) was created. Ciênc. Saúde Colet. 2018; 23(6):1737-50.. It should be highlighted that even with all the improvements and progress in health services, the results of the current study show a large proportion of deaths in the indigenous population, for most age groups, with the exception of the age group of 50 years and over. There are also regional differences in Brazil, indicated by the worst results in the North and Midwest regions, where there is a higher concentration of the indigenous population²¹21 Marinho GL, Borges GM, Paz EPA, et al. Infant mortality among indigenous and non-indigenous people in the Brazilian microregions. Rev Bras Enferm. 2019; 72(1):57-63., as well as poor access to health services and little attention from the government to the demands of the indigenous population²⁸28 Coimbra Júnior CEA, Santos RV, Welch JR, et al. 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.,²⁹29 Nascimento SG, Oliveira CM, Sposito V, et al. Infant mortality due to avoidable causes in a city in Northeastern Brazil. Rev Bras Enferm. 2014; 67(2):208-12..

Concerning the high proportion of infant mortality in the North and Midwest regions, it is important to reiterate the difficulty in access to specialized health services for births in at-risk situations, precarious prenatal care²³23 Lansky S, Friche AAL, Silva AAM, et al. Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care. Cad. Saúde Pública. 2014; 30(supl1):s192-s207.,³⁰30 Almeida WS, Szwarcwald CL. Infant mortality and geographic access to childbirth in Brazilian municipalities. Rev Saúde Pública. 2012; 46(1):68-76., and increasing fragility of self-care practices for delivery, birth, and postpartum. In addition, although the Midwest region has the highest number of obstetric facilities, it does not have enough neonatal Intensive Care Units³⁰30 Almeida WS, Szwarcwald CL. Infant mortality and geographic access to childbirth in Brazilian municipalities. Rev Saúde Pública. 2012; 46(1):68-76., a fact that might have contributed to the results verified in our study.

This precarious access to health services shows evidence of the inequalities and vulnerabilities throughout the entire social structure³¹31 Barata RB. Acesso e uso de serviços de saúde: considerações sobre os resultados da Pesquisa de Condições de Vida 2006. São Paulo Perspect. 2008; 22(2):19-29.,³²32 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad. Saúde Pública. 2004; 20(2):190-8., which have a great impact on indigenous mortality in Brazil. One study identified the lack of availability and quality of health services in the North and Midwest regions³³33 Albuquerque MV, Viana ALA, Lima LD, et al. Regional health inequalities: changes observed in Brazil from 2000-2016. Ciênc. Saúde Colet. 2017; 22(4):1055-64.. Another study, conducted in the city of Cuiabá among indigenous people, also verified difficulties in access to health care by the local indigenous population, such as social-organizational, cultural, and geographic barriers, of medium and high complexity³⁴34 Gomes SC, Esperidiao MA. Acesso dos usuários indígenas aos serviços de saúde de Cuiabá, Mato Grosso, Brasil. Cad. Saúde Pública 2017; 33(5):e00132215., reinforcing the results of the present study.

It is important to emphasize that, regardless of the fact that the National Policy for Indigenous Healthcare guarantees access of indigenous people to full health care, according to the principles of SUS³⁵35 Brasil. Ministério da Saúde, Fundação Nacional de Saúde (Funasa). Política Nacional de Atenção à Saúde dos Povos Indígenas. 2. ed. Brasília, DF: Ministério da Saúde; 2002.. The lack of continuity in care, the lack of professionals, and the prevalence of care focused on emergency care, based on patient relocation⁴4 Mendes AM, Leite MS, Langdon EJ, et al. O desafio da atenção primária na saúde indígena no Brasil. Rev Panam Salud Publica. 2018; (42):e184., are emerging bottlenecks in providing full health care to indigenous populations. There is a need to promote intercultural dialogue in order to promote self-care and articulation with traditional knowledge, allowing the promotion of health beyond curative and biomedical services. This is one of the main challenges in providing effective health care to indigenous people⁴4 Mendes AM, Leite MS, Langdon EJ, et al. O desafio da atenção primária na saúde indígena no Brasil. Rev Panam Salud Publica. 2018; (42):e184..

