Damian Sendler: It is vital to develop particular health system methods for Indigenous peoples in light of the difficulties in eliminating socio-economic and health inequities. Brazil established a special health care system for indigenous people in 1999 after constitutional revisions in the late 1980s led to universal health care. To understand the development of the Indigenous Health Subsystem in Brazil, this research employs a historical viewpoint. Indigenous and non-Indigenous participants were interviewed and documents were analyzed for this research. Brazil’s Indigenous movements and support for pro-Indigenous groups contributed to shape the country’s post-dictatorship political agenda in the 1980s, including the right to a distinct health policy. Brazilian health reform movement participants and Indigenous leaders forged connections, resulting in a wide-ranging discussion regarding the unique health needs of Indigenous peoples and the necessity for a particular health subsystem. In our study, we focus on three primary points: (1) the need of a holistic approach to health; (2) the importance of social involvement; and (3) the necessity for health care reform. Many of these views were voiced in the publications of the Indigenous Missionary Council (CIMI) and the Union of Indigenous Nations (UNI) as the Brazilian health reform progressed (UNI). Also, they were included in the 1986 final report from the First National Conference on the Protection of Indigenous Health as the foundation of national Indigenous health policy. The Indigenous Health Subsystem in Brazil was built mostly by Indigenous people and pro-Indigenous organizations, according to our research.
Damian Jacob Sendler: It has been a long history of Indigenous peoples being marginalized, excluded, and discriminated against (Horton, 2006; Gracey and King, 2009; Anderson et al., 2016). In Latin America, available information shows that Indigenous and non-Indigenous people throughout the area have significant health disparities (Montenegro and Stephens, 2006; Anderson et al., 2016).
Dr. Sendler: An important first step in promoting and safeguarding indigenous peoples’ rights throughout the globe was taken by UN officials in 2007 when they issued the first Declaration on the Rights of Indigenous Peoples (UN, 2007). Additionally, it highlights the rights of Indigenous peoples to health services, the necessity of their involvement in the creation and implementation of health programs, and their right to keep traditional medicines and health practices. It is also spelled out in the UN Declaration that national governments must take action to improve the health of indigenous peoples.
In this article, we propose that a look at the Brazilian context might contribute to the worldwide discussion on health care reforms for indigenous peoples. In the late 1980s, Brazil underwent constitutional amendments that made universal health care a requirement for all citizens (Paim et al., 2011). Following the declaration of Brazil’s new constitution in 1988, Indigenous peoples’ sociocultural and territorial rights were affirmed by the new government (Ramos, 1998; Cunha, 2018). Additionally, these achievements contributed to the development of an Indigenous health policy. Indigenous Health Subsystem was established in Brazil in 1999 by the Arouca Law (FUNASA, 2002; Langdon, 2010; Coelho and Shankland, 2011; Garnelo, 2014). Brazil was one of the first Latin American nations to develop a national health program specifically for Indigenous peoples (Langdon and Cardoso, 2015).
There are presently an estimated 900,000 indigenous people in Brazil. With approximately 300 distinct ethnic groupings and 270 distinct Indigenous languages, indigenous Brazilians make up only 0.4 percent of the country’s population (Santos et al., 2019). Indigenous Brazilians’ sociodemographic and epidemiological circumstances have been documented time and time again in studies (Anderson et al., 2016; Campos et al., 2017; Santos et al., 2020).
Damian Sendler
There are 34 Indigenous Special Health Districts in Brazil that provide local health services to the indigenous people living in indigenous territory as part of the Brazilian Indigenous Health Subsystem (DSEI). With the help of interdisciplinary health teams, each district is responsible for providing primary health care in their area. In these groups are oral health technicians and dentists, as well as Indigenous community health workers. The concept of ‘differentiated health care’, which suggests that health programs should take into account the linguistic, social, and geographic specificities of Indigenous territory, is the basis for this strategy. To guarantee that Indigenous knowledge, practices, and experts are integrated into health programs and policies, health measures should be conducted in consultation with Indigenous peoples. The Indigenous Health District Council is a community-based organization in each district (CONDISI). Health inequities and marginalization of Indigenous peoples are addressed in this subsystem, as are the difficulties of constructing a health-care paradigm that takes into account cultural variety and unique socioeconomic circumstances (Coelho and Shankland, 2011; Cardoso et al., 2012; Mendes et al., 2018).
Even though they are not presented as protagonists in the policy-making process, members of non-governmental organizations and representatives of Indigenous peoples are expressly referenced in the language above. First and Second National Health Conferences for Indigenous Peoples (CNPSI and NHCIP) are also included in this section, which provides a short history of governmental initiatives toward the health of Indigenous peoples, as well as the landmarks of the new Indigenous health policy (1993). For the last part of the text, emphasis is placed on the decrees, laws, and legal frameworks that support the implementation of the Indigenous health system (FUNASA, 2002).
