text:
Stormwater, Dam Safety, and Flood Management HomeSoil Erosion and Sediment ControlStormwater ManagementDam SafetyPlan Review for State and Federal ProjectsMS4 ProgramFlood ManagementRecent
Maryland's NPDES Municipal Separate Storm Sewer System (MS4) Permits
Department of the Environment Issues Stormwater Permits for Large Maryland Jurisdictions, Advances Climate Resiliency and Equity
The Maryland Department of the Environment (MDE) has issued a series of municipal stormwater permits to advance Chesapeake Bay restoration while reducing flooding and making communities more resilient to the effects of climate change.
Maryland's Municipal Stormwater Permits
When it rains, stormwater washes excess nutrients, chemicals, and dirt from impervious surfaces, such as buildings, roads, and parking lots into local waters and the Chesapeake Bay. Excess stormwater runoff can also flood local communities, scour sediment from waterways, and degrade the health of stream systems.
MDE's MS4 permits continue the state's robust work to reduce nutrient and sediment pollution from stormwater as part of a larger effort that requires all sectors, such as sewage treatment plants and septic systems, in Maryland and the surrounding region to protect and restore the Chesapeake Bay.
The MS4 permits are a result of extensive stakeholder engagement. Maintenance of existing infrastructure is essential and the new permits require local jurisdictions to maintain the previous stormwater pollution reduction efforts while also requiring additional stormwater pollution reduction to restore waterways. The additional restoration requirements are to reduce the impacts of impervious surface areas that have little through stormwater treatment with green infrastructure and other techniques. These new permits meet Maryland'sChesapeake Bay commitments and also increase accountability, enhance public education and include innovative and cost-effective monitoring options.
In the next five years the new permits add another 19,000 acres to the 35,000 impervious acres restored under prior permits. This restoration encourages climate resiliency and green infrastructure and at the same time continues to advance innovations such as pay-for-performance contracting, public-private partnerships, and new technologies. The permits also include new incentives for climate resiliency and green and blue infrastructure projects.
Maryland's 11 phase I urban jurisdictions have established themselves as national leaders in reducing stormwater pollution by collectively investing over $1 billion in clean water infrastructure. Since July 2019, MDE's Water Quality Finance Administration has guaranteed $117.8 million in low interest loans to counties and local governments for stormwater restoration projects, and another $257 million in low interest loans are pending for planned projects. During the prior MS4 permit term, which started in 2014, the Chesapeake Bay Trust awarded an additional $36.5 million in grants to stormwater programs for restoration projects, which leveraged another $27.7 million in matching funds. Maryland continues to push for additional federal funding for local stormwater projects – especially for those that increase climate resiliency in underserved communities and for those that help sustain our Chesapeake Bay restoration efforts for decades to come.
Advancing Stormwater Resiliency in Maryland
Urban flooding is a growing issue in Maryland. The increasing number of extreme rainfall events that produce intense precipitation will continue to lead to more urban flooding events unless steps are taken to mitigate their impacts. The Maryland General Assembly recognized the need to address urban flooding with the passing of Senate Bill 227. The Bill tasks the Maryland Department of the Environment (Department) with developing plans to evaluate current flooding risks and update regulations to improve urban stormwater flood management. The "Advancing Stormwater Resiliency in Maryland" report provides a roadmap towards modernizing stormwater management in Maryland.
Where Do We Start?
The Department is taking action through collection of data sets, development of tools and web applications, targeting funding opportunities, developing outreach and education and updating stormwater regulations. Step one is performing a statewide comprehensive urban flood management assessment. With the help of local floodplain and stormwater managers, the Department will identify and characterize Maryland's urban flooding events and report the current state of local stormwater and flood management programs. For more information on this effort, please visit the Advancing Stormwater Resiliency in Maryland page here.
Notice of Final Determination to Issue Stormwater Permit to Carroll County (December 30, 2022)
The Maryland Department of the Environment (Department) has reached a final determination to issue a National Pollutant Discharge Elimination System permit to Carroll County (Discharge Permit No. 22-DP-3319, NPDES No. MD0068331) for Discharges from Medium Municipal Separate Storm Sewer Systems (MS4) on December 30, 2022. This permit covers stormwater discharges into, through, or from the storm drain system owned or operated jurisdiction-wide by Carroll County and the following incorporated municipalities: The Towns of Hampstead, Manchester, Mt. Airy, New Windsor, Sykesville, Union Bridge and the Cities of Taneytown and Westminster (co-permittees). Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and the Chesapeake Bay. Also included in the permit are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system.
The Department has met with various stakeholders over the past several years regarding this permit, held a public hearing on April 12, 2022 to accept testimony, and accepted public comments through June 9, 2022. It is the Department's final determination that this permit complies with the United States Environmental Protection Agency's NPDES regulations to control stormwater pollutant discharges from the County's storm drain system to the maximum extent practicable.
The final permit and fact sheet can be viewed here:
Carroll County Permit
Carroll County Fact Sheet
Response to Comments
MS4 Guidance Includes:
2021 Accounting for Stormwater Wasteload Allocations and Impervious Acres Treated
2021 MS4 Monitoring Guidelines: BMP Effectiveness and Watershed Assessments
The Department used the following documents to help assess the physical and financial capacity of Carroll County to meet restoration goals proposed in the permit.
Maximum Extent Practicable Submission (July 2021)
These analyses were based on instructions and spreadsheets sent to the County. These instructions may be found here:
March 2021 Restoration Portfolio Instructions
Hard copies of the documents listed above may also be obtained from the Department at a cost of 36¢ per page.
The Department's final determination is subject to judicial review at the request of any person that meets the threshold standing requirements under federal law and participated in the public participation process through the submission of written or oral comments. Requests for judicial review in accordance with §1-601 and §1-605 of the Environment Article need to be made on or before January 29, 2023.
Notice of Final Determination to Issue Stormwater Permit to Charles County (December 30, 2022)
The Maryland Department of the Environment (Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Charles County (Discharge Permit No. 22-DP-3322, NPDES No. MD0068365) for Discharges from Medium Municipal Separate Storm Sewer Systems (MS4) on December 30, 2022. This permit covers stormwater discharges into, through, or from the storm drain system owned or operated jurisdiction-wide by Charles County. Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and the Chesapeake Bay. Also included in the permit are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system.
Charles County Permit
Charles County Fact Sheet
Response to Comments
The Department used the following documents to help assess the physical and financial capacity of Charles County to meet restoration goals proposed in the permit.
The Department's final determination is subject to judicial review at the request of any person that meets the threshold standing requirements under federal law and participated in the public participation process through the submission of written or oral comments. Requests for judicial review in accordance with §1-601 and §1-605 of the Environment Article need to be made on or before January 29, 2023.
Notice of Final Determination to Issue Stormwater Permit to Frederick County (December 30, 2022)
The Maryland Department of the Environment (Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Frederick County (Discharge Permit No. 22-DP-3321, NPDES No. MD0068357) for Discharges from Medium Municipal Separate Storm Sewer Systems (MS4) on December 30, 2022. This permit covers stormwater discharges into, through, or from the storm drain system owned or operated jurisdiction-wide by Frederick County. Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and the Chesapeake Bay. Also included in the permit are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system.
Frederick County Permit
Frederick County Fact Sheet
The Department used the following documents to help assess the physical and financial capacity of Frederick County to meet restoration goals proposed in the permit.
The Department's final determination is subject to judicial review at the request of any person that meets the threshold standing requirements under federal law and participated in the public participation process through the submission of written or oral comments. Requests for judicial review in accordance with §1-601 and §1-605 of the Environment Article need to be made on or before January 29, 2023.
Notice of Final Determination to Issue Stormwater Permit to Harford County (December 30, 2022)
The Maryland Department of the Environment (Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Harford County (Discharge Permit No. 22-DP-3310, NPDES No. MD0068268) for Discharges from Medium Municipal Separate Storm Sewer Systems (MS4) on December 30, 2022. This permit covers stormwater discharges into, through, or from the storm drain system owned or operated jurisdiction-wide by Harford County. Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and the Chesapeake Bay. Also included in the permit are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system.
Harford County Permit
Harford County Fact Sheet
The Department used the following documents to help assess the physical and financial capacity of Harford County to meet restoration goals proposed in the permit.
Maximum Extent Practicable (MEP) Submission (July 2021)
MEP Submission (September 2021)
Notice of Final Determination to Issue Stormwater Permit to Howard County (December 30, 2022)
The Maryland Department of the Environment (Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Howard County (Discharge Permit No. 22-DP-3318, NPDES No. MD0068322) for Discharges from Medium Municipal Separate Storm Sewer Systems (MS4) on December 30, 2022. This permit covers stormwater discharges into, through, or from the storm drain system owned or operated jurisdiction-wide by Howard County. Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and the Chesapeake Bay. Also included in the permit are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system.
Howard County Permit
Howard County Fact Sheet
The Department used the following documents to help assess the physical and financial capacity of Howard County to meet restoration goals proposed in the permit.
Notice of Final Determination to Issue Stormwater Permit to Prince George's County (December 2, 2022)
The Maryland Department of the Environment (Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Prince George's County (Discharge Permit No. 20-DP-3314, NPDES No. MD0068284) for Discharges from Large Municipal Separate Storm Sewer Systems (MS4) on December 2, 2022. This permit covers stormwater discharges into, through, or from the storm drain system owned or operated by Prince George's County and all incorporated municipalities within the County except for the City of Bowie. Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and the Chesapeake Bay. Also included in the permit are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system. The Department has met with various stakeholders over the past several years regarding this permit, held a public hearing on December 15, 2021 to accept testimony, and accepted public comments through February 4, 2022. It is the Department's final determination that this permit complies with the United States Environmental Protection Agency's NPDES regulations to control stormwater pollutant discharges from the County's storm drain system to the maximum extent practicable.
Prince George's County Permit
Prince George's County Fact Sheet
2021 Accounting for Stormwater Wasteload Allocations and Impervious Acres Treated
2021 MS4 Monitoring Guidelines: BMP Effectiveness and Watershed Assessments
The Department used the following documents to help assess the physical and financial capacity of Prince George's County to meet restoration goals proposed in the permit. These documents were submitted in July 2019 and April 2020 and some of the information contained within do not incorporate continued program activity and updates.
