I. Seeking Remedies to the Health Plight of Indigenous Women after the 1994 Zapatista Uprising

Traditionally, Mexican Indigenous women have suffered significant oppression and marginalizationFootnote ¹ compared to other groups in Mexican society, in virtue of being subject to a triple stigma: being women, being Indigenous, and being poor.Footnote ² The effects of their oppression are evident in many areas, including access to education, the division and remuneration of labor, vulnerability to sexual exploitation and domestic violence, and participation in the processes of political debate and decision making. However, one of the clearest and most dramatic manifestations of their oppression is the appalling access to healthcare and its ramifications. In particular, the state of Chiapas (in which 27 percent of the population is Indigenous) and its municipality of Chenalhó in the Chiapas Highlands (in which 99 percent of the population is Indigenous) (INEGI 2010, 13 and 57), epitomize the traditional health plight of Indigenous Mexican women. For example, in 1991, Chenalhó women between the ages of 15 and 49 were 1.4 times more likely to die than were their male counterparts. Further, the ratio of the mortality rate of women to men in Chenalhó was more than double that of Chiapas (0.61), which was also higher than the same ratio for Mexico (0.43) (Reference Freyermuth‐EncisoFreyermuth-Enciso 2003, 65). Shortly following the 1994 Zapatista uprising, Indigenous Mexican women tried to improve health levels of their communities by serving as health promoters (promotoras). In this article, we argue that their actions can be considered manifestations of an epistemology of resistance, informed by a particular standpoint, in response to the injustice to which they have traditionally been subjected.

Although the Indigenous communities in Chiapas (most prominently, women) have endured appalling health conditions for centuries,Footnote ³ these were exacerbated in the 1980s and early 1990s.Footnote ⁴ To understand how this systematic oppression led to the 1994 uprising by the Ejército Zapatista de Liberación Nacional (EZLN), we provide a brief historical review of the circumstances that led to it.

Indigenous groups in Chiapas have been dispossessed of their lands and forced to work on plantations to produce cash crops since colonial times, a situation that was not remedied by the land reforms that followed the Mexican Revolution.Footnote ⁵ During most of the twentieth century they were kept under control by a paternalistic politico‐economical model put in place by the Partido Revolucionario Institucional (PRI).Footnote ⁶ In this system (a form of “state corporatism”), workers and peasants were compelled to belong to state‐controlled unions and agrarian leagues, which guaranteed access to minor credits and benefits in exchange for their votes. However, during the 1980s and early 1990s, as the state's coffers progressively emptied due to a convergence of agricultural and economic crises, the corporatist system began to crumble. It was gradually replaced by a neoliberal model, which gave free rein to market forces. In virtue of this, the conditions in Chiapas's Indigenous communities, which were already precarious prior to the crises, worsened. The few modest government programs that funded self‐sustaining agriculture, education, and healthcare during the presidencies of Miguel de la Madrid (1982–1988) and Carlos Salinas (1988–1994) were eliminated.

As a supporter of the neoliberal model, Carlos Salinas was one of the main promoters of the free trade agreement in North America (NAFTA) that aimed to eliminate all barriers for private investors and liberalize trade for a great number of products, including cheap US corn. Since one of NAFTA's provisions required the Mexican government to eliminate 1) protections to small communal agricultural lands (ejidos), which Indigenous communities relied on for subsistence farming, and 2) tariffs on agricultural products, Indigenous communities in Chiapas came to see NAFTA as a threat to their existence. Given this, the EZLN (which represented many Indigenous communities in Chiapas) decided to stage an uprising on the same day that NAFTA was to come into effect (January 1, 1994). They did this to bring attention to the plight of Indigenous communities and propose an alternative socioeconomic model that would remedy the oppression to which they were subjected.Footnote ⁷

