Amazon Peru research study

Socio-cultural Aspects of Health:Women of childbearing age. Results from Missions in Ucayali, Peru

INDEX

- Presentation
- Methodology
- Conceptual and Theoretic Frame
- Introduction to MSF's project

1. OUTLINE OF THE STUDIED AREA
2. SOCIOCULTURAL ASPECTS
3. HEALTH PROBLEMS
4. HEALTH PERCEPTIONS 6
5. REPRODUCTIVE HEALTH
6. HEALTH SERVICES
7. MSF'S EXPERIENCE IN UCAYALI
8. CONCLUSIONS AND RECOMMENDATIONS
9. APPENDICES :

- Villages and Communities included in the study
- Glossary

Presentation This document is a sociocultural report focusing on the health of women of childbearing age in the forest of the Ucayali region of Peru (see map below). The group studied includes the women of the riverside communities belonging to mixed-race and Shipibo groups.

It is the result of a short but comprehensive process of information and data collection, and analysis, that began in October 2000 and ended in June 2001 with the drafting of the final report. The study is part of a health project developed in that area by the non-governmental organisation Médecins Sans Frontières (MSF) during the past six years. The project ended in June 2001 and includes other results obtained during that period.

This study was based on MSF's policy of documenting field experiences and discussing the impact of health actions so as to improve our interventions in the villages of poor rural areas. This will make it possible to identify existing problems as well as new ways to reach our aims.

The main aim of this study is to contribute to the debate surrounding access to health, particularly for peasant women of childbearing age, and on possible ways to improve their conditions of health. It is also an opportunity, and a duty, to listen to the people directly affected by the decisions which are being taken, and to maintain a dialog between all parties who share the same objectives and who study similar populations.

Methodology

The study was developed using an exhaustive survey method consisting of quantitative and qualitative techniques, employing empirical indicators as well as sociocultural and economic factors, in order to reach a global understanding of the problem. By bringing together all these elements it is possible to offer explanations that are more consistent with the daily reality of the communities that were studied.

It should be added that, because of the multidimensional context of the study, it was not possible to tackle all of the issues meticulously. This would have required a deeper and more detailed investigation made by a multidisciplinary team.

Ten field missions were carried out between September 1999 and June 2001 to observe and take part in the daily life of the different communities in order to gain knowledge and understanding of their reality and the problems they face. Surveys, interviews and meetings with local groups were organised to understand more clearly their health systems and local perceptions of health.

As well as reviewing the available literature on the subject, contacts with different local and national organisations were made and epidemiological data from the Ministry of Public Health was used. The latter was complemented with data from other sources, including those collected on a monthly basis in the communities visited by the MSF teams. The reproduction of this data is designed to show the health conditions of the communities as a whole and, in particular, of women of childbearing age during the periods indicated.

Conceptual and Theoretical Framework

The World Health Organisation (WHO) defines health as a state of general wellbeing including the physical, mental and social condition of a person, and not merely the notion of being free from disease.

Whereas the epidemiological data give us information on the existence of diseases and on their profile in given places and times, they do not take into account socio-economic and cultural factors that, according to the WHO model, affect health. Many of the women who took part in this research, the Shipibo women in particular, suffer from a variety of problems related to reproductive processes. For many of them, complications during pregnancy, delivery and puerperium can have fatal consequences. These risks cannot be explained simply in medical or biological terms but sociocultural factors must be taken into account as well.

The wellbeing of women is compromised by the fact that many of them do not have the same access to power (land and resources), salaried employment, education and social status as do men. Some of them are victims of social exclusion, discrimination and violence inside the family. Moreover, as wives and mothers, women are exposed to many health risks related to reproduction which may lead to death.

Introduction to MSF's Project

The French Section of Médecins Sans Frontières (MSF-F) began to operate in the Amazonian region of the Ucayali department, in the Republic of Peru, with two exploratory missions, in November 1994 and January 1995 respectively.

MSF-F produced a diagnosis of the situation in Alto and Medio Ucayali (northern and central area of the Ucayali department), collecting the necessary data in order to analyse and understand the actual conditions in which the central and regional health system was functioning, and its exact coverage. At the end of the visit stage, meetings were held and national health issues were debated with different central and regional authorities, such as AIDESEP1. The MSF-F team proposed a project based on the situation they had surveyed.

