Guaranteeing the right to a safe and culturally appropriate death: the meaning of occupations in the life-death-rebirth triad from the Colombian indigenous perspective

Abstract

The spiritual value attributed to death, by the guardians of the heart of the world in Sierra Nevada de Santa Marta, Colombia, as in other indigenous cultures, integrates a social, physical, ethical, ecological, and emotional preparation to make a healthy accompaniment to life after death. Its importance goes far beyond a vision related to spectacular events or the demystification of the indigenous worldview as being considered “poor or vulnerable”. Through a situated reflection of the health, illness and care processes within an indigenous context at the end of life, we propose to consider the meaning of occupations in the triad of life - death - rebirth, to ensure a compliance with the right of one that alludes to the meaning of a safe and culturally appropriate death. The occupational dimension, as an agent for creating and interpreting the collective meanings of indigenous communities through the espiritugogía preceded by their ancestry, can offer other intercultural perspectives of ancient palliative care and differentiated and respectful support by health systems.

Keywords:
Indigenous Culture; Intercultural Health; Attitude to Death; End of life; Culture; Occupational Therapy; Palliative Care

Resumen

El valor espiritual atribuido a la muerte, para los guardianes del corazón del mundo en la Sierra Nevada de Santa Marta, Colombia, como en otras culturas indígenas, integra una preparación social, física, ética, ecológica y emocional para hacer un acompañamiento saludable a la vida después de la muerte. Su importancia va mucho más allá de una visión relacionada con hechos espectaculares o la desmitificación de su cosmovisión como “pobre o vulnerable”. A través de una reflexión situada de los procesos de salud, enfermedad y cuidado en el contexto indígena del final de la vida, proponemos considerar el sentido de las ocupaciones en la tríada vida - muerte - renacimiento, para garantizar el derecho a una muerte segura y culturalmente adecuada. La dimensión ocupacional, como agente de construcción e interpretación de los significados colectivos de las comunidades indígenas a través de la espiritugogía precedida por su ancestralidad, puede ofrecer otras perspectivas interculturales de cuidados paliativos milenarios y un seguimiento diferenciado y respetuoso por parte de los sistemas de salud.

Palabras clave:
Cultura Indígena; Salud intercultural; Actitud Frente a la Muerte; Cultura; Terapia Ocupacional; Cuidados Paliativos

Resumo

O valor espiritual atribuído à morte, pelos guardiões do coração do mundo na Serra Nevada de Santa Marta, Colômbia, como em outras culturas indígenas, integra uma preparação social, física, ética, ecológica e emocional para fazer um acompanhamento saudável para a vida após a morte. Sua importância vai muito além de uma visão relacionada a eventos espetaculares ou a desmistificação de sua visão de mundo como “pobres ou vulneráveis”. Por meio de uma reflexão situada dos processos de saúde, doença e cuidado no contexto indígena do final da vida, propomos considerar o significado das ocupações na tríade vida - morte - renascimento, para garantir o direito a uma morte segura e culturalmente apropriada. A dimensão ocupacional, como agente de criação e interpretação dos significados coletivos das comunidades indígenas por meio da espiritugogía precedida por sua ancestralidade, pode oferecer outras perspectivas interculturais de cuidados paliativos milenares e um acompanhamento diferenciado e respeitoso pelos sistemas de saúde.

Palavras-chave:
Cultura Indígena; Saúde Intercultural; Atitude Frente a Morte; Cultura; Terapia Ocupacional; Cuidados Paliativos

An Invitation to a Configurative Reflection

This reflection was articulated from the so-called configurative reflection, which involved abandoning beliefs and closing one's eyes, combining tacit learning and elements that extend beyond the limits of Western theorization (Loppie, 2007; Viveiros de Castro, 2010) to expand what is known under these other interactions, such as those evidenced by the indigenous communities, in their discourses and historical narratives that give prominence not to the compilers of the books or the researchers, but to the perception and orality of the protagonists and native collaborators involved (Centro Nacional de Memoria Histórica, 2019). Being able to reflectively approach the complexity that goes through their worldview, under their oral narratives and literary proposals, allowed us to problematize their own practices, knowledge, feelings, human and non-human interconnections (Ortíz Ocaña et al., 2018), in relation to the process of dying and death.

