Marked Women

The Cultural Politics of Cervical Cancer in Venezuela

Rebecca G. Martínez

• Publisher: Stanford University Press
• Year: 2018
• Print ISBN: 9781503606432, 9781503605114
• eBook ISBN: 9781503606449
• Edition: 1
• Topic: Social Sciences
• Subtopic: Cultural & Social Anthropology
• Index: Social Sciences

Cervical cancer is the third leading cause of death among women in Venezuela, with poor and working-class women bearing the brunt of it. Doctors and public health officials regard promiscuity and poor hygiene—coded indicators for low class, low culture, and bad morals—as risk factors for the disease.

Drawing on in-depth fieldwork conducted in two oncology hospitals in Caracas, Marked Women is an ethnography of women's experiences with cervical cancer, the doctors and nurses who treat them, and the public health officials and administrators who set up intervention programs to combat the disease. Rebecca G. Martínez contextualizes patient-doctor interactions within a historical arc of Venezuelan nationalism, modernity, neoliberalism, and Chavismo to understand the scientific, social, and political discourses surrounding the disease. The women, marked as deviant for their sexual transgressions, are not only characterized as engaging in unhygienic, uncultured, and promiscuous behaviors, but also become embodiments of these very behaviors. Ultimately, Marked Women explores how epidemiological risk is a socially, culturally, and historically embedded process—and how this enables cervical cancer to stigmatize women as socially marginal, burdens on society, and threats to the "health" of the modern nation.

1

Hospitals, Patients, and Doctors

Settling In

Before beginning my research at the Razetti and Padre Machado hospitals in October 1994, what would be the start of nearly a year of fieldwork in Caracas, I spent my first month looking for an apartment, getting to know the city and meeting with people who had assisted me during my preliminary field research. At that time, I had quickly learned the importance of meeting the friend of a friend of a friend of an initial contact person. This is the way things get done in Venezuela. Contacts I made previously helped me to set up my research at these hospitals, the only two functioning oncology hospitals in Venezuela. Originally, I had intended to live in the barrios where some of the women whom I would be interviewing would probably be living (at least those seeking medical attention at the public hospital). However, I determined that without a contact person who could help me find a place to live within the barrio, it was best to not pursue that plan. Instead, I rented for approximately US$150 (that I found listed in the newspaper) a bedroom from a widowed schoolteacher in the apartment that she shared with two grown sons and her mother in a middle-class neighborhood of Caracas. It was approximately a forty-five-minute metro and bus ride to either of the two hospitals. Living with a family in this area of Caracas ended up giving me great insight into the class dynamics that I would see throughout my fieldwork. Henriqueta, two of her sons, José and Félix, along with la abuela, Amalia, came to be my family in Caracas. Even Delia, the elderly, chain-smoking upstairs neighbor, who would come over just when it happened to be dinnertime, grew on me. She grated on José’s nerves because he said she came from a wealthy family but always managed to eat their food. Henriqueta, nonetheless, always welcomed her—to José’s chagrin—and the three of us women often ended up playing cards. All of us were in some way alone and kept one another company across generational divides. Even though Henriqueta and her family lived in a middle-class neighborhood, their financial situation was precarious, which is why she had put an ad in the paper to rent one of her rooms. She was working part-time as a teacher, but finances were always a topic of conversation. Félix was in dental school and José is an artist who was working irregularly. Henriqueta had her husband’s pension from the military, but as inflation was hitting Venezuela and the cost of living was going up, she worried that they would have to move out of the apartment. Despite her difficult situation, Henriqueta was a very upbeat woman, always optimistic and only hinting at the things troubling her. One was the health of another son, who lived in another town and was a recovering drug addict, and the other was money. I would often talk with Henriqueta about my days at the hospitals, and she was a source of support when I experienced sexually harassing comments from one of the doctors at Razetti. I elaborate on this challenge in my fieldwork in a later chapter that focuses on gender and sexism in the hospital settings. As time went on, I grew close to Henriqueta, and the apartment, where we interacted daily, became home and also another sort of ethnographic site; Henriqueta, José, and—to a lesser extent—Félix, and I discussed the economy, politics, culture, religion, and health care, as well as personal things that were going on in our lives.