The alternative model that the Zapatistas proposed included the adoption of the Revolutionary Women's Law, drafted by Zapatista women to express their key demands. Since the fifth article of the Law states that “women and their children have the right to primary consideration in their health and nourishment,” the EZLN made clear that one of the aims of its struggle was to address the chronic inequities in access to healthcare that afflicted Indigenous women and their communities.Footnote ⁸ Shortly after the uprising, the Zapatistas began to develop their own healthcare system as part of their quest for autonomy. Prior to that, and for most of the twentieth century, Indigenous communities relied on the federal and state healthcare organizations, such as the Instituto Mexicano del Seguro Social (IMSS) and the Secretaría de Salud (SSA), which were used to co‐opt their demands for equality and autonomy in exchange for modest healthcare services. Other important healthcare grievances included paternalistic treatment of Indigenous patients (especially women) who sought medical care in some of the scarce public rural clinics or, more infrequently, in urban hospitals. For example, they were often scolded for being responsible for their own ill health, and medical aid was often offered with the stipulation that there would be continuous oversight of their condition to ensure that they met certain standards of hygiene (Reference Forbis, Speed, Hernández‐Castillo and StephenForbis 2006, 179–81).

Despite the fact that the Zapatista autonomous healthcare system came about as late as 1997 and is hampered by limited funds, insufficient medical supplies, lack of infrastructure, and few professionally trained medical personnel, there is some evidence that it has delivered positive health outcomes, such as the decrease in women's mortality in Zapatista communities (Reference Heredia CuevasHeredia Cuevas 2007; Reference Blas, Gilson, Kelly, Labonté, Lapitan, Muntaner, Östlin, Popay, Sadana, Sen, Schrecker and VaghriBlas et al. 2008). What accounts for this success? As mentioned above, we argue that the modest success of the Zapatista autonomous healthcare system is partially explained by Zapatista women (who comprise the backbone of the system in their role as promotoras), informed by a particular standpoint, engaging in an epistemology of resistance against the epistemic injustices to which they have been traditionally subjected. If we are right, then their model should be emulated in other contexts involving poor health levels in marginalized communities.

We proceed as follows. In section II, we introduce some key ideas that broadly underpin black and Indigenous epistemologies, highlighting theories proposed by Patricia Hill Collins, Linda Tuhiwai Smith, Mahia Maurial, and Joe Kincheloe and Shirley Steinberg. We briefly consider how these theories can help diagnose instances of what Miranda Fricker calls “epistemic injustice.” We also discuss, following José Medina's account, how victims of epistemic injustice can successfully develop an epistemology of resistance. In section III, we argue that since the oppression endured by Indigenous Zapatista women involved not only economic exclusion and racial and gender exploitation, but also widespread epistemic marginalization (by outsiders as well as men within their own communities), they were in a good position to identify causes of these injustices and develop remedies to it. We also argue that their actions (in particular, becoming promotoras in their communities) constituted an epistemology of resistance that enabled them, through the exercise of beneficial epistemic friction, to challenge traditional gender roles in their communities, empower themselves, and improve the health of their communities. Finally, in section IV we offer a brief conclusion that suggests how the actions of Zapatista women can serve as a model of successful empowerment to help fight other instances of epistemic injustice, especially in healthcare settings.

II. Feminist Standpoint Theory, Epistemic Injustice, and the Fundamentals of an Epistemology of Resistance: A Brief Overview

Beginning in the 1970s and early 1980s, Western white feminists, such as Sandra Harding and Alison Jaggar, started paying attention to the relationship between the production of knowledge and the exercise of power (Reference Harding and HardingHarding 2004; Reference Jaggar and HardingJaggar 2004). Feminist standpoint theory was born out of these endeavors as both an epistemology and a methodology—a prescriptive method for understanding, criticizing, and “doing” epistemology.

According to the traditional epistemological approach, the best epistemic standpoint is one of a neutral, disinterested observer, abstracted from all history and social life, who holds a “view from nowhere,” or a “God's‐eye view.” This standpoint was presumed to produce the most impartial, comprehensive, value‐free, and “objective” knowledge.

As Western standpoint theorists quickly pointed out, there is no such standpoint. Rather, so‐called “objective” knowledge claims are merely the claims of the privileged, “epistemically competent” members of a community—claims that reflect, privilege, and protect their social values and interests, and eliminate those different from their own (Reference Harding and HardingHarding 2004, 136–37). Far from being disinterested and objective, this standpoint actually reflects the privileged (dominant) group's racist, sexist, classist, and heterosexist beliefs.