For the indigenous people, death is the moment where the individual re-enters the mother's womb. Thus, death itself is nothing more than the wait of a lifetime to return to that sacred place with great meaning in the community. Much more so when it is understood that this state is where it is defined how the person will live in the afterlife (Giraldo Jaramillo, 2010, p. 74).

The emergence of communicable diseases with no prognosis of cure, better called external or “afueranas - outside” in indigenous communities (Lozano-Ordoñez & Salazar-Henao, 2018) were implemented since the conquest under oppressive and violent dynamics, which still persist in ancestral territory and have impacted not only the biological matrix, but the cultural, spiritual and occupational aspects of their worldviews and well-being.

However, and paradoxically, indigenous populations are among the least likely to receive and accept care services at the end of their lives (Shahid et al., 2018; Thompson et al., 2019). Leaving “own diseases” relegated to a Western system, which ignores cultural identity and the impact of the imbalance that spiritual symptoms entail, those that cannot be diagnosed through exams and laboratories (Lozano-Ordoñez & Salazar-Henao, 2018), has configured other references of what is really cared for and protected, whether the body or the pathology.

For the older Colombian brothers of the Sierra Nevada de Santa Marta (SNDSM) (the indigenous Koguis, Kankuamos, Arhuacos and Wiwas), the disease is defined as the imbalance reflected in the body, being unwell, lying down all the time, doing improper spiritual actions, negative thinking, having a problem with your partner or with someone, bad attitudes such as anger and spiritual neglect (Barbosa Estepa, 2011; Vila Sierra et al., 2020). For this reason, indigenous people affirm that Western medicine often does not have good results, since it only addresses the material body (Vila Sierra et al., 2020, p. 63).

Internalizing the cycle of earthly and spiritual life that indigenous communities advocate reaffirms that life and death do not become a turning point. Therefore, it is also appropriate to reflect on the commitment, protection and necessity of culturally appropriate dying. Which becomes a challenge that requires a deep understanding of people's underlying beliefs and desires, their worldviews, as well as the human and non-human relationships that accompany the active process of death (Perilla et al., 2021). But also a commitment to analyze health inequalities that, under an ethnic condition framed in “vulnerability and poverty” labeled by health systems, promote higher mortality rates and worse quality of their good life (Viáfara-López et al., 2021; Urrego Rodríguez, 2022).

In Colombia, the state has not managed to vitalize comprehensive health to improve the quality of life of these populations, who from their ancestral practices seek a remedy for negligence, although this is not always enough (Vila Sierra et al., 2020). The types of health insurance have become a structural component of inequality in access to health services for populations with an ethnic-racial condition, such structures being a systematic disadvantage (Aguilar-Peña et al., 2020; Viáfara-López et al., 2021), which exacerbates social inequalities, geographical, economic and linguistic barriers to caring for and embracing beliefs associated with health, illness, dying and death. Those difficulties and limitations that exist in paying attention in terms of identity, belonging and reciprocal relationship to those non-human differences outside the human point of view have long been challenging for our Western erudition (Viveiros de Castro, 2010; Howitt, 2020; Arnold et al., 2021). According to Viveiros de Castro (2013, p. 62):

There are not, therefore, several ways of “seeing”, there is only one. What varies is the world itself, not the way of seeing it. For us, it is the “worldviews” that differ, but the world remains the same as itself. For the Indians, the way of seeing is always the same, no matter how much it changes from one species to another: what changes is the world itself. There is, then, this double inversion. On the one hand, everything is human, even if each species is not the same (exactly as we “Westerners” know that we are not animals identical to crocodiles). Humanity is universal, the spirit is universal, not the body.

It is not a surprise that, from Western science, scientific and demographic research produced by non-indigenous, white people, people with access to resources, privileges and power, seek to determine the reality “[…] of the other and not together with the other” (Viáfara-López et al., 2021; Urrego Rodríguez, 2022). Becoming a projection of biases due to omitted variables that overestimate or underestimate the type of health process between the ritual and the sacred. That everyday cultural resource from which the care process is intended to be generated, without insisting on the spectacularization that, as Suárez et al. (2021) relates has captivated ethnographic attention and turned the lives of indigenous people into a relationship of spectacular events.

