For the first time in history, the Chilean constitution will start to represent the diversity and plurality of Chilean society. Against a long-standing backdrop of social unrest, where high levels of inequality were entrenched into society, an overwhelming majority of Chileans voted in October 2020 to reform the nation’s constitution.
Since then, the country’s newly-installed 155-member assembly convened for the first time on July 4, 2021. There, Elisa Loncón, an Indigenous Mapuche woman, academic, and activist, made history when she became the assembly’s president. This moment marked a watershed in Chilean history as the country took its first step to rewriting the relic from Gen. Augusto Pinochet’s dictatorial rule.
In Loncón’s speech, she expressed her hopes of transforming Chile into an intercultural state; a state that embraces Chile’s Indigenous groups — communities that the current constitution fails to even acknowledge. “It is a dream of our ancestors and this dream has come true. It is possible, brothers and sisters, to re-found this Chile, to establish a relationship between the Mapuche people … and all the nations that make up this country,” Loncón said.
Loncón’s words rest upon the dire socioeconomic and health conditions of Indigenous populations that have long suffered under Chile’s current constitutional system. Currently, the brunt of the COVID-19 pandemic has fallen upon Indigenous Chilean communities, where infection and mortality rates are concentrated as a result of the pandemic’s exacerbation of precarious living conditions. Although health gaps have narrowed in recent years, Indigenous health outcomes are still deeply rooted in a history of marginalization and inherent inequality.
In the 1990s, the government of Chile attempted to mend these historical inequities. By introducing intercultural health care to Indigenous populations, they hoped to make their public health system more inclusive. Thirty-one years after Chileans traded dictatorship for democracy, the country has yet to bring the promise of that society to most Indigenous peoples.
The tension between traditional health beliefs and modern biomedicine embodies the Indigenous struggle for a place within contemporary Chile. Emerging from a history of repression requires an acute effort to fix the stark differences in health outcomes as well as to preserve Indigenous traditional practices and protect their autonomy.
“Universal” Health Care
Chile considers health a basic human right. But, for many people that right remains a promise beyond reach. There is a dual health care system where public and private health systems operate in completely separate spheres. The majority of the population is covered under the public health sector, which is underfunded and ill-equipped to provide care for most of the population. As a result, the health system increases inequalities for low-income, high-risk populations.
The barriers to care uniquely afflict the Indigenous populations. In an interview with the HPR, Avexnim Cojti said, “What we see in many states is the abandonment and the neglect of Indigenous communities. It’s not just their negative health conditions, their accessibility to health services is also very limited.” Cojti is the Maya K’iche’ from the community of Chuwila, Guatemala and the Director of Programs at Cultural Survival. “Even if they do have access to Western services, we have seen many cases of mistreatment within the health system because of the racism and because of the discrimination against Indigenous communities.” These challenges compound one another as Indigenous people are prevented from receiving appropriate health care, exacerbating the health gap.
In Chile, nine different Indigenous groups, the largest of which are the Mapuche, make up 9% of the 19 million total population. Approximately one-third of this Indigenous population lives in multidimensional poverty, an indicator which considers health, education, and living standards.
The long history of economic disenfranchisement explains the social determinants of health that contribute to the disparities that endure. “Health levels of each person depend on their social context,” Rosario Morales, a second-year medical school student at the University of Chile, explained to the HPR, “For example, Mapuche communities in general live in rural areas. That makes it very difficult for them to get to a nearby city where there is a health care center.”
[Translation: Niveles de salud de cada persona dependen de su contexto social … Por ejemplo, las comunidades Mapuches en general están en zonas rurales. Eso hace que tengan un muy difícil acceso para llegar a una ciudad cercana donde tengan un centro de salud asistencial.]
Morales described the difficulties of a Mapuche woman whom she studied in delivery care, saying, “She was 40 and she already had two children that died. She said that from her community there was only one bus a week that went to the city. But, if you have a medical emergency you can’t wait a week to go and she later died from infection.”
[Translation: Nosotros estudiamos un caso de una mujer, era Mapuche. Tenía 40 y algo ya se le habían muerto dos hijos. Ella contaba que desde su comunidad había sólo un bus a la semana que iba a la ciudad. [Pero], si tienes una emergencia médica no puedes esperar una semana para ir y se mueren de más de infecciones.]
Chile has faced this backlash in the past and have taken steps to address their disparate modalities of healthcare services. There is the unrecognized and unregulated traditional Indigenous health system which is widely distributed and utilized. Then there’s the formally recognized and regulated modern health system which is significantly restricted in its accessibility and scope.
Given that by law, Indigenous communities have access to healthcare in the public sphere, an intercultural health system emerges from a “double right” — the right of Indigneous communities to preserve and cultivate their traditional medical practices and the right established in national legislation to health.
With that comes the need to have more culturally appropriate services for Indigenous communities within conventional health systems. Current Westernized biomedical services are not the solution as they may not incorporate Indigenous health values or concepts, such as a holistic approach that recognizes connections to land, community, and familial ties, as well as mental health and spirituality. For instance, as the COVID-19 pandemic ravaged the globe, the Chilean response to the virus had been criticized as ‘monocultural.’ The government’s calls to stay at home largely overlooked the needs and realities of life for Indigenous peoples, many of whom live by the kincentric ecology framework where they view both themselves and nature as part of an extended ecological family that shares ancestry and origins. Relegated to the fringes of society, Indigenous populations’ needs are not at the forefront of mainstream health systems.
