So, I know I’m not in Chile anymore, but I still think about my host families and friends there often. I had the opportunity this semester to take the independent research I did and write another paper, this time in English, on my empirical work abroad. It was for the Tufts University Student Spring Anthropology Symposium, which happened on March 28, 2014. I presented my paper, mom and dad sitting in the audience among professors and fellow students. Dad suggested I put the paper up here so anyone could read it. I think it’s a nice writing sample, and also in English, so those of you who couldn’t read my original paper can read this re-vamped analysis of the work. (Also–It’s pretty long; it was supposed to be a 15 minute speech).
Adrian is a fellow anthropology student at the Universidad Católica in Temuco, a friend of my host family’s, who had agreed to help me get around during my month-long stay in the south of Chile. He didn’t have a car, so we walked almost everywhere. In the countryside, things can be an hour away from a main road, but with a good pair of boots, a good conversation, and the lush, springtime pastures to take in, walking was never that bad. That day, we were headed to visit the family of an old friend of his. They lived in a region I had never been to before, which Adrian informed me was called the “red zone,” because it had historically been the major area of conflict between the indigenous Mapuche peoples and the Chilean government. Issues between the two began in the late 1800’s, when Chile expanded its territory into the region south of Santiago, then inhabited exclusively by Mapuche people. This expansion began with the military, and continued with the extension of Chilean education, health systems, religion, and government structures. Conflict continues to this day, both violently and diplomatically, as the Mapuche fight for autonomy and recognition as an indigenous nation. Adrian himself was a Mapuche activist, so the struggle was often a topic of conversation. Initially, I couldn’t see how this farmland was any more “red” than the rest of the countryside I had seen; it was quiet, save for the occasional bleat of a sheep, and it was covered in green. As we walked on, cutting through pastures, I began to hear noise from above us. I looked up to see a helicopter, high up, circling, then it moved on. Every ten minutes or so, a helicopter would appear, then disappear. Adrian informed me they were military copters, always surveying for activity in the “red zone.” He laughed, and joked that they were after him, because he had kidnapped a gringa. Here was a space where the everyday experience of the Mapuche met the state, an intersection of lives and the top-down rules that governed them. Adrian’s joke was his way of navigating between resisting the influence of the state and living his everyday life. This same tension—and the same pattern of informally negotiated coexistence—exists within the Chilean state health care system, where state-sponsored biomedicine directly influences the Mapuche patient identity. Though this interaction occurs throughout the heath care system, I specifically examined one locus, the Poster of Patient Rights and Responsibilities. This poster must be present in each public and private health care establishment, as part of the Patient Rights and Responsibilities Law, passed in 2012.
Western biomedicine has very largely become the dominant model for understanding health worldwide, and continues to take over spaces or create new ones to challenge altering paradigms. National governments, including the Chilean government, have largely embraced biochemical and epidemiologic explanations of health as a convenient mode of subjectification. We can think of biomedical health delivery systems in terms of Foucault’s governmentality; science and health information can be utilized to both create and control ideal, rule-following subjects. It is not the State’s power acting directly, but the influence of sub-state institutions and the internalization of rules by individuals that work to form these subjectivities. The politics surrounding power over life and bodies, biopolitics, has been extensively examined in the field of Anthropology, and authors such as Paul Rabinow and Nikolas Rose argue that biopolitical spaces can be pockets of positive potential. Indeed, other literature on biopolitics highlights projects to enhance and maximize life, and Rabinow and Rose themselves call for further anthropological exploration of pockets of resistance to top-down employment of biopower.
The idea of a modern liberal state, as we can think of the federal government of Chile, strives to solve social problems within the country; this includes health care problems of access and quality. This model, and indeed, the State of Chile, operates on the idea of equality of all citizens. Equality does not imply sensitivity to specific socioeconomic, cultural, or historical regional differences, and these differences may lead to differing levels and types of need throughout a complex national landscape.
Tensions arise when alternative frameworks of health persist within a larger, state-sponsored biomedical health system. If the people making political decisions take alternative health into account, they often do not consider them on equal terms with the dominant biomedical model. Thus, practitioners of these alternative understandings of health, disease, and illness must somehow navigate spaces of the biomedical system in order to maintain key values of their lifestyle. I argue that, in the case of the Poster of Patients Rights and Responsibilities, rather than inciting a pure resistance to the state-driven biomedical and health rights paradigm, these posters are an intersection in which a hybridization of health and health rights paradigms occur. This results in an alternate form of subjectivity due to a constant, uneven, give and take between localized values and modern liberal state projects.
