Living on the Margins

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

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

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 16.15 uur door Lorena de los Angeles Núñez Carrasco geboren te Santiago, Chile in 1964

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-52-918).

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 13 1.1 Introduction 13 1.2 Migration 13 1.2.1 Rural urban migration and the adaptation of migrants to the urban context 15 1.2.2 Contemporary transnational migration 16 1.3 Migration and health 17 1.3.1 Explaining the relationship between migration, ethnicity and health 19 1.3.2 Transnational migration and migrants health and wellbeing. 21 1.4 Discrimination and health 24 1.4.1 Some theoretical and methodological challenges in measuring the effects of discrimination on health 26 1.5 An approach to discrimination and its effects on migrants health in Chile 28 1.5.1 Structural discrimination as exclusion 30 1.5.2 Discrimination in the public healthcare system 32 1.5.3 Some background to the problem of discrimination in Chilean society 34 Chapter II: Theoretical Approaches and Key Concepts in Medical Anthropology 40 2.1 Introduction 40 2.2 Developments in medical anthropology: In search of the middle ground 41 2.2.1 Changes in the conceptualisation of illness in medical anthropology: Towards an interpretive approach 41 2.2.2 The interpretive approach in medical anthropology 42 v

2.2.3 Political economy of health approach 44 2.2.4 The critical approach in medical anthropology 46 2.2.5 The social suffering approach 48 2.3 The self, embodiment and agency in the context of illness and suffering 50 2.3.1 The self in the context of culture 50 2.3.2 Migrants embodiment of adverse social conditions 53 2.3.3 Agency: recentring the body and self 55 2.4 Making sense of suffering in alien contexts 58 2.4.1 Cultural idioms of distress 58 Chapter III: Methodology 62 3.1 Introduction 62 3.2 Ethnography 63 3.2.1 Ethnography in medical anthropology 64 3.2.2 Multi-sited ethnography 64 3.2.3 Fieldwork location as a point of departure for a multi-sited ethnography 65 3.2.4 Participant observation 69 3.2.5 Household survey 82 3.2.6 Leaving the community of Bandera Street 83 3.3 Methods used for gathering information on migrants mental health 84 3.3.1 Illness narratives 84 3.3.2 Gathering migrants narratives of emotional distress 86 3.4 Methods for gathering information on migrant s reproductive health 90 3.4.1 Research activities conducted outside the healthcare system 90 3.4.2 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 97 4.1 Introduction 97 4.2 Socio-demographic profile 99 4.2.1 Place of origin in Peru 99 4.2.2 Year of arrival 100 4.2.3 Age, employment, gender and legal status 100 4.2.4 Education, training and job opportunities 101 4.3 Transnational characteristics of migrants families 102 4.3.1 Marital status and partner s place of residence 103 4.3.2 Place of residence of children 103 4.3.3 Remittance money 104 vi

4.4 Social networks and interactions with the Chilean society 105 4.5 Migrants health profile 106 4.5.1 Health problems and seeking medical aid 107 4.5.2 Health status and social status 109 4.6 Summary and Conclusions 110 Chapter V: Migrants Living Conditions and Community Life 114 5.1 Introduction 114 5.2 Fieldwork setting 115 5.2.1 N 823, 2nd floor, Bandera Street, downtown Santiago 115 5.2.2 The residents of the housing compound 116 5.2.3 Living conditions 117 5.2.4 Health resources: hygiene and the spread of contagious diseases 118 5.2.5 A whole world in a room 120 5.2.6 Construction of privacy 122 5.3 Community life in the shared housing unit 124 5.3.1 Weekdays and weekend routines 124 5.3.2 Celebrations and alcohol consumption 125 5.3.3 Conflicts in the community 127 5.3.4 From neighbours to compadres: the construction of symbolic kinship 129 5.4 Community life outside of the building 132 5.4.1 The little Lima: Plaza de Armas of Santiago 132 Chapter VI: Families, Identities and Frontiers 134 6.1 Introduction 134 6.2 Transnational families 135 6.2.1 Formation of a transnational family 135 6.2.2 Family reunions 137 6.2.3 Conjugal relations 140 6.2.4 Remittances and transnational parenthood 142 6.3 National and gender identities 144 6.3.1 Food and national identities 145 6.3.2 Gender identities 150 6.4 Frontiers between Peruvians and Chileans 156 6.4.1 Migrants change of status in Chile 157 6.4.2 Experiencing discrimination 159 vii

