Fostering Mental Healthcare in a Postcolonial Continent with Digital Medicine - MHI

ISSUE NO. 6 OCTOBER

THE MARIWALA HEALTH INITIATIVE JOURNAL

Re-Vision

Contesting Global Mental Health

World Mental Health Day, Medicalised Mental Health Awareness, and Psychiatric Subjectivation

Authoritarian Neoliberal Regimes and Global Mental Health

Enough Politeness: Decolonising Mental Health in a Society Oblivious to Its Colonial Wounds

Work with Us, Not against Us

Context

Mental Health in the Time of Genocide

Reshaping Narratives: Reproductive Justice among Women in Kashmir

Mental Health and Marginalisation

Warriors Within: Decoding the Paradox of Strength and Vulnerability among the Naga Tribe

Redefining Queerscapes through Poetry

The Impact of AFSPA on the Mental Health of the Naga People

Engage

Collective Healing and Trauma-Informed Approaches for the Mental Health of Survivors of Trafficking

Assessing the Effectiveness of the Mental Health Equity Global Agenda for Low- and Middle-Income Countries 

Fostering Mental Healthcare in a Postcolonial Continent with Digital Medicine

Tackling Mental Health Inequalities for Roma Communities in the UK

Behind Bars

ENGAGE

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SERVICE DELIVERY

Fostering Mental Healthcare in a Postcolonial
Continent with Digital Medicine

New Road to Care by the
Indigenous Peoples of South America

Mario Incayawar, Lise Bouchard and Sioui Maldonado-Bouchard

AUTHOR

Axel Rogel

illustrator

author’s bio

Mario Incayawar, Lise Bouchard and Sioui Maldonado-Bouchard

Mario Incayawar is an Inca physician-scientist and an educator. He is the recipient of the John Simon Guggenheim Fellowship 2006.  Founder and director of Runajambi Institute – Personalized Medicine for the Indigenous Peoples of the Americas, he also held the Henry R. Luce Professorship at the Claremont Colleges, California and the William F. Quillian Jr. International Professorship at R-MWC, Virginia. 

Lise Bouchard is a linguist-anthropologist interested in Quichua-Spanish contact and exploring the interplay between linguistics, medicine, psychiatry, and anthropology.  She has a B.Sc. in Anthropology and Linguistics from Université de Montréal, Canada and an M.A. and Ph.D. in Linguistics from Université du Québec à Montréal. She is the co-founder and director of research at Runajambi Institute.

Sioui Maldonado-Bouchard is a psychiatry resident at McGill University, Canada. She completed B.Sc. and M.Sc. in Psychology at Université de Montréal, PhD in Neuroscience at Texas A&M University, and a post-doctoral fellowship in Social Modulation of Pain at McGill University.  She is interested in the intersection between social environment, mental health, and the role of empathy in both mental illness and therapeutic alliance. 

illustrator’s bio

Amreeta Banerjee

Alice A. Barwa completed her MA in Education from Dr. B.R. Ambedkar Univerity, Delhi (AUD), in 2022, and is from the Oraon Adivasi community, a native of Chhotanagpur Plateau, Chhattisgarh. She has been an advocate for Adivasi rights and voices as a member of an Adivasi youth collective @TheAdivasiPost, and has been an Adivasi youth representative at UN Climate Change Conference in Glasgow, Scotland, in 2021. Her research interests include education, culture, sociology, and linguistics.

Access to conventional, Western-oriented mental healthcare in a colonised continent is a formidable challenge.  In South America, after more than 500 years of colonisation, first by the Spanish and then by the Mishu (the name of the oppressor in the language of the Incas) that is ongoing, Indigenous Peoples struggle to obtain the most basic psychiatric care.

A majority of Indigenous Peoples do not visit a mental healthcare professional as no country in the region has developed a dedicated and accessible mental health system for them.

A majority of Indigenous Peoples do not visit a mental healthcare professional as no country in the region has developed a dedicated and accessible mental health system for them.

Nevertheless, they have successfully survived atrocious violence, dispossession, serfdom, racism, and systemic discrimination perpetrated by the Mishu without the support of any Western-trained mental health professionals. But new digital mental health technologies have the potential to allow Indigenous Peoples to bypass postcolonial barriers and access mental healthcare.

