[The challenge of providing primary healthcare care to indigenous peoples in BrazilEl desafío de brindar atención primaria de salud a los pueblos indígenas en Brasil]. / O desafio da atenção primária na saúde indígena no Brasil.

In Brazil, the right to health claimed by indigenous peoples interacts with various regulatory milestones, including the Alma-Ata Declaration, which proposes and highlights primary health care (PHC) as a means to increase access and minimize health inequalities. As part of the Brazilian Unified Health System (SUS), an indigenous health subsystem (SASI) was established, along with a National Policy for the Care of Indigenous Peoples (PNASPI), as a strategy to ensure health care access for these populations. PNASPI aims to provide differentiated health care to indigenous populations, considering the sociocultural diversity and the epidemiological and logistic peculiarities associated with the care of these peoples and focusing on the provision of comprehensive care. The present article discusses the implementation of PNASPI, highlighting achievements and challenges faced during this process. Despite the growing financial resources made available for the implementation of the indigenous health subsystem, the initiatives developed thus far have had little impact on health indicators, which reflect historical inequalities in relation to other population segments. Indigenous social control is still fragile, and the discussions in this arena show the dissatisfaction of users toward the system. The discontinuity of care, added to the shortage of and high turnover of health care workers and the need to establish intercultural dialogues that promote articulation with traditional knowledges, challenge the effectiveness of PNASPI. Care is still centered on palliative and emergency measures, usually based on relocation of patients for treatment, which is associated with high cost. To overcome these challenges, PHC must be strengthened and recognized as a regulatory milestone by the PNASPI organizational model.

En Brasil, el derecho a la salud reclamado por los pueblos indígenas interactúa con varios marcos regulatorios, incluida la Declaración de Alma-Ata, que propone y destaca la atención primaria de salud (APS) como un medio para aumentar el acceso a la salud y minimizar las desigualdades en materia de salud. Como parte del Sistema Único de Salud de Brasil (SUS), se crearon el subsistema de salud indígena (SASI)y la Política Nacional de Atención de Salud de los Pueblos Indígenas (PNASPI), como estrategias para garantizar el acceso a la atención médica de estas poblaciones. La Política tiene como objetivo brindar atención de salud diferenciada a las poblaciones indígenas, considerando la diversidad sociocultural y las peculiaridades epidemiológicas y logísticas asociadas con la atención de estos pueblos y centrándose en dispensar una atención integral basada en la APS. En este artículo se discute la implementación de la Política, y se destacan los logros y desafíos enfrentados durante este proceso. A pesar de los crecientes recursos financieros disponibles para la implementación del subsistema de salud indígena, las iniciativas desarrolladas hasta ahora han tenido escaso impacto en los indicadores de salud, que reflejan desigualdades históricas en relación con otros segmentos de la población. La participación social aún es débil, y las discusiones en este campo revelan la insatisfacción de los usuarios con el sistema. La falta de continuidad de la atención, sumada a la escasez y alta rotación de los trabajadores de la salud, así como la necesidad de establecer diálogos interculturales que promuevan la articulación con los conocimientos tradicionales, cuestionan la efectividad de la Política. La atención aún se centra en prácticas paliativas y de emergencia, generalmente basadas en la reubicación de los pacientes para tratamiento, lo que se asocia con un alto costo. La superación de estos desafíos depende del fortalecimiento de la APS y de su reconocimiento como marco regulador importante del modelo organizativo de la Política.

Anthropology, health and illness: an introduction to the concept of culture applied to the health sciences.

This article presents a reflection as to how notions and behavior related to the processes of health and illness are an integral part of the culture of the social group in which they occur. It is argued that medical and health care systems are cultural systems consonant with the groups and social realities that produce them. Such a comprehension is fundamental for the health care professional training.

Representations and care practices of professionals regarding indigenous use of alcohol. / Representações e práticas de cuidado dos profissionais da saúde indígena em relação ao uso de álcool.

Indigenous people's health in Brazil is organized by the indigenous health subsystem, structured according to that of SUS, and described in the National Policy for Health Care of Indigenous Peoples. Alcohol consumption has been regarded as a health issue among indigenous peoples. In this paper, we describe the representations attributed by health professionals concerning alcohol use among indigenous peoples, and how these influence care practices. This is a descriptive ethnographic study based on interviews and participant observation. Analysis and interpretation were made with the support of Software Atlas TI 8.0. Excessive consumption occurs in specific contexts, and professionals view alcohol use as a problem. Drinking patterns vary with ethnicity, religion, and location, thus resulting in the need to develop cultural competencies that support implementation of effective actions and that also allow for collective construction, as stipulated in the policies. A network of supporters is described, among which are indigenous leaders, traditional healers, and the Evangelical Church. The study shows the difficulties of both carrying out policies and implementing actions which correspond to the indigenous peoples' expectations, recognizing the cultural and social rationale related to alcohol use.

