Living on the Margins

Transcription

1 Living on the Margins Illness and Healthcare among Peruvian Migrants in Chile By Lorena de los Angeles Núñez Carrasco

2 Dedicado a la memoria de mi madre Copyright 2008: Lorena de los Angeles Núñez Carrasco Cover Design: Michael Brett

3 Living on the Margins Illness and Healthcare among Peruvian Migrants in Chile PROEFSCHRIFT ter verkrijging van de graad van Doctor aan de Universiteit Leiden, op gezag van Rector Magnificus prof. mr. P.F. van der Heijden, volgens besluit van het College voor Promoties te verdedigen op dinsdag 16 september 2008 klokke uur door Lorena de los Angeles Núñez Carrasco geboren te Santiago, Chile in 1964

4 Promotor: Co- promoters: Referent: Lid: Prof. dr. J.M. Richters Dr. T. Salman (Vrije Universiteit, Amsterdam) Dr. J.C. Skewes (Universidad Austral, Valdivia) Prof. dr. P. Silva Prof. dr. B.J.C. Middelkoop The research described in this thesis was carried out initially at the Research Group Culture, Health and Illness of Leiden University Medical Centre and lately at the Section Medical Anthropology of the Department of Public Health and Primary Care, Leiden University Medical Centre. Parts of the writing process were conducted at the Research School of Asian, African, and Amerindian Studies Centre (CNWS-Leiden University) and at the Department of Anthropology and Development Studies, University of Johannesburg. The research was financially supported by the Netherlands Organisation for Scientific Research (NWO/WOTRO, grant WB ).

5 CONTENTS v Summary Samenvatting xi xii Introduction 1 The Problem 1 Research Objectives 4 Research questions 6 Questions about exclusion, discrimination and health 6 Questions about illness experiences and idioms of distress 6 Questions about access to healthcare in reproductive health 7 Structure and content 7 Part I: Displacement, Discrimination and Distress 11 Chapter I: Towards an Understanding of the Relation between Migration, Discrimination and Health Introduction Migration Rural urban migration and the adaptation of migrants to the urban context Contemporary transnational migration Migration and health Explaining the relationship between migration, ethnicity and health Transnational migration and migrants health and wellbeing Discrimination and health Some theoretical and methodological challenges in measuring the effects of discrimination on health An approach to discrimination and its effects on migrants health in Chile Structural discrimination as exclusion Discrimination in the public healthcare system Some background to the problem of discrimination in Chilean society 34 Chapter II: Theoretical Approaches and Key Concepts in Medical Anthropology Introduction Developments in medical anthropology: In search of the middle ground Changes in the conceptualisation of illness in medical anthropology: Towards an interpretive approach The interpretive approach in medical anthropology 42 v

6 2.2.3 Political economy of health approach The critical approach in medical anthropology The social suffering approach The self, embodiment and agency in the context of illness and suffering The self in the context of culture Migrants embodiment of adverse social conditions Agency: recentring the body and self Making sense of suffering in alien contexts Cultural idioms of distress 58 Chapter III: Methodology Introduction Ethnography Ethnography in medical anthropology Multi-sited ethnography Fieldwork location as a point of departure for a multi-sited ethnography Participant observation Household survey Leaving the community of Bandera Street Methods used for gathering information on migrants mental health Illness narratives Gathering migrants narratives of emotional distress Methods for gathering information on migrant s reproductive health Research activities conducted outside the healthcare system Research activities conducted inside the healthcare system 91 Part II: Migration and its Discontents 95 Chapter IV: Socio-Demographic Characteristics and Health Profile of a Peruvian Migrant Community Living in Downtown Santiago Introduction Socio-demographic profile Place of origin in Peru Year of arrival Age, employment, gender and legal status Education, training and job opportunities Transnational characteristics of migrants families Marital status and partner s place of residence Place of residence of children Remittance money 104 vi

