Epistemics and Social Relations in Mapuche Healing and Chilean Primary Care Medicine
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UNIVERSITY OF CALIFORNIA Los Angeles Accounting for Children’s Illnesses: Epistemics and Social Relations in Mapuche Healing and Chilean Primary Care Medicine A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Anthropology by Jennifer Rhae Guzmán 2012 © Copyright by Jennifer Rhae Guzmán 2012 ABSTRACT OF THE DISSERTATION Accounting for Children’s Illnesses: Epistemics and Social Relations in Mapuche Healing and Chilean Primary Care Medicine by Jennifer Rhae Guzmán Doctor of Philosophy in Anthropology University of California, Los Angeles, 2012 Professor Elinor Ochs, Chair This dissertation examines how indigenous Mapuche children’s illnesses are defined in Mapuche ethnomedicine and Chilean primary care medicine. Based on 11 months of fieldwork in the Araucanía Region of Chile, the study documents the illness account genres of pelotun pronouncements and presenting concerns, which drive the respective diagnostic processes of these two medical systems. The study draws on a data corpus that includes videorecordings of 32 pediatric acute care appointments with general practice physicians and 45 consultations with Mapuche healers. It combines ethnographic and discourse analytic methods to explore how indigenous families and the medical practitioners with whom they seek care negotiate the rights and responsibilities that are associated with representing children’s illness trajectories for the purposes of diagnosis. The study asks what stands to be gained and what is at stake in the representation of illness experience and the cultural construction of clinical realities. To address this question, the study adopts a linguistic anthropological view of genre that sees generic ii conventions as flexible and successful performances as social achievements. In light of this perspective, the study identifies the orienting frameworks, role expectations, and normative features of pelotun pronouncements and presenting concerns in the context of their performance. Analytic attention is given to the process of selection of a primary teller to establish what is ailing a patient, the generic regimentation of tellership rights, the evidentiary grounds on which accounts are based, and the ways participants hold each other accountable for the accounts they produce. Illustrative cases of both felicitous and problematic accounts demonstrate the range of semiotic resources that characterize each genre and show how participants orient to, legitimize, enforce, and challenge generic norms. The close analysis of these medical discursive genres is contextualized by discussions concerning the contemporary situation of ethnic discrimination and unequal medical plurality that exists in southern Chile. iii This dissertation of Jennifer Rhae Guzmán is approved. Linda C. Garro John Heritage Elinor Ochs, Committee Chair University of California, Los Angeles 2012 iv Dedico este trabajo a Gabriel, Diego, y Nicolás y a las familias de Makewe que me acogieron en sus hogares v TABLE OF CONTENTS Abstract of the Dissertation……………………………………………………………….. ii List of Figures…………………………………………………………………………….. ix List of Maps………………………………………………………………………………. xi Transcription Conventions………………………………………………………………... xii Acknowledgments………………………………………………………………………… xiv Vita………………………………………………………………………………………... xix Chapter One - INTRODUCTION 1.1 Illness in the Araucanía………………………………………………………. 1 1.2 Key Terms……………………………………………………………………. 8 1.3 Diagnosis……………………………………………………………………… 11 1.4 An Ordinary Epistemics of Subjective Experience and Related Speaking Rights……………………………………………………………………… 12 1.5 The Epistemics of Symptoms and Signs of Illness…………………………… 18 1.6 Symptom Experience and Symptom Representation ………………………… 20 1.7 Symptom Accounts across Healing Traditions ………………………………. 23 1.8 Overview of the Dissertation Chapters……………………………………….. 24 1.9 Research Methods ……………………………………………………………. 28 1.9.1 Data Collection at the Hospital Makewe Primary Care Center ……. 29 1.9.2 Data collection at the Mapuche Healing Center in Temuco………... 32 1.9.3 Data collection at the Farmacia Mapuche in Temuco……………… 34 1.9.4 Data Collection in Makewe…………………………………………. 36 Notes to Chapter One……………………………………………………………... 41 Chapter Two - THE ETHNOGRAPHIC SETTING 2.1 La Frontera and Its Inhabitants……………………………………………….. 42 2.2 Brief history of the Mapuche in Chile………………………………………… 45 2.3 Mapudungun…….…………………………………………………………….. 49 2.4 A Public Health Portrait of Chile……………………………………………... 50 2.5 Health Disparities and El Problema Mapuche ………………………………. 51 2.6 The Politics of Medicina Intercultural ………………………………………. 52 2.7 Primary Care Medicine ………………………………………………………. 55 2.8 Mapuche Medicine …………………………………………………………… 55 2.9 Wellness, Illness, and Mapuche Sickness Distinctions ………………………. 