MEP Submission (July 2020)
MEP Submission (June 2019)
April/May 2019 Restoration Portfolio Instructions
October 2019 Restoration Portfolio Instructions
Hard copies of the documents may also be obtained directly from the Department at a cost of 36¢ per page.
Notice of Final Determination to Issue Stormwater Permits to Anne Arundel County, Baltimore City, Baltimore County, and Montgomery County (November 5, 2021)
The Maryland Department of the Environment (Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Anne Arundel County (Discharge Permit No. 20-DP-3316, NPDES Permit No. MD0068306), Baltimore City (Discharge Permit No. 20-DP-3315, NPDES Permit No. MD0068292), Baltimore County (Discharge Permit No. 20-DP-3317, NPDES Permit No. MD0068314), and Montgomery County (Discharge Permit No. 20-DP-3320, NPDES Permit No. MD0068349) for Discharges from Large Municipal Separate Storm Sewer Systems (MS4) on November 5, 2021. These permits cover stormwater discharges into, through, or from the storm drain system owned or operated by these Counties. Permit requirements include implementing comprehensive stormwater management programs for addressing runoff from new and redevelopment projects, restoring urban areas where there is currently little or no stormwater management, and working toward meeting stormwater wasteload allocations for local water resources and Chesapeake Bay. Also included in the permits are conditions that require the County to possess the necessary legal authority to control stormwater discharges, map its storm drain system, monitor urban runoff, and eliminate illicit discharges to the storm drain system. The Department has met with various stakeholders over the past several years regarding these permits, held public hearings to accept testimony and accepted public comments. It is the Department's final determination that these permits comply with the United States Environmental Protection Agency's NPDES regulations to control stormwater pollutant discharges from Counties' storm drain systems to the maximum extent practicable.
The final permits, fact sheets, and Response to Comments can be viewed here:
Anne Arundel County Final Permit
Anne Arundel County Fact Sheet
Baltimore City Final Permit
Baltimore City Fact Sheet
Baltimore County Final Permit
Baltimore County Fact Sheet
Montgomery County Final Permit
Montgomery County Fact Sheet
2021 MS4 Monitoring Guidelines: BMP Effectiveness and Watershed Assessments
MEP Submissions:
Anne Arundel County 2019 MEP Submission
Anne Arundel County 2020 Revised MEP Submission
Baltimore City 2019 MEP Submission
Baltimore City 2020 Revised MEP Submission
Baltimore County 2019 MEP Submission
Baltimore County 2020 Revised MEP Submission
Montgomery County 2019 MEP Submission
Montgomery County 2020 Revised MEP Submission
Notice of Proposed Settlement - Prince George's County (January 29, 2021)
The Maryland Department of the Environment and the Prince George's County Department of Environmental Protection have reached tentative agreement on a consent decree to be filed in Prince George's County Circuit Court resolving issues with the county's performance pursuant to the National Pollutant Discharge Elimination System (NPDES) Municipal Separate Storm Sewer System (MS4) permit issued January 2, 2014. The five-year permit expired on January 1, 2019.
While a public comment period is not required by Maryland law as part of the review and approval of such a settlement, the parties are aware of public interest in this and other county MS4 stormwater permits. Accordingly, the Department of the Environment is distributing copies of the tentative settlement to interested parties and making it available on the Department's web page. The tentative settlement can be viewed here:
Prince George's County Consent Decree
Comments will be accepted through March 2, 2021. Those comments may be submitted electronically to Raymond.bahr@maryland.gov or mailed to the attention of Raymond Bahr, Suite 400, Maryland Department of the Environment, 1800 Washington Boulevard, Baltimore, MD 21230.
The consent decree imposes a $475,000 penalty for failure to complete all of the restoration work required by the 2014 permit. The penalty can be satisfied through the construction of one or more Department-approved Supplemental Environmental Projects by December 31, 2024. In addition, the decree requires that the restoration work remaining under the terms of the 2014 MS4 permit be completed in the same timeframe. The settlement calls for additional penalties for failure to meet interim goals.
Prince George's County initiated efforts to address urban stormwater runoff well before the Chesapeake Bay Total Maximum Daily Load (TMDL) was established in 2010 and has been diligent in its efforts. This consent decree requires the county to complete the impervious surface restoration work that remains to be performed notwithstanding the expiration of the 2014 permit.
"We appreciate Prince George's County's commitment to improved environmental performance under its state permit and collaboration on the consent decree, including provisions on penalties, schedules, and supplemental environmental projects", said Secretary Ben Grumbles. "Preventing stormwater pollution can be challenging but it's important for local water quality and the Chesapeake Bay and the state will continue to enforce its laws and provide assistance to counties and communities."
Guidance for Maryland's NPDES Stormwater Permits
NPDES municipal separate storm sewer system permits in Maryland require the restoration of a certain percent of a jurisdiction's impervious surface area (e.g., 20%) that has little or no stormwater management. How to calculate impervious surface requirements and treatment credits has generated numerous questions. This document standardizes procedures for reporting of traditional, new, and alternative best management practices (BMPs) and the impervious area each controls. The guidance can be found below.
The Department has revised Appendix B of the Accounting for Stormwater Wasteload Allocations and Impervious Acres Treated (MDE, November 2021). The revision corrects a technical error and provides additional clarification related to the calculation of total nitrogen load reductions for measuring progress toward meeting total maximum daily load (TMDL) goals. The revision ensures consistency with the guidance and the reporting criteria found in the Department's Urban Stormwater Management Credit Calculator for TN, TP, TSS (MDE, April 28, 2022) and the TMDL Implementation Progress and Planning (TIPP) Tool (MDE, April 6, 2022).
Accounting for Stormwater Wasteload Allocations and Impervious Acres Treated (2021)
Accounting for Stormwater Wasteload Allocations and Impervious Acres Treated (2014)
MS4 Monitoring Guidelines: BMP Effectiveness and Watershed Assessments (2021)
Factoring in Climate Change in Effective Impervious acres (EIAs) for Alternative Practices (November 2021)
The following documents were developed to help the Department assess the physical and financial capacity of Phase I Large permittees to meet proposed restoration goals. The first documents are the instructions and spreadsheets sent to each Phase I large permittee:
April/May 2019 Restoration Portfolio Instructions
April 2019 Presentation to MACo
October 2019 Restoration Portfolio Instructions
March 2021 MEP Spreadsheets (PDF Version)
The following documents were developed by the University of Maryland Environmental Finance Center (UMEFC) and the University of Maryland Center for Environmental Science (UMCES) to assist with financial capacity analyses:
Affordability Assessment Matrix for MD NPDES Phase Communitie (UMEFC)
Willingness to Pay for Environmental Improvements Generated by Stormwater Projects (UMCES)
Presentation to MACo (UMEFC)
Other Guidance Documents:
Since 2014, MDE has distributed several memoranda that provide additional guidance concerning BMPs and impervious area crediting. Please note that these memoranda are intended to clarify, supplement, or replace the information found in the Accounting for Stormwater Wasteload Allocations and Impervious Acres Treated (MDE, 2014). When there are conflicts between these memoranda and the original 2014 guidance, the newest shall supersede. These documents may be found here:
Water Quality Trading Credits Model Updates (February 2021)
Update! Stream Restoration Crediting Clarification for MS4 Permitting Purposes (April 2019)
Letter to MACO on Stream Restoration Credits (December 2018)
Memorandum on Stream Restoration Crediting (October 2018)
Memorandum on BMPs and Completion Dates (April 2018)
Letter to MDOT SHA on Outfall Crediting (April 2018)
Letter to MDOT SHA on Outfall Crediting - Interim Approval (August 2017)
Funding Sources
Additionally, in March 2018, MDE sent a letter to OptiRTC, Incorporated that established requirements and interim credits for the use of continuous monitoring and adaptive control (CMAC) systems for restoration. While this letter is addressed to OptiRTC, the conditions and restrictions apply to CMAC systems in general, includiong those marketed by others. A copy of this letter is available here:
Letter on CMAC Systems (March 2018)
Phase I Large MS4 Permit Tentative Determination Comments
The Maryland Department of the Environment, Water and Science Administration (the Department) reached a final determination to issue a National Pollutant Discharge Elimination System (NPDES) permit to Anne Arundel County (Discharge Permit No. 20-DP-3316, NPDES Permit No. MD0068306), Baltimore City (Discharge Permit No. 20-DP-3315, NPDES Permit No. MD0068292), Baltimore County (Discharge Permit No. 20-DP-3317, NPDES Permit No. MD0068314), and Montgomery County (Discharge Permit No. 20-DP-3320, NPDES Permit No. MD0068349) for Discharges from Large Municipal Separate Storm Sewer Systems (MS4) on November 5, 2021. The Department met with various stakeholders over the past several years regarding these permits, held public hearings to accept testimony on each permit through online webinars in November 2020, and accepted public comments through January 21, 2021. The written comments recieved by the Department and the transcripts of the public hearings are posted below.
Anne Arundel County Department of Public Works
Baltimore County Department of Environmental Protection and Sustainability
Blue Water Baltimore
Carroll County Department of Land and Resource Management
Chesapeake Accountability Project - Anne Arundel County
Chesapeake Accountability Project - Anne Arundel County Appendix
Chesapeake Accountability Project - Baltimore City
Chesapeake Accountability Project - Baltimore City Appendix
Chesapeake Accountability Project - Baltimore County
Chesapeake Accountability Project - Baltimore County Appendix
Chesapeake Accountability Project - Montgomery County
Chesapeake Accountability Project - Montgomery County Appendix
Chesapeake Bay Foundation
Choose Clean Water Council: Comments on Phase I MS4 Permits
Choose Clean Water Council: Recommendations for New Metrics Approach
Charles County Department of Planning and Growth Management
City of Baltimore Department of Parks and Recreation
CityScape Engineering, LLC (Baltimore City)
Farm Alliance of Baltimore
Maryland League of Conservation Voters: Comments on MS4 Accounting Guidance Document
Maryland Municipal Stormwater Association
Metropolitan Washington Council of Governments
Montgomery County Department of Environmental Protection
Mr. Stephen J. Miller
Mr. Tom McCord
Ms. Sally Jones
Prince George's County Department of the Environment
Stormwater Partners Network of Montgomery County
Waterfront Partnership of Baltimore
Anne Arundel County Public Hearing Transcript
Baltimore City Public Hearing Transcript
Baltimore Country Public Hearing Transcript
Montgomery County Public Hearing Transcript
NPDES Phase I Permits
You can view background information on each jurisdiction by clicking on the municipality's name in the chart below. Initial permits, current permits, and links to the agency responsible for administering each local permit are also accessible by clicking on the respective links below.
