Intercultural Health and the Mapuche: Perceptions and Practice in Santiago, Chile

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Authors Moretz, Hayley

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INTERCULTURAL HEALTH AND THE MAPUCHE: PERCEPTIONS AND PRACTICE IN SANTIAGO, CHILE By Hayley Moretz

A Thesis Submitted to the Faculty of the CENTER FOR LATIN AMERICAN STUDIES

In Partial Fulfillment of the Requirements For the Degree of MASTER OF ARTS In the Graduate College THE UNIVERSITY OF ARIZONA 2018

TABLE OF CONTENTS Tables and Figures……..…………………………………………………………………….… 5 Abstract…..……………………………………………………………………………….……. 6 Chapter 1: Introduction………………………………………………………………………… 7 1.1 Background……………………………………………………..………………...... 7 1.2 Theoretical Framework…………………………………………………………….. 11 1.3 Methodology………………………………………………………….…...... 16 Chapter 2: Defining Intercultural Health…..……………………………………………………21 2.1 Intercultural Health ……………………………………………………………...... 21 2.2 Interculturality in Chilean Policy ..…………....…………………………………… 24 2.3 Mapuche Medicine ………..……………………………………………………...... 25 Chapter 3: A Brief History of Mapuche-Chilean Relations………...………………………...... 28 3.1 Historical Context of Mapuche-Chilean Relations………………………………….28 3.2 Urban Mapuche/Mapuche-Warriache………………………………………………..39 Chapter 4: IH from Macro to Micro Level…………………………………………………….. 44 4.1 History of PESPI…………………………………………………………………….44 4.2 History of CESFAM Los Castaños and CRSM “La Ruka”……………………….. 45 4.3 Dimensions of Intercultural Health at the Local Level…………………………….. 47 Chapter 5: Perceptions and Practice…………………………………………………………… 49 5.1 Issues with Design ………..……………………………………………………….. 49 5.2 Issues with Access………………………………………………….……………… 50 5.3 Cultural Relevance ………………………………………………………………... 52 5.4 Politics and Policies ……………………………………………………………….. 52 Chapter 6: ¿Quién contamina más?...………………………………………………………….. 54 Chapter 7: Recommendations & Conclusions ………………………………………………… 62 APPENDIX ...………………………………………………………………………………….. 67 A-1 IRB Approval Letter…………………………………………………………….… 67 A-2 Sample Interview Questions Guide………………………………………….……. 68 B-1 Map of Municipalities of Santiago Metropolitan Region………………..……….. 70 B-2 Infographic of CESFAM in Servicio de Salud Metropolitano Sur Oriente ………..71

B-3 CRSM La Ruka Referral Form…………………………………………………….. 72 REFERENCES…………………………………………………………………………………. 73

TABLES & FIGURES

Table 1. Summary Information of Intercultural Health in each Case Study………………………. 24 Table 2. Obesity and metabolic conditions in aboriginal and Caucasian populations in Chile according to gender and rural/urban condition…………………………………………………….. 42

Figure 1. The Social Ecological Model …………………………………………………………… 10 Figure 2. Classification of kutran………………………………………………………………….. 26 Figure 3. Distribution of the Mapuche Population in Santiago……………………………………. 40 Figure 4. Organizational Structure of the Servicios de Salud de Santiago that implement PESPI: intercultural health pilot……………………………………………………………………………. 45

ABSTRACT

Background: Intercultural health (IH), defined as the integration of western and indigenous medicine, is a public health approach that aims to reduce the divide between indigenous and biomedical health systems based on mutual respect and equal recognition of both knowledge systems. In Chile, IH has become a national strategy of indigenous health improvement through the Programa Especial de Salud y Pueblos Indígenas. With increasing Mapuche populations in urban centers, it is important to understand how these initiatives are conceptualized in urban settings. Methods: Through a qualitative assessment consisting of 10 in-depth, semi-structured interviews, this project sought to understand how IH is implemented in the La Florida municipality of the Metropolitan Region. Results: Results revealed that the current IH model is inadequate to meet the needs of the urban indigenous population. Constitutional recognition of the Mapuche people and culture was considered a prerequisite to restructure the IH model. Issues such as lack of funding, political favoritism, and a fundamental misunderstanding of Mapuche culture were seen as challenges to improving IH programs and indigenous health outcomes. Conclusion: Efforts to improve IH must take into account the indigenous concept of health and healthcare without forcing it into a biomedical model. A more comprehensive curriculum of indigenous healthcare and culture in general and medical education is critical to improve cross- cultural collaboration. An evaluation framework for funding mechanisms of IH at the regional level is needed to improve transparency and accountability among the Servicios de Salud, or Regional Health Departments, and indigenous associations. More research should be conducted in other urban areas with high indigenous populations to gather more representative data on IH implementation in the Metropolitan Region.

CHAPTER 1: INTRODUCTION

1.1 BACKGROUND

The state of Chile has experienced some dramatic sociopolitical shifts in the last century, which have created substantial challenges and opportunities for the country’s indigenous populations. As is the case for many indigenous peoples around the world, the Mapuche have suffered a long history of discrimination, marginalization and resistance. Prior to the “pacification” of the Mapuche from 1860-1883, the Mapuche people resisted centuries of conflict and conquest attempts by Inca, Spanish and

Chilean powers (Carruthers & Rodriguez, 2009). Over the years, the Mapuche have been subjected to the reservation system and assimilationist policies that have further reduced the Mapuche territory and status within the political and economic sphere.

Although land reforms and recognition of indigenous rights were promoted in the 1960s and 1970s, this progress was abruptly halted by the military coup of 1973 and subsequent dictatorship. Post-dictatorship Chile continues to operate under neoliberal ideals while promoting multiculturalism, a political philosophy that advocates for the coexistence and tolerance of various cultures in a society (Cavieres Sepúlveda, 2006;

Garcia, 2012). These shifts have important implications for the health and wellbeing of

Chile’s indigenous communities, as representation and recognition of rights continue to be a point of contention.

Policies directed towards indigenous peoples added several important elements to the concept of multiculturalism that produced the more integrative, dynamic notion of

“interculturality” (Cavieres Sepúlveda, 2006). Interculturality acknowledges that distinct

cultures can not only coexist, but also interact, exchange and learn from one another in a constructive way (Cavieres Sepúlveda, 2006). Incorporating an intercultural component into public policy became the acceptable administrative response to the political mobilization of Mapuche demands for greater representation (Lucic, 2005).

Some argue that these intercultural policies are just an extension of the neoliberal agenda that privilege economic gains over indigenous rights (Lucic, 2005; Richards,

2010) Others contend that these policies can simultaneously work against and for the reforms and changes that the Mapuche and other indigenous communities are fighting for Garcia, 2012).

These apparent contradictions become more visible through the lens of public health and health promotion. Intercultural health is a public health approach that aims to reduce the divide between indigenous and western health systems on the basis of mutual respect and equal recognition of both knowledge systems (Torri, 2011). These types of programs can theoretically mitigate the social and cultural marginalization of indigenous populations, and can take shape in a variety of implementation strategies. It is also, however, a matter of political power and economic interest; and in Chile, has developed within unique neoliberal constraints (Garcia, 2012).

A critical analysis of the formation of intercultural health programming and its effects in Chile is important not only for the emerging field of intercultural health but also for the reconciliation of the Mapuche struggles for rights and recognition. Thus, this analysis explores the social and political forces that shaped the development of Chilean intercultural health policies and the implications of these initiatives on the Mapuche people with the following underlying question in mind: Is the push for intercultural health

programming simply rhetoric or do Chile’s intercultural health policies foster true partnership?

To answer this question, and add to the literature on intercultural health in Chile, my research focused on the unique challenges of intercultural health in a localized area in the capital city of Santiago. Most of the current literature regarding intercultural health in Chile focuses on programs in the southern portion of the country in La

Araucanía, the ancestral territory of the indigenous Mapuche people; particularly the

Makewe Hospital in Temuco and other health centers in this southern region. This thesis project sought to understand how Intercultural Health (IH) was conceptualized in the Metropolitan Region of Santiago, where many Mapuche people have moved in recent decades. Santiago is home to the second largest Mapuche population after La

Araucania, and is therefore an important location for research into this approach, roughly one third of the Mapuche population live in Santiago. This research project targeted locations with higher concentrations of Mapuche residents in the Metropolitan

Region of Santiago, particularly in the La Florida and La Pintana municipalities.

The Centro de Salud Familiar (CESFAM) Los Castaños is one of the healthcare facilities in La Florida that has incorporated Mapuche medicine in recent years. This site was chosen precisely to explore the implications of an urban setting on the incorporation of traditional medicinal practices in the conventional healthcare system.

CESFAM Los Castaños is a family health center located in the municipality of La Florida in the southern portion of Santiago’s Metropolitan Region and is part of a network of health centers under the Servicio de Salud Metropolitana Sur Oriente (SSMSO). This regional system is responsible for providing the funding for the indigenous health

initiatives via the Programa Especial de Salud y Pueblos Indígenas (PESPI). The central offices for PESPI are also located in Santiago, which is another reason why

Santiago was an ideal site to conduct this project and learn more about the national program. The primary data collection for this project took place predominantly in the

Mapuche medical center (“La Ruka”) located at CESFAM Los Castaños, the CESFAM in the neighboring municipality of La Pintana; as well as at the University of Chile

School of Public Health and government offices. Literature review and data collection and analysis were conducted throughout the research period while in Chile as well as in

Tucson, Arizona.

Intercultural practices, especially in the field of health, are necessary to improve the relationship with and health outcomes of indigenous populations; as well as provide the respect and recognition of indigenous peoples that has historically been neglected.

Intercultural health as a conceptual model for health services can only be truly realized when the needs and voices of the indigenous community are heard and incorporated into the scheme of the model. Qualitative assessment of the perceptions of the

Mapuche Community on intercultural initiatives in this municipality are critical for developing an intercultural health model that creates equitable, sustainable and positive changes for the health and wellbeing of the community. Historical exclusion and marginalization have characterized the indigenous people’s relationship to the Chilean state; therefore, this project sought to focus on the Mapuche perspectives of the current conceptualization and implementation of intercultural health in the capital.

