ABSTRACT

The socio-historical process in Brazil is crossed by racism and the agrarian issues, as both are part of the same structural dimension. Thus, the understanding of racism is essential to apprehend the social determination process of racial inequalities in health. This action research had as general objective to analyze the interference of racism in the health-disease-care process of rural black families and, more specifically, to describe the children’s group intervention activities. Primary data were used: field diaries and other documents prepared by the Resident Team; and secondary data: the Participatory Rural Appraisal as a tool of systematization in territorialization. This shared action between professionals residents in Family Health Care and settlement dwellers, located in Caruaru (PE), was developed from the popular health education focusing on health promotion and facing racism as a transversal axis. In this sense, the Family Health team is a powerful tool for promoting Healthy and Sustainable Territories by confronting racism in its non-biocentered issues, with the use of low technology, transdisciplinary, strengthening black identities and building health as recommended in health policies and the Sustainable Development Goals.

KEYWORDS
Community health education; Rural health; Health of ethnic minorities; Sustainable development; Social Determinants of Health

Introduction

Preliminary data from the 2017 Agricultural and Livestock Census of rural producers in Brazil show the majority presence of blacks (52%)¹1 Instituto Brasileiro de Geografia e Estatística. Censo Agropecuário 2017. Brasília, DF: IBGE; 2017. [acesso em 2021 jun 10]. Disponível em: https://censos.ibge.gov.br/agro/2017/
https://censos.ibge.gov.br/agro/2017/... . In Pernambuco, a black population amounts to 64.73% among rural producers. Most, however, do not represent equity in access to available goods and services and political autonomy, since Brazilian agribusiness perpetuates the colonial logic of commodities and land concentration²2 Melo PB. Quilombos: transição da condição de escravizado à de camponês livre. Rev. da ABPN. 2011 [acesso em 2021 jun 12]; 1(3):53-76. Disponível em: https://abpnrevista.org.br/index.php/site/article/view/274
https://abpnrevista.org.br/index.php/sit... .

The relationship between racism, as an ideology that produces inequalities, and the land issue, are the foundations of Brazil’s social formation, and are part of the same structural dimension. The land tenure structure in the country is the product of a long colonization process that prioritized the exploitation of African and indigenous labor forces as a basis for the development and concentration of land. Thus, it is essential to relate the fact that Brazil is the last country to abolish slavery, has a record in land concentration (1% of rural landowners own 45% of arable land) and has the majority of the black population in poverty condition²2 Melo PB. Quilombos: transição da condição de escravizado à de camponês livre. Rev. da ABPN. 2011 [acesso em 2021 jun 12]; 1(3):53-76. Disponível em: https://abpnrevista.org.br/index.php/site/article/view/274
https://abpnrevista.org.br/index.php/sit... ,³3 Barbosa AM, Porto-Gonçalves C. Reflexões sobre a atual questão agrária brasileira: descolonizando o pensamento. Cescontexto. 2014 [acesso em 2020 jul 2]; (05):12-27. Disponível em: https://www.ces.uc.pt/publicacoes/cescontexto/ficheiros/cescontexto_debates_v.pdf
https://www.ces.uc.pt/publicacoes/cescon... .

Nowadays, racial inequalities are expressed in different ways. Studies show that institutional racism interferes with access to services and the quality of healthcare for the black population⁴4 Batista LE, Barros S. Enfrentando o racismo nos serviços de saúde. Cad. Saúde Pública. 2017 [acesso em 2020 jun 2]; 33(supl1):1-5. Disponível em: http://cadernos.ensp.fiocruz.br/static//arquivo/1678-4464-csp-33-s1-e00090516.pdf
http://cadernos.ensp.fiocruz.br/static//... ,⁵5 Werneck J. Racismo institucional e saúde da população negra. Saúde e Soc. 2016 [acesso em 2020 jun 21]; 25(3):535-549. Disponível em: https://doi.org/10.1590/S0104-129020162610
https://doi.org/10.1590/S0104-1290201626... .

Therefore, the understanding of structural racism is essential to apprehend the process of social determination of racial inequities in health, and it is important to highlight that such inequities are one of the expressions of racism as a system of exploitation⁶6 Borde EMS. A subalternização das populações não-brancas no sistema-mundo capitalista/colonial e os processos de determinação social das iniquidades étnico-raciais em saúde. Cescontexto. 2014 [acesso em 2020 jun 21]; (5):145-62. Disponível em: https://www.researchgate.net/publication/318987165
https://www.researchgate.net/publication... . The concept of the social determination of health is an alternative to understanding the ‘social determinants of health’, which, according to its critics, has a probabilistic analysis of the ‘risks’ of becoming ill, fragmenting reality and naturalizing inequalities⁷7 Almeida-Filho N. A problemática teórica da determinação social da saúde (nota breve sobre desigualdades em saúde como objeto de conhecimento). Saúde debate. 2009 [acesso em 2020 jul 12]; 33(83):349-70. Disponível em: https://www.redalyc.org/pdf/4063/406345800003.pdf
https://www.redalyc.org/pdf/4063/4063458... . Authors discuss the importance of this concept in order not to fall back on biological or historical determinism and seek an understanding through a complex and dialectical view of the social-biological and society-nature relationship⁸8 Breilh J. Las tres ‘S’ de la determinación de la vida: 10 tesis hacia una vision crítica de la determinacion social de la vida y la salud. In: Nogueira RP, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes; 2010. p. 87-125. [acesso em 2020 maio 10]. Disponível em: https://repositorio.uasb.edu.ec/bitstream/10644/3412/1/Breilh,%20J-CON-117-Las%20tres%20S.pdf
https://repositorio.uasb.edu.ec/bitstrea... ,⁹9 Borghi CMSO, Oliveira RM, Sevalho G. Determinação ou determinantes sociais da saúde: texto e contexto na américa latina. Trab educ saúde. 2018 [acesso em 2020 jul 12]; 16(3):869-97. Disponível em: https://www.scielo.br/j/tes/a/jJpLdWtYsCMVV8YQm6PqMFk/abstract/?lang=pt
https://www.scielo.br/j/tes/a/jJpLdWtYsC... .

