Care for the indigenous Tembé child in the monitoring of growth and development: a reflection study

Abstract

Objective

to reflect on health care for the indigenous child of the Tembé ethnicity, to monitor their growth and development.

Method

theoretical-reflexive study, based on the authors’ experiences and anchored in the literature on Tembé culture and health care for indigenous peoples.

Results

studies about ethnicity and culture are starting points to produce notes about technical care in relation to the child, based on those already performed by Tembé women. The care based on ethnic issues signals cultural dynamics and is placed, in health policies and in their processes, as primordial to direct instruments, technologies and actions of multidisciplinary teams, with the pertinent participation of indigenous people and/or indigenous health professionals in their development.

Conclusions and Implications for Practice

Equity in health care for the Tembé indigenous child requires the development of specific procedures and devices that consider their particularities, well-being, and cosmology. There is a need for approaching, deepening, and respecting the specificity of this ethnic group. By reflecting on the health care of Tembé children, it becomes possible to understand divergences and convergences with the content of the Ministry of Health manuals.

Keywords:
Health care; Growth and development; Care; Indigenous peoples; Child health

Resumo

Objetivo

refletir sobre os cuidados de saúde em relação à criança indígena da etnia Tembé, para acompanhamento do seu crescimento e do seu desenvolvimento.

Método

estudo teórico-reflexivo, baseado nas experiências dos autores e ancorado na literatura sobre a cultura Tembé e na atenção à saúde de povos indígenas.

Resultados

estudos sobre etnia e sobre cultura são pontos de partida para produzir apontamentos sobre cuidados técnicos em relação à criança, a partir dos já realizados pelas mulheres Tembé. O cuidado fundamentado em questões étnicas sinaliza uma dinâmica cultural e é colocado, nas políticas de saúde e em seus processos, como primordial para direcionar instrumentos, tecnologias e ações de equipes multidisciplinares, sendo pertinente a participação de indígenas e/ou de profissionais de saúde indígenas no seu desenvolvimento.

Conclusões e Implicações para a prática

a equidade na atenção à saúde da criança indígena Tembé requer o desenvolvimento de procedimentos e aparelhos específicos, que considerem as particularidades, seu bem viver e sua cosmologia. Há necessidade de aproximação, aprofundamento e respeito à especificidade desta etnia. Ao ponderar sobre o cuidado à saúde da criança Tembé, é possível compreender divergências e convergências de conteúdo dos manuais do Ministério da Saúde.

Palavras-chave:
Atenção à saúde; Crescimento e desenvolvimento; Cuidado; Povos indígenas; Saúde da criança

Resumen

Objetivo

reflexionar sobre la atención a la salud del niño indígena de la etnia Tembé, para el seguimiento de su crecimiento y desarrollo.

Método

estudio teórico-reflexivo, basado en las experiencias de los autores y anclado en la literatura sobre la cultura Tembé y la atención a la salud de los pueblos indígenas.

Resultados

los estudios sobre etnicidad y cultura son puntos de partida para producir apuntes sobre cuidados técnicos en relación al niño, basados en los ya realizados por las mujeres Tembé. La atención basada en cuestiones étnicas señala dinámicas culturales y se coloca, en las políticas de salud y en sus procesos, como primordial para dirigir instrumentos, tecnologías y acciones de equipos multidisciplinarios, siendo pertinente la participación de indígenas y/o profesionales de salud indígenas en su desarrollo.

Conclusiones e Implicaciones para la práctica

la equidad en la atención al niño Tembé requiere el desarrollo de procedimientos y aparatos específicos, que consideren las particularidades, su buen vivir y su cosmología. Hay necesidad de acercamiento, profundización y respeto a la especificidad de esta etnia. Al reflexionar sobre el cuidado de la salud del niño Tembé, se permite entender divergencias y convergencias de contenidos de los manuales del Ministerio de Salud.

Palabras clave:
Atención sanitaria; Crecimiento y desarrollo; Cuidados; Pueblos indígenas; Salud infantil

INTRODUCTION

The Tembé-tenetehara are an ethnic group who currently live in the Alto Rio Guamá Indigenous Land (TIARG), which was approved in 1993 as the result of a historical process involving the participation of its main indigenous leaders and indigenous institutions. Located in the northeast of Pará, covering the municipalities of Garrafão do Norte, Capitão Poço, Paragominas and Santa Luzia do Pará, the ethnic group has a population of 1,727 individuals, and is limited and organized into 17 villages along the Gurupi River, to the south, and 16 villages around the Guamá River, to the north.¹,²

