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close this bookCERES No. 075 (FAO Ceres, 1980, 50 p.)
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View the documentRecommendations and realities: Women in rural development
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View the documentCentring on Health
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Centring on Health

The double burden of heavy farm work and family leaves its mark on the women of the Peruvian altiplano. Nutritional support and voluntary health services are offering some glimmer of hope

by Daphne Wilson-Ecoli

For most of the developing world, the main issue of women's health is still a desperate need for basic health care, sadly lacking at even the most elementary level for the mass of the population in the rapidly growing cities, but even more difficult to provide in rural areas where even the simplest health facilities are few and far between. According to the World Health Organization (WHO), more than half of the world's population does not have access to adequate health care services and facilities.

WHO has urged governments to correct the present bias, which favours the better-off in urban areas, and to put more emphasis on preventive medicine. Immunization, nutrition programmes, safe water supply and better drainage, and sanitation would greatly reduce health risks.

Just how difficult it is to bring "health for all" to the vulnerable groups was brought home to me when I recently visited some of the poorest mountain areas of Peru. I saw hospitals and health centres distributing supplementary rations of wheat, flour' maize, soya-milk blend, vegetable oil and tinned fish provided by the World Food Programme (WFP) for vulnerable groups. About 120 000 pregnant and nursing mothers and children under six are eligible under the project, which is receiving $13 million worth of food from WFP over a three-year period. Caritas International and other voluntary agencies are also providing food assistance.

Below accepted levels

The absolute poverty of women in the high mountain valleys and the altiplano of the Peruvian Andes is strikingly evident, and one hardly needs statistics to show how badly extra nourishment is needed. The Sierra covers 26 percent of the country, but almost half of the total population (estimated at 17 million) lives there in the densely populated valleys, mainly farming small uneconomic plots, difficult to cultivate and often consisting of small strips terraced from the steep mountainside. Peru has one of the lowest percentages of tillable land in the world: out of a total land area of nearly 3 million km2, only 35 000 are under intensive agriculture. Few crops can be grown at these altitudes (4 000 metres above sea level, on the average), and the local diet, consisting of potatoes and cereals with a little meat or milk from the herds of llamas or sheep, is about 40 percent below accepted levels. Indeed, it is estimated that 70 percent of the children under six years of ace in the Sierra suffer from malnutrition. The majority of the population live in overcrowded conditions: about 90 percent of the houses consist of one room with an average of four occupants. The average GNP per head is below $100 a year as against the national average of $620.

From the train that crosses the high, cold, windswept altiplano going toward Puno on the shores of Lake Titicaca, one sees an awe-inspiring landscape of yellow grassland skirted by the vast mountain peaks, many of them permanently snow-covered. Here we are above the limits of crop cultivation and there are people everywhere. They live almost entirely on the herds of llamas and sheep, using their wool for clothes, their meat and milk for food, their dung for fuel and the animals themselves for transport. The herding of livestock is mainly done by the women, who also spin, weave and knit the wool. About 13 million hectares of land can only be used for this type of pastoral farming.

Recent years have seen an increase in the migration of men away from the Sierra, where the land yields too little, to become wage labourers in the mines and industries of the coastal areas. Where agriculture is possible the men will return to do the heavy work of ploughing with oxen and digging the earth with the chaquitaolla, the ancient wooden hand plough that has remained unchanged since Inca days. The migrants come back again for the harvest. But nearly all the other field tasks - sowing, planting and weeding - are regarded as women's work, as are the feeding of animals, collecting of wood and water and small-scale marketing. Women have the double burden of heavy work on the land and the domestic tasks of feeding and caring for the family.

The many who die

With a poor diet it is small wonder that repeated pregnancies, often beginning in the early teens, seriously undermine the mother's health. The population is growing at an annual rate of 3.1 percent, with 22 percent under six years of age. Forty-six percent of women are in their child-bearing years and, in the health centres I saw every other women seemed to have an infant slung on her back in a stripy shawl fastened across her chest, while other small children clung to her skirts.

Even women who look far too old to have children claimed, when asked, to be in their thirties, and many of them were expecting their sixth or seventh living child. They often spoke of the many who had died. Deaths of children under five years of age account for approximately half of all mortality. The death of a child is accepted by peasant women as "natural and inevitable."

The numbers who attend the health centres preclude any very detailed follow-up of the condition of any individual, though pregnant women and babies are weighed and inoculated and records kept of their treatment.

The poor rural areas do not attract doctors. In 1976, in all Peru, there was one doctor for every 1580 persons (compared with 600 in the United States), but the majority of them are in the urban areas and the coastal region. Near the shores of Lake Titicaca, I spoke to Juan Cusacani, a young health auxiliary, whose small health post serves a population of 10 000 people. He had had six months' training and some short refresher courses. "I am on 24-hour duty call," he said. "I give first aid and do small operations like stitching a bad wound."