Initial Permit Issued Current Permit Issued Local Agency Responsible for Annual Reporting
Large Jurisdictions
Dept. of Public Works / Watershed Protection and Restoration
Dept. of Environmental Protection & Sustainability (EPS) / NPDES
Dept. of Public Works
Dept. of Environmental Protection
12/02/2022
Dept. of Environment
Medium Jurisdictions
Land Use, Planning & Development
05 /01/1997
Planning & Growth Management
Sustainable Development - Watershed Management
Dept. of Public Works - Water Resources
Dept. of Public Works / Stormwater Management Division
State Storm Drain Systems
State Highway Administration
Office of Environmental Design
Summary of Local Requirements
NPDES municipal stormwater permits require the jurisdictions to develop comprehensive programs to reduce storm drain system pollution to the MEP. Typical NPDES stormwater permit conditions require jurisdictions to:
Legal Authority: provide certification from appropriate legal counsel that adequate authority exists to control discharges from the municipal storm drain system
Source Identification: map storm drain pipes and best management practices (BMPs), land use, impervious cover, and watershed restoration projects in geographical information system (GIS) format
Management Programs: implement erosion and sediment control, stormwater management, illicit connection detection and elimination, and public education and outreach programs
Watershed Assessment: evaluate all urban watersheds thoroughly regarding water quality and develop goals and action plans for restoration,
Restoration Projects: restore 20% of uncontrolled impervious surfaces based on watershed assessments during each five-year permit cycle
Assessment of Control: document work toward meeting watershed restoration goals, including total maximum daily loads (TMDLs)*, using chemical, biological, and physical monitoring
Program Funding: provide an annual fiscal analysis of the capital, operation, and maintenance expenditures necessary to comply with permit conditions
More information on TMDLs may be found on MDE's webpage here: Introduction to TMDLs
Questions about NPDES municipal permits may be directed to the Sediment, Stormwater, and Dam Safety Program at 410-537-3543 or emailed to Mr. Raymond Bahr at Raymond.Bahr@maryland.gov.


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Maxime Bernier believes in climate change, but defends argument that CO2 is just 'food for plants'
Bernier's new party will have no specific climate policy, but he said his broader economic policies would allow the private sector to find solutions
Marie-Danielle Smith
OTTAWA — Maxime Bernier believes Earth's climate is changing. However, he has "no opinion" as to the cause, and his new political party doesn't plan to propose any specific climate policy ahead of next year's election, instead trusting the private sector to solve the problem.
In an interview with the National Post, the leader of the fledgling People's Party of Canada lamented the way some people interpreted his recent statements on Twitter — that CO2 is food for plants, not pollution — to mean he is a climate-change denier.
"I believe in climate change," he said. Asked if critics are not taking him literally enough on such statements, Bernier said, "Yes."
PPC spokesman Martin Masse explained, however, that Bernier doesn't want to proclaim any opinions on its causes. "Mr. Bernier recognizes that CO2 can have an effect on climate change. He also recognizes that the majority of scientists believe that human activity is already having a negative impact on climate change, although a minority still believe this is not the case. As a non-scientist, he doesn't have an opinion on this," Masse said in a statement.
Rebate plan bumps support for carbon tax despite concerns it amounts to a tax grab: poll
'An election gimmick': Conservative politicians fire back at Trudeau's carbon-tax rebate plan
Federal carbon tax rebates will exceed the cost for most people affected
"The PPC's focus is not on debating the science but on the measures that should be taken to lower the consumption of carbon energy. No government policy that is now being debated, certainly not the government's carbon tax, is likely to have any effect on global climate change."
In the interview, Bernier said he will propose no specific climate policy as part of the platform for his new party, which has yet to be formally registered by Elections Canada. He said his broader economic policies, including a flat, lower tax rate for business, would allow the private sector to find solutions.
Libs can only sell their carbon tax if they lie.
Lie #1: You'll get back more money.
Lie #2: It's a price on "pollution."
CO2 is NOT pollution. It's what comes out of your mouth when you breathe and what nourishes plants. https://t.co/4O9Q1lA08O
— Maxime Bernier (@MaximeBernier) October 24, 2018
The former Conservative leadership candidate — who in August broke from the party and its leader, his former rival Andrew Scheer, to strike out on his own — has long argued against carbon taxation. He accused Prime Minister Justin Trudeau of being hypocritical for explaining recently on Quebec talk show Tout le monde en parle that if Canada alone took extreme measures to end all its pollution tomorrow, without action from other countries, it would have little impact on the climate.
"You can shut down our economy and the effect on climate change, it will be nothing," Bernier said. "I think, why tell Canadians that you can change the world when you cannot?"
His rhetoric on social media has been more blunt than that: "It proves that his carbon tax will have ZERO EFFECT and is just HYPOCRITICAL VIRTUE SIGNALING," said one post from his Twitter account this week. "But there were more media reports criticizing me for saying the obvious fact that CO2 is food for plants!"
Bernier told the Post there are "a lot of programs at the provincial and federal level" to deal with climate change. "I think that the solution will come with the private sector with new technology."
Independent MP Maxime Bernier speaks to reporters in the foyer of the House of Commons on Oct. 29, 2018. Sean Kilpatrick/The Canadian Press
But asked to clarify if that meant he was in favour of government programs that subsidize the development of clean energy technologies, Bernier said he doesn't support corporate welfare in any situation. "The best program will be to lower taxes to every single entrepreneur in this country," he said.
"The electric car, it's not the government saying, 'Oh, we must have electric cars.' The market was ready for that. People were ready for that, so, we have electric cars. The free market, the people, will find solutions and they always did in the past."
Every one of Bernier's federal competitors have struck a different tone. The Conservative Party is expected to reveal a climate policy that offers an alternative to the Liberals' carbon-pricing program and to the more-aggressive policies proposed by the NDP and Green Party.
Tories seem confident that voters who oppose the Liberals' carbon tax won't vote for Bernier's PPC for fear of splitting the vote on the right side of the political spectrum. "If you're voting on the carbon tax, you're not going to vote for Maxime Bernier," a senior Conservative source said.
— with files from Maura Forrest
• Email: mdsmith@postmedia.com | Twitter: mariedanielles
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redpajama_set_name: RedPajamaCommonCrawl


It's officially fall, NYC's finest season. After morning pre-k yesterday we decided to venture out for our last car outing for a couple days. The Pope comes to town today, and traffic is going to be madness. We picked Queens, New York Hall of Science. You can get there by subway and bus, but it's much easier to drive, plus we get free parking since we're members. We've only been here once before, so it's still new to us and there's a lot we haven't seen.
Brooklyn and I began in a section called Design Lab, this program blew me away! There's a large room with multiple workshops where you're allowed to create/invent something. We did two labs. In the first we were told to solve a problem: There was a big storm in a town and many things were destroyed, the people needed supplies of food and water. We needed to invent something that could both hold the relief and get it there, using the provided zip line. There were several tables full of kids and materials (cardboard, note cards, aluminum foil, straws, string, tape, paperclips, etc) for us to use. Brooklyn just turned 4, so she needed a lot of help, but she was able to think through the problem and decided a hot air balloon would work best. Together we made a modified one…a basket made of note cards taped together with aluminum foil for a handle. I worked quickly with her so the project wouldn't lose her attention, how long she is able to focus is always a mystery. Once assembled she climbed to the top of a platform and put her structure to the test. Her first attempt failed. I helped her add some string and a paperclip and SUCCESS! It sailed down the zip line intact.
The next lab was also a lot of fun. We made a cat character drawing on paper, cut it out and attached it to a stick. Then used provided props to create a scene, wrote a quick story line then snapped some pictures. Our story was about super cat Nico who went to visit the leaning tower of Pisa with his friend a dinosaur…yet to be named.
We then ventured outside to the 9 hole mini golf section where Brooklyn tried to defy the laws of physics, repetitively. There is a small additional fee for this, but much worth it. She LOVED this section. I have to admit I was terrified I'd get clubbed by her or one of the other little scientists. But we both made it out unscathed.
Next stop was another interactive floor where we balanced on a simulated surf board, raced in stationary wheelchairs and tested three different balls by pitching them with a speedometer.
Our last stop at the museum was the playground, the most innovative playground I've been to in NYC. This playground is a reason alone to visit the museum. Almost every apparatus turns, creates energy, pumps water, tweaks light, or does something to demonstrate a cause and effect relationship. And it's FUN.
Our day didn't end there though, the museum is located in Flushing Meadows Corona Park. The Queens Zoo and Fantasy Forest are both within the park just outside of the museum, so we hit both of those before calling it a day.
Today was a really special day with my little girl. I cherish spending one on one time with her and I LOVE blowing her mind. It's so easy to do at this age, I'm definitely savoring it. There's much more of both New York Hall of Science and Corona Park I haven't explored and I can't wait to go back!
Wow, this place sounds amazing!
it is! let's plan a trip together.


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Original Article • Saude soc. 31 (4) 05 Dec 20222022 • https://doi.org/10.1590/S0104-12902022210022en copy
Mapuche health experiences in Primary Health Care from health workers and users in urban Chile
Mónica Manríquez-Hizaut
Data production
Writing of the first draft of this manuscript and further versions
Universidad de Chile. Facultad de Medicina. Departamento de Kinesiología. Santiago, Chile. E-mails: mmanriquezh@uchile.cl; jame.rebolledo@uchile.cl; daniela.ingles95@gmail.com; rocioklett@gmail.comhttp://orcid.org/0000-0002-5325-1749
Jame Rebolledo-Sanhueza
Daniela Inglés-Yañez
Rocío Klett-Fuentes
Cristián Lagos-Fernández
Universidad de Chile, Facultad de Filosofía y Humanidades, Departamento de Lingüística. Santiago, Chile. E-mail: kinelagos@uchile.clhttp://orcid.org/0000-0002-8937-4783
Verónica Figueroa-Huencho
Universidad de Chile. Instituto de Asuntos Públicos. Santiago, Chile. E-mail: v.figueroa.h@iap.uchile.clhttp://orcid.org/0000-0002-5422-6043
This study describes experiences and perceptions on interculturality in Primary Health Care (PHC) from the perspective of health workers and Mapuche health users. For this purpose, a qualitative systematization of these experiences was carried out in a PHC Intercultural Health Program at an urban commune in Chile. Data were collected by means of individual and group interviews, respectively, with 19 users and 13 professionals. The semantic content analysis was performed. While service users perceive Mapuche health positively, assimilating it to the concept of interculturality, health workers reported that Mapuche health is respected but no integrated work is promoted. As barriers, participants cited administrative aspects, lack of integration, and scientific issues. In conclusion, recognition of indigenous health and greater occupational training on indigenous health and interculturality is necessary.