Therefore, in this essay, we propose a configurative reflection on the health, illness, and care processes in an indigenous context at the end of life; and one specifically focused on the natural law that refers to the meaning of death. A reflection which integrates life as transcendence, as a cycle-spiral and part of a spiritual existence enunciated by the Law of Origin, as a sacred mandate and fundamental vision, for the way in which the territories and indigenous communities of the SNDSM remain in movement to date (Centro Nacional de Memoria Histórica, 2019).

Everyday Life of Indigenous Health and Care: “How Can We Be Well Alive if the Land is Not?”

The World Health Organization states that traditional healing systems and Western medicine coexist in all regions of the world, but this traditional medicine plays a vital role in indigenous healing strategies (Araujo et al., 2016). The balance manifested in collective well-being is part of the laws that, for the communities of the SNDSM, the Kakua Serankua¹ left through the Law of Origin.

As a traditional treatment, the value of Payment² is highlighted because it prevents or treats the disease. Other activities are confession to the Mamu, and to the community through spiritual work and consultation with nature in its sacred places. Do not deceive even in dreams (Vila Sierra et al., 2020, p. 129).

In essence, the occupations of the older brothers are a health factor impregnated by the interactive nature that occurs with nature, with the ancestral territory given by the Black Line³ , with the immaterial. It is an ecological process, where occupation is the means of relationship between the person and the environment, from temporal, spatial and symbolic aspects related to the physical environment, linked to social, cultural and spiritual elements (Montaño Mendez, 2011). Giving health and illness a personal, collective and territorial connotation, where the first thing to do is organize the spirit and then prepare the body, as exemplified below:

Health could be defined as feeling good in your daily life, a state in which there are no sudden worries or difficulties, without arguing with another person, that the spiritual part is well to maintain balance. As well as the ability to stay clean and neat, bathed, with clean clothes and have abundance, that is, having enough food, enough land, to plant crops and take food, water, firewood (Vila Sierra et al., 2020, p. 118).

That defense of the attribution of human characteristics and qualities to nature that has long been a way in which indigenous peoples represent their self, not being completely the certainty of one self but the existence of the other, to live it within an interrelated and respectful system (Hall, 2011; Viveiros de Castro, 2013). It is therefore recreated in the territory, with Mother Earth as that transversal axis, that place of healing, of physical and spiritual growth that bases traditions and stories (Fijal & Beagan, 2019). For the indigenous communities of the SNDM, the ancestral territory has become that great master that manifests and provides, contributing to well-being and health (Barbosa Estepa, 2011; Vila Sierra et al., 2020). Likewise, it has constantly offered them lessons and teachings through its waters, animals, peaks and stones, about the finitude of life.

Since the language of death is not merely human, then nature through its cycles and the cycle that integrates all forms of life allows the mountain communities to identify in each occupation they carry out the triad of life - death - rebirth.

Life expressed in the food harvested, in sexuality, the new paths to travel in baptism and puberty. Death is already based on the dynamics of survival, the permission to kill an animal for food, cut the plant for medicine, end a relationship or perform the ritual, the mortuary/eysa of a deceased member of the community and their mourning. The continuous reciprocity that communities offer would be rebirth, payments to Mother Earth, to the flower, to the sun, to water, to life and thus to death (Perilla León, 2023).

This type of learning and connection integrates a worldview that is not only cultural, but also ethical, political, psychoemotional, ecological and social, which resides in a spiral of learning, which, for this purpose, we will call spirituology (Villarreal Tique, 2021, p. 233). Because it allows us to strengthen social cohesion, promote shared values, and promulgate traditional and ancestral knowledge from generation to generation in the territories that are cosmopolitan and cared for. Reflecting a visibility of the occupational commitment of the older brothers through the cosmological and cosmogonic responsibility that they maintain under their territorial organization and Law of Origin.

We could call it, as McKnight (2016) refers, a look at the ontological unity, also composed of its ecosystems, that connection that makes the meaning of its actions intrinsically connected with the care of a whole, of the human and non-human, of the visible and invisible, of life and death. A reciprocal relationship unraveled as that ancestral memory that declares the past and evokes it deeply; or as that pedagogy inherited from the mountains, the trees, the water, the rocks, which, as an emotional, spiritual and connective process, becomes a pedagogy of healing (McKnight, 2016). Which highlights the cultural identity and maintenance of the many traditional and ancestral occupations (Arias Olivero et al., 2020) linked to active participation to share, maintain and restore care, socialization, learning and productivity activities (Gibson et al., 2020).

