Outsiders at Medical School: Indigenous experiences in medical courses at Brazilian federal universities

Abstract

In recent decades, affirmative actions have enabled Indigenous people to access medical school, historically occupied by white people with high family incomes. This research analyzed experiences of otherness by Indigenous people in federal medical schools. This qualitative, exploratory study adopted interviews and conversation circles, with the participation of 40 students from 15 courses. We established four categories of analysis: encounter between “strangers” and the medical school; differences and inequalities; relationships with students and teachers; and conflicts and transformations. We noticed that medical schools are unwelcoming to Indigenous people, with racism, intolerance, and tutelage, when their differences become inequalities, resulting from structural processes in these Brazilian institutions. The Indigenous presence in medical courses reveals social inequalities, causes conflicts, and initial transformations, pointing out paths for plurality and social justice, and possibilities for medical education with visibility and actions for the health of Indigenous peoples.

Key words: Medical Education; Indigenous Peoples; Public Policy; Health Disparate Minority and Vulnerable Populations; Health of Indigenous Peoples

Resumo

Nas últimas décadas, ações afirmativas possibilitaram o acesso de indígenas na graduação de medicina, historicamente ocupada por pessoas brancas e de renda familiar elevada. Esta pesquisa analisou experiências de alteridade experienciadas por indígenas em escolas médicas federais. Trata-se de estudo exploratório, com abordagem qualitativa, com uso de entrevistas e rodas de conversa, com participação de 40 estudantes de 15 cursos. Foram quatro categorias de análise: encontro dos “estranhos” com a escola médica; diferenças e desigualdades; relações com estudantes e professores; conflitos e transformações. Percebeu-se que as escolas médicas são pouco acolhedoras aos indígenas, com práticas de racismo, intolerância e tutela, quando suas diferenças se tornam desigualdades, consequências de processos estruturais dessas instituições e da sociedade brasileira. A presença indígena nos cursos de medicina revela desigualdades sociais, provoca conflitos e transformações iniciais, apontando caminhos para pluralidade e justiça social, bem como possibilidades para uma educação médica com visibilidade e ações para a saúde dos povos indígenas.

Palavras-chave: Educação Médica; Povos indígenas; Ações afirmativas; Populações Desiguais em Saúde; Saúde indígena

Resumen

Las políticas públicas de salud y educación dirigidas a los pueblos indígenas han sido esporádicas y con cobertura irregular. En las últimas décadas, las acciones afirmativas han permitido a los indígenas acceder a la carrera de medicina, históricamente ocupada por personas blancas con altos ingresos familiares. Esta investigación analizó las experiencias de alteridad vividas por los indígenas en las facultades de medicina de universidades nacionales. Se trata de un estudio exploratorio con abordaje cualitativo, que realizó entrevistas y grupos focales, con la participación de 40 estudiantes de 14 instituciones diferentes. Fueron definidas tres categorías de análisis: encuentro entre “extraños” y la facultad de medicina; diferencias y desigualdades; relaciones con alumnos y profesores; conflictos y transformaciones. Se observó que las facultades de medicina analizadas son poco acogedoras para los indígenas, con prácticas de racismo, intolerancia y tutela, resultando en que las diferencias se convierten en desigualdades, como consecuencias de procesos estructurales en estas instituciones y en la sociedad brasileña. La presencia indígena en las carreras de medicina revela desigualdades sociales, provoca conflictos y transformaciones iniciales, pero también abre caminos hacia la pluralidad y la justicia social, así como una educación médica que permita la visibilidad y acciones para la salud de los pueblos indígenas.

Palabras clave: Educación Médica; Pueblos indígenas; Acción afirmativa; Grupos minoritarios; Salud indígena

Introduction

Sporadic actions and irregular scope^1,2 have historically characterized the Brazilian State’s policies directed at Indigenous peoples. In this sense, Indigenous leadership is fundamental in guaranteeing rights and access to services, denouncing institutional violence and slow responses to problems faced by these populations³. The fight for public policies on health, education, and land demarcation stands out in the demand for rights.

Slots for Indigenous people in undergraduate health courses have been recommended for decades, and this has been repeatedly highlighted at Indigenous Health Conferences⁴. However, there is still little access to higher education, making it difficult for them to become graduate professionals, which could directly impact Indigenous healthcare.

