oths assessing variation in health in the andes- a bio cultural model (ssm, 1998) oths

8/2/2019 Oths Assessing Variation in Health in the Andes- A Bio Cultural Model (SSM, 1998) Oths

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ASSESSING VARIATION IN HEALTH STATUS IN THE

ANDES: A BIOCULTURAL MODEL

KATHRYN S. OTHS

Department of Anthropology, University of Alabama, P.O. Box 870210, Tuscaloosa, AL 35487-0210,U.S.A.

AbstractResearch on health status in the Andes highlands is synthesized to demonstrate that intracul-tural diversity in the region is greater than often appreciated. Understanding the range of diversity inhealth status requires a biocultural model of sickness processes. Ecological, sociocultural, political-econ-omic and historical factors, such as altitude, mode of production, labor relations and land reform, areshown to combine to produce varying levels of health as measured at the community level. The model

is illustrated both by comparing communities and by the in-depth examination of a single communityin the northern Peruvian highlands. A rapid assessment checklist is provided to aid health agents in bet-ter assessing the relative health of communities in a potential intervention area. # 1998 Elsevier ScienceLtd. All rights reserved

Key wordsAndes, biocultural, health status measurement, international health, medical anthropology,intracultural diversity

INTRODUCTION

Towards the collaborative aim of updating research

on Andean health, I propose a synthesis of some of

the diverse health status data that has been gener-

ated over the years by Andeanist biological and

social scientists. My aims here are twofold: (1) to

recognize and embrace the biocultural diversity

found in the high Andes, in order to begin to

understand its eects on health status of Andean

people and (2) to suggest that international aid

agencies must take heed of this intra-Andean diver-

sity if their programs are to be implemented suc-

cessfully.

Chugurpampa*, the site of my own research, is

part of an arid potato growing region centered at

3300 m in the western escarpment of the Northern

Peruvian Andes. My ndings regarding health indi-

cators there tend to diverge from those of other

areas, primarily the southern part of Bolivia andPeru, where the majority of anthropological work

has been done. This has led me to consider how we

can integrate cultural, ecological, political economic

and social factors to account for these intra-Andean

dierences in health status.

The need to take into account diversity within a

population is an oft-stated, if seldom heeded, axiom

in anthropology (Pelto and Pelto, 1975; Vayda,

1994). Likewise, the idea of microdierentiation in

the Andes is not a new idea. The 4700 mile-long

Andes mountain range contains within its borders a

tremendous amount of diversity, both ecological

and cultural. The original notion of Murra (1972)

of ecological zonation documented the ecological

diversity within an ayllu. Coming to recognize the

complexity and diversity of Andean ecology, Murra(1985) has recently updated his notion of ecological

zones by taking into account (1) horizontal as well

as vertical dierentiation (what he now calls ``eco-

logical complementarity'') and (2) the need to corre-

late ecological niches with the type of socio-cultural

systems that have developed within, and in turn

inuenced, them.

I suggest that Murra's notion of ecological and

sociocultural dierentiation can be protably

applied to the greater Andes region in general and

to other aspects of Andean life in particular, such

as health. Many years ago, Buck et al. (1968) high-

lighted the health status dierences between fourPeruvian highland and lowland communities. More

recently, Carey (1990) and Leatherman (1994), have

gone further by linking social structural factors

with ecological niches to determine health dier-

ences between three neighboring communities in the

Nun oa district. Their work shows signicant health

dierences by village, each of which obtains its live-

lihood under a dierent set of social, political and

economic arrangements.

In this paper, I hope to build upon these import-

ant earlier contributions by going a step further and

comparing villages from dierent regions of the

Andes. Too often one reads over-generalized asser-tions about Andean health, such as ` infant mor-

tality is high at high-altitude'' or ``malnutrition is

Soc. Sci. Med. Vol. 47, No. 8, pp. 10171030, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98 $19.00 + 0.00

PII: S0277-9536(98)00161-0

*Chugurpampa is a communidad campesina (communal

peasant community) of 902 inhabitants located in theDepartment of La Libertad, in the Province of Otuzco,district of Julcan.

1017


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endemic in the Peruvian highlands''. Assuming simi-

lar health conditions for all marginalized indigenous

groups throughout the Andes would be as ill-

advised as assuming the health of rural Blacks inAlabama were the same as that of rural Blacks in

Minnesota. This paper aims to correct any attempt

to generalize about health conditions in ` the

Andes''.

HEALTH STATUS COMPARISONS BETWEEN

COMMUNITIES

Following the methodological advice of de Meer

et al. (1993), the comparisons below will be based

exclusively upon the results of carefully conducted

empirical studies that include socio-cultural corre-

lates. Data from large-scale national censuses andsurveys are included as reference points only; as

Go mez admits (Go mez, 1988, p. 16), statistics such

as the Pan-American Health Organization collects

for Peru may be based on estimates and inferences.

In the service of making the main point about

health diversity in the highlands, from time to time

I will be introducing heretofore unpublished data

from my own research in northern Peru.

The Chugurpampa health data was collected

from March 1988 through April 1989. Initially, a

census and health survey were conducted of all 166

households of the agricultural hamlet, which are

dispersed over 1000 hectares. Birth and mortality

rates for 1987 were calculated on the basis of thehealth survey and, using the census as a base, all

births and deaths in the community were recorded

by the researcher as they occurred during 1988. All

data was cross-checked against district civil registry

records*. From July to December, 1988, case illness

histories were collected for all members of 32 ran-

domly selected households. Height and weight

measurements of infants and children and adult

CMI scores were also obtained during this period.The stimulus for and verication of the obser-

vations made here would not have been possible

without intensive participant observation for

3 months in 1987 prior to, and throughout, the

study period. This included eating meals with doz-

ens of families, staying in many households, work-

ing in the elds, attending Sunday market and

campesino community meetings, accompanying the

midwife and other healers to see patients, teaching

classes, enjoying estas and in general, immersing

myself in every aspect of daily life (for details, see

Oths, 1991).

