This article presents the design and methodology used in the First National Survey of Indigenous People’s Health and Nutrition conducted in Brazil and reports on general characteristics of the population and households investigated, as well as the nutrition and health profiles of indigenous women and children. The study included a total sample of 113 villages, 5,305 households, 6,692 women, and 6,128 children. The scope of the survey was similar to population-based studies previously conducted for Brazil’s non-indigenous population, such as a recent 2006 national survey of women 15–49years of age and children less than 5years of age, which had a sample size of approximately 15,000 women and 5,000 children . In addition to examining and interviewing a large number of indigenous individuals, the National Survey involved complex logistical planning in order to reach more distant and isolated communities, especially in the North and Central-West regions, many of which could only be accessed by riverboats, small airplanes, or four-wheel drive vehicles.
Considered generally, the results of the National Survey reveal marked differences between the indigenous populations in the country’s major geopolitical regions for many of the variables investigated. In part, these contrasts are associated with the regional histories of Brazil’s expanding demographic and economic frontiers and how these affected indigenous peoples. An interesting aspect of this historical process involves the regional distribution of indigenous reserves, as mentioned in the introduction to this article (Figure1). About 13% of the Brazilian territory is recognized as federal indigenous land . Of this, 98% by area is located in the Amazon (North region and the northern portion of the Central-West region) and the remaining 2% is in the other portions of the country. The indigenous reserves in the northern portion of the country tend to be much larger than those in the coastal Northeast and South/Southeast regions, which were the first to be colonized by Europeans [13, 57]. The indigenous peoples living in these regions often suffered larger territorial losses as a result of early depopulation and historical policies unfavorable to the recognition of their land rights. The colonization of the country subsequently progressed westward and northward, with encroachment of indigenous lands in the Brazilian Amazon region generally occurring more recently, often as late as recent decades when the country’s more favorable policies for recognizing indigenous lands resulted in larger indigenous reserves.
The findings of the National Survey regarding regional patterns of dietary subsistence in indigenous households are likely related to the historical contrasts in the country’s distribution of indigenous lands. As described in the Methods, most of the villages sampled were located in indigenous reserves, although this was not a selection criterion. Accordingly, in the North, the region with the greatest extension of indigenous lands, a larger proportion of indigenous households reported consuming foods obtained from cultivation and animal raising, hunting and fishing, and collecting. Foods obtained by these productive activities were reported less frequently for households in the Northeast and South/Southeast regions. These inter-regional differences in subsistence patterns may partially derive from the regional heterogeneity of access to land with the potential to support indigenous food production activities.
The distribution of materials used for roofing, walls, and flooring in indigenous houses follows a similar pattern. Whereas locally produced materials, such as wood and thatch, predominated in the North, industrialized materials, such as cement, clay tiles, and corrugated zinc/asbestos sheets, were found to be more common in the Northeast and South/Southeast.
Although the observed regional distributions of food production and house construction may partially reflect contrasting patterns of territorial access to natural resources in indigenous reserves, they also appear related to disparate socioeconomic conditions. Households in the North region not only utilize proportionally less industrialized materials in their physical construction, but also have less access to electricity and present lower socioeconomic scores, as measured by the household goods index, which was strongly influenced by electric appliances. Reiterating the pattern of interregional heterogeneity mentioned above, households in the Northeast and South/Southeast regions had the highest socioeconomic scores. Similarly, the results indicate that indigenous women in the North and Central-West regions tend to have less years of schooling than those residing in the Northeast and South/Southeast.
Effective human waste disposal is considered a key intervention in disease prevention and environmental health [58–60]. The results of the National Survey highlight major gaps in the availability of public services to indigenous villages such as basic sanitation, safe drinking water, and waste management. The most typical human waste disposal infrastructure observed in the sample was that of a simple pit latrine, with sewage rarely being collected or receiving any treatment. Even in those regions with higher socioeconomic scores, substantial proportions of interviewees reported that their household members defecate in the open, as in the South/Southeast (35.9%). Household trash management was also found to be precarious, with trash most commonly being buried, discarded, or burned in the peridomicile or elsewhere in the village. Only in the Northeast was there greater access to public garbage collection services, which reached 38.4% of households in this region.
These findings sharply contrast with the non-indigenous population in Brazil. According to the 2008 National Basic Sanitation Survey , 91.8% of households located in Brazil’s rural areas had human waste disposal infrastructure, ranging from 84.8% in the Northeast to 99.1% in the South. With respect to garbage collection, 42.4% of Brazilian rural households had access to public services, varying from 24.2% in the North to 63.0% in the South .
The profile of sanitation conditions outlined by the National Survey reveals marked inequities between indigenous and non-indigenous households in Brazil, with the indigenous population being strongly disadvantaged with regard to access to water, sanitation infrastructure, and management of solid waste. It is important to note that the results of the National Survey show that many villages, particularly in the Central-West region, have artesian well water supply systems, often installed by FUNASA. These are part of an important governmental initiative aimed at expanding the sanitation network in indigenous communities. However, despite the widespread presence of such wells, interviews with indigenous leaders during the survey fieldwork commonly revealed complaints that problems persisted with their daily functioning, such as insufficient water tank capacities, broken valves or pumps, and nonexistent connections between dug wells and installed water tanks, among others.
