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Health, sexuality and reproduction among Chile's indigenous peoples: A research survey, 1990-2004.

The data presented here are based on the project, "National Analysis of Studies and Experiences in Sexual and Reproductive Health among Chile's Indigenous Peoples from 1990 to 2004," undertaken by the Chilean non-governmental organization CORSAPS and financed by the United Nations Population Fund. The findings were first published as Salud, Sexualidad y Reproduccion: Sistematizacion de investigaciones y experiencias en pueblos Indigenas en Chile 1990-2004 by Maria Soledad Moscoso Perez and Claudia Dides Castillo, with contributions by Valentina Fajreldin, Gabriela Gonzalez and Marcela Soto (Santiago, Chile: CORSAPS, UNFPA, 2005).

Introduction

This article presents the results of the first systematization of sexual and reproductive health that addresses the cultural and ethnic diversity of our country. To review the treatment of this topic in Chile, the authors examined information from social and biomedical studies as well as initiatives implemented by a variety of organizations and institutions. We also explored ideas of sexual and reproductive health in traditional medicinal systems of our country's indigenous cultures.

The study sought to reflect on advances made and challenges pending in these areas and to provide inputs for formulating public policies in sexual and reproductive health for indigenous peoples within a human rights framework.

The concept of sexual and reproductive health applied to different cultural settings is a complex matter. Developed in a non-indigenous world through its association with political and human rights movements, the notion of sexual and reproductive health gradually has gained legitimacy and today is used in a variety of geographic and cultural contexts.

We acknowledge the need to take into account the perceptions of indigenous women and men on these issues, and we have paid special attention to how indigenous communities recognize and use this concept while bearing in mind that such "foreign" concepts have been adopted and adapted by indigenous cultures in the past. We believe that the topic of sexual and reproductive health is invaluable for analysis and policymaking.

Therefore, we have decided to approach these issues through different aspects of sexual and reproductive health considering health, sexuality and reproduction as processes that are recognized by indigenous communities and linked to aspects of their culture.

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Background

In seeking health for their members, human societies organize their beliefs, actions, abilities and knowledge into so-called medical systems, which contain two subsystems: a conceptual subsystem about illness and another subsystem centered on health care (Foster and Anderson, 1978). Each culture develops theoretical and technical models and establishes agents to address and solve problems related to illness and the recovery of health in a given geographic context (Citarella, 2000). These systems operate by incorporating and excluding practices and ideas derived from different bodies of knowledge (Menendez, 1994).

Indigenous medical systems in Chile are not legally recognized. The medical systems of modern western culture have tended to hegemonize their scientific, biomedical knowledge and to dominate other medical systems and their own "patients," making coexistence impossible for medical systems based on other paradigms.

Gradually, some public health systems have become more open to indigenous medical systems, which in turn have incorporated their visions into the official system little by little. New models of care tailored to specific cultural contexts have arisen, such as the implementation of Mapuche health-care models in several public health districts. (1)

The last decade has seen a rise in the use of concepts like "intercultural health" and "interculturality in health" as a way of incorporating the culture of indigenous clients and that of their counterparts (health professionals) into the health-care process (Alarcon, et al., 2003). These concepts also refer to a provider's ability to operate in different cultural contexts based on culture-specific knowledge, beliefs and practices regarding health and illness, life and death, and the biological, social and relational body (Ibacache and Oyarce, 1996).

Chile's ethnic diversity (2) has presented health-care teams with the need to facilitate the doctor-patient relationship and overcome barriers to access and timely health care related to the ethnic and cultural diversity of users. This situation has resulted in the implementation of the intercultural facilitators and healthcare models mentioned above, which require coordination among indigenous organizations and healthcare services.

Intercultural medical visions reflect a convergence of different socio-cultural worlds. Because local health-care systems are influenced by geographic realities and cultural diversity, any approach to indigenous health-care systems must take into account the unique cultural history of the indigenous community that has developed in a different context from that of the mainstream population.

Today, Chile's indigenous peoples--Mapuche, Aymara, Atacameno or Likan Antai, Rapa Nui, Kaweskar and Yamana--have adopted many modern cultural forms; but with the exception of the Atacamenos (Gomez and Ahumada, 1998), they have maintained their native languages and many of their ancestral traditions (Perez, 2003).

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More and more, studies on sexuality and reproduction in Chile are incorporating a sexual and reproductive health perspective and taking into account the social and cultural conditions that differentiate women and men (Schiappacasse, et al., 2003). However, ethnic diversity and cultural practices still are not recognized as significant variables in this area. The present investigation identifies the need to incorporate knowledge and practices from indigenous health-care systems.

The term "sexual and reproductive health" arose in recent years after the Programme of Action from the International Conference on Population and Development (ICPD, Cairo, 1994) (3) defined reproductive health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so," adding that the purpose of sexual health is "the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases." (4)

The ICPD Programme of Action also contains a chapter on the rights of indigenous peoples that addresses productive capacities, relationships, the environment and the right to sexual and reproductive health by harnessing the potential of their diversity. (5)

As in most Latin American and Caribbean countries, Chile's population today is comprised mainly of mestizos--people of mixed European and indigenous parentage--and indigenous groups that were incorporated into the nation-State at the end of the 19th century. At that time, indigenous peoples were considered "backwards," "inferior" and "uncivilized;" the usual practice was to control native inhabitants through assimilation policies that sought to "civilize" them and integrate them through a monolingual and monocultural educational process (Bello, 2004).

