Practising intercultural medicine in Ecuador

The ‘good way of living’, the 2008 constitution, and indigenous health in Ecuador

In 2008, Ecuador was the first country globally to anchor a right to intercultural health in its constitution.[1]  The constitution centered around the concept of Sumak Kawsay or Buen Vivir – Quichua[2] and Spanish for ‘the good way of living’ and set up an ambitious goal in its preamble: ‘We hereby decide to build a new form of public coexistence, in diversity and in harmony with nature, to achieve the good way of living, the Sumak Kawsay…’^[3] Intercultural healthcare has long been a lived reality worldwide. For centuries, when facing challenges to their health and well-being, people have relied on remedies stemming from their own cultural context and, at the same time, constantly integrated new and imported medical practices – crossing, blurring, and redefining the borders of different ontological frameworks of health. In the area of Latin-American health politics today, the term interculturality is used to refer to ‘the equitable and respectful interrelations of political, economic, social, cultural, age, linguistic, gender and generational differences established in the space between different cultures (peoples, ethnic groups)’.[4] The adoption of the 2008 constitution was hoped to significantly advance the realization of this ideal in Ecuador. Promoted by the left-wing government of Rafael Correa, and supported by more than 60 percent of Ecuadorian voters,^[5] the constitution surpasses the previous 1998 constitution’s demands for integration of indigenous ancestral[6] medicine into the public health system: for the first time, it formally regulates indigenous participation in public institutions. The new constitutional recognition strengthened the position of indigenous groups demanding respect for ancestralmedicine and its inclusion into the dominant healthcare system.

Following the constitution’s enactment, a State Office of Intercultural Health[7] was established within the Ministry of Public Health and the development of sustainable, non-discriminatory, and equity-based approaches to intercultural healthcare became officially declared policy goal.^[8] In its 2009 National Plan of Buen Vivir, Ecuador committed to integrate the experience and beliefs of ancestral healers with state-provided health services.[9] However, as of today, the struggle for an equity-based intercultural healthcare system can still be characterized as an ‘asymmetrical and incomplete project’. The researchers using this term in a recent paper argue that attempts of respectful intercultural dialogue may be outweighed by a racial political and economic history that has delegitimized indigenous systems of knowledge and belief for centuries and lead to a contempt for ancestral medicine that is still widespread in the Ecuadorian society. ^[10]

The power disbalance within the healthcare system mirrors the generally disadvantaged situation of indigenous people in Ecuador. They face higher barriers to healthcare access[11] and  a 30 percent higher probability of mortality and 63 percent higher incidence of all-cause morbidity than non-indigenous populations,^[12] but also significantly lower socio-economic and educational status.[13]  The search for the causes of these inequalities is complicated by the fact that the concerned group is remarkably diverse: Ecuador’s indigenous population includes 14 distinct peoples, such as the Amazonian Shuar or the Quichua speaking population of the Andean highlands. Even defining the proportion of the indigenous population in Ecuador is a challenge: estimates range from seven to 35 percent.[14]

Due to the cultural diversity of its users and practitioners, ancestral indigenous medicine in Ecuador is extremely diverse itself. Community-based practitioners of ancestral medicine include curanderos (‘healers’), shamans or yachay (‘seers’), hierbateros (‘herbal healers’), parteras (‘midwifes’), and sobadores (‘bonesetters’), with many practitioners performing a combination of several of these roles. Recent qualitative and semi-quantitative interview studies exploring the perspectives of ancestral healers on themes such as public health policies and barriers to a constructive collaboration with other health professionals,[15] added valuable new voices to the discussion on intercultural health and have inspired the analytic focus of this research project.

Project methodology – Active observation and interviews

The present work draws from two sources: A phase of active observation of the medical practice of the Yerbateras de Azuay in the group’s rented locality in Cuenca, Ecuador, and an interview phase with four formal recorded conversations, both realized in May and June 2022. During the active observation phase – a period of about two months – I was realizing a medical internship in Cuenca’s public hospital and repeatedly joined the curanderas in the weekends and in the late afternoons after work to see them treat their patients and gain an understanding of their working routines in informal conversations. The semi-structured interviews comprising the second project source, focused on the following four areas: 1) personal and professional biography, 2) relationship with patients and motives of consultation, 3) experiences with the Ecuadorian government and local politicians as well as practitioners of modern medicine, and 4) suggestions to improve effective collaboration in intercultural health. All interviews werecarried out in Spanish.[16] This website contribution, written in the context of the Global History Dialogues Project in 2022, presents some central aspects from the full project essay that can be obtained from the author.

