Necropolitics, territorial exception, and Indigenous agency in Brazilian health: an integrative review (2019-2025)

Abstract

The health of Indigenous peoples in Brazil is inseparable from political and epistemic disputes, transcending the restricted analysis of epidemiological indicators or access difficulties, under the influence of colonial persistence and the actions of a state that has been historically oriented towards expropriation, invisibility, and abandonment. This study analyzes, through an integrative review of Brazilian scientific literature (2019-2025), how Achille Mbembe’s necropolitics critically examines state abandonment mechanisms, the production of territories of exception, and Indigenous protagonism in the Indigenous Health Care Subsystem. The results demonstrate the naturalization of precariousness as a technology of government, the territorialization of exception, and the emergence of anti-necropolitical practices that reaffirm collective agency in formulating alternatives to the continuity of care and the reduction of preventable deaths.

Keywords
Indigenous health; Necropolitics; Territory of exception; Collective agency

Resumo

A saúde dos povos originários no Brasil constitui objeto indissociável das disputas políticas e epistêmicas, atravessando a análise restrita dos indicadores epidemiológicos ou as dificuldades de acesso, sob a influência da persistência colonial e da atuação de um Estado historicamente orientado pela expropriação, invisibilidade e abandono. Este estudo analisa, por meio de uma revisão integrativa da literatura científica brasileira (2019-2025), como a necropolítica de Achille Mbembe problematiza mecanismos de abandono estatal, a produção de territórios de exceção e o protagonismo indígena no Subsistema de Atenção à Saúde Indígena. Os resultados demonstram a naturalização da precariedade enquanto tecnologia de governo, a territorialização da exceção e o surgimento de práticas antinecropolíticas que reafirmam a agência coletiva na formulação de alternativas para a continuidade do cuidado e a redução de mortes evitáveis.

Palavras-chave
Saúde indígena; Necropolítica; Território de exceção; Agência coletiva

Resumen

La salud de los pueblos originarios de Brasil constituye un objeto indisociable de las disputas políticas y epistémicas, atravesando el análisis restringido de los indicadores epidemiológicos o de las dificultades de acceso, bajo la influencia de la persistencia colonial y de la actuación de un Estado históricamente orientado por la expropiación, la invisibilidad y el abandono. Este estudio analiza, por medio de una revisión integradora de la literatura científica brasileña (2019-2025), cómo la necropolítica de Achille Mbembe problematiza mecanismos de abandono estatal, la producción de territorios de excepción y el protagonismo indígena en el Subsistema de Atención de la Salud Indígena. Los resultados demuestran la naturalización de la precariedad como tecnología de gobierno, la territorialización de la excepción y el surgimiento de prácticas anti-necropólíticas que reafirman la agencia colectiva en la formulación de alternativas para la continuidad del cuidado y la reducción de muertes evitables.

Palabras clave
Salud indígena; Necropolítica; Territorio de excepción; Agencia colectiva

Introduction

The health of Indigenous peoples in Brazil cannot be reduced to a set of epidemiological indicators, as it is a field of political and epistemic disputes traversed by colonial violence. This population’s health conditions result from a state project that historically operates through expropriation, invisibility, and abandonment. In this context, any discussion on the subject is inseparable from the analysis of the power relations that establish which lives matter and which bodies can be exposed to disease and death.¹

To critically examine this logic, the present article is grounded in Achille Mbembe’s theory of necropolitics², which defines modern state sovereignty by its capacity to “make live” in direct articulation with the sovereign power to “let die.” Necropolitics manifests itself in the differential management of populations, subjecting racialized groups to conditions that bring them closer to death, whether through direct violence or through negligence and programmed abandonment³. In Brazil, Indigenous peoples are one of the primary targets of this logic.

This violence is based on structural racism, which, according to Silvio Almeida⁴, is an inherent element of politics and economics and shapes the distribution of fundamental rights, including access to health⁵. In the case of Indigenous people, racism manifests itself both in the state’s refusal to protect their territories - an essential condition for their well-being - and in the hegemony of the biomedical model that delegitimizes traditional healing knowledge⁶.

However, against the politics of death, the politics of life rise, driven by the protagonism of the Indigenous movement⁷. Leaders such as Sônia Guajajara, Ailton Krenak, and Davi Kopenawa have denounced the ongoing destruction project⁸. Therefore, the struggle for health is a struggle for autonomy and territory⁹. The emergence of a scientific production authored by Indigenous people in the field of collective health is a landmark of this movement, disputing the narratives¹⁰.

The decolonial perspective aids the critical examination of state policies by adopting statements from Indigenous peoples as a matrix for understanding risk and care¹¹. The work “A queda do céu”⁵, for example, describes illegal mining and epidemics as a cosmopolitical collapse that simultaneously affects bodies, rivers, and forests. This vision shifts “environment” and “risk” from the technical lexicon to a politics of living, accompanied by the notions of body-territory and ecology of knowledge.

This article presents an integrative review that does not approach the challenges in a descriptive manner. Our objective is to analyze, based on the notion of necropolitics¹², how Brazilian scientific production (2019-2025) documents the mechanisms of abandonment and government of death that affect Indigenous peoples, while also highlighting fissures and resistances that confront this logic. The question that guided the analysis is “How has Brazilian literature published between 2019 and 2025, in light of the notion of necropolitics, documented the mechanisms of state abandonment, territorial exception, and Indigenous agency in the field of health?” We argue that, beyond “barriers to access,” the literature constitutes an archive of state violence and, simultaneously, a testimony of the Indigenous struggle for life.

