The volcano that can be seen from the area surrounding Putre.
For the past two weeks, I have been in Putre again. I’ve been working on my Independent Study Project or ISP. The theme of my ISP is how the community of Putre, especially those who practice traditional medicine, feel about the intercultural healthcare system that Putre has within it’s Family Health Center. The current system is that a Yatiri and two Qulliris (both traditional medics/spiritual guides) work within the Health Center of Putre. Essentially, the system is meant to have both traditional medicine and biomedicine within the same system where they can share information and refer patients to each other. My topic is seeing if the community believes that this is working and if they have any suggestions to improve the system.
The first week in Putre was a little rough. There were no other students from my program there with me. While I did get the surprise of an old high school friend of my from a different SIT program doing her ISP in Putre as well, I didn’t really get to see her as our projects paths didn’t cross that much. Also, no one spoke English. I know that being in an immersion program abroad is the best thing for language learning, but I also really wanted to talk to someone and hash out ideas for my ISP. This would have been very helpful and much more helpful in English.
The van the CESFAM travels in for the Rondas
While in Putre, I have been talking/interviewing the Yatiri, Qulliris, and community members about their perspectives on the topic. I’ve also been traveling with the healthcare team on Rondas, which are medical rounds to the other small towns that don’t have their own health centers. Here, I’ve been able to observe a lot of the interactions between the biomedical doctors and the traditional doctors. Something that’s important to keep in mind with this project is that the complete medical team of Putre changes, at least, every three years. That’s if all of the team stays for their full three-year commitment but often times people will leave within months of their arrival. This is due to the fact that places like Putre are part of a system where doctors can go work for three years after they graduate from medical school and then at the end of that time, their courses required for a specialty will be paid for. It’s pretty similar to buy back programs in the US. Doctors go to underserved areas for a certain amount of time in order to get schooling paid for. This, however, means that the community of Putre does not have a consistent doctor who understands the patients coming to them. This lack of understanding could stem from a lack of understanding the culture of Putre, the history of the Aymara community, or from simply not having the background medical knowledge of the community they are serving. Even with a doctor and medical team who are willing to learn about the Aymaran culture, medicine and the community they are working in, this takes time. Unfortunately, Putre isn’t always so lucky to have a team that takes in interest in learning all of these things.
This has been really interesting to see as I am looking to use a buyback program to help pay for medical school. I hadn’t really thought of the impact that this could have on a community if doctors don’t choose to remain in their location after their commitment is over. It’s really luck of the draw as to who comes each time.
I haven’t been able to post much in the past two weeks because I’ve been out of internet connection. We have been traveling around the south of Chile. We went to Temuco and then to a small, rural town only 20 minutes from Temuco called Maquewe. Even though it was only 20 minutes away from a city there was no cellphone service and most of the houses didn’t have internet. It’s also very spread out. There are buses that travel from Maquewe to Temuco and back daily but other than that there isn’t much local transportation other than walking. While we were in Temuco we were learning about the culture and belief system of the Mapuche people. The Mapuche focus a lot on “duality”, particularly in regards to gender. Additionally, they believe in asking permission from the spirit of each place before entering or taking anything from the location. In theory I really liked this idea of being conscious of the world around us and taking the time out of your day to remember that this world does not belong to us and we do not have the right to enter and take what we want from every place we go. However, what really got me was that in the Mapuche belief system you can be punished in the form of illness by trespassing on a place without asking permission even if you had no bad intentions and if you are not aware that permission needed to be asked. I feel that as long as someone goes into a place respectfully, even if they did not ask permission from a spirituality they were not aware of, they should not be punished.
