by Adele Benzaken, Deputy Director, Department of AIDS, STI and Viral Hepatitis, Ministry of Health, Brazil
Presently, Brazil harbors around 1 million indigenous persons – an estimated 750,000 of whom live within indigenous lands and territories that occupy around 12% of Brazil’s vast landscape.
According to the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística/IBGE, 2010), this indigenous population belongs to around 305 ethnic groups – speaking many different languages –, and occupies sometimes remote areas in Brazil’s still dense forests, along its immense coastline or on the outskirts of its great metropolitan cities
It comes as no surprise, therefore, that, in 2010, Brazil – as part of its free, universal public health system (Sistema Único de Saúde/SUS) – went to great efforts to establish what is presently the world’s largest public health system focused exclusively on indigenous peoples, whilst taking their full diversity into account.
Designed to deliver primary health services within indigenous lands, the Brazilian Ministry of Health’s Special Secretariat for Indigenous Health (Secretaria Especial de Saúde Indígena/SESAI) reorganized the 34 existing Special Indigenous Sanitary Districts (Distritos Sanitários Especiais Indígenas/DSEIs) – established in the 1990s as hubs for Brazil’s public health system and its policy for indigenous populations.
Presently, SESAI delivers health services to every indigenous community, regardless of how remote. (Indigenous people who live within cities are taken care of by SUS, however.)
SESAI’s services are offered by over 800 teams. This workforce includes doctors, nurses, healthcare technicians, psychologists, advisors – and, notably, groups of indigenous health agents (Agentes Indígenas de Saúde/AISs) who belong to the respective ethnic group that is being addressed. Hired as SESAI employees, these specially trained agents ease communications and understanding between SESAI’s health workers and the indigenous peoples it takes care of. Indigenous health agents are also trained to carry out certain procedures such as rapid tests, for example.
FROM PROJECT TO PUBLIC POLICY
A few years ago, current director of the Brazilian Ministry of Health’s Department of STIs, HIV/AIDS and Viral Hepatitis, Adele Benzaken, carried out a groundbreaking project among indigenous communities (including the Yanomami) in the Brazilian Amazon. Funded by the Bill & Melinda Gates Foundation, the project INCREASING ACCESS TO HIV AND SYPHILIS SCREENING IN REMOTE AREAS USING RAPID TESTS IN THE AMAZON REGION contributed to control of syphilis and congenital syphilis among indigenous people in the states of Amazonas and Roraima, both still densely covered in forest and harboring many remote indigenous communities.
The project addressed vulnerabilities that are inherent to indigenous peoples all over Brazil, empowering local communities to face violence against women and prevent syphilis, HIV and other STIs, as well as vertical transmission of these diseases. The pioneering project discussed preventive measures such as condoms; and rapid tests were used to screen the sexually active for syphilis and HIV in remote villages lacking any kind of lab infrastructure. In this way, the project INCREASING ACCESS TO HIV AND SYPHILIS SCREENING IN REMOTE AREAS USING RAPID TESTS IN THE AMAZON REGION introduced Brazil’s first rapid test for syphilis, with dramatically positive results, proving to be the best way to keep children from being born with congenital syphilis and HIV. In 2012, rapid tests became a public policy for Brazil’s general and indigenous population. Over the 2012 – 2017 period, rapid test distribution for the 34 DSEI in Brazil rose from 54.645 (2012) to 152.470 (2017) HIV rapid tests; and from 27.140 (2012) to 66.150 (2107) syphilis rapid tests. Also based on this project, Brazil established verification and validation of testing throughout Brazil.
INDIGENOUS HEALTH AGENTS: TWO ELOQUENT EXAMPLES
Vinicios Ancelmo Lizardo – or Pureenco, in his original, Avaí indigenous name – is an indigenous health agent working mainly in the Amazon region. “To help my people, I have to help them understand what health really means to them,” he says. Before explaining HIV prevention to a group of wide-eyed, smiling Tikuna, he speaks to them in their own language about love, and sex, and freedom, and makes them laugh by teaching them – with the help of a lifelike dildo – how to use a male condom. Mr Lizardo admits that breaking cultural barriers and building bridges between science and tradition is challenging, but he also knows that indigenous communities cannot be left behind.
Indigenous health worker Jijuké Hukanaru Karajá, on the other hand, is a nurse at DSEI Araguaia – a Special Indigenous Sanitary District placed strategically at the border of three great, still wild Center-West Brazilian states: Mato Grosso, Goiás and Tocantins.
At 31, Jijuké is experienced and tireless in doing her job, crossing the often invisible borders between Brazil’s contemporary-urban-city and indigenous-village civilizations to offer the latter crucial health services. She is following in the steps of her father, an indigenous Karajá health agent born at the Santa Isabel do Morro Karajá village in Bananal Island, Tocantins. Jijuké loves her work dearly and says she is very proud to be a part of the Brazilian indigenous public health system. “I’ve worked at the DSEI, in town, and at the other end, in my indigenous village with my own people – and it’s extremely gratifying to help them in this way,” she says. Jijuké explains that many of the people who work in the Brazilian indigenous public health system are indigenous themselves, thus easing communications and cultural distances. HIV and syphilis prevalence remains low among indigenous peoples in Brazil, but evidently increases following proximity and/or interaction with nearby cities. Crossing great rivers and distances with their precious cargo of sophisticated tests, DSEI Araguaia and its health workers carry out HIV, syphilis and other STI testing two to three times a year, in all encompassed indigenous villages. According to Jijuké, these efforts are welcomed by indigenous communities. “Testing always follows a series of lectures and workshops in villages about prevention of HIV and other STIs, and so the whole process flows naturally,” she says. Through SESAI’s intricate indigenous public health system, immediate counselling and treatment are readily available to any indigenous person who find out that he or she has HIV. Importantly, in the scope of this unique system, all HIV response efforts are sensitively made adequate to the different indigenous peoples involved.