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Decolonization and Its Paradoxes: The (Re)envisioning of Health Policy in Bolivia

Author(s): Brian B. Johnson


Source: Latin American Perspectives, Vol. 37, No. 3, BOLIVIA UNDER MORALES. Part 1.
CONSOLIDATING POWER, INITIATING DECOLONIZATION (May 2010), pp. 139-159
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Decolonization
The

and Its Paradoxes

(Re)envisioning ofHealth Policy inBolivia


by
Brian B. Johnson

In one of themost traditionallyhierarchical and "colonial" of theBolivian state appa


ratuses, the officialhealth sector, attempts since 2006 by Evo Morales and theMAS
government at radical restructuringhave proved innovative but inconclusive and divi
sive. Reflecting a series of conflictsand contradictions, a number of oftenfundamentally
competing scenarios are at work: the institutionalization of traditionalmedicine, the
reinterpretationof previous primary health care and community participation models,
social and "socialized" medicine, and thedurability of a deeply ingrained vertical health
system. The challenges and risks inherent inwhat at heartmay be a struggle between
cultural and politicalfactions and ideologiesamong thegovernment's public health author
ities and planners are emblematic of many paradoxes in the effortto decolonize the
Bolivian state as a whole.
Keywords:

Decolonization, Interculturality,Health, State, Bolivia

Since Evo Morales


and theMovimiento
al Socialismo
(Movement Toward
came
to power in Bolivia on January 22, 2006, an unprece
Socialism?MAS)
new
dented
series of structural innovations has been implemented
by the

These include significant reformatting of the state bureaucratic


the
of numerous
land
industries, projected
apparatus,
quasi-nationalization
reforms and possible
future expropriations
of large landholdings,
most
and,
significant, the approval by national referendum of a new constitution. In the
framework of cultural reforms through which
the majority
overriding
indig
enous and mestizo
have
attained
populations
political power after centuries

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

have revolved around


the
ernment), national policy and political discourse
dual concepts of "decolonization"
and "interculturality." Virtually
overnight,
these conceptual pillars have moved
the rarefied worldview
of small
beyond
and international academics,
groups of national
and progressive
agencies to become
development
cial state policy. The
national
brand
peculiarly

intellectual social activists,


the guiding doctrine of offi
of interculturality and the

Brian

B. Johnson has extensive


in the fields of
and
experience
living and working,
anthropology
the political
in Bolivia where
of health,
he is currently the national
director of a rural
economy
health
He
did his doctoral
at Columbia
work
in medical
program.
community
University
and sociomedical
sciences. He
thanks Benjamin
and the LAP reviewers
Kohl
for
anthropology
their comments

and

support.

LATIN AMERICAN
PERSPECTIVES,
DOI: 10.1177/0094582X10366535
? 2010 Latin American Perspectives

Issue 172,Vol. 37 No. 3,May

2010 139-159

139

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140

LATINAMERICAN PERSPECTIVES
to decolonize

accompanying
recognition of the need
rent themes in almost all government
become
institutionalized.

discourse:

the Bolivian
the concepts

state are recur


have,

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

lichealth directorshipand thepersonnel entrustedwith implementingpolicy

on the ground,

conflicts result from a juxtaposition

of factors: newly

formu

lated statepolicy objectives, theabstractguidelines of postcolonial and (inter)


theory, and

the bluntness of Bolivian


reality. Thus, the rapidly evolv
area on the
and
the
health
of
services?a
health
ing (re)envisioning
policy
frontline of the debate over the course of decolonization
in Bolivia
today?
in the construction of an
offers insights into the overall national
experiment
state.
indigenous
cultural

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

in the relationship between


intrinsic his
system"?has

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;

1967),Memmi (1967),Gonzalez Casanova (1976), and BonfilBatalla (1990), as

well

as more

recent subaltern

studies

scholars

such

as Guha

(1982;

1983),

Spivak (1985),and Chatterjee (1993)?in turninfluencedbyGramsci, Foucault,


of diverse Latin American
the ^interpretations
intellectuals,
based
domination
is a form of socioeconomic-cultural
exercised by local and
and racism, and historically
in capitalist hegemony
over subaltern groups. In internal colonialism, with
regional governing elites
of the inherent superiority of one group to another,
its ideological
assumption

and Said?and
internal

colonialism

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Johnson/DECOLONIZATION AND ITS PARADOXES