Through a context of demands, several local and national initiatives have allowed more Indigenous people to access higher education, including undergraduate medical education, over the last two decades⁵. Of note are the differentiated admission programs for Indigenous people in several state and federal universities and Law 12,711, known as the “quota law”.

These strategies can be recognized as affirmative action policies. They cover a specific group of individuals in order to ensure greater equality of opportunities, reducing socioeconomic, cultural, and symbolic injustice and fostering historical reparation^6,7.

The strategic role of higher education is emphasized by different leaders and intellectuals of the Indigenous movement, who discuss new forms of Indigenous struggle and new “weapons”: no longer the arrow, but the pen, and sending young people to universities in the most diverse areas as part of a political project⁸. There is also a whole movement to reclaim the university as Indigenous territory⁶. In other words, a space that has historically used them as an object of study has been claimed and occupied, affirming the possibility of building new ways of being and producing in academia and valuing Indigenous knowledge and narratives in the construction of public policies⁶.

Health is one of the fields that arouses the most significant interest among Indigenous youth and adults, but medical school access is still challenging due to high competition. In 2019, approximately 192 Indigenous people were studying Medicine at federal universities (UF)⁵, corresponding to 0.47% of the total number of students in these courses⁹.

Recognizing the historical exclusion of Indigenous people from medical courses and the development of actions for their admission, the research “Experiences of Indigenous Students in Public Medical Courses in Brazil” was constructed. This article is nested in this project, analyzing the experiences of otherness by Indigenous people in federal medical schools, based on their narratives, focusing on the strangeness and tensions of the encounters, bringing reflections for public policy purposes.

Methods

An exploratory study was conducted with a qualitative approach, focusing on social relationships and advancing towards the subjectivity and understanding of events and processes¹⁰, based on the perspective of Indigenous medical students. Three theoretical-methodological concepts were essential and permeated the options and paths adopted in the research: experience, narrative, and dialogue.

Experience is conceived by Larrosa’s concept¹¹ as that which traverses us and transforms us. It concerns what human beings learn in their place in the world and their actions, expressing themselves in a movement in which the narrated and the lived experience are ingrained¹⁰.

According to Benjamin¹², narrative is understood as the relationship between experience, time, and memory, being a crafted form of communication, imprinting “the mark of the narrator like the potter’s hand on the vase’s clay” without the intention of transmitting an excess of information¹² (p.221).

The third concept, dialogue, brings the perspective of interaction between the primary researcher and research participants, requiring availability to be, listen, and learn from each other, establishing trust, sharing, value of knowledge, and experiences¹³.

The research universe was the set of medical schools with Indigenous students in Brazilian UFs from 2018 to 2020. In 2019, we had 69 UFs located in all states and the federal district, with 80 medical schools, 43 of which had Indigenous students, always in small numbers⁵. Fifteen of these schools were visited, seeking regional diversity.

Up to three Indigenous people were invited for an individual interview at each visit. When the number of Indigenous people increased, they were invited to participate in a conversation circle. The inclusion criteria were self-identifying as Indigenous and being a medical student. The exclusion criterion was being under 18. All participants agreed to the Informed Consent Form and opted for fictitious names to replace theirs in the research. In the narratives cited in the article, age, people, region of the State, and year of graduation in years were included alongside the name; other characteristics were not added to ensure confidentiality and ethical diligence.

Participants were purposefully selected to provide diverse genders, ages, course years, and people. We achieved consensus and controversies, data richness and volume, and coverage of multiple dimensions of the event¹⁴.

Twenty-four individual narrative interviews were conducted, allowing in-depth immersion into their life stories and interweaving with the situational context¹⁵. Moreover, six conversation circles were held for dialogue and problem-solving with the participation of four to eight students¹⁶. Interviews and conversation circles aimed to encourage and stimulate participants to narrate their experience at that medical school. They lasted an average of 50 to 60 minutes.

The researcher’s stance was to be in the field to produce data based on narratives heard and dialogues held, interpreting them in light of methodological choices. Therefore, we aimed to get closer to Indigenous experiences by sharing what was (or was not) being done in the institutions. We should underscore that the principal researcher worked as a professional in an Indigenous health team. He is a professor in a medical course with Indigenous people. He acts as a tutor in the Conexões de Saberes Indigenous Tutorial Education Program, characteristics that brought him closer to the dilemmas of training Indigenous professionals and the challenges experienced by Indigenous people in medical courses.