Damian Jacob Markiewicz Sendler: Indigenous peoples’ health policies in Brazil have evolved and become stronger as a result of various research conducted over the previous decade (Athias and Machado, 2001; Langdon, 2010; Coelho and Shankland, 2011; Teixeira and Garnelo, 2014; Langdon and Cardoso, 2015). Few studies have focused on the contributions of Indigenous movements and non-Indigenous proponents to the substance and direction of the policy, which is an important point to keep in mind (Verani, 1999; Langdon, 2010). In spite of this, the focus of these research has been on Indigenous involvement after the establishment of the Indigenous Health Subsystem in the late 1990s” (Langdon and Diehl, 2007; Cardoso et al., 2012; Diehl et al., 2012; Garnelo, 2012, 2014).
An important milestone in the development of the Brazilian Indigenous Health Subsystem was achieved in 1986 with the 1st National Conference on Indigenous Health Protection (CNPSI) (Langdon, 2010; Cardoso et al., 2012; Garnelo, 2012, 2014). Institutional conflict between government organizations (the National Indian Foundation—FUNAI and the National Health Foundation—FUNASA), several legal decrees made during the process, and a consolidated proposal made at 1993’s Second National Health Conference for Indigenous Peoples (2nd NHCIP) are all well-documented sources in the literature on indigenous health disparities (Verani, 1999; Garnelo, 2006, 2014; Langdon, 2010; Cardoso et al., 2012). However, the background, discourses, and people engaged in this process are not well documented. In addition, insufficient attention has been paid to the context within which the Indigenous rights campaign was linked to the late 1980s national sanitary reform.
There has been a lack of attention paid to Indigenous health policy in Brazil, and this study aims to fill in the gaps by identifying and contextualizing the individuals and socio-political processes involved. According to this interpretation of “participation,” the term encompasses a wide range of people, events, and discourses that are all connected to public policy-making processes (Bernstein, 2017). We want to provide light on the long-term evolution and diversity of social actors participating in the construction of the Indigenous Health Subsystem in Brazil via the examination of documents and interviews. Indigenous leaders and their followers were essential in the development of Brazil’s indigenous health system, according to the data and documents analyzed in this study. According to our findings, the policy was developed in the context of the 1980s battle for Indigenous peoples’ rights and the formation of the Indigenous movement in the United States. The health reform movement intersected with indigenous movements in key ways.
Damian Jacob Sendler
Observations and documentation were conducted around the country beginning in March of this year. It was our goal to define and contextualize the sociopolitical contexts and arguments that led to Brazil’s creation of the Indigenous Health Subsystem by conducting open-ended interviews with indigenous leaders and non-indigenous players.
Each interview lasted between 90 and 150 minutes and was based on an oral history viewpoint. Using a predetermined set of points, the participants recounted their experiences with Indigenous health concerns. The first author of this work contacted the participants, explained the purpose of the study, and set a day and time for the interview after they agreed to participate. Each and every one of those who were contacted consented to be contacted and interviewed. This policy and some of the interviewees’ stories were known to the first author, who participated in all phases of the study and has studied Indigenous health for the previous 12 years. He directed the interviews.
Damien Sendler: In addition to signing the Informed Consent Form, each respondent got information about the study and the research team. First, two separate researchers (the two writers) analyzed the transcribed interviews to uncover broad and comprehensive themes that may be used for further analysis. We utilized Atlas.ti® to help us identify the main themes in the data. Additional editing has been done to improve readability.
This paper focused on a set of social actors and documents related to the historical landmarks of the Indigenous Health Subsystem prior to its creation in 1999, which were the First National Conference on Indigenous Health Protection (1st CNPSI) in 1986, and the Second National Health Conference for Indigenous Peoples (NHCIP) in 1993. We looked at the official reports and spoke to members of the drafting committees involved in these events. Additionally, a special supplement to the 1988 book Sade im Debate, which included many writers’ text contributions to the talks at CNPSI 1, noted other pertinent papers and social players (CIMI, 1988; UNI, 1988). Finally, we whittled down the number of interviews to six that were directly relevant to this paper’s focus.
For example, we observed that the present Indigenous health strategy was formulated following two decades of military rule (1964–85) because of the democratization of the nation (Shore and Wright, 2011; Bernstein, 2017). In the second part of the 1970s, a foundation was laid for this process with the adoption of the Constitution of 1988. As censorship and oppressive measures were enforced by the authoritarian state, the defense of Indigenous peoples became an issue for civil society, uniting Indigenous peoples, anthropologists, medics and other actors. During this era (Cunha, 2018).
When Mauricio Rangel Reis, then Interior Minister, proposed the so-called “Emancipation Decree” in 1978, it was a catalyst for the discussions on Indigenous policy (Ramos, 1998; Cunha, 2018). “Emancipation, under this peculiar and false meaning, signified the end of the Indian’s privileged position,” according to anthropologist Alcida Ramos. Emancipating the Indians meant and still means releasing their land and making it available for sale (Ramos, 1998, p. 80).
