Abstracts
INTRODUCTION: Traditional indigenous knowledge about health is based on a holistic approach, which in turn is founded on harmony between people, families and community and the universe that surrounds them. One of the challenges that precedes the work of health professionals is respect for differences, where the knowledge and technologies of biomedicine cannot be transmitted vertically, showing that recognition of the cultural and social diversity of indigenous people is vital. OBJECTIVE: To identify the self-attention practices of Truká Indians and this population's relationship with biomedicine, witnessing the occurrence or absence of an interrelationship between biomedicinal practices and traditional healing systems. METODOLOGY: This study is characterized as a qualitative research project. To conduct this survey, data were collected at the Truká's central base in Cabrobó and on indigenous territory, on Assunção Island. Data were collected between November 2010 and January 2011, when semi-structured interviews associated with the "Participant Observation" method were conducted, and a field diary was used. Twenty-one individuals took part in that research, including Truká Indians and professionals on a multidisciplinary Indian health team. RESULTS: For the Truká Indians, the cure process is polysemic. It is composed of territory ownership, ritual practices such as the Toré ritual, prayers, and the use of homemade syrups and bottled herbal infusions. They use allopathic medicines in turn, in a process denominated intermedicality.
Intercultural Contexts; South American Indians; Indian Health Policy; Indigenous Health
INTRODUÇÃO: Os conhecimentos tradicionais indígenas de saúde fundamentam-se em uma abordagem holística, cujo princípio é a harmonia de indivíduos, famílias e comunidades com o universo que os rodeia. Um dos desafios que antecede a atuação dos profissionais de saúde é o respeito à diferença, em que os conhecimentos e tecnologias da Biomedicina não devem ser transmitidos verticalmente, tornando-se imprescindível o reconhecimento da diversidade social e cultural dos povos indígenas. OBJETIVO: Identificar as práticas de autoatenção nos índios Truká e a relação dessa população com a biomedicina, constatando a ocorrência ou não de interrelação das práticas biomédicas com os sistemas tradicionais de cura. METODOLOGIA: O estudo é caracterizado como uma pesquisa de cunho qualitativo. Para a realização dessa pesquisa, foram coletados os dados no Polo Base Truká, em Cabrobó e no Território Indígena, na Ilha de Assunção. A coleta de dados foi realizada durante os meses de novembro de 2010 e janeiro de 2011, quando foram realizadas entrevistas semiestruturadas aliadas ao método de Observação Participante e registro em Diário de Campo. Os sujeitos da pesquisa foram vinte e um indivíduos, incluindo índios Truká e profissionais da equipe multidisciplinar de saúde indígena. RESULTADOS: Para os Truká, o processo de cura é polissêmico. Composto por posse do território, práticas rituais, tais como o Toré, rezas, além do uso de lambedor e garrafadas. Por sua vez, fazem uso dos medicamentos alopáticos, em um processo chamado de intermedicalidade.
Interculturalidade; Índios sul-americanos; Política de saúde indígena; Saúde Indígena
PART II - ARTICLES
The intermedicality relationship among Truká Indians, in Cabrobó - Pernambuco1
Hítalo Thiago Gomes VieiraI; Jacqueline Eyleen de Lima OliveiraII; Rita de Cássia Maria NevesIII
IBS in Nursing. Address: Rua José Padilha, 108, cohab VI, Petrolina, CEP 56300-000, Pernambuco, Brazil. E-mail: hitalobodoco@hotmail.com
IIBS in Nursing. Address: Avenida Barão do Rio Branco, 799, ap.04, Centro, CEP 56300-000, Petrolina, PE, Brazil. E-mail: y.leen@hotmail.com
IIIPhD in Social Anthropology. Adjunct Professor at Universidade Federal do Rio Grande do Norte (UFRN). Address: Rua Dr. Otávio Maia, 2.554, Lagoa Nova, CEP 59077-060, Natal, RN, Brazil. E-mail: rcmneves@yahoo.com.br
ABSTRACT
INTRODUCTION: Traditional indigenous knowledge about health is based on a holistic approach, which in turn is founded on harmony between people, families and community and the universe that surrounds them. One of the challenges that precedes the work of health professionals is respect for differences, where the knowledge and technologies of biomedicine cannot be transmitted vertically, showing that recognition of the cultural and social diversity of indigenous people is vital.