This concept was expressed in education, segregation laws and the establishment of several missionary orders in Chilean territory to help native inhabitants to adopt "Chilean customs." The 1930s saw the beginning of a long period of integration policies based mainly on education, " castellanizacion" (replacing native languages with Spanish) and the classification of Chile's indigenous peoples as peasant farmers, a class of Chilean society undifferentiated from the rest of the Chilean people.

However, the most important transformation of the relationship between the Chilean state and the country's indigenous peoples did not occur until the 1990s, after Chile's return to democracy following a period of military rule. A new proposal arose at that time based on respect and justice for all people, which implied changes in state policy. The Acuerdo de Nueva Imperial (Agreement of Nuevo Imperial) was drafted to overcome previous attempts to divide communities and assimilate indigenous peoples. (6) Soon afterward, the Special Commission on Indigenous Peoples (CEPI) (7) was created to draft what was to become the Indigenous Law of 1993 (Instituto de Estudios Indigenas, 2003). One of the central provisions of this law and a key achievement of the entire process was the creation of the Corporacion Nacional de Desarrollo Indigena (CONADI, National Indigenous Development Corporation), which has addressed land disputes and bilingual intercultural education. (8) Nevertheless, to date there has been little support for the constitutional recognition of Chile's indigenous peoples and the ratification of the International Labor Organization's Convention NY169.

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Currently, the legislation governing matters related to indigenous peoples in Chile is Law 19.253 of 1993, which governs political rights and the right to participation. This law lists Chile's indigenous peoples, their main ethnic groupings and communities, as well as their right to hold and to practice their own cultural expressions (Para. 3, Art. 7, On Indigenous Cultures). The law recognizes indigenous peoples' rights over the lands that they historically occupied, promotes their protection and establishes cultural and linguistic rights and the right to development--defined as the State's responsibility to support people in their struggle to overcome social and economic exclusion (Instituto de Estudios Indigenas, 2003). Despite the advances represented by this piece of legislation, it still falls short of the demands expressed by the indigenous movement in Chile.

In addition to the law, the Program for the Comprehensive Development of Indigenous Communities, ORIGENES, was implemented. This program is financed by the Inter-American Development Bank (IDB) and administered by Chile's Ministry of Planning (MIDEPLAN). Its aim is to improve the living conditions and promote identity-based development of the Aymara, Atacameno and Mapuche ethnicities in rural Chile, including economic, social, cultural, environmental and legal aspects. The program has six interrelated priority areas; one of these is intercultural health, which is coordinated through the Ministry of Health (MIDEPLAN, 2004). An important government initiative under this program was the creation of the Indigenous Peoples Health Program, which was launched in 1996 by the Primary Care Department of the Ministry of Health (MINSAL). This program was established in the context of the International Decade of the World's Indigenous Peoples 1995-2004 (UN Resolution NY48/169 of 1993). Today, the program is implemented in Chile's public health clinics in the First, Second, Third, Fifth, Eighth, Ninth, Tenth and Metropolitan Regions. It operates in close collaboration with the Pan American Health Organization and the MINSAL Women's Program and in 2003 pushed for the establishment of a Commission on Health Policy and Indigenous Peoples.

The Indigenous Law makes no specific mention of health among indigenous peoples, in contrast to its provisions on indigenous culture, language and education, which are recognized and protected through programs for bilingual intercultural education.

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Though indigenous peoples' health demands are not addressed in the Indigenous Law, the State deals with these concerns through MINSAL's National Health Program for Indigenous Peoples. This program includes analysis and promotes action based on the epidemiological and cultural particularities of indigenous populations in the country.

Since the 1990s, MINSAL's National Health Program for Indigenous Peoples has aimed to foster the development of more accessible and responsive services for the country's indigenous population to improve the health of indigenous inhabitants. The program takes into account each group's specific cultural, linguistic and socio-economic characteristics and strives to ensure ensure their participation in defining existing problems and ways of solving them (MINSAL, 2004). Epidemiological studies have compared the health profiles of indigenous populations with those of the rest of the population. Although there have been only a few of these studies to date, they reveal a notable improvement in the health status of native peoples. Nonetheless, infant mortality rates show significant and troubling differences. While infant mortality is less then 20 per 1,000 live births nationwide, it is twice as high among indigenous populations (although up-to-date data is not available for this indicator). (9)

Some public health teams have been addressing the indigenous health issue since before the creation of the National Health Program for Indigenous Peoples. These include the Programa de Salud con Poblacion Mapuche (Mapuche Population Health Program) and some initiatives within the Arica Public Health Services that incorporate culturally based health-care criteria. Many local and national meetings with participants from indigenous organizations, government agencies and non-governmental organizations have drawn attention to the tension that exists between official and indigenous health systems, which is expressed in the exclusion and discrimination experienced by indigenous clients both personally and in regard to their ideas and practices. (10) Indigenous groups throughout the country have demanded recognition for the practices of traditional birth attendants, doctors, herbalists and componedores de huesos (traditional chiropractors). After these problems were identified, discussion began on how to collectively create opportunities and care models that maximize complementarity between the two systems of health care.