56 2.10 Makewe ……………………………………………………………………... 58 2.11 The Primary Care Center at Hospital Makewe ……………………………… 63 2.12 Field Research in Temuco…………………………………………………… 68 2.13 The Mapuche Healing Center (MHC) in Temuco…………………………… 69 2.14 Seeking Care from Physicians and Healers …………………………………. 72 2.14 Focal Research Participants………………………………………………….. 77 2.14.1 Focal Families in Makewe………………………………………… 77 2.14.2 Focal Practitioners………………………………………………… 77 Notes to Chapter Two……………………………………………………………. 81 vi Chapter Three - PRIMARY TELLERS AND THE EPISTEMICS OF SYMPTOMS 3.1 Introduction…………………………………………………………………… 82 3.2 Launching Illness Accounts in Mapuche Healing ……………………………. 83 3.2 Beginning Consultations at the Mapuche Healing Center …………………… 87 3.3 Beginning Fernando’s Consultation …………………………………………. 89 3.4 Beginning a Consultation on Behalf of Daniel ………………………………. 91 3.5 Beginning Daniel’s First Visit ……………………………………………….. 96 3.6 Conclusion …………………………………………………………………… 102 Note on Chapter Three…………………………………………………………… 105 Chapter Four - THE SELECTION OF PRIMARY TELLERS IN PRIMARY CARE 4.1 Introduction…………………………………………………………………… 106 4.2 Presenting Concerns in Primary Care Medicine ……………………………... 106 4.3 Beginning Consultations at Makewe PCC …………………………………… 110 4.4 Beginning Mariano’s Consultation…………………………………………… 112 4.5 Beginning Yordan’s Consultation …………………………………………… 114 4.6 Beginning Eustacio’s Consultation ………………………………………….. 115 4.7 Beginning Maria Natalia’s Consultation …………………………………….. 122 4.8 Conclusion …………………………………………………………………… 123 Notes to Chapter Four …………………………………………………………… 128 Chapter Five - GENERIC REGIMENTATION OF TELLERSHIP 5.1 Introduction…………………………………………………………………… 130 5.2 Generic Regimentation, Medical Storytelling, and the Crafting of Illness Realities…………………………………………………………………… 131 5.3 The Healer’s Don and the Empathic Epistemics of Pelotun …………………. 133 5.4 The Style of Pelotun ………………………………………………………….. 135 5.5 Contested Tellership in Pancho’s Consultation ………………………………. 142 5.6 Conclusion ……………………………………………………………………. 155 Notes to Chapter Five……………………………………………………………... 157 Chapter Six - THE PERSUASION OF PELOTUN ILLNESS ACCOUNTS 6.1 Introduction …………………………………………………………………... 158 6.2 The Desire for Insight about Problems ………………………………………. 159 6.2.1 The Value of Illness Interpretations………………………………… 160 6.2.2 The Cultural Injunction to Have Fe………………………………… 162 6.3 Normative Features of Pelotun Accounts ……………………………………. 164 6.3.1 Fernando’s Illness and Ximena’s Faith……………………………... 164 6.3.2 Numerous Claims and the Temporality of Listening ………………. 165 6.3.3 Linguistic Resources for the Representation of Timing in Illness …. 167 6.3.4 Repetition, Parallelism, and the Participation of Clients in Pelotun .. ………………………………………………………. 172 6.3.5 The Sedimentation of Evidence across Multiple Pelotun ………….. 175 6.4 Conclusion ……………………………………………………………………. 185 vii Chapter Seven - TIME DISCIPLINE AND PRESENTING CONCERNS IN PRIMARY CARE 7.1 Introduction …………………………………………………………………... 187 7.2 Acute Care and the Onus of Timely Doctor Visits …………………………... 190 7.3 Calendar Time and Felicitous Complaints …………………………………… 192 7.4 A Problematic Account ………………………………………………………. 203 7.5 Conclusion ……………………………………………………………………. 213 Note for Chapter Seven …………………………………………………………... 216 Chapter Eight – CONCLUSIONS ……………………………………….………………. 217 Appendix A – The Focal Families ……………………………………………………….. 229 Appendix B – The Beginning of Fernando’s Consultation ………………………………. 231 References ……………………………………….……………………………………….. viii List of Figures Figure 1.1: Quepe River running through Makewe …………………………………… 3 Figure 1.2: Winter morning landscape in Makewe …………………………………… 5 Figure 1.3: Videocamera mounted above an examination table in the primary care center ……………………………………………………….. 30 Figure 1.4: The researcher with lawentuchefe Lorena outside the healer’s home ……. 32 Figure 1.5: Storefront of the Mapuche pharmacy in Temuco during a public ceremony ………………………………………………………….. 35 Figure 1.6: Staff working at the Mapuche pharmacy………………………………….. 35 Figure 1.7: Community meeting in Makewe regarding a road pavement project …….. 36 Figure 1.8: Working on homework ……………………………………………………. 37 Figure 1.9: Visiting a seasonal pond during a home tour ……………………………... 38 Figure 1.10: Children watch a neighbor plow his field with a rented tractor…………… 38 Figure 1.11: Children between rows planted with strawberries during a home tour …… 39 Figure 1.12: Ethnographic interview with a focal mother ……………………………… 40 Figure 2.1: Mapuche-Inca Battle Depicted by Guaman Poma ………………………… 45 Fiugre 2.2: 1869 depiction of an encounter between Chilean military leader Cornelio Saavedra Rodríguez and Mapuche leaders during the Occupation of the Araucanía ……………………………………………… 46 Figure 2.3: Chile’s