Santa Catarina , Brasil Reflections on intervention strategies with respect to the process of alcoholization and self-care practices among Kaingang indigenous people in Santa Catarina State , Brazil

This article, based on ethnographic research on the Xapecó Indigenous Reservation in Santa Catarina State, Brazil, examines the sociocultural context of the use of alcoholic beverages among the Kaingang indigenous people. The authors also discuss the experience with an intervention involving government agencies and nongovernmental organizations that attempted to deal with alcohol-related problems on the reserve. Based on the concepts of alcoholization and selfcare practices, the study analyzes the possibilities for organizing health intervention practices with indigenous peoples, in light of the principle of differentiated care under Brazil’s National Healthcare Policy for Indigenous Peoples. Alcoholic Beverages; Health of Indigenous Peoples; Qualitative Research ARTIGO ARTICLE


Resumo
Este texto, baseado em pesquisa etnográfica realizada na Terra Indígena Xapecó em Santa Catarina, Brasil, trata do contexto sociocultural relacionado ao uso de bebidas alcoólicas entre os índios Kaingang.Complementarmente, aborda uma experiência de intervenção institucional, envolvendo órgãos governamentais e não governamentais, que tentou se estabelecer na localidade para atuação frente aos problemas relacionados ao uso de álcool.Assim, a partir dos conceitos de processo de alcoolização e práticas de autoatenção, analisaremos as possibilidades de articulação de práticas intervencionistas em saúde junto a povos indígenas, tendo em mente o princípio de  Various studies have shown that health professionals frequently refer to "alcoholism" as a problem among indigenous peoples 1,2 .Literature review from different fields that analyze this question among Brazilian indigenous peoples reveals a lack of consensus on the meaning of "alcoholism" and the ways to identify it.The category, which refers to an individual disease with an invariable clinical presentation and a natural and chronic prognosis, has proven problematic and anachronistic even for some sectors of biomedicine 3 .Studies show that the term "alcoholism" emerged in Brazil in the 19 th century through a process that turned a popular custom into a "disease" in order to raise social, political and economic standards.During this process, biomedical knowledge constructed a solid basis for the hygienist order to disseminate bourgeois values 4 .Much more than the diagnosis of a disease, "alcoholism" currently serves to justify the accusatory marginalization and stigmatization of certain groups 5 .
In light of such limitations, this study presents an anthropological perspective concerned with the complexity and heterogeneity of the use of alcoholic beverages as a collective phenomenon.The circumstances of alcohol consumption reveal sociocultural particularities important in the emergence of specific meanings assigned to alcoholic beverages that require an understanding of drinking strategies in unique contexts 6 .Not all groups manifest intoxication in the same way, since cultural contexts and values are determinant factors in differences of drinking styles and of acting when drinking 7,8 .
The contemporary uses of alcoholic beverages among indigenous peoples hardly reflect the traditional representations and practices marked by sociocultural control and limits on the use of indigenous fermented beverages 6 .Indigenous societies are inserted in contexts marked by interethnic relations of domination and contact that are not always peaceful, as shown by studies that relate the use of alcoholic beverages to the processes of European colonization around the world 9,10,11 .To understand alcohol-related problems 3 among indigenous peoples requires shifting the issue from the physical/individual to the collective/social domain, in which drinking practices are viewed as a phenomenon constructed through social and historical processes with the dominant society 11,12 .The anthropological perspective thus focuses on observation of the intersection between expectations, attitudes, and other social and cultural factors associated with the use of these substances.
Recent anthropological studies on the use of alcoholic beverages by indigenous peoples in Brazil 13,14 have drawn on the work of Menéndez 15 and his concept of "alcoholization process".The concept of alcoholization focuses on the discourse and use of alcoholic beverages from the point of view of the actors themselves.The process of drinking is perceived as based on social processes and sociocultural codes that express collective recognition of positive and negative aspects related to the use of alcoholic beverages.
