R en la RD: Operativo

Really, I am living the community health major’s dream: designing and implementing a health intervention! Albeit in the face of an arguably minor health problem (I’ll argue otherwise!), in the comfort of my regular place of work, within the walls, daily structure, and resources of the Liceo Cientifico, I am still managing a community health initiative.

My boss, Dr. M, asked me to help with the visual operative. Two years before, the school invited a local optician’s office/glasses provider to come check everyone’s eyes. He assured me this would barely chip into my time, that all I had to do was talk to the secretary, that she’d make the calls to the right places and people, and I just had to figure out dates. I quickly discovered that, unlike 2 years ago, the planning process would not be so simple. The high school has grown (doubled in size just last year—we now have over 300 students, 2 new grade levels, and 4 additional classrooms, around 30 new teachers and staff members). The optician’s office could only come for 2 days to do the operative. My boss suggested I do a pre-screen for everyone, something I could probably easily find online, and send only the students who we were unsure about to the opticians when they came. So, I met with the office assistant, and we began planning.

First, there was researching sources from which I could pull the pre-screening tests. I went with a do-it-yourself webpage from Essilor.com. It is one of those sites where it instructs you how to do the simple tests, but if you think you’ve failed a test, it suggests a visit to the doctor. We had professionals coming anyway, so I went to work creating a power point with the images from the online test, planning and coordinating with the other teachers as to when I would pull out students to actually do the test.

Last Wednesday, the opticians came to the Liceo, and we planned the dates. That day, three other profesores and I got to work with the pre-screening. We took 6 students at a time: three at three computers in the lab we reserved, three taking a written hearing loss survey. I had various help over the three days of the prescreen, and for one class of 10th graders I was on my own, running 3 visual tests at once, making sure everyone had their survey, roster of students and red pen in hand, repeating over and over again in Spanish, “Please stand on the pink line. All right, cover one eye with your hand, do not push on your eyelid, okay let’s begin, look at the circles on the screen. Which one appears more sharply, the red, the green, or do they look the same?”

The pre-screen in action.

The pre-screen in action.

By the beginning of this week, after some data entry and some help from a German volunteer here (thank you, Max) I had a list of all the students who needed to see the opticians. Wednesday they arrived, we set them up in the library with their fancy equipment (made my pre-screen look boring). I spent that day and the next, running back and fourth from there to classrooms, collecting a few students at a time, lining them up to get their visual exams done. The two opticians and the third woman showing the students glasses and payment options, we got through 236 students and a few profesores. Those ladies are champions, because they barely got a break. I at least could wait between groups of students, grab some water, and check my student roster for the 30th time.

I have yet to punch the numbers into the spreadsheets, but I would say about half of those students need glasses, either permanently or reading. Astigmatism was definitely the most common diagnosis as well.

But the project doesn’t stop there! I would be a bad community health major if I thought that getting everyone a simple eye exam was enough to help everyone’s eye health here. We have to do some community engagement as well, specifically with the parents. If you can’t convince the parents that it is important for their children to wear glasses, you haven’t made any difference at all.

Their were parent meetings this past week, and the optician office personnel and I went around to each classroom where parents of each grade level were meeting to hand out bulletins and tell them about the operativo. The 9th grade parents were the most in number, probably about 50 of them. I began timidly introducing myself, I mentioned we were having an operativo in the upcoming weeks to de-parasite the students and staff here (Desparacitación is the most difficult word to say in Spanish, trust me), and gave the floor to the optician to talk more about the visual exams.

We are not going to stop there, however. Two years ago, the optician visit had some success, but most of the kids didn‘t come away with the new frames they needed. My boss explained that there were a few reasons for this. Though the eye exam is free, the glasses are not. The optician office has all sorts of payment plans, agreements with a local cooperative, and even very discounted frames that they all pitch to the students and their parents. Some, still, cannot pay. Others do not consider getting glasses to be a medical or educational necessity, either because they see it as a simple fashion choice, and/or they do not spend much time squinting and trying to read in their day to day, or because they themselves never learned to read. You can’t expect anyone to just appreciate the importance of reading glasses just because some white college educated girl says so. We have to spend time creating materials for the parents when they come for the parent-teacher conferences at the end of the month—movies, infographics, just being there to answer their questions—so we can clarify to them why we think having 20/20 vision is essential for academic success. Thankfully, we have a lot of info and support from the optician’s office here.