As far as mortality according to sex is concerned, it is evident that there is a difference between men and women in terms of age of death. Male individuals in the age group of 20 to 49 years have a higher proportion of deaths than women of the same age. Such results can provide evidence of violence experienced by indigenous males³⁶36 Gomes R. Sexualidade masculina, gênero e saúde. Rio de Janeiro: Fiocruz; 2008.,³⁷37 Schraiber LB, Gomes R, Couto MT. Homens e saúde na pauta da Saúde Coletiva. Ciênc. Saúde Colet. 2005; 10(1):7-17. and, possibly, reflect a higher vulnerability resulting from conflicts for the protection of their land (often invaded by gold miners), as well as resulting from excessive alcohol consumption³⁸38 Malta DC, Minayo MCS, Soares Filho AM, et al. Mortality and years of life lost by interpersonal violence and self-harm: in Brazil and Brazilian states: analysis of the estimates of the Global Burden of Disease Study, 1990 and 2015. Rev Bras Epidemiol. 2017; 20(supl1):142-56.. One study conducted with data from the Interpersonal and Self-Inflicted Violence Surveillance System (Viva/Sinan, in Portuguese), from 2006 to 2017, also indicated a gradual and increasing growth in the cases of violence against indigenous peoples³⁹39 Brasil. Ministério da Saúde. Saúde indígena: análise da situação de saúde no SasiSUS. Brasília, DF: Ministério da Saúde; 2019.. The increased mortality by external causes also subsidizes the hypothesis that the increase in conflicts and violence against the indigenous population also relates to problems already mentioned in literature, such as indigenous suicide and alcoholism³⁹39 Brasil. Ministério da Saúde. Saúde indígena: análise da situação de saúde no SasiSUS. Brasília, DF: Ministério da Saúde; 2019.

40 Azuero AJ, Arreaza-Kaufman D, Coriat J, et al. Suicide in the Indigenous Population of Latin America: A Systematic Review. Rev Colomb Psiquiatr. 2017; 46(4):237-42.

41 Souza MLP, Orellana JDY. Desigualdades na mortalidade por suicídio entre indígenas e não indígenas no estado do Amazonas, Brasil. J Bras Psiquiatr. 2013; 62(4):245-52.

42 Souza MLP. Mortalidade por suicídio entre crianças indígenas no Brasil. Cad. Saúde Pública. 2019; 35(supl3):e00019219.-⁴³43 Guimarães LAM, Grubits S. Alcoolismo e violência em etnias indígenas: uma visão crítica da situação brasileira. Psicol Soc. 2007; 19(1):45-51..

The causes of death among the indigenous population also indicate the occurrence of a triple burden of disease, with the predominance of NCDs, the continuance of infectious and parasitic diseases, and the increase of external causes, which reflect the epidemiological, demographic, and nutritional transition of that population. Although there has been a reduction in mortality by infectious and parasitic diseases, its occurrence illustrates persisting inequalities, which translate into social and welfare gaps: the lack of water supply, sanitation, garbage collection, and no access to health services⁴⁴44 Raupp L, Cunha GM, Fávaro TR, et al. Sanitation conditions of indigenous and nonindigenous households in Brazil according the 2000 and 2010 national censuses. Ciênc. Saúde Colet. 2019; 25(10):3753-63.

45 Raupp L, Cunha GM, Fávaro TR, et al. Saneamento básico e desigualdades de cor/raça em domicílios urbanos com a presença de crianças menores de 5 anos, com foco na população indígena. Cad. Saúde Pública. 2019; 35(supl3):e00058518.-⁴⁶46 Coimbra Júnior CEA. Saúde e povos indígenas no Brasil: reflexões a partir do I Inquérito Nacional de Saúde e Nutrição Indígena. Cad. Saúde Pública. 2014; 30(4):855-59.. Moreover, there is evidence of metabolic and anthropometric alterations in indigenous populations, which may well account for the high proportion of deaths by neoplasms and circulatory system diseases, closely related to changes in diet and patterns of physical activity related to the significant changes in humanity’s life style and social interactions⁵5 Coimbra Júnior CEA, Santos RV, Escobar AL, organizadores. Epidemiologia e saúde dos povos indígenas no Brasil. Rio de Janeiro: Editora Fiocruz; 2003.,⁷7 Krenak A. O amanhã não está à venda. São Paulo: Companhia das Letras; 2020.,³⁹39 Brasil. Ministério da Saúde. Saúde indígena: análise da situação de saúde no SasiSUS. Brasília, DF: Ministério da Saúde; 2019.,⁴⁶46 Coimbra Júnior CEA. Saúde e povos indígenas no Brasil: reflexões a partir do I Inquérito Nacional de Saúde e Nutrição Indígena. Cad. Saúde Pública. 2014; 30(4):855-59.

