Introduction

The human life process is understood as an expression of the life-health-disease-care-death continuum, which reflects the well-being and good living, or lack thereof, of people (1). Colombian health physician Saúl Franco created the human life process in the 1990s as a useful analytical category for collective health (2). It was used in research, initially from nursing in the care processes of human beings and collective care (3,4). It has since been used in public health, social medicine, and Latin American collective health, centered on social determination and the social determinants of health, child rearing in marginal conditions, and education in and for health, among others (5,6,7,8,9,10).

Few public health publications in Colombia have used the paradigm of the human life process to analyze the indigenous healthcare situation. However, some mention it occasionally in relation to the millennium’s historical balances related to indigenous peoples, to suicide in indigenous peoples, and to exploring the possibilities of epistemological interaction of indigenous knowledge and the ethical–political discourse of collective health (1,11,12,13). Few works have been conducted on the subject, and fewer still, those that use narrative analysis starting from their own perspectives. Currently, Colombia has 1,905,617 people belonging to 115 indigenous peoples, 70 of which are at risk of physical and cultural extinction (14). Understanding the absence of specific and culturally appropriate analysis and intervention for the problems that afflict the human group of indigenous people in the country, and even in the world, is essential toward opening up to inter-culturality in health, from training schools to the health field (13,15).

In general, the deep roots between indigenous peoples and their territories and customs are evident. However, indigenous people are migrating from their territories because of the need to escape violence, climate change, land dispossession, and social disadvantages. The limited access to education, healthcare, and employment opportunities encourages the mobilization of these people to cities that can provide these services (16). Regarding undergraduate university education, migrant indigenous students report sociocultural changes and effects after entering university (17). Their contribution to inter-culturality in the framework of university processes has also been verified as has their contribution to the potential decolonization of higher education and the resulting professional practices that hold the promise of making their knowledge, experiences, and ways of life visible (18,19).

Understanding narratives as constructions of language that, from an interpersonal space, account for the social and cultural context wherein they occur, we seek to access concepts about the indigenous human life process from quintessential intercultural agents, such as indigenous university students in the city (18). The narrative approach allows people to conceptualize and communicate their own experiences and representations and put in dialog their experiences in relation to those of others, which, by interpreting them, makes it possible to solve the various problems addressed (20,21).

Within the framework of the study “Human Life Process in Indigenous Peoples of Colombia” and with the purpose of contributing to the improvement of the living conditions of indigenous peoples from the intercultural understanding of their life processes, the objective was to reveal the narratives about the human life process in indigenous peoples of Colombia constructed by migrant indigenous university students in Bogotá.

Materials and methods

This qualitative research work with a narrative approach, from the perspective of Bolívar, is based on the hermeneutic–interpretative paradigm (20,21,22). The narrative analysis of narratives was applied to a set of interviews focused on topics related to the human life process, conducted with eight key informants affiliated with Cabildo Indígena Universitario in Bogotá (23). The sample was configured by convenience from those who agreed to participate after a wide dissemination of the call among indigenous university students affiliated with this indigenous self-government entity. Given that the project was carried out during the lockdown due to the covid-19 pandemic, the interviews were held virtually. They were video-recorded, transcribed line-by-line, and subsequently analyzed manually using matrices to organize the information obtained on the topics addressed in the human life process in the interviewees’ indigenous towns of origin centered on the following deductive thematic categories: life, health, illness, care, and death. Space was also left for emerging thematic categories and subcategories, which are presented in the results section. After reading and rereading the organized material, its content was analyzed under the aforementioned categories. Later on, relationships between them were sought out. Differences in this regard were resolved by consensus among the research team. The results are presented with the stories of the participants intertwined, organized as described above, with those emerged from the researchers’ analytical process on the object of study (22). Excel was used to develop matrices to organize the narrative information under each category.

The triangulation of observers and perspectives on the topic, gathered from the different participants, together with generative self-reference, were used as criteria to ensure the validity of the research (22,24,25). The triangulation of observers was ensured through the participation of more than one person in the analysis and the interdisciplinary configuration of the team that participated in it; the triangulation of perspectives on the topic was sought out through the observation of the same phenomenon from the perspectives of people belonging to different indigenous peoples. It must be clarified that we did not seek to contrast narratives between people belonging to different groups but rather to complement them in order to draw a general picture of the human life process from what was narrated by indigenous students. The generative self-reference was implemented through reflective conversational exercises among researchers, wherein a critical posture was maintained and collectively fed back on all the theoretical, methodological, and ethical decisions made throughout the research process.

The ethical principles for medical research in human beings from the Declaration of Helsinki (2013) were followed, as was Resolution 8430 of 1993, which establishes scientific, technical, and administrative standards for health research in Colombia (26). It was classified as bearing minimal risk. The project was endorsed by the Ethics Committee of the Faculty of Medicine of the Universidad Nacional de Colombia in Act n.º 014-141/11-09-2020. Informed consent was requested from the participants, and from the authorities of the University Indigenous Council in Bogotá (ciub), of which they are a part. Confidentiality was guaranteed by identifying the narratives of each participant with alphanumeric codes that only denoted interview order, gender (F, female; M, male), and town of origin. The leading student of the ciub participated as a co-researcher of the project, from the design phase to the construction of the research article with results, of which he is a co-author; the research results were returned to the Cabildo through him.

