ORIGINAL RESEARCH

Health professionals' perception of maternal health: an ethnography in the Sierra de , ,

Niels Michael Dörr, MD

Abstract (UN, 2013), it is reasonable to question why Maternal health is a complex issue. In maternal health in the region has not improve to an Mexico, the population living in poverty and adequate extent when taking into account MM indigenous peoples are especially affected by (Lozano et al., 2011). It is necessary to examine health disparities, in particular, demonstrated by the way in which the vulnerable population skilled birth attendance. The determinants groups, such as people living in poverty or who mentioned by health professionals, especially are a part of indigenous peoples, are being affected structural barriers, characterize their perception. by this problem. In 2008, 20.9% of all Mexicans However, there are other barriers. The concept of lived in extreme poverty, which was intercultural medicine is understood as the concentrated in rural areas, where 33.5% of its adaptation of medical care to local reality to population is located (Iniguez-Montiel and overcome cultural barriers. This article will Kurosaki, 2018). In 2005, it was estimated conclude with a perspective that focuses on the that 9.8 million indigenous people lived in possibilities and limitations of intercultural Mexico, representing 9.5% of the total medicine for maternal health. Key words: maternal health - maternal mortality - indigenous population (UNDP, 2010) In 2002, extreme people - intercultural medicine - perception poverty in indigenous communities (in which more than 70% of the population is Introduction indigenous) was around 68,5% (Hall and Maternal health is a complex issue. In Patrinos, 2006). When considering the 2010, the global maternal mortality rate (MM) was complexity of the debate about identity and still 240 deaths per 100,000 live births. In Latin ethnicity, statistical surveys must be critically America, according to the UN (UN, 2013), this evaluated (Schmal, no date). Various rate was 72. Despite positive advances in the areas publications have shown that the health status of "skilled birth attendance", "prenatal care" and of the indigenous population is lower than that "use of modern contraceptive methods" (MCM) of other population groups. In terms of

maternal health, maternal mortality and Dr. Niels Michael Dörr, MD morbidity rates are significantly higher Universidad Veracruzana, Institute for Research in (Gracey and King, 2009). A 2006 survey by Education the National Institute for Women showed that Justus-Liebig University of Giessen, Institute for the History of Medicine indigenous women used MCMs much less Email: [email protected] frequently than non-indigenous women. In rural areas, only 48.9% of indigenous women Received: December 2019. Accepted: may 2020.. of reproductive age use MCMs, compared Conflict of interest: none. with 61.1% of non-indigenous women (INMujer, 2009). In 2012, the indigenous