Thus, the relational paradigm in which dying goes hand in hand with the dimensions of spirituality and dignity, that cosmic plenitude, reactivated around death, carries with it a previous good life and dynamics with purpose and meaning in accordance with that ancestral vision. (Guay et al., 2022). That human and spiritual reconnection that occurs around death allows for the manifestation of links with ancestors and sacred beings, combining the dimensions of future, present, and past. Temporalities that challenge the Eurocentric uncertainty about the time frames and predictability of death so studied from palliative care.

The Other Side of Palliative Care: the Ancestral Care of Dying and Death

The spiritual value assigned to death, for the guardians of the heart of the world, as well as for other indigenous cultures, integrates a physical, emotional, social and spiritual preparation to provide a healthy accompaniment to the afterlife; as Patiño (2005, p. 105) explains “[…] in the context of truth, love, forgiveness and reconciliation and thus ensure that life continues for those who remain and for those who leave”.

Could the concept of palliative care within indigenous peoples sound very distant then? Their own cosmogonies have given way to a system of care that developed a territorial structure given by the formation of sacred places of care; as well as social actors responsible for interpreting illness, pain and death within their native science (shamans, healers, Mamus) and taking care of their transition from a specific role as women do (Perilla León, 2023). This functional unit of care, meaning of death, the hidden and the beliefs of the afterlife, has occurred through their ancestral botanical and spiritual knowledge, with rites and congregations such as the mortuary/eysa, where not only it alleviates (shelters, protects) those who are returning to being a seed, but also the family.

Consequently, health care is integrated into ritual processes that are part of cultural and social systems in which beliefs influence behavior (Clark, 2000) and death care has always had a close relationship with social, economic and even technological development of the indigenous communities (Perilla León, 2023). Palliative care therefore develops by adopting the forms of care and transition rites; from the moment man becomes aware of the meaning of death, from his cosmogony as a cycle of life-death-spiritual rebirth.

Now, delving into the contemporary dynamics given by the Western health system, the care of indigenous communities towards death is linked to the purpose of palliative care; this approach has had several practical approaches in Anglo-Saxon indigenous communities (Prince et al., 2019; Thompson et al., 2019; Racine et al., 2022; Woods et al., 2020). In Colombia so far, we have not found any palliative care practice with indigenous communities. The health contributions for the Arhuaca and Kankuama communities have been focused on preventive dynamics, mitigating cases of malnutrition, dental complications and gestational planning (Perilla León, 2023). In this way, without having what hegemonically calls a health infrastructure in the territory, the communities advocate strengthening and maintaining their knowledge and practices based on traditional medicine to heal, help and say goodbye to their brothers and sisters (Caballero, 2018; Urrego Rodríguez, 2022). To reaffirm in the Law of Origin the guidance of its actions in different areas and assist the processes of disease, cure and well-being through the Own Indigenous Health System (SISPI) and the Indigenous Health Promoting Entities (EPS-I) (Vélez et al., 2020). Since that framework is an identity, in the creation of a mixed space in the process of institutionalization, which deepens the dialogues and confrontation mechanisms between traditional medicines and the hegemonic biomedical Western health model. In this sense, Suárez et al. (2021, p. 96) affirm:

There are clear difficulties in incorporating healers, shamans, and indigenous wise men in the “health market,” but in contrast, the role of local health promoters and other proximity services emerges. Local health promoters play a fundamental role in the dialogue of knowledge; they look for protective factors, breaking factors, common fields of knowledge. They materialize an effective reinforcement of traditional indigenous culture and against a decrease in elements arbitrarily imposed by hegemonic models so that once balanced, they truly contribute to the solution of health problems.

The interest in integrating the care of death and dying on the part of indigenous Arhuaca health promoters and Kankuama authorities focuses on strengthening dynamics that aim to dignify death in life; to understand pain and the Western influence on it and revive the value of the spiritual in their worldview for culturally appropriate planning of death, choosing how and where to die (Perilla León, 2023). With the above, we do not try to justify the temporary implementation of exclusive Western palliative care in the indigenous territories of the SNDSM, it would be something illusory, which would generate, perhaps, a provision of services connected to past negative medical experiences (Anderson & Woticky, 2018). Hopefully, starting with the aspects that integrate education and collaborative management of local cases with the IPS-I, can be a path that weaves initial actions without disruptive effects.

