Work, Reproduction, and Health in Two Andean Communities

By Anne Larme, 1993.

Chapter 1 - Introduction

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I begin this study by way of several vignettes. They provide a taste of life, health conditions, and anthropological research in Cuyo Cuyo, Department of Puno, Peru. In particular, they provide insight into the lives of women and girls. Dutifully recorded in my fieldnotes, I did not fully realize their significance until I had returned home to Chapel Hill to analyze my data. Eventually, however, they became central clues in my understanding of the interrelationship of work, reproduction, and health in the Peruvian Andes.

#1. One foggy, rainy morning in Ura Ayllu in January of 1987, I was awakened by a knock on my door. Before me stood Justina, laden with a gift of fresh herbs and newly harvested potatoes. She had brought along her 14 year old son as translator. Her visit was most unusual, because I had only recently arrived and barely knew her. I wondered, given the general timidity of Cuyo Cuyo women, what had caused her to make this daring move. I noted that, although Justina was 39 years old -- only a few years older than I -- she looked at least ten years older than her age.

After the initial pleasantries, Justina came to the point. She reported that she had madre onqoy (womb sickness) and asked if I had any remedios (medicines). Also, what did I know about birth control methods, and could I give her some? She had already had nine children and did not want any more. She had observed that urban and North American women had few or no children, and wanted a remedy that would prevent her from getting pregnant, too.

I found out several months later that Justina was eight weeks pregnant at the time of this visit. This was the second such incident I had encountered. In November of 1986 I had met another woman, thirty years old and from Puna Ayllu, who claimed she was suffering from sobreparto, a chronic illness attributed to childbirth. She, too, was later found to be in the initial stages of pregnancy. I recalled a pre-fieldwork request by two other Andean health researchers.¹ Each had encountered sobreparto, an illness central to the lives of the women they had studied, and wondered what it was. Each had asked me to keep an eye out for it in my ethnomedical research and to try and understand it. When I later discovered that eighty percent of the married women in my sample suffered from madre onqoy and sixty percent from sobreparto, this became all the more imperative.

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#2. The Machicado family had two children, a boy, Wilmar, aged four, and a girl, Yameli, aged two. Throughout 1987, Yameli had been much sicker than her brother, suffering from nearly constant diarrhea, respiratory problems, and intestinal parasites. Despite the greater frequency of illness for Yameli, her mother, María, perceived Wilmar's illnesses to be more frequent. "Why doesn't Yameli get sick as much as Wilmar?" she stated one day. "I don't want/love (Sp., querer) her as much as Wilmar because she's a girl."

Further questioning revealed the rationale for this statement: "We don't want or love girls as much because they are only born to suffer when they grow up. Men treat them poorly, beat them, or they get pregnant before they are married. Girls are much more of a problem than boys."

On a subsequent day, I discussed the same topic with María and her own mother, together. "I love my sons more than my daughters," her mother stated directly in front of María. This garnered no unusual reaction from María. She was treating her own children in the same way.

The third story, condensed from my February, 1988 fieldnotes, relates to women who travel to the Amazonian gold mining site of Maldonado:

#3. Clemencia is worried about her 13 year old daughter who has traveled to Maldonado with her husband and sons to serve as their cook. Women and girls get sick there a lot. This is partly because they don't work and sweat like men in Maldonado, which cleanses bodies of illness.

But it also happens because the heat makes women sleep during the daytime. Saqras (Qu., devils), in the form of snakes, make women fall asleep. They enter women's vaginas, making their bellies swell. The remedy is to tie a piece of cheese outside of the vagina. The snake comes out to eat the cheese and can then be caught. The snakes are more attracted when a woman's clothes are dirty or when she has her period. They want to go in and eat the blood! Women should change their rags frequently during their periods so they don't start to smell and attract snakes. These things don't happen to men, only to women.

Clemencia's twenty year old son who migrates told her about a Cusqueña woman this actually happened to. This frightened her all the more. All of this makes Clemencia very worried about her daughter.

Parts of these vignettes seem curious, even shocking, to the average Westerner. They struck me partially for that reason, because the manner of expression was so strikingly different from that of my own culture. But they are an accurate reflection of the way Cuyo Cuyo women talk about their bodies, children, and lives.

What accounts for the fact that women experience their pregnancies as chronic illnesses? Why are girls thought to be "born to suffer" and how might this attitude affect their health and lives? Why had such incredible stories been fabricated around the bodies and health of women who migrate to the tropical lowlands?

I was drawn to these data in the field, partly due to my longstanding interest in gender issues, and partly due to my identification with these women. But it was only much later, during data analysis, that I shifted from my original focus on the relationship of

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"work stress" and illness in a non-Western setting, to a focus on the interrelationship of work, reproduction, and health.

Andeans live in a "sexualized" world (Allen 1988: 73). Their worldview -- from subsistence, to social life, to cosmology -- is permeated by gender. During fieldwork and data analysis it gradually became clear to me that gender distinctions were as central to understanding the relationship of work and health as they were to understanding other aspects of life in the Andes. Gender was a salient feature of symptom reports by Cuyo Cuyo men and women. It influenced symptoms related to the sexual division of labor and was especially important to understand the symptoms married women so frequently blamed on childbirth.

