ORIGINAL RESEARCH

Understanding -Williche Conceptions of Diabetes Mellitus and Arterial Hypertension from the Perspective of Intercultural Health

Sergio Hernán Bermedo Muñoz, SW

Abstract themselves saw in their understandings and prac- Background: In order to create a culturally tice. relevant health model, we examined how users Results: As explained by our patients, the Ma- from the Mapuche-Williche community, 's puche-Williche cultural system involves a thera- largest indigenous population, understood the peutic process during which traditional Ma- causes of Diabetes Mellitus and hypertension. puche-Williche medicine may complement, al- Objective: To describe both popular concep- ternate with, or substitute for traditional Allopa- tions and traditional therapeutic practices used thic Medicine. by Mapuche-Williche patients with diabetes and Conclusions: Diabetes mellitus and hyperten- hypertension. sion are not recognized illnesses within tradi- Setting: Health clinics located in the Cacicado tional Mapuche-Williche medicine. This creates de Riachuelo Jurisdiction of Rio Negro. difficulties in terms of adherence to biomedical Materials and Methods: This is an explora- treatment. Patients substitute traditional healing tory/descriptive study using the techniques of for biomedicine. These considerations suggest Social Anthropology to incorporate elements of the need to develop an intercultural health model indigenous health concepts into the positivist within the commune of Rio Negro. logic of biomedicine. Recruitment was non-ran- Introduction dom. We employed both case studies and in- Both official reports and a variety of studies depth interviews. Interviews were analyzed by on morbidity and mortality demonstrate that the constructing categories which described the health status and life expectancy of indigenous meanings and significance that the interviewees peoples are lower than that of the general popu- Corresponding Author: Sergio Hernán Bermedo lation. (WHO / PAHO, 1998, IWGIA, 2006, Muñoz, Social Worker and Faculty at the Nursing FID, (2013) This reflects a structural inequality School of the Universidad de Los Lagos, Osorno, which has persisted despite governmental efforts Chile. Address: Departamento de Salud. Municipalidad de Río Negro. Av. Buchmann No. 84. Comuna de Río to improve access to and quality of healthcare Negro. Chile. 64-2362240. Email: [email protected] services.

Submitted: February 17, 2016 During the past few decades in Chile, there Revised: July 30, 2016 have been important initiatives to investigate and Accepted: August 7, 2016 Conflict of interest: None more fully understand the epidemiological pro- Peer-reviewed: Yes file of indigenous . It is clear that their Funding: Programa de Salud y Pueblos patterns of disease and death are different (infe- Indígenas(PESPI), Departamento de Salud. Municipalidad Río Negro,Chile rior) to those of non-indigenous populations. In

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the Chilean province of Osorno, Mapuche-Willi- to the land, etc. Ibacache, McFall and Quidel che health status has the following characteris- (2002:15) note that "within Mapuche medicine, tics: the maintenance of Mapuche identity is an im- Mortality: The Mapuche-Williche population portant health indicator. As individuals become of Osorno has a higher overall mortality rate than more integrated into Chilean society (a process the non-Mapuche population; this is typical for known as wigkawün*) they become susceptible indigenous populations in Chile. However, mor- to diseases hitherto unknown within traditional tality of the Mapuche in Osornio is the highest Mapuche medicine.” recorded among indigenous communities.

(Pedrero, 2012: 76) Figure'1:'Adjusted'mortality'rates'from'' circulatory'diseases'per'100,000'in'Mapuche'and'' Cardiovascular Diseases: Based on survey non'Mapuche'popula