The epidemiological parameters evaluated for indigenous women point to the accentuated occurrence of nutrition transition in all regions of Brazil. In total, 30.3% of indigenous women were classified as overweight and 15.8% as obese. There were also important inter-regional differences, with women in the North region presenting lower prevalence rates of overweight and obesity than those in the other regions. Previous case studies from different indigenous communities in Brazil have documented similarly high prevalence rates of overweight and obesity in adults. For example, obesity was found to affect 22.2% of women among the Suruí, 24.5% among the Xavante, and 30.8% among the Guarani-Kaiowá [19, 20, 62]. Whereas the prevalence of obesity observed among indigenous women in the National Survey is comparable to that of non-indigenous Brazilian women 15–49years (16.1%), non-indigenous women have a higher prevalence of overweight (43.1%) according to the 2006 National Demography and Health Survey .
The overall prevalence rates of hypertension among indigenous women was 13.2%, with higher values in the Central-West (17.5%) and South/Southeast (17.4%). According to the results of the most recent health survey based on a representative sample of the national non-indigenous population, 24.0% of Brazilian women presented hypertension . The prevalence of anemia among non-pregnant indigenous women was also elevated, affecting approximately one in three women in the overall sample. In comparison, the prevalence of anemia among non-indigenous women in Brazil is slightly lower (29.4%) .
Case studies conducted in specific indigenous communities in Brazil since the 1990s, mainly in the North and Central-West regions, call attention to high prevalence rates of chronic undernutrition among indigenous children, characterized by linear growth deficits [21, 64–68]. The results of the National Survey confirm on a national scale that chronic undernutrition, as measured by low height-for-age, is in fact a problem of great magnitude, affecting one in four indigenous children in Brazil. In addition, approximately half of indigenous children in Brazil were found to have anemia. In contrast, the information available for non-indigenous Brazilian children in the same age group indicates lower prevalence rates of anemia (20.9%) and of low height-for-age (7.1%) [33, 55]. The nutritional profile of the overall child population in Brazil has been interpreted favorably as resulting from the recent implementation of a universal public healthcare system, as well as increased sanitation coverage and maternal education . The notable disparities in health indicators observed between non-indigenous and indigenous children in Brazil underscore that these basic services are not yet as widely distributed in Brazil’s indigenous communities as they are in the rest of the country.
The poor sanitary conditions under which the majority of Brazil’s indigenous population lives, without access to human waste management, proper disposal of garbage, and safe drinking water at home, underlies the National Survey results indicating diarrhea as an important cause of recent hospitalization for indigenous children. This situation contrasts with the national Brazilian population, for which diarrhea is no longer considered a leading cause of child hospital admission in pediatric wards, even in the poorer regions of the country. For example, in the Brazilian Northeast, where in the 1990s diarrhea represented 57% of the total causes of hospitalization for children in the general population, this rate is now less than 15% [70
]. These optimistic national results have been attributed to multiple sanitary interventions under way in Brazil for the last three decades, reduction in infant undernutrition, and widespread availability of oral rehydration therapy through the public healthcare system. According to Victora [71
], this set of measures and interventions had such a positive impact on child health in Brazil that
“…Anyone who has worked with child health in Brazil knows that these declines are real. Hospital admissions due to diarrhea have also dropped markedly in the poorest parts of the country, and it is now difficult, if not impossible, to teach our medical students the signs of acute dehydration in children, which once used to be a common finding in our outpatient and emergency services”.
Unfortunately, the results of the National Survey do not permit the conclusion that the indigenous component of the Brazilian population has equal access to these important advances. The results of this National Survey and recent regional studies confirm that diarrhea remains a leading cause of hospitalization for indigenous children, being commonly associated with acute undernutrition and dehydration [25, 26, 72].
The National Survey represents a major step in documenting the health and nutrition conditions of indigenous peoples in Brazil. Its results provide for the first time the information necessary to characterize the health and nutrition profile of indigenous peoples in Brazil on a national scale. One of its most important potential contributions is to identify the social and health inequities that continue to exist among the indigenous peoples in Brazil, as compared to the non-indigenous population, despite the country having made major public health advances in recent decades. Such differences tend to increase the gap between indigenous and non-indigenous populations in Brazil in terms of health and nutrition indicators, as has been documented previously in numerous local case studies conducted in different regions of the country.
It is important to emphasize that despite its significance for characterizing the country’s national and regional indigenous populations, the design of the National Survey does not allow characterization of health conditions for specific indigenous ethnic groups. Although desirable, doing so would be a logistical challenge of enormous scale, considering that there are more than two hundred indigenous ethnicities in Brazil, some of which have populations of less than 200 people residing in remote and inaccessible locations.