INTRODUCTION

Getting sick, feeling pain or suffering some kind of illness, are universal and inevitable facts of human life; the way in which we think of, feel about and go through them, combines particular subjectivities altogether with our social and cultural framework of belonging, establishing for each event of discomfort a series of values, roles, representations, and expectations. Health conditions, as well as the social responses that arise to solve them, make up the health/disease/care process defined by ^{Eduardo Menéndez (1994}; ²⁰⁰²⁾ within social anthropology.

Recovering health is a dynamic exercise that starts not only from the experience itself, but also from the scenario in which it is carried out (^{Sacchi, Hausberger, & Pereyra, 2007}). As ^{Augé (1986)} points out, a disease is anchored to the reality of the body that suffers from it. In this sense, the contextual perspective provided by social sciences becomes of great relevance, since it allows analyzing the health/disease constructions developed and used by social groups in relation to the time and space they inhabit (^{Laurell 1986}).

Taking this approach into account, it is of particular interest to research the conformation of the health/disease/care processes in a context as specific and particular as the migratory space. Because of their strong symbolic load, territorial displacements represent a before and after in the biography of those who go through them. Their undertaking involves changes in the way of life: social links, available resources, and vision regarding the future. Likewise, the disruptive nature of migration can lead to, in many cases, a restructuring in the ways of overcoming and relieving from discomfort. Undoubtedly, if we account for migration and disease as possible instances of social and individual “breakdown” (^{Bar de Jones, 2001}; ^{Luxardo, 2005}), the need arises to analyze the cross-linking of these phenomena in order to gain insight on the interpretations and strategies particular to this social environment.

The paths that subjects must follow to soothe a disease, pain or suffering, reflect their way of seeing the world and organizing their own existence. These paths, or therapeutic itineraries, are formed by the set of beliefs and practices that take place at that particular time. ^{Sindzingre (1985)} defines them as the series of processes involved in the search for a therapeutic solution, initiated after the appearance or perception of a problem. They are configured from all the decisions, conscious or not, that a person or group makes to face a discomfort. These decisions may cover both inaction and models of care with multiple degrees of complexity, either self-administered or provided by third parties.

A therapeutic itinerary is also an interplay of different interpretations and cures that correspond to the social uses of disease and the way in which the biological, social and cultural are linked (^{Perdiguero, 2006}). In this way, care paths become a fundamental part of health/disease/care processes. The way in which they are configured will depend on some factors, such as the available possibilities of healing, the ease or difficulty of access to said healing, cultural beliefs and habits, previous experiences, and personal and group expectations.

This research aims at describing and analyzing the different strategies in the process of striving for health and disease relief in the scenario of Latin American immigration in Spain. It is focused on the perspective of the participants and their discourse, so as to partake not only of the description of the practices but also to the constructions and meanings around the experience of becoming ill in another country.

In Spain, the arrival of migrants from other countries grew exponentially a little over thirty years ago. Currently, the advent of economic crises such as the global financial depression of 2008, confrontations within and among nations, and the increase of nationalist sentiments around the world have transformed and hindered the migratory experience. As ^{Moreno-Preciado (2008)} points out, the presence of “external” people has been instrumentalized by the political and media discourse as a scapegoat for diverse problems. At the same time, the tightening of government regulations regarding permits for entry, permanence, and access to social benefits creates situations of greater exclusion and inequality.

Since 2012 and up to 2018 —as part of deliberate measures taken for economic adjustment and control of public spending—, the Spanish State only guaranteed public health assistance to foreigners holding residence permits. Unregistered or unauthorized persons could only be assisted in case of an emergency due to serious illnesses or accidents. Immigrants under 18 years old and pregnant women, regardless of their administrative situation, had the right to receive health care on equal terms as the Spanish population. The legislative change of 2018, which decreed universal healthcare for all people living in Spanish territory, nowadays presents ambiguities in its implementation, which have been denounced by numerous national and international organizations (^{REDER, 2019}).

The Latin American community is strongly represented in the Spanish territory; it corresponds to the second largest extra-European community, after the African community (especially from the Maghreb) (^{National Statistics Institute, 2017}). The meeting of multiple nationalities under this major regional name requires a series of preliminary reflections, in order to understand the usefulness of this categorization. Undoubtedly, heterogeneity is one of the main characteristics of the migrant Latino population; a natural extension of the diversity present in their continent of origin. However, being Latin American responds to a collective identity category of recognition and self-identification for immigrants, used several times in the discourse they build about themselves. Among the phenomena of interest for this research, we can pick back up and highlight the significance of this as an identification strategy expressed within the social group, associated with common values, practices, and ideas that exceed the borders of each country and partake of a larger entity. In many cases, the ascription to an extra-national identity allows for a greater network of links and reciprocity to be established, since the subjects are taken as a part of the same group with similar experiences (^{Rossi, 2012}).