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population received more support from social populations living in poverty have been neglected programs than the non-indigenous population. in this sense (Ramírez Hita, 2011). In Mexican Notably, more than 50% received support health policy, the concept is generally understood through a nutrition program or the as the adaptation of MA to the local circumstances Oportunidades program. However, the in order to overcome cultural barriers, thus helping improve MA, mainly for the indigenous insurance situation of the indigenous population (Campos Navarro et al., 2017). But in population improved significantly between general, there is no common definition (Salaverry, 2006 and 2012 because, although 64.9% of the 2010). Political understanding and the subsequent indigenous population still did not have health application of IM are criticized in the insurance in 2006, this proportion decreased to anthropological literature. One criticism is that the 22.1% in 2012. By 2012, 61.9% of the concept is applied without significant evidence indigenous population was affiliated with the (Salaverry, 2010). Thus, the question arises as to Seguro Popular de Salud (Leyva-Flores et al., whether the concept should continue to be used, 2013). since there has not yet been any perceptible This publication is based on empirical data improvement with respect to community health from a major German study for the purposes of a (Ramírez Hita, 2011). Therefore, this publication doctoral thesis in medicine (Limits and attempts to clarify the following questions: What possibilities of intercultural medicine for maternal are the possibilities and limitations of the concept health in the Sierra de Totonacapan, Mexico; http: of IM? What benefits can the concept have for //geb.uni-giessen .de / geb / volltexte / 2018/13910 MA? What applications are favorable and how can /), presents a perspective on maternal health in a they be implemented? rural region of the State of Veracruz. It focuses on structural and sociocultural barriers between the "... the doctor is the one who decides" local population and medical attention (MA), and This article is based on extensive the perception of medical personnel (MP) ethnographic field work. For the first focus group, regarding the patients seen. Most of the research a health training was carried out within the on this topic addresses patients' barriers to framework of the Oportunidades program. These equitable health care, for example, socioeconomic trainings were mandatory for pregnant women aspects which contribute to limited access. receiving welfare. The main topics referred to risk (Titaley et al., 2010). In contrast, research factors for pregnancy and childbirth, awareness of on the factors that affect MP is underrepresented to symptoms and preventive measures. The group date (Holmes, 2012). The perception of the MP was made up of 19 pregnant women, a husband, a regarding MA in rural regions is of particular Totonac-speaking interpreter and the male interest in this publication. This article concludes researcher. The objective was to investigate the with a perspective that focuses on the possibilities perception of the participants regarding the and limitations of intercultural medicine (IM). advantages and disadvantages of institutional delivery. At the beginning of the focus group, the Theoretical framework participants were surprised by the format of the The concept of IM has a tradition in event, which was usually oriented towards Mexico in the context of the MA of the indigenous training. Also, it seemed unusual at first that they population (Lerín-Piñón, 2004). The work of the would reveal their opinion regarding MA. anthropologist Gonzalo Aguirre Beltrán is Participants' reluctance was evidenced with the considered of particular relevance. In 1954, statement "So everything is fine at the hospital." Aguirre Beltrán requested to include the concept Particularly impressive was the argumentation of in national health programs (Aguirre Beltrán, one participant: 1994). It is especially used today in the context of “In fact, they make us sign the indigenous culture and traditional medicine consent forms that we want to have the [intrauterine] device and if one cannot, (Menéndez, 2006). Other features are less then the husband does so. I say there is frequently associated with IM. For examples, already negligence, they force you and

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really we as the owners of our bodies, if working in Coyutla, he continued to live in we do not want to, no one can force us neighboring Entabladero. The results of this to do anything we do not want. Precisely publication are based on 62 semi-structured for this reason many people do not want individual interviews. In addition, 24 structured to go to be treated in hospitals or by the doctor because really the doctor is the interviews were conducted with the MP at the end one who decides, not us. They put it in of the field work, three focus groups each with just like that, even if it doesn't fit. “ pregnant women and in the three medical institutions with MP. Interviews and focus groups Participant observation had previously were conducted in Spanish or the Totonac been carried out at the regional hospital, but no indigenous language. The Totonac interviews were complaints had ever been made in such a way. carried out with the help of an interpreter and later After the focus group, some questions arose that translated and analyzed in detail with her influenced and focused the research discourse: collaboration. Why was the doctor-patient relationship so The authorization to carry out the field patriarchal? Which factors prevent a successful work was obtained through the Intercultural interaction? What effect does this practice have on Veracruzana University (Universidad Veracruzana maternal health? Why have there never been any Intercultural) in and by the Veracruz complaints or reports during the participant Health Department (District No. III ). observation at the regional hospital? Why do Informants' anonymity was respected without women continue to attend the regional hospital changing the content of the interviews. All daily to give birth? informants were informed about the record of the data collected and they agreed to its use. Methods The field work is based on prolonged Introduction to the field participant observation in the Sierra de The SdT is an indigenous region of Totonacapan (SdT). The research was carried out Veracruz (Valderrama, 2005). Historically, the in medical institutions in three municipalities in vulnerable population is concentrated in this the region: in the regional hospital of the SdT in marginalized region (Ortiz Espejel, 1995), largely Entabladero (Hospital de la Comunidad living in extreme poverty (CONEVAL, 2015). All Entabladero) and in municipal health centers in municipalities in the region are officially classified Coyutla and . Medical institutions as indigenous (CDI, 2006). Both Spanish and in the region offer the opportunity to observe and Totonac, an indigenous language, are spoken. In understand the core values of the local society Filomeno Mata, for example, 97% of the (Long et al., 2008). For a total of nine months in population speaks an indigenous language and 2011 and 2012, the principal investigator, a male 32% speaks only their indigenous native language medical student trained in qualitative research (INLAI, 2008). Ten years before the research, the methodology, participated in both the regional regional hospital, a public institution, was built in hospital and the health centers. He was an active order to improve MA in the region. During the member of the medical team, as well as a passive research, the regional hospital offered MA to observer, lived next door to the hospital and patients who were both entitled and not entitled to participated in daily life. The methodology and the Seguro Popular de Salud. Pediatric, internal methods were chosen and applied in order to medicine and gynecological consultations were provide a comprehensive view of maternal health offered on different days of the week. Apart from care. The investigation was carried out for four an area for hospitalization, the emergency room months at the regional hospital, as well as at the and the delivery room can be mentioned as the health centers in Coyutla and Filomeno Mata for most important units. The hospital is the only another four months. During the investigation in medical institution in the region that is open Entabladero and Filomeno Mata, the principal around the clock. The health centers of the Coyutla investigator lived in the community. While and Filomeno Mata municipalities offer prevention

