Etnografia: uso, potencialidades e limites na pesquisa em saúde

Etnografia: uso, potencialidades y límites en la pesquisa en salud

Andrea Caprara^I,i; Lucyla Paes Landim^II

^IMD, PhD in Anthropology, Assistant Professor of the Department of Public Health, Ceará State University (UECE); Coordinator of the Humanities, Knowledge and Health Practices Research Group (UECE/CNPq) <caprara@uece.br>
^IIOccupational Therapist, Master in Public Health at the Ceará State University (UECE); FUNCAP grant-holder; Researcher of the Humanities, Knowledge and Health Practices Research Group (UECE/CNPq); Preceptor of the II Regional Territory, Fortaleza-CE. <lucylapaes@uol.com.br>

ABSTRACT 

Ethnography is used more and more often to study different subjects in health domain: the functioning and evaluation of healthcare systems; epidemiological research; laboratorial scientific research; biotechnology research; genetic research, among others. Certain methodological questions arise from critical reading of these works: How has ethnographic research evolved over the last few decades? What elements characterize ethnographic research as applied to healthcare? This paper seeks to reflect on these questions through two successive developments: 1. the evolution of the ethnographic method and its use in research on health; 2. the methodological aspects of an ethnographic study conducted with elderly people in the city of Fortaleza, focusing on participant observation.

Key words:  Ethnography; Qualitative Research; Participant Observation; Public Health.

RESUMO

O método etnográfico vem sendo crescentemente utilizado para estudar uma variedade de temas na área da saúde como: o funcionamento e avaliação do sistema sanitário; a investigação epidemiológica; a pesquisa científica de laboratório; a pesquisa biotecnológica; a pesquisa genética, entre outros. Isto nos leva a formular algumas perguntas metodológicas com base na leitura desses trabalhos: como foi se transformando a pesquisa etnográfica nos últimos decênios? Quais elementos caracterizam a pesquisa etnográfica aplicada em saúde? É buscando refletir sobre estas questões que desenvolvemos o artigo mediante dois sucessivos desdobramentos: 1 o desenvolvimento do método etnográfico de pesquisa e sua utilização na pesquisa em saúde; 2 os aspectos metodológicos de uma pesquisa etnográfica realizada com pessoas idosas na cidade de Fortaleza, focalizando o interesse sobre a observação participante.

Palavras-chave: Etnografia. Pesquisa qualitativa. Observação. Saúde pública.

El método etnográfico viene siendo crecidamente utilizado para estudiar una variedad de temas en el área de la salud como: el funcionamento y evaluación del sistema sanitario; la investigación epidemiológica; la pesquisa científica de laboratorio; la pesquisa biotecnológica; la pesquisa genética, entre otros. Esto nos lleva a formular algunas preguntas metodológicas a partir de la lectura de estos trabajos: ¿cómo se ha ido transformado la pesquisa etnográfica en los ultimos decenios? ¿Qué elementos caracterizan la pesquisa etnográfica aplicada en salud? Buscando reflexionar sobre estas cuestiones desarrollamos el artículo mediante dos sucesivos desdoblamientos: 1 el desarrollo del método etnográfico de pesquisa y su utilización en la pesquisa en salud; 2 los aspectos metodológicos de una pesquisa etnográfica realizada con ancianos en la ciudad de Fortaleza, estado de Ceará, Brasil, enfocando el interés sobre la observación participante.

Palabras-clave: Etnografía. Investigación cualitativa. Observación. Salud pública.

INTRODUCTION

In the last decade, research on health has been accompanied by a growing interest in the use of qualitative methods and its research instruments applied throughout the 20^th century by social sciences and in anthropology in particular, in the study of other cultural groups. This interest is attributed to a number of reasons, such as the importance currently given to national healthcare policies regarding the qualitative dimension of the healthcare services offered to citizens, placing a growing need on the introduction of research and evaluation instruments focused on valuing the users' perception (Gomes et al, 1999). Thus, though somewhat strange to the tradition of research on health and healthcare, the methods of qualitative research assume particular relevance in reference to such works.

