HEALTH CARE SEEKING in NEOLIBERAL NICARAGUA By

"Now There is No Treatment for Anyone": Health Care Seeking in Neoliberal Nicaragua Item Type text; Electronic Dissertation Authors Tesler, Laura Eve Publisher The University of Arizona. Rights Copyright © is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author. Download date 28/09/2021 00:41:34 Link to Item http://hdl.handle.net/10150/194945 “NOW THERE IS NO TREATMENT FOR ANYONE ”: HEALTH CARE SEEKING IN NEO LIBERAL NICARAGUA by Laura Eve Tesler ___________________ Copyright © Laura Eve Tesler 2006 A Dissertation Submitted to the Faculty of the DEPARTMENT OF ANTHROPOLOGY In Parti al Fulfillment of the Requirements For the Degree of DOCTOR OF PHILOSOPHY In the Graduate College The University of Arizona 2006 2 THE UNIVERSITY OF ARIZONA GRADUATE COLLEGE As members of the Dissertation Committee, we certify that we have read the dissertation prepared by Laura Tesler entitled Now There is No Treatment for Anyone: Health Care Seeking in Neoliberal Nicaragua and recommend that it be accepted as fulfilling the dissertation requirement for the Degree of Doctor of Philosophy ____ ___________________________________________________________________ Date: 12/15/05 Linda B. Green _______________________________________________________________________ Date: 12/15/05 J. Stephen Lansing _________________________________________ ______________________________ Date: 12/15/05 Mimi Nichter Final approval and acceptance of this dissertation is contingent upon the candidate’s submission of the final copies of the dissertation to the Graduate College. I hereby certify tha t I have read this dissertation prepared under my direction and recommend that it be accepted as fulfilling the dissertation requirement. ________________________________________________ Date: 12/15/05 Dissertation Director: Mark A. Nichter 3 STATEME NT BY AUTHOR This dissertation has been submitted in partial fulfillment of requirements for an advanced degree at the University of Arizona and deposited in the University Library to be made available to borrowers under rules of the Library. Brief quotations from this dissertation are allowable without special permission, provided that accurate acknowledgment of source made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted the copy right holder. SIGNED: Laura Eve Tesl er 4 ACKNOWLEDGEMENTS While the road to completing this project has been a long one, I am fortunate to have had lots of company along the way. First and foremost, I am deeply indebted to the many people in Nicaragua who have so generously shared their time and friendship with me over the past twelve years. Through their formal charlas, the lifestories they shared with me, and the examples they set in their everyday acts of courage and kindness, they not only inspire d me to pursue this endeavor, but to try to be a better person. In particular, I would like to thank mi familia Nica for taking me into their home. I would also like to thank my field assistants for their wonderful companionship, and for supplying the cu ltural and social capital that proved invaluable to engaging in the complex social relations in the neighborh oods and households we visited. I am grateful to the local health center staff and bridgadistas who aided me with their institutional support, knowledge and time to get the study underway. I am especially appreciative of “Amanda” and “Celia” , for their continuous enthusiasm about the study, their assistance in introducing me to key people in each of the study neighborhoods, and the example they hav e set for me through their unflagging dedication to making their corner of the world a better place . And of course, I am profoundly grateful to the study participants who so warmly received me in their homes, patiently obliging my numerous visits and ques tions, and permitting me to bear witness to the ongoing struggles they face in the course of their daily lives. Here in the United States, I have found the grounding and stability needed to get through graduate school through the support and love of mi fa milia gringa, and my many dear friends. In the Department of Anthropology, I would like to thank my advisor, Mark Nichter, for his invaluable mentorship and for his faith in my abilities. I cannot imagine having walked along this path without him at my side. To my other committee members, Linda Green, Steve Lansing, and Mimi Nichter, I feel most obliged for the insightful feedback they have offered on the earlier drafts of this manuscript, as well as the innumerous ways in which each of them has contributed to my intellectual and professional preparation. I would also like to thank our Department