Indigenous peoples have been one of the hardest hit of all global population groups during the COVID-19 pandemic, with morbidity and mortality rates that are considerably higher than those of majority populations across a wide range of countries in Asia, Oceania, North America and Latin America (Araujo et al. 2021). Indigenous vulnerability to SARS-CoV-2 infection has been compounded by intersecting inequalities and social determinants, including deep economic and political marginalisation. According to the World Bank (2019), although Indigenous peoples account for only 6 per cent of total global population, they include some 15 per cent of the world's extremely poor people. In countries ranging from Australia, Canada and the United States to Guatemala, Peru and Brazil, their experiences of health service provision both before and during the pandemic have been shaped by racism and other forms of discrimination and exclusion that have deep roots in colonial and post-colonial history (Burns-Pieper 2020; Cerón et al. 2016; Davy et al. 2016; Drinot 2006; Milanez 2020; Miller et al. 2020; Ostler 2020). This combination of factors has produced a situation where long before the COVID-19 pandemic struck Indigenous peoples’ health was already ‘behind everyone, everywhere’ (Stephens et al. 2005).
The trajectory of the pandemic amongst Indigenous peoples in Brazil dramatically illustrates the ways in which these intersecting drivers have intensified the vulnerability of Indigenous peoples to COVID-19. Brazil's pattern of colonial and post-colonial land expropriation has led to a concentration of the remaining areas still under Indigenous territorial control in the Amazon region, which has the poorest overall levels of access to health services. This means that the geographical distribution of Brazil's COVID-19 infection has disproportionately affected Indigenous communities, especially during the second wave driven by the highly contagious P1 variant that originated in the Amazonian city of Manaus, which became the focus of global concern when its hospitals ran out of oxygen (Branford and Borges 2021). People of Indigenous descent in urban and rural areas alike were infected in far higher numbers than can be explained by their share of the national population (Hallal et al. 2020).
Under president Jair Bolsonaro, the Brazilian government's response to the pandemic has combined inappropriate practices (including the distribution of hydroxychloroquine and the despatching of military and health service personnel to Indigenous communities without prior testing for COVID-19 infection) with systematic under-reporting of COVID-19 cases and a simultaneous effort to weaken territorial protections and encourage mining and other extractive activities on Indigenous lands, leading the national Indigenous peoples’ organisation APIB to denounce the federal government as ‘the principal vector of the pandemic’ and subsequently to bring claims of genocide (APIB 2020; Terena and Duprat 2021).
Even with this adverse political context, Brazil continues to allocate very significant levels of funding to the country's Indigenous Health Subsystem, which is responsible for providing healthcare to officially recognised Indigenous communities. The Subsystem was established on a promise that it would take a decentralised, differentiated and intercultural approach (Shankland and Athias 2007). For all the efforts of many health teams and local health service managers, the Subsystem's response to COVID-19 has dramatically failed to live up to this promise, compounding shortcomings that were already evident from poor-quality responses to previous disease outbreaks (Ferreira et al. 2019). In particular, there has been a striking failure to emphasise intercultural communication, despite the global evidence on the importance of linguistically appropriate communication and culturally respectful dialogue in key areas of COVID-19 response, from supporting testing and isolation to reducing vaccine hesitancy (Allazi 2020; Hrynick et al. 2020; Translators without Borders 2020).
In Brazil and beyond, at the local, national, regional and international levels, Indigenous peoples’ organisations have arranged emergency social and territorial protection responses to the pandemic, co-ordinated crowd-sourcing of data on infection and mortality levels, and campaigned for a set of response and recovery strategies that reflect Indigenous rights, identities, traditions and knowledges (Araujo et al. 2021). They have been supported in this effort by anthropologists working across a wide range of academic and civil society organisations via informal networks as well as institutionalised collaborations.
This article focusses on the experience of a group of Indigenous leaders and anthropologists working in the Upper Rio Negro region of the Brazilian Amazon, and attempts to draw lessons both from the response to COVID-19 and from the experience of previous outbreaks of infectious disease, in order to inform future epidemic and pandemic response strategies that can promote effective intercultural communication while also supporting concerted political action to challenge the structural factors that intensify Indigenous vulnerability to disease outbreaks. It analyses findings from ethnographic fieldwork conducted before the COVID-19 pandemic (as part of the Unequal Voices research project on accountability for health equity) and from peer-ethnographic and remote research on the response to the pandemic conducted in 2020–2021 (as part of the ‘COVID Collective’ project), as well as from the authors’ long history of engagement with health service provision in the region through their participation in initiatives led by the regional Federation of Indigenous Organisations of the Rio Negro (FOIRN), the federal government Indigenous affairs agency FUNAI and the Brazilian health rights non-governmental organisation (NGO) Associação Saúde Sem Limites (SSL).1
The Indigenous territories of the Upper Rio Negro region are inhabited by ethnic groups belonging to the Arawak, Eastern Tukano and Nadahup linguistic families, with an estimated total Indigenous population of 48,000 (if the Yanomami clans that inhabit the Cauaboris and Marauiá Rivers are also included). Within this wider region, the peoples of the Uaupés-Içana Basin maintain a particularly deep set of interrelationships including different kinship networks and types of exchange that allow this region to be characterised as one of intense and culturally homogeneous interaction (Athias 2007). The cultural system of the Indigenous peoples of the Upper Rio Negro, as described in the ethnographic and ethnological literature, includes important elements of hierarchy and linguistic differentiation. Amongst the Eastern Tukano groups, for example, this is a vital issue in social organisation and in the kinship network, as they all share the ideology of linguistic exogamy, which is prescribed by the kinship system. This system has shaped the different strategies for responding to COVID-19 adopted by different linguistic groups across different territories.