The purpose of this project was to engage with the concept of intercultural health—what it means in theory and how it looks in practice. To understand how the

intercultural health has been implemented in an urban setting, I conducted field research during the summer of 2017 to gather first-hand accounts of intercultural health implementation in Santiago, Chile and explore the indigenous perspectives on how this approach has been conceptualized and executed. The findings of this research have identified and reiterated several fundamental flaws with the construction of ‘intercultural’ programming in the healthcare system.

1.2 THEORETICAL FRAMEWORK

Three important theoretical frameworks are employed to better understand the complexity of the Mapuche experience with the Chilean state and the development of an intercultural health strategy: The Social-Ecological Model (SEM), political economy of health, and sanitary citizenship. Each of these frameworks provide insight into the many sociopolitical, economic, historical and structural forces that shape health problems.

The SEM is a common theoretical model used in public health to identify and address health problems and inform program planning and design. This model asserts a broad understanding of health and acknowledges the social and environmental factors that impact people’s lives and wellbeing. More specifically, this model recognizes that health is shaped at the individual, interpersonal, organization, community, and policy level; with the understanding that multiple determinants converge and interact to create health problems (McLeroy, Bibeau, Steckler & Glanz, 1988). The levels of influence of the SEM are illustrated in Figure 1.

For the purposes of health promotion, the SEM focuses attention on both individual and social environmental factors as targets for interventions (McLeroy,

Bibeau, Steckler & Glanz, 1988). For example, in obesity prevention programs such as the Supplemental Nutrition Assistance Program-Education in the US, efforts target individual behaviors by providing direct nutrition and physical activity education, as well as broader policy, systems and environmental changes that would bolster an environment that makes healthy choices the easiest choice. If someone knows they should eat fruits and vegetables and get exercise, but fresh produce is not available and its unsafe to exercise where they live, the environment does not allow for the healthier behavior change. The SEM allows researchers and program and policy makers to create multi-level interventions that can address multiple levels of influence.

The multi-sectoral nature of SEM shares many similarities with the political economy framework, as the political economy perspective also views health status and health promotion particularly with respect to how individuals, communities and broader social groups are impacted. Political economy is a broad theoretical and interdisciplinary framework that is used to understand and explain the various economic, political and sociocultural dynamics that influence health, reflecting on how these dynamics interact to determine the unequal distribution of power, wealth and health status in society

(Minkler et al., 1994). This framework is useful to organize thought and action for addressing health problems by providing a strategy to approach health within a broad structural context (Minkler et al., 1994). It also focuses on societal patterns of inequality, and how political and economic forces can constrain and encourage individuals and social groups beyond individual belief and behavior.

One of the important characteristics of this approach is the emphasis on the role of history in shaping contemporary health policy (Minkler et al.,1994). To illustrate in the case of alcohol consumption and policy, applying this theory shows that inclusion of a broader historical analysis helps to identify the logic of use patterns, public attitudes and state policies (Minkler et al., 1994). For example, the discourse around the perceived locus of the problem has shifted over time from the bottle (“demon rum”) to the moral weakness of the individual to the more recent focus of alcoholism as a disease. Political economy can help to identify these shifts as well as the agents who gain or lose power as a result of these shifts. The beverage industry has benefited from the heavy drinking as disease logic because it shifts blame from the product to the biological (Minkler et al.,

1994).

Another critical component of political economy analysis is consideration for the role of the state in “defining, legitimating and treating health problems” (Minkler et al.,

1994). The power the state holds to allocate and distribute resources, mediate between different classes and sectors of society, and influence social conditions warrants close examination. Minkler and others (1994) point out the often-contradictory nature of state policies. For example, US state policies toward tobacco illustrate the contradictory forces at work in the state. The state provides funding and resources to prevention and treatment programs to combat the problematic consequences of smoking, but has also promoted tobacco industry interests by providing favorable tax policies and even subsidizing tobacco growing. The intent of these types of policies is to ostensibly increase production, and thereby stimulate the problems that the state seeks to prevent

(Minkler et al., 1994). Because intercultural health in Chile was born out of a need to address the socio-historical factors that have contributed to poor health outcomes among indigenous populations, these frameworks are useful to situate the implementation and challenges of my particular case study into the broader context of intericultrual health efforts in Chile.

Another important concept that has proven valuable to this analysis is Charles

Briggs’ “sanitary citizenship” (Briggs & Mantini-Briggs, 2004). This concept engages with how social inequality can be used to bolster hegemonic power by creating state- supported narratives linking illness and poor health with poverty, low class, and indigeneity. From his research on the cholera epidemic in Venezuela, he described sanitary citizens as those “whose habits and mental dispositions seemed to place them beyond cholera’s grasp…They became complex subjects who possessed a full set of

normative economic, cultural, familial, legal, educational, sexual and medical characteristics. Sanitary citizens were identified by their status as Venezuelans rather than being marked specifically in terms of a single dimension, such as social class”

(Briggs, 2004, p.33).

In contrast, those that are excluded from this classification are considered unsanitary subjects. Briggs writes, “Persons whose ignorance, place of residence, occupation, poverty, race and unhygienic habits placed them at risk for cholera became unsanitary subjects” (2004, p.33). He notes that unsanitary subjects are identified primarily by only one feature of their social identities; becoming simple, one-sided subjects lacking the characteristics that would have allowed them to “fit the model of the modern citizen and thus could be denied access to jobs, legal protections and human dignity” (Briggs, 2004, p.33). Application of this binary within the Mapuche context reflects how the Chilean state and state institutions conceive indigeneity and how the

Mapuche people fit into the healthcare system and society as a whole, which is elaborated later in this work.

These frameworks have helped guide the research presented here and attempts to deconstruct and organize the layers of influence on Mapuche health and healthcare in the context of intercultural health. The complexity of the Mapuche relationship with the Chilean state and the efforts to promote interculturality warrant examination and reflection. The theoretical basis described here bolsters the critical assessment of the conceptual and practical implications of intercultural health in Chile and how it interacts with and informs the social and structural determinants of indigenous health.

1.3 METHODS

I was first introduced to Mapuche culture when I lived in Valparaiso, Chile and studied at the Universidad de Playa Ancha in 2011. While I was there, I learned in depth about the contentious history of the dictatorship and its lingering legacies still present in many Chilean institutions, especially the education system. I experienced firsthand the

Chilean student protests that swept the entire country. These protests, often labelled the

“Chilean Winter” or “Chilean Education Conflict,” surfaced as a result of the intense discontent with the educational framework that prioritized profit over public education and the high levels of inequality. During this time, I witnessed the government response to the country’s youth – a highly militarized response with tanks, tear gas and aggression. I remember thinking at that time that the protest culture was much more visible than anything I had seen in the US. The highly militarized policing in Chile and protest culture continued to be in the news with respect to “the Mapuche Conflict.” I chose to focus on Mapuche health because the rhetoric I continued to hear about the territorial and sovereignty disputes seemed paradoxical to the promotion of a multicultural state and an intercultural health system.

Data Collection

A thorough literature review was completed to contextualize intercultural health theory into the historical, political and sociocultural framework of the Mapuche people and Chilean society. A qualitative assessment of intercultural health programming in

Santiago, Chile was conducted for two months in June and July 2017. Upon arrival in

Santiago and after making the necessary living arrangements, I began observations in

the comuna, or municipality, of La Florida in the Metropolitan Region of Santiago where

Centro de Salud Familiar (CESFAM) Los Castaños and Centro de Referencia Salud y

Medicina Mapuche (CRSM) La Ruka, the Mapuche medicinal center, are located.

Observations were recorded about the ease of locating the health center and ruka, the

Mapuche medical center, as well as the surrounding environment. Before beginning any formal interviews, I met with my site preceptor Ana Maria Oyarce, a medical anthropologist at the University of Chile, to discuss the project and logistics of completing my objectives. Due to time constraints, it was decided to focus solely on health centers with Mapuche medicine in Santiago, and not in Valparaíso, to be able to achieve more strategic, in-depth interviews. Therefore, most observations and interviews were conducted in La Florida at CESFAM Los Castaños, as well as in the neighboring comuna of La Pintana which also houses a ruka where the same traditional healer, or machi, tends to patients. I met members of the Mapuche Kallfulikan community at the CRSM La Ruka to explain the purpose of my project and obtain permission to observe and shadow the machi.

Initial interview subjects were identified and contacted through my site preceptor

Ana Maria Oyarce whose has been working with Indigenous health, racial and ethnic health disparities, and cross-cultural concepts of health among the Mapuche for over twenty years. Participants were then recruited through the snowball method. The study consisted of ten semi-structured, in-depth interviews ranging from forty minutes to two hours in length, covering topics related to how the ruka collaborates with the health center, how to promote Mapuche medicine and Mapuche needs in the healthcare setting, and the strengths and weakness of the current implementation of IH. Interview

subjects were all adults over the age of twenty-five, ranging from Mapuche community members, health center staff, and government officials involved with Indigenous health and development, and university professors. Oral consent was obtained from all participants before interviewing and interviews were recorded on an encrypted, password-protected device.

I also attended a conference entitled “Lawentuwün Trüwa Mapa Mew: La Salud en el Territorio de Tirúa,” which was a colloquium about intercultural health programming in the municipality of Tirúa in the southern Bío Bío region of Chile. The panel of discussants included the Mapuche mayor of Tirúa, indigenous health workers, public health professors from the University of Chile, and leadership from the health service in Tirúa. The topics discussed in this colloquium were highly relevant and illuminating for my own research.

Data Analysis

All data were collected from interviews, observations and field notes. The framework approach was used to analyze the data from in-depth interviews. Framework analysis is an approach to qualitative data analysis that consists of five steps: (1) familiarization, (2) identifying a thematic/theoretical framework, (3) indexing, (4) charting, and (5) data synthesis and interpretation (Srivastava et al 2009; Li et al 2014).

The first stage, familiarization, involves listening to recordings, reading transcripts and observational notes to be able to immerse oneself in the details of the interview and begin to become aware of key ideas and recurring themes. The second stage involves identifying a thematic framework in which categories are developed of the key ideas and

major themes. The third stage, indexing, involves sifting through the data to identify pertinent quotes and refining the themes and sub-themes. Charting, the fourth stage, takes the pieces of indexed data and organizes them into the constructed thematic categories. Finally, the data synthesis and interpretation stage allows for the comparison of themes and sub-themes against original transcripts and field notes to ensure appropriate context (Srivastava et al. 2009; Li et al. 2014). This method of content analysis was chosen because it provides clear, procedural steps and produces highly structured outputs of summarized data (Gale et al. 2013). It is most commonly used for the thematic analysis of semi-structured interview transcripts, from which the bulk of my data is derived.

