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Health in the Highlands
Health in the Highlands
indigenous healing and scientific
medicine in guatemala and ecuador
David Carey Jr.
Foreword by Jeremy A. Greene
university of califor nia pr ess
University of California Press
Oakland, California
© 2023 by David Carey Jr.
Library of Congress Cataloging-in-Publication Data
Names: Carey, David, Jr., 1967- author. | Greene, Jeremy A., 1974- writer
of foreword.
Title: Health in the highlands : indigenous healing and scientific medicine in
Guatemala and Ecuador / David Carey Jr. ; foreword by Jeremy A. Greene.
Description: Oakland, California : University of California Press, [2023] |
Includes bibliographical references and index.
Identifiers: lccn 2022049620 (print) | lccn 2022049621 (ebook) |
isbn 9780520344785 (cloth) | isbn 9780520344792 (paperback) | isbn
9780520975682 (ebook)
Subjects: lcsh: Traditional medicine—Guatemala—History—20th century. |
Traditional medicine—Ecuador—History—20th century. | Medical
care—Guatemala—History—20th century. | Medical care—Ecuador—
History—20th century.
Classification: lcc gr880 .c325 2023 (print) | lcc gr880 (ebook) |
ddc 362.109728105/2—dc23/eng/20221216
LC record available at https://lccn.loc.gov/2022049620
LC ebook record available at https://lccn.loc.gov/2022049621
Manufactured in the United States of America
32 31 30 29 28 27 26 25 24 23
10 9 8 7 6 5 4 3 2 1
To the memory of my mother Margot, suegro Steverino, and
uncle Steve, who all passed away while I was writing this book.
con t en ts
List of Illustrations viii
Foreword xi
Jeremy A. Greene
Acknowledgments xv
A Note on Sources, Methodology, and Evidence xix
Abbreviations xxviii
Introduction: Disease, Healing, and Medicine in
Indigenous Highlands 1
1 • Hookworm, Histories, and Health: Indigenous Healing, State
Building, and Rockefeller Representatives 22
2 • Curses and Cures: Empíricos, Indigeneity, and Scientific Medicine 57
3 • Engendering Infant Mortality and Public Health: Midwifery,
Obstetrics, and Ethnicity 86
4 • “Malnourished, Scrawny, Emaciated Indios”: Perceptions of
Indigeneity, Illness, and Healing 118
5 • Infectious Indígenas: The Ethnicity of Highland Diseases 147
6 • “Prisoners of Malaria”: A Lowland Disease in the Mountains 176
Conclusion: Indigeneity, Racist Thought, and Modern Medicine 209
Notes 227
Bibliography 287
Index 327
i l lust r at ions
maps
1. Ecuador, 1976 xxvi
2. Guatemala, 1922 xxvii
figures
1. Map suggesting correlations between tropical diseases and race in Latin
America, 1937 12
2. Rockefeller photo of malnourished indigenous boy, 1915 15
3. Indigenous couple from San Juan Comalapa, ca. 1910 16
4. Rockefeller photo of boy with hookworm, 1915 23
5. Rockefeller-designed outhouse on a Guatemalan finca, 1915 46
6. Rockefeller photo of an indigenous family infected with hookworm,
1915 47
7. Police Gazette collage of male and female healers, 1935 70
8. Police Gazette collage of male and female curanderos and their
accoutrements, including a magical fish, 1935 72
9. Police Gazette photo of a healer dubbed “The Grave Man,” 1935 74
10. Police Gazette photos of European doctors operating in Guatemala,
1941 77
11. Police Gazette photo of men accused of practicing “ridiculous
witchcraft,” 1943 78
viii
12. Vaccination campaign in Ambato, Ecuador, 1926 81
13. Public announcement of infant protection program, Ecuador, 1935 93
14. Advertisement for condensed milk using an image of a light-skinned
Guatemalan boy, 1936 108
15. Red Cross illustration of a fly contaminating the food of a light-
skinned girl, 1936 112
16. Rockefeller photo of an Indian vapor bath, 1915 124
17. Ecuadorian milk vendor at Latacunga train station, 1945 144
18. Rockefeller photo of a Guatemalan boy identified as a “dirt-eater,”
1915 161
19. Map showing the geographical distribution of malarial mosquitoes in
Guatemala, 1938 185
20. Map suggesting correlations between tropical diseases and race in
Central America, 1937 186
21. Guatemalan Red Cross magazine cover of a malarial mosquito, 1936 193
22. Rockefeller photo of a drainage ditch in Guayaquil, Ecuador, 1920 202
23. Rockefeller photo of a flooded street in Guayaquil, Ecuador, 1920 203
24. Rockefeller photo of a flooded plaza in Guayaquil, Ecuador, 1920 204
25. Rockefeller photo of colored bedspreads and brass knobs “reflecting
Indian influence” in a new hospital ward, 1922 217
i l lus t r at ions • ix
for ewor d
There is no separating health from politics. The history of Latin America—
especially in the early twentieth century, especially in its multiple entangle-
ments with gringoísmo—is especially rich in examples of this. One needs only
to recall the role of yellow fever in justifying US engagements in Cuba and
the Panama Canal at the turn of the twentieth century, or the role of malaria
in justifying new forms of anti-Indigenous assimilationist politics in Mexico
under the auspices of the Rockefeller Foundation a few decades later, to wit-
ness how health and politics are deeply entwined on both micro and macro
scales. And yet the history of Latin America is also full of attempts to deem-
phasize the politics of health in favor of more comforting geographical or
social-scientific narratives that explain away the political economy of health
and disease as natural or inevitable.
