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Intercultural Health: Chile’s Path Towards Recognizing Indigenous Health Sovereignty

Calfin Lafkenche (Mapuche) works locally, nationally, and internationally to assert Indigenous human rights. He is a part of Desarrollo Intercultural Chile, serves as the Latin America coordinator of Alianza MILPA and is the coordinator for the Indigenous Minga, a collective of Indigenous leaders across Latin America. In this interview, Lafkenche reflects on the past, present, and future of Indigenous and state healthcare collaborations in Chile. As the covid-19 pandemic threatens Indigenous communities across Latin America, Lafkenche highlights recent victories and outlines urgent next steps. Cultural Survival’s Bia’ni Madsa’ Juárez López recently spoke with Lafkenche. 


Cultural Survival: What does the health system for Indigenous Peoples look like in Chile?

Calfin Lafkenche: Chile recognizes access to health as a universal right, while recognizing the cultural identity and the spiritual beliefs of a person as well. Working collaboratively, grassroots organizations and government health institutions have launched a program that allows Indigenous patients—and, over time, non-Indigenous patients as well—to access Traditional Indigenous health systems. 

At the beginning it was difficult for Traditional communities to accept a health program with a public role and with government participation in decision making. At first, the program’s focus was on primary services and family care centers—the first line in medical care. In these primary care centers, people could be either treated with intercultural health or they could get transportation to the homes of medicine men or women. This care system was so successful that western doctors began to pursue training from these intercultural health providers. 

Patients would have a western medical file and a Traditional Indigenous medicine file, with access to both specialists. Western physicians could bring in Traditional Indigenous medicine as complementary care and Indigenous health providers could refer their patients to Western physicians. Because of this successful integration, two Indigenous hospitals were launched: two in Mapuche in the south and two more that are being built. All Indigenous people in Chile know that—by law—they have their own health program and care centers in the region. Large numbers of patients use this intercultural health system and the number of non-Indigenous users is higher than Indigenous users. 

Intercultural health professionals are the bridge. Their leadership and their knowledge are very important to the success of this program. The state has facilitated intercultural health learning for professionals on both sides. Teams of western health officials are trained in Indigenous health practices. They do internships in Indigenous villages. People from Indigenous communities can access internships in hospitals or universities. Scholarships have been publicly accessible, allowing western health and Traditional health practitioners to improve their knowledge, know each other, and recognize each other in the work they do to generate these bridges. 

At first, the biggest challenge we had to overcome was ignorance. My mother was a medicine woman. Relatives would request that she visit patients in the cities, especially those who were terminally ill. When she entered hospitals, she could not bring Traditional elements like drums, water, or smoke to make sahumo. Normally, patients who are dying must be smudged in order to clear their way for passage to the other world. They could not do without it. 

This ignorance has changed over time. Indigenous hospitals now have a structure that permits all types of medicine to be used. Western doctors provide complementary care, but there are also Traditional doctors with access to all of their equipment, which you can see in the corridors. It took fifteen years of work, but now all of these elements are budgeted for in the intercultural health system. The budget is very difficult to balance, but it succeeds because of the participation of Indigenous people. The resources are never sufficient, but it lays a foundation so that the political and spiritual will of the peoples can come together to create strength and build an alliance that will achieve this goal. 


CS: When is Traditional medicine used, and when is Western medicine used? When and how do they work together? 

CL: In the Chilean experience, the recognition of Indigenous Peoples began with the return of democracy after decades of dictatorship. This starting point gave rise to work in intercultural education, intercultural health, access to housing, supporting Indigenous businesses, and so on. Each group was working with institutions to create public policies that supported the rights of Indigenous people to develop while respecting cultural practices.

