Power struggle: Indigenous medicines from the Chiapas Highlands, between
two worlds
Disputa de poderes: Las medicinas indígenas de los
Altos de Chiapas, entre dos mundos
Jorge Magaña Ochoa*
ABSTRACT
The
indigenous medical knowledge of the region formerly known as the Chiapas
Highlands, now the Tzeltal-Tzotzil region, has been rendered invisible by
official scientific-hegemonic medicine and made visible again based on obvious
economic advantages that have nothing to do with the recognition of these
peoples' fundamental rights, but rather with the Mexican government's search
for answers to the conditions expressed in the profound economic, political,
and social crisis of the last thirty years.
This
work aims to show and reflect on the impact and social dynamics of the health
control business, in each of its forms and variations, on the inhabitants,
primarily indigenous people, of this region. It aims to demonstrate that the
current crisis is temporary, but, above all, it is the manifestation of
something much deeper: the economic, cultural, and structural control of
indigenous medical knowledge. For this reason, the article explores how
sociocultural changes affect social representations of health, illness, and
medical care, especially in indigenous communities. Highlighting how some
people are abandoning traditional practices but still maintain ancestral
beliefs, facing the prevailing challenges of globalization, poverty, and the
influence of official, hegemonic, capitalist, and modern medicine.
Keywords:
Indigenous medicines, power disputes, medical knowledge, illness and disease,
narratives of illness
RESUMEN
Los conocimientos médicos
indígenas de la región otroramente llamada Altos de Chiapas, hoy región Tzeltal-Tzotzil,
han sido invisibilizados por la medicina oficial científica-hegemónica y
vueltos a visibilizar conforme a conveniencias económicas manifiestas que no
tienen nada que ver con el reconocimiento a los derechos fundamentales de estos
pueblos, sino más bien a búsqueda de respuestas, por parte del gobierno
mexicano, a las condiciones expresadas en una profunda crisis económica,
política y social de los últimos treinta años.
Este trabajo pretende mostrar y
reflexionar la incidencia y dinámica social que el negocio del control de la
salud, en cada una de sus formas y variantes, golpea a los pobladores,
principalmente indígenas, de esta región. Se trata de evidenciar que la actual
crisis es de coyuntura, pero, sobre todo, es la manifestación de algo mucho más
profundo al control económico, cultural y estructural, de los conocimientos
médicos indígenas. Por tal motivo, el artículo explora cómo los cambios
socioculturales afectan las representaciones sociales de la salud, la
enfermedad y la atención médica, especialmente en comunidades indígenas;
resaltando cómo algunos pobladores abandonan prácticas tradicionales, pero aún
mantienen creencias ancestrales, enfrentando los desafíos imperantes ante la
globalización, la pobreza y la influencia de la medicina oficial, hegemónica,
capitalista y moderna.
Palabras clave: Medicinas indígenas, disputas de
poder, conocimientos médicos, padecimiento y enfermedad, narrativas del
padecimiento
INTRODUCTION
Before beginning the discussion in this article and
orienting the reader to the topics that will be addressed—identity, social
representation, cultural configuration, social construction, medicine, power,
modernity/postmodernity/contemporaneity, and disputed heritage (medical
knowledge and expertise)—I would like to make three pertinent clarifications
for the reader: First, the reflection presented here is part of a broader
project that has been underway since 1998, working to understand the change
that has taken place in the medical position and the disputes over power and
control of the discourse on health in the region known today as Tzotzil-Tzeltal
(Altos de Chiapas), by the mainly indigenous groups that cohabit there. Second,
that all the actors and social agents involved in a social space that shapes
its territorialization, even though they can be classified as having a common
origin, have patterns of representation around their medical practices
manifested in a series of social and cultural elements that form a baggage
constructed and appropriated by the social group as a whole in a heterogeneous,
historical and dynamic process (Magaña, 2002); and thirdly, that due to the
phenomena of “globalization” or “glocalization,” disturbances in the context
are affecting the sphere of social reproduction and lifestyles, as well as the
basis of the culture with which the collective identifies (Magaña, 2009). We
will reflect on how the diverse cultures present in a region influence the
exercise of medical practices and representations in situations of
interculturality and dispute. The reflection revolves mainly around the
construction of medical knowledge, referring to a cosmopolitan environment
where tradition and its practitioners have been important factors in the social
structure and cultural development. In this sense, when we are faced with the
construction of social representations based on the rationality of a specific
group (ideas, beliefs, truths constructed, accepted, and shared by the
community about the world around them), it becomes necessary to understand the