At the beginning of the project, health cover was extended to the people living in the district of Masisea, between April 1995 and April 1997. Then, coverage was extended to the communities in the district of Iparia between December 1996 and December 1998. The MSF-F coverage of the Calleria district ceased when MINSA provided the communities of this area with better access to their health services. During the first two stages, 31 health promotion agents worked in the field and 40 tubular wells were built for the communities of both districts, to improve their access to good quality water.

The third stage of the project began in May 1999 and ended in June 2001. From the beginning, it was clear that MINSA's close co-operation in the project, through the Regional Health Office of Ucayali (Direccion Regional de Salud de Ucayali - DSRU), and the co-operation of other NGOs working in the area, such as AIDESEP, CODESAM, PRO-VIDA and AMETRA2, would have a positive influence on the success of this mission.

1 AIDESEP : Asociacion Inter Etnica de Desarrollo de la Selva Peruana - Association set up by different ethnic groups aimed at the development of their communities in the forests of Peru.
2 Non-governmental Association created in 1982 to reassert the value and use of traditional medicine in Shipibo-Conibo communities.

1. OUTLINE OF THE STUDIED AREA

The Shipibo-Conibo group belongs to the Pano language family, which is found in the central forest of Peru. Although there are some differences between the two ethnic groups, the Shipibos and the Conibos are actually treated as a single ethnolinguistic entity. The mixed-race communities make up the largest element of the forest population and are descendants of native Amazonians and peasant mountain peoples. The mixed-race and Shipibo communities that are the focus of this study live along the shores of the Ucayali River's middle reaches and of some of its affluents (Sipiria, Tamaya and Abujao), as well as on the shores of the Imiria Lake, in the districts of Iparia and Masisea. The population of these districts is 13,794 and 18,100 inhabitants respectively3.

According to a census published in 19964, childbearing age women - aged between 15 and 49 years - made up 45% of the total female population recorded. The percentage is higher for urban areas (47%) although in rural areas it falls to 39%. As for fertility rates in the area, INEI declares that the Total Fertility Rate in the Ucayali Department for the 1993-1996 period is of 4.6 children per woman. In rural areas this number rises to 6.4 and in urban areas it drops to 4.05. The group of 20-24 year-old women in rural areas records the highest number of births.

The fertility rate also varies according to the educational level of women. According to data obtained from the IX National Census, in the Shipibo ethnic group, a 27.7% illiteracy rate is recorded among the people over 5. In the case of Shipibo women or men over 15 considered separately, while a 16.2% illiteracy rate is observed among men, it stands at 30.8 for women. Nevertheless, it should be remembered that in a rural context, the survival of the family always demands a certain availability of human resources for productive activities.

Agricultural production is the main activity (76.9% in Iparia and 82.9% in Masisea). The major crops in the area are green banana, rice, butter bean and manioc. Part of this production ensures food self-sufficiency. Fishing and hunting complement the diet. A considerable part of the production is left over to be sold in the market of Pucallpa and the sale of timber provides another important source of income.

As for communications, fluvial transport is the main method of travel in the area, while the radio is the main form of voice communication and information exchange medium between communities.

Given that the State is not present in the villages of Ucayali, a local political structure exists. The local authorities are villagers democratically elected by the population and officially recognised by the State. Theses authorities are the legal representatives of the communities: they govern them, ensure the maintenance of order in the villages and manage their development. Moreover, there are other community organisations such as Parent's Association (Associacion de Padres de Familia) or organisations like the "Vaso de Leche" associations. In some communities, there is a Health Committee concerned with health conditions in the community.

3 INEI, population, forecasts for 2000
4 INEI, population, Mujer y Salud (Women and Health), ENDES, 1996 : p.13
5 INEI, population, Mujer y Salud (Women and Health), ENDES, 1996 : p. 28.

2. SOCIOCULTURAL ASPECTS

The rural populations that live along the Ucayali River have heterogeneous social and cultural structures. The daily activities carried out by the community members, in the mixed-race and Shipibo groups, are mainly aimed at satisfying the needs of the family. The role of each member is culturally well defined from an early age.

For the natives of the forest, nature is populated by supernatural beings, or spirits, with whom individuals are in contact and communicate. Contact with these spirits has a considerable impact on their daily life and wellbeing. In this cosmological vision, each object of the universe influences nature and man, so that an equilibrium, a kind of solidarity, must be reached between the different elements.