Final Considerations: a Compassionate and Culturally Safe Interpretation of Death and the Occupation of Dying

The need to contextualize the occupational nature of indigenous communities within the dynamics of traditional health services and explicitly at the end of life, can mitigate the discrepancy of the processes by which people live and die in contemporary societies. Considering this purely biological event, which only affects the deceased; when it is the local structure, the family, the care staff, the elementals, the infrastructure, religion and spirituality that are interrelated under that occupation. Whether in preparation, accompaniment or mourning, the construction of meanings becomes timeless and cyclically resignified. Thinking about an appropriate way to die, or the good way to die, pigeonholes the being, doing, belonging, and becoming of the occupational expression of death. Therefore, could it be possible to attack the significance of death and the sense of transcendence, pain and suffering that indigenous communities give when integrating these occupations today?

Without a doubt, it is critical to address the integration of health and daily occupation of these peoples, examining the end of life from a Latin American perspective, deconstructing the visions that impose ethnocentric legacies as dominant reductionist models (Muñoz, 2018. Considering the construction of knowledge about human occupation, from a dynamic, sensitive and intercultural perspective, is based on listening to the individuals, their relationships, all their constructions, their environments and their space-time. A deliberation on the authentic nature of this knowledge to transform and respond to local and regional realities (Trujillo Rojas et al., 2011). Emphasizing that the native is not something archaic and exotic in Latin America, since the native communities mix and reconstruct the modern according to the native paradigm of relationality. It is therefore about educating and nourishing ourselves with these intercultural and polysemic experiences. As Lyda Pérez (2014) refers, it is about adopting a perspective in which the relational and complex praxis is not ignored, but rather the ancestral values of this part of the continent are recognized, to discover the original legacies that protect and guide the local towns (Pérez, 2014).

It is in this scenario, based on cultural mixing and hybridization, that very profound and diverse changes can be observed in the perception of health threats in societies, the patterns of use of services and the political argumentation that today replaces the idea of illness for health. Building a commitment to a health that is “[…] less medical and more political, less particular and more universal” (Comelles, 2004, p. 22), corresponds to an expansion of cultural diversity in health and clinical settings, as well as for professionals who address such needs.

Processes, related to the finances and cost of healthcare, professional hierarchies or the dominance of science and clinical concerns over the human scale of intervention, are considerable forces opposing a manifestation of the everyday or the power of the everyday and mundane aspects of occupation, from which many people seem to extract meaning (Pollard & Sakellariou, 2014, p. 71).

To contribute to the good living and good dying of indigenous communities, it is necessary to analyze the objectives of care for their health conditions and their close relationship with the social inequalities they experience: perhaps a daily experience of injustice, restrictions on their participation, in decision-making, due to alignment or violation of their rights. That means being able to approach them from a perspective that values the quality of shared communication, which supports their local care initiatives and which resignifies the experiences of pain accompanied by Western care over time.

• 1
  Creator Father.
• 2
  Ancestral exercise of indigenous peoples, where payments are made to the different spiritual fathers
• 3
  Spiritual demarcation of the territory of the indigenous communities of the Sierra Nevada de Santa Marta.
• How to cite: León Perilla, V. M., & Magalhães, L. (2024). Guaranteeing the right to a safe and culturally appropriate death: the meaning of occupations in the life-death-rebirth triad from the Colombian indigenous perspective. Cadernos Brasileiros de Terapia Ocupacional, 32, e3617. https://doi.org/10.1590/2526-8910.ctoARF277736172

• Funding Source

  Viviana Marcela León Perilla received funding from the Coordination of Superior Level Staff Improvement (CAPES) Financing Code 001. Lilian Magalhães received support from the National Council for Scientific and Technological Development (CNPq), through a Productivity Scholarship in Research – Process 303037/2018-0.

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Edited by

Section editor

Prof. Dr. Rodolfo Morrison Jarra

Publication Dates

• Publication in this collection
  20 May 2024
• Date of issue
  2024

History

• Received
  25 July 2023
• Reviewed
  07 Aug 2023
• Accepted
  13 Feb 2024