conceptual framework that allows us to grasp this world, as well as the logic
with which elements of the various discourses and proposals with which they
interact are accepted or rejected (Magaña, 2009). We must therefore be clear
that knowledge is produced within a social context, in which the individual
agent, when putting their knowledge into practice, interacts within a social
structure in which they have been socialized and which enables them to
participate in the social construction of representations of their everyday
life. Concepts about the cultural process of a people or region are not
universal in nature; just as the processes or criteria of rationality that
justify them are specific to a semantic context. Such processes and concepts
are the foundation of their very knowledge, insofar as they refer to a whole
system of socially constructed norms and values accepted in the local context
(Magaña, 2009). In this sense, we must be very clear about the spatial location
of the research exercise and the contextual reality. Therefore, and in order to
situate the reader, we can say about our physical-territorial space that it is
a territory in which there have been multiple disputes over medical control and
practice, in favor of a hegemonic/capitalist/scientific and official medicine
(Magaña, 2002).
MATERIALS
AND METHODS
The work that precedes these lines has focused its
methodological discussion in general terms on the field of descriptive and
reflective ethnography, if we can call it that, whose very quality is the
exposition of the “narrative” or “narratives.” In other words, from
anthropological studies in health, narrative has become an instrument, or
rather a post-structuralist methodological trend in research, which enables us
to reconstruct events or experiences based on a person's narrated experience.
Through narrative, aspects such as learning, memory,
and the identity of the subject are cultivated. As such, narrative is
configured as a metaphor for human thought that proposes the construction of
reality and its interpretation and understanding by the collective (Eroza and
Magaña, 2023).
Within indigenous contexts, narratives, experiences,
and stories take center stage, as the issues addressed are often very
sensitive, highlighting the need to create spaces for listening and reflection
in the field of health, especially when health becomes a commodity in dispute
and a symbolic struggle for control over its knowledge and practice (Magaña,
2019).
In this case, the production of narratives can be
considered a window into understanding the social culture of the actors present
in this research work; it is the discourse that organizes everything related to
cultural communion and communication with the characters involved in the
personal story and in the history of the context in which the narrator's
experience unfolds. All of them are convinced of the instrumental meaning of
narrative, since it allows them to outline the panorama and environment perceived
in relation to the experiences narrated. However, history or narrative is not a
copy or, better said, a historical account, but rather a field of study that,
through language, frees the emotions of the narrators involved.
Narratives as a methodological tool show us and
propose a way of investigating, a way of delving into individual realities and
their collective life extensions, a way that makes their appropriation
possible. Narrative invites us to understand “Drama,” “Social Drama,” as
proposed by Victor Turner (1974), and the misfortune experienced when expressed
by those who bring to life within themselves a suffering that is part of their
individual-social self and, I reiterate, of the drama they have experienced.
These possibilities, narratives as a methodological
proposal and their construction and/or dialogic constitution, allow us to delve
into the analysis of the permanent and dynamic link between cultural visions
and the personal experiences of the narrator of their experience and living
through broader social processes, in terms of experiences, revealing through
communicative action the profuse meanings and diverse roles played by those who
narrate. This situation will be objectified in the following lines of this
article.
RESULTS
As we all know, both individually and collectively,
health is the result of complex interactions between biological, ecological,
socioeconomic, and cultural processes that occur in society. Therefore, health
is determined by the structure and dynamics of society, by the degree of
development of its productive forces, by the type of social relations it
establishes, by the economic model, by the form of organization of the State
and, finally, by the conditions in which society develops, such as climate, location,
and geographical characteristics and, above all, by the natural resources
available. The link between health and development is reciprocal and complex;
that is, they are complementary concepts. Health is the result of the level and
forms of development of a society, insofar as this determines the limits and
availability of resources for the well-being of the various population groups.
The latter, rather than a necessary good, becomes an
arena for debate for the very populations targeted by public health policies.
