Assessing the Potential of Indigenous-Run ...

Assessing the Potential of Indigenous-Run Demographic/Health Surveys: the 2005 Shuar Survey, Ecuador

Brad D. Jokisch & Kendra McSweeney

Human Ecology An Interdisciplinary Journal ISSN 0300-7839 Hum Ecol DOI 10.1007/ s10745-011-9419-6

1 23

Your article is protected by copyright and all rights are held exclusively by Springer Science+Business Media, LLC. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your work, please use the accepted author’s version for posting to your own website or your institution’s repository. You may further deposit the accepted author’s version on a funder’s repository at a funder’s request, provided it is not made publicly available until 12 months after publication.

1 23

Author's personal copy Hum Ecol DOI 10.1007/s10745-011-9419-6

Assessing the Potential of Indigenous-Run Demographic/ Health Surveys: the 2005 Shuar Survey, Ecuador Brad D. Jokisch & Kendra McSweeney

# Springer Science+Business Media, LLC 2011

Abstract Despite improved national censuses and “microdemographic” studies, demographic processes and health conditions among indigenous populations in Amazonia and elsewhere in lowland Latin America are not well understood. A new source of demographic and health data has emerged in the past decade, namely meso-scale surveys initiated and administered by indigenous organizations. These surveys offer the potential for filling information gaps, shedding light on culturally specific factors that shape demographic processes and health, and empowering indigenous organizations with data that could inform health initiatives. This article assesses the indigenous-run survey “2005 Health Analysis of the Shuar and Achuar Nations” of eastern Ecuador in which the authors were involved, which reached 1,943 households in 257 communities in Morona-Santiago Province. We present findings on fertility, migration, sanitation, and health, and assess the strengths and weaknesses of the survey. We argue that despite flaws in the survey design and implementation, this survey revealed important linkages among fertility, migration, and health. Such surveys have the potential to provide much needed detail, representativeness, and cultural specificity that macro and micro data sources cannot provide. We conclude with recommendations to improve surveys of this type. Keywords Indigenous meso-scale surveys . Demography . Health . Migration . Census . Amazon . Ecuador . Fertility . Shuar

B. D. Jokisch (*) 122 Clippinger Labs, Ohio University, Athens, OH 45701, USA e-mail: [email protected] K. McSweeney Ohio State, Department of Geography, 1036 Derby Hall, 154 N. Oval Mall, Columbus, OH 43210, USA e-mail: [email protected]

Introduction Knowledge of the demographic dynamics of indigenous populations worldwide is notoriously poor (UNICEF 2003; UNESCO 2004). Many countries do not have a good grasp of how many self-identifying indigenous peoples inhabit their borders, and many indigenous societies know little about their own demographic processes. Among other things, the lack of data compounds difficulties in addressing the acute public-health problems that indigenous peoples face (PAHO 2004a, b; Montenegro and Stephens 2006; Heaton et al. 2007). This is the case in Latin America’s lowlands, particularly in Amazonia. While recent research has yielded some preliminary insights into general trends, including high rates of natural increase (Kennedy and Perz 2000; McSweeney and Arps 2005a) and increasing domestic and international migration ( Del Popolo et al. 2007; McSweeney and Jokisch 2007), many important questions remain (Montenegro and Stephens 2006), including identifying the culturally-specific factors shaping indigenous women’s high fertility, how such information can help address the appalling levels of maternal and infant mortality and morbidity reported among these populations (PAHO 2004b; Izquierdo 2005; Mondini et al. 2007), and how increased mobility creates new contexts of vulnerability for indigenous migrants and their families, including a host of conditions associated with rapid transition to urban living (Peña and Bacallao 2000; Uauy et al. 2001; McKay et al. 2003; Bitrán et al. 2005). To answer these questions, researchers have used two very different data sources—national-level censuses/surveys and “micro-demographic” studies (Kennedy and Perz 2000; Banda 2004)—each with their own strengths and weaknesses. For example, the ‘2000 round’ of national censuses in Latin America revealed stark disparities between indige-

