By Courtney Mullen
This essay was one of two winners of the 2013 Finding Big Ideas Essay Contest. The other winning essay was Narissa Iqbal Allibhai’s “Young Artistic Leaders Rising from the Slum.” The winners of the 2014 competition are Shrey Goel’s essay, “Rendering the Private Public: A Collective Approach to Slum Improvement,” and Jennifer Fei’s “The International Rescue Committee’s New Roots Program: Uncovered Terrain in US Refugee Resettlement.”
A small two-lane highway stretches hours into the Andes mountain range from Cusco – a city of over 500,000 near the Urubamba Valley in the south-eastern part of Peru. Concrete buildings, paved roads, and constant blaring of horns on the busy Cusqueñan thoroughfare of Avenida de la Cultura gives way to an marked increase of small adobe buildings, and dirt roads. Each small village is centered on one public plaza for Sunday market. The larger villages may have one Ministerio de Salud (or public health clinic). Further from the main highway, the isolation of the rural Andes is much more apparent. Trash collection, sewage treatment, and running water, becomes more rare. Residence of these remote villages may walk hours to see a doctor, leaving their farms and families a great distance away.
Most of the rural towns surrounding Cusco are based off of subsidence farming. Almost all families make less than 1,000 soles a year (362 USD), which translates to about one dollar a day. In addition, women’s education is not culturally encouraged or favored in these communities. The vast majority of women within the campo regions had a primary education, a partial primary education, or no education at all. Some sign their names by a stamp of their thumb. Illiteracy is not uncommon in Quechuan villages, especially for women.
This past summer, I spent eight weeks volunteering in Cusco for the NGO, CerviCusco, which is dedicated to lowering rates of cervical cancer–especially among indigenous Quechan women living in nearby rural Andean villages. This volunteer experience was a required part of my Minor in Global Poverty & Practice, a popular undergraduate program housed within the Blum Center for Developing Economies at UC Berkeley.
While I was researching CerviCusco before the summer, I came across the name of the Belenpampa Clinic. I learned that it was one of the first clinics in Cusco to adopt the vertical birth method. In Quechan culture, it is customary to give birth vertically at home, with the support of a woman’s husband and family. The decision to adopt the birth method into the clinic’s obstetrics wing shows the clinic recognized a need to serve the cultural and personal preferences of Quechan women looking to give birth comfortably in a culturally sensitive environment. In this way, the clinic recognized a need to adopt indigenous birthing practices into the hospital in order to cater to the health needs of its patient population, who would have otherwise shunned western, sterilized rooms.
However, what surprised me the most was its construction of two small adobe buildings that houses both patients and their families for free leading up to the child’s delivery. The construction of the adobe buildings demonstrates the outward concern the hospital has toward making its patients comfortable in seeking maternal healthcare. Many contemporary clinic births contribute to widespread unattended births—about 52% in the campo regions of Cusco (Fraser, Barbara). Whether the lack of attention to these pregnancies in a rural environment is a byproduct of monetary factors, unreliable transportation, or lack of affordable temporary housing, or perhaps a combination of all three, I am unsure. Regardless, the presence of family for a child’s birth is quite important in Quechua culture.
The Belenpampa clinic of Cusco differs from its many publically funded counterparts in the city by addressing healthcare disparities; particularly those between the rural, often indigenous poor, and the urban center of Cusco. Although Peru has universal healthcare, Belenpampa recognized positive healthcare outcomes are much more dependent on the social factors surrounding access, and cultural values surrounding health care.
Belenpampa’s family houses did not specifically take place within the context of my practice experience, however, I believe it significantly reinforced why the idea is so powerful for increasing positive health outcomes for women living in rural areas of the Andes. If the clinics I visited with CerviCusco were able to house patients in free housing, as with the clinic in Belenpampa, I believe the amount of women seeking care and having an attended birth, as well as for other aspects of primary care, would see a large percentage increase. I believe access to such clinics, not the free cost of Peru’s socialized health care, is the primary limiting factor for women living in isolated rural areas. The need for extra support is crucial in the campo regions–much more so than the urban environment of Cusco due to the lack of infrastructure in regards to ad-hoc transportation of cars converted into taxis, collectivos (small minibuses), and trucks, (which are much easier to obtain in Cusco), and almost unlimited supply of major hospitals and public clinics. Regardless of universal healthcare, lowering the burden on women’s social obligations to their work and families is much more needed.
