During my time in Uruguay on study away in the ‘22 fall semester I interned at a public health NGO called SaludArte, which is oriented towards health promotion and prevention through art and humor. Founded in 1999, SaludArte (Salud = Health and Arte = Art in English) takes inspiration from performing arts movements such as theater of the oppressed, and guerilla theater, as well as the Big Apple Circus Clown Care Unit in NYC. SaludArte facilitates a range of projects and artistic activities  at all levels of prevention as defined by the WHO in order to raise awareness in different - usually marginalized - contexts of the Uruguayan population. The NGO is run by Rasia Friedler, a psychologist and artist, and employs 3 people with medical/nursing background full time and around 15 people who are trained as performers and educators part time. There are a wide range of ways to get involved, with most of the organizations’ day to day operations (social media, advertising, scheduling, recruiting, budgeting) being done by volunteers and interns - everyone who is part of SaludArte, whether in a paid or unpaid position, is incredibly passionate about the work and all of my co-workers went above and beyond to support the initiatives they were involved in.

While the organization works a lot in educational settings (leading anti bullying workshops at schools and teaching educators on how to deal with trauma/conflict/serious illness in students), I worked closely with the branch of SaludArte called Jarabe de Risas (Laughing Syrup in English): a group of employees and volunteers visiting the pediatric floor and emergency room at a local hospital in order to do medical clowning and facilitate art therapy and support groups for families. Some of our activities were structured: every tuesday we would gather children aged 5 to 10 for art therapy lessons around certain topics and once a week we would spend the whole working day in the emergency rooms to support patients by providing distractions, games, cuddles, laughter, and making sure they understood the medical procedures that were going on and to reduce traumatic experiences as much as possible by providing advocacy between them and medical staff. The remainder of the time I would either take part in ‘clowning rounds’ (visiting each patient on the pediatric floor for around 20-30 minutes) or providing 1on1 support with parents where I would take family members of the little patients to a common room to talk and make sure they felt seen and listened to in their often overwhelming situations, while the rest of the Jarabe team would play with their child. I also participated in research through conducting interviews with caregivers as well as medical staff in the hospital around healing practices, beliefs, and needs. 

The broader public health issue SaludArte was trying to address was the lack of emotional and community support available to patients and their families who are facing medical problems, as well as the sense of burnout and overwhelm experienced by medical personnel in the hospital. Rather than seeing patients as a body or a chart of numbers, Jarabe was passionate about improving wellbeing through psychological support and by giving back agency and control over one’s own body to little patients. 

Furthermore, Jarabe de Risas strives to change the way that medical institutions/spaces operate: they advocate for connection, for making sure that emotional needs are met for both patients and medical staff, and to have spaces of holistic healing, where it is not only medical knowledge that can support wellbeing, but also interpersonal relationships. I am seeing this as a trend to incorporate indigenous/historical approaches to healing that emphasize more than just disease into the existing medical approaches - the idea of psychological support, community, advocating for patients, and focusing on autonomy can be seen in the steady rise of popularity that doula services are experiencing worldwide for example. Hospital clowns can be seen as a response to the increasing dehumanization of medicine and society in general. A 1995 article on the Clown Care Unit in New York City describes hospital clowns as "resembling traditional shamans and healers", in that both shamans and clowns represent "liminal figures found in rites of passage that deal with social crisis and distress" (Van Blerkom, 1995). Clowns and shamans share the use of costumes, music, magic tricks, exaggerated movements, different types of voices and the breaking of normative behavior of the social field. 

An interesting point made in the article is that interventions such as hospital clowns or even traditional forms of healing such as indigenous rituals should not be considered "alternative" therapies, but rather "complementary or additional" therapies, as they have a different goal and focus than modern medicine (Van Blerkom, 1995).

The words 'healing', 'health' and 'wellness' have meanings that are determined by personal and cultural experiences, which in turn influence how the different actors involved in hospice clown art-whether clowns, nurse observers or patients-perceive the goals and outcomes of clowning. Of course, the lack of specific and indisputable definitions of these terms leads to an elusive aspect of additional therapies, making their effects difficult to measure. On the other hand, however, precisely the elusive and hard-to-define nature of these terms opens up the possibility of expanding and transcending the meaning of each, as well as the means to achieve the best possible outcome of healing, health and wellness.

