Indigenous psychology in disasters: lines of care construction for the “Buen Vivir” of original peoples

Abstract

Objective

In 2021, the indigenous communities Pataxó, Pataxó Hãhãhãe and Tupinambá, in the state of Bahia, Brazil, were hit by intense floods. The situation required immediate response from local health professionals, with advice from experts in public health disasters and emergencies. This case study focuses on the development of lines of care for the “Buen Vivir” of affected original peoples through collaborative work between indigenous ethnic groups and public health policy professionals.

Method

Analysis of the records of meetings, a training course for indigenous health professionals and three reference documents was carried out.

Results

Possibilities and challenges for assuring the “Buen Vivir” in the post-disaster and public health emergency response phase were addressed, guaranteeing the specificity and protagonism of the communities served.

Conclusion

Contributions were presented along the lines of care construction processes for the “Buen Vivir” of indigenous peoples, pursuing subsidies for public policies in accordance with the socio-historical-cultural particularities of each ethnic group.

Keywords
Disasters; Emergencies; Indigenous peoples; Psychosocial intervention; Mental health in ethnic groups

Resumo

Objetivo

Em 2021, povos indígenas Pataxó, Pataxó Hãhãhãe e Tupinambá foram atingidos por inundações intensas na Bahia. A situação exigiu respostas imediatas das equipes locais de saúde, contando com a assessoria de especialistas em desastres e emergências em saúde pública. Esse estudo de caso aborda o processo de construção de linhas de cuidado ao Bem-Viver dos povos originários afetados, por meio do trabalho colaborativo entre etnias indígenas e equipes de políticas públicas de saúde.

Método

Foram analisados registros de reuniões, um curso de formação para profissionais de saúde indígena e três documentos de referência.

Resultados

Abordou-se possibilidades e desafios no cuidado ao Bem-Viver na fase de resposta pós-desastres e emergências em saúde pública, com a garantia da especificidade e do protagonismo das comunidades atendidas.

Conclusão

Foram apresentadas considerações para o processo de construção de linhas de cuidado ao Bem-Viver de povos originários, buscando oferecer subsídios à conformação de políticas públicas consoantes às particularidades sócio-histórico-culturais de cada etnia.

Palavras-chave
Desastres; Emergências; Intervenção psicossocial; Povos indígenas; Saúde mental em grupos étnicos

Analyzing and developing lines of health care ensuring the specificities of indigenous peoples is not a simple task. In the Brazilian context, despite the legal and constitutional apparatus, it is challenging to ensure care considering the particularities of these people, as recommended by the Subsistema de Atenção à Saúde dos Povos Indígenas (Health Care Subsystem for Indigenous Peoples), created by Law No. 9.836/99, and the Política Nacional de Atenção à Saúde dos Povos Indígenas (National Policy for the Health of Indigenous Peoples), created by Law No. 3.156/99. In general terms, these laws establish guidelines for differentiated care, which aims to ensure full access to health, in accordance with the principles of the Sistema Único de Saúde (SUS, Unified Health System) and recognizing the right of these peoples to their culture and the effectiveness of their medicine. However, an authoritarian use of vertical and homogenizing policies and programs is a common phenomenon observed in different countries, particularly given the need to act in disasters and public health emergencies (Mosurska et al., 2023).

Indigenous peoples are culturally distinct societies and communities comprising approximately 6% of the global population. Nevertheless, they are about 19% of people in extreme poverty in the world (World Bank, 2023). Diversity is a fundamental element in the definition of indigenous peoples (Guimarães, 2022). In this sense, knowing one ethnic group absolutely does not mean knowing another. In Brazil, the 2022 Demographic Census revealed that approximately 1.7 million people declared themselves or considered themselves indigenous, which is 0.83% of the country’s total inhabitants (Instituto Brasileiro de Geografia e Estatística [IBGE], 2023). Furthermore, the 2010 Census recorded that 274 languages were spoken, among 305 different ethnic groups (IBGE, 2012). Two Brazilian states had 42.5% of the total indigenous population, according to the more recent 2022 Census: Amazonas, in the North region, and Bahia, in the Northeast region, with 490.9 and 229.1 thousand indigenous inhabitants, respectively (IBGE, 2023).

In recent decades, international agencies for the study and monitoring of climatic events have highlighted the continuous increase of extreme events, which have triggered disasters and public health emergencies on all continents (Global Climate Change, 2023; United Nations Educational Scientific and Cultural Organization, 2023). Due to the legacy of exclusion and inequality, indigenous peoples tend to be more vulnerable to the impact of climate changes that cause socio-natural disasters (Middleton et al., 2020; World Bank, 2023). Furthermore, in countries where there are higher economic disparities, multiple vulnerabilities, social inequities, public protection flaws, and gaps in the care policies aimed at Integrated Risk and Disaster Management, such events impose worse effects on the health of affected populations (Noal & Rabelo, 2022).