The river in Chol-Chol
Also while we were staying in Maquewe, we had a project where we were split into groups of 4 or 5 people and got sent to a small town around Temuco to learn more about the place and people. I went to Chol-Chol. We had previously visited a high school in Chol-Chol called Guacolda. It’s a high school that focuses on interculturality and keeping the culture and language of the Mapuche alive. The school also has several different technical programs. One of them is a nursing program. Its a two year process in which students take classes similar to a Certified Nursing program in addition to their other classes. They learn about Mapuche healthcare systems and illnesses as well as occidental treatments and diagnoses. We got to talk to several of the students in the first year class. They were all exceptionally mature and determined students. Many of them live in the schools dorms during the week and return home on the weekends because they live so far from the school. During my second visit to Chol-Chol to study the town, I stayed at a hostel with three other girls from the program. The granddaughter of the hostel owner attended Guacolda and was in the health program there so we got to spend more time talking to her and learning about the school. She said that while the program and concept of the school was good, there were still some resources missing in the school itself and that despite the administrations work to boost the self-esteem of their students (many of whom are Mapuche or come from rural areas) the process is slow. She told us about how the walls of the women’s dorm leak when it rains and how their isn’t always hot water. She also said that some classrooms have a wall made of sheet metal because the building was never actually finished.
After our time in Temuco/Maquewe area, we headed to Pucón for two days. These days were partially down time. In the morning we either had presentations on the towns each group went to or a debriefing of the past week to make sure everyone was on the same page. In the afternoon of the first day we went to see some waterfalls and also a beautiful lake. The lake’s water was the perfect temperature to jump in off the dock. The second day we went to some thermal hot springs. I was a little disappointed to find out that the ones we were going to were very built up natural hot springs. It felt more like a spa day than going to hot springs, however the water did feel amazing, especially after it raining most of the past week.In the evenings we explored the town of Pucón. It’s definitely a tourist town. It’s filled with different tour/adventure guide services and cute little coffee shops, chocolate stores and restaurants. I was thrilled to be able to find a tiny climbing wall outside of one of the adventure tour stores. I also hunted down almost every kayak I could find in town. I have wanted to go to Pucón for year to kayak so that was the closest I was going to be able to get to actually being in a boat.
Memorial for President Allende in La Moneda
After our mini-vacation in Pucón, we headed of to Santiago. Santiago felt like a very big change after the past week and a half of traveling we had been doing. In Maquewe we didn’t even have cellphone service or internet for the majority of our time there despite the fact that it’s only 20 minutes outside of Temuco, which is another city. And in Pucón there were mountains and lakes everywhere in site. In comparison, Santiago has towering buildings of varying shades of concrete and it’s close-by mountain range is shrouded in a cloud of smog constantly due to the air pollution in the city. The first full day we were in Santiago we spent the morning at the Museum of Human Rights. It was exceptionally impactful. The majority of the museum was dedicated to the 13 year military dictatorship lead by Pinochet starting in 1973. It was a time of extreme violence in Chile and thousands of people were tortured as political prisoners and many disappeared. We learned about how President Allende, the president in office when the coup took place, died in el Palacio de la Moneda (similar to Chile’s version of the White House) and heard his last speech to Chile as he was trapped in La Moneda with military forces outside bombing the building. After lunch, we got a tour of La Moneda and got to see the memorial set up in the wing were Allende’s body was later found as well as a history of the reconstruction that took place afterwards. Also during our time in Santiago we got to meet with the representatives of the Pan American Health Organization and the World Health Organization. This was exceptionally interesting. The presentations here were about the history of the Pan American Health Organization and it’s connection to the World Health Organization. Additionally, we learned about Chile’s disaster protocols. Afterwards we met with a representative from the Ministry of Health to talk about PESPI which is a program that focuses on the rights and access to healthcare of the indigenous peoples of Chile. This meeting turned out to be very bureaucratic and all the information given to us was the same as what you could read online. It was fairly disappointing. However, we learned about the ways that indigenous people who are living in cities like Santiago are finding ways to create systems of support and access to traditional medicine within city limits from some leaders in the Mapuche community in Santiago. Our last full day in Santiago was a free day. Several of us bought bus tickets and headed to Valparaíso for the day. There we took a walking tour of the city and found a street fair. The murals in Valparaíso are incredible. They are everywhere. It was probably one of the most colorful cities I have ever seen.
All the houses and buildings tend to be bright colors and there are streets and alleys filled with different murals. At the end of the day we got back on a bus and headed back to Santiago for our last night there. The next day was Easter Sunday however. Our flight back to Arica wasn’t until the evening so a group of us went to a cathedral in la Plaza de Armas for Easter service and then out for brunch afterwards before returning to the hotel to start some of the work that’s due this week and pack up to head back to Arica.