The epidemiologic transition Merrick (1986) has

noted for Latin American in general is also occur-

ring in Chugurpampa. Serious problems of infec-

tious disease, infant diarrhea and malnutrition have

been largely alleviated through cultural interven-

tions in the form of immunization, pure water, and

adequate sanitation and diet (see McKeown,

1976){. However, these Andeans are hardly illness

free. Acute viral respiratory and chronic musculos-

keletal illnesses make up nearly 2/3 of the reported

illnesses in Chugurpampa. Gastrointestinal pro-

blems, while accounting for only 14% of all illness

complaints, represent the majority of grave illnesses,

most of which occur in adults.

Similarities as well as dierences in illness pat-terns are apparent throughout the Andes. Table 1

shows that the same three general illness types, res-

piratory, musculoskeletal and gastrointestinal, are

also the most highly ranked in two other highland

Andean communities for which comparable data

was available, Cuyo Cuyo in Southern Peru

(Larme, 1993) and Saraguro in Southern Ecuador

(Finerman, 1985){. A lowland Bolivian community

is included for contrast. The salience of these three

illnesses is widely documented across the Andes by

other researchers, including Little and Baker (1976,

p. 417), Dutt and Baker (1978, p. 33), Donahue

(1981, p. 225), Bastien (1987, p. 50), Leatherman

and Thomas (1987, p. 223), Carey (1990, p. 273)

and Mitchell (1991, p. 30). Comparisons show that

respiratory illnesses are the most common com-

plaint at the higher altitudes, especially where the

climate is dry. Gastrointestinal complaints, which

include infant diarrhea and parasites, tend to be

more frequent at the lower elevations. The amount

of musculoskeletal disorder varies with the mode of

production, which may be partially associated with

altitude and terrain.

While the pattern of illness types varies across

contexts, the severity of illnesses does as well. When

it comes to health status indicators such as infant

mortality, crude death rate, maternal reproductiveloss or days missed from work due to illness,

Chugurpampa's rates stands apart from other sites.

*Relying on civil registry data alone would have overesti-mated the birth rate and underestimated the death ratefor Chugurpampa.

{Of the 25 cases of respiratory infection recorded in a20% random sample of Chugurpampa infants (N= 8)during a 24 week case collection period, four (16%)were grave in severity. Of 8 g.i. ailments, 1 case each

of diarrhea and empachado (intestinal blockage) weregrave (25%). No deaths occurred. These gures weresimilar to the rates for the surrounding district ofJulcan (population 37,000), including 390 infants. Thedistrict health post doctor recorded one infant death,from diarrhea, for the 6 month period that overlappedmy study period.

{Symptom patterns may change seasonally (see Carey,1988, p. 147); whether the eects of these changesmight be reected in the types of illness or simply thequantity of symptoms is not known. Data in Saraguroand Cuyo Cuyo were based on 12 months of data col-lection, compared to 6 months (JulyDecember) inChugurpampa. To achieve comparability across sites,respiratory illnesses included cold/u, sore or swollenthroat, asthma and chest pain. Musculoskeletal com-plaints also included accidents/injuries, rheumatism,

body aches and swollen legs. The category of g.i. pro-blems subsumed stomach aches, vomiting, diarrhea,parasites, liver problems and constipation.

K. S. Oths1018


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Aware of established concerns about the design of

small area variation studies (see Parchman, 1995 for

caveats), I fully recognize the potential lack of uni-

formity in methods, sampling and interpretation of

symptoms among researchers whose data is used

herein. There is insucient data to compare all

samples statistically; nonetheless, some tentative

comparisons might be useful.

The infant mortality of 31 per 1000 live births in

Chugurpampa is one of the lowest reported for the

Andes above 2500 m (Table 2). At the other

extreme, Larme reported 242 deaths per 1000 births

in Southern Peru for the same year, while Cruz-

Coke found a rate of 333 in Chile 30 years ago.

Geographical, altitudinal and temporal trends are

discernible in Table 2. It appears that IMR

increases the more southern the location of the vil-

lage or district (r = 0.50), the higher the altitude

(r = 0.54) and the earlier the date, with the excep-

tion of Cuyo Cuyo (r = 0.43)*. The decrease in

rates over time reects the decline in mortality due

to infectious disease, or demographic transition

(Merrick, 1986).

Similar to its IMR, Chugurpampa's crude death

rate, at 6 per 1000 population, is less than half that

of the next lowest rate found recorded, as shown inTable 3. The high is 50 in Chile in 1965 and, for

more recent years, 27 in Cuyo Cuyo. Altitude, lo-

cation and year are again mildly correlated with the

death rate in degrees similar to that for IMR.

Maternal reproductive loss is measured as the

mean percentage of children who have died at any

time since birth during a mother's lifetime. While

not good, the rate of 18.5% in Chugurpampa is

somewhat lower than Carey found in any of the

three communities in the Nun oa district (p = n.s.)

and nearly 1/2 that of Larme's rate found in two

dierent communities in Cuyo Cuyo (Table 4), with

the dierence (combining Larme's two samples) sig-

nicant at the p < 0.01 level (t = 3.04). Dividing

Larme's and my samples into women older and

younger than 40 reveals an even smaller risk of

reproductive loss for Chugurpampa's younger

women compared to Cuyo Cuyo's, suggesting

greater improvement in Chugurpampa's health over

time.

Finally, the workdays lost due to illness in

Chugurpampa, at 0.44 days per 2 weeks, are a frac-

tion of those lost in Nun oa, as seen in Table 5. The

lowest Carey found was 2.05 days in Nun oa town

and the highest, 3.25 days in Chillihua. While there

were no signicant dierences between any of

Carey's three sites, each of which is engaged in a

distinct mode of production, the dierence between

Chugurpampa and each Nun oa community was sig-

nicant at p < 0.001 (Sincata, t = 5.7; Nun oa,

t = 3.8; Chillihua, t = 6.6). All rates were based on

a 2 week recall period during the same season.

MODELING ALTERNATIVE EXPLANATIONS OF

DIVERSITY

Carey alerts us ``to be sensitive to the possibility

that subtle dierences within sociocultural systems

may have important health consequences'' (Carey,

1990, p. 278). How do the political-economic sys-

tem, sociocultural meanings and biological pro-

cesses generate the dierent patterns of illness? A

biocultural approach is necessary to identify the

combination of factors that might be accounting for

the dierences in health status indicators that are

shown above.