The members of the community have different roles, according to their sex, which create gender divisions that have a fundamental impact on the responsibilities, opportunities and limitations imposed on individuals. These differences are used to justify the unequal access of many women to several social and economic resources.

The socialisation process for children begins at a very early age. They receive an informal education from their parents and are given specific tasks according to cultural norms and standards. It is through this process that they learn to behave as a male or female individual is supposed to. Whereas boys go with their father to farm and fish, and begin to manufacture and handle hunting tools, girls help their mother with the household chores.

Inside a community, individuals with authority are almost always men. Some women have responsibilities in mother's clubs, "Vaso de leche" associations and dressmaking activities, but they seldom have any responsibility in organisations that deal with the affairs of the community as a whole. The opinions and needs of women are not often listened to or taken into account in their own community, as their participation is considered of little importance.

Women tend to begin their married life quite early. According to surveys, 70% of women married for the first time at the age of 17 or earlier. Given that sexual relations begin shortly after marriage, women also have their first child at a similar age. The Shipibo group still maintains a matrilocal system of communal life, in which women of the same family group - mothers, daughters and granddaughters - live close to each other. It is common for a man to leave his own community to live in that of his wife. This helps maintain a close relationship between women, and offers them a better position than in other native groups. For example, in case of illness or marital problems, women are supported by their own kin.

Both the Shipibo and mixed-race woman has to fulfil many obligations as a mother and wife, consisting mainly of reproductive tasks needed for the wellbeing of the family unit, such as preparing food, collecting firewood and carrying water, cleaning the house, washing clothes and taking care of the couple's children. She is also in charge of some farming tasks: she sows, weeds and harvests crops for home consumption, such as manioc and banana that make up the basis of the family diet. She also raises the small cattle and marketable crops. Although women take part in the production of these crops it is the husband who receives the profits.

Most Shipibo women make handicrafts and sell them in Pucallpa or other places. Some travel to Chanchamayo, Satipo or even as far as to the capital to sell their goods. This allows them some economic independence, the opportunity to travel out of their community on their own and a certain prestige uncommon in other ethnic groups.

Violence and maltreatment in the family environment and in the institutional context is still a very serious, underestimated problem, mainly perpetrated by men on children and women. In the family circle, gender violence can be psychological, physical and sexual. Violence can lead to a loss of independence when women take decisions that concern them. In some cases, maltreatment and violence are "normalised", which results when a woman breaks the rules or do not perform her duties knowing it will cause acts of violence or ill-treatment.

Abandonment is quite frequent both in Shipibo and mixed-race communities. This can happen in a variety of circumstances, but mostly the husband leaves the woman because she does not fulfil her duties as a wife or mother. As a result, women come under great pressure, which leads them to try and appease their husbands in order not to be abandoned. Both mixed-race and Shipibo women, therefore, usually does her utmost to satisfy and obey her husband to such an extent that, for example, a pregnant woman will continue doing strenuous work such as carrying water despite the obvious risks to her health.

It should be added that health care professionals sometimes mistreat users of health services. This may take the form of shouting, lack of respect, failure to explain medical procedures, or even violation of their basic rights, including blackmail.

3. HEALTH PROBLEMS

There are many similarities between Shipibo and mixed-race villagers as to what they consider "health problems" and this is shown by the means that they employ to prevent and treat diseases. Financial and socio-cultural aspects must be taken into account. Diagnosing an illness, for example, is useless if the person has no money to pay for the treatment. Frequently, villagers believe health to be linked to the absence preoccupation and worry, to marital harmony and other related factors. In this sense, the instability caused by economic or family problems can lead to health problems.

With regard to the incidence of mortality cases, a global analysis of health problems in Peru shows that diseases of the respiratory system, digestive system and genito-urinary system, as well as infectious and parasitic diseases, still constitute a public health problem for MINSA, given the high number of cases related to them.

In 2000, the major causes of death in Masisea and Iparia were still infectious and parasitic diseases, particularly for those under 5, while in the district of Yarinacocha diseases of the respiratory system have a greater incidence, in the same age group and among adolescents, probably due to the fact that a high rate of MINSA's medical attention given to schoolchildren is free.

In 2000, among the reasons explaining the prevalence of diseases that typically affect women we find inflammatory diseases of the pelvic organs, particularly in Yarinacocha, as well as other diseases of the female reproductive system. In the rural districts studied, acute respiratory infections are still a major cause of illness for women between 15 and 49.