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programs in the form of family planning, health that there are hardly any opportunities to obtain training, vaccination campaigns and prenatal additional income – from a private consultation, examinations, as well as general medical for example - specialists, in particular, avoid the consultations and rooms for examinations and rural region. In addition, working in the SdT deliveries. From Filomeno Mata it takes up to two implies separation from family, a life outside the hours to get to the regional hospital. At night it is usual environment, with the deprivation of many impossible to leave the place without your own resources and the demand to adapt to difficult vehicle. During the field work in Filomeno Mata, circumstances. The resulting understaffing means three consultations were offered until every day that the present doctors have to provide services through the afternoon and Totonac interpreters, for which they have not been trained. This results without medical training, were present in case in a reduction of quality and satisfaction among communication problems were to arise. In the MP. Marginalization not only implies a Coyutla, medical consultation was offered from limitation of personnel, but also translates into a Monday to Friday for eight hours a day. lack of materials and medicines. A doctor from Interpreters were not used. In addition, the Coyutla explains why the work in the SdT is a Filomeno Mata health center is the only one that challenge for the MP. attends deliveries occasionally. Other health “Another important thing: most centers such as Coyutla refer pregnant women, at of the time the basic chart used at the the time of delivery, to the regional hospital. The first level, which is a health center, is not doctors mainly grew up and studied in the urban always complete; that is, medications are centers of and Poza Rica. Some only needed. Pharmacies have improved a lot come to work at the SdT because they live in with the popular insurance program. urban centers. A small part comes from the region Before they were state pharmacies. Now and belongs to the mestizo population. The doctors the drugs are almost 100% but there is do not speak Totonac. A minority of the nursing always a lack of drugs. Before it was the staff and other professional groups can most basic; antibiotics were penicillin communicate in Totonaco. Many of them have and nothing else. " grown up in the region and are used to the local Lack of medicines and materials makes conditions. MA difficult. Often the MP must improvise and initiate less effective therapeutic measures. The perception of the medical personnel Despite the Seguro Popular de Salud, patients The MP encounter several structural sometimes have to buy their medicines and problems. One of these problems is due to the supplies from private pharmacies. In the regional marginalization of the rural region. The hospital, this is common in the case of delivery, consequences for MA are mentioned by a doctor, although coverage of costs is suggested. This who worked in the city for a long time. situation leads to conflicts between the patients “As you have seen, we have what and the MP. Another barrier, especially when is necessary but we lack medical working with indigenous patients, is the language personnel. Medical personnel who do not barrier. Spanish-speaking doctors and Totonac- want to come to work in a place where speaking patients sit opposite each other, without the telephone does not work well and the adequate communication being possible. Even in road is in terrible condition. The hospital situations where an interpreter could support is beautiful, the building, because there mutual aide in successful communication, it is are much uglier buildings, in Poza Rica frequently rejected by doctors. An interpreter of it's ugly, but they don't want to move from Filomeno Mata tells of his work. Poza Rica. In Poza Rica there is a lot of “For example, a doctor comes in work, there is a great need for specialists, on Saturdays. He doesn't ask you to so the big cities absorb them. " support him, but he doesn't understand As the salary in public institutions is low the dialect. Who knows how he does it. and the economic situation of the region means He behaves very aggressively. Well, what

