Consilience: The Journal of Sustainable Development Vol. 5, Iss. 1 (2011), Pp. 176-189 An Exploration into Community Health Charlotte Eloise Stancioff University of North Carolina – Chapel Hill cestancioff@gmail.com 1. Introduction Billowing white clouds begin to form over the horizon as the usual afternoon heavy rain shower, indicative of the rainy season in Bahia, will soon arrive. The air, heavy with moisture, is filled with the smells of fresh earth and sweet overripe fruit. The wind has begun to pick up, clattering the metal tools hanging outside Foringo’s house. We are under the shade of a giant palm, by his coffee plant in the back. He points out Quedra-pedra, “Good for urinary tract infections.” Pushing aside the coffee bush, he swiftly walks to the Quiou plant, “And this here, good for high blood pressure.” Continuing on, he quickly points out countless plants lost under the lush growth of his garden. I struggle to note each plant with their correct medicinal use as he zips through his garden, pointing out plants hidden beneath the bushes of beans and stalks of corn. He turns to me suddenly, “How can I go to the doctor when God gave us all these plants? I don’t need to. I have everything here.” Looking into his sun worn face, I see a man with years of experience and accumulated knowledge. He weaves in and out of the immense tropical plants. Each plant that he identifies for me, he touches, rubbing the leaf between his fingers. “But, the power of plants does not work if people do not believe.” When we finally reach the back fence of his garden, I thank him, explaining that I had no idea how many plants could be used to heal sicknesses, from the common cold to arthritis and paralysis. The sky has now become dark with the inescapable late afternoon rain. As I turn to go with a mango in each hand, a gift from his wife, I know it will be a wet walk home. I hear my name. “Wait, wait, have you already seen Fedegozo? It is good for anti- inflammation.” I often visited Foringo to learn of medicinal plant uses in the month that I spent living in the Nova Suiça settlement, a rural farming community 90 minutes outside of Salvador, Brazil. While studying the Brazilian public health system, Sistema Único de Saúde (SUS), for the previous three months in Salvador, professors, doctors and Ministry of Health officials constantly reminded me that SUS brings primary healthcare to isolated and historically forgotten populations. To assess the accessibility of SUS health programs for remote populations, I lived in the Nova Suiça settlement, a part of the larger social movement, the Movimento Sem Terra (MST), or the Landless Workers Movement. There, I studied the MST’s use of medicinal plants in conjunction with the SUS community health programs found at the nearby health clinic. Throughout my stay, I lived with Rosa, a member of the MST in her home on the Nova Suiça settlement. As both a member of the MST and a community health agent for the SUS health clinic, Rosa served as an ideal guide, allowing me to shadow her visits to the SUS health clinic and the settlers’ homes. By interviewing Consilience Stanicoff: Community Health settlers and health professionals, administering MST community surveys, and conducting fieldwork on the use of medicinal plants, I gained a more complete understanding of both the SUS public health programs and traditional MST medicine. 2. Background on Movimento de Trabaledores Sem Terra (MST) and Expansion in the Northeast of Brazil The darkness of the red brick house and the coolness of the simple cement floor are refreshing as I come in from the heat of the afternoon sun. She welcomes me warmly, offering me a chair and sugary coffee. The noise of chirping birds mingles with her grandchildren’s playful yells from outside. Sitting in a worn wooden chair, she says, “Now I want peace. I was a militant. I went to our marches, I fought for my land.” As one of the original Campenheiros to come to Nova Suiça from Terra Nova, a provincial city south of Salvador, Rita remembers the days of black tarp tents during the occupation. In 1995, MST settlers and new members came to an unused area of an old fazenda, or plantation, laying claim to the land. After attending an MST meeting in her own town that explained the movement and beliefs, Rita packed all that she owned, leaving behind a meager plot of land to become a part of something bigger. Without access to land or loans, rural farmers like Rita have lived a difficult life, as their small fields of manioc remain at the mercy of of cruel weather and they have seen flight to the cities lead to increased poverty. Finding few other options, Rita joined MST. For the next three years, the seventy-three families that first laid claim to land constituting the Nova Suiça MST settlement struggled against horrible rains, extreme droughts and food and water shortages. Yet, they were determined to finally reclaim the land that they felt was unfairly taken away. In 1998, the Brazilian government’s Instituto Nacional e Colonizacao e Reforma Agraria (INCRA), formally recognized the claim in Nova Suiça, granting the seventy-three families twenty-five acres