Indigenous communities' responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision.

AIM: To explore indigenous communities' responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon. METHODS: Mamás del Río is a community-based, MNH programme with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders and health facilities. With the onset of the lockdown, supervisors made telephone calls to discuss measures against COVID-19, governmental support, CHW activities in communities and provision of MNH care and COVID-19 preparedness at facilities. As part of the programme's ongoing mixed methods evaluation, we analysed written summaries of supervisor calls collected during the first 2 months of Peru's lockdown. RESULTS: Between March and May 2020, supervisors held two rounds of calls with CHWs and leaders of 68 communities and staff from 17 facilities. Most communities banned entry of foreigners, but about half tolerated residents travelling to regional towns for trade and social support. While social events were forbidden, strict home isolation was only practised in a third of communities as conflicting with daily routine. By the end of April, first clusters of suspected cases were reported in communities. COVID-19 test kits, training and medical face masks were not available in most rural facilities. Six out of seven facilities suspended routine antenatal and postnatal consultations while two-thirds of CHWs resumed home visits to pregnant women and newborns. CONCLUSIONS: Home isolation was hardly feasible in the rural Amazon context and community isolation was undermined by lack of external supplies and social support. With sustained community transmission, promotion of basic hygiene and mask use becomes essential. To avoid devastating effects on MNH, routine services at facilities need to be urgently re-established alongside COVID-19 preparedness plans. Community-based MNH programmes could offset detrimental indirect effects of the pandemic and provide an opportunity for local COVID-19 prevention and containment.

The face-to-face encounter in indigenous health care: a perspective in Lévinas.

OBJECTIVE: To reflect on the sensitive behaviors of indigenous healthcare professionals based on the philosophy of Emmanuel Lévinas, to ratify completeness, equity, and humanity. METHOD: reflective study. REFLECTION: Studies have identified inadequacies in meeting the indigenous singularities. In the hospital and outpatient settings, they are diluted in the search for care. The difficulty of the professionals to admit them generates conflicts and non-adherence of indigenous individuals to treatments that disregard their care practices. In Lévinas, consciousness requires, "a priori," sensitivity to access the Infinity on the Face of the Other, which in the face-to-face encounters is presented to the Self as radical Alterity, proposing an Ethical relationship through transcendence. The freedom of the Self as to the Other is finite, as the Self cannot possess the Other, and infinite for its responsibility for the Other. FINAL CONSIDERATIONS: The Self builds essence and existence in responsibility. In the Ethics of Alterity, in Lévinas, reflections are proposed that influence sensitive behaviors.

Understanding access to healthcare among Indigenous peoples: A comparative analysis of biomedical and postcolonial perspectives.

As nursing professionals, we believe access to healthcare is fundamental to health and that it is a determinant of health. Therefore, evidence suggesting access to healthcare is problematic for many Indigenous peoples is concerning. While biomedical perspectives underlie our current understanding of access, considering alternate perspectives could expand our awareness of and ability to address this issue. In this paper, we critique how access to healthcare is understood through a biomedical lens, how a postcolonial theoretical lens can extend that understanding, and the subsequent implications this alternative view raises for the nursing profession. Drawing on peer-reviewed published and gray literature concerning healthcare access and Indigenous peoples to inform this critique, we focus on the underlying theoretical lens shaping our current understanding of access. A postcolonial analysis provides a way of understanding healthcare as a social space and social relationship, presenting a unique perspective on access to healthcare. The novelty of this finding is of particular importance for the profession of nursing, as we are well situated to influence these social aspects, improving access to healthcare services broadly, and among Indigenous peoples specifically.

[Intercultural health in Chile: Historical development and current challenges]. / Salud intercultural en Chile: Desarrollo histórico y desafíos actuales.

In 1992, Chile implemented for the first time a health program for indigenous peoples, the Health Program for the Mapuche Population (PROMAP), whose objective was to provide health care with cultural relevance, favoring the complementarity between the indigenous medical systems and the official system The current version of this initiative - named PESPI - has managed to reach almost all the Health Services in the country with this approach. The review that the academic world has made of these experiences, based on public health or medical anthropology, has focused on the analysis of the initiatives taken in rural indigenous contexts, from the point of view of the difficulties they have had to face and the meaning of the interculturality in health that they have managed to consolidate. However, little has been said about this program in urban contexts (currently, a space which our indigenous peoples are occupying progresively) or from the point of view of the notions of interculturality in health that they imply. Considering the above, the article offers a thematic review of national and international scientific publications on the subject, a critical analysis of intercultural health programs developed in Chile and a reflection on their challenges in the framework of urban indigenous dynamics.