Results

The eight people interviewed correspond to indigenous undergraduate university students, in public (six people) and private (two people) universities in Bogotá, with an age range between 18 and 40 years. Five students participated from health professions, three from social sciences, and one from law. They consisted of six women and two men. The oldest person, a woman, occupied the role of traditional doctor in her community. As for the indigenous group of origin, two were Kamentsá, two Pastos, and the rest of the participants from the Pijao, Kankuamo, Nasa, and Misak groups, respectively.

Narratives about life

Around the theme of life, the people interviewed offered a series of narratives linked to the possibilities of enjoying good living under the principles of resistance, unity, culture, territory, and autonomy. Each narrative was constituted in an emerging analytical subcategory that cannot be read as linear and strict subcategories but rather as being related to one other as they share themes and allow for a narrative harmony to be generated through language.

Resistance was exemplified in the narratives, especially from its components of resistance from the cultural point of view. A fundamental subcategory for maintaining one’s own culture in general, including the worldview of each group, their mother tongue, and the ancestral knowledge that allows them to survive is their own education linked to the territory. “Talks are arranged with children and young people in the community to follow the culture. They teach us the worldview; they also try to encourage the language a lot” (E3FNase). “The mother tongue of our people is something important because each word contains great meaning” (E1FKamentsá).

This self-education shapes the sense of historicity and belonging for the new generations as it implies the possibility of a future for peoples and cultures at risk of extinction. “They instill in us the spirit of fighting for our heritage, for our people, for all the history we have, and for what we have had to go through” (E3FNase). “It’s important to recover what is ours. We have to be persistent to survive, resistant… because most groups are already in the throes of extinction” (E1FKamentsá).

Unity within the community is essential for survival. It is sustained in a ritual that exalts cooperation, reciprocity, and integrality with respect to place of origin. “The family is conformed by the whole town, you cannot speak as a part of it, but as the community as a whole” (E1FKamentá). From childhood, they are trained to be part of the government of their town, from different roles, and under the guidelines of ancestral thought, defending the territory and their own ways of life. In addition, within the framework of a positive assessment of older adults, many of their own leaders belong to that age range: “Older people are highly respected and many of them are governors and community leaders” (E3FNase).

The territory, as a space of possibility to enjoy a dignified life, occupied an important place in the narratives obtained. From birth, indigenous people link their lives with that of their territory of origin through ancestral practices that guarantee rootedness and harmony. The form of the rituals reported varied from one group to another, but all the interlocutors emphasized the sense of continuity between the new human life and the land wherein it emerges, which is even perceived as a family member:

“When a person is born, a rope is tied to their hand... it is the first sign that they are part of the territory” (E6FKamentá). “The placenta is taken and buried in the tulpa, which is like the stove where it is cooked. And so, the child is rooted to the earth; after about 30 or 60 days, the umbilicus is buried. This is considered something very sacred… it symbolizes the spiritual roots in the territory” (E7FPastos). “The placenta is collected, put into ashes, and returned to the earth, thanking the grandmother for taking care of that baby” (E8FPijao).

The connection with land and nature is the facilitator of good living, and it is stimulated from one’s self-education in many ways, including what is related to the intergenerational transmission of knowledge that ensures food sovereignty, as a manifestation of autonomy in everyday life: “They taught us to grow what is typical here… beans, squash, and how to take care of them. They taught us when it should and should not be grown. The chagra is a space of knowledge” (E1Fkamentá).

Health narratives

With regard to health, a series of subcategories emerged to be considered: harmony, balance, and the relationship of unity with life, territory, and health.

Harmony was a recurring theme in narratives on indigenous health. “Harmony is related to what we are immersed in” (E2MMisak). “Because health is not only the absence of disease but also being one [with] the environment” (E8FPijao). “The concept encompasses nature” (E1FKamentá).

Intrinsically, such harmony is expressed as integrality between components of the human being, together with the territory and its other beings. “Body and health… soul… something that is inclusive” (E4MPastos). “Then if your body is fine, your spirit can be fine too. And if your spirit is okay, then your body is too” (E5FKankuamo). “And you are incorporating this into your life. One of the plants that we use the most is yagé, and we use it to achieve harmony of the spirit” (E6FKamentsá).

Complementing the above, balance is understood as the equanimity and good sense of acts and judgments. “The path is important, that path traveled... to be happy... This society has made people [want to be] above others, and everything is a competition… it is more important to be humans… You can contribute and let others contribute in a positive way” (E8FPijao). “You have to have a balance to maintain health” (E4MPastos).

The understanding of health from the indigenous point of view agrees with the unit attached to life, within the community and within the framework of self-determination:

The concept of the health of bodies is closely related to the home because the bodies belong to the home… and then something that is very important for us is community circles. So there are three great circles. There is the circle of the home, the circle of the community, and the largest is the circle of governability—of the Cabildo. (E6FKamentsá)

Health is not possible without the framework of territory existence, understood as a living space with balance and harmony:

Back to the roots. For grandparents, the important thing is that one learns to feed themselves. So, pick up a hoe or pick up a machete and see what you can get, plantain and yucca... good living is being able to relate well with others, to be able to cultivate... to have good practices... to think about water... to live in community, that everyone contributes their grain of land. That’s what being healthy is about. (E8FPijao)

Narratives about disease

Narratives on aspects related to disease were plentiful, covering the indigenous cultural constructions on etiology, therapeutics, diagnostic processes, and traditional agents in charge of such matters in the different towns to which the interviewees belong.