each. The settlement received funds from the government for the construction of seventy-three concrete brick houses situated in a large circle around communal land, a school and a health post. Like Rita, each settler uses the land however he or she desires. The most popular crops are corn, beans, and manioc, which is then made into flour at the Casa de Farina, also located on the settlement. According to Rita, life on the settlement is what she has always wanted. She finally has no obligation to anyone, she does not worry about how she will feed her children, and she has peace of mind. According to Carneiro,“49 thousand landowners, representing only 1 percent of all landowners in Brazil, own 45 percent of all agricultural land in Brazil” (Carneiro, 2007). From centuries of discrimination came the outpouring of frustration in the early 1980’s through the form a new movement in the South of Brazil, where pre-existing peasant activism was strong. Unlike past land redistribution movements, the MST settlers saw themselves as a new type of exploited worker, one that lost land through the industrialization of agriculture and neo-liberal economic policies. Now, one of the most successful agrarian reform movements, the MST currently has 1.14 million members and 2,000 agricultural settlements. 3. Background on the Sistema Único de Saúde (SUS) According to Gesler, “Health is, to a large extent, constructed by the health care systems prevailing at any particular place and time” (Gesler, 1991). In Brazil, 178 Consilience health is described in the 1988 Brazilian Constitution as “the right of all persons and the duty of the State,” which is why health “is guaranteed by means of social and economic policies aimed at reducing the risk of illness and other hazards and at universal and equal access to all actions and services for the promotion, protection and recovery of health.” Described as state and society synergy, the subsequently created national health program, Sistema Único de Saúde (SUS), provides any person in Brazil free medical attention and treatment from the most minor treatment to the most complicated operation. Despite the two grounding principles of SUS, universality and equity, health care delivery and access still remain divided along economic lines. Juxtaposed against the rural highway, The Unidade de Saúde da Família Walter de Figuerêdo strikes a stark contrast. Clean, white and gated, it looks out of place in the middle of outstretching green fields. Constructed only two years ago as part of the fifteen-year-old Programma Saúde da Família (PSF), the family health clinic is equipped with a team consisting of one doctor, two nurses, one dentist and twenty community health agents. In the Brazilian health system, the PSF is a relatively new development in community health. Following reforms initiated by the 1988 Constitution and subsequent additions to the SUS, the ideology behind healthcare was explicitly restructured. To combat top down inefficiencies and the inability of large urban hospitals to reach isolated populations, the PSF provides primary care to remote communities while recognizing local culture and beliefs that can be overseen in crowded hospitals. Before PSF, settlers of Nova Suiça had to travel the thirty minutes by public bus to Santo Amaro, the nearest municipality. The PSF has grown tremendously since 1994, becoming one of the world’s largest primary health care systems, serving more than 85 million people. Intending to bring medical access to places previously disregarded with the PSF model, Doctor Arinaldo José Monteiro of the Unidade de Saúde da Família Walter de Figuerêdo, notes that there is still much work to be done. According to the doctor, political corruption in Brazil still continues to strip health infrastructure, and SUS fails to overcome historic disparities in wealth and status that continue to plague Brazil. Despite the shortcomings of the PSF clinic, Dr. Monteiro is adamant that the changing nature of diseases that he encounters at the PSF health clinic indicates that Brazil’s health experience is in transition. He encounters fewer tropical diseases, traditionally found in the countryside of the harsh Northeast environment, and more chronic diseases common in aging populations. He states that the benefits of PSF are found in its attention to ninety five percent of all sicknesses, providing health on three levels: promotion, prevention and treatment. The program is especially effective in rural areas because it provides health to residents rather than forcing a trip to the hospitals of large urban cities, Dr, Monteiro states. 