Articulation between health services and "indigenous medicine": Anthropological reflections on policies and reality in Brazil. / Articulación entre servicios de salud y "medicina indígena": reflexiones antropológicas sobre política y realidad en Brasil.

This paper contributes to the dialogue between the social sciences and social medicine in Latin America by exploring therapeutic pluralism in indigenous health policies and services in Brazil. It reviews recent anthropological research, concepts and current debates to critically examine Brazilian indigenous health policy and its concept of "differentiated care," which proposes articulation between official health practices and indigenous therapies. A number of contradictions and tensions are present in the structural organizational of the indigenous health subsystem at the national level and in the daily practices of health teams at the local level. Guided by the hegemonic ideology of biomedicine, health professionals fail to recognize the dynamics and agency expressed in indigenous health practices.

Este artículo contribuye al diálogo entre las ciencias sociales y la medicina social en América Latina a través de la exploración del pluralismo terapéutico en las políticas y servicios de salud indígena en Brasil. Revisa las investigaciones recientes en antropología, así como los conceptos y debates actuales, para examinar críticamente las políticas de salud indígena en Brasil y su concepto de "atención diferenciada", que propone la articulación entre las prácticas oficiales de salud y las terapias indígenas. Varias contradicciones y tensiones están presentes entre la organización estructural del subsistema de salud indígena en el nivel nacional y las prácticas cotidianas de los equipos de salud en el nivel local. Guiados por la ideología hegemónica de la biomedicina, los profesionales de salud no reconocen las dinámicas y la agencia expresada en las practicas indígenas de salud.

[Participation by indians health agents in health services: the experience in Santa Catarina State, Brazil]. / A participação dos agentes indígenas de saúde nos serviços de atenção à saúde: a experiência em Santa Catarina, Brasil.

This study analyzes the role and training of indian health agents as defined by the National Policy for Health Care of Indians Peoples on two Indian reservations in Santa Catarina, Brazil. The health agent's role in primary care is based on mediation between traditional health practices and biomedicine, subsumed in the concept of differentiated care. On both reservations, a large turnover of indigenous health agents and lack of adequate training were observed. The indigenous health agents expressed difficulty in understanding the reasons for their activities, role ambiguity vis-à-vis the community, and communications problems with other health professionals. Considering the national policy guidelines, this study indicates that the provision of differentiated care is precarious and that a dialogue is necessary, with actual participation by all stakeholders in the health services.

Violência estrutural e adoecer no Haiti: reflexões sobre uma experiência / Structural violence and illness in Haiti: reflections on an experience

Resumo Falar sobre saúde e principalmente da busca pela cura das doenças em sociedades globais empobrecidas e desassistidas traz à tona amplas e conflitivas reflexões. O Haiti é o país mais pobre das Américas e um dos mais pobres do mundo. A extrema vulnerabilidade a que a população está exposta é facilmente percebida por meio da análise do processo saúde/enfermidade/atenção, uma vez que esse é um dos domínios em que se acentuam as vivências de sofrimento, a percepção da inequidade e as intervenções ineficazes, que se pode observar em cada relato de experiência a violência estrutural como um legado histórico. Perpetuada ainda hoje por forças sociais e políticas globais, a violência estrutural pode ser pensada como fator associado ao risco de adoecer e a viabilidade (ou não) da cura ou do controle das doenças. A partir de um relato particular, discute-se com base nessa teoria o processo de adoecimento e o percurso feito até a resolução do padecimento, considerando a realidade da saúde pública do país.

Abstract Talking about health and especially the search for curing diseases in impoverished and unempowered global societies brings out broad and conflicting reflections. Haiti is the poorest country in the Americas and one of the poorest in the world. The extreme vulnerability to which the population is exposed is easily perceived by analyzing its health/disease/attention process, as this is one of the areas where experiencing suffering, the perception of inequity and ineffective interventions are notorious, depicting structural violence as a historical legacy in each case report. Structural violence is perpetuated today by global social and political forces and can be thought of as a factor associated with the risk of illness and the viability of healing or disease control. A private report was used to discuss the process of falling ill based on this theory and the path taken until the resolution of the disease, considering the public health reality of the country.