Within this theoretical-methodological framework, the ethnographic method has been used by several authors to study a variety of themes in the health area, from the functioning of the health system, through the evaluation of the quality of healthcare services from the users'perspective (Andrade & Vaitsman, 2002; Atkinson, 1993), to the doctor-patient relationship and the teaching of medicine (Nunes, 1993; Menezes, 2001; Bonet, 2004; Nations & Gomes, 2007); evaluation of the Family Health Program (Programa de Saúde da Família) (Trad et al, 2001); interpretations and practices of the population (Killinger et al, 2000; Rego et al, 2002; Iriart & Andrade, 2002; Nations & Nuto 2002; Rodrigues & Caroso, 1998; Souza, 1998; Alves, 1998); epidemiological surveys (Almeida Filho et al, unpublished); even themes like laboratorial scientific research (Latour & Woolgar, 1997); biotechnological research (Rabinow, 1999; Rabinow, 1996); genetic research (Bibeau, 2004); discussions concerning the practices of transplants in Japan (Lock, 1995) and others that currently compose the wide field of public health (Paim & Almeida Filho, 1998).

Certain methodological questions arise from critical reading of these works: How has ethnographic research evolved over the last few decades? What elements characterize ethnographic research as applied to health and healthcare? Can a study based exclusively on focal groups or open interviews, with no research process of careful observation of the practices performed be defined as ethnographic (Brink & Edgecombe, 2003)? This last question recalls an article by Trad et al (2001), who presented an ethnographic study where data collection basically occurred in focal groups. It is pertinent to ask whether the recent and growing use of ethnography in research on health would not almost characterize a distortion of its original premises, configuring what could be termed as ethnographic-like observation.

It was in seeking responses to such questions that we decided to develop this article, aimed at reflecting through two successive developments: 1. in the first part, after a brief analysis of the principal debates that marked the development of ethnography in anthropology, we sought to analyze how the ethnographic approach is currently used by diverse authors in research on health and healthcare;  2. and in the second part, we present the methodological aspects of an ethnographic study conducted with elderly people in the city of Fortaleza, focusing on participant observation and recording in a field diary. The study concerned was conducted in a city neighborhood and investigated how elderly individuals who frequented groups for the elderly perceived their own health and how they took care of themselves in their daily experiences.

The ethnographic research method: reflecting on its development

To approach the development of the ethnographic method in the health area, it is first necessary to reflect on the use of qualitative methods in public health. Thus, as the introduction affirmed, over the last few decades, a consistent growth in publications in the health area has occurred involving research using qualitative methods (Meyer, 2000; Jones & Hunter, 1995; Pope & Mays, 2000). Among the themes elaborated, studies concerning the experience of patients with chronic diseases, research regarding the organization of healthcare services and the humanization of attendance, working in multidisciplinary teams were all observed. The Brazilian literature also presents a sizable bibliographic production describing the use of qualitative methods in public health (Minayo & Minayo-Goméz, 2003; Almeida Filho, 2003).

When we speak about qualitative methods, in reality this concerns an extensive range of research methods aimed at data collection regarding the "social universe" (Pope & Mays, 2000). This is why they demand, on the part of the researcher, a trajectory of exploration and interpretation of data originating from several sources. The logic of qualitative research is often of the inductive rather than deductive type and consists of describing people and groups in specific situations. Qualitative research seeks to understand meanings, experiences and is often flexible, dynamic, such that the methods and aspects related to the study design can be modified, in part, as new information is collected. The analysis and interpretation of the data change over time as the researcher adds new elements and improves his or her understanding of the context studied, a common fact in ethnographic studies (Rosaldo, 1993). Thus it can be affirmed that the process is not linear, not sequential; moreover, good qualitative research also seeks to answer well-formulated questions.