For example, according to members of OSECAPIACH/Abejas:
From our experience as health promoters, our
foundation has been around for a long time, our organization, now we are a
civil association. Before, we had in our minds that we had no education beyond
primary school, but from our experience, we thought that health was ambulances
or medicine, but later, thanks to other organizations that began to train us,
several of us here began to receive training. Due to various conflicts, such as
Acteal, as you know, we decided to work as health promoters because there are
many diseases in the camps due to garbage and other things that are thrown
there. So, the first thing we thought was to form groups... What are we going
to do? All of that came about in 1998. That year, diseases such as typhoid
broke out, and women had miscarriages due to fear and the conflicts in the
community. So we thought about what we were going to do, and we formed groups
of young people and started there so that they could get involved. Some were
trained and others were used as translators, because in our area we don't speak
Spanish, except for Tzotzil, and the doctors were from outside the area. We
were the middlemen, translating for the doctors and the patients. We thought
that health at that time was medicine (Fieldwork, 2010-2011).
On the other hand, health is an essential condition
for social development because of its impact on the individual's ability to
work and on the establishment of the climate of stability, tranquility, and
social progress that such development requires (Page, 2010-11; Magaña, 2009;
Eroza, 2008; Ayora, 2000). Jaime Page goes further, telling us that there are
various factors that have had an impact in the short and medium term on the
region's medical systems, which he considers to be ethnomedical (2010-11) and
which this writer considers to be fragments of medical systems or practices
that still survive in the region (Magaña, 2002).
For Page, these factors highlight changing forms of
social and economic reproduction among the Maya population in response to
growing poverty, the persistent influence of religious groups, political
conflict, and migration. This position is supported by the three cases he
analyzes: In the case of Oxchuc, he tells us, one can practically speak of the
emergence of a healthcare system with abundant elements of biomedical diagnosis
and focused on treating illness based on medicinal herbs; while in the cases of
Chamula and Chenalhó, there is still a significant presence of an ethnomedical
system based on ritual which, although it has undergone important
transformations in recent decades, still predominates over others (ibid.).
All of this implies various scenarios of
vulnerability, mainly insofar as both communities and individuals are
increasingly exposed to the effects of historical and social forces that are
beyond their control. We can speak, for example, of entire communities that
have lost their natural resources for subsistence and are disadvantaged in the
dynamics of the market economy; processes that entail a latent tension between
traditional visions and values of social life and the expectations,
particularly among members of the younger generations, to participate fully in
the dynamics of modernity...
I feel that government institutions design development
strategies, such as Felipe Calderón's Millennium Goals, but I feel that here,
when we are in a meeting, it is about supporting communities through
communities, not coming from above. For example, the members of Las Abejas who
are concerned about their situation—it is difficult, it also involves
communication, they go and no one listens to them, So they go and say, ‘This
hurts, I don't feel this,’ but the doctor doesn't understand them because of
the language they speak. That's where change has to come from. Doctors need to
be taught in different ways so that they can understand, open up new paths so
that from there they can promote the development of their community, because
I've seen that more opportunities are given to education, and this is done with
a distinction between rich and poor. There are many indigenous teachers, people
with specialties, but it is difficult for an indigenous person to become a
specialist. I want to learn, I want to use it, but they don't because they
don't know how, so many die because of ignorance and because they are not
treated well (Report, Intercultural Health Forum 2010).
Faced with these kinds of problems, and we must
continue to insist, health institutions lack a solid structure of care focused
on them, partly because this is a problem that has not been sufficiently
visible and, therefore, fully recognized by public health agencies. However,
the latter is complicated by the fact that indigenous people have a series of
representations and practices around health and illness, which often place the
presence of ailments within an interpretive framework whose main references are
notions of divine punishment, witchcraft, and spiritual conceptions that
account for the constituent elements of the person (Magaña, 2002; Eroza and
Magaña, 2010). In this sense, and in relation to the problems of prevention,
detection, and care, this means that the search for diagnosis and care takes
place through channels that are completely unrelated to those that could be
provided by health institutions.