There is no specific database that accurately characterizes the number and dimension of disasters that have affected indigenous or any other traditional peoples in Brazil, such as the quilombolas. However, a good data estimation might be gathered from the Sistema Integrado de Informação sobre Desastres (S2iD, Brazilian Integrated Disaster Information System). Of the two states with the largest indigenous population in the country (IBGE, 2023), Amazonas had nine investigations, in seven municipalities, recording five cases of flooding. In turn, Bahia had 74 investigations, in 73 municipalities, recording 64 cases of drought, according to information retrieved from the S2iD, on August 8, 2023 (Ministério da Integração do Desenvolvimento Regional, 2023).

The state of Bahia, in particular South, Extreme South and Southwest regions, was stricken by intense floods between December 2021 and January 2022, severely affecting the indigenous communities Pataxó, Pataxó Hãhãhãe and Tupinambá (Casa Civil, 2021). Approximately 88 villages were harmed, in 15 municipalities, involving 19 thousand people, according to data released by the Fundação Oswaldo Cruz (Fiocruz, Oswaldo Cruz Foundation), the Distrito Sanitário Especial Indígena da Bahia (DSEI-Bahia, Special Indigenous Health District of Bahia) and the Secretaria da Saúde do Estado da Bahia (SESAB, Bahia State Health Department) (Fiocruz et al., 2022). Damage to plantations, buildings and roads caused a lack of food and basic items for population survival, resulting in material, economic, territorial, and psychosocial impacts. This deepened the pre-existing social disparities that affected these indigenous peoples, amplifying vulnerabilities and exacerbating the spectrum of psychological suffering characteristic of disasters and public health emergencies (Fiocruz et al., 2022).

To mitigate part of these impacts, a task force was set up by the federal, state, and municipal governments, including humanitarian aid bodies, in order to provide a rapid response to the socioeconomic effects of the floods, as well as to meet emerging health demands (Casa Civil, 2021). In this vein, the reconstruction of this territory had to be combined with guaranteeing access to resources and the public equipment available to meet the demands of the affected populations. To survey these impacts and demands, the support of indigenous health professionals and local leaders was necessary. These agents performed as interlocutors (i.e., cultural translators) of the affected populations and co-participants in the process of building lines of care for the Buen Vivir of the affected indigenous peoples, in a collaborative work, which is the focus of this study.

It is noteworthy to underline that although indigenous peoples are more vulnerable to disasters (Middleton et al., 2020; World Bank, 2023), such as floods, their practices have emerged as a safeguard in the extreme climate scenarios predicted for the coming years, especially if the goals of the Paris Agreement are not attained (Yamane, 2019). For centuries, indigenous peoples have used their traditional knowledge to prepare, face and survive disasters (Lambert & Scott, 2019). Such collectives, groups and populations bring with them their own economic, socio-environmental repertoire (Guimarães, 2022), and even psychosocial care, in the face of a universe full of threats, violence and crises (Cianconi et al., 2019; Lambert & Scott, 2019; Middleton et al., 2020).

Notions about mental health and subjective expressions of psychological suffering are based on cultural codes specific to each community (Cianconi et al., 2019). Historically, however, Psychology has ensured little or no visibility of the peculiarities of indigenous peoples (Guimarães, 2022). In fact, although regulated as a profession in Brazil since 1962, it was only in 2022 that the Conselho Federal de Psicologia (CFP, Federal Council of Psychology) managed to consolidate the document Technical References for the Work of Psychologists with Indigenous Peoples (CFP, 2022). This document re-states the silenced history of indigenous peoples in Brazil and, within the field of Psychology, advances in the discussions on the ethical-political dimension, addresses indigenous peoples’ diversity, explains the chronological trajectory of public policies regarding psychosocial care of indigenous peoples and culminates in an in-depth analysis of the psychologists’ practice with those peoples.

Such practice, however, implies a paradigmatic tension over the current psychological knowledge, to shatter previously stipulated structures about body, territory and health (Guimarães et al., 2019; Tuxá, 2022). In this view, for example, we perceive that the great axis of original peoples’ ontological rationale for the phenomena described as disasters is closely linked to the hegemonic ways of living and producing in different societies. Thus, preventing such disasters requires modification of these structuring modes (Browne-Yung et al., 2013; Richmond et al., 2005). Such modification leads to overcoming the dichotomous Cartesian polarization between body and spirit, culture and nature, as well as body and territory. In the indigenous cultures, there is a symbiotic relationship between the health of the body, the health of the people and the health of the land. It is, in its essence, a body-territory, a single relational and codependent condition (Tuxá, 2022).