The Indigenous Peoples of South America – Living without Psychiatrists

In the fifteenth century, Spanish armies invaded and subjugated the Indigenous Peoples and instigated a devastating regime of oppression and dispossession.2 Since the nineteenth century, the ruling Mishu – people of mixed Spanish and Indigenous ancestry who identify as white Westerners and repudiate their Indigenous roots – have replaced the Spaniards as perpetrators. This long-lasting colonisation has transformed the Indigenous Peoples into one of the most impoverished and dispossessed peoples in the world.3 Currently, it is estimated that 30 million Indigenous Peoples live in the region and 420 languages are spoken. 
The Indigenous Peoples have not been able to expel the colonisers and repossess their homeland as in Asia and Africa. In the present-day postcolonial era, there is a caste-like social stratification that, along with the political structure, marginalises Indigenous Peoples, discriminates through institutionalised racism,4 and creates severe health inequities.5

Despite centuries of oppression, Indigenous Peoples of South America have shown exceptional resilience and self-sufficiency, continuing to nurture their traditional resources for mental health and well-being in order to cope with this adversity.

They have always trusted traditional medical knowledge and traditional healers7 as well as relied on family and community support.

Mental Health Status


The Outrageous Neglect and Calls for a Moral Case
Little is known about the mental health status of the Indigenous Peoples of South America or their psychological needs, with only a handful of scientific papers on the subject. The World Health Organization (WHO) has published only one small booklet on the mental health of the Indigenous Peoples around the globe, in which South America is briefly mentioned.8

Though the Pan American Health Organization (PAHO), WHO has created the Health of the Indigenous Peoples of the Americas Initiative, followed by similar initiatives in several countries, there is no mention of mental health. In 1998, PAHO sponsored an international workshop called ‘Mental Health Programmes and Services for the Indigenous Communities’ in Bolivia.  Twenty-five years later, no specific programme of mental health designed for the Indigenous Peoples exists.

Referring to the neglect of mental health worldwide, Arthur Kleiman from Harvard University suggests not to wait for studies but to instead build a moral case.9 As much is true for the pervasively overlooked mental healthcare needs of the Indigenous Peoples of South America

Mishu Healthcare Workers’ Biased Care
Postcolonial perspectives view the Indigenous Peoples of South America as backward, subhuman, dirty, prone to spread disease or violence, and a barrier to progress.10 The WHO reported in 1999 that Indigenous Peoples are racially discriminated against and are treated as second-class citizens and inferiors.11 Mishu psychiatrists and other mental health professionals more often than not embrace these biases. This makes for failed medical encounters between Mishu practitioners – who largely only speak Spanish and might be hostile, patronising, and racist – and the Indigenous clients – who might not speak the dominant languages of Spanish or Portuguese and might be suspicious, distrustful, and fearful.

Troublesome Perceived Empathy and Healthcare Refusal
Empathy perceived in physicians has a positive effect on patients’ experience, both at physical and biological levels.12 In South America’s long sociohistorical context of colonialism, even well-meaning clinicians are likely to be perceived as threatening by Indigenous patients.  The mistrust, which has helped Indigenous Peoples survive centuries of oppression and unlikely to wither away, can lead to miscommunication, gaps in critical information gathered to make proper diagnoses and treatment plans, and poor adherence to treatment. And this is in the best, albeit rare, scenario – when an Indigenous patient does go see a clinician, and the clinician is in fact sensitive, well-meaning, and cognisant of their biases. 

Digital Medicine for Blunting Barriers to Care?

In this historical, sociopolitical, and medical context, it is hard for an Indigenous patient to find suitable pathways to mental healthcare. Unwittingly, the new digital mental health technology could allow Indigenous patients to bypass this colonialist healthcare system.

The Arrival of Cell Phones – Bypassing Discrimination and Racism


A foreign resident waiting to make a phone call in a small town in the Andes in the 1980s experienced the following. The Mishu operator ignored the Indigenous women in line and aimed to serve the foreigner first. When the white woman insisted that the operator serve people in the order they arrived, the operator, though angry, reluctantly then served the Indigenous women.  For the operator, it was normal to serve Indigenous People last.