Vaginal infections, unlike other syndromes, are still very frequent. It must be stressed that these infections are not yet consistently dealt with, given that none of the 3,538 cases diagnosed were adequately treated, in some cases because no treatment was given to people having contacts with the patient, and in other cases because the PROCETSS program did not have sufficent medical supplies.

During the first five months of 2001, the most frequent cause of maternal death is a haemorrhaging during delivery or puerperium, death occurring at home rather than in a health establishment, which shows that health control is still deficient. Early detection and accurate follow-up care of pregnant women who have signs of risk is not sufficiently developed. Pregnant women do not receive adequate information about signs of risk that can arise during pregnancy, delivery and puerperium.

Nevertheless, a better management of information and notification of perinatal deaths and abortions can be noted compared to preceding years. The data collected show that a major cause of perinatal mortality is premature labour. However, direct medical attention provided for women and newborn children during and after delivery are still inadequate. This is due to the fact that many health care staff lack motivation when it comes to taking appropriate measures when faced with health problems linked to maternal perinatal care.

During recent years, there has been a high level of unwanted pregnancies resulting in abortion. Of the 313 recorded abortions in 2001, 23% of the women concerned were teenagers. This is caused by the insufficiency of educational work intended for women on issues such as family planning, by the rejection of some contraceptive methods and by the attitudes of fathers.

4. HEALTH PERCEPTIONS

Most inhabitants of the communities and villages in the area where the study was carried out consider health as a personal matter that reflects the way in which an individual acts in the physical world, as well as the existence or absence of certain key elements such as physical well-being, food and hygiene.

There still is a health system based on traditional or local knowledge which is transmitted from generation to generation though practice, experimentation and the use of a great variety of plants, tree barks and other traditional methods (such as dieting). Nevertheless, this knowledge tends to disappear little by little because the processes of modernisation and urbanisation. According to popular opinion, plants are effective thanks to the combination of their chemical properties and their "spirit". Each plant has its own spirit, which gives the curandero a power, enabling him to "see", or identify, the disease and know how to cure it. In this way, the curandero learns while he uses the plants, as they teach him what must be done.

6 In this document, words in bold type are regional expressions and concepts less known in other parts of the country. Their meaning is given in the glossary at the end of the report.

The medical system of the Shipibo and mixed-race groups impregnates reality with supernatural beliefs, so that the two become intertwined. Relationships between the human being and its natural environment on one hand, and the human being and the supernatural world on the other hand, are very important; a balance must be reached for both of them.

Traditional medicine, unlike conventional medicine, regards the individual as a whole - body, mind and environment - which looks for the real causes of the "illness", not only the elimination of its symptoms. The curandero can establish which illnesses may require a therapy by magic, which must be treated with traditional plants, and those which must be left to the "hospital doctor".

Nevertheless, the probability that a sick person will go to a health centre is low due to economic and cultural factors and a lack of confidence in the MINSA staff. In these circumstances, sick people often come to official health establishments when the disease is already at an advanced stage, reducing the effectiveness of the treatment and consequently increasing the villagers' mistrust towards official medicine.

The group of diseases whose causes are thought to be found in the animistic world are always cured by the shaman. Within the etiology of these illnesses three causes are possible: an attack from the spirits of plants, animals, water, climatic phenomena or the spirits of the dead; an attack from the "brujo", called "virotear", motivated by envy and/or vengeance; and the failure to observe the rules of the "covada".

If it is considered that the cause of the disease is to be found in the supernatural world, or when a conventional drug treatment is tried without success, the sick person will look for the help of a curandero. The latter performs a curative session for an individual or a group, "takes the pulse"7 and has turns to ayahuasca or other hallucinogenic substances when patient-observation is not sufficient to determine the cause of the illness. He sings the icaro and smokes his mapacho, and with the smoke of tobacco and other substances held in his mouth he begins to suck the patient's body in the ailing part. After this, he may apply some herbal remedy.

For children, contamination is thought to occur via other people, usually parents, when they do not respect the covada. According to this account, a young girl's belly may become swollen like a ball after her father plays football. With regard to the cutipa, it is interesting to note that the symptoms frequently associated with this illness such as, in the case of new-born babies, diarrhoea, fever, crying and a swollen belly, are quite usual in infants born in rural areas.