Head, John Olsen, and the Department Staff, especially Cathy Snider, Ellen Stamp and Dirk Harris, for the ongoing administrative assistance and moral support they have provided. Finally, I remain indebted to Jim Trostle, my first mentor in medical anthropology, who offered me the opportunity to explore this field of research prior to the commencement of graduate studies, and helped me to locate the program in which I could best achieve my goals. Institutional support for this research was provided by a Dissertation Improvement Grant from the National Science Foundation, a Dissertation Fellowship from the Marshall Foundation, and a Riecker Grant from the Departmen t of Anthropology at the University of Arizona. 5 In memory of my grandfather, Sidney Stang. 6 TABLE OF CONTENTS ABSTRACT………………………………………………………………………..…….15 INTRODUC TION………………………………………………………………….…....17 Research Questions and Chapter Outlines…………………………….….……...25 The Study Site, Methods and Social Relations of Fieldwork………...……….....33 The Social Relations of Fieldwork………………………………………37 CHAPTER ON E “WE ARE RICH, BUT OUR GOVERNMENT MAKES US POOR ”: THE HISTORY OF POLITICAL ECONOMY AND DEVELOPMENT IN NICARAGUA…………………………………………..………………..…………...….42 Introduction………………………………………………………….……...……42 Part One: Development and Nicaraguan History…………………………..…….45 The Nicaraguan Nation-State from 1821 – World War II…………….…45 The Cold War and the Introduction of Development Aid………….……47 Revolution and War: 1979 – 1990…………………………………...…..52 The Rise of Neoliberalism: 1990 – Present…………………………...…55 Part Two: Nicaraguan History as Experienced in San Rafael………………...…61 “Development” in San Rafael: Economics…………………………...….62 Development and Infrastructure…………………………………...…….74 Global and Local Linkages in San Rafael……………………..…………82 Politics, War, and Social Memory……………………………….………84 Politics, Poverty, and Violence…………………………………………..98 7 TABLE OF CONTENTS – Continued Nicaragua es Pobre, Nicaragua es Rico … Is Nicaragua a Poor or Rich Country?...................................................................................................103 Indicators of “El Progreso” versus “El Atraso” in Nicaragua’s Future…………………………………………………………………...106 Conclusion……………………………………………………………………...113 CHAPTER TWO “WE WERE ALMOST BETTER OFF DURING THE WAR ”: THE HIS TORY OF HEALTH CARE SERVICES IN NICARAGUA ……… …..…….117 Inte rnational Devlopment Aid and Health: Ideologies, Rhetoric and Policy…..117 The History of Health Care in Nicaragua………………………………………120 The Origins of Biomedical Health Care………………………………..120 Health Care Services during the Somoza Dynasty……………………..120 The Sandinista Years: 1979 – 1990………………………………….....122 Conflicts in Rhetoric and Policy at the Global and National Levels… ...125 Health Care Transitions during a Transitional Regime: The UNO Coalition, 1990 – 1996…………………………………………………130 The Ascendancy of Neoliberal Health Policies: 1990s – Presen t………137 Health Care Services in San Rafael…………………………………………….145 Primary Health Care in the New Millennium…………………………..150 Other Health Care Services……………………………………………..155 Conclusion……………………………………………………………………...161 8 TABLE OF CONTENTS – Continued CHAPTE R THREE “GOD PROTECTS ALL PEOPLE, BUT ONLY THE RICH CAN CURE THEMSELVES IN CLINICS ”: THE POLITICAL ECONOMY OF HEALTH CARE SEEKING……………………………………………………..……..163 Introduction……………………………………………………………………..164 To Become Sick is a Luxury, Now We Can’t Even Afford to Die…….164 General Patterns of Resort in the Context of Health, Illness and Povery………168 Case Study One: Health Care Seeking in Response to Changes in Employment Status……………………………………………………..176 Case Study Two: Prioritzing Urgent Care in the Contex t of Multiple Ailment s and Multiple Household Members with Illnesses… …………181 Case Study Three: Non-Treatment and Cessation of Care in Conditions of Extreme Poverty………………………………………....185 Using la Inteligencia in Health Care Seeking…………………………..190 Utilization of Public Health Care Services……………………………………..196 The Health Center……………………………………………………....196 “Going to the Health Center is a Waste of Time”……………...………199 Hospitals………………………………………………………………..206 Worker’s Insurance……………………………………………………..208 Utilization of Private Health Care Services………………………………….…210 Pharmacies, Local Healers, and Church -Sponsored Health Care………213 Private Physicians………………………………………………………217 9 TABLE OF CONTENTS – Continued Seeking Government Health Center Do ctors in Their Private Practices ……………………………………………………………. …..220 Public/Private Physicians: A Conflict of Interest?...................................225 Securing Credit…………………………………………………………227 Practitioners’ Perspectives………………………………………..…….231

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