School of Health in Social Science

Name of Course Contemporary Issues in Health and

Wellbeing
Course Organiser Divya Sivaramakrishnan

Name of assignment Summative Assignment - Course

Paper
Exam number: (Please do B222110
not include your name or
UUN anywhere on this
submission)
Date of submission: 1 December 2022

Word Count: 3256

 Health Inequality in the Amazon: Health and Barriers to Health of
Indigenous Communities of the Peruvian Amazon

Introduction
Indigenous peoples are defined as ‘the original inhabitants of an area, the descendants of the
original inhabitants who are colonised, and those who live in an Indigenous way and are
accepted by the Indigenous community’ (Montenegro and Stephens, 2006). It is estimated
that 45 to 48 million people, 10% of the population of Latin America and the Caribbean, are
part of the 400 Indigenous groups scattered across the area. In Peru alone, 6 million people
make up around a quarter of the total population of the nation (Instituto Nacional de Estadística
e Informática, 2017). Despite being a significant presence, Indigenous peoples experience
disparities compared to the general population which could be attributed to social, economic,
and access inequities. These are connected to the effects of colonization which still exist
today, which include discrimination and poverty.
Structural problems facing Indigenous populations in Peru is connected to poor health
outcomes. Indigenous populations have higher rates of infant mortality, lower access to health
services, worse nutritional status, and limited access to clean water. This lead to higher
incidence of gastrointestinal problems, infectious diseases, anaemia, and chronic malnutrition
compared to the general population (Anticona and San Sebastian, 2014; Gianella et al., 2019;
Badanta et al., 2020). On average, Indigenous people in Latin America live 20 years less than
non-Indigenous populations (Martín de Dios, 2020).
Although the economy of Peru is a rapidly developing along with its healthcare system,
conditions for Indigenous communities in isolated regions have not improved much
(Hernández-Vásquez, Bendezu-Quispe and Turpo Cayo, 2022). Recent changes in the
Amazon due to extractive practices, increasing contact with outsiders, and climate change are
aggravating the issue by driving change in agricultural practices, diet, and other cultural
stressors. Most communities have no access to roads and no other means of transport except
small boats (Nawaz et al., 2001). Healthcare access remains a challenge due to geographical
and economical barriers, as poverty is rampant and healthcare facilities are sparsely
distributed and often lack resources (del Mastro N., 2022). Cultural barriers to healthcare
access also exist due to low cultural sensitivity of existing healthcare systems and dismissal
of Indigenous knowledge and medicine (Montenegro and Stephens, 2006).
This paper aims to examine the current state of health in Indigenous communities of the
Peruvian Amazon, such as nutrition and sexual health, as well as healthcare access and
barriers to health. Effect of economic development and climate change to agricultural
practices, diet, and nutrition and its connection with Indigenous culture and local perceptions
of health is discussed.

Literature Review
Among the disparities documented are those regarding nutrition, maternal and infant mortality,
and low birthweight (Anderson et al., 2016a). In children, another study identified higher
incidence of anaemia, diarrhoea, cough, and chronic malnutrition (Díaz et al., no date). There
is evidence of poorer health for Indigenous peoples compared to the non-Indigenous
population (Anderson et al., 2016b).
Perception of health
In some Indigenous communities of the Peruvian amazon such as the Matsigenka and Shawi,
the concept of health and wellbeing extend beyond the biomedical individual health. Health
encompasses emotional, collective, and environmental well-being, productivity, and/or
happiness. The maintenance of traditional practices and values and having a harmonious
relationship with nature and the surrounding environment were central to individual wellbeing.
Some communities perceive a decline in health in recent decades which they connect to
contact with outsiders and extractive work in the Amazon (Bussalleu, King, et al., 2021)
(Izquierdo, 2005).

Access to healthcare
In a study on the Indigenous communities along the Ampiyacu and Yaguasyacu rivers in Peru
(n=179), 38.5% of respondents reported never having consulted a doctor; 57.0% stated they
had previously been unable to seek medical attention when necessary (Arora et al., 2014). In
a study on the Loreto area, the region with the highest number of indigenous communities,
only 45.9% of communities are within 1 hour away from the nearest health facility and 15,4%
were more than 8 hours away (Hernández-Vásquez, Bendezu-Quispe and Turpo Cayo, 2022).
The group which was the least likely to seek healthcare were women due to language barriers
and a reluctance to be examined by male medical personnel (Fraser, 2006).
Traditional healing methods and herbs is the first choice of care (Williamson, Ramirez and
Wingfield, 2015; Bussalleu, Pizango, et al., 2021) and most only seek medical help when they
deem traditional healing does not solve the problem. After seeking medical help, treatment is
often discontinued after symptoms disappear in preference of traditional methods (Badanta et
al., 2020).