These young adults are in the Liceo Cientifico because they excelled in their previous schools, and they have a drive to better themselves and find opportunities through a rigorous education. Getting bad grades at this stage because you can’t read the chalkboard should not be a limit.

Thank you to all the profes who let me interrupt your classes these past two weeks to give the kids eye exams!

Sorry, Grandma, that I have not kept up writing my blog very regularly!

Also please check out how you can support our kids at Liceo Cientifico!

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Chica en Arica: Anthropology Symposium

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).

Introduction

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.

 

Theoretical Framework

 

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.

Background

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.

Ethnography

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.

Discussion/Conclusion

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.

 

References

 

Alarcón, A. M., Astudillo, P. D., Barrios, S., & Rivas, E. (2004). Política de Salud Intercultural: Perspectiva de usuarios mapuches y equipos de salud en la IX región, Chile. Revista Médica De Chile, (132).

Arancibia, E. R., Bugueño P, H., & Giorgio. (1999). Municipio y Atención Primaria en Salud. Asociación Chilena de Municipalidades.

Biblioteca del Congreso Nacional de Chile. (2012). Reportes Estadísticos Comunales 2012: Nueva Imperial. Retrieved from http://reportescomunales.bcn.cl/2012/index.php/Nueva_Imperial

El Gobierno de Chile. (2012, February 10). Ley de Derechos y Deberes de los Pacientes. Retrieved from http://www.gob.cl/especiales/ley-de-derechos-y-deberes-de-los-pacientes/

El Gobierno de Chile. Regula los Derechos y Deberes que Tienen las Personas en Relación con Acciones Vinculadas a su Atención en Salud. , Pub. L. No. 20.584.

Entrevista con una Asesor Cultural en un CESFAM. (2013, November 15).

Entrevista con una Trabajadora de la Oficina de Informaciones, Reclamos, y Sugerencias. (2013, November 11).

Instituto Nacional de Estadísticas, Ministerio de Planificación Nacional. (2002). Estadísticas Sociales de los Pueblos Indígenas en Chile: Censo 2002.

Jaramillo Salgado, V. (2013, November 11). Entrevista con el Director del Hospital Intercultural de Nueva Imperial.

Ministerio de Salud. (1993). De Consultorio a Centro de Salud. Santiago, Chile.

Ministerio de Salud. (2012). La Carta de los Derechos y Deberes de los Pacientes.

Nahuelcheo, Y. (2013a, November 13). Políticas Públicas y Medicina Tradicional. Presented at the Día de Estudiante Mapuche, Liceo Guacolda, Chol-Chol, Araucanía, Chile.

Nahuelcheo, Y. (2013b, November 14). Entrevista con la Coordinadora Regional de Salud Intercultural.

Paillaleo Bañares, A. (2013, November 18). Entrevista con Coordinador del Centro de Medicina Mapuche en Puerto Saavedra.

Pichinao, E. H. J., & Mellico, F. (2003). Pu Mapunche Ñi Gijañmawün: La forma mapuche de hacer religión.

Rabinow, P., & Rose, N. (2006). Biopower Today. Biosocieties, 1, 195-207.

Chica en Arica: Lo que parece differente…

About to leave for a whole new experience in the south of the country, I’m just realizing how comfortable I actually am in my host family’s house here in Arica. When I first arrived, I could only help but notice all of the differences between here and “allá” as my host parents say, “over there,” referring, of course, to Boston. Sometimes my host dad tries to pronounce “Massachusetts,” and I’ve just learned to nod and smile and say “correcto” because he is really proud of being able to say such a long, difficult, gringo word. But, yes, the differences were my biggest concern; I took pictures of the square-shaped light switches and became very frustrated that first week when I tried to turn on the gas stove top to make tea and it wouldn’t light automatically. The shapes and materials of the houses, squat and stucco, or the constant construction, or trash in the streets, or stray dogs, or sand and dust in all of my shoes, or later meal times, or men whistling at me in the street, I scrutinized all of these, deeming, at least in my head for a few weeks, that Chile was simply different than the US.

