Академический Документы
Профессиональный Документы
Культура Документы
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/
info/about/policies/terms.jsp
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content
in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship.
For more information about JSTOR, please contact support@jstor.org.
Sage Publications, Inc. is collaborating with JSTOR to digitize, preserve and extend access to Latin American Perspectives.
http://www.jstor.org
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
Decolonization
The
government.
of subjugation,
the process has led many
and foreign
observers?Bolivian
concur that a
alike?to
revival
and
national
"refound
genuine revolutionary
new
is
well
in
under
the
"Plurinational
State
of
Bolivia."
way
ing"
this "process of change"
(as it is referred to by the MAS
Throughout
gov
Brian
and
support.
LATIN AMERICAN
PERSPECTIVES,
DOI: 10.1177/0094582X10366535
? 2010 Latin American Perspectives
2010 139-159
139
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
140
LATINAMERICAN PERSPECTIVES
to decolonize
accompanying
recognition of the need
rent themes in almost all government
become
institutionalized.
discourse:
the Bolivian
the concepts
in effect,
in the proposed
This article examines the ongoing processes
and actual radi
cal restructuring as exemplified by that of the official health sector. "Paradox"
to imply the inherent contradictions
ismeant
in the design and implementa
tion of what
is still a developing
formal state policy and the resultant exacer
bation by the reforms of tensions present in Bolivia
In this
for generations.
struggle between
cultural
and political
factions within
the government's
pub
on the ground,
of factors: newly
formu
IN THEORETICAL
DECOLONIZATION
CONTEXT
it is important to under
of decolonization,
any proposal
as a "colonial
to be "colonized."
By identifying Bolivia
as "subalterns,"
the
state" and referring to themajority
indigenous population
in
and sympathetic intellectuals place the discussion
the court of postco
MAS
as numerous
and
theorists
lonial and subaltern
And,
theory.
(e.g., Quijano
Before discussing
itmeans
stand what
Wallerstein, 1992;Mignolo, 2001; Young, 2001) have noted with regard to the
conditions of Latin
special "postcolonial"
toQuijano
definitions.
According
precise
a
the
for
discussion),
(see Lander, 2000,
nature
of
essential
being
coloniality?the
and weak
nations within
this categorization
America,
requires
and Wallerstein
(1992) and later others
reveals that
history of Latin America
"colonial"
the "interstate
powerful
to ethnicity
torical links (since the sixteenth century and European
expansion)
after formal independence;
and racism, and does not disappear
rather, it "con
and non-European"
tinues in the form of a social-cultural hierarchy of European
and cultural
1992: 550). This political, economic,
and Wallerstein,
(Quijano
in a racialized Eurocentrism,
and power, grounded
structure of subjugation
its own rules.
and makes
thus constitutes its own brand of modernity
colonialism"
hold
of
"internal
theories
In a broader Latin American
context,
position.
prominent
In the work
of early
theorists
including
Fanon
(1963;
well
as more
recent subaltern
studies
scholars
such
as Guha
(1982;
1983),
and Said?and
internal
colonialism
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
141
In Bolivia,
revitalization
in these
influential
denounced
historical
discussions,
social, economic,
in both theory and practice, between
racial divides,
the "two
a /co/Zfl-autochthonous Bolivia"
and
mestiza-Europeanized
an "Indian Revolution"
inwhich
advocated
(1970: 174, my translation)?and
cultural, and
Bolivias"?"a
"the policy of the indian is a total struggle for the liberationof his people"
(1971: 143) and theoverthrow of the criolloelite,by violence ifnecessary. The
militant
community-organizing
work
done
by
pri
DECOLONIZING
COLONIALITY
AND
THE NATION
INTERCULTURALITY
In theMAS
the notion of
strategies for state decolonization,
interculturality
A simple and
of the term identifies the
definition
oft-quoted
integrated relationships between persons or social groups of diverse cultures
or world views and,
by extension, the attitudes of bearers of one culture toward
is fundamental.
the elemental
norms
of another. This is
a dialectical
relation
fundamentally
two poles?one's
own
and
that
of
the
"other"?that
should
identity
occur
an
in
environment
of
and
honest
optimally
respect, reciprocity,
exchange
of beliefs and practices, resulting inmutual
growth, enrichment, and transfor
mation
is not to be confused with
(Albo, 2004). However,
interculturality
between
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
142
LATINAMERICAN PERSPECTIVES
as the shared
here perceived
multiculturalism,
occupation
of a common
space
narrow
terms and
toward
integration?hence,
nialist model
conditions
and
very
oriented
more
toward assimilation
than
a further
a
of
colo
likely only
propagation
an effective process of
impossible without
that
that con
the
of power
balance
interculturality. They
unequal
tinues in Bolivia?social,
economic,
gender, linguistic, cognitive?
political,
or
on the part of those in control:
any
"respect"
genuine
"dialogue"
impedes
a
the structure itself remains intolerant and propitious
only to mono-cultural
the
the
of
intercultural
discourse
should be
ultimate
Thus,
objective
dialogue.
that true decolonization
is likewise
conclude
to move
talk about
becomes
increasingly controversial
interests of certain power sectors.