4. Walking with Rosa: Community Health Door by Door We enter João’s home and the brick of his walls and cement floor are refreshingly cool after spending the day in the afternoon sun. Rosa and I have spent the day administering blood pressure checkups as part of her monthly checkups for the settlement through the PSF program of SUS. João gives each of us a stool to sit on and offers coffee. Having lived in the same settlement as João for the past ten years now, Rosa asks him how his family is doing. João discusses how life has been hard Consilience Stanicoff: Community Health because there has been little rain, causing his family to worry about the prospect of an unsuccessful crop this year. With a livelihood so dependent on a dry landscape and unforgiving weather, João’s worries are similar to many of the families who live on the settlement. The settlers work hard to grow enough manioc or corn to sell in the market in Santo Amaro. She takes his blood pressure, asks him if he is taking Captopril, the drug of choice for high blood pressure, and how he has been feeling. João responds in a long sigh as he reaches for all the pills that he has been given by Doctor Monteiro at the PSF clinic. He empties the multicolored pills into his hand and tries to remember when he takes each one, morning or night, after dinner or before, once a day or twice. With a clipboard and blood pressure monitor, we continue the walk from home to home to speak with settlers who have high blood pressure. This checkup shows how the PSF program attempts to bring health care to remote areas or populations that may be unable to visit the PSF clinic. Occurring monthly, the visits are intended to reach aged populations, track those with high blood pressure, provide prenatal care and administer vaccines. During these visits, Rosa liaises between the PSF health post and the families. Walking back to her home after a long day of health door-to-door visits, Rosa and I often discussed the problems encountered throughout the day. We were often invited into the homes of settlers, and offered coffee or water. Discussions of health were usually short, as the conversation mainly covered news, weather and neighborhood gossip. Many times, settlers were unaware of the health care options available at the clinic, or unwilling to go the clinic for a follow-up procedure. Rosa explained that many settlers feel uncomfortable and judged in the presence of the doctor, especially when treated for the most common diseases on the settlement, hypertension and high cholesterol. In the heat of the afternoon sun, I find Ovo sweeping her front walk. After giving me a tour of her garden, she invites me into her home for tea. According to Ovo, the heavy afternoon sun is an indication that it is time for an afternoon tea, believed to combat high blood pressure. She creates an infusion of Chu Chu leaves and hot water and sips delicately in the cool of her home. We continue chatting about the varying strengths of herbal remedies the needed cautions, and the possible cures. She explains that her knowledge of the healing properties of each plant was passed to her from her mother, who in turn learned them from Ovo’s grandmother. She doesn’t believe that the pills Dr. Monteiro gave her are working. She understands that she has high blood pressure, but is not bothered by it as she is still capable of living her life as she did before. Besides, she adds, a life spent consuming pills each day is not her opinion of health. Any symptoms she may experience, such as dizziness or shortness of breath, can all be cured by drinking her own tea, trading allopathic medicine for her family’s own practice of traditional medicine. Rosa explained that Ovo is not alone in her misuse of the Captopril pills provided by the doctor. Settlers may take it for a day or two, but soon they revert back to treatments from medicinal plants that lower blood pressure (Table 1). Although Rosa always advises settlers to follow what the doctor’s prescription, out of the eighteen people on the settlement diagnosed with high blood pressure, only one, José, is currently taking his medicine properly. According to Dr. Monteiro, his first step in treatment is providing information and education. For example, he says that for hypertension and high cholesterol, the only changes that need to be made are in some of the habits of the affected populations, including smoking, alcohol consumption, and diet. Despite his efforts, he explained that no one changes their habits, referring to the rich feiojada, a meal of black beans and meat commonly eaten in the northeast countryside of Brazil with strong cultural links to African, Portuguese and indigenous influences. He 180 Consilience suggests that his rural patients should realize that their own lifestyle choices are the causes of some ill health, such as hypertension and high blood pressure. While Dr. Monteiro claims that health education programs, such as workshops and outreach on hypertension, are present at the clinic, he had only a few pamphlets listing risk factors of hypertension to express the programs’ offerings. What he did have available was a chart outlining dosages of Captopril, the drug of choice for hypertension. I discussed the Doctor’s opinion that the lack of education and willingness to change lifestyle habits result in the poor health of rural residents who live with Rosa. According to Rosa, many rural families, including MST settlers, lack traditional schooling, but possess a rich knowledge of health that the doctor fails to understand. Rosa was quick to note that a diet of cachaça, beans and manioc flour is not a new development, but results from century old traditions of the Northeast. While diet is not the first example of misunderstandings between doctor and patient, I found that these misinterpretations had strong impacts with the rural settlers. Such rural traditions have been ingrained in a community long before the PSF clinic ever arrived outside the settlement, and they continue to serve as important manifestations of identity. 