Culturally Competent Care; Health of Indigenous Peoples; Mapuche Health; Ethnicity and Health; Cultural Diversity
According to the last Population Census (INE, 2017INE - INSTITUTO NACIONAL DE ESTADÍSTICAS. (Chile). Censo de Población 2017. Santiago: INE, 2017.), Chile is a multiethnic, multicultural and multilingual country; 12.8% of the population self-report to belong to some indigenous people, among whom 79.8% self-report to be Mapuche. Despite having a significant population representation, there is a cultural and political asymmetry that marks the relations between the national society and the indigenous world. For example, indigenous people have less access to health and poor results in critical health indicators (Heise et. al, 2009HEISE, K. et al., Incidence and survival of stomach cancer in a high-risk population of Chile. World Journal of Gastroenterology, Pleasanton, v. 15, n. 15, p. 1854-1862, 2009. DOI: 10.3748/wjg.15.1854
https://doi.org/10.3748/wjg.15.1854... ; Oyarce et al., 2009OYARCE, A.; PEDRERO, M. Una metodología innovadora para la caracterización de la situación de salud de las poblaciones indígenas de Chile: limitaciones y potencialidades. Notas de población, Vitacura, n. 89, p. 119-148, 2009.; Moloney, 2010MOLONEY, A. Protests Highlight Plight of Chile's Mapuche. The Lancet, Amsterdã, v. 375, n. 9713, p. 449-450, 2010. DOI: 10.1016/s0140-6736(10)60181-x
https://doi.org/10.1016/s0140-6736(10)60... ).
The Mapuche medicine perceives health from its cosmovision of life; as regards wellbeing, they consider both origins and spirituality, as well as the balance with nature. Therefore disease involves the rupture of this balance (Diaz et al., 2004DÍAZ, A. et al., Conceptos de enfermedad y sanación en la cosmovisión mapuche e impacto de la cultura occidental. Ciencia y enfermería, Concepción, v. 10, n. 1, p. 9-16, 2004. DOI: 10.4067/s0717-95532004000100002
https://doi.org/10.4067/s0717-9553200400... ). In response to the need for belonging in health care and improved access, intercultural health becomes relevant as a public health strategy to provide care to indigenous peoples.
In 1992, the Mapuche Population Health Program (Programa de Salud con Población Mapuche, PROMAP) was created, and in 1996, the National Health and Indigenous Peoples Program (Programa Nacional de Salud y Pueblos Indígenas) was implemented. Some authors consider that these intercultural health programs were oriented to solve health problems by integrating resources from different medicines. However, they received little recognition from an administrative point of view, weakening their implementation.
In 2008, the Special Health Program for Indigenous Peoples (Programa Especial de Salud para Pueblos Indígenas, PESPI) was created, aimed to consolidate an intercultural health system, which previous programs failed to install, accepting the existence and validity of other healing systems complementary to the existing health systems (Manríquez-Hizaut et al., 2018MANRÍQUEZ-HIZAUT, M., LAGOS-FERNÁNDEZ, C., REBOLLEDO, J., FIGUEROA-HUENCHO, V. Salud Intercultural en Chile: Desarrollo histórico y desafíos actuales. Revista de Salud Pública, Bogotá, v. 20, n. 6, p. 759-763, 2018. DOI: 10.15446/rsap.v20n6.65625
https://doi.org/10.15446/rsap.v20n6.6562... ). This program aims to:
Contribute to the reduction of inequity gaps in the health status of indigenous peoples, through the participatory construction of health plans that recognize cultural diversity, promote complementarity between medical systems, and provide adequate health services responsive to specific needs, rights and epidemiological profiles. (Minsal, 2013MINSAL - MINISTERIO DE SALUD. (Chile). Orientaciones Técnicas Programa Especial de Salud Indígena (PESPI). Santiago: MINSAL, 2013. Disponível em: <Disponível em: http://www.bibliotecaminsal.cl/wp/wp-content/uploads/2018/01/030.OT-y-Guia-Pueblos-indigenas.pdf >. Acesso em: 27 maio de 2022.
http://www.bibliotecaminsal.cl/wp/wp-con... , free translation).
Three main axes are established for the PESPI execution: Equity, Intercultural Approach to Health, and Indigenous Social Participation (Minsal, 2013MINSAL - MINISTERIO DE SALUD. (Chile). Orientaciones Técnicas Programa Especial de Salud Indígena (PESPI). Santiago: MINSAL, 2013. Disponível em: <Disponível em: http://www.bibliotecaminsal.cl/wp/wp-content/uploads/2018/01/030.OT-y-Guia-Pueblos-indigenas.pdf >. Acesso em: 27 maio de 2022.
http://www.bibliotecaminsal.cl/wp/wp-con... ). These principles are consistent with the guidelines of the Primary Health Care (PHC) Model existing in Chile (Minsal, 2012MINSAL - MINISTERIO DE SALUD. (Chile). Orientaciones para la implementación del Modelo de Atención Integral de Salud Familiar y Comunitaria. Dirigido a equipos de salud. Santiago: MINSAL-OPS, 2012. Disponível em: <Disponível em: https://www.minsal.cl/portal/url/item/e7b24eef3e5cb5d1e0400101650128e9.pdf >. Acesso em: 27 maio 2022.
https://www.minsal.cl/portal/url/item/e7... ).
It is worth mentioning that the Chilean Health System is made up by subsystems, a public system (which covers more than 70% of the population) that has a health insurance called FONASA, and several health care centers throughout the country that make up the Assistance Networks administration. The second subsystem is the private system, made up of the Social Security Health Institutions (Instituciones de Salud Previsional, ISAPRES), which manage private health insurance (covering more than 20% of the Chilean population), and also counts on health care centers. The FONASA population may receive care in private health care centers through the free choice modality, but both systems operate independently under the regulations of the Chilean Health Authority.
It is particularly striking that the Chilean intercultural health programs mentioned above have only been designed and developed in the Public Health System, not being mandated to be implemented in the private system, although the indigenous population could opt for private health institutions (both insurance and care centers).
Studies in the Chilean health system expose a criticism towards the normativization or bureaucratization of the Mapuche health under the institutional logics of the Chilean State (Alarcón et al., 2004ALARCÓN, A. et al. Política de salud intercultural: perspectiva de usuarios mapuches y equipos de salud en la IX región, Chile. Revista Médica de Chile, Santiago, v. 32, n. 9, p. 1109-1114, 2004. DOI: 10.4067/S0034-98872004000900013
https://doi.org/10.4067/S0034-9887200400... ; Anigstein; López, 2006ANIGSTEIN, M.; LÓPEZ, V. Medicina mapuche en la ciudad. Resignificaciones de la práctica médica mapuche en el siglo XXI. Gazeta de Antropología, Granada, n. 22, p. 1-9, 2006 DOI: 10.30827/Digibug.7106
https://doi.org/10.30827/Digibug.7106... ; Boccara, 2007BOCCARA, G. Etnogubernamentalidad. La formación del campo de la salud intercultural en Chile. Chungará, Arica, v. 39, n. 2, p. 185-207, 2007. Disponível em: <Disponível em: https://scielo.conicyt.cl/pdf/chungara/v39n2/art03.pdf >. Acesso em: 27 maio 2022.
https://scielo.conicyt.cl/pdf/chungara/v... ), and the professionalization of indigenous cultures' knowledge (Bolado, 2012BOLADO, P. Neoliberalismo multicultural en el chile postdictadura: la política indígena en salud y sus efectos en comunidades mapuches y atacameñas. Chungará, Arica, v. 44, n. 1, p. 135-144, 2012. DOI: 10.4067/s0717-73562012000100010
https://doi.org/10.4067/s0717-7356201200... ) as a lack of recognition and assimilation of these to the practices and ideologies of the Western medicine. Other studies identify communication issues between health professionals and Mapuche health agents, lack of referral mechanisms, and lack of training in the Mapuche cosmovision (Alarcón et al., 2004ALARCÓN, A. et al. Política de salud intercultural: perspectiva de usuarios mapuches y equipos de salud en la IX región, Chile. Revista Médica de Chile, Santiago, v. 32, n. 9, p. 1109-1114, 2004. DOI: 10.4067/S0034-98872004000900013
https://doi.org/10.4067/S0034-9887200400... ; Vásquez, 2009VÁSQUEZ, M. Salud Intercultural y políticas públicas: La experiencia de la organización Taiñ Adkimn en la comuna de la Pintana. 2009. 133 f. Tesis (Magíster en Antropología y Desarrollo) - Universidad de Chile, Santiago, 2009.).
This study was conducted in the context of primary health care, in an urban commune of Santiago de Chile, together with the Mapuche community Kallfulikan that has been implementing the PESPI program for 20 years. The aim of this study is to describe the experiences and perceptions about interculturality in PHC, from the perspective of health workers and the Mapuche health care providers.
A case study was conducted, systematizing the experience as a participatory research process carried out with the Mapuche community that leads the experience studied. This specific scientific communication considered the interviews of workers and users related to the Mapuche health, in the context of PHC.