At the same time, Indigenous people did not go to hospitals, and they did not go to Western primary health centers. They would seek the advice of Traditional doctors—the machi—who know about medicine and plants. Then people came to the communities with diseases that the local Traditional doctors did not know, specifically sexually transmitted diseases that were new to the population. This was what prompted that first need to consult with Western care centers, to ask “What happened? What is this?” From there, Traditional doctors were taught to identify these diseases. They could be the ones to talk to their patients because, you know, Traditional doctors are the ones who understand and have seen the patients’ medical histories from birth. So, they are usually the most trustworthy people. They have the respect of young people, who can ask them everything. Birth control, for example, is provided by Traditional doctors using plants that prevent the conception of children. So when Traditional doctors recognized the symptoms of a sexually transmitted infection, they could give their patient a red card and a yellow card. The red one was for a blood test and the yellow one was for a urine test. With that, each patient didn’t have to say any more at the primary care centers. The hospitalists understood that they came from Indigenous communities, and that they needed a blood or urine test for some kind of sexually transmitted infection. 

From there, the need to include Traditional doctors began to be recognized. It was understood that they either had the right to participate in public health care systems, or that the public system needed to strengthen their care systems. From there, a competitive government fund was generated for Traditional doctors to improve their care centers. They could use the fund to build ceremonial houses or care homes. They could also buy supplies such as stretchers, chairs or—in our case, in my community—through philanthropy, we were able to create a hospital space. Some Traditional medical providers still think that the state should not participate in Traditional medical care: that there are bad groups working within the state programs. They will not work with complementary medicine and will not work hand-in-hand with the state. But today the demand is so high that both groups continue to have many patients in need of care.

Childbirth is another example. Chile and Argentina respect Peoples’ right to decide how they wish to give birth. Hospitals and care centers accept that midwives can enter delivery rooms and go with the children when they are born. And they recognize the rights of the women and their families to request their placentas. The placenta plays a very important role in the divine relationship between a man—or a woman—and nature. When the hospitals kept and incinerated the placenta, what they were doing was destroying the children’s spiritual relationship to the earth. Traditionally, the placenta is buried in a private family space where the spirit of the living being, of the human, can live. Usually this site is part of a sacred space, called a menoko, where Indigenous medicine grows and is managed over time. Nowadays, both Indigenous and non-Indigenous people can write a letter, requesting that the government deliver the placenta after delivery. And the day can end with burying the placenta, generating that connection between the earth and the human being. 

And another example is mental health. Like therapy, forms of food or music such as Indigenous instruments, Indigenous dance, prayers, or the interaction with fire, with musicians, or things like traditional songs, the use of the drums, and fire, and clothes...  all these aid in the healing process and in caring for mental health patients in anguish, in depression, through all types of loss. All of these can be included in therapy for Indigenous people. To me, it seems that this is another kind of preventative medicine. 


CS: What does the future of Indigenous health look like in your community? What must happen to optimize it both from the state side but also from the community itself?

CL: What we always lack from the state are resources. There are never enough resources. It’s not only vital to strengthen our intercultural health systems, western medicine is also needed. It is indisputable that primary health care centers need the necessary supplies to provide good care. For example, there are ambulances which travel through the communities, allowing grandparents to be cared for in both the national system and the herria system in cases like, for example, diabetic patients. And this is an achievement. But some territories still lack access because there are no good roads. We need a push for accessible community health care, good roads, access to technology, and communication networks to reach places without telephones, for example, in case of a public emergency. These are the places where there is the greatest mortality risk for those patients who fail to reach the primary health care system.

We need to improve the capacity of Traditional medicine providers, improve access to these spaces for members of the communities, improve the clinics, our hospitals, care centers, and Traditional care centers. We need to strengthen public policy that recognizes Indigenous Peoples’ rights to full and effective health access, to a clear and effective and precise diagnosis by their own Indigenous medical providers. And that has to be accomplished at a resource level. A health policy cannot be implemented without resources. 

Indigenous Peoples also have to make a commitment to recognize their medicine as a material and immaterial cultural heritage, and to safeguard the sacred spaces where medicine is and Traditional practices happen. The state has the obligation to recognize these spaces of cultural and spiritual significance. Many are within national parks, where institutional policies limit access for Traditional doctors. These policies need to be rethought so that traditional leaders can enter at any time, because prayers and spiritual practices must be done at certain moments, medicines collected as specific times. And these times don’t always match the hours of access set by national parks, for example.