Despite the consistency in criticism, there is still a limitation in the understanding of race relations as the foundations of the Brazilian social structure. Therefore, it is important to defend a critical approach to the social determination of health so that racism is seen as a central problem that is expressed in the health-disease-care process⁶6 Borde EMS. A subalternização das populações não-brancas no sistema-mundo capitalista/colonial e os processos de determinação social das iniquidades étnico-raciais em saúde. Cescontexto. 2014 [acesso em 2020 jun 21]; (5):145-62. Disponível em: https://www.researchgate.net/publication/318987165
https://www.researchgate.net/publication... . In the research, it was necessary to carry out mediations between the urgency of recognizing racism as a producer of diseases and injuries; the importance of using tools that identify the health needs of the territory; and the need to intervene with a focus on promoting Healthy and Sustainable Territories (TSS).

Family health assumes a priority strategy for Primary Care (AB), being a privileged field to understand racial inequities in health. As provided for in the National Primary Care Policy (PNAB)¹⁰10 Brasil. Portaria nº 2.436. Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS), Brasília, DF: Ministério da Saúde; 2017. [acesso em 2020 jun 9]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
https://bvsms.saude.gov.br/bvs/saudelegi... , AB is the priority gateway for users in the Health Care Network (RAS); it must coordinate care; values the comprehensiveness of care; encourages bonding; it has a territorial base and co-responsibility for care between professionals and users. The strictly biological and procedural dimension, overestimated in medium and high complexity services, is challenged by the social demands that users bring to these health facilities¹¹11 Barbosa RRS, Silva CS, Sousa AAP. Vozes que ecoam: racismo, violência e saúde da população negra. Rev. Katálysis. 2021 [acesso em 2021 jun 14]; 24(2):353-63. Disponível em: https://doi.org/10.1590/1982-0259.2021.e77967
https://doi.org/10.1590/1982-0259.2021.e... .

In the territory, transformations and relationships between social practices and their effects on the social determination of health take place. The concept of TSS in public health can be addressed in two ways: one related to theoretical and abstract determinations; and another directly linked to the determination of social relations of a given territory, so that the process of social reproduction territorialized and conditioned by determining factors, or sustainability assumptions that shape spaces and determine social characteristics of territories, may or may not promote health, according to its predominance, presence or absence¹²12 Machado JMH, Martins WJ, Souza MS, et al. Territórios saudáveis e sustentáveis: contribuição para saúde coletiva, desenvolvimento sustentável e governança territorial. Com. Ciênc. Saúde. 2018 [acesso em 2020 jun 30]; 28(2):243 249. Disponível em: http://www.escs.edu.br/revistaccs/index.php/comunicacaoemcienciasdasaude/article/view/245
http://www.escs.edu.br/revistaccs/index.... .

TSS can be defined as relational and belonging spaces where life is made possible, through community actions and public policies that interact with each other and materialize in results for global, regional and local development, in the environmental, cultural, economic, political and social dimensions¹²12 Machado JMH, Martins WJ, Souza MS, et al. Territórios saudáveis e sustentáveis: contribuição para saúde coletiva, desenvolvimento sustentável e governança territorial. Com. Ciênc. Saúde. 2018 [acesso em 2020 jun 30]; 28(2):243 249. Disponível em: http://www.escs.edu.br/revistaccs/index.php/comunicacaoemcienciasdasaude/article/view/245
http://www.escs.edu.br/revistaccs/index.... . Given the importance of territoriality in the construction of TSS, this agenda has been prioritized in social and development policy guidelines, which includes AB and, more recently, the negotiation of the 17 Sustainable Development Goals (SDGs) that make up the so-called 2030 Agenda, prepared by the international society with the support of the United Nations (UN)¹³13 Organização das Nações Unidas. Transformando Nosso Mundo: A Agenda 2030 para o Desenvolvimento Sustentável. 2015. [acesso em 2020 maio 15]. Disponível em: https://odsbrasil.gov.br/home/agenda
https://odsbrasil.gov.br/home/agenda... .

From this perspective, this study was developed and guided from the territory’s needs. For this, the permanent dialogues between the National Policy for Comprehensive Health of Rural, Forest and Water Populations (PNSIPCFA)¹⁴14 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. Política Nacional de Saúde Integral das populações do campo e da floresta. Brasília, DF: Editora do Ministério da Saúde; 2013. 48 p. [acesso em 2020 ago 12]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_populacoes_campo.pdf
https://bvsms.saude.gov.br/bvs/publicaco... , the National Policy for Comprehensive Health of the Black Population (PNSIPN)¹⁵15 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. Política Nacional de Saúde Integral da População Negra: uma política para o SUS. 2. ed. Brasília, DF: Editora do Ministério da Saúde; 2013. 36 p. [acesso em 2020 jun 20]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_integral_populacao.pdf
https://bvsms.saude.gov.br/bvs/publicaco... and the UN’s SDGs are highlighted. This article had as general objective to analyze the interference of racism in the health-disease-care process of black families living in rural areas and, more specifically, to describe the intervention activities carried out in the group of children, using popular health education, having the fight against racism as a transversal axis.