Intercultural Health Care
Makewe Hospital sits at the end of a dirt road that winds through the lush countryside of Chile, past fields of crops and slow-moving cows that are visible along the hour-long bus ride from Temuco. The double-right is on display daily here. The usual scene of white coats rushing around a sterilized multi-story concrete building is replaced with simple wooden buildings, rukas (the Mapuche version of a grass hut), and gardens of medicinal herbs.
The Makewe Hospital is the first intercultural health initiative undertaken in Chile. Created in 1998, the Makewe Hospital intercultural program provides a range of Western health services under the direction of a Western trained Mapuche medical director. It is located in the middle of several Mapuche communities and serves approximately 20,000 people.
Aimed to reduce the gap between Indigenous and Western health systems, intercultural health offers traditional medicine and practices alongside Western medicine. Through the consultations of machis, or traditional healers, this program built a system where the power of Indigenous medicine became complementary to Western medicine as machis gained the right to participate in public health care systems.
The traditional medicine clinic does not handle severe illnesses, births, or surgery, while the conventional hospital does. On the other hand, patients say that traditional medicine works better than conventional treatments for certain issues such as arthritis, depression, and spiritual matters. The bilateral effort between Mapuche medicine and Western medicine is improving healthcare in Chile as intercultural facilities coexist to offer both conventional and traditional treatments.
Healthcare has become a cultural borderland in Chile, and the clinic at Makewe suggests that health can counter marginalization that cuts across the culture and society. Speaking with the HPR, Gabriela Soto Laveaga, Professor of the History of Science at Harvard, says, “It’s about equal understanding of the type of health and health care that is needed… [It’s] where you have a Western conceptualization of what health and healing is together with a native understanding of what health and healing is.”
The synergistic interplay fostered by the blend of Western and Indigenous practice can help to restore the role of the machi and other traditional healers within an institutional system where healthcare is intertwined with Indigenous cultural significance. This system becomes part of a larger vision shared by Indigenous health leaders to recover the power of their medicine and to restore self-governance to their communities.
Indigenous Self-Determination
The Makewe Hospital is often cited as a successful example of the implementation of intercultural health. While intercultural health might seem like a panacea to remedy the broken health contract that Indigenous people face, Indigenous voices can still become stifled as hegemonic health care systems encroach upon Indigenous sovereignty. Simply stated, intercultural healthcare can become a prescription for social oppression as communities are forced to choose between assimilation or isolation.
While intercultural health ensures that all citizens are able to exercise their right to protect their health, Indigenous communities face competing threats of cultural erasure by integrating into mainstream healthcare. In an interview with the HPR, Thomas Bossert, Senior Lecturer and the Director of the International Health Systems Program of the Harvard T. H. Chan School of Public Health, commented on the Mapuche community’s response to the state’s attempts to integrate them into the Public Health Service, “Over time it became kind of interesting, because the Mapuche community became a bit more defensive … They began to think that this [intercultural health] was, in a sense, undermining their own identity.”
Given the prevalence of cultural erasure in the past, integrating any kind of community into a dominant culture bears the potential for assimilation and a well-founded fear of losing one’s traditional ways of life. Although intercultural health systems intend to serve as an alternative to hegemonic health systems, Indigenous sovereignty must be protected in the face of cultural impositions.
Avexnim Cojti elaborates with the HPR ways to address these issues, “Decolonizing means who manages that system of health. And for Indigenous communities, decolonizing means starting to have control, and the decision-making power is within the community and is not within the public health system … Indigenous communities should have that ownership.” Rather than paternalistic policies governing Indigenous health, there is an imperative to include those whose voices have been historically pushed to the margins.
Despite the need to decolonize medicine, the same legitimacy that’s offered to conventional medicine is not commonly lent to traditional medicines. As Cojti explained, “the challenge is that there’s no evidence. Indigenous healing systems and alternative systems are seen as pseudoscience or very primitive. And it should not be seen that way. It needs to have more weight and more credibility, and that credibility is only going to be generated by evidence-based research on traditional medicines.”
Recognizing the legitimate role that Indigenous approaches play in the health of the patient and acknowledging the diverse cultural meanings associated with health reflect a fundamental respect for Indigenous medicine.
Reflecting on how she hopes her country’s health system evolves while she’s pursuing her medical degree, Morales shared, “In Chile and in most countries there is probably a long way to go … because we believe that Western medicine is the only correct one. I think it is necessary to be able to learn from the [machis] in order to be inclusive for all … We should have equal access to health and health that is suitable for all.”
[Translation: En Chile y en la mayoría de los países probablemente falta mucho … porque creemos que la medicina occidental es la única correcta. Creo que es necesario poder aprender de los [machis] para que todos sean inclusivos … Deberíamos tener igual acceso a salud y a una salud que sea de gusto de todos.]
As Elisa Loncón becomes one of 17 Indigenous representatives in the constitutional assembly, Indigenous people are finally getting a seat at the table in reforming Chile’s constitution. The vision of intercultural health systems is not just to have a Western medical file alongside a traditional Indigenous medicine file, but rather, to have intercultural health programs serve as one component of a larger effort for Indigenous self-determination and autonomy. As a nation that prides itself on serving all, there is a need for epu imple kelluwun, for mutual collaboration.