These symptoms could easily lead to a conventional medical diagnosis since they are often associated with the drinking of contaminated water. Yet, for many villagers the cutipa is still an explanation more consistent with their belief system and, in the case of the Shipibo group, with their cosmological vision. It is nevertheless clear that the beliefs associated with the cutipa are gradually being lost, especially for young people who doubt this phenomenon, after having put it to the test without anything happening to their children.

Plants are still widely used as treatments because of their low cost, availability and simple use for self-medication. Official medicine has not been able to solve the health problems from which people suffer in Amazonian communities and consequently a harmonious relationship has not been created between modern and traditional ways. The native villagers, and to some degree the mixed-race villagers, continue to consult, in the first instance, their curanderos and shamans, who usually make use of the great variety of plants and traditional techniques available in their natural environment.

7 Here, to "take the pulse" means to touch different parts of the patient's body as in a physical examination, in order to make the diagnosis and identify the illness.

5. REPRODUCTIVE HEALTH

Although pregnancy and delivery are natural processes, rural women are confronted by situations that carry many risks during these stages. The safety of women during these processes depends mainly on their living conditions and on their access to the medical methods that make it possible to avoid or resolve complications. Yet many women do no have access to professional care or, because of traditional habits and beliefs, follow current practices that are dangerous to their health and wellbeing.

69.4 % of the peasant women who participated in this research work declared that they had no previous knowledge of the conception process or methods of preventing pregnancy. This figure stands at 80.7% for Shipibo women. Many young women begin to have sexual relations without having received adequate information on family planning. In the districts of Pucallpa, only 15.0 % of those questioned had had no previous knowledge of contraception. Here, women have better access to information and consequently tend to use more contraceptive means.

During pregnancy, Community Health Agents in the villages ensure the medical supervision of pregnant women, with their consent. In the department of Ucayali, the probability of a woman choosing to be supervised during pregnancy depends on several factors, such as ease of access, economic resources, culture, religion and her (and her partner's) level of knowledge and awareness of possible risks. A pregnant woman will look for someone's assistance when she feels some discomfort or pains resulting from the bad position of the foetus.

When a problem arises, women will in most cases turn to a sobador, an elderly woman or a traditional midwife before going to a professional midwife or to a health care professional. Generally, Shipibo women rely on traditional midwives because of the practical experience they acquired giving birth themselves and providing care and assistance to other women in the community during childbirth. Women will go to a MINSA health care establishment only in extreme cases, when other methods haven't worked. It should be added that some of them are probably more motivated by the vitamins they receive than by the medical supervision itself.

According to our surveys, 59.4% of women living in the riverside communities and villages did not receive any kind of supervision during pregnancy. For the Shipibo communities, this figure rises to 62.0%, while in the city less than a third of women questioned decided to continue with their pregnancy without any medical supervision.

During pregnancy, the pregnant women's daily diet is modified according to their cravings and to prevailing cultural habits. Most pregnant women prefer to eat meals prepared with rice, manioc and fish. Vegetables, caimito, sapote and acidic fruits like green mango with salt and lemon are also appreciated. At the same time, the majority of women stop eating at least some type of food. It is believed that certain foods are noxious or may contaminate the baby ("cutipa") or affect the mother, causing for example haemorrhaging. Some animals are also believed to cause problems when the woman gives birth, and it is thought by some people that deformities in the baby can be caused by some foods.

Delivery and puerperium

In the rural communities, pregnant women usually give birth at home. It is the most convenient place, as the woman does not have to leave her community and travel far from her family to be attended by a stranger. Surveys show that 87.5% of peasant mothers delivered their children in this way, while only 22.6% of women from the districts around Pucallpa gave birth at home. Logically, mothers living in an urbanised area choose to go to a health care establishment because it is close by, but they also rely more on the personnel and feel safer than peasant women.

Some Shipibo women who, on very few occasions, went to these establishments, declared that they did not want to give birth in a hospital. They confessed of being afraid of dying there, and even of being "killed" by the people attending them. In some discussion groups, women reported cases of physical or psychological abuse, inadequate medical attention and even blackmail.

Obstetric complications during delivery are a major cause of maternal morbidity and mortality. Institutions working in this field are concerned by the lack of healthcare staff sufficiently qualified for the management of risks and having adequate access to sterile medical equipment.