An especially sensitive issue--and a very private one for indigenous people in general--is what we call sexual and reproductive health. This area has been a source of tension with the official health system. Indeed, one study of sexual and reproductive health services for Aymara women in the north of Chile showed that public health staff violated the strongly held beliefs of indigenous populations by failing to obtain informed consent for certain procedures. For example, in pregnancy and childbirth, certain hospital practices--such as a poor quality diet, cold water baths and cold birthing rooms--go against the indigenous birthing model, which offers new mothers a more suitable--diet and herbal infusion baths in accordance with a cultural belief system in which cold and heat play an important part (CEDEMU, 2001-2002) In the National Health Program for Indigenous Peoples, there are no directives that address the inclusion of such practices; however, in some regions of the country, concrete initiatives are being implemented in collaboration with the Women's Program. (11)

One important provision on pregnancy and childbirth is Article 16 of Chile's Health Code, which establishes the State's responsibility to protect mothers and children through the Public Health Service. In practice, public health staff have used this article as a way of forcing women to give birth in hospitals. (12) In response, indigenous originations have opened homes and shelters to help women in their communities maintain their traditions and have generated other initiatives to lower transportation costs to hospitals, thereby faciliating women's compliance with the official requirement of hospital-based birthing, which has been imposed by force in some cases. (13)

Despite their lack of training in these issues, the intercultural facilitators of the National Health Program for Indigenous Peoples have made a number of interventions in the area of sexual and reproductive health. They accompany pregnant women and those in labor through the hospital admission process, encourage women to obtain gynecological services such as PAP tests and explain available contraceptive methods.

Methods

The information for this systematization was gathered in two stages and focused on Chilean regions with the highest concentration of indigenous peoples: the First, Eighth, Ninth, Tenth and Metropolitan Regions. The Second and Fifth Regions also were included because they are home to the Likan Antai and Rapa Nui indigenous groups. First, the indigenous communities themselves were identified. According to Article 1 of the Indigenous Law, Chile recognizes indigenous peoples as the descendants of human groups that inhabited the national territory from pre-Columbian times and who maintain their own ethnic and cultural identity, with the land as the foundation of their existence and culture. It recognizes the following indigenous peoples in Chile: Mapuche, Aymara, Rapa Nui (or Pascuense), the Atacamena communities, the Quechuas and Collas in the north and the Kawashkar (or Alacalufe) and Yamana (or Yagan) communities in the southern archipelago.

During the first stage of the study, it became apparent that researchers in this field were not completely familiar with the concept of sexual and reproductive health; this was even more evident at the level of local indigenous communities where many individuals and even organizations found the concept incomprehensible. Given this situation, thematic sub-areas of sexual and reproductive health were identified, including sexuality, fertility control, contraception, abortion, sexual violence, HIV/AIDS, sexually transmitted infections (STIs), quality of care, sexual and reproductive rights, the body, fertility and pregnancy, and childbirth. This organization in turn guided our search for information, specifically bibliographic references in libraries, document centers and the Internet (online catalogues). A format was designed with the keywords "sexual and reproductive health," "sexuality" and "gender" cross-referenced with the names of indigenous groups. (14)

No ethnicity-specific statistical data was found related to sexual and reproductive health, although we requested information from a variety of public agencies on the following topics: births by ethnic group, country and region; age of first sexual experience by ethnic group; use of contraceptive methods; voluntary sterilization; rates of hospital discharge after abortion; cervical cancer rates; and sexual violence. Nevertheless, on the topic of fertility among indigenous peoples, the National Statistics Bureau (INE) and MIDEPLAN's Origenes Program indicated that, in the 2002 Census, all women 15 years of age and older were asked their total number of live births (total lifelong fertility rate). This data offered a record of reproductive behavior by generation. The overall fertility rate (OFR) was calculated for each indigenous ethnicity. This rate represents the average number of children that a woman will have during her entire reproductive life (excluding prenatal mortality) if current fertility rates persist. Without additional vital statistics for specific ethnic groups, we used as a reference the national OFR, which in 2001 was 2.1 children per woman, including all women from 15 to 49 years of age and children from 0 to 4 years old. However, while this rate is probably quite accurate, seven of the eight indigenous ethnicities taken into account by the Census have very small populations, which could lead to statistical distortions. In addition, the OFR is a hypothetical measure of overall fertility, meaning that an individual woman's experience may diverge broadly from the mean (MIDEPLAN, 2004).

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Indigenous rural women bear on average one child more than urban indigenous women, except for Rapa Nui women whose fertility resembles their urban counterparts. According to the 2002 Census, the reproductive dynamic among ethnic groups has shifted. With the exception of the Kawashkar, indigenous women today are having fewer children than women of previous generations: while indigenous women 50 years and older have an average of four children, women 30-34 years old have had only two.

Migration is another piece of this puzzle. Migration rates are highest among the Rapa Nui (11.6%), Colla (9.6%) and Kaweskar (8.2%) peoples and lowest among the Aymara (3.4%). Kaweskar men are more likely to migrate than women (9.4 versus 6.7%).

Women acquire new roles in the migratory process. For example, men's migration expands women's role in the family: they must become the head of the household and take on financial responsibilities often in unfavorable employment conditions and work long hours while also tending to domestic tasks. (MIDEPLAN, 2004)

In the second stage of the study, researchers gathered information on experiences that have been implemented in the regions under study. Data on 15 interventions was obtained mainly through interviews with members of different indigenous groups, ministry officials and local academics and other researchers also studying indigenous issues and sexual and reproductive health. Information also was collected from people responsible for health initiatives and with staff of indigenous entities and NGOs, as well as through attendance at Trawun (Mapuche gatherings), visits to indigenous organizations, rural communities and hospitals with intercultural health programs and NGOs working in this and related areas.