[Intermedicality and protagonism: the role of indigenous health agents on the Kwatá-Laranjal Indian Reservation in Amazonas State, Brazil]. / Intermedicalidade e protagonismo: a atuação dos agentes indígenas de saúde Munduruku da Terra Indígena Kwatá-Laranjal, Amazonas, Brasil.

This article summarizes the results of an ethnographic study on the role of indigenous health agents on the Kwata-Laranjal Indian Reservation in Borba, Amazonas State, Brazil. The study aims to contribute to understanding the role of indigenous health agents in the expansion of the hegemonic medical model in a context of medical pluralism. The analysis included data from participant observation and interviews conducted from 2009 to 2011. Semi-structured interviews were held to record narratives on their work routine, experiences, and difficulties. The authors conclude that work by indigenous health agents is essential to primary care, and that their role extends beyond technical activities. The Munduruku indigenous health agents hold a key position in the links between indigenous and biomedical knowledge in contexts of intermedicality, emerging as new political actors in interethnic contexts.

Representações e práticas de cuidado dos profissionais da saúde indígena em relação ao uso de álcool / Representations and care practices of professionals regarding indigenous use of alcohol

Resumo A saúde indígena no Brasil está regulamentada pelo subsistema de saúde indígena, estruturado a partir do Sistema Único de Saúde e descrito na Política Nacional de Atenção à Saúde dos Povos Indígenas. O uso do álcool tem sido visto como um problema entre povos indígenas. Nesse artigo descrevemos as representações atribuídas por profissionais de saúde em relação ao uso do álcool entre indígenas e como estas influenciam nas práticas de cuidado. Estudo descritivo baseado em entrevistas e observação participante por inserção etnográfica. Análise e interpretação se deu com apoio do Software Atlas TI 8.0. O uso do álcool é observado como problemático pelos profissionais, e o consumo excessivo é reproduzido em contextos específicos. Os modos de beber variam de acordo com a etnia, religião e local, e isso resulta na descrição da necessidade de desenvolver competências culturais que apoiariam na execução de ações efetivas e contemplassem a construção coletiva prevista nas políticas. Uma rede de apoiadores é descrita, dentre eles, as lideranças, curadores tradicionais e a igreja evangélica. O estudo mostra as dificuldades na efetivação das políticas e na implementação de ações que correspondam às expectativas dos povos indígenas, reconhecendo as lógicas culturais e sociais relacionadas ao uso do álcool.

Abstract Indigenous people's health in Brazil is organized by the indigenous health subsystem, structured according to that of SUS, and described in the National Policy for Health Care of Indigenous Peoples. Alcohol consumption has been regarded as a health issue among indigenous peoples. In this paper, we describe the representations attributed by health professionals concerning alcohol use among indigenous peoples, and how these influence care practices. This is a descriptive ethnographic study based on interviews and participant observation. Analysis and interpretation were made with the support of Software Atlas TI 8.0. Excessive consumption occurs in specific contexts, and professionals view alcohol use as a problem. Drinking patterns vary with ethnicity, religion, and location, thus resulting in the need to develop cultural competencies that support implementation of effective actions and that also allow for collective construction, as stipulated in the policies. A network of supporters is described, among which are indigenous leaders, traditional healers, and the Evangelical Church. The study shows the difficulties of both carrying out policies and implementing actions which correspond to the indigenous peoples' expectations, recognizing the cultural and social rationale related to alcohol use.

[The dialogues between anthropology and health: contributions to public policies]. / Os diálogos da antropologia com a saúde: contribuições para as políticas públicas.

In order to examine the development of anthropological paradigms and their dialogue with medicine, I divide the discussion into two general, but non-exclusive, approaches: one that focuses on health and disease as social and cultural experience and construction, and another that examines health from an interactional and political perspective. For the first approach, I focus on North American and French theories that find resonance in the anthropological dialogue in Brazil. For the second political approach, the discussion originates in the dialogue among anthropologists in Latin America who have been developing models to contribute to an interdisciplinary approach necessary for health policies and intervention in health. The concepts of practices in self-care and intermedicality, among others, are explored due to their contribution in anthropology to public policies in health. These anthropologists have argued that health practices should be understood through the notions of autonomy, collectivity, agency and praxis, as opposed to the notions of the biomedical perspective characterized as being universalist, biological, individualist and a-historical.