Methodology

This is an integrative literature review (Jan/2019 - Jan/2025) on the health of Indigenous peoples in Brazil. The objective was to analyze how scientific production documents state abandonment, territorial exception, and Indigenous agency in the field of health in light of the notion of necropolitics. The time frame covers the Covid-19 pandemic and the intensification of territorial conflicts that impacted the Indigenous Health Care Subsystem of the Brazilian National Health System (SASI-SUS).

The searches were conducted in the PubMed/MEDLINE, ScienceDirect, SciELO, and LILACS databases. Controlled descriptors from the DeCS and MeSH vocabularies were used, prioritizing English terms (health of indigenous populations, indigenous health services, health education, Brazil), given their predominance in the main international databases.

Empirical studies (quantitative, qualitative, or mixed methods) that had Indigenous peoples residing in Brazil as their population and addressed health policies, management, or care were included. Editorials, letters, commentaries, strictly biomedical studies without an interface with care organization, and duplicates were excluded. Screening was performed in two independent stages, and disagreements were solved by consensus, in accordance with the PRISMA 2020 recommendations.

Initially, 956 studies were identified (PubMed = 22; SciELO = 32; LILACS = 116; ScienceDirect = 786). After removing 53 duplicates, 903 studies remained for screening by title and abstract, of which 881 were excluded. Twenty-two articles were then selected for full-text reading, of which 13 were excluded for not meeting the criteria. Thus, nine studies were included in the review. The process is represented in the PRISMA flowchart below.

Figure 1
Prisma Flowchart.

In addition to the main corpus, an expanded archive was created with supporting documents relevant to the field of Indigenous peoples’ health, including legal and programmatic frameworks, Indigenous health district plans, technical reports, and publications authored by Indigenous people. These documents were not included in the study corpus for the review, nor in the PRISMA flowchart. Their function was to serve as an analytical context to situate continuities and deviations, enabling an interpretive triangulation with the statements present in the corpus and the qualification of the political and administrative vocabulary mobilized in the articles, particularly when these referred to regulations, health emergencies, and environmental conditions that modulate the production of territories of exception.

The protocol for this review was registered in the Open Science Framework (OSF), and access to it is available in the “data availability” section at the end of the article. The analysis, carried out through a critical thematic synthesis, organized the discussion into three axes: state abandonment and production of precariousness; territorial exception and production of risk spaces; Indigenous agency and anti-necropolitical practices.

The critical thematic synthesis was conducted using an extraction matrix developed to standardize full-text reading, recording the study design, population and territory, analytical object, main findings, and relevant excerpts. Subsequently, the findings were coded by approximations of meaning and enunciative recurrences, with progressive grouping into themes and subthemes until the three analytical axes were consolidated. When the same study had elements that belonged to more than one axis, the predominant axis was recorded for the purpose of organizing Table 1. Co-occurrences were maintained as interpretive material mobilized in the discussion. Divergences in coding and thematic allocation were resolved by consensus, in order to stabilize the internal coherence of the synthesis and modulate the inferential strength attributed to each statement.

Results

After reading the nine articles included in the research, convergences and divergences were identified, and, in dialogue with the theoretical and analytical necropolitics framework, were organized into three thematic axes. Table 1 summarizes the corpus based on these axes, indicating the year, title, authorship, and, in the Central statements column, the central ideas mobilized in the analysis. A predominant axis was assigned to each study (without implying exclusivity) in order to organize and critically examine the shifts.

The reading takes into account the previously assessed methodological quality to modulate the inferential strength in the discussion, avoiding simplistic hierarchizations; the purpose of the table is to map enunciative patterns and their tensions, rather than to rank the studies. The co-occurrences between axes are explored throughout the discussion, taking Frame 1 as a guiding map for the analytical argumentation.

Frame 1
Distribution of studies across axes A1-A3 with central statements.

Analytical axis	Year	Title	Authors	Central statements
A1 - The Necropolitics Archive: Evidence of State Abandonment	2022	COVID-19 vaccination, incidence, and mortality rates among indigenous populations in Brazil.	Machado et al.	Heterogeneous and lower vaccination coverage; COVID-19 incidence and mortality rates higher than those of the general population; vaccination is associated with a reduction in cases and deaths.
	2019	Epidemiological aspects of HIV infection and AIDS among Indigenous peoples	Graeff et al.	An increasing trend in HIV/AIDS incidence in MS, with high rates among the Guarani and Kaiowá; indications of underdiagnosis and the need to expand testing, treatment, and follow-up.
A2 - Geographies of Exception: Production of the Risk Territory	2023	Effectiveness in the Indigenous Health Care Subsystem (SASI-SUS): analysis in a referral service in Amazonas, Brazil	Ahmadpour et al.	CASAI operates as a care coordination device; strategies of negotiation, culturally responsive care, and improvisation emerge to overcome barriers.
	2021	Local action plan to promote access to the health system by indigenous Venezuelans (Warao) in Manaus: mixed-methods study.	Jezus et al.	Local action plan with Indigenous participation improves access to the SUS; structural barriers persist (language, transport, distance).
A3 - The Struggle for Life: Indigenous Agency and Counterpower	2023	Planning and management of the health work process: achievements and constraints in the Indigenous Health Care Subsystem of the SUS	Cunha et al.	Planning identified in seven DSEI, with variations; effectiveness depends on the SIASI and intersectoral coordination; need to expand participation at the management level.
	2023	Effects of Covid-19 in Indigenous primary health care: professionals’ perceptions	Oliveira et al.	The pandemic impacted the work process, the comprehensiveness of care, and mental health; reports of work overload and gaps in support, with partial local responses.
	2020	Covid-19 pandemic and motivations underlying the demand for health services in Indigenous villages	Ribeiro et al.	Care-seeking mediated by dialogue with community leaders, programs, and case resolution; isolation and adherence depend on local negotiations and community engagement.
	2020	Relations between scientific production and public policies: the case of the Indigenous health care area in the field of collective health	Kabad et al.	Growth in scientific production since 2010, with a policy interface; evidence of a reconfiguration of the field and of the role of the social sciences in the Indigenous health care agenda.
	2019	Attributes of Primary Care in the context of Indigenous health	Rocha et al.	PCAT indicates stronger essential/derived attributes in the DSEI than at the municipal level; suggests local organizational capacity for care coordination.