in that itpotentially
PLAN
and
the
strategy,
Productiva
y
Bolivia Digna,
de Desarrollo:
Soberana,
Plan: Bolivia Dignified,
Vivir
Bien
(National Development
para
to Live Well). The plan declares at the
and
Democratic
Productive
Sovereign,
.... has been marked
and
outset that "the history of Bolivia
by colonialism
consid
since the mid-1980s,
and that the country (especially
neoliberalism"
dominated
by "transnational
ering structural adjustment policies) has been
"external
of the powerful
and international
nations," while
organizations
. . . and the 'national
listened
colonialism
only to the
grew
bourgeoisie'
the Plan
Nacional
Democratica
of the
2006: 21, my translation). Because
con
it
that
and
resulted,
poverty
rights,
colonialism
of
the
initiated
"has
the
tinues,
process
dismantling
government
of a new
and neoliberalism
and, at the same time, initiates the construction
strate
state." Specific national
and communitarian
society of a plurinational
areas: economic,
interna
the following
"sociocomunitarian,"
gies include
of "the
the stated objective
all with
tional relations, and "social power,"
inclusive society in which
of a new socially and productively
construction
are combined with the knowledge
of our ancestors,
advances
technological
of foreign countries"
(MPD,
inequality, diminished
dependency,
orders
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
based
and
the capacity
derived
from our
cultural
143
identity"
(MREC, 2007).
10,my
translation),
a
"Quality of life" is deeper reflection upon the "human condition." It considers
that cultural identity, the physical, mental, and spiritual ties to one's llacta
raw materials of life.The loss
[people], one's land, is of equal importance to the
of common values, the disintegration of communal structures, and the alienation
from the spiritual world can affect the individual more than the lack of physical
items_The
struggle against poverty ismore than just improving the economic
base and access to public services.
and horizontal
contribu
lates "progress as beginning with mutual discovery
2009b:
tions and not imposition and authoritarianism"
(MSD,
5).
in practice,
esoteric
this
somewhat
innovative,
translates,
concept
Although
a
into what has become
for
programs, par
ubiquitous
slogan
governmental
as a backdrop
in the media
of most
promotion
ticularly for health. It is used
official programs
and serves as the link between
the modernity
of the MAS
economic
and
and
the
social
programs
government's
imagined
indigenous
past that is held up as an ideal for national
precolonial
identity. In thisway, To
Live Well may be seen as a contrasting model
state?
evoking the pre-MAS
in the official conceptualization,
which was,
the colonial state?to
emphasize
the fact that the nation did not live well in the past.
STATE INSTITUTIONALIZATION
the complementary
discourses
of interculturality
and decolonization
by creat
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
144
LATINAMERICAN PERSPECTIVES
and projects/' "foment the participation
of the indigenous original
nations and peoples,
intercultural communities, and Afro-Bolivians
programs
campesino
in the public management
of the Plurinational
State," and "develop policies for
the prevention and eradication of racism and cultural intolerance," all as part of
"the struggle against intellectual,
social and economic
which
colonization,
on
some
in
to
continues
live
both
(VMD, 2009). However,
parts of the nation"
for long-range
funded and staffed and lack firm proposals
as such,
remain
relative
theoretical
they
showpieces.
power, theMAS
Bolivia.
of 2006,
The
STRATEGY
to the national
results would
inwhich
elections
thatwould
to
the health
Plan
later form part of the National
Development
sector is framed as a vestige of historical colonial
The state has a social debt concerning health with the Bolivian population accu
mulated since the colonial past [and] aggravated in the past 20 years by neolib
eral health policies thathave resulted in the privatization of the health sector, the
mercantilization of services, and the establishment of an individualistic health
culture. . . .The health system has not responded to the needs and demands of
the Bolivian population; on the contrary, ithas reproduced the inequalities and
inequities of the economic structure.
a number
on to
of prevalent
structural problems:
identify
plan goes
based in
the
and
differentials
among
population,
epidemiological
pathological
access
to
health
to
and
related
determinants
socioeconomic
poverty
unequal
without practical access
77 percent of the population
services (for example,
in children under 5, and maternal mor
to services, 26.5 percent malnutrition
The
talityat 320 per 100,000 live births, thehighest in South America); an ineffi
service that fails to take into account cultural and ethnic differences;
little or no
of the national health service network, with
poor management
finan
sectors and dependence
international
between
social
upon
cooperation
and a lack of satisfaction with the
cial aid that carries ties and conditions;
services on the part of an unmotivated,
alienated, and disempowered
popula
cient health
and
out of this situation specifically directed at "the promotion
mobilization
and sociocommunitarian
of a space of organization
that the state guarantee
the plan proposes
in order To Live Well,"
equitable
in the pro
of the population
access to health services and active participation
colonial structures and devel
cess. This is to be achieved by (1) dismantling
As a way
constitution
the
health
system that includes
intrinsically
sovereign national
market-driven
the
and (2) eliminating
of traditional medicine;
incorporation
a communitarian
and
and
economic
(neoliberal)
replacing itwith
apparatus,
between
and coordination
intercultural system based on social participation
a
social sectors. Five specific policies make
up the overall
strategy:
single
oping
an
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
145
and sover
health system; state proprietorship
intercultural, communitarian
of financial, judicial,
eignty over the health system through the consolidation
resources
to
the
and human
(while allowing
private health services);
right
to be implemented
health promotion,
social mobilization;
through coordina
tion among social sectors; and solidarity, focusing on the causes and outcomes
of extreme
poverty,
malnutrition
especially
and
domestic
violence
(MPD,
(2009b)
at large.
of health as a priority of the population
formulated in the ministerial
documents
would
later
planning
new
in
into
the
which
the
be incorporated
universal
constitution,
guaranteed
services
and
of
social
receives
(health
education)
provision
priority. Several
life and a revalorization
The process
articles make
Bolivia, 2008):
specific
reference
to health
and health
services
(Repiiblica
de
The state . . .will protect the right to health, promoting public policy oriented
toward improving the quality of life, the collective welfare, and free access to
services by the population. (Article 35)
The state has the undeniable obligation to guarantee and support the right to
health. . . .Priority will be given to health promotion and disease prevention.