Interviews and conversation circles valued orality, recognizing that different Indigenous cultures are based primarily on oral tradition¹. All of these meetings were held in person, led by the first author of this article, and staged in a location chosen by the students participating in the research. The audio recordings were transcribed using a naturalistic method. The profile of the research participants is shown in Table 1.

Table 1
Profile of Indigenous people participating in the research. Brazil, 2018 to 2020.

Characteristics	Total	Description	Frequency
Gender	40	Male	26
		Female	14
Age group	40	Less than 20 years	7
		20-25 years	19
		26-30 years	7
		31-35 years	5
		35 years and above	2
Marital status	40	Single	34
		Married/Common-Law marriage	6
		Divorced/Separated	0
		Widower	0
Children	40	No children	27
		1 child	6
		2 children	2
		3 children	2
		Not informed	3

• Source: Authors.

Recommendations of thematic content analysis according to Gomes¹⁷ and Minayo¹⁰ were adopted for data preparation, analysis, and interpretation.

The main theoretical framework used was the explanatory model of relationships between established and outsiders, described by Elias and Scotson¹⁸, as it allowed us to elucidate the experiences of the Indigenous students participating in the research, who perceived themselves as newcomers and “strangers” to the university environment¹⁸.

In the ethnography by Elias and Scotson¹⁸ in the 1950s in a small English industrial town - which received the fictitious name of Winston Parva - the authors described the heterogeneity of the community based on the social differences and inequalities of specific groups, identified as the established and the outsiders¹⁸. The term established was used for a group of individuals who occupied positions of prestige and power and who perceived themselves and were recognized as a “good, better, and more powerful society”¹⁸ (p.7). These people had a social identity built on a unique combination of tradition, authority, and influence, as they based their power on the fact that they were a moral model for others. Outsiders were those individuals who were not members of a “good society” because they were outside it. They were a heterogeneous and diffuse group of people united by social ties that were less intense than those that united the established, environmentally-controlled ones¹⁸.

Although Elias did not specifically address Indigenous issues in his studies, he defended adopting this explanatory model for various relationships, including the possibility of approaching it to the relationships of Amerindian populations in Latin American countries¹⁸ (p.32). Thus, in this text, we discussed this explanatory model to discuss the relationships between those established in medical courses and newly arrived Indigenous people, who entered as “foreigners”, outsiders.

Although the authors understand that the narratives and experiences of students are permeated by historical violence and structural racism and that it is necessary to expand the reference to the literature that addresses these conditions, this article opted to dialogue mainly with the analyses of Elias and Scotson¹⁸, as it understood that they allowed access to and interpretation of the interlocutors’ understandings about medical school as a space where Indigenous people have never been historically.

The National Research Ethics Commission approved the research project under CAAE: 01510018.4.0000.5411.

Results and discussions

Based on the narratives of the Indigenous students participating in the research, we identified five categories or significant questions for analysis, which appeared in the interviews and discussion groups held: encounters between “strangers” and the medical school; differences and inequalities; relationships with students and teachers; conflicts and transformations.

Category 1. Encounters between “strangers” and the medical school

When I arrived here at the university, it was a very hostile environment for those who were in affirmative action [...]. People openly positioned themselves; they morally harassed. They were all very tall and blond people, which was funny to watch. [...] They were all teachers’ relatives and nephews, the director’s grandsons, and cousins of I don’t know who (Araguaci; Pankará; 31a; Sul; 4º).

The research participants reiterated the high competition and the insufficient number of reserved places in the institutions, similar to what was described in other research, such as in the UF of São Carlos⁵ and Rio Grande do Sul¹⁹, with high competition among Indigenous people for health courses and, more specifically, Medicine.

For many Indigenous people, studying Medicine meant living in a distant and unknown region, but one that had institutions that had affirmative action policies. Figure 1 shows the travel from their locations to the universities, revealing a tangle of origins, routes, and destinations across the country.

Figure 1
Movement of Indigenous students, participants in the research, since their origins. Brazil, 2018 to 2020.

They were thus close to the first characteristics of Elias and Scotson’s outsiders, as they were newcomers to the place, heterogeneous, and with few previous social ties among themselves¹⁸.

Although the other medical students could have come from other regions, the Indigenous people came from very different personal and collective trajectories. In this sense, Baniwa²⁰ (p.99) argues that Indigenous cultures are not subcultures of the dominant culture, as they hold “their logic, rationality, and cosmological and epistemic systems”, which reinforces their context of foreignness in medical school, since most of the other people in medical school are part of the non-Indigenous hegemonic culture.

