Presentation on Andean Culture and the Political Economy of Health, Medicine, and Social Inequality in Quecha-Speaking Communities of Ecuador

Natives

Presentation on Global Health in Ecuador 

Summer 2019

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Introduction

The Native peoples of the Andes are disproportionately among the poorest of the world. Like many minority populations, their communities are often marginalized by language, location, and cultural beliefs and practices that distinguish them from the dominant social system. This is especially true for Quechua-speaking communities. Ethnomedical bias, structural inequalities, and institutionalized stigma make it difficult for native communities to realize their right to health care and good living, as is their constitutional mandate. 

Marginalization based on culture, race, or language is forbidden by the constitution, but native peoples remain among the most disadvantaged.

The Andes is an interesting region were large modern cities are situated in valleys, surrounded by small communities plagued by poverty and social stigma. The stark contrasts make it an ideal setting to study health outcomes from an anthropological perspective, especially because of its traditional practices and high degree of medical pluralism. Andean medicine has traditionally been stigmatized by the Ecuadorian mestizos; the ethnic group that throughout history has dominated social, economic, religious and political spheres.

Ecuador is a very hierarchical country, and these inequalities manifest themselves in each of the determinants of health. Being poor and living in rural areas not only signifies numerous challenges to health and wellbeing, but also limits one’s access to health services, social capital, human and natural resources, education, employment, clean water, and cultural knowledge like biomedical practice.

The greatest threat to health among the native peoples of the rural Andes is stigma, and the ongoing conflict between the dominant culture and indigenous cosmovision among Quecha-speaking minorities. This historical struggle has its roots in the conquests of colonialism and continues to play out in contemporary society as a product of Andean culture and the political economy of health in Ecuador. Native peoples’ health is shaped by a variety of sociopolitical, economic, behavioral, biogenetic and cultural ecological factors. These forces are maintained by institutional bias in the public health system and a system of stigma that operates on multiple levels in native communities.

Some of the greatest health problems in Ecuador today include malnutrition, diabetes, and heart disease which is the leading cause of death. Among native communities, these problems are exacerbated and health outcomes disproportionately greater. Despite advancements in public health and human development in Ecuador, equitable healthcare among the 40-plus indigenous groups in the rural Andes has not be achieved. Many communities receive no medical treatment from the two main public sources- the Public Health Ministry and the Social Security Institute. It is estimated that 40% of Ecuador’s Amerindian population- those pre-Columbian natives that do not identify as Mestizo- lack immediate access to health services, and 70% do not have the means to pay for care. These marginalized communities often rely on traditional medicine and aid from volunteers and NGOs to meet their basic medical needs.

I identified several key health problems among the Quecha-speaking peoples and examined the patterns of causation and consequences of systemic bias and structural inequalities in Ecuador’s social, political, and economic institutions and surmised their effects on overall health outcomes. My investigation found a single issue underlying each of the primary health problems: STIGMA. 

When people have an interest in keeping other people down, in or away, stigma is a resource that allows them to obtain the ends they desire.

This resource is called “stigma power” and is used to refer to instances in which stigma processes achieve the aims of stigmatizers with respect to the exploitation, control or exclusion of others.

In this case, the dominant social structures of Ecuador and the political economy that supports it, uses stigma to systematically undermine the success of rural communities and oppress the native peoples that live, work, and play there. 

In order to understand how stigma intersects each of the determinants of health and surmise its effects on community health outcomes, it is important to define the population in question, and identify cultural characteristics and methods for approaching its analysis.

• Population defined according to historical processes that shaped culture in the region.

• Quechua designates the language that the Inca, in the course of their military expansion, disseminated across wide expanses of the Andean highlands.
• Dispersed throughout this vast region of western South America, an estimated 8.5 to 11 million people speak dialects of Quechua, which makes it the most widely spoken surviving Indian language of the Americas.

• If we conceptualize culture in the Andes as a single regional system, we can better understand how native communities define their health; and identify patterns of causation and consequences of stigma shaping the population.  

• The Inca Empire once extended throughout the entire region in red, resulting in similar cultural traits across the highland borders of the continent

• Ecological adaptation to the high altitudes and harsh climates contributed to the development of cultural similarities.

