Building an explanatory model for snakebite envenoming care in the Brazilian Amazon from the indigenous caregivers' perspective

Abstract

Background: In the Brazilian Amazon, snakebite envenomings (SBE) disproportionately affect indigenous peoples. Communication between indigenous and biomedical health sectors in regards to SBEs has never been explored in this region. This study aims to build an explanatory model (EM) of the indigenous healthcare domain for SBE patients from the perspective of the indigenous caregivers.

Methodology/principal findings: This is a qualitative study involving in-depth interviews of eight indigenous caregivers who are representatives of the Tikuna, Kokama and Kambeba ethnic groups, in the Alto Solimões River, western Brazilian Amazon. Data analysis was carried out via deductive thematic analysis. A framework was built containing the explanations based on three explanatory model (EM) components: etiology, course of sickness, and treatment. To indigenous caregivers, snakes are enemies and present conscience and intention. Snakebites have a natural or a supernatural cause, the last being more difficult to prevent and treat. Use of ayahuasca tea is a strategy used by some caregivers to identify the underlying cause of the SBE. Severe or lethal SBEs are understood as having been triggered by sorcery. Treatment is characterized by four components: i) immediate self-care; ii) first care in the village, mostly including tobacco smoking, chants and prayers, combined with the intake of animal bile and emetic plants; iii) a stay in a hospital, to receive antivenom and other treatments; iv) care in the village after hospital discharge, which is a phase of re-establishment of well-being and reintroduction into social life, using tobacco smoking, massages and compresses to the affected limb, and teas of bitter plants. Dietary taboos and behavioral interdictions (avoiding contact with menstruating and pregnant women) prevent complications, relapses, and death, and must be performed up to three months after the snakebite. Caregivers are in favor of antivenom treatment in indigenous areas.

Conclusions/significance: There is a potential for articulation between different healthcare sectors to improve the management of SBEs in the Amazon region, and the aim is to decentralize antivenom treatment so that it occurs in indigenous health centers with the active participation of the indigenous caregivers.

Fig 1. Location of the study area, in the Special Indigenous Health Districts named Alto Solimões River, in the state of Amazonas, western Brazilian Amazon.

The location of the village of each caregiver is presented. The base used to create map is from the IBGE (Brazilian Institute of Geography and Statistics), which is freely accessible for creative use in shapefile format, in accordance with the Access to Information Law (12,527/2011) (https://geoftp.ibge.gov.br/cartas_e_mapas/bases_cartograficas_continuas/bc250/versao2019/).

Fig 2. Etiology of snakebites according the caregivers’ perspective.

A) The pajé is the only individual able to discover whether a snakebite has a natural or supernatural etiology, based on rituals including tobacco and ayahuasca. B) The natural cause of snakebites is related to attacks and bites of snakes disturbed in their natural space. An inattentive or careless person may step on a snake or get too close to it, and be attacked during their work in the forest. C) The supernatural cause of snakebites is mediated by a sorcerer’s spells. In this case, an indigenous person orders a sorcerer to arrange the death of his enemy or competitor via a snakebite envenoming.

Fig 3. Ritual performed by indigenous villagers of the Alto Solimões River area, western Brazilian Amazonia, for protection from snakebites.