I believe the adoption of Belenpampa’s free housing to families of expecting mothers should be adopted in the surrounding rural Ministerio de Salud clinics outside of Cusco, due to the variety of answers I garnered while conducting CerviCusco’s surveys this summer. Mainly, there is still a severe disconnect between the health of the rural poor, and the inhabitants of the metropolitan Cusco city center. Regardless of a rural village supplying medication, and access to nurses, doctors, and widwives, for comprehensive health care to be effective and utilized routinely there needs to be some cushion that incentivizes the cost of leaving their precarious farming household and livelihood for a short period of time to increase maternal and other aspects of primary health care in the surrounding rural areas of Cusco.
While working with CerviCusco this summer, the clinic conducted a variety of “campaigns” to rural villages on average about 2 hours away from Cusco. While the majority of the visiting medical students were conducting pap smears, and the Peruvian clinic staff helping with the intake of patients, I conducted surveys surrounding patient knowledge of cervical cancer, and how accessible doctors are to these women. The survey included a variety of personal questions including but not limited to education level, annual income, and number of children.
I must have asked this question, “Cuanto dinero gana tu familia en un año?” or, “How much money does your family make in a year?” countless times this summer. Almost every reply was “un poco,” a little, nothing, or less than 1,000 soles. I remember being told by a Ministerio de Salud worker, or, equivalent to a public health worker that everyone makes less than 1,000 soles annually in the campo regions of Cusco. There was no point of even asking that question on the survey.
It was through these many campaigns, and speaking to so many women, that the idea I witnessed made me much more cognizant of the fact that the Peruvian government should take steps to implement this idea throughout all of their public Ministerio de Salud clinics.
The “family houses” based in Belendpampa, if constructed next to other Ministerios de Salud in the campo regions of Cusco, would significantly alleviate the cost burden of finding housing for family members wanting to support their loved one, and the baby’s delivery. This would encourage Quechan women to have their kids under the oversight of medical personnel, rather than forced, out of financial constraints, to have their child at home.
While giving the survey, I also needed to ask the patients, “Que distancia viajaste por el Panaicolaou hoy?” How long did you travel for your pap smear today? The responses ranged from 10 minutes of walking, to 2 hours. For one woman to walk to up to 2 hours to get to the nearest clinic where we were conducting the pap smears demonstrates the fact that there is a severe lack of accessible and reliable transportation to and from surrounding areas of the rural villages. Though many of the clinics we visited kept an ambulance, there did not seem to be any off-road jeeps or cars that could get quickly and reliably to farms accessible only by dirt roads. I inferred that the ambulances were only kept for emergency transportation to and from Cusco, which is much more equipped to handle more advanced surgical procedures, and diagnostic tests. Therefore, if transportation is precarious and at times inaccessible during the rainy season, then, housing should be the next piece of concern to meeting the needs of Cusco’s surrounding rural areas.
Though Peru’s Comprehensive Health Insurance covers women of all childbearing age, “in order to be effective, public health insurance should also cover transportation to and from the health center and the cost of pre-delivery stay at the waiting house” (Fraser, Barbara). In addition, according to Ramirez in Fraser’s article, maternal mortality is “not just a matter for the health ministry, it is a social problem. Maternal deaths have to do with poverty, education, access to employment, access to roads, transport, and housing.”
My time in Cusco thoroughly supported these assertions. Positive healthcare outcomes are much more dependent on surrounding social factors, rather than universal healthcare itself. The adoption of other family houses to one of the many surrounding rural communities of Cusco, and developing an impact report before and after its construction would be quite useful to see if the “family house” idea could be extended outside of the urban setting of Cusco. The adoption of the women’s houses in Belenpampa into surrounding rural clinics of Cusco would likely alleviate maternal and infant mortality, and result in an increase in positive women’s health outcomes in Peru.