• Source: Created by the authors, 2025.

Analysis and discussion

The critical reading of the selected corpus, guided by the necropolitics framework, interrogates how recent scientific production on Indigenous health formulates relationships between government, territory, and care. Taken together, the articles constitute an archive¹³, in the sense of a regularity of statements, that makes forms of precariousness administration and differential exposure to harm become intelligible. At the same time, the corpus itself records shifts and counter-conducts that reconfigure care flows and dispute the decision-making locus.

The necropolitics archive: evidence of state abandonment

The necropolitics archive in A1 presents absence as a deliberate administrative rationale, not an accidental event. Bureaucratic devices, such as systemic regulation failures (SISREG) and the chronic scarcity of supplies, drive the management of waiting time and the institutionalization of vulnerability, converting the lethal outcome into a predictable and statistically normalized event.

In the corpus, absence is administratively produced by transport interruptions, opaque regulation queues, and chronic shortages of supplies, staff, and connectivity. These operations are not episodic failures because they function as a rationale that unequally distributes protection and vulnerability, organizing differential exposures to harm and death, in line with the notion of necropolitics². In the context of preventable health problems, the epidemiological study conducted in the State of Mato Grosso do Sul reveals a pattern of prolonged vulnerability among the Guarani and Kaiowá: “The highest HIV detection rates occurred among the Guarani […] and the mortality and case fatality rates were higher among the Kaiowᔹ⁴ (p. 1, 6-7). The discourse suggests an accumulated effect of administrative decisions and institutional arrangements that make the fatal outcome repeatable, stabilizing conditions of discontinuous care and unequal access to diagnosis, follow-up, and treatment.

On a national scale, the analysis of incidence, mortality, and vaccination during the pandemic shows how logistics and vaccination coverage modulate risk and protection. Heterogeneities in vaccination coverage were identified among Indigenous peoples, with lower percentages when compared to the non-indigenous older population. Additionally, the analyses showed higher cumulative incidence rates of Covid-19 among Indigenous populations compared to the Brazilian population in general¹⁵.

The subsequent reduction in mortality after the start of vaccination, reported in the study, suggests that exposure to harm is not explained by an alleged territorial naturalization of risk¹⁵. On the contrary, it indicates that logistics modulation and the implementation of interventions, such as vaccination coverage and field response capacity, reconfigure the profile of illness and death, disclosing the decisional dimension of the material chains that sustain protection or abandonment.

In the daily routine of services, absence takes the form of a bureaucratic expedient that subordinates care to authorization flows. Barriers to specialized access, detailed below in a discussion on the geography of care, ratify the insufficiency of regulatory policies for Indigenous populations¹⁶. From the perspective of work management and process, multi-case qualitative studies identify the concreteness of this expedient: “Interviewees indicated the lack of centralized training […] due to the lack of internet in most base centers”¹⁷ (p. 7) and “Regarding infrastructure, the lack and/or insufficiency of logistics and transport resources were indicated”¹⁷ (p. 8). At the Primary Health Care (PHC) level, precariousness affects workers and users: “professionals became ill […] due to the lack of personal protective equipment”¹⁸ (p. 5). These statements make it clear that the “lack” does not operate as an accident. It functions as a device that distributes waiting time, regulating circulation through authorizations and queues, establishing who is subject to loss to follow-up, and reorganizing vital priorities within the SASI-SUS.

The technical discourse that attributes causality to “distances” and “remoteness” is challenged when the articles themselves show shifts following managerial decisions. Even in studies that highlight organizational capabilities, such as the assessment of PHC attributes — “the highest overall score was observed in the Indigenous Health District”¹⁹ (p. 1) —, the legibility of the abandonment remains: where transport, staff replacement, and connectivity are guaranteed, precariousness decreases; where they are not, it becomes routine. The literature on collective health and social sciences helps to qualify this selectivity: institutional racism operates as a matrix that establishes access to goods and services²⁰, while “structural violence” places certain groups “on the path to harm” through political, economic, and administrative arrangements²¹. In this context, the set of documented “lacks” — SISREG, internet access in the centers, transport, and personal protective equipment (PPE) — produces hierarchies of lives and deaths in Indigenous body-territories.

Recent regulatory frameworks reinforce that these are practices, not fate: the National Policy for Indigenous Peoples’ Health Care (PNASPI) has established responsibilities for differentiated care since 2002²²; Law No. 14021/2020 sets forth an emergency plan to address Covid-19 in Indigenous territories²³; the resolutions of the 6^th National Indigenous Health Conference re-establish logistics, personnel, and Indigenous participation as conditions for the possibility of care provision²⁴. The persistence, in the articles, of “lack of internet”, “lack of transport”, “SISREG queue”, and “lack of PPE” reveals a fracture between statements and implementation; a fracture that, according to Mbembe², manifests itself as a government by precariousness.