The Latin American migration process is particular since its participants share the same language with the society they arrive at, and there is a —identified by themselves— common cultural root as a result of the historical relationship between both territories. However, there are also divergent cultural elements that create the idea of being Latin American as different from being Spanish. These points of contact and divergence make their migratory experience a distinctive context in which to study health/disease paths and the evolution of their insertion in the new space. Therein, the different forms of use and articulation of assistance models (institutional, alternative, domestic and popular) are simultaneously erected as forms of resistance, identity revitalization, negotiation and adaptation to the new living environment.

METHODOLOGICAL NOTES

This work is based on an ethnographic research carried out in the autonomous community of Castile and León, mainly in the region of Salamanca and its surroundings, during 2016 and 2017.

A qualitative study based on the phenomenological approach was designed (^{Schutz, 1967}) to describe and understand the health/disease/care experiences of the Latin American population residing in the area. The selected informants were thirty-five adults (twenty women and fifteen men) aged between 29 and 75, from Bolivia, Brazil, Colombia, Honduras, Mexico, Peru, the Dominican Republic, Uruguay, and Venezuela; all under different administrative regularity situations (irregular, holders of temporary residence permits, long-term residents, nationalized and asylum seekers), staying in the country for already one-year minimum. Most of the participants were found through local community organizations, while others were contacted by references from other informants. In order to preserve their identity, the names presented in the testimonies are fictitious.

Intensive fieldwork was carried out using participant observation techniques and conducting semi-structured and in-depth interviews. To guide the interviews, a thematic model was established that addressed the following core concepts: health/disease/care conceptualizations, habits related to the treatment of illnesses, therapeutic choices, preferences and experiences before and after migrating (changes, permanence, negotiations and available resources). The same structure was employed for each interview, adding new questions based on the particular stories. Most interviews were conducted individually, except on three occasions when participants requested to attend in company and be interviewed in groups. Each conversation was recorded in digital audio with the consent of the interlocutors and then transcribed verbatim for processing. These transcripts and their corresponding field notes formed the main body of data to work with throughout the research.

The analytical method selected was thematic analysis (^{Boyatzis, 1998}; ^{Braun & Clarke, 2006}; ^{Guest, Namey, & MacQueen, 2012}), by means of elaborating systematized codes based on the topics of the guide questionnaire and in new emerging categories based on the participants’ discourse. The emphasis on particular stories seeks to deepen on the specific meanings, values, and practices at interplay in individual and social health processes (^{Kleinman, 1980}).

This analysis corresponds to a first approach to the subject, within a major ongoing research on the multidimensionality of the therapeutic itineraries of Latin American migration in Spain.

CARE ITINERARIES WITHIN THE CONTEXT OF MEDICAL PLURALISM

All human groups have what is known as “illness behavior”; that is, a variety of possible responses to what is perceived and identified as a malaise. As Haro-Encinas points out (2000), the dynamic nature of health actions is subject to “both temporary decisions, class habits and cultural patterns, which gives it a complex character that needs to be particularized and contextualized in each individual or collective case” (^{Haro-Encinas, 2000, p. 142}). The beginning of the health search process —alleviating the disease, or therapeutic itinerary— is established merely upon the appearance of certain symptoms, the assessment made of them and the consequent decision to act (or not) on it (^{Perdiguero, 2006}).

In this regard, ^{Chrisman (1977)} pointed out a series of usual steps taken in the search for health, although they do not necessarily appear in a sequential or complete structure. Its description includes the definition of the symptom or symptoms, changes in behavioral roles, consultation with other people (professionals or laypeople), the use of treatment practices and finally, the follow-up to them. Beyond any possible seriation, the assistance occurrences that take place in each case will be strongly related to the explanatory models that arise at that time (^{Kleinman, 1980}). From this, that which individuals do, who they consult and how they carry out the treatment will depend on how they perceive what is happening to them and to which causes they attribute it.

The study of the health/disease/care processes of Latin American migrants in Spain is framed within a structural phenomenon of the globalized world: the pluralism of medical systems and models. We understand models of care as to those activities related to the conscious care of ailments, either through prevention, treatment, control, relief and/or cure. Therefore, medical pluralism refers to the articulation within a society of different care and therapeutic instances, whether officially recognized or not (^{Perdiguero, 2004}).