The enormous process of social transformation that this region has undergone as part of its intensifying contact with non-Indigenous society since the beginning of the last century has mainly affected the groups belonging to the Tukano and Arawak linguistic families, with their riverine village-based residential model. These larger and more populous villages suffered a greater initial impact, but the strong growth in subsequent infection levels amongst the less populated villages of the forest hinterland (predominantly inhabited by the Nadahup-speaking Hupd'äh and Yuhupdëh, classified by the Brazilian state as ‘recently contacted peoples’) reflects the socio-environmental interconnectedness of the entire region.
This interconnectedness extends to the regional urban centre of São Gabriel da Cachoeira, one of Brazil's few Indigenous-majority municipalities and the headquarters of one of the country's most important regional Indigenous movements, the Federation of Indigenous Organisations of the Rio Negro (FOIRN). Many rural Indigenous households in the region have members living temporarily or permanently in São Gabriel, having moved there to seek education, employment or access to health services. The history of the concentration of services in this urban centre was reflected in the mass movement of rural Indigenous people into town after the Brazilian government's announcement early in the COVID-19 pandemic that an ‘emergency assistance grant’ would be made available only to people who registered in person at specific banking facilities. The crowds and queues that formed outside the banks provided ample opportunities for the transmission of coronavirus infections, which were then taken back to the remoter villages by returning grant recipients.
The emergency grants policy was eventually modified after an intense mobilisation by a coalition of Indigenous leaders and anthropologists, which secured intervention from the Public Prosecutor's Office. This mobilisation drew on a long history of engagement with Indigenous health rights struggles amongst anthropologists in Brazil, which we discuss in the next section.
Anthropology, Intercultural Communication and Indigenous Health in Brazil
According to Natália Ramos (2007), health communication involves the understanding that linguistic, cultural and comprehension diversity concerning the processes of illness, therapeutic practices and healing constitute cross-cutting and fundamental dimensions for the quality of trust, bonding, listening and ethics in healthcare. Communication depends on the ability to generate trust and understanding through gestures, attentive listening, accessible words, translation and attitudes of respect and empathy. Difficulties and communication barriers may be present between the professionals themselves within the health institution and also between patients and the health professionals and the institution.
The literature in the field of the anthropology of Indigenous health emphasises the practice of intercultural communication and the need to recognise the importance of ‘intermedicality’ (Follér 2004). These approaches require recognition that both Indigenous medical knowledge and biomedicine are constituted as objects of discourse through intercultural relations and acquire meaning as they are delimited in the field of human sciences, in which they express their will to power in relation to the domain of the bodies of language and cultural life. In other words, Western medicine must also be seen as a cultural system, and not as the only science of truth. It is a system of knowledge based on empirical observation, which has been able to develop highly effective technical therapies against certain biological conditions. The main focus of biomedicine, in its strictest sense, is human biology and physiology, or pathophysiology, in which disease is seen as a universal biological process, with a view of the body that is in line with Western thought. Within an intercultural approach, we should not speak of a singular ‘Indigenous medicine’, but rather of various Indigenous medicines inserted into specific cultural systems.
Ensuring intercultural communication involves understanding the ontological differences in modes of communication and healing. For many systems of Indigenous medicine, communication involves the shaman's direct interaction with particular spirit entities associated with the condition or treatment. These entities are seen as inhabiting worlds parallel to the human one, which are similar enough to allow for interaction but distant enough that the interaction is dangerous. Placing intercultural communication at the centre of a healthcare service for Indigenous peoples would therefore require biomedically trained health team members to take into account the active participation of shamanic practitioners in people's therapeutic itineraries.
Understandings of ‘interculturality’ compatible with these insights from anthropology and other social sciences have long been present in the discourse of health policy actors in Brazil as well as in other Latin American countries, such as Chile (Pérez et al. 2016). The principle of intercultural engagement is recognised in the Brazilian Federal Constitution of 1988 and its complementary legislation as a central element of the conceptual underpinning of the Indigenous Health Subsystem, and one which should guide the organisational model of policy towards an ethnically differentiated group on the part of a state that recognises its own nature as multi-ethnic. It is this principle which guided the organisation of the Subsystem into a series of 34 Special Indigenous Health Districts (DSEIs; see Figure 1), whose coverage is designed to reflect Indigenous territorial logics and systems of inter-ethnic relations, rather than the politico-administrative boundaries of the municipalities that are responsible for primary healthcare delivery within Brazil's mainstream Unified Health System (SUS).
DSEIs in Brazil and the location of the Upper Rio Negro DSEI. Source: SESAI/Ministério da Saúde.