(Article37)
The state will guarantee public and private health services; itwill regulate and
monitor the quality of attention by means of sustainable medical audits that
evaluate personnel performance, infrastructure, and equipment. (Article 39)
In addition,
other articles
insurance, medications,
in the constitution
medical
negligence,
address
and
such
issues
as health
traditional medicine.
of the MSD
and the respective Servicios Departamentales
de Salud
one
Health
for
of
each
the
nine
Services?SEDES),
(Departmental
depart
that implement policy at the regional level,
ments,
including epidemiology
and statistics,
nutrition
celebrated
the
immunizations,
(the most
being
Desnutricion
Cero [Zero Malnutrition]
with
the
of
plan,
objective
eradicating
child malnutrition
child, and repro
by 2015), infectious diseases, maternal,
ductive health interventions, etc. The Vice Ministry
of Traditional Medicine
and Interculturality is of particular
interest here and will be discussed
below.
work
INTERCULTURAL
cornerstone
Comunitaria
model.
FAMILY HEALTH
of the restructured
health
Intercultural
Under
LATINAMERICAN PERSPECTIVES
146
social
National
participation,
intersectoral
justice, etc.),
agriculture,
cooperation
and
interculturality,
Declaration
on
primary
health
by theWorld
care, promulgated
the declaration
ning
and
implementation
of their health
care,
and
illness,
in the plan
sectors should
1978).
ments
be incorporated
In other countries
and experiences.2
on an
and
into biomedical
systems
equal basis
at other times there have been similar
In Bolivia,
nongovernmental
organizations
(WHO,
experi
(NGOs)
is to re-create and
has done since 2006, however,
care
and other previous
community-participation
reinterpret primary health
considerations:
models, with two additional
interculturality, in both its theo
limited success. What
Bolivia
its programmatic
of these considerations
uniqueness,
gives the Bolivian model
care is (re)imagined
as
the
intercultural lens, Bolivian
health
through
primary
the outcome of the experiment. However,
style; the second largely determines
of the SAFCI model
to smoother implementation
one of themain hindrances
as
lack of
is
the
continued
discussed
below)
(aside from political differences,
at
most
it
levels
of the
a clear theoretical and operational
of
understanding
levels.
system, especially at the regional and community
alliances
between
communities,
SAFCI,
through strategic
implemented
health ser
and institutional actors (local governments,
social organizations,
has two
and
communication
shared
and
social
education,
mobilization,
vices),
man
attention.
and
medical
Participatory
management
foci?participatory
struc
and
involves communityorganizational
municipal-based
agement3
chosen and elected Local Health Authorities
tures. At base level, organically
as
act
advocates
for local health needs, rotating annually;
(one per community)
Health Committees,
these
of
groups
representatives
together make up Local
are
or
The committees
clinics.
health
with
affiliated
posts
particular
directly
with
the
health
with
district
local
planning,
personnel,
together
charged,
of all health-related
and evaluation
administration,
execution,
monitoring,
activities in the community or barrio. As an echo of the traditional Bolivian
health
decision-making
including
health services,
as of late 2009
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
147
and municipalities
had yet to form local
the great majority of communities
a
had
relative scattering of municipalities
authorities or committees, and only
Rudeness
as part of an
and traditional medicine
limitations of bothbiomedicine
"exchange
. . .between
two medical
and practices
of knowledge
cultures ... in order to
achieve articulation and complementarity between these actors, equally sharing
the solution of problems and ensuring quality attention" (MSD, 2007: 39). This
a sort of
proposes
workshop
"cultural-sensitivity"
approach, which has yet
even within the MSD,
to produce
results.
The
is that the
consensus,
tangible
a slow starter and calls formore concerted
of
is
SAFCI
medical-attention
aspect
a few
a
spend
days in given municipal
a
to
somewhat parallel MSD
struc
ity and report directly and competitively
ture financed by theWorld Bank. These
a
did
include
not,
however,
brigades
or social worker.
In
team
the
mobile
this
func
structure,
person
sociologist
tions as an (intercultural) broker between
themedical
and the com
personnel
assists in local
munity,
including any local traditional medicine
providers,
with
the
Local
Health
and conducts
(for example,
Committees),
organizing
relevant applied
research. Fifty-two mobile
teams were working
throughout
the country by late 2009, predominantly
in the highlands.