By taking the articles as an archive, the A1 axis becomes fluid beyond an inventory of problems: indicators of recurrence and duration of interruptions (time without a complete team; days without transport; referral cycles without counter-referral), as well as indicators of the burden of preventable events (hospitalizations for sensitive causes; loss to follow-up in tuberculosis and HIV; discontinuity of prenatal care) can be linked to decisional accountability.

The A1 axis demonstrates that precariousness is produced and managed by decisional chains that interrupt the continuity of care. However, this management does not operate in a vacuum. It is unevenly distributed across the territory and becomes more intense when care routes are captured by security regimes, extractive economies, and mobility control arrangements. In this context, the analysis of political rationales identifies spaces in which resistance practices or counter-conducts emerge in opposition to government practices²⁵. Therefore, the analytical shift from A1 to A2 establishes a change of scale rather than a change of object, transitioning from the administrative routinization of absence to the political spatialization of the suspension of guarantees, a scenario in which the right to health derives from contingent permissions and extraordinary protocols.

Geographies of abandonment: the territory as a zone of exception

The production of “risk territories” emerges when care is subordinated to logics of security, exploitation, and mobility control. This constitutes a spatialization of exception, in which the protection of rights is conditioned by devices that suspend guarantees and reorganize access according to priorities that are external to health needs². In Brazil, the regulatory framework itself recently acknowledged the situation by declaring a “Public Health Emergency of National Importance (ESPIN) due to lack of health care provision to the Yanomami population”²⁶, followed by federal measures “to combat illegal mining in the Yanomami territory”²⁷.

On the operational level, institutional blockages materialize the territorial exception in specialized access: “Another major challenge […] concerns delays in appointment scheduling within the SUS network”¹⁶ (p. 6). Unlike the administrative failure of A1, A2 demonstrates the spatialization of exception. Insufficient infrastructure in the Special Indigenous Health Districts (DSEIs) is captured by insecurity regimes, such as illegal mining and drug trafficking, transforming geography into a vector of interdiction. The right to health ceases to be an ordinary guarantee and becomes an occasional operation, conditioned by hydrological windows (periods of navigable river conditions), escorts, and extraordinary surveillance protocols.

The conversion of the territory into a “zone of exception” produces health damages converging with ontological damages, affecting the body-territory unit, a place of life where materiality and spirituality, knowledge and social reproduction intertwine²⁸. In conflicts marked by extractive economies and militarization, Indigenous women experience specific forms of vulnerability, in which coloniality of gender structures differentiated exposures, increased care burdens, and regulation silences²⁹. From this perspective, environmental contamination, circulation restrictions, and the need for escorts cease to be logistical contingencies and become devices that discredit temporalities and practices inherent to care, reducing rights to precarious permissions.

The “zones of exception” emerge when vital routes are captured by extractive and security regimes that suspend guarantees and produce differential exposures to diseases and poisonings. Kopenawa reveals the equivalence between illegal mining and “epidemics” that contaminate rivers and bodies, reconfiguring the territory as a place of slow death and imposing ruptures in ritual temporality. This perspective broadens the interpretation of empirical findings on contamination and mobility blockages by situating them as necropolitical technologies that articulate nature, politics, and health⁵.

The security dimension is explicit when, in accordance with Decree No. 11405/2023, the “Air Force Command is authorized to create the Air Defense Identification Zone – ZIDA over the airspace overlying and adjacent to the Yanomami territory” (p.2), aiming at the adoption of “airspace control measures against all types of traffic suspected of illicit activity”³⁰ (p. 2). Although airspace protection fulfils a legitimate purpose, it establishes, in terms of care, a regime where health access depends on exceptional arrangements, generating direct implications for the movement of teams, patients, and supplies².

The institutional cartography of the DSEI highlights the co-presence of illegalities and physical barriers that, combined, configure zones of exception. The District Plan of the Vale do Javari DSEI reports “illegal hunting, fishing and even drug trafficking, resulting in numerous conflicts”³⁰. Furthermore, it mentions “illegal mining areas […] and contaminated areas” and “Geographical Barriers […] limiting navigation” (p. 25-7), and records that “the Vale do Javari Indigenous Land cannot be accessed by land routes […] exclusively by river and/or air” (p. 25). In these settings, the movement of helth teams depends on hydrological windows, fuel, aircraft and escorts, reducing care to the condition of occasional operation.

The health effects of territorial exception are measurable. Studies coordinated by Fiocruz report that “Yanomamis from 9 villages harassed by illegal mining are contaminated by mercury”³¹ and that “84% recorded levels above 2.0 µg/g; 10.8% above 6.0 µg/g”³². Such data indicate a regime of environmental and sanitary damage produced by extractive chains that interdicts care and converts the territory into a vector of illness.

Even when the studies do not explicitly name illegal mining, they describe mobility restrictions and institutional blockages that, on the ground, operate as mechanisms of exception. In the city of Manaus, the fact that effectiveness depends on the “SISREG queue”¹⁶ (p. 6) shows that specialized access is mediated by a regulatory device that makes waiting time become an exercise of administrative sovereignty over displaced bodies. In the SASI-SUS multi-centers, local management records the insufficiency of logistical and transport resources added to the lack of connectivity in most base centers, factors that, in border districts and seasonal waterways, determine the effective interruption of care chains¹⁷. Among PHC professionals, the pandemic exacerbated this situation by imposing a shortage of personal protective equipment, hindering travel and the permanence in the field¹⁸. These statements, combined with regulatory devices and environmental evidence, consolidate the discourse of exception, in which access is fulfilled under conditions of practical suspension of guarantees. In this context, distance and seasonality cease to operate as sufficient explanations, because what is consolidated is a regime of permissions and interruptions that transforms the circulation of care into a contingent event, dependent on authorizations, resources, and control devices.

