Indigenous people in the Amazon are frequently in pain but do not complain

A study of three indigenous communities on the Brazil-Peru border finds that 77% of the population report pain but rarely complain because they consider pain a natural process and not something abnormal.

By Elton Alisson  |  Agência FAPESP – The Sateré-Mawé indigenous people living deep in the Amazon have a coming-of-age ritual in which boys demonstrate willpower and courage by plunging one hand into a specially made straw glove (saaripé) teeming with fierce inch-long bullet ants (Paraponera clavata) and keep it there for at least 15 minutes while being repeatedly stung by the ants.

Elisabeth Ribeiro Leão, RN, PhD, is a professor at the Albert Einstein Jewish Teaching and Research Institute (IIEPAE) in São Paulo, Brazil, who studies pain management in hospital patients and vulnerable populations, such as the city’s rough sleepers. She was intrigued by the Sateré-Mawé manhood ritual and wanted to determine how these indigenous people withstood such intense pain and treated the stings in their remote Amazon village. “I imagined the inflammatory process exhibited when they removed the hand from the ritual glove and was curious about what they used to heal it,” she said.

In search of answers to these and other questions, Leão helped design the first-ever scientific study of pain management among indigenous peoples in the Amazon. The project resulted from the master’s research of Elaine Barbosa de Moraes, which was supervised by Leão, and was supported by FAPESP. A paper on the study was presented in July at the University of São Paulo’s Sixth Interdisciplinary Conference on Pain (Cindor) and will also be presented in September at the World Congress on Pain, to be held by the International Association for the Study of Pain (IASP) in Boston, MA (USA).

“It’s a well-known fact that indigenous people are able to withstand the pain caused by rituals like the bullet ant glove ordeal, but no one had ever studied how they communicate this and other kinds of pain or how it’s treated,” Leão told Agência FAPESP. “We set out to map the pain profile of these indigenous people. We investigated their experience of pain and the type of therapy they use to relieve it.”

For 23 days in June-July 2017, Leão and Moraes visited the Matis, Kanamari and Marubo communities in Javari Valley, Amazonas State, on the border with Peru and approximately 1,000 km from the state capital of Manaus.

To reach the area, which is home to the largest number of isolated indigenous people in the world, the researchers traveled by boat, carrying enough fuel for the return trip and under constant threat of theft. The journey to Atalaia do Norte, the nearest town, took 22 hours.

With the aid of interpreters, they interviewed 45 members of the three communities, asking them what kind of pain they experienced; whether it was severe, moderate or mild; and what made it worse or better.

To their surprise, 77.8% of the interviewees said they were in pain. The main type of pain was musculoskeletal (73.2%), located in the lower limbs (46.6%), back (37.9%), joints (35.5%), upper limbs (33.3%) and abdomen (24.4%).

The interviewees’ answers regarding pain intensity were mixed. While 37.8% reported acute pain, 33.3% said the pain they were experiencing was moderate or mild, and 26.7% were unable to answer the question.

“We observed that pain is highly prevalent among these indigenous people and relates closely to their lifestyle,” Leão said. “All three communities work in the fields on their crops every day, go hunting, and carry heavy loads, such as tree trunks, for long distances. This leads to musculoskeletal system overload and causes the types of pain reported, which closely resemble those experienced by farm workers.”

Pain management

The researchers also evaluated the “quality” of the pain experienced by the interviewees, who were asked to describe it themselves because no questionnaires have been validated for use with this population.

According to Leão, the McGill Pain Questionnaire (MPQ) is complex and can be hard to understand. It was developed at McGill University in Canada and includes 72 descriptors of pain quality in the sensory, affective and cognitive dimensions. Each dimension is individually scored, and a cumulative total score is also recorded.

The spontaneous words the indigenous interviewees used to describe their pain experience were very similar to the descriptors in the MPQ, which is widely used to quantify pain in hospital patients and other groups. However, the interviewees used only sensory descriptors, such as “stabbing” or “burning”.

“We found that these people didn’t describe pain in emotional terms, as we do. For example, in some situations, we may say a pain is dreadful or horrible. They don’t complain about pain,” Leão said.

None of the female interviewees who were asked to describe past experiences of pain referred to labor pains. “This shows that for them, pain is part of a natural process and isn’t seen as something abnormal,” she noted.

A possible explanation for the lack of emotional words to describe pain experience is that the culture of these indigenous people affects their pain threshold. From childhood, they are taught to manage pain, and they undergo painful rituals, such as the bullet ant ordeal, throughout their lives; consequently, their pain threshold may be higher, which may limit the range of their emotional expression with regard to pain.

Another hypothesis is that living as these indigenous people do in a subsistence economy, it makes little sense to complain about pain today because tomorrow, they must resume working the soil, hunting, and obtaining enough food for survival.

“Their survival and that of their village depend on activities that can cause pain, such as hunting, cropping, and carrying heavy loads. As a result, they end up adapting to painful situations and living with pain in order to survive,” Leão said.

Forms of treatment

In Leão’s view, the reluctance of these indigenous people to speak about pain in emotional terms does not mean that pain has no impact on the quality of their lives. More than 60% said pain interfered with their sleep and day-to-day activities, while more than 50% said it affected their relationships. “They may withdraw when they’re in pain. They don’t go out to work on that day, and some say they feel sad,” Leão recalled.

Conventional medicine – “white” medicine, according to the interviewees – was mentioned as a treatment for pain by 86.7%. This includes nonsteroidal anti-inflammatory drugs, muscle relaxants, and corticosteroids. Traditional indigenous medicine was mentioned by 80%. This includes “forest remedies” produced from herbs and other plants in accordance with each community’s tradition.

Only 22.2% considered “white medicine” effective for treating pain. “Indian medicine”, which includes faith healing, chanting, smoking, bathing, prayer, toad venom and ant stings, was considered capable of relieving pain by 64.4%, followed by “forest remedies”, which consists mainly of plant extracts (60%).

“We imagined they took a lot of medications by mouth, such as herbal infusions, but we found that actually, they make frequent use of herbal poultices made with resin from the amescla tree [Protium heptaphyllum] and annatto [Bixa orellana],” Leão said.

The researchers also interviewed 36 health workers with the Javari Valley Special Indigenous Health District, an agency of the Brazilian government that is part of the National Health System (SUS). The researchers wanted to know how these professionals dealt with pain when caring for the three communities in Javari Valley, and they found that 73% of the health workers said they did not investigate pain experience as part of their work.

According to the interviews with the 45 members of the studied indigenous communities, 37% said they self-medicated with modern drugs, such as nonsteroidal anti-inflammatory medications. “The prevalence of self-medication is probably because they don’t have appropriately trained health workers to evaluate their pain experience adequately,” Leão said.

Based on the results of the study, the researchers produced a handbook with pain management information and recommendations that included the use of both modern drugs and traditional medicine with its associated cultural practices to facilitate a dialogue between health workers and indigenous communities.

“The booklet will be translated into several indigenous languages and distributed to health professionals in Special Indigenous Health Districts as well as community leaders and volunteer health agents,” Leão said.