OBJECTIVE: To identify the self-attention practices of Truká Indians and this population's relationship with biomedicine, witnessing the occurrence or absence of an interrelationship between biomedicinal practices and traditional healing systems.
METODOLOGY: This study is characterized as a qualitative research project. To conduct this survey, data were collected at the Truká's central base in Cabrobó and on indigenous territory, on Assunção Island. Data were collected between November 2010 and January 2011, when semi-structured interviews associated with the "Participant Observation" method were conducted, and a field diary was used. Twenty-one individuals took part in that research, including Truká Indians and professionals on a multidisciplinary Indian health team.
RESULTS: For the Truká Indians, the cure process is polysemic. It is composed of territory ownership, ritual practices such as the Toré ritual, prayers, and the use of homemade syrups and bottled herbal infusions. They use allopathic medicines in turn, in a process denominated intermedicality.
Keywords: Intercultural Contexts; South American Indians; Indian Health Policy; Indigenous Health.
Introduction
The current model of attending to indigenous health in Brazil has been managed since 1986 and the First National Conference on Protecting the Health of Indians; yet, even after all these years, it can still be considered a process under construction. We can include in this context the 1988 Federal Constitution itself, which recognizes the multiethnic nature of the Brazilian State. Article 215 § 3 item V affirms the "valorization of ethnic and regional diversity" in the country
These alterations in public policy related to indigenous health services show the need for a deeper discussion about the inter-relation between traditional healing practices and interventions in the field of biomedicine
Yet according to the National Policy for the Health of Indigenous Peoples (Brasil, 2002), the knowledge and technology of biomedicine should not be transmitted vertically. Recognizing social diversity and indigenous culture has become indispensable, as has giving the greatest value to respect for traditional health knowledge in providing specialized assistance.
It is in this sense that we speak of the importance of bringing together the relationships which exist between the different models of health care. As affirmed by Menendez (2003, 2009), biomedicine is conducted by specialized professionals, using practices which focus on the technical-scientific field and are based on biological, biochemical and genetic concepts. On the other hand, practices which Menendez calls "self-care" are broad and take into account the social, cultural, and economic aspects which influence decision making in relation to the process of health and illness, as well as the best path towards a cure while seeking balance for the individual as a whole.
The connection between this knowledge and these practices should be stimulated by achieving improvements in the state of indigenous peoples' health. One of the challenges which precedes actions by health professionals is respect for differences. It is in this sense that we speak of inter-medically as a "contact zone" in which biomedical and science-based knowledge interact with other non-medical knowledge in theory and in practice, as in the case of traditional knowledge regarding indigenous health (Greene, 1998; Follér, 2004). In general, health interventions are permeated with prejudices from common knowledge about Indians; these interventions are conducted without paying due respect to the socio-cultural aspects of the group, making it difficult to form connections between professionals and the population, compromising the successful execution of health activities and services.
In this project we sought to understand the relational process between traditional self-care practices and the use of biomedicine by the Truká Indians. It is important to stress that the objective of the study did not include specific knowledge of medicines and secret rituals. The research which generated this article was guided by the understanding of the inter-relation of various bio-medical practices and traditional cure systems.
Methodology
Population
The Truká Indians have a population of approximately 6,065 people, according to 2010 data from the Health Information System for Indigenous Peoples (Sistema de Informação da Atenção à Saúde Indígena: SIASI). The Trukás' territory is located in the municipality of Cabrobó, in the interior of the state of Pernambuco and includes the Island of Nossa Senhora de Assunção and another eighty small islands which are called the Assunção Archipelago, in the Lower-mid São Francisco River. This group has, in its process of constitution, remained in contact with the local society for more than three hundred years; it is historically composed of Indians from the old Rodelas region, as affirmed by Batista (2000, 2005a, 2005b).
This population's income is principally derived from the cultivation of rice and fish farming. Besides this, part of the population works in the city of Cabrobó. Fishing in the São Francisco River, which was common in the past, no longer takes place due to the scarcity of fish and the transformations through which this ethnic group has passed over the years of permanent contact with non-Indians.