Since these are the
areas
to the MAS,
this concentration
however,
generally more
sympathetic
BRISAS
adds
to
health brigades,
the element
achieving
The other
more
which would
of political
difference,
identified
coverage.
comprehensive
is a specialized
key program
medical
residency
(Residencia
Medica SAFCI), which in 2009 had 220 residents either in trainingor in the
field. This
involves
three-year
commitment
to work
in a rural health
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
post
148
the supervision
to the
in addition
of a regional second-level
hospital;
a
on
curriculum
focus
and
clinical medical
imparted (with
family
community
health and primary health care), it involves
tech
training in ethnographic
the
and
cul
interviews, participant
observation),
niques
(qualitative
history
tures of indigenous peoples,
the precepts of traditional medicine,
the keeping
under
of community
family health histories, and the active organization
an affiliated
with
structures.4
participatory-management
Along
postgraduate
in intercultural health at the central state university
in La
certificate program
at
aims
the
outlook
and
behavior
the
this
of
Paz,
program
changing
"typical"
Bolivian physician.5
of detailed
MEDICINE
model
minister
is related
is that of "socialized"
of health
single-payer
health
under
the MAS,
medicine.
Nila
service guaranteeing
An
Heredia,
attention
to the entire
population.While she did not achieve thisduring her tenure inoffice,she did
a
to the previously
existing programs
complement
lay the foundation for it.As
and infant health insurance, which provides
free care to
of universal maternal
until
age 65
administra
de Lozada
has initiated an insur
established
the Bono
Juana Azurduy
de Padilla,
income
than expected
enrollment
among
pregnant
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
there have
been doubts
about
the ultimate
solvency
149
of the program.
and
the program
has achieved
international
opposition
scrutiny are other high-profile actions such as the donation
as
and Venezuelan
to all
of 719 ambulances
part of Spanish
cooperation
327 municipalities
the country?nearly
600 of which, however,
throughout
have yet to be delivered.)
The bonus has also received not-so-predictable
criti
cism from some progressive health care and development
workers, who see it
under
as a step backward
and dependency
toward mercantilism
from long-standing
efforts by social movements
and progressive NGOs
to raise awareness
and
women
to
with
health
and
behav
empower
regard
knowledge
health-seeking
and periodic
interested
personnel
flare-ups of politically
and Venezuelan
in Bolivian internal affairs"
"involvement
unqualified
accusations
of Cuban
and even
"espionage,"
donates medical
supplies, finances hospital and health post construction (nation
and provides
for low-income
ally, 42 second-level hospitals),
scholarships
(pri
to
Bolivians
in
medicine
Cuba.
marily indigenous)
study
TRADITIONAL
MEDICINE
motion
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
150
LATINAMERICAN PERSPECTIVES
SAFCI model and thereforeis present (at least theoretically) inmost pro
for achieving
the fusion
grams. The most frequently stated concrete means
use
and
the
local
medicinal
of traditional medicine
biomedicine
involves
of
their pharmaceutical
and commercial
industrialization
including
fallen out of
the promotion
have
that
of nutritious
crops
indigenous
as
and
such
amaranth);
consumption
popular
(e.g., grains
quinoa
widespread
mutual
referrals between physicians and traditional medicine
(curan
providers
as
and the incorpora
deros, or healers, and traditional midwives),
appropriate;
interventions (for example,
tion of traditional practices into common biomedical
plants,
ization;
nongynecological positions during labor and birth and the "calling of souls"
prior todirectmedical intervention)(MSD, 2006: 9-11).
have
been
ers throughthe centralhospital.8 It is also at the regional SEDES level that the
and accrediting
traditional medicine
in regulating
tangible progress
more concerted and concrete efforts by the Vice
in
is
lieu
of
seen,
providers
to set standards:
programs have been established
Ministry. Local validation
most notable
shown
the
and
SEDES
have
the Potosi, Chuquisaca,
Tarija
results. Tarija, for example, requires that all traditional providers who wish to
most
be officially
experience,
authorities,
accredited
recognition
etc. (El National,
CHALLENGES,
INSTITUTIONAL
September
years of
by local
4, 2009).
CONTRADICTIONS,
AND PARADOXES
OPPOSITION
the discourse
and emphasis on inter
field are still "in process." Despite
and internal power
external
from
and
decolonization
structures,
culturality
an
in
the
to
dominance
maintain
continues
biomedicine
practical
indisputable
to its his
traditional medicine
state
the
health
of
system,
relegating
operation
the
status. A few professional
institutions?for
torical minimized
example,
and the Oruro Nurses'
of Physicians
national College
openly
College?have
as threatening undue control over their activi
the SAFCI model
condemned
from community and barrio representatives.
Thus, it is still
ties, presumably
in
a
the
lack
of
the
of
much
(or
respective socio
power
power)
very
question
attitudes are somewhat
context. These confrontational
and
cultural
political
health
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
151
of Physicians)
of, for example,
(e.g., by the College
by assertions
to
with
traditional-medicine
but the actual
openness
practioners,
working
It
thus be seen by many
and commitment
is minimal.
may
appropriation
and nurses as something of a one-way
establishment
street; for
physicians
some
cross
to
the
and
bio
healers
line
learn
basic
community
indigenous
as
is
and
medical
acceptable
nonthreatening
applications
generally perceived
few physicians
have recognized
However,
and, indeed, to be encouraged.
as
in an alternative
traditional
health workers
and
and accepted
equals
some
of the SAFCI medical
system (although among
complementary medical
success in this regard). This is a fun
residents there is evidence of moderate
to all
itself as rejection of and opposition
damental divide that often manifests
mitigated
of the biomedical
profession.
POLITICAL OPPOSITION,
AND
INTERNATIONAL
More
MAS,
Beni.