We know that there are a number of deep-rooted
problems related to community issues. When the regional hospital, which is not
regional but general, was inaugurated, it began operating with 70 beds, and now
they realized that they had to hire nurses, and no one wanted to come to San
Cristóbal because they didn't want to, but they hired women who knew how to
give injections, and these women were racist, discriminatory, and abusive. I
saw the social workers, who were also treated very badly. Here, the important
things are respect, dignity, and equality. For them, that is quality, but we
are seeing it from their perspective, which is why it is an achievement for
them. Elsewhere, it is logical to fight against the system in order to enter
it. We continue to believe that traditional medicine should be tolerated, but
that is not the case. We must understand traditional medicine in order to
combine knowledge. Doctors have been taught to cure diseases, but they are not
taught how to prevent them. Everything that is done to prevent or treat a
disease is a strategy, a way of fighting a system that serves to see systems
and tear them down, our comrades in Oventic of the EZLN and they are
not (Report, Intercultural Health Forum 2010).
For researchers such as S. Igor Ayora (2000), the
field of debate is manifested in the way that the social political discourse
managed by what is considered official Mexican medicine, or in its recognized
theoretical conceptualization: Hegemonic Medicine, subsumes and subordinates
indigenous medical practice in its regional actions. In other words, for Ayora,
the so-called traditional medicine practiced in the region and known as Mayan,
due to its roots and cultural-local manifestations prior to the arrival and
establishment of allopathic medicine, is a type of medical practice that is
accepted as such within the framework of official or modern medicine, as he
calls the latter; and that becomes a category that brings together medical
practices that have no equivalent in modern medicine.
The researcher argues that, in this sense, traditional
and indigenous Mayan medicine is a contemporary product and that official,
modern, cosmopolitan, and allopathic medicine validates it as medicine (ibid.).
The indigenous practice and knowledge of the healer is subordinated, forcing
them to act in accordance with federal and state health regulations and laws.
Some shamans or iloletik (as indigenous healers are
known in the region), midwives, and other “indigenous” health specialists
expressed their feelings to us in the following interview conducted during the
1st Intercultural Health Forum in the city of San Cristóbal de Las Casas,
Chiapas, in 2010:
We need to have a health promoter certification that
allows us to move around the hospital like doctors or nurses, which was not
possible before. Once they have settled the patient in, they make sure they are
not left alone in the hospital... But we had experiences where they didn't want
to listen to us, we complained to Ms. Lety and they fired them because they
didn't want to listen to us, and now there are changes. They were going to give
us badges and uniforms, but because of our culture, we would be embarrassed to
dress like that in the new hospital. In other municipalities, they treat us
well, but based on our experiences with other organizations, they train us.
They didn't before, but now they do. The conflict that exists with community
health workers or health centers is because they work with official medicine,
because they know how to use and administer IV fluids, or because they apply
mainstream medicine. but here we had to do this to reduce people's suffering
from disease. But it's this whole thing, how can there be such a dominant and
oppressive system that in order to be treated, people had to move? We are
finally working to change the dominance of these activities. We had to adhere
to the model in order to get in, but we have to do even more to be able to say
that it is intercultural medicine.
These types of demands and calls for attention are not
new. In a state where there is deep inequality in the way health services are
implemented, affecting population groups that require immediate service, in
addition to other problems that in this specific context are intended to be
eradicated:
a) Misallocation of resources. Public funds are spent
on health interventions that are not cost-effective.
b) Inequality. The poor, especially indigenous people,
lack access to basic health services and the care they receive is of poor
quality.
c) In recent years, during the transition to more
market-oriented economies, real public spending on health has declined sharply.
d) The public sector has suffered from severe
shortages of medicines and equipment, as well as a lack of the specialized
knowledge needed to manage health institutions undergoing change and facing
intercultural phenomena.
e) Misunderstanding of social participation as a
contribution to health promotion. In most cases, the concept of participation
continues to be based on a vertical relationship, in which traditional
instruments of collective participation are increasingly ineffective in
gathering citizens' demands, and the limitation is even greater in regions such
as ours, which have poorly developed social networks.
f) The indigenous population living in these regions
has traditionally been subject to strong pressures, mostly from national
society. Migration, their relationship with the environment, the unequal
penetration of capitalism into the indigenous world, the imposition of new
religions, and their own cultural dynamics have placed new stresses on the
indigenous world (Farías, 1997). At the same time, they have the highest
mortality rates and lowest life expectancy compared to any other group, both
within the state and nationally.