The systematization of experiences corresponds to a participatory research process. Through qualitative methodology, the experience of workers and users in relation to the Mapuche health, in the context of PHC carried out in "La Ruka" (traditional Mapuche house that serves as a place for the preparation of medicinal herbs) of the Mapuche community Kallfulikan, was surveyed. In order to describe the whole experience, quantitative and qualitative data were systematized to rescue 20 years of implementation of a Mapuche medicine program in the context of PHC. In that program, social actors think over and review the processes, recovering local knowledge through a critical understanding of the factors that made them possible (Jara, 1994JARA, O. Para Sistematizar Experiencias. San José de Costa Rica: Centro de Estudios Publicaciones Alforja, 1994.). This methodology has been recommended for these purposes (Hasen, 2012HASEN, F. Interculturalidad en salud: competencias en prácticas de salud con población indígena. Ciencia y enfermería , Concepción, v. 18, n. 3, p. 17-24, 2012. DOI: 10.4067/s0717-95532012000300003
https://doi.org/10.4067/s0717-9553201200... ).
Participants and context
This study on the implementation of a Mapuche health program in the PHC context was conducted in an urban commune of Santiago, Chile. The fieldwork was developed from August to November 2017. Nineteen users participated in individual semi-structured interviews. For PHC workers, three group interviews were conducted, with a total participation of 13 people from different professions and roles, with non-medical professionals presenting a numerical prevalence (Table 1). The final number of interviews allowed saturating information to respond to the objective of this study.
Participants' characterization
Interviews were transcribed and reviewed before the next data production journey, in order to investigate emerging areas of interest to the project.
A semantic content analysis was conducted on the experiences of PHC users and workers. The preliminary results of this study were analyzed with the Mapuche community in charge of the program, as part of the overall systematization process of the experience through a day of results presentation and discussion of the main findings. For this communication, this instance allowed validating the interpretations shown in results which, although not corresponding to their own stories as a community, seemed to be coherent in the global context of the experience. On the other hand, these results contributed to an internal analysis by the community, which is not part of this communication.
This study sought to know the experience of people linked to Mapuche medicine in PHC valuing and respecting their opinion. The research process was carried out jointly with the Mapuche community in charge of the program. All participants were volunteers, and a process of informed consent was carried out with each of them. Participants were identified with their age or profession and gender, respecting their anonymity. The results of this communication were discussed with the Mapuche community in charge of the program that authorized its publication, respecting their autonomy and following the agreements reached during dialogues between the community and the facilitating team. It should be noted that this study contributed with information for the internal analysis by the Community in charge of the program, pursuing greater engagement with the western health.
Of the total number of participating users, 6 self-reported to be Mapuche and, of the workers, only one person identifies their Mapuche origin, but indicates to not keep any cultural practice (Table 1). Both groups present a positive vision of the Mapuche health and different opinions regarding interculturality and its application in PHC. They highlight the positive aspects of working with a Mapuche health team, identifying barriers to the recognition and valuation of Mapuche health in coexistence with biomedical practices. Following a description of Mapuche health experiences and intercultural health practices is disclosed, highlighting their characteristics, barriers and facilitators.
Mapuche health linkage experiences
Users access the Mapuche care optimistic about its effectiveness. Most have received recommendations from acquaintances and relatives, so they present high expectations, as reflected in the following statement: "I don't mind waiting all afternoon, because it will work" (man, 60 years old).
Those who have been receiving care for longer (6 months to 5 years) positively evaluate the care provided by the Machi (spiritual authority for the Mapuche people's culture) because they recognize improvements in their lives, such as a decrease in pain, and better state of mind. A woman (60 years old), with emotion in her eyes and voice, relates her first care process; "he (machi) sees your life". For her, the care with the machi was revealing. He discovered and inquired about aspects of her life that she thought were irrelevant to her current health situation. She was surprised that the machi "sees the urine and knows so many things".
For users, the Mapuche health is understood as natural medicine. They value its accessibility, since it is easy to book a visit and there are no age or residence requirements. There is no costs for them, they do not ask for exams or purchase of medicines. So, there is no associated out-of-pocket expense, as it happens in the Chilean health system. In addition, they value "natural medicine" agreeing that the use of herbs is a non-industrialized therapy and, therefore, is better than the use of drugs. This is expressed in this statement "water is water" (woman, 70 years old).
There is a belief that herbs, being natural, are healthier because they do not harm the stomach and have no side effects; "pills are good for one thing and bad for others" (woman, 67 years old). They also add they do not have to take herbs for every illness. Herbal water, in its diverse and secret preparations, acts on different ailments.
A woman (39 years old) reports that since the first week she felt changes in her organism, for her "coming to the Ruka is relaxing". The respondents reported to believe in the Mapuche medicine, trusting that it will heal them of all their ailments because of its natural character. They also have general knowledge about the Mapuche cosmovision related to the holistic understanding of health, the use of herbs as natural medicine and its effects on the body. However, none of them participated in other Mapuche traditions, more due to lack of time than for lack of interest.
Regarding the PHC workers, most of them are linked to Mapuche health because of their current work activity; when they arrived to work at the PHC center, the Ruka already existed. Some of them were introduced to this program, and others report to have participated in trainings on Mapuche cosmovision, although this is not an experience shared by all of them.
"[...] I spent about two months not knowing that the Ruka existed, and they talked to me about a Ruka and I said, where is it? Where is it? I'm going to go for a walk (laughs) and I went for a little walk and there I found it, but I didn't have the experience of talking to the Machi" (Woman, Administrative position)
Some workers have had a Mapuche health care experience, either their own or of family members, which allowed them to learn about their worldview and their way of providing healthcare.
"[...] I have a lot of knowledge because I have accompanied my relatives' treatment, so I know how they use the protocol, how they provide care" (Woman, Social Worker)
In general, they positively value the existence of the Ruka. They point out that its presence and recognition have given fame to the PHC center among the people who are attended at the Ruka and those who know about this experience;
"Person 2: [...] I think we hang on their fame (laughs)." (E3, P2: Nurse)
"Person 1: Yes because in reality patients come here from all sectors [...] patients get engaged and (they) want to change to this Center, because there is the Ruka" (E3, P1: Administrative)
Intercultural health in PHC
For one user, intercultural health is the encounter of cultures, with the recognition of ethnic culture and its valuation in dialogue between health systems. Based on this belief the user identifies the lack of interculturality in the Chilean health system and in the country in general, as reflected in her statement:
"is that there is no intercultural health, there is a lack of merging both, they have to work together and for that there is a lack of more dissemination and for people to stop seeing Mapuche medicine as something esoteric, schools should teach Mapudungun (Mapuche language) so that since childhood children grow up with that" (woman, 38 years old).
For the other users, intercultural health is synonymous with Mapuche health, it is materialized in the Ruka, "this is intercultural health" (woman, 39 years old), as an alternative system, with different means and ends;
"The Mapuche do not have the same technology as public health, they can do complex procedures, each one does their own thing and each health system fulfills different purposes" (Male, 87 years old)
Healthcare practices recognized by users do not account for interculturality as a dialogue between different cultural understandings of health. For example, there is no clear referral from the PHC center, nor do they receive information about this medicine, not even those who self-report to be a Mapuche. Although in the Ruka people are instructed to continue with medical treatment, some of them point out that they should stop the pharmacological treatment because they prefer herbs, but they do not report it in their medical check-ups at the PHC.
Regarding workers, most of them recognize intercultural health as the encounter of different cultures in dialogue, respect and complementarity. They identify positive experiences of linkage in the context of health promotion and prevention, and in family and/or individual referral, as well as recognize barriers for a better implementation of interculturality in the PHC (Table 2).
Characteristics of Intercultural Health in Primary Health Care
Health professionals recognize that they do not perform anamnesis or provide differential care for people belonging to Mapuche communities. They even consider that it is not necessary since from their perception the Mapuche population does not request it, and they are adapted to the practices of the western system. On the other hand, they consider that interculturality takes greater importance to address the care of foreign population;
"[...] here we have perceived with our foreign users, Haitians; they do not perceive health as self-care, they perceive it differently [...] so perhaps knowing not only our ancestral cultures but also knowing these new brothers who are arriving, also allows us to know how to approach this person from the point of view of health" (Woman, midwife)
They recognize "cultural clashes" with migrant population, especially with the Haitian population, both due to language barriers and lack of knowledge of the health practices and beliefs of this population, which hinders the encounter with PHC activities in Chile;
"[...] in fact, the Haitian pregnant women are checked late because they are not used to having a preventive birth control" (Woman, midwife)
When professionals consider the possibility of incorporating changes in health care practices, they identify that the existing barriers would not allow local changes without changes in the national PHC guidelines and policies. Even when these policies indicate that approaches such as integrality and interculturality should be incorporated, for professionals the care at the Ruka is more comprehensive and generates stronger link with users, in comparison with what is done at the PHC center. This is associated to the management based on health goals that do not incorporate interculturality and, in addition, to the inflexible timetable definition that hinders community work or coordination with the Mapuche health agents. Another aspect that hinders joint action is the unsuccessful instances of health workers training, whose experiences have not been continuous or universal and some of them have had problems with certification. This meant they were not recognized and therefore participation was discouraged.
On the other hand, in order to formalize a joint work some workers propose that the "Ruka services", such as the Machi's care and the delivery of medicinal herbs, should be incorporated to the PHC services basket and thus institutionalize the practices as a form of recognition. On the other hand, the Mapuche health agents should participate in team meetings held to coordinate management or address complex cases, thus contributing with their vision and being considered as a single team.
