HEALTHȱPOLICY:ȱSERVICESȱANDȱCULTURALȱ PRACTICESȱȱ

HEALTHȱPOLICY:ȱSERVICESȱANDȱCULTURALȱ PRACTICESȱȱ

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EstherȱJeanȱLangdonȱ ȱ ȱ

Duringȱtheȱlastȱfiftyȱyears,ȱtheȱpositionȱofȱminorityȱgroupsȱwithȱ respectȱ toȱ theȱ largerȱ societyȱ hasȱ transformedȱ significantly.ȱ Internationalȱ decrees,ȱ asȱ wellȱ asȱ nationalȱ legislations,ȱ haveȱ recognizedȱtheȱpluriȬethnicȱnatureȱofȱtheȱStateȱandȱtheȱnecessityȱ toȱ guaranteeȱ theȱ rightsȱ andȱ theȱ respectȱ forȱ differentȱ ethnicȱ groups.ȱ Inȱ Latinȱ America,ȱ theseȱ legalȱ changesȱ haveȱ beenȱ accompaniedȱbyȱtheȱemergenceȱofȱindigenousȱorganizationsȱasȱ anȱ importantȱ forceȱ inȱ theȱ politicalȱ arena.ȱ Inȱ Brazilȱ increasedȱ visibilityȱofȱethnicityȱhasȱresultedȱinȱchangesȱinȱtheȱpolicyȱandȱ organizationȱ ofȱ healthȱ servicesȱ thatȱ aimȱ atȱ inclusionȱ ofȱ indigenousȱ peoplesȱ throughȱ “differentiatedȱ attention”.ȱ Differentiatedȱ attentionȱ aimsȱ atȱ inclusionȱ ofȱ Indianȱ peoplesȱ throughȱ theȱ creationȱ ofȱ aȱ subsystemȱ ofȱ healthȱ servicesȱ thatȱ isȱ separateȱfromȱtheȱUnifiedȱNationalȱHealthȱServiceȱ(SUS),ȱwhichȱ isȱ responsibleȱ forȱ providingȱ healthȱ attentionȱ toȱ Brazilianȱ citizens.ȱ Likeȱ SUS,ȱ theȱ subsystemȱ isȱ basedȱ onȱ theȱ principlesȱ ofȱ socialȱcontrolȱbyȱtheȱcommunityȱandȱincludesȱspecialȱreferenceȱ ofȱ“recognition”ȱandȱ“respect”ȱforȱtheȱculturalȱparticularitiesȱofȱ eachȱ groupȱ andȱ itsȱ “traditional”ȱ knowledge.ȱ Afterȱ aȱ reviewȱ ofȱ theȱ changesȱ inȱ theȱ Indianȱ healthȱ policyȱ andȱ services,ȱ Iȱ presentȱ recentȱ researchȱ thatȱ highlightsȱ theȱ problemsȱ facingȱ theȱ organizationȱ ofȱ differentiatedȱ attentionȱ andȱ theȱ problemsȱ hinderingȱ implementationȱ ofȱ aȱ healthȱ systemȱ thatȱ pretendsȱ toȱ includeȱ notȱ onlyȱ theȱ membersȱ ofȱ aȱ minorityȱ group,ȱ butȱ alsoȱ theirȱknowledgeȱandȱpracticesȱinȱhealth.ȱȱ

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TheȱRiseȱofȱEthnicityȱ ȱ

Conventionȱ 169ȱ regardingȱ Indigenousȱ andȱ Tribalȱ peopleȱ inȱ IndependentȱCountries,ȱapprovedȱbyȱ85%ȱofȱtheȱmemberȱStatesȱ ofȱ theȱ Internationalȱ Laborȱ Organizationȱ inȱ 1989,

ȱ wasȱ theȱ firstȱ internationalȱlegalȱinstrumentȱdesignedȱtoȱprotectȱIndianȱrightsȱ (Luzȱ 1995:102).ȱ Itȱ calledȱ forȱ theȱ recognitionȱ ofȱ andȱ respectȱ forȱ theȱ culturalȱ diversityȱ ofȱ nativeȱ peoplesȱ inȱ allȱ dimensions,ȱ includingȱ employment,ȱ education,ȱ andȱ health,ȱ amongȱ othersȱ (italicsȱbyȱtheȱauthor).ȱAnȱearlierȱConvention,ȱadoptedȱinȱ1957,ȱ promotedȱtheȱgradualȱintegrationȱofȱIndiansȱintoȱtheirȱnationalȱ societiesȱandȱregardedȱtheȱnativeȱpeoplesȱasȱcollaboratorsȱinȱtheȱ effortsȱtoȱachieveȱtheirȱintegration.ȱConventionȱ169ȱrevertsȱthisȱ directiveȱ andȱ defendsȱ theirȱ rightsȱ toȱ socialȱ andȱ culturalȱ distinctiveness.ȱBesidesȱcallingȱforȱfullȱcitizenshipȱandȱequality,ȱ theȱ latestȱ Conventionȱ alsoȱ substitutesȱ theȱ notionȱ ofȱ eventualȱ collaborationȱ forȱ thatȱ ofȱ activeȱ participationȱ ofȱ theȱ indigenousȱ communityȱ inȱ legislativeȱ measuresȱ andȱ decisionsȱ thatȱ affectȱ itȱ directly.ȱ

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Theȱ changesȱ betweenȱ theȱ firstȱ andȱ secondȱ Conventionȱ reflectȱ theȱ growthȱ ofȱ indigenousȱ movementsȱ inȱ allȱ ofȱ Latinȱ America.ȱ Duringȱ theȱ 1950´s,ȱ theȱ Indiansȱ wereȱ anȱ ethnicȱ andȱ culturalȱ minority,ȱ excludedȱ fromȱ theȱ nationalȱ ideologiesȱ (Gussȱ 1994).ȱ Theirȱ presenceȱ inȱ variousȱ countriesȱ wasȱ ignored.ȱ Theyȱ wereȱ invisibleȱ inȱ theȱ laws,ȱ nationalȱ censuses,ȱ andȱ activitiesȱ ofȱ governmentalȱ institutionsȱ suchȱ asȱ thoseȱ relatedȱ toȱ health.ȱ Inȱ Brazil,ȱasȱinȱmanyȱcountries,ȱtheȱIndianȱwasȱseenȱasȱanȱobstacleȱ toȱ progress,ȱ whichȱ justifiedȱ theȱ policyȱ ofȱ integration.ȱ Theȱ formationȱ ofȱ Indigenousȱ movementsȱ andȱ politicalȱ associationsȱ overȱ theȱ lastȱ threeȱ decades,ȱ isȱ evidenceȱ ofȱ theȱ importanceȱ ofȱ identityȱ politicsȱ andȱ pointsȱ toȱ theȱ growthȱ ofȱ consciousnessȱ ofȱ Indianȱ identityȱ thatȱ isȱ expressedȱ inȱ variousȱ formsȱ (Turnerȱ 1991a,ȱ1991b;ȱLangdonȱandȱWiikȱ2008).ȱWithinȱtheȱlastȱ30ȱyears,ȱ Indigenousȱ movementsȱ haveȱ becomeȱ particularlyȱ visible,ȱ

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ȱȱItȱmustȱbeȱnotedȱthatȱBrazilȱonlyȱsignedȱthisȱdocumentȱinȱ2002.ȱ

givingȱ voiceȱ toȱ theirȱ identityȱ andȱ demandsȱ forȱ inclusion,ȱ andȱ Indiansȱ areȱ increasinglyȱ electedȱ toȱ publicȱ officesȱ inȱ variousȱ countries.ȱ

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Theȱsignificantȱincreaseȱinȱtheȱnumberȱandȱforceȱofȱindigenousȱ associationsȱ hasȱ influencedȱ nationalȱ andȱ internationalȱ politicsȱ regardingȱethnicȱminorities,ȱandȱtheȱpluriethnicȱcompositionȱofȱ theȱLatinȱAmericanȱStatesȱcanȱnoȱlongerȱbeȱnegated.ȱQuestionsȱ ofȱpower,ȱethnicity,ȱandȱinterethnicȱfriction

ȱpermeateȱeffortsȱforȱ inclusionȱ ofȱ Indianȱ peoples.ȱ Indigenousȱ associationsȱ areȱ farȱ fromȱ realizingȱ fullyȱ theirȱ objectives,ȱ andȱ theȱ attemptsȱ toȱ guaranteeȱ theȱ Indiansȱ theirȱ rightsȱ haveȱ notȱ beenȱ aȱ simple,ȱ norȱ alwaysȱ peaceful,ȱ process.ȱ Inȱ spiteȱ ofȱ theȱ factȱ thatȱ indigenousȱ peoplesȱ haveȱ yetȱ toȱ experienceȱ fullȱ citizenshipȱ inȱ aȱ societyȱ withoutȱ prejudiceȱ andȱ exploration,ȱ theȱ riseȱ ofȱ ethnicityȱ asȱ anȱ importantȱ politicalȱ forceȱ inȱ Latinȱ Americaȱ hasȱ hadȱ importantȱ consequencesȱinȱIndianȱhealthȱpolicy.ȱ

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Itȱisȱnecessaryȱtoȱconsiderȱtheȱriseȱofȱethnicityȱasȱaȱcentralȱfactorȱ inȱ theȱ historyȱ ofȱ Latinȱ Americaȱ inȱ theȱ recentȱ decadesȱ andȱ asȱ aȱ factorȱthatȱconfrontsȱtheȱLatinȱAmericanȱgovernments,ȱresultingȱ inȱtheȱreformulationȱofȱhealthȱpolicyȱandȱtheȱprovisionȱofȱhealthȱ servicesȱforȱnativeȱpeoples.ȱBrazil,ȱwhichȱbeganȱthisȱdiscussionȱ inȱtheȱ1980’s,ȱisȱconsideredȱbyȱmanyȱtoȱhaveȱtakenȱtheȱlead.ȱ ȱ

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TheȱEthnicȱSituationȱinȱBrazilȱ ȱ

Inȱ Brazil,ȱ theȱ Indianȱ isȱ aȱ minority,ȱ numericallyȱ andȱ ethnically.ȱ Theȱ Indigenousȱ populationȱ composesȱ approximatelyȱ 0.2%ȱ ofȱ theȱ Brazilianȱ populationȱ (Ricardoȱ 2002:15),ȱ estimatedȱ toȱ beȱ betweenȱ450,000ȱ(FUNAI)ȱandȱ600,000ȱ(InstitutoȱSocioambientalȱ 2010).ȱ Besidesȱ beingȱ numericallyȱ fewȱ inȱ comparisonȱ withȱ theȱ

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ȱ Interethnicȱ frictionȱ isȱ aȱ conceptȱ developedȱ byȱ Robertoȱ Cardosoȱ deȱ Oliveiraȱ

(1976)ȱtoȱcharacterizeȱtheȱtensionsȱbetweenȱtheȱindigenousȱandȱnonȬindigenousȱ

societiesȱinȱBrazil.ȱ

totalȱ population,ȱ theyȱ areȱ characterizedȱ byȱ aȱ multiplicityȱ ofȱ groupsȱandȱnativeȱlanguages.ȱTheȱmajorityȱofȱBrazilianȱIndiansȱ belongȱ toȱ microȱ societies.ȱ TwentyȬeightȱ percentȱ (28.2%)ȱ ofȱ theȱ 227ȱ indigenousȱ groupsȱ haveȱ aȱ populationȱ ofȱ fewerȱ thanȱ 200ȱ individualsȱ andȱ 77%ȱ haveȱ lessȱ thanȱ 1000.ȱ Consequently,ȱ itȱ isȱ impossibleȱ toȱ characterizeȱ aȱ singleȱ Indianȱ “culture”ȱ orȱ

