Work, Reproduction, and Health in Two Andean Communities

By Anne Larme, 1993.

Chapter 1 - Introduction

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home from paid employment to face another unpaid job at home. The issues of role stress and the "double day" have therefore gained increasing attention in the literature on gender and health.

Role stress, the double day, and their effects on women's health are even more important when viewed within the context of the economic and social subordination of women in American society (Barnett, Beiner and Baruch 1987; Frankenhaeuser, Lundberg and Chesney 1991). In addition to widespread job segregation, women earn less than men with the same level of education. Women who choose to care for home and children while their husbands are employed are devalued by a society which places a higher value on paid employment. Statistics on domestic violence, rape, and incest attest to the effects of social subordination on the health and well-being of women (United Nations 1991: 19).

Lack of power and control is hypothesized to be a major cause of ill health (Steptoe and Appel 1989). Lack of power and control, influenced by women's lower social status and the norms and demands of the female gender role, is hypothesized to be the major cause of stress and depression for women in the United States (Barnett, Beiner and Baruch 1987: 359-60). A high level of responsibility, combined with lack of autonomy and control over their lives, may be the central reason why women experience more mental and physical symptoms than do men. Although cross-cultural data are limited, this is likely to be true in other societies as well (Barnett, Beiner and Baruch 1987: 1).

Gender and Health in Developing Societies

In developing societies, concerns about gender and health are more basic, and center on the effects of poverty and malnutrition. Proper nutrition is critical to compensate for the heavy physical work people perform in these societies, to compensate for the loss of nutrients due to intestinal parasites, and to promote resistance to disease. Other health stresses in addition to, and interacting with, malnutrition include inadequate public health measures and resultant exposure to pathogens, and lack of economic and social access to health care (Scrimshaw 1978).

Poor women in developing societies face additional stresses due to their reproductive roles and due to their generally subordinate social and economic status (Maine 1981; Paolisso 1989; PAHO 1983: 1-13; WHO 1985). Inadequate nutrition for pregnant and lactating women means that a woman's health is depleted in order to sustain her offspring. This problem is exacerbated by lack of access to family planning methods. With more control over their fertility, women could prevent the depletion of their own health, reduce infant mortality, and protect limited family resources (Maine 1981; Rinehart, Kols and Moore 1984). Women who have children after age 40, especially after a life of repeated pregnancies, face additional health stresses. The physical and psychological toll of having babies in rapid succession, combined with undernutrition, heavy workloads, and lack of economic resources, is just beginning to be recognized (PAHO/AARP 1989: 28, 39, 92-96).

Since the 1970s, feminist social scientists have been exploring the hypothesis that economic development and the change to a market economy have increased women's social and economic subordination in many societies (e.g. Boserup 1970; Bourque and Warren 1981; Leacock and Safa 1986). Many of the problems women in industrialized countries face are also faced by women in developing societies, but in developing societies the problems are more acute. In general, women in developing societies have less access to

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economic resources, less access to education and health care, and less political and social autonomy than men. Like their counterparts in industrialized nations, they work longer hours than men, in addition to their childbearing responsibilities (Paolisso 1989: 1-2; Seager and Olson 1986: 13). They also face physical and sexual violence at the hands of men (United Nations 1991: 19).

In short, women in developing countries face many of the same stresses as women in industrialized countries, with many additional ones. These extraordinary stresses take their toll on women's physical and mental health and prevent them from protecting the health and well-being of their families.

Gender and Health in the Peruvian Andes

As a socially and economically subordinate class within the developing society of Peru, Andeans as a whole suffer negative health consequences from poverty, undernutrition, and hard work. As in other societies, however, there is a gender differential. Andean women bear additional burdens on their health compared to men, due to their reproductive roles, their combined responsibilities for domestic and subsistence work, and their subordination to men. The chronic marginal nutrition of rural Andeans is, in addition, especially detrimental to the health of mothers and infants. There is some evidence that when food is scarce in the Andes, "productive" family members are fed at the expense of "unproductive" members -- pregnant and lactating women, children, and the elderly. Poor nutrition during the childhood of future mothers, and during pregnancy and lactation jeopardizes the health of females of all ages, in addition to the health of their unborn children (Picón-Reátegui 1976: 245).

