[Cosmology, environment, and health: Baniwa food myths and rites]

Integrating lay knowledge and practice into snakebite prevention and care in central Africa, a hotspot for envenomation

The WHO has identified the goal of halving deaths and disability from snakebite envenomation (SBE) by 2030 through a four-pillar program that promotes accessible and affordable treatments, strengthens health systems, promotes community and multi-level engagement, and mobilizes partnerships, coordination and resources to advocate for global action. This initiative could accelerate multi-disciplinary research and action in central Africa, a “hotspot” for SBE, but it offers little specific guidance about anthropological research to be conducted. This commentary develops that research agenda. It surveys anthropological, ethnohistorical investigations in the central African forest to elaborate the socio-cultural and historical significance and practices around snakes and snakebites. It draws from south and southeast Asian and Latin American literatures to illustrate anthropological contributions to SBE research. It then outlines a Central African research agenda employing ethnobiological investigation of snake ecologies, participatory evaluations of humans-snake contacts, and interviews and participant-observation of local prevention and treatment practices and knowledge. This research will co-develop policies and practices with forest communities and leaders and regional and national authorities to reduce the burden of SBE.

•

Central African forests are a hotspot for snakebite envenomation.

•

SBE research in central Africa has not mobilized anthropological literatures or methodologies.

•

Policies to reduce SBE burden in central Africa should build on participatory research.

•

Policies to reduce SBE burden should be co-developed with local and national stakeholders.

A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study)

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.

Providing Antivenom Treatment Access to All Brazilian Amazon Indigenous Areas: 'Every Life Has Equal Value'

Snakebites are more frequent in the Brazilian Amazon than in other parts of Brazil, representing a high cost for the health system since antivenoms are only available through medical prescription from central municipal hospitals in most cases. The need for a cold chain and physicians usually restricts access to the only effective treatment of a snakebite, the antivenom. The complex topography of the rivers contributes to delays in treatment, and consequently increases the risk of severe complications, chronic sequelae and death. Thus, decentralization of antivenom treatment to primary healthcare facilities in the interior would increase access by indigenous population groups to proper healthcare. To standardize and evaluate the decentralization to low complexity indigenous healthcare units, we suggest the (i) development and validation of standardized operational procedures, (ii) training of professionals in the validated protocol in a referral health unit, (iii) implementation of the protocol in an indigenous healthcare unit, (iv) assessment of perceptions towards and acceptability of the protocol, and (v) estimation of the impact of the protocol's implementation. We expect that antivenom decentralization would shorten the time between diagnosis and treatment and, as such, improve the prognosis of snakebites. As health cosmology among indigenous populations has an important role in maintaining their way of life, the introduction of a new therapeutic strategy to their customs must take into account the beliefs of these peoples. Thus, antivenom administration would be inserted as a crucial therapeutic tool in a world of diverse social, natural and supernatural representations. The information presented here also serves as a basis to advocate for support and promotion of health policy initiatives focused on evidence-based care in snakebite management.

Articulation between health services and “indigenous medicine”: Anthropological reflections on policies and reality in Brazil

Este artículo contribuye al diálogo entre las ciencias sociales y la medicina social en América Latina a través de la exploración del pluralismo terapéutico en las políticas y servicios de salud indígena en Brasil. Revisa las investigaciones recientes en antropología, así como los conceptos y debates actuales, para examinar críticamente las políticas de salud indígena en Brasil y su concepto de “atención diferenciada”, que propone la articulación entre las prácticas oficiales de salud y las terapias indígenas. Varias contradicciones y tensiones están presentes entre la organización estructural del subsistema de salud indígena en el nivel nacional y las prácticas cotidianas de los equipos de salud en el nivel local. Guiados por la ideología hegemónica de la biomedicina, los profesionales de salud no reconocen las dinámicas y la agencia expresada en las practicas indígenas de salud.

[Sociocultural aspects of vaccination in an indigenous region]

The article analyzes interactions between the Baniwa, an indigenous group from the Alto Rio Negro region, and the multi-disciplinary healthcare teams that conduct vaccination there. Approaching from the perspectives of the anthropology of disease, studies of Rio Negro ethnology, and the theory of social representations, the study endeavors to comprehend indigenous interpretations of vaccination and the diseases these seek to prevent. Results show that biomedical ideas about vaccines are re-interpreted through Baniwa cosmology. It is concluded that the vigor of Baniwa thought encourages these indigenes to interpret biomedical action in accord with cultural features and that the clash between Baniwa outlooks and those of healthcare providers has negative repercussions on the vaccination process.

Formação técnica de agente comunitário indígena de saúde: uma experiência em construção no Rio Negro

Este relato descreve a experiência de formação técnica profissionalizante de 250 agentes comunitários indígenas de saúde vinculados ao Distrito Sanitário Especial Indígena do Rio Negro, no estado do Amazonas. A iniciativa promove a elevação da escolaridade e o respeito às especificidades culturais dos alunos. Os eixos pedagógicos 'cultura', 'território', 'política', 'cuidado', 'informação', 'educação' e 'planejamento em saúde' estruturam uma matriz curricular operacionalizada por meio do ensino pela pesquisa, multilinguismo, multidisciplinaridade e intersetorialidade, em consonância com os princípios da educação escolar indígena, da atenção diferenciada à saúde dos povos indígenas e dos referenciais curriculares de formação técnica de agente comunitário de saúde. O processo pedagógico estimula a obtenção de habilidades e competências para diagnosticar e monitorar a situação de saúde e condições de risco e vulnerabilidade das populações indígenas rionegrinas, para subsidiar ações de prevenção, promoção, tratamento e reabilitação nas diversas fases da vida e desenvolver ação política e comunitária nas lutas pela melhoria da saúde. Resultados preliminares da experiência mostram o reconhecimento e fortalecimento do trabalho dos agentes indígenas de saúde, a melhoria da qualidade do trabalho em saúde na comunidade e a maior satisfação dos líderes do movimento indígena pela ampliação do acesso à educação qualificada e diferenciada.