141

to national power bases and


the emphasis
shifts from outside colonial powers
over
their control apparatuses
domestic
These domi
relegated
populations.
nant institutions
ties
to
external
have
economic
but power
models,
frequently
through local structures and dynamics.
a militant
these theoretical currents helped
shape
indigenous
a
state
colonial
dominated by a European
against
quasi-apartheid
are
and cno//o-descended minority. Fausto Reinaga, whose
indigenista texts
highly
ismanifested

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

the katarista movement,

pri

marily on theAymara altiplano during thedictatorshipsof the 1970s,drew on


an end to the "colonial state," and this has influ
Reinaga's work in calling for
to this day, including theMAS
enced indigenous political movements
(Rivera

Cusicanqui, 1984; 2006). As furtherdeveloped by the latest generation of


Bolivian

theorists (e.g., Ticona,


decolonization
2005; Patzi, 2006; Mamani
takes on a more
Ramirez, 2007; Quisbert Quispe,
2007), internal colonialism
immediate aspect, containing a mixture of defensiveness
and aggressiveness,
in the wake of theMAS
electoral triumph. On the one hand, the
particularly
successes
of
the
movements
social
and the "indigenous
significant
govern
ment" are seen as under attack from reactionary
the right
interests?including
elites of the so-called Media
Luna
eastern
lowland
(Half Moon)
wing
(states), with their calls for a highly racialized and economic self
departments
interested political autonomy. On the other hand, Evo Morales
and theMAS
are criticized for not
far
in
the
entrenched
having proceeded
enough
attacking
colonial state and are accused by some of having been co-opted by it.1
It is in this theoretical context that theMAS
situates its active
government
a
in
initiatives.
that
has
been
Decolonization,
policy
country
formally inde
an
for nearly 185 years, thus becomes
in national
soul
pendent
experiment
searching and (re-)creation in a variety of aspects of daily life?from education
to law, entertainment, and health.

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

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142

LATINAMERICAN PERSPECTIVES
as the shared

here perceived

multiculturalism,

occupation

of a common

space

by people of differentcultures,and frequentlylimited to interrelationshipson

narrow

terms and

toward

integration?hence,

nialist model

conditions

and

very

oriented

more

toward assimilation
than
a further
a
of
colo
likely only
propagation

(Fernandez Juarez, 1999; TARI, 2003; Albo, 2004). In Bolivia

is simply a given; interculturality, in contrast, is an active


today, multiculturalism
of
transformation.
process
an
There are, however, dissenting views. Some hold that in Bolivia
today
in
and
constant
abstract interculturality becomes
coexistence
the
tangible only
and the
conflict of a very unequal
balance of power between
the indigenous
et al. (2009: 7-8) argue that true
and
Estermann
Viana,
Claros,
nonindigenous.

isvirtually impossible ifinequalityand colonialitypersist, and


interculturality

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

respect and tolerance, and open up channels of


and
power sharing between differing visions. Consequently,
genuine exchange
of
is synonymous with the discourse
of "true" interculturality
the discourse
an
is primarily
essentialist
"true" decolonization,
whereas
"multiculturalism"
the
and
decolonization
for concealing
discourse
pro
neutralizing
inequalities
cess (Rivera Cusicanqui,
2006: 10). At this point, the intercultural argument
beyond

talk about

becomes

increasingly controversial
interests of certain power sectors.

THE NATIONAL DEVELOPMENT

in that itpotentially

threatens the entrenched

PLAN

in Bolivia, President Evo Morales


after taking power
Six months
new MAS
their
official social development
issued
government

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

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Johnson/DECOLONIZATION AND ITS PARADOXES


in the energy

based

and

the capacity

derived

from our

cultural

143

identity"

(MREC, 2007).

known as "Para Vivir Bien" (To Live


At the core of the plan is the paradigm
referred to, as the cultural context
also frequently and colloquially
Well),
or Guarani
inAymara
Quechua
demands,
(Suma Qamana),
(Sumaj Kawsay),
a
as
most
for
standard
theoretical
govern
(Nande Reko). Adopted
guiding
use of an
the MAS's
mental policy and programs, To Live Well exemplifies
a form of
itself perhaps
to promote state ideology?in
indigenous discourse
is
that
of
the
notion
living comfortably and
interculturality. Simply expressed,
excess.
As described
one's means, without
with dignity within
by Javier

Medina, one of themost prolific intellectualproponents of the concept (2006;


2008:

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.