En 1992, Chile implementó por primera vez un programa de salud para los pueblos indígenas, el Programa de Salud para Población Mapuche (Promap), cuyo objetivo fue entregar una atención de salud con pertinencia cultural, favoreciendo la complementariedad entre los sistemas médico indígena y el sistema oficial. La versión actual de esa iniciativa - el Programa especial de Salud para Pueblos Indígenas (PESPI) - ha logrado llegar con este enfoque a casi la totalidad de los Servicios de Salud del país. La revisión que el mundo académico ha hecho de estas experiencias, basados en la salud pública o en la antropología médica, se ha centrado en el análisis de las iniciativas llevadas en contextos indígenas rurales, desde el punto de vista de las dificultades que han debido enfrentar y las nociones de interculturalidad en salud que han logrado consolidar. Sin embargo, poco se ha abordado este programa en los contextos urbanos (espacio en que mayoritariamente están ocupando hoy nuestros pueblos indígenas) o desde el punto de vista de las nociones de interculturalidad en salud que implican. Considerando lo anterior, el artículo ofrece una revisión temática de publicaciones científicas nacionales e internacionales acerca del tema, un análisis crítico de los programas de salud intercultural desarrollados en Chile y una reflexión acerca de sus desafíos en el marco de la dinámica indígena urbana.

The face-to-face encounter in indigenous health care: a perspective in Lévinas / El encuentro frente a frente en el cuidado en la salud indígena: una perspectiva en Lévinas / O encontro face a face no cuidado em saúde indígena: uma perspectiva em Lévinas

ABSTRACT Objective: To reflect on the sensitive behaviors of indigenous healthcare professionals based on the philosophy of Emmanuel Lévinas, to ratify completeness, equity, and humanity. Method: reflective study. Reflection: Studies have identified inadequacies in meeting the indigenous singularities. In the hospital and outpatient settings, they are diluted in the search for care. The difficulty of the professionals to admit them generates conflicts and non-adherence of indigenous individuals to treatments that disregard their care practices. In Lévinas, consciousness requires, "a priori," sensitivity to access the Infinity on the Face of the Other, which in the face-to-face encounters is presented to the Self as radical Alterity, proposing an Ethical relationship through transcendence. The freedom of the Self as to the Other is finite, as the Self cannot possess the Other, and infinite for its responsibility for the Other. Final considerations: The Self builds essence and existence in responsibility. In the Ethics of Alterity, in Lévinas, reflections are proposed that influence sensitive behaviors.

RESUMEN Objetivo: Reflejar sobre los comportamientos sensibles de los profesionales en salud indígena desde la filosofía de Emmanuel Lévinas, para ratificar la integralidad, la equidad y la humanidad. Método: Estudio reflexivo. Reflejo: Estudios están identificando inadecuaciones en la atención a las singularidades indígenas. En los escenarios hospitalarios y de ambulatorios, ellas se diluyen en la búsqueda por cuidados. La dificultad de los profesionales en admitirlas genera conflictos y no aceptación de los indígenas a tratamientos que no consideran sus prácticas de cuidado. En Lévinas, la consciencia requiere, "a priori," sensibilidad para acceder el Infinito en el Rostro del Otro, que en los encuentros frente a frente se presenta al Yo como Alteridad radical, proponiendo una relación Ética por la transcendencia. La libertad del Yo cuanto al Otro es finita, porque de él no puede apropiarse, e infinita por su responsabilidad por el Otro. Consideraciones finales: El Yo construye la esencia y la existencia en la responsabilidad. En la Ética de la Alteridad, en Lévinas, se proponen reflejos que influencien los comportamientos sensibles.