DOMESTIC
courage any cooperationwith SAFCI policy not on public health grounds but
because
it is perceived
as "MAS
politics."
In the extreme
residents or mobile
teams working
in the depart
cooperate with the SAFCI
ment. The SAFCI workers do not, unfortunately, help their own case much
by
a
structure: receiving their pay
maintaining
nearly parallel
organizational
health districts and reporting their statistical data only to La Paz. The discour
from the lowlands apply for the
fewer physicians
aging fact is that, because
those
to
these
eventually assigned
regions are very frequently from
residency,
local communities?indeed,
there is the possibility
that in composition
and
the
case
is
In
the
of the southern
training
residency
overly "highlands-centric."
SAFCI
department of Tarija, however, the opposition has been more adaptable:
is tenuously
in place, but its various
have been given different
components
names?"Local
Health Caretakers,"
for example,
instead of "Authorities"?
as if to deny any ultimate
the
of
"MAS
institutions." Similarly, in
authority
in rural health districts where
the
many parts of other eastern departments,
model
is recognized
(specifically, the participatory management
component)
as
for
and
center
health
potentially positive
community planning
functioning,
not used
(USAID) was
Development
initially another source
a
United
The
States
had
been for decades
opposition.
of
the
financer
Bolivian
health
it
with
services, annually
major
supplying
financial assistance
and supplies ranging from vaccines
to paper and pencils.
Agency
of politically
oriented
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
152
LATINAMERICAN PERSPECTIVES
requested
in the name
the closure
new MAS
of national
sovereignty, the
of the USAID-operated
Proyecto de Salud
decision-making
at the national
level. With
loss of
the subsequent
relationswith theMSD
to the
and less-than-subtle
slid downhill
into unilateral planning
resistance
new health model
In early 2007 USAID
and programs.
ordered a pull-out of
dominantly
MAS)
departments
and
a relocation
to the lowland
(predomi
and prohibited
any contact, let alone coordi
In addition,
rival
nation, with "foreign personnel"
(i.e., Cuban
physicians).
a
were
them
for
established,
among
programs
physicians
postgraduate
degree
Health Master's
called the "Family and Community
Degree,"
paid for with
MAS-controlled
municipalities,
a
transparently
political attempt at competition with the SAFCI resi
located in the low
recipients were
dency, and virtually all of the scholarship
a
as
itwas abruptly
land departments;
two-year program,
originally planned
of pressure from theMSD.
closed down after only a year because
a somewhat
maintained
sullen silence and
From 2007 into 2008, USAID
new health structures that were gradually
of
the
studied
being
ignorance
the SAFCI Supreme Decree was signed, however, making
implemented. Once
at the
that occurred,
the model
unavoidable?a
coincidently,
development
were
same time that
from bad to
Paz relations
progressing
Washington-La
forced closure of politically
worse,
government's
resulting in the Bolivian
This was
in general
alternative devel
coca-related
(USAID
the
initiative") and
"democracy
opment, Drug
Agency presence,
to a
became
of then-Ambassador
the expulsion
apparent
Philip Goldberg?it
out
Bolivia
more
to
thrown
of
avoid
that
USAID
being
enlightened
suddenly
The result was
be best to coordinate whenever
possible.
entirely itwould
a sudden and
and
MSD
increased financing for programs
supporting
goals
encour
semienthusiastic
involving active
jump onto the SAFCI bandwagon,
norms
into USAID
agement of the incorporation of local health-management
at the technical (ifnot
financed projects and smoother relations with theMSD
level.
always political)
questioned
U.S.
programs
Enforcement
lowland
in high-level
positions Gorge
6,
interview, La Paz, November
Jemio [Federation de Asociaciones
Municipales],
a few months, however,
for
Heredia
lasted
initial
The
2009).9
only
replacement
the
of a lack of political
and left because
initiative;
support and personal
(citizens
departments)
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
153
on for
considerably
longer, through
succeeding minister, Ramiro Tapia, held
out 2009. Other central positions have also seen constant changes, generally
due to internal political favoritism, which have seriously affected institutional
of
there have been three vice ministers
continuity and clarity: for example,
and
directors
health
three
six
directors
of
of
health,
promotion,
epidemiology,
four chiefs of community health and social mobilization.
of
The most debilitating
situation, however, has been at the Vice Ministry
and Interculturality. Following
the untimely death of
Traditional Medicine
the first vice minister and a renowned ethnobotanist,
after only
Jaime Zalles,
a year and a half in office, the succeeding
soon dismissed
vice minister was
for incompetence
(and alcoholism). His replacement was also forced to resign
and false identity. In
because
embezzlement
of legal questions
concerning
the
has
of
functionaries
addition,
sup
process
proved mysterious:
appointing
were established
traditional medicine
practitioners, but all
posedly, all of them
that
the very organizations
(e.g., the Bolivian Society for Traditional Medicine)
owe
more
to
to
the
seemed
them.
Thus,
appointments
represented
old-style
result has been a nearly moribund
Vice
partisan politics.10 The unfortunate
a reduced staff, few results to show, and no clear functional ties
with
Ministry,
to obvious allies in theVice Ministries
of Interculturality and of Decolonization;
ironic
there are even rumors that a complete shutdown may be at hand?an
one of the
if so, forwhat
is supposedly
of
the
intercul
outcome,
showpieces
tural and decolonized
MSD.