Another factor must be taken into consideration in the Andes -- the effects of high altitude. While in many ways Andeans have physiologically and culturally adapted to high altitude (Baker and Little 1976; Mazess 1975), hypoxia, cold, and other factors increase health and reproductive risks (Clegg 1978; Haas et al. 1980; Moore and Regensteiner 1983; Way 1976). The special stresses of reproduction in the hypoxic Andean environment must be considered in any analysis of gender and health in the Andes. Higher rates of miscarriage and neonatal death mean that women must undergo repeated pregnancies to achieve desired family size, which, under conditions of marginal nutrition, further depletes their health. Childbirth is also more dangerous at high altitude due to an increased risk of maternal hemorrhage, which contributes to maternal mortality.

There is another, less direct, effect of high altitude on women's health. At high altitude, extra calories are required in order to perform physical work, maintain proper body temperatures, and walk to worksites (Picón-Reátegui 1976: 224; 1978: 226-236). Pregnant and lactating women often perform heavy physical labor in the rural Andes, and therefore need an especially high level of nutrition. Follow Thomas' reasoning regarding energy flow in the Andes (1976: 379-404), it may be biologically adaptive for women at high altitude to perform more sedentary tasks than men, such as herding, food processing, housework, and child care. This would help to balance the caloric requirements of men and women and improve women's health. In a developing economy, however, what is adaptive for women's health in one respect may be maladaptive in another: The restriction of women to non-income-producing productive and reproductive work may increase women's economic and social subordination, a condition detrimental to women's overall health and well-being.

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In prehispanic times, Andean gender relations were characterized by sexual parallelism. Both men and women controlled land and its products, and tribute was based upon the complementary economic activities of males and females. Both men and women could hold important political and religious posts. Parallel religious cults existed where women were responsible for the worship of female deities representing the forces of creation and reproduction. The interdependence and complementarity of men and women was considered indispensable for the maintenance and reproduction of the household, the community, and the Inka empire (Silverblatt 1980: 151-161).

The impact of European colonialism on Andean economic, political, social, and ideological structures was devastating and extensive. While both men and women were subjugated economically, politically, and socially, the burden placed on women by Spanish law was different and more intense. Women were considered minors without independent rights to land or property, and they were prohibited from formal education. The Spaniards legitimated only masculine-dominated pre-conquest political activities, and denied women access to political and religious posts. They also imposed a patrilineal and patrilocal kinship system that undermined parallel structures of descent and inheritance. Colonial pressures altered the relation of ayni (Qu., reciprocity, complementarity) between Andean men and women, and men, according to Western norms, began to "own" their female relatives. Andean peoples resisted these pressures to varying degrees, accounting for the survival of some indigenous Andean cultural forms in the present (Silverblatt 1980: 160-173).

Complementary gender relations have been documented in contemporary Andean societies by some ethnographers (e.g. Allen 1988; Isbell 1978). The existence of bilateral inheritance; the importance of a female deity, the Pachamama; and complementary roles of males and females in agriculture, and to a limited extent in the household, suggest that complementarity remains an important theme in Andean gender relations. Fertility imagery and an idealized role of women are also central to Andean gender ideology, as represented by the fecund Pachamama and the importance of women in agriculture to plant the seed and nurture the crops. A woman's fertile womb, analogous to the fertile Pachamama, perpetuates Andean society, just as the Pachamama sustains Andean society with her agricultural produce. These aspects of Andean gender ideology remain despite centuries of Western influence.

Other ethnographers document how the sexual subordination that began in colonial times is promoted by modernization and industralization in Peru. Bourque and Warren (1981), for example, found that although women in the communities they studied were active participants in agriculture, they were excluded from critical resources including cash, land, irrigation, and education. They were denied the full economic benefit of their work by a strong sexual division of labor, justified by social ideology, that minimized the work of women and accorded higher value to the work of men. Women's heavy responsibilities also meant that they did not have the "extra" time needed to engage in pursuits that would have improved their lot.

