Work, Reproduction, and Health in Two Andean Communities

By Anne Larme, 1993.

Chapter 4 - The Health Context

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rates are based upon the number of live births in a given year (i.e., with more accurate reporting of births, the maternal death rate would appear lower). However, death rates by age-group after the first year of life are probably accurate. Beginning with the naming of a child and official entry into the birth registry (i.e., after the first few weeks of life) official permission must be obtained before burial, and, according to the District Secretary, Cuyo Cuyeños carefully follow the law.

Thus, comparisons between the Cuyo Cuyo health indicators I have calculated and official governmental figures must be made with caution, because departmental and national statistics are based upon incomplete local data, as in the case of Cuyo Cuyo. Gomez (1986: 55), in his report on the Health Sector Analysis of Peru (HSAPERU), a national health survey conducted in 1984, concurs that official mortality statistics are misleading. He estimates that infant deaths are under-recorded in Peru by at least 55-63%, affecting the quality of all official mortality statistics.

My work with Cuyo Cuyo birth and death registries has brought up a set of issues related to cultural attitudes surrounding when human life begins, infanticide, and the interpretation of official statistics in Peru and in other developing countries. These issues are beyond the scope of this study. However, my experience provides a cautionary note for medical anthropologists and public health specialists working in international settings. In many countries the health situation is considerably more precarious than that which can be inferred from official statistics.

Morbidity

Official data on morbidity and on causes of mortality provide additional information on the context of health in Cuyo Cuyo. Morbidity and mortality data for the Department of Puno are collected by Ministry of Health (MINSA) workers at government health posts throughout the department, and are tabulated annually by MINSA officials in the city of Puno. These must be seen as conservative estimates, because many Puneños treat themselves at home or do not have access to MINSA clinics.

MINSA data (Gomez 1986; UDES 1988) rank acute respiratory illness as the worst health problem in Puno. Respiratory problems are the principal cause of death, accounting for 34% of total deaths, and 45% of the deaths of children under the age of one. Dysentery and gastroenteritis are also important health problems in Puno, accounting for 9% of infant deaths, and 12% of infant illnesses diagnosed by health workers. Respiratory problems and gastroenteritis/dysentery are the top communicable diseases in Puno, followed by respiratory tuberculosis, helminthiasis (parasitic worms), typhoid and paratyphoid, measles, whooping cough, and chicken pox.

Because many Cuyo Cuyo males spend a good portion of the year in the lowlands of Madre de Dios, it is interesting to compare the Department of Madre de Dios with the Department of Puno. In Madre de Dios, the top communicable disease is malaria. This is followed by acute respiratory infections, helminthiasis, gastroenteritis/dysentery, respiratory tuberculosis, influenza, chicken pox, and typhoid and paratyphoid. Leading causes of death in Madre de Dios are intestinal infections, accidents and violence, respiratory illnesses, viral infections, and malnutrition. General health indicators appear slightly better in Madre de Dios than in Puno. The IMR is 93 in Madre de Dios compared with 114 in Puno, the general mortality rate is 10 compared to 11, and there is a higher life expectancy, 57 years compared with 52 (Gomez 1986: 68; UDES 1987: 3, 1988: 71). These data suggest that although Cuyo Cuyeños are exposed to different

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pathogens and more violence when they migrate to Madre de Dios, overall health conditions may be slightly better, including the presence of better health care facilities.

The 1984 HSAPERU, a self-report illness survey,⁴ also found respiratory and digestive symptoms to be the most prevalent health problems in Peru. Respiratory problems accounted for the most significant portion of symptoms (17%), followed by digestive problems (7%), dental problems (3%), and accidents (2%). Overall, 35% of the total populaton of Peru reported some symptoms of illness in the two weeks prior to the survey.