As part of “settling in,” this chapter gives an overview of the hospitals where I conducted ethnographic fieldwork, as well as the patients and health-care providers who I interviewed and interacted with at the hospitals. The context of place and people sets up later chapters, where I analyze perceptions of risk, medical encounters, public health, and the gendering of hospital interactions. As often happens with ethnographic research, spaces that I had not anticipated providing insights into social dynamics did, in fact, open up fissures that could not be explored as readily through formal or informal interviewing. In the following section, I reflect on one such space on my first day of fieldwork that put race in Venezuela at center stage. Because Venezuelans often deny that race is as an organizing principal of society, paying attention to the snapshots of race in quotidian spaces is important for understanding this obfuscated reality.

Café con leche in the Cafeteria

On my first day at Razetti, I learned that the cafeteria hospital in Venezuela was no different than in the United States: everyone who visits or works there will find their way to the cafeteria. And so did I, in search of coffee. A man wearing a doctor’s coat and a woman in a nurse’s uniform caught my eye because they were chatting excitedly, and she had what looked like a framed, 8˝ × 10˝ picture in her hand. Coffee mugs, plates, utensils, X-ray placards, and even mobile IV drips are things commonly found in a hospital cafeteria, but not a framed photo that could hang on a wall or sit on a table. And this photo, in particular, was oddly out of place. I could make out that it was a portrait of a woman in a long white wedding gown. This had now really piqued my interest, so I focused on them and let the clamor of voices and clanking of dishes around me fade away. She was telling him pointedly, “Look, she is white! She is white! I told you my daughter is white.” Her tone was filled with a sense of urgency that conveyed her desperate attempts to convince him of this fact. His body language was saying no before the words came out of his mouth: arms crossed with a slight smile while he shook his head from side to side. The oddness of the interaction took me a moment to register and to reflect on what I was witnessing and hearing. It certainly was not the schema of a conversation I would imagine while gazing at a wedding photo. He insisted—in a declarative manner that seemed more as if he were commenting on the world being flat rather than rendering a personal opinion on a photo—that the woman in the photo was not white: “She is black,” and he added, “She isn’t even light.” The conversation wasn’t tense but instead ended with an exasperated laugh on the woman’s part. She had failed to convince him of her daughter’s whiteness, and she slipped the picture back into the bag that had protected it. I would later learn that the woman was indeed a nurse, and she worked in the hospital’s breast cancer department, along with the unconvinced doctor, who was the head of that department.

I was left to contemplate what had just transpired. I had not heard the entire conversation, but I was still privy to enough that left me formulating some of the following questions in the immediate aftermath: Why was she interested in seeking agreement from this doctor that her daughter is white? Why did it seem that her daughter’s being white was so important to her? What did it mean that she, a black nurse, was seeking this verification of whiteness from a white doctor? Why did the doctor appear so certain in commenting on her whiteness? Race, some Venezuelans had already told me, is unimportant in the sense that they see themselves as a racially blended society. In addition, according to Winthrop Wright (1993), for more than a century, Venezuelans have claimed their society to be a racial democracy, referring to themselves as a racially mixed, or mestizo, people, likening themselves to café con leche, or coffee with milk. This phrase refers to the “racial mixture” of Venezuela’s population, which reflects a colonial legacy of slavery from Africa and the Caribbean, as well as European immigration and native indigenous populations. Venezuela’s population in the 1990s was estimated at approximately twenty million people: 68 percent mestizo (mixed race), 21 percent Caucasian, 10 percent African, and 1 percent Indian (Haggerty and Blutstein 1993). Venezuelans thus pride themselves on the belief that because they are a “blended” society, they have achieved racial democracy—the popular belief of racial equality as the notion that people of all races live free from prejudice and discrimination (Wright 1993). Given the claims of harmonious racial mixture, I was struck by the cafeteria conversation I stumbled upon on my very first day, which put race at center stage. What about the café con leche society where everyone is blended and color doesn’t matter? It’s not that Venezuelans claim to not notice color in a U.S. “color-blind” sense. They have similar or the same color-conscious “nicknames” that exist in much of Latin America (e.g., negro to refer to a dark-skinned person).