Hence, the concept of territory is constitutive of the idea of Buen Vivir and health of indigenous peoples and, therefore, fundamental to understanding the different strategies to be constructed in a psychosocial care approach, complying with the territoriality of those specific peoples (Lacerda, 2020). The dimension of territoriality, consequently, will determine the entire structure, logic, consolidation of networks, players and support that an approach can activate or build in a scenario that requires intervention (Lacerda, 2020; Lambert & Scott, 2019). It is also important to consider that the local conception of the territory affected by a disaster may go beyond the area directly affected and the suffering experienced by one ethnic group may be shared by several other groups, even if they are spatially distant from each other (Richmond et al., 2005).

Thus, ancestry, territoriality, and collectivity become constitutive dimensions of the conception of health, which transcends physiological aspects and consolidates the expanded notion of Buen Vivir (Lacerda, 2020). According to Lacerda, in the Buen Vivir, there is a total relativization of the Western idea of progress, now transfigured into the idea of harmony, balance, and transgenerational abundance. There is also a conversion in the idea of a singular and atomized subject, propagated by hegemonic rationality, and an opposition to the monoculture thoughts in favor of a diversity of knowledge that constitutes collective, historical and territorial subjectivations, elements that directly affect the form of understanding mental health.

In short, this scope of understanding supports the psychosocial care strategies used by indigenous peoples in the face of extreme events. Evidently, in a broad sense, there is a line of psychosocial care that is related to practices of biosocial reproduction, such as rites of passage, cultural practices that feed and structure the cosmo-perceptions of a given population (Inter-Agency Standing Committee [IASC], 2007). In turn, in a strict sense, regarding the therapeutic practices, medical-centered models originating from a biocentric science prevail. However, in the indigenous territories, those models are always in a dialogue with traditional practices, with specific cultural players, rituals and remedies that apply an ecocentric vision to the prevention and healing process, breaking away from the thesis of incapacity and sociocultural inferiority of the indigenous peoples, advancing the legitimization of diversity and multiplicity (CFP, 2022).

Given the above, the present case study is anchored in the understanding of subjects, territories, and phenomena in a codependent way in the processes of subjective construction. Thus, the construction of lines of care for the Buen Vivir of the indigenous peoples Pataxó, Pataxó Hãhãhãe and Tupinambá, affected by floods in the state of Bahia, Brazil, is presented, considering the collaborative work between the indigenous ethnicities and the public health policy teams. In particular, meeting records, one training course for indigenous health professionals, and three reference documents were analyzed, discussing the challenges of caring for the Buen Vivir in the post-disaster response phase, ensuring the specificity and protagonism of the addressed communities.

Method

This paper aims to present a qualitative, descriptive, and exploratory case study. The case discussed refers to the work carried out by disasters and health emergencies specialists associated to a federal public institution. These specialists operated at the request of state health managers, during the sudden and intense floods that occurred between December 2021 and January 2022, in Bahia. The case in focus serves as an instrumental study, as proposed by Stake (2006), since the case described is secondary and serves as an anchor to facilitate understanding of the investigation issue. To assess the case, the following guiding questions were considered: How did the process of constructing lines of care for the Buen Vivir of the affected indigenous peoples occur? Who participated and what are the features of the training course for indigenous health professionals and the reference documents produced in the post-disaster response phase?

Because the present study was not previously planned, the methodological path was constructed based on the emergency needs, considering the demands identified throughout the intervention in the territory. The main intention was to mitigate damage and health impacts in the affected communities. Therefore, the assumption in Resolution No 510/2016, of the National Health Council, was taken into account. Such assumption regards the non-registration and evaluation by the system of Research Ethics Committees and the National Research Ethics Committee of proposals that emerge contingently from the professional practice. Furthermore, to ensure ethical principles of privacy and identity protection, only the participating institutions and information already in the public domain were mentioned.

Data sources were the lines of care construction records for the Buen Vivir of the affected indigenous peoples, based on information retrieved from the minutes of meetings and from reference documents, as well as technical materials prepared in the post-disaster response phase. This phase consisted of interviews with nationally renowned researchers and indigenous people, which provided subsidies for the online training course and three textual productions. Specifically, the data analyzed in the present study were derived from: (a) Minutes of five meetings, held in January 2022, which were attended by indigenous representatives, managers, indigenous health professionals and researchers; (b) Online training course titled Mental Health and Psychosocial Care for Indigenous Health Teams during Floods in Bahia, aimed at the DSEI-Bahia workers. Classes duration was approximately 3.5 hours (200 minutes), carried out synchronously. Subsequently, the course was made available through the Telessaúde Bahia channel on the YouTube platform (https://youtu.be/SZ46iSazfmE); (c) Reference documents and technical materials produced in the post-disaster response phase, through collaborative work between indigenous representatives and the Fiocruz, DSEI-Bahia and SESAB personnel, namely: Recommendations on Mental Health and Psychosocial Care/Buen Vivir for Indigenous Peoples Affected by Floods in Bahia (16 pages); Emergency Preparedness Research, Evaluation & Practice (EPREP) for Indigenous Peoples (five pages); and Practical Guide for Care Strategies for Indigenous Peoples in Brazil (seven pages). It is noteworthy that, in the graphic configuration of these three documents, it was sought to include elements familiar to the indigenous cultures, from a semiotic and symbolic point of view as well as the use of accessible language.