During the research project, we identified that the Truká Indians have thirty villages; one of these was located in a part of the island which pertains to the municipality of Orocó, Pernambuco. There are still Indians who live outside the villages, in the city of Cabrobó; they are called desaldeados (non-villagers). These individuals did not receive primary health services in the city of Cabrobó. They traveled to the island and were sporadically served by temporary health clinics installed in the villages, but without direct monitoring by health agents.
The Truká received basic care from two Multidisciplinary Indigenous Health Teams (Equipes Multidisciplinares de Saúde Indígena: EMSI), which were composed of thirty-three health professionals: two doctors, two nurses, four nursing technicians, two dentists, two dental clinic assistants, eleven indigenous health agents, five community health agents and five indigenous sanitation agents.
Methodological Procedures
This study is characterized as a qualitative research study. To conduct this study, data were collected from the Truká central base in Cabrobó and in the Indigenous Territory on Assunção Island. Data were collected during the months of November 2010 and January 2011, when semi-structured interviews were conducted according to the method of participant observation, and observations were recorded in a field diary. The subjects of the research were twenty-one individuals including Truká Indians and professionals from the multidisciplinary indigenous health team.
Once this material was collected, a comprehensive reading was conducted by means of the content analysis method (Bardin, 2009) in the modality of "thematic transversal analysis". After transcribing the recorded interviews and reading them carefully, the data were organized into thematic categories to form the analytical corpus.
The steps adopted in analyzing all the data were: Categorization, with thematic transversal analysis, when the objectives of the research and the statements of the individuals interviewed were considered. Inference: The time when, looking again at the field diary and all the material collected about the Truká, premises were brought forth in accordance with the survey's objectives. Explicative Analysis: With the explicative models and the data which were already discussed, analyses were made with reference to the relation between traditional medicine and biomedicine in the Truká Indians.
The research on which this article was based followed the principles of the Helsinki Declaration, which was approved by the Research Ethics Committee of the Universidade de Pernambuco under registry number 182/08. All the interview subjects freely chose to participate in the interview, having been informed about and signed the Free and Clarified Terms of Consent.
Results and discussion
To consider the relationship of intermedicality between the Truká Indians and the Multidisciplinary Indigenous Health Teams (EMSI), it is imperative to discuss what traditional medicine means to the Truká. Further, it is necessary to understand the ways that the EMSI must act in considering cultural specifics in the area of health.
Truká Traditional Medicine
The Truká, as a group in permanent contact with non-Indians, occupy a situation which is similar with regards to health and sanitation to that of other groups in the region. Nevertheless, different from the surrounding population, the Truká have specific characteristics which place them into a unique context of understanding about health, sicknesses and healing processes.
Among these specific characteristics, it is necessary to consider that this population has always lived on islands in the São Francisco River. Besides Assunção Island, the place where they currently live and farm rice and onions, there are also indigenous people inhabiting other small islands in the São Francisco River.
Further, on the islands in the São Francisco, the Truká conduct rituals they call particular. Accordingly, the understanding of health for the natives of Assunção Island is more than curing the body, in the biological perspective. Health, for the Truká, holds a poly-semic significance and is made up of the Territory - homologated and uninvaded
It is also for this reason that the Truká oppose the rerouting of the São Francisco River, as well as the construction of dams by the São Francisco Hydro-Electric Company (Companhia Hidro Elétrica do São Francisco: Chesf). These enterprises alter the course and the flow of the river, affecting the Trukás' way of life. Furthermore, the dams could submerge islands which the Truká use for specific rituals, such as Ilha da Onça, which is inhabited by humans but is also the place where rituals take place and the Enchanted live.