When a woman is going to give birth in her village, she always waits for the onset of labour before calling for the person who will attend her. Sometimes, out of embarrassment or when no one is available in the community to help delivery, Shipibo women give birth alone, at home or in the forest. 6.3% of women questioned in the communities stated having given birth without any assistance. Women declared that it was preferable to be squatting or kneeling during labour, as it is the easiest position to push the baby out. Mixed-race and Shipibo women attach great importance to the possibility of choosing the position that is most convenient to them - a choice not offered by staff in public health establishments.

Traditionally, the umbilical cord used to be cut with a cane stick sharpened like a knife, a custom that is sometimes still followed today. Nowadays, scissors, usually boiled, or razor- blades, are mostly used. Generally, the person who cuts the umbilical cord is the godmother or godfather, a parent or the attending midwife. In Shipibo as well as in mixed-race communities, several traditional techniques are used to extract the placenta when it is not delivered normally.

These methods vary according to the qualifications of the attending midwife and the beliefs of the community members. Some of these methods can endanger the woman's life. To begin with, the midwife will generally manipulate the woman's belly or heat some clothes belonging to the husband (his pants, for example) which are then used for this manipulation. If these methods give no result, the woman may gently blow air into a bottle in order to stimulate the placenta's delivery. The umbilical cord is often tied to the woman's toes and gently pulled. Some plants, which can be brewed in the same way as tea leaves, are also used to assist labour.

Only a few women declared having had complications during childbirth. When complications occurred they were dealt with in the community, mostly with plants prepared as a hot beverage. Treatments are sometimes prepared beforehand, buying phials when delivery is near. When these methods fail, taking the woman to a place where she could be attended by health professionals is difficult, because of the lack of economic resources and, given the risks, a reluctance for her to travel after delivery.

Although pregnant women are given information on the importance of the colostrum for new-born babies, many of them do not give it to the baby as they believe it is bad milk. Because of its yellowish colour, and because it is "cold", they infer that first milk is dangerous for children and can cause vomiting and diarrhoea. Nevertheless, in communities
where a trained midwife is operating, more and more women give first milk to their child, as they have understood its nutritional qualities.

According to the villagers, the period of delivery and puerperium is the most dangerous for women and their babies. It is a time during which they face many problems and incur many risks. Following childbirth, women will have to avoid physical effort and heavy work for three months. But when there is no one else to help they must sometimes perform their tasks without observing the necessary rest time. Some women choose to eat foods that help cicatrization and quicken the recovery process. A number of plants that have medicinal properties are also used. Some foods must be avoided after childbirth, just like during pregnancy, to prevent complications such as haemorrhage and "cutipa" for the newborn baby.

Family Planning

Family Planning is almost exclusively the responsibility of women, given that only a few men use contraceptive methods. Surveys carried out during this research work show that modern methods are mostly used for family planning, although some differences can be noted between the inhabitants of Pucallpa and the Shipibo groups. 41.3% of Shipibo community members do not practice any kind of family planning methods while 65.1 totally reject modern contraceptives preferring traditional means, folkloric methods, or no method at all.

With regard to the population studied in this research work, among those who choose to use one of the modern family planning methods, there is a strong tendency to use injectable contraceptives. It is an easy and effective method and the State promotes its use in the country, particularly for the native population.

According to the surveys carried out by the research team in the rural communities and in the city, 56% of the population use injectable contraceptives for birth control. 21% use contraceptive pills and 18% choose a ligating of the uterine tubes. The use of condoms and of copper IUDs is almost insignificant : 3% and 2% respectively. Among Shipibo women, 65% of the female population receive a contraceptive injection every three months, and 19% had their uterine tubes tied. The contraceptive pill is less used, and condoms and copper IUDs are totally rejected by this group, as well as by the rural mixed-race group.

The degree of acceptance of modern contraceptive methods is also linked with the perception that the population has of their side-effects. Each time this subject was raised by the research team it triggered off a debate. Many women said that the MINSA personnel do not perform a physical examination or explain indications before initiating a contraceptive treatment. According to several accounts, women who use injectable contraceptive do not go through the recommended medical examinations, such as blood pressure control.

They have little access to the information and psychological support that would save them the concerns and confusion they experience, besides the obstacles they face in order to benefit from alternative methods.

Women living in rural communities and in the city feel that the attitude of health professionals goes against their right to be informed about family planning and to think about it before accepting a particular method. These factors sometimes lead to a complete rejection of all contraceptive methods.

