Living on the margins : illness and healthcare among Peruvian migrants in Chile
De los Angeles Núnez Carrasco, L.
Citation
De los Angeles Núnez Carrasco, L. (2008, September 16). Living on the margins : illness
and healthcare among Peruvian migrants in Chile. Retrieved fromhttps://hdl.handle.net/1887/13105
Version: Corrected Publisher’s Version
License: Licence agreement concerning inclusion of doctoral thesis in the
Institutional Repository of the University of Leiden
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: Prof. dr. J.M. Richters
Co- promoters: Dr. T. Salman (Vrije Universiteit, Amsterdam) Dr. J.C. Skewes (Universidad Austral, Valdivia) Referent: Prof. dr. P. Silva
Lid: 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).
v CONTENTS v
Summary xi
Samenvatting 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
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
vii 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
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
ix 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
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