The Yerbateras de Azuay collective as an economic and political project

The Yerbateras de Azuay[17] are a group of women practicing ancestral indigenous medicine as curanderas in the city of Cuenca, the 330.000 citizens capital of the Azuay Canton in the Andean Highlands of Southern Ecuador. In 2020, seven woman that were previously working under very adverse conditions in the public markets in Cuencacommitted to fight for economic and political autonomy themselves and other ancestral healers.  Following a suggestion of their member Jhoana Cruz, a political sociologist and the only non-indigenous co-founder of the Yerbateras, they invested 50 U.S. dollar each to rent a room in the city center and take turns attending patients. Since then, each women attends patients on one morning or afternoon of the week and sells self-produced products such as teas, ointments, or herbal soaps. All earnings are shared after deduction of running expenses, currently yielding around 60 dollar per person and month.[18] The Yerbateras meet regularly to discuss current business as well as political issues. As all group members except Jhoana belong to the Andean Quichua speaking population, one of the largest indigenous groups in Ecuador, experiences of discrimination are a recurring theme in their exchange, but also motivate the women to fight for their rights together:

Blanca, 45 years: ‘Many times, we people from the countryside, politicians hardly take us into account. They just keep us on the side, sometimes they deceive us, they think we don’t understand… but it’s not because we are from the countryside that we won’t defend ourselves! […] When I used to work alone, they came and told me ‘it’s not allowed’ – and I know it’s not allowed but I need to work… That’s why my sister told me ‘don’t you want to come to work here’? And I came. It’s much better in a group.‘

‘They do not give us space’ – The gap between the ancestral healers’ constitutionally guaranteed right to practise intercultural health and the adverse conditions they face in their daily work

As laid out in the introduction, the 2008 constitution first acknowledged a right to intercultural health for all Ecuadorians. According to Jhoana, these formally granted rights considerably strengthened the Yerbateras’ position for political engagement.

Jhoana: ‘I think the constitution must always have utopias. That is to know where you have to go. […] Before the constitution, the state not only did not help you walk, but attacked you on your way. For us it is great that the constitution is there, because it allows us to fight.’

While they perceived the constitutional rights as a strong backing for their cause, most Yerbateras reported to regularly face discrimination and expressed a general aversion to national and local ‘politicians’. Tying in with previous scientific research,[19] they emphasized the limited relevance of formal rights for their daily work if these rights are not complemented with practical initiatives to fight social marginalization, disadvantage, and discrimination.

Rosa: ‘No, they [the politicians] haven’t given us any support or anything. It is the knowledge of the people. […] There are also politicians who tell us: ‘that doesn’t work, I’ve never heard of this, it’s a lie, it’s not true.’ ‘You want to steal money,’ they say. That exists, that they discriminate against you. They do not give us space for ancestral medicine, not in the markets, not in political meetings.’

Rosa’s referring to the ‘knowledge of the people’, that is finally not understood by the politicians, ties in with the concern about the appropriation and instrumentalization of the ancestral indigenous concept of Sumak Kawsay^[20]and its conflicting interpretations^[21] that is also discussed in the scientific community. However, among the Yerbateras, the gap between ideal and reality seemed not to lead to resignation. While many women expressed to have limited knowledge of concrete legal regulations, many initiatively mentioned the right to intercultural health and required it to be granted: to the curanderas, the indigenous people, or simply ‘all people’. The Spanish word ‘lucha’, indicating a fight or struggle, was central to their narratives.

Blanca: ‘That [the political change] depends on oneself. Sometimes oneself must step out for this fight. Because politicians don’t know, they don’t understand our work. And for how they treat us, one has to defend oneself. And my colleagues tell me ‘come on, compañeras [Spanish for colleague, friend or companion], let’s see what we can do!’ and we go out. Yes, we can defend ourselves.’