The first stage of data analysis sought to characterize the work process involved in the construction of lines of care for the Buen Vivir of affected indigenous peoples, describing the different collaborators, as well as the agreed referrals, based on the records of the minutes of the meetings. In a second stage, the theoretical-practical supporting information was assessed by examining all the didactic, training and informative material created collaboratively between the public health teams and the indigenous representatives, both for the composition of the online training course and for the three reference documents produced in the post-disaster response phase.

Results and Discussion

The process of building lines of care for the Buen Vivir of indigenous peoples affected by the floods in the state of Bahia, Brazil, which is the focus of this case study, began on December 31, 2021, when technicians from the Ministry of Health activated the health disasters and emergencies’ experts, linked to Fiocruz, to form a working group. On January 4, 2022, the first author of the present study moved from the Federal District, her work base, to Bahia; other two authors of the present study remained in Brasília, for the direct support of the disaster post-response phase.

Five online meetings were held in January 2022, all recorded in minutes, with the participation of indigenous representatives, managers, indigenous health professionals and researchers, aiming to plan and agree on strategies to meet the emerging demands. Table 1 presents a summary of the meetings’ participants, topics discussed and referrals. An interdisciplinary working group was formed, with members from different training areas (Psychology, Medicine and Anthropology) and specialties (Public Policies, Human Rights, Indigenism, Disasters and Public Health Emergencies); indigenous people also contributed with their advice. This was an effort to integrate the traditional knowledge of indigenous peoples, from the perspective of the diversity of knowledge that constitutes collective, historical, and territorial subjectivities – elements that directly affect the way we view care –, in line with what is recommended for the psychosocial care of indigenous populations (CFP, 2022; Lacerda, 2020).

After the fifth meeting of the working group, the online training course on Mental Health and Psychosocial Care for Indigenous Health Teams during Floods in Bahia was disseminated among DSEI-Bahia workers and occurred on January 21, 2022. Around 30 people participated in the web conference. Its aim was to reach a consensus on indigenous health and Buen Vivir guidelines in the Bahia state, in response to the socio-natural disaster (floods). The IASC Pyramid (2007) was selected as the guiding resource, to be constructed and validated collectively by those present. Thus, the adopted strategy was aligned with the particularities of the affected indigenous ethnicities, which is an aspect to consider when working with indigenous peoples (CFP, 2022; Lambert & Scott, 2019).