The health care system currently in place in Chile is a mixture of publically and privately funded health infrastructures. Huge reforms of the public health care system have been implemented since the 90’s, many of which focus on placing the patient at the center of their health care. These reforms work to bolster patient empowerment and active participation in their health, and the Patient Rights and Responsibilities Law of 2012 is an extension of these attempts.
In a similar vein, health care reforms have also worked towards the autonomy of indigenous peoples in Chile, such as the Mapuche. For example, both Western biomedical care and traditional healing practices must be available in Mapuche communities, but several regulations allow community leaders, without state input, to decide the most appropriate integration of the two health systems. The state labels this integration as “Intercultural Health.”
The Mapuche model of health care, on the other hand, views the individual body as a single sphere of his or her greater spiritual, psychological, and social existence. Basic to the Mapuche cosmovision is the concept of Küme Mongen, translated from the native language of Mapudungun as “well being.” It is a comprehensive and integral concept in health; it indicates equilibrium throughout every level of a person. This equilibrium encompasses not only the state of the family, the community, and the environment in which a person lives, but also the state of their beings on all planes of existence, physical, spiritual, and social. Illness occurs when equilibrium is disrupted. The Mapuche framework for understanding health is a framework for understanding Mapuche identity and Mapuche lived experience; one’s all-around well being cannot be separated from one’s physical body.
To explore the relationship between localized, everyday Mapuche experience and the public health system, I will compare two versions of the Poster of Patient Rights and Responsibilities. During my fieldwork, I identified information sources and characterized attempts by the state and health institutions to make the information in this law visible and understandable for Mapuche patients. I conducted patient surveys, interviews with health care professionals and government personnel, and observed the Poster of Patient Rights and Responsibilities in these centers. The first version of the poster is the government-distributed one. The second version I observed was a custom-made poster, on display in the traditional medicine wing of an intercultural hospital.
The federal government poster is 3-by-3-feet and blue, with pictures and short accompanying descriptions of 15 specific rights that apply to the entire patient population of Chile. Examples of included rights are the right to have timely and comprehensible information related to a patient’s state of health, the right to be informed of the costs of health care, and the right to receive visitors, company, and spiritual assistance. Not all rights included in the law are displayed on the poster. Intercultural health rights, for example, though stated in the law, are not displayed on the poster.
I observed that the government-distributed poster hung prominently in some spaces, such as the entrance waiting room of the local hospital. In fact, this hospital had eight posters visible, in different waiting rooms. One was set up adjacent to a trophy cabinet, which displayed various awards won by the hospital and staff. The emergency room displayed the poster in a giant wooden frame on the wall immediately in front of the sliding double doors (Imagine being wheeled in on a stretcher and before even seeing a doctor, you see a big blue list of patient rights). On the window to the reception was a miniaturized version, taped on the inside surface of the glass.
In the primary health care center in town, only one 3-by-3-feet poster was displayed; yet it was not entirely visible as it was hung on a wall behind the chairs, easily covered by patients’ heads.
Finally, in the rural health post I visited, which was about a 30-minute drive outside of town, I observed three miniature posters, outside of the three examination rooms. These health posts are staffed once a month by a full medical team and twice a week by a doctor. These spaces are predominantly used to do routine check ups on the elderly and less mobile farming population who live in the countryside.
I visited two primary care intercultural health centers, in addition to the public health centers. One, which was also located in the countryside, did not display a poster at all, even in their western medicine wing. The second center, located in a different town had a custom-made poster on display in the waiting room. I learned from the coordinator of traditional medicine in this center that it was only a temporary space for their operations, and that they were soon to move into the wing of the new hospital down the road. The waiting room therefore had few posters (unlike all other waiting rooms in both western and biomedical health centers in Chile, which usually had their walls plastered with health messaging signage). The only posters were one detailing the signs and symptoms of Hanta virus, and, two stacked 8 ½ by 11 inch papers, mounted on green construction paper, typed and printed and produced on an office computer. This was the custom-made Patient Rights and Responsibilities poster.