Both aspects of Andean gender relations -- links with pre-contact Andean culture and the political economic perspective -- are important in unraveling the reality of present-day Andean gender relations and their effect on women's health.

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Work and Reproduction

It is important to note the contradictory uses of the terms "work" and "reproduction" in the social science literature, and to clarify my own use of the terms, before proceeding. Are "work" and "reproduction" economic, physiological, or sociocultural phenomena -- or a combination of all three? How has the use of these terms contributed to -- or confused -- our understanding of the human experience, which is simultaneously biological and cultural? How should "work" and "reproduction" be conceptualized in relation to women's activities and their effect on women's health and well-being?

"Work" in conventional Western usage is synonymous with "paid employment." This narrow economic definition, however, excludes many people anthropologists commonly study: peasants and others in subsistence economies (see Brush 1977), workers in the informal sector of market economies, and the unpaid labor of individuals, especially women, in the home. Noting this problem, Kahn (1991: 70) proposes to broaden the definition of work to include "productive activity...any activity that adds to the stock or flow of valued goods and services." Webster's Dictionary defines "work" in even broader terms, as an "activity in which one exerts strength or faculties to do or perform something." These broader definitions of "work" help to incorporate much of women's work, which has been ignored under the conventional economic definition.

Yet a question remains: Where does biological reproduction fit? Women clearly "expend their energy" and "exert their strength and faculties" to produce "valued goods" -- children. Can women's roles in "biological reproduction" thus be construed as "work"? What would be the implications of this for economic and sociocultural analyses? If biological reproduction were considered as "work," would women's activities in general be more highly valued by Western economists and academicians, or at least understood in their complexity?

An equally confusing term, especially as it relates to women, is "reproduction." "Reproduction" has been used to refer to the biological process of human reproduction, to the process of reproducing economic systems, and to the sociocultural process of reproducing and perpetuating social systems. Women have an essential role in all three types of reproduction. They bear the burden of biological reproduction. In Marxist terms, women's unpaid labor in the home reproduces and sustains laborers biologically and socially; their underpaid labor in the market underpins capitalist accumulation and the reproduction of the capitalist economy (Kelly 1986: 1-10). Women also play an important part in sociocultural reproduction, especially through their domestic roles and through the socialization of children. There is a need to explore how the distinct dimensions of reproduction are interrelated and determined culturally and socially (Browner and Sargent 1990: 217). Until women's overlapping roles in biological, economic, and social reproduction are acknowledged and incorporated into economic and social analyses, the problem of women's subordination in society cannot be addressed (Benería and Sen 1986).

An understanding of the many dimensions of "reproduction" is essential to analyze the context of women's health in various societies. Women's reproductive roles and the interaction among them create stresses unique to women. These include the health risks of biological reproduction, the stresses of the double day, and the stresses caused by women's overlapping roles in biological reproduction (pregnancy, childbirth, and breast-feeding) and in economic and social reproduction, which often are carried out simultaneously. Finally, women's stress is heightened by their subordination to men. In many societies this subordination is rationalized by the limitations women's physiology and

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biological roles place on more highly valued "productive" activities. This compounds the stress already posed by biological reproduction. What are the implications of the overlapping dimensions and unique stresses of "reproduction" for women's health?

The current focus on the body in the social sciences specifically acknowledges humans' simultaneously biological and cultural nature (e.g. Turner 1984). This focus is especially important in feminist theory and in medical anthropology, for both women and ill people have a heightened sense of their bodies and what it means to be simultaneously biological and cultural (see Scheper-Hughes and Lock 1987 and Martin 1987). The controversies surrounding "reproduction" thus highlight issues in feminist and medical anthropology, and in social theory in general.

One final note about the terminology I will use in the following chapters: I use "reproduction" in its biological sense, unless clearly specified to the contrary. The phrase "women's reproductive roles" (in the plural) will be used because "reproduction" includes women's roles in gestation, birthing, and breast-feeding.

