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Intercultural Sensitivity Nunez.pdf



The practice of integrating western and traditional indigenous medicine is fast becoming an accepted and more widely used approach in health care systems throughout the world. However, debates about intercultural health approaches have raised significant concerns. This paper reports findings of five case studies on intercultural health in Chile, Colombia, Ecuador, Guatemala, and Suriname. It presents summary information on each case study, comparatively analyzes the initiatives following four main analytical themes, and examines the case studies against a series of the best practice criteria.




Intercultural Sensitivity Nunez.pdf


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The practice of integrating western and traditional indigenous medicine is fast becoming an accepted and more widely used approach in health care systems throughout the world [1]. However, debates about intercultural health approaches have raised significant concerns regarding regulation, efficacy, effectiveness, intellectual property rights, lack of cross-cultural research, access and affordability, and protection of sacred indigenous plants and knowledge [2]. Further, the practice of integrating both systems is progressively taking place in correspondence with increased organization among indigenous communities and the development of their own health services [3].


This paper reports on the findings of five case studies on intercultural health in Chile, Colombia, Ecuador, Guatemala, and Suriname, conducted by the First Nations Centre for Aboriginal Health Research at the University of Manitoba with the assistance of consultants in each of the countries (most of whom were indigenous). The study was funded by the Inter-American Development Bank (IDB) to provide evidence for program and policy development of socio-culturally appropriate solutions to increase availability and quality of services in health among indigenous peoples in the Americas. At the proposal stage a study framework was developed by the research team to assess initiatives of intercultural health against the above mentioned best practice criteria and to comparatively analyze the cases across four common analytical themes: Cultural, financial and management approaches to intercultural health service development; Opportunities and benefits provided by the intercultural health initiatives; Constraints and risks associated with the articulation of indigenous and western health systems; Assessment of impacts of intercultural health system development. The themes were developed to articulate broader health system domains when analytically comparing the intercultural initiatives. They add a level on inquiry to the understanding of how well best practice criteria were met in the different case studies. The best practice criteria utilized were derived from a study conducted by the National Aboriginal Health Organization of Canada that had developed a framework of best practices for aboriginal health and health care [4].


The cases were chosen in consultation with the IDB and the Pan-American Health Organization (PAHO), exemplifying ongoing intercultural health initiatives with differential organizational structures and background. Data collection took place between August 2004 and January 2005, with an average of eight days of fieldwork in each country by the Canadian researchers, accompanied by the local consultants. Additionally, these consultants conducted prior in-country work to produce background documents in advance of the fieldwork, and organized the extensive, and often complex and sensitive, fieldwork logistics. The study proposal was approved by the Research Ethics Board of The University of Manitoba.


The intercultural program focuses primarily on building a system where the power of traditional medicine embodied in the Machi (traditional healer) is offered as an equal and complementary alternative to western medicine. This vision is strongly embedded in a context of self-determination, as the recovery of traditional medicine is directly linked to social, political, and economic development in the Mapuche communities. The first initiative undertaken in 1998 was the development of the Makewe Hospital intercultural program, owned and operated by an association of Mapuche leaders. This Association is accountable to a Council of Mapuche Community Presidents from communities in the surrounding Makewe region. The Makewe Hospital provides a range of western health services under the direction of a western-trained Mapuche medical director. These include full-time physician services that are supported by nurses and nurse auxiliaries, midwives, visiting specialists, a dental clinic, and a social work department. An intercultural health worker is on staff and patients are seen by a Mapuche staff member and a western physician to ensure that if the patient has health needs that can only be met by traditional medicine, they are referred appropriately. The hospital holds a medical ward with 35 beds, a polyclinic, and a waiting room with a reception. The Mapuche Association is a not-for-profit corporation, and as such sells western health services to the government. Although linked to the work of the hospital, Mapuche medicine is not provided in the hospital, and Machis or other healers are not paid by the Association.


The second intercultural initiative was the development of a health centre in the community of Boroa, which was spearheaded by 25 Mapuche communities that did not have easy access to physicians and traditional services at the Makewe Hospital. The Boroa-Filulawen Health Care Centre has a Machi who attends the clinic one day per week but then treats patients at her home. Patients pay directly for her services similar to the system described above for the Makewe Hospital, although the health centre subsidizes the Machi with a small direct payment. Patients who have been diagnosed by either a western physician or a Machi have the choice of selecting herbal medicine instead of western medications, or as a complement to the latter.


This section comparatively analyzes the five cases following the four main analytical themes of the study: 1) cultural, financial and management approaches to intercultural health service development; 2) opportunities and benefits provided by the intercultural health initiatives; 3) constraints and risks associated with the articulation of indigenous and western health systems; 4) and assessment of impacts of intercultural health system development.


The notion of interculturality has different expressions across the case studies. Suriname is relatively clear-cut with two clinics, a western and a traditional, interacting in indigenous villages. The informal collaboration between these entities enhanced the work of each and has garnered significant community support. The case studies in Chile, Ecuador and Colombia are western health care organizations offering intercultural health care services, although each attempts this in somewhat different ways. The initiative in Guatemala attempts to articulate a western health care public institution with indigenous organizations in the area of midwifery.


The case studies suggested a number of interesting opportunities provided by intercultural health initiatives. Opportunity for exchanging knowledge between both types of practitioners was particularly visible in Suriname and Ecuador, and to a somewhat lesser extent in Chile and Colombia. Despite efforts in Guatemala, the model emphasized western practitioners "training" the comadronas instead of a two-way exchange, and this approach constrained opportunities for knowledge exchange.


Another significant opportunity was an increase in trust among community members towards the health care system. Community trust of both the western and traditional clinics in Kwamalasamutu, Suriname, originated from a positive experience with each clinic separately, but also seemed to be reinforced by the collaboration between the two. On the other hand, in the Guatemala experience, the lack of trust between the comadronas and the western health centre has hindered the development of trust in intercultural work.


One set of constraints on intercultural health initiatives was related to the resistance from certain churches to traditional medicine or aspects of it. In Suriname, this was evidenced in the sidelining of the ceremonial spiritual practices of Shamans, not the use of traditional medicines per se. In the other cases, the resistance by mostly evangelical Christian churches was at times more overt. However, these contraints based on religious beliefs do not seem to have seriously limited any of the intercultural health iniatives studied.


Constraints related to health professionals differed across cases. In Suriname doctors and nurses working in remote areas were quite open to collaboration with traditional medicine. In Guatemala western health professionals indicated a degree of acceptance, but also felt that traditional practitioners should work as adjuncts to the western system. In Chile there was evidence that recent medical graduates are interested in practicing in indigenous settings precisely because of the experience of interculturality. In Ecuador integration between western and traditional practitioners works well in a specialized intercultural clinic, but there was little support for indigenous medicine among western health professionals in general.


In all cases, the relationship with personnel at the hospital level was not particularly positive, thus limiting the cultural appropriateness of services. The lack of clarity in relation to the legal framework for the practice of traditional medicine, and its interaction with western medicine, also creates many constraints. The legal situation in Chile is not currently of concern, but ambiguity in the legal codes places the experiences at risk if the government's position changes. Even in Colombia, where important legislation provides reasonable legal backing for intercultural initiatives, the lack of proper regulations supporting an integrated system constrain further developments. Ecuador constitutionally protects traditional healers, but lacks clear regulations as to how the public health system can interact with them. In Guatemala, the legislative situation of comadronas is unclear, although the public health system seeks to both regulate them through a registration system and entice them to receive training. In Suriname, the lack of a regulatory framework does not seem to have constrained the intercultural initiatives.


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