As becomes apparent in Blanca’s and the other women’s testimony, their shared experiences of adversity and discrimination lead the Yerbateras to identify increasingly as members of a marginalized group, strengthened their solidarity with curanderas outside the group, and raised their determination to become actively involved in defending their rights – a phenomenon that has been often described in the context of indigenous movements in Ecuador. [22] In this way, it was the gap between the constitutionally guaranteed right to intercultural health and the adverse conditions the ancestral healers face in their daily work that lead to the Yerbateras’ decision to take space physically and politically.

‘Ancestral knowledge is not just an adornment, an appendix’ – Dialogue and respect are needed to fully exploit the complementarity of modern and ancestral medicine in Ecuador

 Among the Yerbateras recommendations to advance the right to intercultural health, one aspect stood out: Ancestralmedicine must not be instrumentalized to serve as a mere illustration of a progressive political attitude. Instead, respect and authentic efforts to understand the curanderas’ practices and the ontological framework of their work are the basis for successful collaboration. As  geographer Sarah Radcliffe puts it in her thorough analysis of the promise and limits of the Sumak Kawsay concept in Ecuador, ‘interculturalism is to be ‘‘mainstreamed’’ across all sectors of the state and put into all public policy as a benchmark for attitudes and behaviour.’[23] In Jhoana’s eyes, documents such as the 2009 National Plan of Buen Vivir requiring the government to integrate the experience and beliefs of ancestralhealers with state-provided health services^[24]  are far too vague to have a tangible impact.  More concrete and measurable goals are needed to avoid what she refers to as ‘fair culture’:

Jhoana: ‘Local politicians are always under pressure from the state to do something fast and visible, […] so they always end up holding a fair of ancestral knowledge. And there they spend all the money and it is not sustainable and it does not change things. […] The theme of ancestral knowledge should not be just an adornment, an appendix.’

From the Yerbateras’ perspective, ancestral Ecuadorian medicine deserves to be more than an ‘adornment’, yet does not pose a threat to the existing healthcare system. In contrast to the majority of physicians working in public hospitals, many curanderas share the modest socio-economic background of most of their patients and tend to pass on knowledge that they had found helpful themselves. ‘I like my job because I learn to take care of myself’, explains Blanca, ‘we ourselves can also be well’. Interacting with their patients as peers amongst equals, curanderas can act as authentic role models for coping with illness and disease, making patients feel valued, respected, and understood in their concerns. [25] The Yerbateras emphasized the complementarity of the diseases treatable with modern medicine and the diseases that could be resolved by their own intervention.

Blanca: ‘A lady comes with a headache and she has already been to the hospital five times and they tell her ‘there is nothing’… but I see that it is ‘mal aire’[26] and I can help her with a cleaning and a massage. Sometimes a case is for ancestral medicine, sometimes it is for the doctor to cure. Healing is not only for the doctor, nor only for ancestral medicine. We are two parts.’

In fact, ancestral Ecuadorian medicine as practiced in the current day defines a certain group of diseases, such as cancer, sores, or bone fractures, to require treatment with modern medicine.[27] Accordingly, current and potential collaboration with providers of modern medicine was conceived very positively not only by Blanca, but all the Yerbateras I talked to. ‘The hospital doctors and we should get together, become a team’, Sofía states, ‘If a patient doesn’t get better here or there, they should send him to get the other medicine.’ Rosa emphasizes the importance of patient self-empowerment and shared-decision making between patient and healthcare practitioner in this regard: ‘He [the patient] has to choose. If he is good with both remedies, or if he feels better with ancient medicine only, or only with modern medicine. It is the patient’s choice.‘

Overall, the Yerbateras felt that to deliver on the constitution’s promises centered around the concept of Sumak Kawsay and intercultural health, healthcare professionals and policy makers must recognize the value of ancestralhealers’ contributions for the physical, mental, and social well-being of their communities. Echoing research on intercultural health, such as the best practice report published by the First Nations Centre for Aboriginal Health Research at the University of Manitoba[28], the Yerbateras argue that a respectful dialogue is needed to fully exploit the complementarity of modern and ancestral medicine.