At the outset, I acknowledge that any compari-

son between communities can suer from unad-

justed demographic dierences, such as age

distribution or sex ratio. Since health conditions

change over time, the period in which data werecollected can also inuence comparisons, as

Leonard (1989) found with nutritional status in

Table 1. The highest ranked illness types and their frequencies by Andean community

Community

Cuy o Cuyo ( 19 88 ) Chugu rpa mpa (1 98 8) Sar agu ro ( 19 84 ) Mont ero ( 19 77)

Illness typeRespiratory (%) 26 40 22 20Musculoskeletal (%) 28 18 10 NAGastrointestinal (%) 18 14 18 26Altitude (m) 3600 3300 2500 lowlandZone South Peru North Peru South Ecuador BoliviaSource Larme (1993) Oths (1991) Finerman (1985) Frerichs et al. (1980)

Larme: Convenience sample of 10 households in each of two communities ( N= 107 individuals) chosen to represent a range of economicstrategies, income levels, household composition and stages in the domestic cycle. Symptom rates were collected by researcher throughrepeat illness follow-up interviews with household heads for 1 year.

Oths: Random sample of 32 households (approximately 20% of population) drawn from censused community. Researcher collected ill-nesses cases at 2 week intervals for 6 months for all family members from all household members present at time of interview.

Finerman: Sample of 140 women (approximately 3% of population) drawn from volunteers of 4 Saraguro communities who had com-pleted one or more successful pregnancies. Researcher had each woman complete a monthly health questionnaire on family's symp-toms for 1 year.

Frerichs: Household health survey of 605 randomly selected households (3372 individuals) in Montero region carried out by 6 nursesaliated with health services delivery demonstration project.

NA = data not available.

*The rank order correlations reported take the commu-nities as the unit of analysis.

Assessing variation in health status in the Andes 1019


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Table 2. Infant mortality rates for high-altitude andean peasant communities per 1000 live births

Site Rate Location Year Altitude Source

Saraguro 100 South Ecuador 1981 2500 Finerman (1985)Chugurpampa 31 North Peru 1988 3300 Oths (1991)Vicos 122 Central Peru 1952 2800 Alers (1965)Vicos 143 Central Peru 1963 2800 Alers (1965)Quinua district 124 South Peru 1955 3250 Mitchell (1991)Quinua district 54 South Peru 1985 3250 Mitchell (1991)Nun oa district 135 South Peru 195069 4000 Spector (1971)Nun oa district 129 South Peru 197584 4000 Carey (1988)Cuyo Cuyo 242 South Peru 198186 3600 Larme (1993)Belen 142 North Chile 1966 3200 Cruz-Coke et al.

(1966)Chapiquin a 130 North Chile 1966 3400 Cruz-Coke et al.

(1966)Hullatire 333 North Chile 1966 4300 Cruz-Coke et al.

(1966)

Ecuador 66 national 1987 all USDC (1987)Peru 90 national 1987 all USDC (1987)Bolivia 127 national 1987 all USDC (1987)

Chile 19 national 1987 all USDC (1987)

Finerman: Infant mortality rate was calculated in 1981 by researcher from birth histories of a subsample of 76 of the 140 women volun-teers selected for the symptom survey (see Table 1). The recall covered the years from 1931 to 1981 and deaths are counted only ifoccurring in the rst 6 months of life, in contrast to the standard method of using the rst 12 months. This results in an underestima-tion of the rate compared to the others in the table. On the other hand, due to the epidemiologic transition, the rate probably smoothout a dierence between a higher IMR in 1931 and a lower rate by 1981.

Oths: Calculated on health survey and census data of entire community conducted by researcher, which included current pregnancies.Pregnancies and births followed-up for 1 year through collaboration with village midwives, illness research, community surveillance,and monitoring of cemetery. Data was cross-checked through review of District birth and death records. Method helped avoid biasessuch as the ocial underreporting of births or deaths, especially of preterm or very young infants, as well as the misreporting ofbirths and deaths for communities in which they did not occur.

Alers: Rates based on records kept by Cornell-Peru Project and registry of Marcara District. The Project's two community censuses, in1952 and 1963, serve as baseline. This population study was the rst of its kind for the Andes.

Mitchell: Longitudinal data on births and deaths obtained by researcher for district of Quinua from municipal records, with total popu-lation derived from national census for closest years.

Spector: Rate based on civil registry birth and death records and national census data reviewed by various researchers from years 1950through 1969 for Nunoa district. Mean for period presented, with range of 83 to 237.

Carey: Mortality rate generated from longitudinal data on births and deaths obtained by research team for district of Nun oa from mu-

nicipal records, with total population derived from national census. Mean for period presented, with range of 104 to 186.Larme: Infant mortality was calculated by researcher from Cuyo Cuyo birth and death records, Ministry of Health epidemiologic data in

Puno, and review of local health post records. Average for 19811986 period presented.Cruz-Coke: Demographic surveys of communities' inhabitants (sampling method not specied) and review of civil registry records by

researchers and health team.US Department of Commerce: Large-scale, systematically sampled government survey.

Table 3. Crude death rates for high altitude andean communities per 1000 population

Site Rate Location Year Altitude Source

Chugurpampa 6 North Peru 1988 3300 Oths (1991)Vicos 15 Central Peru 1952 2800 Alers (1965)Vicos 25 Central Peru 1963 2800 Alers (1965)Quinua district 18 South Peru 1960 3250 Mitchell (1991)

Quinua district 15 South Peru 1980 3250 Mitchell (1991)Nun oa district 20 South Peru 195069 4000 Spector (1971)Nun oa district 15 South Peru 197584 4000 Carey (1988)Cuyo Cuyo 27 South Peru 1981 3600 Larme (1993)

Belen district21 North Chile 1965 3200 Cruz-Coke et al.

(1966)

Lauca district50 North Chile 1965 4300 Cruz-Coke et al.

(1966)

Ecuador 8 national 1987 all USDC (1987)Peru 9 national 1987 all USDC (1987)Bolivia 14 national 1987 all USDC (1987)Chile 6 national 1987 all USDC (1987)

Oths: See Table 2. Sex and age adjusted rate does not dier from crude rate.Alers: See Table 2.Mitchell: See Table 2.