A) Prayers, chants and smoking. Prayers and chants were widely cited by the indigenous caregivers as viable forms of protection, and can be done by anyone before entering the forest. “During collective prayer rituals, snakes will reunite to know what is happening in the ritual, and understand that the people will be protected (Participant 3).” However, if the villagers use prayers and songs as a joke, they will be harmed. Rituals of protection may also include smoke from the burning of dried tobacco or garlic leaves, and bee and wasp hives. In this technique, with prayers, chants and smoking, people and environments are protected against all illnesses, including SBEs. The procedure must be repeated by the indigenous caregiver from time to time to renew the protection. B) Rituals of ‘acauã’, the snake-eater falcon. The laughing falcon, also called snake hawk (acauã or águia-cobreiro, in Portuguese Herpetotheres cachinnans L.), is known for its characteristic song (changing from a joyful to a sad sound) and for feeding on snakes. Participant 4 explained this ritual. At the new moon, one of these falcons is killed, and its feathers, beak and talons are removed, burned and used to make an infusion. A spoonful of this infusion is given to a newborn baby. This baby will grow up protected from snakebites as will acquire the look of a falcon. As falcons have excellent vision for capturing snakes in the wild during a flight, snakes will not be able to resist the falcon’s gaze, and will be chased away. The imitation of the falcon song by the indigenous people and chants about these snake predators are also used for protection, for yourself and for a loved one who is going to go into the forest. The falcons are recruited to take care of this person. C) Blessings of the legs using snake simulacrums. Some vines and bush stems have features reminiscent of snake skin. These simulacrums are used to beat the legs of individuals, especially children, who are going to start carrying out activities in the forest. This blessing promotes the protection of this child throughout life. The ritual "scares the snake away (Participant 6)". "The snake does not come close to him. When the jararaca looks at the person, it runs away (Participant 8)”. Participant 8 reports that she uses this form of protection for her children and husband, and recites the imperative "Don’t bite, snake, don’t bite, snake, don’t bite, snake!", while performing the ritual. D) Amulets made from snake parts. Participant 4 explains that wearing a necklace with a bushmaster fang brings protection from evil and from the attack of snakes. The same pajé also quotes another amulet, a stone or pearl that is extracted from the inside of the boa constrictor’s head. This stone has the power to hypnotize animals, such as birds and other prey, that would be attracted to the bushmaster’s mouth. A human who carries this stone would have the same power as the serpent, and not recognized as a different one, i.e., a potential prey. Additionally, "the amulet will increase the visual force of its carrier, saying ‘you are mine’ to the prey via thought (Participant 4)”. She explains that the bracelet works as a shield, and the pajé recognizes an evil person who comes close to her.

Fig 4. Some dietary and behavioral interdictions used to prevent complications arising from snakebites.

A) Fish are the main source of protein among indigenous villagers, and the exclusion of many fish species from the diet is what characterizes the major dietary changes. Consumption of these forbidden foods by a snakebite victim, causes rotting of the affected limb, increases pain and swelling, and restarts bleeding, which can lead to limb paralysis, amputation, and even death. Fishes with a long and fusiform body (traíra—Hoplias spp.), sharp teeth (piranha–Serrasalmus rhombeus Linnaeus), or those with stingers (surubim—Pseudoplatystoma corruscans Spix & Agassiz), cannot be eaten. Tapir meat is also prohibited. Sardines (Triportheus spp.) and curimatã (Prochilodus spp.) can be eaten without any restrictions. The meat of wild birds in general are allowed. B) Contact with pregnant women is totally contraindicated for snakebites patients. Thus, it is common for indigenous people bitten by snakes to move away from the community to avoid contact with women in general, and even avoid eating a meal prepared by a pregnant woman.

Fig 5. Therapeutic itinerary of an indigenous snakebite patient from the perspective of the indigenous caregivers from the moment of the bite to rehabilitation.

Snakebite envenomings occur mostly in the forest, during fishing, hunting and forestry. At this time, self-care practices include the use of tissues of the dead snake that caused the injury. Bitten individuals require immediate transfer to the village, and rituals and plant-derived medicines and bile are part of the therapeutic arsenal. In the community, the therapeutic itinerary may be planned depending on the patient’s severity and the perception of the different actors in the village. In some cases, there may be a refusal to go to the hospital, or there are no means of transport available (1). However, transport of the patient to the hospital is done almost whenever possible (2). In the hospital, the patient will receive medical care, especially antivenom treatment, and then return to the village to continue the treatment with the indigenous caregiver in the rehabilitation phase. Dietary taboos, and sexual and social interdictions are noticed throughout this itinerary.