“indigenousȱmedicine”.ȱȱ ȱ

Toȱ contributeȱ toȱ thisȱ situationȱ ofȱ culturalȱ heterogeneity,ȱ theȱ groupsȱareȱinȱvariousȱstatesȱofȱcontact.ȱAtȱoneȱextreme,ȱisolatedȱ orȱ semiȬisolatedȱ groupsȱ sufferȱ fromȱ theȱ impactȱ ofȱ theȱ violenceȱ andȱdiseasesȱofȱcontact.ȱAtȱtheȱother,ȱwhichȱisȱtheȱsituationȱforȱ theȱ majority,ȱ Indianȱ communitiesȱ areȱ inȱ frequentȱ orȱ continualȱ contactȱ withȱ theȱ greaterȱ society.ȱ Thisȱ latterȱ situationȱ characterizesȱmostȱregionsȱoutsideȱtheȱAmazon.ȱInȱtheȱSouth,ȱasȱ wellȱ asȱ inȱ theȱ Northeast,ȱ theȱ Indiansȱ sufferȱ fromȱ aȱ healthȱ situationȱsimilarȱtoȱthatȱofȱtheȱpoorȱinȱgeneral:ȱhighȱprevalenceȱ ofȱ malnutrition,ȱ tuberculosis,ȱ dentalȱ problems,ȱ intestinalȱ parasites,ȱalcoholȱandȱsubstanceȱabuseȱandȱsexuallyȱtransmittedȱ diseases,ȱ asȱ wellȱ asȱ highȱ rateȱ ofȱ infantȱ mortalityȱ andȱ lowȱ lifeȱ expectancyȱ(Santosȱ&ȱCoimbraȱ2003).ȱ

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Legislationȱ ȱ

Theȱ Brazilianȱ Federalȱ Constitutionȱ ofȱ 1988,ȱ consideredȱ toȱ beȱ progressiveȱ inȱ itsȱ inclusionȱ ofȱ indigenousȱ rights,ȱ devotedȱ anȱ entireȱchapterȱtoȱtheȱissue.ȱItȱguaranteesȱtheirȱ“originalȱrightsȱtoȱ theȱ landsȱ thatȱ theyȱ traditionallyȱ occupy”ȱ andȱ recognizesȱ theȱ authenticityȱ ofȱ theirȱ socialȱ organization,ȱ customs,ȱ language,ȱ beliefsȱ andȱ traditions.ȱ Inȱ practice,ȱ theȱ Constitutionȱ hasȱ notȱ resultedȱ inȱ theȱ guaranteeȱ ofȱ theseȱ rightsȱ andȱ thereȱ haveȱ beenȱ variousȱ attemptsȱ toȱ modifyȱ itȱ andȱ toȱ reduceȱ nativeȱ lands.ȱ However,ȱitȱmustȱbeȱrecognizedȱthatȱtheȱChapterȱwasȱtheȱresultȱ

“ofȱ aȱ strongȱ movementȱ ofȱ Indianȱ leadersȱ andȱ theirȱ

organizations,ȱ asȱ wellȱ asȱ theȱ differentȱ nonȬgovernmentalȱ

organizations,ȱ scientificȱ entities,ȱ churches,ȱ etc.”ȱ (Santosȱ

1995:104).ȱTheȱnumberȱofȱIndianȱorganizationsȱhasȱcontinuedȱtoȱ grow,ȱ andȱ variousȱ “emergent”ȱ groupsȱ haveȱ risenȱ fromȱ anonymityȱasȱaȱresultȱofȱtheȱadvantagesȱofȱinclusionȱinȱaȱsocietyȱ thatȱ hasȱ traditionallyȱ excludedȱ themȱ (Oliveiraȱ 1999,ȱ Bartoloméȱ 2006).

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IndianȱHealthȱPolicyȱandȱOrganizationȱ ȱ

Theȱ Constitutionȱ ofȱ 1988ȱ signaledȱ theȱ returnȱ toȱ democracyȱ inȱ Brazil.ȱ Inȱ thisȱ sameȱ decade,ȱ theȱ sanitaryȱ healthȱ reformȱ movementȱ resultedȱ inȱ theȱ Unifiedȱ Nationalȱ Healthȱ Systemȱ (Sistemaȱ Únicoȱ deȱ Saúde,ȱ SUS),ȱ thatȱ delegatesȱ moreȱ responsibilityȱandȱpowerȱtoȱtheȱmunicipalitiesȱandȱparticipationȱ ofȱitsȱcitizensȱinȱaȱprocessȱofȱdecentralization.ȱInȱtheȱfaceȱofȱthisȱ reform,ȱ theȱ firstȱ Nationalȱ Conferenceȱ forȱ theȱ Protectionȱ ofȱ Indianȱ Healthȱ wasȱ organizedȱ inȱ 1986ȱ inȱ orderȱ toȱ evaluateȱ theȱ healthȱ situationȱ andȱ toȱ formulateȱ aȱ specialȱ policyȱ thatȱ wouldȱ guaranteeȱ Indiansȱ theȱ rightȱ toȱ inclusionȱ inȱ healthȱ services,ȱ includingȱ inȱ theȱ municipalitiesȱ whereȱ theyȱ haveȱ beenȱ traditionallyȱexcluded.ȱ

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Untilȱ theȱ firstȱ Conference,ȱ thereȱ wasȱ noȱ definedȱ healthȱ policyȱ forȱ Indianȱ populationsȱ andȱ primaryȱ andȱ specializedȱ attentionȱ forȱ themȱ wasȱ neverȱ adequate.ȱ Initiallyȱ missionariesȱ providedȱ someȱhealthȱservicesȱtoȱIndianȱpopulations.ȱInȱ1910,ȱtheȱServiceȱ forȱ theȱ Protectionȱ ofȱ Indiansȱ (SPI)ȱ wasȱ createdȱ andȱ healthȱ wasȱ amongȱ itsȱ responsibilities.ȱ Whileȱ theȱ Serviceȱ mayȱ haveȱ savedȱ manyȱ tribesȱ fromȱ extermination,ȱ “pacificationȱ ofȱ hostileȱ tribesȱ occasionedȱ theȱ spreadingȱ ofȱ hunger,ȱ illnesses,ȱ disintegration,ȱ makingȱ theȱ Indiansȱ partȱ ofȱ theȱ mostȱ miserableȱ groupȱ ofȱ theȱ

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ȱ Forȱ anȱ excellentȱ discussionȱ regardingȱ theȱ importanceȱ ofȱ theȱ Indianȱ inȱ theȱ politicalȱarena,ȱinȱspiteȱofȱtheirȱsmallȱpercentageȱofȱtheȱBrazilianȱpopulation,ȱseeȱ Ramosȱ(1998).ȱ

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marginalȱsegmentsȱofȱsociety”ȱ(Costaȱ1989:68).

ȱThroughoutȱitsȱ existence,ȱ healthȱ servicesȱ wereȱ fewȱ inȱ number,ȱ sporadicȱ andȱ disorganized.

ȱ Systematicȱ dataȱ regardingȱ healthȱ conditionsȱ wereȱnotȱmaintainedȱandȱthereȱwasȱlittleȱresearch.ȱȱ

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Establishedȱinȱ1952,ȱTheȱNationalȱServiceȱofȱTuberculosisȱ(SNT)ȱ wasȱ perhapsȱ oneȱ ofȱ theȱ mostȱ effectiveȱ programsȱ duringȱ theȱ periodȱ ofȱ SPI.ȱ Itȱ wasȱ notȱ aimedȱ specificallyȱ atȱ Indianȱ groups,ȱ butȱ directedȱ itsȱ effortsȱ toȱ theȱ treatmentȱ ofȱ tuberculosisȱ amongȱ ruralȱ populationsȱ inȱ theȱ regionȱ ofȱ Upperȱ Xinguȱ andȱ Araguaiaȱ Rivers.ȱ Inȱ 1956ȱ theȱ Serviceȱ ofȱ Airȱ Sanitaryȱ Unitsȱ (Unidadesȱ Sanitáriasȱ Aéreasȱ Ȭȱ SUSA)ȱ alsoȱ beganȱ toȱ treatȱ isolatedȱ Indianȱ populations.

ȱ However,ȱ Indiansȱ inȱ greaterȱ contactȱ withȱ theȱ nationalȱsocietyȱwereȱnotȱcoveredȱbyȱtheseȱservices.ȱȱ

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TheȱSPIȱwasȱextinguishedȱandȱtheȱNationalȱIndianȱFoundationȱ (FUNAIȱ –ȱ Fundaçãoȱ Nacionalȱ doȱ Índio)ȱ wasȱ createdȱ inȱ 1967ȱ withȱaȱDepartmentȱdedicatedȱtoȱIndianȱhealthȱandȱchargedȱwithȱ prevention,ȱthroughȱvaccinations,ȱcontrolȱofȱagriculturalȱtoxins,ȱ andȱ parasitesȱ provisionȱ ofȱ primaryȱ healthȱ servicesȱ inȱ Indianȱ landsȱ andȱ mediationȱ withȱ specializedȱ healthȱ servicesȱ inȱ urbanȱ areas.ȱ However,ȱ aȱ systemȱ ofȱ adequateȱ andȱ regularȱ primaryȱ attentionȱwasȱneverȱcreatedȱdueȱtoȱlackȱofȱfinancialȱandȱhumanȱ resources.ȱ Healthȱ postsȱ establishedȱ withinȱ theȱ Indianȱ Areas

ȱ wereȱ generallyȱ staffedȱ byȱ aȱ singleȱ attendant,ȱ whoseȱ activitiesȱ wereȱ supplementedȱ byȱ infrequentȱ visitsȱ ofȱ healthȱ teams.ȱ Difficultȱ casesȱ andȱ thoseȱ needingȱ sophisticatedȱ treatmentȱ orȱ

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ȱThisȱcanȱbeȱclearlyȱwitnessedȱinȱtheȱhistoryȱofȱtheȱgenocideȱofȱtheȱXetáȱIndiansȱ inȱParanáȱinȱtheȱ1960´sȱ(Silvaȱ1998).ȱ

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ȱ Noelȱ Nutels,ȱ aȱ wellȱ knownȱ medicalȱ doctor,ȱ isȱ theȱ mostȱ knownȱ ofȱ theȱ SPI´sȱ healthȱprofessionalsȱforȱhisȱdedicationȱtoȱisolatedȱIndianȱgroups.ȱ

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ȱ Inȱ 1967,ȱ theȱ Paulistaȱ Schoolȱ ofȱ Medicineȱ foundedȱ itsȱ healthȱ assistanceȱ andȱ researchȱ programȱ inȱ theȱ Xinguȱ Indigenousȱ Park,ȱ whichȱ treatedȱ aȱ numberȱ ofȱ Indianȱgroupsȱofȱtheȱpark.ȱȱ

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ȱ Indianȱ Areaȱ (Áreaȱ Indígena)ȱ isȱ theȱ designationȱ forȱ territoryȱ thatȱ hasȱ beenȱ

demarcatedȱasȱIndianȱlandȱandȱisȱequivalentȱtoȱaȱreservationȱinȱmanyȱrespects.ȱ

diagnosisȱ wereȱ toȱ beȱ referredȱ toȱ theȱ localȱ hospitalsȱ and/orȱ theȱ Ministerȱ ofȱ Healthȱ servicesȱ withȱ whichȱ FUNAIȱ maintainedȱ agreements.ȱ Whenȱ required,ȱ patientsȱ wereȱ sentȱ toȱ FUNAI’sȱ regionalȱ headquarters,ȱ whereȱ theyȱ wouldȱ stayȱ atȱ theȱ “Indianȱ House”ȱ(CasaȱdoȱÍndio)ȱwhileȱreceivingȱtreatment.ȱ

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Theseȱ servicesȱ wereȱ highlyȱ unsatisfactoryȱ andȱ ineffective.ȱ Theȱ networkȱ didȱ notȱ functionȱ well,ȱ andȱ healthȱ servicesȱ wereȱ unprepared,ȱdisorganized,ȱinefficientȱandȱinsufficientȱtoȱattendȱ allȱ theȱ Indianȱ communities.ȱ Thereȱ wasȱ notȱ fullȱ coverageȱ ofȱ vaccinations,ȱ contributingȱ toȱ highȱ mortalityȱ rates.ȱ Attendantsȱ workingȱ inȱ Indianȱ healthȱ postsȱ lackedȱ adequateȱ training,ȱ systematicȱ evaluationȱ andȱ continuingȱ educationȱ programsȱ (Costaȱ 1989).ȱ Oftenȱ theirȱ roleȱ wasȱ limitedȱ toȱ distributionȱ ofȱ availableȱmedicationsȱshippedȱtoȱtheȱareaȱperiodically.ȱOutsideȱ theirȱ reservations,ȱ Indiansȱ wereȱ excludedȱ fromȱ accessȱ toȱ localȱ hospitalsȱandȱotherȱservicesȱdueȱtoȱdiscrimination.ȱTheȱ“Indianȱ Houses”ȱ inȱ theȱ regionalȱ centersȱ hadȱ inadequateȱ fundingȱ andȱ wereȱ overȱ crowdedȱ withȱ patientsȱ andȱ theirȱ families.ȱ Food,ȱ healthȱ supplies,ȱ andȱ professionalsȱ wereȱ oftenȱ insufficientȱ toȱ careȱ forȱ theȱ ill.ȱ Theseȱ housesȱ becameȱ knownȱ asȱ centersȱ ofȱ infectionȱ andȱ theȱ spreadȱ ofȱ disease,ȱ includingȱ sexuallyȱ transmittedȱdiseases.ȱȱ

