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EXPERIENCES IN THE AMAZON: INTERNSHIP IN INDIGENOUS
HEALTH IN THE FORMATION OF FAMILY AND COMMUNITY
DOCTOR
Lays Costa Silva1
Abstract: The text explores the formation of family and community doctors with a specic focus
on acting in rural areas and the health of the indigenous population, a frequently neglected aspect
in residency programs in large urban centers. The narrative details an internship at the Macapá
Indigenous Health Support House (Casai) and at the base hub of the Manga village, located in
Oiapoque, Amapá. During this internship, the resident doctor of the municipality of Rio de Janeiro-
RJ had the opportunity to provide medical attention directly to indigenous communities of the
villages of Amapá and northern Pará. A central aspect of the text is the importance of exchange
between scientic knowledge and traditional indigenous practices. The respect demonstrated
by the indigenous population and the credibility attributed to their beliefs were essential to the
eectiveness of the care performed. This experience oered the resident signicant learning about
person -centered medicine, allowing enriching contact with dierent cultures and traditions. These
cultures have unique visions and understandings about the process of getting sick and healing,
which contributed to a broader and more integrated understanding of health care. The internship
stressed the importance of recognizing and respecting cultural practices in medical practice.
Keywords: Medical Residency; Family and community medicine; Health of the rural population;
Health of indigenous populations.
1 Family and Community Medical, Master in Family Health and PhD student in Collective He-
alth from the State University of Rio de Janeiro
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INTRODUCTION
In the training of family and community physicians (FCM), especially in metropolises, there
is little emphasis on the work of this professional in rural areas and on the health care of the indigenous
population. The rural internship, therefore, becomes an opportunity for the resident to experience
medical practice in dierent contexts, understanding the specic needs of these populations. Caring
for indigenous health, however, presents signicant challenges, such as the cultural barriers between
the Western health system and traditional indigenous practices. These dierences make it dicult to
build trust and establish an eective dialogue between health professionals and communities, which can
compromise the quality of care (Ferreira et al, 2020). Thus, it is essential that physicians be exposed
to these contexts in order to develop an approach that is more inclusive and sensitive to the cultural
particularities of the populations served.
The Special Indigenous Health District (DSEI) is the unit responsible for the decentralized
management of the Indigenous Health Care Subsystem (SasiSUS). It presents itself as an organizational
model adapted to serve a specic region, considering its ethnic, cultural, geographic, and demographic
diversity (Brasil, 2021).
In Brazil, there are 34 DSEIs strategically distributed according to territorial criteria and
not necessarily state, taking into account the geographical distribution of indigenous communities. In
addition to the DSEIs, the health system also includes health posts, Base Centers, and Indigenous Health
Houses (CASAI) to provide adequate assistance (Brasil, 2024).
According to Ordinance No. 1,801, of November 9, 2015, CASAI is the establishment
responsible for supporting, welcoming and assisting indigenous people referred to the SUS Service
Network to carry out complementary actions of primary care and specialized care. The main objective
of the Base Care Centers, in turn, is to oer basic health care services in indigenous communities. These
centers are the rst line of assistance for the Multidisciplinary Indigenous Health Teams (EMSI), which
work directly in the villages (Brasil, 2015).
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Considering that FCM is a specialty that values the integral view of the individual, taking into
account various aspects related to health and disease, it is important to highlight that the curriculum
of residents in programs located in large metropolises, such as Rio de Janeiro, often does not include
experiences of contact with rural and indigenous health. In this context, the option for an elective
internship in rural health with an emphasis on indigenous health is not only necessary, but also becomes
a valuable opportunity.
This study aims, therefore, to share experiences of rural internships with an emphasis on
indigenous health as a way to expand the training of family and community physicians in a residency
program in a metropolis. Through the analysis of the experiences during the internship, it is intended to
highlight the importance of a culturally sensitive approach in medical practice in rural and indigenous
contexts.
EXPERIENCE REPORT
The elective internship of the resident in FCM of a residency program in the city of Rio de
Janeiro took place at the Indigenous Health Support House of Macapá (CASAI) and at the Polo base of
Aldeia Manga, in Oiapoque, both located in the state of Amapá.
To theoretically support the experience, the course “The Making of Indigenous Health” was
proposed by the Open University of SUS (UNA-SUS), with a workload of 60 hours, carried out online.
This stage of theoretical training was conceived as a preparation prior to the practical activities of the
internship, allowing the future FCM to acquire fundamental knowledge about the particularities of
indigenous health before entering the eld activities.
The practical activities lasted for 4 weeks, with a workload of 40 hours per week. During
this period, medical care was provided to the indigenous population of villages located in Amapá and
northern Pará. This direct clinical practice provided the resident with a valuable opportunity to apply
the theoretical knowledge acquired in the UNA-SUS course combined with the knowledge of FCM,
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in addition to developing practical skills and promoting a deeper understanding of the specic health
needs of these communities.
At CASAI, the daily medical evaluation of the service users was carried out, the patients’
evolution was recorded, treatments were prescribed, and complementary tests were requested and
evaluated. About 20 people were directly monitored during the period, among the more than 40 present.
