A Culture of Solidarity?

Medical Anthropology Cross-Cultural Studies in Health and Illness

ISSN: 0145-9740 (Print) 1545-5882 (Online) Journal homepage: http://www.tandfonline.com/loi/gmea20

A Culture of Solidarity? Kate Centellas To cite this article: Kate Centellas (2015) A Culture of Solidarity?, Medical Anthropology, 34:3, 192-209, DOI: 10.1080/01459740.2014.911295 To link to this article: http://dx.doi.org/10.1080/01459740.2014.911295

Published online: 14 Oct 2014.

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Date: 06 November 2015, At: 04:23

Medical Anthropology, 34: 192–209, 2015 Copyright © 2014 Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI: 10.1080/01459740.2014.911295

A Culture of Solidarity? Kate Centellas

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University of Mississippi, University, Mississippi, USA

In this article, based on interviews, ethnographic data, and documentary evidence, I examine the case of a Bolivian-Iranian hospital in the context of south-south scientific and economic collaboration. This hospital provides a lens through which we can understand the tensions between local and global processes. Medicine, in particular, has become a site where such alignments are made visible and tangible: the term ‘biogeopolitics’ helps to describe this process. I use the hospital as a way to illustrate what theory from the south might look like ethnographically, and conclude with a discussion of the contradictions and promises of theory from the south within south-south collaborations. Keywords Bolivia, Iran, biogeopolitics, interculturality, theory from the south

The year 2009 was momentous in Bolivia. A new constitution was passed by Evo Morales’s MAS (Movimiento al Socialismo, Movement Toward Socialism) party, which declared Bolivia a ‘plurinational republic.’ It also guaranteed the right to free expression of indigenous knowledges, most notably in law and medicine. Morales had made improving health care under an ‘articulated intercultural’ rubric a key component of his platform, and he quickly undertook systemic reforms (Johnson 2010). He received significant international aid targeted at reducing Bolivia’s astonishing rates of maternal mortality, childhood malnutrition, and deaths due to communicable diseases. A significant portion of this aid was in the form of Cuban doctors, who began operating in Bolivia’s hospitals and clinics in 2006. They were paid, in part, by Venezuela as an act of ‘solidarity’ under ALBA (Bolivarian Alternative for the Americas, Tockman 2009). In this context of “medical internationalism” (Brotherton 2012), these multilateral alliances were locally understood as counter-hegemonic to Western, particularly United States, models of health care delivery. The same year that the new consitution was passed, a hospital opened in El Alto, the rapidly growing and dominantly indigenous city located just up the cliffside from La Paz, on the Altiplano. Even given the presence of Cuban doctors and other aid activities, the hospital that opened in 2009 was unique. It was funded entirely by the government of Iran and, unlike the Cuban model, hired an almost exclusively Bolivian staff. KATE CENTELLAS received her PhD from the University of Chicago. Her research focuses on bioscientific and biomedical research in contemporary Bolivia, and how it relates to postneoliberal and pluralist processes of identity formation, knowledge production, governance, and citizenship. Address correspondence to Kate Centellas, University of Mississippi, PO Box 1848, University, MS 38677, USA. E-mail: [email protected]; [email protected]

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In this article, I use the example of the Iranian hospital—and its initially problematic local reception, due to images that circulated in the Bolivian press of Bolivian nurses made to veil at the hospital—to better contextualize and analyze what global health diplomacy may look like when it is conducted from an overtly south-south perspective. In particular, I argue that the Bolivian case is an example that is particularly ‘good to think with’ because of how politicized health care reform has been under Morales, and the complicated southern aligments and entanglements, often under the rubric of solidarity, that have emerged as part of an explicit project of decolonization.


THEORY FROM THE SOUTH AND BIOMEDICAL COLLABORATION The Bolivian example must be understood as “theory from the south” because of how it encapsulates local and global tensions in emerging south-south health collaboration paradigms. The Comaroffs define theory from the south in the interrogative: “What if we subvert the epistemic scaffolding upon which [Euromodernity] is erected? What if we posit that, in the present moment, it is the global south that affords privileged insight into the workings of the world at large?” (Comaroff and Comaroff 2012:1). Later in their introduction, they noted that: The first argument is that modernity in the south is not adequately understood as a derivative or doppelganger, a callow copy or counterfeit, of the Euro-American “original” . . . it is the south that often is the first to feel the effects of world-historical forces, the south in which radically new assemblages of capital and labor are taking shape, thus to prefigure the future of the global north. (7–12)

That is, theory from the south is fundamentally relational (47). It is not caught up in universal historicist narratives, but rather, is dialectically entangled with history, geopolitics, globalization, and the production of localities. The Comaroffs also note the importance of Bolivia in their delineation of how a “new species of political action” has emerged in the global south: Often produc[ing] new social categories (like “the poors” in South Africa; see above), citizens’ movements (like La Coordinadora in Bolivia and the Landless Workers’ Movement in Brazil), coalitions (like the Urban Poor Consortium in Indonesia), even political parties (like Evo Morales’s Movimiento al Socialismo) . . . often conjure with new modes of collective action, new notions of political subjectivity and community, new sorts of sociality and citizenship. (41)

The Comaroffs pointedly use “conjure” to describe the magical, nonlinear, and unpredictable ways in which new modes of being come into existence, a process that occurs with more visibility—even creativity—in the global south. The Bolivian-Iranian hospital illustrates the reconstitution and reimagining of older models of medical diplomacy, internationalism, and geopolitics. I gloss this as biogeopolitics, the overt political alliances made via recuperative biomedical projects. This is not isomorphic with medical diplomacy, but medical diplomacy is often a part of it. And, crucially, there is a reflexive awareness of being en contra to northern modes of subjectivity, politics, even epistemologies. Intellectual property regimes are overtly flouted, medicial systems are formally promoted as ‘intercultural,’ and there is a focus on local practice-making as fundamental. Yet there are missteps, and echoes of older unidirectional models of development aid and global flows of information. The current terrain of health diplomacy is different from past models in the first/second/third worlds schema, even if some of the players, notably Cuba, remain. What is new is the way in