Similarly,in theofficialstrategicplan of theMinisterio de Salud and Deportes


(MinistryofHealth and Sports?MSD), To Live Well is "a demand for the

so that it is transformed into one of collective


of development,
a
a society that is an active
action
from
and
subject and not
making
a
on
and
is
based
"cosmocentric
vision
receiver
of
vertical
initiatives,"
passive
contents" and postu
that transcends
the typical ethnocentric development
humanization
decision

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

InMarch 2009,Bolivia took a step toward formalizing(or institutionalizing)

the complementary

discourses

of interculturality

and decolonization

by creat

and theViceMinistry ofDecolonization,


ing theViceMinistry of Interculturality

theMinistry of Culture. For interculturality, the stated functions of


theVice Ministry are, among other activities, to "foment an intercultural
dialogue
between the various nations and indigenous peoples"
and "promote intercultur
as an instrument of
the
(VMI, 2009). For decolonization,
ality
development"
functions of the office are to "coordinate
the implementation
of decolonization
both under

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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"

offices are poorly


implementation;

for long-range
funded and staffed and lack firm proposals
as such,
remain
relative
theoretical
they
showpieces.

THE (POSTCOLONIAL) TRANSFORMATION


OF THE BOLIVIAN HEALTH CARE SYSTEM
HEALTH DEVELOPMENT
In late 2005, prior

power, theMAS
Bolivia.

of 2006,

The

STRATEGY
to the national

results would

inwhich

elections

thatwould

bring Evo Morales

to

undertook a diagnostic study of the health situation in

the health

ity (MSD, 2006: 37):

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

tion (MPD, 2006: 37-38).

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

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/DECOLONIZATION AND ITS PARADOXES


Johnson

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,

2006: 40-42). These programmatic lines are echoed in theMSD's

(2009b)

Institutional Strategic Plan and complemented


by strategies for disaster relief
are a restora
of both documents
and climate change. The desired outcomes

tion of state responsibilityformaintaining integralhealth and thequality of

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.

As thekey player, theMSD has been reconfiguredinto threeviceministries.


The Vice Ministry ofHealth isprimarilyoccupied with the core public health

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

The Vice Ministry of Sports, located inofficesdistant fromtheMSD buildings,


sense
is largely ignored in a programmatic
administration
by the central MSD
to be slated for reorganization
and appears
into another ministry. All three
vice ministries operate under the same
guiding norms and principles.
COMMUNITY
The

INTERCULTURAL

cornerstone

Comunitaria
model.

FAMILY HEALTH

of the restructured

health

system is the Salud Familiar


Intercultural
(Community
Family Health?SAFCI)
and implementation
since 2006 but not yet an
development

Intercultural

Under

actual law,SAFCI was formallyadopted by Supreme Decree 29601, signed by


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LATINAMERICAN PERSPECTIVES

146

PresidentMorales in 2008. This establishes itas the "officialhealth policy of


theMSD, with the objective of improving the health of the individual, the
family,and thecommunity."In theory,SAFCI should eventuallybe applied at
all levels of thenational health system?from thenational (ministerial) to the
departmental (SEDES), the regional (district),and themunicipal and commu
nity. It is based on fourguiding principles, approximately drawn from the
Plan:
Development
(between education,
housing,

social

National

participation,

intersectoral

justice, etc.),

agriculture,

cooperation
and

interculturality,

the idea thathealth is integral to all other aspects of familyand community


life.The ultimate objective is a Bolivia "mobilized for the right tohealth and
life?To LiveWell" (MSD, 2009c).
The historical precedents for SAFCI may be found principally in the
of Alma-Ata