Though standpoint theorists rightly questioned the claim that the production and transmission of knowledge (traditionally undertaken by privileged white men) are impartial and objective by arguing that social location shapes and limits what we know,Footnote ⁹ in the late 1980s and 1990s some theorists raised worries that Western standpoint theory had important shortcomings. For example, Chandra Mohanty accused some white feminists of unwarranted generalization, noting that, “there is no universal patriarchal framework that this scholarship attempts to counter and resist—unless one posits an international male conspiracy or a monolithic, transhistorical power structure” (Reference MohantyMohanty 1988, 63). Further, by focusing on Western white women's experiences of oppression, some white feminists were limiting “the definition of the female subject to gender identity, completely bypassing social, class and ethnic identities” (72). This led them to homogenize women's oppression across the globe, thus ignoring how race, nationality, class, sexual orientation, and other markers determine specific social locations and shape women's experiences.

Responding to worries raised by Mohanty and other theorists, such as Kimberlé Crenshaw, concerning the uniformizing and colonizing gaze that some white Western feminists displayed (Reference CrenshawCrenshaw 1989), several nonwhite feminists have provided far more nuanced analyses of women's oppression that take into account not only gender, but also other social identities informed by class, nationality, race, and sexual orientation. For example, Patricia Hill Collins persuasively argued that the oppression to which black women in the US are subjected is quite different from that which is experienced by white women. More specifically, she stressed that since “controlling Black women's reproduction was essential to the creation and perpetuation of capitalist class relations” during the slavery period, this legacy has affected their opportunities in our contemporary “free” market economy (Reference CollinsCollins 2000, 51). Since black women are often seen as “fair game for all men” (54), they are frequently pushed to remove themselves from labor activities.Footnote ¹⁰ As a result of common (though not uniform) experiences of oppression by black women, Collins argued that a black feminist epistemology has emerged in which different forms of knowledge creation, preservation, and transmission (for example, storytelling, folklore practices, and music) challenge the dominant epistemological paradigm that emphasizes the crucial role of “objective” standards and “institutional” repositories. The significance of such an epistemology rests on “its ability to enrich our understanding of how subordinate groups create knowledge that fosters both their empowerment and social justice” (269).

Linda Tuhiwai Smith advocates a decolonizing methodology for Indigenous people, questioning the superiority of the Western epistemological paradigm. As she maintains, this methodology involves “recovering our own stories of the past (and) this is inextricably bound to a recovery of our language and our epistemological foundations” (Reference SmithSmith 1999, 39). According to Mahia Maurial, this entails the development of an Indigenous epistemology that is both local and holistic (Reference Maurial, Semali and KincheloeMaurial 1999). It is local insofar as it is tied to the specific ways of life of individual Indigenous communities as they interact with their natural environment, such as the agricultural techniques developed by the Mexica (or Aztecs) to farm the shallow lakes of the Valley of Mexico.Footnote ¹¹ It is holistic in the sense that “ideas and practices are one… . What Western thinking calls ‘religion,’ ‘law,’ ‘economics,’ ‘arts’ are united within a whole entity of [sic] worldview” (63). As Smith mentions, although the Western epistemological paradigm assumes a clear‐cut distinction between various disciplines that promotes a classification of things to exercise control over them (in order to justify its positional superiority), Indigenous worldviews assume a unity or wholeness of the world that can be grasped effectively only by connecting with others and the world to the extent that “many Indigenous creation stories link people through genealogy to the land, to stars and other places in the universe, to birds and fish, animals, insects and plants” (148).

Joe Kincheloe and Shirley Steinberg, writing about Indigenous knowledges in education, propose a “multilogical” epistemology, which sharply contrasts with the monological epistemology of “class elitist,” “white‐centered,” “colonial,” “patriarchal” “power blocs” that reject the need to listen to marginalized people and take their knowledge claims seriously (Reference Kincheloe, Steinberg, Denzin, Lincoln and Tuhiwai SmithKincheloe and Steinberg 2008, 145–46). According to them, “Understandings derived from the perspective of the excluded or the ‘culturally different’ allows for an appreciation of the nature of justice, the invisibility of the process of oppression, the power of difference, and the insight to be gained from a recognition of divergent cultural uses of long hidden knowledges that highlight both our social construction as individuals and the limitations of monocultural ways of meaning making” (140).