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are people going to say? They don't like they are going to waste their time and the fact that he gives the consultation. money. For them it is a total loss because For example, there are people who have they work every day. That is our main a stomachache, diarrhea, headache, and need: the support of specialists in because he does not understand them, the hospitals. " The statement shows that this informant doctor gives them the wrong medicine associates the performance of a blood test with and they do not get well.” poverty and absence of personnel. Although this Interpreters are often disposed of due to reasoning seems realistic at first, it conceals the lack of time or interest. In some cases, Totonac- multifactorial influence of the population. speaking patients bring their bilingual children to Regarding prenatal diagnosis, resources are only the consultation. In exceptional situations, one of the reasons for the discrepancy between MP bilingual nurses are consulted. Although the and patients. During another interview with a Totonac nurses and interpreters employed at doctor from the same health center, a completely Filomeno Mata come from the region and know different perception arises. the local circumstances, it should be mentioned “They don't realize if they are that at the time of field work, there were no trained pregnant, because most patients don't go interpreters. down to the valley for an ultrasound. The perception of the MP influences their They are afraid to travel. Not a single interpretation and behavior. These perceptions analysis will be done. Most don't travel, must be analyzed in their respective frameworks. they just don't want to. They don't do In the case of prenatal care and in the context of their analysis, ultrasound, nothing. diagnostic procedures, discrepancies frequently Therefore they lose so much time and occur. While the MP would like to perform at least when the labor pains start, their baby is four exams, the population tries to limit them to a already dead. “ minimum, because they are forced to travel for a In fact, part of the population does not go blood test or ultrasound. Furthermore, the down to the valley. Some of the informants had socioeconomic status of the patients is relevant. never left their communities. The aforementioned Although child exploitation is rampant, usually informant argues that this behavior makes work men are in charge of economically supporting the difficult and denounces his patients for family. Many families are supported by the endangering the lives of their children. The Oportunidades cash transfer program. A large part decisions and actions of the local population are of the population supports itself through often interpreted by the MP in the context of occasional work, especially through harvesting or alleged habits, traditions, customs and culture. construction, making it nearly impossible to save. Trust in the traditional midwives of the local This means that a consultation with the doctor population is understood literally by the MP as an must be carefully weighed when taking into act based on "cultural roots". account direct expenses and lost wages. The "Custom! The custom is that they following quote from a doctor from Filomeno believe the midwife more than the doctor. Mata is intended to illustrate the problem. If you have already gone to see the doctor “There is a lack of specialists in and the doctor tells you that you have to the hospital, because it is a reference. go to the hospital. No! They are very When people arrive and cannot find the closed in their customs and one of their specialist, what happens? Many return to customs is the midwife. " their units and if they overcome the The fact that many people in the SdT problem, fine. But if not? After we insist consult traditional midwives is strange to most of on sending them to the hospital for a the MP. The understanding and resulting actions of simple laboratory test, they no longer the local population are considered inferior to want to go. Why? Because they remember institutional MA and are punished as dangerous that there are no specialists there and