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which medicine has become overtly linked to political projects and alliances, with flexible international funding tied directly to official state projects (e.g., Cuban doctors working in Bolivia and paid by the Venezuelan government, with official approval, from all governments involved, see Johnson 2010:149). This is further inflected by the need to understand and work within local traditions, and the overt emphasis on health within new projects of governance among many nations in the global south. Now this has become global health diplomacy, to borrow a term, with an explicit recognition of “improving global health and bettering international relations, particularly in conflict areas and in resource-poor environments” (Adams, Novotny, and Leslie 2008:316). But in Bolivia, the involved parties are southern nations. The role of medicine here is crucial, as it is where new forms of southern collaboration and expertise, new forms of governance and identification, and complex entanglements of global health and local pressures collide. These processes are writ large in the field of medicine, since it deals with the “limits of bare life” (Comaroff and Comaroff 2012:41) in a fundamental way, and with how body politic(s) are constituted. In Bolivia, this manifests as sweeping health care reforms concurrent with the reconceptualization of Bolivia as a plurination (at least rhetorically). This is meant to remedy the injustices of years of colonialism, oppression, and racism; to create radical equality and pluralism via a healing move to ‘decolonize’ Bolivia (see also Johnson 2010 for a discussion), causing a displacement of “the hegemonic role of western epistemology” (Breidlid 2013:7). In Bolivia, this has lead to a health care reform that valorizes local traditions and practices as more appropriate, perhaps even more effective, then a Western biomedical paradigm. Yet Bolivia also has some of the worst health care indicators in the hemisphere, particularly in maternal and infant mortality, making health care reform both pressing and fraught in the current context of social change. Bolivian reforms were based on pluralist, intercultural, and articulated conceptualizations of medicine and health care delivery, concepts that emerged from global health and the Bolivian context of revolutionary plurinationalism to refound the body politic in order to address profound inequities. Next, I describe the terrain of medicine and health care practices in Bolivia. I then examine how health care reform fits into the Bolivian project of creating a plurinational republic, and analyze the contemporary emphasis on pluralism, interculturality, and articulating medical systems relative to histories of health reform in Bolivia. I discuss the promises and controversies over the Bolivian-Iranian hospital and the biogeopolitical strategy it signals. I contextualize the hospital by describing other forms of global health diplomacy in Bolivia, and how this terrain demonstrates tensions inherent in the south-south model: caught between local, particularist tendencies and more homogenizing forms of self-conscious counter-hegemony and international solidarity. These are the same tensions that some (e.g., Postero 2010) point to as fundamental, even irresolvable, issues within the Morales regime itself.

METHODS This article is based on interviews with medical personnel—doctors, nurses, and biomedical researchers—I conducted in Bolivia in 2011 and 2012. I interviewed 16 Bolivian professionals, many of whom I have known for several years and have been active participants in my ongoing research into Bolivian science (Centellas nd). These interviews, conducted using a semistructured schedule, inquired about the changes to Bolivian healthcare under Evo Morales, the role of


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Cuban medical personnel, and how they viewed the Bolivian-Iranian hospital. These interviews were coded using a minimal coding tree to flag mentions of international collaboration, local impact, interculturality, and decolonization. The quotes I have selected for inclusion were chosen because of their clarity. They crystallized sentiments I heard in my other interviews, however, and are representative of the interview pool. In addition, I visited several government ministries and conducted short interviews with personnel there, and collected any available official publications regarding health care reform. I also visited the Bolivian-Iranian hospital on several occasions. Finally, I conducted extensive newspaper searches in four major Bolivian dailies for mentions of the hospital in popular press articles, and analyzed these. I have assigned pseudonyms to all interviewees quoted in the text and all translations from Spanish are my own.

MEDICINE AND REFOUNDING BOLIVIA Bolivia is a location of multiple intersecting medical traditions. Not surprisingly, much foundational anthropological research on medical pluralism and social change have focused on Bolivia (Bastien 1985, 1987, 2003; Crandon-Malamud 1991; Koss-Chioino 2003). Diverse and distinct practices have always coexisted in Bolivia, sometimes, but not always, linked to specific indigenous groups or ethnic identities. This includes highly respected and institutionally recognized formal traditions such as Kallawaya herbalism (Fernández-Juárez 2006; Johnson 2010); Aymara shamans known as yatiris and female healers known as amautas (Sikkink 2010); urban polymathic herbalists; naturistas (natural medicine practitioners); practitioners of Chinese medicine; and syncretic traditions that incorporate Catholic saints, Andean herbs, and lowland items into curing rituals (Beatriz Loza 2008; Pérez Mendoza and Fuentes Mamani 2009; Sikkink 2010; Spedding 2011; Tapia, Royder, and Cruz 2006;). Bolivians—urban and rural, indigenous and nonindigenous—utilize a range of medical traditions in their lives, and recognize certain practitioners as being particularly skilled for specific conditions. Navigating the complexities of medicine in Bolivia requires passing through what a recent book pithily termed “the labryinth of healing” (el laberinto de curación) with individuals undergoing highly variable, idiosyncratic, and extended therapeutic itineraries in order to arrive at a diagnosis and effective treatment (Beatriz Loza 2008). As Bolivia rapidly urbanized in the 1980s—a process that began with neoliberal structural adjustment that closed many government-run mines and industries during the debt crisis—instead of an erosion of what is locally referred to as traditional medicine, there has been a diversification and strengthening of nonbiomedical approaches to health and illness (Sikkink 2010:3). This has continued in the postneoliberal period, beginning about 2000, concomitant with the rise of indigenous-ethnic populist politics (Madrid 2008) and a drive to decolonize Bolivia from Western epistemologies (Artaraz 2012). Given this diversity, it is not uncommon for Bolivians to decide between “Mentisan, paracetamol, or wira-wira?” as a book on health and interculturality was recently entitled (Tapia et al. 2006).1 Bolivian biomedicine is historically linked to a hierarchy of knowledge systems that operated under a West-is-best mentality, including an outright rejection of local epistemologies and healing practices as antimodern or backwards. However, Bolivian biomedicine was always already political for how it tried to address the ‘indian problem’ during the late nineteenth and twentieth centuries (Gotkowitz 2007; Larson 2004). Racism and severe, pervasive discrimination by