Clues such as the ones presented above and others throughout my fieldwork clearly demonstrated that something important was going on in Cuyo Cuyo with regard to women's bodies, health, reproduction, work, and gender relations. Thus gender became an appropriate way to understand the relationship of work and health.

The Research Problem

The nature/nurture debate runs deeply throughout the history of anthropological inquiry. For many years, the discussion of difference focused on race, as researchers attempted to explain behavioral differences between white-skinned Europeans and Americans and dark-skinned "primitives" by attributing it to either biology or culture. More recently, however -- especially with the rise of feminist theory in the 1960s -- the nature/nurture debate has focused on gender. Are behavioral differences between males and females due to physiological differences, or due to social and cultural differences in the ways males and females are treated?

Feminist theory itself tends to fall within the two opposing camps of biological or cultural determinism (Rhode 1990: 3). Generally speaking, biological determinists celebrate difference and seek to embrace and admire characteristics historically associated with women, demanding their equal recognition. Cultural determinists deny the extent or essential nature of differences between men and women. This lack of agreement has created conflict among feminist theorists, and confusion among those attempting to understand the issues. Similar conflicts are evident in the social and political arenas as feminists debate reproductive rights, fight job discrimination, or promote the recognition of Premenstrual Syndrome as an important women's health issue.

Not surprisingly, much of the debate over gender differences focuses on women's reproductive physiology and roles. The Cartesian dualism of Western science and biomedicine favors biological, material explanations over sociocultural, ideal ones. Reproductive physiology and roles, as the primary features separating males and females, have therefore become a central focus in the debate over male and female differences.

The materialist approach has had a profound effect on the study of women's health, shaping the questions and concerns investigated within the fields of biomedicine and public health. For example, the study of women's health in the workplace focuses on the effects of chemical exposures and ergonomics on reproduction; "maternal and child health" is an important specialty within the fields of public and international health. But the crucial question we need to ask is: Does the focus on biological reproduction and women's reproductive physiology occur at the expense of other more overarching concerns in

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understanding women's health status? Why do we continue a materialist approach when there are obviously many other factors involved in women's health?

The use of the term "gender" rather than "sex" in the anthropological literature points to the complexity of the issue. The term "gender" emphasizes that there are important cultural and social processes in addition to biological differences that affect the treatment of men and women in most societies. Yet in many societies biological difference -- "sex" -- becomes an easy rationale for the differential access to resources and status accorded to men and women. This is despite the fact that the actual constraints posed by women's biology are few.

Research on gender differences must therefore emphasize the complex interplay between biology and culture in all human groups. In particular it is important to focus on the variations that occur among particular historical, social, cultural, and economic contexts, and especially on the role power differentials play in creating gender differences (Dupré 1990: 47-62).

An understanding of women's biology is an essential basis for understanding their health. But an exploration of women's health must also include questions such as: Beyond reproductive roles, what are the underlying causes for women's ill health? What is the relationship of women's nearly universal subordination to men to women's nearly universal experience of ill health when compared to men's? Why do societies ignore the broader view and opt to focus on reproduction? Why do women do so themselves?

Similar contextual questions are required when attempting to understand cross-cultural conceptions of the female body. Why do societies limit women's access to resources and power, using women's reproductive physiology and roles as the rationale? What is the process by which this occurs in each particular context?

Research Goals

This study explores issues of gender and health in the peasant society of Cuyo Cuyo, Puno, Peru. It provides a cross-cultural and feminist perspective to current concerns about gender and health in medical anthropology, feminist studies, and public and international health.

In Cuyo Cuyo as in the West, reproduction, as the most visible representation of male-female difference, is a central focus of women's health concerns. However, I will argue that in Cuyo Cuyo reproduction must be considered not only in biological terms, but in cultural, social, and political terms. Many symptoms Cuyo Cuyo women attribute to biological reproduction can only be interpreted in relation to other aspects of their lives -- their work in subsistence and in the household, their position vis á vis men in the household and in Cuyo Cuyo society, and their position politically and economically in Peruvian society-at-large. This approach has significance for understanding the interrelationship of gender, work, and health in Cuyo Cuyo and in many cultural contexts.

A Review of the Literature

As a background to my analysis of work, reproduction, and health, I will briefly discuss several bodies of literature. These include previous research on the

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interrelationship of gender, work, and health, most of which has been done in industrialized contexts, and on gender and health in developing societies, with specific attention to the Andes. A final topic I consider is how "work" and "reproduction" have been defined and discussed in the literature, with particular attention to how their definitions and discussions have helped or hindered our understanding of women's work and lives.

What We Know About Gender and Health

There has been a growing interest in the topic of gender and health since the rise of the women's movement in the 1960s and 1970s. Many health researchers are no longer content to use men as the standard by which health is measured. Increasingly they are exposing differentials in male and female health status and attempting to analyze their origins. Most of what we know about gender and health, however, comes from industrialized countries, where the majority of research has been conducted. Care must be taken in extrapolating these findings to cross-cultural contexts.