Citation: Anthropology in Action 29, 1; 10.3167/aia.2022.290105
The notion of ‘interculturality’ has featured in policy debates on Indigenous health in Brazil at different times since the establishment of the Subsystem in 2000, especially in the DSEI and national-level Indigenous health conferences that have been established as key policymaking forums for the Subsystem since its inception. Conference debates tend to associate the notion with traditional healing practices, which draw on concepts of health and disease that are different from those that guide Western medicine. The National Policy for Indigenous Healthcare (PNASPI) uses the term ‘articulation’ to suggest that bridges should be established, within the scope of the services provided by the Indigenous Health Subsystem, between the two medical systems. It is worth emphasising that this effectively represents the incorporation of Indigenous medicine into official Indigenous health services with the aim of achieving greater effectiveness in state healthcare strategies targeting Indigenous people.
The effort to achieve ‘articulation’ was given an initial impulse in the first decade of this millennium by the World Bank–Ministry of Health VIGISUS II project, which included an Indigenous traditional medicine component (Consórcio IDS-SSL-Cebrap 2009). This project sought, through a series of actions in the DSEIs, to support concrete activities to operationalise this ‘articulation’ proposed by the PNASPI document (Ouriques Ferreira and Osório 2007). However, the implementation of the project was abandoned as the management of the Indigenous Health Subsystem became increasingly integrated with the mainstream SUS over the course of the following decade. This process accelerated after the establishment in 2010 of the Special Secretariat of Indigenous Health (SESAI) within the Ministry of Health to take over responsibility for the Subsystem from the arm's-length agency FUNASA (the National Health Foundation), which had become the focus of Indigenous movement protests over poor service quality and was hopelessly mired in corruption allegations (Ramos and Pimentel 2021).
The principles of interculturality and differentiated care emphasised by the PNASPI remain formally in place as the basis for the work of the multidisciplinary health teams delivering primary care in the DSEIs, potentially allowing for efforts to tackle health problems to take as their parameters the ethnic community and the whole person, creating the conditions for the therapeutic use of Indigenous medicines alongside biomedical care. In practice, however, these principles have been largely abandoned by the DSEIs. Discussions of intercultural issues were included in the preparatory phase of the 6th National Conference on Indigenous Health, which was supposed to take place in 2019 but was postponed (first as a result of political tensions between Indigenous peoples’ organisations and the incoming Bolsonaro government and then as a result of the COVID-19 pandemic). However, these preparatory discussions concluded that the DSEIs were failing to make progress with regard to articulation because the non-Indigenous health professionals working in the Subsystem were unable to engage in a way that took a culturally relativist stance on their own biomedical knowledge, positioning it alongside and in dialogue with Indigenous medical knowledges. As Ramos notes:
Social and cultural aspects may present important barriers to healthcare, on the one hand because of their influence on the ways in which health and disease are perceived and on the other because of the difficulties that healthcare providers experience in dealing with populations from different cultures at the linguistic and cultural levels. The encounter with ‘cultural difference’ in healthcare settings can lead to strongly emotional reactions or attitudes of rejection on the part of health professionals, particularly when they do not have a good level of understanding of the patient's culture and training in the area of interculturality. (Ramos 2007: 156, our translation)
Anthropologists have been active participants in these debates on the need for intercultural approaches to healthcare in Brazil from the outset, speaking from their positionality as activists and practitioners (frequently with direct involvement in the delivery of government or NGO health services) and not only as academics. As Bruce Albert (1995) proposes, this involves acting from an ‘implicated’ anthropological perspective, allying scientific research and social commitment. Ethnographic work takes place over a longue durée, and reflects the engagements of both Indigenous leaders and non-Indigenous and Indigenous anthropologists within the inter-ethnic border. This consolidates an inter-ethnic communication field through which analysis is based on the socio-political network and criss-crosses discursive figures, generating communication as an inter-ethnic socio-symbolic dispositive (1995: 117).
The partnership between anthropologists and Indigenous leaders in the Upper Rio Negro region has been underpinned on the anthropologists’ side by an attitude of going beyond the dichotomy between applied and scientific research. In the region, there is a deep and long-standing engagement between FOIRN and anthropologists working for the environmental NGO Instituto Socioambiental (ISA), which has focussed on supporting territorial rights (including community mapping and demographic surveys), communication and bilingual education as well as carrying out some work on livelihoods. Anthropologists working specifically on Indigenous understandings of health and disease in the Rio Negro (particularly amongst the Hupd'äh people) have been active for many years in health policy advocacy, healthcare provision and support for FOIRN's social accountability work through the health rights NGO Associação Saúde Sem Limites (SSL). Recently, an informal group of anthropologists with a long history of working with the Hupd'äh and Yuhupdëh started to take more visible advocacy-based collective action through the Coletivo de Apoio aos Povos Yuhupdëh e Hupd'äh (CAPYH). These were the groups that came together to engage with the Rio Negro DSEI and support FOIRN in responding to the COVID-19 pandemic in 2020 and 2021. Before examining the experience of this engagement, in the next section we provide an overview of the traditional systems of Indigenous leadership and medicine and discuss how they have interacted with the processes of Indigenous movement organisation and the establishment of state health services in the Upper Rio Negro region.