• Blue represents Native descendants inhabiting the region, all of whom speak Kichwa and share a unique vision of health and ‘good living’ that defines their community.

• The Quichua are arguably the single largest indigenous people in the world. So while they are a minority in Ecuador, they represent a enormous population of South America. Their story is indicative of the struggle of native peoples across the Americas. 

I used anthropological theories and methods to generate unique insights into how native peoples experience, interpret, and respond to questions of health, illness, and wellness, especially questions of inequality, power, and stigma in the context of development in Ecuador. Native culture is understood in its own terms, not as superior or inferior to others. This way of thinking assumes practical implications for research and encourages both material (or Marxist) and symbolic (interpretive) applications aimed at advancing the interests of the population in question. It confronts colonialism, neoliberalism, capitalism, and other structures of domination and hierarchy that threaten native communities and limit the scope of human freedoms to achieve good health and well-being.

Biomedicine and marginalization at health clinics

How is poor health linked to social inequalities?

How do political and economic structures create inequalities in health?

How are they faced? Or not faced? Or determined by the surroundings?

Power of Culture: Manifestations of social hierarchy in health care

Structural Violence

Intersection of poverty and marginality 

I argue that being marginalized as poor, rural and indigenous, the people in Toa, like the Alto do Cruzeiros, face a structural injustice.

how poverty prevents good health, and social stigma further deteriorates the situation, hindering good health care.

I looked at how stigma manifests in the specific context of individual behavior, policymaking, social factors, health services, and biogenetics.

Stigma was defined in terms of its effects on each of the determinants of health among native Andean communities.

Stigma is society’s negative evaluation of particular features of behaviors.

Stigma is a resource used by policymakers and governments to marginalize communities.

It is bias in medical practices.

It is the perception of certain conditions.

It is a preference.

It is a system.

How do stigmatized communities cope with societal insults that engender their personal identity, social life, and economic opportunities. 

Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally.

Stigma enables varieties of discrimination that ultimately deny the individual/group full social acceptance, reduce the individuals’ opportunities, and fuel social inequalities.

Stigma influences population health outcomes by worsening, undermining, or impeding a number of processes, including social relationships, resource availability, stress, and psychological and behavioral responses, exacerbating poor health

The new constitution adopted in 2008 invokes the guiding principle of a firmly established concept in indigenous culture, sumak kawsay (a Kichwa expression meaning "good living", or "buen vivir" in Spanish).

This one-size-fits-all, centralised, and vertical governance model in the past decade has diminished the role of civil society and other actors in developing a comprehensive and community-based approach. The Ecuadorian Government systematically endeavoured to hamper criticism, which had a chilling effect on grassroots women, indigenous people, and environmental movements and organisations  who would likely enrich the health-reform debate. In a geographically and culturally complex Ecuador, contextualising health promotion on the basis of local autonomy and cultural traditions is crucial to transformation. However, community-level efforts in schools, for example, have been drastically curtailed. The community school meal programme, which offered children a prepared lunch, was replaced by humanitarian-aid-style provision of beverages and snacks with added sugars, further benefitting the food industry to the detriment of local small farmers, who were better placed to provide fresher and more culturally appropriate foods.9

 Similarly, small and rural (and primarily indigenous) schools, a hub for community activities including health promotion, were closed or abandoned in favour of a more centralised model of public education.

Elders and youths alike talk about how much healthier ancestral foods are than the highly processed, chemical-laden foods that for economic reasons are now staples of many indigenous peoples’ diets. They express frustration with the decline in labor reciprocity within their communities, attributing the decline to labor migration and the increased need for cash within rural economies. The proximate cause of change is usually identified as increased contact with nonindigenous society.

For example, by prioritizing development in urban settings, the availability of resources afforded to native communities is insufficient and has widespread implications for determining individuals access to educational and employment opportunities (considering most of them work as temporary construction labor), wages, and therefore food. (Cause=effect) resource scarcity reinforces poverty and socioeconomic conditions in native communities that prevent individuals from pursuing a ‘good living’, or access to food, health care, and education.

Another fundamental health determinant stressed is the disruption or severance of ties of Indigenous Peoples to their land, weakening or destroying closely associated cultural practices and participation in the traditional economy essential for health and well being

Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.