Spector: See Table 2. Rate is sex and age adjusted. Mean for period presented, with range of 14 to 33.Carey: See Table 2. Rate is sex and age adjusted. Mean for period presented, with range of 11 to 18.Larme: See Table 2.Cruz-Coke: Rate for each community based on data extracted from civil registry records by researchers and assisting health team.

K. S. Oths1020


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Nun oa. This acknowledged, I now turn my atten-tion towards other factors of anthropological inter-

est that might be systematically generating the

observed health status dierences between commu-

nities.

The model depicted in Fig. 1 is divided into 2

major parts, microrisk and macrorisk factors, fol-

lowing the distinction Brown (1987) makes between

micro- and macroparasites. Though the distinction

is somewhat articial, it helps to dierentiate

between stresses produced at the local level and

those produced in exogenous arenas of power. Of

course, there can be interactions between any two

or more factors regardless of their levels. The

model takes into account aggregate-level factorsthat can distinguish between one community and

another. These factors are hypothesized to aect

community health either directly or indirectly.

The microrisk portion of the model is subdivided

into ecological considerations and socio-cultural

factors. Ecological risks result from environmental

factors that, through their action on the human

organism, produce physiological conditions that are

potentially stressful. Andean zones are customarily

demarcated longitudinally as being north, central or

south and latitudinally as the east or west escarp-

ment or central puna (high plains). Each zone has

its own general climatic and cultural characteristics,

with further distinctions within each zone (micro-niches and ethnicities). There are two ways of

thinking about altitude. One is in absolute meters

above sea level, which gives an indication of oxygen

pressure and UV radiation. Another is the altitude

of a community relative to other communities sur-

rounding it. Climate, measured in terms of humid-

ity, temperature and wind, may vary diurnally,

seasonally and by ecological microniche between, as

well as within, places in the Andes. UV radiation

increases directly with altitude and well as nearness

to the Equator. Barometric pressure drops with

increasing altitude; the lower the pressure, the

higher the risk of mountain sickness and other

severe physiologic problems characterized byedema, fatigue and dizziness.

The sociocultural microrisk factors merit some

explanation as well. Settlement patterns when dis-

persed tend to be more sanitary, whereas nucleated

villages tend to put dwellers in close contact with

human and animal waste. While the general consen-

sus is that health problems in a family increase with

the density of household occupation, the other

extreme, living alone, also puts one at high risk

in a labor intensive agriculture-based economy.

Demographic distributions, such as age (for depen-

dency ratio), sex (for gender ratio) and education

levels should also be considered. The primary mode

Table 5. Adult workdays lost due to illness by Andean community

Site

Chugurpampa Nun oa district

Sincata Nun oa town Chillihua

N 90 18 47 18Mean (SD) 0.44 (0.54) 3.22 (4.52) 2.05 (3.99) 3.25 (3.90)Year 1988 1984Source Oths Carey (1990)

Oths: See Table 1. My workdays lost are comparable to those of Carey's third phase of research in that our denitions are similar andour data is gathered from the same late year season (July to mid-December and August through October, respectively). As little vari-ation exists in workdays lost across the study period, I averaged my data collected over 10 two-week recall periods so as to be consist-ent with Carey's two-week recall period.

Carey: See Table 4. Sample sizes, as they are for the 3rd phase of Carey's research, exhibit some loss to follow up. Data obtained, how-ever, are comparable to the initial phase, in which the three household sample sizes were 90% (of 117) 8% (of 483) and 100% (of127), respectively.

Statistical signicance (2-tailed): Chug-Sincata p < 0.001, Ch ug-Nun oa p < 0.001, Chug-Chillihua p < 0.001.

Table 4. Maternal reproductive loss among Andean communities

Site

Cuyo Cuyo Nun oa district

Chugurpampa Ura Ayllu Puna Aylllu Sincata Nun oa town Chillihua

N (individuals) 180 10 10 21 47 18Mean (SD) 18.5% (19.4) 30.1% (32.1) 35.4% (17.3) 20.9% (19.5) 20.9% (24.8) 22.8% (27.3)Women 40+ 26.5% 36.3% 46.5% NAWomen


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of production in Andean settlements is usually one

or a combination of the following: agriculture,herding, wage labor and mining. Each brings its

own host of related health problems, the latter two

modes more likely to produce the worst health

rates. Wealth is a variable that may also be viewed

in absolute or relative terms, depending on whether

the comparison is with other local communities,

other peasant regions or the nation as a whole. The

degree of equity in distribution of the land base is a

critical factor determining the health of peasant

communities. Community cohesion may be measured

by, among other things, the degree of stability of

residence and the size of kinship networks. Some

communities have abandoned traditional work

arrangements based on social networks, such as

labor exchange, while in others these arrangements

are quite viable. Social stratication varies from one

Andean community to the next. For instance, a

higher ratio of mestizos to indigenous people is

often related to inequalities for the latter, such as

restricted access to health care (see Crandon, 1983).

Wide variation in gender relations is reported

throughout the Andes, with male dominance and/or

preference found in some places while not in others.

Finally, certain regions possess greater traditional

medical resources than others, thereby increasing

options with which to maintain or restore highlan-

ders' health.On the macrorisk side, political-economic pro-

cesses and historical antecedents may also have a

bearing on modern day health status. One political-

economic dimension, market participation, refers tothe extent to which peasants production is oriented

to the satisfaction of needs exogenous to the local

community, in contrast to production for subsis-

tence. The more a community participates in the

former, the more economically vulnerable it is to

the vagaries of world markets. A corollary of mar-

ket participation is market penetration, or the

quantity of externally produced goods purchased by

peasants. These include foods, pesticides, clothing,

medicines and luxury items, among other things

goods which may increase dependency or lead to

unwise investment of limited cash resources. Labor

relations refers to the work arrangements between

kin groups; producer, middlemen and buyer; or

employer and employee. The degree of exploitative

relations, e.g. sharecropping, in a community is a

good indicator of its degree of social stability and

stratication. The political stability in a region

depends upon the integrity of local political insti-

tutions and the integration of the area into national

politics, as well as the amount of competition for

power in an area (e.g. guerrilla insurgency). The

availability (in terms of distance and cost) of state-

provided and private biomedical services may aect

morbidity and mortality levels, especially for serious

conditions such as acute respiratory illness.