Listening to the Yerbateras to strengthen intercultural healthcare worldwide

Ecuador assumed a pioneering role in the global community by including the right to intercultural health in its 2018 constitution. Yet, the experience of the Yerbateras shows that – as in many other countries – there is a hefty discrepancy between the ideal and practice of intercultural health. The struggle for an equity-based intercultural health system reflects the complex and long-existing power dynamics within the Ecuadorian society. As the authors of a recent study point out: ‘health care systems in various countries are modified with a goal of creating ‘hybrid’ structures that make room for traditional practices within a dominant Western model. But genuine intercultural health care is elusive.’^[29]From a global perspective, Ecuador’s difficult path towards intercultural health is representative of a larger struggle inherent to our globalized world. Countries worldwide need to resolve the tension between our longing for evidence-based modern medicine, characterized by universality and unified standards, and the desire to acknowledge the strengths and advantages of alternative ontological frameworks of health. To borrow the words of Latin America historians Gabriela De Lima Grecco and Sven Schuster, they must ‘combin[e] unity with diversity’.^[30]

Against this background, the Yerbateras de Azuay collective can be perceived as an example of an economic and political project advancing both unity and diversity from within the Ecuadorian society. It aims to promote the right of ancestral healers to practice their profession but also the right to intercultural health of all Ecuadorians. As has been laid out above, from the Yerbateras’ perspective, ancestral Ecuadorian medicine is not a threat to the existing healthcare system, but rather holds the potential to complement modern biomedical approaches. The interviewed women perceive a clear gap between the formally granted right to intercultural health and their every-day experienceand suggest this gap may be overcome only through the means of equity-based dialogue and respect between practitioners of ancestral and modern medicine.

By tracing the personal experiences of a group of women practicing ancestral medicine in Cuenca I hope to contribute to an objectivity as defined by historian Felipe Fernández-Armesto – an objectivity that lies in ‘the sum of all possible subjectivities’^[31] and can only be reached if we collect, compare, and contrast an ever wider spectrum of diverse voices, integrating personal experiences with global phenomena. The presented results speak of an important universal insight: respecting ancestral medical knowledge systems and truly accepting their complementarity with modern medicine has the potential to significantly improve peoples’ health in Ecuador and worldwide. As a first step, let us listen to the Yerbateras.

[1] Constitutional Assembly of Ecuador “Constitución Política de la República del Ecuador”, 20 October 2008, available at: https://www.refworld.org/docid/3dbd62fd2.html [accessed 18 May 2022]. The concept of Buen Vivir also appears in Bolivia’s constitution, adopted in 2009.

[2]After Spanish, Quichua is the most used language in Ecuador. It is spoken primarily by indigenous communities throughout the central Andes Mountains.

[3]Constitutional Assembly of Ecuador “Constitución Política de la República del Ecuador” (20 October 2008), available at: https://www.refworld.org/docid/3dbd62fd2.html [accessed 18 May 2022].

[4]Pan American Health Organization/Organización Panaméricana de la Salud. “Armonización de los sistemas de salud indígenas y el sistema de salud convencional en las Américas”. 2003;(2):52. Cited from: E. Bautista-Valarezo, V. Duque, V. Verhoeven, et al. “Perceptions of Ecuadorian indigenous healers on their relationship with the formal health care system: barriers and opportunities”, BMC Complement Med Ther (2021): 21, 65. https://doi.org/10.1186/s12906-021-03234-0

[5] G. W. Knapp, H. P. Vélez and M. J. MacLeod, “Ecuador from the late 20th century” in “Ecuador” in Encyclopedia Britannica, November 15, 2021. https://www.britannica.com/place/Ecuador [accessed 18 May 2022].

[6] The terms ‘ancestral’ and ‘traditional’ medicine or knowledge are often used interchangeably by political stakeholders in Ecuador and also the Yerbateras themselves. The World Health Organization and other international institutions tend to use the term ‘traditional’ to refer to long-established medical practices worldwide that differ from ‘modern medicine’; however, this term was and continues to be used in many colonial and post-colonial contexts as a way of delegitimizing certain forms of knowledge. Throughout this text, I therefore use the term ‘ancestral’ when describing the Yerbateras’ work.

[7] The Dirección Nacional de Salud Intercultural (State Office of Intercultural Health) was created within the Ministerio de Salud Publica (Ministry of Public Health) in 2008.