g) There is currently significant underreporting in
statistics on the most common diseases in indigenous and mestizo communities in
these regions, as well as on causes of death, because the health sector does
not have sufficient human and material resources to maintain a permanent and
efficient epidemiological surveillance system.
h) Community participation is still very limited
because neither the population using health services nor the health sector
itself has managed to implement intervention models that do not clash with the
cultural structures of the social groups in which health actions requiring the
participation of the local population are to be carried out.
i) The problem of health and disease in the social
context of these regions is understood as a matter strictly within the
competence of the health sector and government agencies, so that the actions
taken by the population to prevent disease and/or restore health are
practically non-existent, insofar as the population sees itself as a passive
object of institutional action. Disease prevention and health recovery are not
understood by the population as instruments of social and political struggle:
Most communities mention that they are not cared for because they do not belong
to political parties, ...(Fieldwork, 2010-2011).
As Ayora says, we cannot settle for the simple idea
that indigenous people are forced to turn to traditional healers because of
their cultural patterns. It is true that there are cultural elements that have
great importance and influence on the behavior of indigenous people when
solving health problems (Ayora, 2000), but we must bear in mind that the
production of practices and patterns of perception and representation of
diseases in indigenous contexts marked by situations of multiculturalism
generates changes in their meaning, disrupting known signs and symptoms,
showing an inability to generate useful interpretative frameworks to explain
the conflicting and critical situations of an active illness (Magaña, 2015
[2002]); however, it is also true that many indigenous people prefer to go to
allopathic doctors rather than indigenous healers (Ayora, 2000; Magaña, 2002).
DISCUSSION
Knowledge in dispute:
between indigenous knowledge and medical knowledge...
Chiapas, the setting for our
research
Over the last two decades, the state of Chiapas has
faced a number of historical events that have abruptly triggered and/or
accelerated multiple social processes. In most cases, given their rapid pace,
scope, and complexity, these processes have escaped the attention of
decision-makers in the field of social policy. The dynamics of the global
era have also contributed to shaping the social landscape of the state.
More specifically, it can be observed that Chiapas has
the highest rates of marginalization in the country. In general terms, this
means that the standard of living of its population is on the threshold of
extreme poverty, with 82% of the population surviving on two minimum
wages, more than 42% of the child population suffers from some degree of
severe malnutrition, and the epidemiological profile is classified as
poverty-related diseases. In addition, it is also noteworthy that the state of
Chiapas ranks second in marginalization in the Mexican Republic, and more than
half of the municipalities have “very high” and “high” degrees of
marginalization (53% and 40%, respectively). According to data presented in the
Chiapas Solidarity Development Plan 2007-2012, the state ranks fifth in social
inequality in Latin America and among the highest in the world. This situation
is aggravated by the impacts of the international economic and financial crisis
and by the unequal distribution of opportunities, resources, and power among
groups, social classes, ethnic groups, genders, and individuals in a society
where poverty is one of its expressions.
On the other hand, we must take into account that
Chiapas is a true cultural and multiethnic mosaic, ranking second among the ten
states with the largest indigenous-speaking population in the country,
surpassed only by Oaxaca. Throughout its history, this factor has caused its
ethnic groups to undergo successive internal transformations, both biological
(miscegenation) and cultural, and in their relationships with the different
agents of the dominant society, this has led to adaptive changes that have affected
their cultural physiognomy and their way of becoming ill and caring for the
sick, both in terms of physical ailments and mental health issues.
It should be noted that in Chiapas there is no
comprehensive specialized mental health care structure that responds to all the
needs of the population. This is complicated by indigenous conceptions of
suffering, which often translate into a reluctance to discuss such problems for
fear of social shame, understood as suffering rather than as a label or
disqualification, as is the case in mestizo urban cultures. (Magaña,
2019:51)
In turn, the emergence of social processes such as the
Zapatista movement in 1994 and its direct and indirect effects have led to
significant changes in the profile of the various resident populations of the
identity. For example, at a certain point, sociopolitical violence played a
crucial role in the flow of population movements toward urban centers, which
mainly involved the indigenous population. We can also mention the military
presence, the magnitude of which served as a trigger for the increase in sex
work, which also mainly affected women from poor sectors of the population,
particularly indigenous women (Magaña, 2012).