This article focuses on strategies employed by Kaingang people to control what they perceive as negative in relation to alcohol consumption.We thus adopt the concept of "self-care" 16 to identify efforts by the community to prevent or control what they view as threatening to collective wellbeing.Self-care refers generically to representations and practices that social groups use to deal with health and disease processes in a way that is autonomous to professional medical treatment.This concept shifts the view from the biomedical notion of disease and focuses on meanings that social groups assign to their ailments, problems, and feelings.Self-care practices operate at two levels: in a restricted sense that refers to intentional acts based on people's decisions in dealing with misfortunes, and in a more ample sense that refers to practices that ensure the group's biosocial reproduction as a whole.

Methods
The article is based on a study conducted in the Xapecó Indigenous Reservation in 2009 according to anthropological methodology for qualitative data collection through observation and participation in the local context that is recorded in a field diary.The study identified settings for the local population's consumption of alcoholic beverages, such as dances and soccer games.We also recorded complaints and control strategies related to alcohol abuse.Semi-structured interviews were conducted, and given that it is a controversial topic, the identifying features of the narratives and statements have been changed in order to maintain individual anonymity, allowing preservation of the group's confidence 17

The Xapexó Indigenous Reservation
The lands that today comprise the Xapecó Indigenous Reservation were claimed by Chief Vanhkrê as payment for the labor of clearing a path through the forest to lay a telegraph line from 1890 to 1893 21 .The definitive deed to the lands in the mid-1940s resulted in the forced transfer of indigenous people from the State of Paraná to this location 22 .The Reservation's territory initially measured 50,000 hectares between the Xapecó and Xapecozinho rivers, but was reduced to 15,000 hectares in the 1960s 22,23 .As shown by Almeida 22 , the reduction occurred together with deforestation and sale of native Araucaria (Araucaria angustifolia) and Imbuia (Ocotea porosa) forests.The Indian Protection Service (SPI) itself was responsible for lumber extraction and the fraudulent sale of parts of Xapecó territory to descendants of Italians from the neighboring State of Rio Grande do Sul.Only in 1978 were measures taken to remove the intruders, "leaving behind a trail of co-paternity (compadrio), alliance, and marriage between settlers and Indians, the marks of which are visible on the faces of those who stayed in the area" 22  According to the last census, the Reservation's indigenous population was 4,056 24 .Ipuaçu, in which the largest part of the Reservation belongs, had a total of 3,436 indigenous persons 24 .
The Reservation is arranged internally in 10 villages.The study that served as the basis for this article concentrated on the two largest villages, Sede and Pinhalzinho, both located in Ipuaçu municipality.The Sede village has some 1,500 inhabitants and several important agencies such as the National Indian Foundation (FUNAI) post, the Chief Vanhkrê Primary and Junior High School, an armadillo-shaped gymnasium, a cultural center, a daycare center/preschool, and a relatively well-equipped health post.An unpaved road connecting the municipality of Entre Rios to Bom Jesus cuts through this village.Pinhalzinho village, with some 1,200 inhabitants, is located approximately seven kilometers from the municipal seat of Ipuaçu.It has a primary school and health post and is crossed by state highway SC-480, resulting in heavy automobile traffic between Ipuaçu and Bom Jesus.
It is important to recognize the presence of Christian affiliation on the Reservation with allegiance to one of two groups 22,25 .The first group identifies as "Catholic" and is the result of missionary efforts implemented from the late-19 th to the mid-20 th centuries.The other group is composed of Kaingang belonging to Evangelical denominations organized in the area since the mid-20 th century and these followers are locally called "believers" (crentes).Visitors to the Reservation cannot fail to notice the numerous Evangelical churches and variety of denominations established in all the villages.For reasons that will become obvious in the course of this article, we will focus on the attitudes of the believers in relation to alcoholic beverages.

Abuses related to alcoholic beverages according to the Kaingang
Alcoholic beverages play positive roles in the modes of sociability of local indigenous and non-indigenous people; they appear as motivating factors for participation in soccer games and dances that occur on the Reservation, mediate relations with merchants in the local towns, and are consumed during collective work groups, called "puxirão".
For the purposes of this article, we emphasize that the Kaingang use a term for a specific type of drinker when referring to negative aspects associated with alcoholic beverages: the "bêudo" (drunkard).As an accusatory category for certain individuals, the term signals abusive drinking or immoral conduct, associating the individual in question with incidents viewed locally as undesirable.Various discourses associate bêudos with episodes of public and domestic violence, theft, or other transgressions.
