Post-cataract surgery assessment in the Zoé indigenous village. Photo by Erik Jennings.

In January 2023, the Brazilian Minister of Health — faced with a regional scenario of malnutrition and a lack of medical assistance — declared a state of emergency on Yanomami lands. The Yanomami People are the largest isolated Indigenous tribe in Brazil; theirs is the biggest forested Indigenous territory in the world, measuring approximately 17.8 million hectares. This territory — located on the northern border of the Brazilian rainforest and mountainous southern border of Venezuela — is home for over 38 thousand Indigenous People. At the moment, another 20 thousand illegal miners and prospectors have invaded their habitat in a gold rush to commoditize the Amazon rainforest. The results have been immediate and catastrophic: rivers have been polluted with mercury; forests have been leveled by loggers and miners. The Yanomamis’ way of life has been endangered, threatening the very existence of this ancestral people.

“Healthcare should go to the village, and not wait for them [the Indigenous] to come here to the city”, said President Luiz Inácio Lula da Silva “Lula” after declaring he was horrified at the situation of the Yanomami Casa de Saúde Indígena (Home for Indigenous Health) (Casai), in Boa Vista (RR). The home shelters the Indigenous peoples of the Yanomami, Sanöma and Ye’kuana ethnicities who are transported to the state capital in search of treatment.

Lula is correct. Attending to the Indigenous on their own territory is beneficial in several ways. The bad news is that it is not enough to send healthcare teams; they must be provided with the right infrastructure, training and humanized care, so that local culture is respected. In other words, investment is what is required. The good news is that all this is perfectly feasible, as demonstrated by the experience of the Zo’é people, situated in the north-west of the state of Pará.

Returning to the case of the Yanomami, what went wrong for more than 570 children to die of negligence (from hunger and other treatable illnesses) in the last four years? Why were exploding cases of malaria and instances of malnourishment not being addressed? Why were 21requests to help the Indigenous ignored, as revealed by the press? Wasn’t Sesai (Secretaria Especial de Saúde Indígena) (Special Secretary for Indigenous Health) looking after the Yanomami people? Weren’t healthcare professionals going to the village? Weren’t we spending millions of reais [the Brazilian currency] on flying for hours to transport patients to the nearest hospitals?

The answer is yes. Care was being provided throughout this time, but under precarious conditions as the fruit of the ill will of the previous Jair Bolsonaro government that declared itself anti-Indigenous.

Two factors can explain the tragic scenario of the Yanomami Indigenous Territory. The first is the modern medicine model marked by inequalities and attuned to a logic of predatory capitalism. Healthcare is treated as a standardized, individualized commodity more focused on treatment than prevention. Throughout all these years, the sub-system of Indigenous healthcare has not been able to encompass the cultural particularities of each Indigenous people. It has never been, therefore, an adequate model for dealing with the Indigenous populations.

The second factor is the invasion of Yanomami territory by thousands of illegal miners—aptly denominated as “the commodity people” by Indigenous leader Davi Kopenawa. These invaders contaminate the waters, indirectly causing the death of children and strangulating the Yanomami culture. They have taken away the people’s socioeconomic autonomy. They have made the Indigenous dependent on rice and biscuits and soda sold at the fringes of their villages.

Lula also stated on Saturday that: “A way we can resolve this is to establish a task force, you know? There in the villages, so that we can look after them there. It is easier for us to transport ten doctors than to transport the two hundred Indigenous that are here.”

It was on this new, old way of practicing healthcare that we reflected in an article published in Folha de S.Paulo, in April 2020. In the text, we considered what we called “culturality in healthcare.”  In short, culturality in healthcare means solving problems within the territory and establishing a healthcare system based on the diversity of cultures and communities and on the social and epidemiological variables. This means abandoning the model based on the individual, a clinical case, or a determined pathology. The central tool of this model would not be large hospitals and cities, but small health centers in the villages.

Unfortunately, what we have seen in Brazil, in most cases, is the opposite of this. We are equipping hospitals, not the community. We are producing specialists who know how to do heart transplants, but we lack those that see culture and the environment as part of treatment.

Lula and the Minister for Indigenous Peoples, Sônia Guajajara, understand that “going there to treat” the Yanomami presupposes creating, on their territory, a minimal structure for medical care and hospitalizations of low complexity. Medical technology must also be integrated into the villages. Front-line professionals must know or learn the Yanomami language and culture, establishing teams with the time to coordinate modern medicine with Indigenous medicine. Restricted-use medicines,such as antibiotics and even antiophidic serums that can be used by the local medical team should be made available, as well as basic medecines.. Going to the villages also means investing in satellite communication and in small bases of solar energy production. The medical teams also should be stable to gain the confidence of the people that are being cared for.