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

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

O desafio da atenção primária na saúde indígena no Brasil / The challenge of providing primary healthcare care to indigenous peoples in Brazil / El desafío de brindar atención primaria de salud a los pueblos indígenas en Brasil

RESUMO No Brasil, o direito à saúde pleiteado pelos povos indígenas dialoga com diferentes marcos regulatórios, incluindo a Declaração de Alma-Ata, a qual propõe e valoriza a atenção primária à saúde (APS) como promotora de maior acesso e forma de minimizar as desigualdades em saúde. No âmbito do Sistema Único de Saúde (SUS), o subsistema de atenção à saúde indígena (SASI) e a Política de Atenção à Saúde dos Povos Indígenas (PNASPI) foram criados como estratégia para garantir o acesso à saúde aos povos indígenas. A PNASPI prevê atenção diferenciada às populações indígenas com base na diversidade sociocultural e nas particularidades epidemiológicas e logísticas desses povos e focando no desenvolvimento da APS com garantia de integralidade da assistência. O presente artigo traz reflexões acerca da implementação da PNASPI, destacando os avanços e desafios apresentados durante esse percurso. Apesar dos crescentes recursos financeiros disponibilizados para implementar o subsistema de saúde indígena, as ações têm apresentado poucos resultados nos indicadores de saúde, que refletem desigualdades historicamente descritas entre esses povos e os demais segmentos. A participação social ainda se mantém frágil, e suas discussões refletem a insatisfação dos usuários. A descontinuidade do cuidado somada à carência e alta rotatividade de profissionais, assim como a necessidade de estabelecer diálogos interculturais que promovam a articulação com saberes tradicionais, são fatores que desafiam a efetividade da PNASPI. O cuidado ainda é centrado em práticas paliativas e emergenciais, geralmente baseado na remoção de pacientes, gerando altos custos. A superação desses desafios depende do fortalecimento da APS e de seu reconhecimento enquanto importante marco regulador do modelo organizacional da PNASPI.

ABSTRACT In Brazil, the right to health claimed by indigenous peoples interacts with various regulatory milestones, including the Alma-Ata Declaration, which proposes and highlights primary health care (PHC) as a means to increase access and minimize health inequalities. As part of the Brazilian Unified Health System (SUS), an indigenous health subsystem (SASI) was established, along with a National Policy for the Care of Indigenous Peoples (PNASPI), as a strategy to ensure health care access for these populations. PNASPI aims to provide differentiated health care to indigenous populations, considering the sociocultural diversity and the epidemiological and logistic peculiarities associated with the care of these peoples and focusing on the provision of comprehensive care. The present article discusses the implementation of PNASPI, highlighting achievements and challenges faced during this process. Despite the growing financial resources made available for the implementation of the indigenous health subsystem, the initiatives developed thus far have had little impact on health indicators, which reflect historical inequalities in relation to other population segments. Indigenous social control is still fragile, and the discussions in this arena show the dissatisfaction of users toward the system. The discontinuity of care, added to the shortage of and high turnover of health care workers and the need to establish intercultural dialogues that promote articulation with traditional knowledges, challenge the effectiveness of PNASPI. Care is still centered on palliative and emergency measures, usually based on relocation of patients for treatment, which is associated with high cost. To overcome these challenges, PHC must be strengthened and recognized as a regulatory milestone by the PNASPI organizational model.

RESUMEN En Brasil, el derecho a la salud reclamado por los pueblos indígenas interactúa con varios marcos regulatorios, incluida la Declaración de Alma-Ata, que propone y destaca la atención primaria de salud (APS) como un medio para aumentar el acceso a la salud y minimizar las desigualdades en materia de salud. Como parte del Sistema Único de Salud de Brasil (SUS), se crearon el subsistema de salud indígena (SASI)y la Política Nacional de Atención de Salud de los Pueblos Indígenas (PNASPI), como estrategias para garantizar el acceso a la atención médica de estas poblaciones. La Política tiene como objetivo brindar atención de salud diferenciada a las poblaciones indígenas, considerando la diversidad sociocultural y las peculiaridades epidemiológicas y logísticas asociadas con la atención de estos pueblos y centrándose en dispensar una atención integral basada en la APS. En este artículo se discute la implementación de la Política, y se destacan los logros y desafíos enfrentados durante este proceso. A pesar de los crecientes recursos financieros disponibles para la implementación del subsistema de salud indígena, las iniciativas desarrolladas hasta ahora han tenido escaso impacto en los indicadores de salud, que reflejan desigualdades históricas en relación con otros segmentos de la población. La participación social aún es débil, y las discusiones en este campo revelan la insatisfacción de los usuarios con el sistema. La falta de continuidad de la atención, sumada a la escasez y alta rotación de los trabajadores de la salud, así como la necesidad de establecer diálogos interculturales que promuevan la articulación con los conocimientos tradicionales, cuestionan la efectividad de la Política. La atención aún se centra en prácticas paliativas y de emergencia, generalmente basadas en la reubicación de los pacientes para tratamiento, lo que se asocia con un alto costo. La superación de estos desafíos depende del fortalecimiento de la APS y de su reconocimiento como marco regulador importante del modelo organizativo de la Política.