The Mapuche health experience in an urban commune is positively valued by users and by primary health care workers who are bound to it. These experiences, however, reflect a gap in the incorporation of interculturality in PHC, since users do not recognize dialogue between cultures or health knowledge. Workers identify a lack of recognition and joint work attributable, on the one hand, to administrative aspects of the Chilean health model that do not allow for flexibility in their practices and adaptation to a different health worldview. On the other hand, it is attributable to the will and attitudes of some professionals regarding the lack of scientific validity of the Mapuche medicine, and the risks that this would imply for the population's health. Similar results are reported in contexts of maternal and child health in Colombia, where health professionals consider that indigenous women are not aware of the health risk involved in pregnancy and particularly childbirth (Castillo-Santana et al., 2017CASTILLO-SANTANA, P. et al., Salud materna indígena en mujeres Nasa y Misak del Cauca, Colombia: tensiones, subordinación y diálogo intercultural entre dos sistemas médicos. Saúde e Sociedade, v. 26, n. 1, p. 61-74, 2017. DOI: 10.1590/S0104-12902017168743
https://doi.org/10.1590/S0104-1290201716... ). It clearly evidences a hegemony of biomedical health as a standard of quality in health, based on its scientific effectiveness, and a difference in the understanding of physiological processes that in the indigenous worldview may be considered part of the life cycle of women (Castillo-Santana et al., 2017CASTILLO-SANTANA, P. et al., Salud materna indígena en mujeres Nasa y Misak del Cauca, Colombia: tensiones, subordinación y diálogo intercultural entre dos sistemas médicos. Saúde e Sociedade, v. 26, n. 1, p. 61-74, 2017. DOI: 10.1590/S0104-12902017168743
This study shows a parallel coexistence of two health systems, which enable access to Mapuche health in the city, both for the Mapuche and non-Mapuche population. As another study points out, the experience of urban context allows the maintenance of cultural projects strategically aligned with the guidelines of the Chilean system for access to resources. This, however, implies greater control, subordination and standardization of the Mapuche health system (Anigstein; López, 2006ANIGSTEIN, M.; LÓPEZ, V. Medicina mapuche en la ciudad. Resignificaciones de la práctica médica mapuche en el siglo XXI. Gazeta de Antropología, Granada, n. 22, p. 1-9, 2006 DOI: 10.30827/Digibug.7106
https://doi.org/10.30827/Digibug.7106... ). Other studies have identified the asymmetry of the Chilean biomedical system with the Mapuche health system, and the lack of theoretical and practical clarity about the concept of intercultural health as main barriers for the implementation of interculturality (Pérez; Nazar; Cove, 2016PÉREZ, C., NAZAR, G., y COVE, F. Facilitadores y obstaculizadores de la implementación de la política de salud intercultural en Chile. Pan American Journal of Public Health , Brasília, v. 39, n. 2, p. 122-127, 2016. Disponível em: <Disponível em: https://www.scielosp.org/article/rpsp/2016.v39n2/122-127/ >. Acesso em: 27 maio 2022.
https://www.scielosp.org/article/rpsp/20... ). Asymmetry is common in other contexts, and demonstrates the unwillingness of health personnel to make room for indigenous health, relying on structural and ideological biomedical hegemony (Castillo-Santana, 2017CASTILLO-SANTANA, P. et al., Salud materna indígena en mujeres Nasa y Misak del Cauca, Colombia: tensiones, subordinación y diálogo intercultural entre dos sistemas médicos. Saúde e Sociedade, v. 26, n. 1, p. 61-74, 2017. DOI: 10.1590/S0104-12902017168743
https://doi.org/10.1590/S0104-1290201716... ; Mendes et al., 2018MENDES, A. et al. O desafio da atenção primária na saúde indígena no Brasil. Pan American Journal of Public Health , Brasília v. 42, e184, 2018. DOI: 10.26633/RPSP.2018.184
https://doi.org/10.26633/RPSP.2018.184... ).
In the Latin American experience, an analysis of planning for equity in health points out that, although the countries consider the "marginalized" population, less than half address indigenous peoples and only in four cases the attention to migrant population is explicit (Kavanagh et al., 2021KAVANAGH. M. et al. Planificación para la equidad en la salud en la Región de las Américas: Análisis de los planes nacionales de salud. Pan American Journal of Public Health , Washington, DC, v. 45, e106.2021. DOI:10.26633/RPSP.2021.106
https://doi.org/10.26633/RPSP.2021.106... ). On the other hand, comparative case studies in the region (Mignone et al., 2017MIGNONE, J. et al. Best practices in intercultural health: five case studies in Latin America. Journal of Ethnobiology and Ethnomedicine. Springer Science and Business Media, Nova York, v. 3, n. 31, 2007. DOI: 10.1186/1746-4269-3-31
https://doi.org/10.1186/1746-4269-3-31... ) point out that, despite the attempts to articulate cultural approaches within the broader health system, it is not as effective, evidencing institutionalized racism in hospitals and other sectors of the health care system.
In general, interculturality policies in health has been considered of low impact, either due to weak social participation, lack of continuity and satisfaction with care and the need for intercultural dialogues for the articulation of knowledge, as reported in the case of Brazil (Pedrana et al., 2018PEDRANA, L. et al. Análise crítica da interculturalidade na Política Nacional de Atenção às Populações Indígenas no Brasil. Pan American Journal of Public Health , Brasília, v. 42, e178, 2018. DOI: 10.26633/RPSP.2018.178
https://doi.org/10.26633/RPSP.2018.178... ; Mendes et al., 2018MENDES, A. et al. O desafio da atenção primária na saúde indígena no Brasil. Pan American Journal of Public Health , Brasília v. 42, e184, 2018. DOI: 10.26633/RPSP.2018.184
https://doi.org/10.26633/RPSP.2018.184... ), or due to lack of resources and the sequence of arbitrary and exclusionary policies, as found by a study in Mexico (Campos; Peña; Maya, 2017CAMPOS, R., PEÑA E., MAYA, A. Aproximación crítica a las políticas públicas en salud indígena, medicina tradicional e interculturalidad en México (1990-2016). Salud Colectiva, Lanús, v. 13, n. 3, p. 443-455, 2017. DOI: 10.18294/sc.2017.1115
https://doi.org/10.18294/sc.2017.1115... ). In particular, as in our study, the lack of trust between traditional health agents and Western health professionals is identified as an obstacle to intercultural work, pointing out in some cases not only a resistance from medical systems, but also religious ones, even if they seemed to be not so influential (Mignone et al., 2017MIGNONE, J. et al. Best practices in intercultural health: five case studies in Latin America. Journal of Ethnobiology and Ethnomedicine. Springer Science and Business Media, Nova York, v. 3, n. 31, 2007. DOI: 10.1186/1746-4269-3-31
https://doi.org/10.1186/1746-4269-3-31... ).
The challenges for primary care in Chile to effectively incorporate interculturality are: first, to allow spaces for integration in which indigenous health agents participate in the health team on equal terms and without the need to adjust or validate their practices; second, to strengthen the initial and continued training of health professionals and workers on interculturality and Mapuche or indigenous health in general; and, third, to know the cultures present in their territories, especially, due to the coexistence with other cultures due to migration. Workers participating in this study recognize this last, which has been the subject of interventions that include cultural competencies to perform the health anamnesis (Chepo; Astorga-Pinto; Cabieses, 2019CHEPO, M.; ASTORGA-PINTO, S.; CABIESES, B. Atención inicial de migrantes en Chile: iniciativa en atención primaria de salud a un año de su implementación. Pan American Journal of Public Health, Brasília, v. 43, e71, 2019. DOI: 10.26633/RPSP.2019.71
https://doi.org/10.26633/RPSP.2019.71... ). Fortunately, new doctors in Chile show interest in practicing in indigenous settings precisely because of the interculturality experience (Mignone et al., 2017MIGNONE, J. et al. Best practices in intercultural health: five case studies in Latin America. Journal of Ethnobiology and Ethnomedicine. Springer Science and Business Media, Nova York, v. 3, n. 31, 2007. DOI: 10.1186/1746-4269-3-31
This study corresponds to a particular experience; therefore, its results are not transferable to the national reality of implementation of the indigenous health program in Chile. Other studies have clearly stated the need to increase research in indigenous population, pursuing a reversal in inequalities of access, and resolving inequities in indigenous morbidity and mortality indexes (Kolahdooz et al., 2015KOLAHDOOZ, F. et al., Understanding the social determinants of health among Indigenous Canadians: priorities for health promotion policies and actions. Global Health Action, Londres, v. 8, n. 1, 27968, 2015. DOI: 10.3402/gha.v8.27968
https://doi.org/10.3402/gha.v8.27968... ; Cortés-García, 2020CORTÉS-GARCÍA, M. Etnicidad y salud. Una reconceptualización necesaria. Revista Ciencias de la Salud, Bogotá, v. 18, n. 1, p. 6-9, 2020. Disponível em: <Disponível em: https://revistas.urosario.edu.co/xml/562/56262799001/index.html >. Acesso em: 27 maio de 2022.
https://revistas.urosario.edu.co/xml/562... ). In Chile, new studies should investigate experiences of intercultural health implementation in rural areas and other regions of the national territory.
Finally, we should consider that neoliberal policies, deepened after the dictatorship, fostered the bureaucratization of indigenous health practices (Bolado, 2012BOLADO, P. Neoliberalismo multicultural en el chile postdictadura: la política indígena en salud y sus efectos en comunidades mapuches y atacameñas. Chungará, Arica, v. 44, n. 1, p. 135-144, 2012. DOI: 10.4067/s0717-73562012000100010
https://doi.org/10.4067/s0717-7356201200... ), and reflect the barriers imposed by the Chilean State on the implementation of programs that seek to recognize and maintain the coexistence of indigenous health. Therefore, even if progress is made in intercultural health policies, without a comprehensive and structural response that overcomes fragmented policies on indigenous rights, which attempt to separate environmental issues and territorial claims from health issues, a situation common to all of Latin America (Martínez, 2015MARTÍNEZ, M. Reconocimiento sin implementación: Un balance sobre los derechos de los pueblos indígenas en América Latina. Revista Mexicana de Ciencias Políticas y Sociales, v. 60, n. 224, p. 251-278, 2015. DOI: 10.1016/s0185-1918(15)30010-6
https://doi.org/10.1016/s0185-1918(15)30... ), it will be impossible to comply with international treaties that protect and recognize the rights of indigenous peoples, signed by Chile.
To the Mapuche community Kallfulikan, and to the participants of this study for supporting us in the challenge of moving toward cultural relevance in health. And to the Ministry of Social Development of Chile that contributed by Funding the project of Systematization of Experiences "Exploración de la percepción de usuarios, agentes tradicionales de salud y equipo de salud acerca del acceso, atención intercultural y participación de población indígena en el Centro de salud mapuche Kallfulikan, Ruka Cesfam Los Castaños, La Florida" through the Fondo Chile de Todas y Todos 2016.