The leading causes of death among the Ma- 50$ puche are Cerebrovascular disease, Coronary ar- 0$ tery disease, and Hypertension. Death rates in the Urban$ Rural$ Mapuche population for these conditions are Mapuche$ Non$Mapuche$ higher than in non-Mapuches. Compared to non- Source: Pedrero, 2012 Mapuches, the Mapuche-Williche have a 80% increased risk of death from cerebrovascular dis- Epidemiological studies of Chile's indigenous eases and a 30% increased risk of death from populations have clarified the differing epidemi- Cardiac ischemia and Hypertension. ological profiles of these groups when compared 34.3% of Mapuches die of cerebrovascular to non-indigenous Chileans. They also shed light disease in comparison to only 29.9% of non-Ma- on the sanitary conditions within the specific ge- puches. This would suggest that non-Mapuches ographical areas served by various governmental have a better understanding of these conditions health services. Epidemiological studies per- and are more adherent to allopathic treatments. formed by the health authorities in Bio Bio, Ar- Pedreros (2012: 53) argues that higher mor- auco, Araucanía North, Araucanía South, Valdi- tality from vascular diseases may be explained via, Osorno, Chiloé, and Reloncaví, demonstrate by "the loss of specific protective factors found that mortality rates are higher in the Mapuche in Mapuche culture and the harmful way that the population than in the non-Mapuche. Osorno had Mapuches have been integrated into modern so- the third highest overall mortality rates. (Figure ciety." Protective factors might include cultural 2) aspects of Mapuche identity such as their tradi- The UN Report on the Health Status of the tional lifestyle, the existence and acceptance of World's Indigenous Populations drew attention traditional authorities and healers, participation to "alarming rates of diabetes. Worldwide over in spiritual events, access to sacred spaces, ties

* Wigkawün: refers to a person who has adopted a life- style that alienates him or her from Mapuche society.

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half of indigenous adults over 35 have type II di- Materials and methods abetes. These numbers are expected to increase. Based on the June 2012 monthly census†, In some indigenous communities diabetes has there were 320 diabetic and hypertensive pa- reached epidemic proportions and has threat- tients enrolled in the Cardiovascular Health Pro- ened the very existence of the community. (p. gram and thus eligible for the study. 164). The International Diabetes Federation Inclusion and Exclusion Criteria: All patients notes that while diabetes is present throughout who had either diabetes and/or hypertension the world, indigenous peoples have a greater dis- were eligible irregardless of their level of con- ease burden than other populations. trol. They needed to be enrolled in the SIGGES database in conformity with Law No. 19.966.‡

Figure'2:'Adjusted'overall'mortality'rates'per'100,000'in'Mapuche'and' They needed to have at least one Mapuche sur- non=Mapuche'popula>ons'Selected'Health'Services.'(2004'to'2006)'

16$ name and/or be registered as an indigenous per- 14.3$ 14$ son by the CONADI. 12$ 12.3$ 12$ This was a descriptive study and we used a 10.3$ 10$ convenience sample. Data was collected through 8.7$ 8.4$ 7.5$ 8$ 7$ 6.6$ structured surveys and semi-structured in-depth 5.6$ 5.7$ 5.6$ 6$ Mapuche$ 6$ 5.2$ interviews. As noted by Rodriguez et al.: "Inter- Non$Mapuche$ 3.6$ 4$ 3.1$ views allow one to access the knowledge, be- 2$ liefs, and rituals of a society or culture in the lan- 0$ guage of the subject." (Rodríguez, Gil and Gar- Chiloe$ Bio$Bio$ Arauco$ Valdivia$ Osorno$ Reloncavi$ cía, 1999:168). Araucania$North$Araucania$South$ Source: Data drawn from the Epidemiological Profiles Table: Distribution of the research Series of the Mapuche Population (2016) subjects based on their pathology DM& Total We undertook this descriptive, exploratory Sector DM HTN HTN study to better understand how Mapuche-Willi- Riachuelo 5 54 17 76 che patients with diabetes and hypertension un- derstood their illnesses and how they integrated Millantue 0 4 2 6 concepts from traditional Mapuche medicine Costa into their therapeutic itinerary. Our patients were Blanco drawn from the Cardiovascular Health Program River 1 10 4 15 (PsCV), provided by the Family Health Commu- Total 6 68 23 97 nity Center (CECOSF) in Riachuelo and from the Rural Medical stations (EMR) in Millantue 57.3% of the subjects were women. In addi- and Costa Rio Blanco. These were all primary tion to these 97 subjects we also interviewed 3 care centers located in the territory of Cacical de Lawenche and 2 Lawentuchefe. Lawenche are in- Riachuelo. dividuals who have knowledge of traditional remedies but do not prepare them. Lawentuchefe are individuals who are not (traditional