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 166 7.1 Introduction 166 7.2 Migrants mental health status 166 7.2.1 Migrants mental health self-report 167 7.2.2 Screening of depression and anxiety symptoms 168 7.2.3 Eliciting narratives of emotional distress 170 7.3 Symptoms of anxiety and depression and migrants perceptions of their emotional distress 170 7.3.1 General results 170 7.3.2 Gender and symptoms of anxiety and depression 171 7.3.3 Perception of symptoms of emotional distress as narrated by the respondents 173 7.3.4 Nerves in migrants explanations of their emotional distress 174 7.4 Displacement, exclusion and the arising of migrants emotional distress in Chile 176 7.4.1 Conjugal relationships and emotional distress 178 7.4.2 Transnational families and emotional distress 180 7.4.3 Emotional distress and work situation 185 7.4.4 Illegal status and emotional distress 190 7.5 Conclusions 192 Chapter VIII:Continuities and Changes in Migrants Illness Experiences and Idioms of Emotional Distress 195 8.1 Introduction 195 8.2 Old idioms and experiences of distress emerging under new circumstances 196 8.2.1 Conflicts in the community 196 8.2.2 Discrimination and transgressions in the host society 201 8.2.3 Uprootedness and the displacement of migrants lives 204 8.3 New experiences and idioms of distress emerging under new circumstances 207 8.3.1 Exclusion and illness identity talks 212 8.4 Conclusions 217 viii

Chapter IX: Old Ways of Coping with New Forms of Emotional Distress in Chile 220 9.1 Introduction 220 9.2 Changes in illness experiences: confronting new plights in the absence of emotional support 221 9.3 Coping with emotional distress in the migrant community; killing the stress by dancing and drinking 224 9.4 Medicalisation of migrants emotional distress 229 9.5 Managing emotional distress at the workplace 233 9.6 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 241 10.1 Introduction 241 10.2 Gender, migration and reproductive health 242 10.3 Use of contraceptive methods among migrant women 243 10.3.1 Demographic profile of respondents 243 10.3.2 Contraceptive methods used 244 10.3.3 Preferred method 245 10.3.4 Actual use of contraceptive methods 246 10.3.5 Attendance to medical check-ups 247 10.4 Discrimination, exclusion and barriers to access of medical care 247 10.4.1 Economic and legal barriers 248 10.4.2 Fear and mistrust 249 10.4.3 Practical barriers and the lack of workers rights 250 10.5 Cultural barriers to contraception 251 10.5.1 Women s embodied perceptions of their anatomy influencing their (non) use of modern contraception 257 10.6 Strategies to avoid pregnancy in a context of multiple barriers to contraception 261 10.6.1 Resorting to traditional contraceptive methods 261 10.6.2 Changing to another modern contraceptive method 262 10.6.3 Obtaining contraception in Peru 263 10.7 Conclusions 263 ix

Chapter XI: Migrant Women in Interaction with Chilean Health Practitioners: The Construction of a New Category of Patient 266 11.1 Introduction 266 11.2 Migrant women as patients in reproductive healthcare 267 11.3 Migrant patients in interaction with Chilean healthcare providers 268 11.3.1 Constructing migrant women as a new category of patients 268 11.3.2 Assumptions being made about migrant women s identity and sexuality 274 11.3.3 Women s silenced cultural conceptions of the body and its reproductive processes 280 11.3.4 Mismatches and miscommunication 284 11.3.5 Migrants perceptions of being discriminated against and what healthcare providers think about it 288 11.4 Migrant women s specific reproductive needs 291 11.4.1 Unwanted pregnancies 292 11.4.2 Addressing women s cultural differences 292 11.5 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