Cases such as malaria, accidents by venomous animals (snakebite) and leishmaniasis stand out for their
local prevalence, oering a unique opportunity to revisit these less common themes in large urban
centers. In addition, the doctor took her knowledge acquired in residency, such as dry needling, an
eective method for the treatment of myofascial pain, which was not practiced on site. This exchange
of knowledge was benecial for patients, because, by introducing a new and dierent technique, it was
possible to expand the therapeutic options available, enriching both local practice and the care provided.
The eld activity took place at the Polo base of Aldeia Manga, in the municipality of Oiapoque
- AP. At the Polo-base, about 60 medical consultations were carried out per week for people from Aldeia
Manga and neighboring villages. Most of these consultations involved low-complexity care, including
women’s health, prenatal care, children’s health, elderly health, and infectious diseases. However, a
serious case of neurological condition was also treated, which required an urgent transfer to the capital,
ensuring adequate care for the patient. This episode highlights the importance of the presence of health
workers in remote areas, where access to specialized care is limited.
An example of the need for specialized care is the case of the Yanomami, where malaria
represents one of the greatest threats, aggravated by malnutrition and dicult access to medical care.
Logistical barriers and poor infrastructure further complicate eective disease control (Lima et al,
2022). Similarly, the high prevalence of tuberculosis among indigenous peoples is exacerbated by late
diagnosis and lack of continuity in treatment, resulting in high mortality (Possuelo, 2023). Health is a
right of every Brazilian citizen (Brasil, 1988), and the presence of health professionals in rural areas,
especially in villages, is essential to ensure that this right is ensured, regardless of geographic location.
It is important that care respects cultural specicities, ensuring greater acceptance of interventions and
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improving the quality of care.
In the internship, the so-called “itinerants” were also carried out, which consist of serving
people from more distant locations, whose access is only through the river. In these places, care was
provided in community centers and home care. In the community centers, the team organizes a temporary
space with tables, scales and basic medical materials, such as a sphygmomanometer, stethoscope,
ophthalmoscope, among others, to serve the local population. Most of the consultations focused on
chronic diseases, such as hypertension and diabetes, as well as acute complaints, such as respiratory
and gastrointestinal infections. The team also provides medicines from the Polo-base pharmacy and
donations from the doctors themselves to the population, given the diculties in accessing the local
pharmacy. In addition, we carry out home visits for people with mobility restrictions, who cannot leave
their homes. These visits are the only means of providing access to healthcare for these people, ensuring
that they receive care in their homes.
Among the activities in the indigenous territory, the opportunity to assist in a vaginal labor
that was conducted together with a midwife is also highlighted. This experiencewas of fundamental
importance, as it allowed us to learn from traditional knowledge and local practices, while applying our
medical skills collaboratively. By participating in a vaginal birth with an indigenous midwife, we are
not only providing medical care, but also integrating cultural and technical knowledge to ensure the best
possible care for the mother and baby.
REFLECTIONS ON THE EXPERIENCE
The exchange between scientic knowledge and indigenous traditions is something unique.
During the consultations, we always respect the traditional health methods and practices that are part of
the culture of these peoples. This respect, as well as the recognition of the value that these communities
attribute to their beliefs, was essential to establish a relationship of trust. In the context of FCM residency,
the idea of person-centered medicine comes to life by connecting with people from dierent cultures,
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who have their own views on getting sick and the healing process. These experiences allow for deep
learning, because when we are faced with challenges such as cultural, geographical, and logistical
barriers, we realize how important it is to build health care that not only takes into account biological
particularities, but also cultural ones.
FINAL CONSIDERATIONS
The lack of cultural adequacy in the care of indigenous peoples makes it dicult to communicate
and adhere to treatment, especially in remote areas of the Amazon. The contact with indigenous peoples
during this internship during this internship raised reections on the obstacles to access to health faced
by these peoples, the need for a better understanding of the cultural, traditional and historical aspects of
falling ill, and the importance of inserting FCM residents in situations in which they can have contact
with indigenous health, in order to improve an integrated medical, political and social education, which
should not be disconnected.
THANKS
Thanks are due to the Acari Institute and Dr. Alceu Karipuna, physician and professor at the
Federal University of Amapá, for the extraordinary work developed in the community. The dedication
and commitment shown has been truly inspiring. The opportunity oered to the physician of the FCM
Residency Program of the Municipal Health Department of Rio de Janeiro, as well as the unique and
transformative chance granted, were deeply appreciated. The experience gained has been enriching in
unexpected ways, and the positive impact is sure to be long-lasting.
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REFERENCES
FERREIRA, M. E. V.; GARNELO, L.; PONTES, A. L. M. Intercultural health: experiences and
challenges of indigenous healthcare in Brazil. Cadernos de Saúde Pública, v. 36, n. 9, p. e00197219,
2020.
BRAZIL. Ministry of Health. Special Indigenous Sanitary District. Brasília-DF, 2021. Available at:
<https://www.gov.br/saude/pt-br/composicao/sesai/estrutura/dsei#:~:text=Trata%2Dse%20de%20
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POSSUELO, L. G., et al. (2023). Tuberculosis among Indigenous peoples in Brazil: a systematic review
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