In Winston Parva’s situation, there was no social, ethnic, or racial difference between the outsiders and the established ones. Furthermore, in that context, only the time of arrival in the city differentiated them¹⁸. Here, the issue of ethnicity and social class is added to the fact of coming from another region. Additionally, it can be said that the arrival time in the medical course was different since the Indigenous people were recently included as students in an initial movement to overcome inequality of access.

In a report on the experiences of the first Indigenous people to enter the University of Brasília, they described that interacting with other people was most challenging in the most elite courses, such as Medicine²¹. This attitude was not only due to the differentiated admission process but also due to some intolerance towards the presence of Indigenous people in the academic environment, which points to racism against people from other cultures and epistemologies. We understand racism as a valid category to think not only about the discourses and forms of treatment given to Black people historically in the country but also to Indigenous peoples, who were submitted to enslavement, forced integration, and different forms of physical and symbolic violence based on ethnic-racial categorizations that dehumanized their bodies and their cultures:

Some people saw us as... I forgot the word... as someone who didn’t have the profile to be a doctor. Non-medical people and medical people who understood that we didn’t have the profile to be doctors. That’s how it is. People determine our profile. So, I think it’s this: “I didn’t have the profile to be a doctor” (Nenxah; Kaingang; 34a; Sul; 6º).

Thus, the other subjects in medical school brought views that Indigenous people did not fit into the conventional profile of medical students, that is, future doctors. Traditionally, medical school comprises a profile of a white majority from private schools with a household income higher than the average of the Brazilian population^5,22.

Analyzing data from the 2019 National Student Performance Exam (ENADE)²², it is clear that 67.1% of Brazilian medical school graduates were white, and only 0.3% were Indigenous. A classic American study, Boys in White, conducted by Becker et al. in 1961, analyzed socialization in medical school and, not by chance, received this title since medical students were, in their overwhelming majority, white boys wearing white²³.

We could say that the usual medical students, white people with a household income higher than the Brazilian average, recognized themselves and were recognized as an established group, using Elias and Scotson’s concept¹⁸. The professors are also part of this established group in medical school, as they are primarily white doctors from similar families and social backgrounds. Therefore, students and teachers in medical school make up a group of individuals who base their distinction on the principle of seniority (those who have been there the longest), and their power is strengthened by tradition, authority, and influence¹⁸.

In the case of Indigenous people, outsiders in the context of medical school, some aspects unite them as relatives¹. While of different ethnicities, regions, genders, and ages, they seek to build a common Indigenous identity based on the experience of otherness and opposition/contrast with established groups, in the sense of collectivity and search for an education that does not only represent the possibility of individual mobility but the improvement of some living conditions for the family and community to which they belong.

Category 2. Differences and inequalities

I arrive all painted up, with our clothes and attire too [...]. However, they find it strange, and I see disapproval in their eyes. That is a reason for me to come and show myself, show my presence (Apy-Mamã; Curuaia Xipaia; 19a; Norte; 1º).

In this initial narrative, the narrator alludes to distinct corporalities and ways of presenting oneself in the institution between the “outsiders” and the “established”, highlighting their differences and inequalities.

In this sense, another aspect that distinguished Indigenous students from most other medical students was the difficulty of remaining in economic terms and the need to rely on institutional support and assistance:

We spent the whole semester running around looking for assistance... struggling... Meanwhile, “Medicine” was there holding its events, receiving people and “initiating” them... [...] When I arrived, I was already holding an event with the other Indigenous people from other courses. I didn’t even have time to think about my medical course. Most of my fellow students didn’t need to think about where to live, how to go to university [...] Most already had an apartment and a car (Tauá; Pankararu; 25a; Centro-Oeste; 3º).

Some participants described having difficulty with the Portuguese language and more academic discourses and that universities have difficulty addressing these differences. Besides Portuguese, many respondents spoke Indigenous languages:

It’s a bit more difficult for Indigenous people, mainly because Portuguese is not our mother tongue, let’s say. Sometimes, you see things written in books because I do, let’s say, a translation so I can understand. However, some things are not in my language, right? So, it hinders this. After several years, I still have to do this (Khante; Suyá-Kaiabi; 29a; Centro-Oeste; 4º).