Perhaps the most pernicious of these exculpatory narratives is the recur-
rent naturalization of steep health disparities between Indigenous peoples
and Criollo/Ladino/mestizo populations that can be found within every
state in the Americas. Vast differences in maternal and infant mortality and
fatalities from non-communicable and infectious diseases have repeatedly
been explained away through tropes of inherent geographical differences on
the one hand or cultural differences on the other. Yet as David Carey Jr.
shows in this important book, these differences are overwhelmingly
the result of social and structural forces—racism, dispossession, unequal
citizenship—whose legacies we continue to live with today.
For the most part, late twentieth and early twenty-first century medicine
and public health have learned to decry biological racism—even if new forms
continue to emerge each year. But cultural difference remains a common
retreat for even the liberal-minded to redirect blame for the perpetuation of
xi
health disparities on those who suffer the most from them. Over the past
century, many historians, sociologists, and anthropologists have perpetuated
this belief as well. In the culturalist model of disease disparity—long favored
by official publications of the Pan-American Health Organization (formerly
the Pan-American Sanitary Bureau) and the World Health Organization—
the pluralism of health care encompassing home remedies, traditional herbal-
ists, and spiritual healers was often depicted as a distraction from meaningful
engagement with scientific medicine. This distraction is then thought to have
fatal consequences when meaningful biomedical interventions (such as anti-
biotics and vaccines) are eschewed. In this model, cultural difference—here
read as a static, timeless traditional health system—is remade as the leading
barrier to acceptance of modern, effective clinical and public health interven-
tions for Indigenous populations.
Observing in 1997 that similar narratives were used to explain the dispari-
ties in tuberculosis outcomes between Mayan communities in Chiapas com-
pared to Blanco-Mestizo populations elsewhere in Mexico, the late anthro-
pologist and infectious disease physician Paul Farmer pointed out that it was
all too easy to blame health disparities on cultural differences. Yet the links
themselves, when examined closer, were specious and threadbare—and cov-
ered up other, more important differences in political economy that all too
often played a determining role in producing health outcomes. “In medical
anthropology,” Farmer continued, “often enough culture is held up as the
determinant variable. Surely these immodest claims of causality amount to
inadequate phenomenology and are underpinned by inadequate social the-
ory. Because culture is merely one of several potentially important factors,
anthropologists and other researchers who cite cognitivist ‘cultural’ explana-
tions for the poor health of the poor have been the object of legitimate cri-
tiques.” If one looks beyond convenient explanations of cultural difference,
one sees a more powerful map of political economy and lack of access behind
what is painted as lack of knowledge or poor choice. “Throughout the world,”
he concluded, “those least likely to comply are those least able to comply.”