The degree of historical as well as present daySpanish inuence in an area can determine among

other things its economy, language, political organ-

Fig. 1. Model for systematizing diversity among Andean communities.

K. S. Oths1022


7/14

ization, religious inuence and other customs. Land

reform has not been carried out evenly throughout

the Andes. As a result several types of community

organization currently exist in the Andes, such asthe hacienda, free peasant community, private prop-

erty, state-run cooperative and mining camp.

Hacienda workers and miners characteristically

exhibit the worst health, while cooperative members

(Leatherman, 1994) appear to fare the best.

Agricultural communities that have not benetted

from land reform are also at increased risk for ill

health (Leatherman, 1994; Luerssen, 1994).

In the center of the model are listed some key

risk mediators of special interest to international

health workers which may modify health outcomes.

These modiers, including water quality, sanitation,

diet and medical treatment, result from the conu-ence of the antecedent micro- and macrorisk fac-

tors. Diet, for instance, might be poor at the

community level under the following conditions:

land is scarce and distributed poorly, men migrate

to the coast for wage labor, and women are left to

shoulder typical men's roles, such as plowing.

Health outcomes, then, can be viewed as a pro-

duct of, or dependent on, the micro and macrorisk

factors and key risk mediators which obtain in any

given community. While this model cannot yet be

tested completely with data from Andean commu-

nities, it may prove helpful in framing appropriate

questions to ask in the search for explanationsabout health diversity.

Initial comparisons across communities could be

made eciently with an ecological model; besides

making comparative research easier, the model

could help national and international health

agencies identify those communities with the great-

est need for health intervention programs. Later,

large-scale research could t a model for multi-level

analyses using data from both a large number of

communities as well as a random sample of individ-

uals within each of those communities. Such a con-

textual model could then look at the eect of an

aggregate measure, say community cohesion, on thehealth of individuals, of the entire community or

the interaction between variables at both levels

(Sampson, 1991).

APPLYING THE MODEL TO A COMMUNITY EXAMPLE

Infant mortality

The utility of this model can be illustrated usingthe indicators of health status already presented.

For instance, one health outcome that can be exam-

ined with this model is infant mortality and some

of its known risk mediators. Infant mortality is a

sensitive measure of the overall health of the com-

munity. In Chugurpampa, potable water is available

from capped and free owing springs, in contrast to

that from rivers, gutters and irrigation ditches

reported in many places. Ecologically,

Chugurpampa is located on a hilltop at an altitude

high not only in absolute terms but relative to

neighboring villages, i.e. they are not downstream

from anyone. Politically, community leaders' asser-

tiveness has aided in getting PROJECT CARE as-

sistance to cap their reservoir and provide piping to

part of the community. Community cohesion has

been essential to initially build and then maintain

the reservoir and piped water system through the

collection of user fees and communal labor.

Infant diarrhea, often the result of fecal contami-

nation, is a leading cause of infant mortality

worldwide. Adequate sanitary conditions in

Chugurpampa follow from its dispersed and low

density community settlement pattern, which allows

for elimination and garbage disposal at a distance

from the home. This contrasts sharply with that of

nucleated, low density villages or nucleated highdensity towns where, for privacy, elimination

usually takes place near or within the house com-

pound, increasing chances of human contamination.

Childhood infectious diseases often lead to early

mortality. With few exceptions, low rates of infec-

tious bacterial and parasitic diseases are reported

throughout the high Andes. Buck et al. (1968) meti-

culously demonstrated this with their Andean

research of nearly 30 years ago. This is due in part

to UV radiation, cold temperatures and low air

pressure which inhibit the growth of infectious dis-

ease agents (Heath and Williams, 1989; Ward,

1989).

Immunization coverage of children ve and

under in Chugurpampa reached 60% complete cov-

erage for measles and polio and DPT series (an ad-

ditional 16% lacked only one of the total required

doses)*. Peruvian national averages for full cover-

age for the same time period were 43% for urban

areas and 10% for rural areas (Instituto Nacional

de Estadistica, 1986, p. 64). The hamlet relies heav-

ily on the active representation and commitment by

the Ministry of Health, the international aid project

and community leaders all of whom organize and

promote the vaccination campaigns at the commu-

nity level.

In reference to diet, Chugurpampans, in a fertilenorthern zone, appear to produce and consume

adequate calories to sustain healthy life. Children's

*For several weeks before beginning eldwork inChugurpampa, I assisted with the vaccination drivethroughout the district, visiting dozens of communities.This allowed me to familiarize myself with local vacci-nation routines and record keeping procedures. TheChugurpampa rate is drawn from my review of chil-dren's vaccination cards as part of the census. Thesecards are well-guarded by parents, as school admissionis dependent upon proof of full coverage. Incidentally,local health ocials overestimated the actual rate of

coverage by about 20%. For more detail on vaccinesgiven and the percent covered at each year of age, seeOths (1991, p. 187).



8/14

height and weight, infant growth curves, daily ob-

servation of household consumption patterns and

the highlander's own perceptions (see vignette

below) corroborate this. The children ve andunder in my study sample (N= 39) compared

favorably with the Peruvian National averages for

the northern rural sierra, with 40% of

Chugurpampans height-for-age less than 2 standard

deviations (SD) below the median compared to

67% for the national sample and 24% of their

weight-for-age below 2SDs compared to 29% over-

all (Instituto Nacional de Estadistica, 1986). Infant

growth curves, while remaining in the lowest per-

centiles, showed steady progress for all 8 children

under one year old in the study*. The quality of

diet cannot be divorced from a general discussion

of labor relations, access to land and fair marketprices (Leonard et al., 1990). Leonard et al. (1990)

note that the stature of Nun oan children is among

the lowest in the Andes, which they attribute to

poor nutrition, again conrming the notion of inter-

regional diversity. For a Nun oan town, peasant

community and cooperative alike, Leatherman

(1994) found rates of at-risk children based on

height-for-age that ranged from 54 to 73%, all

exceeding Chugurpampa's rate{.

