Planning Quechua Families: Indigenous Subjectivities, Inequalities and Kinship under the Peruvian Family Planning Programme Rebecca Irons University College London PhD Anthropology 2020 1 I, Rebecca Irons, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 2 ABSTRACT Quechua people have a fraught history with the Peruvian national family planning (FP) programme, with an estimated 300,000 individuals (forcibly) sterilised during the 1990s Fujimori-government in a biopolitical act that saw indigenous people as less ‘desirable’ and therefore sought to restrict reproduction in this group (Ewig, 2010). The state is now targeting the ‘rural, poor’ (often synonymous with ‘indigenous’) specifically for family planning intervention once more, based on perceived unmet need in this population. Now, for the first time in history, the 2017 national census included a question about identification of indigeneity, further suggesting heightened governmental interest in the demographics of this group. State intervention in Quechua reproductive health is not limited to FP. In 2005 an ‘intercultural birth’ policy was introduced that sought to bring women away from communities and into hospitals through the implementation of ‘Quechua cultural elements’ of birth amongst the biomedical settings. However, it has been argued that this policy was a veiled attempt to alter the subjectivities of Quechua women through an enforced association with biomedicine, thereby ‘whitening’ them (Guerra-Reyes, 2014). Social whitening through biomedical- association is well documented in the Andes; for example, women may seek IVF treatment or caesarean scars as proof of their interaction with the ‘whiter’ biomedical environments (Roberts, 2012). Yet, not all Andeans actively seek this racialised subjectivity, and instead may have it forced upon them as an imposition of state ‘coloniality of power’ that hierarchies race in Peru, to the disadvantage of the indigenous (Quijano, 2000). Such reproductive health policies can irreparably disrupt not only corporeal-subjectivity but kinship relations (Berry, 2010), inalterably affecting subjectivities at multiple levels. Through an ethnographic investigation into the contemporary FP programme offered to low-income Quechua women free-of-charge in a health-network in rural Ayacucho, this timely study interrogates if/how, through biomedical FP, the Peruvian state influences indigenous subjectivity, inequalities, and kinship. 3 IMPACT STATEMENT As a work of anthropology focusing on global health concerns, this thesis has the ability to impact cross-disciplinarily, in and outside of academia. The new knowledge presented would prove beneficial to a number of stakeholders from different disciplines and non-academic positions, including public health policy makers, governmental health ministries, NGOs, and charities working in the health sector. The text analyses and suggests recommendations of improvement for a Peruvian health network serving the indigenous Quechua population, with a focus on women’s experiences. Thus, this work could be used to give further insight into the intersections of state-health services and vulnerable populations, responding directly to the UCL Grand Challenges of Global Health & Human Wellbeing and therefore contributing to the overarching research focuses of UCL. The benefits within academia specifically would come from this work’s contribution to knowledge and development of theory, addressing topics of particular importance and widespread concern at present (decolonial academia; gender; race). This could benefit not only other anthropologists but a diverse range of scholars working across disciplines, including those within the social sciences & humanities, but also extending further to global & public health, women’s health, and medicine. The impact of this study has both local and international potential. The results of the thesis were presented to the Ministry of Health Peru so that the findings could be communicated to policymakers who could then take the recommendations into consideration for future policies. Here, the potential for impact is significant as this approach could eventually have a direct health benefit on the population with whom the research was undertaken. Internationally, the impact will be made through dissemination of outputs within academia, through submission to international scholarly journals, in both English and Spanish in order to reach a wider audience (five peer-reviewed articles published thus far from this research). Other forms of public outreach, such as the UCL Medical Anthropology blog and in-house magazine, have also be utilised to disseminate the research further. 