A major challenge for researchers was the difficulty of locating some bibliographic sources in documentation centers, universities, NGOs or public institutions. Some materials were available only in private collections. Not all field sites were visited due to time and budget constraints. For example, no field visit was made to Easter Island, but information and experiences were collected through phone interviews with key informants.

Results and Discussion

The regions studied are home to different medicinal cultures that have given rise to a variety of unique, complex health-care systems, each with its own set of practices and resources. The public health system also is utilized by the inhabitants of indigenous communities. Indigenous groups adapt to their geographic, social and cultural circumstances and establish socio-cultural strategies for health and illness, incorporating knowledge about health and treatment options. Nevertheless, some individuals living in rural and even urban settings are treated exclusively by specialists from their own traditions.

Today, some individuals are attempting to incorporate indigenous and popular medicinal knowledge into official health practices. They have recommended an approach to reproductive health based on the protocols of different indigenous traditions, including proper behavior during marriage, how to address sexuality and traditional family planning methods, as well as care practices for different stage of women's reproductive life cycle. Nevertheless, many of these aspects still are confined to their specific cultural context and are socialized only among group members.

In the course of this systematization, we found 49 studies and 36 experiences on different topics related to sexual and reproductive health which cover seven regions of Chile.

The Studies

Seventeen of the studies are student undergraduate and graduate theses. Another 13 were conducted by government entities, three by NGOs, two by associations and one was done independently. Ten studies were conducted by Chilean academics. Some other studies were included that did not refer directly to the topics under discussion but did offer important information for the present review. (16)

The institutions that conducted studies on sexual and reproductive health and indigenous peoples were mainly government entities and universities. Thirteen government studies were conducted in total, with four each in the First and Ninth Regions.

Most of the university theses were done in the First Region [11] and were carried out by students in health programs, mainly obstetrics and medical technology.

Most of the studies adopted a biomedical approach and lacked a gender perspective. However, in the First and Ninth Regions, some studies done in rural areas focused on ideas and practices related to sexuality and reproductive health among the Aymara and Mapuche.

One surprising discovery was the lack of studies in the Second, Eighth and Metropolitan Regions, given the many government agencies, universities and social organizations working on indigenous issues in these areas, as well as the large population of indigenous inhabitants.

The methodologies used in the studies are predominantly quantitative. However, more recent Chilean and international research on sexuality and reproduction for the general (non-indigenous) population has tended to employ complementary methodologies that combine quantitative and qualitative approaches. A few of the more recent studies collected under this project have adopted this approach as well.

This blend of quantitative and qualitative approaches is better able to broaden our understanding of social and cultural phenomena. Qualitative methodology in these fields allows us to identify and become familiar with the motivations, feelings and subjective processes that influence the health practices of men and women.

This is especially important when addressing issues of sexuality and reproduction among indigenous peoples. Although they are part of the national socio-cultural landscape and therefore share similar living and health conditions as the rest of Chilean society, indigenous communities and ethnicities also are repositories and users of their own culture's concepts related to health, sexuality and reproduction.

Most of the studies were funded by public institutions, probably reflecting the lack of available international or independent resources. However, there is no government earmarking of funds for the study of the sexual and reproductive health of indigenous peoples. Twelve of the 22 studies with relevant information were financed by government institutions, while six received funding from international agencies and five from universities. (17)

The 49 studies collected cover a wide range of sexual and reproductive health topics. Pregnancy and childbirth were the most popular topics, and most of these studies were conducted in the First Region. The second most-studied topics were sexually transmitted diseases and quality of care, which also were concentrated in the First Region. The least-addressed issues were menopause, amenorrhea and breastfeeding.

No studies offered information on user satisfaction with the care received for sexual and reproductive health. However, some studies did address the lack of information indigenous women receive about the procedures to which they are subjected and the fact that some techniques are in conflict with their cultural norms, such as cold water baths during labor, as well as the birthing position itself. (18)

Eight of the 17 theses found focused on the topic of sexually transmitted infections, mainly in the First Region, and most were associated with health professions (obstetrics and medical technology). Five theses addressed pregnancy and childbirth, and three more looked at the postpartum period, quality of care and sexuality. These last three were conducted in the First, Second and Fifth Regions.

A gender perspective has been used previously in sexual and reproductive health studies among indigenous peoples. Gender in this context refers to the different experiences of men and women with regard to health and illness. Of a total of 49 studies, only seven included a gender perspective in their analyses. (19) In addition, three nationwide studies were found. Two of these had been financed by official entities--the Ministry of Health and the Pan American Health Organization (PAHO)--while the third did not identify its funding source. Two studies used qualitative as well as quantitative approaches, and the third was only qualitative. One of the studies was published in conference proceedings and in a journal. The topics addressed were quality of care [3] and pregnancy and childbirth [2].

Experiences

In contrast to the concentration of studies in only a few regions, we found that interventions have been implemented in most of the regions studied. Most of these focused on the Mapuche people of the Ninth Region. The only exception was the Second Region, which had neither interventions nor studies.

In general, the experiences are fragmented and isolated and always take place for a limited period of time. The only exception to this pattern is found in the various homes and shelters for pregnant and birthing women (in the First and Tenth Regions), which opened in the 1990s and continue operating to this day. There were 36 experiences collected across all regions studied; these include a broad range of initiatives implemented by indigenous organizations, NGOs and government entities.

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The topics included most often are prenatal care, childbirth, sexuality, HIV/AIDS and STI prevention. Abortion, menopause and the body are rarely addressed.

