The Limits of Warmth: Cultural Adaptation and the Politics of Temperature in a Bolivian Hospital

This article is part of the following series:

In the small municipal hospital in the Bolivian highland town of Machacamarca (a pseudonym), the chilly air of the Andes seeps into the building, traveling through the thin walls and tile floors. The delivery room, situated next to the surgery ward, is especially cold; the air makes the metal gurney sitting in the middle of the room icy to the touch. Surrounding the gurney are white counters and walls that display medical supplies. Overhead, a bright, white fluorescent lamp lights up the room but provides little heat.

Figure 1. The laboratory-like birthing room in the Machacamarca Hospital (all photographs by the author)

However, if one leaves the ward and walks into the adjacent hall, one feels an immediate contrast. Here, three “culturally adapted” birthing rooms (salas con adecuación cultural) are warm. Recently constructed, the rooms’ floors are wooden and their walls, a deep, terra cotta orange. Two beds, draped in patterned wool blankets, take up much of the room. In the corner, a portable gas stove sits on a counter next to a sink. Pots, cups, and bowls are displayed inside a locked glass cabinet, while medical supplies are hidden from sight in a wooden chest. The sturdy construction buffers the cold air and creates a sheltered enclave within the hospital.

Figure 2.  The culturally adapted birthing room in the Machacamarca Hospital (photographs by the author)

In 2008, an internationally-funded non-profit organization constructed the first “culturally adapted” birthing room in the hospital in Machacamarca, a small, predominantly Indigenous Aymara town on the Bolivian Altiplano. The same organization completed construction on two additional rooms in 2011. Non-governmental organization (NGO) workers, as well as Bolivian state officials, suggested that the new rooms would create conditions for a more comfortable birthing experience for Aymara women, many of whom preferred to give birth at home. They pointed out that, in the culturally adapted room, women could give birth in the company of a family member and a midwife. Although not an exact reproduction, the room was designed to evoke the familiar environment of Aymara women’s homes (Morales 2018).

Across numerous Latin American contexts, national and regional governments (often with substantial support from NGOs and global health agencies) have sought since the 1990s to adopt intercultural health (salud intercultural) policies, framed in terms of making biomedicine more inclusive of Indigenous patients’ cultural practices. Especially when it came to childbirth, such policies often involved a transformation of the hospital space itself, so that the paradigmatic referent shifted from the laboratory to the home. Initiatives ranged, for example, from installing hammocks in a hospital in the Mexican state of Campeche (Campos Navarro et al 1997; Vega 2018), incorporating beds and radiators in clinics near Cusco, Peru (Guerra-Reyes 2019), and, in highland Bolivia, building warm, orange-hued rooms with beds and small kitchens. While resonant with recent moves to create more “patient-centered” hospital spaces around the globe (cf. Bates 2018), these architectural initiatives were specifically couched in terms of recognizing cultural difference — and thereby reducing maternal mortality by bringing more patients into the hospital.

This contribution to “The Hospital Multiple” series ponders how one effort to remake the hospital in terms of the affective, sensorial, and embodied warmth of the home reinscribed — rather than challenged — the ways that rural public hospitals had long been used to manage threats to life ostensibly posed by Indigenous culture. Attending to the problem of temperature, specifically, I show how institutional assumptions that warmth would be a means to provide “psychological support” (apoyo psicológico) for patients maintained continuities with racialized forms of medical intervention.

Notes on Culture and Temperature

Attention to temperature as site of ethnographic analysis obliges us to consider what warm and cold do in the hospital. In their work on freezing technologies, Joanna Radin and Emma Kowal (2017) remind us that temperature is both social and political. Yet temperature is rarely discussed in the anthropological literature on hospitals, even as it is always implicit, hanging in the air, shaping modes of intervention (too hot and bacteria might grow; too cold and cutting into bodies becomes challenging). In the high-altitude town of Machacamarca, the cold, dry air that leaked from the outside into the hospital was experienced by many Aymara patients as yet another form of neglect and bodily harm they associated with the clinic. While the cold lingered year-round, it was especially icy in the winter months, when the cool air stayed trapped in the floors, walls, and equipment. Residents of Machacamarca knew that during childbirth, the body was especially porous and vulnerable to the forces of temperature. When women gave birth at home, their husbands were expected to keep them warm — bundling them in blankets or rubbing their bodies in animal fat, preparing hot soups and teas. In designing hospital spaces that were warmer, NGO workers acknowledged local etiologies of temperature and bodily wellness; yet they also refigured them in new terms, more commensurate with the hospital setting. Those I interviewed suggested that certain home practices — like using fat or giving birth on a sheepskin on the floor — would be too unhygienic to incorporate into the hospital, but they could incorporate elements like warm-colored walls and a small kitchen. The culturally adapted room ultimately looked very little like the interiors of homes across the Altiplano, but rather rendered warmth in stylized terms — designed to exude invitation, psychological support, and other “good feelings” mobilized around Indigenous alterity in the name of liberal cultural recognition.