In synthesis, numerous authors agree in identifying three strategies of data collection that characterize qualitative methods: 1) face-to-face interviews, which in turn can be semistructured, open, in-depth and/or life stories; 2) group interviews and/or focal groups; 3) direct observation of human life, participating in social and cultural events with people in their life situations (direct and/or participant observation); and, as a fourth element, it is also worth noting data collection in written documents (Patton, 1987). The data collected are then organized according to major themes, categories, similar cases, and their analysis consists in the constant comparison of the elements that emerge in the diverse interviews and observations, seeking common elements and possible differences. Particular attention is paid to the semantics of the phrases used, the transcription of the final text of phrases originating from these interviews and the thematic organization. Data analysis is not limited to predefined categories. The phenomenon cannot be understood outside of its context, which is why meaning emerges from the relationship with other signs and in anthropology, meaning is always culturally constructed: "nothing is what is seems to be" (Banyai, 2002).

These are the characteristics of qualitative research that are at the center of the debate between the scientific community and society, influencing the development and application of qualitative methods in research, including the ethnographic approach, in a wide range of sectors and institutions, such as economy and communication. In the field of public health, the development of policies and forms of socio-sanitary organization (information systems, demand analysis, services evaluation) has enriched the debate in a field traditionally marked by epidemiology linked to quantitative research methods.

The second reason refers to the changes that have occurred in anthropology, principally in the last few decades, through the specific attention of researchers oriented toward their own western societies. The shift in attention from the tradition task of studying "primitive" societies to cultural analysis of the society to which you belong produces a series of central methodological questions, such as reflection regarding the object, context and the very instruments of anthropological research (Latour & Wolgar, 1997; Rabinow, 1996). This is a reflexive change that has illuminated the relativity of definitions, including those of the individual, society and identity, centering the discourse on the relational and linguistic nature of the cultural resources constructed and used by people (Benini & Naclerio, 2004).

The third reason is linked to the historical trajectory that marks the development of human sciences as opposed to natural sciences. For the first few decades of the 20^th century, anthropology was characterized by a certain "biologicism", together with the development of positivism in the biomedical sciences. In successive stages, anthropologists began to counter the dominant scientific ideologies regarding health, disease and the body, with the culturally constructed character of these concepts, seeking to understand the forms through which individuals express and interpret pain and suffering. In the last few decades, growing interest in understanding the cultural construction of health and disease elaborated by different cultural groups has emerged in research on public health, which has been studied through ethnographic research. Thus, an interest on behalf of researchers in the health area concerning the individual, familial and cultural experience of disease was stimulated, principally through the use of qualitative methods (Wiklund et al, 2002; Souza, 1998; Nations & Nuto 2002; Rodrigues & Caroso, 1998; Caprara, 1998).

The investigation method of choice in anthropology is ethnography, considered by Hammersley & Atkinson (1994) as the most basic form of social investigation that works with an ample array of information sources. By ethnographic method, we mean a ground level research activity, for prolonged periods of time, in direct contact with the object of study, followed by the systematization of the experience in a text format (Fabietti & Remotti, 1997). Besides the long period on the ground, ethnographic research is not an empirical space in which an anthropological theory is applied or evaluated. It is an activity during which the theoretical knowledge is constructed together with data collection (Pizza, 2005). Thus, it is not only a research method, but a process conducted by sensitive reflection, taking into account the field experience itself together with the people who the anthropologist is working with (Geertz, 1989). According to Cardoso de Oliveira (2000: 24), this makes the "semantic horizons involved - that of the researcher and the native - open up to each other in a way that transforms the confrontation into a true ‘ethnographic encounter'". According to the author, the work of the anthropologist consists of looking, listening and writing. This last aspect cannot be left out or neglected by the researcher, such that "when penetrating forms of life that are strange to the researcher, the living experience that these begin to take on fulfills a strategic function in the act of elaborating the text, since this living experience - only attained by participant observation, ‘being there' - is evoked during the entire phase of interpretation of the ethnographic material in the process of its inscription in the discourse of the discipline" (Cardoso Oliveira, 2000:34).

Initially, during the foundation of social sciences, ethnography was considered to be the simple collection of data to represent the authenticity of a culture. The researcher did not explain how these data had been collected, how the field work had been developed, or the theoretical presuppositions that oriented them. According to Clifford (2002), ethnographs were not always written by anthropologists and prior to the end of the 19^th century, the ethnographer and anthropologist were distinct actors. It was Boas and Malinowski who identified ethnography with the social investigation method characteristic of anthropology. These two authors lived at the same time and both prioritized field work and participant observation as primordial methods of ethnographic research (Laplantine, 2001).

