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Estado De La Investigación En Salud Sobre Pueblos Indígenas En Colombia, 1998-2018

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Estado De La Investigación En Salud Sobre Pueblos Indígenas En Colombia, 1998-2018 ESTADO DE LA INVESTIGACIÓN EN SALUD SOBRE PUEBLOS INDÍGENAS EN COLOMBIA, 1998-2018 ANDREA GUACÁN MUÑOZ, MARY LILIANA SOTELO HOYOS TUTORA: MARCELA ARRIVILLAGA RESUMEN Objetivo. Este estudio tuvo como objetivo describir el estado de la investigación en salud de los pueblos indígenas en Colombia entre 1998 y 2018. Método. Se realizó una revisión sistemática de la literatura de artículos originales de investigación que cumplieran los criterios de calidad de adecuación epistemológica, relevancia, validez y reflexividad. Resultados. Se identificaron 56 artículos que muestran que la investigación se ha realizado principalmente en cosmovisión, servicios de salud y enfoque diferencial, salud sexual y reproductiva, enfermedades infecciosas, nutrición, salud mental, enfermedades crónicas no transmisibles y salud oral; los departamentos donde se realizaron el mayor número de trabajos de investigación son Antioquia y Cauca; el pueblo indígena más abordado ha sido Embera, y metodológicamente los estudios han sido de orientación cualitativa. Conclusiones. Para los investigadores es fundamental el reconocimiento cultural, ligado a las creencias y prácticas en salud, así como los conceptos y estrategias propias de cada pueblo para la prestación de servicios con principios de equidad, inclusión, prevención y promoción de la salud. En adelante, se recomienda la articulación de los núcleos de investigación en el país, de manera que se puedan potenciar sus esfuerzos y contribuir al desarrollo de la salud de los pueblos indígenas de Colombia. Palabras clave: población indígena, salud de poblaciones indígenas, medicina tradicional. 1 ABSTRACT Objective. This study aimed to describe the state of the health research of native peoples in Colombia between1998 and 2018. Method. We conducted a systematic review of the literature of original research articles that fulfilled the criteria of quality of epistemological adequacy, relevance, validity and reflexivity. Results. We identified 56 articles that show that research has been conducted mainly in worldview, health services and differential focus, sexual and reproductive health, infectious diseases, nutrition, mental health, chronic diseases Non- contagious and oral health; The departments where the largest number of research projects were carried out are Antioquia and Cauca; The most-approached native people have been Embera, and methodologically the studies have been qualitatively oriented. Conclusions. For researchers, cultural recognition is fundamental, linked to beliefs and practices in health, as well as the concepts and strategies of each people for the provision of services with principles of equity, inclusion, prevention and health promotion. From now on, we recommend the articulation of the research nuclei in the country, so that their efforts can be strengthened and contribute to the development of the health of the indigenous peoples of Colombia. Keywords: indigenous population, health of indigenous populations, traditional medicine. 2 INTRODUCCIÓN Los pueblos indígenas se establecen como sociedades con patrones culturales que marcan gran diferencia con las prácticas culturales occidentales; asuntos como la tierra y los recursos naturales están estrechamente vinculados con su identidad, cultura, prácticas ancestrales, convivencia y medios de subsistencia. Éstos permiten preservar las costumbres naturales y mantener una organización diferente a la del estado moderno. Esta perspectiva intercultural tiene en cuenta las interrelaciones equitativas y respetuosas de las diferencias políticas, económicas, sociales, culturales, lingüísticas, de género y generacionales, establecidas en un espacio determinado entre las diferentes culturas, pueblos y etnias1, De esta manera, la interculturalidad en salud involucra distintas percepciones y prácticas que conciernen al proceso salud, enfermedad y atención, las cuales se sintetizan en estrategias y acciones de cuidado que incluyen los saberes tradicionales y la cosmovisión de los pueblos en la búsqueda de una mejor calidad de vida. Esta visión está orientada a la disminución de barreras culturales que limitan el acceso a los servicios de salud, generando un proceso de formulación de políticas de salud incluyentes en el territorio, como respuesta a reivindicaciones de pueblos indígenas y de su derecho a la identidad cultural2. Así, este enfoque posibilita la disminución de los eventos en salud pública con la prestación de servicios pertinentes, integrales, oportunos y de calidad. En el mundo hay alrededor de 370 millones de indígenas en más de 90 países. Si bien, constituyen el 5 % de la población mundial, los pueblos indígenas representan