To be clear, we do not reject feminist standpoint epistemology altogether. Our argument depends on showing that the promotoras’ actions were informed by a particular vantage point, a particular way of viewing the world. Rather, we reject a certain approach to standpoint epistemology, advocated by some white feminists, which generalizes across all women's experiences. Smith, Collins, and Kincheloe and Steinberg recognize that occupying different social locations within a particular group produces unique standpoints. For example, Collins notes that “while life as Black women may produce certain commonalities of outlook, the diversity of class, region, age, and sexual orientation shaping Black women's lives has resulted in different expressions of these common themes” (quoted in Reference SmithSmith 1999, 167–68).

The core ideas that underpin the proposals of Collins, Smith, and Kincheloe and Steinberg constitute the need 1) to develop an epistemology that explains how oppressed groups can create knowledges that empower them, and 2) to conceive these knowledges as something radically different from the knowledge associated with the Western epistemological paradigm.

To appreciate how these two ideas can be used to account for cases of epistemic injustice and develop an epistemology of resistance, we briefly discuss Miranda Fricker's conception of epistemic injustice. As Fricker notes, since many oppressed groups, such as blacks or Indigenous people, have traditionally been stereotyped such that they have been associated with “some attribute inversely related to competence or sincerity or both” (Reference FrickerFricker 2007, 32), people who belong to these groups tend to be given little, if any, epistemic credibility. In virtue of this, they tend to be victims of epistemic injustice because their status as epistemic agents is often questioned, or in extreme cases denied. Since actions that undermine the credibility of certain persons in virtue of their social location are done from a standpoint in which a particular view of knowledge is presupposed (as “universal” and “disinterested”), one can diagnose these acts as epistemic injustices by stressing that the conception of knowledge from which these judgments are made is tied to a patriarchal, colonialist project that aims at “the imposition of Western authority over all aspects of Indigenous knowledges, languages and cultures” (Reference SmithSmith 1999, 64).

We now briefly discuss how these two ideas (especially the first) can be used to develop an epistemology of resistance. José Medina has advocated for the development of an epistemology that involves “the obligation to confront internal and external resistances, that is, resistances that can be found in the inner workings of the community and resistances that can be found in the interactions between the community in question and other communities” (Reference MedinaMedina 2013, 52). According to him, the confrontation of these resistances can generate epistemic friction, which can either be negative (when it is used by privileged groups to silence others, to inhibit the formation of beliefs or the formulation of questions) or positive (when it is used by oppressed groups to force privileged groups to acknowledge and engage alternative viewpoints and reach epistemic equilibrium among alternative perspectives on a given problem or situation).Footnote ¹²

The foregoing raises an important question: How can oppressed groups develop beneficial or positive epistemic frictions? In response to this, we should appeal to Collins's insights, since she suggests that one way to develop beneficial epistemic friction is through the development of discussion groups among black women within US families, churches, and communities. Since these groups promote the sharing and preservation (through storytelling, singing, and other practices) of black women's lived experiences, they provide a basis to develop an epistemology that empowers them, as Collins has argued in her discussion of black church services. Insofar as these religious services are dialogues that aim “to examine lived experiences for the presence of an ethic of caring” (Reference CollinsCollins 2000, 266), they enable black women to develop an alternative perspective to the dominant view that empowers them, since “gaining the critical consciousness to unpack hegemonic ideologies is empowering” (286).

Collins's insights provide a model to develop an epistemology of resistance, which Medina advocates. For Medina, the potential payoff of this strategy is that when acts of resistance are no longer isolated but become chained actions of individuals and groups linked through social networks, they become echoable. They acquire a repeatable significance and are therefore memorable, imitable, and have the potential to lead to social change (Reference MedinaMedina 2013, 225).Footnote ¹³

We contend that the efforts of the promotoras who have participated in creating and maintaining the Zapatista autonomous healthcare system have fostered, in their communities, the progressive development of an epistemology of resistance, informed by a particular standpoint, in which their actions have acquired repeatable significance and have led to positive social change. To show this, in the next section we provide a detailed account and analysis of their actions.