Table 1
Participants, topics discussed, and referrals made from team meetings

Date		Meeting Summary
1st meeting 6/1/2022		Expanded meeting, with the participation of 42 representatives from the following institutions: DSEI-Bahia, SESAB, Universidade Federal do Sul da Bahia, Núcleo de Saúde Mental e Atenção Psicossocial (NUSMAPS, Center for Mental Health and Psychosocial Care) of Fiocruz and the Pan-American Health Organization (PAHO).   Aim: to begin the process of participatory construction of the care strategy for populations affected by floods, based on the IASC Pyramid (2007)a, indicating actions and responsibilities at each level.   Psychologists from DSEI-Bahia expressed their concern about the focus exclusively on shelters and accommodations.   Referral: a specific document ought to be developed, aligned with the matrix document, focusing on mental health and psychosocial care for affected indigenous peoples.
2nd meeting 7/1/2022		Five participants, including the Head of the Indigenous Health Care Division of DSEI-Bahia, mental health professionals from DSEI-Bahia and representatives from NUSMAPS-Fiocruz.   Aim: to begin the process of formulating a document to address mental health and psychosocial care for affected indigenous peoples.
3rd meeting 7/1/2022		Sixteen participants, representatives of NUSMAPS-Fiocruz and DSEI-Bahia (psychologists, social workers, nutritionist, pharmacist and health advisor, four of whom were indigenous professionals).   Aim: to address response strategies in mental health/Buen Vivir for indigenous peoples affected by floods in Bahia, targeting the participatory mapping of the following issues: (a) What could not be missing in a care strategy for indigenous populations, in the phase of response, and which partners to articulate?; (b) What are the strengths of the affected indigenous communities that would facilitate the implementation of this strategy?; (c) What are the weaknesses of the affected indigenous communities that would make it difficult to implement this strategy?   The discussions allowed to raise central demands; articulate public policies and their relevant institutions; structure the first version of the document, which was subsequently presented to the expanded group for evaluation and additions (called, at the end of the process, Recommendations on Mental Health and Psychosocial Care/Buen Vivir for Indigenous Peoples Affected by the Floods in Bahia); list aspects of vulnerability in the post-disaster response (e.g., restoration of water, housing and roads) and recovery (e.g., food security) phases (Noal et al., 2022; United Nations Office for Disaster Risk Reduction, 2015).
4th meeting 11/1/2022		Four participants: three members of NUSMAPS-Fiocruz and an indigenous psychologist of national reference, a professional linked to DSEI-Bahia and member of the Brazilian Articulation of Indigenous Psychologists.   Aim: explore historical aspects of indigenous peoples in the Northeast of Brazil and the importance of the territorial struggle for indigenous Buen Vivir; emergency and medium-term approaches, seeking to mitigate the impact of floods in Bahia.   Referrals: proposal for an online training course aimed at DSEI-Bahia workers (which will be discussed later in this article), as well as the creation of a video with psychologist NitaTuxáb, with support from Fiocruz, for the Acolhe Bahia series, entitled Acolhe Parente (Welcome Relatives): Buen Vivir and Psychosocial Care (https://youtu.be/63QViroLsYM).
5th meeting 14/1/2022		Two participants: a representative of NUSMAPS-Fiocruz and a representative of the Head of the Indigenous Health Care Division of DSEI-Bahia.   Aim: discuss the process of developing activities; present the proposal for the online training course; present the preliminary version of the reference document Recommendations on Mental Health and Psychosocial Care/Buen Vivir for Indigenous Peoples Affected by Floods in Bahia.   The follow-up of activities was approved.

• Note:
• ^a
  Pyramid composed of four levels, from the most basic to the most specialized:
• (a) social considerations in basic services and security; (b) strengthening community and family supports; (c) specific non-specialized support; (d) specialized services (IASC, 2007; Noal et al., 2022).
• ^b
  Citation of name authorized by the professional, to whom the authors are grateful.

Together with the welcome greetings from the institutions and representations’ members, part of the working group (indigenous advisors, DSEI-Bahia, SESAB and Fiocruz), the course began with the presentation of the agenda. Afterwards, the following topics were addressed: (a) Indigenous Buen Vivir; (b) Mental Health and Psychosocial Care in Disasters; and (c) IASC Pyramid, integrating indigenous specificities. Subsequently, using participatory strategies, a detailed systematization of previous meetings (described in Table 1) was carried out, addressing the players and actions associated with the levels of the IASC Pyramid (2007) and the dialogue with the public to collect suggestions.

This training course was a fundamental step towards consolidating the reference documents produced in the post-disaster response phase. These reference documents were written by 14 health professionals and managers as well as researchers who collaborated with Fiocruz, DSEI-Bahia and SESAB (two of whom were nationally recognized indigenous individuals). They all participated in the elaboration of the strategy, under the coordination of NUSMAPS-Fiocruz.

The materials produced addressed aspects related to mental health and psychosocial care/Buen Vivir for indigenous peoples, with the aim of supporting the work of public health professionals, through specific information on the most common impacts and reactions in communities affected by extreme events (Noal et al., 2022), as well as the meanings and signifiers peculiar to indigenous communities, considering their values and practices (El Kadri et al., 2021). In this sense, the three documents prepared propose guidelines for professional practice, in addition to care related to ensuring the rights and needs of indigenous peoples.

The first document developed by the working group was entitled Recommendations on Mental Health and Psychosocial Care/Buen Vivir for Indigenous Peoples Affected by Floods in Bahia, being systematized by Fiocruz, reviewed and validated by DSEI-Bahia and SESAB, as well as shared by those three institutions, in digital format. The preparation took place between January and February 2022, in order to cover the response initiatives and the recovery phase of extreme events (IASC, 2007). Therefore, the central guidelines and premises included in this document aimed at the response and recovery phases (United Nations Office for Disaster Risk Reduction, 2015). Likewise, the inclusion of specific cultural references on the ethnicities most affected in the state of Bahia was identified, which is in line with the literature that highlights the importance of addressing the particularities of different indigenous peoples (Guimarães, 2022; Mosurska et al., 2023), as well as technical recommendations from the Brazilian and international health sector institutions, in addition to the SUS principles (CFP, 2022). Hence, the idea was to address the emerging demands and the overlapping of inequities and challenges already known in the Brazilian socio-political-cultural context.