The state needs to make a very significant step to recognize Traditional spaces where Indigenous people can strengthen their Traditional medicine. For example, the arrival of the clean energy program including hydroelectric power greatly affects Indigenous territories. As does the highway, with the government’s plans to improve the roads and make new ones for the forestry companies. These same forestry companies’ pine tree plantations are drying up all the water and the Traditional land where medicine grows is dying. Indigenous communities need access, for example, to international spaces like the business or human rights forum, where everything related to the ways in which these companies must respect the rights of local communities is debated. Indigenous people must reach these spaces so that they can carry a voice from their communities, insisting that their understanding of protecting their territories is considered as a requirement within these policies and practices that governments and companies are creating.


CS: Could you also tell us a bit about the current state of Indigenous Peoples in Chile in the context of COVID-19?

CL: We, as Indigenous Minga, are constantly meeting with leaders from Mexico, Panama, Guatemala, Colombia, Venezuela, Ecuador, Peru, Chile, Bolivia, Argentina, and we have first a very worrying vision of what is going to happen. Our community is going to be greatly affected, and what we are asking from the world of politics is that public health authorities generate special assistance programs. Our community does not have access to masks. Our community does not have access to ventilators. Our community does not have access to our minimum needs. Nowadays, community members are forced to go into towns for basic necessities, at minimum foods like rice, salt, oil, and flour, which are necessary staples to complement Peoples’ traditional meals. It is difficult for the towns to keep them safe and the daily cultural activities of communal life make communities very susceptible to transmission. So when one person gets infected, the rest of our community will be infected too. So, we implemented a mandatory quarantine and closed access to our communities. In Mexico, municipalities are closed. The island of Guna Yala is closed, they stopped accepting tourists a long time ago. In Panama, in Ecuador, it is the same. The governments have not declared a quarantine in these territories but the Peoples, seeing the emergency, are already implementing it. We are working with the communities to provide assistance for older adults who do not have support, who mainly need food staples. We have begun to work with the communities to manage emergency funds, especially for the elderly who live alone and in extreme poverty. We have boxes which, for 30 dollars, provide everything necessary to make food. So now, with philanthropic support, we are managing to generate resources for our communities and raise enough funds to provide basic food for at least the three, four, or five months this pandemic will last. We also started to donate cloth, so that the communities can manufacture masks to prevent contagion when the disease arrives. 

Indigenous Peoples are going to be seriously affected because the majority of Indigenous workers are waiters, they are cooks, they are workers. Companies are going bankrupt, closing, laying off workers. No company is sustainable when going three months without generating income. The workers, mainly Indigenous, will be left without jobs. Then they will return, unable to pay their rent in the cities. They will return to the communities. And that is the main fear we have. 

In three or four months we are going to finish the food that we have stockpiled in the communities. Then, it will be urgent that the government develop a food assistance program for our people. And if the pandemic virus reaches the communities, we will have a large number of fatalities, especially in older adults. It will be because the primary care center is not prepared, we do not have the ambulance capacity within the communities, and the communities do not have vehicles to drive emergency patients to the cities. We have already made calls through international channels. We have a few donations: a mechanical respirator, an artificial respirator. So the ambulance can transport critically ill patients for two hour trips, and the primary care centers can have artificial respiration equipment. We do not know if this will be sufficient but we are working to respond to the urgent needs of the communities. 

Many people are concerned about the global pandemic situation, but they are not concerned about protecting the cultural identity of Indigenous Peoples. We have to do that work. We have an intercultural understanding of the communities’ situations. We need to reach public health systems, and tell them that we need treatment in a certain way, a special program of care. And we are working on that. But it has been very difficult.

This pandemic will cause a worldwide shift in how we think about global development up until now. We will not be the same in September, November, when this ends. The world will be another. On that day, traditional crops, traditional medicine, medicine through food will be of great value. This knowledge must begin to be cultivated in non-Indigenous society as well: an understanding of the importance of Traditional community knowledge of crops, the protection of biodiverse spaces, and the importance of water. How we are all going to work in the future.



Photo by David Suazo Quintana.

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