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Atȱ theȱ sameȱ time,ȱ Indianȱ healthȱ statusȱ wasȱ deplorableȱ dueȱ toȱ factorsȱofȱmarginalizationȱandȱexclusion,ȱasȱwellȱasȱtoȱterritorialȱ lossȱ andȱ environmentalȱ degradationȱ thatȱ underminedȱ theȱ practiceȱ ofȱ traditionalȱ subsistenceȱ techniques.ȱ Theȱ followingȱ diagnosisȱ characterizedȱ Indianȱ healthȱ atȱ theȱ timeȱ ofȱ theȱ Firstȱ NationalȱConferenceȱforȱtheȱProtectionȱofȱIndianȱHealthȱinȱ1986:ȱ

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Theirȱ sanitaryȱ conditionsȱ inȱ generalȱ areȱ notȱ satisfactory.ȱ Amongȱ otherȱ

problems,ȱweȱcanȱciteȱtheȱhighȱprevalenceȱofȱendemicȱdiseasesȱsuchȱasȱ

tuberculosis,ȱ malaria,ȱ intestinalȱ parasitesȱ andȱ theȱ frequentȱ epidemicȱ

outbreaksȱ ofȱ diseasesȱ provokedȱ byȱ viruses.ȱ Thereȱ isȱ aȱ highȱ prevalenceȱ

ofȱ diseasesȱ dueȱ toȱ deficiencies,ȱ amongȱ these,ȱ malnutrition;ȱ mentalȱ

problemsȱ dueȱ toȱ alcoholism;ȱ precariousȱ oralȱ health;ȱ andȱ poorȱ basicȱ

sanitationȱconditionsȱ(Mirandaȱetȱal.ȱ1988:25).ȱȱ

Inȱsum,ȱatȱtheȱtimeȱofȱtheȱFirstȱConferenceȱinȱ1986,ȱtheȱsituationȱ ofȱ Indianȱ healthȱ wasȱ precariousȱ andȱ theȱ servicesȱ wereȱ characterizedȱ byȱ inadequateȱ infrastructureȱ inȱ theȱ Indianȱ Areasȱ andȱ lackȱ ofȱ healthȱ professionals,ȱ economicȱ resourcesȱ andȱ anȱ efficientȱ networkȱ ofȱ primary,ȱ secondaryȱ andȱ specializedȱ attention.ȱThereȱwasȱnoȱsystematicȱcollectionȱofȱepidemiologicalȱ data.ȱ Furthermore,ȱ FUNAI,ȱ withȱ itsȱ variousȱ problemsȱ andȱ incapacityȱtoȱattendȱtheȱdemandsȱofȱIndianȱhealth,ȱintendedȱtoȱ abandonȱ itsȱ educationalȱ andȱ healthȱ responsibilitiesȱ andȱ dedicateȱitsȱeffortsȱtoȱlandȱdemarcation.

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Attendedȱbyȱhealthȱprofessionals,ȱanthropologists,ȱmembersȱofȱ nonȬgovernmentalȱ organizationsȱ andȱ governmentalȱ functionaries,ȱtheȱFirstȱConferenceȱalsoȱhadȱaȱsizeableȱgroupȱofȱ Indianȱ representatives.ȱ Theirȱ inclusionȱ wasȱ indicativeȱ ofȱ theȱ growthȱofȱtheȱpoliticalȱforceȱofȱȱtheirȱorganizationsȱinȱBrazilȱandȱ wasȱ importantȱ forȱ theȱ successȱ ofȱ theȱ Conferenceȱ (Uniãoȱ dasȱ Naçõesȱ Indígenasȱ 1988).

ȱ Amongȱ theȱ concludingȱ resolutions,ȱ threeȱ areȱ importantȱ forȱ understandingȱ subsequentȱ Indianȱ healthȱ policiesȱ andȱ organizationȱ ofȱ servicesȱ designedȱ toȱ guaranteeȱuniversalȱrightȱtoȱhealth:ȱimmediateȱestablishmentȱofȱ aȱspecificȱsubsystem,ȱwithȱtheȱcreationȱofȱanȱagencyȱlinkedȱdirectlyȱtoȱ theȱ Ministryȱ ofȱ Health;ȱ aȱ modelȱ ofȱ differentiatedȱ attentionȱ thatȱ respectsȱ theȱ culturalȱ particularitiesȱ andȱ traditionalȱ practicesȱ ofȱ eachȱgroup;ȱandȱinclusionȱofȱcommunityȱmembersȱinȱplanning,ȱ organization,ȱ execution,ȱ andȱ evaluationȱ ofȱ healthȱ servicesȱ (italicsȱ byȱ theȱ author).ȱ Inȱ 1988,ȱ theȱ Nationalȱ Constitutionalȱ

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ȱ ȱ Oralȱ communicationȱ madeȱ byȱ Marcosȱ Antonioȱ Guimarâes,ȱ Headȱ ofȱ theȱ Healthȱ Sectorȱ ofȱ FUNAI,ȱ inȱ aȱ symposiumȱ onȱ Indianȱ Healthȱ andȱ theȱ Unifiedȱ Systemȱ ofȱ Health,ȱ 26Ȭ27ȱ ofȱ Octoberȱ ofȱ 1989,ȱ Rioȱ deȱ Janeiro.ȱ FUNAI´sȱ positionȱ regardingȱ itsȱ responsibilitiesȱ inȱ theȱ areaȱ ofȱ healthȱ hasȱ changedȱ severalȱ timesȱ duringȱ theȱ lastȱ fifteenȱ yearsȱ dependingȱ uponȱ theȱ legislationȱ inȱ vigorȱ andȱ politicalȱandȱeconomicȱfactors.ȱȱ

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ȱInȱspiteȱofȱtheirȱactiveȱandȱrespectedȱparticipationȱinȱtheȱConference,ȱtheȱbetterȱ

hotelsȱ inȱ Brasíliaȱ wereȱ notȱ accustomedȱ toȱ receivingȱ Indians,ȱ andȱ certainȱ

problemsȱ aroseȱ betweenȱ theȱ Indianȱ guestsȱ andȱ theȱ hotelȱ workersȱ whereȱ Iȱ andȱ

otherȱanthropologistsȱwereȱlodged.ȱȱ

Assemblyȱ incorporatedȱ theseȱ principlesȱ andȱ guaranteedȱ theȱ rightȱ toȱ completeȱ andȱ differentiatedȱ healthȱ attentionȱ forȱȱ Indians.ȱ However,ȱ itȱ tookȱ anotherȱ tenȱ yearsȱ forȱ legislativeȱ approvalȱofȱtheȱdifferentiatedȱsubȬsystem.ȱ

ȱ ȱ

Inȱ 1991,ȱ aȱ Presidentialȱ Decreeȱ setȱ inȱ motionȱ reȬorganizationȱ ofȱ Indianȱ healthȱ servicesȱ byȱ creatingȱ theȱ Coordinationȱ ofȱ Indianȱ Healthȱ (Coordenaçãoȱ deȱ Saúdeȱ Indígenaȱ Ȭȱ COSAI),ȱ withinȱ theȱ NationalȱFoundationȱofȱHealthȱ(FundaçãoȱNacionalȱdeȱSaúdeȱȬȱ FUNASA)

.ȱ Theȱ Coordinationȱ wasȱ chargedȱ withȱ theȱ responsibilityȱforȱhealthȱattentionȱinȱIndianȱareasȱbutȱitȱdidȱnotȱ haveȱ theȱ autonomyȱ specifiedȱ byȱ theȱ Firstȱ Conference.ȱ Inȱ addition,ȱ theȱ Decreeȱ resultedȱ inȱ aȱ seriesȱ ofȱ conflictsȱ andȱ bureaucraticȱ confusionsȱ withȱ FUNAIȱ thatȱ continuedȱ throughoutȱtheȱdecade.ȱȱȱ

ȱ

Inȱanȱattemptȱtoȱresolveȱtheȱproblemsȱandȱestablishȱanȱadequateȱ system,ȱ theȱ Secondȱ Nationalȱ Conferenceȱ onȱ Indianȱ Healthȱ inȱ 1993ȱ calledȱ forȱ theȱ creationȱ ofȱ anȱ autonomousȱ subsystemȱ ofȱ primaryȱ servicesȱ inȱ Indianȱ Areasȱ organizedȱ throughȱ Specialȱ Indianȱ Healthȱ Districtsȱ (Distritoȱ Sanitárioȱ Especialȱ Indígenaȱ –ȱ DSEI)ȱ(Vargaȱ&ȱAdornoȱ2001).ȱItȱalsoȱreaffirmedȱtheȱprincipleȱofȱ communityȱ participationȱ fundamentalȱ toȱ theȱ conceptȱ ofȱ theȱ healthȱdistrictȱ (Mendesȱ1995)ȱasȱ wellȱasȱ respectȱforȱindigenousȱ culturesȱandȱtheirȱtraditionalȱhealthȱpractices.ȱInȱ1994ȱaȱsecondȱ DecreeȱattemptedȱtoȱresolveȱtheȱdisputeȱbetweenȱFUNASAȱandȱ FUNAIȱ byȱ dividingȱ theirȱ responsibilitiesȱ respectivelyȱ betweenȱ preventionȱ(vaccinations,ȱsanitation)ȱandȱprimaryȱattention,ȱbutȱ itȱ failedȱ toȱ recommendȱ aȱ systemȱ basedȱ onȱ Sanitaryȱ Districts.ȱ Throughoutȱ theȱ 1990s,ȱ Indianȱ healthȱ servicesȱ continuedȱ toȱ beȱ basedȱ onȱ anȱ unsuccessfulȱ distributionȱ ofȱ responsibilitiesȱ betweenȱ governmentalȱ andȱ nonȬgovernmentalȱ institutions,ȱ includingȱFUNASA,ȱFUNAI,ȱmunicipalities,ȱnonȬgovernmentalȱ organizationsȱandȱuniversities.ȱThereȱwasȱaȱlackȱofȱcoordinationȱ

10

ȱ FUNASAȱ wasȱ createdȱ outȱ ofȱ aȱ seriesȱ ofȱ otherȱ healthȱ institutesȱ andȱ Indianȱ

healthȱhasȱneverȱbeenȱitsȱmostȱimportantȱresponsibilityȱ(Teixeiraȱ2008).ȱ

andȱ clearȱ delegationȱ ofȱ responsibilities.ȱ Theȱ exactȱ roleȱ ofȱ theȱ universitiesȱ wasȱ notȱ wellȱ defined,ȱ andȱ itȱ includedȱ research,ȱ consultancies,ȱ provisionȱ ofȱ servicesȱ andȱ theȱ trainingȱ ofȱ healthȱ professionalsȱ and/orȱ Indians.ȱ Aȱ lawȱ proposingȱ theȱ Indianȱ Healthȱ subsystemȱ calledȱ forȱ byȱ theȱ Firstȱ andȱ Secondȱ Nationalȱ ConferencesȱandȱbasedȱonȱtheȱdemocraticȱprincipleȱofȱSanitaryȱ Districtsȱ wasȱ presentedȱ toȱ Congressȱ inȱ 1994,ȱ butȱ itȱ wasȱ notȱ approvedȱuntilȱmidȬ1999.ȱȱ