The differential dimension of this arrangement is also demonstrated in aggregate indicators. In the context of Covid-19, regional heterogeneities in vaccination coverage and the high incidence among Indigenous people derive from a convergence between geographical barriers, repressive actions, and illegal economies, factors that reorganize flows of people and goods beyond the distance factor¹⁵. The result, from Mbembe’s perspective², is the transformation of entire areas into zones where the right to life is continuously negotiated by extra-state actors and by the state itself.

Recent regulations reinforce the perception that exceptionality constitutes a structural, rather than episodic, trait of state management. Devices such as Directive GM/MS No. 28/2023, which establishes “lack of health care provision” as an emergency criterion²⁶, and Decree No. 11405/2023, which links health care response to the fight against illegal mining²⁷, materialize necropower by acknowledging the failure of ordinary care channels. This control movement extends to the regulation of the very “access to the Yanomami Indigenous Land”³³, subordinating circulation and care to extraordinary surveillance protocols. The exception becomes territorialized: border dynamics, extractivism tensions, and environmental degradation impose the coordinates that make the right to health become a permanently threatened possibility.

The struggle for life: indigenous protagonism as an anti-necropolitical practice

In this article, the notion of anti-necropolitical practices is an analytical operator to describe actions that shift the administration of scarcity and reconfigure the locus of care-related decisions, transcending the function of a regulatory marker of resilience. In the corpus, such practices become observable when they reorganize access routes and continuity of care, institute local mechanisms of surveillance, regulation, and communication with services, produce cultural and technopolitical mediations that alter the temporality of the response, and challenge institutional arrangements that naturalize interruptions and contingent permissions. With this, Indigenous agency is treated as a situated production of conditions for the possibility of care, not as a participatory appendix to previously defined policies.

The corpus shows that Indigenous protagonism practices, ranging from social oversight to the development of local protocols and plans, operate as counter-conducts that destabilize management by scarcity, reordering care flows and priorities in an anti-necropolitical manner². At the institutional level, the National Policy and recent guidelines acknowledge and prescribe this centrality: the social oversight bodies, which include the Forum of Presidents of Indigenous District Health Councils (FPCondisi), the Indigenous District Health Council (CONDISI), Local Indigenous Health Councils (CLSI), and the Intersectoral Commission on Indigenous Health (CISI), state that:

Social oversight needs to be related to the management of health services, but maintaining political independence from district coordinations and the Indigenous health department. The funding of social oversight actions is the responsibility of Sesai, and managers must ensure the political independence of the local and district councils and of the forum²⁴. (p. 300)

In line with this, the assessment of PHC attributes carried out by Rocha et al.¹⁹ shows that the DSEI achieved a higher overall score in the Primary Care Assessment Tool and in essential/derived attributes compared to the municipal PHC services, indicating care coordination, empanelment, and community orientation. This constitutes evidence of organizational capacity and the ability to reconstruct care pathways within the SASI-SUS, consistent with A3 (agency/counterpower): when there is local decision-making and stable institutional arrangements, the care chain is sustained despite logistical constraints. In summary, the study supports A3 and contrasts with A1, indicating that precariousness is not fate - it is a reversible regime.

The Indigenous agency that reorganizes flows and priorities constitutes a critical interculturality practice, overcoming the notion of multicultural coexistence by consolidating a political project to contest regulations, knowledge, and institutionalities³⁴. Protocols implemented by the Indigenous people themselves, deliberations in CLSI/CONDISI, and co-authorships in research studies materialize this turn, shifting the decision locus and reconfiguring power relations within the system. At the same time, the incorporation of Indigenous women’s agendas and leadership challenges the coloniality of gender, recentering dimensions such as reproductive care, food security, and the protection of girls and youths²⁹, while the defense of the body-territory guides care and environmental surveillance priorities²⁸.

Participatory density increased in the most recent conference cycle: “There were 302 local conferences and 34 district conferences, with the participation of thousands of Brazilian Indigenous people”²⁴. This regulatory and participatory architecture empirically delimits axis A3 of the synthesis.

In the field of interventions, the mixed-method study on Warao migrants in Manaus demonstrates that co-authorship and action agreed with leaders produce concrete access effects: “The [local action] plan proved to facilitate access to the health system for Venezuelan Indigenous people of the Warao ethnicity in Manaus”³⁵ (p. 2). The same study identifies barriers (language, distance, and transport costs) that were addressed through the plan’s participatory design, reinforcing that Indigenous agency is not decorative but a possible alternative to shift care pathways. In parallel, recent collective health syntheses record, in the pandemic context, the “creation of sanitary barriers” and the constitution of a “situation room” as self-protection technologies produced by the peoples themselves and their institutional allies³⁶.

In the services and district management, statements extracted from the corpus indicate the emergence of Indigenous protagonism in micro-management decisions and arrangements. In SASI-SUS multi-centers, the recommendation for “radicalizing participation […] to guarantee differentiated care and the principles of the SUS”¹⁷ (p. 1) appears as an explicit horizon for the qualification of planning and coordination. In the Manaus reference, practices of intercultural negotiation and supportive reception, performed with the Indigenous health agent, family members, and leaders, are described as ways to recompose the effectiveness that was hindered by slow regulatory flows¹⁶. Although not always called a “protocol,” such practices constitute local technologies (e.g., translation arrangements, route agreements, management of ritual times) that reenact care outside the discourse of lack.