The river is the most important thing. From here we take our sustenance, from here the enchanted are peopled with light. Here are the trees, the birds, the otters, thesigns of life and death. We are the river, and only one
(Truká pajé
When the Truká refer to health, however, they do not refer to only physical health or the body, but this entire complex system. In this way, they believe not only in the efficacy of biomedicine, but also in medicinal teas, offerings of prayers, the pajés and in the power of the São Francisco River, through its "Enchanted". In their shamanic-cosmological system, they consider the existence of diseases which are not curable by the bio-medical model, which does not mean that they do not adopt biomedical behaviors simultaneously connected to self-care practices, as this statement from a Truká Indian attests:
I began to feel something strange, my body was weak, it was as if I could see some image, and then I began to get weak, I kept going to the doctor and there was no solution. When this happened to me, the only way I could be cured was through our table, our ritual. We have diseases that doctors cure and diseases that doctors do not cure. The diseases that doctors cure are those diseases which can be treated with medicine, with drugs, and the diseases that doctors don't cure are those that we seek out our Enchanted of the Light, for our way of working with our ritual
(Truká Indian 01, interview 2011).
This does not mean that there is a clearly defined separation between the types of disease. We verified in our research that the Truká make use of various health practices which are available to the indigenous population. In other words, they seek to follow biomedical directives together with the directives of traditional healing professionals. In addition, for some years now the Truká have suffered external influence within their territory through public enterprises such as the rerouting of the São Francisco River and the construction of hydro-electric dams which directly affect health in the most general terms.
Among the Truká, we identified a preoccupation with valorizing indigenous medicine which, according to reports, has been losing ground among the younger generations. It was also noted that even among all the difficulties and conflicts over territory, the Toré is a healing ritual as well as a cultural element which characterizes and distinguishes the Truká from the non-Indians of the region.
...the Indians here today are very civilized, seeking more alternatives, they forget that there are good things that nature offers and many don't look for. Some look for them, others don't and go to the doctor.... (Truká Indian 03, interview 2010).
we have our defenses too, with our prayers, our toré that can cure this disease (Truká Indian 01, interview 2011).
...I feel relieved, I don't know if it is because it is my family belief, but when I go there for him to pray over me I feel good. Today many people no longer believe in the prayer, and just go out dancing, having fun and they don't want to know about these things, but I believe in them very much (Truká Indian, interview 2010).
Therapeutic itinerary and healing practices
With relation to the therapeutic itinerary and healing practices, it was noted that the Truká regularly use biomedicine and indigenous medicine simultaneously. It is the path taken from the moment that the illness is perceived until treatment which varies greatly. Some initiate the process by using teas and homemade syrups, often relying on indigenous healers (pajé, prayer-healers, etc.); others in turn first sought out the biomedical clinic and only when this proved ineffective did they seek another cure. Actually, the most important factor in working with the therapeutic itinerary and the various healing practices is not just identifying where the therapeutic process begins, but understanding the network of connections between traditional and biomedical health practices and the sociocultural process of interaction and negotiation relative to what we call malaise (Young, 1976). We verified that, in both cases, the Truká used traditional medicine based on the interpretation and the perceived dimension of the illness.
...in many cases [the Truká] ask for prayer and the child really improves, with no medication, only prayer, and the prayer-healer prescribes some type of tea; they go home and make it, and the child gets better, and it isn't necessary to go to the doctor"
(professional 01, Community Health Agent, interview 2010).
The inter culturally dimension represents an important factor when we consider the diversity of healing practices that the Truká use, especially as this is an indigenous community and legislation recognizes the need to connect diverse health practices. The Truká complained on many occasions that the EMSI doctors were not interested in the community. The closest relationship they had was with the nurses, the nursing assistants and the health agents, but even this relationship was often the target of problems in day-to-day work with the Truká population.
In field work, upon observing a dialog between an indigenous health agent and a Truká Indian in a clinic in the village, we perceived the difficulty in communication, even considering that both parties were indigenous people. The indigenous health agent stated that the samples collected in exams to prevent cervical cancers had been lost in Recife and that it was necessary to get new samples. The Truká woman responded that the exam had made her feel ill (malaise) and that she would not repeat it, because for several days after the first exam she had an "impatience" which, according to her, "made me want to run away like a mad woman" and furthermore, she had bled for a few days. The health agent affirmed that it was very important to repeat the exam because the bleeding could have been a result of some infection, but the woman reassured the agent that she was fine thanks to a "a little white medicine" that the neighbor had given her, followed by taking a bath in the river and being prayed over. She also stated to the indigenous health agent that she would not risk getting ill again because of an exam.