INTERNAL CONTRADICTIONS
Aside
in the
other contradictions
challenges,
them
the
is
centraliza
persist. Among
enduring
implementation
tionof theMSD
of programs
and
model
calls
etc.?
authorities,
forming committees,
accepting
respective responsibilities,
and simply understanding
how SAFCI
is supposed
towork and how it should
fit intomunicipal
program and budgetary planning. Yet many state and regional
have
neither the finances nor the personnel
to operate at these
governments
some
are
or
in
and
uninterested
for
levels,
simply
opposed
political reasons to
so. The end result is that the
on
falls
the various NGOs
doing
responsibility
that the Bolivian
operating in Bolivia, if they are so inclined. It is thus paradoxical
and decolonize,
finds itself relying on
state, in its desire to "de-neoliberalize"
internationally based institutions or those with international financing, many of
which have played leading roles in the neoliberal
history of international devel
one
to
its
of
decolonization
opment,11
implement
leading
policies.
The possible
between
contradictions
the socialized
and the intercultural
are more
health models
It is here that the potential
profound.
divergences
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
LATINAMERICAN PERSPECTIVES
154
and "political"
"cultural"
interests become most apparent. At one
extreme and pushing
for greater influence within theMSD
is a minority "cul
turalist" (predominantly Aymara)
that adheres to a hard
faction of the MAS
between
view advocating
the supremacy of precolonial
line, quasi-autarkical
indigenous
and
practices
political structures, including health care, and the exclusion of
and precepts from political power
individuals
q'ara (white, European-descent)
(MSD official, interview,La Paz, October 12, 2009). At the other extreme is
the establishmentof a purely "socialist" medical system,exemplified by the
Cuban
nal
and influence. Thus, and while taking into account the con
an inter
these positions,
there would
ultimately appear to be
and practical conflict brewing
that may or may
contradiction
volunteers
tinuum between
ideological
spread medical
is hardly
public health concerns and political affinity.12Yet, the Cuban model
a
struc
vertical
it
is
intercultural;
physician-based,
thoroughly biomedical,
with
the
latent
distaste
albeit
with
combined
ture,
This,
popular participation.
establish
for an intercultural system among much of the Bolivian biomedical
In the face of an
the intercultural component.
ment, could very well doom
or not,
entrenched medical
system, decolonized
interculturality could slowly
a mere
and inexorably become
institutionalized,
controlled, and defanged,
themost
Another
to gain with
perspective
ally voices
exem
it as an
itself: Loza views
tion the legitimacy of the intercultural paradigm
a kinder, gen
to
biomedicine
stealth
concept designed only
provide
imported,
into the state
tler facade. The ultimate objective, she argues, is to lure people
is
thus
The
model
SAFCI
services and into biomedical
designed
hegemony.
with
and the
the biomedical
and articulation of both health models,
acceptance,
rationale
of
to
official
the
ethnomedical.
interculturality, neither
According
is superior to the other; they have equal status, albeit relative: many
model
are deemed
for the "scientific" doc
illnesses (e.g., cancer, AIDS)
appropriate
tor at the health post or hospital and others (e.g., soul loss) are not. Both the
toward
and the ethnomedical
biomedical
(the latter looking more
provider
must
their
to
the social and community
illness)
recognize
diagnose
body
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
155
these converg
this ideal has yet to be fully achieved,
limitations.13 Although
a crucial part of the official intercultural
ing realities are
experiment, haltingly
even more prominent
in the near
in
Bolivia
applied
today, and they will be
future if the official state policies
are maintained?and
there is indisputable
in the still
2009. For example,
reelection victory inDecember
new
in
autonomies
of
the
uncharted
gradually being implemented
territory
inwhich
the traditional community
Bolivia, including indigenous
autonomy,
the decisive MAS
in all aspects
of society,
including
"indigenous
original campesino peoples"
the historical Bolivian nation-state.
DECOLONIZATION
In August
2009,
health
and health
steadily decolonize
FROM WITHOUT
held
services, as the
themselves from
Conference
delegates
on
Health Management.
Both events brought together
Municipal
at each, the
from across the country, approximately
200 persons
with
of
MSD
and
other state
the
representatives
along
indigenous,
majority
At both
human
offices, theWHO,
rights groups, and social organizations.
and
there were speeches, panel presentations,
the
group discussions,
sharing
on such topics as intercultural health, the social determinants
of experiences
of disease,
and municipal
and community
control
community participation,
and administration
of health services. At their respective conclusions,
their
were similar,
a national health
redacted declarations
for
based
calling
policy
on social determinants
and on health promotion, universal
free health care,
control over the health system, and intercultural health promotion.
popular
"colonized"
government
social
context of Bolivia.
to demonstrate
that, despite
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
156
paradoxes,
constitute
goes beyond
politics
to
and discourse
NOTES
1. The most
prorninent
representative
of this current
is the
monthly
Pukara.
newspaper
sellout
torical and
2.
its his
liberation
and as having
of true indigenous
betrayed
and programs.
the
veiled
continuation
of
neoliberal
policies
origins
through
and Venezuela.
The recent (since
America,
Cuba, Nicaragua,
Ecuador,
Brazil,
as
to a certain
Barrio Adentro
Mision
program was
degree
adopted
by Bolivia
cultural
In Latin
2002) Venezuelan
3. Participatory
is specified
management
of the population
the organized
participation
"The
constitution:
and
in decision-making
Financial
difficulties
however,
have,
often hampered
and
commitment
personal
profes
sional implementationof the residencyprogram.At one point in 2009, afternot having received
salaries for sixmonths, residentswere on the verge of strikinguntil they received an input of
assistance.