ȱ ȱ

Duringȱtheȱ1990s,ȱdiscussionȱaboutȱtheȱroleȱofȱtheȱIndianȱHealthȱ Agentȱ (AIS)ȱ emergedȱ asȱ aȱ strategyȱ promotingȱ communityȱ participationȱ inȱ theȱ deliveryȱ ofȱ healthȱ servicesȱ andȱ culturallyȱ sensitiveȱ healthȱ careȱ (Langdonȱ etȱ al.ȱ 2006,ȱ Langdonȱ etȱ al.ȱ inȱ press).ȱ Theȱ Indianȱ Healthȱ Agentȱ wasȱ conceivedȱ ofȱ asȱ theȱ mediatorȱ betweenȱ biomedicalȱ servicesȱ andȱ indigenousȱ healthȱ practices.ȱ Inȱorderȱ toȱfulfillȱ thisȱ role,ȱ trainingȱ wasȱ supposedȱ toȱ includeȱ anthropology,ȱ healthȱ politicsȱ andȱ theȱ organizationȱ ofȱ theȱ healthȱ systemȱ asȱ wellȱ asȱ basicȱ notionsȱ ofȱ biomedicineȱ (etiology,ȱ diagnosis,ȱ treatment),ȱ nursingȱ techniquesȱ andȱ communityȱ health.ȱ Itȱ shouldȱ alsoȱ includeȱ aȱ discussionȱ onȱ traditionalȱmedicineȱandȱindigenousȱviewsȱofȱtheȱhealthȬillnessȱ process,ȱ curingȱ andȱ deathȱ asȱ relatedȱ toȱ theȱ cosmologyȱ ofȱ theȱ communityȱ(Santosȱetȱal.ȱ1996,ȱcf.ȱCardosoȱ2001).ȱSponsoredȱbyȱ NGOs,ȱ universities,ȱ andȱ FUNASA,ȱ aȱ numberȱ ofȱ coursesȱ wereȱ implemented.ȱSomeȱIndiansȱwereȱalsoȱtrainedȱandȱemployedȱinȱ aȱparallelȱgovernmentalȱprogramȱofȱCommunityȱHealthȱAgentsȱ (PACS).ȱ However,ȱ throughoutȱ theȱ 1990´sȱ thoseȱ trainedȱ oftenȱ wereȱ notȱ subsequentlyȱ employedȱ dueȱ toȱ lackȱ ofȱ funding,ȱ andȱ thoseȱ luckyȱ toȱ beȱ contractedȱ frequentlyȱ lackedȱ adequateȱ supervisionȱ(Langdonȱ2004).ȱ

ȱ ȱ

Socialȱ control,ȱ anotherȱ importantȱ principleȱ associatedȱ withȱ theȱ healthȱpoliticsȱofȱinclusion,ȱisȱdefinedȱbyȱMachadoȱ(1986:299)ȱasȱ

“aȱ setȱ ofȱ interventionsȱ inȱ whichȱ theȱ differentȱ socialȱ forcesȱ

influenceȱ theȱ formulation,ȱ executionȱ andȱ evaluationȱ ofȱ publicȱ

policyȱ inȱ health”.ȱ Itȱ functionsȱ throughȱ theȱ creationȱ ofȱ healthȱ

councilsȱ andȱ nationalȱ conferencesȱ withȱ democraticȱ

representation.ȱ Duringȱ theȱ 1990sȱ thereȱ wereȱ attemptsȱ toȱ createȱ localȱ andȱ regionalȱ Indianȱ healthȱ councilsȱ toȱ guaranteeȱ Indianȱ participation,ȱ butȱ theirȱ institutionalizationȱ confrontedȱ variousȱ problemsȱandȱfewȱwereȱeffectivelyȱestablishedȱpriorȱtoȱ1999.ȱAtȱ theȱ nationalȱ level,ȱ theȱ Intersectorialȱ Commissionȱ ofȱ Indianȱ Healthȱ (Comissãoȱ Instersetorialȱ deȱ Saúdeȱ doȱ Índioȱ Ȭȱ CISI)ȱ wasȱ createdȱinȱ1991ȱasȱanȱadvisoryȱcommitteeȱtoȱtheȱNationalȱHealthȱ Councilȱ (Conselhoȱ Nacionalȱ deȱ Saúde).ȱ Overȱ theȱ yearsȱ itsȱ compositionȱ hasȱ varied,ȱ andȱ Indiansȱ haveȱ gainedȱ inȱ representationȱ andȱ leadership.ȱ CISIȱ foughtȱ forȱ theȱ establishmentȱ ofȱ aȱ subsystemȱ ofȱ Indianȱ healthȱ andȱ forȱ indigenousȱ representationȱ onȱ theȱ Nationalȱ Healthȱ Councilȱ throughoutȱtheȱdecade.ȱȱ

ȱ

Inȱ spiteȱ ofȱ theseȱ activities,ȱ theȱ questionȱ ofȱ Indianȱ healthȱ occupiedȱ littleȱ spaceȱ inȱ theȱ Nationalȱarena.ȱ Financialȱ resourcesȱ wereȱ insufficient.ȱ Theȱ Indiansȱ didȱ notȱ benefitȱ fromȱ fullȱ inclusionȱ inȱ theȱ Unifiedȱ Systemȱ ofȱ Nationalȱ Healthȱ andȱ theirȱ healthȱ situationȱ continuedȱ toȱ beȱ deplorableȱ (Verdumȱ 1995).ȱ Epidemiologicalȱdataȱwereȱlackingȱforȱmostȱgroups,ȱandȱneitherȱ FUNASAȱ norȱ theȱ municipalȱ healthȱ servicesȱ thatȱ wereȱ partȱ ofȱ theȱ Unifiedȱ Nationalȱ Healthȱ Systemȱ respondedȱ adequatelyȱ toȱ variousȱoutbreaksȱofȱdisease.ȱTheȱvoiceȱofȱCISIȱremainedȱweak,ȱ itsȱrecommendationsȱhavingȱlittleȱimpactȱonȱtheȱdeliberationsȱofȱ theȱNationalȱHealthȱCouncil.ȱȱ

ȱ ȱ

Researchȱ conductedȱ duringȱ thisȱ periodȱ revealsȱ aȱ stateȱ ofȱ

abandonmentȱ ofȱ primaryȱ healthȱ servicesȱ inȱ Indianȱ areas.ȱ Oneȱ

analysis,ȱ whichȱ examinedȱ oneȱ ofȱ theȱ municipalitiesȱ withȱ

adequateȱ quantitativeȱ data,ȱ comparedȱ mortalityȱ figuresȱ

betweenȱnonȬIndianȱandȱIndianȱpopulationsȱinȱtheȱStateȱofȱRioȱ

GrandeȱdoȱSulȱbetweenȱ1986ȱandȱ1995.ȱTheȱstudyȱfoundȱthatȱtheȱ

Indianȱ Areasȱ differedȱ fromȱ theȱ restȱ ofȱ theȱ Stateȱ byȱ aȱ higherȱ

numberȱofȱdeathsȱdueȱtoȱillnessesȱwithȱpoorlyȱdefinedȱcausesȱorȱ

toȱ thoseȱ thatȱ canȱ beȱ avoidedȱ throughȱ basicȱ healthȱ assistance,ȱ

suchȱ asȱ malnutrition,ȱ tuberculosis,ȱ andȱ cervicalȱ cancerȱ

(Hökerbergȱ etȱ al.ȱ 2001).ȱ Rioȱ Grandeȱ doȱ Sulȱ isȱ locatedȱ inȱ

Southernȱ Brasil,ȱ aȱ prosperousȱ regionȱ butȱ oneȱ inȱ whichȱ Indianȱ healthȱ statisticsȱ reflectȱ thoseȱ ofȱ theȱ poorestȱ regionsȱ ofȱ NortheasternȱBrazil.ȱ

ȱ ȱ

Inȱ 1995ȱ aȱ newȱ actorȱ enteredȱ theȱ sceneȱ inȱ theȱ formȱ ofȱ theȱ NationalȱProgramȱforȱSexuallyȱTransmittedȱIllnessesȱandȱAIDSȱ (Programaȱ Nacionalȱ deȱ Doençasȱ Sexualmenteȱ Transmitidasȱ eȱ AIDS),ȱ linkedȱ directlyȱ toȱ theȱ Ministerȱ ofȱ Health.ȱ Inȱ 1996ȱ itȱ initiatedȱactivitiesȱwithȱIndianȱcommunities.ȱAsȱopposedȱtoȱtheȱ situationȱofȱFUNASAȱandȱFUNAI,ȱthisȱprogramȱbenefitedȱfromȱ moreȱ autonomyȱ andȱ muchȱ greaterȱ financialȱ resourcesȱ inȱ theȱ formȱofȱinternationalȱloans.ȱUnderȱtheȱdirectionȱofȱaȱsociologistȱ assistedȱ byȱ anȱ anthropologist/physician,ȱ regionalȱ meetingsȱ wereȱ heldȱ inȱ 1997ȱ inȱ allȱ partsȱ ofȱ theȱ countryȱ inȱ orderȱ toȱ stimulateȱ preventionȱ andȱ educationalȱ programsȱ forȱ theȱ Indianȱ population.ȱ Inȱ 1998ȱ theȱ Programȱ financedȱ variousȱ projectsȱ proposedȱ byȱ theȱ universitiesȱ andȱ nonȬgovernmentalȱ organizationsȱinȱaȱpreventionȱcampaign.ȱInȱ1999,ȱitȱexpandedȱitsȱ activitiesȱ andȱ financingȱ toȱ includeȱ theȱ problemȱ ofȱ alcoholismȱ amongȱIndianȱcommunities.ȱBetweenȱ1996ȱandȱtheȱapprovalȱofȱ theȱSpecialȱIndianȱHealthȱDistrictsȱinȱ1999,ȱthisȱProgram,ȱwithȱaȱ farȱ betterȱ financialȱ situationȱ thanȱ FUNASA,ȱ perhapsȱ contributedȱmoreȱtoȱtheȱdiscussionȱofȱIndianȱhealthȱthanȱanyȱofȱ theȱotherȱgovernmentalȱprograms.ȱ

ȱ ȱ

Presidentialȱ Decreesȱ ofȱ 1991ȱ andȱ 1994,ȱ aimedȱ atȱ delegatingȱ

institutionalȱ responsibilitiesȱ forȱ theȱ organizationȱ ofȱ theȱ Indianȱ

healthȱ services,ȱ failedȱ toȱ establishȱ aȱ viableȱ structureȱ ofȱ

differentiatedȱ attention.ȱ Theȱ organizationȱ proposedȱ resultedȱ inȱ

confusedȱ andȱ complicatedȱ bureaucraticȱ andȱ administrativeȱ

structuresȱ characterizedȱ byȱ theȱ lackȱ ofȱ aȱ clearȱ definitionȱ ofȱ

responsibilitiesȱ inȱ planningȱ andȱ administrationȱ andȱbyȱ conflictȱ

ofȱ interestsȱ betweenȱ theȱ institutionsȱ involved.ȱ Healthȱ servicesȱ

forȱtheȱIndianȱpeoplesȱcontinuedȱtoȱbeȱchaoticȱandȱtheirȱhealthȱ

problemsȱ wereȱ withoutȱ effectiveȱ solution.ȱ Indianȱ communitiesȱ

didȱ notȱ knowȱ whoȱ wasȱ responsibleȱ forȱ theȱ resolutionȱ ofȱ theirȱ

chronicȱandȱemergentȱhealthȱproblems.ȱSomeȱgoodȱexperiencesȱ

ofȱ collaborationȱ betweenȱ theȱ variousȱ governmentalȱ andȱ nonȬ governmentalȱ institutionsȱ occurredȱ inȱ certainȱ locations;ȱ however,ȱtheyȱwereȱfewȱinȱcomparisonȱtoȱtheȱgeneralȱsituationȱ inȱ whichȱ servicesȱ forȱ indigenousȱ peoplesȱ sufferedȱ fromȱ organizationalȱ problems,ȱ conflictsȱ betweenȱ theȱ participatingȱ institutions,ȱ lackȱ ofȱ humanȱ andȱ financialȱ resources,ȱ lackȱ ofȱ communityȱ participation,ȱ andȱ anȱ increasingȱ dependenceȱ uponȱ theȱnonȬgovernmentalȱorganizationsȱtoȱprovideȱhealthȱservices.ȱȱ ȱ

ȱ

TheȱCreationȱofȱtheȱSpecialȱIndianȱHealthȱDistrictsȱ(DSEI)ȱ ȱ

Theȱ 1994ȱ proposalȱ forȱ theȱ creationȱ ofȱ aȱ subsystemȱ ofȱ Indianȱ Health,ȱ basedȱ onȱ theȱ organizationȱ ofȱ Specialȱ Indianȱ Healthȱ Districtsȱ (DSEIs),ȱ wasȱ finallyȱ approvedȱ inȱ 1999,ȱ andȱ FUNASAȱ wasȱ delegatedȱ fullȱ responsibilityȱ forȱ theȱ administrationȱ ofȱ Indianȱ health.ȱ Theȱ Coordinationȱ forȱ Indianȱ Healthȱ becameȱ theȱ Departmentȱ ofȱ Indianȱ Healthȱ andȱ beganȱ toȱ receiveȱ substantialȱ financialȱ support.ȱ Byȱ theȱ endȱ ofȱ thatȱ year,ȱ thirtyȬfourȱ Specialȱ IndianȱHealthȱDistrictsȱhadȱbeenȱorganized,ȱandȱtheȱnumbersȱofȱ professionalsȱ workingȱ inȱ Indianȱ healthȱ increasedȱ significantlyȱ asȱ multidisciplinaryȱ healthȱ teamsȱ wereȱ contractedȱ throughoutȱ theȱcountryȱtoȱattendȱinȱtheȱIndianȱAreas.ȱInȱtheȱfollowingȱyear,ȱ attemptsȱtoȱcreateȱsystemȱofȱlocalȱandȱDistrictȱHealthȱCouncilsȱ wereȱinitiatedȱforȱtheȱpurposeȱofȱsocialȱcontrol.