My own data, 1,149 symptoms reports collected for 107 individuals of all ages over the period of one year in Cuyo Cuyo (Table 4.3), are generally consistent with HSAPERU data. Respiratory symptoms accounted for the majority of complaints (23.0%). Second in importance, in contrast to the HSAPERU, were musculoskeletal complaints (20.5%), described as "rheumatism," and lower back, shoulder, and work-related pains in other body areas.⁵ The third major complaint, again consistent with HSAPERU, was gastrointestinal problems (16.5%). These were followed by lesser complaints, including accidents and injuries (7.8%), headaches (7.6%), toothaches (6.3%), eye infections (3.2%), earaches (2.7%), scabies (2.2%), and others.

Gender and Health

Gender-specific health indicators, supplemented by ethnographic observations, provide insight into factors that differentially affect the health status of Cuyo Cuyo males and females. Comments by informants and my own observations led me to suspect, for example, that male and female offspring were treated differently in Cuyo Cuyo, in ways that resulted in increased sickness and death for females.

Attempting to verify this, I calculated sex- and age-specific mortality rates from 1981 vital statistics and census data (Table 4.2). In 1981 the overall female death rate is only slightly higher than the male death rate, 27.9 compared with 24.5 per thousand population. Broken down by age groups, however, striking differences between males and females can be noted, especially for small children. The female infant mortality rate is 274.2 deaths per 1000 live births, compared with a male rate of 154.9. At ages one through four, the female death rate continues to be higher, 28.6 per thousand, compared with 18.1 for males. After age five, no consistent sex differential is discernable until age 55. Then, in contrast to the early years of their lives and following the biological norm (Chapter 1), the female death rate becomes consistently lower than the male rate. At ages 55-59 the female rate is zero per thousand compared with 16.4 for males; at ages 60-64 it is 35.7 compared with 54.0; and for ages 65 and over the female rate is 62.1 per thousand compared to 107.1 for males.

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Higher female mortality rates through age five in Cuyo Cuyo contradict the finding that biologically male mortality should exceed female mortality at every age (Chapter 1). They also contradict Haas et al.'s finding (1980: 473-474) that female infants have a greater buffering capacity than male infants against the stresses of high altitude hypoxia, illness, and malnutrition. Higher female mortality rates through age five in Cuyo Cuyo suggest that active or passive infanticide and selective neglect of young children are occurring in Cuyo Cuyo, with the survival of males being preferred over females (Johannsen 1984; Scrimshaw 1984: 450). At the other end of life, however, Cuyo Cuyo patterns follow the biological and demographic norm: Cuyo Cuyo females, if they survive their early years, tend to outlive males.

The maternal death rate of 1022.4 per 100,000 live births (Table 4.1), although somewhat inflated due to inaccurate recording of live births, demonstrates that pregnancy and childbirth take a heavy toll on Cuyo Cuyo women, ages 15-44 years. Reproductive histories of married women aged 40 and above in my sample provide additional insight into the relationship of reproduction and women's health in Cuyo Cuyo (Table 4.4). Although the sample size is limited (n = 12, six from Ura Ayllu and six from Puna Ayllu), Table 4.4 illustrates the reproductive histories of a few typical Cuyo Cuyo women nearing the end of their reproductive lives. To obtain these data, women were asked how many times they had been pregnant and whether or not they had had a miscarriage. They were then asked about the age, sex, and cause of death of each child who had died. In order to get accurate information on total offspring, I also made sure to inquire about adult children living in separate households. (See Appendix II.)

Women 40 years and above in my sample had had an average of 7.4 pregnancies. Of these, 0.5 had resulted in miscarriage and 2.5 children had died, most in infancy and early childhood, leaving an average of 4.4 children still living in March of 1988. Despite the fact that the Puna Ayllu women in the sample were older and most had completed their reproductive years, Puna Ayllu families were smaller. Lower numbers of reported pregnancies and higher numbers of miscarriages and child deaths in Puna Ayllu may reflect the greater amounts of time Puna Ayllu women spend at higher altitudes, which, as previously noted, creates risks for pregnancy and neonatal survival. Cultural knowledge in Puna Ayllu reflects scientific knowledge. Puna Ayllu women stated that it was dangerous to give birth in Ancoccala (located at approximately 4500 m) because the neonates frequently died, a fact they attributed to the "cold" of Ancoccala.