Proud of their status

He is a good example of a keen and dedicated community health worker, who had trained his own volunteer helpers from a largely illiterate population. He introduced with some pride his assistant midwives - four old women and one old man - a group representative of the 20 volunteers who work under his supervision in the widely scattered community. Poor, simple and seemingly old, they are obviously proud of their status. They showed me the book of tickets on which they record deliveries performed. The top scorer was an old lady who had delivered a hundred babies during the year (I did not have the heart to ask how many survived). Midwives are trained, they said, to refer complicated cases to the nearest health post with a trained doctor, some 10 km distant over the rutted cart track we had jolted down ourselves, and I pitied the poor woman in labour whose "complicated case" had to follow that route.

I asked the midwives if they were able to give their patients any advice on family planning. They shook their heads, perhaps a little disappointed that I had found something lacking in their service. Obviously, the "complicated case," if she survived, would continue to conceive at her peril.

The impact of supplementary feeding programmes on nutrition standards is hard to measure. How much does the food do for the health of the mother and child when it is given in the form of rations, which may be shared among the whole family? We do not know if a mother keeps such food for herself and her latest child if several others are hungry. However, nutritionists and health workers at the distribution level consider food aid to be a most valuable. Some regret the fact that the food aid is restricted to pregnant and nursing mothers or to severely malnourished preschool children. "It seems unfair," one said "and it is hard for us to justify, when the need is so great, that a mother can no longer receive food when her baby is six months old or her malnourished child passes its sixth birthday."

The risk of misuse

In some cases, the mothers who are not eligible earn WFP food rations for their families through "food-for-work" projects: building and painting their own club premises, improving the health centres or creating a garden or children's playground.

As far as supplementary feeding projects for mother and child are concerned, there has been a growing awareness in recent years within the World Food Programme that these need to be looked at more critically. Since they require considerable resources over a long period from governments and do not give an immediate return, they do not usually have a very high priority in national development plans. To make a real impact, the international community would have to commit larger quantities of food aid, guaranteed over a longer period, and combine it with other programmes providing for basic health services, safe water, better sanitation, nutrition, family planning, education and improvement of the condition of women.

Deep concern has also been expressed about the effect of the use of dried skim milk for babies and infants, and the twin dangers of discouraging breast-feeding while encouraging mixing of milk with contaminated water. Provisions are made to avoid these dangers, but the risk of misuse through ignorance and unhygienic conditions still exists.

It has also been pointed out that poor mothers who receive free food only when they are pregnant or nursing a baby for the first six months of its life find themselves in dire straits when they are no longer entitled to it.

They may well feel that free food is a "reward" for becoming pregnant again, an idea that certainly conflicts with the message other UN bodies are trying to convey.

Hence, the current interest in trying to give mothers some other kind of help to prepare them to provide the necessary nutritious food for themselves and their children when their entitlement to WFP food ends.

Food aid has considerable power to attract mothers to attend the health centres. They need an incentive to overcome such obstacles as the distances they have to walk with small children, the long hours they have to wait to see the nurse and collect their rations - time that is difficult to spare from their many household and farming tasks. When they are together, there is an opportunity for instruction in better nutrition practices, maternal and child care, family planning and hygiene. But unless adequate premises and qualified staff are also available, the opportunity is lost.

Practical benefits

At several of the health centres I visited, mothers' clubs had been formed. Some of these women had organized a savings club, had built their own club premises, had their own plot of land under cultivation and teachers who came to give literacy classes. Much of the initiative had come from the nutrition and health workers, but once the idea was established, the women were ready to devote time and energy, especially to activities that resulted in practical benefits and increased income. Women brought together in such groups, provided it is clear to them what the advantages will be, can form the basis for more ambitious community action. Income-producing activities are initially more attractive because women whose whole energies are devoted to making ends meet are far more likely to spend time at a class that holds some promise of economic benefit than to listen to exhortations about hygiene, although this can be added once the group is formed.

In a study for the Copenhagen Women's Conference Ruth Dixon has made a number of suggestions as to how such rural women's groups could be developed with training, loans and technical assistance to organize small enterprises such as fish cultivation, poultry and rabbit raising, beekeeping, mixed vegetable farming, fruit drying and so on. Where arable land is scarce, other cooperative enterprises, such as crop processing and handicrafts in which women are already engaged, could be upgraded to make their products more marketable and profitable. The emphasis is on work that produces income.

An insult

If rural women are expected to improve the health and nutrition standards of their families as well as increase food production, there will have to be a far greater concentration on them by government planners as a target group for aid: for education, to provide income-generating possibilities, to give them access to membership of credit and cooperative associations, to introduce them to technology to release them from their endless drudgery and enable them to spare some of their energies for making life a little more bearable.

It is a fact that rural women are certainly not afraid of hard work. When one sees what they undertake, it seems an insult to speak of "involving women in the development process." What they can contribute depends on improving their status and their access to resources and opportunities. The building up of women's groups for self-help, training and income-producing activities could be a valuable first step which, despite the low esteem in which international and government planners usually hold women's organizations, could release a considerable resource of hitherto untapped energy for development.