Materials and methods

This is an action-research carried out during the training process in the Multiprofessional Residency Program in Family Health with emphasis on rural populations (RMSFC-UPE). The research was carried out in the settlement of the district of Cachoeira Seca, rural area of Caruaru, close to the cities of Toritama and Santa Cruz; region known as the clothing hub of the Pernambuco countryside.

The settlement is made up of 25 mostly black families. Such political statement comes, above all, from the phenotype and experiences of racism reported by the families during the assistance provided by the Residents Team (ER)¹⁶16 Gomes NL. Por uma indignação antirracista e diaspórica: negritude e afrobrasilidade em tempos de incertezas. Revista da ABPN. 2018 [acesso em 2020 maio 24]; 10(26):111-24. Disponível em: https://redib.org/Record/oai_articulo2209874-por-uma-indigna%C3%A7%C3%A3o-antirracista-e-diasp%C3%B3rica-negritude-e-afrobrasilidade-em-tempos-de-incertezas
https://redib.org/Record/oai_articulo220... ,¹⁷17 Souza NS. Tornar-se negro: as vicissitudes da identidade do negro brasileiro em ascenção social. Rio de janeiro: Edições Graal; 1983.. These reports guided the ER’s choices in the development of care strategies. Among them, the group of children was the longest-lasting and most adherent community work, justifying its choice for this study.

The ER was composed of professionals with different backgrounds: physical education, pharmacy, physiotherapy, veterinary medicine, nutrition, dentistry, psychology, social work and occupational therapy. The Family Health team (eSF) consisted of a doctor, a nurse, a nursing technician and four community health agents.

The action research had three stages: i) territorialization, ii) intervention and iii) analysis, as detailed: i) Territorialization: Participatory Rural Diagnosis (DRP) was used, a methodology in which the community builds its own diagnosis, serving as an instrument for data collection, encouraging community self-knowledge and guidance for planning political action¹⁸18 Verdejo ME. Diagnótico rural participativo - Guia prático DRP. Brasília, DF: Ministério do Desenvolvimento Agrário, Secretaria da Agricultura Familiar; 2006 [acesso em 2020 maio 18]. Disponível em: https://www.projetovidanocampo.com.br/livros/Diagnostico_rural_participativo.pdf
https://www.projetovidanocampo.com.br/li... . The DRP tool chosen was the spoken map, in which community members designed their territory according to their perceptions of available spaces and devices for sociocultural integration. After drawing up the map, the community identified the risk and protection factors for health and life in the territory, which allowed them to understand the dynamics of the territory in terms of its arrangements, identities and health needs.

ii) Intervention: The intervention was developed through training processes and participatory and horizontal care strategies, conducted by the ER and by professionals from the ESF, aimed at children in the community. 22 meetings were held, lasting 2 hours, on average, from July 2017 to February 2019. The meetings had, on average, the presence of 15 children aged from 2 to 10 years old. One of the meetings provided an opportunity for the assessment of the group of children based on the perception of their guardians.

From the DRP, educational activities were constructed and methodologically guided by Popular Education in Health (EPS). The EPS, as a political-pedagogical tool, proposes the development of new relationships based on dialogue, the appreciation of popular knowledge and the search for insertion in the dynamics of the territory, with cultural identity as the foundation of the education process¹⁹19 Vasconcelos EM, Prado EV. A saúde nas palavras e nos gestos: reflexões da rede de educação popular e saúde. 2. ed. São Paulo: Hucitec; 2017.,²⁰20 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. II Caderno de educação popular em saúde. Brasília, DF: Ministério da Saúde; 2014.. In these spaces, playing was used as a TSS promotion strategy, considering the fight against racism as a transversal axis. The following techniques were used as pedagogical strategies: experiential, audiovisual, conversation circles and workshops.

iii) Analysis: The previous steps allowed the production of a database formed by documents: field journals²¹21 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 11. ed. São Paulo: Hucitec; 2010., residency thesis, activity registration book, reports, photos and meeting minutes. These instruments made it possible to record the activities according to the perception of those who build them, providing a reflective practice from the author/or, with the details perceived in their multiple dimensions and interrelationships²¹21 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 11. ed. São Paulo: Hucitec; 2010.. Exhaustive reading of all material was carried out, organization in Excel spreadsheets and workshops to discuss the results among the team, building a dialogue with the theoretical framework. The activities were described considering as categories: the themes and activities developed; the main objectives; the date of the activity; and the number of participants. The data collected in the DRP were the basis for the systematization of the elements that promote and threaten the life of community members according to the theoretical matrix of Breilh²²22 Breilh J. De la vigilancia convencional al monitoreo participativo. Ciênc. Saúde Colet. 2003 [acesso em 2020 maio 16]; 8(4)937-51. Disponível em: https://www.scielo.br/j/csc/a/84YH3CqTdpFzPByK9Z7kmWJ/?format=pdf
https://www.scielo.br/j/csc/a/84YH3CqTdp... . This analysis makes it possible to identify vulnerabilities and potential in the territory.