Articulación entre servicios de salud y "medicina indígena": reflexiones antropológicas sobre política y realidad en Brasil / Articulation between health services and "indigenous medicine": Anthropological reflections on policies and reality in Brazil

RESUMEN Este artículo contribuye al diálogo entre las ciencias sociales y la medicina social en América Latina a través de la exploración del pluralismo terapéutico en las políticas y servicios de salud indígena en Brasil. Revisa las investigaciones recientes en antropología, así como los conceptos y debates actuales, para examinar críticamente las políticas de salud indígena en Brasil y su concepto de "atención diferenciada", que propone la articulación entre las prácticas oficiales de salud y las terapias indígenas. Varias contradicciones y tensiones están presentes entre la organización estructural del subsistema de salud indígena en el nivel nacional y las prácticas cotidianas de los equipos de salud en el nivel local. Guiados por la ideología hegemónica de la biomedicina, los profesionales de salud no reconocen las dinámicas y la agencia expresada en las practicas indígenas de salud.

ABSTRACT This paper contributes to the dialogue between the social sciences and social medicine in Latin America by exploring therapeutic pluralism in indigenous health policies and services in Brazil. It reviews recent anthropological research, concepts and current debates to critically examine Brazilian indigenous health policy and its concept of "differentiated care," which proposes articulation between official health practices and indigenous therapies. A number of contradictions and tensions are present in the structural organizational of the indigenous health subsystem at the national level and in the daily practices of health teams at the local level. Guided by the hegemonic ideology of biomedicine, health professionals fail to recognize the dynamics and agency expressed in indigenous health practices.

Anthropology of health in Brazil: a border discourse.

This article traces the development of anthropological research on health in Brazil in light of discussions on modernity/coloniality and world anthropologies. Originating in the 1970s, stimulated by external and internal pressures for scientific production and along with the expansion of graduate programs, a network of anthropologists has consolidated and multiplied in Brazil. We describe the development of research groups, meetings, and publications in order to characterize Brazilian anthropology of health as a research program that distinguishes itself from North Atlantic medical anthropology. We examine the visibility and circulation of references in academic publications to explore the participation of Brazilians in the global discourse and, more specifically, in the North-South dialogue. From a comparative perspective, we argue that anthropological investigations of health reflect a perspective and ethos distinctive to Brazil and its historical and political processes.

[The contribution of indigenous community health workers to special healthcare for Brazilian indigenous peoples]. / Contribuição dos agentes indígenas de saúde na atenção diferenciada à saúde dos povos indígenas brasileiros.

Indigenous community health workers are part of a strategy developed by Brazil in the last two decades to promote a special healthcare model for indigenous peoples. Their role is designed to deal with various aspects of the special health policy, including the link between the heath team and the community and mediation between scientific and indigenous medical knowledge. Despite a significant increase in the number of indigenous community health workers in recent years, an evaluation of their responsibilities and contributions to the success of special care had not been conducted previously. This article, based on a literature review and original research by the authors, analyzes the role of the indigenous community health workers vis-à-vis their training and participation in health teams in different contexts in Brazil. Considering the importance assigned to the role of indigenous community health workers, this analysis reveals various ambiguities and contradictions that hinder both their performance and their potential contribution to the special health services.