The different systems of care that operate in a given society are related to its economic/political, religious, ethnic, and technical status. By means of relationships of alternation and complementarity, the needs and possibilities of different groups can lead to a dynamic conjugation between elements “paradigmatically” seen as antagonistic. According to ^{Hernández-Tezoquipa, Arenas-Monreal, and Valde-Santiago (2001)}, this responds to the principle of pragmatic efficacy that is a common part of the health/disease/care processes.

Studying this phenomenon, ^{Menéndez (1992)} developed different models for typifying the main medical systems that operate in capitalist societies. These are a) the hegemonic medical model, b) the subordinate alternative medical model, and c) the self-nursing medical model.

Biomedicine can be categorized within the first, characterized by biologicalism, individualism, formalized professionalization and ideological identification with scientific rationality “as a manifest criterion that excludes the other models” (^{Menéndez, 1992, p. 102}).

The second model is represented by practices seen as “traditional” or “popular,” and also by those defined as “alternatives.” Naturally, this encompasses a wide variety of activities organized and structured to different degrees. The author acknowledges that many of them are clearly influenced by the hegemonic medical model, and poses their relationship from subordination and/or complementarity.

Finally, the third model stands as the one based on the direct action of individuals in the diagnosis and relief of diseases; it may involve other people in the family and community environment, but it is characterized by the absence of professional resources. This last model is actually the first real level of care in all societies, and may or may not coexist with other therapeutic proposals (^{Menéndez, 1984}). This type of care, alternatively designated by ^{Haro-Encinas (2000)} as profane care or lay care, combines the actions of self-care, self- nursing, and self-help in terms of health and illness.

This research’s description and analysis of therapeutic itineraries shows to what extent these three models are present in the health-seeking process of the Latin American migrant collective in Salamanca (Spain).

GROUP-LEVEL CARE: THE SELF-NURSING MODEL

In the process of reconstructing therapeutic itineraries —through interviews and observation activities— it was found that lay care enters almost immediately after the identification of an ailment. Most informants acknowledged their preference for trying to alleviate health conditions by their own means, either through knowledge of their own or their families, knowledge acquired through experience or by trying new ad hoc options. Therefore, as a starting point, the “severity” of the disease is usually assessed according to a personal (or social) scale, which determines the range of possible actions and the degree of autonomy to carry them out:

It all depends on the type of illness you have. Because, if it’s only mild... Well, fortunately I am quite healthy, right? There’s been no need for me to go to the doctor very much around here. Because if it's the kind of illness that I know I can handle, well, I’ll take care of it myself (Eloísa, Colombian, personal communication, December 13, 2017).

Folk medicine home treatments —especially aided by botanical or home available resources— constituted a strategy highlighted by informants. Resting in bed and additional care in food or hygiene were also widely mentioned, altogether with the idea that the body must naturally restore its balance. Many of these healing practices were learned in their countries of origin, and according to availability, replicated after migration as part of the care habits of the entire group at home:

Coca tea. Yes, when we have a bellyache we drink coca tea. It is made from coca leaf. You prepare tea, regular tea; you drink it hot and the bellyache is relieved. But it is amazing; it works. Yes, Yes. It is not nonsense […] Now that my older children are here, they tell me that I am a yaya , that I want to heal them as if I were a witch doctor... But I just tell them that it works. Well, my daughter lets me cure her; she does or takes whatever I say. She doesn’t like going to the doctor, since that time... she’s afraid. She thinks they are going to tell her that she needs surgery, and she doesn’t want that. If I tell her “drink this,” she drinks it (Felicia, Bolivian, personal communication, August 22, 2016).

Therefore, it can be said that it is in the family where the highest occurrence of ailments, diagnoses, care, and healing activities is, therein we can identify the beginning of the patient’s path (^{Menéndez, 1993}). On certain occasions, the family represents the only possible space for health intervention, which grants their care functions an even more important value than that of formally established or professionalized systems (^{Haro-Encinas, 2000}). Additionally, the way in which different cultural health models are employed in the treatment of a condition will largely depend on the functioning of families and the resources available for the given group (^{Kleinman, 1980}; ^{Menéndez, 1993}).

Specifically, migratory displacements can affect the structure of the family unit, by locally reducing the number of members, and therefore also the domestic network of links for alleviating health issues. This can complicate matters, as it minimizes the available resources (particularly so when there are members of the nuclear or extended family in charge of care duties for the group) and increasing the feeling of discomfort and helplessness in face of an illness. As alternatives, favored by improvements in telecommunications, new forms of “therapeutic” connection and networking have been established with those who are far away, allowing for an international circulation of healing advice and recipes, along with remote healing and spiritual requests (^{Escandell & Tapias, 2010}). This form of care was mentioned on numerous occasions during fieldwork.

