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Chungará (Arica)

versión On-line ISSN 0717-7356

Chungará (Arica) vol.49 no.4 Arica dic. 2017 



Vivian Gavilán1 

Patricia Vigueras2 

Carlos Madariaga3 

Michel Parra

1Departamento de Antropología, Universidad de Tarapacá, Arica, Chile.

2Escuela de Enfermería, Universidad Arturo Prat, Iquique,Chile.

3Escuela de Salud Pública, Facultad de Medicina Universidad de Chile, Santiago, Chile.

4San Isidro 292 Depto. 2510, Santiago, Chile.

The health policies aimed at the indigenous peoples of Chile are designed to comply with several legalframeworks (Law 19,253 of 1993, Law 20584 on Rights and Duties of Patients, Law 19,937 on Health Authority, Organic Regulations of the Ministry of Health, Organic Regulations of the Health Services, General Administrative Norm N° 16 on Interculturality in the Health Services, and article 25 of the ILO Convention 169). The objective of these frameworks is to reduce the inequalities in health provision and incorporate the ethnic demands put forward by the representatives of the nine indigenous peoples recognized by the State.

Among the strategiesfor the decade (2010-2020) are the healthpolicies andplans, the intercultural healthcare framework, and the intercultural health model. In this context, the following, among other, actions have been taken: the Health and Indigenous Peoples Program was created; epidemiological diagnosesfrom a sociocultural perspective have been made in regions with a high density of indigenous population; specialized teams have been set up to carry out intercultural community work; zonal interdisciplinary meetings have been held with the participation ofcommunity workers in order to create programmatic proposals in thisfield (Ministry of Health [MINSAL 2010]; and, more recently, technical guidelines to address mental health issues have been developed (MINSAL 2016). Thus, progress is being made towards the implementation of interculturality in health, both in the regulatory framework and in the training of health teams, especially of doctors in the destination and training cycles.

The initiatives are original considering that throughout the XX Century the Chilean State did not recognize cultural differences nor the health conditions of the indigenous population in relation to the non-indigenous. Neither did it set out to reduce the inequality gap. They are also innovative by taking into account the social sciences as a field of knowledge that can contribute both to the design and to the health practices. Nevertheless, a critical approach to these initiatives reveals conceptual issues that contradict their proposed objectives and the demands by the organizations representing the indigenous peoples.

Based on the work experience in the north of Chile, here we address the notions of interculturality, health cultural traditions of the indigenous peoples, and ethnicities as key issues to understand the actions of the State regarding pubic health. Even though different theoretical frameworks coexist in anthropology to understand these phenomena, there is agreement in that science is historic. Therefore, it is politically and ethically right to make them explicit and it is also necessary to provide empirical data to support them.

The Intercultural Programs Aimed at the Aymara People

Some of the actions that have been implemented in the Arica and Parinacota Region and in the Tarapacá Region include the participation of women cultural facilitators in the regional hospitals, the birthprograms , the inclusion of healers in city and rural clinics and in the medical rounds visiting distant localities in valleys and the high plateau. The agents participating in these initiatives are health authorities, public servants (including social anthropologists), Aymara healers and representatives of Aymara organizations (including health and social science professionals).

The study of the documents and of the meanings the actors give to the so-called intercultural practices shows that these are activities aimed at facilitating access to health centres and providing health care for the regional indigenous population. Emphasis is placed on the culture of the indigenous peoples, while the cultural dimensions of the health practices, which include both the medical actions and the models of which they are apart, are invisibilized. The intercultural approach in health is based on the assumption that indigenous medicine is traditional, in opposition to biomedicine, which would be scientific medicine. In the history of anthropology, this idea is part of the ahistorical perspectives that view tradition as opposed to modernity. And in the professions involved in public health, medical actions tend to assume the positivist perspective that sees the subject as a biological individual, alienating them from social life. These two paradigms are still present in university curricula, which explains the reproduction of these assumptions.

The naturalization of the biomedical model and the assumed existence of two pure and uncontaminated medical models that are in opposition, is based on the idea that the first model falls within the cultural tradition of the western society, whereas the second, within the indigenous cultural tradition; each one with their own agents (non-indigenous and indigenous); and each one with their own group of speakers, Spanish speakers, on the one hand, and Aymara speakers, on the other. These ideas follow what was set out by the Aymara leaders in the report of the Grupo de Trabajo Aymara de la Comisión para el Nuevo Trato (2004) [Aymara Work Group of the New Deal Commission] on health as a strategy to claim the rights to cultural difference. Influenced by the indigenous movement of neighbouring countries, the Aymara leaders use the concept of interculturality not only as referring to the interrelations between different cultures, but also to strengthen what is own, that which they see as subordinated by colonialism (Walsh 2007). The results of the organizational process, however, led to the affirmation of essential identities/otherness.