ALARCÓN, A. et al. Política de salud intercultural: perspectiva de usuarios mapuches y equipos de salud en la IX región, Chile. Revista Médica de Chile, Santiago, v. 32, n. 9, p. 1109-1114, 2004. DOI: 10.4067/S0034-98872004000900013
» https://doi.org/10.4067/S0034-98872004000900013
ANIGSTEIN, M.; LÓPEZ, V. Medicina mapuche en la ciudad. Resignificaciones de la práctica médica mapuche en el siglo XXI. Gazeta de Antropología, Granada, n. 22, p. 1-9, 2006 DOI: 10.30827/Digibug.7106
» https://doi.org/10.30827/Digibug.7106
BOCCARA, G. Etnogubernamentalidad. La formación del campo de la salud intercultural en Chile. Chungará, Arica, v. 39, n. 2, p. 185-207, 2007. Disponível em: <Disponível em: https://scielo.conicyt.cl/pdf/chungara/v39n2/art03.pdf >. Acesso em: 27 maio 2022.
» https://scielo.conicyt.cl/pdf/chungara/v39n2/art03.pdf
BOLADO, P. Neoliberalismo multicultural en el chile postdictadura: la política indígena en salud y sus efectos en comunidades mapuches y atacameñas. Chungará, Arica, v. 44, n. 1, p. 135-144, 2012. DOI: 10.4067/s0717-73562012000100010
CAMPOS, R., PEÑA E., MAYA, A. Aproximación crítica a las políticas públicas en salud indígena, medicina tradicional e interculturalidad en México (1990-2016). Salud Colectiva, Lanús, v. 13, n. 3, p. 443-455, 2017. DOI: 10.18294/sc.2017.1115
» https://doi.org/10.18294/sc.2017.1115
CASTILLO-SANTANA, P. et al., Salud materna indígena en mujeres Nasa y Misak del Cauca, Colombia: tensiones, subordinación y diálogo intercultural entre dos sistemas médicos. Saúde e Sociedade, v. 26, n. 1, p. 61-74, 2017. DOI: 10.1590/S0104-12902017168743
» https://doi.org/10.1590/S0104-12902017168743
CHEPO, M.; ASTORGA-PINTO, S.; CABIESES, B. Atención inicial de migrantes en Chile: iniciativa en atención primaria de salud a un año de su implementación. Pan American Journal of Public Health, Brasília, v. 43, e71, 2019. DOI: 10.26633/RPSP.2019.71
» https://doi.org/10.26633/RPSP.2019.71
CORTÉS-GARCÍA, M. Etnicidad y salud. Una reconceptualización necesaria. Revista Ciencias de la Salud, Bogotá, v. 18, n. 1, p. 6-9, 2020. Disponível em: <Disponível em: https://revistas.urosario.edu.co/xml/562/56262799001/index.html >. Acesso em: 27 maio de 2022.
» https://revistas.urosario.edu.co/xml/562/56262799001/index.html
DÍAZ, A. et al., Conceptos de enfermedad y sanación en la cosmovisión mapuche e impacto de la cultura occidental. Ciencia y enfermería, Concepción, v. 10, n. 1, p. 9-16, 2004. DOI: 10.4067/s0717-95532004000100002
HASEN, F. Interculturalidad en salud: competencias en prácticas de salud con población indígena. Ciencia y enfermería , Concepción, v. 18, n. 3, p. 17-24, 2012. DOI: 10.4067/s0717-95532012000300003
HEISE, K. et al., Incidence and survival of stomach cancer in a high-risk population of Chile. World Journal of Gastroenterology, Pleasanton, v. 15, n. 15, p. 1854-1862, 2009. DOI: 10.3748/wjg.15.1854
» https://doi.org/10.3748/wjg.15.1854
INE - INSTITUTO NACIONAL DE ESTADÍSTICAS. (Chile). Censo de Población 2017. Santiago: INE, 2017.
JARA, O. Para Sistematizar Experiencias. San José de Costa Rica: Centro de Estudios Publicaciones Alforja, 1994.
KAVANAGH. M. et al. Planificación para la equidad en la salud en la Región de las Américas: Análisis de los planes nacionales de salud. Pan American Journal of Public Health , Washington, DC, v. 45, e106.2021. DOI:10.26633/RPSP.2021.106
» https://doi.org/10.26633/RPSP.2021.106
KOLAHDOOZ, F. et al., Understanding the social determinants of health among Indigenous Canadians: priorities for health promotion policies and actions. Global Health Action, Londres, v. 8, n. 1, 27968, 2015. DOI: 10.3402/gha.v8.27968
» https://doi.org/10.3402/gha.v8.27968
MANRÍQUEZ-HIZAUT, M., LAGOS-FERNÁNDEZ, C., REBOLLEDO, J., FIGUEROA-HUENCHO, V. Salud Intercultural en Chile: Desarrollo histórico y desafíos actuales. Revista de Salud Pública, Bogotá, v. 20, n. 6, p. 759-763, 2018. DOI: 10.15446/rsap.v20n6.65625
» https://doi.org/10.15446/rsap.v20n6.65625
MARTÍNEZ, M. Reconocimiento sin implementación: Un balance sobre los derechos de los pueblos indígenas en América Latina. Revista Mexicana de Ciencias Políticas y Sociales, v. 60, n. 224, p. 251-278, 2015. DOI: 10.1016/s0185-1918(15)30010-6
» https://doi.org/10.1016/s0185-1918(15)30010-6
MENDES, A. et al. O desafio da atenção primária na saúde indígena no Brasil. Pan American Journal of Public Health , Brasília v. 42, e184, 2018. DOI: 10.26633/RPSP.2018.184
MIGNONE, J. et al. Best practices in intercultural health: five case studies in Latin America. Journal of Ethnobiology and Ethnomedicine. Springer Science and Business Media, Nova York, v. 3, n. 31, 2007. DOI: 10.1186/1746-4269-3-31
» https://doi.org/10.1186/1746-4269-3-31
MINSAL - MINISTERIO DE SALUD. (Chile). Orientaciones para la implementación del Modelo de Atención Integral de Salud Familiar y Comunitaria. Dirigido a equipos de salud. Santiago: MINSAL-OPS, 2012. Disponível em: <Disponível em: https://www.minsal.cl/portal/url/item/e7b24eef3e5cb5d1e0400101650128e9.pdf >. Acesso em: 27 maio 2022.
» https://www.minsal.cl/portal/url/item/e7b24eef3e5cb5d1e0400101650128e9.pdf
MINSAL - MINISTERIO DE SALUD. (Chile). Orientaciones Técnicas Programa Especial de Salud Indígena (PESPI). Santiago: MINSAL, 2013. Disponível em: <Disponível em: http://www.bibliotecaminsal.cl/wp/wp-content/uploads/2018/01/030.OT-y-Guia-Pueblos-indigenas.pdf >. Acesso em: 27 maio de 2022.
» http://www.bibliotecaminsal.cl/wp/wp-content/uploads/2018/01/030.OT-y-Guia-Pueblos-indigenas.pdf
MOLONEY, A. Protests Highlight Plight of Chile's Mapuche. The Lancet, Amsterdã, v. 375, n. 9713, p. 449-450, 2010. DOI: 10.1016/s0140-6736(10)60181-x
» https://doi.org/10.1016/s0140-6736(10)60181-x
OYARCE, A.; PEDRERO, M. Una metodología innovadora para la caracterización de la situación de salud de las poblaciones indígenas de Chile: limitaciones y potencialidades. Notas de población, Vitacura, n. 89, p. 119-148, 2009.
PEDRANA, L. et al. Análise crítica da interculturalidade na Política Nacional de Atenção às Populações Indígenas no Brasil. Pan American Journal of Public Health , Brasília, v. 42, e178, 2018. DOI: 10.26633/RPSP.2018.178
PÉREZ, C., NAZAR, G., y COVE, F. Facilitadores y obstaculizadores de la implementación de la política de salud intercultural en Chile. Pan American Journal of Public Health , Brasília, v. 39, n. 2, p. 122-127, 2016. Disponível em: <Disponível em: https://www.scielosp.org/article/rpsp/2016.v39n2/122-127/ >. Acesso em: 27 maio 2022.
» https://www.scielosp.org/article/rpsp/2016.v39n2/122-127/
VÁSQUEZ, M. Salud Intercultural y políticas públicas: La experiencia de la organización Taiñ Adkimn en la comuna de la Pintana. 2009. 133 f. Tesis (Magíster en Antropología y Desarrollo) - Universidad de Chile, Santiago, 2009.
Universidad de Chile. Facultad de Medicina. Departamento de Kinesiología. Santiago, Chile. E-mails: mmanriquezh@uchile.cl; jame.rebolledo@uchile.cl; daniela.ingles95@gmail.com; rocioklett@gmail.com
Universidad de Chile, Facultad de Filosofía y Humanidades, Departamento de Lingüística. Santiago, Chile. E-mail: kinelagos@uchile.cl
Universidad de Chile. Instituto de Asuntos Públicos. Santiago, Chile. E-mail: v.figueroa.h@iap.uchile.cl
Correspondence: Mónica Manríquez Hizaut - Universidad de Chile. Avenida Independencia, 1027, Comuna Independencia, Santiago, Región Metropolitana, Chile. Postal Code 8380453.