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the governing white super-elite against Bolivia’s indigenous majority meant that many Bolivians were at best hesitant to use the clinic, if even available (Zulawski 2007). Yet this was tied to a long rhetorical tradition of health care as a citizen’s right, a national commitment that emerged following the devasation of disease during the Chaco War (1935–1939) and the rise of socialism and populism (Gotkowitz 2007; Zulawski 2007). In the early- to mid-twentieth century, “It was a populist, democratic discourse about health and medicine that helped cement doctors’ professional authority” (Zulawski 2007:84) in Bolivia, such that in the 1930s and 1940s “Western medicine became central to the country’s reform effort” (194). Thus, in Bolivia, medicine has always been a political issue, one of identification, culture, and governance, tied to state-making plans and the constitution of the national body (see Cohen 2012 for culture and medicine more generally, as well as Yúdice 2003 for the uses of culture). The focus on health care as a right of Bolivian citizens was reinforced following the Movimiento Nacionalista Revolucionario (Nationalist Revolutionary Movement)-led 1952 Revolution. However, for years there was little change in people’s health status. Indigenous peoples remained marginalized from biomedicine due to distance, cost, and structural discrimination, and medical facilities were understaffed and underequipped. From 1952 to 1985, however, the number of Bolivians covered under some sort of social security plan doubled, from 13.8% to 26.3% (Wanderley 2009:255), due, in part, to the social constitutionalism that had emerged in the populist period of the late 1930s–1940s, culminating in the 1952 Revolution and reforms. This social constitutionalism ended, in part, in 1985, when the New Economic Plan was signed by then-president Victor Paz Estenssoro. This formally began the program of structural adjustment that strictly followed the recommendations set out in the Washington Consensus (Postero 2010; Wanderley 2009). Then, under president Gonzalo (Goni) Sánchez de Lozada’s first term in office (1993–1997), the Law of Popular Participation (LPP) was passed, which strengthened neoliberal reforms while increasing local autonomy in decision-making, local authority, and formally recognizing the state as a multicultural one, with more rights given to indigenous peoples. The LPP “through the medium of neoliberal multiculturalism, it offered a new form of citizenship based on a decentralized system of popular participation in municipal development decision making” (Postero 2007:62). For many Bolivians, however, these reforms were not profound enough to dismantle the exclusionary institutions and practices of the old Bolivian state (Canessa 2012; Johnson 2010; Lazar 2008; Postero 2007). And these reforms, along with their unrealized promises, were the conditions of possibility for the formation of MAS (Postero 2010). Crucial to this neoliberal multiculturalism, and alongside notable reforms in education and municipal power, was the emergence of several universal health care schemes for women and children as a way of ameliorating inequities and persistent racism in Bolivia. Maternal and infant mortality became a foil for state irresponsibility, a narrative quickly shifting and slipping from one of state abdication despite promises, to one of state healing and nurturing future citizens. The targets of governmental health care programs were dominantly women and children due to the astonishing death rates of both women and children, and, I think, also because of how women are often thought of as ‘social mothers’ to the nation in Bolivia (Stephenson 1999). Locally women are understood to literally birth the body politic, and therefore are deserving of specialized programs. Of course, women’s bodies were therefore the ones under scrutiny, surveillance, and possible enrollment into hegemonic biomedical practices, often contra indigenous ones, and therefore were the locations of resistance and politics writ small. For instance, Morales also started other health care and nutrition support plans that specifically target women and children.