During the research, it was observed that the Truká Indians believe in forms of medical treatment as long as a coherent investigation into the possible causes of the illness occurs. When this does not occur, or when the explanation is not convincing, the tendency is to seek other modes of healing, just as in non-indigenous society. Gil (2007) also identified an appreciation for pharmacy drugs among the Yaminawa Indians, but affirms that when someone becomes ill the search for these medications happens alongside the use of other native techniques. In actuality, this is a common reality among Indians and non-Indians. Humans have an imminent need to understand the meaning of the ills that they are afflicted with.
"You have to go to the doctor if that medicine doesn't work, then they'll tell me, they'll request some tests to see what it is that's happening to me, because it's not normal, if you are so sick and you take medicine and you don't get better, then you have to take other measures, you can't stay sick.... he [the doctor] prescribes the right medicine for the illness, it depends on what I tell him, he will check the whole person..." (Truká Indian 02, interview 2010).
"I went to the doctor, and he gave me a medicine, a medicine that passes out into the urine [....] that does nothing, then I went home and took the coconut berries and I got better. He has prescribed it several times to other people and it doesn't work (Truká Indian 03, interview 2010).
"I always take the pharmacy medicine right away, because it works more quickly on the disease, fighting the pain more right away (Truká Indian 04, interview 2010).
Final considerations
Four national health conferences were realized in order to debate the indigenous issue: the first occurred in 1986, titled the First National Conference on Protecting the Health of the Indian, and its objective was the recognition of traditional health knowledge. The Second National Conference on Health for Indigenous Peoples took place in 1993, and reiterated the defense of the DSEI model. Next was the Third National Conference on Indigenous Health in 2001, which sought to analyze the obstacles faced and progress made by the National Health System in implanting DSEIs; last was the Fourth National Conference on Indigenous Health in 2006. Although it was highly criticized, it emphasized the need to respect traditional healing practices. Despite the difficulties and problems faced over the years, these conferences formed the base upon which a model of differentiated care was built.
These conferences, as well as the legislation that was the foundation for the national policy on indigenous health, also stressed respect for the "traditional medicine" practiced by indigenous populations. However, it did not make any advances in bringing about a policy aimed at this field of knowledge. During the survey, it was observed that often the health professionals encouraged patients to use traditional healing practices, but without great concern for making a connection. Actually, we observed that FUNASA is not, at least not in the reality of the Truká population, concerned with guiding a health policy which would form a connection between diverse health practices. This continues to be the responsibility of each professional. When he or she is concerned with establishing communication with the population, the connection is made, but when the professional is not interested, there is no concern on the part of the agencies which are charged with establishing activities focusing on this issue.
This indicates important concepts such as "interculturality", which appears often in official documents, and the concept of "intermedicality" or "therapeutic plurality" as presented in this project. When we take interculturality as a community praxis, in the sense proposed by Ozório (2005), it appears to us not as realities which are in themselves heterogeneous, labeled "traditional indigenous medicine", or "biomedicine", but as spaces of tradeoffs, resources which are shared, contested, negotiated.
With relation to intermedicality, as utilized by Follér (2004), the concept is considered to present biomedicine interacting with other knowledge in theory and practice. It is presupposed that in intermedicality there is at least one link between the various discourses of knowledge. Although the logic of biomedicine and indigenous medicine makes use of different criteria to evaluate the outcome or conclusion of a treatment, attributing efficacy or not, there are certainly points of contact which interact and establish intercommunication.
Professionals should understand that the individuals are entering into contact with another cosmological system with different norms when they move from one field to the other. The relationship with the other system of meaning and norms may not lead to a significant change, as the individual may have had prior experience with this reality; its values may not even be extremely different from those which were proposed, as in the case of the Truká. Even so, this is a demanding and difficult experience, even more so when other values are imposed as something to be accepted.
For Garnelo and Langdon (2005), it is important to know the forms of organization and the social networks which sustain the existence of a multiplicity of therapeutic systems. It should not be forgotten that all people routinely utilize various therapeutic practices simultaneously. In the Truká population, these modes of healing are often the target of prejudice, leading people to hide their traditional practices, especially when referring to rituals and beliefs.