Indigenous Medicine, Political leadership and the Health System in the Rio Negro
Thinking about traditional medicine amongst the Indigenous peoples of the Rio Negro must take into account the collective memory and the specificity of each ethnic group regarding their position within this ethnic and cultural context. Each of the Indigenous groups has its shamans (known as kumu and baiás), who have their own practices of preparing their peers for life, according to the mythical tradition of their group. Preparing the body for life, as they put it, means determining what the individual will be for the group and its clan, and that the ‘paths of life’ are open for them to exercise their social role or simply to live out their existence. The individual is prepared and protected following a set of clan-appropriate practices, even before birth. After birth, during life and even at death enchanted words are spoken so that the person can live well in this world. These words are recited by the Kumu (healing specialist), who must be knowledgeable about mythological narratives and seek therapeutic and protective knowledge appropriate for the different stages of a person's growth as part of a preventive practice emphasising protection from the external forces that cause the imbalance which enables the entry of diseases into the body.
This practice, according to the Indigenous knowledge-holders themselves, is differentiated by the hierarchical position existing in the current social structure amongst the various ethnic groups, in which, according to this position, traditional proper names (baséséwamé) are received that reflect hierarchical levels in the structure of the respective kinship reference group. However, this does not mean that a kumu cannot carry out preparatory, preventive and curative measures for a person who does not belong to their ethnic group of origin.
While full shamanic status is limited to very few individuals, most older men command repertoires of spells, chants, ethno-pharmacological knowledge, myths and ritual life practices. For example, Hupd'äh people differentiate shamans as käh hup ih (ayahuasca shamans),2 bi'id hup ih (spell shamans) and säw (full shamans). Incantation plays a central role in the cultural and intellectual life of the Indigenous peoples of the region. The incantations fall into two principal categories: healing (‘sickness blessing’) and protection (‘surround blessing’), and include extensive sub-genres of incantations for major life phases, such as childbirth. A counterpart to curative and protective spells consists of the incantations for causing harm.
According to traditional knowledge-holders, diseases and death amongst the Indigenous peoples of the Rio Negro are mainly caused by the decline in traditional practices and in the transmission of traditional knowledge, as well as by the disruption of the proper balance of nature promoted by ‘agents of the surrounding society’. Certain deaths and illnesses may be the result of internal order factors, where explanations are sought within the ethnic group, while others are of external origin.
In general, amongst the Indigenous peoples of the Rio Negro diseases could be etiologically classified as follows: (a) those caused and sent by others (shamans) through spells whose origin is difficult to know, the most serious of which lead to death; (b) those caused by poison prepared and mixed in drinks and food, which can be cured if the origin is known, including the identity of the person responsible; and (c) those whose causes originate in the forest, in the river or amongst beings in the air, for which cures can be achieved through specific blessings.
All healing is carried out and mediated by enchanted words, translated as ‘breath’ or ‘blessing’, in a set of traditional healing practices that range from a simple ‘recitation’ for protection to more complicated incantation practices. The use of the term ‘breath’ refers to the way the specialist repeats the formulas of enchanted words in a whisper with a gourd close to his mouth. In regional Portuguese, the term soprar (‘to blow’) is associated with shamanic practice. In these rituals, the shaman usually uses a small gourd in which water or plant material is placed for the person to ingest, or which is passed over the body, but the most important thing is not the content of the gourd but the ‘breath’ (bi'in), and its power lies in knowing how to recite the formula.
The search for an ‘articulation’ between Indigenous medical knowledges (and knowledge-holders) and the non-Indigenous health system has been a key site of collaboration between anthropologists and Indigenous leaders in the Rio Negro region. Supported by anthropologists working for SSL and other NGOs, shamanic practitioners have mobilised politically for formal recognition by the state under the aegis of the regional Indigenous movement organisation FOIRN, which in turn has drawn on the support of Indigenous knowledge-holders as a source of political legitimacy (Athias et al. 2007).
FOIRN drew heavily on this source of legitimacy in the early years after it was established in 1987 as a platform for the struggle of the region's 22 different Indigenous groups for collective territorial rights. This collective struggle was perceived as a necessary response to a military-backed plan to fragment the legally recognised Indigenous territories and open up the areas in between them to mining and other extractive activities, while bringing in non-Indigenous colonists to settle what was perceived as a ‘vulnerable frontier’ because of its proximity to areas of Colombia controlled by the Marxist FARC rebel group. FOIRN's unique federal structure drew directly on traditional practices of inter-ethnic exchange and alliance-building known as dabucuri, as well as on shared ritual reference points such as the jurupari myth cycle. Since the organisation's inception, its leadership has traditionally been drawn from amongst male members of the chiefly lineages of the hierarchically dominant groups within the different language families of the region. In recent years, however, FOIRN has elected its first female president, and power has gradually passed to a new generation of leaders, who are generally urban-based and have higher levels of formal (non-Indigenous) education.