† Monthly Statistical Review, Series P-4, June 2012. ‡ [SIGGES stands for the Sistema de Información para la Gestión de Garantías de Salud, the Database to Manage Guaranteed Health Services]

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healers) but know how to prepare and administer based on rankings obtained from the Social Pro- traditional remedies. They have training in Ma- tection Classification of Social Vulnerability. puche diagnosis and medical practice. All five of 13.4% of survey respondents lived with a these individuals were from the study area. spouse or with children. The remaining 83.6% Both the survey and the interviews were de- lived with other relatives, primarily grandchil- signed to capture data on the following ques- dren, nephews, or nieces. 76% had not com- tions: pleted a primary school education. 1. What are the knowledges and practices of Among the 32.8% of Mapuche - Williche pa- Mapuche-Williche medicine? 2. How were the tients who are followed in the Cardiovascular knowledges and practices of Health Program (PsCV), 64.9% had consulted is conserved and passed down? 3. A description with a Mapuche-Williche healer and 67% admit- of the subject's therapeutic itinerary. 4. The sub- ted to using remedies for various prob- ject's understanding of diabetes mellitus and hy- lems. Some of these patients had learned about pertension. 5. The subject’s relationship to the traditional healing from their families as part of official healthcare system. their general cultural upbringing. Others had spe- cialized knowledge of traditional medicine that Analysis of the indepth Interviews: allowed them to address more complex prob- We initially developed categories for analy- lems; within the community they acted as Machi, sis; these were revised in the course of the anal- Lawenche, Lawentuchefe and Ngütamchefe, etc. ysis. We looked for similarities and differences All users identified diabetes and hypertension in thematic content. This was an exploratory as diseases "that we didn't have previously." study whose conclusions require further investi- They attributed these diseases to the consump- gation and confirmation. tion of processed foods with high fat and sugar content and associate these foods with a modern Results lifestyle. Thirty-two percent of the Cardiovascular These diseases of modernity are not limited to Health Program's patients are Mapuche-Willi- indigenous communities. They cross ethnic bar- che. riers and threaten the general society. Bengoa For 74% of the households, the main source (1996:7) has noted: of income are pensions. These included govern- § The accelerated adoption of modern lifestyles ment supported old-age pensions, savings from throughout the world both challenges and the pre-1988 social security system,** and †† threatens indigenous societies. Chile has ex- indvidually-funded pension funds. Payments perienced a decade of rapid economic devel- averaged $ 85,000 per month (approximately opment which has led to profound social USD $130). Over 65% of subjects were classi- changes whose local impact may be imper- fied in the first and second income quintiles, ceptible within the larger society. Moderniza- tion, understood as the uncritical adoption of

§ Law No. 20.255 enacted on March 11, 2008 reformed ** Law No. 18.689 enacted on January 13, 1988 merged the Social Security system and established a Solidarity multiple social security funds into the Instituto de Nor- Guarantee. This includes a set of state benefits that malización Previsional. subsidize payments into the Social Security System for †† Law No. 3.500 approved on November 13, 1980 and its those individuals who do not have sufficient savings or subsquent modifications established a Pension System are not eligible for a Social Security Pension. based on individual savings.