6. HEALTH SERVICES

During previous years essential reforms were carried out in the sector of health, including a development of the services' infrastructure and efficiency, as well as the creation of programs focused on the more marginalized groups. Native and mixed-race communities are visited by the MINSA personnel at different levels and intervals.

The program called "CampaÃ?±a de Salud Integral" (Integral Health Campaign) provides free health care across the region through medical specialists of different fields who travel from Pucallpa periodically. Moreover, the health centres and points situated in villages far from the city are staffed by health professionals including technicians, doctors, nurses and obstetricians.

Nevertheless, economic problems still deny access to a series of medical interventions which are not included in existing programs, such as some examinations, x-rays, surgery, and even delivery. Moreover, many people who participated in this study pointed out the indifference shown by health professionals towards the population. In some cases, the health centres do not have adequate equipment to ensure a basic provision of services. A greater cause for concern is that medical teams do not always have enough drugs at their disposal, so that they sometimes give incomplete treatments to patients.

For women belonging to peasant and native communities, leaving their home and chores for a long time to be treated would involve an important social and economic cost. Their commitment to their family and to the many tasks they have to perform can influence their decision to leave. This means that very often women's health is not a priority, even for themselves. Another difficulty faced by Shipibo women regarding access to official health services is language : many of them do not speak Spanish, while most health professionals do not speak the Shipibo language, and this seriously affects the quality of care given.

The presence of a Community Dispensary (called "botiquin communal") is a key element in providing easier access to modern medical care, given that it is situated in the community itself and is run by trained community members. This strategy is one of the alternative solutions that can be implemented in rural areas such as the Ucayali department to solve existing problems.

Most communities where MSF works have a dispensary where medical care is provided. It is operated through a rotary fund acquired mainly by selling medicines, the aim being to replenish drugs that have been sold in order to ensure a constant stock of medical supplies.

The fund is managed by a health committee and its health promotion agents and traditional midwives, collectively called Health Community Agents, are recognised by MINSA in Pucallpa. The MINSA personnel help Community Health Agents by training them for the prevention, diagnosis and treatment of diseases with biomedicine. Nevertheless, the management and use of the dispensary, and therefore the improvement of access to health, does not only depend on this training, it also involves co-ordination with the community through the health committee.

The function of this committee is complementary to the activities of health promotion agents and midwives, and includes the administration of the dispensary and the control of its rotary fund, as well as the promotion of the community's participation in health care actions and support activities. These elements are essential to ensure the sustainability8 of the dispensaries and an improved access to health services.

8 Sustainability means that the community should be able to manage the community dispensary without assistance from other organisations.

7. MSF'S EXPERIENCE IN UCAYALI

The policy on which the "Program of Basic Health Care for the Ucayali Department" is based was developed to reach two main objectives: provide medical care to patients who have little access to official health care - due to poverty, geographical isolation and different cultural values - and train health promotion agents and traditional midwives.

Thanks to the work done by traditional midwives trained by MSF and MINSA, the cover of health care provided to childbearing age women has been widened. The number of medical attentions given to women increased in 2001 compared with 2000, as well as the proportion of medical care related to delivery, puerperium and care to new-born children9.

The Support Team for the sustainability of the community dispensaries played an important part in MSF-F actions since April 1999. Its main objective was to ensure the continuity of basic health care through the long-term functioning of community dispensaries and their rotary fund. Activities were developed in 12 native and mixed-race communities in the districts of IparÃ?­a and Masisea. The criteria used to select the communities that were to be supported were mainly linked to their own internal conditions, the possibility of setting up responsible Health Committees and the community's involvement in the sustainability of their dispensary. On this basis, we were able to devise strategies adapted to the needs of each community.

This stage of the project had two essential aims: facilitating community participation in the decisions and processes that affect its members, and establishing Health Committees, a key entity that acts as an intermediary between Community Health Agents and other community members.

After two training courses focusing on the sustainability of the community dispensary, and thanks to the activities performed during the team's visits, the communities improved their ability to manage and maintain the dispensaries, with the effort of the Committee itself, the Health Community Agents, the local authorities and the community as a whole. At the end of the program the members of these committees were more involved in their work, participated more actively, showed that they wished to manage the dispensaries efficiently and developed initiatives to reach this aim.