The study is part of the project Analysis of the development and application of the TSS concept in the Brazilian Semi-Arid Region of Pernambuco, approved by the Research Ethics Committee, under number 31982820.3.0000.5190.

Results and discussion

Health and Life promoting and threatening elements in the territory

The particularities and dynamics of the settlement’s black families guided the reading of the territory. Table 1 presents a summary of the identified elements that promote and threaten health and life:

For a long time, agriculture was the main productive activity in this region, establishing itself not only as an economic activity, but also as a way of life and in the processes of subjectivation. However, due to the lack of conditions for working in the field, such as the long periods of drought and the absence of public policies that would make agricultural production viable, the apparel industry became predominant in the local economy (table 1 - Items 16 and 31). Despite this, such subjective heritage expresses the coexistence with a farmer ethos that presents itself through customs, values and traditions, immersed in practices and their effects both in the ways of managing life and in the relationship with themselves and their peers (table 1 - Item 1).

Textile production, in addition to not guaranteeing labor and social security rights, does not offer adequate conditions for the worker, as the work is highly fragmented, non-ergonomic, with precarious structure, low light and extended working hours, reaching more than 12 hours a day. Payment is made only by production, whose remuneration is equivalent to cents on the piece²³23 Lira PVRA, Gurgel IGD, Albuquerque PCC, et al. Superexploração e desgaste precoce da força de trabalho: a saúde dos trabalhadores de confecção. Trab. Educ. e Saúde. 2020 [acesso em 2020 maio 20]; 18(3). Disponível em: https://www.scielo.br/j/tes/a/jpLw4dXR9yJvzsFJjvNJjJw/?lang=pt
https://www.scielo.br/j/tes/a/jpLw4dXR9y... . According to DRP data, one of the families received 20 cents for each zipper sewn onto the jeans, and, therefore, everyone was involved in the production, including children and the elderly (table 1 - Items 17 and 18).

Precarious work contributes to the fragility of community organization, despite this having been pointed out by families as essential for the guarantee of rights and resolution of territorial issues. The instability of informal work directly influences the living and health conditions of these populations and exposes workers to intense journeys, with little time and resources for health care²³23 Lira PVRA, Gurgel IGD, Albuquerque PCC, et al. Superexploração e desgaste precoce da força de trabalho: a saúde dos trabalhadores de confecção. Trab. Educ. e Saúde. 2020 [acesso em 2020 maio 20]; 18(3). Disponível em: https://www.scielo.br/j/tes/a/jpLw4dXR9yJvzsFJjvNJjJw/?lang=pt
https://www.scielo.br/j/tes/a/jpLw4dXR9y... . As a result of this context, were identified illnesses and harms of both physical order, such as urinary tract infections, back problems, pain in the upper and lower limbs; and psychosocial order, such as anxiety, depression, child labor, food insecurity and family conflicts, intensified by the overlapping of family and work environments (table 1 - Item 18).

The settlement’s families are expanded, not meeting a nuclear/house pattern. It was common to find members of the same family in the territory, mother, sisters, sisters-in-law and aunts. This matrix-centered family relationship was presented in the potential for collective care, evidencing an important social support network. The matricentric organization dialogues and at the same time reflects aspects of matriarchy, thus contributing to collective and cooperative values, extrapolating the individualistic and competitive feeling, which gives women a position of authority as well²⁴24 Oliveira FC. O matriarcado e o lugar social da mulher em África: uma abordagem afrocentrada a partir de intelectuais africanos. ODEERE. 2018 [acesso em 2021 out 30]; 3(6). Disponível em: https://periodicos2.uesb.br/index.php/odeere/article/view/4424
https://periodicos2.uesb.br/index.php/od... . This configuration of the settlement strengthened community work and collective care strategies (table 1 - Items 2 and 3).

Another protective factor in this territory is the existence of traditional health practices. Spirituality and the relationship with the land were evident in the figure of the community healer, the same one who cultivates a small vegetable garden with medicinal plants and some fruit trees in her backyard, being recognized for her knowledge and care (table 1 - Item 4). Popular practices are concrete forms of resistance of rural peoples to the destructive effects of industrial modernity and to the hegemony of Western medicine, in addition to being often the only alternative of care due to the difficulty in accessing public health services²⁵25 Fernandes VR, Luz ZP, Amorim AC, et al. O lugar da vigilância no SUS - entre os saberes e as práticas de mobilização social. Ciênc. Saúde Colet. 2017 [acesso em 2020 jul 27]; 22(10):3173-81. Disponível em: https://www.scielo.br/j/csc/a/tBBGN3ZsyVmwDzJcvNfkL5m/abstract/?lang=pt
https://www.scielo.br/j/csc/a/tBBGN3ZsyV... ,²⁶26 Castro MR, Figueiredo FF. Saberes tradicionais biodiversidade, práticas integrativas e complementares: uso de plantas medicinais no SUS. Hygeia - Rev. Bras. Geogr. Médica e da Saúde. 2019 [acesso em 2020 maio 24]; 15(31):56-70. Disponível em: http://www.seer.ufu.br/index.php/hygeia/article/view/46605
http://www.seer.ufu.br/index.php/hygeia/... . The use of teas, tinctures and blessings as care alternatives for mental and physical suffering is carried out concomitantly with the use of psychotropic medications²⁷27 Dimenstein M, Leite J, Macedo JP, et al. Condições de vida e saúde mental em contextos rurais. Natal-RN: Intermeios; FAPEPI; CNPQ; UFRN; UFPI; 2016., overcoming the logic of medicalization as one of the only care devices offered to rural populations.