In using the term cultural recognition, I refer to the globalized political logics of offering limited legal protections for the cultural practices of minoritized communities (including members of Indigenous nations). As scholars have argued, while such policies at times offer new points of aspiration and political claims-making (cf. Postero 2007), they also extend apparatuses of domination, “permitting” Indigenous difference only insofar as practices do not transgress dominant structures and sensibilities (Povinelli 2002; Rivera Cusicanqui, cited in Hale 2004). Largely in response to a growing global Indigenous rights movement, national governments as well as global agencies have variably embraced policies that offered limited protections for cultural difference — often as a development tactic of bringing more people into the institutions of modernity, such as hospitals.

When I was conducting ethnographic research in Bolivia in 2014-2015, the administration of President Evo Morales officially embraced a project of decolonization (descolonización) that would go further in dismantling exclusionary structures. Yet in practice, national health reforms often re-entrenched the cultural recognition models proposed by global health and development agencies — and continued to rely on NGOs to help implement them. Elizabeth Povinelli (2002), Audra Simpson (2020), and other scholars have highlighted the centrality of affect and moral sentiment to projects of liberal politics of recognition; such policies proffer “good feelings” of sympathy and inclusion around cultural difference while continuing to maintain the oppression and dispossession of Indigenous peoples. In putting this line of argumentation in conversation with an analysis of hospital temperatures, I show how NGO promises of Indigenous inclusion were not only affective, but also material, embodied, and sensory. Cultural adaptation could enable moments of intimacy, sensations of warmth, the easing of bodily pains during contractions — but always in ways that rendered care commensurate with the hospital as an infrastructure of racialized intervention.

Material Histories of Cold

The Machacamarca Municipal Hospital was a small, red-brick building, located just off the main highway that cut through the rural — if rapidly urbanizing — highland town of about 11,000 residents. Constructed in 2001 to serve residents of the town and surrounding villages, the public establishment offered mainly primary care and emergency services, along with a handful of specialties like internal medicine and pediatrics. Doctors and nurses (most of whom commuted in from the cities) referred more complex cases to larger public hospitals in El Alto and La Paz, about two hours away by car. With the exception of the newer, culturally adapted spaces, much of the interior of the hospital was made up of white tile floors and plaster walls, echoing the laboratory-like architectures that had been the standard of care in Bolivian public clinics and hospitals since the mid-twentieth century. Following the National Revolution of 1952, the state began investing in rural health care with the idea of building clinical monuments to progress that, through the display of scientific equipment and architectures, would inculcate patients with a modern health consciousness (Pacino 2013). Architectures were designed to be a bit crisp, cold, and uncomfortable for patients. Paralleling the ways that hospitals were used as tools of postcolonial nation-building elsewhere (see Street 2014), rural health establishments became key infrastructures for the racialized management of life.

Scholars working in the Andes have noted that categories of race are malleable and often coded in the language of “culture,” contingent on social and material markers like education, language, dress, and, certainly, engagement with healing systems and medical technologies (de la Cadena 2000; Roberts 2012). Policymakers positioned hospitals and clinics as an avenue to full integration in the modern Bolivian nation-state, in which patients might learn to reject traditions and become more mestizo (a category meaning racially mixed, but often associated with social whitening) (Pacino 2013; 2015). These architectural logics were especially central to managing childbirth in rural areas, as the bounded, cold space of the clinic was designed to be distinct from the warm space of the home and sealed off from the influence of potentially life-threatening “cultural” practices.

Yet Bolivian health infrastructure, fragile and underfunded, was not always maintained. Cold — built, to some degree, into the laboratory form — also blew fiercely through the thin walls and cracks of the Machacamarca Hospital; it lingered in the floors and equipment. For many Aymara patients, institutions that had been designed with the promise of providing access to social mobility ended up re-entrenching racialized and classed differences, as they were unable to afford the warmer and more personalized care of private clinics in the cities (see also Roberts 2012). Hospital practitioners, most of whom identified as mestizo, often drew on their own class and educational status to differentiate themselves from their patients. In the laboratory-like birthing room of the Machacamarca Hospital, they required laboring women to sit on the chilly gurney and sent all family members out of the room. When women complained of pain, discomfort, or cold, some practitioners berated them for not helping or collaborating (“No me estás colaborando!” in idiomatic Bolivian Spanish) or insisted that procedures were for their own good (“Es por tu bien”). The cold fed into experiences of institutional neglect, as patients described not only being berated by practitioners, but also being left alone, without family, without sufficient blankets or coverings. Never only one single thing, temperature pulled together the sensorial, the affective, and ontological experience of institutional abandonment.

Letting the Home into the Hospital

What did it look like, then, to transform the cold conditions of the hospital — and make them warm? When might warmth be allowed into the space of the hospital, and on what terms?  As I have noted, when women gave birth at home, their kin (and especially, their husbands) attended to temperature as a lively, potentially dangerous force that could determine bodily health or illness. Yet NGO workers and hospital practitioners interpreted such engagements with temperature primarily in terms of “psychological support” during childbirth. More easily legible to institutional actors, more easily commensurate with hospital-based care, the paradigm of “psychological support” rerouted warmth from a potent agent of bodily well-being to a technology for calming patients and quelling their fears. It carried echoes of earlier presuppositions — that cultural difference (as code for race) explained patients’ fundamental fear of biomedicine, that they needed to be urged to “collaborate.”