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Two—the Bono Juancito Pinto and the Bono Juana Azurduy—have proved extremely popular, with significant publicity and public participation. The Bono Juana Azurduy is named after a militant indigenous/mestiza independence leader, often pictured riding into battle with long braids while carrying a baby in a traditional aguayo (woollen woven shawl) in one hand and a rifle in the other, a strikingly militant and nationalist image. Juancito Pinto pays families for their children to attend primary school and provides nutritional support, while Juana Azurduy pays mothers to attend prenatal checkups and to bring infants to bimonthly checkups. The two are often discussed in Bolivia as signs of commitment to Bolivia’s future by the Morales government.2 The most recent iteration, SUMI (Maternal and Child Insurance), became law just before the fall of Goni in 2003. SUMI varied from its predecessors—the National Maternal and Child Insurance and Basic Health Insurance—in that it did not cover all women of reproductive age, only pregnant women, and did not provide comprehensive women’s health services. All plans covered children up to the age of five. Under these plans, maternal and infant mortality did fall, at least initially. Yet, as a recent report notes, the earlier decline in maternal mortality has almost been erased despite gains in infant mortality statistics. In 1989, there were 419 maternal deaths per 100,000 live births and 230 deaths per 100,000 in 2003. This increased to 310 deaths per 100,000 in 2008 (Silva and Batista 2010:12), in part due to the more restricted coverage SUMI offered beginning in 2003. This rate is the highest in the Americas, after Haiti, and illustrates the profound challenges in health care in Bolivia, challenges made more acute when the rural maternal mortality rate is considered, with some estimates ranging as high 887 deaths per 100,000 live births (UNICEF 2001). Previous plans emphasized a hierarchical, biomedical approach at the expense and exclusion of traditional medical practices and epistemologies. Long-standing promises of providing health care for Bolivian citizens, particularly the women and children who would reproduce the future nation, thus appeared unfulfilled in 2005, at the end of the period of social crisis that led to the election of Evo Morales. The period from 2003–2005 was characterized by chronic instability and frequent conflict. Protesters’ demands included an end to neoliberal reforms, re-nationalization of many industries, better social welfare programs, a greater voice for Bolivians of indigenous descent, and more local control over national resources. Morales was elected on a decolonizing and antineoliberal platform. He quickly began reforms after his inaugaration in 2006, with the release of the MAS National Development Plan, in which health care reform plays a central role. Part of this was to extend SUMI benefits to reach more Bolivians, and to implement SAFCI (Salud Familiar Comunitaria Intercultural, Intercultural Family and Community Health), signed into law in 2008 (Johnson 2010:144-146), with interculturality of both biomedical and traditional approaches prominent in the program itself. This approach is echoed in the new Bolivian constitution, passed in 2009. The constitution promises that “traditional medicine . . . will be valorized, respected, and promoted,” (Cap. IV, Art. 30.9) and guarantees a “universal and free healthcare system that respects [indigenous] cosmovisions and traditional practices” (Cap. IV, Art. 30.13). Alongside this legalese was the implementation, at least in some hospitals and public facilities, of consultations by yatiris or kallawaya healers, if desired by the patient, and an expansion of the state health care system, including traditional medicine practitioners. These indigenous healers can consult with biomedically trained physicians (in Bolivian Spanish known as galenos or Galenic physicians) and prescribe certain remedies, which are supposed to be respected and integrated into patient care even within biomedical institutions. More than 2500 traditional medical practitioners, many working in state


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medical clinics, had been accredited by the Ministry of Health by mid-2013. This is discussed in Bolivia as the “articulation” of different medical systems in an intercultural framework, and ministry officials have recently touted how multiple different systems work together “without problems” yet remain epistemologically distinct (Pérez 2013a, 2013b:1). Locally, Bolivians have viewed this as a tremendous step toward ameliorating the barriers to adequate patient care for the majority indigenous population because of how it enables a more holistic approach, though without necessarily blurring or hybridizing biomedicine with indigenous practices. Articulation and interculturality are widely discussed in Bolivia as being part of a process— specifically of decolonization—and not yet as fixed outcomes. How far these reforms go in practice and implementation is still undefined, and varies from case to case. And, as Johnson (2010) has noted, decolonization and interculturality go hand in hand, one is required for the other, with both concepts essentially ‘institutionalized’ in Bolivia. I turn to this relationship in the next section.

ARTICULATION AND INTERCULTURALITY Interculturality is not without its critics. In Carmen Beatriz Loza’s masterful book, The Labyrinth of Healing (2008), she excoriates how interculturality has been used and deployed within some of the new Bolivian healthcare programs. First, she argues that interculturality is still an “imported concept,” often funded by aid programs (76); she in turn emphasizes the need for fundamentally local solutions. Further, she argues that by adopting the idea of interculturality, the Ministry of Health strengthened biomedical hegemony (77) due to the verticality, low funding, and centralization of intercultural healthcare programs in Bolivia (83–85). There is perhaps some truth to this—particularly in her argument that interculturality has become a catch-phrase but not a substantive or fully developed approach, and that intercultural health care in Bolivia has been promoted by external interests (see Fernández Juárez 2006 for example). However, considering SAFCI was only signed into law in 2008, the same year of Loza’s book, it is difficult to tell how far the intercultural portion of the reform will go, and what impact it may have on the material practices and health outcomes of Bolivians. However, critically, interculturality assumes there are limits to knowledge; not every specialized practitioner is appropriate to treat a specific malady. And, in theory, these different traditions are supposed to be “equal in hierarchy,” according to the constitution, a move meant to remove some of the lip service paid to traditional medicine and provide it with authority and epistemic weight on par with biomedicine. Crucial to these limits to knowledge is the local emphasis on articulation of intercultural spaces, as I have discussed in detail elsewhere (Centellas 2011). Interculturality could not exist without a mechanism by which different groups can interact, yet maintain some degree of autonomy and agency. Articulation here implies a touching, a mutual recognition, yet with some forms, practices, and knowledge traditions mutually identified as distinctive and independent even if potentially complimentary. This is not about blending, syncretizing, or homogenizing. It is about maintaining the space for difference with a mechanism for dialog and communication. There are distinct linkages institutionally and conceptually with earlier neoliberal health care models, particularly in the emphasis on mothers and the appeal to liberal institutions such as government ministries as a way of gaining recognition and fomenting change (Postero 2010). Yet



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interculturality and decolonization—both processes, not achievements, unlike how multiculturalism was perceived in Bolivia (Johnson 2010)—have the potential to trouble the neoliberal lineage. My argument here is not that interculturality is always already going to point to a biomedical model with a veneer of indigeneity, as Loza suggests and a multiculturalist model implies, although this potential exists. In some ways, this argument misses the point. Rather, interculturality has taken on its own local meaning and power in Bolivia, not just in government ministries but also among community organizations, activist groups, and others (Delgado and Escóbar 2006). The meaning of interculturality and the existence of intercultural spaces where articulation can occur are profoundly motivating in local contexts. Yet there is still concern about knowledge, practices, technologies, and people being imported from ‘outside’ (often heard in Bolivia as simply afuera), with these foreign things seen somehow inappropriate for local needs and desires and therefore impinging on Bolivian sovereignty. This is where the complicated issue of biogeopolitics, which I define as the overt political alliances made via recuperative biomedical projects, enters my story. The MAS government, like other administrations before it, recognizes and emphasizes the importance of better health care for Bolivians. Yet it cannot achieve better health without some foreign assistance, despite careful plans to foster better medical training and encourage the utilization of health care facilities (broadly defined) within Bolivia. The Iranian hospital is located at the nexus of these tensions, contradictions, and promises.