Reproductive history data, combined with infant mortality data, are consistent with studies that show increased mortality of fetuses, infants, and young children in the Andes due to the combined effects of high altitude stressors, marginal nutrition, and poor hygiene. The effects of repeated childbearing and high child mortality rates on the physical and psychological health of Cuyo Cuyo women are important considerations when assessing Cuyo Cuyeñas' overall health and well-being.

Parents want and need children of both sexes to carry out subsistence tasks in the family, to earn cash, and to care for them when they are elderly. Children are also essential in establishing ties of compadrazgo, linking the nuclear family to reciprocal networks in the community. Too many children, however, are viewed as an economic liability, especially if a family has an undesirably high ratio of females to males. High infant and child mortality rates mean that women must repeatedly undergo the physiological stress of childbearing in order to achieve desired family size and sex ratio. The psychological stress of miscarriage and child mortality is less clear. However, when combined with women's marginal nutrition and heavy workloads, the physiological and psychological stresses of childbearing and child loss undoubtedly bear serious consequences for women's health.

(page 61: Table 4.4)

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Women do not have a choice in how many children they will bear, nor when they will bear them, since they lack information about artificial birth control methods and abortifacients are rarely, if ever, used. Single and married women in Cuyo Cuyo frequently bear unwanted children, although there is evidence that parents control family size and composition to some degree through infanticide, by selling infants, and by sending daughters to work in the city as domestics.⁶

Data on "postpartum family planning," in addition to the number of times I was approached by both women and men about family planning methods, demonstrate that the burden of unwanted children is considerable for Cuyo Cuyo parents. Both men and women worry about having enough economic resources to raise their children, and therefore seek to limit family size. But the cost of bearing an unwanted child is much greater for women. In addition to the physiological cost, women bear most of the social and psychological costs of unwanted children. Married women are responsible for most childrearing activities; married or single women who bear children out of wedlock are stigmatized; and women who find themselves alone have difficulty supporting their children on the meager economic or social resources available to them. The death of an unwanted infant, as I observed, can be a relief to both women and men.

Another factor to consider in the relationship of gender and health in Cuyo Cuyo is the overall conditions of women's lives when compared to men's. Men and women in this peasant society must perform hard physical labor all of their adult lives. Adult women in Cuyo Cuyo deal with additional stressors on their health. Marriage for women is synonymous with constant hard work, frequent childbearing, and subordination to husbands, which often includes domestic violence. This combination of factors contributes to women's experience of ill health.

Present political economic conditions, another important factor affecting gender differentials in health status, are discussed in the final section of this chapter.

Coping With Illness: The Health Care System

Cuyo Cuyeños have several alternatives when they become ill, including home treatment with herbal or patent remedies, ritual cure by a hampikuq (Qu., indigenous curer), or biomedical treatment. By far, the majority of symptoms are treated at home with remedies derived from Andean ethnomedicine and from the Greek humoral tradition introduced by the Spanish colonists. Medicines consisting of herbs, foods, minerals, and animal substances are applied topically or internally, especially through infusions of herbal teas (Photograph 4.1). These remedies are obtained by Cuyo Cuyeños in their travels to different ecological

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zones, at market stalls in Cuyo Cuyo or Juliaca, or from traveling healers.⁷ Massage and other cures involving the manipulation of body parts are additional features of the Cuyo Cuyo curing repertoire. Over-the-counter medications, especially cold remedies, tonics, worm remedies, and Terramycin are available in every local store (Photograph 4.2). These are important in self-medication, whether used alone or in combination with Andean cures. Women treat the majority of family health problems in their role as family caretakers, assisted by their mothers and husbands.

Two types of indigenous healers exist in Cuyo Cuyo communities. A few women in each community treat childbirth-related symptoms with herbs and massage. They also occasionally serve as birth attendants, although women are ordinarily assisted by their mothers or other female relatives. One Puna Ayllu midwife, who received specialized training in midwifery through a Swiss development project in the 1970s, is in demand throughout the valley.