ȱ

ȱ ȱ

Geographicalȱ boundariesȱ ofȱ theȱ Healthȱ Districtsȱ doȱ notȱ followȱ

thoseȱ ofȱ theȱ municipalitiesȱ orȱ states,ȱ andȱ Districtsȱ varyȱ

significantlyȱ inȱ sizeȱ andȱ ethnicȱ composition.ȱ Someȱ encompassȱ

severalȱstatesȱandȱmultipleȱethnicȱgroups;ȱothersȱcorrespondȱtoȱ

partȱ ofȱ aȱ state’sȱ territoryȱ withȱ aȱ singleȱ orȱ aȱ fewȱ ethnicȱ groupsȱ

residingȱ withinȱ it.ȱ Eachȱ Districtȱ hasȱ anȱ administrativeȱ

headquartersȱ whichȱ isȱ inȱ chargeȱ ofȱ organizingȱ andȱ reȬpassingȱ

financialȱ resourcesȱ forȱ healthȱ servicesȱ thatȱ areȱ carriedȱ outȱ byȱ

nonȬgovernmentalȱ organizationsȱ andȱ municipalities.ȱ Districtȱ

healthȱ servicesȱ areȱ organizedȱ throughȱ “centralȱ bases,”ȱ whichȱ

hasȱ oneȱ orȱ moreȱ multiȬdisciplinaryȱ medicalȱ teams,ȱ composedȱ

minimallyȱ ofȱ aȱ physician,ȱ surgeonȱ dentist,ȱ andȱ nurse,ȱ chargedȱ withȱ theȱ deliveryȱ ofȱ primaryȱ attentionȱ ofȱ theȱ healthȱ postsȱ locatedȱ inȱ Indianȱ Areasȱ withinȱ theȱ base’sȱ territory.ȱ Indianȱ healthȱ postsȱ haveȱ permanentȱ nursingȱ auxiliariesȱ orȱ Indianȱ Healthȱ Agents,ȱ whoȱ provideȱ attentionȱ betweenȱ theȱ team’sȱ visits.ȱ

ȱȱ

Inȱmostȱcases,ȱIndianȱhealthȱteamsȱprovidingȱprimaryȱattentionȱ areȱ contractedȱ byȱ nonȬgovernmentalȱ organizations,ȱ whichȱ inȱ turnȱ receiveȱ financingȱ fromȱ theȱ Districtȱ headquarters.ȱ Municipalities,ȱ hospitalsȱ andȱ otherȱ institutionsȱ thatȱ areȱ partȱ ofȱ theȱ Unifiedȱ Nationalȱ Healthȱ Systemȱ provideȱ secondaryȱ andȱ tertiaryȱ attention.ȱ Theyȱ receiveȱ fundingȱ directlyȱ fromȱ FUNASA’sȱnationalȱheadquartersȱforȱtheirȱservicesȱdeliveredȱtoȱ Indians.ȱ Inȱ certainȱ places,ȱ theȱ NGOsȱ thatȱ contractȱ theȱ multidisciplinaryȱ medicalȱ teamsȱ areȱ indigenousȱ organizationsȱ themselvesȱ orȱ NGOsȱ thatȱ haveȱ experienceȱ withȱ Indianȱ health.ȱ Inȱ others,ȱ suchȱ asȱ inȱ twoȱ extremelyȱ largeȱ Districtsȱ inȱ southernȱ Brazil,ȱ aȱ specialȱ NGOȱ wasȱ createdȱ toȱ contractȱ healthȱ teamsȱ toȱ provideȱ primaryȱattentionȱinȱ Indianȱ Areas.ȱ Inȱ theȱ absenceȱ ofȱaȱ NGO,ȱ municipalitiesȱ receiveȱ fundsȱ destinedȱ forȱ provisionȱ ofȱ primaryȱ attentionȱ inȱ Indianȱ Areas.ȱ Theȱ questionȱ asȱ toȱ whetherȱ municipalities,ȱ asȱ partȱ ofȱ theȱ Nationalȱ Unifiedȱ Healthȱ System,ȱ orȱ NGOs,ȱ asȱ partȱ ofȱ theȱ subsystem,ȱ shouldȱ provideȱ primaryȱ attentionȱisȱaȱcontroversyȱthatȱhasȱplaguedȱIndianȱhealthȱpolicyȱ sinceȱ theȱ creationȱ ofȱ theȱ Specialȱ Districts.ȱ Also,ȱ interfaceȱ betweenȱtheȱsubsystemȱandȱtheȱUnifiedȱSystemȱhasȱnotȱresultedȱ inȱ adequateȱ coordinationȱ betweenȱ itȱ andȱ theȱ secondaryȱ andȱ tertiaryȱservices.ȱ

ȱ

Theȱ Indianȱ healthȱ subsystemȱ hasȱ beenȱ criticizedȱ sinceȱ itsȱ

inception.ȱ Vargaȱ (Vargaȱ &ȱ Adornoȱ 2001),ȱ directorȱ ofȱ theȱ

Coordinationȱ ofȱ Indianȱ Healthȱ inȱ theȱ earlyȱ 1990s,ȱ arguedȱ thatȱ

theȱ organizationalȱ structureȱ ofȱ theȱ DSEIsȱ violatesȱ theȱ originalȱ

ideaȱ ofȱ Indianȱ healthȱ districtsȱ asȱ proposedȱ byȱ theȱ IIȱ Nationalȱ

Conferenceȱ ofȱ Indianȱ Healthȱ inȱ 1993ȱ andȱ criticizedȱ theȱ

increasingȱ dependenceȱ uponȱ NGOsȱ forȱ theȱ provisionȱ ofȱ

primaryȱ healthȱ services,ȱ whichȱ heȱ sawȱ asȱ aȱ federalȱ obligation.ȱȱ TheȱrapidȱorganizationȱofȱtheȱDSEIsȱoccurredȱinȱsomeȱpartsȱofȱ theȱcountryȱwithoutȱcommunityȱinput,ȱviolatingȱtheȱprincipleȱofȱ socialȱcontrolȱinȱtheȱdecisionȱmakingȱprocessȱ(FIOCRUZȱ2000).ȱ Oneȱ ofȱ theȱ fewȱ comparativeȱ evaluationsȱ regardingȱ theȱ implantationȱ ofȱ DSEIsȱ showsȱ differencesȱ inȱ inclusionȱ ofȱ indigenousȱparticipationȱbetweenȱtheȱDistrictȱofȱtheȱRioȱNegroȱ andȱ thatȱ ofȱ Pernambucoȱ (Athiasȱ eȱ Machadoȱ 2001).ȱ Inȱ theȱ firstȱ case,ȱ thereȱ wasȱ aȱ goodȱ interinstitutionalȱ articulationȱ betweenȱ theȱmunicipality,ȱNGOsȱandȱnativeȱorganizations,ȱwhileȱinȱtheȱ second,ȱ theȱ implementationȱ occurredȱ inȱ aȱ verticalȱ manner,ȱ withoutȱIndianȱparticipation.ȱȱ

ȱ

Socialȱ controlȱ isȱ anȱ importantȱ principleȱ forȱ theȱ strategiesȱ ofȱ inclusionȱ withinȱ Brazilianȱ healthȱ policies,ȱ andȱ onceȱ theȱ subsystemȱ wasȱ implemented,ȱ thereȱ wereȱ concertedȱ effortsȱ toȱ createȱlocalȱandȱdistrictȱhealthȱcouncilsȱinȱpreparationȱforȱtheȱIIIȱ Nationalȱ Conferenceȱ ofȱ Indianȱ Healthȱ heldȱ inȱ 2001.ȱ However,ȱ thisȱ processȱ hasȱ demonstratedȱ aȱ seriesȱ ofȱ weaknessesȱ atȱ theȱ localȱ levelȱ asȱ wellȱ asȱ theȱ Districtȱ level.ȱ Localȱ healthȱ councilsȱ tendȱ toȱ beȱ dominatedȱ byȱ theȱ Indianȱ Healthȱ Agentsȱ andȱ otherȱ politicalȱleaders,ȱratherȱthanȱbyȱmembersȱfromȱtheȱcommunityȱ atȱ large.ȱ Selectionȱ ofȱ membersȱ followsȱ theȱ existingȱ powerȱ distributionȱwithinȱtheȱcommunityȱ(GarneloȱandȱSampaioȱ2003;ȱ Garneloȱ2003).ȱDistrictȱcouncilȱmembershipȱhasȱparityȱbetweenȱ Indianȱ representativesȱ andȱ thoseȱ ofȱ FUNAI,ȱ FUNASAȱ andȱ otherȱparticipatingȱinstitutions.ȱHowever,ȱinȱmanyȱcases,ȱIndianȱ participantsȱ areȱ employeesȱ ofȱ FUNAI,ȱ FUNASA,ȱ orȱ NGOs,ȱ indicatingȱ possibleȱ conflictȱ ofȱ interestȱ (Langdonȱ andȱ Diehlȱ 2007).ȱ Dependingȱ uponȱ theȱ DSEI,ȱ frequencyȱ ofȱ Districtȱ healthȱ councilȱ meetingsȱ variesȱ tremendously.ȱ Inȱ someȱ cases,ȱ theȱ meetingsȱareȱheldȱonlyȱeveryȱfewȱyears,ȱaȱseriousȱobstacleȱtoȱtheȱ principlesȱofȱsocialȱcontrolȱthatȱcallȱforȱcommunityȱparticipationȱ inȱtheȱplanning,ȱexecutionȱandȱevaluationȱprocessȱ(Langdonȱ&ȱ Diehlȱ2007).ȱȱ

ȱ

Anȱearlyȱevaluationȱofȱtheȱsubsystemȱmadeȱinȱ2003ȱ(Garneloȱetȱ al.ȱ2003,ȱGarneloȱ&ȱBrandãoȱ2003)ȱindicatedȱthatȱitȱresultedȱinȱaȱ significantȱ increaseȱ inȱ accessȱ toȱ primaryȱ attentionȱ inȱ Indianȱ communities.ȱ However,ȱ bureaucraticȱ andȱ organizationalȱ problemsȱcontinueȱtoȱcauseȱinefficientȱservicesȱandȱtheȱinabilityȱ toȱresolveȱmanyȱhealthȱproblems,ȱbothȱthoseȱofȱaȱchronicȱnatureȱ asȱwellȱasȱemergencyȱsituations.ȱMoreȱrecentȱstudiesȱshowȱthatȱ theȱproblemsȱofȱorganizationȱandȱefficiencyȱevidentȱinȱtheȱ1990sȱ haveȱ continued,ȱ includingȱ theȱ lackȱ ofȱ clearȱ delegationȱ ofȱ theȱ responsibilitiesȱ ofȱ institutionsȱ andȱ healthȱ programsȱ chargedȱ withȱ servicesȱ (FUNASA,ȱ FUNAI,ȱ municipalȱ andȱ stateȱ departmentsȱ ofȱ health,ȱ universities,ȱ andȱ NGOs).ȱ Theȱ distributionȱofȱmedications,ȱadministeredȱbyȱtheȱDepartmentȱofȱ Indianȱ Healthȱ atȱ theȱ nationalȱ level,ȱ doesȱ notȱ correspondȱ necessarilyȱ toȱ localȱ needs,ȱandȱ moreȱ adequateȱ distributionȱ isȱ aȱ continuingȱ demandȱ byȱ bothȱ localȱ healthȱ professionalsȱ andȱ Indians.ȱ Theȱ networkȱ ofȱ ȱ primaryȱ healthȱ servicesȱ withȱ secondaryȱandȱspecializedȱhealthȱservicesȱoutsideȱIndianȱAreasȱ continuesȱ toȱ beȱ problematic,ȱ andȱ theȱ hospitalsȱ andȱ otherȱ servicesȱ thatȱ receiveȱ fundingȱ toȱ attendȱ Indianȱ patientsȱ areȱ notȱ heldȱ accountable.ȱ Collectionȱ ofȱ accurateȱ epidemiologicalȱ dataȱ continuesȱ toȱ beȱ aȱ difficulty,ȱ andȱ theȱ systemȱ thatȱ hasȱ beenȱ implementedȱ doesȱ notȱ interactȱ withȱ otherȱ nationalȱ healthȱ databases.ȱ Finally,ȱ financialȱ accountabilityȱ hasȱ beenȱ problematicȱ forȱ bothȱ theȱ municipalitiesȱ andȱ NGOsȱ receivingȱ funds.ȱ