4 ACKNOWLEDGMENTS Firstly, I would like to thank the Vilquinos who kindly participated in this study, answering my questions with patience and allowing me into their world. This study would not have been possible without their kind cooperation. My thanks also extend to those working for the Ministry of Health Peru, both in Vilcashuaman and Huamanga. I am indebted to all the obstetras who shared their professional wisdom, opinions, and time with me whenever I asked. In the Ayacucho Directorate, I am particularly grateful to Lorena Roca for her continued help and support with logistics. This project could not have come together without her. In the UK I extend my gratitude to my PhD supervisors, Sahra Gibbon and Jennie Gamlin, with whom I always felt supported and in good hands to successfully bring this dissertation to life. To those colleagues in the UK, US, and Peru, and particularly my fellow Andeanists, with whom I have shared ongoing thoughts, literature, and laughs – thank you. Finally, I would like to thank all my family and friends, in the UK and in Peru, who have endured three years of my emotional and professional journey through my doctorate. Your support has been invaluable. 5 CONTENTS Abstract…………………………………………………………………………………3 Impact Statement ……………………………………………………………………..4 Acknowledgements……………………………………………………………………5 List of Tables and Figures……………………………………………………………9 List of Abbreviations and Useful Terminology……………………………………12 ONE: INTRODUCTION…………………………………………………………...…15 Research Questions and Aims……………………………………………..19 Background and Literature…………………………………………….…………20 Race and ‘Modernity’……………………………………………………..…28 Fluidity of Race in Peru…………………………………………………...…32 Biomedicine and Whitening…………………………………………………34 The State and Indigeneity………………………………………………...…37 Theoretical Perspectives……………………………………………………….…42 Coloniality of Power…………………………………………………….……42 Biopolitics and Reproductive Governance………………………...………44 Intersectionality…………………………………………………………….…46 Structure of the Dissertation………………………………………………….….49 TWO: METHODOLOGY……………………………………………………………55 Introducing Ayacucho……………………………………………………….……55 Vilcashuaman…………………………………………………………..……55 Reproductive Health in Ayacucho……………………………………….…63 The Shining Path and Inca Paths…………………………..………………67 Quechua Population and Terms…………………………………………………72 Further Context Considerations………………………………………….…76 The Health System in Peru……………………………………………………..…77 The Health Workers……………………………………………………….…78 Data Collection Language………………………………………………...……………………………82 Participant Ages………………………………………………………………………82 Participant Recruitment…………………………………………………..............…82 Participant Observation…………………………………………………………...…83 6 Interviews…………………………………………………………………..…84 Permissions and Ethical Considerations………………………………..…86 Limitations………………………………………………………………….…86 Researcher Positionality…………………………………………………….89 THREE: STERILISATIONS…………………………………………………………99 Embodied Fear and Mistrust…………………………………………………….105 Understanding Obstetric and Corporeal Experiences on a Continuum of Violence……………………………………………………………………………..112 Reproductive Governance and Selective Attention to Events in the Continuum……………………………………………………………………….…119 Conclusion……………………………………………………………………….…124 FOUR: FAMILY PLANNING…………………………………………….…………129 Biomedicine, Whiteness, and Family Planning Discourse………………...134 Marca Peru and Family Planning……………………………………………….149 Privacy and discipline……………………………………………………………155 Conclusion……………………………………………………………………….…159 FIVE: GENDER………………………………………………………………..……163 Gender Complementarity, Machismo, and the Coloniality of Gender…...169 Gendering Reproductive Responsibility……………………………………...184 The ‘Gender Focus’ and Reproductive Governance………………………..200 Conclusion………………………………………………………………………….203 SIX: PARENTHOOD……………………………………………….………………209 State Welfare: Looking after the children…………………………………….211 A Future Generation of ‘Professionals’……………………………………….220 Financial Prioritisation…………………………………………………………...228 ‘Good Fatherhood’………………………………………………………………..237 Conclusion………………………………………………………………………….241 SEVEN: HEALTH WORKERS…………………………………………………….245 Local Inequalities within the Health Network………………………………...249 Fulfilling Metas and the Blame Game………………………………………….258 7 Evaluations and Administration: An Obstetra’s World……………………..265 Data, Census, Discipline…………………………………………………………271 Conclusion………………………………………………………………………….275 EIGHT: CANCER…………………………………………...………………………279 Cancer in the Clinic: (In)Visibilities…………………………………………….283 The Pishtaco and the Speculum………………………………………………..289 Hormonal Pharmaceuticals and Blood Accumulation……………………..298 Conclusion………………………………………………………………………….308 NINE: CONCLUSION………………………………………………………………313 Quechua Reproductive Identity………………………………………………...315 Towards