5. Discussion When I asked settlers to describe a common illness and how they would treat it, the clinic was never mentioned as a primary option for care. From my interviews, only people who needed vaccines, re-filled prescriptions or pre-natal exams went to the health clinic. This was not due to maltreatment, as only two people mentioned clear examples of being treated poorly at the clinic. Despite acknowledgement of the usefulness of the biomedical practices found at the health clinic, many settlers did not believe their health would be affected negatively or positively if they chose to use the health clinic. When asked why they did not use the PSF clinic, thirty-five households reported that the doctor lacked understanding. Many believed it was unnecessary to visit a medical clinic where their own knowledge regarding health and illness, such as the use of medicinal plants, was not appreciated. One settler mentioned that he did not visit the doctor because the doctor thought he was ignorant. To most settlers, the doctor represented the elite and city life, making him incapable of understanding life in the Brazilian countryside. Health, whether actual or perceived, is actively defined as better because of fewer environmental and social stressors. According to other thirty-four heads of households, life on the settlement is healthier without pollution, violence, and stress; furthermore, all food is naturally grown, without chemicals or pesticides, and all residents enjoyed leisure time. Rather than the absence of disease, the settlers attributed their health to the freedoms provided by their life on the settlement. An influx to Nova Suiça of previously urban residents suggests a growing upheaval in the surrounding cities. As economic policies further concentrated the geography of wealth, remaining unbalanced but influential to cut across local boundaries, a global agricultural modernization that severely disrupted the social structure and existence of the traditional family agriculturalist. The population of Nova Suiça created a different Consilience Stanicoff: Community Health definition of health than what could be found at the PSF clinic. The mental freedom gained from controlling the place in which they live brings awareness of other environmental and built factors that previously impacted a negative health experience in the city. After historically being socially excluded, settlers define health by improved social and mental well-being, instead of actual illnesses experienced. Appendix Table 1. Commonly Mentioned Medicinal Plants - Uses at MST and Known Uses Plant (scientific name) Use from Interviews Observed Use Known Uses from Studies Abacate (Persea americana) -cited once Leaf- urinary tract infections (used with folha de Cana and cabelo de milho); rheumistism (used with inhame do brejo) Tintura- grated avacodo heart and rubbed on the area Diuretic, used for muscle pains, including arthritis. Must use dry leaves- because fresh ones can cause taquicardia Alcerim (Lippia sidoides C.) -cited twice Leaf- anti-inflamatory and diuretic, in high doses is toxic and abortive Anti-inflamatory and anti-spasmodic Calmant and heart tonic Alfavaca(Ocimums gratissimum L.) -cited five Leaf- anti inflamatory and gastric ulcers -studies are being done on HIV drugs Xarope for gripe Used for digestion and coughing Alho (Hippeastrum psittacinum) -cited twice Leaf/Clove/oil- used for rheumatism, ashtma and respiratory problems, stops the formation of gases and stomach ulcers Anti-vermin, natural bug replent,anti- bactarial • reduz o colesterol e diminui a formação de placas. diabetes. throat pains-gargling. Aroeira (Myracrodruon urundeuva -cited three Used to make soap, anti- microbial Soap Anti-infection, diuretic, hypertension Inflammations of ovaries and ulcers. Ass (Verbesina macrophylla) -cited once Leaf- lower fevers Berinjela (Solanum melongena L) -cited once Fruit- juice for high cholesterol 182 Consilience Calendula (Calendula officinalis) -cited once Leaf- made into a pomade topic use of cuts, bruises, contusions, acne, mosquito bites Figure 1. Map of Bahia, Brazil http://www.v-brazil.com/tourism/bahia/map-bahia.html http://www.v-brazil.com/tourism/bahia/map-bahia.html Consilience Stanicoff: Community Health Figure 2. Photo of community health visit. Figure 3. Photo of community garden with medicinal plants 184 Consilience Figure 4. Photo of Rosa’s home in the Nova Suiça settlement. Figure 5. Photo of Rosa conducting monthly checkups. Consilience Stanicoff: Community Health Bibliography Agrovila, V. Acocap. Itaberá. Airhihenbuwa, C. (1995). Health and Culture: Beyond the Western Paradigm. London: Sage Publications. Almeida, C, et al. (200). Health Sector Reform in Brazil: A Case Study of Inequity. 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