Limitations & Lessons Learned

This thesis presents preliminary research on a very complex topic. Several limitations of this project have been identified. Time constraints were a major challenge, as two months in the field is a very brief time frame to understand the nuances and complexities of a community or organizational structure of an institution. I learned that patience is extremely important in order to take the necessary time to build trust with potential participants, which benefits the collection of reliable data for qualitative study.

Language was another limitation. While I speak Spanish, it is not my native language, which may impact the way people communicate with me as an interviewer and a foreigner. The sample captured a variety of different perspectives on the implementation of intercultural health in Santiago, however the research focused on just one Mapuche community in La Florida. Other communities in the region have been identified for further study on alternative intercultural implementation practices. Further research

should engage with the other indigenous associations in the Metropolitan Region to understand how they conceptualize their programs and how they choose to use their resources.

In the pages to follow, Chapter 2 defines interculturality and intercultural health in theory and in the context of Chilean Policy, and briefly describes medicine and disease from the Mapuche cosmovision. Chapter 3 provides a brief summary of the historical sociopolitical interactions of the Chilean State and the Mapuche people, with particular attention to how interculturality and intercultural health have impacted this relationship.

Chapter 4 describes what I saw on the ground about the structure of intercultural health programs in Santiago and the elements of interculturality at my research location in La

Florida. Chapter 5 outlines the four major themes that arose from my interviews and discussions about intercultural health implementation. In Chapter 6, I make the case for how the Mapuche experience contributes to the political economy of health and sanitary citizenship frameworks and Chapter 7 summarizes the conclusions and recommendations for the future of intercultural health programming in Santiago.

CHAPTER 2: DEFINING INTERCULTURAL HEALTH

Understanding the concept of interculturality and the theoretical foundations of intercultural health is central to this work. This chapter will describe how interculturality and intercultural health are defined within existing literature, particularly within Chilean public policy. This chapter will also outline how intercultural health has been conceived in other countries.

Interculturality within the Chilean context can be understood as an extension of multiculturalism, which became a state strategy to acknowledge and accept ethnic differences in society (Richards, 2010). Multiculturalism refers to the coexistence of diverse cultures, including cultural, racial, ethnic and religious groups that constitute a society (Richards; 2010). In contrast to assimilation for example, multiculturalism purports the maintenance of distinct, collective identities and practices (Torri, 2011;

Richards, 2010). Interculturality as a concept goes beyond multiculturalism to suggest that diverse cultures should not only coexist, but that these cultures can interact and relate to one another to create positive connections between all members of society

(Cavieres Sepúlveda, 2006). An intercultural approach infers that cultural diversity enriches the social fabric of the State; and implies that the interaction and exchange between individuals and cultures is respectful and reciprocal (Cavieres Sepúlveda,

2006).

Accordingly, intercultural health is a public health approach intended to reduce the cultural and social marginalization of indigenous peoples (Torri, 2010). It can be

understood as a bridge between indigenous health knowledge and medicine and western medicine, or biomedicine, wherein both knowledge systems are considered equal and complementary (Mignone et al. 2007). The basic principles on which intercultural health is based include mutual respect, equal recognition, willingness to interact and collaborate, and flexibility based on those interactions (Mignone et al.

2007). According to the Health and Indigenous Peoples Policy from the Chilean Ministry of Health, interculturality is defined as “a socially interactive process of recognition, respect, horizontalidad, and collaboration between two or more cultures (MINSAL,

2006, p. 21). It embodies the promotion of relationships of trust, mutual recognition, effective communication, cooperation and coexistence, and the right to difference

(MINSAL, 2006; Ríos & Leyton, 2014). This policy incorporates the following components:

• Socially interactive process, respect, horizontality

• Collaboration between two or more cultures in a defined space

• Relationships of trust

• Mutual recognition

• Effective communication

• Coexistence and cooperation

• Right to difference

The policy goes on to say that intercultural health establishes the recognition and respect of the diverse and singular characteristics of each indigenous group and aims to create an environment where these differences can coexist and support the health promotion of all people, even when it occurs in an unresolved setting of power

asymmetries as a result of the hegemony of the official medical system (Ríos & Leyton,

2014).

A comparative study of international experiences of traditional indigenous medicine promotion conducted through Chile’s Ministry of Health identifies strategic guidelines for the practical application of an intercultural focus in health in three main focus areas: conceptual harmonization, legal harmonization and practical harmonization

(Cavieres Sepúlveda, 2006). The first focus area deals with the development of conceptual frameworks, tools and methods to recognize the indigenous knowledge, practices and resources; and establish a new paradigm that allows for the understanding of the complexity of the theoretical and practical responses the indigenous systems of health have to offer for health promotion (Cavieres Sepúlveda,

2006). The second focus area, legal harmonization, involves the process of adapting legal frameworks to the sociocultural characteristics of indigenous peoples in such a way that establishes an equitable relationship between indigenous communities and the national society (Cavieres Sepúlveda, 2006). More specifically, the need for a legal framework that not only allows indigenous populations access to healthy environments and quality healthcare but that recognizes and makes official the contributions of the indigenous healthcare systems on the maintenance and restoration of the health of the population (Cavieres Sepúlveda, 2006). The third focus area involves the practical implications of the planning and implementation of models of care wherein the sociocultural characteristics of the indigenous population, their community resources and epidemiological profiles should be taken into account (Cavieres Sepúlveda, 2006).

The practice of integrating indigenous and western healthcare is becoming a much more widely used approach around the world (Mignone et al., 2007). The promotion of interculturality in health has been interpreted and constructed differently across and within countries. For example, a replicative case study conducted by

Mignone et al. (2007) in five Latin American countries found a wide range of implementation strategies; from an indigenous-operated health insurance company enrolling indigenous clients in Colombia, to government health centers training Mayan midwives in Guatemala, to hospitals and health centers run by indigenous organizations that offer both western medical services and traditional services in Temuco, Chile. Table

1 below summarizes those intercultural implementation strategies.

However, debates about intercultural health approaches continue to raise significant concerns about their design and implementation, which often emphasize issues with the conceptual, legal and practical application of interculturality in health.

One of the recurring debates about interculturality is that the interaction, in the majority of cases, does not occur on an equal plane (Cavieres Sepúlveda, 2006). This happens when the relationship develops from the vertical structure of the State and is directed towards the cultural content of indigenous communities. This flow of authority and information from one institution to the other creates an asymmetric power dynamic in terms of political power and access to resources. For this reason, interculturality demands horizontality and the search for a “new inter-ethnic relationship” between the

State, society and the indigenous populations (Cavieres Sepúlveda, 2006). The controversy associated with this relationship should not be avoided, especially with respect to its political and economic content. Interculturality from this perspective does not come from one to the other, but is constructed from the fusion of cultural spheres in a truly democratic political and epistemological context (Cavieres Sepúlveda, 2006).

MAPUCHE MEDICINE

Mapuche medicine and the traditional health system are linked to the Mapuche philosophy and vision of the cosmos (Torri, 2010; Kraster, 2003). According to this cosmovision, the world is inhabited by both natural and supernatural forces that protect life and health as well as evil spirits that can cause illness and misfortune (Torri, 2010).

Their vision acknowledges that good and evil coexist on earth in a dynamic juxtaposition, and that the conjunction of these opposing forces is necessary to achieve equilibrium (Grebe et al., 1978). The polarity of good/bad and health/illness are also

seen as necessary forces to maintain equilibrium and harmony in the universe (Grebe et al., 1078; Torri, 2010). The concepts of harmony and balance are integral to their philosophy as well as their medicine.

Diseases, or kutran, are caused when the harmony or balance in a human life or community are disturbed. Figure 2 shows the various different classifications of disease that fall into winka (non-Mapuche) and Mapuche disease.

They recognize that winka diseases pertain to the western world and should be treated in the westernized, biomedical way (Kraster, 2003). Mapuche kutran are typically provoked by forces or powers recognizable within the Mapuche culture and worldview.

The three types of diseases within the Mapuche kutran (Re, Wenu, and Weda) have different causes. Re kutran are diseases caused by nature, weda kutran are diseases caused by supernatural forces, and wenu kutran are supernatural diseases caused by

spirits (Kraster, 2003). Consequently, these Mapuche kutran must be treated by a traditional Mapuche healer, called a machi (Kraster, 2003).

Machis are the traditional healer and spiritual leader in Mapuche culture, and are mostly female (Torri, 2012). A machi is said to be chosen by Chaw Ngenechen through pewmas (dreams) and perimontún (visions) when they are relatively young (Torri, 2012;

Kraster, 2003). A new machi inherits the spirit of an ancestor through the maternal line, and must acknowledge this vocation or they will remain sick the rest of their lives. Once the machi accepts the call, she must seek out an elder machi to train her (Torri, 2012).

The process of becoming a machi is long, in which the ancestral knowledge of the many endemic plant species beneficial for health is passed down orally through generations (Torri, 2012). The machi make use of lawen, the medicinal plants and herbs, to create treatments for patients. The connection to nature is not only important for the preparation of herbal remedies but is also fundamental to the Mapuche being, the equilibrium of forces within the body, the community and the world. For these reasons, Mapuche healing is considered holistic, in contrast to the often reductionist and mechanistic practices in biomedicine.

CHAPTER 3: A BRIEF HISTORY OF MAPUCHE-CHILEAN RELATIONS

An understanding of the historical underpinnings that shape present-day indigenous health and intercultural policies is essential to critically assess the current efforts to promote intercultural health programs and examine the indigenous response to these efforts. The history of the relationship between the Mapuche people and the

Chilean state demonstrates the complexity of a state-sponsored intercultural health program and illuminates some of the underlying attitudes and tensions that constitute the current controversies over intercultural policies in Chile.