Many works on gender and health begin with this seemingly contradictory set of data: Although slightly more males than females are born, male mortality exceeds female mortality at every age. Females in nearly every society have longer life expectancies, despite the stresses of their reproductive roles, amount of illness symptoms they report, domestic and sexual violence they experience, or type of work they perform. Yet females everywhere and of every age tend to suffer from higher rates of morbidity than do males (Barnett, Beiner and Baruch 1987: 1-4; Scrimshaw 1984: 450; Seager and Olson 1986: 26; Stellman 1977: 30; Waldron 1983: 1107-1115, 1991: 18).

In the United States, for example, males suffer a higher rate of accidents, violence, and acute life-threatening health problems. Females are at risk due to childbearing and their more complicated reproductive physiology, and they suffer from higher rates of chronic, non-life-threatening illness (Verbrugge 1985; Waldron 1983). Women are also at risk from domestic and sexual violence (United Nations 1991: 19). Women seek professional help for health problems more than do men, even without considering reproductive events, although there are undoubtedly many non-biological factors involved in women's help-seeking behaviors (Verbrugge 1985: 162). In spite of the many insults to their health, however, American women still tend to outlive men. This paradox has been the driving force behind much of the research on women's health in industrialized societies.

An important focus within women's health research has been biological reproduction. The conventional view, upheld by biomedicine, is that reproductive risks are a liability for women, and reason to exclude them from various roles in society, especially paid employment. Such thinking has a long history in Euro-American culture (Bleier 1984; Hubbard 1990; Martin 1987). Feminist researchers, however, have pointed to considerable conflicting data. They note that historically these ideas applied only to middle and upper class women. Poor women, at least since industrialization, have always been expected to carry out remunerative and subsistence activities, no matter what their health or reproductive status (Bleier 1984; Hubbard 1990).

In many present societies, including the United States, women can and do function in their many roles up until the day of giving birth, returning to their normal activities and work soon after birth. A pregnant woman with a normal pregnancy and adequate nutrition can remain physically active up until the onset of labor. The physiological adaptations of

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pregnancy, including increased hemoglobin, blood, and heart volume, largely prevent health problems or loss of productive capabilities. A healthy, well-nourished woman who gives birth without complications is physically capable of getting up immediately after childbirth, and of returning to work within a few weeks. In short, most women suffer few negative health effects and disruptions as a result of their reproductive roles (Guttmacher 1986: 133-186; Hunt 1979: 49-54; OTA 1985: 106).

Feminist researchers hold that what is most detrimental to women is not their reproductive physiology and roles, but the cultural practices and attitudes surrounding women's physiology and roles (Bleier 1984; Birke 1986; Hubbard 1990; Martin 1987). In the West, for example, women have historically been labeled as the "weaker" sex, largely due to their reproductive roles. This has served as a rationale to limit women's other roles in society. Yet, aside from a few weeks to recuperate after childbirth, and the hours actually spent in breast-feeding, there is no biological imperative to have one or another type of sexual division of labor.

Another example relates to childrearing. In most societies childrearing is considered to "naturally" follow from women's roles in biological reproduction, and women do most of the childrearing. Women's work and social roles in most societies have therefore been organized around, and restricted by, their childrearing responsibilities, since women who are tending young children need flexible work hours, and need to perform tasks that can be interrupted and resumed without difficulty, that do not place their children in danger, and that do not require them to range very far from home. Yet, there is no biological reason that women have been assigned the childrearing role. Cultural practices, such as assigning child care to fathers, other adults or older children, could spread the burden of child care among several social groups, freeing women to perform other activities.

The view that reproduction is a limitation or a liability when assessing women's contributions is widespread among human societies. It is important to understand this phenomenon as a cultural elaboration of a biological attribute of females, however, not a biological necessity. There are countless other ways cultures could view women's physiology and reproductive roles, and divide up the labor necessary to perpetuate society.

The growing gender consciousness of the 1960s and 1970s gave rise to a literature on gender, work, and health (e.g. Hunt 1979; Liebowitz 1980; Stellman 1977), much of it dealing with women in industrial work settings. Again, pregnancy and childbirth were found not to interfere significantly with women's industrial work. In addition, women's body size, muscle strength, and ability to walk long distances were found to overlap considerably with men's (Hunt 1979: 39-42). These authors note that discussions of women's health in industrial contexts typically focus on the deleterious effects of chemical and electromagnetic exposures on women's reproductive capacities, and then this evidence is used to support job discrimination against women. They point out, however, that these concerns should also extend to the protection of men's reproductive capacities. In short, when women's work capacity is compared to men's, it has been found that women's bodies and reproductive roles do not necessarily limit them.

More recently the literature on gender, work, and health has broadened to non-industrial occupations and especially to the broader context of women's lives (e.g. Barnett, Beiner and Baruch 1987; Frankenhaeuser, Lundberg and Chesney 1991). In present-day American society two incomes are often necessary to support a family; there is also a growing number of female-headed households. Women are increasingly essential to the economic stability of households, yet the household division of labor has not changed significantly to reflect this fact. Women, whether married or single parents, often return