Each ayllu has three or four hampikuqs, middle-aged to elderly men who specialize in divination, ritual cures, sirvisqa rituals and, allegedly, sorcery (Sp./Qu., dañu). Hampikuqs diagnose and treat illnesses determined to be of supernatural origin, either when a supernatural cause is known or because an illness resists normal treatments. Due to their close communication with the supernatural, which may be employed for good or evil ends, hampikuqs are both feared and respected. This ambiguous status, heightened by the fact that many are widowers who live alone, contributes to their marginal status in the commmunity. In other ways, however, hampikuqs are much like other comuneros: they work in the fields, they mine gold, and they migrate.

Comuneros readily introduced me to hampikuqs, who were open and helpful. Several performed divinations and ritual cures for me. None mentioned sorcery; all stressed their positive healing powers. I learned about sorcery only through research assistants and other comuneros with whom I had established some intimacy.

The initial visit to a hampikuq consists of a divination with coca or tarot cards to determine the cause of an illness, after which an appointment is made to perform a ritual cure (Photograph 4.3). Ritual cures take place at night when communication with the supernatural is most propitious. The most common cure is the urañasqa (Qu., fright sickness cure), which involves praying to Andean and Christian spirits, "cleansing" the body of illness by "bathing" it with water in which sweet-smelling herbs have been boiled. In this way the body is prepared for the return of the soul, which has been frightened out of the body, and therefore, the return of health. More serious illnesses require "cleansing" and "exchanging" the illness by rubbing the ill person with the body of an animal (Aym., turqasqa, the exchanging) or with an iron rawk'ana (Qu., hand hoe) blade (Qu., pichasqa, the sweeping). In all three cures, the illness is symbolically transferred to the water, animal, or rawk'ana blade as it is rubbed over the body. These, along with the illnesses they contain, are disposed of in the river or by burial at a crossroads. Illnesses are then thought to be carried downstream out of the valley or to other communities by travelers passing through the crossroads.

In extreme cases, especially when a serious illness is part of a string of misfortunes, a hampikuq may be hired to perform a sirvisqa ritual. This ritual atones for any wrongdoing that may have incurred the spirits' wrath and caused the illness. In other

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extreme cases, sorcery is suspected, particularly if the person has reason to suspect that other comuneros may be angry or envious. One of the women in the sample, for example, suspected sorcery after a year of disharmony with her husband and other comuneros, an unwanted pregnancy, and a series of emotional and physical health problems. Another couple decided that sorcery had been performed by a brother-in-law whom they suspected had murdered the wife's sister. They had attempted to vindicate her death through legal means, and when they began to suffer many health problems, they suspected sorcery. In such cases a divination may be requested to confirm suspicions, and a hampikuq (in this case called dañuq, or sorcerer) employed to perform a counteractive ritual.

Cuyo Cuyeños also have limited access to biomedical care. The most important source is the Puesto Sanitario de Cuyo Cuyo, a MINSA Health Post staffed by one or two sanitarios (Sp., paramedics), nurses, or health technicians assigned to the post by MINSA authorities in Puno. Although the clinic is poorly equipped by U.S. standards, health personnel are available daily for walk-in consultations and for emergencies. Biomedical care is also provided in the pueblo by one of the French Catholic missionaries who is trained as a nurse. In Puna Ayllu there are two male "health promoters," community volunteers under supervision of the Cuyo Cuyo sanitario, who are charged with promoting public health in indigenous communities. In actuality, however, they function as health care providers themselves, applying injections and dispensing medications as a means of earning supplementary income (and status). Finally, Cuyo Cuyeños occasionally travel to Sandia or to Juliaca for health care at larger MINSA clinics or with private physicians.

The Puesto Sanitario is rarely used by Cuyo Cuyeños (Photograph 4.4). A review of 1986-87 health post records indicates that a maximum of fifteen patients per day were seen over a seven hour period; days with only two or three patients were not infrequent. Cuyo Cuyeños told me that biomedicine was effective only for a circumscribed set of problems including high fevers, infections, and injuries requiring sutures. Biomedical treatments generally were considered to be superficial and temporary, because they did not deal with the root causes of symptoms. In most cases Cuyo Cuyeños prefer Andean medicine, where treatments address symptom causes, in addition to the symptoms themselves.