Chapter Reviews

With the introduction to the research problem, goals, and literature complete, I now turn to a discussion of the methods I used to explore the interrelationship of work, reproduction, and health in Cuyo Cuyo. In Chapter 3 I describe the rural Andean research setting. I discuss the centrality of the mountain environment in the lives of the Cuyo Cuyeños, both ecologically and socioculturally. Kinship and gender relations are discussed within the context of the social and economic transformations Cuyo Cuyeños have undergone from prehispanic times to the present.

In Chapter 4 I consider the context of health in Cuyo Cuyo. Health indicators show that Cuyo Cuyo, like other developing societies, faces health problems stemming from poor socioeconomic conditions. Other health problems are unique to life in their mountain environment, including those caused by hypoxia, and by their migratory lifestyle, a longstanding adaptation to the Andean ecology. Females face additional health stresses related to childbearing and to their subordinate status in Cuyo Cuyo society, as represented by high maternal mortality rates, sex differentials in child mortality, and ethnographic evidence of domestic violence. In the final section I discuss the health care options available to Cuyo Cuyeños to cope with these health stresses.

"Work" in Cuyo Cuyo is the subject of Chapter 5. Cultural conceptions of work, the division of labor, typical daily and seasonal work patterns, and time allocation studies in Cuyo Cuyo are discussed, comparing and contrasting men's and women's work. Andeans place a lower value on women's work, which is considered to be lighter than men's. Time allocation studies quantify the division of labor by age and sex, and show that women spend more time in combined household and subsistence work than men. The additional burden that the "work" of biological reproduction places on women is largely invisible, both according to Cuyo Cuyo gender beliefs and according to time allocation data. I suggest that by making biological reproduction visible as work," perhaps the true burden of biological reproduction and its effect on women's health and well-being might be illuminated.

In Chapter 6, I outline ethnomedical concepts central to an understanding of the interrelationship of work, reproduction, and health in Cuyo Cuyo. I then discuss data on symptoms and their causes reported by Cuyo Cuyeños over a one year period. These data

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illustrate a close correspondence between symptom reports and men's and women's productive work and social roles. One category of causation, however, is not so easily explained. Many women who had given birth blamed their symptoms ultimately on childbirth, regardless of their age or whether they had given birth during the research year.

In Chapter 7, I return to the broader context of Cuyo Cuyo society to understand differences in male and female symptom reports. Gold mining poses health risks for men, especially when they migrate to the tropical lowlands. Yet ultimately the cash men earn gives them social and economic power in Cuyo Cuyo. Women are placed in a paradoxical position. Their important roles in maintaining Cuyo Cuyo culture through agricultural work and through biological and social reproduction are valued and encouraged by men. Yet, these same roles are the ones least valued in the outside world, whose values are being incorporated into Cuyo Cuyo culture, particularly through seasonal male migration. The context of Cuyo Cuyo's economic and social transformation is an essential backdrop to the analysis of women's reproductive symptoms and illnesses in the chapter that follows.

In Chapter 8, I return to the question of why women blame many of their symptoms and illnesses on childbirth, utilizing a critical-interpretive framework. I focus on a set of reproductive illnesses including madre onqoy, sobreparto, and sopla. While the ultimate cause of these illnesses is reported to be childbirth, proximate causes range from reproductive events and physiology, the strain of women's daily work routines in agriculture and in the home, exposure to temperature extremes in the worksite, to domestic violence, the most physical reminder of women's subordination to their husbands. I illustrate how, through reproductive illnesses, Cuyo Cuyo women intertwine their experiences in biological and social reproduction, and their experiences of gender relations in Cuyo Cuyo. Through reproductive illnesses they express and embody their distress and suffering as they carry out their multiple social and biological roles within the context of sexual subordination.

In Chapter 9, I link this study to broader methodological and theoretical issues in anthropology as a whole, as well as in the areas of international health, Andean studies, medical anthropology, and gender studies. Most important, this study illustrates that the human body and illness have sociocultural and political, as well as biological, dimensions. A multi-dimensional approach to the body and illness is essential in any context, and especially in the realm of women's health. I also underscore the need to acknowledge women's roles in biological reproduction in economic theory and in social theory in general.