Great importance is conferred to the description of field work and how the process of insertion, observation and the collection of information occurs on the part of the ethnographer, remembering that "in ethnography, the distance between the raw material of information (…) and the presentation of the final results is frequently enormous" (Malinowski, 1986). It is in this sense that Geertz (2000), founder of Interpretive Anthropology, the current affiliated with hermeneutics, refers to "being there", in the field, and "being here", in the office. It is the introduction of this detailed report of the vicissitudes that the ethnographer goes through, together with a full and passionate description of that know as "the imponderables of real life", the subtle daily facts that are rich in meaning, such as caring for the body, eating habits, the tone of conversations and social life, friendship, sympathy or aversion between the people and others, that will "create, for the reader, a living human image of a people completely different from ourselves" (Durham, 1986:9).

This aspect of the living report of the ethnographic discourse is highly emphasized by Malinowski (1986) and is determined as fundamental for the posterior development of ethnography. As Clifford (2002:21) highlights: "Ethnography is, from start to finish, immersed in the discourse. This discourse includes, at the very least, a translation of the experience in written form". For Geertz (1989), the text is of great importance, since it is in the form of the text that the interpretation, which can be multiple, occurs, since it is inherent to text to be open to interpretations as different as the readers and their points of view, visions and conceptions of the world.

This second methodological form, to which Geertz adheres, acquired greater relevance from the 1960s onwards, in which greater importance is given to an in-depth analysis of specific phenomena rather than trying to identify generalities (Geertz 1993). At that time, a series of interpretive theories were postulated interested in studying the social structure/human relations; social rules/forms of communication; things in common/differences, and other themes. Geertz's ideas permitted the differentiation between systematic studies that analyzed a culture as a system of relationships and studies of processual analysis, which determined the importance of life stories, concrete case studies, which Geertz denominated "thick description".

Nowadays, besides studies concerning global policies and culture (Appadurai, 1996) and epistemological critiques of structural theory in defense of a practical rationality (Obeyesekere, 1997; Da Silva, 2002), we must also consider that ethnographic research is understood as more of a dialogue between the interpretative constructions of the researcher and the people studied (Clifford & Marcus, 1986; Rabinow, 1996). With the dialogical model, the "pure objectivity" of the ethnographer is abandoned and a polyphonic model is developed, based on the dialogue between the ethnographer and the person interviewed, including negotiation concerning the meanings of the experiences of the subjects in the field (Clifford & Marcus, 1986). Thus, the results are never definitive.

This model is also proposed by Renato Rosaldo (1993), who criticizes the Weberian concept of passionate distance, introducing the concept of positioned subject. Rosaldo suggests that the researcher has to explore the subjects of their research from a given position, which he calls the repositioned subject. The researcher begins with a series of questions that are modified during the process of the research. For example, Rosaldo's own ethnographic experience with the Ilongot, head-hunters in the Philippines, and the anger that group members felt after the death of someone in the family. In the position of researcher, Rosaldo had difficulty in understanding this rage and this emotion as the principal motor of the hunt. The experience of the death of his wife in an accident led him to the theme and the analysis of anger within mourning, analyzing it in a completely different way. His personal experience served as a vehicle so that the anger of the Ilogont was more accessible to the reader's understanding. In this sense, a criticism of previous sociological and ethnographic studies was established.

Taking the example of studies concerning death (death rituals), Rosaldo (1993) affirms that authors who touch on this theme while eliminating the intense emotions, not only distort the descriptions, but also eliminate important analysis variables. Thus, he criticizes studies concerning death in which the researcher remains in a position of detached observer. In so doing, he emphasizes the researcher who constantly repositions themselves as the "positioned subject".

The concept of position refers to how the researcher's life experience can facilitate or inhibit the study of specific types of problems, such as their age, sex, etc. Given that culture is linked to power, the researcher has to question themselves, at the onset of their work, concerning the social position that they occupy and that of the interviewees. For example: does the person being interviewed speak from a position of power or subordination? What kind of experience do they have? What are the complex forms that constitute their social identity?