By understanding the dialectic relationship between individuals and the environment, the social and physical determinants of health can be identified and used to define the patterns of causation and consequences to health, determined by these interactions.

Discrimination is another example that determines health outcomes in the community as a driving force for social isolation and stigmatization of norms and attitudes about native culture that distinguish them from dominant groups, and ultimately determining their values as part of the lower class system. In this way, their specific needs are not prioritized and their unique beliefs and practices are not represented in the dominant structures of social support and interaction with the public health system. Discrimination becomes an almost insurmountable barrier to reaching better health outcomes in native communities, by limiting their interactions with , and access to mainstream society. 

Community access to health resources is also limited by the lack of transportation options that connect rural areas to urban centers, making it difficult for individuals to reach medical and emergency care.

Poor health outcomes are exacerbated by the absence of sufficient travel and tradeways to connect native communities with the resources of the urban environment.

Together, the social situations circumscribing native communities define the context of residential segregation that keeps the problems of the Andean rurality away from the urban valleys that initiate these determinants of health.

There are also physical barriers to achieving good health, such as climate change and inadequate infrastructure for WASH. Climate change is redefining the growing seasons that native peoples rely on to feed their families, and poor WASH systems burden the community with diarreal disease and chronic parasites. Together, these environmental factors place additional constraint on the peoples capacity for developing ‘good living’ in their communities; and as such, form another determinant of health in the Andes.

Examples of social determinants include:

Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods

Social norms and attitudes, such as discrimination

Social support and social interactions

Socioeconomic conditions, such as concentrated poverty

Transportation options

Public safety

Residential segregation

Examples of physical determinants include:

Natural environment, such as plants, weather, or climate change

Built environment, such as buildings or transportation

Worksites, schools, and recreational settings

Housing, homes, and neighborhoods

Physical barriers, especially for people with disabilities

Stigma in the healthcare system perpetuate distrust with health care providers and have a negative impact on health outcomes. Indigenous peoples also often face geographical barriers given that many communities are located in rural, remote, and seasonally isolated areas. Lack of access to health services for indigenous peoples is a widespread problem in the Americas for many reasons, which include geographical barriers, discrimination, stigma, lack of social and cultural adaptation to indigenous health needs, and a lack of integration of traditional medicine.

Of all the barriers faced by indigenous peoples, it is perhaps the cultural barriers that present the most complicated challenge because there is little understanding of the social and cultural factors deriving from the knowledge, attitudes, and practices in health of the indigenous peoples.

Systemic bias towards western medicine and intervention can be offensive or inappropriate for practitioners of traditional medicine. Finding health staff that speak and understand indigenous languages is difficult, and poor communication between providers and clients, at all levels, compromises access to quality care. Moreover, indigenous peoples are often discriminated against in health centers by non-indigenous staff and both fear and distrust caused by the attitudes and behaviors of health care workers prevent indigenous people from seeking the health care they need.

Andean medicine has traditionally been stigmatized by the Ecuadorian mestizos; the ethnic group that throughout history has dominated social, economic, religious and political spheres.

Yachaks , Andean healers with spiritual powers, have often had to heal in secret to avoid accusations of witchcraft.

“In its most general sense, buen vivir [Sumak Kawsay] denotes, organizes, and constructs a system of knowledge and living based on the communion of humans and nature and on the spatial-temporal harmonious totality of existence. That is, on the necessary interrelation of beings, knowledges, logics, and rationalities of thought, action, existence, and living. This notion is part and parcel of the cosmovision, cosmology, or philosophy of the indigenous peoples of Abya Yala.”

Some indigenous Ecuadorians are also unwilling to make use of healthcare services available to them. According to researchers, indigenous Ecuadorians in the Andean region regard health in the context of harmony between body, mind and environment. Under these circumstances they are much more likely to place greater confidence in their communities' own traditional medical practitioners and use them as their first option. Up to the early 1990s, Ecuadorian law limited the practice of medicine only to persons holding qualifications from the University of Ecuador. Under the new more culturally inclusive Constitution, however, recognition and regulation of traditional indigenous medicine came into force in August 1998. Included are stipulations that the state acknowledge, respect and promote the development of traditional medicine, monitor its application and legally control the operation of traditional medical practitioners.