RESUMO Objetivo: Refletir sobre os comportamentos sensíveis dos profissionais em saúde indígena a partir da filosofia de Emmanuel Lévinas, para ratificar a integralidade, a equidade e a humanidade. Método: estudo reflexivo. Reflexão: Estudos têm identificado inadequações no atendimento às singularidades indígenas. Nos cenários hospitalar e ambulatorial, elas se diluem na busca por cuidados. A dificuldade dos profissionais em admiti-las gera conflitos e não adesão dos indígenas a tratamentos que desconsideram suas práticas de cuidado. Em Lévinas, a consciência requer,"a priori," sensibilidade para acessar o Infinito no Rosto do Outro, que nos encontros face a face se apresenta ao Eu como Alteridade radical, propondo uma relação Ética pela transcendência. A liberdade do Eu quanto ao Outro é finita, porque dele não pode se apossar, e infinita pela sua responsabilidade pelo Outro. Considerações finais: O Eu constrói essência e existência na responsabilidade. Na Ética da Alteridade, em Lévinas, propõem-se reflexões que influenciem comportamentos sensíveis.

Birth and breastfeeding dynamics in a modernizing indigenous community.

BACKGROUND: Changes in health care access and birthing practices may pose barriers to optimal breastfeeding in modernizing rural populations. OBJECTIVES: We evaluated temporal and maternal age-related trends in birth and breastfeeding in a modernizing Maya agriculturalist community. We tested 2 hypotheses: (1) home births would be associated with better breastfeeding outcomes than hospital births, and (2) vaginal births would be associated with better breastfeeding outcomes than cesarean births. METHODS: We interviewed 58 Maya mothers (ages 21-85) regarding their births and breastfeeding practices. General linear models were used to evaluate trends in birthing practices and breastfeeding outcomes (timing of breastfeeding initiation, use of infant formula, age of introduction of complementary feeding, and breastfeeding duration). We then compared breastfeeding outcomes by location (home or hospital) and mode of birth (vaginal or cesarean). RESULTS: Timing of breastfeeding initiation and the rate of formula feeding both increased significantly over time. Younger mothers introduced complementary foods earlier, breastfed for shorter durations, and formula fed more than older mothers. Vaginal hospital births were associated with earlier breastfeeding initiation and longer breastfeeding durations than home births. Cesarean births were associated with later breastfeeding initiation, shorter breastfeeding durations, and more formula feeding than vaginal hospital births. CONCLUSION: We have observed temporal and maternal age-related trends toward suboptimal breastfeeding patterns in the Maya community. Contrary to our first hypothesis, hospital births per se were not associated with negative breastfeeding outcomes. In support of our second hypothesis, cesarean versus vaginal births were associated with negative breastfeeding outcomes.

[Professional education and work of indigenous health agents in the Brazilian health system]. / La formación y el trabajo del agente indígena de salud en el Subsistema de Salud Indígena en Brasil.

OBJECTIVE: To discuss the role of indigenous health agents in the implementation of the model of differentiated attention or intercultural health in Brazil. MATERIALS AND METHODS: We revised the scientific literature about the work and professional education of indigenous health agents in the Brazilian indigenous health system. RESULTS: There is a subordination of the agents to the hegemonic medical model. With regards to professional education, we observe the absence and irregularity of these processes, with a general emphasis the biomedicine. There are conflicts with the health team and community, with devaluation of the agents. The agent does not plays the role of mediator between the different health knowledge and practices. CONCLUSIONS: We suggest that the discussion of the model of differentiated attention should strengthen the relationship between the health system and the selfcare.

Cultural adaptation of birthing services in rural Ayacucho, Peru.

PROBLEM: Maternal mortality is particularly high among poor, indigenous women in rural Peru, and the use of facility care is low, partly due to cultural insensitivities of the health care system. APPROACH: A culturally appropriate delivery care model was developed in poor and isolated rural communities, and implemented between 1999 and 2001 in cooperation with the Quechua indigenous communities and health professionals. Data on birth location and attendance in one health centre have been collected up to 2007. LOCAL SETTING: The international nongovernmental organization, Health Unlimited, and its Peruvian partner organization, Salud Sín Límites Perú, conducted the project in Santillana district in Ayacucho. RELEVANT CHANGES: The model involves features such as a rope and bench for vertical delivery position, inclusion of family and traditional birth attendants in the delivery process and use of the Quechua language. The proportion of births delivered in the health facility increased from 6% in 1999 to 83% in 2007 with high satisfaction levels. LESSONS LEARNED: Implementing a model of skilled delivery attendance that integrates modern medical and traditional Andean elements is feasible and sustainable. Indigenous women with little formal education do use delivery services if their needs are met. This contradicts common victim-blaming attitudes that ascribe high levels of home births to 'cultural preferences' or 'ignorance'.