The main formats used were workshops, colloquia, meetings, seminars and conferences. Ongoing systematic training and education, such as that for Mapuche paramedics in the Ninth Region and intercultural health technicians in the Metropolitan Region, are rare. More often the experiences involve workshops [8] on different topics, such as sexual and reproductive rights, HIV/AIDS and STI prevention, sexuality, safer sex, breast cancer prevention, contraception and fertility control.

Most experiences do not include evaluations of their process or impact; nor do they include follow-up. Therefore, it is not clear whether any of them actually have improved the health of the population participating in the experience or have achieved more complementarity between indigenous and official medical systems. This methodological weakness certainly reflects the fragmentary nature of the experiences.

Not all initiatives identify their funding source. However, among those that do, most are financed by the National Health Program for Indigenous Peoples and/or by other MINSAL programs. Indeed, while it lacks an official policy focused specifically on sexuality and reproduction in indigenous groups, the Ministry has responded positively to the interest shown by some indigenous organizations in designing experiences especially for these communities.

Unlike the usual practice in research, indigenous organizations have played a central role in initiating, participating, implementing and even funding the interventions identified. In some cases, experiences organized by government institutions even incorporated the use of indigenous languages. These experiences could reflect the gradual recognition of the cultural practices of indigenous groups among government agencies and cultural acceptance of native languages.

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We found little disaggregated data on indigenous groups among official statistics. This is of special concern given the need to identify the frequency, recurrence and/or impact of health matters such as the use of contraceptive methods; prenatal, childbirth and postnatal care; voluntary sterilization; cervical-uterine and breast cancer; and HIV/ AIDS/STIs. Such data could facilitate comparisons between the indigenous peoples and the overall Chilean population to identify gaps in health and respond to these by designing studies, defining areas of action and formulating public policies.

Finally, one major issue that is closely related to the above is the recognition of Chile's multiculturalism and multi-ethnicity. Such recognition involves acknowledging the collective rights of indigenous populations and recognizing their medical systems and their health agents, thereby granting full expression and legitimacy to the diversity of their cosmovisions.

Bibliography

Alarcon, Ana Maria; Vidal, Aldo; Neira, Jaime. "Salud intercultural: Elementos para la construccion de sus bases conceptuales," in Revista Medica de Chile 131: 1061-1065, 2003.

Bello, Alvaro. Etnicidad y ciudadania en America Latina. Santiago: Comision Economica para America Latina y el Caribe, CEPAL, 2004.

CEDEMU. Sentando bases para el desarrollo de un modelo intercultural en salud sexual y reproductiva entre las mujeres aymara del norte de Chile: Un estudio de epidemiologia intercultural, balance del proceso. Arica: CEDEMU, 2001-2002.

Citarella, Luca, ed. Medicinas y culturas en la Araucania. Santiago, Chile: Editorial Sudamericana, 2000.

Enlace Continental de Mujeres Indigenas en CEPAL. Reunion de la Comision Economica para America Latina, CEPAL, San Juan, 28 de junio 2004. Available online at www.radiofeminista.net, accessed May 2005.

Foster, G.; Anderson B. Medical Anthropology. New York: John Wiley Sons Editors, 1978.

Gobierno de Chile. Nuevo trato con los pueblos indigenas. Derechos indigenas, desarrollo con identidad y diversidad cultural. Santiago: Gobierno de Chile, 2004.

Gomez, Domingo; Ahumada J., Necul E. Medicina tradicional atacamena. Antofagasta: Fondart, MINEDUC, 1998.

Ibacache, Jaime; Oyarce, Ana Maria. "Reflexiones para una politica intercultural en salud." Paper presented at the Primer Encuentro Nacional de Salud y Pueblos Indigenas, Puerto Saavedra, Chile, 1996.

Informe de la Conferencia Internacional sobre Poblacion y Desarrollo. El Cairo, 5 a 13 septiembre de 1994. Available online at www.cinu.otg.mx/temas/desarrollo/dessocial/poblacion/icpdf1994.htm, accessed September 2004.

Instituto de Estudios Indigenas. Los Derechos de los pueblos indigenas en Chile. Informe del Programa de Derechos Indigenas. Temuco: Instituto de Estudios Indigenas, Universidad de La Frontera, 2003.

Instituto Nacional de Estadisticas, Programa Origenes (MIDEPLAN-BID), Estadisticas Sociales de los Pueblos Indigenas en Chile. Censo 2002. Santiago, Chile: INE 2005.

Instituto Nacional de Estadisticas, Programa Origenes (MIDEPLAN-BID), Estadisticas Sociales de los Pueblos Indigenas en Chile, Censo 2002, Santiago, Chile: INE, 2005. Available online at www.origenes.cl, accessed June 2005.

Ministerio de Cooperacion y Planificacion, MIDEPLAN, Gobierno de Chile. Pueblos Indigenas/Programa Origenes. Available online at www.mideplan.cl/publico/categoria.php?secid2&catid12, accessed September 2004.

Ministerio de Salud, MINSAL, Gobierno de Chile. Programa Especial de Pueblos Indigenas. Available online at www.minsal.cl, accessed November 2004.

Ministerio de Salud, MINSAL, Gobierno de Chile, PAHO/WHO, Perfil epidemiologico. Situacion de Salud de los Pueblos Indigenas de Chile, Santiago: MINSAL, PAHO/WHO, 1997.

Menendez, Eduardo. "La enfermedad y la curacion [??]que es la medicina tradicional?" in Revista Alteridades (Mexico) 4, 1994.