Section of a mural found on one of the buildings at the Posta Rural de Azapa.
This week we were able to visit two different public health centers in Arica and the nearby valley of Azapa. The first location that we visited was a primary care health center that focuses on family medicine. It’s one of several in Arica and throughout Chile and they are called CESFAM (centro de salud familiar). Each CESFAM serves a different sector of Arica or the surrounding area. The CESFAM that we visited was a very small building in more residential area of Arica. We were told that the building was constructed with the intent of the clinic serving 20,000 habitants in it’s region. However, that this point the region has grown to a population of 44,000 people who are all required to use this center if they have public insurance. Essentially all of the people in the region don’t have the income level to pay for private insurance so that means almost all of them are using the health center. This means long wait times to see doctors or to make appointments. Despite the apparent lack of space, many of the professionals that gave us presentations during our time their claimed that the wait times were 15 minutes, although one did mention that was an ideal number but did not give us a better estimate for what the wait time actually looks like. I feel this has been a trend at all the health centers we have visited. On paper the Chilean healthcare systems seems amazing with free healthcare at the primary level and very inexpensive care at the hospital (where only those with a higher income are required to pay anything at all) however many people who have the available income to pay for private insurance (ISAPRE) are doing so. Why? What does the private sector have to offer that the public sector doesn’t? For the most part people have been saying that it’s faster to see doctors on the private system. It seems like when we go to see the public health system in practice they are telling us more about what the system looks like on paper and not mentioning the shortcomings that they are seeing in practice so it is hard for me to really know.
Part of the Aymara ceremony at the Posta Rural de Azapa
The other health center we went to is called a Posta Rural. It is a smaller scale primary care clinic in the more rural and agricultural valley of Azapa. The building was very small but there is a full medical team they said. The main difference that I noticed with the Posta Rural is the intercultural aspect of the clinic. Every other CESFAM we went to mentioned that they are an integrated and intercultural facility that uses both traditional and occidental medicine. They mentioned practices like massage and Aymara births. However, all women who give birth do so in the hospital and it is at the hospital that there is a Usuyiri (Aymara midwife) and a room designed to replicate a traditional Aymara home birth as well as a traditional occidental delivery room. The other clinics do not have Usuyiris and none of them mentioned having other Aymara medicinal specialists available. To me, this doesn’t feel intercultural. When I walked into the buildings they very much felt like an occidental medical clinic with little to no hints that other types of medicine might be practiced there. The Posta Rural was very different. When we first arrived we were lead to the back of the building where there is a garden full of herbs used for medicinal purposes in Aymara medicine. They also allowed us to watch an Aymara ceremony called a Phawa. There were two blankets laid out, one diagonally on top of the other with coca leaves and small pink and white candies that we were told were sweets for the Earth. The ceremony always much be completed by one man and one woman. During the ceremony they started a fire in a small grill-like container and poured two bags of incense into the fire before kneeling facing west and speaking to Pacha Mama (Mother Earth). Then they stood up and took two cups, one with red wine and the other with water, and started to walk around the blankets pouring a little liquid at each corner and saying a wish they had. To end the ceremony the returned to kneeling facing the west and poured the rest of the incense into the fire. Inside the clinic, all the names of the rooms were in Spanish and Aymara. I asked if there were many people who identified as Aymara working at the clinic and they told me that there were a fair number. The woman who participated in the Aymara ceremony at the beginning was also a Usuyiri/Quillri (Aymara midwife and healer). This was the first time true intercultural medicine that I had see in Chile thus far. We were told that they make salves and creams out of the plants they grow and they also teach classes about how to do so at home. These options are available to Aymara and non-Aymara people. While this was the first example of intercultural medicine I have seen and not just been told about, the Posta Rural was not perfect. From the moment we walked in with our white lab coats we overwhelmed the space available and took the attention of the medical team away from the patients. I watched as one elderly woman sat waiting from the moment we walked in to after we left and she wasn’t the only one. I felt awful coming into a place where many of the patients waiting need to get to work or get their children to school and taking over the building.