ȱ

Afterȱ aȱ decade,ȱ theȱ statusȱ ofȱ thisȱ subsystemȱ ofȱ differentiatedȱ

attentionȱ basedȱ onȱ theȱ organizationȱ ofȱ Specialȱ Indianȱ Healthȱ

Districtsȱ separateȱ fromȱ theȱ Unifiedȱ Nationalȱ Systemȱ ofȱ Healthȱ

continuesȱtoȱbeȱchallenged.ȱTheȱoriginalȱdemandȱforȱaȱsystemȱofȱ

IndianȱhealthȱresponsibleȱdirectlyȱtoȱtheȱMinistryȱofȱHealthȱwasȱ

seenȱ asȱ aȱ strategyȱ ofȱ inclusionȱ andȱ guaranteeȱ ofȱ universalȱ

access.ȱ Asȱ itȱ resulted,ȱ primaryȱ attentionȱ becameȱ theȱ

responsibilityȱ ofȱ theȱ Departmentȱ ofȱ Indianȱ Healthȱ withinȱ theȱ

Nationalȱ Foundationȱ ofȱ Health,ȱ whichȱ hasȱ aȱ numberȱ ofȱ otherȱ

responsibilitiesȱ andȱ preoccupationsȱ withȱ nonȬIndianȱ healthȱ onȱ

itsȱ agenda.ȱ Separationȱ andȱ autonomyȱ fromȱ theȱ municipallyȱ basedȱ systemȱ hasȱ notȱ beenȱ possible,ȱ norȱ doȱ manyȱ politiciansȱ considerȱ aȱ subsystemȱ compatibleȱ withȱ theȱ principlesȱ ofȱ theȱ NationalȱUnifiedȱSystemȱofȱHealth.ȱIndianȱcommunitiesȱtendȱtoȱ sufferȱ marginalizationȱ andȱ exclusionȱ inȱ theȱ faceȱ ofȱ localȱ andȱ regionalȱ politicalȱ processes,ȱ butȱ anȱ increasingȱ numberȱ ofȱ municipalitiesȱ areȱ receivingȱ fundingȱ forȱ theȱ provisionȱ ofȱ primaryȱhealthȱteamsȱ(ratherȱthanȱNGOs),ȱinȱspiteȱofȱcriticismsȱ regardingȱimproperȱuseȱofȱfunds.ȱThoseȱinȱfavorȱofȱaȱsubsystemȱ fearȱ theȱ “municipalization”ȱ ofȱ Indianȱ healthȱ andȱ itsȱ consequences.ȱ Othersȱ argueȱ thatȱ theȱ Unifiedȱ Nationalȱ Healthȱ Systemȱisȱuniversal,ȱdesignedȱtoȱattendȱallȱmembersȱincludedȱinȱ theȱ democraticȱ society,ȱ andȱ thusȱ aȱ separateȱ subsystemȱ privilegingȱ specialȱ populationsȱ shouldȱ notȱ exist.ȱ Itȱ isȱ notȱ clearȱ howȱ thisȱ debateȱ overȱ theȱ provisionȱ ofȱ primaryȱ attentionȱ toȱ Indianȱ Areasȱ willȱ beȱ resolved.ȱ Earlyȱ inȱ 2010,ȱ theȱ positionȱ ofȱ SecretaryȱofȱIndianȱHealth,ȱdirectlyȱresponsibleȱtoȱtheȱMinisterȱ ofȱ Health,ȱ wasȱ created,ȱ butȱ theȱ implicationsȱ ofȱ thisȱ changeȱ areȱ unclearȱatȱthisȱtime.ȱȱ

ȱ ȱ

Differentiatedȱ Attentionȱ asȱ Inclusionȱ ofȱ Culturalȱ Healthȱ Practicesȱ

ȱ ȱ

Asȱ aȱ finalȱ partȱ ofȱ thisȱ paper,ȱ Iȱ focusȱ onȱ relationȱ betweenȱ

inclusionȱandȱtheȱBrazilianȱnotionȱofȱdifferentiatedȱattentionȱasȱ

itȱ pertainsȱ toȱ theȱ multiculturalȱ dimensionȱ ofȱ Indianȱ healthȱ

services.ȱ Sinceȱ theȱ firstȱ discussionsȱ inȱ theȱ 1980s,ȱ theȱ notionȱ ofȱ

differentiatedȱattentionȱhasȱreferredȱtoȱinclusionȱinȱtwoȱwaysȱ–ȱ

(1)ȱdifferentiatedȱsubsystemȱofȱhealthȱthatȱguaranteesȱuniversalȱ

accessȱ andȱ socialȱ controlȱ andȱ (2)ȱ differentiatedȱ medicalȱ

attentionȱ thatȱ guaranteesȱ theȱ group’sȱ rightȱ toȱ itsȱ culturalȱ

particularities.ȱ Inȱ 2000,ȱ aȱ documentȱ dedicatedȱ toȱ theȱ

formulationȱ ofȱ nationalȱ policyȱ underȱ theȱ newlyȱ createdȱ

subsystemȱaffirmedȱthisȱlatterȱformȱofȱdifferentiatedȱattentionȱtoȱ

beȱtheȱrecognitionȱofȱ“theȱefficacy”ȱofȱindigenousȱmedicineȱandȱ

“theȱrightȱofȱtheseȱpeoplesȱtoȱtheirȱculture”ȱ(Brasilȱ2002:13).ȱTheȱ sameȱdocumentȱstates,ȱȱ

ȱ

TheȱprincipleȱthatȱpermeatesȱallȱtheȱdirectivesȱofȱtheȱNationalȱPolicyȱofȱ Healthȱ Attentionȱ forȱ Indianȱ Peoplesȱ isȱ respectȱ forȱ theȱ conceptions,ȱ valuesȱ andȱ practicesȱ relativeȱ toȱ theȱ processesȱ ofȱ healthȱ andȱ illnessȱ belongingȱ toȱ eachȱ indigenousȱ societyȱ andȱ theirȱ diverseȱ specialistsȱ (Brasilȱ2002:18).ȱȱ

ȱ

Inȱ anotherȱ part,ȱ theȱ documentȱ characterizesȱ traditionalȱ indigenousȱhealthȱsystems:ȱ

ȱ

(…)ȱ asȱ basedȱ onȱ aȱ holisticȱ approachȱ toȱ health,ȱ whoseȱ principleȱ isȱ theȱ harmonyȱ ofȱ individuals,ȱ familiesȱ andȱ communitiesȱ withȱ theȱ universeȱ thatȱ surroundsȱ them.ȱ Curingȱ practicesȱ respondȱ toȱ eachȱ indigenousȱ community’sȱ internalȱ logicȱ andȱ areȱ theȱ productȱ ofȱ theȱ particularȱ relationȱwithȱtheȱspiritualȱworldȱandȱtheȱbeingsȱinȱtheȱenvironmentȱinȱ whichȱtheyȱlive.ȱTheseȱpracticesȱandȱconceptionsȱare,ȱgenerally,ȱhealthȱ resourcesȱ ofȱ empiricalȱ andȱ symbolicȱ efficacy,ȱ inȱ accordȱ withȱ theȱ mostȱ recentȱ definitionȱ ofȱ healthȱ byȱ theȱ Worldȱ Healthȱ Organizationȱ (Brasilȱ 2002:17).ȱ

ȱ

Threeȱ directivesȱ forȱ theȱ practiceȱ ofȱ differentiatedȱ attentionȱ areȱ outlined:ȱtrainingȱofȱhumanȱresourcesȱforȱworkȱinȱinterculturalȱ contexts,ȱ articulationȱ withȱ traditionalȱ indigenousȱ healthȱ systems,ȱ andȱ trainingȱ ofȱ Indianȱ Healthȱ Agentsȱ inȱ orderȱ toȱ stimulateȱ theȱ Indianȱ peoplesȱ appropriationȱ ofȱ theȱ knowledgeȱ andȱtechniquesȱofȱwesternȱmedicine,ȱ“notȱasȱaȱsubstitution,ȱbutȱ asȱanȱadditionȱtoȱtheȱcollectionȱofȱtheirȱownȱtherapiesȱandȱotherȱ culturalȱ practices,ȱ whetherȱ theyȱ beȱ traditionalȱ orȱ not”ȱ (Brasilȱ 2002:16).ȱȱ

ȱ

Althoughȱ theȱ documentȱ emphasizesȱ theȱ importanceȱ ofȱ Indianȱ

traditionalȱ practicesȱ andȱ theirȱ maintenanceȱ inȱ theȱ faceȱ ofȱ

biomedicalȱ healthȱ services,ȱ theȱ themeȱ wasȱ givenȱ minimalȱ

attentionȱ duringȱ theȱ firstȱ yearsȱ ofȱ theȱ Indianȱ healthȱ subsystemȱ

(Garneloȱetȱal.ȱ2003).ȱInȱaȱmeetingȱforȱtheȱpreparationȱofȱtheȱIIIȱ

Nationalȱ Conferenceȱ onȱ Indianȱ Health,ȱ theȱ Directorȱ ofȱ theȱ

Departmentȱ ofȱ Indianȱ Healthȱ affirmedȱ toȱ meȱ thatȱ thisȱ wasȱ notȱ

theȱprimaryȱpreoccupationȱofȱtheȱIndians.

ȱTheȱDepartmentȱofȱ Indianȱ Healthȱ atȱ theȱ nationalȱ levelȱ didȱ notȱ orientȱ healthȱ professionalsȱatȱtheȱDistrictȱorȱlocalȱlevelȱtoȱreflectȱuponȱclinicalȱ practiceȱ andȱ deliveryȱ ofȱ primaryȱ attention.ȱ Someȱ healthȱ teamsȱ implementedȱ effortsȱ toȱ provideȱ differentiatedȱ attentionȱ inȱ thisȱ sense

,ȱbutȱthisȱhasȱnotȱbeenȱtheȱcaseȱforȱtheȱmajority,ȱandȱafterȱ aȱdecade,ȱitȱisȱpossibleȱtoȱaffirmȱthatȱclinicalȱpracticesȱinȱIndianȱ communitiesȱ doȱ notȱ differȱ inȱ natureȱ fromȱ thoseȱ inȱ nonȬIndianȱ communities.ȱȱ

ȱ

Inȱ 2004,ȱ withȱ theȱ changeȱ ofȱ theȱ Directorȱ ofȱ theȱ Departmentȱ ofȱ Indianȱ Health,ȱ renewedȱ discussionȱ wasȱ madeȱ withȱ regardȱ toȱ theȱ relationȱ betweenȱ primaryȱ healthȱ servicesȱ andȱ traditionalȱ practices.ȱInȱanȱOrdinanceȱissuedȱbyȱtheȱMinisterȱofȱHealth,ȱtwoȱ paragraphsȱ referȱ toȱ inclusionȱ ofȱ traditionalȱ medicine,ȱ butȱ inȱ slightlyȱ differentȱ concepts.ȱ Oneȱ recommendsȱ articulationȱ betweenȱ theȱ officialȱ servicesȱ andȱ Indianȱ Medicine.ȱ Theȱ otherȱ callsȱforȱintegrationȱofȱtheȱtwoȱpractices.ȱItȱinstructsȱtheȱmedicalȱ professionalsȱ