Among the cure practices, the Toré ritual is a cultural element which identifies and characterizes Indians in the northeast region of Brazil. Just like health, the Toré is polysemic: it involves a joyful dance called the brincadeira de índio, a private ritual and a public ritual which consecrates the ethnic group, as well as being totally incorporated into the indigenous movement as a form of political expression. The Truká utilize the Toré in the search for cures and in the process of defining territories, as affirmed in interviews and in the literature on the subject (Oliveira, 1999; Grünewald, 2005; Athias, 2007).
As cited earlier, Menendez (2003, 2009) uses the concept of self-attention to attempt to understand this diversity in healing processes. This concept is made up of techniques used individually or collectively to diagnose, explain, control, relieve, cure, or prevent the processes which affect well-being without direct intervention from specialized professionals. It is observed that the Truká Indians value rituals very much; they also value homemade medicines and allopathic medicines, and typically keep a small stock of medicine in their homes as a resource in emergencies.
The majority of health professionals are not capable of recognizing diversity in self-care practices. For Menendez (2003), the majority of the population uses various forms of care not only for different problems, but also for the same health problem. When we speak of understanding self-care practices and relationships established between biomedicine and traditional medicine, we keep in mind that this method should be guided by a relational process of "treatment and dialogue".
As affirmed by Gadamer (2006) in "The hidden character of health", in the area of medicine, dialog is more than a simple introduction to the treatment, it is the treatment itself. The problem is that "treatment" is also connected to the notion of "therapy", which is the Greek word for "service"; in other words, in the field of biomedicine, the treatment is determined by submission (service) and the distancing of the patient from the medical professional. How can we speak of intermedicality if biomedicine presents itself as being superior to other "wisdom"?
Still in agreement with Gadamer (2006), the objective of the (technical) art of medicine is a cure, and the cure is not fully under the doctor's control. There is an illusion in medical science that makes us believe that anything is possible. Really, what we should ask is where does science fit into the art of medicine? It is only one part. We should not, therefore, take biomedicine as a synonym for science. Only in this way can we think about intermedicality or therapeutic plurality.
In seeking to understand the relationship between treatment and dialogue, we will obtain instruments to evaluate the indigenous health subsystem, mainly in relation to current health policy, which declares that traditional healing practices should be respected and not substituted with biomedical services in primary care, but which does little to implement inter cultural policies for care.
With relation to the biomedical professional who works in indigenous areas, a special concern with health requires this professional to work with special attention, capable of understanding not only his or her own health system, but also respecting the knowledge, strategies, meanings and traditions of the populations with whom he or she works, which does not mean "instrumentalize traditional practices which can be tested and verified by biomedicine with regards to their efficacy" (Langdon and Diehl, 2007, p. 31). In conclusion, we point to the need for new research on the topic of intermedicality, mainly because, as we have already seen, the issue of indigenous health is continuously in a state of political restructuring and reformulation. Furthermore, in this new configuration, with the creation of the Special Secretary for Indigenous Health (Secretaria Especial de Saúde Indígena -SESAI), it is necessary to look at the victories in indigenous health, but also at the failures and shortcomings of National Indian Foundation (FUNAI) and FUNASA in directing this care and mainly consider the proposals set forth in the documents, experiences and reports which were created in this period and which were left outside the structure of the system. It is, consequently, important to establish measures which give value to the "connection" between traditional healing practices and biomedicine.
Acknowledgements
We would like to thank the Truká Indians for dedicating their time to this research, especially Neguinho Truká and Yssor Truká for giving their consent for us to carry out this research in indigenous territory. Also, we thank the professionals on the Multiprofessional Indigenous Health Teams, the Local and District Councils, as well as the managers of the National Health Foundation. Special thanks go to Maria de Fátima, Rosa, Wilson and José Pedro for their support and cooperation during the study.
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Publication Dates
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Publication in this collection
23 Aug 2013 -
Date of issue
June 2013
History
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Received
17 June 2011 -
Accepted
19 Oct 2012 -
Reviewed
29 Sept 2012