Regarding etiology, disease was predominantly described as energetic or spiritual imbalance or disharmony, which must be rebalanced or harmonized from medicine itself through a therapeutic arsenal that includes herbal medicine, manual practices, traditional ritual processes that, on many occasions, are hybridized with mestizo religiosity and diets based on products traditionally obtained in the territory itself. Preserving ancestral customs is considered protective against disease. “When there is disease, you lose your balance, just to give you an understanding of how we see disease” (E8FPijao).

The narratives analyzed gave an account of how the etiologies of disease from the indigenous perspective transcend the limits of the human body, also finding themselves in the spiritual, relational, and territorial spheres. Violating the norms of traditional life causes disease. “So when there is some kind of disease or some evil, it has a great deal to do with [altering] respect and living in nature” (E2MMisak). Contact with the Western world weakens the indigenous aspect and predisposes you to get sick. “The soul is weak when it loses its innocence and is filled with the Western and corrupted world [sic]... another problem [that makes someone sick] could be violence [alluding to the armed conflict]” (E4MPastos).

Regarding therapeutics, nutritional and herbal practices are of common use in the community and the family, being taught by the elders and ubiquitously used by community members (without excluding the fact that there are also experts in them). “The chagra allows us to grow crops… so that we can eat. Medicinal plants are also grown there, so if something hurts, like the stomach or something, well, there it is” (E1FKamentsá). “We use plants a lot… you have to know which plants to use for what situations… for certain illnesses, you prepare some water… or to balance energies, you can use other particular plants” (E6FKamentsá). “There are hot and cold plants. And you have to find the balance” (E8FPijao).

Sacred plants, such as yagé and tobacco, are some therapeutic resources that many of these traditional doctors use with ritual meaning to achieve spiritual cleansing and harmonization or balancing of energies. “Rituals are made with yagé, also known as ayahuasca” (E3FNase).

Multiple practices to determine a diagnosis are transmitted to the appropriate people for them to be traditional health agents. These vary in different towns although they share the common feature of seeking trust and a strong therapeutic partnership with the person seeking help, basing the possibility of finding a good diagnosis on overall experience. “Most of the taitas are not young and have gone through the experience of being prepared to be traditional doctors since they were children, for Tatsembua. That builds more confidence in them, seeing that they are older” (E1FKamentsá).

In addition to diagnosing entities culturally established by each group, such as descuaje, supai, bad wind, and many more, traditional medical agents also learn to identify when a person is sick because of entities acquired in contact with the mestizo world, and when these are “serious” and need referral to biomedical services in search of complementarity. “And when things are serious, they seek another type of medicine, which is hospital medicine, doctors” (E7FPastos).

Regarding the traditional agents in charge of therapeutic matters, men and women play different expert roles in indigenous peoples, around traditional medicine. “The wise ones… are the people in charge of establishing a relationship and harmonizing” (E2MMisak). “I work as an ancestral doctor, like Mohana” (E8FPijao).

Training in traditional health agent follows patterns of intergenerational transmission of ancestral knowledge, which are in danger of disappearing. “Midwives also have a long process that is transmitted between women: from mother to daughter. Before there were many, now I haven’t seen them in numbers… [also] in the past, there were more wise ones and [they treated] any joint pain or... a cut” (E1FKamentsá).

It is necessary to comply with basic conditions to be instructed in traditional indigenous medicine. “And one is born... it’s like a gift. Grandfathers and grandmothers nurture them” (E8FPijao).

Narratives about death

The following analytical subcategories emerged around death: one’s own rituality and mestizo; modes of death; and etiologies or meanings of death.

Death emerges from the indigenous narratives analyzed as a continuity of life, returning to the origin. “Death is like going back to the meeting place, like another life to come back to earth and transcend” (E1FKamentsá). “We believe that the person transcends in their spiritual plane” (E6FKamentá). “We talk about another dimension… not heaven or hell … another dimension where [those who die in this one] exist” (E2MMisak).

As preparation for this new existence, the narratives showed a community ritual around death wherein the person who departs is surrounded with the daily elements they would require for this new life. “It’s worn in a ritual when you die, the ancestors wore it as a new traditional costume... the dead are prepared, dressed, and veiled” (E1FKamentsá). “The day of the wake, there is sharing with the entire community that knew that person, they make private meals… with what the person liked” (E6FKamentsá).

Part of the ritual is remembering the person leaving with joy, thus accompanying them with good spirits on their way to the new plane of existence. “When a person dies, we should not say goodbye with sadness… a tribute is paid to them, a feast is held, and they are remembered with joy… for around three days” (E7FPastos). “Dancing and music are part of all moments of life [talking about funerary rituals]” (E2MMisak). “The dead are remembered, and offerings are made, the whole community and the family of the person who died gather… a plate is put out, and space is left for the person [who died], it is shared as if they were there at the dinner table and they are remembered” (E3FNase).

However, contact with the mestizo religions has changed some ancestral burial customs, especially in the towns that suffered processes of coloniality and have only recently reaffirmed their identity as indigenous. “There is a very strong influence of Catholicism, so the practices at the time of death... are clearly Catholic” (E4MPastos).