Indigenous health in Latin America and the Caribbean.

This review is the second in a series on Indigenous health, covering different regions and issues. We look briefly at the current state of Indigenous health in Latin America and the Caribbean, a region with over 400 different indigenous groups and a total population of 45 to 48 million people. We describe the complex history and current reality of Indigenous peoples' situation within the American continent. We discuss the importance of Indigenous health systems and medicines, and look at changing political environments in the region. The paper concludes with a discussion of the changing political and legislative environment in Latin American countries.

Bonesetting and radiography in the southern Maya highlands.

Maya bonesetters and their clients have been affected by the entry of radiographic technology into highland Guatemala. Bonesetters rely on a form of embodied knowledge to perform their manual work, the kind of knowledge X-rays threaten to supersede. This article examines how Maya bonesetters are meeting this challenge to their legitimacy and how they are positioning themselves pragmatically within a world of changing biomedical resources and contested health knowledge.

Authorizing tradition: vectors of contention in Highland Maya midwifery.

In Guatemala, midwives deliver the majority of children and play an important health care role in rural areas. Maya midwives, using time-proven methods, are the chief providers of care for mothers and infants in these areas. In recent decades, however, the medical establishment has become interested in Maya midwives, and is currently engaged in training and certifying many of them. This study examines how Guatemalan health authorities have sought to change Maya midwifery, refashioning its vocational framework and retooling it in accordance with Western medical principles. I focus on the place of obligatory formal training and the use of biomedical materials in the experience of Kaqchikel Maya midwives, and consider how the health officials employ these means to undermine the midwives' knowledge base. Encounters between midwives and formal health personnel reveal an ongoing privileging of biomedical knowledge, one that preserves asymmetrical relationships between these practitioners. This creates an environment favorable to health personnel, and helps them to extend their influence through the midwives into the community. Given this, I contend that health personnel value local Maya midwives primarily for their role in furthering the goals of biomedicine.

Representación social del proceso salud enfermedad en comunidades del resguardo de puerto Córdoba (yucunas) y del yaigoje apaporis (Bajo Apaporis), Amazonas-Colombia / Social representation of the health-disease process in the Indians of the Amazon, Colombia

La presente investigación de tipo cualitativo, desarrollaba en las comunidades indígenas de la Amazonía Colombiana, se propuso identificar y analizar las representaciones sociales del proceso salud-enfermedad y los métodos de curación y prevención, con el fin de adecuar y rescatar antiguas prácticas indígenas en salud. La metodología utilizada fue de corte cualitativo, enmarcando en la Investigación Acción Participativa IAP, con técnicas como: observación participante, acción participante, diarios de campo, entrevistas semiestructuradas, charlas educativas y talleres, por medio de las cuales se encontró que las comunidades indígenas amazónicas aún conservan sus métodos de curación y prevención, aunque algunos de sus pobladores han ido perdiendo sus creencias, debido principalmente a la cercanía del hombre blanco. Esta visión del mundo indígena frente al saber tradicional lleva a plantear que la representación social de la salud y la enfermedad está ligada a las creencias milenarias, a la funcionalidad y, definitivamente , al complejo cuerpo-espíritu-medio ambiente.

Aspectos odontológicos de la medicina popular en el Distrito Monagas (Edo. Guárico-Venezuela) / Odontological aspects of the popular Medicina in Monagas District (Edo. Guarico-Venezuela)

El conocimiento de la medicina tradicional constituído por una gran variedad de plantas usadas como terapéuticas, su prevalencia en ciertos ambientes naturales así como las estructuras socio-culturales y el manejo de recursos mágico-religiosos, son características que motivan el intereés de aquellas disciplinas. Se señalan técnicas y procedimientos que la medicina maneja en el tratamiento de afecciones bucales. Se tomó como muestra una región central del país: Distrito Monagas del Edo. Guárico; usando para recoleccion de datos la entrevista. La primera parte del trabajo se hace comfrontación entre medicina popular y la científica y señala algunos aspectos de la odontología popular de dicha región. Luego se recoge la operacionalización del trabajo y el procedimiento de la información obtenida. Por último se intenta la caracterización de la odontología popular venezolana en dicha zona, con sus semejanzas con la medicina tradicional iberoamericana y sus raíces históricas

The changeability of health care systems. Latin American experience.