The dichotomy between traditional medicine and modern medicine, this last one understood as biomedicine, simplifies a complex reality, as in colonial contexts the development of actions in health has led to mixed and heterogenous systems and models. As pointed out by Menéndez (1987), they are seen as ifboth were externally-isolated and internally-homogeneous cultural systems, thus denying the existence of cultural heterogeneity within them. In this regard, it is relevant to acknowledge that indigenous peoples possess medical knowledge and carry healthcare knowledge, and, therefore, it is not appropriate to talk about indigenous traditional medicine and western or mestizo medicine. The traditional and the scientific are not homogenous, closed, static, or isolated categories, nor are they the only ways of healthcare people turn to (Menéndez 1987).

In fact, in the care practices of the public health system we can find variants of modern medicine, and the actions for the health and sickness of indigenous peoples can include modern medicine, the indigenous tradition, and the popular medicine practiced by both indigenous and non-indigenous. Additionally, we find health professionals that belong to the Aymara people who adopt biomedicine as the care model, as well as non-indigenous health experts who adopt indigenous health practices. Some are Aymara speakers but practice modern medicine, while others do not know the indigenous language but practice indigenous medicine.

The socioeconomic and sociocultural heterogeneity in which the Aymara live, as a result of the policies of integration to the national society, show that the levels of schooling, marital breakdowns, wage labor are increasing, the residence in more dynamic urban centres is reducing the number of born children per woman (Gavilán et al. 2017); and the access to public health centres is increasing. On the other hand, qualitative research about the situation and condition of the contemporary Aymara community shows how the integration patterns have taken place subordinating their cultural traditions and how they have been excluded from the design of the policies aimed at improving their situation and condition (Gavilán et al. 2010; 2011; Gundermann and González 2008, 2009). The Ministries of Education and Health have played an important role in these processes. The historical records confirm that the hegemonic model has been imposed with total disregard for the health practices passed on by past generations which contributed to maintain health and face illness in the indigenous group (Guerrero 1995; van Kessel 1983,1985).

Cultural Traditions in Health and Ethnicities

The heterogeneity of the indigenous population implies that the approach to collective health issues must acknowledge that health traditions are mixed and that the demands for cultural difference addressed to the State and the national society fall within the realm ofpolitics. In the context ofthe claims ofthe indigenous peoples in the Chilean north, ethnic identity refers to a type of differentiated social citizenship (Gundermann et al. 2014). In this regard, the affirmation of an ethnic identity does not necessarily imply cultural difference, just as the indigenous language may not index a cultural and/or ethnic tradition.

If ethnicities are understood as a phenomenon that refers to the idea of naturalized group identities (Appadurai 2001), it is possible to see how collective and individual subjects understand and characterize their cultural traditions in relation to those of other social groups as either inferior or superior. Oommen (1994) suggests that to the extent that ethnicities are transformed, they can be seen as processes; consequently, they change depending on the socio political contexts. In the current social pact between the State and the Aymara people, the affirmation of otherness tends to reproduce, rather than reverse, the power relations in health.

The fact that health practices do not distinguish between ethnicities and cultural traditions in health results in additional difficulty to achieve the objectives aimed at reducing the equality gaps. The data collected regarding the medical practices in the indigenous community of the Tarapacá Region show that they vary less by residence area (rural-urban) than by education level, access to modern medicine, religious affiliation and closeness ofmass media. The school has promoted the secularization and rationalization of social life as well as a growing individualism. Hence, the notions of body and the medical knowledge are not homogenous among the population. In the valleys, the own medical system has been more rapidly replaced by modern medicine. It is possible to observe, for example, the gradual disappearance of healers. The localities in the valleys, towns where the population concentrated until the mid XX century, have no healers. While in some cases they are replaced by the new generations, this time as professionals, in other cases they are replaced by healers from the high plateau and by a greater use of the public services. Even though the high plateau communities also show a similar trend, the clear presence of healers practicing daily, is evidence of a greater vitality of Andean medicine. Nonetheless, the tendency does not stop. In Isluga, a community located in the border of Bolivia and Chile, it is possible to observe the disappearance of women yatiris. This gradual loss is evident in the disappearance of the chriguano, a healer who used to walk across towns to offer their healing services. Further, there would only be one waytiri (from Chipaya), a highly regarded healer who possesses healing knowledge and techniques to deal with complexproblems (Gavilán et al. 2010; 2011).

Another visible aspect of the shift of the Andean medical system and acknowledged by the healers is seen in birth care. Births, attended at homes until the end of the XX century, are now forced to be attended in the hospital. On the other hand, a critical issue involves the language shift from the indigenous language to Spanish, which is to the detriment of the preservation of health knowledge.

Thus, the intercultural policies that regard the indigenous models and medical systems as traditional medicine and invisibilize the hegemony of the biomedical model, that do not distinguish between the health tradition ofthe Aymara community and the ethnic demands and -most importantly- the health conditions of the community, can be understood as another way of managing cultural and ethnic differences by the Chilean State to continue subalternizing the Aymara people.

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