The integration approach

In the 1970s, the WHO promoted the participation of traditional healers in national PHC efforts. The rationale was that traditional healers could play a role in proving basic primary health care services, such as vaccination, because they were respected by communities and there was a limited number of health care professionals. The idea of bringing traditional healers seemed to be a good strategy to help fill a void and increase the number of trained health providers who were reaching out to the population. Traditional healers could promote key protective health behaviors such as hand-washing and provide basic preventive and curative care (WHO 1978; WHO 1978; WHO 1995). The integration approach involved two core strategies:

identify traditional healers and promote their participation in health service provision in governmental health facilities.

The earliest efforts to integrate indigenous healers into Western-based healthcare services in Latin America occurred in the 1980s. During that decade, training programs for indigenous healers were widely implemented. In Brazil and Mexico for example, indigenous healers received training in oral rehydration therapy (WHO 1995). In Bolivia, traditional healers were appointed as staff at state health posts (Bastien 1982) and a similar project was implemented in the Colombian Vaupés (Jackson 1995). Maternal health was a key area for training midwives to follow biomedical protocols for birth in Mexico (Sesia 1996) and Guatemala (Maupin 2008).

The WHO stressed that effective integration of both systems entailed giving credit to the merits of both the traditional and the modern systems of medicine, ensuring “mutual respect, recognition and collaboration among the practitioners of the various systems concerned” (WHO 1978:16). In practice, however, most of the efforts to integrate both medical systems did little

expected to quietly support the strategies planned by national health boards and international organizations (Ramírez Hita 2010).

For example, in Guatemala, the impact of training programs for midwives were studied by Maupin (2008) in the town of San Martín, Jilotepeque. Such programs aimed at reducing infant and maternal mortality. The author found that these programs did little to recognize the important knowledge that midwives have regarding maternal health and the role that midwives hold in their communities. This training program redefined the role of midwives as low-paid attendants of the health system. Midwives’ knowledge, practices, and authority in the community were not fully taken into account. They were participating under the banner of an international agenda where they had to comply with the biomedical model of obstetric care (Maupin 2008).

The integration approach had other shortcomings besides the submission of indigenous healers as simple aides of broader agendas. The top-down nature of the integration approach left little or no room for the incorporation of an indigenous medical approach. In the context of integrating traditional healers into the national health system, healers were told how to treat specific health problems using a biomedical rationale. Efforts to incorporate local remedies into the treatment or prevention of health problems were absent. For instance, a report about how traditional healers were trained to help reduce levels of childhood mortality from diarrhea in Brazil shows that healers were taught to identify when a child is dehydrated and how to prepare and administer a simple homemade oral rehydration solution (Hoff 1995). There is no evidence of asking traditional healers how they used to treat dehydration according to their medical traditions.

Projects based on the integration approach led to situations in which the knowledge of indigenous people was ignored and the perspective of indigenous people was not taken into

account (Knipper 2006). Early efforts at the integration approach aimed at fulfilling health outcomes from a Western perspective using traditional healers.

Another shortcoming had to do with the way traditional healers were to become “agents”

of national health systems. One common strategy was to give traditional healers a physical space within governmental health facilities (Bastien 1992; Castañeda, García Barrios et al. 1996). The rationale was that indigenous people trust traditional healers more than health workers and including traditional healers would make people come more readily to the health facility.

Traditional healers would subsequently “recruit” their patients to receive other primary health care services such as vaccinations or prenatal care.

Ramirez Hita (2009) conducted a study in the early 2000s on the Intercultural Hospital in Tiquipaya, Bolivia. Health officials hired traditional healers and traditional birth attendants under the assumption that this would increase the number of indigenous people who sought care.

Health authorities thought indigenous people did not come to governmental health facilities because they preferred to be seen by indigenous healers. Ramirez Hita’s (2009) study shows that health authorities’ assumptions were wrong. When indigenous people needed an indigenous healer, they would go to the healer’s homes since they were already familiar with them and knew where they lived (Ramírez Hita 2009). Going to the health facility to receive the services of indigenous healers was a foreign idea to the community members. Ramirez Hita (2009) found that when indigenous patients go to a health facility they want to receive biomedical treatment and Western remedies for ailments like fever or toothaches. The “integration” of traditional healers into existing governmental health facilities was not an improvement in the quality of services indigenous people received. It also did not respond well to the way the indigenous population makes their healthcare decisions (Ramírez Hita 2009).

In Mexico, Jimenez et al. (2008) found another reason the integration approach was not successful. She argues that the integration approach was unsuccessful because of its failure to critically analyze the social contexts in which indigenous healers were to become part of the health system. A crucial element of the social context was the perception the health professionals had of indigenous healers. Such perceptions involved issues of race and class where health professionals considered themselves better prepared to address health problems than indigenous healers. Jimenez et al. (2008) found despite the efforts of an NGO in training midwives (parteras) in basic biomedical principles, doctors working at public hospitals in Morelos, Mexico chose to ignore the training of the parteras. Parteras learned they had to pretend they had not referred a patient to a doctor, so the doctors would not feel threatened by the encroachment of traditional healers into their realm of expertise (Jiménez, Pelcastre et al. 2008).

The Bolivian and Mexican examples show that health efforts oriented at integrating medical systems failed because those who designed such projects ignored the social context and the existing perceptions of indigenous healers and indigenous medicine by health professionals (among other reasons). Contemporary intercultural health efforts differ from past integration approaches in that they stress the importance of health professionals learning about indigenous medicine and cultural traditions.