National health care systems of Latin America have long consisted of a mixture of several subsystems, principally traditional healing; religious charity; Ministries of Health; social security organizations; other government agencies; voluntary agencies; enterprises; and a modern private market. Observations in Brazil and Peru in 1984, compared with 1962, show great changes in the proportions and character of all of these subsystems, particularly an expanding impact of the social security programs, in terms of people covered and the financial support of health services.

An Amerindian derivation for Latin American creole illnesses and their treatment.

We present an extended argument which we consider to be sufficient demonstration that a humoral tradition, notably a hot and cold classification, underlies medical etiologies and treatments used by certain groups of South American Indians, and that this is indigenous. We argue that several major, widespread categories of illness and treatments also have a mainly indigenous, Amerindian derivation: that they have not been derived, as often assumed, from unique importations from Spain or other Old World countries, so dating only from the Conquest and surviving in Latin American folk systems up to the present. Our ethnographic data derive from the Akawaio and northern Pemon (Arekuna, Taurepan and Kamarakoto), Carib-speaking Indians in the Guiana Highlands of the border areas of Venezuela, Brazil and Guyana. We stress the following points: The existence amongst these Amerindians, as amongst many Latin American creole and peasant groups, of certain specific and distinctive forms and interpretations of illness, their causations and cures. These include the binary oppositions of hot and cold and the notion of imbalance accompanying the concept of the mediate and harmonious state: sould loss through shock and fright: the capture of soul: whirlwind or cold air sickness: illness from contagious and powerful forces. Similarities between practitioners and remedies also exist. An interdependent relationship between indigenous concepts and language relating to the medical system Is demonstrated. Close associations between the medical system and the physical environment and the depiction of these in metaphors and symbols are detailed. Historical evidence in 17th century literature on Carib peoples is taken into account as well as evidence from remote, mostly unacculturated Amerindian societies of the recent past and of today. In the case of the Akawaio and Pemon, only the beginnings of syncretism in the medical system have been discovered. If our ethnographic data and the conclusions we draw are accepted, then question arises as to whether the hot/cold opposition and other medical concepts and practices relating to a humoral tradition in other Latin American groups, Amerindian and creole, are not wholley or in the main indigenous--as some scholars have already begun to suggest. If they are indigenous then they should be studied as such. We consider that there is a case for studying syncretism in medicine. We see this as a process whereby adoptions and adaptations are made selectively from incoming systems; where essential, indigenous elements may be reinforced and modified by the incoming, but where basic structures, objectives and characteristics of the indigenous remain identifiable and a continuity is achieved.

Traditional medicine in Ecuador: the structure of the non-formal health systems.

This paper summarizes the main findings of a four village study, carried out during 1979 and 1980 in the highlands and lowlands of northwest Ecuador concerning Western and traditional medicine practices and their relationship with the health status of the people. The methodology used was based on a census and cross-sectional survey on morbidity, mortality and healthy-seeking behaviour; on structured an open-ended interviews with healers, traditional midwives and local medical personnel; and on case studies and follow-ups of individual cases of illness, as defined by the population. Morbidity and mortality data show that the health situation is similar or worse in those villages with local medical services than in those with remote access to hospital facilities. The reported consultation and follow-up of actual cases revealed the existence of complex social networks for disease interpretation and management which combine Western and traditional medicine practices, religious and lay family healing procedures.

The survival of traditional medicine in a Peruvian barriada.

Current trends in population dynamics reflect increasing movement from rural to urban environments. As a result the provision of health care for migrants has become a national priority in many countries 'in development'. Information describing the extent to which traditional medical beliefs and practices persist is crucial to the formation of systems of health care for migrant communities. This paper describes the dynamics of medical conservatism. Data analysis obtained from a comparative study of 52 Peruvian women living in a rural highland province and 50 Peruvian women from a migrant squatter settlement, a barriada, indicates that length of exposure to an urban environment is less of a determinant in medical conservatism than age of enculturation. Positive and negative implications of medical conservatism for the delivery of health services are discussed. Recommendations are suggested for greater emphasis on the coordination of programs of health care with community education.