Perez, Maria Soledad. Reflexiones sobre la medicina tradicional y medicina occidental en Chile a traves del proceso de salud-enfermedad. Anuario de Escuela de Postgrado Facultad de Filosofia y Humanidades. Santiago, Universidad de Chile, 2003.

Schiappacasse, V.; Vidal, P.; Casas, L.; Dides, C.; Diaz, S. Chile: Situacion de la Salud y los Derechos Sexuales y Reproductivos. Santiago: CORSAPS, ICMER, SERNAM, 2003.

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Maria Soledad Perez Moscoso and Claudia Dides Castillo Ms. Perez Moscoso has a degree in psychology from the Universidad de la Frontera (Chile) and a master's in gender and culture from the Universidad de Chile. She currently teaches at the Universidad Academia de Humanismo Cristiano (Chile). Ms. Dides Castillo has a degree in sociology and master's in gender and culture from the Universidad de Chile and is director of the Gender Equity Studies program at FLACSO-Chile.

RELATED ARTICLE: Indigenous peoples' rights on hold.

The Second International Decade of the World's Indigenous People was originally proclaimed by the United Nations General Assembly on December 22, 2004, in Resolution A/RES/59/174 and officially began January 1, 2005.

The Decade has five main objectives:

* Promoting non-discrimination and inclusion of indigenous peoples in the design, implementation and evaluation of international, regional and national processes regarding laws, policies, resources, programs and projects;

* Promoting full and effective participation of indigenous peoples in decisions that directly or indirectly affect their lifestyles, traditional lands and territories, their cultural integrity as indigenous peoples with collective rights, or any other aspect of their lives, considering the principle of free, prior and informed consent;

* Redefining development policies that depart from a vision of equity and that are culturally appropriate, including respect for the cultural and linguistic diversity of indigenous peoples;

* Adopting targeted policies, programs, projects and budgets for the development of indigenous peoples, including concrete benchmarks, and particular emphasis on indigenous women, children and youth;

* Developing strong monitoring mechanisms and enhancing accountability at the international, regional and particularly the national level regarding the implementation of legal, policy and operational frameworks for the protection of indigenous peoples and the improvement of their lives.

The draft Declaration on the Rights of Indigenous Peoples was presented to the UN General Assembly for adoption this year after over two decades of negotiation. The first meeting of the United Nations' Human Rights Council approved the Declaration in June 2006 and recommended its approval by the UNGASS, which would incorporate this document into the body of international human rights instruments currently in force.

The Declaration recognizes the right and authority of the indigenous peoples to maintain and strengthen their institutions, cultures and traditions. It also sets forth indigenous peoples' rights to promote their own development based on their own needs. The Declaration asserts the rights of indigenous peoples to have control over their own lives, to defend their cultural identity for future generations, and to have secure access to their lands and resources.

Some of the articles of the draft resolution are:

Article 2

Indigenous individuals and peoples are free and equal to all other individuals and peoples in dignity and rights, and have the right to be free from any kind of adverse discrimination, in particular that based on their indigenous origin or identity.

Article 3

Indigenous peoples have the right of self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development.

Article 21

Indigenous peoples have the right to maintain and develop their political, economic and social systems, to be secure in the enjoyment of their own means of subsistence and development, and to engage freely in all their traditional and other economic activities. Indigenous peoples who have been deprived of their means of subsistence and development are entitled to just and fair compensation.

Article 22

Indigenous peoples have the right to special measures for the immediate, effective and continuing improvement of their economic and social conditions, including in the areas of employment, vocational training and retraining, housing, sanitation, health and social security.

Particular attention shall be paid to the rights and special needs of indigenous elders, women, youth, children and disabled persons.

Article 23

Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to determine and develop all health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions.

Article 24

Indigenous peoples have the right to their traditional medicines and health practices, including the right to the protection of vital medicinal plants, animals and minerals.
 They also have the right to access, without any discrimination, to
 all medical institutions, health services and medical care.


Although the Human Rights Council approved the draft Declaration on June 29, 2006, by a vote of 30 to 2, and this document is supported by hundreds of indigenous organizations around the world, the UNGASS must approve the Declaration. Nevertheless, the Indigenous Peoples Caucus reported that on November 30, 2006, Namibia proposed to shelve the Declaration, acting on behalf of the African governments. African States remain undecided on whether to acknowledge the indigenous peoples living in their own countries.

[ILLUSTRATION OMITTED]

The Caucus stated: "Without shame or regret the African States, well supported by the Arab States, decided that 23 years of hard work in UN expert bodies and promises by the UN General Assembly to deal with the human rights of Indigenous Peoples was irrelevant. They wanted to decide for themselves what human rights the Indigenous Peoples can have. These States used their numbers as a political block, coached by Australia, New Zealand and Canada, as they trashed the concept of universality of human rights and brought the UN into disrepute with the peoples of the world."

* For more information on the Declaration on the Rights of Indigenous Peoples, visit the website of the Indigenous Peoples Caucus at www.ipcaucus.net.

* To see the draft version of the Declaration, visit the UNHCHR website at http://www.unhchr.ch/huridocda/huridoca.nsf/(Symbol)/ E.CN.4.SUB.2.RES.1994.45.En?OpenDocument.

[ILLUSTRATION OMITTED]

Notes

(1.) Makewe-Pelale Hospital and the Boroa Filulawen Intercultural Health Center in the Ninth Region and the Huilliche Complementary Health Model in Chiloe.