In speaking with the director of the government Hospital, the one with eight visible blue posters, I learned about the limitations of the law, poster, and ideas of equality. I asked several questions about whether or not the public hospital has any special materials or practices to help Mapuche patients understand their rights and responsibilities. The director frequently cited equality of all patients under the law, and equality of all citizens under the constitution, as the reason for a lack of Mapuche-specific educational materials. The law assumes that all patients can read Spanish and understand the poster, so there is no differentiation between patients when informing them of their rights. General materials, in addition to the posters can be found extensively online, and I picked up a few pamphlets as well. All were targeted at a general Chilean population. Through later interviews, I learned that not all Mapuche patients are literate in Spanish, especially the elderly. The hospital does take this into account, and tries to provide ample audiovisual materials to help patients understand health care reform. The hospital, however, cannot measure the effectiveness of their messaging among specific groups. They are paralyzed by equality; as an arm of the liberal state, they cannot conduct studies targeting one ethnic group over another. Here, I found the state as a strong entity, and the government-distributed poster a space of limited negotiation. If you are a patient here, you are expected to conform to a singular type of citizenship.
The second, custom-made version of the poster, showed potential for a different type of patient identity. The director of the center noted that the primary method of informing patients is through “citizen participation” of attending monthly meetings, called trawun. During trawun, members of the 91 surrounding communities gather to discuss relevant issues, and to make decisions about the intercultural health system. He mentioned the poster as a small way in which patients stay informed. Upon further examination of this makeshift poster, I noticed that, in addition to not being blue or having the splashy little cartoons, it listed slightly different information. Some rights were exactly the same as written on the government poster; others were rights indicated in the official law, but not included on the government poster (intercultural health rights); others still seemed identical in sentiment to government mandated rights but featured specifically Mapuche characteristics. For example, what would have been an obligation of a doctor in the original law was now replaced as an obligation of a Machi, or traditional healer.
The coordinator explained that the law as it currently stands has a very westernized focus, and does not take into consideration traditional medicine protocols, or the Mapuche way of life. He highlighted the lack of attention to intercultural health rights, and said that one of the regional projects is to support and make sure these rights are fulfilled.
My goal for this research was to explore the level of cultural relevance of the Patient Rights and Responsibilities Law in essence and in practice. I hoped to see a model in which authorities of both biomedicine and traditional Mapuche medicine came to the table as equals to make political decisions. Rights of indigenous peoples were taken into account when writing the law and designing the main poster, however, it still appears as if “cultural relevance” at least federally is about helping the Mapuche conform to the major biomedical framework. It becomes about making them into doctor-seeing, pill-taking, normalized members of the public health system while allowing them to seek spiritual healing on their own time. The poster is an example of governmentality. It is a mechanism through which the public health system attempts to form Chilean subjects who fit a model of equality for all.
So where does this leave us in terms of compatibility of the government-sponsered biomedical system and community sponsored traditional medicine? The government system may remain as the dominant force in state-run establishments. This idea of citizen equality, ironically, inhibits the ability of actors in both systems to come to the table and make decisions as equals.
On the other hand, in other settings the poster can help facilitate the transformation of national raw legal material into a localized expression, contributing to a space in which users of both medical systems negotiate the meaning of their health rights, a space where two medical paradigms meet and interact unpredictably. Patients here, will therefore not follow a traditional form of subjectivity under a simple biomedical health rights model, but will embody a mixture of the liberal state power and local, non-state autonomy. And this does not indicate an either-or situation; as long as there exists the space in which to realize it, each community as well as each individual will represent fluid and idiosyncratic combinations of influences in their health care. Do these spaces of negotiation represent that federal laws can be translated to the local? Is this a translation, or a transformation of state laws? The government is dedicated to promoting patient autonomy. What does this autonomy look like when Mapuche patients exist as an unstable mixture of part-state, part-local identity? Is this uneven mixing of national and regional, of biomedicine and traditional medicine the actual meaning of intercultural health?
For Foucault, it was exactly within spaces of governmentality where man would find the paths to freedom from subjectification, the spaces of a hopeful and positive life. The Poster of Patient Rights and Responsibilities, though not an example of freedom from subjectivity, may illustrate that spaces of governmentality can also be ripe sites for negotiating and reinventing subject identity. The poster may be one of these positive and idiosyncratic spaces of biopolitics that Rabinow and Rose sought to explore; it is a sight of ethnographic investigation which allows us to see the fine-grain negotiations and details of an ever-fluxing subjectivity between Mapuche patients and the Chilean State. The opportunities for resistance to subjectivity are often very small openings; they can be hidden in plain sight, they can be as mundane as a poster on the wall.
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