This category is also often used didactically to lecture children, especially concerning places where they should not go: "there are bêudos there"; or to scare them when they are misbehaving: "Don't do that, or I'll call the bêudo."Children use the category to tease a child who has a family member labeled as such: "... your father is a bêudo!"They also imitate, in moments of diversion, the performance of bêudos, especially the way they walk, gesticulate, and speak.
The recognition of a specific public bodily performance as the result of consuming alcohol is crucial for the characterization of the bêudo, in which stigma and accusation emerge from the interpretation of certain signs shared by the larger group: tipsy walking, shouting, cursing, growling, and mumbling.Public appearances of bêudos are a spectacle to be enjoyed by the population.When someone notices an unusual noise, especially on the street, they invite all those around to watch.The comments are usually made in a taunting tone.
However, public appearances by bêudos are sporadic, considering the local population's daily dynamics.The practice of "drinking on the highway", observed particularly on weekends along state highway SC-480 in the village of Pinhalzinho, is also considered inappropriate.The drunkards often hurl jokes and insults at drivers or pedestrians.Regardless of whether they are merely carrying their alcoholic beverages or actually consuming them, it is common to see Kaingang sleeping on the highway shoulder after their drinking sprees.When asked about this practice, the local residents are unanimous in calling them bêudos.
The villages have side paths called "carreiros" that serve as alternatives to the regular roads and trails.Such paths cut across fields and yards and connect points in the villages by shortcuts.Various carreiros cross the forests or uninhabited areas and become prime spots for encountering Kaingang drinking alone.If a stranger comments that he intends to take such a shortcut, he is invariably warned to beware of violent attitudes by the bêudos.However, our field experience showed that most of these bêudos avoided contact when we tried to approach them.
Field observation showed that drinking or getting drunk in public places is not viewed in a positive light by the Kaingang, particularly if the beverage of choice is cachaça (high-proof sugar cane spirits).It is as if there is a spatial and temporal border demarcating styles of drinking associated with morality, which is transgressed through appearing intoxicated in public on inappropriate occasions.In addition to dances and soccer games, the private space of the home is considered the most adequate place for alcohol consumption, where "you can drink without being bothered".As alcohol users confirmed: "If you don't raise a fuss and don't fight, there's no problem in having a couple of drinks." Given the above, one can say that the consumption of alcoholic beverages and the recognition of specific problems associated with this process are points of reflection among the local population.In this sense, the ethnographic context leads us to question the stigmatizing Western representations that tend to view alcohol consumption on indigenous lands as "unbridled licentiousness".Here we highlight the expressiveness of two internal ideological groups, the Res-ervation's indigenous leaders and the believers.Both groups produce parameters on the status alcoholic beverages according to diverse reasons for regulation of the substances themselves, of the possibilities and ways of their use and of the individuals that wish to drink.
Self-care practices: indigenous leaders and "believers" The Kaingang indigenous leaders can be viewed as a corpus of actors with legitimate power to make decisions and take action pertaining to maintenance of the internal organization, to attempt to resolve conflicts, and to represent the group as a whole on political issues vis-à-vis the surrounding society 26 .
The highest position in the indigenous leadership hierarchy is the cacique or "chief", the figure that centralizes the power over political decisions and mediates the process for the formation of this local corpus.The chief's assistants in the various Reservation villages are called "captains", who have legitimate power to make certain emergency decisions at the micro-social level.People usually turn to the captains when they have complaints.It is up to the leaders to verify the grievances and take the appropriate measures.
The leaders work according to an indigenous justice system 27 that guides their handling of unwanted situations.This system must follow certain steps to guarantee the legitimacy of such actions.In the case of a grievance between neighbors or spouses, for example, the leader convenes what is called a "hearing".He attempts to consider all parties involved in order to come to a decision.The most basic measure is generally "counseling", done individually with the parties during the hearing itself seeking a verbal proposal for a peaceful settlement.If the problem persists and the misunderstanding causes new harm to one or both of the parties, they are called on again by the leaders for more serious measures.One example is to use the stocks or tronco as a punitive measure; the delinquent person is tied by the wrists to a tree trunk located on the land of one of the leaders.