It is in this sense that Geertz (1989) states that a continuous tension has to exist between scientific analysis and the experiences of daily life. The term that most reflects this tension between participation and detached observation is participant observation, which expresses a paradox: the first term (participant) expresses emotional involvement; the second term (observation) expresses distance. James Clifford (2202) tried to overcome this paradox by defining participant observation as a dialectic between experience and interpretation. A continuous passage exists between the "internal", the interpretation, the analysis of the facts, and the "external", the wider context: "understood literally, participant observation is a paradoxical and deceitful formula, but it can be considered seriously if reformulated in hermeneutic terms, as a dialectic between experience and interpretation" (Clifford, 2002:33). In this sense, it is necessary to understand the meaning of the experience as a process of knowledge and not simply as personal experience (Fabietti, 1999).

This interest in studying specific phenomena encounters its expression in studies of subjective experience. Life stories become important methods and are incorporated in public health studies (Van Manen, 1990, 2002; Alencar, 2006). Therefore, modern ethnography provides space for the ethnographer's subjectivity, the use of the first person in ethnographic texts, the use of self-reflective considerations. This produces self-reflection among the members of the group studied.

The first question was raised by Claude Lévi-Strauss (1986), who entitled one of his books "The distanced look". A researcher who observes his own society has greater difficulty in determining the cultural specificities in relation to an external observer. The second aspect refers to the way scientific practices are observed. In his recent book on genetics research, Gilles Bibeau (2004) identifies two groups of researchers: the first closely analyzing the spaces of the production of scientific thought. For Bibeau, these studies appear reductionists, especially those that approximated the style of Bruno Latour, who mainly analyzes the processes of the construction of scientific thought. A second group of researchers who study scientific processes within a wider vision that analyzes not only life in the laboratory, but also the production of inventions through their copyrights and the market, with its alliances, conflicts and with special attention to what is referred to as the bioindustrial actionist market.

In the second part of this article, we discuss the methodological aspects regarding participant observation from recordings in a field diary and the research report of an ethnographic study conducted with elderly people in the city of Fortaleza by the coauthor of this work. 

Observe, participate, interpret: pathways of an ethnographic study

Paes Landim (2004) conducted an ethnographic study, particularly influenced by the interpretive anthropology of Geertz, aimed at investigating how elderly individuals in an unfavorable economic situation and who frequented groups for the elderly, perceived their own health and how they took care of themselves in their daily lives. The study was approved by the Ethics in Research Committee of the Ceará State University (Universidade Estadual de Ceará, UECE).

From this perspective, great importance is conferred to the observation of events, rituals, which reveal elements or aspects regarding the rules, the culture of the group. Therefore, the study design made use of the beneficial dialogue between the social sciences and the areas of health and healthcare, specifically anthropology, which, as Durham (2004) stated, presents provocative and stimulating material for rethinking social reality.

The field research was developed in Fortaleza, from January 2003 to February 2004, with a group of elderly individuals from the Luiza Távora Community Center, located in the Vicente Pinzón neighborhood. This neighborhood, the context of the study, possesses a population of 39,551 people, among whom 2,371 are 60 years-old or over. The number of literate individuals totals 28,757 and among those who are 60 years-old or over, the total is 1,423 (Brazilian Census Bureau - IBGE, 2000).

However, these data are insufficient to contextualize the neighborhood. A neighborhood, besides retaining historical, esthetic, topographical, socioprofessional and other characteristics, is also a place where: "the space/time relationship is more favorable to an actor who desires to walk through it on foot, upon leaving his home. Consequently, it is a piece of the city permeated by a limit distinguishing the private space from the public space: it is the result of a walk, the succession of steps on a sidewalk, little by little imbued with meaning due to its link with the residence" (Certeau et al, 2003: 41). It is in this sense that it becomes understandable what is revealed by the slow gait of the elderly who freely walk through the streets, alleys and side streets of the neighborhood they actively helped to construct.