Though indigenous populations represent a majority in several countries and geographical areas in the Region, 40% of them lack access to conventional health services and 80% depend on traditional healers as their main health services providers.

This situation is exacerbated by gender-based inequalities, particularly in the case of indigenous women who face countless difficulties in obtaining quality health care, especially regarding reproductive health services.

Geographical barriers prevent indigenous peoples from gaining access to health care, among other reasons, due to the long distances between their homes and available health facilities, lack of transportation, non-existent or poorly maintained roads and seasonal inaccessibility. Even if, formally, health care for indigenous peoples is free of charge in certain countries, in practice, the real costs of i.a. transport and mobilization, lodging, expenses incurred by accompanying relatives or friends, adverse effects on the patient’s dependants livelihoods and loss of earnings, they all represent as many threats to the patients’ economic situation and their access to primary health care

Diet

Physical activity

Alcohol, cigarette, and other drug use

Hand washing

At the same time, societal stigma related to substance use disorders further marginalizes rural users and creates additional barriers to recovery. It is  generally more difficult to seek treatment for behaviour disorders of an illegal nature than it is for legal behavioural problems, especially in areas where population density is low and there are reduced possibilities of receiving help anonymously

Rural areas also suffer greater issues with stigma and a lack of anonymity given the more limited availability of services.224 These same challenges and lack of resources make it difficult to develop recovery and peer-support services in rural areas.

Biological Determinants

Stigma/ Shame & Teen Pregnancy

Having a uterus is a biological determinant of health. Disparities in access to health services, especially barriers to sexual and reproductive health services, are the result of systemic inequalities in Ecuadorean society and stigma in the Andean culture system as a whole.

1:5 teens from 15-19/ 1:20 between 12-14 years old is pregnant. This is disproportionately higher among native communities. Early sexual debut and childbearing has widespread consequences for individual and community health.

78% drop out of school definitively.

Many seek unsafe abortions.

Exposed to HIV/ STI infections

Intimate partner violence

Sexual violence

Abortion is illegal in Ecuador, except under two circumstances: to save the life or preserve the health of the mother, or if the pregnancy is the result of rape to a woman with intellectual disability. The secrecy means that by the time pregnancies come to light, it’s too late to provide the girls and unborn babies with the essential medical care they may need to save their lives. The clandestine nature of teen pregnancy means most receive no health checks at any point during the nine months. Most give birth with only their mother’s help, in remote villages where resources are limited.

Worldwide, pregnancy and childbirth complications are the leading cause of death among 15 to 19 year-old girls, with hypertension and abnormal bleeding as the most frequent causes. 

In 2007 traditional midwives began fighting this problem. Completely embedded in their local communities, they occupy a position of trust, alerting doctors when they hear of teenage pregnancies. However, in 2011, the gov.’t initiated a model for integrated family and community health, which led to a disruption of adolescent friendly services.

There is limited data to reflect the effects of this uninformed policymaking or the reality of teen pregnancy complications among natives.

Stigma manifests in the biological determinants of health for native women and girls, as a function of gender inequality and structural bias in health services development.  

Cultural barriers pose the most complex challenge since there is little understanding of the social and cultural factors linked to the knowledge, attitudes and practices related to indigenous peoples’ health. Western medicine and intervention bias could be offensive or inappropriate for traditional medicine practitioners. It is difficult to find health staff members who can speak and understand indigenous languages and the lack of meaningful communication between health services providers and patients at all levels of health care undermines their access to quality care. Furthermore, indigenous individuals are often discriminated against by non indigenous staff. Fear and mistrust fuelled by the attitudes and behaviour of health care workers are yet additional barriers that deter indigenous peoples from seeking the health care they need. For example, traditional practices and beliefs regarding childbirth are often disregarded in institutional contexts.

(1) Researchers need to develop systems for data collection in rural populations that allow policymakers and community leaders to assess the needs of native peoples.

(2) Methods for inquiry must be culturally grounded and rooted in the context of advocacy and activism.

(3) Public health officials should work on understanding the practical applications of indigenous cosmovisions for the political economy of health and how best to implement these perspectives and practices in the development of both traditional and biomedical services.