SOLIDARITY BIOGEOPOLITICS Ethnographic examples are good to think with. The Iranian hospital is an example of solidarity biogeopolitics—an alliance among two nations that is manifested via a medical program or project, with solidarity serving as a reference to how it is locally perceived as counter-hegemonic, with the allies standing together against northern models, practices, and alliances. Recall that the same year the new constitution passed, a large, well-equipped hospital opened in El Alto, Bolivia. It was financed and promoted by Iran and is named Hospital of the Islamic Republic of Iran. The logo is not subtle: the Iranian red crescent is prominently featured on the building and in promotional materials. A blog, established at the time to promote the hospital and Iranian collaboration with Bolivia, stated that the goal of the hospital was to “contribute to the improvement of the population of El Alto’s health by developing and offering primary health services of quality, warmth, and accessible prices for the community, seeking the maximum satisfaction from our users and to achieve excellence in our institutional performance in the field of healthcare” (iranboliviah.blogspot.com). The emphasis on the hospital as a place of warmth perhaps represents an attempt to differentiate this hospital facility from others, by emphasizing a particular form of medical culture and praxis that is more open and respectful of diverse individual needs, what Briggs has termed a “medical humanitarian habitus” (2011:1040). Prior to the hospital’s inauguration in late 2009, coverage in Bolivian papers emphasized, often quoting Ministry of Health and other MAS officials, how the hospital was equipped with “appropriate” technology for the location, how desperately El Alto needed medical facilities, and how costs would be very low despite high quality, particularly in maternal-infant care (see El Diario 2009a, 2009b). This interpretation also was fostered by local media outlets promoting the Iranian perspective on the hospital, including the blog mentioned previously and several featured newscasts published on YouTube. These stories generally included an implicit criticism


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of northern nations, in contrast to Iran for not ‘collaborating’ in locally appropriate ways, such as providing effective yet low-cost technologies to hospitals (i.e., the frequent use of the term ‘appropriate,’ thus implying there is some technology that is inappropriate to Bolivia for various reasons). For instance, Iranian officials repeatedly emphasized how the medications used in the hospital are Iranian and of high quality but low cost, unlike patent-restricted Northern name brands (iranboliviah.blogspot.com). Several reports from MAS-affiliated news sources, particularly the party newspaper Cambio and the affiliated radio network Erbol, referred to the hospital as an example of “solidarity in the midst of poverty,” between the nations, with the socialist overtones intended (Revista 7 Días 2011:1). Yet pictures soon surfaced on Bolivian blogs and newspaper sites showing Bolivian professional staff members—many of them women of indigenous heritage—wearing a veil as a condition of employment during the official inaugaration ceremony and immediately after, as they attended to their first patients. The inaugaration ceremony was presided over via teleconference by President Ahmedinijahd during one of his several official visits to Bolivia (see Figures 1 and 2), which is indicative of the importance the Iranian government placed on the hospital. Bolivian blogs and newspapers were outraged by these images. They claimed that veiling was a similar violation of sovereignty and cultural self-determination as indigenous Bolivians had experienced for decades, and soon there were calls to boycott the hospital. Bolivian officials claimed that the veil regulation was leading to a “loss of identity of Bolivian women,” and impinged on the right to self-determination of the 36 officially recognized nationalities within Bolivia (El Diario 2009c). And then, without much further fanfare, the issue faded away. Nurses are now able to dress in the typical Bolivian nurse uniform of a white laboratory coat and white slacks, no veil. In interviews I conducted in 2011 and 2012, health care workers and health care researchers in Bolivia indicated that this hospital does not hire Iranian or Iranian-trained personnel, except for the director and vice-director. This is unlike the Cuban model of medical brigades of physicians

FIGURE 1 Bolivian nurses at the opening ceremony of the Bolivian-Iranian Hospital, 2009. Image originally appeared in Los Tiempos (2009), but soon was reproduced on multiple blogs.



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FIGURE 2 Bolivian nurses and doctors at the opening of the Bolivian-Iranian Hospital, 2009. Image originally appeared in El Diario (2009c), but also was quickly picked up by Bolivian and other Spanish-language blogs.

that work in Bolivian facilities, often alongside Bolivian professionals. The hospital employs Bolivian doctors, nurses, and professionals, most of who claim indigenous or, at minimum, mestizo/a identity, and are familiar with and utilize traditional remedies in their personal health care. Most with whom I spoke felt that the hospital was a sign of solidarity among like-minded nations against traditional northern forms of aid, using a phrase that I often heard repeated (“solidarity”) in interviews and newspaper articles. A young nurse with an MA in biomedical research, from a background she describes as “humble” and indigenous, told me that: Well, you see [author’s name], we need this hospital. They know what it is like, working with scarce resources, and we don’t have many facilities, you know, quality facilities, here [meaning El Alto]. Our problems here are so difficult, seeing the mamas and babies get sick. And we don’t have to worry about some of the rules about materials and medicines that you might get in other clinics, those funded by Europe or the US. Plus the cost is very low, even for here, so that it is more democratic. Interview with Ana Mamani, June 14, 2012

Here, Ana references both pressing biomedical needs (though possibly excluding plural forms of medicine), and a different form of medical practice, a different set of ‘rules’ than northern nations (she assumes). She also makes the connection overt between local concepts of democracy—here, an egalitarian and accessible ethos, even habitus, despite scarcity—and medicine. In other words, she is not claiming that a northern model of medicine is desirable in Bolivia, nor even appropriate.


