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As a “wild,\" drumming thunder shaman, a warrior mounted on her spirit horse, Francisca Kolipi’s spirit traveled to other historical times and places, gaining the power and knowledge to conduct spiritual warfare against her community’s enemies, including forestry companies and settlers. As a “civilized\" shaman, Francisca narrated the Mapuche people’s attachment to their local sacred landscapes, which are themselves imbued with shamanic power, and constructed nonlinear histories of intra- and interethnic relations that created a moral order in which Mapuche become history’s spiritual victors. Thunder Shaman represents an extraordinary collaboration between Francisca Kolipi and anthropologist Ana Mariella Bacigalupo, who became Kolipi’s “granddaughter,\" trusted helper, and agent in a mission of historical (re)construction and myth-making. The book describes Francisca’s life, death, and expected rebirth, and shows how she remade history through multitemporal dreams, visions, and spirit possession, drawing on ancestral beings and forest spirits as historical agents to obliterate state ideologies and the colonialist usurpation of indigenous lands. Both an academic text and a powerful ritual object intended to be an agent in shamanic history, Thunder Shaman functions simultaneously as a shamanic “bible,\" embodying Francisca’s power, will, and spirit long after her death in 1996, and an insightful study of shamanic historical consciousness, in which biography, spirituality, politics, ecology, and the past, present, and future are inextricably linked. It demonstrates how shamans are constituted by historical-political and ecological events, while they also actively create history itself through shamanic imaginaries and narrative forms.

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Bill & Melinda Gates Foundation.

Chile's Law of Food Labeling and Advertising, implemented in 2016, was the first national regulation to jointly mandate front-of-package warning labels, restrict child-directed marketing, and ban sales in schools of all foods and beverages containing added sugars, sodium, or saturated fats that exceed set nutrient or calorie thresholds. The objective of this study is to evaluate the impact of this package of policies on household beverage purchases. In this observational study, monthly longitudinal data on packaged beverage purchases were collected from urban-dwelling households (n = 2,383) participating in the Kantar WordPanel Chile Survey from January 1, 2015, to December 31, 2017. Beverage purchases were linked to nutritional information at the product level, reviewed by a team of nutritionists, and categorized as \"high-in\" or \"not high-in\" according to whether they contained high levels of nutrients of concern (i.e., sugars, sodium, saturated fat, or energy) according to Chilean nutrient thresholds and were thus subject to the law's warning label, marketing restriction, and school sales ban policies. The majority of high-in beverages were categorized as such because of high sugar content. We used fixed-effects models to compare the observed volume as well as calorie and sugar content of postregulation beverage purchases to a counterfactual based on preregulation trends, overall and by household-head educational attainment. Of households included in the study, 37% of household heads had low education (less than high school), 40% had medium education (graduated high school), and 23% had high education (graduated college), with the sample becoming more educated over the study period. Compared to the counterfactual, the volume of high-in beverage purchases decreased 22.8 mL/capita/day, postregulation (95% confidence interval [CI] -22.9 to -22.7; p < 0.001), or 23.7% (95% CI -23.8% to -23.7%). High-educated and low-educated households showed similar absolute reductions in high-in beverage purchases (approximately 27 mL/capita/day; p < 0.001), but for high-educated households this amounted to a larger relative decline (-28.7%, 95% CI -28.8% to -28.6%) compared to low-educated households (-21.5%, 95% CI -21.6% to -21.4%), likely because of the high-educated households' lower level of high-in beverage purchases in the preregulation period. Calories from high-in beverage purchases decreased 11.9 kcal/capita/day (95% CI -12.0 to -11.9; p < 0.001) or 27.5% (95% CI -27.6% to -27.5%). Calories purchased from beverages classified as \"not high-in\" increased 5.7 kcal/capita/day (95% CI 5.7-5.7; p < 0.001), or 10.8% (10.8%-10.8%). Calories from total beverage purchases decreased 7.4 kcal/capita/day (95% CI -7.4 to -7.3; p < 0.001), or 7.5% (95% CI -7.6% to -7.5%). A key limitation of this study is the inability to assess causality because of its observational nature. We also cannot determine whether observed changes in purchases are due to reformulation or consumer behavioral change, nor can we parse out the effects of the labeling, marketing, and school sales ban policies. Purchases of high-in beverages significantly declined following implementation of Chile's Law of Food Labeling and Advertising; these reductions were larger than those observed from single, standalone policies, including sugar-sweetened-beverage taxes previously implemented in Latin America. Future research should evaluate the effects of Chile's policies on purchases of high-in foods, dietary intake, and long-term purchasing changes.