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for maternal health. This perception is reinforced going to do it as she wants or as her by the assumption that these are anachronistic husband says.' This day she just didn't habits in the form of "cultural roots." Although it want to 'You know what? I’ll write the is possible for pregnant women to give birth in the reference for her, Go ahead, let's go!' Filomeno Mata Health Center, they frequently They took her to Poza Rica. She wanted seek their traditional midwife at the time of to have the baby down on the floor at all delivery. In most cases, the midwife has already costs. There was a translator, there were cared for them during the pregnancy. two nurses who speak Totonac and they Comparatively few women tend to give birth in told her, and her husband was just quiet, the health center. Due to this observation, he didn't say anything 'You know what? If decisions at the time of delivery were further you don't talk to her, let's go! You’re investigated. A doctor from Filomeno Mata going to the hospital, because the lady explains the behavior of pregnant women with the does not want to spread her legs, she following casuistry. does not want to collaborate, she does “They are very modest. I tell you, not want to push, she does not want everything has to do with their ignorance. anything, she just wants to get off, but not So in the deliveries that I have attended here, she will not have it like that.' As I here, I just tell her 'Let's see, lady look, tell you, ignorance is one of the main you're about to have your child, pull your reasons for the main factors.” dress up'. They don’t want to do it. She’s The doctor highlights the ignorance and embarrassed and I say things like 'How shame of the pregnant woman. In addition, he are you going to have your child?' I say reports on vertical birth ("They put a laso on them, 'Spread your legs!' They do not want to. I they grab the laso and have the baby down on the have had several such cases. 3 or 4 years floor"). In his view, it is not compatible with ago a lady was already upstairs. She was institutional medicine. The casuistry shows that, already in the expulsion room and I said above all, the patriarchal behavior of the doctor to the nurse 'Talk to her!' and the other should be considered responsible. This assumption nurse arrives and says' Open your legs, if is intensified during interviews with the not your child will not come out like this, population. Some informants report similar open your legs! She did not want to and situations. In the present case the negligence she kept pulling down her dress, and she consists of the transfer to another hospital, which was very close to delivering. Then later is costly and risky at the same time. the midwife says ‘Doctor, she doesn't Family planning and MCM are central want to have it there, she says. She’s themes of MA within the region and for the prefers to get off, and give birth on the reduction of maternal mortality (Cleland et al., floor. ' I tell her ‘What are you thinking, 2006). The MP's perception of family planning how could she do that, first of all I will varies widely. A doctor from the regional hospital not allow it and if she wants to have it on perceives the problem as follows. the floor, she won't have it here. If you "They know that there are want to have it on the floor, then go contraceptive methods. They know that home. Here in the clinic we are going to these exist and that they can be obtained do as should be done, in the expulsion in the health center, but they do not go room up here, in bed, here she will have because they do not have time and it. ' The midwife said, 'Well, she doesn't because they have many children. They want it, she won't have it, she won't have do not go to the health center because her it up there, she says it's better to have it husband gets angry. The men find out that down there.' They put a lasso on them, they haven't been home. Machismo! They they grab the lasso and have the baby don't come because they don't know how down on the floor. I say 'But not that! We to ask us for a method. Because we can't are doctors and nurses, and we are not speak the indigenous language. It's a

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matter of trust. Many women come and mortality prevention program, our bosses say: 'I don't want to have more children, told us that if a pregnant woman dies, we but don't tell my husband. What we are will go to jail. You lose your job and your talking about right now no one should work permit, so our priority is to take know because if my husband finds out ... care of the pregnant woman and prevent 'There are many people who can and her from dying. That is why I have the want it, but there are many barriers. impression that we as doctors are always Sometimes there is no doctor when they afraid that a pregnant woman will die. " need it. Women sometimes visit you when This quote shows that the structural factors you're not working. Because we don’t that influence MA and MP perception are directly know, we reject them and don’t help them. linked to fundamental fears. The influence of But if we had known they wanted a higher structures leads to an essential fear. method, I think we would all have been willing. “ Determinants of health beyond medical control The doctor explains that the reasons for The MP rationalizes poor maternal health this unmet need are multiple. In particular, one and MM by referring to factors beyond their reason is the hierarchy between men and women, control (Allsop and Mulcahy, 1998). In particular, which is expressed in terms of stereotyped genders doctors blame the lack of human resources for roles. The statement of a physician from the same inadequate care. They also argue in terms of institution contradicts the statement of the availability, the need for sufficient quantity and aforementioned physician. quality of health goods. Previous literature points “Lately we see that the hormonal to similar evidence, since the quality of MA is the method is rarely used. It is very little, now most important factor in the reduction of MM all the women who give birth return with (Maine, 2007). While the nursing team perceives the device. Not with pills nor injections the quality of MA and high MM to be related to anymore. The population is already poor training of physicians, physicians do not accepting the device. And that is why we address this issue at all. However, there is a here in the hospital place the device on significant relationship between skilled birth every postpartum woman. Other methods attendance and MM (Holmes, 2012). Furthermore, are no longer used. " the perception of the MP is influenced by the While one informant perceives family media. Anthropologists Menéndez and Di Pardo planning as a problematic issue in MA, another analyzed the perspective on health through the explains that the population "accepts" MA. Both Mexican media. The authors consider that issues perceptions must be considered in the context of related to maternal health are presented as the empirical material of the focus group described catastrophic (Menéndez and Di Pardo, 2009). One at the beginning of this manuscript. The perception of the results is the construction of a fearful of MP is determined by several factors. During perspective of pregnancy and childbirth that makes research in medical institutions in the region, it a potential risk (Smith-Oka, 2012). On the one different experiences, more or less striking, lead to hand, the MP assesses the conditions within the a perception that is condensed into a stigmatizing institutions, but on the other hand they blame the and stereotyped image. poverty, behavior and culture of the patients. Beyond the evidence, taken from Poverty is related to a shortage of prenatal care, participant observation and the contextualization lack of financial resources to pay for of interviews, the field work also identified less transportation or health goods, poor living obvious factors that required a basis of trust conditions, lack of health-related education, etc. between informant and researcher. The following Also, the MP blame the culture of the patients. The doctor's appointment provides an in-depth insight ability to speak an indigenous language or the into MA. willingness to go to a traditional midwife, based "When we started the maternal on the existing power structure, is considered to