The people interviewed attributed various etiologies to death according to their modes. In death by one’s own hand, a spiritual etiology was mentioned, unlike in other modes of death, where a somatic etiology was mentioned. “We believe that suicide is something that has a spiritual component” (E6FKamentá). Both types of death were frequently related to the loss of their own ways of life and thinking, which disharmonize the indigenous. Preference for traditional management of ongoing suicidal behavior was brought up. “We tend to work with traditional medicine, rather than with psychology... we look to the taita, the wise ones, and the wisdom of the elders... so that the person becomes stronger and avoid those emotions and those thoughts… We believe that there is a disharmony and it is about harmonizing” (E7FPastos).

Narratives about care

Regarding the category of care, the following analytical subcategories emerged: traditional self-care, biomedical care, and intercultural care.

In addition to the practices for dealing with illness carried out by traditional medical agents recognized in each community, all the community members carry out daily practices to care for their health and life. These practices vary from town to town and have as their central organizer the stages of the human life cycle, transcending a single person’s individuality.

The care and conservation of harmony in the community has its own collective practices, including the celebration of carnivals, among others. “[We celebrate] the Betsknate, which is like reconciliation. And what’s important is to live well among each other” (E1FKamentá).

In addition, the territory of origin played an important role in community care practices. “Caring for nature is part of health… it gives us food, it gives us security, it gives us water from the earth, it gives us everything. All this isn’t ours... it’s from where we live.”

The indigenous woman is a recipient of community care throughout her life, and during key moments, such as her first menstrual period, pregnancy, childbirth, and postpartum, as an important agent for intergenerational transmission and provision of such care to other people in the community, from and to the territory itself:

From birth, indigenous women get used to providing specific care that is manifested in food, what to eat, body care, protection from the cold. There are some foods that are restricted. The spiritual aspect is also important to maintain harmony. And this harmony also has a lot to do with community life, and it is both physical and spiritual health... to balance the physical and spiritual... they maintain a diet with vegetables, greens, items derived from the chagra, and this is implicit in health. (E7FPastos)

In the case of midwifery, it is like an accompaniment from long before conception. And there is a focus on spiritual accompaniment so that the mother is strengthened for when the baby is born. Many plants are used, such as calendula, and therapy with hot and cold elements is widely used. (E5FKankuamo)

Care in adulthood, toward a conjugal couple, seeks to facilitate the health of new beings gestated, from the health of their parents. “In marriage, there are also treatments that are done not only by traditional doctors but also by something like the groomsmen. And you have to focus on the mental health of the couple” (E2MMisak). As for newborns, the chumbe is very important and very traditional. It’s a kind of fabric, long... like a belt... it’s important so that the baby’s umbilical cord doesn’t come out, and then it won’t have bad posture either” (E3FNase).

There are specific practices to facilitate maintaining child health. “The burial of the placenta, which is like sowing in our Pachamama so that thinking flourishes within the child… at five years old, it is the haircut for men” (E1FKamentsá). “Deer lard or bear lard... is smeared on the child before they start to walk, on their knees... they smear it on their little legs so that they learn to walk fast, and when they walk, they also stand tall” (E2MMisak).

The indigenous narratives analyzed recognize the potential derived from organizing knowledge around indigenous well-being today, noting a general mistrust and highlighting the barrier to biomedicine access. “We should think more about intercultural health, exchanging knowledge, adapting… for example, midwives not only need to know a bit about biomedicine to provide treatment but also need to apply everything they already know from their ancestral knowledge” (E1FKamentá).

The indigenous human life process from indigenous university students

The narrative about the indigenous human life process, expressed by indigenous university students in Bogotá, showed how, for this group, human life—anchored in the territory of origin—is the key organizing concept of all understandings of health, illness, death, and care. Their territory is not only a place but also the indissoluble relational complex generated between the earth and those that inhabit it, including humans. Thus, person, community, and land are drawn as an interconnected unit configuring the territory; the indigenous woman occupies a central place in the framework of these relationships, understood from a protective role of life.

Harmony between the aforementioned components, within the framework of following traditional indigenous mandates, results in maintaining life and enjoying health. On the other hand, breaking such cultural codes disharmonizes relationships, generating disease.

Disease transcends the biomedical view centered on the individual body and covers the disturbances in the relationship within the territory–community–person unity, with its effects. Hence, the etiologies described for disease from the indigenous point of view are broader than those accepted from the biomedical framework are. Proper interventions to manage disease seek to recompose the altered relationships between the members of the land–community–person territorial unit, just as they do within the person, between their bodily and spiritual components. To this end, a wide-ranging therapeutic arsenal is used, where spirituality and herbalism occupy an important, but not unique, place. Care is the fulcrum, centered on which all the inhabitants of a territory have an essential role.

Unlike the dominant mestizo views, death did not appear in the narratives as the opposite of life but in continuity with it as an entrance to life in another dimension, as a return to earth, which carries the meaning of generator and sustainer of life. Regardless of whether death occurs after disease, by one’s own hand, or in other ways, it contained a harmonizing meaning of the being that dies with the territory of origin and within the framework of their vitality.

So, differentiating one’s health concept from those of others that propose health as the opposite of disease from the narrative view obtained regarding the indigenous human life process, there is rather a relational triad. This triad is organized by harmony—between life, health, and death—when the cultural mandates of each people are followed as opposed to the emergence of another triad, this one of disharmony with the integration of disease as a disturbance, which arises when cultural norms are broken, precipitating health and possibly precipitating death. However, with disease and its disharmonious triad (health–disease–death), there is an option to return to the harmonic triad of the indigenous human life process (life, health, death). This can be done both through interventions that reharmonize and allow for a return at the moment of health within the process, carried out by health agents and the community in general, as well as through death itself, which returns to the moment of restarting life.