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norms, behaviors, and products coming from My mother stopped making catuto when she "developed" countries, is now a universal re- could no longer do it. We didn't make it any ality. longer because wheat became hard to find. In For Mapuche-Williche patients, the initial- the old days, my grandfather cultivated wheat, consultation in health facilities, represents just and we ate this, but now we had to buy it. And the first step on a therapeutic journey. Patients we used potatoes to make milcao. We ate a lot attempt to use medical therapies as a comple- of trutruyeco. We would roll it into a stick and ment to traditional therapies. Strategies are used eat it with honey. in which traditional Mapuche-Williche treat- The International Diabetes Federation (2013: ments can substitute for, replace, alternate, or 80) has conducted various studies on the preva- even be mixed with allopathic medicines. The at- lence and incidence of diabetes in indigenous tempt to maximize treatment outcomes involves communities; these studies show that "some a synthesis of therapeutics. communities who still maintain a very traditional lifestyle have a relatively low prevalence of dia- Discussion betes." While the human experience of illness is uni- The socio-demographic profile, the low levels versal, each culture has its individual approaches of education, and the difficult economic condi- towards alleviating suffering and restoring tions of the Mapuche-Williche users who partic- health. These are expressed in disease models, in ipated in this study suggest that they lack the ap- therapeutic interventions, and by the involve- propriate social and family support to appropri- ment of specialists. Within the Mapuche-Willi- ately monitor and follow the treatments neces- che medical system disease is understood as a sary for serious medical problems such as cardi- breakdown of an order that is natural, social, and ovascular disease. Within the WHO's approach spiritual. Individuals become ill when they upset to the Social Determinants of Health, factors their inner natural balance. This occurs when in- such as economic status, gender, and ethnicity dividuals violate the laws and norms that main- serve to determine differential exposures to path- tain harmony and balance between the earth (ad ogens and different vulnerabilities to illness. mapu, the law of the earth) and society (ad che, These findings have been amply confirmed in human law). Disease also occurs when individu- studies of Chilean indigenous populations and als neglect traditional cultural practices. Follow- represent a significant barrier to health equity. ing this logic, our patients understand diabetes Users with either diabetes and/or hyperten- and hypertension as being caused by an abandon- sion operate in a context of medical pluralism ment of their traditional diet. One of our subjects (Kazianka, 2012) which is not without conflict. described how difficulites obtaining wheat Therapy may begin within one of several sys- forced a change the family diet. Cooked, hulled tems, each of which has its own methods of di- wheat grains were used by the Mapuche - Willi- agnosis, its own form of help-seeking, use of che to prepare a food called “miltsrin” or medications, therapeutic prescriptions, manners “catuto” which was consumed instead of bread. of addressing the illness, etc. As wheat became less available these foods were During this therapeutic itinerary – which Mer- no longer prepared (this also occurred with foods cado (1998) has called a "trajectory of suffering" based on potatoes and flour). following the lead of Corbin & Strauss (1992) – we can uncover key behavioral aspects of both