Now, however, the goal was to offer a modicum of comfort to bring patients into the hospital. Practitioners couched measures — like having patients lie on the bed, allowing a husband to be present, or simply absorbing the warm air — in terms of new kindness and inclusivity, of letting patients give birth “as they wanted.” Yet, as I describe elsewhere (Morales 2018), many hospital practitioners were also concerned that allowing too much warmth into the hospital would disrupt their ability to intervene effectively in patient bodies. Warmth as psychological support was acceptable; warmth as a material force, less so. In interviews, physicians described how warm technologies like the blanket-covered bed made it harder to maneuver the emerging infant. Teas and soups — making the body warm from the inside — were potentially dangerous and should only be allowed after birth. Hospital practitioners improvised a number of measures to regulate when warmth could flow into the hospital. Some used the culturally adapted space as a labor room before moving the patient to the laboratory-like room at the moment of birth. Others used the culturally adapted room, but obliged family members to leave in the moment of birth. Warmth could be invoked in terms of soothing patients in preparation for birth but needed to be minimized in the moment of birth itself, when practitioners continued to engage in authoritative, often harsh, interventions.

Figure 3. A model, built by the NGO, of the culturally adapted birthing room (photograph by the author)

Amid these constraints, warmth took on multiple forms for patients, shifting between commensurability and incommensurability with hospital procedures. Husbands, although not allowed to take on a more central role, sat on the edge of the bed and held their wives’ foreheads. Midwives gave patients massages on their lower back to ease the pain of contractions. Extended family members brought a pot of soup to put on the stove after birth. Warm air, materials, and touch helped create vital intimacy and ease pain — even as they could not always fully maintain bodily wellness, or fully transform the conditions of obstetric violence in the hospital. When I asked women about their experiences using the culturally adapted room, the most common response — echoing like a worn refrain — was that it was “bien no más” (“just okay.”) This response differed from the more triumphalist accounts of Bolivian intercultural birthing that appeared in international news coverage and transnational aid circuits, which often centered representations of newly grateful and self-actualized Aymara patients. Instead, “bien no más” was a kind of verbal shrug; it carried resonances with the invocations of “not good enough” that Simpson (2020: 5) describes in response settler offers of sympathy and repair. It was a reminder that if warmth was central to well-being, in its current institutional form it maintained continuities with the spaces and practices of violent intervention in the hospital.

Beyond Warmth?

Beatriz Loza (2013) powerfully critiques development experts who purport to offer “cultural adaptation” as a solution to inequalities in maternal health in Latin America, arguing that approaching cultural adaptation as a simple technical fix is insufficient. As Loza writes, “In Bolivia, for example, there have been experiments in [cultural adaptation] with few encouraging results; for if hospitals have been transformed in their decorations, the quality of care continues to be undesirable” (Loza 2013: 1085, translation mine). I am largely in agreement with her argument about the continuities of obstetric violence and inadequate care under conditions of cultural adaptation. Yet rather than approaching cultural adaptation as a superficial decoration — a mere shell — we might turn our attention to how these continuities are intentionally built, made to provisionally allow new forms of warmth, but only insofar as they maintain the functioning of the hospital as such. Architecturally distinct spaces are made to reinscribe the hospital as a space for managing Indigenous life in postcolonial and settler colonial contexts.

Examining these continuities has implications for intercultural health initiatives in Latin America — but also, potentially, for hospitals more globally, given the increasing turn to creating more welcoming and humanized spaces. Warmth can be appealing, preferable to purely cold interventions; the culturally adapted rooms in the Machacamarca Hospital could at times be sites of intimacy and rest. Yet ethnographic attention to the rooms suggests that there is more slippage between warm and cold than one might initially assume. Benevolence can sometimes slip into violence, happiness can be exclusionary, and compassion might mask ongoing oppression (cf. Ahmed 2010; Stevenson 2014; Ticktin 2011). Warm temperatures — able during labor to offer bodily comfort and ease pain — also facilitate ongoing forms of harsh treatment during birth. In pointing to slippages and tensions, I do not mean to summarily dismiss endeavors to transform the affective architectures of hospitals. But rather, we might consider what politics give shape to these efforts, on what terms well-being is “permitted.” We might remind ourselves that hospitals are fundamentally (bio)political infrastructures — opening up questions, too, of what it might look like to imagine care beyond these dominant forms.

Gabriela Elisa Morales is an Assistant Professor of Anthropology at Scripps College in Claremont, California. She received her PhD in Anthropology from Yale University in 2017. Her research bridges approaches from Medical Anthropology, Science and Technology Studies, and Indigenous Studies to examine how colonial and racializing logics have shaped medical care in Latin America — as well how such forms of intervention reach limits, are challenged, or are refused. She is currently is working on a book manuscript, Decolonizing Medicine: Politics and Practices of Care in Bolivia, that examines care practices under Bolivian state efforts to decolonize health care services during Evo Morales’ presidency. Her work has been funded by the National Science Foundation, the American Council of Learned Societies, and the Reed Foundation.

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