Estimated travel time to nearest health facility in Lorato region of Peru (Hernández-Vásquez,
Bendezu-Quispe and Turpo Cayo, 2022).
Food and nutrition
A study of haemoglobin levels, anthropometrics, and blood lead levels on six communities
(n=330) in the Peruvian amazon show that the prevalence of anaemia, stunting, and low
weight were 51.0%, 50.0%, 20.0% (Anticona and San Sebastian, 2014). In some areas of the
Peruvian Amazon, the prevalence of anaemia is as high as 80% for children aged 17-24
months (Huamán-Espino, Valladares and Resumen, 2006). The rate of chronic anaemia and
stunting is higher than national average.
Food insecurity is a significant problem in some communities. There is a perceived decrease
in food availability in the Amazon (Zavaleta et al., 2017). In a study on the Loreto region
(n=139), almost two-thirds of respondents experience moderate food insecurity. 65.9%
skipped meals or ration their portions and 8.5% has felt hungry or did not eat for a whole day
due to lack of food or lack of money to buy food (Rondoni, 2022).
Helminth diseases are a major health problem in the Peruvian Amazon. There is significantly
higher risk for soil-transmitted helminths (STHs) for Indigenous groups compared to settlers
(Briones-Chávez et al., 2013). STHs are correlated with malnutrition, anaemia, and impaired
cognitive development in children. In a study comprising subjects from 52 family clans in the
Peruvian amazon (n=225), 63.2% of subjects and 46% of subjects under 19 years old who
provided stool samples were infected by at least one helminth parasite (Cabada et al., 2014).

Sexual health
Little data is available on sexually transmitted infections (STIs) and HIV prevalence among
Indigenous peoples in America. A sero-epidemiologic survey of HIV and syphilis in 2009 on
the Chayahuita community in the Peruvian Amazon (n=80) shows seroprevalences of 7.5%
and 6.3% (Zavaleta et al., 2007), which are much higher compared to average, and the
Peruvian Amazon is recognized as a high-HIV epidemic zone (Orellana et al., 2013).
Unprotected sex is common with an early age of sexual initiation: the median age of sexual
encounter is 16 (Collins, Bowie and Shannon, 2019), and some interviews show that the
earliest age sexual encounter is as early as 12 (Orellana et al., 2013). Teenage pregnancy is
also common, with rates double the national average (del Mastro N., 2021).
Sexual health knowledge is limited in the Peruvian amazon. In a study with four Indigenous
Amazonian communities, almost 60% of the population did not know about HIV/AIDS, and
only 6.4% were aware that condoms can be used to prevent transmission of the disease
(Bartlett et al., 2008). A different study showed that most Indigenous people did not know that
antiretroviral treatment for HIV exists (Orellana et al., 2013). In a study of women of the Yantalo
community (n=217), 25% have not heard about HPV and/or cervical cancer and 20.9% said
‘no’ or ‘maybe’ when asked if they will accept a free cervical cancer screening test (Gochenaur
et al., 2020).

Health education, health risk behaviours, and sanitation practices

Due to lack of health education, Indigenous peoples of the Peruvian Amazon often engage in
high-risk behaviour. Although most aged over 15 are sexually active (Bartlett et al., 2008), a
most of the population do not practice protected sex or know how to prevent STIs.
Understanding diseases and transmission is poor. One of the studies previously mentioned
showed only 50.3% of Indigenous Amazonian respondents were aware that mosquitoes
transmit malaria (Arora et al., 2014).
A 2001 survey of the Indigenous population living along Yanayaku River (n=179) showed that
a local river was the source of drinking water for 95% of the respondents. Only 51% boiled the
water before use, and 19% did not believe that boiling water prevents disease. More than a
decade later, a different study on a different population produced similar numbers, with 80.4%
of respondents agreeing that boiling water prevents disease, but as much as 45.8% boiled
their water sometimes or never (Arora et al., 2014).
Many Indigenous Amazonians believed the cause of illnesses to be sorcery and rely heavily
on traditional and spiritual healing. prevalence of alternative medicine practitioners was high.
The same study (Arora et al., 2014) showed 83.2% of respondents had sought opinion from a
healer or used traditional medicine in the past year and 76.0% believed traditional medicine
to be equal or superior to Western medicine.

