State Healthcare and Yanomami Transformations: A Symmetrical Ethnography

2. Particularizing the Upper Orinoco Health System

34 chapter two Particularizing the Upper Orinoco Health System Our focus in this chapter turns directly to the health system and the doctors working in it. I begin by describing the organization of the health system in the Upper Orinoco and continue with a review of doctors’ motivations and their first-impression accounts. The usually taken-for-granted figure of “the doctor” is thus particularized in the circumstance of fresh graduates from Venezuela’s urban middle class, working among the Yanomami . Getting to know these doctors seeks to counter a trend that, by and large, has invested greater analytical effort in the indigenous side of interethnic relations (Thomas, 1994:13). The chapter closes with an examination of some of the critical shortcomings of this health system as seen from the standpoint of doctors, on the one hand, and its compatibility with the Yanomami conditions of conviviality, on the other. Functioning and Organization of the Health System The Yanomami of the Upper Orinoco have a state-run health service with six rural clinics (Parima B, Koyowë, Ocamo, Mavaca, Mavaquita, and Platanal) attending exclusively to Yanomami communities. Ideally, this type of clinic, known as Ambulatorio Rural Tipo II (AR II), is staffed by a rural doctor, normally a recently graduated physician working his/ her compulsory rural year of service to the state, along with a Yanomami nurse, a Yanomami malaria microscopist, and a motorist who drives and maintains the clinic’s boat and motor. Every ten weeks or so, a final-year The Upper Orinoco Health System • 35 medical student joins this group for eight weeks, although in recent years this arrangement has been more sporadic. Two Ambulatorio Rural Tipo I (AR I) clinics, staffed only by a Yanomami nurse, are also in operation, one in the Mavaca area and one in Sejal, a community on the Orinoco close to the mouth of the Casiquiare Channel. AR I clinics have more basic equipment and medicines. All these health posts work alongside mission bases, Salesians along the Orinoco, and ex-NTM in Parima B and Koyowë. Orinoco Yanomami also make frequent use of the clinic in La Esmeralda, the municipality political seat and the health district headquarters (see fig. 1.4). Yanomami nurses, Auxiliares de Medicina Simplificada, are trained in the Simplified Medicine Programme, a community health-worker project pioneered in Venezuela in the 1960s to expand health services in rural areas. Training consists of a course in Puerto Ayacucho lasting six to seven months. A first generation of three Yanomami nurses was trained in the late seventies and early eighties, and a second of another four Yanomami from the mid-nineties until 2002. Since 1995 shorter courses have been used to educate microscopists in malaria diagnosis. Missionaries have also provided a few Yanomami of ex-NTM communities with informal and basic health training. Each health post is assigned responsibility for communities according to their distance from the post by boat—or on foot in the cases of Parima B and Koyowë—and the frequency with which they should be visited by the clinic’s health team. On the Orinoco and Mavaca rivers, communities classified as close are within one hour’s boat ride. Distances on foot in Parima B and Koyowë are greater. Ideally, the health post’s team should visit each community once a week. Communities classified as intermediate are anywhere between one and five hours by boat. In theory , these are visited every two to four weeks. Distant communities, those located at more than five hours by boat and often requiring additional hours or even days on foot, are supposed to be visited three or four times a year. These are only rough approximations, however, for distances vary from one post to another, and travel times change considerably from wet to dry seasons. These schedules are extremely variable, more frequently breached than observed, depending on a number of factors such as the presence of a doctor on hand in the clinic at a particular moment, the regularity of fuel supplies, and the health situation among the close communities. Rural clinics constitute the operational level of the health system, engaging daily in mostly curative primary care activities and executing nation 36 • Chapter 2 or statewide disease control programs. The most relevant programs are for the control of malaria, onchocerciasis, and tuberculosis, alongside the immunizations program. The referral of patients to the hospital in Puerto Ayacucho and epidemiological registering and...