FOIRN has developed a number of ‘traditional medicine’ projects in partnership with Indigenous community associations and anthropologists based in research institutions and NGOs. These projects have generally aimed at ‘systematising’ traditional healing practices in a way that strengthens knowledge-holders’ ability to negotiate with the non-Indigenous health authorities while preserving principles of secret and clan-specific knowledge. The most intense period of activity in this field took place after 1996, when FOIRN allied with SSL and other NGOs to take over control of the São Gabriel da Cachoeira Municipal Health Council, a statutory body responsible for the oversight of primary healthcare provision under the mainstream SUS, whose institutional framework allows for extensive decision-making power on the part of the ‘health service user representatives’ who by law must make up half the membership of the councils (Shankland and Cornwall 2007). FOIRN used the Municipal Health Council to bring Indigenous dynamics of discussions and decision-making into the debate on the organisation of health services throughout the region. This provided a model for the implementation of the Rio Negro Special Indigenous Health District (DSEI-RN) after the establishment of the Subsystem at the national level in 2000. The DSEI established its own oversight body, the District Indigenous Health Council (CONDISI), which provided a productive site for dialogue on priorities and strategies for the delivery of culturally appropriate health services.
The Subsystem's initial service delivery model was heavily based on outsourcing to NGOs, as the federal government recognised that it had a severe shortage of staff who were sufficiently trained in working interculturally to be able to deliver on the aspirations of the PNASPI, and this enabled a period of intense innovation in the search for appropriate models for delivering healthcare to remote and culturally differentiated communities (Coelho and Shankland 2011). Outsourcing allowed SSL and other NGOs allied to FOIRN to take on responsibility for the delivery of health services throughout the region, and anthropologists working for these NGOs were able to work with Indigenous leaders to put in place strategies for supporting both Indigenous medicine and community oversight (controle social) of the delivery of health services. This included convening specific events in dialogue with Indigenous traditional medicine specialists throughout the region to generate guidance for the strategies to be implemented by the DSEI-RN. These ‘traditional medicine meetings’ led to a resumption of traditional healing practices in many communities where they had been in decline, and community-based organisations from amongst FOIRN's membership came increasingly to demand that biomedical health services be developed and delivered in dialogue with traditional healing practices.
Indigenous knowledge-holders were also brought in to work alongside anthropologists and non-Indigenous health professionals in the induction training provided to new members of the DSEI's health teams. This strong emphasis on preparation for working interculturally in the training process for local health personnel was reflected in rising levels of satisfaction amongst Indigenous health service users, and combined with the strengthened provision for oversight by Indigenous leaders through the controle social system it led to a decline in the number of complaints of racist or culturally inappropriate behaviour on the part of health professionals.
However, a series of political and management challenges led the federal government to move away from the NGO-based outsourcing model. After a period of administrative instability, there was a significant recentralisation of decision-making in Brasília (initially in FUNASA and then after 2010 in SESAI), and the patchwork of smaller NGOs with their locally specific knowledges and political relations with regional Indigenous movements like FOIRN was replaced with a small number of multi-DSEI contracts awarded to large provider organisations which often lacked any experience in the regions where they were to deliver services. Under these new arrangements, the strong training provision that had been put in place by FOIRN, SSL and their partners in the traditional healers’ movement was abandoned, and inexperienced health professionals recruited from urban areas of Southern Brazil were once again deployed to remote Indigenous communities without any preparation for the challenges of working interculturally. Subsequent ethnographic research in the Uaupés region of the Rio Negro found growing complaints at the disrespectful attitude of white professionals towards Indigenous medicine, as well as a general decline in levels of interest in traditional knowledge amongst young people, who were perceived by their elders as being attracted by the ‘things of the city’ as a result of their schooling, which failed to provide them with knowledge of their traditional realities.
This situation persisted until 2016, when the DSEI's failure to respond to a severe malaria outbreak led to renewed Indigenous protests, which included demands for a resumption of efforts to ‘articulate’ Indigenous and biomedical care as part of an effort to rebuild trust between communities and health teams. These demands were ignored by the government's response, which allocated funds for new infrastructure (swiftly captured by the patronage networks of local politicians) but excluded any provision for changes in training or operational procedures that might support a more intercultural way of working.
The Rio Negro CONDISI failed to channel grassroots demands for change, as it had been captured by clientelistic political networks which were interested in avoiding scrutiny of their efforts to gain access to the still-significant budgetary resources of the DSEI. In the 2018 CONDISI elections, a weakened FOIRN – whose leadership was itself increasingly enmeshed in municipal politics – proved unable to wrest control away from the politicians (Ferreira et al. 2019). These politicians had established a dense network of connections linking the region to Brasília, where a coali = tion of evangelical religious groups and mining interests were paying increasing attention to the mineral-rich Rio Negro region. The power of these groups was to grow significantly after the election of President Bolsonaro in October 2018. In the next section, we examine how this combination of factors was to shape the strategies and opportunities for Indigenous leaders and anthropologists to influence the response to the COVID-19 pandemic in the Rio Negro.
Pandemic Responses: Top-Down Communication and Indigenous Mobilisation
In early 2020, on the eve of the arrival of COVID-19 in the Brazilian Amazon, SESAI carried out a mass dismissal of the anthropologists and education specialists who were then working in the DSEIs, adding lack of trained personnel to lack of political support as a further barrier to intercultural communication in health during the pandemic (ABA 2020). The PNASPI emphasises the role of these professionals in training health team members to work in intercultural and inter-ethnic contexts, as well as in translating materials and information and advising on strategies to foster interculturality and intermedicality in health actions. In the DSEI-RN, the anthropologist who was fired by SESAI was herself Indigenous and had played a central role in resuming the training of non-Indigenous health team members and in promoting dialogue between biomedical and Indigenous medical specialists on healing practices and the use of medicinal plants, as well as in advising on emergency actions to tackle the alarming rise in suicide cases mainly amongst the recently contacted Nadahup-speaking peoples.