Discussion
Structural barriers are identified in literature, such as access to healthcare, access to clean
water, poverty, and lack of education. Some of these issues can be correlated to changing
living conditions, from contact with non-Indigenous populations to destruction and/or pollution
of the Amazonian environment. The local perception of health which includes collective and
environmental well-being, happiness, and productivity also made changing surroundings and
lifestyles a health stressor for the people in the Peruvian Amazon.
Since the Indigenous Amazon communities are diverse and spread over a large area, the
conditions for each community can vary greatly, making direct comparisons difficult. Surveys
and interviews often have limitations. Some studies are conducted in health posts rather than
Indigenous settlements, which might not properly represent part of the population which does
not seek medical care. Studies are conducted only on specific regions, communities, or river
streams, making available data scattered. There has been no systemic study, literature review,
or government database that covers the general Indigenous Amazonian population in Peru.
Many communities in the Peruvian Amazon speak only their native tongue, and for
communities exposed to Spanish, interviews are conducted in Spanish. While quantitative
surveys give a good general description of health metrics and behaviours, qualitative studies
provide valuable insight to indigenous experiences and perspectives, which might be the
reason some studies are conducted in mixed methods of quantitative and qualitative
approach. However, some studies are held in a non-confidential environment which might
influence the results.

Barriers to healthcare access

One of the main barriers to health in the Peruvian Amazon is access, as there is only a single
team in basic medical posts to cover every 500-800 families in rural areas (Bartlett et al.,
2008). Although there is evidence of improvement of healthcare access in recent decades,
this remains inadequate as existing healthcare services are limited in its effectiveness due to
geographical isolation of the communities, minimal road access, and lack of equipment
(Williamson, Ramirez and Wingfield, 2015). Distance and waiting times at health posts remain
a hurdle in getting diagnosis and treatment of diseases (Arora et al., 2014). Financial issues
are also a key barrier to healthcare access (Arora et al., 2014), further strengthening the
paradigm that health issues in the Peruvian amazon is a problem that needs to be addressed
structurally. Administrative barriers prove to be a problem in accessing the free healthcare
insurance scheme from the Peruvian government (Gianella et al., 2019). In addition to external
factors, barriers to seek healthcare also come from within the community, as most prefer to
follow customs and chose traditional treatment over medical treatment.
In providing healthcare, collaboration with local shaman healers approaching treatment with
incorporation of local healing practices could help increase trust among the community.
Instances of medical professionals working in tandem with traditional healers in order to
overcome lack of resources have been documented in literature, and with good outcome (del
Mastro N., 2022). There is evidence that many of the plants used in traditional Indigenous
Amazonian medicine are biologically active with antimicrobial properties and/or antibiotic
activity (Roumy et al., 2020). This proves Indigenous knowledge might be a valuable tool in
Indigenous health, and a better understanding of their traditional medical system could be
useful.

Barriers to education
In the Peruvian Amazon, education has been proven to be useful to prevent disease
(Izquierdo, 2005). However, this issue must be approached carefully in the framework of the
concept of health within the Indigenous community. Historically, educational institutions and
strategies rarely emphasized the retention of Indigenous knowledge (Dean, 2015). Outside
influences, including formal education and teachers, could be perceived as stressors because
of the disruption they bring to local culture and lifestyle. Some may view education as outside
indoctrination that contradict Indigenous notions of family size, work, and lifestyle. Alongside
Christianisation, education has created cultural identity confusion in some Indigenous
communities (Izquierdo, 2005).
In some communities, gender inequality is a barrier to education. There is an observable
gender gap in education within Indigenous communities in the Loreto region (Williamson,
Ramirez and Wingfield, 2015; Bussalleu, King, et al., 2021). Gender norms related to
femininity also prevent educational advancement for women due to limited social mobility and
access to information (Orellana et al., 2013).

Sanitation, access to clean water, and hygiene

Poor water quality with inadequate sanitation and hygiene are recognised as a global problem
which disproportionately impacts the health of Indigenous peoples (Torres-Slimming et al.,
2019). Many Indigenous communities do not have treated water. Lack of hygiene practices
and access to clean water is linked to malnutrition and anaemia as they lead to gastrointestinal
infection and episodes of diarrhoea (Badanta et al., 2020). Even though most knew the
benefits of boiling water, A study showed that 87% of households with a child younger than 5
years drink water that is microbiologically contaminated (Miranda et al., 2010). This might
indicate lack of understanding of hygienic practices or suboptimal practices.
Despite the abundance of water in the Amazon jungle, recent political, economic, and
ecological changes have led to problems with water access and water source contamination
in some indigenous communities, making them unable to rely on the river as much as they
previously did (Tallman, 2019). It is important to note that community members as young as
25 have a perceived experience of better health before contact with the outside world and the
introduction of the need of sanitary practices (Izquierdo, 2005). This creates a complex
problem between health measures and happiness because “new” practices (e.g. boiling water,
washing dishes, washing hands) are distancing the Indigenous from their culture which is
tightly tied to their way of life. Additionally, water insecurity scores were associated with worse
self-reported physical health and greater odds of reporting symptoms including diarrhoea,
nausea, fatigue, and chest pain (Tallman et al., 2022), further burdening the health of the
population.
When designing infrastructure for clean water access, measures must be taken to ensure
continued use. Many factors determine whether individuals will use a drinking water system
continually or intermittently, the most important being distance, followed by inclusion within
community, and perception of drinking water systems (Nelson-Nuñez et al., 2022).
Fluctuations and changes in water quality due to seasons and development, outreach to
community members, as well as Indigenous perception of water systems must be considered
to ensure availability and continual access of clean water.