Cuyo Cuyeños also seek out pharmaceuticals and biomedical treatments when home remedies and rituals prove ineffective, or in emergencies when they simultaneously -- and often desperately -- resort to every health care option available. Biomedical personnel may be called upon, for example, for difficult births, truck accidents, or other accidents, such as a mass poisoning that occurred in Ura Ayllu in 1987.⁸ The Ministry of Health also conducts an annual vaccination campaign which is enthusiastically received. Children are regularly vaccinated for polio, diptheria, whooping cough, tetanus, measles, and tuberculosis. Vaccinations appear to be relatively effective in controlling these diseases in Cuyo Cuyo.

Cuyo Cuye¤os also tend to self-medicate when living at their various migration sites. In the mining communities of Madre de Dios and Ancoccala they rely on patent remedies and pharmaceuticals more than in Cuyo Cuyo, because familiar folk remedies are unavailable, and because they have access to markets, pharmacies, and cash. For the same reasons, men who traveled to the yunka and to Madre de Dios also stated that they frequented MINSA health posts more in these locations than at home. One additional

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reason they gave for this behavior was that they were unsure of how to treat lowland maladies.

Health in Cuyo Cuyo: The Critical Perspective

How do we rationalize the contrasting views of health in Cuyo Cuyo -- the views of Cuyo Cuyeños themselves, who are generally satisfied with their health situation, and the contrasting view presented in this chapter? I have demonstrated that high altitude, tropical pathogens, poor sanitation, and marginal nutrition, among others, all pose health risks for Cuyo Cuyeños. Mortality and morbidity data attest to these risks. In addition, Cuyo Cuyeños lack education about the most basic health matters, and they have minimal access to biomedical care.

One likely interpretation of this discrepancy is that frequent and sometimes fatal illness, and a lack of resources to deal with it, are taken-for-granted in the world of Cuyo Cuyeños. Most are unaware that the situation could be any different. Their lives and thinking reflect this basic fact of life.

Gomez (1986: 7) notes the linkages between health and socioeconomic status in Peru: Peruvian departments with the highest mortality rates and lowest life expectancies have the worst demographic, economic, social, and environmental conditions, and the poorest health resources and services. Poor socioeconomic conditions in the Department of Puno are reflected in a comparison of its basic health indicators with those of other Peruvian departments. Out of the 26 departments in Peru, Puno has the third highest infant mortality rate, and it ranks fifteenth in terms of life expectancy (p. 68). It is clear that in order to illuminate all facets of health and illness in Cuyo Cuyo, a critical perspective is necessary.

Cuyo Cuyo's basic health indicators reflect its poor socioeconomic conditions. Cuyo Cuyeños obtain limited cash through gold mining. However, public health measures, nutritious foods to supplement agricultural production, and better health care, including family planning methods, appear to be of low priority in the allocation of their limited funds. In addition, some ethnomedical beliefs are detrimental to their health. For example, intestinal worms are commonly thought to be caused by eating too much sugar, scabies (parasitic mites) by scratches or insect bites, yellow fever by experiencing sudden temperature changes, and infant diarrhea by "cold" or uraña (Qu., fright). These beliefs could be addressed by health education in District schools and by MINSA personnel.

"Vertical" adaptations to the mountain environment and the migratory lifestyle this entails have undoubtedly always created health risks for Cuyo Cuyeños. The emphasis on cash in the present day economy has exaggerated this longstanding pattern of vertical adaptation, however. Men migrate for longer periods than in the past to lowland gold fields and to urban areas; women are left alone to handle the burden of subsistence, household, and community work while they are gone. These changes in work roles have negatively affected the health of both men and women. Women's subordination to men, reinforced by the economic and social changes accompanying migration and the shift to a market economy, are an additional strain on women's health.

Cuyo Cuyeños' poor health is clearly related to their marginal position in the national economy and society, and in the global economy. The critical perspective is thus an essential component of any analysis of health and illness in Cuyo Cuyo.