It is important to note that Indigenous languages should not be considered a barrier or “hindrance” to student performance. On the contrary, they express knowledge and worldviews of great richness, representing an act of sociopolitical resistance. However, there was no report on their valorization in the context of medical courses. Paradoxically, there was a reference to the need to learn English, revealing the path to homogenization.

The formative processes in primary education were highlighted by several research participants as experiences that also marked differences and inequalities against the trajectories of non-Indigenous peers:

Our education was different at my school. I learned, but some of the subjects were new to us. [...] We had to take longer to understand and dedicate ourselves much more than they did. So, being an Indigenous student is like that, right? Proving constantly that you can reach that level, although sometimes it may take a little longer (Tenetehar; Tembé; 24a; Norte; 6º).

By highlighting the differences in their primary schooling, it is not a question of pointing out that Indigenous schools should be oriented towards teaching the knowledge required at university, but that the learning developed by these students differed from that of most medical students.

According to school education policies, Indigenous peoples can use their “traditional educational systems, with their methods, pedagogies, worldviews, philosophies, ontologies, and epistemologies”²⁰ (p.41). However, these differentiated processes are not always valued by public policies.

A common way of seeing Indigenous people as different in medical school was the vision of a “generic Indian”²⁴. This image of a unique Indigenous person, living in the forest and feeding only on what he gathers, fishes, and hunts, comes from the idealized and stereotyped conception created by history, the media, literature, and school education²⁴. Thus, students reported having been repeatedly confronted with the expectations of the various subjects that make up the university space regarding the romantic imagination of the savage and primitive, disregarding cultural and socio-historical dynamics:

We had that air of prejudice, that thing that we go through because I use a cell phone and I don’t have straight black hair. Sometimes, even because I speak Portuguese correctly, they would make jokes because I wasn’t Indigenous. They always tried to distance me from what I was because I looked like them. So, about that, I always remember a sentence from an Indigenous person where my name comes from, who said: “I can be who you are, without ceasing to be who I am” (Focaj; Xerente; 24a; Norte; 6º).

For Lima²⁵, Brazilian society has been reimagining prejudice over time and always seeking to relate the Indigenous to the “primitive, to the authentic Indian, based on the romantic imagination”²⁵ (p.437). Therefore, in some situations, because they had some similarities with their peers in the medical course, their identity was denied, as if they could not be Indigenous and medical students at the same time.

At the same time, strangeness arose when they revealed cultural diacritics, using adornments and body painting in daily university activities. However, these uses were precisely to value aspects other people stereotyped assertively. Thus, they were an act of valorization and boldness to survive and transcend hostile environments, as described by Collins²⁶ for the case of Black sociologists, based on the “outsiders within” category. The author discusses the creative potential of Black women in American universities, highlighting that their personal and cultural biographies are their power²⁶.

In this way, Indigenous students interacted with people at medical school in a context of relationships permeated by differences, which often became inequalities in opportunities and treatment, highlighting social injustice and racism in that environment.

Category 3. Relationships with students and teachers

When I got a better grade, a good grade, higher than the general average in the first subjects, people would compare to my grade, as if mine always had to be the worst (Ratriksiê; Tuxá; 25a; Sul; 3º).

The students interviewed described situations in which it was expected that Indigenous people would be “inferior” in carrying out academic activities in the process of group stigmatization¹⁸, with some surprise regarding their good performance, as in the situation described above.

Goffmann²⁷ affirms that stereotypes are constituted by categorizing people through attributes common to groups. Thus, in the routines of social relationships, when the “stranger” appears, “evidence may emerge that he has an attribute that makes him different from others”, and he may be seen as a “weak and diminished person”, evidencing the stigma towards those who are not part of the established group²⁷ (p.12).

In some situations, teachers stigmatized the group of Indigenous students due to stereotypical imaginaries. In Elias and Scotson’s theory¹⁸, this generalization and group stigmatization was favored by gossip among the established, associating the outsiders with a group that, “by nature”, would be humanly inferior:

I met with a professor on Wednesday, his first class [...]. Then, he asked only the quota students [...] to stand. So, I, the other Indigenous student, and two of my friends [...] stood there, and he started a speech, saying that he would not slow down his class pace because the students needed to know that as future doctors and that we would end up lowering the university’s ranking (Tauá; Pankararu; 25a; Centro-Oeste; 3º).