Conducting an ethnographic study presupposes a period of living with a group that you want to get to know. Every investigation involves one or more trips to the field before the more intensive work begins, evaluating the situation in which you will be working, seeking: "to foresee the details of the initial impact of the research, that is, how to present it, how to present yourself, who to present yourself to, through whom, with whom should you establish your initial contacts" (Minayo, 2000:103). This moment is recorded in the researcher's field diary:

Another extract portrays this initial moment of the researcher entering the field and indicates that the first incursions into the group that a researcher wants to study are characterized by the adoption of strategies of acceptance, so common and necessary to conduct research work using the ethnographic method:

 "At 9 o'clock I follow the coordinator to the patio and to the large room where the elderly people are gathered. The sun is strong, it's hot. Like the last time that I was with the group, they are all sitting in plastic chairs in the shadow of two tall, leafy almond trees in the middle of the patio; others are seated in the shadow of the veranda. I perceive that the people recognize me. I say good morning to everyone and sit with them. The people who I talked more directly to the last time welcome me with a wave. I am happy to see them again" (Paes Landim, 2004).

The field diary is the most basic instrument for the researcher who is conducting an ethnography. It is a personal document and in it we write observations, experiences, feelings, sensations, even subjective insights; however, the image of a diary inspired by the works of the first anthropologists of a hard cover notebook, manuscript, is being surpassed by the growing use of laptops/notebooks "with the conditions to support sophisticated programs for receiving and managing qualitative data" (Víctora et al, 2001: 73). Even when using an electronic field diary, the researcher should maintain the function of this instrument, which is to record as faithfully and in as much detail as possible each trip to the field: "often it is the information in the field diary that provides the information to analyze the data collected by other means. It should maintain the logic of a travel diary, in which you write every day without restrictions" (ibidem).

Entering into the field is a moment rich in subtle significance that requires care and empathy on the part of the researcher.

On the first day, I chatted to some people who were seated beside me. I heard stories of love, stories of disease, I saw people chatting loudly, smiling, being quiet, praying, dancing, eating and, eventually, leaving, though not before (many of them I didn't yet know by name) hugging me, or kissing me, or shaking my hand and welcoming me. No unfamiliarity, rather consideration. These people accepted my presence in the group with simplicity and spontaneity and, because I had been presented as a researcher, with a certain curiosity (Paes Landim, 2004).

Once accepted by the group, the researcher can achieve participant observation, which necessarily implies a social relationship between the researcher and the researched. The quality of the data obtained depends to a great extent on how this relationship is established. For Cardoso de Oliveira (2000), true interaction between the researcher and the informant occurs when the latter assumes the condition of interlocutor. Thus, it is possible to maintain a dialogical relationship of proximity and trust, based on ethical principals. It is important that the research report clarifies how this came about:

I began to attend the group meetings once a week and participate in the activities developed, such as the moment of prayer, the body work, the forró [popular regional dance], and others. In a short period, my presence became part of the group scenery. The elderly people and the coordinator developed a reciprocal relationship of trust and affection with me. However, body contact was intense, especially with the elderly people. I was literally hugged by seventy people every time I attended the group. And I returned the hugs with the same intensity. However, the affectionate reciprocity did not dissolve my alterity, present independent of the desire of the researcher, as Zaluar would say, in the gestures, in the possession of objects like a recorder, in my hard cover red agenda… Rather, this reciprocity was positive and based on a relation of trust that was being constructed in the field work (Paes Landim, 2004). 

For James Clifford (2002:20), the ethnographic field work "remains as a notably sensitive method. Participant observation obliges its practitioners to experiment, both in physical and intellectual terms, the vicissitudes of the translation. (…); as a means of producing knowledge from intense intersubjective involvement, the practice of ethnography maintains a certain exemplary status".  

Since I participated up to the end of group's meetings, which usually ended around midday, I ended up establishing a routine of giving lifts to some people who lived along my route. I also accepted invitations for coffee in some homes, invitations always accompanied by "my home is simple, but you'd be very welcome" or "it's a poor man's home, there's nothing there, but it has a big heart" (confirming DaMatta (2000) concerning our hospitality). And so I bonded with these people. I got to know the neighborhood better and already knew how to locate their homes (Paes Landim, 2004).