Intermedicalidade e protagonismo: a atuação dos agentes indígenas de saúde Munduruku da Terra Indígena Kwatá-Laranjal, Amazonas, Brasil / Intermedicality and protagonism: the role of indigenous health agents on the Kwatá-Laranjal Indian Reservation in Amazonas State, Brazil / Intermedicalidad y protagonismo: la actuación de los agentes indígenas de salud en la Tierra Indígena Kwatá-Laranjal, Amazonas, Brasil

Resumo O artigo sintetiza resultados de pesquisa etnográfica sobre a atuação dos agentes indígenas de saúde (AIS) na Terra Indígena (TI) Kwatá-Laranjal, Município de Borba, Amazonas, Brasil. Visa a contribuir para a compreensão do papel dos AIS frente à expansão do modelo médico hegemônico em contexto de pluralidade médica. A análise inclui dados de observação participante e entrevistas realizadas de 2009 a 2011. Entrevistas semiestruturadas foram realizadas com objetivo de registrar narrativas sobre a rotina, experiências e dificuldades no trabalho. Concluímos que a atuação dos AIS é essencial para a atenção primária, e seu papel transcende atividades estritamente técnicas. O AIS Munduruku ocupa posição central na articulação entre saberes indígenas e biomédicos em contextos de intermedicalidade e emerge como um novo ator político em contextos interétnicos.

Abstract This article summarizes the results of an ethnographic study on the role of indigenous health agents on the Kwata-Laranjal Indian Reservation in Borba, Amazonas State, Brazil. The study aims to contribute to understanding the role of indigenous health agents in the expansion of the hegemonic medical model in a context of medical pluralism. The analysis included data from participant observation and interviews conducted from 2009 to 2011. Semi-structured interviews were held to record narratives on their work routine, experiences, and difficulties. The authors conclude that work by indigenous health agents is essential to primary care, and that their role extends beyond technical activities. The Munduruku indigenous health agents hold a key position in the links between indigenous and biomedical knowledge in contexts of intermedicality, emerging as new political actors in interethnic contexts.

Resumen Este artículo sintetiza los resultados de una investigación etnográfica sobre la actuación de los agentes indígenas de salud (AIS), en la tierra indígena Kwata-Laranjal, Amazonas, Brasil. Dicha investigación procura contribuir a la reflexión sobre el papel que los AIS desempeñan, frente a la expansión del modelo médico hegemónico, en un contexto de pluralidad médica. Los datos fueron obtenidos a partir de observación participante y de entrevistas realizadas entre los años 2009 y 2011. Las entrevistas semi-estructuradas se llevaron a cabo con el fin de registrar la rutina, experiencias y dificultades en el trabajo. Concluimos que el papel de los AIS es fundamental para los servicios de atención primaria, y que su actuación trasciende las actividades técnicas, dado que los AIS Munduruku realizaban un importante papel como articuladores entre los saberes biomédicos e indígenas en contextos de intermedicalidad, y actuando como nuevos actores políticos en contextos interétnicos.

Os diálogos da antropologia com a saúde: contribuições para as políticas públicas / The dialogues between anthropology and health: contributions to public policies

No intuito de examinar o desenvolvimento dos paradigmas antropológicos e seu diálogo com a medicina, a discussão está organizada segundo dois eixos gerais, porém não exclusivos: o que enfoca a saúde e a doença como experiência e construção sociocultural, e o que examina a saúde a partir de uma perspectiva interacional e política. No primeiro eixo, privilegio as teorias estadunidenses e francesas que encontram reflexo no diálogo antropológico no Brasil. Para o último eixo, o da política, a discussão parte do diálogo entre antropólogos na América Latina que vêm desenvolvendo modelos para contribuir com a interdisciplinaridade necessária para as políticas e a intervenção na saúde. Os conceitos de práticas de autoatenção, intermedicalidade, entre outros, são explorados por causa de sua contribuição na antropologia para as políticas públicas em saúde. Estes antropólogos vêm argumentando que as práticas de saúde precisam ser entendidas através das noções de autonomia, coletividade, agência e práxis, em oposição à perspectiva biomédica caracterizada como universalista, biologista, individualista e a-histórica.

In order to examine the development of anthropological paradigms and their dialogue with medicine, I divide the discussion into two general, but non-exclusive, approaches: one that focuses on health and disease as social and cultural experience and construction, and another that examines health from an interactional and political perspective. For the first approach, I focus on North American and French theories that find resonance in the anthropological dialogue in Brazil. For the second political approach, the discussion originates in the dialogue among anthropologists in Latin America who have been developing models to contribute to an interdisciplinary approach necessary for health policies and intervention in health. The concepts of practices in self-care and intermedicality, among others, are explored due to their contribution in anthropology to public policies in health. These anthropologists have argued that health practices should be understood through the notions of autonomy, collectivity, agency and praxis, as opposed to the notions of the biomedical perspective characterized as being universalist, biological, individualist and a-historical.