I remember reading these words the summer of 1997, before starting my
first year of medical school that fall. Farmer’s approach to social medicine was
the reason I enrolled, and I was fortunate enough to be mentored by him first
as a clinician, then as an anthropologist and then as a historian. As a medical
student, intern, and resident, I worked with Farmer and other physician-
scholars on health equity projects with ethnographic components to under-
stand health disparities among Aymara-speaking populations in the Andean
xii • for e wor d
highlands of Bolivia and in Mayan populations in the Sierra Madre of
Chiapas, Mexico. Aymaran residents in the shantytowns of La Paz who had
stopped taking their tuberculosis treatments were often dismissed by provid-
ers as being poorly-educated in the ways of scientific medicine, or castigated
for pursuing treatments with local herbalists and spiritual healers instead of
their prescribed antibiotics. But all of the Aymara who let me follow along as
an ethnographer in their daily lives could recite with great precision the role
of Koch’s bacilli and antituberculosis chemotherapy in determining tubercu-
losis outcomes. They were very clear that their use of Aymara healing practices
did not interfere at all with their understanding of the etiology and treatment
of tuberculosis. What interfered, instead, was the inability to comply with the
extensive fiscal and temporal demands of treatment while also holding down
a job in a vulnerable labor market. Several Mayan residents living in remote
villages along the southern Sierra Madre suffering from treatable bacterial
and parasitic diseases pointed to the well-painted but shuttered health clinic
in their town and the empty shelves of the local pharmacy, even as the metro-
politan physicians responsible for staffing them blamed poor health outcomes
on the backwardness and ignorance of the people they were failing to serve.
While La Paz and Chiapas may be worlds apart in terms of their physical
geography, infectious disease epidemiology, and chronology of settler coloni-
alism, independence, and revolution, the prevalence of culturalist explana-
tions for Indigenous health disparities shared common roots—as did the
overall refusal by those responsible for the health of the public to acknowl-
edge the structural violence and ongoing political economy as important
determinants of health disparities past, present, and future.
Carey’s book starts with this problem and works backwards to move for-
wards. He uses the tools of the social historian to extend a historical dyna-
mism and range that restores to Indigenous actors the agency and history
that our self-serving narratives of cultural difference elide. Comparing two
very different Indigenous contexts in South and Central America—one
Andean, one Mayan—he works through neglected records of Latin American
state reckonings with disparities in health and diseases between Indigenous
and Mestizo/Ladino/Criollo populations in Ecuador and Guatemala. In the
process, he recreates a vernacular of how physicians and public health officials
in both locales wielded their authority in describing health differences to
create self-satisfying narratives about cultural determinants of health, and
then used them to justify further forms of structural dispossession which,
paradoxically, augmented disparities in health. But if the stories of medicine,
for e wor d • xiii
public health, and Indigenous health disparities have similarities, the two
states are not the same. Throughout the early twentieth century, political
positioning of Indigenous rights and Indigenous health played out differ-
ently in these locales, with quite different outcomes. It is here that the
connected—not merely comparative—history that Carey recounts allows
the reader to understand not only the plurality of paths not taken, but also
just how much agency and potential still resides in the possibility for mean-
ingful interventions to achieve health equity in the present day.
So, too, with the possibility for restoring agency and plurality in our
understanding of the complex landscape of healthcare which Indigenous
peoples face in both one-on-one clinical encounters and in the face of massive
public health interventions like COVID-19 vaccination in the present day.
The Kaqchikel and Kichwa actors whose traces Carey teases from the state
archives did not perceive a stark choice between “scientific medicine” on the
one hand and “traditional medicine” on the other, no matter how much
Ecuadorian physicians, Guatemalan public health officials, or traveling rep-
resentatives of the Rockefeller Foundation may have liked to portray it that
way. From the very beginning of the introductory chapter, through to the
end of the coda, Indigenous Americans seeking health care in the twentieth
century faced a range of choices and demonstrated practical savvy. They
demanded access and equity in receiving the benefits of biomedicine as well
as the freedom to benefit from traditional birth attendants and the grounded
use of remedias caseras, naturistas, and other curanderos.
In recent years, the Pan-American Health Organization has promoted a
more syncretic approach to intercultural primary health care and integrated
health systems, recognizing that the ability of Indigenous peoples to move back
and forth across a number of healing frameworks and practices is crucial to the
success of future health systems and public health efforts moving forward. That
the existence of Indigenous healing practices and healers could be an asset to
public health efforts, rather than a distraction or competition. That disparities
in access to key economic, political, medical, and public health resources—seen
so dramatically in the present COVID-19 pandemic—is as much or more of a
determinant of disparities in health outcomes as any simple clash between
traditional Indigenous healing and modern scientific medicine.
Health in the Highlands shows this has always been the case.
Jeremy A. Greene
Baltimore, MD
August 27, 2022
xiv • for e wor d
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