Yesterday I went to a conference led by the Universidad Nacional’s research group “Antropologia Medica Critca.” Anthropologists, doctors (both in “Western” and traditional medicine), social workers, lawyers, health insurance representatives, and students all attended. The conference focused on intercultural interactions within the health system at various levels. We discussed ‘interculturalism’ amongst health workers (e.g. doctor to nurse interactions), within doctor to patient relationships (e.g. indigenous patients with Westernized doctors), and between health workers and the capitalist system they are subjected to that influences protocols. Specifically, we focused on the problem of language and understanding with medical interpreters and the ethical/problematic implications of administering “Westernized” health care to people with different interpretations of disease or different concepts of how to confront health issues.
The most interesting part of the conference was questioning the role and responsibility of the Anthropologist who conducts ethnography within the health/medical context. One of the key note speakers, an Anthropologist who conducted fieldwork in Laeticia with an indigenous group of people living with HIV, commented: “You have to ask yourself, what is the purpose of this ethnography? If I interview someone and hear that they are having difficulty receiving care, is it ok just to sit and listen and transcribe the interview? I say no. Ethnography within the health field is political, it should be approached as Participation Action Research, or participant observation. In other words, the Anthropologist has the responsibility of acting based on the information he/she collects.” I really enjoyed this point because it gives Anthropology a significant role in its capability to produce change. I have been asking myself this question as I interview street people about their experiences in access to health. When they tell me, for example, that a doctor has refused to operate on them because the operation is costly for the hospital and the patient is entitled to free service based on their socioeconomic condition, what do I do to help them? I think that multidisciplinary teams could work miracles in these cases. If I could work with a conscientious lawyer and doctor, we could see to that the operation had to occur based on the constitution’s definition of the right to health. I am actually referring to a true story, based on an interview I conducted today with a sex worker. I’ll call her Mona because that’s her nickname (it refers to her lightish skin, and hair, people call blonds ‘monas’). Here is her story:
Last April of 2009, Mona was thrown off the third story of an apartment building. She woke up in the hospital of San Jose with a fractured pelvis, broken leg, and disfigured face, not remembering anything from the day before. Mona was held there 6 days and when she was told that she would have to pay more than 1 million pesos (over $500) for her stay, she shouted at the doctors to release her as she could not pay the fee. The doctors agreed to her leaving provided that she pay eventually, but Mona left immediately, forgoing the payment and still in critical condition. Mona arrived home in a taxi unable to move for two months. She did not want to go to another Dr. after her treatment in San Jose and was afraid that she would have to pay more fees. Then, a friend of hers came to visit and told her about Dr. T from the Parche of the Procrear foundation. Mona agreed to seeing Dr. T and received her for home visits.
Dr. T discovered that the fees Mona was required to pay were due to her pending SISBEN (System for the Selection of Beneficiaries of Social Programs) situation that did not correlate with her current economic situation. The San Jose hospital had not attempted to understand this problem despite the fact that Mona told them that she was a sex worker living in a lower class neighborhood. Mona was still declared status 3 (middle class, required to pay 30% of fees for medical visits. Note there are 6 statuses, with 0 as the lowest) under her mother’s affiliation in Medellin. How was Mona supposed to return to Medellin to change her SISBEN status when she could not even walk? Luckily, Dr. T helped write a letter declaring her incapacitated so that her aunt could disaffiliate her there. Finally, Mona was able to receive a “special populations card” declaring her incapacitated and a street person so that she could receive free medical care. As a result, Mona was finally well attended to in the hospital San Permendoza and Santa Clara. Until, it came to repairing her face.
Even though Mona had x-rays proving fractures along her jaw on both sides of her face, and that she could no longer smell or taste, the doctor refused to offer facial reparative surgery for her type of medical coverage. He simply installed some new false teeth and told her that was all he could do. She could try a private doctor, but it would not be reimbursed by the health system. It hurt her to laugh and swallow. It affected her work, because her former clients could no longer look at her face. Today, she no longer works and is still pining for the day when her face might return to normal and she might enjoy her food again.
One might ask, well what about her family? Couldn’t they help her pay for the operation if she needed it? Why did she leave Medellin and how did she fall into prostitution after belonging to a middle class family? In Medellin, Mona ran a micro industry, selling empanadas on the street with her husband. She was quite successful and had no troubles getting by with her two kids. Then one day her husband borrowed a large sum of money to be able to pay for his father’s health bills, only to realize that he could not pay it all back. He started stealing from Mona’s mother. Mona’s mother’s landlord happened to be affiliated with the paramilitary and caught on to Mona’s husband’s stealing and subsequent drug trafficking for revenue. He called upon security forces to siege Mona’s house. Her husband grabbed her and told her that they MUST leave the city. So Mona was dragged to Bogotá, leaving her comfortable lifestyle at home. She began to do drugs with her husband and drifted in to the prostitution business. And then, after sniffing many pots of glue, Mona got into a fight with another prostitute and was pushed out the window, to end up broken on the sidewalk.
During Mona’s interview, she showed my fellow researcher and I a photo of her with her smiling family from a few years back. She held the photo with trembling fingers and said, “Look at my face there. I am unrecognizable now. I don’t think my family could even point me out on the street.” Then she tilted her head down and sobbed. In addition to lamenting her disfigurement, she seemed to mourn the death of her former happy family life. Although her husband beats her, she told us that she didn’t dare going back home for the fear of paramilitaries and embarrassment from her husband’s actions. Her current situation is a product of relationship abuse and structural violence (e.g. the hospital’s negligence). Mona deserves a face, but what can be done? Beyond publishing her story in some academic journal that might stir some, but will eventually accumulate dust, how can I turn my participatory research into action? I have phoned a doctor I know in the hospital Tunal who is very supportive and proactive in sex worker health, so hopefully this case will receive the attention necessary to incite legal action and compel the hospital to pay for her reconstructive surgery.
 Ironically, one of the greatest barriers in access to healthcare is the SISBEN. If someone moves, they must return to their original location and disaffiliate themselves with the SISBEN there, in order to receive a new one in the new location. This process can take months.