I now realize that there are so many more similarities between the two countries than differences. I would argue that the whole of the occidental world is more similar than it is different, that football here and football there is still a male-dominated, franchise-dripping, fanatic-drawing, beer-drinking afternoon television event, for example. Chile has developed rapidly in the past 30 years, and now people here suffer from the same chronic health problems as people “allá:” heart disease, diabetes, cancer. Most importantly, the people are the same. They value family time and are a little more laid back than most North Americans, I’d argue, but people are people wherever you go, and especially when our culture is actually so close and interconnected to their culture, it’s not hard to relate. People are hard working, others are lazy, some people care a lot about their health and physical well-being, others are happy to munch on churros and empanadas and not move from their sillas in front of the TV.

One thing has stood out to me though, the entire two months that I’ve been here, that is very different. Blame the fact that I’m in a public health program, and have been focusing on the public health system here in Chile, but I think we can take a lesson from the Chileans here: Every single citizen of this country has health insurance, and there are 50 million citizens of the US without any. Just for reference, that’s almost almost 3 times as many people as the entire population of Chile, 3 times the entire population of Chile. My point here, if I wasn’t clear enough, is that that is a lot of people. We’re all suffering from the same health issues, but a Chilean with diabetes, no matter what his/her social class, ability to work, age, race, ethnicity, gender, whatever, will get treatment. An American may have to suffer and ultimately die due to the fact that, as a country, we don’t believe in access to health care as a human right. Here, in Chile, it’s written in the constitution that every citizen will get necessary health care, so they try to deliver this. And Chile is no Cuba. The basics of their modern public and private health care system were established under the Pinochet dictatorship, a dictator who was staunchly anti-socialist and supported by the communist-fearing US.

The system is far, far, far from perfect. There are long wait times to get same-day appointments; to see specialists in the hospital, a person can wait months. The thing is, though, is that with recent reforms here, there’s a heavy focus on primary care (there’s enough to say about this for an entirely different post), so people don’t just go to the doctor when their sick. They go often, for multiple check ups, to prevent going to a specialist or urgent care, to promote a healthier, higher-quality lifestyle. This means that waiting doesn’t have to happen as often.

Nothing will be perfect, and politics are politics everywhere in the world (election season here, I cannot escape the campaign posters), but people are also people everywhere in the world and deserve to be treated with dignity and deserve to get help when they need help. I believe that every person in the US should have access to healthcare, and that in this sphere, Chile proves to be the more developed, modern country.

Inspiration for the post:

This is Why We Need Obamacare-NYT

Chica en Arica: Bienvenidos a Putre

The past four days, I spent without wifi or a computer, in the rural area of the XV region of Chile, Parinacota, in the “city” of Putre. In this entire region, there are only about 1,300 people, mostly living  in the main pueblo of Putre, others in smaller, farther out communities of 30-40 people. Health care in this region is not only complicated by the geography (the huge rolling desert hills of the Altiplano make for very treacherous windy roads) but is also enriched by the influence of the Aymara traditional healing practices (Aymara are another indigenous group in Chile; they inhabit northern Chile, Bolivia, Argentina, and Peru). This half of the region of Chile is 90% Aymara.

Despite feeling a little dizzy from the lack of oxygen (Putre sits at about 3,000 meters above sea level), I really enjoyed the excursion. The first day, we toured the public family health center in the city, and talked to the doctors, nurses, nutritionists, techs etc. there. The next day, we learned about the herbs and medicines of the Aymara, ate lunch with some locals and discussed community empowerment with them (Side note: lunch was alpaca meat, actually pretty good!). We got a chance to go to one of the smaller pueblos, Socoroma, to visit the primary school and play with the children. Also in Socoroma, we learned about the monthly rounds the health team in Putre makes to the smaller surrounding villages, to do check ups and lab work for patients who can’t travel to the center in Putre. Some of these villages are 3 hours away from Putre. In cases of emergencies, these villages have radios, from which they can call an ambulance, but if you live 3 hours from Putre, you’ll need to wait, and the center there is only a primary care center: barely equipped to handle the most basic emergencies. The closest secondary or tertiary (more serious) care hospital is in Arica, which can be an additional 3 hours away, on a good day.

On the last day, we took a trip up to one of the highest lakes in the world, lake Chungara, which sits up there at 4,500 meters or 14763.8 feet above sea level. There were a lot of llamas hanging out, this is probably my favorite shot of the day.