Reflections on intervention strategies with respect to the process of alcoholization and self-care practices among Kaingang indigenous people in Santa Catarina State, Brazil / Reflexiones sobre estrategias de intervención en relación al proceso de alcoholización y las prácticas de auto-atención entre los Kaingang, Santa Catarina, Brasil / Reflexões sobre estratégias de intervenção a partir do processo de alcoolização e das práticas de autoatenção entre os índios Kaingang, Santa Catarina, Brasil

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

Este texto se fundamenta en una investigación etnográfica realizada en la Tierra Indígena (TI) Xapecó, Santa Catarina, Brasil, y aborda el contexto sociocultural relacionado con el consumo de bebidas alcohólicas entre los indígenas Kaingang de la región. De forma complementaria, se observa una experiencia de intervención institucional que intentó desarrollarse en la zona y en la cual participaron órganos gubernamentales y no gubernamentales, con la intención de hacer frente a los problemas relacionados con el consumo de alcohol. A partir de los conceptos de proceso de alcoholización y prácticas de auto-atención, analizaremos las posibilidades de articulación de prácticas intervencionistas en el ámbito de la salud para grupos indígenas, teniendo en consideración el principio de atención diferenciada presente en la actual Política Nacional de Atención a la Salud de los Pueblos Indígenas en Brasil.

Este texto, baseado em pesquisa etnográfica realizada na Terra Indígena Xapecó em Santa Catarina, Brasil, trata do contexto sociocultural relacionado ao uso de bebidas alcoólicas entre os índios Kaingang. Complementarmente, aborda uma experiência de intervenção institucional, envolvendo órgãos governamentais e não governamentais, que tentou se estabelecer na localidade para atuação frente aos problemas relacionados ao uso de álcool. Assim, a partir dos conceitos de processo de alcoolização e práticas de autoatenção, analisaremos as possibilidades de articulação de práticas intervencionistas em saúde junto a populações indígenas, tendo em mente o princípio de atenção diferenciada presente na atual Política Nacional de Atenção à Saúde dos Povos Indígenas no Brasil.

Contribuição dos agentes indígenas de saúde na atenção diferenciada à saúde dos povos indígenas brasileiros / The contribution of indigenous community health workers to special healthcare for Brazilian indigenous peoples

Os agentes indígenas de saúde (AIS), no Brasil, fazem parte de uma estratégia desenvolvida nas últimas duas décadas para a promoção de um modelo de atenção diferenciada à saúde indígena. Seu papel objetiva atender vários aspectos da política de atenção diferenciada, tais como o elo entre a equipe de saúde e a comunidade, e a mediação entre os saberes médico-científicos e os indígenas. Apesar do aumento significativo dos AIS nos últimos anos, falta ainda uma avaliação sobre suas competências e contribuições para a realização da atenção diferenciada. Este artigo, baseado em pesquisas realizadas pelas autoras e em uma revisão bibliográfica, analisa o papel do AIS por meio da sua incorporação, formação e participação nas equipes de saúde em diferentes contextos no país. Em que pese a importância dada ao papel do AIS, esta análise demonstra um conjunto de ambiguidades e contradições que dificulta o seu desempenho e uma contribuição maior para a atenção diferenciada.

Indigenous community health workers are part of a strategy developed by Brazil in the last two decades to promote a special healthcare model for indigenous peoples. Their role is designed to deal with various aspects of the special health policy, including the link between the heath team and the community and mediation between scientific and indigenous medical knowledge. Despite a significant increase in the number of indigenous community health workers in recent years, an evaluation of their responsibilities and contributions to the success of special care had not been conducted previously. This article, based on a literature review and original research by the authors, analyzes the role of the indigenous community health workers vis-à-vis their training and participation in health teams in different contexts in Brazil. Considering the importance assigned to the role of indigenous community health workers, this analysis reveals various ambiguities and contradictions that hinder both their performance and their potential contribution to the special health services.

Anthropology, health and illness: an introduction to the concept of culture applied to the health sciences / Antropologia, saúde e doença: uma introdução ao conceito de cultura aplicado às ciências da saúde / Antropología, salud y enfermedad: una introducción al concepto de cultura aplicado a las ciencias de la salud

This article presents a reflection as to how notions and behavior related to the processes of health and illness are an integral part of the culture of the social group in which they occur. It is argued that medical and health care systems are cultural systems consonant with the groups and social realities that produce them. Such a comprehension is fundamental for the health care professional training.