ȱ

Toȱ respectȱ theȱ culturesȱ andȱ valuesȱ ofȱ eachȱ ethnicȱ group,ȱ asȱ wellȱ asȱ integrateȱ theȱ actionsȱ ofȱ traditionalȱ medicineȱ withȱ healthȱ practicesȱ adoptedȱbyȱtheȱIndianȱcommunitiesȱ

ȱ

Toȱ articulateȱ Indianȱ Healthȱ practicesȱ withȱ traditionalȱ medicine,ȱ respectingȱtheȱcharacteristicsȱofȱIndigenousȱcultures.ȱ

ȱ ȱ ȱ ȱ (PortariaȱNo.ȱ70,ȱdeȱ20/01/2004)ȱ

ȱ

Inȱ 2005,ȱ aȱ projectȱ entitledȱ “Innovativeȱ Interventionsȱ inȱ Indianȱ Healthȱ –ȱ Traditionalȱ Medicine”ȱ wasȱ financedȱ byȱ theȱ Worldȱ Bankȱ andȱ administeredȱ byȱ aȱ sectorȱ differentȱ thanȱ theȱ Departmentȱ ofȱ Indianȱ Healthȱ butȱ partȱ ofȱ FUNASA.ȱ Thisȱ programȱ hasȱ conductedȱ aȱ numberȱ ofȱ projectsȱ throughoutȱ theȱ

11

ȱ Thisȱ viewȱ isȱ supportedȱ byȱ severalȱ studiesȱ thatȱ showȱ theȱ conquestȱ ofȱ equalȱ accessȱ toȱ healthȱ servicesȱ andȱ medicationsȱ asȱ theȱ primaryȱ goalȱ andȱ perceivedȱ benefitȱofȱtheȱsubsystemȱ(Cardosoȱ2001;ȱGarneloȱandȱWrightȱ2001;ȱPortelaȱ2010).ȱ

12

ȱSeeȱLangdonȱandȱGarneloȱ(2004)ȱforȱaȱreflectionȱonȱaȱnumberȱofȱexamples.ȱ

countryȱ withȱ Indianȱ communitiesȱ onȱ traditionalȱ birthingȱ systemsȱandȱmedicinalȱplantsȱ(FerreiraȱandȱOrsórioȱ2007).ȱTheyȱ haveȱ beenȱ innovativeȱ inȱ theȱ senseȱ thatȱ theyȱ joinȱ researchȱ withȱ activeȱ communityȱ participationȱ (aȱ methodologyȱ calledȱ pesquisaçãoȱ inȱ Portuguese)ȱ forȱ theȱ developmentȱ ofȱ “traditionalȱ medicineȱprojects”,ȱaȱcontextȱinȱwhichȱ“tradition”ȱwasȱexplicitlyȱ recognizedȱ byȱ theȱ coordinatorȱ asȱ emergentȱ andȱ aȱ resultȱ ofȱ theȱ dialogueȱ betweenȱ theȱ variousȱ actorsȱ (Ferreiraȱ 2010).ȱ Thisȱ project,ȱ affectingȱ aȱ limitedȱ numberȱ ofȱ Indianȱ communities,ȱ isȱ oneȱofȱtheȱfewȱdirectivesȱbyȱtheȱDepartmentȱofȱIndianȱHealthȱatȱ theȱ nationalȱ levelȱ forȱ differentiatedȱ attentionȱ conceivedȱ ofȱ asȱ attentionȱthatȱrespectsȱandȱarticulatesȱwithȱdifferentȱindigenousȱ healthȱpractices.ȱȱ

ȱ ȱ

Althoughȱ thisȱ projectȱ recognizesȱ theȱ dynamicsȱ ofȱ healthȱ practicesȱinȱIndianȱcommunitiesȱandȱdoesȱnotȱregardȱtraditionalȱ medicineȱ asȱ aȱ setȱ ofȱ fixedȱ customsȱ orȱ beliefsȱ thatȱ representȱ survivalsȱ fromȱ theȱ past,ȱ mostȱ healthȱ professionalsȱ workingȱ inȱ theȱ subsystemȱ doȱ notȱ shareȱ suchȱ aȱ vision.ȱ Thisȱ isȱ trueȱ ofȱ bothȱ thoseȱ inȱ healthȱ fieldsȱ asȱ wellȱ asȱ theȱ Indianȱ Agentsȱ ofȱ Health.ȱ Fewȱ membersȱ ofȱ theȱ multidisciplinaryȱ healthȱ teamsȱ offeringȱ healthȱ servicesȱ inȱ Indianȱ Areasȱ haveȱ receivedȱ trainingȱ thatȱ addressesȱ thisȱ issue.ȱ Itȱ hasȱ notȱ beenȱ aȱ preoccupationȱ ofȱ theȱ trainingȱcoursesȱthatȱhaveȱbeenȱoffered;ȱmostȱfocusȱonȱtechnicalȱ aspectsȱofȱhealthȱcareȱproblems.ȱInȱaddition,ȱtheȱhighȱturnoverȱ ofȱhealthȱteamȱmembersȱhasȱcontributedȱtoȱaȱlackȱofȱpreparationȱ forȱworkingȱwithȱculturallyȱdifferentiatedȱIndianȱcommunities.ȱ Forȱ theȱ mostȱ part,ȱ healthȱ servicesȱ areȱ deliveredȱ withȱ noȱ considerationȱ forȱ theȱ socialȱ orȱ culturalȱ practicesȱ ofȱ theȱ specificȱ group,ȱ andȱ “culture”ȱ isȱ conceivedȱ asȱ anȱ obstacleȱ toȱ fullȱ acceptanceȱorȱcomplianceȱofȱbiomedicalȱtherapies.ȱȱ

ȱ

Inclusionȱ ofȱ “traditionalȱ practices”ȱ inȱ differentiatedȱ attentionȱ

facesȱ conceptualȱ problemsȱ thatȱ haveȱ notȱ beenȱ addressed.ȱ

Withoutȱ adequateȱ preparationȱ ofȱ theȱ healthȱ teamsȱ norȱ

orientationȱ guidingȱ aȱ reflectionȱ aboutȱ theȱ culturalȱ aspectsȱ ofȱ

differentiatedȱattention,ȱtheȱprofessionalsȱthatȱworkȱwithȱIndianȱ

groupsȱ continueȱ toȱ holdȱ misconceptionsȱ aboutȱ theȱ natureȱ ofȱ Indigenousȱhealthȱpracticesȱandȱbehavior,ȱaȱsituationȱnotȱunlikeȱ otherȱpartsȱofȱtheȱworldȱ(Yoderȱ1997).ȱCultureȱisȱseenȱasȱstatic,ȱ homogeneousȱ andȱ normative.ȱ Cultureȱ isȱ conceivedȱ toȱ beȱ aȱ complexȱ ofȱ beliefsȱ thatȱ controlȱ bothȱ behaviorȱ andȱ perception.ȱ Oneȱconsequenceȱofȱthisȱnormativeȱandȱstaticȱviewȱofȱcultureȱisȱ theȱideaȱthatȱtheȱIndiansȱareȱlockedȱintoȱtheirȱbeliefs,ȱfailingȱtoȱ recognizeȱ theȱ benefitsȱ orȱ rationalityȱ ofȱ otherȱ practices.ȱ Cultureȱ isȱ seenȱ asȱ anȱ obstacleȱ forȱ theȱ adoptionȱ ofȱ “rational”ȱ healthyȱ behavior.ȱBrazilianȱpublicȱhealthȱworkersȱblameȱIndianȱcultureȱ asȱtheȱcauseȱofȱwhatȱtheyȱconsiderȱtoȱbeȱtheȱIndians’ȱincapacityȱ toȱ understandȱ modernȱ hygienicȱ principlesȱ orȱ theȱ directivesȱ ofȱ theȱhealthȱprofessionals.ȱȱ

ȱ

Anotherȱmisconceptionȱthatȱplaguesȱtheȱnotionȱofȱdifferentiatedȱ attentionȱ asȱ inclusionȱ ofȱ nativeȱ practicesȱ andȱ cultureȱ isȱ theȱ perspectiveȱ thatȱ Indigenousȱ medicalȱ knowledgeȱ andȱ practicesȱ areȱbasedȱonȱmagicalȱnotionsȱofȱtheȱuniverse.ȱEarlyȱpioneersȱinȱ medicalȱ anthropologyȱ arguedȱ thatȱ theȱ differencesȱ betweenȱ primitiveȱ andȱ scientificȱ medicineȱ areȱ soȱ greatȱ thatȱ transformationȱ fromȱ primitiveȱ thoughtȱ (magical)ȱ toȱ theȱ scientificȱ (scientific)ȱ isȱ impossible.ȱ Despiteȱ theȱ effortsȱ ofȱ anthropologistsȱ toȱ changeȱ suchȱ misconceptionsȱ (Menéndezȱ 2003),ȱ theȱ notionȱ thatȱ thereȱ isȱ aȱ radicalȱ discontinuityȱ andȱ oppositionȱ betweenȱ theȱ rationalitiesȱ ofȱ theȱ twoȱ systemsȱ isȱ stillȱ currentȱamongȱmostȱhealthȱprofessionals.ȱ

ȱ

Theȱ impactȱ ofȱ suchȱ aȱ viewȱ hasȱ resultedȱ inȱ inequalitiesȱ andȱ

hierarchicalȱ rankingȱ ofȱ medicalȱ practicesȱ accordingȱ toȱ theȱ

scientificȱ visionȱ ofȱ efficacy.ȱ Asȱ aȱ consequence,ȱ traditionalȱ

medicalȱ practicesȱ validatedȱ byȱ biomedicineȱ areȱ thoseȱ thatȱ

shouldȱ beȱ encouragedȱ andȱ thoseȱ thatȱ doȱ notȱ passȱ suchȱ aȱ

scientificȱ proofȱ shouldȱ beȱ excluded.ȱ Thisȱ visionȱ isȱ evidenceȱ ofȱ

theȱdevelopmentalȱviewȱthatȱestablishesȱbiomedicalȱhegemonyȱ

overȱ traditionalȱ practicesȱ (Frankenbergȱ 1980)ȱ andȱ thatȱ isȱ seenȱ

amongȱ manyȱ whoȱ advocateȱ theȱ collaborationȱ betweenȱ

traditionalȱandȱscientificȱmedicines:ȱȱ

Traditionalȱ medicineȱ comprisesȱ thoseȱ practicesȱ basedȱ onȱ beliefsȱ thatȱ wereȱinȱexistence,ȱoftenȱforȱhundredsȱofȱyears,ȱbeforeȱtheȱdevelopmentȱ andȱ spreadȱ ofȱ modernȱ scientificȱ medicineȱ andȱ whichȱ areȱ stillȱ inȱ useȱ today.ȱ ...ȱ Generallyȱ speaking,ȱ however,ȱ traditionalȱ medicineȱ hasȱ beenȱ separatedȱfromȱtheȱmainstreamȱofȱmodernȱmedicine.ȱAȱbasicȱapproach,ȱ therefore,ȱ hasȱ beenȱ toȱ promoteȱ theȱ bringingȱ togetherȱ ofȱ modernȱ scientificȱ medicineȱ withȱ theȱ provenȱ usefulȱ traditionalȱ practicesȱ withinȱ theȱ frameworkȱofȱtheȱlocalȱhealthȱcareȱsystemȱ(Akereleȱ1987:177Ȭ178.ȱItalicsȱ addedȱbyȱme).ȱ

ȱ

Suchȱ aȱ viewȱ wasȱ expressedȱ inȱ theȱ herbalȱ medicineȱ projectsȱ ofȱ theȱTraditionalȱMedicineȱprojectȱinitiatedȱinȱ2005.ȱCallingȱuponȱ theȱ principlesȱ outlinedȱ inȱ theȱ Nationalȱ Policyȱ ofȱ Medicationsȱ andȱ Pharmaceuticalȱ Assistance,ȱ pharmacistsȱ confrontedȱ theȱ Indianȱ participantsȱ andȱ insistedȱ thatȱ onlyȱ substancesȱ withȱ rationallyȱ approvedȱ efficacyȱ couldȱ beȱ developedȱ (Santosȱ 2007;ȱ Ferreiraȱ 2007).ȱ Theirȱ argumentȱ underscoresȱ theȱ contradictionȱ implicitȱ betweenȱ theȱ hegemonyȱ ofȱ scienceȱ containedȱ inȱ theȱ Nationalȱ Policyȱ ofȱ Medicationsȱ andȱ Pharmaceuticalȱ Assistanceȱ legislationȱandȱtheȱprincipleȱofȱinclusionȱandȱrespectȱpresentȱinȱ theȱNationalȱPolicyȱforȱHealthȱAttentionȱforȱIndianȱPopulations.ȱȱ ȱ

