Final Version of Dissertation For

UNIVERSITY OF CALIFORNIA, SAN DIEGO Ujuk Usu. Medicine, Tuberculosis and Race among the Aymara of the border between Bolivia and Chile. A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Anthropology by Paula Francisca Saravia Committee in charge: Professor Nancy G. Postero, Chair Professor Thomas Csordas Professor Cathy Gere Professor Christine Hunefeldt Professor Janis H. Jenkins 2015 Copyright Paula Francisca Saravia, 2015 All rights reserved. The Dissertation of Paula Francisca Saravia is approved, and it is acceptable in quality and form for publication on microfilm and electronically: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Chair University of California, San Diego 2015 !iii DEDICATION To Jorge !iv TABLE OF CONTENTS Signature Page …………………………………………………………………… iii Dedication ………………………………………………………………………… iv Table of Contents ………………………………………………………….………….v List of Figures………………………………………………………………………. x Acknowledgments ………………………………………………………………… xiii Vita ……………………………………………………………………………….….xv Abstract of the Dissertation ………………………………………………….…. xvi Introduction ……………………………………………………………………….. 1 1.Tuberculosis: A silent killer…………………………..…………………… 3 1.1. Social conditions of tuberculosis……………………………….. 5 1.2. The biomedical framework for tuberculosis…………………… 9 2. Transnational Aymaras: across decolonization in Bolivia and authoritarian neoliberalism in Chile……………..……………………….. 11 3. Race and nation in Bolivia and Chile…………..……………………….. 23 4. A medical anthropological perspective…………………………………… 26 5. Methodological aspects of the field research………………………………32 5.1. Research participants…………………..……………………… 34 5.2. Data gathering…………………………………………………. 35 6. The dissertation chapters………………………………………………… 36 7. Conclusions…………………………………………………………… 39 !v Chapter 1 Framing from Above: International Public Health and State approaches to tuberculosis and the working of biopolitical frameworks………………………….41 1. Unidos venceremos a la tuberculosis: the state framings of TB………….. 42 2. The development of international TB control and eradication programs… 46 3. National anti-tuberculosis programs……….………………………………52 3.1. El efecto concreto: PROCET an the anti-TB framework in neoliberal Chile……………………………………………………….54 3.2. The Making of a national health priority..…….………………… 58 3.3. Biopolitics at work……………………………………………. 66 4. Medicalization and Pathologization: race and medicine……………….… 69 5. Tuberculosis control in Bolivia…………………………………………. 75 5.1. Illness and race in Bolivia……………………………………… 75 5.2. “Proceso de cambio” and decolonization: challenging projects within a challenging contexts…………………………………………79 5.3. The Vice-Ministry of Traditional Medicine and Interculturality (VMTI)……………………………………………….81 5.4. When statistics are not enough……………………………….… 84 6. Tri-national referral and contra-referral form…………………………… 87 7. Conclusions……………………………………………………………….. 93 !vi Chapter 2 Medicine and Race……………….……………………………………. 95 1. Delivering healthcare in the Chilean altiplano..……………………………96 2. Intercultural health in Chile………………………………………………101 2.1. Making interculturality happen in the Chilean Altiplano………103 3. Race and Illness in the Yungas……………………………………………113 3.1. Challenges of healthcare……………………………………………… 116 4. Race has many shapes…………………………………………………….123 5. Conclusions……………………………………………………………… 129 Chapter 3 Precarious Engagements, Contested Compliances, and Resistance……..……………………………………………………………..… 131 1. Medications as languages of recovery……………………………………132 1.1. TB diagnosis……………..…………………………………….. 132 1.2. Illness ass emerging borderlands……………………………. 135 2. Healing through pain…………………………………………………… 140 2.1. Don Saturnino………………………………………………… 142 2.2. Gender inequality a healing………………………….…………145 3. Precarious engagements…………………………………………………. 147 3.1. How do medications exclude………………………………… 147 3.2. Active engagement and precarity……………………….………149 !vii 4. Aymara healing and agency: “coming through” and “prosperity”…….……..… 152 5. Conclusions………………………………………………………………163 Chapter 4 A strike of cold, a sense of bitterness…………………………………… 164 1. Tales of the mountains………………………………………….…………165 2. Sajama………………………………………………………………… 167 3. The Aymara Body/Mountain metaphor………………………………… 172 4. Usuña Aruskiparañani: let’s talk about pain and illness……………….…174 4.1 The Aymara tuberculosis illness semantic network………….… 177 5. Illness and emotions…………………………………..………………… 183 5.1 Kuliratawa (I feel angry)………………………………………..184 6. Conclusions……………………………………………………………… 192 Chapter 5 From suffering to citizenship……………………………………………..194 1. Political framing of healing and indigenous bodies……………..………. 