[8]Ministerio de Salud Publica del Ecuador, Comisión Nacional de Organización y Participación Social del CONASA “Políticas Públicas de Salud para la Diversidad Plurinacional y Plurcultural – Proceso de Normatización del SNS – Subproceso de Medicina Intercultural” (2009). The original text reads: ‘Estar “bien“, es estar en armonía consigo mismo, con su comunidad, su entorno y sus espíritus protectores’ [Translation by the autor, VW]

[9] Secretaria Nacional de Planificación y Desarrollo, Ecuador, “Plan Nacional Buen Vivir” (Quito; 2013)

[10] Diego Herrera, Frank Hutchins, David Gaus and Carlos Troya, “Intercultural health in Ecuador: an asymmetrical and incomplete project”, Anthropology & Medicine (2018), DOI: 10.1080/13648470.2018.1507102

[11] Daniel F López-Cevallos, Chunhuei Chi, “Health care utilization in Ecuador: a multilevel analysis of socio-economic determinants and inequality issues”, Health Policy and Planning (2010), Volume 25, Issue 3, Pages 209–218, https://doi.org/10.1093/heapol/czp052

[12] Alexandra Reichert, “Toward Intercultural Health Care in Ecuador: A Roadmap For Equitable Reform”, Health Affairs Blog (April 10, 2020). DOI: 10.1377/hblog20200406.329120

William Kuang-Yao Pan, Christine Erlien, and Richard E. Bilsborrow, “Morbidity and mortality disparities among colonist and indigenous populations in the Ecuadorian Amazon”, Social Science & Medicine (2010), Volume 70, Issue 3, Pages 401-411, ISSN 0277-9536, https://doi.org/10.1016/j.socscimed.2009.09.021.

[13] José Manuel Castellano, Efstathios Stefos et al., “The Educational and Social Profile of the Indigenous People of Ecuador: A Multidimensional Analysis”, Review of European Studies (2017): 9, 1, 1

[14] While about seven percent of all Ecuadorians self-identified as indigenous in the last national census (Ecuador National Institute of Statistics and Census INEC, August 2020. See: https://www.ecuadorencifras.gob.ec/institucional/home/), the Confederation of Indigenous Nationalities of Ecuador (CONAIE, See: https://conaie.org)^[14] estimates that indigenous people comprise between 25 percent and 35 percent of the country’s total population, arguing that some respondents might prefer to identify as mestizo, people from mixed indigenous and European descent, to avoid discrimination and stigma.

[15] E. Bautista-Valarezo, V. Duque, V. Verhoeven, et al. “Perceptions of Ecuadorian indigenous healers on their relationship with the formal health care system: barriers and opportunities”, BMC Complement Med Ther (2021): 21, 65. https://doi.org/10.1186/s12906-021-03234-0

Adriana Orellana-Paucar, Valeria Quinche-Guillén, Danilo Garzón-López, Rafaella Ansaloni, Geovanny Barrera-Luna, and Lourdes Huiracocha-Tutiven. “Perceptions towards the Practice of Andean Traditional Medicine and the Challenges of Its Integration with Modern Medicine. Case Cuenca, Ecuador.” MASKANA (2021) 12 (1): 26–34. https://doi.org/10.18537/mskn.12.01.03

[16] All citations were translated by the author. Original wording can be found in the Spanish version of this essay.

[17] While the group’s name Yerbatera, Spanish for ‘herbalist’ or ‘herb woman’, is often used in a pejorative manner in the region, it was chosen to express the pride the curanderas take in their profession.

[18] The minimum salary in Ecuador, applying for government employees and employees of large firms in full-time employment was raised to 425 USD per month in January 2022.

[19] Braveman and S. Gruskin, “Poverty, Equity, Human Rights and Health,” Bulletin of the World Health Organisation 81/7 (2003), pp. 539-545.

Radcliffe, Sarah A. “Development for a postneoliberal era? Sumak kawsay, living well and the limits to decolonisation in Ecuador.” Geoforum 43.2 (2012): 240-249.

Goicolea, Isabel, Miguel San Sebastián, and Marianne Wulff. “Women’s reproductive rights in the Amazon basin of Ecuador: challenges for transforming policy into practice.” health and human rights (2008): 91-103.