Anthropologicalȱresearchȱhasȱdemonstratedȱthatȱitȱisȱsimplisticȱ

toȱviewȱbiomedicalȱservicesȱandȱIndianȱmedicineȱoperatingȱinȱaȱ

socialȱ fieldȱ inȱ whichȱ theȱ Indianȱ choosesȱ oneȱ orȱ theȱ otherȱ

dependingȱuponȱhisȱperceptionȱasȱtoȱwhichȱisȱmoreȱefficaciousȱ

(aȱ benefitȬcostȱ model).ȱ Inȱ everydayȱ practice,ȱ theȱ dynamicsȱ ofȱ

therapeuticȱ choiceȱ andȱ healthȱ practicesȱ isȱ farȱ moreȱ complexȱ

thanȱ theȱ rationalityȱ implicitȱ inȱ thisȱ modelȱ (Buchilletȱ 1991,ȱ

Menéndezȱ2003).ȱMoreover,ȱpracticesȱofȱhealthȱattentionȱdoȱnotȱ

fitȱ clearȬcutȱ categoriesȱ ofȱ traditionalȱ versusȱ biomedicalȱ

practices.ȱ Biomedicalȱ resourcesȱ areȱ presentȱ inȱ theȱ formȱ ofȱ theȱ

healthȱȱpost,ȱtheȱmultidisciplinaryȱhealthȱteam,ȱtheȱdistributionȱ

ofȱmedicationsȱandȱtheȱlocalȱprivateȱpharmacies.ȱBesidesȱthese,ȱ

thereȱareȱaȱnumberȱofȱmodalitiesȱofȱtherapyȱusedȱthatȱareȱpartȱ

ofȱ theȱ popularȱ medicalȱ systemȱ ofȱ theȱ surroundingȱ nonȬIndianȱ

populations.ȱ Theseȱ rangeȱ fromȱ theȱ useȱ ofȱ plantsȱ andȱ bottledȱ

concoctionsȱ andȱ autoȬmedicationȱ toȱ theȱ useȱ ofȱ healingȱ

specialistsȱ andȱ ritualsȱ thatȱ areȱ foundȱ inȱ popularȱ Catholicism,ȱ evangelicalȱcultsȱandȱAfroȬBrazilianȱreligions.ȱȱ

ȱ

Researchȱ hasȱ demonstratedȱ thatȱ theȱ frontiersȱ betweenȱ officialȱ healthȱ servicesȱ andȱ theȱ localȱ practices,ȱ beȱ theyȱ ofȱ indigenousȱ originȱorȱnot,ȱareȱnotȱwellȱdefined,ȱnorȱareȱtheyȱimpermeableȱinȱ theȱ practiceȱ ofȱ dailyȱ life.ȱ Curingȱ practicesȱ doȱ notȱ conformȱ toȱ mutuallyȱ exclusiveȱ categoriesȱ markingȱ aȱ simpleȱ oppositionȱ betweenȱ ethnomedicineȱ andȱ biomedicine.ȱ Moreover,ȱ perceptionsȱ andȱ acceptanceȱ ofȱ biomedicalȱ practicesȱ areȱ notȱ uniformȱorȱhomogenousȱinȱanyȱoneȱgroup.ȱInstead,ȱmembersȱofȱ aȱ communityȱ holdȱ differentȱ ideas,ȱ whichȱ canȱ appearȱ toȱ beȱ contradictoryȱevenȱwithinȱtheȱsameȱindividualȱdependingȱuponȱ theȱ particularȱ context.ȱ Recognitionȱ ofȱ thisȱ situationȱ ofȱ heterogeneityȱ hasȱ implicationsȱ forȱ theȱ kindsȱ ofȱ informationȱ aboutȱ theȱ nativeȱ cultureȱ thatȱ isȱ relevantȱ forȱ medicalȱ professionals.ȱTheseȱareȱissuesȱthatȱhaveȱyetȱtoȱbeȱaddressedȱbyȱ Indianȱhealthȱpolicy.ȱ

ȱ ȱ

Finalȱcommentariesȱ

ȱ ȱ

Inclusionȱ ofȱ Indianȱ peoplesȱ inȱ Brazilianȱ healthȱ servicesȱ hasȱ

becomeȱ operationalȱ throughȱ theȱ subsystemȱ ofȱ differentiatedȱ

attentionȱ basedȱ onȱ Specialȱ Indianȱ Healthȱ Districts.ȱ Theȱ

implantationȱ ofȱ theȱ subsystemȱ ofȱ Indianȱ healthȱ inȱ 1999,ȱ alongȱ

withȱ considerableȱ increaseȱ inȱ financialȱ resources,ȱ hasȱ madeȱ

importantȱstridesȱinȱtheȱexpansionȱofȱhealthȱservicesȱinȱorderȱtoȱ

includeȱtheȱindigenousȱpeoplesȱandȱguaranteeȱthemȱtheȱrightȱtoȱ

health.ȱ Theȱsecondȱ aspectȱ ofȱ inclusion,ȱ thatȱ whichȱ callsȱforȱ theȱ

respectȱofȱnativeȱculturesȱandȱarticulatesȱwithȱtraditionalȱhealthȱ

practices,ȱ hasȱ beenȱ lessȱ successful.ȱ Asȱ discussedȱ above,ȱ mostȱ

healthȱprofessionalsȱworkingȱinȱIndianȱhealthȱhaveȱnotȱreceivedȱ

theȱ properȱ trainingȱ thatȱ preparesȱ themȱ forȱ workȱ inȱ ethnicallyȱ

differentiatedȱ communities.ȱ However,ȱ thisȱ articleȱ arguesȱ thatȱ

theȱ greaterȱ problemȱ facingȱ inclusionȱ of,ȱ orȱ articulationȱ with,ȱ

indigenousȱ healthȱ practicesȱ stemsȱ fromȱ theȱ complexitiesȱ andȱ

contradictionsȱ ofȱ theȱ hierarchiesȱ ofȱ knowledgeȱ implicitȱ inȱ theȱ goalȱ ofȱ improvingȱ healthȱ conditionsȱ ofȱ aȱ communityȱ throughȱ theȱ expansionȱ ofȱ biomedicalȱ servicesȱ whileȱ attemptingȱ toȱ incorporateȱ orȱ collaborateȱ withȱ theȱ group’sȱ existingȱ healthȱ practices,ȱ mostȱ oftenȱ expressedȱ asȱ traditional,ȱ indigenousȱ orȱ cultural.ȱ Asȱ longȱ asȱ biomedicalȱ scienceȱ maintainsȱ theȱ hegemonicȱ positionȱ ofȱ validatingȱ theȱ practicesȱ thatȱ shouldȱ beȱ implemented,ȱ inherentȱ inequalityȱ betweenȱ scientificȱ andȱ communityȱpracticesȱexists.ȱCulturalȱpracticesȱareȱrelegatedȱtoȱaȱ secondaryȱposition,ȱoneȱinȱwhichȱtheyȱareȱviewedȱasȱinherentlyȱ static,ȱ magicalȱ andȱ rationallyȱ ineffective.ȱ Consequently,ȱ ifȱ articulationȱ orȱ incorporationȱ ofȱ theseȱ practicesȱ inȱ biomedicalȱ serviceȱ isȱ viewedȱ asȱ anȱ aspectȱ ofȱ inclusion,ȱ mostȱ healthȱ professionalsȱbelieveȱthatȱtheȱpracticesȱtoȱbeȱincorporatedȱmustȱ beȱsubjectȱtoȱselectionȱaccordingȱtoȱtheirȱscientificȱefficacy.ȱȱ ȱ

Bonfilȱ (1966)ȱ expressedȱ decadesȱ agoȱ thatȱ aȱ conservativeȱ viewȱ permeatesȱ healthȱ projectsȱ thatȱ conceivesȱ ofȱ cultureȱ asȱ anȱ obstacleȱ toȱ progressȱ andȱ ignoresȱ theȱ greaterȱ politicalȱ implicationsȱofȱhealthȱprogramsȱinȱtheȱthirdȱworld.ȱDespiteȱanȱ enlightenedȱ Nationalȱ Policyȱ ofȱ Indianȱ Health,ȱ whichȱ consciouslyȱ recognizesȱ theȱ validityȱ andȱ importanceȱ ofȱ nativeȱ healthȱ practices,ȱ theȱ developmentalȱ perspective,ȱ asȱ characterizedȱ byȱ Bonfil,ȱ Frankenbergȱ andȱ others,ȱ continuesȱ unconsciouslyȱtoȱguideȱtheȱmajorityȱofȱtheȱhealthȱprofessionalsȱ workingȱ withȱ Indianȱ communitiesȱ inȱ Brazil.ȱ Theȱ wellȬ intentionedȱprinciplesȱoutlinedȱinȱtheȱNationalȱPolicyȱforȱIndianȱ HealthȱAttentionȱhaveȱnotȱbecomeȱaȱreality.ȱȱ

ȱ ȱ

Brazilȱ isȱ aȱ longȱ wayȱ fromȱ fullyȱ implementingȱ anȱ effectiveȱ

systemȱofȱdifferentiatedȱhealthȱattentionȱforȱIndianȱpopulations,ȱ

althoughȱtheyȱhaveȱbenefitedȱfromȱincreasedȱservicesȱasȱaȱresultȱ

ofȱ considerableȱ financialȱ support.ȱ Bureaucraticȱ andȱ

organizationalȱ problemsȱ continue.ȱ “Differentiatedȱ attention”ȱ isȱ

yetȱ toȱ beȱ constructedȱ asȱ aȱ workingȱ conceptȱ forȱ localȱ services.ȱ

Attemptsȱ toȱ developȱ culturallyȱ adequateȱ attentionȱ areȱ isolatedȱ

andȱ receiveȱ littleȱ supportȱ atȱ theȱ nationalȱ level.ȱ Thoseȱ involvedȱ

inȱtheȱprovisionȱofȱservices,ȱparticularlyȱtheȱFUNASAȱworkersȱ andȱ theȱ healthȱ teams,ȱ mustȱ beȱ fullyȱ committedȱ toȱ offeringȱ differentiatedȱhealthȱcareȱandȱrespectingȱtheȱcommunitiesȱwithȱ whomȱtheyȱwork.ȱAsȱofȱyet,ȱthisȱcommitmentȱhasȱnotȱbeenȱfullyȱ evidentȱatȱtheȱnational,ȱdistrictȱorȱlocalȱlevelȱofȱhealthȱservices.ȱ

ȱ ȱ

Finallyȱtheȱdynamicsȱandȱheterogeneityȱofȱtheȱlocalȱsituationsȱofȱ intermedicalityȱ (Greeneȱ 1998)ȱ denyȱ simplisticȱ solutionsȱ forȱ theȱ satisfactionȱ forȱ theȱ callȱ forȱ inclusionȱ ofȱ traditionalȱ healthȱ practices.ȱ Traditionalȱ medicineȱ andȱ biomedicineȱ areȱ notȱ twoȱ systemsȱinȱopposition.ȱTheȱsuccessȱofȱhealthȱprogramsȱdependsȱ farȱmoreȱuponȱexternalȱandȱinternalȱpoliticalȱfactorsȱthanȱuponȱ theȱ scientificȱ valueȱ ofȱ biomedicine.ȱ Healthȱ isȱ asȱ muchȱ politicalȱ asȱitȱisȱclinical.ȱThereȱisȱaȱneedȱforȱanȱunderstandingȱasȱtoȱhowȱ theȱ nationalȱ politicalȱ decisions,ȱ bureaucraticȱ structuresȱ andȱ localȱ decisionȱ makingȱ processesȱ affectȱ theȱ outcomeȱ ofȱ theȱ efficacyȱofȱdailyȱclinicalȱpractice.ȱ

ȱ

Acknowledgments:ȱ Aȱ grantȱ fromȱ CNPq,ȱ anȱ institutionȱ ofȱ theȱ BrazilianȱGovernmentȱdedicatedȱtoȱscientificȱandȱtechnologicalȱ development,ȱmadeȱthisȱstudyȱpossible.ȱȱ

ȱ ȱ

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