However, it is difficult to imagine that Venezuela has achieved racial democracy given the interconnectedness of race, gender, and class. In a society where class differences are quite marked, one cannot dismiss the role of gender and race in the configuration of these distinctions. While I do not attempt to provide in-depth analysis of race in the medical encounter, there are instances that come up in my observations that I believe reflect not only attitudes about gender and class but also attitudes about race. A number of Venezuelan scholars are attempting to get at this very issue of current-day racism. Not a lot of work has been done toward understanding racism in Venezuela in a systemic and interdisciplinary way (Bolivar 2009). However, Venezuelan scholars have addressed this café con leche contradiction through various disciplinary lenses. Bolivar and colleagues point, in particular, to the work of psychologist Ligia Montañez (1993, 292), who notes that Venezuela is “a society that has historically boasted about valuing egalitarianism but that maintains racism in a ‘hidden’ way, so that prejudice and discrimination ‘persist, hidden by the apparently non-racist society of current Venezuela.’ . . . Consequently, behind the metaphor of the ‘café con leche’ country, there seems to be a hidden desire for the ‘equality’ that is not necessarily practiced in everyday life.”

And, in a more forceful argument that links racism and classism in Chávez-era Venezuela, Jesús María Herrera Salas (2004, 10:2, 111) states: “a profound racism exists in Venezuela, not just against Afroamerican and indigenous inhabitants, but also, particularly, among the common people in general—the ones who are continually discredited as ‘tierrúos,’ ‘niches,’ ‘zambos,’ ‘negros,’ ‘indios,’ ‘pata en el suelo,’ ‘chusma’ by the upper classes and those opposed to the processes of change.” These derogatory terms intersect with race and class, and they demarcate some of the divisions that were already present. Under Chávez, discourses around race were brought to the fore, so much so that some Venezuelans suggested that Chávez fomented divisions by openly discussing racism. For example, in a 2005 interview in El Nacional with journalist Milagros Socorro, Venezuelan anthropologist Michaelle Ascencio was asked, “Do you think President Chávez invented the idea that there is racism here to divide and manipulate us?” I quote Ascencio’s response at length because she provides important insight into the national dynamics of racism:

In Venezuela there has always been racism against the Indians and against the black people, fundamentally. What President Chávez has done is to uncover that and utilize it like a flag that divides and confronts us. But the thing is that Venezuelans are determined to repeat that we are a racially mixed country—we are biologically speaking—and because of that there aren’t any conflicts between the races, that we are harmonious and don’t have racism. And we don’t see, like in all societies (more in the Caribbean ones where the rates of poverty are highest), we have a series of contradictions that we haven’t resolved and that we don’t want to see. We are mixed, yes, but that doesn’t mean the racial mixture has been consented to by both sides, nor much less is it idyllic; racial mixture can be an indication of violence. Racism is an attitude about certain people for their physical characteristics; and in Venezuela, many times, that attitude is to reject. But since the nineteenth century there has been a discourse determined to deny the tensions between diverse groups that comprise Venezuelan society. And because our local racism isn’t like that of the United States, for example, that has served as an alibi to continue denying it because in Venezuela they don’t kill anyone for being black. . . . [T]hey use a barometer of extreme violence to minimize the violence that we live. In reality, the violence is the same but it is expressed more subtly among us; its the looking you over from top to bottom; its the twisted mouth; its the delivery person, when I open the door of my house, asking me to please call the lady of the house. (Socorro 2010)

The question posed by the journalist of whether Chávez “invented” the idea of racism in Venezuela to divide the populace is provocative and speaks to the attention brought to racism under his administration. It also reflects the idea that there is no racism in Venezuela, an example of the café con leche ideology. The other part of the narrative, that bringing up racism is itself racist and causes division, is a way to close down any discussion of it—a trope that is also popular in the United States. Global histories of colonialism and imperialism have a collective desire to mask the realities of their legacies in the present. Chávez did not invent the idea of racism in Venezuela, but he did make it part of his critiques of inequality. As is the case in most parts of the world, one cannot speak of classism without reference to its intersection with racism. The lack of willingness to broach the subject of racism in Venezuela has contributed to its tepid acknowledgment by citizens. When I was there the first time in 1994, the absence of the subject was even more pronounced than it is today.

My own observations in hospitals before the Chávez era reflect this “hidden” racism that Montañez (1993) articulates and the intersections with class that Herrera Salas (2005) points to. When discussions of race would come up in my conversations with hospital personnel, the emphasis would often be on the lack of racism in Venezuelan society. Not surprisingly, the well-blended society of cafe con leche was invoked in these descriptions. In fact, when I questioned one of the social workers at Razetti about the use of the category “skin color” on the interview schedule for the department of social services, she went to great lengths to explain that it was a useless category. She said that there was really no reason for its inclusion on the form, and it was probably there because the form had been modeled after American forms, which contain categories of race and ethnicity. She went on to explain, as if to persuade me of the inappropriateness of this category for Venezuela, that it would not appear on the new interview schedule that was being developed. Any suggestion that racial categories have relevance in Venezuela was quickly disavowed. The implication is that there was no basis for racism to exist there. As will become clear in later chapters, class distinctions, in contrast, were widely invoked to explain difference—bodily, psychological, and behavioral. Race, however, was always beneath the surface, intersecting with class and gender, framing many of the interactions that I observed in the hospital settings, if not at the individual level, then at a structural one. The myth of racial harmony that is part of historical and contemporary (re)constructions of café con leche society was not overtly betrayed in these conversations but rather insistently maintained and defended.