Discussion

The two triads of the indigenous human life process, described and identified in this research work, differ from the usual epidemiological formulations on the ecological triad based on the Natural History of Disease (hne, by its Spanish acronym) and recognize territorialized and historicized frameworks of relationships, inclusive of nature and shaped by culture. This enables existence in harmony as a prerequisite for health and life, and the disturbance can then be channeled back into harmony through intervention on disease or death.

On the other hand, the ecological triad—natural history of the disease from Leavell and Clark —talks about the existence of a host, an agent, and an environment, from whose relationships, mediated by equilibrium and not by harmony, disease is engendered and can either progress or not (27). The host is understood as a distinguishable subject independent of the environment, and the agent is deemed an external noxa that can have an effect, given a certain environment. Such an environment, understood from a naturalistic perspective and therefore apprehensible by the ecological means of the natural sciences, reduces the explanatory potential of the sociohistorical and cultural context and the human being to an eminently biological dimension (28). This is unlike what is proposed from the perspective of the indigenous human life process and its harmonic and disharmonic triads.

When Blum talks about the environment and health, he understands the environment as the sum of physical, educational, economic, and social characteristics that, in interaction with three other main factors, namely, genetic inheritance, healthy habits and behaviors, and healthcare services, gives rise to disease or its absence (29). Between 1968 and 1974, he turned his model into a more complex one, until he reached a formulation in which he understood such factors as conflicting forces that mutually influence and modify each other when acting on a given population (30). In his latest versions, his model gave greater value to the environment when compared with the other forces at play within the field, and they gave centrality to the concept of health understood as well-being (31). Although his proposal makes progress when compared with that of Leavell and Clark, it has a clear orientation toward the planning of healthcare services, for which it continues to be morbi-centric despite considering well-being a goal. Despite the greater value of the environment within the model over the years, the formulation achieved does not match the centrality and eminently related nature of land, community, and person that the concept of territory has ingrained in the description of the human life process and its harmonic and disharmonic triads as posited by indigenous narratives.

In 1973, Laframboise takes up elements of contentions previously raised by Blum and organizes them in his model as four components of the field of health to be considered to make health service planning more manageable (30,32). These are human biology, environment, lifestyle, and organization of care, with each of them acting as a force of equal value in the process of configuring risks within the field of health. A year later, this perspective is assumed and popularized by Lalonde, who achieves concrete developments in Canadian public policy (33).

The Laframboise–Lalonde Health Field model also focuses on the planning of health services for the prevention of and cure for disease with care based on levels of complexity. The model has the expectation of balancing the competing forces of equal importance within the field in favor of health, while not raising social–historical concerns regarding the configuration of such forces or their effects. It differs from Blum’s model by downplaying the centrality of the environment in understanding the construction of well-being (31). In these aspects, the health field is distinguished from the general proposal of the human life process, and it moves away from the emphasis on vitality described for the indigenous human life process. Something similar can be said about the model developed in 1976 by Dever, on the basis of what was stated by Blum, Laframboise, and Lalonde (34).

On the basis of the foregoing discussion, it is worth asking whether public health interventions guided by models, such as those of Blum, Laframboise, Lalonde, and Dever, can be appropriate to support public health actions aimed at human collectives, such as the indigenous, with understandings and practices centered on living, dying, healing, and getting sick that are strongly anchored to the territory and that emphasize collective health care, understood as harmonization.

In light of the above, intercultural approaches to healthcare in indigenous populations can be made that connect and hybridize with mestizo biomedicine and public health, not only in the field of therapeutic practices, but also in understanding the meanings and relationships that sustain them from the point of view of the native peoples themselves. The findings described around the human life process from indigenous narratives and around what we call the Harmonic Triangle and Disharmonic Triangle of the human life process emerge as useful inputs for these purposes.

Effective health research for indigenous peoples and work for social justice for indigenous communities must be based on participatory approaches (35). While indigenous health narratives are often still shaped by colonial logics, research must acknowledge all points of view on life, health, illness, and care even if they differ from the Western biomedical care model, with the aim of building intercultural health systems that empower all ancestral knowledge (36,37).

In their research with English-speaking indigenous people, Braun, et al acknowledge that after negative experiences with Eurocentric research of positivist methodologies, they have recognized decolonizing research methodologies as an effort to empower indigenous people as researchers (38). Along the same lines, Smith, Devine & Preston (2020), after a review of the literature, recommend indigenous research methodologies, community-based participatory research, and the use of stories as a data collection method (39).

The use of qualitative methodologies of narrative approaches has been well documented in research on indigenous peoples in different countries. For example, in North America, the narrative approach in research on suicide among indigenous peoples was found compatible with indigenous culture and facilitated research (40). On the other hand, in Ireland, indigenous health narratives support fluid relationships with biomedicine and elicit broader cultural debates and belief models (41). Hence, in this work, qualitative research with a narrative approach is consolidated as a research methodology appropriate toward determining the constructions encompassed by the concept of the human life process and circulated among university students who are members of Colombian indigenous peoples. Its main strength lies in the participatory nature of the project, from the moment of its conception to the dissemination of the final results; in the appreciation of indigenous thought as a fundamental input to nurture; and its remodeling of basic theoretical and conceptual formulations in the design of public health interventions aimed at indigenous peoples. This is the result of a commitment to decolonizing research that should be addressed in more detail.