In March, SESAI released its National Contingency Plan for COVID-19 Infection in Indigenous Peoples (2020). This included guidance for DSEI planning in the areas of laboratory support, infection control measures, care provision, drug supply, health surveillance and health risk communication and management. Although it referred to the PNASPI and Decree No. 4094, which established the guidelines for healthcare for Isolated and Recently Contacted Indigenous Peoples (PIIRC), it made no provision for social oversight or Indigenous participation, and contained no mention of Indigenous medicine or the role of Indigenous specialists in therapeutic itineraries.
The national strategy framed health communication as ‘emergency communication’, with no reference to intercultural or intermedical principles. This approach was reflected in the local response plan produced by the Rio Negro DSEI in April 2020, which emphasised the collection of data for the centralised SIASI reporting system, defining ‘communication flows’ as the processes through which teams input data into epidemiological spreadsheets for reporting upwards and the onward transmission to front-line health teams of the technical information and guidance periodically sent from Brasília to the DSEI. The plan also included the distribution to the Indigenous population of educational materials on COVID-19 risks and prevention that would be produced centrally by SESAI, and a requirement that ‘all communication with external media (newspapers, radios, other institutions, television, etc.) must be mediated by SESAI at the central level’ (DSEI-ARN 2020: 28).
This emphasis on central control of communication flows and the imposition of hierarchy and asymmetrical relationships through ‘risk communication’ involving messages about ‘health education’ written by SESAI and transmitted unidirectionally to Indigenous populations in a supposedly universal way was clearly embedded in a semantic context of biomedical and state meanings, intentionally disregarding intercultural and linguistic diversity. There was, however, a mention of the need for information materials to be written in ‘Indigenous language’ – but expressed in the singular, as if all the Indigenous peoples of Brazil (which has over 160 different Indigenous languages) spoke just one ‘Indigenous language’. Unsurprisingly, given this attitude and the fact that all the anthropologists and educators who could have produced culturally and linguistically appropriate materials had already been sacked by SESAI, no materials fitting this description were actually generated.
The strategy of establishing centralised state control over the flow of information (including epidemiological data), combined with the disabling of the publicly accessible web interface of the SIASI system, restricted the access that Indigenous health councils, the media and civil society were able to have to the epidemiological situations of the DSEIs. The increasingly blatant underreporting of COVID-19 infections and deaths amongst Indigenous peoples in Brazil was to become a major focus of contention, with national Indigenous peoples’ organisation APIB launching its own crowd-sourced parallel count as a direct challenge to SESAI, which systematically refused to meet requests made by researchers, universities and Indigenous organisations to gain access to epidemiological data on COVID-19.
Insisting on unidirectional control of communication based on state agents’ power/knowledge (Foucault 1989), SESAI implemented a mode of communication in health based on screening operations, aiming to restrict access to information and limit data circulation (Fiorin 2017: 161). This negates the value of difference and of contextualised understanding through desemanticisation and decontextualisation of information and epidemiological data. This emphasis on asymmetrical or one-way communication seemed to express a desire to impose authoritarian control, adopting underreporting and omission as systematic and intentional practices, with no commitment to ethics in health, to the right to life or to Indigenous rights in the broader sense.
In the Rio Negro, the CONDISI proved unable to challenge this process of centralisation despite the apparently strong provision for Indigenous voice in its remit and composition, with 28 of its 56 members being grassroots Indigenous leaders and its mandate clearly setting out a key role in the planning, inspection and monitoring of Indigenous healthcare service provision and the ensuring of an inter-institutional and intersectoral approach that respects cultural differences and community interests (CONDISI 2017). Having already lost a lot of credibility amongst grassroots Indigenous leaders as a result of its failure to articulate an effective response to the malaria outbreaks affecting the region since 2016, the CONDISI ended up responding to the COVID-19 pandemic by following government orientations rather than establishing its own agenda. The CONDISI co-ordinator played an active and visible role during the pandemic, but this consisted mainly of putting pressure on health teams to meet the targets established by SESAI, rather than of seeking out the perspectives of grassroots Indigenous leaders and using them to provide input into the response strategy.
Even before the spread of the pandemic led to restrictions on travel to and from the upriver villages where most of its Indigenous councillors live, the CONDISI had been unable to convene meetings because it lacked budgetary autonomy to pay for travel and subsistence costs and depended on increasingly rare spending authorisations from the DSEI's management. This lack of budgetary autonomy was compounded by restrictions on the CONDISI's legal autonomy, as new directives from Brasília began to curb the PNASPI's provisions for social oversight at both the DSEI and central levels (Ramos and Pimentel 2021).