The history of Mapuche-Chilean relations began during the Spanish conquest of the mid 15th century. During this time, many other indigenous peoples through the region were subdued by the Spanish, including those of Chile’s Central Valley. The

Mapuche, however, fiercely resisted conquest, restricting the conquistadores to the northern regions of Chile (Richards, 2010). The Spanish and Mapuche signed more than 30 treaties establishing the Bío Bío River as the boundary between Mapuche territory called “La Araucania” and Chilean territory (Richards, 2010). This initial relationship must be emphasized as it denotes their officially recognized rights to independence and sovereign territory by the Spanish, albeit precarious.

Mapuche resistance persisted for centuries. From these experiences, the symbolism of the strong Mapuche warrior surfaced. The Chilean revolutionaries fighting for independence from the Crown tried to incorporate the Mapuche warrior imagery into their nation- and identity-building discourse to illustrate their own strength and

“connection” to the Patria. Most Mapuche, however, supported the Spanish, preferring their existing treaties to the newly formed Chilean State (Richards, 2010).

After the criollos gained independence from Spain in 1810, border relations with the Mapuche were maintained for several years. However, shifting economic and geopolitical interests in Chile led to a notable shift in the discourse surrounding the

Mapuche, from strong warrior to primitive savage (Carruthers & Rodriguez, 2009;

Richards, 2010). Bolstered by this uncivilized savage discourse, the state began a war against the Mapuche, occupying their lands and exterminating their people. This period of extermination was euphemistically called the “Pacification of the Araucanía [the

Spanish name for the Mapuche]” from 1860 to 1883 (Richards 2010).

Over the course of the next 30 years, the Chilean state relegated Mapuche people to reducciones that reduced their lands to only about 6% of their original territory

(Haughney, 2012: Richards, 2010). Much of the appropriated lands were deeded to

Chileans or European immigrants, and significant portions of the reducciones were lost due to contradictory land titles, fraud, violence and other questionable practices

(Richards, 2010). This confiscation of land left the Mapuche economically devastated and politically disenfranchised (Carruthers & Rodriguez, 2009).

Throughout this era and into the early 20th century, nationalist discourse emphasized assimilation to homogenize the national citizenry and eliminate ethnic and racial identities, fueled by concepts of mestizaje and la raza chilena (Richards, 2010). Here, identity politics and citizenship became spaces for negotiation. Any claims to rights based on a collective, indigenous identity were rejected by the state because they were construed as “unfair to other citizens” (Richards, 2010). In most cases, once indigenous

peoples were demarcated as citizens, their sovereign rights and cultures were ostensibly suppressed; or rather, citizenship was granted to take away rights.

In Chile, the araucano (Mapuche) was incorporated into the mestizo and nationalist identity, if only symbolically. The Mapuche were marginalized and excluded socially, politically and economically; despite the fact that parts of their culture were used to construct the Chilean nationalist imaginary. However, the historical existence of the border between Chile and the “Araucanía” allowed for their relationship to be understood in dichotomous terms. Even after “integration” into the Chilean nation, the

Mapuche were still seen as the “other” (Richards, 2010).

The second half of the 20th century is characterized by both progress and reversals in the struggle for recognition of indigenous rights (Lucic, 2005). During the agrarian reforms of the 1960s and early 1970s, some of the Mapuche lands were recovered— approximately 70,000 hectares of land were restored to indigenous ownership by 1971

(Carruthers & Rodriguez, 2009). Under the Allende administration, a law originally proposed by indigenous organizations was passed in 1972 that formally recognized the indigenous people of Chile and established the Indigenous Development Institute whose aim was to promote socioeconomic, educational, and cultural development of indigenous communities and encourage integration into the national community while respecting their customs and practices (Lucic, 2005). This law also included a promise to restore Mapuche lands (Lucic, 2005; Richards, 2010).

However, any progress of the Agrarian Reform was abruptly stopped during the military coup of 1973 wherein a counter-agrarian reform began (Lucic, 2005). Lands that had been expropriated were returned to former owners or sold. The military government

saw the Chilean state as homogenous, with no special recognition of or rights for indigenous people. The homogenous Chilean state was established in the Constitution

(Lucic, 2005). The Indigenous Development Institute was dismantled and the indigenous communities in the country suffered intense repression, dispossession, violence and discrimination (Richards, 2010).

The military dictatorship of Pinochet (1973-1990) was exceptionally hard for the

Mapuche, as they were often associated with leftist parties. The introduction of neoliberal policies reduced the sociocultural and economic space of the Mapuche by opening up their lands to privatization. Neoliberalism, as an ideology and political model, hinges on deregulation, privatization and decentralization, with the underlying assumption that the private sector is more efficient than the public sector. Many Latin

American countries adopted neoliberal economic policies, and neoliberal health reforms, in order to stabilize their economies and address failing health systems

(Homedes and Uglade 2005).

Pinochet decreed a law that prohibited traditional communal land use, facilitating the division of indigenous lands, attempting to erase Mapuche identity while giving generous land concessions, subsidies and tax breaks to timber companies and large corporations (Carruthers & Rodriguez, 2009). Mapuche organizations reemerged to fight the decree, but ultimately, nearly all Mapuche lands were subdivided (Haughney,

2012). Patricia Richards notes that this re-dispossession of Mapuche communities under Pinochet is “the immediate antecedent of the current conflicts among Mapuche communities, local farmers, forestry companies and the state” (2010).

Another important law to surface during the dictatorship is the Anti-Terrorism Law

18.314, which was used to crush political dissidence, enabling due process restrictions, secret witness testimony and police brutality with impunity (Human Rights Watch,

2004). Many of the legal frameworks as well as the discourse about the Mapuche people used during the dictatorship, including the Constitution and the Anti-Terrorism

Law, are still used to this day, which pose considerable concerns for addressing indigenous health problems amid State-Mapuche conflict (Lucic, 2005; Amnesty

International 2018).

With the return of democracy in the 1990s, Chilean government officials became preoccupied with multiculturalism and the political recognition of “culturally differentiated groups” due to increased demand from the grassroots, in an attempt to correct past wrongs against the indigenous groups (Torri, 2012). Multiculturalism and by extension interculturality became the new nation-building discourse in Chile, renouncing the previous discourse of a homogenous Chilean society (Richards, 2010). The government sought to reinvent its relationship with the indigenous population and launched a substantial initiative to foster a more inclusive public health system. This ideological and political shift to “accept and embrace ethnic differences” can be seen as the recognition of the damaging effects of the exclusionary and assimilationist policies of the past

(Richards, 2010).

However, the political processes to reshape this relationship also set in motion a process of state-produced knowledge of indigenous people (Boccara, 2007). The mechanisms through which the State began to negotiate the terms of “culturally differentiated groups” (i.e. indigenous peoples) illustrate how indigenous health and

indigenous medicine are renegotiated into a framework that superimposes models and logics in biomedicine, the official health system, with politics and bureaucratic administration. The power asymmetries become implicit and nuanced when the State began to formalize its relationship to the indigenous groups of the country under the guise of indigenous development.

In 1990, the Chilean government established the Special Commission of

Indigenous People (CEPI) to coordinate the new state-indigenous relationship

(Carruthers & Rodriguez, 2009). This came about in part due to global shifts in awareness of indigenous communities—the Pan-American Health Organization and the

International Labor Organization’s (ILO) Convention 169 on Indigenous and Tribal

Peoples was adopted as international law, explicitly advocating for the protection and promotion of indigenous medicinal knowledge, local health knowledge and experiences

(Garcia, 2012). As indigenous welfare was now given a platform in regional and global politics, CEPI, composed of both indigenous and non-indigenous members, proposed three main initiatives: the first was the intellectual framework for the 1993 Indigenous

Law; the second recommendation was constitutional reform concerning indigenous peoples; and the third was the ratification of the ILO Convention No. 169, the major binding international law concerning indigenous peoples. Only one of these recommendations was realized within the next twenty years.

The Indigenous Law was passed in 1993, which created the state institution

Corporación Nacional de Desarollo Indígena (CONADI), responsible for promoting the cultures and development of indigenous peoples and administering the policies set out in the law (Carruthers & Rodriguez, 2009). The mandate of the law signifies that it is the

responsibility of the State and its institutions to recognize, respect and protect indigenous cultures (MINSAL 2006). While this is arguably a step in the right direction, the complexity and controversy of the paradigm shift in the State-Mapuche relationship surface in the ways that “recognizing, respecting, and protecting” indigenous cultures are conceived. The Indigenous Law officially recognized eight indigenous groups, including the Mapuche (the largest constituent), Aymara, Atacameño, Colla, Kawashkar,

Yámana, and Rapa Nui (Lucic, 2005). A ninth indigenous group, the Diaguita, would later be recognized in 2006. This categorization process is problematic in that it recognizes certain groups of people and rejects others, based on the state’s construction of what counts as indigenous.

Here, we can see the biopolitical paradigm manifest itself in the institutionalization of socially-constructed, and governable, definitions of indigeneity.

Lucic (2005) notes that the rural communities and larger indigenous networks became weakened or divided as a consequence of the Indigenous Law itself. The law mandated

CONADI the right of designating “indigenous communities,” a legal status needed in order to receive economic aid (Lucic 2005). Many scholars argue that this is part of the state’s tactics to weaken and/or suppress indigenous movements in the country. Those indigenous groups that are not officially recognized are ostensibly nonexistent in the eyes of the state and do not merit the rights and services set aside for indigenous

Chileans.

This becomes even more complex with respect to the health sector, wherein certain aspects of indigenous life are advocated, such as health, and other aspects are ignored or outright rejected, such as political representation, claims to natural resource

rights and territorial restitution (Garcia 2012; Moloney, 2010). The contradictions become more apparent when efforts to promote inclusion of indigenous medicine and to develop intercultural health programs are pursued only to the extent to which the state sees fit.

Throughout the 1990s, Chile experienced a number of diverse initiatives directed at improving the quality of care for indigenous people. The first program directed at the

Mapuche population in the Araucanía region, and consequently the first intercultural health program, was called PROMAP (Garcia, 2012). This program held workshops, trainings and lectures throughout the country to try to build capacity and research to improve quality of care for indigenous peoples (Garcia, 2012). Garcia notes that the discourse by the state and international organizations regarding the successes of

PROMAP gave way to the second wave of intercultural health development that sought to detach the politics of indigenous health from the territorial and environmental demands of the Mapuche (2012).

