By Barbara Fraser
The Lancet
Copyright 2006
Underfunded and underequipped, Peruvian health workers make do with what they have to deliver services to indigenous communities deep in the Amazonian jungle. But with some villages several days away from health services, reaching them is no easy task. Barbara Fraser reports.
When the roosters begin to crow and riverboat motors grumble to life on the muddy Corrientes River, Gaspar Zamora Ramírez can never be sure what the day will bring to his tiny clinic in this jungle town. It could be typhoid fever, tuberculosis, yellow fever, a poisonous snake bite, or a child with an illness brought on by an enemy’s curse.
Whatever it is, Zamora and his staff of five nurse technicians, a nurse, and an obstetrician must handle it with a limited stock of medicines, basic laboratory equipment, and a large dose of ingenuity. In the vast Peruvian Amazon, chronically under-funded Health Ministry workers battle distance, loneliness, language barriers, and lack of equipment and emergency services.
In this mestizo village of about 2000, the closest thing to an ambulance-indeed the only motor vehicle-is a motorised tricycle. The nearest hospital is in Iquitos, the departmental capital, a 2-day trip by riverboat.
The spartan but spotless Villa Trompeteros health centre operates around the clock. On one wall is a map of the area for which he is responsible. About 7800 people live in dozens of communities scattered along the rivers that snake southward from the Ecuadorian border. Three communities have health posts staffed by one or two nurse technicians. The most distant is 4 days away by riverboat. The system relies heavily on doctors who are assigned to work in the region as part of a year of public service required of graduating medical students.
When a case of yellow fever was confirmed this summer near the village of Pampa Hermosa, Zamora headed upriver with a stock of vaccine. Because there is no electricity-and therefore no refrigeration-in the villages, Zamora can usually do only 2-day vaccination campaigns before he must return to Trompeteros for a fresh stock of vaccine and ice. To handle the yellow fever outbreak, however, he hauled his backup generator to the health post in Pampa Hermosa.
Most of the people along the Corrientes River are Achuar, and women and small children speak only their native language. Because indigenous women are the group least likely to use health-care services, partly because of the language barrier and partly because of a reluctance to be examined by male doctors or nurses, lowering maternal and infant mortality and morbidity is a constant challenge.
Although such cultural differences often prove to be the greatest challenges young doctors and nurses face when they are assigned to remote jungle areas, they receive little or no cultural training in school. Instead, they learn on the job, says Mario Tavera Salazar, health officer for UNICEF in Peru, “and they learn very well”. But, he adds, “They’re always looking for a way to get out of there.”
Zamora has adapted to the remoteness of Villa Trompeteros, but he speaks wistfully of classmates who are doing advanced studies and plans to ask for a transfer as soon as he is eligible.
Others find it harder to leave. José Baca asked for an assignment in the Amazon soon after graduation-"I liked Tarzan movies and thought that’s what the jungle was like”, he says. When he arrived at his post near the Brazilian border, he was afraid he had made a serious mistake. He changed his mind in the morning. “I bought a pair of rubber boots and went to work”, he says, making 2-week journeys by river to visit communities.
Baca, who learned the language of the local Matsés people and gained an appreciation of their culture, now coordinates the regional health strategy for indigenous people in Loreto. The regional strategy is part of a national effort aimed at addressing infant mortality, overall mortality, malnutrition, and emerging and re-emerging diseases such as malaria, yellow fever, and hepatitis B, with an emphasis on respect for indigenous cultures.
In addition, as part of this national initiative, a series of studies known as the Health Situation Analysis (ASIS) is taking a closer look at the intercultural aspects of health care in each ethnic group. So far, seven analyses have been drafted by representatives of indigenous communities and teams that include Health Ministry personnel, anthropologists, and lawyers specialising in indigenous affairs.
Because Health Ministry statistics have traditionally been broken down geographically but not by ethnic group, “indigenous people were practically invisible”, says Melvy Ormaeche, coordinator of the Ministry’s Technical Unit for Indigenous Peoples of the Amazon. “The official view does not take into account the world view of these populations. The novelty of the ASIS is that it incorporates their vision.”
Where a doctor sees a child with bronchitis, the parents may see a curse laid by an enemy, she says. They may try traditional remedies first, turning to the health centre only when those fail-and leading the doctor to berate them for irresponsibly delaying treatment. “There’s a huge gap in interpretation”, Ormaeche says.
Across the river from Villa Trompeteros, a community health worker in the town of San Cristóbal, Fidel Sandi Hualinga is the first line of health defence for about 30 Achuar families. He provides first aid, gives advice on nutrition and hygiene, and reports to Zamora every month.
He and the other villagers live in a cluster of open-sided, raised-platform, palm-thatched houses. To eat, the villagers gather food from the jungle, fish, and raise cassava on small plots of land. Sandi worries about the village children, who he says are “getting skinny from malnutrition”.
Streams and ponds have been polluted from petroleum production on the community’s lands, however. A study done in 2005 found raised blood lead concentrations in 66 of children and adolescents under 17 years old in villages along the Corrientes River and high cadmium concentrations in 98·6. “With the levels (of metals) we’ve found, there won’t be deaths, but it means having a population with lower development levels and poor reflexes. It means condemning them to a subhuman existence”, Baca says.
Although health officials also suspect the pollution is to blame, they say more studies are needed because the symptoms overlap those of chronic malnutrition.
The villagers have asked PlusPetrol, the Argentine company operating on their land, to drill a well for drinking water, but have not yet received an answer. Meanwhile, they use river water for drinking, washing, and cooking. And they turn to the company for airlifts of medical emergencies-an irony not lost on residents or health-care personnel.
Loreto’s Regional Health Office has worked with other government agencies and the Federation of Native Communities of the Corrientes River to draft a 10-year plan to improve health and environmental monitoring and nutrition, provide safe drinking water, reinforce existing services, and encourage increased community participation in health care.
The first hurdle is economic. The projected budget is nearly US500000 the first year, just under 2 million the second year, and about 1 million a year thereafter. “Those are amounts that the health sector doesn’t have”, Baca says.
Besides more and better-equipped health centres in remote jungle communities, there is a need for incentives to encourage professionals to work in those areas.
More indigenous health workers also need to be recruited, not only because they understand the local culture, but also because they are more likely to work in their home communities. But recruiting and training indigenous students has proven difficult because the education in their home village does not prepare them to compete in urban universities. Nelson Kuji, an Aguajún, did not make the cut for medical school but was accepted into the nursing programme at the National University of the Peruvian Amazon in Iquitos, 6 days by riverboat from his village on the Marañón River. “We come to the city and it’s a different kind of education”, he says. “We don’t know how to use a computer; we know nothing about the Internet.”
A special course of study should be designed for indigenous students, says Tavera, and the health services be redesigned to emphasise prevention and take into account indigenous customs and traditional health-care practices. Ormaeche agrees, “Our services have to be intercultural, and the staff must be intercultural.”