Most of the families were beneficiaries of the Bolsa Família program and worked in sewing to supplement their income, mainly in the removal of leftover thread - ‘hairs’ from jeans (table 1 - Item 5). During periods of high service, it was common to observe women and children in circles, sitting on the floor or in chairs, gathered for the collective task of removing the ‘hairs’. The families also carried out the work of ironing the pockets of their jeans, and they worked intensively together on the days scheduled for delivery of the goods. Payment was not always made immediately. Few families in the settlement had a sewing machine and/or knew how to sew, and this explains the performance of less complex services, which require only scissors as an instrument.

The conditions of social lack of protection, exposure to long working hours and irregularities in equipment maintenance, in addition to the non-use of individual and collective protective equipment, lead to early exhaustion and the consequent illness of workers²³23 Lira PVRA, Gurgel IGD, Albuquerque PCC, et al. Superexploração e desgaste precoce da força de trabalho: a saúde dos trabalhadores de confecção. Trab. Educ. e Saúde. 2020 [acesso em 2020 maio 20]; 18(3). Disponível em: https://www.scielo.br/j/tes/a/jpLw4dXR9yJvzsFJjvNJjJw/?lang=pt
https://www.scielo.br/j/tes/a/jpLw4dXR9y... .

According to the DRP, the lands of this settlement were occupied in 1997, and, in 1999, possession was granted, with 25 families being settled. Tensions generated during the negotiation with the National Institute of Colonization and Agrarian Reform (Incra) culminated in the non-organization of the settlement in agrovillages and plots, typical structures in the land tenure process, where houses are built and where agricultural practices are carried out, respectively. Despite the lack of planning, some families resisted and planted in land not yet occupied, as well as in their own backyards. The political mischaracterization of the territory, in which part of the settlers do not know the local history in depth, means that the place is called ‘Landless’.

The settlement has a soccer field, two workshops and a grocery store. The soccer field and the grocery store are important equipment for interaction between and/with the community, facilitating the development of collective activities, important aspects for promoting quality of life. The streets were unpaved, and garbage collection took place only twice a week, so it was possible to visualize accumulated waste, including scraps of jeans. The river that runs through the settlement is polluted by the jeans industry’s laundries, making it dark blue and fetid. There was no sewage system, but some houses had a septic tank. Few families had their own cisterns, a fragility alleviated by two communal cisterns, supplied by the army weekly. However, it was still necessary to store water in individual buckets and plastic bottles, which commonly became the focus of vector-borne disease mosquitoes, such as arboviruses (table 1 - Items 6, 7, 8, 24, 25, 26 and 30).

Other needs and demands identified in the territory were the following: insufficient public transport, with ‘toyotas’ (private cars that offer transport service) the most used; distance and difficulty in accessing social assistance services; insufficiency of oral health care; lack of lighting and public infrastructure; weakness in health surveillance; presence of stray animals and/or zoonoses carriers; insufficiency of rural technical assistance and policies for coexistence with the semi-arid region; absence of day care; school dropout rate high, illiteracy and unemployment (table 1 - Items 15, 27, 28, 29, 30 and 31).

With regard to mental health, the diagnosis allowed us to identify the presence of people with Common Mental Disorders (CMD), such as insomnia, anxiety and stress; problems arising from the use of alcohol and other drugs; indiscriminate/abusive use of controlled medications (benzodiazepines, etc.) and a situation of social isolation, which is in line with the symptoms found in research with countryside populations in Brazil²⁸28 Neto MCC, Dimenstein M. Cuidado psicossocial em saúde mental em contextos rurais. Temas em Psicol. 2017 [acesso em 2020 jul 19]; 25(4):1653-64. Disponível em: http://pepsic.bvsalud.org/pdf/tp/v25n4/v25n4a09.pdf
http://pepsic.bvsalud.org/pdf/tp/v25n4/v... ,²⁹29 Pirró JCF. Cuidado integral em saúde mental do campo: caminhos para um novo amanhecer. [monografia]. Recife: Universidade de Pernambuco; 2019. 43 p.. According to them, both isolation and frequent exposure to situations of violence can cause psychosomatic symptoms and abuse of alcohol and other drugs (table 1 - Items 19, 20 and 21). In addition, mental health is impacted when rights are violated or education and income generation opportunities are excluded²⁷27 Dimenstein M, Leite J, Macedo JP, et al. Condições de vida e saúde mental em contextos rurais. Natal-RN: Intermeios; FAPEPI; CNPQ; UFRN; UFPI; 2016..

According to the World Health Organization (WHO), there is a relationship between situations of vulnerability and mental health problems, with an association between mental disorders and precarious living and working conditions³⁰30 World Health Organization. Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group. Geneva: WHO; 2010. [acesso em 2020 maio 19]. Disponível em: http://apps.who.int/iris/bitstream/handle/10665/44257/9789241563949_eng.pdf;jsessionid=E18FC58F992DC0BBBE49A2FA25A14F3C?sequence=1
http://apps.who.int/iris/bitstream/handl... . In this sense, socio-historical issues have repercussions on the mental health of the rural population, as their place of life and work is constantly threatened by environmental degradation and poverty, being a stage for conflicts and struggles for rights²⁹29 Pirró JCF. Cuidado integral em saúde mental do campo: caminhos para um novo amanhecer. [monografia]. Recife: Universidade de Pernambuco; 2019. 43 p..