Taken together as an archive, these movements enable to characterize axis A3 with three marks: i) shared decision-making with measurable effects (e.g., a local plan that “facilitated access”³⁵); ii) institutionality of social oversight (CLSI/CONDISI) recognized and protected by regulations — “administrative independence of social oversight”²⁴ — that safeguard Indigenous decision-making; iii) collectively organized self-protection repertoires (sanitary barriers, situation rooms), such as self-governance and territorial governance technologies, in threat contexts³⁶.

The anti-necropolitical practices described in the corpus can be viewed as world-preservation engineering, in the sense proposed by Kopenawa: arrangements that protect the “forest-world” and reconstruct care pathways through intercultural translations and community-grounded decisions. Instead of adaptive responses to shortages, they configure counter-conducts that redistribute power and reorder care flows⁵.

In evaluative terms, A3’s anti-necropolitical key shifts the question from generic “participation” to effect and power indicators: deliberative presence (CLSI/CONDISI/CNSI), Indigenous authorship in research and protocols, and impact on outcomes (vaccination coverage, continuity of treatment, waiting times). In the materials examined here, this shift can already be noticed when decisions in participatory bodies or in local agreements lead to the reorganization of flows^16,17,35. By articulating social oversight institutions, Indigenous care technologies, and co-authorship, Indigenous protagonism is consolidated not as a supplement to the policy, but as a form of government that challenges the administration of precariousness and opens space for life².

Conclusion

The collected evidence supports the hypothesis that health care for Indigenous peoples in Brazil has been organized by three interconnected regimes: the administration of scarcity as a technology of government (A1), the territorialization of exception (A2), and counter-conducts that institute anti-necropolitical practices (A3). Based on Mbembe’s framework, the transition from the notion of “access barriers” to the notion of “measurable state abandonment” establishes a repositioning of the analytical object and defines it as the result of administrative decisions and political arrangements responsible for the production, distribution, and normalization of preventable risks and deaths. Thus, it replaces the thesis of a natural infrastructure deficit².

In axis A1, studies indicate a recurring pattern of preventable outcomes and routinization of absence: HIV trends showing a higher burden among the Guarani and Kaiowá in Mato Grosso do Sul¹⁴, heterogeneous Covid-19 vaccination coverage¹⁵, qualitative records of “lack” of transport, connectivity, and PPEs, and effectiveness mediated by opaque regulatory queues^16,18. Examined together, these data corroborate interpretations of institutional racism and structural violence as inequity matrices^20,21, shifting the analysis from “logistical difficulties” to accountability for interruptions and delays that materialize the abandonment.

In axis A2, the territory operates as a zone of exception when the provision of care comes to depend on security devices, illegal economies, and environmental conditions that suspend guarantees, especially in border districts and seasonal waterways. The recent public documentation on the Yanomami emergency, the activation of air defense zones, and district plans acknowledging illegal mining, drug trafficking, and river-only access demonstrate a spatialization of exception whose health care effects were made measurable by mercury contamination studies³². This territorial discourse reduces care to the condition of occasional operation, dependent on hydrological windows, fuel, aircraft, connectivity, and extraordinary authorizations.

In contrast, axis A3 demonstrates that the protagonism of Indigenous peoples configures solutions, problematizing the logic of an additional component to the public policy. The mixed-methods study with the Warao in Manaus shows that a local plan agreed with leaders facilitated access to the SUS³⁵. In SASI-SUS multi-centers, “radicalization of participation” is recommended to improve planning and coordination¹⁷, while referral and PHC services describe local technologies (intercultural negotiation, translation arrangements, route agreements, supportive reception) that restore effectiveness in view of slow regulation^16,18. The recent conference cycle and the regulatory frameworks (PNASPI; 6^th CNSI; Law 14021/2020) recognize and prescribe the centrality of social oversight (CLSI/CONDISI), offering an institutional basis for the anti-necropolitical shift.

From a programmatic point of view, the results justify a twofold reorientation. First, abandonment indicators should be instituted as an object of management: (i) recurrence and duration of interruptions (days without transport; time without a complete team; referral cycles without counter-referral; time until restoration of supplies/connectivity); (ii) burden of preventable events (hospitalizations for sensitive causes; loss to follow-up in tuberculosis/HIV; discontinuity of prenatal care and immunization). These indicators must be auditable by social oversight bodies, with binding targets and deadlines at the DSEI level and inter-federative agreement. Second, existing anti-necropolitical repertoires should be consolidated: co-management with the protagonism of Indigenous peoples, implementation of their own protocols (including sanitary barriers), logistical routes agreed with communities, and translation and cultural mediation devices.

The reorientation also entails strengthening the regulatory framework: updating the PNASPI using metrics of abandonment and territorial exception; tying funding to verifiable commitments on logistics, connectivity, and staff replacement; and protecting the administrative independence of Indigenous social oversight. The research agenda should combine participatory studies authored by Indigenous peoples, time series of interruption and outcome indicators, georeferencing of exception factors (illegal mining, contamination, militarization), and impact assessment of A3 interventions on continuity of care, vaccination coverage, and waiting times.

As a contribution, the study shifts the debate from “barriers” to “government by precariousness” and offers an operational framework to measure abandonment and hold the responsible parties accountable, linking it to territorial exception and Indigenous counter-power repertoires. As limitations, the heterogeneity of study designs, the underrepresentation of Indigenous authors in part of the corpus, and the time frame may underestimate long-term processes; even so, the triangulation between studies, regulations, and environmental evidence supports the consistency of the inferences. In practical terms, the synthesis shows that the reduction in the number of preventable deaths and the expansion of continuity of care depend less on “overcoming distances” and more on an anti-necropolitical shift: deciding to govern against abandonment, with Indigenous decision-making power and continuity metrics as the core of the performance of the SASI-SUS.