Other studies, based on reports and experiences of Indigenous students from several undergraduate and graduate courses, also report situations in which non-Indigenous professors and peers question the abilities of Indigenous students. However, their ethnic identity is questioned when they excel in grades and performance. In other words, the fact that an Indigenous student or researcher speaks, dresses, or performs very well (as per established academic standards) causes strangeness among university professors and students⁷ (p.55).

This adds to the tutelary stance of teachers, transforming their differences into incapacities. Lima argues that the relationships between national society and Indigenous people are historically tutelary, conceiving them as “relatively incapable” and seeking an “adaptation to civilization” even after the 1988 Constitution²⁵ (p.432).

Thus, the stigma and the tutelary stance generated a form of unequal treatment, and the Indigenous students participating in the research highlighted the fact that they perceived themselves to be in a fragile position in their relationship with the teacher, suffering violence in this relationship:

You are in an internship, and the tutor says she doesn’t like my stretcher. [...] Then she says, “Is that an Indigenous thing?” Then I say that I am Indigenous, and she replies, “So, why don’t you go back to the tribe you came from, where these incivilities are allowed?” (Ubá Krikri; Xucuru de Ororubá; 21; Nordeste; 4º).

Group stigmatization is destructive. It weakens and disarms the individual as if he or she were not up to the standards of the established group¹⁸. Therefore, the Indigenous people interviewed reflected that suffering discrimination from teachers was even worse than prejudice and discrimination from their peers. At the same time, they identified teachers as “key people” who could transform their experience in medical school:

Having professors who cared about our presence and wanted to build with us made a huge difference in my career. I did extension projects and research, and she helped me develop this side of my experience that I brought to university. She welcomed us and also helped us develop the more academic side (Arapuá; Pankará; 44a; Sudeste; 6º).

Drawing a parallel with notes by Urtiaga²⁸ on teaching practices of medical professors at the Federal University of Pelotas, Indigenous students also valued professors with the capacity for cultural mediation, establishing bridges between theoretical knowledge and personal and daily experiences of medical practice; those considered supportive and affectionate and who valued them as subjects²⁸.

Thus, some recommended that teachers take on the role of mediating the learning process of that student, recognizing the differences of those who came from another historical-cultural trajectory, and overcoming a place of invisibility.

Narratives also emerged that described a kind of repetition of oppressive and intolerant attitudes throughout generations of doctors, which would be directly linked to the profile of medical schools. Therefore, the attitudes of professors towards Indigenous students were not only individual, of prejudice, stigma, intolerance, invisibility, and guardianship but resulted mainly from coloniality and institutional and structural racism in Brazilian society, which are reproduced in universities and medical schools.

Category 4. Conflicts and transformations

We are different people, just like trees. Guava trees, Açaí trees, and ice-cream bean trees are unique. A guava tree will never be the same as an Açaí tree, and an Açaí tree will never be the same as a guava tree. The course and the people need to value this, but I think the institution has gradually changed, albeit slowly, with slow steps, since our arrival (Toteem; Kambeba; 25a; Sudeste; 5º).

The Indigenous people reported that they sought to demand their rights in their relationships with the established groups, organizing themselves and denouncing oppression, violence, and racism. Conflicts between established groups and outsiders¹⁸ are situations with tensions or struggles to change inequality in relationships:

I reported to a professor. It was something I did to be a protester. However, I also received support from the academic community. However, I was the arrow in the bow in that situation. [...] The professor was removed (Abaçaí; Pankararu; 29a; Centro-Oeste; 5º).

As a way of reacting to situations of oppression by teachers, students also described the strategy of not confronting them and not showing their Indigenous identity, remaining silent:

They told me not to say that I was Indigenous [...] for the sake of our protection. [...] We know that, despite being university professors and having a very good education level, they are not necessarily more open to cultural diversity (Tenetehar; Tembé; 24a; Norte; 6º).

In some medical schools, research participants noticed transformations as a result of their presence, gathering people with very different backgrounds and indicating the possibility of raising awareness for the recognition of differences:

It’s an experience that involves many feelings, from the moment you start to the moment you leave. [...] because you kind of go through an adaptation process at the beginning, and even then, you face some exclusion and prejudice from people and the university. However, we understand that this is what we’re here for: to show people about these issues and change this preconception a little, right? (Abaçaí; Pankararu; 29a; Centro-Oeste; 5º).