Regardless of the possible processes of change and adaptation, the application of popular lore to the care of diseases remains a recurring element in social discourse, providing diseases with meaning and aiding in the development of identities. Among the members of the migrant community, there is a certain apprehension in telling about these practices to the native population, or the health personnel of medical institutions. The association of popular therapeutic actions with superstitions, lack of education or lower social strata results in concern or fear of being judged and ridiculed. However, through this work we have been able to recognize how widely they are taken into account as one of the main therapeutic strategies of this population group. To explain this preference, participants mentioned the historicity and effectiveness of, and faith entrusted in, tradition:

It is that you have believed... that popular wisdom that you have believed for so long and perhaps it is merely comforting. Whether it’s true or not... you don’t bother confirming... (José, Dominican, personal communication, June 17, 2017).

I leave the newspapers with the ointment on and dress him on top. It will work then, supposedly. As we believe in those things they teach us, then we put faith on it, and luckily, thank God, many things have worked (Felicia, Bolivian, personal communication, August 22, 2016).

At the same time, the knowledge and use of these strategies was valued as an expression of self-reliance, a quality that is seen as “the Latino way.” It can be said that the idea of having certain cultural attributes, useful in the face of adversity, is part of a frequently appearing resource that helps migrant groups adapt to their new social sphere, centering themselves around their own resilience (^{Hernández-Pulgarín 2016}).

CONCLUSION

The conformation of a therapeutic itinerary comes with a series of personal or group choices that determine the conjugation and/or exclusion of practices and knowledge, according to an expected result. From the fieldwork, it was noted that for the Latin American collective that lives in Salamanca, visits to formal health institutions have not become a prioritized alternative or the first step taken in the path of health care. In some cases, this may be related to structural inequalities that make access to care difficult (for example, lack of legal residence permit). In other instances, specific cultural and ideological elements arise in the discourse, reaffirming the opposition to the Biomedical Model and leading to the choice for other options.

Thus, the importance of self-care strategies as the first real level to alleviate diseases was confirmed. For these people, this form of organization represents a continuation of the medical resources used in their home society, able to respond to the structural differences in access to the institutional health system and to establish itself as a way of replicating the values deemed essential by the group itself, such as reciprocity, heritage, community membership, and autonomy. These expressions remind us that not all migration represents a loss, but also negotiation and cultural claim.

Additionally, ailment management finds a substrate in the network of links and affiliation groups with which cultural meanings about the disease are shared (^{Pescosolido, 1992}). This helps to displace the prevailing idea of individual responsibility for health and to account for a participatory and intricate social structure, both local and transnational.

As ^{Sacchi, Hausberger, and Pereyra (2007)} point out, a therapeutic itinerary is a journey “that is not only rational, but is mediated by feelings, memories, sensations, assessments that are not cognitive factors but rather attitudinal and emotional” (2007, p. 277). In short, the use of self-care strategies is part of a way of doing, or ethos, able of positioning both the social group and the individuals as active agents in their own health.

Medical pluralism is a pre-existing phenomenon that accompanies individuals from their countries of origin, whit varying degrees of application and extension. The possibility of adapting practices to each disease episode and the alternation in the use of models provides an account of the flexible nature of the itineraries and the pragmatic construction built around healing, which seeks to meet needs as they arise (^{Leslie, 1980}). In the migratory context, however, the presence of the different available devices acquires a unique character, mirroring the way that the new social space is inhabited.

A “bifocal approach” as described by ^{Vertovec (2004)} gives an account of the coexistence of intentions and the possible struggle between preserving one’s own cultural practices and the desire/need to adapt to the host society. According to this perspective, migrants and their identities are simultaneously placed between the “here” and “there.” Through ethnographic research, it was noticed that together with the continuity of original therapies, the decision to complementarily visit health institutions responded, in some cases, to matters of social adaptation and integration with the current environment.

The value of social sciences, particularly anthropology, lies in incorporating cultural representations of diseases, their emotional/subjective aspects in conjunction with their social dimension and the context that produces them. As acknowledged by ^{Haro-Encinas (2000)}, health care and treatment are a daily occurrence, so they should be studied with instruments that allow recording its everyday nature. This can only be achieved if proper interest is put again on the stories of the individuals involved, on their discursive constructions regarding their own reality. What happens behind the walls of a hospital or a primary care center is only a small fraction of a process that begins outside such system, a process with own rules and meanings. The ethnographic approach, especially by the use of qualitative techniques such as in-depth interviews and participant observation, provides an advantage for the reconstruction of the social and individual practices that make up the experience of getting ill and healing.