194 2. Citizenship……………………………………………………………. 197 2.1. Classical Theories of Citizenship……………………………….197 2.2. Cultural Citizenship……………………………. …………… 199 2.3. Flexible Citizenship.………………………………………… 206 3. Citizenship through a medical lens …………………………………… 210 3.1. From sufferers to citizens……………………………..…….. 210 !viii 3.2. Sanitary citizens and unsanitary subjects………………..…… 216 3.3. Biological citizenship………………………………………..…221 4. Politics of TB diagnosis……………………………………………… 224 4.1. Diagnosis and emerging political categories……………..….. 230 4.2. The treatment………………………………………………..… 233 4.3. Engaging human pharmakons?……………………………..… 237 4.4. Illness and citizenship: A double bind?………………………. 239 5. Conclusions ………………………………………………………….… 242 Conclusions………………………………………………………………………….244 Bibliographic References……………………………………………………..…… 251 !ix LIST OF FIGURES Figure 1. Estimated tuberculosis incidence rates 2013…………………..….….. 4 Figure 2. Tuberculosis Incidence Rates (all forms), Chile 2002-2012…………. 7 Figure 3. Indigenous communities of Bolivia……………………………….….. 8 Figure 4. Map showing the Parinacota region in Chile and the Aymara communities visited with the medical rounds…………………….…..33 Figure 5. Map that shows the distribution of the ethnographic research field sites in Bolivia and Chile and the circuits followed…………….34 Figure 6. Anti-tuberculosis propaganda distributed by the public health office in Chile………………………………………………….43 Figure 7. Anti-tuberculosis campaign in the city of La Paz, Bolivia..…….……44 Figure 8. Medical technician performing a blood test in Puquio……………….69 Figure 9. Map of Parinacota that shows the coastal city of Arica and the Aymara communities in the highlands…………..……………………97 Figure 10. Medical providers from Putre working in one of the medical rounds, Guallatire………………………………………………..……99 Figure 11. The tuberculosis room in the healthcare center in Putre signaled with the biomedical post and its translation to Aymara language… 104 Figure 12. Photograph from the interculturality workshop with medical providers in Iquique…………………………………………..……..108 Figure 13. An intercultural medical encounter in Guallatire…………..……… 112 Figure 14. A representation of a Yatiri, the Aymara traditional healers and wise men……………………………………………………… 112 !x Figure 15. Map of crook that shows the hospital at the center and the 109 communities that it serves………………………………………117 Figure 16. A view of one of the open markets in Coroico………………………118 Figure 17. Admiral J. T. Merino referring to the Bolivian claim……………….123 Figure 18. Poster advertising a rally against immigration………………………129 Figure 19. Hospital of thorax in the Miraflores neighborhood of La Paz………141 Figure 20. Alasitas: small trucks are very popular during these festivities……..154 Figure 21. A medical record of a TB patient in Chile…………………….…….162 Figure 22. A regular TB corner in a CESFAM in Chile………………….…..…162 Figure 23. The Sajama mountain ……………………………………………….167 Figure 24. The Pallachatas, Parinacota and Pomarapi mountains………….….. 170 Figure 25. Aymara men taking care of the load after a climbing tour to Sajama…………………………………………………………….170 Figure 26. Chullpas located on the road to Tambo Quemado…………………..171 Figure 27. A touristic map showing the Mountains in Sajama and Parinacota…171 Figure 28. Scheme of the Aymara illness semantic network……………………179 Figure 29. Yatiris performing a ritual for the celebration of the Plurinational state in La Paz…………………………………………193 Figure 30. Map of the Bolivia-Chile border showing the town of Jaiña………..195 Figure 31. An anti-tuberculosis campaign poster in Chile…………………… 227 Figure 32. Drawing of the differences between a sensitive tuberculosis strain and a non-sensitive or resistant strain…………. 232 !xi Figure 33. Drawing of the structure of Aspacont as compared with the PNCTB………………………………………………………………236 !xii ACKNOWLEDGEMENTS I would like to thank many people and institutions that helped me in many ways during my doctoral studies at UC San Diego and during my research in Bolivia and Chile. I feel most grateful to the Aymara people who shared their personal experi- ences with me, and to all the medical providers and indigenous healers who kindly ex- plained to me the complexities of their work. I would like to thank the UC San Diego department of Anthropology faculty, staff, and fellow graduate students for giving me the opportunity to develop my research in such great company. To my advisor Nancy G. Postero, for being such an amazing mentor and supporting me and my family in our darkest hours. I always felt I was part of a team, thank you. I feel very grateful to professor Janis H. Jenkins

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