Fortunately, some 20 years later, an unexpected social phenomenon occurred in the Andes with the arrival of cell phones. Until then, owning a telephone landline was a privilege for a few wealthy Mishu people. Indigenous Peoples had to go to the telecommunication office, wait to make a call, and be at the mercy of the operator’s will. Unexpectedly, the cell phone brought a quick democratisation of telecommunications, and Indigenous Peoples were able to make phone calls as they pleased on their own cell phones.

Likewise, the arrival of smartphones in the Indigenous communities of South America and the development of digital mental health technologies, which include self-help courses and AI software, may allow Indigenous Peoples to gain empowerment with regards to mental healthcare.

The Promising Contribution of Digital Mental Health

With digital mental healthcare, be it personalised mental health apps or platforms, Indigenous Peoples could have access to more equitable care, avoiding the discriminatory hurdles of the system in place. Although digital mental health services are often considered more impersonal, Indigenous Peoples may find this to be of comfort, reducing their exposure to hurtful interactions.  Safety and privacy issues notwithstanding, digital mental health could have a beneficial impact on the betterment of the mental health of colonised and marginalised populations.

As physicians, we like to believe that high-quality medical care is based on good human interaction between patients and practitioners. However, when these interactions are tarnished by conscious or unconscious social and racial biases, the service provided by healthcare practitioners will be of poor quality, unequal, and unjust.  Although the new developments of artificial intelligence in medicine are viewed with caution,13 it could be a promising pathway to care for the marginalised Indigenous Peoples of South America. 
 
Despite more than five centuries of colonisation, Indigenous Peoples in South America have adapted to new challenges and adversity. In the near future, they may likely find their own ways of integrating digital technology to access mental healthcare.

Cite this Article View all References

references

  • Maldonado-Bouchard, Sioui, et al. ‘Broken Promises: Indigenous Peoples’ Mental Health in South America.’ Lancet Psychiatry, vol. 2, no. 1, 2015, pp. 8–10.
  • ‘South America: Human Geography.’ Education, National Geographic Society, education.nationalgeographic.org/resource/south-america-human-geography/.
  • Maldonado-Bouchard, Sioui, et al. ‘Baffling Clinical Encounters: Navigating a Pain and Psychiatric Quichua Syndrome.’ Troublesome Disguises: Managing Challenging Disorders in Psychiatry, John Wiley and Sons, 2014.
  • Casagrande, J.B. ‘Strategies for Survival: The Indians of Highland Ecuador.’ Cultural Transformations and Ethnicity in Modern Ecuador, edited by Norman E. Whitten, Jr., University of Illinois Press, 1981, pp. 260–77. 
  • Incayawar, M., and S. Maldonado-Bouchard. ‘The Forsaken Mental Health of the Indigenous Peoples – A Moral Case of Outrageous Exclusion in Latin America.’ BMC International Health and Human Rights, vol. 9, no. 1, 2009, p. 27.
  • Incayawar, M., et al. ‘Living without Psychiatrists in the Andes: Plight and Resilience of the Quichua (Inca) People.’ Asia-Pacific Psychiatry, vol. 2, no. 3, 2010, pp. 119–25.
  • Incayawar, Mario. ‘Efficacy of Quichua Healers as Psychiatric Diagnosticians.’ The British Journal of Psychiatry, vol. 192, no. 5, 2008, pp. 390–391. 
  • Cohen, A. The Mental Health of Indigenous Peoples: An International Overview. Geneva: Nations for Mental Health, Department of Mental Health, World Health Organization, 1999. 
  • Kleinman, Arthur. ‘Global Mental Health: A Failure of Humanity.’ Lancet, vol. 374, no. 9690, 2009, pp. 603–604; Patel, Vikram, et al. ‘Beyond Evidence: The Moral Case for International Mental Health.’ American Journal of Psychiatry, vol. 163, no. 8, 2006, p. 1,312.
  • Maldonado-Bouchard. ‘Baffling Clinical Encounters.’
  • Cohen. The Mental Health of Indigenous Peoples. 
  • Decety, Jean. ‘Empathy in Medicine: What It Is, and How Much We Really Need It.’ The American Journal of Medicine, vol. 133, no. 5, 2020, pp. 561–566. 
  • Voelker, Rebecca. ‘The Promise and Pitfalls of Ai in the Complex World of Diagnosis, Treatment, and Disease Management.’ JAMA, vol. 330, no. 15, 2023, pp. 1,416–1,419. 

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