The Tembé have their own health care, which is based on beliefs and traditional therapeutic healing practices left by their ancestors, which have been perpetuated to this day.³ The so-called differentiated care, provided for in the Indigenous Health Care Subsystem (SasiSUS) through the National Policy for the Health Care of Indigenous Peoples (PNASPI)⁴ and the Organic Health Law of 1990, distinguishes the ethnic and cultural specificities and territorial rights of each national indigenous population.⁴ These singularities are ratified by the 5th National Conference on Indigenous Health (CNSI),⁵ which supported the Federal Constitution of 1988⁶ and which has highlighted the health care of indigenous children as an essential area, including in research.⁵,⁷

Cultural and ethnic issues relating to this age group are particular to childhood, which includes the period from birth to puberty rituals or their equivalents.⁸ However, the Tembé do not classify children by age group, which means that their understanding of childhood, or a similar social category, requires the construction of specific and differentiated views.⁹ This view, which is marked by well-defined phases within their own universe, is characterized by the occurrence of culturally organized environments and by children who are born, live and are welcomed, by their parents, with beliefs, representations and ritualized and symbolized goals, which range from birth to adulthood. It can therefore be seen that for the Tembé, childhood is the phase of life that goes from birth to the ritual called Festa da Moça or Moqueado, when the girl becomes an adult woman and the boy an adult man, respectively.¹⁰-¹²

It can be seen that there are provisions in the law, but no health instruments that signal ethnic specificities, as these are guided by systematizations and Eurocentric processes in general.¹³ In view of the above, it is important for health professionals who work with this population to know and study the ethnic group to be cared for, both in terms of its cosmology and its implications for health care, as this is essential for improving and implementing care that takes cultural diversity into account.¹⁴

Thus, understanding that health care includes monitoring the child’s growth and development, observing comprehensive care, it is essential to promote the health of indigenous children, considering the close and necessary relationship with ethnic issues.¹⁵

As there is a gap in knowledge about the care provided by health teams, this work is justified by the need to understand health care for indigenous children of the Tembé ethnic group, according to their cosmology. In addition, the aim is to provide data that can contribute to possible studies on the specificities of this ethnic group. Furthermore, there is the motivation of indigenous protagonism, since the author, an indigenous member of this ethnic group, has closely followed this whole process, which has been part of her daily life, literally since birth.

In this sense, the identified studies deal with cosmology and culture, but there is no association between these and the importance of the role of the health team in relation to the stages of development and growth of the children of this ethnic group, which has the potential to subsidize instruments for childcare.¹⁵ The aim of this study is to reflect on the health care provided to indigenous children of the Tembé ethnic group to monitor their growth and development.

METHODS

This is a study reflecting on health care for indigenous children of the Tembé ethnic group. By delimiting the problem to be discussed, and as a contribution to reflection, a non-systematic search was carried out for studies on the subject in question, relating the universe of the Tembé ethnic group and considering the territories and cosmology of this people.

The research took place between August and October 2022, in the following databases: Virtual Health Library (VHL); Scientific Electronic Library Online (SciELO); and Google Scholar. The following keywords were used: “Tembé child”; “health care for the Tembé indigenous child” or “health care for the Tembé indigenous child”; and “importance of the health team for the Tembé indigenous child”. As a result, 29 studies were obtained, divided between dissertations, theses, and articles. The materials were organized and filed, and then the titles and abstracts of the papers were read in order to select the most relevant ones, especially those that dealt with the cosmology and health of the Tembé child from the Alto Rio Guamá Indigenous Land.

The proposed reflections were based on the search for literature substantiated by the authors’ experiences with caring for indigenous peoples and the fact that the main researcher is a representative of that ethnic group, which allowed conjecture to be based on the concepts of protagonism, experience and place of speech. Thus, the study approached the health of the Tembé indigenous child from the point of view of the practices in caring for this child and the importance of equitable care centered on ethnicity in order to mitigate gaps in actions and to help shape care instruments.

As this is a theoretical-reflective study, based on a bibliographical survey and the authors’ own experiences, it was not necessary for the work to be approved by a Research Ethics Committee.