O objetivo deste artigo foi apresentar uma reflexão de como as noções e comportamentos ligados aos processos de saúde e de doença integram a cultura de grupos sociais onde os mesmos ocorrem. Argumenta-se que os sistemas médicos de atenção à saúde, assim como as respostas dadas às doenças, são sistemas culturais, consonantes com os grupos e realidades sociais que os produzem. A compreensão dessa relação se mostra fundamental para a formação do profissional da saúde.

Este artículo presenta una reflexión acerca de como las nociones y comportamientos asociados a los procesos de salud y enfermedad están integrados a la cultura de los grupos sociales en los que estos procesos ocurren. Se argumenta que los sistemas médicos de atención a la salud, así como las respuestas dadas a la enfermedad son sistemas culturales que están en consonancia con los grupos y las realidades sociales que los producen. Comprender esta relación es crucial para la formación de profesionales en el área de la salud.

Percepção e expressão de sintomas depressivos em três grupos culturais catarinenses: açorianos, italianos e alemães / Perceptions of the symptoms of depression between members of three ethnic communities in Santa Catarina: azoreans, italians and germans

OBJETIVOS: Comparar a percepção da depressão, incluindo a percepção dos sintomas e dos tratamentos considerados apropriados, pelos membros de três grupos étnicos (descendentes de açorianos, italianos e alemães residentes em Santa Catarina, Estado da Região Sul do Brasil), assim como a expressão de depressão por meio do Inventário Beck de Depressão nestes grupos. METÓDO: Em um estudo transversal, com uma parte quantitativa e uma qualitativa, foram avaliados 60 indivíduos, sendo 20 de cada uma das comunidades étnicas escolhidas: açoriana, italiana e alemã. Realizou-se uma entrevista semi-aberta, tendo como questões orientadoras: Para você, o que é depressão?; O que pessoas deprimidas devem fazer?; e Qual atividade de lazer você mais gosta de fazer? Depois, foi aplicado o Inventário Beck de Depressão (BDI). Os escores do BDI (subescalas: cognitiva-afetiva e somática) foram comparados entre os diferentes grupos por meio do método ANOVA. No estudo qualitativo, verificaram-se as percepções compartilhadas no discurso dos indivíduos de cada grupo, quanto à depressão e seu tratamento. RESULTADOS: Os principais sintomas relatados por descendência foram: irritabilidade (açorianos), autopunição (italianos) e falta de energia (alemães). Não houve diferença estatisticamente significativa quanto à freqüência de sintomas cognitivos e somáticos nas diferentes comunidades. O padrão de percepção da depressão caracterizou-se nos descendentes de açorianos por isolamento ("... a gente não quer ver ninguém"). Nos italianos, a depressão esteve relacionada a afastamento da família ("Depressão é vontade até de deixar o filho, o marido"), sendo esta vista como a responsável por ajudar na melhora. Já entre os alemães, a depressão esteve relacionada à dificuldade no trabalho ("Depressão é... não ter mais vontade de trabalhar") e este foi relatado como a solução. CONCLUSÃO: De acordo com o grupo étnico, a expressão, a percepção e a busca de tratamento para a depressão...

OBJECTIVES: To compare perceptions of the symptoms of depression and its management between members of three ethnic communities (descendants of Azoreans, Italians and Germans in Santa Catarina, which is a State in the South of Brazil) and to compare the expression of depressive symptoms via the Beck Depression Inventory. METHODS: In a cross-sectional study, with both a quantitative and a qualitative design, 60 individuals (20 of each of the above ethnicities) were interviewed. A semi-structured interview was conducted, oriented by the following questions: In your opinion, what is depression?; How should persons cope with depression? and What is your preferred leisure time activity? After that, the subjects completed the Beck Depression Inventory (BDI). The BDI scores (subscales: cognitive/affective and somatic) were compared among the three groups using ANOVA. In the qualitative study, patterns of perceptions concerning depression were identified analyzing the responses of the individuals to the semi-structured interviews. RESULTS: The most frequent self-reported symptoms according to each ethnicity were: irritability (Azoreans), self-punishment (Italians) and low energy (Germans). There were no statistically significant differences between cognitive or somatic scores among the groups. The Azorean descendants suspected depression if the individuals evidenced social withdrawal ("... we don't want to see anybody"). For the Italian descendants, the family was cited as important in detecting ("Depression is feeling like leaving your son, your husband") and managing depression. The German descendants attributed depression to difficulty with work ("Depression is... not wanting to work") and work was also seen as the solution. CONCLUSIONS: According to ethnicity, the detection, expression of symptoms and search for treatment was related to: the community (Azoreans); the family (Italians) and work (Germans).