Bearing in mind the need for specific and practical emergency guidelines (Noal et al., 2022), the document was organized to cover topics such as the disaster scenario, including general data on the most affected people, methodological aspects related to the composition of the working group, as well as specificities concerning the line of care regarding mental health and psychosocial care (following the Buen Vivir principles) for indigenous peoples affected by the floods in Bahia. In particular, it was sought to offer specific theoretical and propositional support for each segment of expanded health care, addressing basic and security services, support for communities and families, including municipal, state, federal and non-governmental bodies, in the areas of health, education, social assistance, rural development, civil defense, infrastructure, human rights and citizenship. Additionally, the document included risk and protective factors, besides the recommendations for indigenous Buen Vivir in response to the disaster, with emphasis on listening groups and conversation circles, preparation of informative materials, territorial strengthening actions, as well as assumptions and guidelines to steer these actions.

This first document (Recommendations on Mental Health and Psychosocial Care/Buen Vivir for Indigenous Peoples Affected by Floods in Bahia) served as the basis for four of the authors of the current study, who are associated with NUSMAPS-Fiocruz, to begin preparing the EPREP Indigenous Peoples. This second document (EPREP Indigenous Peoples) was anchored in the Brazilian and international relevant literature on humanitarian aid in public health emergencies and disasters (e.g.: Fiocruz, 2020; IASC, 2007; United Nations Office for Disaster Risk Reduction, 2015), as well as on the practical experiences of some of the authors of the present study, in territories with indigenous and traditional peoples and communities in Brazil (e.g.: with the Vale do Javari Indigenous Land’s peoples and the Luciano Mendes de Almeida Observatory of Social and Environmental Justice).

The EPREP Indigenous Peoples was prepared after the completion of the first phase of response to the emergency in Bahia, when experts from NUSMAPS-Fiocruz met to evaluate and assess the suggestions that covered the needs and demands of other indigenous peoples in the Brazilian territory. At the same time, these professionals considered the relevance of offering support to the work of health professionals in indigenous territories, as well as recommendations to public policy managers in order to promote understanding of ways to intervene and ensure that minimum needs would be covered working with indigenous peoples in disasters and public health emergencies.

In terms of structure, EPREP Indigenous Peoples was organized as follows: contextualization; basic aspects to consider when working with indigenous populations in disasters and emergencies; recommendations for professionals who work in the Psychosocial Care Network (Rede de Atenção Psicossocial [RAPS]) at SUS; and, recommendations for managers. In a meeting held in December 2022, a preliminary version of the document was presented to the members of the NUSMAPS-Fiocruz, who made suggestions for adjustments, with the final version completed in January 2023.

In February and March 2023, two of the authors of the current study went to support the SUS National Force at the Yanomami Mission, in the state of Roraima, Brazil. This interministerial initiative, coordinated by the Public Health Emergency Operations Center in the Yanomami Indigenous Land, the most populous territory in the country (27,152 people; IBGE, 2023), was carried out due to the state of public health emergency resulting from hundreds of cases of severe malnutrition, malaria, acute respiratory infection, among other issues (Ministério da Saúde, 2023). From this experience, the demand for a didactic and specific document was perceived, to be shared with teams that work with indigenous peoples in disasters and public health emergencies.

Thus, based on the second document (EPREP Indigenous Peoples), a third document was prepared, entitled Practical Guide for Care Strategies for Indigenous Peoples in Brazil. This third document was prepared by three authors of this paper, members of NUSMAPS-Fiocruz who worked at the SUS National Force. Their role was to support professionals from different areas who work, in the response phase, in disasters and public health emergencies with the indigenous peoples of Brazil. The structure of the Practical Guide for Care Strategies for Indigenous Peoples in Brazil is made up of the following sections: essential behaviors; what not to do at all; and, ways to guide care strategies. During the Yanomami Mission, a preliminary version of the text was evaluated by professors, scholars, and researchers in indigenous health, indigenous physicians, as well as professionals from the SUS National Force. The final version was presented in March 2023 to the teams participating in this interministerial initiative in the Yanomami Indigenous Land.

In general terms, the three reference documents produced systematized recommendations to support a more assertive practice in the construction of lines of care for indigenous peoples in disasters and public health emergencies. Together, these documents emphasize that each indigenous culture has a cosmology that supports the understanding of the world and its phenomena (Cianconi et al., 2019). Therefore, thinking about plans and actions in disaster contexts with these populations, means, firstly, understanding their explanations of the event, in order to counteract it in all its dimensions, without ignoring the vast body of indigenous knowledge fostering technical-scientific strategies based on other cultures (Lambert & Scott, 2019). In this sense, the perspective of spirituality, territoriality and ancestry of these peoples must be assumed as a central dimension of the approach to be developed (Lacerda, 2020). Furthermore, in the face of disasters, it is important to immediately diagnose the priority areas for approach, in relation to the indigenous peoples’ degree of vulnerability and impact (Lambert & Scott, 2019).