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Furthermore, she is making a connection that Iran and Bolivia are more similar to each other than to northern nations, which she sees as a benefit. No one I interviewed who works for the hospital wanted to discuss the veil, claiming it had been a mistake, or something that had been done only for an official opening ceremony. My questions regarding the veil were either brushed off, with responses along the lines of “I don’t know about that, I remember the articles but I wasn’t involved,” or saying it was justified for the opening ceremony, as a sign of respect for Iranian culture. Personnel who are not directly affiliated with the hospital were quicker to criticize the veil pictures as an example of exploitation or of locally inappropriate cultural norms. An official in the Vice-Ministry of Traditional Medicine told me that he “did not like that, not at all. We’re fighting for awareness and respect for our traditions, that needs to be the first thing, to focus on valorizing our local beliefs” (Diego Choque, May 23, 2011). Another official at the vice-ministry told me that the focus should be on articulation between and across systems, not hybridization, which she thought the veil represented (Jasmín Ascarrunz, May 24, 2011). Here, of course, both officials allowed for interculturality among Bolivian epistemologies, but not Bolivian-Iranian interculturality. Nationalist interculturality is fine, but internationalism remains suspect. Yet, after I asked about the veil, the female nurses and doctors affiliated with the Iranian hospital all were quick to claim that they are free to provide ‘appropriate’ treatments and that their (Christian/indigenous) traditions are respected and allowed within the hospital. Several pointed out that they conduct periodic ch’allas—ritual blessings—in the facility and with the participation of the staff.3 A young female obstetrician told me “well, our population here is mainly indigenous, and we focus on birth here. So I try to make sure that their beliefs are respected, as much as possible, you know, making sure the room is warm, lots of blankets,” (Maria Quispe, June 22, 2012). Despite her biomedical training and her employment in a biomedical facility, she made it a point to let me know how they try to accommodate local beliefs around birth, in part, perhaps due to the widespread local concern with the high maternal (and infant) mortality rate. Hospital personnel are quick to say that because the price for a consulation is very low, the medicines are often off-patent (sometimes purposefully breaking international patent law and intellectual property regimes), and the hospital is staffed by Bolivians, they are able to provide good care to the people who need it most, generally women and children, in a familiar environment, aligning the hospital with the goals of SAFCI. Here again is where the local and the global collide, in what Didier Fassin has called “that obscure object of global health” (2012:96). He argues that “in spite of globalization, most health issues and policies remain national, even local” (96) while simultaneously “global health implies the transnationalization of medical practices” (103), including technologies, expertise, and people. This leads back to the tension between local norms and the solidarity biogeopolitics that the Bolivian-Iranian hospital is caught up within and between. I suspect that if the veil requirement had not been lifted, the hospital would not have succeeded. Instead, the hospital itself has become part of the panorama of health care delivery in Bolivia. There are limits to interculturality, particularly when one of the parties is from outside and thus cannot claim a particularly Bolivian subjectivity. Thus, the hospital reflects and represents the overt political motivations behind Iranian-Bolivian collaboration (which goes beyond simply the hospital, although the hospital is the most tangible result at this point). This alliance is overtly discussed within Bolivia to be counter-hegemonic, against Eurocentric and US modes of development and collaboration. What are some other motivations behind this alliance? And


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how does it fit into the broader context of global health diplomacy (a kind of biogeopolitics) in Bolivia? I turn to these questions in the remaining sections.


BUT THEY COLLABORATE! RUMORS, CONFLICT, AND MEDICAL INTERNATIONALISM It is not just in medicine that Bolivia and Iran have ties. At least, that is the rumor. Certainly, Morales and Ahmedinijahd becoming allies, with several official state visits by each leader and copious photo opportunities, has made many northern powers, notably the United States, extremely nervous. In Bolivia, this alliance has transmuted into gossip about how Iran is collaborating (collaborar) with Bolivia in health care in order to gain access to some of Bolivia’s precious mineral resources and thus skirt international sanctions.4 This is an old narrative, with aid promised in exchange for the right to extract nonrenewable resources to enrich foreign coffers, and it presumes a fundamental geopolitical asymmetry. For instance, in 2011, I was in a taxi heading from Sucre, Bolivia to Potosí, the former mining capital that produced much of the riches that built the Spanish empire. The narrow paved road wound through green valleys, past large rivers, and quickly began climbing to the Altiplano. Soon the terrain became much drier and austere. The road, too, was soon clinging to the sides of mountains, and I could hear the engine straining to accelerate uphill at 14,000 feet above sea level. We passed an oddly European looking feudal bridge and drove into a canyon with even sparser vegetation and stunningly colored cliffs of purple, orange, and green. I soon felt myself drifting off to sleep. Then the taxista leaned over and elbowed me gently: Hey. Hey! You know, I drove some Iranians here a few months ago. They say we have some of the best uranium around and they were looking for it here. Not much has been explored in this area, all the focus has been on Potosí for so long. That’s why nothing lives here, the radiation kills everything. That’s why the fish are dying.