Violence is an extremely important category to understand the experience of black families, given the exposure to annihilating episodes in face of state institutions and socially established relationships. Politics centered on death, or sovereignty expressed “in the power to dictate who can live and who should die”³¹31 Mbembe A. Necropolítica: biopoder, soberania, estado de exceção, política da morte. São Paulo: N-1 Edições; 2018.(5) are the foundations of the concept of necropolitics. In the territory, situations of exodus due to violence and a common history of homicide deaths were identified; imprisonment without trial, resulting from petty crimes; exposure to institutional racism at school, in the health system and in the judiciary; conflicting relationships between settlement members; intrafamily violence and difficulties in expressing affection; in addition to situations of non-recognition of racial identity and self-depreciation, such as straightening curly hair in children and preference for light-skinned black children³²32 Brito TCS. Raça importa! Saúde, doença e cuidado da família no assentamento Lampião. [monografia]. Recife: Universidade de Pernambuco; 2019. 36 p. (table 1 - Item 33 and 35).

Despite the difficulties found in this territory, it is possible to recognize the presence of local integration and social support existing in the settlement, which can be listed as protective factors for mental health, positively impacting the lives of community members (table 1 - Item 3).

The coverage by the Family Health Unit (USF), together with the ER in rural health, presented potential for the expansion of care, as well as the possibility of a greater bond with the eSF (table 1 - Items 9 and 13). The monitoring supervised by the coordination of the RMSFC contributed to thinking about territorialized and articulated strategies with other health and intersectoral devices, such as the oral health task force held in the settlement, articulation with surveillance for the vaccination of stray animals and articulation with the archdiocese for policies for coexistence with the semiarid region (table 1 - Items 12, 13 and 14).

Faced with Health and Life promoting and threatening processes, individual and collective activities were planned that sought to recognize its particularities in the territory, placing the experience of black families in the settlement in hegemonic power relations, which are guided by necropolitics and the denial of racism as a producer of inequalities.

Care strategies: the experience of the children’s group

It is based on the understanding of care as part of health work and, in addition, as a dimension of life that takes place in the meeting. Thus, care practices cannot be understood only as actions, but as an ethical attitude that demands concern, responsibility and affective involvement with the other²⁸28 Neto MCC, Dimenstein M. Cuidado psicossocial em saúde mental em contextos rurais. Temas em Psicol. 2017 [acesso em 2020 jul 19]; 25(4):1653-64. Disponível em: http://pepsic.bvsalud.org/pdf/tp/v25n4/v25n4a09.pdf
http://pepsic.bvsalud.org/pdf/tp/v25n4/v... .

Care is also based on the political dimension of social determination and EPS, since the horizontal, dialogical relationship, based on autonomy and problematization, generates critical awareness and community empowerment, contributing for the population, based on this care, to engage if in a process of transformation not only individual, but also social and of the community²⁰20 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. II Caderno de educação popular em saúde. Brasília, DF: Ministério da Saúde; 2014..

In this sense, the reasons for creating the group were multifaceted. They involved the absence of leisure and daycare activities, the presence of child labor, delay in motor and cognitive development, complaints about disobedience and aggressiveness of some children, as well as the receptivity and community engagement so that the activities were possible.

From the beginning, the place defined for the group’s meeting was in front of one of the houses, which was also the settlement’s bar and grocery store, a space provided by one of the residents. The area was covered with brasilit tiles, which provided shade, despite the heat, and allowed for greater comfort. In carrying out the activities, the ER and the children usually sit on the floor, in a circle format, seeking greater horizontality and interaction.

The themes of the meetings were chosen from the continuous process of evaluating the priority demands and the possibilities of intervening in face of them. We sought to promote the potential of social actors in the territory to engage in the learning process, from the EPS, which allowed the suggestions of children and their guardians. The activities developed and the themes addressed were in line with the following SDGs: health and well-being; gender equality; reduction of inequalities; sustainable cities and communities¹³13 Organização das Nações Unidas. Transformando Nosso Mundo: A Agenda 2030 para o Desenvolvimento Sustentável. 2015. [acesso em 2020 maio 15]. Disponível em: https://odsbrasil.gov.br/home/agenda
https://odsbrasil.gov.br/home/agenda... .

Through playing, this intervention enabled dialogues and reflections on the social determination in the health-disease-care process; exercise of creativity, criticality and autonomy; stimulation of sociability and neuropsychomotor development in children. Racism and its multiple facets were prioritized at all meetings, being a transversal element in the activities developed, based on the understanding that it is impossible to achieve the SDGs without fighting racial inequalities.

Table 2 describes the activities developed, main themes, objectives, dates and number of participants in each meeting.

In general, the themes sought to broaden environmental perception and identification with the territory; promote knowledge about the health care of children and families; stimulate neuropsychomotor and social development; promote citizenship; strengthen community and family affective bonds and the children’s black identity, boosting self-esteem and rescuing their ancestry.