As previously discussed, most indigenous communities build their Buen Vivir based on their relationship with the land and what they produce on it (Lacerda, 2020; Lambert & Scott, 2019). Therefore, geographical elements such as mountains and rivers assume a sacred character in some cases (Tuxá, 2022). Assessing the impact on these structures and, sometimes, proceeding with a territorial and collective grieving process is crucial (Krenak, 2019). It is important to consider that the loss of land caused by a disaster can bring back ancestral pain, which refers to the arduous and continuous process of struggling for territory (Krenak, 2020).

Also as explained, ancestry and the sense of collectivity are structuring elements of indigenous health (Lacerda, 2020; Tuxá, 2022). Therefore, in cases of disasters and public health emergencies, the health and safety of elders and leaders must be safeguarded. Valuing the community and the spaces for transmitting oral knowledge should guide the care strategies (CFP, 2022). If there is a need for removal or displacement, it is not advisable to disaggregate the community’s collective units, as the entire force of response to the event is linked to maintaining understanding and eminently collective traditional health practices (Pontes et al., 2020).

In the same way that practices centered on conventional medical sciences are structured, indigenous communities have for centuries possessed knowledge that provides local understandings about the body, health, and diseases, which should be considered and incorporated into the construction of care approaches (Cianconi et al., 2019). Popular practices and knowledge have been part of the history of health since the oldest civilizations and are still present today (Cianconi et al., 2019; CFP, 2022). Even with the advancement of Western medicine, based on the Cartesian paradigm of science, the traditional knowledge and medicines of indigenous peoples continue to provide contributions and constitute an endless legacy of our ancestors, rooted in their cosmologies (CFP, 2022).

Thus, through intersectoral actions (involving local governments, federal agencies, such as the Secretariat of Indigenous Health and the National Foundation of Indigenous Peoples, non-governmental organizations, among other institutions), it is necessary to ensure services that address the biopsychosocial demands of each group, taking as an example: food security, territorial protection, drinking water, health care, education, housing, capacity for social isolation when necessary, among others (Lambert & Scott, 2019). Furthermore, the mapping of risk and protective factors can favor the identification of topics sensitive to communities, in relation to which informative materials can be prepared (such as booklets, videos, podcasts for circulation via WhatsApp), with language culturally appropriate to indigenous populations (preferably using local communicators).

In a pragmatic way, Table 2 summarizes recommendations for RAPS professionals and managers at SUS, derived from the materials analyzed in this case study, regarding the process of building lines of care for the Buen Vivir of indigenous peoples in a context of disasters and public health emergencies.

Table 2
Recommendations for Psychosocial Care Network professionals and managers at Unified Health System

Category		Recommendations
Professionals		Engage interpreters for effective dialogue with the community. Identify the DSEI and the Indigenous Health Houses in the territory, including them in the Contingency Plans of the health establishments at SUS reference network.   Ensure ethnic registration in the indigenous person’s screening and/or care form, ensuring reliability of statistics on the impacts of the event on that specific population.   Map and join the health actions already carried out by indigenous movements organized in each municipality.   Observe the National Policy for the Health of Indigenous Peoples in the construction of strategies.   Promote the ambience of the health establishment, according to the ethnic specificities of the indigenous populations served.   Enable equitable access and reception criteria, ensuring that strategies are feasible.   Ensure comprehensiveness in health care, considering respect and appreciation of cultural aspects, under penalty of socio-emotional suffering resulting from these absences worsening clinical conditions related to other conditions.
Managers		Strengthen intersectoral responses, with federated entities, community leaders and civil society organizations for actions at all levels of the IASC Pyramid.   Map risk and protective factors for affected people, drawing on knowledge from community leaders, indigenous health agents and DSEI professionals.   Consider local temporality in response strategies.   In Primary Care, promote matrix support in mental health in the most impacted territories, in addition to support for training and guidance on how to act in disaster situations.   In non-specialized focused support, monitor cases of suicide attempts and self-mutilation, abuse of alcohol and other drugs, liaising with professionals from DSEIs, Psychosocial Care Centers, mental health outpatient clinics, indigenous leaders, etc.   Promote listening, supporting and conversation groups, especially aimed at those considered most vulnerable and who demonstrate suffering prior to the disaster; spaces for sharing ancestral narratives and stories, which promote intergenerational dialogue and value cultural practices (singing, dancing, craft production), favoring young people’s feeling of belonging to their collectives; meetings of pajés/shamans to safeguard and disseminate traditional knowledge.   Promote spaces for listening to workers (care for caregivers) and also to indigenous leaders, addressing processes of territorial and collective mourning.