I must have looked skeptical, for he continued: No, I’m serious. They’ve been coming here more and more since Evo has been in office. We have a lot that they want, and they have technologies that are more appropriate for us, for our conditions. But I don’t know what they’ll find, or if it will help us at all. Better them than some of the others, though. I don’t know if they found anything here. I don’t know, (June 2, 2011)

I was surprised that my taxi driver took it upon himself to tell me where the uranium was supposed to be and that he personally had taken a group of Iranians there. But, I thought to myself, of course there is a local story of Iranians hunting for ‘the best’ uranium in Bolivia. The healing hospital does not come without a potential external danger to self-determination. This story encapuslates the fear many Bolivians have about outside meddling and loss of control of resources, yet with an asterisk. The Iranians are portrayed again as somehow better for Bolivia than the typical northern powers because “they have technologies that are more appropriate for us, for our conditions,” even if the rough outlines of the relationship between Bolivia and Iran seem to follow traditional lines. They are, to use a trite term, seen by many Bolivians as a less bad alternative. This rationale is similar to the reasons I heard for the Iranian hospital after the veil controversy had died down.


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The Iranian hospital must also be understood in the context of ALBA and Cuban medical internationalism. ALBA (the acronym means “dawn” in Spanish) was founded in 2004 by Chávez and Castro to counter neoliberal forms of aid and regional trade agreements, and includes Bolivia, Venezuela, Cuba, Nicaragua, and Ecuador as member states. It has been described as a fundamentally new geopolitical paradigm, one based on the innovative dimensions of the social revolutions based on the “politics of recognition” underway in member states, rather than social reform “following imported recipes” of aid and development (Artaraz 2012:36). Although Iran is not a member of ALBA, it is an ally of many ALBA affiliates. The connections and alliances made via (or in the name of) ALBA are not soley economic, at least at the outset. The goal is to challenge northern models of diplomacy, aid, economics, power, and epistemology. Perhaps the most striking way in which this bloc has manifested as an entity—the way material support and connections have been forged, flowed, and perpetuated—has been via medical collaboration and medical diplomacy. In particular, Cuban doctors have played crucial roles in health care reforms in many of these nations, most notably Bolivia and Venezuela. There are more than 1200 Cuban physicians in Bolivia as of 2012, located in rural public health posts, hospitals, and specialized clinics (Embajada de Cuba in Bolivia 2012), their salaries paid by Venezuela. This is a convoluted arrangement, yet one that makes strategic sense if we think like politicians trying to strengthen ties between allies and thinking consciously about how to make tangible their alignments and interrelationships for observation by other nations. A few years prior to the opening of the Iranian hospital, Morales invited many Cuban brigades to Bolivia to work directly in health care, locally described as a collaboration. Many Bolivian physicians were upset by the presence of Cubans in Bolivia, feeling that Bolivian health care should be the responsibility of Bolivian physicians, who were well-trained but underpaid. The medical college of La Paz even threatened to strike if the Cubans were not sent home (Beatriz Loza 2008:70–86; Johnson 2010). But this proved ineffective, and the Cubans stayed. One biomedical researcher—herself not a physician, although her research focuses on communicable dieseases of early childhood—reflected on the Cuban controversy: It is better for the Cubans to be here, to be here in solidarity with us, than to have no one. Yes, it would be better for Bolivians to work in these rural areas, but we are working on it, trying to change the curriculum, get more of a sense of responsibility and respect into medical training. Bolivia needs that, we need to see all of our traditions. That will take some time. But at least the Cubans have a sense of the social aspect of medicine, and can help us. I’ve had good luck with them [in the hospital where she obtains many research samples], they aren’t as overbearing as some of the foreigners who come here, the ones who think they know better and should have the right to our resources. (Dra. Helga Gutierrez, June 1, 2012)

Again, the tension between local needs and desires, and international practices and interventionism, is clear. The Cubans, at least in Dra. Gutierrez’s view, are better than other foreigners because they do not embody a kind of imperial notion of north-south transfer. She reserves her critique for the system of medical education, once a bastion of elite (or at least urban and upper-middle class) training in Bolivia. Of course, there is a long history to medical internationalism as a way of inclucating noncapitalist values. Cuba has been sending doctors abroad since the 1960s as part of its project of medical diplomacy and internationalism. This model is by no means pluralist or intercultural



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(Briggs 2011; Brotherton 2012:169–181; Hickling-Hudson 2004), but rather vertical and hierarchical, with biomedical knowledge privileged. Furthermore, physicians from all over the global south have trained in the Cuban model of social medicine in Havana, via scholarships to the Escuela Latinoamericana de Medicina (Brotherton 2012:172). This training “is about producing physicians on an international scale, physicians who reflect the country’s socialst values and ideals” (171–172). These Cuban physicians are thus a good fit for Morales’ socialist project, perhaps even more so than some Bolivians trained in the universalist biomedical model, as hinted at by Dr. Gutierrez. But the Cuban model is not intercultural, nor does it provide space for the diverse medical traditions that are supposed to be represented and respected in Bolivia. And, of course, the Cubans displace Bolivians while healing Bolivian bodies, creating some notable local resistance. The Cuban model is influential in the Iranian hospital, and locally understood as an example of solidarity against northern meddling, a tangible example of how southern nations can go at it themselves, without reliance on traditional hegemonic powers. Yet it is not without local dissent and contradiction, particularly around how it still privileges foreign experts and a homogenizing (not intercultural) model of health care delivery. This circles us back to the tension between local and nationalist desires—a profoundly decolonized and intercultural approach that ameliorates inequalities—and global processes and alliances, a more traditional form of alliances, with universalist approaches dominant.