Although hospital clowns use "humor and fantasy to create an alternative world radically different from the reality of the hospital," they also mimic in many respects actual hospital circumstances and procedures. "Clowns...parody doctors and play games with health care personnel to make children less afraid of doctors and their instruments," but this tactic has another benefit: psychosocial support (Raviv, 2012). "By involving the social group, the illness and healing receive public recognition and the patient receives group support" (Raviv, 2012) So, the medical symbolism used by the hospital clowns actively sympathizes with the experiences of their little patients, a tactic similar to the role-playing exercises sometimes employed during group psychotherapy sessions. This comedic approach to medical situations improves mood and allows patients and their families to de-dramatize circumstances that are serious, which is a relief. 

Durkheim states that alienation and disconnection from the environment and social context are common outcomes of anomie, and when coupled with the anxieties and instability of inhabiting a liminal state, pediatric patients must cope with a loss of belonging and security. This feeling is exacerbated by the fact that they have no control over what happens to them, are deprived of intimacy and comfort, and experience varying levels of pain. In this case, the clowns intervene as an intermediary, transitional figure, who does not belong entirely to the hospital space, but neither to the outside world. They are able to reach out to children in a way that medical staff and sometimes even family members cannot. Hospital clowns become allies with children, and sometimes joke with nurses or physical therapists during stressful situations. Not being constrained by the rules of politeness and conventional behavior, they can take the patients' side in any situation and thus validate their emotions and experiences. In addition, they offer children the possibility to choose and control their environment, which they do not have otherwise. During interventions, children can choose what they want to do, what songs they would like to sing, when an activity is over or whether they would like to keep a toy. In this way, the hospital artist "uses his sense of humor to deal a blow to the intimidating hierarchy and anxiety-producing routine of the hospital" and helps the patient regain a sense of confidence and belonging within the space (Van Blerkom, 1995).

Because clowns interact not only with patients but with everyone in the room, they are able to transform the child's entire social field. A hospital clown working in a hospital in a war zone between Palestine and Israel states that "the presence of the clown and the playfulness he brings to the hospital can create social connections that transcend the confined space and lack of privacy. The clown helps patients and their families break down emotional barriers, making it possible for them to share their feelings and emphasize others" (Raviv, 2012) This transformation and reconnection alleviates feelings of isolation and anomie beyond the time the clown is present in the hospital. Working with puppets, for example, is "functioning as an intermediary object that favors the communication of feelings, emotions, allows to say things that sometimes are difficult to express in a direct way" (Pasero, 1998).

The biggest lesson I learned from my time at SaludArte was how meaningful and important holistic support is in the journey towards health and wellbeing. It gave me such a passion for public health to see that medical training is absolutely not the only way to improve health, that taking the time to really investigate a community’s needs and then finding ways of bringing together support initiatives to meet those needs are a powerful way to positively impact people’s health. It was also really great to learn about the role that culture plays in determining what healthcare and wellbeing initiatives look like - many aspects of being a hospital artist, such as the easy way of showing physical affection to patients/staff/caregivers, lack of formalities, asking very personal questions off the bat and creating intimate relationships with the families we met in the hospital in a very short span of time were specific to the way Uruguayan society operates at large, and what norms and beliefs are common in the country. It motivated me to be much more aware of circumstances and to really get to know the population I will be working with in the future in order to give them the best possible support for their specific situation, and to never forget about cultural facets impacting any work in public health I will engage in. 

Pasero, Christine L. “Pain Control: Is Laughter the Best Medicine?” The American Journal of Nursing, vol. 98, no. 12, 1998, pp. 12–14. JSTOR, https://doi.org/10.2307/3471701. Accessed 14 Apr. 2023.

Raviv, Amnon. “Still the Best Medicine, Even in a War Zone: My Work As a Medical Clown.” TDR (1988-), vol. 56, no. 2, 2012, pp. 169–77. JSTOR, http://www.jstor.org/stable/23262915. Accessed 14 Apr. 2023.

Van Blerkom, Linda Miller. “Clown Doctors: Shaman Healers of Western Medicine.” Medical Anthropology Quarterly, vol. 9, no. 4, 1995, pp. 462–75. JSTOR, http://www.jstor.org/stable/648831. Accessed 14 Apr. 2023.

Image Credits: Javier Paciello Audiovisual Montevideo