RESULTS AND DISCUSSION

Practices in caring for the Tembé child

In order to better understand Tembé culture, it is necessary to consider that this ethnic group’s trajectory of struggles stems especially from constant contact with non-indigenous society. Therefore, the individuals of the ethnic group in question are constantly seeking to strengthen their culture and affirm the identity left by their ancestors, which was broken in the process of acculturation of these people.¹⁰ In the course and changes resulting from this movement, there is continuous resistance and the strengthening of local culture, which must be taken into account by health professionals.¹²

The Tembé’s care practices are founded on their cosmology, which is based on their beliefs of origin and their understanding of the universe, which is also fundamental knowledge for planting, fishing, hunting and their relationship with nature in general. For the Tembé, there are two symbolic ways of presenting relationships: as belief, myth and religiosity; and as everyday knowledge, related to traditional knowledge, including social rules.⁸

This ethnic group considers rituals to be of the utmost importance for social formation, as it is through them that the people reaffirm their cultural identity, which goes hand in hand with the development of the Tembé child, whose care practices are guided by teachings passed down between generations, through orality, symbolized by festivals, rites of passage, language, body painting, handicrafts, and beliefs. Therefore, the birth of a Tembé child is an extremely important moment, as it is considered to be the arrival of happiness and a certainty that culture and tradition will be passed on to subsequent generations through orality.¹¹

In this sense, with regard to health care in early childhood, we understand the need to include cultural factors, identities and development and growth milestones in the child’s follow-up. Understanding this dynamic is important, because in the community, children live in culturally organized environments from birth and are welcomed by their parents with beliefs, representations and goals, and their lives are marked by well-defined phases, according to the culture. Therefore, in the health professionals’ process of monitoring, this is an opportune moment to identify actions that may pose risks to child development, adjusting them to their technical knowledge, such as the symbolism of painting with jenipapo (American Genipa).²,³

It should be noted that the Tembé begin to integrate children into the social environment from birth, through their own rites that guide the transition between the social positions of individuals in the village. In the Tembé’s view, these festivals and rites are designed to train and prepare children to take on responsibilities in the family and the village community.³ Social inclusion plays a significant role in a child’s development and is noticeable, especially from the sixth month of life onwards, through play and imitation of gestures, which should be recognized by the health team in recreational activities, considering the perspective of a village child’s well-being.³,⁴

This care begins as soon as conception is identified, as it is understood that the parents’ negative behavior has implications for the baby’s health during pregnancy. As a result, prohibitions and limitations are imposed on future parents, encompassing activities, places, and transit times in the village. For example, pregnant women are kept under “guard” and cannot carry objects or eat game of animal origin, such as lowland paca (Cuniculus paca), South American tapir (Tapirus terrestris), white-lipped peccary (Tayassu pecari), surubim fish (Pseudoplatystoma corruscans), among others. Likewise, food and spiritual relationships stand out as potential influencers on the child's health,³,¹¹ because the parents are connected to the fetus.

As for the rites, they begin at birth and are marked by stages of development, represented by the festivals of the child and the girl. The first takes place at the age of six months and aims to make medicines, guaranteeing the child's healthy and protected growth, introducing new foods into their diet, and initiating them in the use of jenipapo. Here we can see some points of similarity and difference in relation to other indigenous groups, such as the use of jenipapo as a means of purifying the body and preventing illness.²,³ The ritual called Festa da Moça, which marks the passage from childhood to adulthood, is characterized by the prevention and maintenance of health. The child-girl ceremony, in turn, is marked by three phases, called Tocaia, Festa do Mingau, and Festa da Moça.³,⁸

The Tocaia takes place when the girl reaches menarche and is characterized by the painting of the girl's body with dye extracted from the jenipapo tree, with the same purpose as in childhood, as well as aiding fertility. In the second phase, the Festa do Mingau (Porridge Festival), the girl makes her own paintings, highlighting the textures of the moon (Zahy), the surubim or the jaguar, prepares porridge and produces natural remedies for protection purposes, ending the stage with the sharing of the prepared food. The third stage is the Festa da Moça, which includes dances, paintings and singing, in which men also take part, with the help of maracas, and women, who do the second voice. The festival lasts seven days and ends with the making of handmade decorations, the cutting of the indigenous women’s bangs and the distribution of food based on ground game.⁸,¹⁰,¹⁶

These rituals contribute to the affirmation and resistance of the people's culture and identity, as the Tembé have undergone a strong process of acculturation over time, losing their mother tongue and some of their traditions, but even with this, they have continued to resist and have revived a strong point of their tradition, which persists to this day: the ritualistic festivals. In this sense, the festivals of the girl and the moqueado represent the reaffirmation of the Tembé’s knowledge.¹⁶

Therefore, the childhood of Tembé children, right up to their rites of passage, have important ceremonies, which must be understood and identified by health care workers outside the village during childcare and consultations with young indigenous people.⁴,¹⁵

Equitable and ethnic-centered care, to support care practice tools for indigenous communities

The SasiSUS aims to increase access to growth and development consultations, expand nutritional control and increase vaccination coverage and the number of indigenous pregnant women with access to prenatal care. It therefore dialogues with indigenous child health care⁴ and complies with Law 9.836 (Arouca Law) and the Federal Constitution of 1988, along with the rights to territory and education.⁹ However, there are limitations to the inclusion of traditional indigenous knowledge within the scope of Western medicine, as well as to its efficiency and high degree of originality due to the prevalence of the biomedical model.¹³