7 4.4 Social networks and interactions with the Chilean society Migrants health profile Health problems and seeking medical aid Health status and social status Summary and Conclusions 110 Chapter V: Migrants Living Conditions and Community Life Introduction Fieldwork setting N 823, 2nd floor, Bandera Street, downtown Santiago The residents of the housing compound Living conditions Health resources: hygiene and the spread of contagious diseases A whole world in a room Construction of privacy Community life in the shared housing unit Weekdays and weekend routines Celebrations and alcohol consumption Conflicts in the community From neighbours to compadres: the construction of symbolic kinship Community life outside of the building The little Lima: Plaza de Armas of Santiago 132 Chapter VI: Families, Identities and Frontiers Introduction Transnational families Formation of a transnational family Family reunions Conjugal relations Remittances and transnational parenthood National and gender identities Food and national identities Gender identities Frontiers between Peruvians and Chileans Migrants change of status in Chile Experiencing discrimination 159 vii

8 Part III: Migrants Mental Health Status in Chile: Old and new illness experiences, idioms of distress and Coping mechanisms in a hostile context 162 Chapter VII: Migrants Emotional Distress in the Context of their Displaced Lives and Social Exclusion Introduction Migrants mental health status Migrants mental health self-report Screening of depression and anxiety symptoms Eliciting narratives of emotional distress Symptoms of anxiety and depression and migrants perceptions of their emotional distress General results Gender and symptoms of anxiety and depression Perception of symptoms of emotional distress as narrated by the respondents Nerves in migrants explanations of their emotional distress Displacement, exclusion and the arising of migrants emotional distress in Chile Conjugal relationships and emotional distress Transnational families and emotional distress Emotional distress and work situation Illegal status and emotional distress Conclusions 192 Chapter VIII:Continuities and Changes in Migrants Illness Experiences and Idioms of Emotional Distress Introduction Old idioms and experiences of distress emerging under new circumstances Conflicts in the community Discrimination and transgressions in the host society Uprootedness and the displacement of migrants lives New experiences and idioms of distress emerging under new circumstances Exclusion and illness identity talks Conclusions 217 viii

9 Chapter IX: Old Ways of Coping with New Forms of Emotional Distress in Chile Introduction Changes in illness experiences: confronting new plights in the absence of emotional support Coping with emotional distress in the migrant community; killing the stress by dancing and drinking Medicalisation of migrants emotional distress Managing emotional distress at the workplace Conclusions 236 Part IV: Migrants Reproductive Health and the Chilean Healthcare System 239 Chapter X: Reproductive Health of Migrant Women in Chile: Barriers to Healthcare and Contraception Introduction Gender, migration and reproductive health Use of contraceptive methods among migrant women Demographic profile of respondents Contraceptive methods used Preferred method Actual use of contraceptive methods Attendance to medical check-ups Discrimination, exclusion and barriers to access of medical care Economic and legal barriers Fear and mistrust Practical barriers and the lack of workers rights Cultural barriers to contraception Women s embodied perceptions of their anatomy influencing their (non) use of modern contraception Strategies to avoid pregnancy in a context of multiple barriers to contraception Resorting to traditional contraceptive methods Changing to another modern contraceptive method Obtaining contraception in Peru Conclusions 263 ix

10 Chapter XI: Migrant Women in Interaction with Chilean Health Practitioners: The Construction of a New Category of Patient Introduction Migrant women as patients in reproductive healthcare Migrant patients in interaction with Chilean healthcare providers Constructing migrant women as a new category of patients Assumptions being made about migrant women s identity and sexuality Women s silenced cultural conceptions of the body and its reproductive processes Mismatches and miscommunication Migrants perceptions of being discriminated against and what healthcare providers think about it Migrant women s specific reproductive needs Unwanted pregnancies Addressing women s cultural differences Conclusions 295 Conclusions 297 Ethnography and the linkages between social determinants and individuals health 297 Emotional distress as a manifestation of migrants social suffering 298 The context related nature of the emergence of emotional distress 301 Findings obtained outside the healthcare system 302 Findings obtained inside the healthcare system 303 The limitations of the study 305 Final remarks 306 Epilogue 308 Packing up 308 Departure 309 Chimbote 311 Endnotes 314 References 315 Annex 1: Questionnaire for immigrants in Santiago 329 Annex 2: Illness Narratives 338 Annex 3: The Residents of the Compound in the Building of Bandera Street 340 Annex 4: Respondents to the mental health interview: Short biographies 344 Annex 5: Symptoms of migrants self-defined depression, stress and distress 352 Annex 6: Interview schedule: Key Informants 355 Annex 7: Interview schedule to be conducted with migrant female patients of family planning programs and antenatal care 356 Curriculum Vitae 359 Acknowledgments 361 x