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the medical professionals and the users. Medical highest possible level of physical and mental professionals tend to ignore the patient's histori- health." (OIT, 1989)‡‡ cal and cultural context. They are primarily con- Although patients may attend their appoint- cerned with the use of biomedicine. ments and get their prescriptions filled on a reg- The doctors never discussed using herbs with ular basis, their behavior at home may be quite me. All they did was force me to take all these different. Once back in their own environment pills. patients will independently make decisions about their medications, reducing doses, increasing Lerin (2007: 752) has examined the various doses, spacing out doses, or stopping the medi- cultural barriers between health personnel and cation altogether. They justify this behavior by their indigenous patients. To begin with the two pointing out that they suffer the side effects groups use different languages. Matters are com- caused by the pills. For those patients who con- plicated by the high rates of illiteracy among in- tinue their treatment this is more a matter of habit digenous groups, their lack of acculturation to than of being truly convinced the medications are modern medicine, and the dismissive attitudes helpful. They point out that the doctors always shown by doctors towards traditional therapies. have the final say. Patients cannot contradict the Doctors will often present a new diagnosis in professionals "unless you get them to like you." terms that are frightening to patients, explaining Some patients reported that their doctor didn't that if they don't faithfully follow orders the con- care if they used traditional medicines "as long sequences could be disastrous. Patients are led to as they continued to take their pills." believe that if they are non-adherent to therapy (or use another form of therapy) there will be re- "The doctor said nothing to me about it. Doc- prisals on the part of the clinic. As a conse- tors don't discuss herbal medications. The quence, they hide their non-compliance. only important thing is that I take their pills. If I were to die, they tell me they won't let me The last time I saw the doctor, he told me into the hospital. (...) Sometimes the doctors that I had to keep taking the pills even if they tell you that if you don't take the medications made me sick." this or that will happen to you and you are Seppilli (2000: 38) describes this type of clin- frightened. For example, they say you will go ical behavior as one that involves a "pathological blind. They are very cruel. They should find process, rather than focusing on the patient and another way of talking to us. I was very his or her concerns. This leads to depersonaliza- scared my children would be left orphans. tion and an emotional impoverishment of the therapeutic bond between the physician and the Such behavior on the part of allopathic prac- patient." titioners violates Article 25 of Agreement 169 This positivist discourse is used as a strategy which obliges governments to "assure that ade- to perpetuate the biomedical model. This prac- quate services are made available to tice should be understood within the context of interested peoples (...) so that they can enjoy the institutions which legitimize such knowledge and practice. This requires the creation of an

‡‡ The Convention concerning Indigenous and Tribal and ratified by Chile in September 2008. It became Peoples in Independent Countries was adopted by the law in Chile on September 15th, 2009. International Labor Organization on June 27th, 1989

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asymmetrical relationship of knowledges be- population. A new model needs to overcome lan- tween doctor and patient. There are important guage and communication barriers and to respect barriers – both linguistic and cultural – that im- the different conceptions of health/disease/care, pede dialogue between providers and users. that are part of the cosmovision of indigenous These barriers also affect the project of building peoples. intercultural health in areas with a significant presence of indigenous population who live in a Conclusions complex world of beliefs and values, norms, The Intercultural Approach to Cardiovascular knowledge and experience related to health and Health was created as a theoretical model that in- illness behaviors. Interculturalism in health has corporated cultural diversity into the health/ill- been described by Myrna Cunningham in these ness process. This was done by recognizing di- terms: versity, understanding it, and respecting it. All health systems have the potential to be The Mapuche-Williche culture has developed practiced on terms of equality by those who a body of knowledge to respond to the manifes- have traditionally worked within them. But tations of acute human distress: pain, suffering, this requres the creation of spaces where dif- and death. The allopathic categories of diabetes ferent healing systems can share their and hypertension are not part of this cultural ma- knowledge, understanding, abilities, and trix. One way of recognizing this would be to re- practices in a way that serves to both develop classify users as "people with a chronic illness" and maintain these same systems. (2002:9) and to understand their individual experience. This approach is part of sociocultural epidemiol- Wash (2010: 78) has argued that "multicultur- ogy as well as the traditional Mapuche-Williche alism" has been presented as a tool, a process, practice of treating "the person" and not simply and a project that was built by the people; the re- "the disease." ality, however, is evidently very different. What The fact that diabetes and hypertension do not we see in practice is a biomedical model that in- fit into traditional Mapuche-Williche healing stills in users the idea that health is a matter for poses major challenges to long-term patient officially-recognized professionals, primarily compliance with pharmacological treatment. Us- doctors. They alone have the knowledge and ers expect treatments to restore their health rather tools to diagnose illness and decide on treatments than cause further damage (i.e. adverse effects); without exploring the user's own cultural under- the role of drug therapy in these diseases needs standings. to be reconceptualized and presented in a way These ideas were also expressed by Ivan Illich that does not simply rely upon the dictates of al- (Illich 1975: 146): "the doctor controls through lopathic medicine. We need to reassess the value his use of language. The patient's own expression of biomedical treatments for diabetes and hyper- of distress is no longer meaningful. The use of tension in indigenous populations. In our partic- language to mystify only hightens the patient's ular case, it may be useful to mention Bonfil's distress.” The use of a positivist discourse within (1987) concept of "cultural control." We would healthcare as a strategy to perpetuate the biomed- argue that Western allopathic medicine is part of ical model entails the establishment of an asym- an "imposed and hegemonic culture." Both the metrical relationship of knowledge, which fur- clinical entities of diabetes and hypertension, as ther complicates dialogue and the building of in- well as the recommended drug treatments are tercultural health in areas with a large indigenous