The progressive depoliticization of health took shape in the Programa Especial

Salud y Pueblos Indígenas (PESPI), which received international support to promote the implementation of multi- or intercultural policies (Garcia, 2012). Beginning in 1996,

PESPI was formed by the Ministry of Health, dedicated to the generation of technical guidelines and policies for intercultural health at the national level. This program, along with CONADI and others to follow, represent state apparatus that combine bureaucratic administration and privileged biomedical models and dictate how intercultural health programs can and should operate. PESPI is said to be one of the first steps to constructing the field of intercultural health.

Another significant project in recent history affecting the Mapuche-Chilean relations and the field of intercultural health was the indigenous development program, Orígenes, established in 2001 through an Inter-American Development Bank (IDB) loan of approximately $180 million (Garcia, 2012; Richards, 2013). Orígenes was considered a novel and comprehensive program aimed at funding projects in five areas: intercultural health and education, production and institutional and community strengthening

(Richards, 2013). In the years that followed, the first indigenous-run hospital, the

Makewe Hosptial, was created in the Araucanía region (Garcia, 2012). Other projects led by indigenous organizations that emerged include the family health center Boroa

Filulawen and the Mapuche health center Ñi Lawentuwün in 2005 (Garcia, 2012; Torri,

2012). While these types of organizations and programs were lauded as huge advancements in the promotion of indigenous peoples and intercultural health, issues of participation and interculturality surface.

This restrained interculturality is what Paula García would call “governable spaces of indigeneity” in which what is deemed indigenous is constructed by the state

(2012). For example, while some presidents of the Concertación, a coalition center-left political parties that won every presidential election since the end of military rule in 1990 until 2010, spoke to the needs of the indigenous, little was actually done to create real change. President Lagos, for example, established the Comisión de Verdad Histórica y

Nuevo Trato but did not follow their recommendations to recognize indigenous peoples, demarcate their territory or rights to natural resources (Richards, 2010). The neoliberal ideology of Chile’s economic system superseded the social obligations to indigenous populations. This trajectory shifted slightly under the Bachelet presidency wherein the

UN Declaration on the Rights of Indigenous Peoples was voted in, and the ILO

Convention 169 was finally ratified in 2008, twenty years after its inception (Richards,

2010). However, many fundamental injustices persist, further demonstrating the hegemonic undertones of multiculturalism in Chile.

The perceived success of these programs overshadows some of the more structural inequalities that are embedded within these indigenous development and intercultural health programs. For example, Orígenes the large-scale indigenous development program was designed entirely without indigenous input (Richards, 2013).

Garcia (2012) and Richards (2013) note that many indigenous leaders see these efforts by the state as a new strategy to pacify the conflicts over land, a new cultural hegemony to control indigenous peoples under the guise of multiculturalism. Moreover, conflicts surrounding the field of intercultural health rose with the implementation of the mega- program Orígenes (Garcia, 2012). This can be seen through the efforts to depoliticize health by separating it from the other issues that the Mapuche are fighting for—what

Richards (2010) argues to be the “new mestizaje” under the veil of diversity and multiculturalism.

Conflict arises when indigenous goals contrast with those of the neoliberal project (Richards, 2010). Nowhere is this clearer than the confrontation between indigenous demands and transnational interests over the appropriation of ancestral lands and natural resources (Garcia 2012). These lands not only form an integral part of their identity and culture, but also encompass the basis of their sense of wellbeing and traditional health knowledge (Garcia 2012; Moloney 2010). Although efforts have been made to transfer land back to some Mapuche communities during the Bachelet

administration, the large-scale commercial timber plantations have made it increasingly difficult for Mapuche healers to find trees, plants and herbs used in traditional medicine and the government actively promotes this industry (Moloney, 2010).

The scope and limits of intercultural policies manifest in this contradictory way— promoting indigenous rights insofar as they do not impede with economic gains

(Richards 2010). The new role of the state as administrator of intercultural health prefers only a certain type of indigenous citizen, and rejects those that put at risk the political economy imposed by the neoliberal system (Garcia 2012). This “unacceptable” type of indigenous citizen, typically those protesting for the return of ancestral land, is then labeled a terrorist. The Bachelet government has received scathing criticism for the aggressive police response to Mapuche protests in recent years—a controversial anti- terrorist law (Ley de Seguridad Interior) created during the Pinochet dictatorship has been applied to Mapuche activists and protestors indiscriminately (Moloney 2010;

Richards 2010).

The terrorist rhetoric associated with the Mapuche mobilization illustrates a gap in the understanding of the knowledge systems held by the Mapuche and Chilean society. To promote interculturality in only one realm of Mapuche livelihood—health— and not in other areas such as politics or economics seems to support the claim that these developments are a ‘new cultural hegemony’ (Richards, 2010).

Furthermore, there is considerable evidence that racism is institutionalized in hospitals and other sectors of the health system (Mignone et al., 2007). Debates over intercultural health approaches spark concerns over regulation, reciprocity, effectiveness and the protection of sacred indigenous practices and plants (Mignone et

al. 2007). These intercultural health programs “on the ground” maintain many of the structural inequities found in conventional western healthcare systems, calling into question the actual interculturality of this new system.

For these reasons, examining the role of history in shaping contemporary health policy as well as the role of the state in “defining, legitimating and treating health problems” is critical to understand the perceptions and practice of intercultural health

(Minkler et al.,1994). Furthermore, it is important to critically assess how indigeneity and indigenous medicine are being defined and legitimated by the State in the process of creating intercultural health systems to ensure that the fundamental principles of interculturality are employed.

URBAN MAPUCHE/MAPUCHE-WARRIACHE

It was not until 1992 that indigenous population was included in the National

Census; and with the 1992 Census the urban society of Santiago “discovered” that its population was not culturally homogenous. The Mapuche “became” the largest ethnic group in the city, constituting 7.7% of the population of Santiago (Ojeda, 2009). A new term was coined to describe this new spatial category of indigeneity: warriache (warria means city and che means people, i.e. “the people of the city”) (Ojeda, 2009).

Figure 3 below shows the distribution of the Mapuche population and income quintiles across the municipalities in the Metropolitan Region of Santiago (Ojeda, 2009).

It also shows that the urban Mapuche live in the poorest areas of the region, illustrating the social and economic marginalization of this community.

With the need to address this population, the PESPI began piloting intercultural health programs in the Metropolitan Region in the early 2000s. The urban landscape, however, posed even more problems for design and implementation of a system that fosters Mapuche medicine. First and foremost, the Mapuche cosmovision, or worldview, is a complex philosophical system for which the concepts cannot simply be reduced to make them analogous to other systems of belief or thought (Ojeda, 2009). Furthermore, the regional variation of Mapuche society has led to a multitude of different types of practices linked to spirituality (Ojeda, 2009). In the urban context, this multiplicity can be even more complex, as members of indigenous associations within the Metropolitan

Region may come from very different communities of origin. Many of the elder

community members of the Kalfulikan Association that I spoke with shared stories of their journeys to Santiago from their homes en el campo, in the countryside. For example, one individual shared that she has lived in the comuna (La Florida) since she was twenty years old. She arrived in Santiago at seventeen looking for work. Likewise, another Mapuche man I spoke with at the ruka in La Pintana told me that he was originally from Valdivia and came to Santiago about twelve to fifteen years ago to search for work.

Stories such as these illustrate how economic and social changes have forced a greater number of Mapuche to migrate from their communities of origin in the South to large urban centers (Uauy et al., 2001). The search for more job opportunities in the city is a main motivator to move to Santiago. Approximately one third of the Mapuche live in urban centers (Ojeda, 2009). However, the shift from rural, communal living to an urban area leads to a different lifestyle and eating patterns. These changes have led to higher prevalence of modern health problems such as obesity, diabetes, and other chronic disease among the urban Mapuche (Uauy et al., 2001). A study conducted by

Uauy and others (2001) found a significantly higher prevalence of obesity and diabetes in urban Mapuche compared to their rural Mapuche counterparts or the rural Aymara.

Table 2 shows a summary of those findings.

Another study by Albala and others (2002) conducted in Santiago found similar results, revealing a prevalence 4.1% of diabetics in rural Mapuche, to over double that proportion of 9.8% in urban Mapuche and 5.3% in Caucasian population of Santiago.

These statistics demonstrate the social and economic inequities for the urban Mapuche that significantly impact their health and wellbeing. The lower rates of diabetes among rural Mapuche also indicate that certain sociocultural protective factors are missing in the urban context. While PESPI has served as the institutional response to the need for improved healthcare for the Mapuche, there exist many structural, social and environmental factors that hinder progress, including urbanization, loss of native forests, water sources and indigenous heritage, among many others (interview 3, 2017).

One of my informants, a younger Mapuche woman in her late twenties, expressed that the lifestyle in the city hinders her, and many urban Mapuche, from seeking treatment from the machi: “Here in Santiago, it is especially difficult because more than anything it is the style of life that is so fast-paced that does not allow for people to approach [traditional medicine] in the same way that they go see a doctor. In the end, they leave this type of health and lifestyle even more peripheral and marginalized, for a health [care] that is quicker, that agrees with the neoliberal system

that is also fast-paced. You pay and go to the doctor and in five minutes there is your

[prescription]… which is not the same as following a treatment with medicinal herbs”

(interview 8, 2017). The poorer health outcomes among the urban Mapuche compared to rural and non-indigenous Chileans warrants close examination. The influence of urbanization on Mapuche health and lifestyle must also be explored in the context of intercultural health programming.

CHAPTER 4: INTERCULTURAL HEALTH IN CHILE: FROM MACRO TO MICRO

4.1 Macro Level – Programa Especial de Salud y Pueblos Indigenas (PESPI)

The Programa Especial de Salud y Pueblos Indígenas, or PESPI, is a national program originally developed in 1996 by the Ministry of Health (MINSAL) to facilitate indigenous, primarily Mapuche, organizations to recover their systems of health practice to be offered to the population in a validated and accessible manner. The Policy on Health and Indigenous

Populations states that interculturality should be understood as a socially interactive process of recognition, respect, balance and collaboration between two or more cultures in a determined space (MINSAL 2006). The policy also notes that interculturality purports the promotion of relationships of trust; mutual recognition; effective communication, cooperation and coexistence and the right to difference (MINSAL 2014).