It is likely that in the future, other inquiries involving new indigenous participants—not only migrant university students but also indigenous people living in their territory of origin and who belong to groups in addition to those addressed by this work—will allow the findings to be more complex and nuanced. The main purpose of this article was to unveil the narratives on the human life process in a general way in the group of participant indigenous students in the city. Given this, a differentiated analysis of the conceptualizations of the phenomenon under study among different indigenous peoples, by contrasting the narratives offered by the different students, is a task for the future.

From these contributions, it was possible to assess how the concept of the human life process is more in line with indigenous views of health, disease, life, death, and care, than it is with other models and conceptualizations usually used to form and implement health interventions aimed at indigenous peoples. This harmony was particularly evident in the recognition of the historicized nature of the phenomena considered as part of the human life process, and the centrality given to life as the organizer of the derived understandings and actions.

However, the indigenous narratives on the components of the human life process in their groups of origin distanced themselves from the formulation constructed by Franco that guided our approach to the project (2). The author understood the process as a linear course, beginning with life and ending with death, in a context crossed by the contradictions of the determinant processes of health. As for the narratives analyzed, although the central organizing concept continued to be life, it is not conceived in isolation but triangulated with health and death through harmony. Thus, we traced what we have called the Harmonic Triangle of Life–Health–Death in the framework of the territory understood as a relational unit between land, community, and person. Illness emerging in a triangulated way with health and death in the Disharmonic Triangle as a result of disharmony imposed in that unit-territory from the rupture of the order indicated in their own traditions. This is usually due to its contradiction in disadvantage toward the surrounding mestizo world.

In light of the findings of other researchers who have addressed similar issues with indigenous peoples, national and international research related to indigenous narratives on the meanings and practices of health, illness, care, life, and death clearly correspond closely to what was found in this study. In general, health refers to the integrality of life, where the worldview of each group; harmony and balance with the territory–land and its care; the environment; the community; production; and nutrition are fundamental (42). In this sense, the conceptualization of health involves a holistic vision of reality, subsuming the individual, family, and community. According to our results, it is the harmony between the physical–biological, historical–cultural, natural, and spiritual dimensions (43). As for disease, its causality is usually due to disorders and imbalances of the commoner or the community with respect to ancestral rules (43). Our findings reflected the category of disharmony, instead of imbalance, to explain the disorders that lead to illness. This was attained with a broader etiology in terms of the possible generators of such an imbalance, transcending spirits to include power disputes between individuals and groups, violence suffered as a human group and territory, and pressures on one’s own culture from the dominant mestizos, among other possibilities.

On the other hand, life was found related to the meaning of living, feeling good, and good living (44). Life is related to harmony and balance between “the social context, significant subjects and groups, daily life, physical and mental well-being, emotionality and spirituality” (42). In addition, it is considered “a path, a transit, a learning, [...] an opportunity, a result, a value or a force that mobilizes” (45). Once again, our findings favored the category of harmony over that of balance in this regard as a path to a full life. In the bibliography consulted by other authors, death, on the other hand, was associated with the exacerbation of spiritual beings and existences that alter the territory’s order (12). It is considered a transcendence and/or a transformation as hope for life, liberation of the spirit, and a return of energy to the earth (45). This was in agreement with our results, where we demonstrated that death acted as a harmonizer on the road to life, represented in the return to the potential of being reborn or continuing to live from another dimension after returning to the earth. The concept of care is mainly related to the collective construction of the Value of Life and processes of prevention, protection, well-being, and adaptation (45). In our findings, they represented interventions capable of re-harmonizing the being, to help it return to the harmonic triad of life, health, and good death.

In conclusion, this study clearly shows the narratives of Colombian indigenous university students related to the human life process in their native groups and concludes that the concepts of life, death, health, illness, and care have a frame of reference related to the ancestral heritage disseminated in oral traditions and external events nuanced by their own life experiences. In addition, they show how the classical category of the human life process is more in line with the indigenous views of their life course, in terms of their valuation of the social–historical character of such a process. Additionally, the indigenous student narratives studied allowed us to specifically delineate the formulations of the human life process for indigenous peoples. Thereby was exposed how it is not understood as a linear course of concatenated processes, from life to death, nor as something disentangled from the territory of origin. Before this, we proposed the constructs of the harmonic and disharmonic triads of the indigenous human vital process, as well as the understanding of its territorialization from the earth-community-person unit. These specific formulations of the human life process related to the indigenous world likely support the design of interventions aimed at protecting the health and life of these populations instead of other, more distant approaches from those espousing the indigenous worldviews that generally abound in the health field.

Author contributions

Zulma Consuelo Urrego-Mendoza: supervision and leadership in planning; research – research process; methodology – design and development; drafting – original document; writing – revising and editing.

Daisy Mariana Moreno Martínez: research – research process; methodology – design and development; drafting – original document; writing – revising and editing.

Giovanni Andrés Numpaque Arcila: research – research process; methodology – design and development; drafting – original document; writing – revising and editing.

Rodrigo Armando Fuentes Arias: research – research process; methodology – design and development; drafting – original document; writing – proofreading and editing; writing – revising and editing.