(2.) According to the 1992 Census, the indigenous population of Chile numbered 998,385. A decade later, the 2002 Census registered 692,192 people as members of indigenous groups, only 4.6% of the total population. This decrease is questioned by some organizations that suggest that the difference is due to a change in the format of some questions that makes comparisons with the 1992 figure difficult. Whereas in 1992 people were asked to identify their own ethnicity, in the later census only eight indigenous peoples explicitly recognized in the Indigenous Law were listed could be chosen by respondents. Some indigenous organizations viewed this change as an "intentional invisiblization" of indigenous peoples in Chile.

The indigenous population is found primarily in urban areas (64.8%) with less than a third living in rural areas. By contrast, 86.6% of the non-indigenous population lives in urban areas. Of the total indigenous population of Chile, 29.5% lives in the Ninth Region, followed by the Metropolitan Region (27.7%), the Tenth Region (14.7%), the Eighth Region (7.8%) and the First Region (7.1%). Mapuches comprise 52% of all indigenous peoples in the Eighth, Ninth and Tenth Regions.

(3.) Report of the International Conference on Population and Development (Cairo, September 5-13, 1994), available online at http://www.un.org/popin/icpd/conference/offeng/poa.html, accessed September 2004.

(4.) Paragraph 7.2 of the ICPD Programme of Action also states in regard to reproductive freedom: "Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems" (Para. 7.2 of the Programme of Action from the International Conference on Population and Development (Cairo, September 5-13, 1994), available online at http://www.un.org/popin/icpd/conference/offeng/poa.html, accessed September 2004.

(5.) The Enlace Continental de Mujeres Indigenas (Continental Coalition of Indigenous Women), which is part of the Foro Internacional de Mujeres Indigenas (International Forum of Indigenous Women), has held a number of regional meetings to draft recommendations to governments, ECLAC and other UN agencies to recognize and draw attention to the demands of indigenous peoples and especially women by guaranteeing mechanisms of participation for indigenous women in the design, implementation and evaluation of state policies and programs. "Enlace Continental de Mujeres Indigenas en CEPAL, Reunion de la Comision Economica para America Latina, CEPAL, San Juan, 28 de junio 2004" available online at www.radiofeminista.net, accessed May 2005.

(6.) The main objectives were the recovery of lands, the recognition of indigenous peoples' rights in constitution, the ratification of ILO Convention No. 169 and the creation of a new public agency for indigenous affairs. In Gobierno de Chile, Nuevo trato con los pueblos indigenas. Derechos indigenas, desarrollo con Identidad y diversidad cultural (Santiago, Chile: 2004).

(7.) Created in 1990 to advise the President on policies affecting the indigenous populations, analyze the realities, concerns and needs of the indigenous populations and propose plans and projects for achieving the economic, social and cultural development of indigenous peoples. In Gobierno de Chile, Nuevo trato con los pueblos indigenas. Derechos indigenas, desarrollo con Identidad y diversidad cultural (Santiago, Chile: 2004).

(8.) CONADI has responsibility for executing government activities in favor of indigenous peoples in the economic, social and cultural realms. The CONADI website is http://www.conadi.cl.

(9.) Ana Maria Oyarce, Marisabel Romaggi and Aldo Vidal, Como viven los mapuches: Analisis del censo de poblacion de Chile de 1982 (Santiago: PAESMI, 1989); UFRO, CELADE, PAESMI, Tabulaciones basicas. Censo de reducciones indigenas seleccionadas (Santiago: INE, 1989); Victor Llancaqueo Toledo, Situacion de los pueblos indigenas de Chile. Perfil epidemiologico (Santiago: PAHO/ MINSAL, 1997).

(10.) For example, the "Taller nacional de salud y pueblos indigenas, Salud, cultura y territorio: Bases para una epidemiologia intercultural," organized by Likanray-Brotes de luna nueva, in the Region of Araucania, Chile, 1998; the "I Encuentro de Agentes de Salud Intercultural de Alto Bio-Bio," 2002, held in the community of Ralco Lepoy, was the first dialogue between traditional Mapuche healers and health-care professionals from the Bio-Bio area.

(11.) See, for example, the 2004 report published by the obstetrics department of the Iquique regional hospital, Proyecto de salud intercultural. Desde una maternidad.

(12.) Article 16 states that until the child is six months old, all pregnant women and their children have the right to care and protection by the corresponding agencies, in this case health-care services.

(13.) For example, there are reports of police searches for pregnant women to force them to give birth in the hospital and threats against women who choose to have home births. See: Maria Soledad Perez, Significados de la salud-enfermedad en el pueblo de Talabre. Un acercamiento desde la perspectiva de Genero, Thesis for a Masters degree in gender and culture in Latin America, Department of Philosophy and Humanities, Universidad de Chile, Santiago, 2005.

(14.) The libraries and documentation centers were classified as: a) universities; b) NGO documentation centers; c) governmental agencies; d) international organizations; e) public and private libraries; and f) research centers.

(15.) Each individual was informed that the information taken down in the interview would be anonymous and used exclusively for this systematization.

(16.) Maria Eugenia Santa Coloma, "Transicion demografica y social: El caso rapa nui" and Luca Citarella, ed., Medicinas y culturas en la Araucania (Santiago, Chile: Editorial Sudamericana, 2000).