• Caceres ONV, Vieira L, Costa ELM, Oliveira ACM, Marques CAM, Sanches LC. Necropolitics, territorial exception, and Indigenous agency in Brazilian health: an integrative review (2019-2025). Interface (Botucatu). 2026; 30: e260245 https://doi.org/10.1590/interface.260245

Data Availability

The dataset supporting the results of this study is available on the Open Science Framework and can be accessed at: https://doi.org/10.17605/OSF.IO/QS4C8 and on the ScieloData: https://doi.org/10.48331/SCIELODATA.TCY5S3

References

• ¹ Veronese O, Almeida JR. O descaso com o direito fundamental à saúde dos povos indígenas no enfrentamento da pandemia de Covid-19: a consolidação de uma necropolítica no Brasil. Pensar Rev Cienc Jurid. 2021; 26(3):1-17. doi: 10.5020/2317-2150.2021.11838.
  » https://doi.org/10.5020/2317-2150.2021.11838
• ² Mbembe A. Necropolítica. 3a ed. São Paulo: n-1 edições; 2018.
• ³ Santos ECP, Lima PLC. O poder público é um agente mirando um fuzil para a favela: metáforas de uma necropolítica brasileira. Rev Bras Linguist Apl. 2024; 24(2):e22551. doi: 10.1590/1984-6398202422551.
  » https://doi.org/10.1590/1984-6398202422551
• ⁴ Almeida SL. Racismo Estrutural. São Paulo: Pólen; 2019.
• ⁵ Kopenawa D, Albert B. A queda do céu: palavras de um xamã yanomami. São Paulo: Companhia das Letras; 2015.
• ⁶ Krenak A. Ideias para adiar o fim do mundo. São Paulo: Companhia das Letras; 2019.
• ⁷ Coletivo Vozes Indígenas na Saúde Coletiva. Vozes indígenas na produção do conhecimento: para um diálogo com a saúde coletiva. São Paulo: Hucitec; 2022.
• ⁸ Moreira LGG. O cocar e a caneta: a luta intelectual indígena no Brasil dos militares. Intellectus. 2024; 23(2):34-61. doi: 10.12957/intellectus.2024.84494.
  » https://doi.org/10.12957/intellectus.2024.84494
• ⁹ Conselho Indigenista Missionário. Relatório de Violência Contra os Povos Indígenas no Brasil - Dados de 2023 [Internet]. Brasília: Conselho Indigenista Missionário; 2024 [citado 23 Maio 2025]. Disponível em: https://cimi.org.br/wp-content/uploads/2024/07/relatorio-violencia-povos-indigenas-2023-cimi.pdf
  » https://cimi.org.br/wp-content/uploads/2024/07/relatorio-violencia-povos-indigenas-2023-cimi.pdf
• ¹⁰ Pontes ALM, Hacon V, Terena LE, Santos RV. Vozes indígenas na saúde: trajetórias, memórias e protagonismos. Belo Horizonte, Rio de Janeiro: Piseagrama, Fiocruz; 2022. doi: 10.7476/9786557081709.
  » https://doi.org/10.7476/9786557081709
• ¹¹ Silva KT, Bicalho PSS. Uma abordagem decolonial da história e da cultura indígena: ente silenciamentos e protagonismos. Rev Crit Cult. 2018; 13(2):245. doi: 10.19177/rcc.v13e22018245-254.
  » https://doi.org/10.19177/rcc.v13e22018245-254
• ¹² Bonin IT, Liebgott RA. Necropolítica e violências contra os povos indígenas no Brasil. Caminhos Dialogo. 2022; 10(16):46-63. doi: 10.7213/cd.a10n16p46-63.
  » https://doi.org/10.7213/cd.a10n16p46-63
• ¹³ Aquino JG, Val GM. Uma ideia de arquivo: contributos para a pesquisa educacional. Pedagogia Saberes. 2018; (49):41-53.
• ¹⁴ Graeff SV-B, Piccoli RP, Arantes R, Castro VOL, Cunha RVl. Aspectos epidemiológicos da infecção pelo HIV e da Aids entre povos indígenas. Rev Saude Publica. 2019; 53:71. doi: 10.11606/S1518-8787.2019053000362.
  » https://doi.org/10.11606/S1518-8787.2019053000362
• ¹⁵ Machado FCG, Ferron MM, Barddal MTM, Nascimento LA, Rosalen J, Avelino-Silva V. Covid-19 vaccination, incidence, and mortality rates among indigenous populations in Brazil. Lancet Reg Health Am. 2022; 13:100319. doi: 10.1016/j.lana.2022.100319.
  » https://doi.org/10.1016/j.lana.2022.100319
• ¹⁶ Ahmadpour B, Turrini RNT, Camargo-Plazas P. Resolutividade no subsistema de atenção à saúde indígena: análise em um serviço de referência no Amazonas. Cienc Saude Colet. 2023; 28(6):1757-66. doi: 10.1590/1413-81232023286.13672022.
  » https://doi.org/10.1590/1413-81232023286.13672022
• ¹⁷ Cunha MLS, Casanova AO, Cruz MM, Suárez-Mutis MC, Marchon-Silva V, Souza MS, et al. Planejamento e gestão do processo de trabalho em saúde: avanços e limites no SASI-SUS. Saude Soc. 2023; 32(2):e230127. doi: 10.1590/S0104-12902023220127.
  » https://doi.org/10.1590/S0104-12902023220127
• ¹⁸ Oliveira AT, Tombini LHT, Souza JB, Madureira VSF, Pilger KC. Efeitos da Covid-19 na atenção primária à saúde dos indígenas: percepções dos profissionais. Rev Pesqui Cuid Fund. 2023; 15:12081. doi: 10.9789/2175-5361.rpcfo.v15.12081.