Author's personal copy Hum Ecol

nous and non-indigenous populations within and across nations (e.g., Montenegro and Stephens 2006; Heaton et al. 2007). But disaggregation of the data by specific regions or individual ethnic groups reveals multiple problems associated with the state’s coverage and definition of indigenous peoples (Banda 2004; UNESCO 2004; Del Popolo 2005; Pereira et al. 2009). On the other hand, micro-demographic studies of individual indigenous populations, typically conducted over time by academics, health workers, missionaries, and others, offer ethnographically rich, detailed subsamples (see Kennedy and Perz 2000; McSweeney and Arps 2005a)1 that shed light on cultural, historical, and political factors shaping demographic dynamics in specific indigenous societies, although these same characteristics limit generalization. Both separately and in combination, these standard data sources have provided some important insights into indigenous demographic trends in Amazonia (Kennedy and Perz 2000; UNESCO 2004; Pereira et al. 2009). Nonetheless, they leave large information gaps, particularly with regard to the demographic/health dynamics of individual indigenous groups in excess of approximately 2,000 people too large for adequate microdemographic representation but small enough to be lost in censal aggregations (UNESCO 2004; McSweeney and Jokisch 2007). In light of the scarcity of good data on such groups, it is no surprise that state-level and international health policies tend to default to the promotion of generic, one-size-fits-all “indigenous” programs (McKinley 2003; Kramer et al. 2007). However, meso-scale demographic and health surveys initiated and administered by indigenous organizations have the potential to fill the information data gap. At least three such surveys have been carried out in Amazonia since 2003. Funded in part by NGOs and the United Nations (e.g., UNICEF, UNFPA), these high-profile surveys have been conducted among Sateré-Mawé (Brazil), Shuar (Ecuador) and multiple groups in Brazil’s Upper Rio Negro region (see Teixiera 2005; UNICEF 2007; Azevedo 2003, respectively). While still unusual, these are seen as “pioneering” efforts (Teixiera 2005) to be replicated as part of international efforts to “maximize the use of different source of data on indigenous people” (Banda 2004:16). Surveys run by indigenous organizations of their own populations have considerable potential for improved 1 We do not consider surveys conducted by academics that included demographic information on indigenous populations within a broader sampling of a multi-ethnic rural population, because they were not intended as comprehensive assessments of specific indigenous groups’ demographic and/or health profiles (e.g., Bilsborrow et al. 2004, Carr et al. 2007). Similarly, the Demographic Survey of Maternal and Infant Health (CEPAR 2004) and the Living Standards Measurement Survey (cited in Larrea and Montenegro Torres 2006) are national samples, but they are distinct from the autonomous indigenous surveys under discussion.

understanding of demographic and health dynamics, for several reasons: a) they are flexible, easily tailored to offer the rare combination of ethnically-specific data and a relatively large sample size (e.g., at least hundreds of households) (Banda 2004); b) the means by which inclusion/exclusion in the population of interest is defined is established endogenously; c) they generate data at multiple scales (e.g., individual, household, village) that reflect forms of collective organization that are locally meaningful, and also allow for cross-scalar analysis of attribute data (cf. Pereira et al. 2009); d) as ideally designed, administered, and evaluated by indigenous peoples, they are likely to yield highly relevant and high quality data and subsequently useful policy insights (see Puertas and Schlesser 2001; UNESCO 2004); e) finally, and importantly, indigenous organizations recognize these surveys as potentially powerful political tools—“instrument[s] of liberty and equality” (J. Cabral, in Teixeira 2005), in large part because they are geared to specific group concerns and because indigenous organizations anticipate that survey results can be used to leverage funding from states or NGOs for health, education, or other self-defined projects. There are a number of reasons, however, to be less sanguine about the merits of indigenous-run surveys. One, they might be seen as only a temporary stop-gap as states continue to improve their national censuses to accommodate indigenous realities (including a separate ‘indigenous census’ as is used, for example, in Venezuela). Such national instruments, in effect, should be able to generate accurate demographic and health indicators at the level of individual ethnic groups (e.g., Pereira et al. 2009), making indigenousrun efforts largely redundant. Second, independent, indigenous efforts are costly, and their idiosyncratic development runs the risk of generating poor quality and non-comparable data. They may thus contribute little to standardized databases on indigenous health that demographers and others are calling for as a critical step towards meaningful and coordinated improvement in that sector (e.g., Montenegro and Stephens 2006). Third, the long-term experiences of North American indigenous peoples with the generation of demographic/health information points to the many ways in which the process can sideline indigenous perspectives and ultimately serve outsider interests rather than redress internal health concerns (e.g., Gray et al. 2004). In addition, funders’ schedules may overwhelm native preferences for the pace and timing of the survey; research partners may not make data and results accessible to communities, and so on (UNESCO 2004). This paper weighs in on this debate by critically assessing one indigenous-run survey in which the authors were involved: the “2005 Health Analysis of the Shuar and Achuar Nations,” (hereafter the Survey). Led by the Interprovincial Federation of Shuar Centers (FICSH) in the