ARTICULATING COUNTER-HEGEMONIC MEDICAL PRACTICES In recent interviews I conducted in Bolivia, many health care providers claimed that the plurinational reforms foster different kinds of national and international collaborations than what came before. In particular, they argued that these reforms help create articulated intercultural medicine in an appropriate way, and cited the Iranian hospital as one example. My interviewees, as well as local Bolivian media, note how these are collaborations in solidarity with Bolivians, as opposed to the more overtly hierarchical and asymmetrical relationships of traditional north-south aid. Using this emic category, it helps to think of the Iranian-Bolivian hospital is an example of a kind of articulated intercultural medicine, one that utilizes different knowledge traditions and practices together but without attempting to hybridize them. Yet the global entanglements and contradictions are apparent, with distinct variation in approach by various southern nations in collaboration with others. This is related to the goals for the health care system set forth in the constitution, a model that emphasizes how different medical practices and knowledge traditions can work together, are not mutually exclusive, and yet can maintain some degree of autonomy or independence from one another. In the hospital, certain traditions are respected, such as women being able to give birth in a warm and dark room while moving around and so on. The pictures of nurses wearing the veil are glaring in this context, yet this requirement was quickly eliminated (perhaps for geostrategic reasons). Since medicine in Bolivia is explicitly political as well as plural, regardless of institutional support, the move was perhaps intended to signal an alliance and growing power among two southern nations who have shaky relations, at best, with the United States. This is how we can understand the very calculated pictures of Ahmadinejad and Morales embracing that surfaced at the same time as the hospital opened, the publicity surrounding the hospital and other promises of Iranian cooperation, and the taxi driver’s story about uranium.


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There are strategic interests at play here of a traditional kind. But there is also much that is a performance of a kind of counter-hegemonic stance, a rejection of northern models of development, aid, knowledge production, and, within that, medical practices and procedures. This alliance chooses to global pharmaceuticals and does not respect intellectual property regimes. This is not simply because such things are locally viewed as unethical and emergent from neocolonial institutions, for instance. Instead, the Bolivia-Iran collaboration emphasizes local connections, practices, and the political and epistemic implications of such southern alliances. Within that, there is a story of self-consciously counter-hegemonic bodies being treated by, but also utilizing and being healed by, what is locally called articulated intercultural medicine. This needs to be thought of as a space where particularist instantiations of biomedicine, inexpensive Iranian-supplied pharmaceuticals and equipment, and traditional practices like a ch’alla or visits by a yatiri coexist, yet do not necessarily hybridize or synthesize. In this way, the story of Iranian-Bolivian collaboration can be understood as theory from the south, particularly when contextualized within the backdrop of ALBA, Morales’ move to decolonize Bolivia, the rise of south-south collaboration generally, and the long history of Cuban medical diplomacy. An articulated intercultural system is one manifestation of theory from the south because of how it presents a challenge to hegemonic norms of health care delivery, development aid, and geopolitical cartographies, a specific kind of biogeopolitics that imbricates nationalist and internationalist ideologies in how it is instantiated. The emphasis—not on hybrids but on articulation, not on multiculturalism but on pluralism, not on ‘tradition’ and ‘modernity’ but instead ‘inter,’ with a rather postmodern awareness that medicine, knowledge, science are always already political—is quite insightful. It reminds us of the Comaroffs’ recent discussion of how “contemporary world-historical processes are disrupting received geographies of core and periphery, relocating southward—and of course eastward as well—some of the most innovative and energetic modes of producing value. And, as importantly, part or whole ownership of them” (2012:7). Yet there is still the ghost of the veil on indigenous women as a condition of aid, one that was erased quickly, but hints that even in south-south collaborations—both those created for overtly counter-hegemonic reasons and those whose challenges to traditional models are more subtle— there remains the potential for hierarchies of knowledge and development aid with ideological strings attached. The irreducible tension here may be between global homogenizing or universalizing forms—even if they are counter-hegemonic and done in solidarity with one another—of collaboration and aid, and the local particularities of health, culture, and knowledge. The contours of what this means long term, and if these models are really different, remain undefined.

ACKNOWLEDGMENTS This manuscript benefited greatly from the careful and critical comments of three anonymous reviewers. I also am thankful for the tremendous support I receive in Bolivia. This project was approved by the IRB of the University of Mississippi.

NOTES 1. Mentisan is a locally commercialized Bolivian herbal salve, paracetamol is a biomedical product, and wira-wira is a well-known Andean herb used for home treatments of colds and other maladies.



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2. Venezuela has provided some of the funds for these programs. 3. A ch’alla is a blessing done on a building and people within it at propitious times of year, often to ask for pachamama’s (often glossed as the Andean “earth mother”) good wishes in the months and year to come. Often a small packet filled with incense, coca leaves, cigarettes, a dried llama fetus, and small sugar models of important items is burned and then buried on the grounds. The walls and doors are decorated with flowers, confetti, and streamers. Generally, copious amounts of beer and grain alcohol are consumed, with the participants themselves also draped in streamers and wreathed in flowers. These are common in governmental facilities and private homes in Bolivia during particular festival events, most notably the Aymara New Year at the end of June, in early August, and around Carnival. In my previous research, I observed many ch’allas in laboratories, research institutes, university facilities, and hospitals. In June 2012, at the time of the Aymara New Year, the hospital was decked out and properly ch’alla’d. 4. Collaborar is widely used in Bolivia. Literally translated, it means “to collaborate.” But there are subtle implications of the term in Bolivian Spanish. Specifically, it is often used to indicate how a higher-status actor is financially aiding or contributing to a project or a request by a lower-status actor, and therefore creating social ties and bonds of reciprocity. In this case, Iran is higher status, due to greater wealth and awareness on the global stage. It is not simply a neutral term, but one that conveys an insightful social analysis.

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