Furthermore, environmentally, in the Northern

Peruvian Andes the cold temperature, while con-

stant, is less severe than in the Central and

Southern portions. In Chugurpampa, diurnal tem-

perature uctuations are less drastic, frost is rare

and snow unknown. Frigid temperatures in other

parts of the Andes are associated with higher infant

mortality rates.

Cultural practices which can contribute to high

infant mortality are found in some areas of the

Andes. de Meer et al. (1993) in Peru and McKee

(1984) and Scrimshaw (1978) in Ecuador, found

male gender preference, early weaning of females

and female infanticide. There was no evidence of

these practices in Chugurpampa. While Scrimshaw

reports a sex-ratio imbalance of 68 males to 32

females for the rst child born (Scrimshaw, 1978, p.

389), implying infant neglect of rst-born females,rst-born females slightly outnumbered males in

Chugurpampa.

Loss of function and morbidity

Measures of function and morbidity are more

subjective than mortality rates. Still, striking dier-

ences occur in the total number of workdays lost

between Chugurpampa and Nun oa. Here, not

simply morbidity, but the incentive to work or not

work must be considered in arriving at an adequate

explanation. Are households in a particular commu-

nity employed in wage labor, in a cooperative, or

independently in cooperation within kin networks?

What is the marginal utility of a day of work for a

peasant who is sick and might otherwise be recuper-

ating? Labor relations and land ownership are im-

portant here. In Carey's study, the peasant villagers

of Sincata experienced 40% more symptoms on

average than in Chillihua, a cooperative, yet their

``workdays missed'' relative to their symptoms wasnearly 1/3 lower. In Sincata, as in Chugurpampa,

independent peasants receive no secondary gains

from missing work. Every day missed just means

that much more work to do when they return

(Leatherman (1992) concurs on this point).

Women's health appears to be quite directly re-

lated to the parity of gender roles, which in turn

are highly conditioned by the mode of production.

In Cuyo Cuyo, where women were left alone to run

the household due to men's migration to the mines,

they suered a noticeable health burden (Larme,

1993; Luerssen, 1994). Inevitably, the health of the

entire family suers when the head female of thehousehold suers.

The drier, desert conditions of the northern

Peruvian Andes may be implicated in the high num-

ber of respiratory conditions in Chugurpampa (see

Table 1). The aridity and low absolute humidity in

this region cause rapid dehydration in humans,

which contributes to respiratory and g.i. ailments.

Ventilation and sweating with exertion compounds

the eect (Heath and Williams, 1989; Ward, 1989).

Diurnal temperature uctuations contribute to res-

piratory, musculoskeletal and g.i. illness (Ward,

1989). In Chugurpampa, highs average around 708F

and lows around freezing.

In Chugurpampa, the association between muscu-loskeletal problems, economic strategy and labor re-

lations is clear. It is characteristic of peasant

populations that food production be directed by the

politically dominant, coastal elite. In the northern

Peruvian Andes, agricultural production of potatoes

for the market nds the highlanders caught in a

vicious cycle of spiraling costs of petrochemical pro-

ducts and deating market prices, thus necessitating

ever-increasing production to stay ahead (also see

Mitchell, 1991){.

Potato agriculture requires constant stooping and

the lifting, carrying and swinging of sharp tools and

heavy loads, usually 100150 lb at a time. Duringharvest in Chugurpampa, for example, old and

young, men, women and children alike, may typi-

*WHO (1983) measurements of medians and standard de-viations were used for assessing height and weight.One infant's growth curve was at for 1 month due toillness, but recouped the growth in the followingmonths. Some of the repeat measures of infant datawere lost as a consequence of political unrest.Therefore, my recall does not permit more precisedetails.

{The percentage of children 2SDs below the medianfor height- and weight-for-age in the southern ruralsierra are 67 and 22%, respectively (Instituto Nacional

de Estadistica, 1986).{Ination on government agricultural loans to peasants

was 70% for 1988.

K. S. Oths1024


9/14

cally transport up to one ton of sacked potatoes per

day. The result of such arduous labor with little

respite under harsh climatic conditions is a high

incidence of physical degenerative illness such asmusculoskeletal aches, pains, strains, injuries,

lacerations, arthritis and kidney problems.

What cannot yet be determined, but could be

articulated by using the proposed model of diver-

sity, is the extent to which musculoskeletal com-

plaints are associated with (1) the degree of

exploitative labor relations found in dierent com-

munities and (2) the degree to which the eects of

exploitation are modied by other resources within

the community.

Historically speaking, the CajamarcaLa

LibertadSan Martin corridor in which

Chugurpampa resides was more heavily occupiedby the early colonizers than other areas of the

Andes. This early Spanish inuence has resulted in

the virtual loss of the Quechua language, traditional

dress, and native species of camelid, a point which

Brush (1977) corroborates*. Thus, lacking llamas

and with burros being expensive, people have

become accustomed to carrying heavy weight on

their own backs, with obvious musculoskeletal

health eects. Chugurpampans own fewer pack ani-

mals than peasants in certain other Andean areas:

with 14% of households owning horses or mules

(0.2 per household) and 56% owning burros (1.0

per household), Chugurpampa fares more favorably

than Vicos (Alers, 1965, p. 445) or Ura Ayllu(Bullard, 1990), but less so than Quinoa (Mitchell,

1991, p. 60) or Puna Ayllu (Bullard, 1990). Data of

Figueroa (1982, p. 135) show the great variability in

animal ownership among eight communities in the

southern sierra of Peru.

The heavy use of pesticides should not be over-

looked as another potential agriculture-related con-

tributor to the categories of respiratory (through

inhalation) and gastrointestinal (through consump-

tion) illness (see Bull, 1982, p. 37). Pesticides are

commonly used, despite their high cost, due to their

promotion by agricultural agents and the eventual

dependency on the product after several years ofuse (Mitchell, 1991, p. 108, 212; Hamilton, 1994).

Additionally, musculoskeletal and respiratory

problems are a near inevitable outcome of mine

labor. Nash (1979) among others has documented

the abysmal conditions of industrial mining in the

Andes. The amount of mining activity in each com-

munity correlates with musculoskeletal illness.