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foreign constructs for those users who are part of Healthcare personnel must not only accept and the Mapuche-Williche culture. acknowledge the existence of Mapuche healing It is true that there are important national and therapies, but they must also consider the ideo- international agreements – ratified by the Chil- logical bases which forms an inseparable part of ean government – that set forth minimum stand- the Mapuche-Williche medical system. (UN, ards for the healthcare of indigenous peoples. 2007) These minimum standards include the active par- Intercultural health practice means imple- ticipation of indigenous populations in the de- menting the Ministry of Health's mandate to sign and implementation of health programs. "modify health programs ... so that they do not Nonetheless, the Cardiovascular Health Program clash with the cosmovision and health practices (created in areas with a high indigenous popula- of indigenous people." (MINSAL, 2012: p. 22) tion such as the Jurisdiction of Cacical de This approach opens up the culture of the patient Riachuelo) seems to have given little attention to using the tools of socio-cultural epidemiology cultural questions, and it could be seen as "cul- and the Health Rights of Indigenous Peoples. It turally inappropriate." (Montenegro & Stephens seems appropriate to conclude this paper with a (2006:1865) To remedy this situation will re- quote from Fuenzalida: quire mainstreaming an intercultural approach. It What does intercultural health look like in will be necessary to consider the Ministry of practice? Negotiation, consultation, and po- Health's advice that "the Western scientific litical engagement of the state with indige- model is not the only desirable and valid model.” nous peoples. It is the State's duty to reform, (MINSAL, 2013) The Mapuche-Williche culture restructure, refurbish, and/or create the nec- and its indigenous adherents have their own ex- essary institutional structures to make inter- planatory models which they use to order the cultural health policies truly effective. [...] In health/disease/care process. Their cultural un- addition, the State's functionaries must be derstanding is strongly anchored in their beliefs trained in approaches that will allow them to and values. Methods are needed to connect these understand, interact, and develop intercul- models with those of allopathic medicine. tural relations with indigenous peoples. Health interventions should not be targeted (2015:123) solely to modifying risk factors; they need to of- fer a holistic approach to the person. Silvestre References notes: Bengoa, José (1996) Población, familia y migración It is well known that program implementation mapuche. Los impactos de la modernización en la often fails because the local context and cul- sociedad mapuche 1982 – 1995. Revista N° 6. Ac- ture were ignored. Programs need to consider cessed 10 January 2016 from: http://200.10.23.169/im- ages/publ/PENTU6.pdf the contextual and cultural factors that mould people's daily lives. (2012: 156) Bonfil, B. (1987). La teoría del control cultural en el estudio de procesos étnicos. Revista papeles de la casa Intercultural health, considered as a public Chata, 2(3), pp 23-43. Accessed 2 July 2016 from: health strategy in Mapuche-Williche communi- http://www.ciesas.edu.mx/publicaciones/Clasicos/00_ ties, implies changing the allopathic paradigm of CCA/Articulos_CCA/CCA_PDF/001_BONFIL_Teori care delivery. Health teams need to develop in- adelcontrol_20140703.pdf tercultural skills that will allow them to function Cunningham, M. (2002). Etnia, Cultura y Salud. La in different - often dynamic - cultural contexts. experiencia de la salud intercultural como una

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