Indigenous leaders act in the social control of alcoholic beverages in two ways: sporadic authorizations for the sale of alcohol on the Reservation -at soccer games and dances -and the restraint of unpleasant behavior by individuals that transgress expected conduct.In the latter case, when situations of intoxication are considered problematic, tying to the trunk is justified as a safety measure to prevent serious incidents.Intoxicated individuals never spend more than a few hours tied to the trunk "to calm down and sober up".This punishment is public and is used routinely.
In the case of bêudos as well as other unpleasant situations, repeat offenses by individuals can lead to further measures by indigenous leaders, first as a request to leave the village and then as a "transfer" to another indigenous Reservation.
The believers also intervene in alcoholrelated abuses.They represent one of the most outspoken voices on moral issues, which is witnessed by the large number of Evangelical sects on the Reservation.
One joins the community of believers by birth or by conversion, understood as rites of passage 22 to a "new life" guided by "the doctrine".During the period that a person belongs to one of these churches, a series of rules pertaining to bodily habits, such as wearing specific clothing (trousers and dress shirts for men and skirts for women) and haircuts (long hair tied in a ponytail for women and short hair with well-shaven faces for men).They must also abstain from certain activities such as participating in games and dances, committing adultery, and, primarily, from consuming alcoholic beverages 22 .
For those who are not into the religion, conversion can occur after a visit to a church motivated by various circumstances: drinking problems, a serious illness, or by invitation from a spouse or family number.The convert is accepted during the worship service, which is almost a daily ritual for "believers", and the moment when the individual is encouraged to reconsider his mistakes in life, reinterpreting past events through the prism of Evangelical doctrine.
One characteristic of believers is the task of proselytizing to those who have still not accepted the "word" of Jesus.They always seek to emphasize the correct form of behavior and that there are no alternatives for salvation other than joining the group 22 .This constant pursuit of new followers by the believers has implications for indigenous social organization.The mode of organization and administration of the churches in the various villages contributes to the formation of close circles of sociability among groups of worshippers, routinely reinforced in the alliances and practices of reciprocity among each congregation's members.These circles also structure the emergence and empowerment of Evangelical religious leaders (pastors, presbyters, etc.), who have an important influence on the local group, despite being subject to the general guidance of the indigenous political leaders.
The worship service is a special moment that constantly focuses on the opportunity and ne-cessity to form a covenant with Jesus: the Evangelical pastors' sermons gain strength through intensification of the Pentecostal experience, both individual and collective.
The pastors underscore abstinence from alcoholic beverages during the worship services, focusing on "replacing alcohol with acceptance of the word of God".Problematic cases are the target of testimonials, which always emphasize threshold experiences that serve to provoke conversion.The converts, in turn, become fervent preachers on such issues by the testimony of their own life histories.
Criticisms are also common for individuals that have "strayed" from the doctrine and deviated from religion by drinking.In moments of disbelief in the word of Jesus due to drunkenness, they get involved in fights and misunderstandings.Such actions are associated with "evil spirits" that follow the individual and take advantage of a moment of distraction to over-power the soul.The weakness of those who drink is portrayed a process of "disturbance"; evil spirits grasp the person and consume him physically and spiritually.As interpreted by believers, this is a disturbance in which the very substance of alcohol can be the recipient of such destructive agents.In reference to the name of a popular brand of cane liquor, they say "cachaça possesses 51 demons".
The believers' discourse is often associated with moral ideals defended by the indigenous leaders, since it is assumed that converts cause fewer problems due to their strict conduct.During counseling, indigenous leaders may recommend conversion to the group of believers as a way of containing some problematic situation.The general population commonly emphasizes the combined efficacy of the believers' and indigenous leaders' efforts.
The Xapecó Indigenous Reservation also has practices that are independent of these ideological groups and reflect strategies to regulate abusive cases associated with alcohol.In one case during fieldwork, repeated transgressions committed by an individual accused of being a violent "bêudo" culminated in his unexplained death: "he was simply found dead".The episode did not result in any major concerns or punishment for the perpetrators.The population acknowledged that "it was better this way (...), otherwise nobody was safe".