Referencing Table 1 again, Cuyo Cuyo has the

highest percentage of musculoskeletal complaints at

28%, Chugurpampa is next at 18% and Saraguro

has only 10%. The communities of Cuyo Cuyo

viewed their principal work to be migrant gold

mining and, probably not coincidentally, had corre-spondingly poorer health status than most commu-

nities. Larme showed this as due not only to the

physical cost of mining, but also to the social disor-

ganization and increased workload on women pro-

duced by the absence of males from the

community. The four ex-silver miners in the

Chugurpampa sample (11% of adult men) were

also the sickest persons. Finerman relates no mining

activity in Saraguro.

The intra-Andean diversity of general community

level factors such as social stratication and wealth

can also be examined. It might be instructive not

only to gauge the overall degree of social stratica-

tion within a community, and the relative wealth of

households, but also the wealth of one community

vis-a-vis another. Ethnicity and wealth may be

highly correlated within a region but not always

across regions, as Crandon-Malamud (1991) has

shown for the highland Bolivian mestizos and

Aymara after the 1952 revolution. Although in my

unstratied community of indigenous peasants

(there were no mestizos) there was dierentiation in

socio-economic standing, it appears from the sket-

chy absolute indicators of wealth available (such as

hectares of land, number of animals, cash income,

etc.) that the poor in Chugurpampa are less poor

than those of other regions. For instance, a mini-mum of 3.5 hectares is considered necessary for ade-

quate household production in the highlands (Deere

and de Janvry, 1979, p. 604). The mean of 5.8 hec-

tares of arable land per Chugurpampan household

exceeds other published gures for peasant commu-

nities: 4.5 in Cajamarca (Deere and de Janvry,

1979), 2.9 in the Latacunga-Ambato region of

Ecuador (Hamilton, 1994), 1.6 in Uchumarca, San

Martin (Brush, 1977, p. 86), 0.8 in Soqa, Puno

(Lewellen, 1978, p. 187), no more than 0.5 in

Quinoa, Ayacucho (Mitchell, 1991, p. 56) and from

0.4 to 1.8 among various communities in the district

of Moho, Puno (Collins, 1988, p. 100). This fact, of

course, is tied directly to several micro- and macro-

risk factors, such as land reform, soil depletion,

mode of subsistence, labor relations, market entry,

etc. Regarding landlessness, in Chugurpampa, while

16% held land rights to 1 (or, equally, 0.5) hectare

or less, only 3% were without access to land by

other means (tenancy, rental, etc.). This degree of

landlessness is similar to what Deere and de Janvry

(1979) has recorded for Cajamarca, where 13%

have 0.25 or fewer hectares and much less than

cited for other communities in southern Peru: 29

and 54% have less than 1 hectare in the Tambopata

Valley, Puno, and Andarapa, Ayacucho, respect-

ively (Collins, 1988, p. 161; Sanchez, 1982, p. 163)and 59% have less than 0.5 in Soqa, Puno

(Lewellen, 1978, p. 42). The relationship within a

*Alers (1965) notes that in 1951, of those persons seven orolder in Vicos, Ancash, the department that bordersLa Libertad to the south, 98% spoke no Spanish. No

Chugurpampans could recollect anyone ever havingspoken Quechua, though remnant words remain intheir Spanish.



10/14

community between lower wealth, based on indi-

cators such as land, and poorer health, as measured

by nutritional status and workdays lost, has been

quantied by Leonard (1989) and Luerssen (1994).While this discussion has been speculative, the

observed health dierences among Andean commu-

nities appear to be generated out of the unique con-

uence of ecological factors, local meaning and

political-economic and historical processes which

combine to shape systematic intra-Andean diversity.

Because of the tremendous diversity that exists in

the Andes, it is clear that health research must rest

upon a solid ethnographic foundation.

IMPLICATIONS FOR HEALTH PROGRAMS

How does the foregoing apply to national and in-ternational health programs? I relate the following

anecdote to illustrate the necessity of understanding

the extent to which there is local variation in health

and illness throughout the Andean regions:

The setting is Chugurpampa, a large peasant

community in the northern highlands of Peru, at a

meeting of the newly formed Club de Madres

(mother's club). A festive luncheon awaits the repre-

sentatives of the internationally funded health and

nutrition project that sponsors the club: the fare

consists of soup, potatoes, beans, guinea pig, corn,

hot pepper sauce, salad and beverages. The under-

lying emphasis of the health project is child survi-

val; the goal is to eliminate infant mortality and

childhood malnutrition by re-educating mothers.

The rst comments to be heard from the arriving

nurses and nutritionists are ``me muero de hambre''

(I'm dying of hunger). After the lling lunch, the

mothers are invited to gather in a vacant classroom

to listen to lectures on nutrition, infant feeding and

the basic food groups; in short, to teach Andean

mothers how to cook and feed their families. Later

that week, several women express that they are

quitting the Club de Madres.

Applied health care personnel are not interested

in nor capable of solving the root causes of exploi-

tation and hunger, such as an inequitable distri-bution of land or exploitative market prices. But

they need to know the type and extent of actual

health problems that exist before they can begin to

redress them. It would be benecial for inter-

national health agents to perform a rapid assess-

ment and scoring of the micro- and macrorisk

factors of several potential recipient communities in

the area in which they wish to work. In addition to

identifying the greatest perceived health problems

of a community, the model aords a reasonable in-

dication of the general health of the community,

which could help them target those communitieswith the greatest health decits.

Scrimshaw and Hurtado (1987) have pioneered

the rapid assessment procedure and others have

adapted the idea to specic illnesses or ethnographic

uses. A rst attempt to develop a usable instrument,

based on the foregoing evidence, appears in Table 6.

While the checklist is by no means all-inclusive and

will hopefully undergo renements if eld testing

proves it useful, the operationalization of many key

community factors contributing to health that it

provides is designed to be applicable by health and

social science professionals. The rst section can be

completed with a brief visit to the community, with

the second part (or any portion thereof) obtainable

within a 1 to 2 day stay in the community. For an

even quicker assessment, in lieu of assigning absol-

ute values on items, an alternative coding scheme

would be to rank all villages under consideration

for each item; again one would represent the best

and the highest number the worst, condition.

