Thinking outside the modern capitalist logic: health-care systems based in other world views

Erika Arteaga-Cruz & Juan Cuvi

The Lancet | Open Access | Published: October, 2021 | DOI:

Latin America is home to about 800 different Indigenous Peoples and Nationalities, the equivalent to 9·8% of its population. The average infant mortality rate in Indigenous children is 60% higher than that in non-Indigenous children.1 In 2018, Ecuador reported that 50·6% of its Indigenous population lived in poverty, compared with 20·9% of the non-Indigenous population.2 Between 2014 and 2017, maternal mortality was 69% higher in Indigenous than in Mestizo women.3 Chronic malnutrition affects one in four Ecuadorian children, and the rate doubles in Indigenous children.4
These figures evidence historical and structural inequalities. Despite discourses of modernisation and development, the old process of colonisation and subjugation of Indigenous Peoples continues. Violent appropriation of territory, forced displacement of peoples and communities, or depredation of their vital spaces for oil and mining are some facets of this domination.

One of the most subtle and, simultaneously, most violent forms of subordination is cultural imposition. In the field of health, this imposition is maintained through the biomedical model developed in high-income countries. But Indigenous Peoples have highly efficient health-care systems of their own. During the COVID-19 pandemic, and in the face of poor state responses, they implemented concrete actions to respond to the health crisis: isolating voluntarily in their communities, preventing the entry of oil and mining companies to their territories, promoting food exchange between regions with low contagions and regions with high contagions (for which there was no government provision for food security), registering the number of COVID-19 cases, prioritising plant-based remedies, producing information material in their own languages,5 and having traditional birth attendants deliver babies, among other measures.6 The pandemic also highlighted the serious limitations of the hegemonic biomedical model based on technological and pragmatic conceptions of health care.
This lived experience reactivates a debate in Latin America: the possibility of building other health systems that, while acting as a counterweight to the official system, respond to specific needs of Indigenous and rural sectors. The proposal of plurinationality of the Indigenous movement implies a radical questioning of a national state that systematically ignores the diversity on which society is based. This diversity is not restricted to the cultural sphere, but raises issues ranging from recognition of collective rights to demanding community self-governments.7 Reconstituting ancestral health practices and knowledge tied to a horizontal relationship with the state is a substantial part of these requirements.
The idea of intercultural health-care systems (ie, unity in diversity in a dialogue among equals) has faced several limitations. In 1999, the possibility of combining the model of evidence-based medicine with some specialties of alternative medicine—a branch called integrative medicine—was debated. The main difficulty is that the two conceptions differ at their core: accumulated experience, practice, and knowledge (alternative medicine) versus linear, ascending, and infinite technological sophistication (evidence-based medicine).8
The ancestral knowledge of the Indigenous Peoples of the Andean region of South America has another epistemological entry: it is historical, forged in resistance, and characterised by oral transmission. For these Peoples, energy, astronomical understanding, the significance of the cosmos and complementarity are important. Andean culture is closely related to natural and cosmic forces. Balance is achieved through rituals at equinoxes and solstices, with a constructive relationship between opposite elements (complementarity) and through reciprocity with the Earth. Andean time is multidimensional. The future is, linguistically and experientially, behind, whereas the past is ahead. History is not the unfolding of an Hegelian absolute spirit, and even less of unlimited progress or development, but a cyclical repetition that corresponds to the order of the universe on which the worldview of Andean cultures is based, through careful observation of astral movements expressed in nature’s rhythms.9 The health–disease process is thus a permanent recovery of the collective equilibrium.
Thinking of health as a collective right and as a responsibility to the Earth10 implies building alternative health-care systems with a territorial base, communal land management, food gathering, seed conservation, and availability and reproduction of therapeutic resources. Therefore, a relationship with the state should consider an articulation based on the decision-making power of the communities, to ensure the understanding of ancestral health practices.
The integration of such a medical model would generate a culture of social participation. The body–spirit–environment articulation broadens and expands the traditional vertical medical view. The inclusion of many and varied elements in the course of disease favours an extensive type of knowledge, opposed to the intensive, vertical type of knowledge of biomedicine. By focusing its attention on the biological element, biomedicine reduces the horizon and breadth of the health–disease process and prioritises the role of the physician and technology. In contrast, ancestral medical models involve the whole community in the process.
The struggle for health equity in Latin America translates into demanding national systems for the provision of services, services usually financed by the extraction of natural resources from the Earth for economic purposes. Asking whether the fight for universal health coverage promoted by WHO goes hand in hand with the colonisation of ancestral health systems, which are local expressions of resistance to the expansion of capitalism, is a valid question. The Andean model of health precedes and transcends the Declaration of Alma-Ata. It incorporates not just the vision of necessary equity, but also a different epistemology: the balance of all the elements and factors of life.
We declare no competing interests.
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Published: October 2021

© 2021 The Author(s). Published by Elsevier Ltd.
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