Funding

The Faculty of Medicine of Universidad Nacional de Colombia funded the project “Human Life Process in Indigenous Peoples of Colombia,” code Hermes 50415, through a Call for Funding Research Incubator Projects 2020.

Acknowledgments

To Cabildo Indígena Universitario in Bogotá (ciub).

References

1. Ramírez OS, Puerto JS, Rojas MR, Villamizar JC, Vargas LA, Urrego ZC. El suicidio de indígenas desde la determinación social en salud. Rev Fac Nac Salud Pública. 2018;36(1):55- 65. https://doi.org/10.17533/udea.rfnsp.v36n1a07

2. Franco S. Proceso vital humano: el proceso salud-enfermedad: una nueva perspectiva [conference on internet]. Seminario Marco Conceptual para la Formación de Profesionales de la Salud, Universidad Nacional de Colombia. Available from: https://parquedelavida.co/index.php/publicaciones/banco-de-conocimiento/item/130-proceso-vital-humano-proceso-salud-enfermedad-una-nueva-perspectiva-saul-franco-medellin-1993

3. Hackspiel M. ¿Es el cuidado parte de la esencia de la vida? Av Enferm. 1994;12(2-3):60-2.

4. Cardona S. Dimensión del cuidado de enfermería a los colectivos: un espacio para la promoción de la salud y la producción de conocimiento. Investig Educ Enferm. 1999;17(1):75-85.

5. López O, Rivera J, Blanco J. Determinantes sociales y salud-enfermedad en México. Cambios, rupturas y perspectivas. En: Chapela Mendoza MC, Contreras Garfias ME coord. La salud en México. Ciudad de México: Universidad Autónoma Metropolitana Xochimilco. 2011 1ª Edición; p. 93-123.

6. López O, Escudero J, Carmona L. Los determinantes sociales de la salud: una perspectiva desde el Taller Latinoamericano de Determinantes Sociales de la Salud, alames. Med Soc. 2008;3(4):323-35.

7. López O. Determinación social de la salud: desafíos y agendas posibles. Divulg. Saúde em Debate. 2013;49:150-6.

8. Betancurth D, Peñaranda F. La crianza como asunto fundamental para una salud pública alternativa. Rev Cubana Salud Pública. 2016;42(3):470-83.

9. Castro Carvajal JA. Los paradigmas sobre el proceso salud-enfermedad y sus consecuencias en la educación para la salud. Expomotricidad. 2007; p. 13-28.

10. Valdez I, Villaseñor M, Alfaro M. Educación para la Salud: la importancia del concepto. Rev Educ Desarr. 2004;1:43-8. Available from: https://www.cucs.udg.mx/revistas/edu_desarrollo/anteriores/1/001_Red_Valadez.pdf

11. Franco S. La salud al final del milenio. Anal Político. 1995;24:51-65. Available from: https://revistas.unal.edu.co/index.php/anpol/article/view/75677

12. Urrego-Mendoza ZC, Bastidas-Jacanamijoy MA, Coral-Palchucán GA, BastidasJacanamijoy LO. Narrativas sobre la conducta suicida en pueblos indígenas colombianos, 1993-2013. Rev Fac Nac salud Pública. 2017;35(3):400-9. https://doi.org/10.17533/udea.rfnsp.v35n3a10

13. Rocha A. Pueblos indígenas y salud colectiva: hacia una ecología de saberes. Physis: Revista de Saúde Coletiva. 2017;27(4):1147-61. https://doi.org/10.1590/S0103-73312017000400015

14. Departamento Administrativo Nacional de Estadísticas. Población indígena de Colombia: resultados del censo nacional de población y vivienda 2018. Bogotá: dane; 2019. p. 54.

15. Guzmán SC. La interculturalidad en salud: espacio de convergencia entre dos sistemas de conocimiento. Rev Gerenc Polít Salud. 2015;15(31):10-29. https://doi.org/10.11144/Javeriana.rgyps15-31.isec

16. Gonzáles C. 5 aspectos clave sobre la migración de los pueblos indígenas [Internet]. Oficina Internacional para las Migraciones. Available from: https://rosanjose.iom.int/es/blogs/5-aspectos-clave-sobre-la-migracion-de-los-pueblos-indigenas

17. iesalc-unesco, Organización Nacional Indígena de Colombia (onic), Consejo Regional Indígena del Cauca (cric). Educación Superior indígena en Colombia: una apuesta de futuro y esperanza. Cali: Editorial Universidad de San Buenaventura. Available from: https://www.humanas.unal.edu.co/colantropos/files/7314/5615/3384/EducSupIndigena.pdf

18. Di Caudo MV. No estamos de acuerdo con el título: escribir un libro con estudiantes universitarios interculturales. Rev Int Investig Educ. 2020;13:1-27. https://doi.org/10.11144/Javeriana.m13.neat

19. Viana I, Tonial FA, Leques MF, Maheirie K. Colonialidade, invisibilização e potencialidades: experiências de indígenas no ensino superior. Rev Psicol Política. 2019;19(46):602-14.