  » https://doi.org/10.9789/2175-5361.rpcfo.v15.12081
• ¹⁹ Rocha ESC, Toleto NN, Pina RMP, Fausto MCR, D´Viana AL, Lacerda RA, et al. Atributos da Atenção Primária à Saúde no contexto da saúde indígena. Rev Bras Enferm. 2020; 73(5):e20190641. doi: 10.1590/0034-7167-2019-0641.
  » https://doi.org/10.1590/0034-7167-2019-0641
• ²⁰ Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000; 90(8):1212-5. doi: 10.2105/ajph.90.8.1212.
  » https://doi.org/10.2105/ajph.90.8.1212
• ²¹ Farmer P. An anthropology of structural violence. Current Anthropol. 2004; 45(3):305-25. doi: 10.1086/382250.
  » https://doi.org/10.1086/382250
• ²² Brasil. Ministério da Saúde. Política Nacional de Atenção à Saúde dos Povos Indígenas. Brasília: Ministério da Saúde; 2002.
• ²³ Brasil. Presidência da República. Lei nº 14.021, de 7 de Julho de 2020. Institui medidas de proteção social para prevenção do contágio e da disseminação da Covid-19 em territórios indígenas. Diário Oficial da União. 8 Jul 2020.
• ²⁴ Brasil. Ministério da Saúde. Conselho Nacional de Saúde. 6ª Conferência Nacional de Saúde Indígena – CNSI: relatório final. Brasília: Ministério da Saúde; 2025.
• ²⁵ Costa HS. O lugar das contra condutas na genealogia foucaultiana do governo. Rev Filosofia Moderna Contemp. 2019; 7(1):61-78.
• ²⁶ Brasil. Ministério da Saúde. Portaria GM/MS nº 28, de 20 de Janeiro de 2023. Declara Emergência em Saúde Pública de importância Nacional (ESPIN) em decorrência de desassistência à população Yanomami. Diário Oficial da União. 20 Jan 2023.
• ²⁷ Brasil. Presidência da República. Decreto nº 11.405, de 30 de Janeiro de 2023. Medidas para enfrentamento da ESPIN e combate ao garimpo ilegal no território Yanomami. Diário Oficial da União. 31 Jan 2023.
• ²⁸ Cabnal L. Tejiendo de otra manera: feminismo, epistemología y apuestas descoloniales en Abya Yala. Popayán: Editorial Universidad del Cauca; 2014.
• ²⁹ Lugones M. Toward a decolonial feminism. Hypatia. 2010; 25(4):742-59. doi: 10.1111/j.1527-2001.2010.01137.x.
  » https://doi.org/10.1111/j.1527-2001.2010.01137.x
• ³⁰ Brasil. Ministério do Planejamento e Orçamento. Exposição de Motivos nº 44, de 28 de Julho de 2023. Brasília: Ministério do Planejamento e Orçamento; 2023.
• ³¹ Escola Nacional de Saúde Pública Sergio Arouca. Informe ENSP. Pesquisa: todos os Yanomami de 9 aldeias assediadas pelo garimpo estão contaminados por mercúrio [Internet]. Rio de Janeiro: ENSP; 2024 [citado 23 Maio 2025]. Disponível em: https://informe.ensp.fiocruz.br/noticias/55050
  » https://informe.ensp.fiocruz.br/noticias/55050
• ³² Vaz C. Novo estudo detecta contaminação de indígenas Yanomami por mercúrio no Norte do país [Internet]. Rio de Janeiro: OHS; 2024 [citado 23 Maio 2025]. Disponível em: https://ohs.coc.fiocruz.br/posts_ohs/novo-estudo-detecta-contaminacao-de-indigenas-yanomami-por-mercurio-no-norte-do-pais/
  » https://ohs.coc.fiocruz.br/posts_ohs/novo-estudo-detecta-contaminacao-de-indigenas-yanomami-por-mercurio-no-norte-do-pais/
• ³³ Brasil. Portaria Conjunta Funai/Sesai nº 1, de 30 de Janeiro de 2023. Estabelece procedimentos de acesso à Terra Indígena Yanomami no período de vigência da Portaria GM/MS nº 28, de 20 de Janeiro de 2023. Diário Oficial da União. 1 Fev 2023; Sec. 1, p. 48.
• ³⁴ Walsh C. Interculturalidad, Estado, Sociedad: Luchas (de)coloniales de nuestra época. Quito: Universidad Andina Simón Bolívar y Abya Yala; 2009.
• ³⁵ Jezus SV, Silva AI, Arcenio RA, Terena NFM, Pinheiros JS, Sacramento DS, et al. Local action plan to promote access to the health system by indigenous Venezuelans from the Warao ethnic group in Manaus, Brazil: mixed-methods study. PLoS One. 2021; 16(11):e0259189. doi: 10.1371/journal.pone.0259189.
  » https://doi.org/10.1371/journal.pone.0259189
• ³⁶ Matta GC. Pandemia de Covid-19 e os povos indígenas no Brasil. Rio de Janeiro: SciELO Livros/Fiocruz; 2021.

Edited by

• Editor
  Rosamaria Giatti Carneiro https://orcid.org/0000-0003-0469-5447

• Associated editor
  Fabiane Vinente dos Santos https://orcid.org/0000-0002-1271-7645

Publication Dates

• Publication in this collection
  22 May 2026
• Date of issue
  2026

History

• Received
  24 July 2025
• Accepted
  18 Feb 2026