French
development
5. An additional
of the national
and
medical
fundamental
but
schools,
objective
resistance
is to revamp
of the MSD
from entrenched
the basic
curriculum
faculty members
has
proved
daunting.
6.
of American
States and the United Nations-affiliated
International
By the Organization
and Leaders.
of Authorities
for the Training
on an extended
went
strike in protest of
7. At one point
in 2006, the College
of Physicians
and expulsion.
their immediate
in the country, demanding
the Cubans7
presence
suspension
Center
There was,
the Bolivians
however,
soon
no official
quietly
reaction whatsoever,
and
ended
and unceremoniously
the Cubans
stayed
ifnot
their actions,
to work.
returned
effort to "standardize"
may be seen as an early, limited, semiofficial
in order to regulate
traditional medicine
interventions
(see
providers
remain concerning
their impact and efficacy, both practi
Navarro,
2004), but questions
Campos
some traditional medicine
had previously
who
For example,
providers
cally and ideologically
to the hospital's
found themselves
worked
janitorial staff follow
relegated
alongside
physicians
also a reflection of poor sustainability
issues, once Italian financing
termination;
ing program
corre
Its premise
was discontinued.
is still functioning.
The Oruro
however,
(directly
program,
cul
Andean
fusion of revitalized
is a methodological
the "To Live Well"
lated with
paradigm)
the
in
models
visions with development
tural and communitarian
individualistically
predominant
Tiawanaku
context. The chakana cross figure (from the pre-Incaic
oriented Westernized
culture)
8.
and
The Potosi
accredit
is used
programs
ethnomedical
as a model
on
cos
in Andean
and mythological
of its symbolic
representation
its four
and
dualities
(heaven /earth; masculine/feminine)
as
for present
purposes
political
energy/spirituality,
interpreted
the basis
and
of parallel
mology
which
dimensions,
may
ordered
be
(albeit
reasons
unsubstantiated)
often
cited
for Heredia's
dismissal
include
pres
sure fromthemilitant and powerful civic groups inEl Alto, who accused her ofnot being radical
enough
(e.g.,
for not
ties with
severing
suspect
foreign
aid providers
such
himself
reasons
but
casino
chain
as
being
"Mafia-tainted"?thus,
as USAID),
and
sus
Heredia
sacked
due
to
influence.
was,
because
seminarian
background.
For example, with
was
by all UN members,
11.
(i.e., community
regard
to the health
implemented
was
empowerment)
by only
fully understood,
of Alma-Ata,
its potentially
similar
ostensibly
although
"subversive"
alternative
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
signed
nature
strategies
such
"Child
approach
local social,
as did
adopted.
and economic
political
in terms of technological
solutions
isolation and primarily
1997).
(see Werner,
to the Cubans
in the Cuban model.
As
of subtle resistance
there are also pockets
cultural,
in "safe"
issues
holistic
Instead
of taking a wide-ranging,
and recognizing
social determinants
incorporating
on
these models
focused
contexts,
specific health
were
programs
the declaration,
Survival"
to health
157
12. However,
oneMSD official in La Paz toldme, although theMAS physicians in government are generally
(and pro-Chavez
pro-Cuban
to the more
This is unrelated
ings,
or
sentiment:
popular
the recent Venezuelan
with Cuban
influence, primarily with
public health
experience
were
so
into
in this perception,
the Cubans
absorbed
thoroughly
it to their own style, rhythm, and norms?
that is, to their
the Venezuelan
system that they shaped
own medical
the Cubans
culture. In the end, the Venezuelans
grew to depend
upon
exceedingly
a Bolivian
was
lost. "We want
local cultural
and their own
and their expertise,
sanitary history
La
La
in
Paz
said
the
official
Paz, May
15, 2007).
revolution,"
(interview,
perceive
Mision
Barrio Adentro.
13.
For
There,
and
discussion
biomedical
between
and
of the possible
convergences,
analysis
in the Bolivian
ethnomedical
systems
and
coordination,
fusion
for example,
see,
context,
Crandon-Malamud (1991), Bastien (1992). Castellon Quiroga (1997), Fernandez Juarez (1999),
Bradby andMurphy-Lawless (2002),TARI (2003), and Fernandez Juarez (2004; 2006).
REFERENCES
Albo,
Xavier
"Interculturalidad
2004
en America
Arnold,
in Gerardo
Fernandez
Perspectivas
antropologicas. Quito:
Y. and Juan de Dios Yapita
et al.
Dense
2002
Las wawas
Paz:
ILCA.
Bastien,
y salud,"
Latina:
la salud maternal
intercultural
en
e interculturalidad
comunidades
algunas
andinas.
La
Joseph
University
Bonfil Batalla,
1990 Mexico
Bradby,
Press.
Guillermo
profundo: Una civilization
and JoMurphy-Lawless
Barbara
negada. Mexico:
Editorial
Grijalbo.
Formal
Campos
2004
Ivan
Quiroga,
1997Abril es tiempo de kharisiris: Campesinos
Editorial
Serrano.
in Gerardo
Fernandez
antropologicas.