By contrast, FOIRN seemed to regain during the pandemic a lot of the power and visibility that it had begun to lose in previous years, not least because of its ability to use national and international solidarity networks to mobilise funds and other resources for emergency response in the region. After an initial moment when the organisation seemed paralysed by fear, as COVID-19 began to claim the lives of many of the Indigenous elders who were the holders of collective wisdom and memory (including the memory of community strategies used to respond to previous epidemics of infectious disease), FOIRN's young urban-based leaders began to use their social media communication skills to mobilise a powerful range of supporters across the humanitarian and environmental fields, including both NGOs based in Southern Brazil such as Expedicionários da Saúde and Instituto Socioambiental and international NGOs such as Médecins Sans Frontières and Greenpeace. These partnerships soon brought a wave of material resources to the region, ranging from oxygen compressors to satellite broadband base stations, as well as donations for the parcels of food and hygiene supplies that FOIRN's women's unit provided for families seeking to self-isolate in the upriver villages as infection levels grew in the urban centre of São Gabriel.
FOIRN's leaders also established a partnership with the municipal authorities, setting aside concerns over the mayor's links with evangelical Christian networks (a major source of misinformation during the pandemic and later a key contributor to high levels of vaccine hesitancy amongst some Indigenous groups with a strong missionary presence) and his vocal support for the Bolsonaro government's policy of opening up Indigenous territories to mining companies. This partnership focussed solely on ensuring deliveries of food parcels to upriver communities, but it enabled both municipal politicians and FOIRN directors to travel extensively throughout the Rio Negro region ahead of the elections which took place both in the municipality and in the Indigenous organisation in the last quarter of 2020, undoubtedly contributing to their successful re-election campaigns.
This focus on securing material resources, directly providing social assistance and establishing alliances with local politicians, was successful in terms both of political visibility and in terms of the effective provision of material support to vulnerable Indigenous communities. However, it did nothing to reduce levels of COVID-19 infection or to build the trust and understanding between Indigenous communities and health professionals that would be required to overcome the emerging problem of vaccine hesitancy in the region. It also privileged direct service provision over FOIRN's traditional advocacy role, as the organisation chose not to seek to hold to account locally powerful actors such as the Brazilian Army (which has one of its largest bases in São Gabriel and an extensive network of air-supplied forward positions throughout the Rio Negro Indigenous Territory) for failing to deploy adequate logistical resources in support of the relief effort. This led to increasing tensions between FOIRN's leadership and the alliance of anthropologists and Indigenous leaders who had been calling for greater emphasis on political autonomy and intercultural communication in the response to COVID-19. In the final section of this article, we examine these tensions and seek to draw some conclusions for future epidemic and pandemic response efforts.
Intercultural Communication and COVID-19 Response in the Rio Negro
In addition to its social assistance role, FOIRN served as an important actor in health communication during the pandemic, maintaining daily contact with remote communities through its two-way radio network. The organisation also worked with NGO partners to produce COVID-19 prevention guidance materials in Portuguese, Nheengatú, Tukano and Baniwa, the four officially recognised languages of the municipality of São Gabriel da Cachoeira. However, these efforts were mainly directed towards larger and more accessible communities in the region, as logistical and communication difficulties made it hard to reach the remoter communities. FOIRN's strategy did not include any commitment to specific actions to support the recently contacted Hupd'äh and Yuhupdëh peoples, whose villages are mostly located in remoter forest areas, away from the main rivers.
The COVID-19 prevention guidance materials themselves were written by non-Indigenous media professionals, drawing on literature from the Ministry of Health, and literally translated into Indigenous languages without any other process of intercultural mediation of their embedded meanings or contextualisation in terms of Indigenous understandings of health and disease. This represented a missed opportunity to co-construct intercultural communication resources with grassroots leaders, community health workers and Indigenous knowledge-holders. FOIRN also avoided calling for greater recognition of the importance of traditional healers in the DSEI's pandemic response, largely avoiding the question of Indigenous medical knowledge until President Bolsonaro provoked a response from the organisation after he opportunistically defended his own claim that hydroxychloroquine was analogous to Indigenous healing practices during a visit to the region (Lima and Farias 2021).
In May 2020, a group of anthropologists and Indigenous leaders who were concerned about the absence of a coherent strategy for supporting intercultural communication in the COVID-19 response (including the authors of this article) came together to persuade FOIRN to lend its political support to a new institution, the Rio Negro Indigenous Health Forum (FSIRN). Convened by a FOIRN director and meeting virtually (via WhatsApp and Google Meet), the FSIRN successfully brought together front-line managers of the DSEI and the federal Indigenous affairs agency FUNAI with anthropologists from SSL and CAPYH and communication professionals from ISA, as well as representatives of other NGOs involved in the emergency response.
The FSIRN deliberately positioned itself as a technical advisory and discussion space, where the political positioning that marked the meetings of the municipal Crisis Committee (the formal space in which decisions on lockdowns and other response measures were made) could be put to one side as participants engaged in dialogue on effective and culturally appropriate responses to the complex challenges of the pandemic. It also helped to secure laboratory supplies (rapid and PCR test kits) for the DSEI, and served as a platform for discussing the allocation of emergency funding secured through participants’ international networks. However, the emphasis was clearly on prioritisation and not self-promotion – as when a donation secured from the United Kingdom by SSL was channelled through the ISA and Expedicionários da Saúde instead of being used to promote SSL's own ‘brand’.