Development vs. deteriorating health

A number of extractive industries such as mining, forestry, and agribusiness are affecting the
health of the people living in the Amazon. Laws passed in the past decade granted the central
government of Peru powers to allocate land rights for large projects (Gianella et al., 2016) on
top of the already common illegal extractive activities. The change of land use in the rainforest
and increasing contact with outsiders bring health problems, either directly through spread of
diseases previously unknown to the Indigenous population or indirectly through lifestyle
changes caused by their presence.
Although development bring better access to resources such as transportation, education, and
health, it can also bring unwanted negative effects. For example, construction of roads
generates soil that is dumped into the river, creating pools during low levels in which
mosquitoes can reproduce (Hofmeijer et al., 2013a). Furthermore, resource extraction,
construction of infrastructure, settlement of people from outside of the Amazon, market
integration, and overall transitions in settlement patterns polluted rivers with sewage, refuse,
and hazardous waste (Tallman, 2019).
Road access and integration with non-Indigenous population also caused changes in the
lifestyles and diet of Indigenous communities. Market integration and trade drove agricultural
changes as communities shift into intensive agriculture in order to generate profit. Because
land is prioritized for profit, the variety of plants in Indigenous gardens decreased, and nutrition
is impacted (Tallman, Valdes-Velasquez and Sanchez-Samaniego, 2022). Although it can be
argued that the wide range of available choices in market food can increase nutrition and
variety in diet, the first foods to be added to the diet of Indigenous communities are typically
cheap and less nutritious foods such as pasta, rice and sugar. Consumption of Indigenous
food decreased to 10% from previous amounts, even though Indigenous diets have better
nutritional content such as high levels of protein, fat, and micronutrients (Creed-Kanashiro et
al., 2009; Tallman, Valdes-Velasquez and Sanchez-Samaniego, 2022).

Effects of climate change

The connection of climate change and emergence of infectious is established in literature.
There is a close correlation between water- and vector-borne diseases and weather (Hofmeijer
et al., 2013b). Transmission of helminth diseases are also influenced by weather and climate
change. Furthermore, deforestation decreases food and water for wildlife. This increases the
frequency of wildlife contact with humans as animals migrate to other habitats, potentially
cause pathogen spillovers (Ellwanger et al., 2020).
From a nutritional perspective, climate change is affecting Indigenous food systems, making
Indigenous populations vulnerable to food and nutritional insecurity. In the Ucayali and Loreto
regions of the Peruvian amazon, climate change caused severe foraging and agricultural
challenges. Household plantations produce fewer fruits, wild fruit became less abundant, crop
harvest diminished due to decline in yield and size, and heat stress problems emerged due to
rising temperature. Other factors also contribute to the high sensitivity of Indigenous peoples
to climate-related health risks. Identified factors in Indigenous communities of the Peruvian
amazon include habitation in poor quality houses and associated living conditions, (Hofmeijer
et al., 2013a).

Conclusion
The health of Indigenous communities in Peru is tightly linked to social, economic, cultural,
and environmental issues. Indigenous communities have higher incidence of nutritional health
problems compared to the general population, and are correlated to food insecurity,
diarrhoea, gastrointestinal infections, and parasite infections. Sexual health is poor with limited
awareness of cervical cancer, limited knowledge on STI prevention, and poor use of
protection, in addition to increased spread of HIV.
Inadequate healthcare access, suboptimal water and sanitary practices, and education are
among the factors most identified in literature. Furthermore, recent changes in living conditions
due to extractive industries and development bring negative effects. Changes in diet, spread
of disease, as well as lifestyle changes impacts physical health and is perceived to be
disruptive to local perceptions of health which does not only include individual well-being, but
also has a collective, cultural, and environmental aspects. Due to present inequalities,
Indigenous communities are also more vulnerable to the effects of climate change, which is
tied to crop failure and a general decrease in availability of food in the Amazon.
Communities would benefit greatly with improvement to healthcare access with a culturally
relevant approach. It is important to acknowledge local perceptions of health and incorporate
it to strategies in improving Indigenous healthcare. Collaboration of medical personnel with
local healers and incorporation of Indigenous knowledge could be useful alongside education
to inform and prevent disease. In order to improve health of Indigenous communities, it is
important to identify and address the structural factors that increase the vulnerability of
Indigenous communities, including environmental and cultural aspects.
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