Disregarding the diversity in the Andes and fail-

ing to perceive the relevant local cultural, material

and environmental conditions can lead to inap-

propriate interventions, the likes of which I wit-

nessed during my stay in Chugurpampa. Now, the

problem of program inappropriateness has plagued

international aid eorts since their inception (Paul,1955). This Andean case illustrates just one of the

``generic problems'' Jordan (1993, p. 175) identied

that can cause health intervention eorts to fail: the

inappropriateness of contentin this case writ

large*. My critique regards the assumption that a

model paradigm of child survival, popular since the

1980's, is inherently applicable everywhere there are

poor people. With this paradigm, topics such as

infant diarrhea, oral rehydration therapy, infant

mortality, nutrition and breast-feeding receive

major attention regardless of actual local conditions

(for review, see WHO, 1986; Scheper-Hughes, 1987;

UNICEF, 1989; Mosley et al., 1990; Nightingale et

al., 1990; Nichter and Kendall, 1991).

Health care workers made assumptions about

Chugurpampa's overall health based on national

and regional statistics, gearing their eorts toward

children and ignoring adult morbidity and mor-

tality. Unfortunately, this led to the failure of their

program, depicted in the vignette. They deigned to

teach their mother-hosts how to cook for and rear

their already healthy hamlet children. Interventions

were geared toward particular illnesses (diarrhea,

malnutrition) that were assumed to be causing high

infant and childhood mortality. That was not the

case. The result was much eort wasted on introdu-

cing well-meaning programs that were meaning-lessto the people they were intended to serve. There

were two other such examples of child survival

*Jordan also notes the ``multiple agendas'' of aid pro-grams which can include the political aim of imposingpower and authority on a marginalized people throughthe guise of superior knowledge (Jordan, 1993, p. 169).

While this paper seeks to make a dierent point, herobservation certainly applies to the Andean context aswell.

K. S. Oths1026


11/14

Table 6. Checklist for rapid assessment of relative need for intervention in Andean peasant communities. For rating two or more villages.The highest score indicates the greatest potential for health problems. Community name: ( F F F)

Table 6continued overleaf



12/14

strategies the agency employed concurrently with

the Mother's Club in Chugurpampa: a Community

Garden (Huerto Comunal) and a Height and

Weight Monitoring of Children (Control de Peso de

Nin os Infantiles). I will briey detail the case of the

garden.

On the instigation of the international aid agency

working in Chugurpampa, a community garden was

planted near the school to provide for hot school

lunches. Mothers were to come on a rotating basis

to prepare the food. The implication was that chil-dren were malnourished in their own home and

thus inattentive during the school day. Ironically,

community mothers ended up supplementing the

meager garden produce from their own larders.

A common belief of the international aid commu-

nity, that children's inattentiveness in primary

school is a result of poor nutrition at home, served

as the rationale for this project. On the contrary, by

the reckoning of Chugurpampa mothers, it is pre-

cisely a young child's presence in school that can

cause sickliness, debility and weight loss. Day-long

school attendance curtails the young ones' habit of

constant snacking between meals to fulll high-alti-tude high-carbohydrate energy needs (Ward, 1989).

Consistent with the mother's belief, the school aged

children in my sample accounted for nearly two-

thirds of those who exhibited nutritional stress.

The aid programs met with reactions ranging

from mild amusement or consternation to suspicion,

defensiveness and anger. Locals simply viewed the

program aims as irrelevant. Instead of a participa-

tory spirit, a distrust of aid workers was instilled in

the community members, certain to disadvantage

future intervention eorts.

Involvement of Chugurpampans in the identi-

cation and denition of health problems which needto be addressed would result in a list of problems

very distinct from that produced by the Ministry of

Health and foreign aid agencies. People really want

advice and therapy for their most prevalent and

intractable problems such as respiratory, musculos-

keletal, stomach and dental ailments (see Oths,

1996). Infant and childhood illnesses certainly are

not isolated as the only, or even the major, health

risks which face these highlanders on a daily basis.

It should be noted that in other contexts, there

might be dierent but equally compelling reasons

that the poor resist well-intended child health pro-

grams. Elsewhere, where high morbidity and mor-tality are viewed as `normal', the ` apathetic

response to programs attempting to improve the

6Use WHO (1983) standards.

Table 6continued

K. S. Oths1028


13/14

health of children may have a valid underlying (but

unconscious) purpose'' as a strategy to control

family size where resources are scarce (Scrimshaw,

1978, p. 393).

CONCLUSION

The international health community alone should

not be faulted for assuming a homogeneity of

health problems within developing countries. Social

science in general, and anthropology in particular,

has not paid enough attention to intracultural or

intrasocietal diversity. The explanatory sketch pre-

sented in this paper has been intended to suggest

the importance of going beyond models that, at

best, examine intracommunity dierences to the

development of models that incorporate intercom-munity dierences as well.

In epidemiology, there is a perspective developing

for ``contextual'' or ``multi-level'' models (Von

Kor et al., 1992). Here, in essence, the community

has been the unit of analysis. Because I have largely

worked from published sources I have not been

able to examine how intracommunity dierences in,

for example, wealth might have dierent impli-

cations for health status depending on the overall

level of wealth of that community (i.e. what the

health implications are of being poor in a poor

community versus poor in a wealthy community).

Multi-level analyses can address these issues. The

model and rapid assessment checklist are oered asan on-the-ground tool for health care deliverers. A

systematic program of research designed to examine

diversity in health status in the Andes, using a

multi-level methodological strategy, would help to

answer many of the questions raised in this paper,

and to point the way to the more rational allo-

cation of helping resources. Ultimately, it is up to

us, as social scientists, to appreciate, describe and

explain the diversity in health found within the

Andean landscape.

AcknowledgementsThis work was funded by grants from

the National Science Foundation (No. 8813774) and theInter-American Foundation (No. F1-135-A1). I am grate-ful to William W. Dressler and several anonymousreviewers for invaluable comments on earlier drafts. Also,I wish to acknowledge the aid and support of my eld as-sistants, Amable Burgos and Genaro Aguilar and theTrujillo-based PRAS project, without whom this workwould not have been possible.

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