Declaration

on

primary

health

by theWorld

care, promulgated

Health Organization (WHO) and theUnitedNations Children's Fund (UNICEF)


in 1978. With

the declaration
ning

and

a strong focus on the social determinants


of disease
holds that communities have a right to participate

implementation

of their health

care,

that all social

and

illness,
in the plan
sectors should

participate equally in thepromotion of health, and that traditionalmedicine


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)

have periodically attempted to implementprimaryhealth care systems,with

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

reticaland applied forms,and thedefining element of politicalwill. The first

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

union systemof elected dirigentes,in theorytheyhave a significantdegree of


power and control over the local government
In practice,
evaluations.
budget and performance

decision-making
including

health services,
as of late 2009

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Johnson/DECOLONIZATION AND ITS PARADOXES

147

and municipalities
had yet to form local
the great majority of communities
a
had
relative scattering of municipalities
authorities or committees, and only

progressed to thenext level, thatof theMunicipal Social Health Council; the


two levels?Departmental
Social Health Councils
and theNational
succeeding
unrealized.
relative
Social Health Council?remained
(The
exceptions
largely
are in Potosi and Tarija, where
the departmental
councils have recently been

put on paper but are still largely nonfunctional.)


The second SAFCI
attention, involves the actual health ser
focus, medical
are
vices, and both interculturality and decolonization
key in this regard: the
reforms are directly related to the perceived necessity of a change in outlook and
behavior on the part ofmedical personnel and the quality of attention provided.
and disrespect
for clients and misunderstanding
and rejection by
and
the
cultural
the population
medicine
of
beliefs
of traditional
physicians
as
a
to
have long been identified
fluid physician
the most frequent obstacles
and
Arnold
1991;
Crandon-Malamud,
(see,
e.g.,
patient dialogue
Yapita et al.,

Rudeness

2002;Dibbits and de Boer,2002). SAFCI calls forrecognitionof thestrengthsand

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

requiresa significantideological shifton thepart of thosewith deeply ingrained


beliefs and prejudices on both sides of themedical divide; to thisend, theMSD

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

La Paz, November 5,2009).


efforts(JuanCarlos Delgadillo [MSD], interview,

Two central SAFCI programs have been established


to "reorient" physi
cians and change attitudes within
the medical
establishment.
The first is the
teams (Equipos Moviles
formation of mobile
made
SAFCI)
up of a physician,
a nurse
a dentist, a
a driver, each
or
social
and
worker,
auxiliary,
sociologist
team based permanently
in a municipality
and rotating among its rural health
these teams are improved versions
(with a community
posts. In many ways,
an
of
MSD
earlier
the Extensa
added)
empowerment
component
experiment,

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

as one of the limitations

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

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post

148

LATIN AMERICAN PERSPECTIVES

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

SOCIAL AND "SOCIALIZED"

MEDICINE

A centralcurrentrunning throughouttheMSD and one towhich theSAFCI

model

minister

is related

is that of "socialized"

of health

single-payer

health

under

the MAS,

medicine.

Nila

service guaranteeing

An

Heredia,
attention

explicit goal of the first


was
to create a state-run
free of charge

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

allwomen beginningwith theirpregnancy and covers bothmother and child


the latter is 5 years old, and universal
coverage
Sanchez
(both of these programs dating to the Gonzalo
theMAS
tions, 1993-1997 and 2002-2003),
government

until

for those over

age 65
administra
de Lozada
has initiated an insur

ance program that proposes


to cover all citizens up to age 25 for essentials and
a wide
care.
Gas revenues will supposedly
of
elective
range
support eventual
entire
but
the
of
universal
coverage
they have not yet
population,
complete
so.
to
do
sufficient
proved
of a more comprehensive
An additional
system, aimed at
key component
insti
is the planned merging of the various and competing
salaried workers,
a
as
to
which
known
insurance
tutional health
programs,
cajas,
beneficiary
a percentage
from the
is deducted
and
for
which
belongs through employment
include everyone who
that would
into a single super-aya
monthly paycheck,
labor force). The not
of
the
30
is formally employed
percent
(approximately
so-veiled intention, however, seems to be to phase out the caja system entirely
once the hypothetical
universal health care system is in place. At any rate, all
from the unions
to
have
been
date
stalled by considerable
opposition
attempts
a loss of revenue
fear
who
and
affiliated
both
insurers
physicians,
representing
and institutional autonomy, ifnot a significant degree of control.
bonuses
offer monetary
Other related programs
(bonos) to select popula
tions. In 2009 the government