Table 1 Participants' characterization
Number of participants: 19 13
Women 15 10
Men 4 3
Age range (years) 39-84 23-55
Ties to Mapuche culture 6 1
Time of link to Mapuche medicine 1 month to 5 years from 6 months to 10 years
Table 2 Characteristics of Intercultural Health in Primary Health Care
PHC workers' experiences and perceptions
Intercultural health conception A dialogue between cultures is recognized, identifying the need to learn about other cultures, in health care practices, horizontality and supplementarity with Mapuche medicine is emphasized. "interculturality is the relation between cultures that have a common work" (Man, Psychologist)
"I believe that interculturality has to do with the practical, focused on health care, (...) that deep down may we be tolerant and respectful towards all the arriving ethnicities and cultures (...) a framework of respect, tolerance, and finally not only of competence but complementation, that finally a hypertensive patient, for example, does not stop taking enalapril for meeting with the Machi or a Brazilian witch doctor, what do I know" (Woman, Matron)
"what I understand by intercultural health care is that it has to do a little with this field… it is more natural than Mapuche medicine and all, but also… in the way we are as actors and how we not only work with indigenous people, but also foreigners" (Woman, Social Worker)
Bonding experiences in promotion and prevention activities Productive work experiences are found, which allow to understand the Mapuche world view and improve practices in health prevention activities. "(...) we organized the vaccination campaign… we had the opportunity to get together and obviously talk about the theme (…) on that moment they explained to us what their vision was and it obviously had many of the typically known myths; that is a business, what do I know, but they also gave us some tips to encompass that population, and one of the things they commented is that they cared a lot about who got vaccinated, (...), to them, those who got vaccinated were really important because there is an energy subject attached to it, so… it was suggested that we show them the different vaccinated people so that they would finally see that subject and open us the doors (...)" (Woman, Nurse)
Bonding experiences in referral As referral to Mapuche medicine, some professionals refer to users who consider complex cases or did not respond to biomedicine. "(...) when we do family work and the family has a Mapuche surname and there is a situation because they do not want to come or have a reason behind and the family cannot articulate, we refer them, to matters more related to bonding, if working there is possible (in La Ruka) beyond that, and it works sometimes" (Woman, Social Worker)
"As a psychologist, I accompanied many patients when registering or making an appointment, but at the same time were referred with mental health doctors and according to the patient if they wanted to go or not, as it eventually happened" (Man, Psychologist)
Bonding barriers Lack of integration of the Mapuche healthcare workers as part of the PHC health team. To some, the professionals are not welcoming to other, the traditional Mapuche health workers are not available for integration. "they feel discriminated, so much so that they do not greet them, (...) they are shyer (...) and do not facilitate for them, and listen! but they are coworkers, and you facilitate things for your coworker (...) Therefore, not everyone feels that they belong [to the health team] and appreciates them, I believe there is a general respect for Mapuche culture but not any... appreciation" (Woman, Social Worker)
"(...) they do not integrate much, as an example of when it happened, when we did the pie de cueca on September 18, they gave us sopaipillas and came as the Kallfulikan community to present themselves on a stand (...) they have been opening up (...) due to the circumstances, but they are closed off" (Woman, Social Worker)
Controversy about the scientific validity of Mapuche medicine and lack of a regulatory framework to protect intercultural practice. "We are measured by the accreditation of health centers, and we all work to accredit clinics, but this is non-existent on a regulatory or legal level for health... supplementary medicine, so you can find many shysters in this field" (Woman, Matron)
"there is a weakness (...) that has to do with the legal framework, for example you, as a doctor, when referring to the Machi, who supports you legally? (...) the patient decompensated, it ended badly for them, if auditing or summarizing [make a summary or investigation] who referred them to the Machi, and why the Machi and not a cardiologist?" (Woman, Matron)
"But this is inviting them to be Westerners (...) meaning we interfere by our means, where is the dialogue in that? "please dress like doctors, put on a white suit, and work on an office with no smoke" then it is not Mapuche medicine" (Man, Psychologist)
Bonding barriers The Chilean healthcare system has inflexible guidelines or protocols of health that would limit incorporating intercultural practices daily. "(...) it has to with listening, taking your time with someone and... things we cannot do, because there can be employees or even patients knocking on your door if you are over your 15 minutes (...), they (Mapuche health) take their time and people know it and respect it, we also have our own time, with the minutes being counted" (Woman, Nurse)
"... if it is a low-risk diabetic they will go once to the doctor and then to a nurse or nutritionist, (...) however in La Ruka I believe you have the option to go talk, sit down and talk to everyone, maybe not because you have the Machi's attention but they are a community, and I think that helps the patients a lot" (Woman, Preschool Teacher)
Source: Own elaboration based on the conducted interviews
Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. SP - Brazil
E-mail: saudesoc@usp.br
Experiencias de salud mapuche en Atención Primaria de Salud desde trabajadores sanitarios y usuarios/as en zona urbana de Chile


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Last friday Angela and the team met with residents and businesses from Bringelly – next to the Western Sydney Aerotropolis (Badgery's Creek Airport).
Members of the Southern Gateway Precinct group came together at the Bringelly Childcare Centre to express their concerns over planning decisions to rezone their entire neighbourhood – to agricultural.
When plans initially proposed the region become industrial or mixed-use, the local residents were excited. This zoning would allow the almost 1000 businesses to continue or expand, and would provide new opportunities for others to move into the region.
At the same time, developers began approaching residents and offering purchase prices well above market. When planning decisions were revised late in 2017 these interested parties walked away, plummeting property prices and destroying any chance of fair market value being achieved for these residents.


1) I discovered Lauren B. Davis, on SheWrites, and started following her extremely well written, thought-provoking and soulful blogs. I ended up writing to her and now we're modern day pen pals, 2) Lauren suggested I friend one of her friends, another debut YA writer hailing from Seattle named Lish McBride, (Hold Me Closer, Necromancer - fall, 2010) DID IT, (and might I use this as a platform to beg Lish to get thee a website? With her coolth, quirkiness, humor and intelligence, I have very high expectations!) 3) Lish in turn suggested I friend her friend from her MFA program in New Orleans called Jen Violi, who is ALSO a debut YA writer with a book coming out in summer 2011. Putting Make-up on Dead People. (You see, these gals are much funnier than I am!) Granted, we are getting to know each other through Facebook, but how else would we get to know each other I ask you? We even play Lexulous . . .
Now, besides being a writer, Jen has come up with some creative and I must say ENVIABLE side businesses, such as coaching, weddings, (did I ever tell you how I almost became an interfaith minister?) and theses inimitable LOVE NOTES. I'm clunking myself on the head I tell you: why didn't I think of this? She writes "Give yourself or someone you love the gift of fun, tangible mail combined with a reminder and encouragement to take a moment and reconnect to a place deep within."
I came back from Myrtle Beach to a Love Note from Jen. Inside a beautiful card was a packet of Forget-me-nots, and the charge to TRUST IN GROWTH. And it worked, yes it did! It made me feel all warm and fuzzy and helped soothe the cranky beast inside. Her concept of LOVE NOTES aligns with the philosophy I try my best to practice: seeing the glass half full and looking for the best in everyone, INCLUDING MYSELF! If I need constant reminders that the Source is all around me, then I'm sure many others do. We need all the help (and LOVE) we can get!
So take a little trip to Jen's website and check this out for yourself!
Lena,thanks so much for spreading the word about Love Notes--you are one, you know.
Also, I am so grateful at this moment for "like-minded souls"and all of the ways we can find each other!
I swear, the website is being built as we speak. I'm slooooow. Thanks, lady!
That's three titles to add to my list! Congratulations on your upcoming book -- I'm on that road, too, just much, much farther behind.
Chazley - love your name! It's phonetically so pleasing - CHAZZZ-LEEE. Right? Wotchya doin' in South Korea?
Jen dahhlink! I'm pretty sure that I rigged it so that anybody who clicks on your name will be taken straight to your website - it only shows up highlighted in the preview though. Does anybody know how I can fix?
Oh--totally see it now! Don't know how to make it highlighted, though . . .
I look forward to both of your websites launching, and I will smash champagne on something to celebrate--but not my laptop, as I think that might cause some problems.
LOVE NOTES with Jen is amazing notes for everyone. After read this notes my thinking is change towards the Love. He has good research on it and plus point is he like to shared with us. Any how, I want to get essaytigers writing service but this website is very impressive for me to get a lot of information.


Enter 'Baker Beach Parking Lot' into Google Maps or into your Uber/Lyft.
From Lincoln Blvd, turn right onto Bowley St.
You will see a sign on your right that says Baker Beach. Take your first right at that sign onto Gibson Rd.
Less than 1/4 mile down, you'll see a fork in the road. There, turn right onto Battery Chamerlin Road which will take you to the north parking lot.
From that parking lot, walk down the steps to the beach. You will see us right there on the beach, at the base of the steps, set up with our yoga + headphones check-in station!
Please enter into google maps or into your uber/lyft - Fulton and Great Highway. Or, the Beach Chalet, which is the restaurant on the corner.
From Fulton and Great highway, walk slightly north to stairwell 14. Walk down the steps to the beach, and directly towards the water. You will see prayer flags set up.
Enter '610 Old Mason St, San Francisco' into Google Maps or into your Uber/Lyft.
From sports Basement, walk west (continuing along Old Mason Rd). You will see a big meadow on your right. Walk across the meadow and down to the beach. We will meet you there, on the beach!
Enter 'Burton Statue, Fort Mason' into Google Maps.
We meet in the middle of the meadow! Note we do not meet at the pier.
A yoga mat. We have just a few extra we can bring for you. Email the teacher teaching if you need a mat.
Warm layers - like a down jacket or heavy fleece, hat, and socks! Socks are great for end of practice. Depending on timing and wether of class, it can get chilly. We keep it moving and keep you warm, but we always want to make sure everyone is warm and cozy before we take savasana. Please do not forget warm layers, even if it's warm outside when you leave!
CAN I COME IF I HAVEN'T SIGNED UP?
Yes! We'd much prefer it if you sign up online because it makes it easier for us to check you in at the beginning of class. But the more important thing is that you come. Occasionally classes are sold out. In that case, you are welcome to show up anyway and we will do our best to make a spot for you! We do have permits that limit the numbers we can host in each class, hence the reason for our limits.
Come anyway! And bring a layer. We will be flowing and moving throughout the class, you will warm up.
AND RAININg or bad weather?
If it's raining, we're not going to practice! We will post on the homepage, and email you if you have signed up for the class to let you know it is cancelled 2 hours or more prior to class. Your class will be credited your class to use for a future date.
WHAT IF I CAN'T FIND YOU?
Email us: julie@outdooryogasf.com and we'll get back to you ASAP. Please include your phone number.


Please join us on Sunday, August 5, 2012, from 2PM to 4PM, at the Osborn-Cannonball House Museum.
A display of wedding gowns from 1895-2000 will be featured. Costumed docents will be on hand to explain the history and origin of the fashions, and in general, about the museum and local history.


ESSEX BROWNELL BC-1020M-165 MOTOR START CAPACITOR 2-9/16" DIAMETER 1020-1264 MFD, 165V, 50/60 Hz, -40C TO 65C, Plastic, 1/4" Spade Terminal, UL Approved NOTE: SPECIAL PRICING APPLIES FOR CURRENT STOCK ONLY. IF QUANTITY REQUIRED EXCEEDS OUR ALL FOR CURRENT INVENTORY, PLEASE CONTACT US FOR A QUOTE.
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