Therefore, in addition to the Zapatista conflict, we
can observe that processes such as migration, economic development closely
linked to agribusiness, large-scale environmental degradation, modernizing
public policies, the deepening of inequalities, technological development,
access to global information, illicit economic activities, and in recent years,
migration to urban centers in other states but mainly to the United States.
Along with all these references to change, however, colonial vestiges survive in
Chiapas that also give a unique flavor to Chiapaneca modernity. Regardless of
the order in which they are mentioned, all of these factors together have
created a new scenario of poverty in which the references of globalization take
on many very particular nuances when interacting with a great sociocultural
diversity, both in rural and urban areas (ibid.).
In terms of the health of the population, the
interaction of all these aspects can also be encompassed as structural
violence, which translates into differential forms of vulnerability in relation
to different groups and individuals, whose only common denominator seems to be
deprivation. Within this context, various health problems can be framed that
require urgent attention in the search for solutions: maternal mortality, child
malnutrition, acute respiratory diseases, and acute diarrheal diseases; that is,
diseases that are considered preventable in most cases with a simple vaccine,
but in this context, the vaccine becomes pure gold, and in recent years, there
has been an increase in suicide attempts among young people and children in
indigenous populations, not to mention actual suicides (Magaña, 2015).
The impact of all this within indigenous populations
is such that it leads to serious fractures in traditional values, which
translate into and are related to religious and political conflicts, or to the
effects of modernizing trends. These conflicts take place in family, community,
and inter-community life and end up placing certain individuals or groups in
various situations of vulnerability in terms of health.
Focusing on the region of interest in this proposal,
and in addition to the above, it can be said that since 1994, with the
emergence of the Zapatista Movement and the problem of religious conflicts
(mass expulsions of indigenous populations, for example, in the Altos de
Chiapas), there has been a proliferation of conflicts that prevent the
conditions for a dignified, healthy, and peaceful life, where there is respect
and tolerance for human rights and for the religious, social, ethnic, and
cultural diversity of communities. In this regard, we can observe that over the
last 40 years there have been significant changes in the Tzotzil-Tzeltal region
(Altos) that are not uniformly manifested in the different municipalities that
comprise it. State policies toward indigenous communities, the presence of new
political groups, the integration of Protestant groups or the Catholic Church
itself into the communities, migration in search of work, and the abuse of
power by indigenous caciques are some of the factors that have had an impact on
the formation of new cultural processes.
These are times of great population movement, of
interethnic relations that did not exist before, and of forms of social and
political organization that go beyond the limits of the village, the region,
and the linguistic group. Changes are observed in indigenous communities that
are responses to the influences of the modern world, but which are rather the
result of a process of reconstitution and reinvention of ethnic identity in new
social contexts. The indigenous people of these regions of Chiapas are more
complex than those who inhabit the pages of ethnographies from the 1950s to the
1970s (Magaña, 2013).
Even with the changes that are taking place, a large
part of the indigenous peoples retain their traditional forms of political and
religious organization. However, although some communities tacitly reject the
use of traditional medical practices, for example, in general, the way in which
illness is conceived has more to do with the indigenous worldview than with
scientific medical practice. Some inhabitants no longer turn to indigenous
doctors, but the causes they attribute to their illness are part of what are
known as “traditional illnesses” and, in their view, modern medicine is
synonymous with drugs (Magaña, 2012 [2002]).
Although indigenous medicine addresses, albeit in a
very limited way, the precarious conditions in which the population lives,
through specialists who devote much of their time to healing the sick, are
recognized by their community, and possess knowledge acquired through the
internalization of their daily experiences, death from diseases that in other
parts of the world would be preventable at low cost (such as malnutrition,
“EDAS” or “IRAS”), in this region, points to economic, infrastructure, and health
policy factors, as well as cultural issues and inequalities in gender, ethnic,
and generational relations (ibid.).
In general terms, we can say that, since the
indigenous uprising in January 1994, there has been a gradual but constant
change in the collective perception of health problems as a result of social
interaction in terms of injustice and inequality. This has led many residents,
and mainly their representatives, to demand greater participation in health
recovery and disease prevention processes, with institutional support and
recognition (Magaña, 2015).
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