established

the Bono

Juana Azurduy

de Padilla,

which pays women directly forprenatal checkups during pregnancy,delivery


a woman
checkups until age 2. If
facility, and infantmedical
to
can
receive
she
the
entire
US$261.
schedule,
up
approximately
completes
cost of this bonus for the first few years comes from gas
The US$25 million
revenues and a credit from theWorld Bank; however, because of the declining
in a state medical

income

from gas sales and higher

than expected

enrollment

among

pregnant

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/DECOLONIZATION AND ITS PARADOXES


Johnson
women,

there have

been doubts

about

the ultimate

solvency

149

of the program.

may be some justificationforthebonus in termsof thepromo


Although there
tion of maternal

and child health

and

the program

has achieved

international

recognition,6ithas predictablybeen sharply criticizedas blatant populism by


the political opposition, especially during the electoral year of 2009. (Also

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

ior (AliciaAliaga [MSD], interview,La Paz, October 15, 2009).

of the health care system's goals of universal


Integral to the implementation
free coverage is the participation?in
"socialist solidarity"?of
volunteer Cuban
an
medical
900
estimated
and 800 para
mid-2009,
personnel.
By
physicians

medics were working in 243 of the country's327municipalities (MSD, 2008).


for two-year rotations in remote regions or crowded barrios,
Usually
placed
with their nominal
salaries paid by the Venezuelan
government,
they have
earned predictable
ire from their local counterparts. Ostensibly
in com
based

plaints fromtheBolivian College ofPhysicians about allegedly uncertifiedand


Cuban

and periodic
interested
personnel
flare-ups of politically
and Venezuelan
in Bolivian internal affairs"
"involvement

unqualified
accusations

of Cuban

and even

"espionage,"

this opposition has much more to do with simple pro


fessional competition:
the Cubans provide medical
attention free of charge, and
remains
Bolivian
In general, however,
among
unemployment
high
physicians.7
the volunteer doctors have earned themselves an overall positive
reputation
based in large part on the success of Operation
among the general population,
the provision of free operations
for cataract blind
Milagro
(Operation Miracle),
which
2009
had
restored
functional
vision to approx
ness,
by early
reportedly

imately 319,000 persons (MSD, 2009a). In addition, theCuban cooperation

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

innovation has been the Vice Ministry of


Institutionally, themost prominent
Traditional Medicine
and Interculturality, whose
theoretical and practical
in the new constitution: "It is the
objectives are enshrined
responsibility of the
state to promote and guarantee
the respect, use, investigation, and
practice of

traditionalmedicine" (Article42). The Vice Ministry is chargedwith thepro

motion

of traditional medicine, which


is seen as emblematic of a historical and
medical
and
its
active
into a sanitary structure
sovereign
system,
incorporation
with
the
establishment
of academic programs for
biomedicine;
complementary
its study and promotion;
its regulation, certification, and accreditation, based
on
use and proven
of beneficial
and its
appropriate
knowledge
practices;

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150

LATINAMERICAN PERSPECTIVES

protection as a cultural resource and heritage codified in law (MSD, 2006:6-7).


Internal coordination problems,
inadequate
funding, and frequent turnover of
made
and concrete
have, however,
(limited) personnel
tangible programs
the Vice Ministry's
results few and weakened
advocacy power.
on the
in theMSD
the emphasis
and
However,
importance of recognizing
an
on
terms
is
of
the
medicine
traditional
equal
integral aspect
incorporating

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).

to date regarding this articulation


notable practical experiences
in
in regional
rather than nationwide:
(SEDES-based)
programs
a
based
for
Oruro,
program
symbolically
planning
example,
participatory
chakana symbol; and in Potosi both a postgraduate
upon the ancient Andean
in intercultural health and a certification program for traditional heal
degree
The most

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

comply with specific requirements?proven


authorization
by the community, written

recognition
etc. (El National,

CHALLENGES,
INSTITUTIONAL

September

years of
by local

4, 2009).