This silence around racism in public health in Venezuela, in particular, would later be shattered by Charles Briggs and Clara Mantini-Briggs (2004) in their seminal work on the topic, Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare. The authors trace the roots and aftermath of a cholera epidemic in the Orinoco Delta region in the Venezuelan state of Delta Amacuro, located in the northeastern part of the country. The epidemic killed nearly five hundred people between 1992 and 1993. Briggs and Mantini-Briggs document the structural racism in various government public health agencies at local and national levels that both led to the outbreak of cholera and allowed it to reach epidemic status. Their work was instrumental in bringing the issue of racism in medicine and public health painfully to the fore in the country.

One of the most forceful contemporary arguments about the broad and enduring role of racism in Venezuela can be found in Jesús María Herrera Salas’s 2005 book, The Political Economy of Racism in Venezuela. In this work, Herrera Salas, a Venezuelan anthropologist, argues: “Racism has been a fundamental element of the ideology, practices and hegemonic politics in Venezuela from the Conquest to the present day. One of the principal ideological functions has been precisely to legitimize the economic and political privileges of the dominant classes” (13). While he takes seriously a complex understanding of racism that does not underestimate the many matrices that shape it, he argues that a political economy approach is of great value not only for analyzing racism but also for increasing the necessary political consciousness to effectively combat racial discrimination in Venezuela. His approach centers the actions, strategies, policies, and organizational forms that government adopts that privilege the economic and political interests of the dominant classes and, in doing so, either enact racist policies and/or effectively function as such, given the relationship between racism and classism. The result is that generally speaking it is the indigenous and Afro-Venezuelan populations that also experience the greatest poverty and economic inequities.

In thinking about the silence around racism that I encountered, Herrera Salas’s work helps to illuminate the political economy of racism that existed in the public health-care system at the time of my initial fieldwork, and that Briggs and Mantini-Briggs (2004) later documented in the cholera epidemic. As a result, the neoliberal austerity projects of the 1980s and 1990s can then also be understood as political economies of racism. Moving from the political economy of racism to the political economy of health care, the following section provides an overview of Latin American Social Medicine and the works of those researchers who have critically examined the relationship between societal conditions of marginalization and the health of populations.

Latin American Social Medicine and the Political Economy of Health Care in Latin America

The problem of health cannot be reduced to the phenomena of disease, nor does it merely comprise the individual dimension. Health is a complex, multidimensional process that requires focusing on the social processes that generate or determine health conditions.

Jaime Breilh (2010a, 3)

The origins of Latin American Social Medicine (LASM) can be traced to Rudolph Virchow, a nineteenth-century physician and social scientist. Virchow insisted on understanding health and disease in their social context and sought to prevent disease, rather than simply focus on treatment after the fact. He also advocated for state-sponsored health-related initiatives that would help workers and women. Later, Virchow would influence Salvador Allende, who became Chile’s first minister of health and then president of Chile from 1970 to 1973. It was Allende who introduced national policies based on social medicine and was a catalyst for progressive health reforms across Latin America (Hartmann 2016). Across Latin America, LASM is a broadly known and well-respected field of research focu...

Table of contents

• Cover
• Copyright
• Title Page
• Dedication
• Contents
• Acknowledgments
• Introduction: Caracas, Venezuela: On Arrival
• 1. Hospitals, Patients, and Doctors
• 2. The Ambiguities of Risk: Morality, Hygiene, and the “Other”
• 3. Targeting Women: Bodies out of “Control,” Public Health, and the Body Politic
• 4. The Hospital Encounter: Bodies Marked, Mended, and Manipulated
• 5. Women’s Agency and Resilience: “The Way I Want to Be Treated”
• Epilogue: From Neoliberalism to Chávez
• Appendix
• Notes
• Bibliography
• Index