Initially, the FSIRN's main focus was on ensuring that the pandemic response took into account the social and cultural specificities of the recently contacted Hupd'äh, Yuhupdëh, Dâw and Nadëb peoples, since the DSEI was failing to comply with Decree No. 4094, which set out the national guidelines on the provision of specific PIIRC (Isolated and Recently Contacted Indigenous Peoples) health services. This determines that PIIRC should be treated as at-risk groups requiring specially adapted care strategies, due to their differentiated forms of social organisation, specific livelihood strategies and lack of full mastery of the behavioural and communication codes of non-Indigenous society, as well as their high levels of epidemiological vulnerability (Rodrigues 2014). One of the most important initial actions of the FSIRN was to draw up and agree on technical reference documents to support the DSEI's efforts to comply with this specific requirement, alongside an ethical protocol for consultation and consent for COVID-19 treatment adherence (highlighting the need to respect family decisions and to respect the therapeutic itineraries in Indigenous medicines) and general guidance designed to improve the cultural appropriateness of the emergency response.
The FSIRN also promoted an important series of discussions on the need to improve communication infrastructure alongside the quality of intercultural communication, which led to a survey that identified gaps in the two-way radio network in order to inform the location of new equipment that was being purchased with international donations. Three of its members (the authors of this article) subsequently collaborated on a project to combine methodological support for intercultural communication with the development of a digital platform for transparent and multi-directional information flow, designed to be integrated with both FOIRN's communication network and the formal CONDISI social accountability structure.3
The FSIRN also recommended that the DSEI should support the strategy of ‘health barriers’ that was being used by several Indigenous communities to isolate their territories from the risk of infection being transmitted by visitors from urban areas. This was to lead to conflict with both FOIRN and the municipality, and ultimately to the suspension of the Forum's activities.
As noted above, FOIRN's leaders and the municipal politicians (who enjoyed increasingly significant influence over the DSEI) had a shared interest in being able to travel freely around the Indigenous territories of the Rio Negro in the run-up to the elections in late 2020. After the municipal Crisis Committee relaxed the lockdown measures in São Gabriel da Cachoeira in July and August 2020, the FSIRN's support for ‘health barriers’ was clearly in tension with this desire for an electorally advantageous physical presence in the Indigenous communities. The Forum became a space where inconvenient questions might be asked of leaders who were keen to preserve an international image that emphasised fighting for the protection of Indigenous communities from COVID-19 (an essential ingredient in the continued flow of material support for the emergency relief effort) rather than exposing them to infection while trying to secure electoral advantage.
FOIRN's leaders chose to prioritise engagement with the municipality and other actors via the Crisis Committee, and declined to formalise the status of the FSIRN as a permanent advisory institution. Along with the reduced frequency of meetings as leaders were increasingly away on visits to the communities, this meant that the FSIRN's technical recommendations were only partially incorporated into the implementation of the DSEI's emergency plan. Other Indigenous leaders who questioned the priorities of the FOIRN's leadership continued to engage with the anthropologists who had helped FOIRN to establish the FSIRN, but this engagement took place through a combination of informal networks and NGO projects rather than through a multiinstitutional discussion space, and as political tensions grew between the national Indigenous peoples’ movement and the Bolsonaro government they found themselves less and less able to maintain contact with the managers from the DSEI and FUNAI who had participated in the FSIRN.
Ultimately, the inter-ethnic effort of socio-symbolic communication had to accommodate the tension between maintaining local party political alliances by undermining health prevention measures, even where this risked an increase in cases and deaths, and the ethical commitment to contain COVID-19 and save lives, in order to maintain the political basis for the continued flow of resources from national and international solidarity networks. This experience has taught us that while alliances between ethno-political leaders, local politicians and health managers can help to drive dynamic local responses to an emergency such as COVID-19, these alliances will prioritise simple, visible, materially-based – and sometimes counterproductive – measures, and there are clear limits on the ability of anthropologists and Indigenous leaders who are more concerned with ethical, technical and cultural appropriateness than political visibility to guide the response in a more intercultural direction.
This, in turn, has implications for the practice of what Bruce Albert (1995) terms ‘implicated anthropology’, where this is predicated on solidarity with the political strategies of Indigenous movement organisations. Prioritising intercultural communication in emergency response means engaging with complexity and alterity, and actively seeking out knowledges and identities that are subaltern and often stigmatised. Time, space and support are needed to build the trust and mutual understanding that allow intercultural communication to succeed. Securing these conditions necessarily also means finding a combination of political alliances and incentives that can overcome the forces that push so powerfully in the opposite direction.
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Notes
The Unequal Voices research project was funded by the ESRC-DFID Joint Fund for Poverty Alleviation Research (Grant No. ES/N014758/1), and the COVID Collective project is funded by UK aid from the Foreign, Commonwealth and Development Office (FCDO). For more information, see https://www.ids.ac.uk/projects/unequal-voices-the-politics-of-accountability-for-equity-in-health-systems and https://www.covid-collective.net.
Ayahuasca is a psychoactive drink whose ingredients include the vine species Banisteriopsis caapi, which is widely used in shamanic practices throughout the Western Amazon.
This platform, which includes the findings from the action research on Indigenous perceptions of the government's COVID-19 response that was conducted by an Indigenous field team led by one of the authors of this article (D. Barreto) in 2021, can be viewed here: https://ssl.timby.org.