aproximadamente el 15 % de las personas que viven en pobreza extrema3, debida a la vulnerabilidad de derechos relacionados con la tierra y la propiedad, la discriminación social, y los riesgos territoriales de tipo topográfico y climático por asentarse primordialmente en áreas rurales. Además, enfrentan inequidades en salud y en educación por la no inclusión de aspectos culturales que generan barreras de acceso a estos servicios. Estas condiciones los hacen vulnerables en materia de salud pública. En Colombia, la última información disponible del censo nacional identificó 1.392.623 indígenas, que corresponden al 3,43 % de la población total, organizado en 87 pueblos y en 710 resguardos titulados. Ocupan una extensión de aproximadamente 34 millones de hectáreas, equivalentes al 29,8% del territorio nacional. Se encuentran en 27 departamentos y en 228 3 municipios; en especial en áreas rurales en resguardos legalmente constituidos, parcialidades indígenas o en territorios no delimitados por ley4. Una revisión publicada en 20185 sobre la evolución histórico-política de la salud indígena muestra cómo antes de la pre-conquista los pueblos indígenas tenían su propia forma de concebir la salud bajo premisas de naturalidad y espiritualidad. Con la conquista española arribaron nuevas enfermedades y el manejo de la salud indígena sufrió cambios radicales al intervenir los conceptos y métodos de los nuevos visitantes, sin respeto real por la cultura indígena y sus creencias. En la colonia no hubo mayores transformaciones, e históricamente, sólo hasta el siglo XX se puede identificar un cambio en cuanto a los derechos y políticas en salud para los pueblos indígenas con la Constitución de 1991, que en su artículo 1 introdujo el concepto de Estado Social de Derecho y el reconocimiento y protección de la diversidad étnica y cultural de la nación. Ese mismo año, la Ley 21 ratificó el Convenio 169/1989 de la Organización Internacional del Trabajo, donde se establece que los gobiernos deben velar por la existencia de servicios de salud adecuados a dicha población y proporcionar los medios para que dichos grupos y pueblos puedan organizarse y prestar tales servicios bajo su responsabilidad y control. Dos años más tarde, con la Ley 100 de 1993, que pretendía ofrecer garantías a los ciudadanos para la prestación de los servicios de salud y seguridad social, se explicitó la necesidad de ampliar la cobertura hasta lograr que toda la población accediera al sistema, incluidos los pueblos indígenas. A pesar de ello, siguió existiendo un vacío de implementación que no tenía en cuenta las particularidades culturales, el respeto a la autonomía, los usos y las costumbres de los pueblos indígenas en el sistema de salud; esto contribuyó a aumentar las brechas existentes, hasta que en 2001, la Ley 691 reglamentó la participación de los grupos étnicos en el Sistema General de Seguridad Social de Salud en Colombia. Con esta norma, se definieron los principios, régimen de beneficios, financiación, administración de subsidios, afiliación y movilidad en el sistema, y participación en órganos de dirección. La ley permitió la creación de Administradoras Indígenas de Salud (ARSI), hoy Entidades Promotoras de Salud Indígenas (EPSI), y la adecuación de los planes de beneficios conforme a las particularidades de estos pueblos. En 2014, un decreto del Ministerio del Interior estableció la creación de un régimen especial con el fin de poner en funcionamiento los territorios indígenas respecto a la administración de 4 sistemas propios. En 2015, la Ley Estatutaria 1751 reconoció el derecho de los pueblos indígenas a la salud integral, entendida según su propia cosmovisión; y para el año 2018, la Circular 11 del Ministerio de Salud y Protección Social emitió las directrices para construir e implementar un Sistema Indígena de Salud Propio e Intercultural (SISPI), el cual propone como eje el saber tradicional, ancestral y los planes integrales de vida, de los que se desprenden cuatro componentes: el político organizativo, la gestión y administración, la atención intercultural, y la educación, formación e investigación propia. A pesar de estos avances normativos en cuanto a la protección de los pueblos indígenas, siguen siendo comunidades vulnerables con relación a la garantía del derecho a la salud. Por ejemplo, al revisar la pirámide poblacional de mortalidad comparando población general y población indígena, se observa que el 18,63 % de la población indígena fallece entre los 0 y los 4 años de edad, mientras que en la población no indígena este porcentaje es de 4,92 %, lo que significa que la mortalidad de los niños indígenas es 2,79 veces más alta. Cabe destacar, además, que dos de las causas de mortalidad que aparecen en la población indígena no están presentes en población no indígena, como son las infecciones respiratorias agudas que representan el 5,54 % de
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