CONTRADICTIONS,

AND PARADOXES

OPPOSITION

Official efforts to achieve the proposed decolonization of the Bolivian

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

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Johnson/DECOLONIZATION AND ITS PARADOXES

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

related officialhealth policies on thegrounds that they threatenthe integrity

of the biomedical

profession.

POLITICAL OPPOSITION,

AND

INTERNATIONAL

comes from the


opposition
political rivals of the
in
Luna
the
Media
Santa
of
Cruz, Tarija, and
particularly
departments
In these areas the departmental
both
governors,
subtly and overtly, dis

More
MAS,
Beni.

DOMESTIC

overt and clear-cut

courage any cooperationwith SAFCI policy not on public health grounds but

because

it is perceived

as "MAS

politics."

In the extreme

case of Santa Cruz,

in theSEDES there is open rejectionof SAFCI and an unofficialorder not to

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

checks directly fromtheMSD

inLa Paz ratherthan fromtheSEDES and local

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,

thehighlands and have greaterpersonal troublebecoming integratedinto the

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,

theessentials are cautiously implementedprovided thatthename "SAFCI" is

and no political sensibilities are offended.


a number
of international
(most promi
Although
cooperation
agencies
and those of France, Japan, and Spain) assist and
nently theWHO
frequently

not used

fund parts of the differing


MSD
for International

and SAFCI components, theUnited States

(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

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152

LATINAMERICAN PERSPECTIVES

In early 2006, however,


government

requested

in the name
the closure

new MAS
of national
sovereignty, the
of the USAID-operated
Proyecto de Salud

Integral (IntegralHealth Project), which since 2000 had achieved virtual


power

decision-making

at the national

level. With

active political influenceon health policy,USAID's

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

all itsdirectly financedand administeredhealth projects in thehighland (pre

dominantly

MAS)

departments

and

a relocation

to the lowland

(predomi

nantly opposition) departments, stronglydiscouraged any involvementwith

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,

USAID scholarships and coordinatedwith thenational College of Physicians.

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

BUREAUCRACY AND RIVALRIES


and
in general have also suffered from bureaucracy
policies
of this are the frequent turn
internal politics. The most visible consequences
the
over of key personnel.
The firstMAS minister of health, Nila Heredia,
and reforms and for the most part highly
architect of many of its programs
was nevertheless
forced to resign for somewhat murky
respected and praised,
The new MSD

reasons, apparently tomollify thepolitical opposition by placing more cambas


from the eastern

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)

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Johnson/DECOLONIZATION AND ITS PARADOXES

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

exceptZalles were judged illegitimate(in termsof experience and practice) by

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

from these difficulties

implementation

tionof theMSD

of programs

and

inLa Paz and of thedepartmentalSEDES, while thenew health

and local levels. How


for a significant shift to the municipal
this
will
how
out?for
much
real
control
the
apparent inconsistency
play
example,
Local Health Committees will have, especially when confronted by entrenched
and possibly uncooperative
local health post bureaucracies?remains
to be
a
seen. Another question
one:
is practical
both communities and municipalities
need concerted technical assistance in implementing the SAFCI
model?electing

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

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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

not pose a danger to the intercultural


model itself.This has to do with the
nature

of the interculturality paradigm


partnered with cost-free and wide
seems to be
attention. In many
respects, the MSD
moving

spread medical

toward thegradual adoption of the socialisthealthmodel on thebasis of both

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,

discourse accepted on the termsof those (thephysicians)with themost to lose


and

themost

Another

regard to power and influence.


is offered by dissenting yet would-be

to gain with

perspective

ally voices

exem

plified by theBolivian historianCarmen Loza (2008),who go so faras toques

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.