The funding for this program is distributed to regional health networks called Servicios de Salud. The Servicio de Salud Metropolitano Sur Oriente (SSMSO) is the network that encompasses the CESFAM included in this study. The Servicios are responsible for deciding the quantity of funding distributed to each indigenous association. Surprisingly, this funding does not channel through the CESFAM itself; even though the CESFAM and the indigenous association are the two organizations meant to generate interculturality “on the ground.” In some instances, the funding is passed from the Servicio to the local, municipal government and is then distributed to the indigenous associations. How each indigenous association uses the resources can vary greatly. Figure 4 illustrates the organizational structure of how PESPI funds intercultural health programs.

4.2 Micro Level – CESFAM Los Castaños and CRSM “La Ruka”

The Kallfulikan is the Indigenous Association that operates the Mapuche medicine center at CESFAM Los Castaños located in the La Florida municipality that is home to 7.1% of

Mapuche population in Santiago (Ojeda, 2009). The building where Mapuche medicine is practiced is called a ruka, a word from the indigenous Mapuche language of Mapudungun. The ruka at Los Castaños, formally called Centro de Referencia Salud y Medicina Mapuche “La

Ruka” (CRSM La Ruka), is the space where the machi, the traditional healer/spiritual leader, tends to patients; and where the herbal specialists, called lawentuchefe, prepare herbal remedies for treatment. The ruka also serves as an indigenous cultural center for Mapuche community gatherings, celebrations and rituals.

CRSM La Ruka is located behind the health center and can be accessed by walking around the outside of the health center. It is only operational two days a week, meaning that the machi sees patients only on Wednesdays and Thursdays due to budget constraints. Many respondents noted that they would like to be open every day of the week, but do not have enough funding to do so. The remainder of the week they use the space for cultural promotion

and awareness activities as well as other cultural rituals. Members of the CRSM La Ruka indicate that they have high demand, and would be able to see patients every day of the week if they had the resources to stay open. People come from all over the country to see the machi according to several respondents. The machi stated that patients came from as far as Arica in northern Chile to receive Mapuche medical treatments. The main reason noted by my informants for which people sought out Mapuche medicine was the holistic nature of the experience. The machi noted that he will spend as much time as necessary with each person to hear their story and understand how they feel.

The Kallfulikan community also run the ruka at one of the health centers in the neighboring municipality of La Pintana, which has one of the highest proportions (7.1%) of

Mapuche people in the Santiago Region. This ruka has even less integration with the accompanying CESFAM. They first constructed the ruka in La Pintana in 2000 with funding from

Canadian government, and the one in La Florida a few years later. While the Kallfulikan receive funding to operate in La Florida, they no longer receive funding from the municipal government in La Pintana. The machi volunteers his time at the ruka in La Pintana once a week and asks for donations only to be able to purchase the medicinal herbs and plants, and gas for the fire to prepare the treatments.

This particular community is unique in that the machi here is a man, while machi tend to be women. Furthermore, the Mapuche community leader, called a lonko, serves as the political head of the community and is not typically involved with the provision of Mapuche medicine.

The lonko of this community, however, serves a double role and is also involved with the health component. According to a 2014 impact evaluation report, the program implemented by

Kallfulikan represents the most traditional Mapuche medical model in which the machi is a resident of the territory (MINSAL 2014). In other experiences in the region, IH is conceptualized differently. For example, one association has generated an interdisciplinary intercultural team to

develop protocols to repair historical damage to the culture and people (MINSAL 2014). Another has chosen to develop strategies to focus on the poor mental health of the population (MINSAL

2014). One component of the PESPI that was not present in the Kallfulikan experience is the use of an intercultural facilitator, whose role is meant to liaise between the traditional medicinal offering and the biomedical services of the health center.

4.3 Dimensions of Intercultural Health at the Local Level

Several elements do exist at CESFAM Los Castaños and CRSM La Ruka that promote interculturality between the two facilities; including bilingual signage in Spanish and

Mapudungun, a referral form, informal Mapuche medicine orientations and intercultural health working group meetings. The Kallfulikan Association created an official referral form that allows doctors in the CESFAM to refer patients to the machi, shown in Appendix B-3. However, the use of this document is minimal. One respondent stated that they weren’t even sure if the doctors knew about the document or how to use it. This further illustrates the need for greater buy-in and mutual collaboration between the health center and the ruka.

Several respondents mentioned that they hold orientations in the ruka for medical student groups and new employees of the CESFAM. However, there was mixed messaging as to the frequency and audience of these orientations—one respondent mentioned that these had not occurred for some time. One suggestion made was to create formal, written policies of many of the informal agreements made between the two centers, which could lead to systems changes that promote greater collaboration. For example, creating a formal policy document that orientations and trainings with the ruka will be held for CESFAM staff.

Working group meetings on intercultural health, called mesas de trabajo, occur two to four times throughout the year between the Indigenous Associations and the directors of the nine CESFAM in La Florida. This element seems promising to open the dialogue between the

two models; however, attitudes toward the mesas de trabajo did not indicate that these meetings bridged the gap. One respondent noted that the CESFAM directors are not obligated to go to these meetings and often do not show up. I do believe that these meetings are an important dimension of interculturality at the local level and should continue to be used to bolster collaboration and reciprocity. There are also efforts in place to create a formal informatics system that would allow doctors and machi to register patients in both systems in order to monitor information on patient history, treatments and follow-up to better inform the health professionals (both doctors and machi) on patient context. Overall, among respondents involved with IH in La Florida, there was a consensus that the fundamental principles of IH were not being implemented in the current state. One respondent stated when asked if the current program could be called intercultural health, “No, we are in the process of putting interculturality into practice.” (interview 4, 2017) Another respondent summarized the experience saying “we

[the CESFAM Los Castaños and CRSM LA Ruka] share space, and nothing more” (interview 2,

2017).

CHAPTER 5: PERCEPTIONS & PRACTICE

Ten individuals involved with or knowledgeable of local and national implementation of intercultural health were interviewed. Among the respondents, five respondents were

Mapuche, three represented the national PESPI program, and two represented the conventional health center. Eighty percent work in the field of indigenous health to some degree. Results revealed that the current intercultural health framework is inadequate to meet the needs of the urban indigenous population. Findings of this qualitative analysis were consistent with many of the studies conducted in other areas. Analyses yielded four thematic areas that characterize the perceptions of the current intercultural health model at both the micro and macro level of implementation.

5.1 Theme 1: Issues with Design

Almost all respondents discussed concerns with the design of the intercultural health model at the institutional level. Eighty percent mentioned that the intercultural health framework at the national level has fundamental flaws that impede the process of interculturality. When discussing the development of intercultural health in Chile, one respondent said, “Even though many years have passed, I think the concept of intercultural health doesn’t have much content. Rather it has remained in a form [or structure] and is something that has happened throughout Latin America… the [idea] of intercultural health was conceptualized as the relationship between the biomedical and indigenous health services, but then was given very little conceptual content as to what it actually is” (interview 1, 2017). More theoretical reflection is needed to conceptualize

what and how these complementary relationships can be generated in a way that provides a reciprocal respect for indigenous belief and cosmovision.

Currently, the model for intercultural health is seen as a reproduction of the biomedical model and the Western epistemology of health and healthcare. MINSAL policy conceives of intercultural health as a biomedical model with an intercultural focus.

Many of the respondents mentioned that indigenous health cannot simply be restructured into that format, and doing so eliminates any symmetry of knowledge.

These discrepancies were made evident in the defining of vision, mission and objectives, particularly that of the target population. One respondent suggested that the entire PESPI should be restructured or removed entirely because “every program [or public health department] should have an intercultural focus” (interview 7, 2017). This respondent made the interesting point that PESPI was designed as a reinforcement program, and is not capable of addressing the problems that are currently being demanded of it. Fifty percent of respondents mentioned that capacity building, for both public health professionals as well as the indigenous communities themselves, is critical to promote intercultural health. Transparency of the funding, evaluation and monitoring of resources was mentioned as another major issue of design; partially stemming from inconsistent interpretations of the purpose and objectives of the program.

5.2 Theme 2: Issues with Access

Access and availability of the program to indigenous peoples was a major theme that emerged in the interviews. One of the biggest concerns with PESPI and one of the largest sources of conflict between the CRSM La Ruka and the Servicio de Salud is who the beneficiaries of intercultural health services actually are. Seventy percent of

respondents identified the conflict between the Indigenous Association and the Servicio de Salud based on the contradicting definitions of the target population. The Policy on

Health with Indigenous Peoples indicates that the principal users and beneficiaries should be indigenous, and mandates that Indigenous Associations participating in providing Mapuche medicine see at least 70% indigenous patients and 30% non- indigenous. This policy is in place ostensibly to ensure that the funding from PESPI meant to serve the indigenous populations actually reaches this underserved target population. At CRSM La Ruka, it was noted that about 80% of their patients are non- indigenous, a fact that has become quite contentious between the Kallfulikan and the

Servicio; but also illuminates ideological differences at the administrative level.

For the Mapuche, this mandate doesn’t coincide with their beliefs because they see it as their duty to treat anyone that comes through the door seeking help. This mandate was “introduced by the Law, but is not our law,” illustrating how the policies set forth by the State via PESPI were not created with the Mapuche knowledge and belief systems in mind. One respondent argued, “[At the ruka] we don’t comply with this mandate because it doesn’t coincide with our belief system… who is the government to decide that [she] is indigenous and [he] is not indigenous. I cannot guarantee that you are “winka” [non-Mapuche] or Mapuche” (interview 3, 2017). From their perspective, the services they offer are not only for other Mapuche individuals, but for the whole community, anyone that comes to their doors.

Likewise, another respondent reaffirmed this responsibility to provide care: “…in this process [of reaching interculturality] we have to continue following it. We are trying step by step to do the best possible and show that our [Mapuche] medicine also serves

[the people as does biomedicine] and the people need it. And that is what is demonstrated in the demand [for our services]” (interview 5, 2017).

When referring to proportion of non-indigenous people who access indigenous health services, one respondent pointed out that “in the end, we [PESPI] do a double discrimination” (interview 7, 2017). PESPI supports programs like the one at Los

Castaños, but those who access those services are not indigenous, so the funds and resources targeted to the Mapuche communities are not being utilized by those communities and the health inequities persist.