Paes Landim (2004) used as a reference, Éclea Bosi, who reports in her text: "The principal support for my method of approach was the formation of a bond of friendship and trust with the reminiscers. This bond does not only result in the spontaneous sympathy that developed during the research, but also in the maturing of those who desire to understand their own life revealed by the subject" (Bosi, 1994: 37).

I remembered the name of Liberalina from the first moment we were formally introduced. Her gracious appearance, tiny, always wearing a blue crochet hat that, I later learned, she made herself; she caught my attention on the first day of observation. The empathy was reciprocal and during my incursions in the field, from conversations between one group activity and the next, from lifts at midday, we established a relationship of affectionate trust. Liberalina, 86 years-old, was an assiduous participant in the group. Her slim body had an impressive readiness, in my eyes, for movement. She actively participated in the body work, dancing, games, dramatizations, proposed by the group coordinator (Paes Landim, 2004).                 

In this moment, a series of questions arise regarding the how to understand the reality that presents itself and what theoretical tools you can count on. More than ever, the following reading of Geertz makes sense: "What the ethnographer faces, in fact - except when the researcher is following more automated routines of data collection - is a multiplicity of complex conceptual structures, many of them overlapping or tied to one another, which are simultaneously strange, irregular and unexplained, and which the researcher has to first learn somehow and then present. (…). Doing an ethnography is like trying to read in the sense of constructing a reading - a strange manuscript, full of ellipses, incoherencies, doubtful amendments and biased comments, discourses not like conventional signs of sound, but with transitory examples of modeled behavior" (Geertz, 1989:7).

At times in the field, an intense activities exchange of information occurred. The informal chats that I maintained with the people began revealing to me the universe in which they lived, what they thought, what they did in their daily routine, and many of the questions I had put to myself were answered during participant observation (Paes Landim, 2004).

The participant observation conducted with the group revealed that the limits attributed to the elderly are not defined by them, rather by others, generally much younger, who try to dismiss the power of those who are living through old age. The ethnographic study shows that these people are in constant movement, seeking to overcome the limitations imposed by the hard conditions of the existence in which they have lived since infancy and that have perpetuated throughout their lives: working during infancy, hunger, privations, the absence of studying, the absence of honestly valued paid work, the absence of adequate healthcare, dependence on state assistance. The caring for themselves observed on a daily basis revealed a series of daily life tactics of medicinal, dietary and bodily care and the development of new knowledge, such as craftwork and the return to studying, and the intense participation in elderly groups and, prayer groups that contributed to maintaining the sociability, autonomy, interest in life and new projects that directly influenced the health and well-being of these elderly people.

Conclusion 

The article seeks to open up the debate concerning ethnographic research by showing how it has been transformed over the last few decades and how it is currently being used to study a variety of themes in the areas of health and healthcare. The recent and growing use of ethnography in research on health should provide better understanding of the issues studied; however, many of these studies are not founded on careful observation of the practices performed. It is pertinent to ask whether the recent and growing use of ethnography in research on health would not almost characterize a distortion of its original premises, configuring what could be termed as ethnographic-like observation. It is understood that this could be occurring as a consequence of certain difficulties currently faced by researchers, including the short time periods given by postgraduate programs and by research support agencies, as well as by the difficulties inherent to the method that demands prior training of the researcher and a familiarity with the classical texts of anthropology, readings of research reports and field diaries and, of great importance, the capacity to write. Ethical questions are also current for the researcher who proposes to make use of ethnography. When entering a group or institution to conduct research with this method, the researcher begins to watch, listen and write everything that he perceives as important to elucidate the object of study. How should you obtain free, informed consent from all the subjects within the field of the research? How should you enter the homes of people, get to know their families, the way they live? And in institutions, like those of healthcare services? These are but some of the ethical questions raised and that researchers who seek out this field of study need to formulate and balance.

We believe that despite the profound transformations produced, the principal element that still characterizes ethnographic research today is founded on the careful observation of the practices performed, in a continuous tension between scientific analysis and life experiences.

COLLABORATORS 

Andrea Caprara was responsible for the article's conception and the development of the introduction and first part. Lucyla Paes Landim participated in the conception, collection and interpretation of the research presented in the second part.

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