III. The Actions of Zapatista Promotoras: A Case Study of Epistemic Resistance

Although adequate access to healthcare services by Indigenous communities (especially Indigenous women) was one of the crucial demands made by the EZLN after the uprising, the main problem these communities faced was neither the scarcity of infrastructure, nor the shortages of medical personnel. Rather, it was the attitudes they encountered when they sought medical treatment in government‐run clinics and hospitals: in the best cases, they were treated paternalistically and their experiences were dismissed or ignored; in the worst, they were denied attention and driven away.Footnote ¹⁴ As a consequence of this systematic discrimination, and their awareness of the conditions that oppressed them, women began to take actions to remedy this injustice on multiple fronts, as this example illustrates:

Zapatista women responded to their oppression by developing a form of epistemic resistance manifested in the promotion of traditional plant‐based medicine.Footnote ¹⁵ In so doing, they challenged an oppressive normative structure that has been internalized by a great number of poor women in Mexico—a structure that conditions the acceptance of inadequate, or even nonexistent, access to healthcare in virtue of belonging to a low socioeconomic class.Footnote ¹⁶ Moreover, not only did Zapatista women try to remedy their conditions of oppression by developing free or low‐cost health treatments dependent on local resources, rather than relying on drugs produced by Western pharmaceutical companies, they also sought to remedy their conditions of oppression and dependence in a second manner.

Since they recognized that the use of medicinal plants sometimes provided limited treatment options, some Zapatista women decided to become promotoras to educate community members about various health risks and suggest preventive care. The women realized that given the dearth of professional medical personnel and modern medical infrastructures in their communities, prevention was a better strategy to reduce 1) the vulnerability of their communities to contagious diseases, such as malaria or tuberculosis,Footnote ¹⁷ and 2) the risk of maternal deaths due to lack of reproductive and prenatal care.Footnote ¹⁸ Undertaking these actions, the women challenged another oppressive normative structure, which maintained that the restoration and maintenance of health depend primarily (or even exclusively) on alleviating the symptoms of physical ailments with drugs. Further, they vindicated the Indigenous conception of health, which is not based exclusively on freedom from disease but which crucially involves a notion of happiness and harmony.

By becoming promotoras, Zapatista women also engaged in a form of epistemic resistance in a third respect. Given that Indigenous communities in the Chiapas Highlands have traditionally followed a system of governance based on usos y costumbres (customs and traditions) and that some usos y costumbres were used to ensure the preservation of patriarchal structures and attitudes, the promotoras’ actions challenged traditional gender roles. When Zapatista women began assuming active roles after the uprising, and demanded to participate in meetings and engage in the process of decision‐making, they met resistance from some men in their communities.Footnote ¹⁹ Resistance against their challenge to traditional gender roles, which first emerged in military and political activities, subsequently extended to their activities as promotoras. Some men in Zapatista communities reacted to the promotoras’ activities by asserting patriarchal rights (for example, by threatening to deprive women of their children),Footnote ²⁰ or by spreading malicious rumors. For example, they claimed that the real goal of the promotoras’ workshops and meetings was to allow organizers and attendees to meet lovers (Reference Forbis, Speed, Hernández‐Castillo and StephenForbis 2006, 195–96).

Although men who resisted challenges to traditional gender roles created negative epistemic friction, some Zapatista women fought against attempts to assert patriarchal oppression by appealing to their communities to voice their plight and seek remedy in a collective fashion. The actions of Zapatista women, though not radically alleviating their poverty, have nevertheless proved to be of crucial importance, because they have helped to develop “a space to speak out against the traditions that continue to disempower and discriminate against them” (Reference JungJung 2008, 211). The creation of this space has led to a progressive change in the perceptions of many men in Zapatista communities, as the following statement, given in 2006 by a member of the Junta de Buen Gobierno (Good Government Council), illustrates:

As the statement makes clear, the actions of Zapatista women have become, in Medina's words, echoable, by providing a model of successful empowerment, which has led to social change, including the progressive erosion of patriarchal beliefs and attitudes in some men.Footnote ²¹

Finally, the promotoras’ actions can be considered to be an expression of an epistemology of resistance in a fourth respect. Since Indigenous people (especially women) were often treated condescendingly in state‐run clinics,Footnote ²² women increasingly realized that their discrimination was at least partially rooted in the perception, by professional medical personnel, that they were not (nor could they be) reliable epistemic agents. In virtue of this, they came to see the state‐run healthcare system as an instrument of oppression and control that ultimately curbed and restricted their efforts to achieve autonomy—a notion that the Zapatistas understand in terms of “knowing how to do something” (Reference KleinKlein 2015, 207). Consequently, their efforts to collect and cultivate medicinal plants, and their attempts to recover knowledge from community elders about their use (to share with other community members), constituted not only a way to address the economic and political oppression created by their prior dependence on state‐sponsored healthcare, but also vindicated the importance of traditional medical knowledge against the epistemic oppression exercised by local practitioners of Western medicine: “The Zapatista communities participating in the project were not rejecting Western medicine as a healing practice but as a space of domination tied to assimilationist and neoliberal practices” (Reference Forbis, Speed, Hernández‐Castillo and StephenForbis 2006, 200).

Professional medical personnel's failure to recognize the knowledge possessed by Indigenous women (in particular, by midwives) was also perceived by Indigenous communities as a further example of discrimination, and may partially explain why Indigenous women are reluctant to use state‐run clinics (Reference Tucker, Ochoa, Garcia, Sievwright, Chambliss and BakerTucker et al. 2013). In virtue of this, it seems clear that if the state of Chiapas and the Mexican federal government want to help substantially improve the health conditions of the Indigenous communities, they must recognize traditional forms of medicine and knowledge and valorize their practitioners, just as promotoras who acknowledge the importance of Indigenous medical knowledge and practices are not altogether hostile to using Western medicine when it is necessary and adequately implemented.

IV. Assessing the Impact of the Zapatistas's Epistemology of Resistance

We have argued that the promotoras’ actions can be seen as expressions of an epistemology of resistance on several different fronts. But has this contributed to positive health outcomes in Zapatista communities? Although there are no precise and indisputable figures concerning improved women's mortality rates in Zapatista communities compared to other Indigenous communities in Chiapas, in the last twenty years some studies suggest that Zapatista communities have partially succeeded in reducing the high mortality rate of women as a result of the promotoras’ actions (in particular, Reference Brentlinger, Sánchez‐Pérez, Arana‐Cedeño, Vargas‐Morales, Hernán, Micek and FordBrentlinger et al. 2005).Footnote ²³ Although this improvement might initially be attributed to the fact that both the Mexican federal government and the government of the state of Chiapas have devoted more resources to improve health coverage in Chiapas since the 1994 uprising, access to state‐sponsored healthcare in Indigenous communities is heavily politicized. The federal and state governments have used it as leverage to undermine support for demands for autonomy in Indigenous communities,Footnote ²⁴ thus pushing the Zapatista communities to be as self‐reliant as possible. Moreover, the perception of several members of Zapatista communities is that the progressive empowerment of women since the uprising has led to important health improvements, as the following testimony from 2006 shows:

Considering all of the aforementioned evidence, the actions of Zapatista women can be taken to be manifestations of an epistemology of resistance, and this epistemology, which reflects the core ideas of the proposals made by Collins, Smith, and Kincheloe and Steinberg, may be credited, at least in part, with improving health levels in their communities. Further research is needed to quantify more precisely the impact of these actions and to uncover, in more detail, the ways in which this epistemology of resistance has led to other social changes. But we strongly believe that the implicit use of an Indigenous feminist epistemology by Zapatista women has been crucial for them to identify various forms of epistemic injustice and to develop an epistemology of resistance that has partially ameliorated health outcomes in their communities. If our claims are correct, then standpoint epistemology can be an effective tool in the hands of traditionally oppressed minority communities (in our case, Indigenous ones) to develop an epistemology of resistance that would help them effect positive social change.