(17.) Three of the government-supported studies were financed by institutions such as FONDECYT, five by the Ministry of Health, one by the Ministry of Cooperation and Planning and two by the National Women's Service. International agencies that financed projects are: UNFPA, UNDP, the WHO Special Programme of Research Development and Research Training in Human Reproduction, Italian Cooperation, GTZ and the Ford Foundation. Five of the seven studies that do not list information are related to health-care institutions, one to a primary care center, and four to other health-care services. We assume that they were supported at least in part by the Ministry of Health.

(18.) Seminario mujer, cultura y salud en los andes, Arica, 2002.

(19.) Three of the seven studies were done in the First Region, two are part of studies being undertaken by nongovernmental organizations and one was undertaken by the Universidad de Tarapaca in collaboration with the Taller de Estudios Andinos (TEA, Andean Studies Workshop). One study in the Second Region is being carried out by SERNAM. Among all the national studies only one incorporates a gender perspective: the research being undertaken for CONASIDA-MINSAL by the Gender Studies Center of the Department of Social Sciences at the Universidad de Chile.
Indigenous Peoples in Chile

Distribution of the Population, 2002 Census

Indigenous People # of Inhabitants Percentage of the
 Indigenous Population

Mapuche 604,349 87.31

Aymara 48,501 7.01

Atacameno 21,015 3.04

Quechua 6,175 0.89

Rapa Nui 4,647 0.67

Colla 3,198 0.46

Alacalufe-Kaweskar 2,622 0.38

Yamana-Yagan 1,685 0.24

Total 692,192 100

Source: UNESCO, CONADI, CASEN.

Table 1
Theses by Discipline and Region

Region I II V MR VIII IX X TOTAL

Academic Discipline

Anthropology - 1 1 - - - - 2

Psychology 1 - - - - - - 1

Social Work - - - - - 1 - 1

Obstetrics 6 - - - 1 - - 7

Medical Technology 4 - - - - - - 4

Sociology - - - - - 1 - 1

Doctorate - - 1 - - - - 1

Total 11 1 2 - 1 2 - 17

Table 2
Research Topics by Region

Region I II V MR IX X TOTAL

Research Topic

Interculturalism 1 1 - - 1 - 3

Medical Systems - - - - 1 - 2

Epidemiology 1 - - 1 2 - 4

Pregnancy and Childbirth 7 - - 1 3 1 12

Amenorrhea - - - - 1 - 1

Breastfeeding - - - - 1 - 1

Fertility Regulation 4 1 - - 1 - 6

Abortion 1 1 - - - - 3

Parenting - 1 - - - - 1

HIV/AIDS - - 1 - 1 - 2

Menopause - - - 1 - - 1

Sexually Transmitted
Infections 3 - - - - - 3

Domestic and
Intrafamily Violence 1 - - - 1 1 3

Sexual and
Reproductive Rights 1 - - - - 1 2

Quality of Care 3 - - 2 1 2 8

Sexuality 2 1 1 - 1 1 6

Adolescent Sexuality - - 1 - 1 - 2

Fertility - - - - 3 1 4

The Body 2 - - - 1 - 3

Gynecological Exams 1 - - 2 - - 3

Table 3
National Studies, by Topic

Research Topic Number

Maternal Mortality 1

Fertility 1

Pregnancy and Childbirth 2

Fertility Regulation 1

Sexually Transmitted Infections 1

HIV/AIDS 1

Quality of Care 3

Sexuality 1

Violence 1

The Body 1

Public Policies 1

Table 4
Experiences by Region

Region Number of Initiatives

First Region 6

Second Region -

Fifth Region 5

Metropolitan Region 7

Eighth Region 2

Nineth Region 12

Tenth Region 4

Total 36

Table 5
Initiative Topic by Region

Region I II V MR VIII IX X TOTAL

Topics Addressed

Sexuality 1 - 2 6 - 3 - 12

Fertility Regulation 1 - - 1 - 5 - 7

Pregnancy
and Childbirth 4 - 1 3 2 2 3 15

Sexual and
Reproductive Rights 2 - 1 - - - 1 4

Postpartum 1 - - - - 3 1 5

Medical Systems 1 - - 1 1 1 1 5

Quality of Care 1 - - - 2 1 - 4

The Body 1 - - - - - - 1

HIV/AIDS Prevention - - 4 2 - 5 - 11

Sexually Transmitted
Infections - - 2 - - 1 - 3

Violence - - - 2 1 2 1 6

Gynecological Care - - - 1 - - - 1

Breast Cancer - - - 1 - - - 1

Contraceptive
Methods - - - 1 - 6 - 7

Menopause - - - - - 1 - 1

Abortion - - - - - 1 - 1

Total 13 - 10 18 6 31 7 84

Table 6
Type of Experiences by Region

Region I II V MR VIII IX X TOTAL

Format

Discussion Group - - - 1 - 2 - 3

Workshop 1 - - 2 - 4 1 8

Working Group - - 3 - - - - 3

Meeting, Seminar,
Colloquium, Congress 1 - - 1 2 4 - 8

Campaign, Publication
of Materials,
Radio Programs - - 2 1 - 1 - 4

Training - - - 1 - 1 - 2

Program or initiative
in the health-care
services 2 - - 1 - - 1 4

Shelter, Safehouse 2 - - - - - 2 4

Total 6 - 5 7 2 12 4 36
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Title Annotation:PANORAMA
Author:Perez Moscoso, Maria Soledad; Castillo, Claudia Dides
Publication:Women's Health Journal
Article Type:Survey
Geographic Code:3CHIL
Date:Oct 1, 2006
Words:7859
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