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blame for the high rate of MM among the (Kleinman and Benson, 2006: 1673). It can be said indigenous population, rather than interpreting it that the synonymous and thoughtless use of the as a representation of structural violence. This terms leads to an essentialization of ethnic and perception is already established during medical cultural belonging. Most of the programs and school when future doctors normalize a clinical projects in the context of IM focus on the visible view based on hierarchical power structures in expression of traditions (Castañeda, 2010). For society (Foucault, 1994). Such relations should be this reason, a large part of them deals with the especially considered when working with practical knowledge of traditional healers and their vulnerable indigenous patients (Jenks, 2011). medicine (Menéndez, 2006). This perspective goes This can lead to stereotypes and an beyond the material dimension, which is often essentialist understanding of culture. In addition, ignored or avoided. However, knowledge of the MP's own cultural identity plays a central role, cultural facts produces ethnocentrism and conditioning models of thought and action, encourages discrimination (Jenks, 2011). This is perceptions and moral values. However, it must precisely where IM's ambivalence and challenge also be taken into account in both cases that they lie. The first objective of IM should be, in this are very heterogeneous groups, so that sense, to establish a realistic concept of culture. generalizing statements is practically impossible. Cultural symbols described as foreign can be However, MP (although they are often considered useful to convey the concept of culture. A the most objective, scientific and thus neutral differentiated perception of traditional midwives professions) can be biased and impartial due to can be an argument both for a repertoire of models societal, cultural and economic structures. Even of thought and action, perceptions and moral scientific, medical professions remain unimmune values that cannot be objectified, and for the to prejudice. continuous transformation of the alien. Research in the SdT has shown that the MP tend to Possibilities and limits of Intercultural culturalize the problems of the region. Medicine Furthermore, determinants of health that are Culture and the encounter of different beyond medical control are often referred to as cultures are often important in the medical context causal. Many of the problems the MP faces have (Kleinman & Benson, 2006). At the same time, IM been shown to be political, socio-economic or must be seen as a human rights issue, since it links structural in nature. It is particularly notable that the right of indigenous peoples and ethnic precisely those people who are affected by social minorities to preserve and develop traditional determinants of health are considered responsible medicine and the right to health. Therefore, the for inappropriate MA. Consequently, this concept serves as an instrument for the respect of interpretation represents the reproduction and human rights (Anderson, 2011). If culture is continuity of colonial structures (Mignone et al., considered a human right, justice will only be 2007), since "the act of colonization itself was done if the understanding of the concept of culture legitimized through postulates of difference" is adapted to its real existence. If culture is (version in the original language: Akt der considered relevant in the medical context, the Kolonisierung selbst wurde durch human right to health can only be realized if the Differenzpostulate zu legitimieren gesucht) necessary attention is also paid to the cultural (Kerner, 2012: 29). Dichotomies such as dimension. Therefore, two aspects must be taken traditional and modern, black and white, into account. On the one hand, what concept of progressive and primitive, used to separate what is culture is used? On the other hand, what aspects of culturally proper from what is alien, express culture are considered? hierarchies and sustain (post-) colonial structures. It is often shown that the MP has an In MA, the understanding of individuals as essentialist conception of the culture of others. The "determined incarnations of their culture” should synonymous use of culture, language, ethnicity be avoided (version in the original language: and nationality, frequently used in the medical determinierte Verkörperungen ihrer Kultur) context, leads to “dangerous stereotypes” (Randeria, 1999: 426). The effort of health