The activities dedicated to valuing regional and primary processed foods and stimulating the production of the agro-ecological garden sought to consider both the effects of the high consumption of pesticides and transgenics on health, as well as the global syndemic of obesity, malnutrition and climate change, consequences of the agribusiness food production system (table 2 - Item 1). It is understood that, in addition to providing guidance on the importance of healthy eating, it is also necessary to encourage contact with the land and the defense of agroecology as a strategy to strengthen health in rural areas³³33 Burigo AC, Porto MFS. Trajetórias e aproximações entre a saúde coletiva e a agroecologia. Saúde debate. 2019 [acesso em 2020 jul 21]; 43(8):248-62. Disponível em: https://www.scielo.br/j/sdeb/a/Qsg8HMWDTqBPtgGys7Krm3P/abstract/?lang=pt
https://www.scielo.br/j/sdeb/a/Qsg8HMWDT... .

Epidemiological data point to the vulnerability of the black population, as the most prevalent diseases for this group are related to genetic factors aggravated by environmental issues, such as high blood pressure and diabetes mellitus. While in the white population, death from hypertension was stable between 2005 and 2012 and death from diabetes decreased between 2000 and 2012, for the black and indigenous population, this rate increased³⁴34 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Articulação Interfederativa. Painel Temático Saúde da População Negra. Brasília, DF: Ministério da Saúde; 2016. [acesso em 2020 ago 12]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/tematico_saude_populacao_negra_v._7.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

Issues related to the environment, environmental injustices and implications of environmental racism on the health of vulnerable populations also guided the activities carried out in the group. The concept of environmental racism places the process of economic and political state management as a producer of inequalities³⁵35 Bullard RD. Enfrentando o racismo ambiental no século XXI. In: Acselrad H, Herculano S, Pádua JA, organizadores. Justiça ambiental e cidadania. Rio de Janeiro: Relume-Dumará; 2004. p. 41-66.. Only 32.8% of rural households are connected to the water distribution network, which directly and indirectly influences the emergence of Diseases Related to Inadequate Environmental Sanitation (DRSAI)³⁶36 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Amostras por Domicílios - Síntese de indicadores. Rio de Janeiro: IBGE; 2010.. The lack of adequate water supply, sanitary sewage and solid waste treatment contributes to the genocide of the black population and configures one of the faces of environmental racism that, in Brazil, results in the death of a black person by DRSAI every one and a half hours³⁷37 Jesus V. Racializando o olhar (sociológico) sobre a saúde ambiental em saneamento da população negra: um continuum colonial chamado racismo ambiental. Saúde e Soc. 2020 [acesso em 2020 maio 18]; 29(2):1-15. Disponível em: https://www.scielo.br/j/sausoc/a/5LRzfP3sP8kCDbhnJy6FkDH/abstract/?lang=pt
https://www.scielo.br/j/sausoc/a/5LRzfP3... .

Affected communities and their democratic allies have the capacity to face these and other environmental conflicts, which is directly related to the production of health in the territories. Mobilizations for environmental justice fight for the autonomy of communities, their cultures and the right to maintain their livelihoods. The production of counter-hegemonic knowledge is essential for these mobilizations to gain strength in epistemological power disputes. Combating the manipulations and uncertainties of those who produce environmental injustices through the strengthening of the shared production of knowledge and the mobilization of communities is a powerful coping strategy³⁸38 Porto MF, Ferreira DR, Finamore R. Health as dignity: political ecology, epistemology and challenges to environmental justice movements. J Polit Ecol. 2017 [acesso em 2020 maio 16]; 24(1):110-24. Disponível em: https://journals.librarypublishing.arizona.edu/jpe/article/1989/galley/2248/view/
https://journals.librarypublishing.arizo... ,³⁹39 Holifield R, Chakraborty J, Walker G. The Routledge handbook of environmental justice. Reino Unido: Routledge; 2017..

In this sense, the discussion on basic sanitation and its importance for health promotion was emphasized, considering the difficulty of access of this community to infrastructure services, operational facilities for urban cleaning and solid waste management, drainage and management of urban rainwater, sewage and drinking water supply³⁷37 Jesus V. Racializando o olhar (sociológico) sobre a saúde ambiental em saneamento da população negra: um continuum colonial chamado racismo ambiental. Saúde e Soc. 2020 [acesso em 2020 maio 18]; 29(2):1-15. Disponível em: https://www.scielo.br/j/sausoc/a/5LRzfP3sP8kCDbhnJy6FkDH/abstract/?lang=pt
https://www.scielo.br/j/sausoc/a/5LRzfP3... .

Therefore, the importance of stimulating children’s perception about the territory and criticality in the face of environmental issues, in an environmental education involved in the search for environmental justice⁴⁰40 Layrargues PP, Puggian C. Convergências na ecologia política: quando a educação ambiental abraça a luta por justiça ambiental. Pesquisa em Educ Ambient. 2016 [acesso em 2020 maio 15]; 11(2):72-82. Disponível em: https://www.revistas.usp.br/pea/article/view/128732
https://www.revistas.usp.br/pea/article/... . The puppet theater (table 2 - Item 5), whose character was ‘Mosquivaldo’, a playful representation of the Aedes aegypti mosquito, allowed for the discussion of how state interventions in fighting arboviruses blame the population, while denying the negligence of the State facing the social determination of health⁴¹41 Peixinho BC. Análise do processo de trabalho de uma médica veterinária em Unidades de Saúde da Família do campo em Caruaru-PE: desafios e potencialidades da prática. [monografia]. Recife: Universidade de Pernambuco; 2019. 66 p.. Still on the environmental theme, a panel was assembled with images of habits related to the prevention and control of helminthiasis (table 2 - Item 13). Recycling workshops for the construction of toys were held, discussing how the proper disposal and reuse of solid waste contribute to a healthier and more sustainable territory (table 2 - Item 17).