A factor that obviously limits the possibilities of success of a community dispensary is the extreme poverty of the population. In the course of the first visits, the team had to work with the CHA's and the committees on the financial aspect, because adequate records of accumulating debts were not being kept. Now, a reduction of these debts can be noticed in most communities, which seems to reflect a general change of attitudes and increased economic control of community dispensaries. Besides providing for the access to drugs, additional funds must be set aside for the transport to a hospital and clinical treatment of patients whose condition is too serious for them to be attended by CHA. It is difficult to estimate the amount needed to create an emergency fund, because of the irregularity of accidents, complications occurring in a community and of the wide range of treatment costs. The first objective was to establish these funds in the communities that showed the best organisational capacities. In reality, this aim was not attained because of difficulties linked to the management of rotary fund, although some communities had started a minimal emergency fund.

9 MSF-F Final report, Pucallpa mission, June 2001

A positive aspect is that a change of attitude could be noted in some communities, where initiatives were made to find local solutions to some of the existing problems and difficulties, not only concerning health but in many areas of their daily lives. This does not justify the absence of the State or of positive changes at the national level, but it helps give back some dignity and value to people and communities who are politically and socially marginalised.

8. CONCLUSIONS AND RECOMMENDATIONS

- The continued exclusion of women living in rural areas from the economic, social and political national life is a major concern, given that their wellbeing is seriously limited by the lack of representation and of the possibility of making themselves heard.

- The difficulty of access to health, for a significant part of the population studied in this research work, must be considered from different angles: the complexity of the cultural standards and practices related to health, the beliefs of villagers, the low socio-economical conditions and transport problems.

- More infrastructure, personnel, equipment and drugs are needed to attend the rural population, which is poor and geographically isolated. Moreover, many problems faced by these populations are ignored : socio-economical problems, fears, lack of education and lack of comprehension of the language and of the technical terms used.

- Very often, the health programs and projects that manage to extend health service coverage increase the number of users without necessarily having a positive long-term impact on the perceptions and practices of the local population.

- There are different ways for the people to participate, and they greatly improve the possibility of achieving long-term changes. It has been demonstrated that sustainability is an essential element for projects that aim to achieve a long-term human development.

- In most cases, the rural population showed that they were able and eager to participate actively in projects designed to improve their living and health conditions.

- In view of what has been achieved in different fields in most communities, we consider that the project to train villagers and set up health committees in rural communities is feasible and tends to promote a better functioning of the dispensary.

- It is obvious that the underprivileged, in economical and social terms, will never have access to adequate health care and living conditions with the present privatised health system. Health policies must be a priority in development strategies, and must take into account the great variety of factors and processes that have an impact on health, to offer the population the opportunity to overcome poverty as well as political and social exclusion.

- We have to look at the world of the poor and of the women of the Amazon through their eyes.

9. APPENDICES

Calculation of hours needed with an outboard motorboat during the rainy season. As people travel by collective boats or by peke-peke motorboat, one needs to multiply this distance by two approximately. These distance vary according to the season.

GLOSSARY

Brujo: Means "Sorcerer" and refers to a traditional doctor who can cure, but is also in some cases an evil-doer

Chupar: Old way to cure by extracting with the mouth diseases or stings from the patient's body.

Communero: Villager, inhabitant of a native or peasant community.

Community dispensary: Community centre where a health promotion agent attends and where medicines are stocked.

Covada: A series of prohibitions that a father must observe before and after the birth of a child. It includes food taboos and interdictions of some activities, like playing football, touching petrol, as well as sexual abstinence. The food taboos apply also to the mother.

Curandero: Traditional doctor

Cutipar: Phenomenon through which a person is "contaminated" by the characteristics of some animal, plant, object or soul, as a result of activities performed by other people (usually by the parents).

Community Health Agent (CHA): A villager trained by some organisation that works voluntarily to help his community or people, in health services.

Icaro: An oration which is sung or whistled and has curing effects.

Mapacho: Pure tobacco that the curandero smokes before blowing the smoke on a patient to cure him/her.

Sobar: To massage (sometimes to relive muscular pains). This is done by the "sobador".

Virotear: To bewitch someone using the "virote", an invisible sting that brujos (sorcerers) introduce in the body of their victims.

Rotary fund: The financial management system used by a health committee, aimed at improving the ability to buy drugs and other supplies needed to run the community dispensary.