• Note: DSEI: Distrito Sanitário Especial Indígena, IASC: Inter-Agency Standing Committee.

Final Considerations

This case study focuses on the construction of lines of care for the Buen Vivir of indigenous peoples affected by intense flooding in the state of Bahia, Brazil, from December 2021 to January 2022, through a collaborative work between representatives of indigenous ethnicities and public health policy professionals. The meeting records, a training course for indigenous health professionals and three reference documents were analyzed. With regard to the training course for indigenous health professionals and the three reference documents assessed in the current study, the participation of indigenous people took place through meetings to survey demands and needs, as well as in the materials planning and production. Thus, it is noteworthy that the first document (Recommendations on Mental Health and Psychosocial Care/Buen Vivir for Indigenous Peoples Affected by Floods in Bahia) was prepared during meetings in which agreement was sought between representatives of the affected peoples and public health professionals. The other two documents (EPREP for Indigenous Peoples and Practical Guide for Care Strategies for Indigenous Peoples in Brazil) were prepared based on notes from meetings with those peoples in disaster situations, as well as using relevant literature and consultation with recognized indigenous health professionals in Brazil.

Furthermore, the process of preparing both the course and the documents was anchored by precepts in favor of an Indigenous Psychology. This is evident, initially, in the graphic configuration of these materials, which dialogues in a semiotic and symbolic way with familiar elements of indigenous cultures. Likewise, the language used sought to be accessible and familiar to indigenous populations, even though, only in a few cases, these reference documents were translated into their mother tongues. This evokes the reflection that, still, the construction of response strategies to extreme events in indigenous communities is aimed, almost exclusively, at health professionals who are able to communicate in Portuguese. Therefore, more specific guidance for the indigenous population in general is uncovered. It is known that, dynamically, during the work of teams in the territories, the use of interpreters aims to remedy this gap. However, this does not overcome the importance of maintaining records in local languages.

The precepts of respect for cultural diversity, conception of subject, territoriality and collectivity were also observed throughout the construction of these materials, giving clues to health workers about expanded ethnocultural conceptions regarding such categories for indigenous populations. However, approaches that specifically delve into mental health for such populations are still incipient. It is estimated that this is due less to a failure in the construction of such strategies and more to a historical absence of this reflection within the field of Psychology, as previously pointed out.

There was no procedure to evaluate the effectiveness of the practices analyzed in the current study as those practices were intended to resolve an emergency demand. In this vein, studies with specific indicators may be carried out, jointly with the communities involved and the health professionals to find out the real impact of these strategies constructed in the response and recovery phase of extreme events, such as the one, which occurred in Bahia. This could offer support for understanding aspects related to the practices that did not offer effective support in the desired response. Studies concerning the experience of indigenous populations in urban contexts affected by disasters may also be carried out, as data in this regard are scarce, which makes it difficult in these cases to formulate strategies, actions and programs aimed at Buen Vivir.

Finally, as a background for considerations on the construction of strategies and public policies aimed at improving the development of plans for the response and recovery phase with the indigenous populations, it should be taken into account that Brazilian as well as international Integrated Risk and Disaster Management policies usually focus their attention on the response phase. Thus, they become less effective due to the emphasis on consequences, rather than causes. The culture of Buen Vivir, focused on spirituality, territoriality, collectivity, and indigenous ancestry, calls for a strategic look that allows preventing, preparing and mitigating the occurrence of extreme events. In this connection, public policies should focus on improving assurance and security of their territories, as well as policies to support the (ethno)territorial development of these communities, in order to safeguard the maintenance of their lives in their localities and, also, advance in the implementation of specific health and education programs that effectively respond to the demands of the indigenous peoples.

Acknowledgements

The authors are grateful to all the members of the working group that involved representatives of indigenous ethnicities, in partnership with the Oswaldo Cruz Foundation, the Special Indigenous Health District of Bahia and the Bahia State Health Department, in the planning and execution process of the training course for indigenous health professionals, as well as preparing the three reference documents analyzed in the current study.

• How to cite this article: Noal, D. S., Lacerda, L. F. B., Medeiros, C. P., Santos, R. A., Cardoso, Y. C., Coelho, L. G., & Schmidt, B. (2024). Indigenous psychology in disasters: lines of care construction for the “Buen Vivir” of original peoples. Estudos de Psicologia (Campinas), 41, e230096. https://doi.org/10.1590/1982-0275202441e230096en

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Edited by

Editor

Danilo Silva Guimarães

Publication Dates

• Publication in this collection
  15 July 2024
• Date of issue
  2024

History

• Received
  08 Aug 2023
• Accepted
  04 Mar 2024
• Published
  03 June 2024