Today, medicine enables us to perform an ultrasound using a small transducer connected to a cellular phone. Surgical drapes have become light and disposable. Laboratories are compact, the size of a shoe box. All this technology needs to be at the service of the people like the Yanomami who look after the planet,. At the same time, there is a need to humanize medical activities, to bring them closer to the people.

The alternative to the model that we have in Brazil today needs to be based on a paradigm of culturality—that is, not organizing healthcare services in medical centers in big cities, but in the community and in the culture in which the patients are immersed. From this point of view, the cultural dimension of each human is as important as their anatomy: it is something to be understood, cared for and protected.

This is not only a theoretical experience. It exists in practice and has been happening for more than 20 years on the Indigenous territory of the Zo’é people in northwest Pará.

The medical care of the Zo’é aims to resolve as many problems as possible in the forest itself, avoiding contact with the city and, thus, with epidemics and the prejudices of the non-Indigenous. This experience has been financed since the year 2000 by the Ministry of Health acting in partnership with the National Indigenous Foundation (Funai).

On various occasions, the Sesai team had assisted Funai in the resolution of conflicts among the Zo’é. At other times, it is the Funai team that helps the healthcare agents make the best therapeutic decision in a given circumstance. The Zo’é are always informed about what is going on, and, one way or another, participate in the decisions.

Dr. Jennings explaining digital X-ray results in the small hospital inside of the Zo’é territory. Photo by Zo’é Team.

The care given to the Zo’é people is guided by three fundamental premises. The first is respect for the culture and the social specificities, taking into consideration taboos and the traditional medical knowledge of the Indigenous. The second premise is to minimize morbidity and mortality risks. As such, removal of patients from the place where they live is avoided, as they have low immunity to external pathologies. Finally, the third premise is the need for institutional covenants to construct this policy, enabling the voluntary agent to professionalize and be able to work with multidisciplinary teams.

This model seeks to expand the knowledge of the Indigenous regarding non-Indigenous diseases and medical practices, in addition to promoting a dialogue between traditional knowledge and Western knowledge. During the process, the Indigenous learn the relationship between epidemics, environmental health and contact with people from the outside.

On the Zo’é territory, the healthcare teams film and make audio recordings of interactions with the Indigenous. This includes interviews on traditional methodologies, techniques and medications from the local culture. The curative practices used by the Indigenous people are also recorded, as is the health of the population prior to contact with the doctors. Also registered on the recordings is how the Zo’é see the medicine of the “whites.”

This material, which has been collected since 2016, will be analyzed and systematized as a database at the service of Zo’é health. In future, it may serve to develop an educational program.

It is difficult to compare the situation of the Zo’é with that of the Yanomami. They are peoples with different histories, who do not have the same level of contact with the rest of society. One thing is certain, however, the territories of both peoples are the target of numerous economic pressures. The lust for gold also impacts the Zo’é. So, why aren’t the Zo’é experiencing a crisis of malnutrition? Why has their territory not been taken over by illegal mining?

The work of the Funai staff in the territorial protection of the Zo’é people has always been intense and highly efficient, and healthcare has always been a part of this work. When there was an outbreak of malaria on the Zo’é Indigenous Lands, in 2006, the medical reports helped Funai get a state decree that created a buffer zone, an area around an Indigenous territory where there are restrictions on determined activities. This zone was essential to containing mining activities and, more recently, in protecting the Zo’é from the pandemic.

Back in 2016, for example, a small mining operation situated in the vicinity of Zo’é territory was rapidly dismantled. The operation was carried out by the Ministério Público Federal (Federal Prosecutions Office), leaving no opportunity for the miners to prosper. On Yanomami territory, on the other hand, numerous reports of invasion failed to result in concrete actions on the part of the State and as the years passed, the government lost control of the territory.

The interaction between Sesai and Funai enabled the condemnation of at least one white man who subjected Zo’é Indigenous to slavery in the local production of nuts. Health reports, supported by information from Funai, led the nut groves to close during the pandemic, limiting the circulation of people in that region. The consequences of the policy are undeniable. Until today, Covid has not entered Zo’é Indigenous lands (Covid não entrou na Terra Indígena Zo’é). Only three Zo’é have caught the disease, precisely when they had to leave their territory in December 2022 to go to a hospital to be treated for highly complex cases.

The experience of the Zo’é worked and should be followed. This care model uses the territory and Indigenous culture as the main barrier against epidemics. If there was not a small hospital there with basic equipment, the Zo’é may not have resisted a government whose chief actively worked in favor of the virus.

It is necessary to pluralize the ways of thinking about Indigenous healthcare. Going to the village, as suggested by Lula, is much more than taking a healthcare team inside the territory. It must involve being integrated with the community. If correctly implemented, it will be a new way of caring for Indigenous health in Brazil. It is important that we stimulate a system that sees the forest as the largest and most well equipped hospital that a native people can have.