Introduction Substance use among adolescents is a public health problem. We culturally adapted The Social Competence Promotion Program for Young Adolescents (SCPP-YA) program to the school context in Chile (henceforth “Mi Mejor Plan or MMP”) and assessed the acceptability, feasibility, fidelity, and quality of the implementation among 6 th graders. We also explored the efficacy of the program in improving individual protective factors and reducing risk factors and substance use. Methods Cluster randomized controlled trial conducted in Chile. The schools were randomly assigned to one of two conditions in a 1:1 ratio: 1) the \"MMP\" intervention group, and 2) the Control group. The program consisted of a 16-h class-based curriculum promoting social problem-solving skills delivered by a trained facilitator. Primary outcomes were acceptability, feasibility, fidelity, and quality of the implementation using detailed reports of facilitators and from observers of the performance of the facilitators in vivo. Additionally, we explored the efficacy of the intervention on secondary outcomes: 30-day prevalence of tobacco, alcohol, and cannabis use and individual risk and protective factors promoted by MMP. We performed an intention-to-treat analysis using mixed models, taking into account the hierarchical nature of the data. Results Seven hundred sixty-five 6th graders from 11 schools were enrolled (one school dropped out after the randomization); 608 were analyzed at baseline, and 538 were analyzed post-intervention. 52.5% were male, and the average age was 11.3 in both groups. All 16 sessions were implemented, and students’ attendance at each session ranged from 83.8% to 92.4%. The program was generally well-received, with up to 91.3% of students rating acceptability positively. Facilitators and observers reported high adherence to the contents of the program in most sessions. Protective factors, such as negative beliefs about tobacco and alcohol, increased significantly in the IG. Still, there were no significant changes in substance use, risk factors, emotion regulation, or school membership. Conclusions The MMP program was well accepted, and we achieved high levels of implementation and fidelity. The program improved some individual protective factors, such as negative beliefs about tobacco and alcohol, with no changes in substance use among adolescents. Trial registration ClinicalTrials.gov, number NCT04236947; registration date: 17/01/2020.

We set out to investigate the potential impact of unemployment on HIV viral load in individuals living with HIV at the biggest HIV-related healthcare centre in Chile. We analysed a cross-sectional dataset of 803 adults living with HIV on antiretroviral therapy. The main exposure was employment status. The outcome, detectable HIV viral load, was operationalised using a cut-off of HIV viral load at 20 copies/mL. We applied a propensity score method, the inverse probability of treatment weighting to control for measured confounders. We found that 219 (27.3%) of participants were unemployed. Being unemployed was associated with increased odds of being detectable (OR = 1.78, 95%CI = 1.18–2.71) compared to being employed. Additionally, we found that those unemployed and non-adherents have higher odds of being detectable (OR = 2.53, 95%CI = 1.18–5.41). Unemployment status may influence HIV viral load. However, further research is needed to determine and understand the social structure behind those relationships in the Chilean people living with HIV.

We estimated excess mortality in Chilean cities during the COVID-19 pandemic and its association with city-level factors. We used mortality, and social and built environment data from the SALURBAL study for 21 Chilean cities, composed of 81 municipalities or “comunas”, grouped in 4 macroregions. We estimated excess mortality by comparing deaths from January 2020 up to June 2021 vs 2016–2019, using a generalized additive model. We estimated a total of 21,699 (95%CI 21,693 to 21,704) excess deaths across the 21 cities. Overall relative excess mortality was highest in the Metropolitan (Santiago) and the North regions (28.9% and 22.2%, respectively), followed by the South and Center regions (17.6% and 14.1%). At the city-level, the highest relative excess mortality was found in the Northern cities of Calama and Iquique (around 40%). Cities with higher residential overcrowding had higher excess mortality. In Santiago, capital of Chile, municipalities with higher educational attainment had lower relative excess mortality. These results provide insight into the heterogeneous impact of COVID-19 in Chile, which has served as a magnifier of preexisting urban health inequalities, exhibiting different impacts between and within cities. Delving into these findings could help prioritize strategies addressed to prevent deaths in more vulnerable communities.

