My fieldwork experiences in Ecuador provided me unique insight
into the cultural contexts and primary health issues of the Andes’ poor and
most vulnerable communities. Working in both urban and rural settings, I used a
variety of data collection methods, including: interviews, medical chart
reviews, participant-observation of traditional healing practices, focus groups,
formal tours of the private hospital system, and enrichment lectures on
national health, global development and culture. I used this knowledge to identify
several ubiquitous health issues and surmise patterns of causation and
consequences of systemic disparities in the health care delivery system. The
primary health issues I observed were: (1) Water, Sanitation and
Hygiene-related Diarrheal Disease (WASH), (2) Acute Respiratory Infections
(ARI), (3) Machismo and Gender Health Equity, (4) Access to
Emergency Medicine in Rural Communities and (5) Stigma, and Ethnomedical Bias
in the Treatment of Supernatural Illness.
Diarrheal Disease: Water,
Sanitation, and Hygiene in Ecuador’s Rurality
Lack of access to safely managed drinking water and sanitation
services, and unsafe hygiene practices, has profound effects on people’s
health. Beyond the immediate, obvious advantages of clean water and good
hygiene practices, access to improved drinking water, sanitation and hygiene,
(known collectively as WASH), has wider socioeconomic impacts, particularly for
women and girls. WASH-related disease, such as diarrhea, is a significant
public health problem for Ecuador’s rural communities, where limited access to
health care and poor sanitation infrastructure, together with environmental and
cultural factors in development, contribute to disease transmission.
Diarrhea causes a person to lose both water and electrolytes,
which leads to dehydration and, in some cases, to death. Diarrheal morbidity is
especially dangerous for children because it makes them vulnerable to other
diseases and malnutrition, and to stunted growth and poor physical and
cognitive development. Its impact on child mortality and morbidity rates is
significant, with 131 Ecuadorean children under five dying from diarrheal
disease due to poor sanitation, poor hygiene, or unsafe drinking water last
year. Moreover, it affects the overall quality of life and contributes to
socioeconomic inequalities between urban and rural communities, where the
disease burden is higher. Prevalence rates are highest among the Indigenous,
who have a unique way of understanding diarrheal-disease; and because of this
cosmovision, and ineffective treatment, there are higher incidences of disease.
Acute Respiratory
Infections
This section uses data collected from fieldwork observations and
national agencies of statistics to describe the burden of acute respiratory
infections (ARI) in Ecuador from 2015 to the present. Cases of acute upper
respiratory infections, Influenza and pneumonia, and Bronchitis and other acute
lower respiratory infections were frequently listed in the medical histories at
Camp Hope; and were frequently cited in focus group discussions in Otavalo. ARI
prevalence also stood out in data collected at the hospital in southern Quito. Over
the last 5 years, there were 14.84 million cases of ARI, with 17,757 deaths
reported. The yearly burden of disease ranged between 98,944 to 118,651 DALYs,
with an estimated loss of productivity of USD 152.16 million. This burden is
primarily attributed to years life lost due to premature mortality in
populations under 5 years-old and over 60 years-old.
Respiratory infections are often difficult to diagnose. In
Ecuador, as in other tropical latitudes, the absence of a well-defined flu
season, the coexistence of other respiratory viruses and the variability of
clinical presentation of acute respiratory infections, predispose health
services to underestimate the burden of ARI. Additionally, diagnostic tests can
be time-consuming and costly, making laboratory confirmation of each case
impractical.
Nonetheless, ARI make up a huge proportion of the global disease
burden in Ecuador, United States, and across the planet, with an estimated
94,037,000 DALYs and 3.9 million deaths each year. In Ecuador, ARI is the
second most common environmental cause of illness and is attributed to risk
factors like living in crowded conditions, malnutrition, lack of immunization,
HIV, and exposure to tobacco or indoor smoke. Cultural factors also have a role
in transmission. Indigenous interpretations of ARI are primarily linked to
supernatural causes, making it unlikely for folks to be treated by biomedical
practice. Instead, an ethnomedical treatment will be used.
ARI mortality is highest among indigenous communities; and while
it’s important to respect cultural difference and contextuality in health care,
many ethnomedical practices pose a significant risk to already vulnerable
communities.
Machismo and Health Equity
“Por el machismo” (because of machismo) was a
constant theme in the focus groups, interviews, and lectures about culture,
health, and sexuality in Ecuador. When machismo is the norm in
a society, it strongly and negatively impacts the lives of women. Women are
considered inferior to men and are pigeonholed into socially constructed models
of femininity that reinforce male domination. This power over women restricts their
agency, discouraging them from talking openly about their health, especially
sexual and reproductive health.