Institutional intervention to deal with alcoholism
In 2009, the multidisciplinary indigenous people's health team working in the Sede village con-sisted of 2 nurses, 1 nutritionist, 1 dentist, 1 physician, and various nurse technicians.The indigenous persons in this team were restricted to the positions of nurse technicians and indigenous health agents.The latter are local residents and act as facilitators between the actions offered by the Indigenous Health Care Subsystem and the local sociocultural realities.
Another important place occupied by a Kaingang in the health team was that of "health director".He was affiliated with the Health Department of the Ipuaçu Municipal Government.In practice, he worked to mediate communications among the various local health spheres, that is, watching over the indigenous community's interests and needs and those of the official agencies, ranging from the health team to the National Health Foundation (FUNASA) and occasionally FUNAI.The Kaingang who occupied this position was not a health professional, but was highly active in local political dynamics.
The non-indigenous members of the health team frequently expressed the idea that the "Kaingang have high incidence of alcoholism", an affirmation which displayed a lack of clarity in relation to the local problems of drinking.The health professionals who developed the programs to treat hypertension on the Reservation 28 complained frequently that alcohol consumption interfered with allopathic medication among Kaingang patients.
The strategies of such programs were based on educational efforts to change habits during monthly meetings with their patients.The health professionals tirelessly explained the ill effects of salt and lard and urged users to comply rigorously with their medication and to avoid alcohol.
At one point, FUNAI took the initiative to develop a specific program with users of alcoholic beverages through a partnership with a nongovernmental organization (NGO), Outro Olhar (Another View), from the city of Guarapuava, in the neighboring State of Paraná.The plan was to implement a mutual help model based on the Hudolin method for what the NGO referred to as "problems related to alcohol consumption" rather than FUNAI's designation of "alcoholism" 29 .
The method is an Italian initiative with less visibility in Brazil than Alcoholics Anonymous (AA).Its overall objective is "to help families in trouble, through a family (systemic) approach, a multi-family community of 2 to 12 families, to reach sobriety and a change in behaviour and life style" 30 .The basis for the method is a "socialecological" approach, in which individuals are seen as interdependent.Thus, problems related to alcohol consumption are approached at the collective level and not, as in the methods of AA, at that which is primarily individual.AA focuses its work on weekly meetings in which members share their idiosyncratic experiences anonymously, while the Hudolin method works in the opposite direction by forming clubs.
Ideally, these clubs are conceived as spaces for contact among families with alcoholic relatives.The families are articulated in a multifamily network through the involvement created by the functioning of the administrative system maintaining the club.The club has a teacher as the central mediator who may or may not be from the community, and who engages the families according to the methodological orientation.Club participation should create a space for systematic surveillance intended to reformulate the alcoholic's bonds of interaction and sociability.Theoretically, knowledge of the family member's specific problems creates a collective health responsibility among club members, changing the entire family's behavior and lifestyle, as well the general culture of the local community.
The method was organized on the Xapecó Indigenous Reservation on two fronts: one through the multidisciplinary indigenous people's health team, in which the health director and another Kaingang were invited to participate in methodological training courses in Italy, and the second through the "mothers' group" in Pinhalzinho village for identification of families to participate in the project.In addition to the women in the group and health team staff spreading the project through word of mouth, the project and invitations to participate were announced on posters displayed at various locations where the Kaingang circulate, such as health posts, schools, and churches.
The first step was to organize the clubs.FUNAI scheduled several meetings during the latter half of 2009, attempting to coordinate them with visits to the Reservation by members of the Another View NGO.FUNAI relied on crucial assistance from one of the founders of the mothers' group, a key community figure known as a remedeira (herbal healer).This Kaingang woman helped schedule meetings in the Catholic Church in the village of Pinhalzinho and at the house that hosted the mothers' group.