Drawing on anthropologist Ana Mariella Bacigalupo's fifteen years of field research, Shamans of the Foye Tree: Gender, Power, and Healing among Chilean Mapuche is the first study to follow shamans' gender identities and performance in a variety of ritual, social, sexual, and political contexts. To Mapuche shamans, or machi, the foye tree is of special importance, not only for its medicinal qualities but also because of its hermaphroditic flowers, which reflect the gender-shifting components of machi healing practices. Framed by the cultural constructions of gender and identity, Bacigalupo's fascinating findings span the ways in which the Chilean state stigmatizes the machi as witches and sexual deviants; how shamans use paradoxical discourses about gender to legitimatize themselves as healers and, at the same time, as modern men and women; the tree's political use as a symbol of resistance to national ideologies; and other components of these rich traditions. The first comprehensive study on Mapuche shamans' gendered practices, Shamans of the Foye Tree offers new perspectives on this crucial intersection of spiritual, social, and political power.

Background Confinement during the COVID-19 pandemic has placed great stress on older adults, which may be affecting their quality of life. Thus, this study aims to describe the changes in mental and physical health, isolation and loneliness, residence and socioeconomic resources in a national cohort of Chilean older adults before and during the COVID-19 outbreak. It also analyzes the changes in depressive symptoms by changes in the other quality of life indicators before and during the COVID-19 outbreak. Possible methodological biases of telephone surveys in older adults living in non-developed countries are also discussed. Methods Between June and September 2020, a random subsample of 720 people who had participated in the face-to-face V National Survey on Quality of Life in Older Adults in Chile conducted at the end of 2019 was followed up by telephone. Descriptive bivariate analyses were performed using t-test and non-parametric tests for independent variables, comparing the baseline sample with the current 2020 follow-up sample during the peak of the pandemic outbreak in Latin America. Furthermore, descriptive bivariate analysis through t-test and non-parametric test for paired samples compared the follow-up subsample at baseline with the not-included sample, examining possible biases of the telephone interview compared with the face-to-face interview. Results In the panel, there was no variation in self-rated health. The health symptoms that worsened were memory, stomach, and mood problems. Depressive symptoms and anxiety increased; similarly, smartphone users, social contacts, intergenerational co-residence and resilience increased. The telephone follow-up sample had a higher educational level and greater smartphone use than those not included in the subsample. Conclusions Although some physical and mental health indicators have worsened during the pandemic, older adults mobilized resources that could allow them to maintain their quality of life, such as improved resilience. Thus, these findings can guide future research and the development of efficient strategies to improve these resources among older adults to ensure wellbeing.

Background Front-of package (FoP) nutrition labels are an option to guide consumer’s decision at the point of food purchase. Chile was the first country worldwide to implement a FoP warning label and thereafter several countries have followed this model. The objective of this study is to describe the process of development of the Chilean FoP warning label. Methods A stepwise study was conducted including literature review, qualitative phase (lay audience & expert group meetings) and quantitative phase in women/adolescents from low-middle-socioeconomic status neighborhoods, Santiago, Chile (2 sub-studies, using point-of-sale questionnaires). Outcomes were prototype visualization, ease of understanding, and ability to modify purchase behavior. Results The literature review and qualitative phase provided information on general text (e.g. short wording) and design characteristics (e.g. use of a logo, use of red or black colors); based on these characteristics 15 prototypes were created and quantitatively tested. In the first survey, a black-&-white stop sign and a black-&-white hand were preselected; in the second survey, the stop sign stating ‘Excess of < nutrient >’ had significantly better performance than the hand in terms of visualization, intention to purchase, and ability to modify intended purchase. Due to legal reasons the “excess of” was replaced by “high-in” in the final implementation of the law. Conclusions A simple black-&-white stop sign warning label was the best option to flag pre-packaged foods with an excess of energy or nutrients of concern for non-communicable diseases; this FoP warning label was implemented in Chile in June 2016 as part of the Chilean Food Labeling and Marketing Law.