this intention; its structure is vertical, and the traditional medicine


prac
to the physicians who
titioners will always be at the bottom, mere assistants
their privi
claim to respect other forms of curing but will never relinquish
an
ardent socialist and with
Former minister Heredia?both
leged positions.
this danger. Traditional medicine
strong intercultural
leanings?recognizes
into the state system, but they
she
be
must,
says,
incorporated
practitioners
or have their
also need to feel safe, certain that they will not be mistreated
or stolen and that they will be recog
or techniques
materials
appropriated
nized, respected, and treated as equals
(interview, La Paz, September 9,2009).
state is key to the concept of the
intercultural
the
For Bolivia
today, then,
versa.
"Intercultural health" requires the recognition,
decolonized state and vice

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

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Johnson/DECOLONIZATION AND ITS PARADOXES

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

evidence that theywill be, with inevitable tinkeringand refining,following

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

will theoreticallyhold equal political status and power with thedecentralized


will become the undisputed institutional
civil government, interculturality
norm

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

two similar events were

held

services, as the
themselves from

AND FROM WITHIN


in La Paz:

the First National

Forum for theHealth of thePeoples and Nations of Bolivia and theNational

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

The high-levelMSD officialsparticipating inboth events pledged to analyze

at least in part, into official public policy.


integrate these conclusions,
the
will
of
is crucial here?the
official will to support
Again,
question
political
and
to
active
the
and
accept
power of
change
participation
decision-making
and

the community and the barrio.


There are many
interests at stake in the push to implement an intercultural,
in Bolivia. Significant changes are occurring with
decolonized
health model
the encouragement
to be irreversible

and the participation


of the state, and the process appears
inmany
respects. Yet, questions
persist for the health field
and others. Many within
the state apparatus,
or
for personal,
ideological,
political
(power) reasons, subtly reject the intercultural focus and any talk or
actions of decolonization:
these voices alone may slow the
process,
proposed
for "there can be no discourse
no
about decolonization,
theory of decoloniza
in practice"
2006: 7). Indeed,
tion, without decolonization
(Rivera Cusicanqui,
structural innovations such as SAFCI are
to
to success
prove impossible
likely
as
envisioned
without dramatic
shifts in the still racialized
fully implement
and

"colonized"

government

social

context of Bolivia.

to demonstrate

that, despite

it remains for theMAS


Ultimately,
the challenges,
and
inconsistencies,

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156

LATIN AMERICAN PERSPECTIVES


its concept of decolonization
a viable
option for change.

paradoxes,
constitute

goes beyond

politics

to

and discourse

NOTES
1. The most

prorninent

representative

of this current

is the
monthly

Pukara.

newspaper

Often featuringarticleswith decolonization themes, theeditors typicallydenounce theMAS as a


if not

sellout

torical and
2.

a traitor to the cause

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

a framework,with the addition of the interculturalitycomponent (seeDe Vos et al., 2007).


in the new

3. Participatory
is specified
management
of the population
the organized
participation

state will guarantee


in the administration
of

"The

constitution:

and

in decision-making

the entirepublic health system" (Article40) (Republica de Bolivia, 2008).


4.

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,

at their posts, while


and
their objections,

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

organization, economic production, and art/technology (seeUNDP, 2007; UNICEF, 2007).


9. Other

(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

picions thatshewas simply too ethical forthe job,opposing theMSD's


the local Bingo Bahiti
Bingo Bahiti political
10. Zalles
fessional

himself

reasons

but

casino

chain

as

being

"Mafia-tainted"?thus,

as USAID),

and

sus

ties to tax revenues from


was

Heredia

sacked

due

to

influence.
was,

factions not for pro


"culturalist"
however,
by the stricter
questioned
and Catholic
of his nonindigenous
roots, Western
education,

because

seminarian

background.
For example, with
was
by all UN members,
11.

(i.e., community

regard

to the health

implemented
was
empowerment)

field: the Declaration


a few. Once

by only
fully understood,

of Alma-Ata,

its potentially
similar
ostensibly

although
"subversive"

alternative

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signed
nature
strategies

Johnson/DECOLONIZATION AND ITS PARADOXES


as

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

are not all


Revolution,
Bolivarian)
prcnCuban-doctors-in-Bolivia.
they
earn
over work
common
issues of professional
jealousy
availability,
the Bolivian
officials
rather, in this instance, ithas to do with the way

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).

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