5.3 Theme 3: Cultural Relevance

All respondents discussed the importance of promoting cultural awareness among the broader Chilean community. Several respondents mentioned that the visibility of Mapuche culture in society is low, which contributes to the misunderstanding of the culture and the medicine. Many respondents suggested that intercultural health and intercultural education should be incorporated more comprehensively into the educational system, particularly in medical schools. Feelings of discrimination and depreciation of the Mapuche people and culture were common. One respondent noted that “human rights [in Chile] are directed toward one political sector” and that sector does not historically encompass the indigenous people (interview 6, 2017).

5.4 Theme 4: Politics and Policies

All respondents discussed the need for constitutional recognition of indigenous peoples as a fundamental step toward creating intercultural health. “If we want to arrive at interculturality in any context, it is obligatory and necessary that there exists a

constitutional recognition of what is the practice and exercise of indigenous medicine in

Chile.” (interview 3, 2017) This was the most widely agreed-upon recommendation among all respondents across the spectrum of perspectives on intercultural health models. Nearly all respondents, both indigenous and non-indigenous, noted that this political recognition is a historical debt owed to the indigenous peoples of the region.

Several respondents mentioned that this debt and indigenous rights in general were often used as political bargaining chips, which foments mistrust of the political system.

Political willingness was another important sub category. Sixty percent of respondents discussed that political will from the local to the national level is an important factor to affect change. One respondent stated, “interculturality moves very slowly, it depends on the willingness of each doctor’s office, each health center” (interview 4, 2017). More than half of respondents discussed how these changes need to be made at the institutional level before any meaningful changes can be made on the ground. One of the respondents mentioned that change must occur at the policy and programmatic level—that public policymakers must take into account indigenous culture in all public programming. Likewise, the need for these changes must be accompanied by transparency. Lack of transparency of the funding given to each indigenous association was considered a huge concern. Many on the Mapuche medical team believe that the funding mechanisms are unstable because they are dependent on political leanings.

CHAPTER 6: ¿Quién contamina más?

The paradigm shift that occurred when the Chilean state sought to reinvent and improve its relationship with the indigenous population produced even more complex and subjectifying effects on the Mapuche people that has left many feeling even more isolated and marginalized (interview 3, 2017). The government’s attempts to promote indigenous participation in Chilean society reflects the neoliberal and westernized ideologies that value the individual and the free market.

In its attempt to shift away from the paternalistic approaches of the past, the state simply transformed its governing power from being overt and explicit to a subtle and implicit biopower which took the form in many people’s eyes as the “bureaucratization of indigenous medicine” (Foucault, 1978; Garcia, 2012). The new machinery of the state generates what Boccara calls an “ethno-administrative knowledge” about the conditions of life, beliefs, health, habits, illness and therefore culture of indigenous communities

(2007). In this way, indigenous development is a path decided not by those taking it, but by the state through the administrative power of its institutions. One doctor involved with the health service in La Araucanía commented that interculturality is a topic of interest to the state to figure out how to make indigenous communities behave the way the state wants (Boccara, 2007). This observation illustrates the paradigm that inclusion in Chilean society, as a sanitary citizen, is contingent on conforming the indigenous body to a certain ideal of indigeneity. Deviants of this ideal, those that do not fully embrace the societal norms that support Westernized medical understandings of health, illness, hygiene and healing, are considered unsanitary.

One of my interviewees spoke at length about the Sanitary Code of the State, which establishes codes and regulations for hygiene within medical facilities, health centers, etc., and how it is meant to regulate a system for which indigenous epistemology and indigenous medicine do not correspond. For example, this individual spoke about how health officials require a hand-washing station in the ruka, to avoid contamination, suggesting that many of the traditional practices are inherently unsanitary. Yet, he argued the state allows for industries, cars and other pollutants that contaminate our environments and make people sick—to which he concluded: “¿Quién contamina más?”/Who contaminates more? (interview 3, 2017). The lack of will to understand the Mapuche logic behind their health practices illustrates how the indigenous knowledge system is still considered inferior to that of the biomedical system.

This commentary also evokes the importance of looking at the broader social, political, environmental and cultural context of a person’s health. Many of the Mapuche health workers I spoke with talked about how indigenous medicine is more holistic, looking at the patient as part of their social and physical environment, whereas biomedicine is reductionist and does not treat patients as people but as isolated body parts. A young Mapuche women I spoke with talked about how such a Westernized system of health “ultimately makes our bodies sick in one way or another; and it’s not just that but the earnings of the large pharmaceutical companies that invade the same territories that we [the Mapuche] are supposedly recuperating… This is the conflict as well. The model that is established in this country [Chile] and in many others over the indigenous communities is regrettably extractivist” (interview 8, 2017). Her commentary

points out key elements of the political economy of health, particularly the neoliberal economic machine that privatizes essential components of Mapuche livelihood such as land, water medicinal plants and herbs. She notes that the state continues to allow forestry and hydroelectric projects in the natural pathways and landscapes that create severe problems for the machi and lawentuchefe to obtain their own herbs. The environmental impacts of the deforestation of native forests and medicinal plants is one of the biggest problems for not only Mapuche medicine but their way of life as well. The economic greed of the state devastates the Mapuche culture and community both ecologically and socio-culturally.

Her commentary also illustrates the contradictory role of the state outlined in the political economy analysis introduced in Chapter 2. The neoliberal policies that characterize Chile’s economic practices negate the institutional efforts to help indigenous communities recuperate their culture. In the end, the effects of the convergence of multicultural ideals and neoliberalism tend to separate the State from its traditional obligations to regulate and provide social services, and hold citizens responsible as consumers of their own culture (Garcia, 2012). The Chilean state highlights diversity, by promoting intercultural programs, and grants a limited measure of autonomy, by merely acknowledging that there exist other cultures and types of health systems; but construes demands for radical redistribution, autonomous territory and self-governance as counterproductive to their multicultural society (Richards, 2010).

Patricia Richards points out, “the result is cultural recognition without the economic and political redistribution that would lead to greater equality” (2010).

Furthermore, this distorted cultural recognition is based upon state-produced knowledge of indigenous people and indigenous health, which is informed by biomedical reasoning. This can be seen as what Steve Epstein refers to as “categorical alignment,” in which categories used in biomedicine are superimposed on those used in identity politics and bureaucratic administration (2011). Thus, there is no equal recognition or respect of other systems of knowledge when the framework persists as a biomedical one. This is one of the most consistent criticisms I heard during my fieldwork looking at perceptions of intercultural health. Almost all of my Mapuche informants, along with scholars from the School of Public Health in Santiago who work in the field of intercultural health, agree that the current system is built on a biomedical foundation and attempts to fit Mapuche medicine into a biomedical model; and agree that no intercultural health program will work if, in this case, the Mapuche epistemology and cosmovision are not critically reflected and understood.

The paradox of intercultural health in Chile is produced by normalizing indigenous citizenship through a biomedical lens. To illustrate this point, I will adapt the concepts of sanitary citizens and unsanitary subjects from Charles Briggs’s research to apply to this argument. In his research on the cholera epidemic in Venezuela, Briggs coined the terms sanitary citizen and unsanitary subject to describe the differences between those fit into the legitimized space of the state and those that fail to do so.

Sanitary citizens, he writes, are “individuals who conceive of the body and disease in terms of medical epistemologies, adopt hygienic practices for disciplining their own bodies and interacting with others” and recognizing biomedicine as the dominant mode for disease treatment and prevention (Briggs & Mantini-Briggs, 2003). Unsanitary

citizens, on the other hand, are those that fail to “internalize medicalized epistemologies” and bodily practices (Briggs& Mantini-Briggs, 2003). He notes that being a sanitary citizen or an unsanitary subject depends upon the relationship to the state, which “claims primary responsibility for the health of its sanitary citizens”, and also assumes responsibility to “transform bodily, culinary, childcare and other practices”

(Briggs & Mantini-Briggs, 2003). In the written policies for health and indigenous people created by the Ministry of Health through PESPI, the Chilean government assumes this exact role with respect to indigeneity: the mandate of the Indigenous Law of 1993 designates that it is the responsibility of the State and its institutions to recognize, respect, and protect indigenous cultures (MINSAL 2006).

Briggs argues that health is a “key dimension of the process of transforming immigrants into citizens” (Briggs & Mantini-Briggs, 2003; Ong, 1995). In the Chilean context, health is used to transform indigenous peoples into these sanitary citizens. The issue of sanitary guidelines came up in my discussions with traditional Mapuche healers and Mapuche community leaders. As mentioned previously with the handwashing station example, they noted that these types of guidelines do not acknowledge to their world view and methods for practicing medicine, illustrating yet again that intercultural health has been constructed to fit indigenous medicine into a biomedical framework and rationality.

Consensus from my interviews and observations is that intercultural health needs to be taken back to its conceptual level and given proper theorizing to imagine how indigenous epistemologies can be acknowledged in a way that does not stem from a biomedical ideology. In a conversation with one of my informants within PESPI, they

discussed how the national program, from the State’s perspective, became a sort of scapegoat wherein all indigenous affairs were funneled, noting that PESPI doesn’t have the capacity to handle all the demands from indigenous communities.

From the indigenous perspective, health cannot be disconnected from the social, economic and environmental factors nor the political demands that contribute to the circumstances within which these communities live. Boccara and others mention that these institutionalized programs operate to depoliticize and decontextualize indigenous health from the multifarious issues that they face. My informant’s frustration with the

PESPI exemplifies not only the constrained design of the program, but the constraints placed on people through bureaucratization of indigenous health via intercultural health programs. Likewise, in her ethnography of the Boroa Filulawen and Ñi Lawentuwün health centers in southern Chile, Garcia points out that even though these centers are run by indigenous organizations, they are losing their autonomy by having to align with the administrative culture of the state (2012). Many authors suggest that this is due to the neoliberal values that pervade Chilean society—what Garcia calls the

“neoliberalization of indigenous medicine” (Richards 2011; Garcia 2012). In this example, the bureaucratic burden associated with Orígenes limited the particular projects that organizations were allowed to undertake as well as the scope of their indigenous practices that could be implemented (Garcia, 2012). The boundaries of the sanitary citizen are contrived through policy and administrative control.