20. Capella C. Una propuesta para el estudio de la identidad con aportes del análisis narrativo. Psicoperspectivas. 2013;12(2):117-28. https://doi.org/10.5027/psicoperspectivas-Vol12-Issue2-fulltext-281

21. Domínguez de la Ossa E, Herrera JD. La investigación narrativa en psicología: definición y funciones. Psicol Caribe. 2013;30(3):620-41. Available from: https://www.redalyc.org/articulo.oa?id=21329176009

22. Bolívar A. Metodología de la investigación biográfico-narrativa: recogida y análisis de datos. In: Passeggi MC, Abrahao MH, editors. Dimensões epistemológicas e metodológicas da investigação (auto)biográfica. Tomo II. Porto Alegre: Editoria da pucrs; 2012; p. 79-109.

23. Bolívar A. ¿De nobis ipsis silemus?: epistemología de la investigación biográfico-narrativa en educación. Rev Electrón Investig Educ. 2002;4(1):1-26.

24. Garzón DI. Autorreferencia y estilo terapéutico: su intersección en la formación de terapeutas sistémicos. Diversitas. 2008;4(1):159-71.

25. Varela, F. (1998) Las múltiples figuras de la circularidad. En: Elkaim, M (Comp.) La terapia Familiar en Transformación. Barcelona: Ediciones Paidós

26. Resolución 8430/1993, por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. Bogotá, Colombia: Ministerio de Salud.

27. Leavell HR. The basic unity of private practice and public health. Am J Public Health Nation Health. 1953;43(12):1501-6.

28. Quevedo E, Hernández M, Miranda N, Mariño H, Wiesner C. La salud en Colombia: análisis socio-histórico. Tomo I. Bogotá: Ministerio de Salud la Salud en Colombia; 1990. p. 111-217.

29. Blum H, Sully E. What is comprehensive planning for health? Inquiry. 1969;6(2):3-16.

30. Blum HL. Social perspective on risk reduction. Fam Commun Health. 1980;3(1):41-61. https://doi.org/10.1097/00003727-198005000-00006

31. Valles-Medina AM. Modelos y teorías de salud pública. Mexicali: Universidad Autónoma de Baja California; 2019. Available from: https://libreriauabc.com/products/modelos-y-teorias-de-salud-publica

32. Laframboise HL. Health policy: breaking the problem down into more manageable segments. Can Med Assoc J. 1973;108(3):388-91 passim.

33. Lalonde M. A new perspective on health of Canadians. Otawa: Office of the Canadian Minister of Health and Welfare; 1974.

34. Dever GEA. An epidemiological model for health policy analysis. Soc Indic Res. 1976;2(4):453-66. https://doi.org/10.1007/BF00303847

35. Hardy LJ, Shaw K, Hughes A, Hulen E, Sanderson PR, Corrales C, Pinn T, Esplain J, Begay RC. Building a narrative of equity: weaving indigenous approaches into community-engaged research. Int J Environ Res Public Health. 2020;17(14):5148. https://doi.org/10.3390/ijerph17145148

36. Cormack D, Reid P, Kukutai T. Indigenous data and health: critical approaches to ‘race’/ ethnicity and Indigenous data governance. Public Health. 2019;172:116-8. https://doi.org/10.1016/j.puhe.2019.03.026

37. Bautista-Valarezo E, Duque V, Verdugo Sánchez AE, Dávalos-Batallas V, Michels NRM, Hendrickx K, Verhoeven V. Towards an indigenous definition of health: an explorative study to understand the indigenous Ecuadorian people’s health and illness concepts. Int J Equity Health. 2020;19(1):101. https://doi.org/10.1186/s12939-020-1142-8

38. Braun KL, Browne CV, Ka’opua LS, Kim BJ, Mokuau N. Research on indigenous elders: from positivistic to decolonizing methodologies. Gerontologist. 2014;54(1):117-26. https://doi.org/10.1093/geront/gnt067

39. Smith RL, Devine S, Preston R. Recommended methodologies to determine Australian Indigenous community members’ perceptions of their health needs: a literature review. Aust J Prim Health. 2020;26(2):95-103. https://doi.org/10.1071/PY19078

40. Mehl-Madrona L, Mainguy B. Narrative approaches to North American indigenous people who attempt. Perm J. 2020;24:19.032. https://doi.org/10.7812/TPP/19.032

41. Foley R. Indigenous narratives of health: (re)placing folk-medicine within Irish health histories. J Med Human. 2015;36(1):5-18. https://doi.org/10.1007/s10912-014-9322-4

42. Ruiz Eslava LF. Salud mental en tiempos de guerra, una reflexión sobre la relación conflicto armado-salud mental en la comunidad indígena Emberá en situación de desplazamiento forzado. Rev Fac Med. 2015;63(3):399-406.

43. Cardona JA. Sistema médico tradicional de comunidades indígenas Emberá-Chamí del Departamento de Caldas-Colombia. Rev Salud Pública. 2012;14(4):630-43.

44. Pineda Martínez EO, Orozco Pineda PA. Narrativas y relatos del Buen Vivir de infancias indígenas como estrategia de construcción de paz. Ciudad Paz-Ando. 2018;11(1):40-50. https://doi.org/10.14483/2422278X.12728

45. Coral G. 2015. Narrativas sobre la vida, la muerte y la conducta suicida en indígenas estudiantes de la Universidad Nacional de Colombia – sede Bogotá – pertenecientes al pueblo Camëntsá [tesis degree on internet]. Bogotá: Universidad Nacional de Colombia; 2015. Available from: https://repositorio.unal.edu.co/handle/unal/54265

Author notes

* Corresponding author: zulcurregom@unal.edu.co