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programs and projects with an intercultural acceptance and respect, horizontal relationships approach that integrate traditional medicine into between the different actors, inclusion and institutional medicine is also questionable. The integration of disadvantaged population groups, obligation to protect a culture based on human and solidarity among and with them (Torri, 2010). rights is often used as an argument for integration. Stereotypes, stigma, discrimination and racism can However, the broad dimensions of local culture be overcome. This in turn contributes to the cannot always be understood by foreigners as they recognition and respect of human rights, pivotal in are inevitably interpreted within the framework of the access to medical care. In addition, the ability their own cultures. In general, the to differentiate between the various relevant institutionalization of the traditional medicine aspects allows for a comprehensive view of real systems that have survived to date should be causes, including those of MM. Empirical material discussed in the context of IM, since they have has shown that the established use of an been maintained and developed independently essentialist concept of culture favors dichotomies without the active participation of institutional instituted by violence. Overcoming this violence medicine and the support of health programs must be the political moment of IM. (Knipper, 2007). Therefore, a useful definition of IM must be based on a realistic concept of culture. Acknowledgments The subject area of IM is concerned with any Special thanks to Dr. Francisco J. Pancardo interaction in the medical field between actors Escudero for his support during the field research from different cultural contexts. In order to do and to our Totonac interpreter Ana García Pérez de justice to this situation in terms of human rights, Filomeno Mata. Without her support, no dialogue two fundamental conditions must be created: On with the monolingual population would have been the one hand, in medicine, a concept of culture possible. Also, special thanks to Prof. Gunther based on the social sciences must be established. Dietz, the local InterSaberes project On the other hand, the relevant aspects (social, (http://www.intersaberes.org/) and the Institute for political, historical and structural) must be the History of Medicine of the Justus Liebig differentiated from the cultural aspects in order to University in Giessen / Germany, where I make culture usable as an analytical concept in especially appreciate the support offered by Dr. medicine. IM's task is to create these conditions. Michael Knipper. IM does not only play a role in the care of ethnic minorities or patients with immigrant Reference backgrounds. In all cases, there must be a sensitivity to culture within medical contexts. 1. Aguirre Beltrán G. Programas de salud en la Furthermore, this means that the issue of IM situación intercultural. 1st ed. Instituto should not focus solely on the doctor-patient Mexicano del Seguro Social. Xalapa: relationship. Culture should also be considered in Universidad Veracruzana; Instituto Nacional health decisions, programs and projects, in Indigenista; Gobierno del Estado de Veracruz; epidemiological surveys (Ramírez Hita, 2009) or 1994. in the analysis of MA for pregnant women in an 2. Allsop J, Mulcahy L. Maintaining indigenous region such as the SdT. The term professional identity: Doctors’ responses to "Analytical concept" implies the recognition and complaints. Sociol Heal Illn. 1998;20(6):802– differentiation of relevant aspects, but also 824. recognizing when cultural aspects are not relevant 3. Anderson J. Mortalidad materna y derechos to the interaction. In this way, the MP has the humanos. Apunt Rev Ciencias Soc. opportunity to obtain a more differentiated 2011;38(69):101–128. perspective on the behavior of patients, thus being 4. Campos Navarro R, Peña Sánchez EY, Paulo able to adapt MA to the real living conditions of Maya A. Aproximación crítica a las políticas the population (Holmes, 2012). In this way, the públicas en salud indígena, medicina essential aspects of MA can be reinforced: tradicional e interculturalidad en México

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