Quito:
Castellon
Partha
Chatterjee,
1993 The National
and
Its Fragments:
y medicos
Colonial
en comunidades
and Postcolonial
andino-quechuas.
Histories.
Cochabamba:
Princeton:
Princeton
Press.
University
Libbet
Crandon-Malamud,
1991 From theFat ofOur Souls: Social Change,PoliticalProcess, andMedical Pluralism inBolivia.
Berkeley
De
Vos,
Dibbits,
Pol, Wim
Ineke
and Mariska
de Boer
con la
propia historia:
equipo de salud. La Paz: TAHIPAMPU.
2002 Encuentros
Journal ofHealth
Interculturalidad
y trato humano
desde
las perspectivas
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
de un
158
LATINAMERICAN PERSPECTIVES
Frantz
Fanon,
Fernandez
Juarez, Gerardo
OMS.
Fernandez
Juarez, Gerardo
(ed.)
Salud e interculturalidad
2004
Abya-Yala.
2006 Salud
e interculturalidad
Ediciones
Quito:
Gonzalez
en America
en America
Latina:
Perspectivas
Latina:
antropoldgicas.
de la salud y critica
Antropologia
Ediciones
Quito:
intercultural.
Abya-Yala.
Pablo
Casanova,
Oxford
2000
Buenos
colonialidad
Aires:
Carmen
Loza,
Press.
University
del
saber:
Eurocentrismo
y ciencias
sociales,
latinoamericanas.
perspectivas
CLACSO.
Beatriz
de Teologia.
Ecumenico
Andino
Superior
Pablo
Ramirez,
con
2007 "Hacia un estado multicentrico
construido
tecnologia
153-159.
Mamani
Medina,
2006
Javier
Suma Qamana:
La Paz:
postindustrial.
comunal."
indigena
Garza
Azul
Willka
1 (1):
Editores.
Memmi,
and
the Colonized.
Boston:
Press.
Beacon
Walter
Mignolo,
2001 "Coloniality of power and subalternity,"in Ileana Rodriguez (ed.), The LatinAmerican
Subaltern
Studies
Reader. Durham
and London:
Duke
University
MPD
2006 Plan
national
Bolivia
de desarrollo:
La Paz.
digna,
soberana,
productiva
Press.
y democrdtica
MREC
2007
Vivir
cambial
jBolivia
La Paz.
Viceministerio
2007
Salud familiar
e Interculturalidad.
Tradicional
intercultural: Documento
comunitaria
1 (3). La Paz.
2008 Boletin Informativo
3 (15). La Paz.
2009a Boletin Informativo
2009b
La Paz.
estrategico institutional, 2009-2015.
intercultural.
salud familiar comunitaria
Plan
2009c
Reglamento
Felix
Patzi,
2006 Etnofagia
Culturas.
estatal: Modernas
formas
de violencia
Anibal
and Immanuel Wallerstein
Quijano,
as a concept, or The Americas
1992 "Americanity
Social Science Journal 134: 549-557.
Quisbert
Quispe,
tecnico-estrategico.
La Paz.
La Paz.
simbolica.
La Paz: Ministerio
in the modern
world-system."
de Educacion
International
Maximo
Fausto
Reinaga,
1970 La revolution
1971 Tesis
india. La Paz:
india. La Paz:
Ediciones
Ediciones
PIB.
PIB.
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions
159
Silvia
Cusicanqui,
utxiwa:
"Chhixinakax
Mario
(ed.), Modernidad
Yapu
una
sobre
reflexion
y pensamiento
practicas
descolonizador.
in Subaltern
deconstructing
historiography,"
and Society. Delhi: Oxford University
History
in
descolonizadores,"
y discursos
La Paz: Fundacion
PIEB.
Studies
on
IV: Writings
Press.
en salud: Problemas
Interculturalidad
Ticona
y respuestas.
La Paz.
Esteban
Alejo,
Lecturas
2005
Plural
para
la descolonizacion:
UNDP
2007 Objetivos
de desarrollo
del milenio:
Oruro,
situation
CA: UNDP/JICA.
UNICEF (UnitedNations Children's Fund)
2007
Guia
de planificacion
Oruro: UNICEF/ACDI.
Viana,
2009
Andres
VMD
2009
(Liberemonos
qhispiyasipxanani
Taqpachani
todos). La
Paz:
Editores.
Bello/Instituto
en salud
participativa
basada
actual,
evaluation
en la chakana,
et al.
and Josef Estermann
Fundamentos
critica y descolonizacion:
de Integracion.
Internacional
para
y perspectivas.
Departamento
el debate.
La
Paz:
La Paz,
de Oruro.
Convenio
(ViceMinisterio de Descolonizacion)
"Atribuciones
de Descolonizacion."
.bo/index.php?option=com_content&task=view&id=847&Itemid=
http://www.minculturas.gob
November
(accessed
30,
2009).
VMI (ViceMinisterio de Interculturalidad)
2009 "Funciones del Vice Ministerio de Interculturalidad."http://200.87.127.215/unoticias/
(accessed
index.php?option=com_content&task=view&id=919&Itemid=
Werner, David
November
30,2009).
Care?Declaration
An Historical
ofAlma-Ata.
Introduction.
Geneva.
Oxford:
Blackwell.
This content downloaded from 128.122.149.145 on Fri, 05 Feb 2016 21:51:43 UTC
All use subject to JSTOR Terms and Conditions