Machismo has an enormous impact on gender
health equity in Ecuador. Limited decision-making power makes it difficult for
women to negotiate family planning methods and condom use; and is ultimately
responsible for the highest teen pregnancy rates in South America. Unplanned
adolescent pregnancies trap women in intergeneration cycles of ill-health and
poverty that circumscribe women’s health disparities; and lead to higher rates
of maternal and child mortality, and infectious disease. For example, lack of condom
use increases sexual transmission of Zika, causing microcephaly and other co-morbidities
in newborn babies. This is also true for HIV and STI transmission. Estimating
the human toll of machismo on gender health equity in Ecuador is
essential for advancing towards a healthier society.
Universal Health Care in
the Specific Context of Access to Emergency Medicine in Rural Communities
Ecuador adopted a new constitution over a decade ago, with the
goal of creating a society in which all citizens would have “buen vivir”, or
good living, through the eradication of poverty, promotion of sustainable
development, and fair distribution of resources and wealth. An aim of this goal
included unimpeded access to high-quality health care services at no direct
cost to individuals. With a strong focus on primary care, this health model was
thought to increase the responsiveness and fair financing of the country’s
health care delivery system. Despite universal coverage and the establishment
of a comprehensive public health system, a lack of access to emergency medicine
is a critical health concern for many people living in Ecuador’s rural
communities.
The nearest hospital is often several hours away, and public transportation
doesn’t extend into many rural communities. Focus group participants in Otavalo
indicated they are more likely to choose a local private health agency,
including traditional healers, despite the high cost of care, state trust in
traditional medicine as the reason. However, when asked about the quality of
emergency ethnomedicine, most respondents said they would choose a public,
allopathic, option next time. This suggests that the provision of free health
services is not sufficient to reach universal health coverage for patients with
medical emergencies, especially those living in rural communities.
Ethnomedical Stigma and Institutional
Bias in the Public Health System
A global initiative of Healthy People 2020 addresses the need for
culturally competent healthcare in multicultural societies, where ethnomedical
models for health are not fully embraced. In Ecuador, indigenous peoples make
up only 7% of the population, but they bear an overwhelming burden of disease. Poverty,
lack of access to education and healthcare, stigma towards Kichwa-language and ethnomedical
culture, and environmental constraint in development, places indigenous
communities at a disadvantage. Despite universal coverage, the supply and
quality of healthcare provided by the government is inefficient and poor; and
it doesn’t always extend to the many communities of the Andean rurality. Thus,
the health of indigenous peoples largely depends on traditional healers and
ethnomedical care. This distinction is exacerbated by the stigma experienced by
indigenous peoples in public health care settings that favor occidental
approaches to care. By dismissing ethnomedical interpretations, medical
providers are effectively asserting their cultural dominance over the indigenous
experience, segregating them from biomedical care; and the wall between
worldviews is built to keep this cultural divide.
Institutionalized bias in the public health care system undermines
indigenous community health, by refusing to embrace ethnomedical models of
treatment. Culture-specific ailments including brujeria (witchcraft), mal de
ojo (evil eye), envidia (envy
sickness), mal aire (evil air), nervios (anxiety or depression), susto (magical fright), espanto (soul loss), alcohol abuse, and empacho (constipation) are dismissed by
the dominant culture, and traditional healers are delegitimized by biomedical
providers. This gives power to the stigma which ultimately prevents indigenous
communities from receiving the medical care they need to be healthy; and
further isolates the burden of disease in the already vulnerable rurality.
Understanding the etiology of supernatural illness is necessary for the
promotion of health and well-being in indigenous communities. By incorporating both traditional and
biomedical models for care into the public health system, indigenous people can
actualize their right to health care in a manner that is culturally competent
and grounded in the health beliefs of their community. Developing intercultural
care involved a profound level of mutual respect and cross-cultural
understanding that goes beyond the intersubjectivity of patient-doctor relationships,
to embrace indigeneity and the historical struggle for cultural agency that
circumscribes the indigenous experience.
Cultural Comparisons of
Health in the U.S. Context
Unlike Ecuador, the United States does not
afford the right to healthcare to its citizens and invests very little in the
public health system. As a result, millions of people are left to piece
together their healthcare from free clinics and public health departments or
pay the high cost of private insurance and out-of-pocket expenses. Medical
treatment is primarily for the privileged and isn’t designed to meet the
specific needs to the poor and most vulnerable communities. In the U.S. as much
as in Ecuador, social determinants and environmental constraint define the
health of a community and the disparities they experience. Comparing the top 5
health issues of Ecuador to the U.S. will reveal the power of cultural
differences and contextuality in healthcare; and will a shed light on causality
for the disease burden in diverse communities.
Comments
Post a Comment