For indigenous communities, autonomy and self-determination, which constitute some of the core political demands of the Mapuche people, are brought to the table only on the platform of development conceived by the state. The role of the state as

administrator prefers only a certain type of indigenous citizen, and rejects those that put at risk the political economy imposed by the state (Garcia, 2012). The unacceptable type of indigenous citizen is deemed unsanitary, backward, and even construed as a terrorist. The Mapuche individuals that advocate for land restitution and sovereignty are seen as threats to the state and are punished as terrorists in order to demonstrate that they are not part of normalized conventions of citizenship. This rhetoric set to the back drop of intercultural health demonstrates a huge gap in the understanding of indigenous epistemology and the concept of interculturality itself that the States praises itself for promoting.

The institutions established to empower indigenous communities and promote their health and wellbeing only do so to the extent that indigenous citizens remain governable. This is demonstrated by the fact that the Chilean government selectively decides what aspects of indigeneity to empower and what to deny. For example, while the ILO Indigenous and Tribal Peoples Convention 169 was created in 1989, the

Chilean government waited nearly twenty years before ratifying it in 2008, ending

Chile’s standing as the only Latin American country not to be a part of the most important international law concerning indigenous peoples (Garretón & Garretón, 2010).

Similarly, one of the enduring concerns for most if not all indigenous groups is the

Constitution, which is one of the only examples in the world of a Constitution adopted under military dictatorship that continues as valid doctrine under a democratic regime; and that does not acknowledge indigenous peoples as citizens with particular rights.

These political omissions raise questions about the motivations to pursue indigenous

health in this way and who decides and benefits from defining indigeneity in this manner.

The liminal space between sanitary citizens and unsanitary subjects exists prominently within the discourse of the development of intercultural health practices in

Chile. The task of defining what intercultural health is and what aspects of indigeneity fit into that model is a power-laden and historically biased process. The organizational power, which in this case is the ability to define the “rules of the game” (i.e. characteristics of intercultural health), fall to those who already hold the power—the non-indigenous, Westernized state with a biomedical lens.

CHAPTER 7: RECOMMENDATIONS & CONCLUSIONS

“we want to be the author of our own destinies” – Shareena Clanton, Indigenous Australian actor

The development of an intercultural health framework, both conceptually and pragmatically, necessitates indigenous involvement in the process from the beginning.

What has been stated over and over again is that the concept itself was defined in a skewed way from a Westernized, biomedical lens and thus fundamentally contradicts the values it presumes to uphold and promote. Efforts to correct the power asymmetry without building the system from scratch only place a bandage over the historical wound of marginalization and discrimination.

One of the problems that perpetuates a misunderstanding of Mapuche culture is the disconnect between the programs and courses to designed to improve understanding and the target audience. More of the non-indigenous Chilean society should be engaged in this education; or rather, Mapuche culture should be better integrated into the educational system, which was one of the themes that came up in many of my conversations on the topic. For example, the “Salud y relaciones interculturales: Curso de formación para asesores culturales y facilitadores Mapuche

2005-2007,” a course designed to introduce Mapuche health knowledge and practice the intercultural health facilitators, was directed to 70 Mapuche participants. While, this type of educational program is valuable, the target audience should be expanded to those that are so far removed from that understanding—non-indigenous Chilean society.

Framing the results in terms of the SEM, the majority if not all respondents discussed the need for changes at the institutional and national level, at the outermost levels of the model. Constitutional recognition of indigenous peoples was the principal action needed to improve indigenous health and generate intercultural health models.

Almost everyone framed this need as an historical debt to the Mapuche and all indigenous groups in the country. The following quote exemplifies the contradiction of the state’s policies toward indigenous peoples:

“Porque Chile como estado no tiene reconocido al pueblo indígena…en el fondo no

existe, el pueblo indígena no existe. Entonces, como tú vas a instalar una salud

intercultural plena con un pueblo que no existe constitucionalmente, legalmente?”/

Because Chile as a State does not recognize the indigenous population… ultimately the

indigenous population doesn’t exist. So how are you going to establish an intercultural

health program with a population/community that doesn’t exist, constitutionally or

legally? (interview 3, 2017)

Additionally, the current model is perceived as trying to force indigenous health practices into a biomedical format and biomedical logic. It must be reimagined at the public policy level with the inclusion of the Mapuche epistemology of a holistic medicine.

At the organizational level of the SEM, the Servicios de Salud must provide more transparency in their funding and decision-making processes. The Kallfulikan community noted that they monitor their own program and evaluates it for their own efficacy, but it is not required by the Servicio de Salud. Below is a summary of the main recommendations derived from this research.

RECOMMENDATIONS

• Political and constitutional recognition of indigenous peoples and indigenous

health practices are imperative to fulfill the principles of mutual respect and equal

recognition in the intercultural health framework.

• A more transparent evaluation framework developed with local input is necessary

to improve effectiveness and efficiency of PESPI resources. This framework

should be developed through a participatory approach which would allow for the

variability of implementation strategies.

• Mapuche culture and Mapuche medicine should be incorporated more

comprehensively into the school system, particularly in the medical school

curriculum, with the goal of providing a more symmetrical representation of

health knowledge.

CONCLUSION

Intercultural health has emerged in post-dictatorship Chile as a new paradigm toward the reduction of social and cultural marginalization (Torri, 2010). The neoliberal system in which this paradigm surfaces creates competing discourses about the promotion of indigenous rights. The perceived successes in the intercultural policies of the health sector contradict the policies regarding environmental discourse and indigenous politics. The idea behind intercultural policies and programs is ostensibly to remedy past wrongs and incorporate indigenous participation (Richards, 2010). The historical analysis of Mapuche relations with the state show how neoliberal multiculturalism is problematic and often work against true participation. For example,

the findings from my research echo the same conclusions from an PESPI program evaluation in the SSMO in 2013. Specifically, the same issues of transparency, political will and cultural relevance persist five years later, which begs the question of whether or not policymakers even concern themselves with these demands.

Debates over intercultural health policies spark concerns over the directionality and/or reciprocity of intercultural health approaches, regulation, effectiveness, and lack of cross-cultural research among others (Mignone et al., 2007). While some progress has been made, the long struggle for rights and recognition (of collective identity of indigenous pueblos) illustrates how precarious an intercultural health system can be.

Part of the problem is that multiculturalism “does not require people to deal directly with the way in which racial hierarchy continues to pervade social life” (Richards, 2010). The empirical acknowledgement of Mapuche medicine and culture within Chile’s intercultural programming does not necessarily challenge racial dominance at the societal level. This can be seen in the fact that the same problems identified in my research mirror those from five to ten years ago.

The current intercultural health framework in the Metropolitan Region is inadequate to meet the needs of the indigenous populations in Santiago. While I originally had a goal of providing recommendations at the local level implementation of intercultural health, the findings of my research suggest that higher level changes are critical to creating a model that demonstrates, in principle and in practice, an understanding of the indigenous conception of health and healthcare. Several fundamental issues must be addressed before any effective changes can be made to the intercultural health model to improve indigenous access to health services.

Constitutional recognition of indigenous rights, greater cultural awareness and appreciation and improved education on Mapuche culture are essential to facilitate true partnership and collaboration between the biomedical system and the indigenous system. Efforts to improve intercultural health must take into account the indigenous concept of health and healthcare without forcing it into a biomedical model. The intercultural health framework in Chile must be reconceptualized from an even playing field. An evaluation framework for funding mechanisms of IH at the regional level is needed to improve transparency and accountability among the Health Services and indigenous associations. These preliminary findings suggest that more research should be conducted in other urban areas with high indigenous populations to gather more representative data on IH implementation in the Metropolitan Region.

APPENDIX A-1 IRB Approval Letter

A-2 Sample Interview Questions Guide

SAMPLE INTERVIEW QUESTIONS

Project Title: Evaluation of intercultural health programming in Santiago and Valparaiso, Chile Principal Investigator: Hayley Moretz

INTRODUCTION

Thank you for agreeing to participate in this interview. My name is Hayley Moretz. I am a graduate student at the University of Arizona. I am conducting this interview to evaluate the effect of the intercultural health initiative at CESFAM Los Castaños. The purpose of this interview is to help better understand the effect that this intercultural health programming has had on you and/or your community.

Your participation is completely voluntary and you can choose to not answer a question or stop the interview at any point.

Do you have any questions before we begin?

BACKGROUND QUESTIONS 1. What is your name 2. What is your age? 3. Where are you from?

SUBSTANTIVE QUESTIONS 1. Have you heard of or have you ever been to CESFAM Los Castaños or Hospital Peñablanca? a. If yes, why did you choose to go to this health center? b. How was your experience? c. What was the process like navigating through the system? d. Any challenges? 2. Intercultural health can be seen as means to provide more culturally appropriate and culturally sensitive health care. In your opinion, does this program reach that objective? a. Why or why not? 3. In what ways has it met your expectations or needs? 4. In what ways has it failed to meet your expectation or needs? 5. How do you feel about the government’s attempts to promote integration of Mapuche medicine and western medicine? a. Positive or negative? b. What has been done right (or wrong) in your opinion? 6. What does intercultural health mean to you? a. What things would you like to see in an intercultural health program?

7. Can you think of ways to improve this system? 8. How would you rate the overall success of this system, using a scale from one to ten, where one is a complete failure and ten is a total success? a. Why? 9. In your opinion, how effective do you think this program has been in: a. Valuing both knowledge systems as equal in respect and recognition? b. Creating a safe and supportive environment for the sharing of knowledge? c. Building a sense of trust among patients and caregivers? d. Improving information communication? e. Improving quality of care and service? 10. Are there other factors or circumstances that you think contributed to the success (or failure) of this program? a. Please explain. 11. Did you experience any challenges or barriers that kept you from receiving the information or care you needed? 12. Can you think of anything that could be done differently to address the challenges or barriers that you faced? 13. Are there any other comments you would like to provide? Thank you very much for you time. This concludes the interview.

B-1 Map of Municipalities of Santiago Metropolitan Region

B-2 Infographic of CESFAM locations in the Servicio de Salud Metropolitana Sur Oriente

B-3 CRSM La Ruka Referral Form

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