In the field of social relations, it was essential to consider the legacy of colonial violence and its contemporary implications⁴²42 Hooks B. Vivendo de Amor. In: Werneck J, Mendonça M, White EC, editores. O Livro da Saúde das Mulheres Negras Nossos Passos Vêm de Longe. Rio de Janeiro: Pallas; Criola; 2006. p. 188-98. in the affectivity of black families, due to the contrast that violence produces between the repression of emotions, as a defense mechanism, and community solidarity as a daily strategy of survival. In the group of children, in addition to situations in which affection was the central theme of the meeting, the practice of love²⁰20 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. II Caderno de educação popular em saúde. Brasília, DF: Ministério da Saúde; 2014. was encouraged through group hugs and the expression of emotions and feelings, which influenced the children’s relationships not only with each other, but also with family members and the community (table 2 - Item 8).

The historical reasons that affect affectivity interfere in the process of self-denial of the black body, which fuels the pursuit of whitening, generating low self-esteem and insecurity since childhood¹⁷17 Souza NS. Tornar-se negro: as vicissitudes da identidade do negro brasileiro em ascenção social. Rio de janeiro: Edições Graal; 1983.. At the first meeting, in which images of black references were taken for the children to paint, questions arose regarding the beauty of these references and the rejection to make the paintings (table 2 - Item 2). In another moment, during the proposal to elaborate a drawing based on the self-perception of body image, listing its characteristics, the children drew themselves as white, with light eyes and straight hair (table 2 - Item 12). In the reports of evaluation meetings with family members, there are statements from mothers about the racism suffered by children at school, which reflected in the way they saw themselves, understood and understood their peers (table 2 - Item 9).

During the meetings, with the insertion of positive references of blackness, dialogues about the stories of resistance and origin of black people, problematization about the ‘skin color’ pencil and the diversity of phenotypes, it was possible to identify changes in behavior and in children’s self-esteem. It was common to see them fighting for black and brown pencil for the paintings, and they no longer portrayed their eyes and hair in blue and yellow colors. Over time, they became more and more participative and confident to carry out the proposed tasks.

In the assessment carried out with the children at the end of 2018, the Black Awareness Day and the Angola capoeira workshop were remembered as the best meetings of the year. At the end of the meetings, the children’s joy at seeing themselves portrayed in a positive way was noticeable. On Black Awareness Day, the turban and body painting workshops got the children excited. One of them expressed: “I am beautiful, miss. I’m looking like an African queen”, as recorded in the field journal (table 2 - Item 19).

The above reports demonstrate the evolution of children’s personal skills and social interactions, stimulated in the proposed activities. The lack of stimuli and mediation, resulting from the context of vulnerability and racism to which families and their territory are subjected, directly impacts the subjectivity and emotional, motor and mental dimensions of children, compromising their full development⁴³43 Pereira MÂCM, Amparo DM, Almeida SFC. O brincar e suas relações com o desenvolvimento. Psicol. Argumento. 2006 [acesso em 2020 set 2]; 24(45):15-24. Disponível em: https://periodicos.pucpr.br/index.php/psicologiaargumento/article/view/19861/19165
https://periodicos.pucpr.br/index.php/ps... . As a strategy to overcome these damages, playful encounters contributed to the elaboration of emotions, increased body awareness and self-perception, influencing neuropsychomotor development and sociability.

The other activities sought to equip children for self-care in health and knowledge of their rights, through dialogues and games involving the themes of hygiene, oral health, right to leisure, citizenship and community participation (table 2 - Items 3, 14, 15, 16, 18, 19, 20, 21, 22 and 23). Participatory methodologies encouraged the effective performance of children and their families in the educational process, valuing their knowledge, experiences and involving them in the identification and search for solutions for the territory’s needs.

Final considerations

During the twenty months of activities, it was possible to follow the children’s development, their stories and the family and community contexts that play a fundamental role in the construction of their subjectivities and biographical trajectories. The results include significant advances in development, in the strengthening of community ties and in the creation of a consolidated bond with the families in the territory. From the group, it was possible to systematically monitor the health care of the families in the settlement, so that the identified demands, especially those that pointed to the racist dimensions, were worked out for the care of the families in a broader way.

Meetings with children and family members still resonate with powerful pulses in the ER. The transdisciplinary work, from different professional backgrounds, as well as the moments of care experienced with the families in the territory, ensured mutual learning about health, resistance and community action. In view of the turnover and the short period of the training process in the residency, it was essential to guarantee the continuity of the group with the contribution of professionals from the subsequent ER.

From this action-research, it was possible to perceive the eSF as a powerful instrument for promoting stronger TSS to face a highly complex issue, namely racism. Due to the territorial and longitudinal nature of care, working with families and enhancing bonds allowed focusing on racial and non-biocentric issues with the use of low technology, strengthening and building health as recommended in AB, in health policies and in the SDGs, in an integral and preventive manner. As a last reflexive point: the promotion of citizenship and the strengthening of black identities are fundamental parts in health promotion and prevention strategies, as well as in the establishment of TSS.

References

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