In the context of health and strategic research themes for the SUS (Brazilian Unified Health System), indigenous health is one of the axes, and the focus on indigenous child development includes the development and validation of health indicators for this child, considering the issue of child development; improving tools and techniques for monitoring and evaluating actions in indigenous child health; and analyzing the relationship between dietary patterns and the health of the indigenous child population.¹⁷ However, we understand the ethnic-cultural and cross-cutting aspects of caring for indigenous children, as well as the need to promote a differentiated approach to its indicators.

Like others, the Tembé ethnic group has its own peculiarities and, in their view, health is not separate from education and political activity; nature is not opposed to culture and the ways in which society is organized; and the natural and supernatural worlds are transmuted, presenting various perspectives in dialogue. All these elements constitute and delimit places loaded with symbolic and identity meanings for the Tembé, which demarcate their territory and constitute their logic for managing resources and their relationships with other beings based on these cosmological perspectives, which should be included in the actions of the health care team.¹⁸ Records of statements made by indigenous leaders highlight these assertions:

Our doctors have always been the shamans. What’s interesting is that our doctor deals with spiritual and mental health, while the white man only deals with the body and mind, but we don't see the spiritual. Many of the illnesses are spiritual. So we tried to bring this together in the Indigenous Health Subsystem, but at the time of implementation this was forgotten ¹⁸

The Tembé world, fully constituted and concatenated, collided with the conceptualized and segmented custom of the Western ontological model, which fractions human understanding and practices. When Eurocentric Western thinking comes into contact with the ancestral knowledge of indigenous peoples or other traditional populations, it often leads to disagreements and opposition in different contexts.¹³ This has resulted, for example, in indigenous women giving birth in hospitals, devaluing and forgetting the knowledge of midwives and childbirth in the villages, even though in some cases there is a need for external action in the event of complications, demonstrating the intervention of the biomedical model.³,¹³

The indigenous health policy, which expands indigenous peoples’ access to public health resources, on the one hand also allows greater contact with medicalization, on the other, distancing these peoples from their traditional practices.¹³ Given this, it is clear that there is a lot to be reviewed in this respect because, despite advances in medicine, health professionals are unable to unify modern science and indigenous knowledge, which is easily pushed aside, perpetuating practices of hierarchizing knowledge as an exercise in coloniality and reinforcing the abyssal lines of thought constructed by Eurocentric modernity.¹³,¹⁹,²⁰

In this sense, Growth and Development (G and D) monitoring, which is a process that involves observing, recording and evaluating physical growth and cognitive, social and emotional development over time, allowing for early interventions when necessary, when carried out with Tembé children, should, in short, observe the endogenous and exogenous factors that shape the villages, considering the surveillance model and the methods of the SUS, identifying the expected milestones for each age at an early stage, which is fundamental to ensuring that the child is growing properly.⁴,¹⁵

There are tools for carrying this out, especially those used by the primary care team, such as the G and D forms, documents used to record measurements and carry out evaluations. During monitoring, apart from the child’s card and the manuals, which are generalized, there is a clear lack of elements for an ethnic approach.⁴

Updating the instruments should take into account dietary practices, symbologies, family relationships and, above all, the importance of rituals and spiritual knowledge, including the stages of implementing childcare, which should be modulated by the indigenous people themselves.¹⁵

Furthermore, it is necessary to review mechanistic and reductionist approaches to human nature, seeking more holistic and systemic conceptions of life. It is therefore important that, as soon as health professionals are trained, are established teaching-assistance activity programs called “extramural”, outside the academic environment, taking students into the realities of patients and bringing them closer to their socio-cultural contexts. An important example has been the inclusion of Human Sciences in curricula, such as Anthropology and Sociology, which is fundamental in the training of indigenous or non-indigenous professionals.¹⁹

Health team professionals should get really close to the indigenous people, get to know their way of life, their family group and, whenever possible, try to keep the patient in their village – or even in their home, surrounded by relatives and friends. Health professionals should also look among the members of the family group for people who can be responsible for caring for the sick, paying attention to the indigenous peoples’ own way of caring.¹³ In other words, they should humanize their care, taking into account their physical, social and cultural aspects, in order to be more coherent in all forms of communication.²¹