47 Mazzucchetti L, Galvão PPO, Tsutsui MLS, et al. Incidence of metabolic syndrome and related diseases in the Khisêdjê indigenous people of the Xingu, Central Brazil, from 1999-2000 to 2010-2011. Cad. Saúde Pública. 2014; 30(11):1-11.

48 Cardoso AM, Mattos IE, Koifman RJ. Prevalência de fatores de risco para doenças cardiovasculares na população Guaraní-Mbyá do Estado do Rio de Janeiro. Cad. Saúde Pública. 2001; 17(2):345-54.-⁴⁹49 Salvo VLMA, Rodrigues D, Baruzzi RG, et al. Perfil metabólico e antropométrico dos Suyá. Parque Indígena do Xingu, Brasil Central. Rev Bras Epidemiol. 2009; 12(3):458-68..

Despite a reduction in the causes of ill-defined mortality among indigenous populations, as a consequence of the improvement in SIM coverage⁵⁰50 Frias PG, Szwarcwald CL, Morais Neto OL, et al. Utilização das informações vitais para estimação de indicadores de mortalidade no Brasil: da busca ativa de eventos ao desenvolvimento de métodos. Cad. Saúde Pública. 2017; 33(3):e00206015., it is important to remember that Brazil has been classified as intermediate in terms of coverage and completion of registry of vital events⁵¹51 Mahapatra P, Shibuya K, Lopez AD, et al. Civil registration systems and vital statistics: successes and missed opportunities. Lancet. 2007; 370(9599):1653-63.. The proportion of ill-defined mortality causes is still high among indigenous people.

The results of this study prove the relevance of knowing the epidemiological profile of indigenous people, considering their wide ethnic and regional social diversity. This knowledge is vitally important to guide the organization, as well as in planning for and improvement of healthcare quality. In general, given the history of higher morbidity-mortality by infectious and parasitic diseases among the indigenous population, health care is generally aimed at these diseases; however, the present study highlighted the magnitude of chronic NCDs and of the external causes. Therefore, the planning and reorganization of health services are imperative in order to address all the healthcare needs of that population when faced with the changes brought about by epidemiological, nutritional, and demographic transition.

Among the limitations of this study, one must consider that the method of proportional mortality analysis does not allow for the estimation of rates, since it does not use the denominator (reference population). Consequently, caution must be taken when interpreting the data, since it measures proportion of deaths, not risks. Likewise, the data from the SIM was not adjusted, and might be under-reported, especially in relation to indigenous people. Moreover, errors in the registration of deaths related to the underlying causes might compromise the consistency of this indicator, which may also be influenced by the age and gender structure of the population.

Conclusions

In the years analyzed in this study, proportional mortality in indigenous people was higher than in the rest of the Brazilian population. This study revealed persistent inequalities in the living conditions of this population, which are reflected in worse conditions of birth, life, illness, and death. An epidemiological, demographic, and nutritional transition is currently ongoing, as is a triple burden of diseases in the indigenous population, with the predominance of NCDs, concomitantly with infectious and parasitic diseases, together with an increase in external causes.

The fact that the indicators related to the indigenous population did not improve in the studied period indicates the persistence of problems which are inadmissible and avoidable, such as the high mortality of children under 1 year of age, premature deaths among young adults, and the small proportion of deaths among the elderly. Pubic policies must guarantee the right to life and cultural diversity, as a means through which to achieve a fairer and more diverse society. Furthermore, it is imperative to make progress in terms of reducing health inequalities, and in so doing, justify the motto of the 2030 Agenda’s Sustainable Development Goals to leave no one behind⁵²52 United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. 2016. [acesso em 2020 out 11]. Disponível em: https://sustainabledevelopment.un.org/post2015/transformingourworld
https://sustainabledevelopment.un.org/po... .

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