Thus, there was a perception that the presence of Indigenous people in medical courses could impact the training of future doctors, similar to that described by Whitla et al.²⁹ in American universities. In both contexts, students reported that contact with students from diverse groups improved their educational experience, with shared values and basic training for cultural sensitivity²⁹.

The encounter between Indigenous people and the subjects of the medical course brought a range of characteristics that pointed them out as “strangers”, as “outsiders”, even over time. The presence of these strangers generates tensions but brings new paths as outsiders within, as their differences can sensitize established standards and paradigms²⁶. It is an opportunity to unite their personal and cultural experiences with academic learning without subordinating one to the other, preserving a creative tension that favors “the freedom both to be different and to be part of human solidarity”²⁶ (p.123).

Discussing inclusion and exclusion, Baniwa²⁰ describes that Indigenous peoples do not want to become identical; they want to continue being different. However, the surrounding society considers them strange, obstacles, and undesirable. Due to this stance, inclusion can lead to exclusion, as there is no openness to “those who are strange and want to continue being strange”²⁰ (p.99). Therefore, the best perspective would be that of “interactive and dialogical acceptance”, overcoming the “binary opposition between inclusion and exclusion”²⁰ (p.99).

Thus, the Indigenous students narrated some of their achievements, highlighting that the path to the sound development of their trajectories was the appreciation of the differences and singularities of those who arrived “from outside”, partially overcoming stigmatization.

Final considerations

Experiences of otherness in medical school were narrated from the daily lives of Indigenous students in situations of estrangement, prejudice, racism, invisibility, guardianship, stigmatization, and violence. Situations of acceptance, curiosity, commitment, and the construction of new paths were also described, although they were not the most common. Thus, focusing on experiences of otherness allowed us to recognize the existence of “others” in the academic space and the need to build a more democratic and fair space.

In this context, the relationship between established groups and outsiders is one of the characteristics of this encounter (or disagreement); however, the universe of relationships transcends this theoretical model. Other historical and ethnic factors are also related, both in the face of the situation of oppression and colonization experienced by Indigenous peoples and the configuration of medical schools. Thus, contradictorily, Indigenous peoples in medical courses are the “outsiders” in a country where they are the native populations, the original peoples, that is, the “insiders”.

Furthermore, not only are Indigenous people “strange” and invisible in medical school, but also Black people, quilombolas, people with disabilities, transgender people, immigrants, and people experiencing poverty, experiencing the complexity of relationships with the established.

There were striking narratives that the oppression and violence suffered in medical school were silenced and made invisible. Silencing emerged as a protection strategy and as a consequence of attitudes of silencing those who are different, “strangers”, and sometimes unwanted. Giving visibility and valuing their singularities can be the way to ensure that inclusion does not lead to homogenization.

Narrating these experiences was a space to break with a form of invisibility. A path of affirmation in the conquest of space and rights in a dialectical movement, which sometimes advances and sometimes retreats.

The stages of interviews and conversation circles thus became spaces for learning, involving different perspectives and knowledge. In this sense, dialogicity required trust and availability to be with, listen to, and learn from the other in the exercise of alterity, overcoming the vertical and sterile relationships between researcher and research participants to be an encounter that enabled new constructions.

For the leading researcher, this dialogical relationship with Indigenous students affected and enabled new ways of thinking about his teaching and professional practice, with strategic movements for implementing counter-hegemonic and anti-racist processes in the medical school.

Thus, by listening to Indigenous medical students, we understood their possible encounters with others in their experiences in medical schools, often composed of an unwelcoming corporate group vis-à-vis those who are different, “strangers”, and “outsiders”. The presence of Indigenous people in medical courses reaffirms inequalities and invites medical schools to overcome limits, build paths of plurality and the inclusion of other epistemologies, promote social justice, and develop strategies for Indigenous healthcare with their leading role.

Acknowledgments

We are grateful to the Indigenous students in medical courses who trusted in our commitment to research and shared their experiences in such a vivid and affectionate way. We are also grateful to our interlocutors at federal universities for their availability and hospitality during face-to-face and remote meetings. We thank the Indigenous peoples for their resilience and insistence on building a more just society.

References

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• Funding
  Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) - 2019/09426-7; Organização Pan-Americana de Saúde in partnership with the Ministério da Saúde - Letter Agreement SCON 2017 - 02638.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  16 Dec 2024
• Date of issue
  Dec 2024

History

• Received
  15 Sept 2023
• Accepted
  29 Feb 2024
• Published
  20 Apr 2024