However, there are incongruities between indigenous and Western medicine, as the actions follow the logic of the Eurocentric model.¹³ It is necessary to converge on the well-being of children, which can be achieved through the Ministry of Health (MH) programs. On this path, it is important to emphasize that the actions must include the participation of the family and the indigenous community, promoting spontaneous choices between the resources of one medicine or another, observing the solutions present in Western medicine that come from the indigenous communities, including therapeutic resources in the process.¹³

In practice, this has not been done, because health teams do not take into account traditional indigenous knowledge and their ways of caring.¹³ In the Tembé villages, this is no different: the professionals in the external health teams are unaware of the culture and care practices of the ethnic group, a position identified by deficits in the training of health professionals, related to the inclusion of content on the care to be given to indigenous peoples, enabling conflicts and distancing themselves from health care that meets the real needs of these individuals.¹⁶ Therefore, in addition to including the topic in training, it is relevant and necessary to give vent to this process in permanent and continuing education, considering their practices.¹⁹,²²

It is known that indigenous care practices differ from those of non-indigenous societies. This is already noticeable during prenatal care, which includes the use of a balanced diet, carrying out light activities and sheltering at home, with limited mobility in terms of places and times, among other aspects, because in the Tembé’s view, if women don’t follow the rules, there will be punishments for her and the baby.²³ In addition, the indigenous people highlighted here have rituals organized in phases that converge in the processes of growth and development, as pointed out in the MH manuals.²⁴ However, these practices are not covered in the MH manuals and notebooks, showing that the existing instruments are not enough to understand and meet the demands and realities of indigenous health care for Tembé children.

Although the Ministry of Health aims for comprehensive care provided by health services, understanding child development as the result of interventions by the family, the health system, the school and the community, in the context of the health promotion environment²⁴ there is a disconnection between indigenous health care for Tembé children, revealing that current instruments are not adequate to understand and meet specific demands and realities, showing a significant gap in the generalist approach.

With a focus on meeting needs, in terms of networked care and prioritizing health research, the theme raised in this reflection is covered by axes 13 (Indigenous health) and 14 (Maternal and child health),²⁵,²⁶ so it is clear that there is an obligation to align what is proposed with the actual practice of indigenous children's health, with its specificities.

The topic of indigenous children’s health needs to be brought closer together, deepened and made more specific with regard to the aspects established by the Ministry of Health and its effective practice with indigenous communities, especially with regard to child monitoring, due to its repercussions on indicators and the ethnic-cultural demands that guide its approach.

Moreover, dialoguing on the subject points to ways of developing actions to complement curricula, as well as extension, research and teaching projects.¹⁹,²²,²⁷,²⁸ Such a measure will make it possible for professional training to understand well-being, cosmologies and convergence with the PNASPI, as well as, in the context of the Tembé people, helping to promote the strengthening of differentiated care, which is necessary for coordination between the Ministries of Health and Education.

Another important point is the strengthening of the link between universities and indigenous movements, ensuring the participation of forest representatives in the control of social training spaces through direct cooperation in the construction of instruments that support the work of health professionals.⁵ In this scenario, SaSISUS managers have the role of making the subsystem’s integrality effective and promoting its continuous monitoring through specific, inclusive and plural methods, with information on the ethnic group’s cultural practices for monitoring growth and development, which could improve the combination of technical and ancestral knowledge.⁹,¹³

When considering health care for the Tembé child, the aim is to understand the divergences and convergences signaled in the Ministry of Health manuals, whether on growth and development or on the health of indigenous children.⁹,¹⁵ Therefore, there is a need to develop technologies and instruments that specify the diversities and singularities that exist between the Tembé and other indigenous ethnic groups, given that the documents that support these practices are general and do not provide data on the ethnicities of indigenous patients.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

This reflection sought to highlight the importance of recognizing the ethnic differences of indigenous peoples. To this end, it has focused on the care provided to children of the Tembé ethnic group, revealing how the peculiarities of their cultures should be included in training and in medical care itself. This inclusion should guide the construction of systems for monitoring children’s growth and development, based on specific elements.

Discussing health care in relation to the Tembé child has shown the need to reformulate the curriculum for health team professionals, in order to make them committed to reducing ethnic-racial inequalities in health, as well as to prepare them to practice their profession with respect for the cultures, customs, knowledge and singularities of each group, which should potentially be discussed.

The scarcity of articles dealing with the health care of indigenous children, considering their ethnicity, limits the debate on the subject, which demonstrates the need for primary research and methodological studies to base specific processes and products on this aspect. On the other hand, one must consider the bureaucratic difficulties faced in carrying out research with indigenous peoples, just as it is imperative to recognize their importance through affirmative policies and potential researchers in the field.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  04 Dec 2023
• Date of issue
  2023

History

• Received
  01 Dec 2022
• Accepted
  08 Sept 2023