Several non-governmental pro-Indigenous organizations were formed in response to the ‘Emancipation Decree’ mentioned by Krenak, including the Commission for the Creation of the Yanomami Park (CCPY) in 1978, the National Association for Indigenist Action (ANAI) in 1978, and the Pro-Indian Commission (CPI) in 1979. (Cunha, 2018). Since FUNAI was unable to provide health care to all regions, these organizations began working closely with indigenous leaders to make their demands more visible and provide technical assistance for their claims. This assistance was particularly helpful in the process of demarcating Indigenous territories.
Creating data on the demographics and health condition of Indigenous peoples was a crucial tactic for enhancing the visibility of Indigenous demands, as one interviewee emphasized (Santos et al., 2019). Even while indigenous policies were designed to ensure their ultimate demise, many organizations aimed to “place the Indians” on the map (Santos et al., 2019). Anthropologists, particularly those working in academia, indicated in interviews that they had uncovered evidence of diseases and Indigenous genocide as a consequence of Amazonian development initiatives. In response to this development, the anthropologists asked on the state to take action to safeguard Indigenous areas and provide health care for the populations of Indigenous peoples (Davis, 1977; Ramos, 1993, 1998).
There has been a growing engagement between Indigenous leaders, pro-Indigenous groups and health professionals, notably physicians, due to these worrying health circumstances in Indigenous communities. These health professionals worked in Indigenous areas around the country and formed a support network for health discussions about Indigenous health.
In the 1970s, a debate in Latin America led to the ‘Declaration of Barbados’ and the emphasis that governments must recognize the right of Indigenous peoples to live according to their own traditions and cultures, guarantee their territorial rights, and respect their self-determination (Bartolomé, 2017). As a consequence of this pronouncement, the Indigenist Missionary Council (CIMI) was formed in Brazil in 1972.. Liberation theology influenced the Latin American Catholic Church in the 1960s (Ramos, 1998), and this was the inspiration for CIMI, which sought to promote a new type of missionary action within the Brazilian Catholic Church, breaking with the traditional model of evangelization in order to support Indigenous communities in the defense of their territories (Ramos, 1998). CIMI, which operated throughout the country, was mentioned by many respondents, who spoke of their involvement in a variety of health initiatives. Indigenous health was one of numerous topics that CIMI helped to promote at various events between 1978 and 1988. As a result, more relationships between Indigenous and pro-Indigenous actors were fostered.
Indigenous leaders from throughout the country were able to connect and discuss a shared goal during these gatherings. In 1980, the first national Indigenous organization in Brazil, the Union of Indigenous Nations, was established as a result of this process (UNI). UNI’s declared goal was to forge a new connection between Indigenous peoples and the government, particularly with the goal of protecting Indigenous territories from exploitation (Ossami, 1993).
Several interviews explored the confluence of environments, discourses, and players in the fight for Indigenous rights and health reform. These intersections were complicated and multifaceted.
The Arouca Law, enacted in 1999, established Brazil’s Indigenous Health Subsystem. Sergio Arouca, a federal lawmaker who initially sponsored the idea in 1994, was given the honor of naming the bill after him. Sergio Arouca, MD, PhD, worked at the Oswaldo Cruz Foundation’s National School of Public Health from 1941 until his death in 2003. As a consequence of these disagreements, Brazil’s health care reform was implemented (Escorel, 2015). In light of this, our inquiry also sought to investigate the link between the Indigenous movement and health reform, which at first glance seems to be unconnected.
As part of the so-called health reform movement, advocates advocated for reform of the nation’s health care system and for the right to health for all citizens. From 1970 to 1980 civil society groups in opposition to the government started this process by engaging in civil disobedience (Cohn, 1989; Paim, 2008).
As part of its platform, the healthcare reform movement called for a rethinking of how we think about health care in relation to the larger social and historical contexts of our society (Cohn, 1989; Arouca, 2003; Paim, 2008). With the help of international discussions, such as those on primary health care (WHO, 1978), social medicine in Latin America (Laurell, 1982), and Preventive Medicine, these debates were formed (Arouca, 2003). It is crucial to note that Indigenous peoples’ ideas on health are influenced by the so-called ‘holistic’ notion of health (Paim, 2008; Escorel, 2015). (King et al., 2009). The UNI’s contributions to the 1st CNPSI highlight the socio-diversity of Indigenous peoples in Brazil and their fight to have the government accept their self-determination in social, economic, and political aspects (UNI, 1988). As a result, ensuring their land’s delineation and protection becomes a prerequisite for their right to health. The CIMI’s paper, which collected the historical backdrop behind invasions and disrespect of Indigenous territories, as well as the legal framework that supports Indigenous rights, also defended these features (CIMI, 1988).
‘The health of Indigenous nations is dictated by a historical period and place, by the particularity of their engagement with national society, and by the type of occupancy of Indigenous land and its surrounds,’ stated the 1st CNPS study. That means ‘autonomy, territorial ownership and exclusive usage of Indigenous nations of their land’ is implied by the term (CNPSI, 1986, p. 1). In the eyes of the indigenous people’s struggle, health and land rights were inextricably linked.