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Chica en Arica: Meeting the Mapuche

Today, we drove out of the city of Temuco to Hospital Makewe, run by the Mapuche. The Mapuche are one of the indigenous populations in Chile; there are 1,442,214 people in Chile as of the 2002 census that claim Mapuche ancestry. The history with their relationship to the government is long and complicated. I was introduced to this history by a Chilean friend, who told me about how they were the last group of native South Americans to resist the Spanish conquest.

We arrived at the hospital and entered a Raku, or house. The Raku was one room, with a fire pit in the middle (It’s pretty cold here and the Rakus are heated only by the fires). Our first lecture was about the cosmovision of the Mapuche and their spirituality, taught by our Mapuche leaders/guides/friends. The Mapuche’s spiritual beliefs are not separate from their everyday lives. The word Mapuche literally translates into “People of the earth/land” but this translation lacks a lot of special connotations and additional meanings of the word Mapu (it means not only earth and land, but also space, physical and spiritual). A lot of words don’t translate well from Mapuzugun (language of the Mapuche) to Spanish, and then, of course, it’s going through another translation into English right now. I won’t get too into my limited understanding of the cosmovision, though, considering the fact that I took a single 2 hour class on the topic.

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La Chica en Arica va a Peru (health care, home visits, and HIV)

Sunday, the group hopped on our tour bus (we’re now calling it oruga, which means caterpillar) and headed up to Tacna, Peru. With a quick passage through border control, the trip took about an hour total. I heard that if you take a public bus, the trip costs a whopping $2, which I will keep in mind for my personal excursion up to Machupicchu.

The next morning, we arrived at a community health center to learn about the Peruvian health care system. Despite various health care reforms in the 1990s, there remains a lot of inequality in the system, and around 30% of Peruvians are uninsured. In the next 5 years, goals of reform include inclusion of all socioeconomic classes in the system, and especially universal coverage. This will prove to be difficult, considering hospitals and major primary care centers are located in the capital cities of each region (province) of Peru. In the most drastic case, it could take a patient 7 days of travel to reach the capital city of their region, if they happen to live at the border of their region and another. Medications tend to be pretty cheap in Peru, but are still only feasible to obtain with insurance. Even so, the Ministry of Development and Social Inclusion in Peru is in charge of a few programs that caught my eye: Cuna más, in which the state hires nannies for parents who both need to work during the day, Beca 18 which allows the top students in public high schools in each region to get a full ride to a university (again provided by the state), and PRONAA which provides breakfast for students in public elementary schools as a means of supplementary nutrition.

The overall focus of health care in Peru is on prevention. A biopsychosocial approach is stressed in settings of primary care, and the medical staff, which works with patients in teams of doctors, nurses, obstetricians, social workers, and medical technicians, is dedicated to being companions to the patients. This allows for a horizontal approach to a patient’s care, in which all parties work together on equal playing field, and all aspects of a patient’s life are respected as components to overall health. After our class, we were able to see this approach first-hand, as we accompanied staff out into the community to do home visits.

Individual staff members walk from the clinic to the homes of patients who cannot make it to the clinic themselves or who have missed appointments. My group visited with a woman to encourage her to go into the clinic for her first pap smear, and give her information about cancer screening. She had set out chairs for us to meet in her front yard, and we discussed her home and marriage situation, the health of her children, her insurance, and her own health concerns. The whole appointment lasted a little over an hour. The attention she was able to receive was incredible to me; a free consultation with a health care professional, who was not busy taking notes or checking vital signs during the entire conversation, just listening and laughing with the patient, and nodding and offering advice. On the other hand, this method goes slightly against the whole horizontal model, considering that the doctors, nurses, and social workers come into a patient’s home and play a bit of the “we know what’s best for you” game.

Yesterday, we went to the private University in Tacna, la Universidad Jorge Basarde G. Concha, to help the obstetrician students run an HIV testing fair. We handed out condoms and pamphlets of information to the students. I got to perform a few of the tests myself, and give the results to some students (that part was the hardest for me, trying to compose myself in a professional manner and explain complicated and serious things in Spanish, but I did it).

The end of the trip brought a trip to a pisco vineyard. Pisco is hard alcohol made from grapes, and it tastes like a very dry wine, with a flavor of dried fruit. We took a tour of the vineyard and learned how to make pisco sours from the campesinos. Needless to say, there were a lot of pictures of us sampling various types of pisco.

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