[20]Rafael Domínguez, Sara Caria and Mauricio León, “Buen Vivir: Praise, instrumentalization, and reproductive pathways of good living”, Ecuador, Latin American and Caribbean Ethnic Studies (2017): 12:2, 133-154, DOI: 10.1080/17442222.2017.1325099

Fernández, Blanca Soledad. “Indigenous Intellectuals in Contemporary Ecuador: Encounters with “Seven Erroneous Theses about Latin America”.” Latin American Perspectives45.2 (2018): 190-204.

[21]Joe Quick and James T. Spartz, “On the Pursuit of Good Living in Highland Ecuador: Critical Indigenous Discourses of Sumak Kawsay.”, Latin American Research Review (2018): 53(4). pp. 757–769. DOI: https://doi.org/10.25222/larr.132

[22] For example, the Confederation of Indigenous Nationalities of Ecuador (CONAIE), described itself as a movement resulting from a shared experience of discrimination and a long process of resistance and struggle. Source: Backlund S. Ecuadorian indigenous youth and identities : cultural homogenization or indigenous vindication? [Internet] [Dissertation]. 2013. Available from: http://urn.kb.se/resolve?urn=urn:nbn:se:lnu:diva-29122

[23] Radcliffe, Sarah A. “Development for a postneoliberal era? Sumak kawsay, living well and the limits to decolonisation in Ecuador.” Geoforum 43.2 (2012): 240-249; drawing on: Dávalos, P., 2008a. El ‘Sumak Kawsay’ (‘Buen vivir’) y las cesuras del desarrollo: 1a parte. Boletin ICCI-Rimay ano 10 (110), p13; and Quintero Lopez, R., 2009. Las innovaciones conceptuales de la constitución del 2008 y el sumak kawsay. In: Acosta, El buen vivir. Abya-Yala, Quito, pp. 81.

[24] Secretaria Nacional de Planificación y Desarrollo, Ecuador, “Plan Nacional Buen Vivir” (Quito; 2013)

[25]Adriana Orellana-Paucar, Valeria Quinche-Guillén, Danilo Garzón-López, Rafaella Ansaloni, Geovanny Barrera-Luna, and Lourdes Huiracocha-Tutiven. “Perceptions towards the Practice of Andean Traditional Medicine and the Challenges of Its Integration with Modern Medicine. Case Cuenca, Ecuador.” MASKANA (2021): 12 (1): 26–34. https://doi.org/10.18537/mskn.12.01.03

[26] ‘Mal aire’ [Spanish for ‘bad air’] is caused when strong winds are present while a person walks through cemeteries or places with hidden treasures (‘burials’) or contact with cold air. Its major symptoms are dizziness, headache, vomiting, stomach pain, fainting, and general body discomfort.’ Cited from: Adriana Orellana-Paucar, Valeria Quinche-Guillén, Danilo Garzón-López, Rafaella Ansaloni, Geovanny Barrera-Luna, and Lourdes Huiracocha-Tutiven. “Perceptions towards the Practice of Andean Traditional Medicine and the Challenges of Its Integration with Modern Medicine. Case Cuenca, Ecuador.” MASKANA (2021) 12 (1): 26–34. https://doi.org/10.18537/mskn.12.01.03.

[27] Elizabeth Currie, John Schofield, Fernando Ortega Perez & Diego Quiroga, “Health beliefs, healing practices and medico-ritual frameworks in the Ecuadorian Andes: the continuity of an ancient tradition”, World Archaeology (2018): 50:3, 461-479, DOI: 10.1080/00438243.2018.1474799

[28] Mignone, J., Bartlett, J., O’Neil, J. et al. Best practices in intercultural health: five case studies in Latin America. J Ethnobiology Ethnomedicine 3, 31 (2007). https://doi.org/10.1186/1746-4269-3-31

[29]Diego Herrera, Frank Hutchins, David Gaus and Carlos Troya, “Intercultural health in Ecuador: an asymmetrical and incomplete project”, Anthropology & Medicine (2018), DOI: 10.1080/13648470.2018.1507102

[30] Gabriela De Lima Grecco and Sven Schuster, “Decolonizing Global History? A Latin American Perspective.”, Journal of World History (2020), 435.

[31] Felipe Fernández-Armesto, “Epilogue: What is History Now?” in What Is History Now?, ed. David Cannadine (Houndmills, New York: Palgrave MacMillan, 2002), 155.