Several attempts to schedule meetings were made, but they failed to attract interested people and in the end did not happen.This led to tension between the various parties involved in the intervention and resulted in placing the health director and his work in check.There was a certain insistence that he was not really interested in the issue, which eventually led to accusations that his activities were merely for self-interest.His trip to Italy for training in the Hudolin meth-Cad.Saúde Pública, Rio de Janeiro, 30(6):1250-1258, jun, 2014 odology became the target of internal allegations among members of the health team who claimed that it had been nothing more than a "tourist trip".Other research colleagues that visited the area in this period heard the same accusations by other residents of the Reservation.
Meanwhile, from the health director's perspective, the initiative failed because of a methodological misalignment stemming from a basic demand by the Guarapuava NGO that the clubs meet in public and not in closed meeting rooms.According to the director, his knowledge of the community assured that "the best thing would be to hold closed meetings in the health post or school".
Thus, during the field research conducted in the second semester of 2009, the impasses had still not been resolved.No real progress had been made in implementing the intervention project, which was "at a standstill" according to some of the Kaingang involved.

Final remarks
The Brazilian National Healthcare Policy for Indigenous Peoples 31 has promoted the principle of differentiated care for indigenous peoples.The policy specifies the need to respect the communities' cultural practices and traditional knowledge, including them whenever possible in routine health work 32 .The policy also stipulates that primary care provided by health units should articulate with indigenous health practices.In other words, Brazilian legislation explicitly manifests a concern for the need to articulate official health intervention with the various indigenous forms of self-care.This is a difficult task for health professionals, since it requires rethinking their biomedical understanding of diseases and the respective treatments, as well as being receptive to dialogue.Thus, labeling some forms of drinking as "alcoholism" overlooks the indigenous people's thoughts on their own behaviors 6,33,34 .
This case study on an intervention program designed by governmental and nongovernmental institutions allows us to reflect on the strategies for articulating with indigenous communities based on the concepts of alcoholization 16 and self-care practices 18 .These concepts highlight the importance of sociocultural processes in the biosocial reproduction of groups, emphasizing the contributions of anthropological research for the development of approaches to complex health problems -such as mental health and alcohol abuse.
The experience examined was based on a proposal of intervention originating from outside the indigenous community and oriented by non-consensual preoccupations with the problem held by the institutions involved.In practice, it sought to identify the alcoholics and their families, organizing them in groups in order to educate and to modify behavior and lifestyles according to Hudolin directives.
The project overlooked or ignored the use of alcoholic beverages from a sociocultural perspective, that is, the process of alcoholization in the community.The intervention efforts thus failed to consider the Kaingang's own thoughts on adequate and inadequate forms of consuming alcoholic beverages according to local morality.The efforts also failed to articulate with selfcare practices developed by community members to deal in relatively autonomous ways with problems related to alcohol consumption.
It was based on a generalization of the problem without taking into consideration the unique aspects of the Reservation's social organization.The attempted intervention ended up provoking a social drama in which latent conflicts emerged among the actors.Similar to what Diehl 35 has demonstrated, accusations and disagreements about the problems of the proposal's implementation cut across internal disputes that emerged from preexisting schisms that revealed political processes in the local health field.
We are aware of experiences in Brazil that have achieved better results with the same question.Ferreira 34 shows how participation in discussion groups on alcohol abuse by Guarani leaders and shamans, together with the FUNASA team, resulted in a better understanding of the problem experienced by the community.Through the traditional dialogic practice of "good words", group dynamics fostered reflections on coping strategies and generated positive effects, not only through reduction of alcohol abuse but also through the reaffirmation of Guarani identity.
We attempted here to analytically situate the intervention experience within an ethnographic context, with the goal of making a contribution for the expansion of the comprehension of the question starting from the community's own concerns in relation to alcohol abuse on the Reservation.This kind of exercise can present important tools against the reproduction of widespread stigmas towards Brazilian indigenous peoples, such as generalizations of "alcoholism" or "alcohol-related problems", providing greater consistency for health action in relation to national policy.
Bebidas Alcohólicas; Salud de Poblaciones Indígenas; Investigación Cualitativa Contributors A. Ghiggi Junior contributed to the elaboration of the field research, data analysis, writing of the article, revision of the content, and submission of the article.E. J. Langdon collaborated in the orientation of the field research, data analysis, writing of the article, and revision of the content.