Ecuadorian Amazon province of Morona Santiago, the Survey was designed to form a demographic and health baseline for the province’s approximately 45,000 Shuar, with emphasis on Shuar living in rural areas.2 Reaching 1,943 households, it is to our knowledge the largest survey of its kind conducted of an indigenous group in lowland Latin America. The Shuar Survey offers support for both perspectives. For example, data generated by the Survey yield important insights into the conjoined dynamics of Shuar demography and health—of the kind specifically desired by the Shuar Federation and by outside organizations involved in Shuar-led programmatic improvements in health care (e.g., UNICEF, regional state hospitals). In this respect, the Survey conformed to our expectations that, indeed, much can be learned from such surveys that is unlikely to be learned without them, and that such surveys deserve to be taken seriously for the useful insights they offer into ethno-specific health/demographic dynamics. But while the richness of Survey-derived findings point strongly to the merit of such endeavors, our assessment also confirms that important questions and concerns remain about the process of designing, conducting, and evaluating such surveys. In what follows, we locate Shuar demography and health within their historical and regional context. We then discuss the Survey from its design to the dissemination of results, with attention to our role in the process. This is followed by a review of some of the more important and suggestive findings that we feel illustrate key strengths of this type of Survey, particularly on what it revealed about trends in fertility, migration, sanitation, health, and the links among them—topics of interest and concern to Shuar survey planners (see UNICEF 2007 for a comprehensive review of the findings). We then discuss specific strengths and weaknesses of the Survey, and conclude with some ways that the latter might be overcome in other indigenous surveys.

Shuar Demography in Historic and Political Context Of Ecuador's 14 million people, an estimated 25% are indigenous. The majority are highland Quichua, with a much smaller fraction (F=0.000). The model indicates that, holding other variables at their means, centros with a higher incidence of maternal sickness overall also: had significantly more migrants; were significantly further from modern medical facilities (clinic or hospital); were significantly more likely to rely on surface water (river) for drinking; were more likely to have no traditional or modern health care providers living in the community; had significantly larger household sizes (which suggests greater crowding); had significantly fewer births per household over the previous year; had fewer community latrines; and were significantly less likely to have legal title to their communal lands.

400

Shuar (n=2519; TFR~7) Indigenous Ecuador (TFR=4.9)

350

Mestizo Ecuador (TFR=3.1) Sateré Mawé (n=1367;TFR=8.08) Baré (n=613; TFR=4.83)

300 250 ASFR

Fig. 3 Age-specific fertility rates (ASFR), comparing indigenous and non-indigenous populations. See legend for sample size of women and estimated total fertility rate (TFR) for that population. Shuar (Survey, 2005); Indigenous and Mestizo Ecuador (INEC 2001); Sateré Mawé (Teixeira 2005), Baré (Azevedo, 2003)

With the exception of the incidence of migrants (see following section), the model suggests that the well-being of Shuar women of child-bearing age is significantly affected by the crowding, sanitation and transportation infrastructure of their community, as well as the community’s overall legal status (which is closely associated with the level of community organization and the years since the centro was established). These findings suggest that investments in sanitation are essential to a comprehensive health program, particularly in light of the larger demographic context: Shuar communities are growing rapidly, and growing land-use constraints, particularly within the Upano Valley, mean crowding of centros will only intensify. Improvements in

200 150 100 50 0 15 19

20 24

25 29

30 34 age cohorts

35 39

40 44

45 49

Author's personal copy Hum Ecol Table 2 OLS regression model of community-level determinants of average reported sickness of Shuar women (aged 15–49) per household (mean=0.21±0.35 sick women/household)

Asterisks indicate the confidence level of the result: *p≤0.10, **p≤0.05, ***p≤0.01

Variable

Coefficient

Intercept Number of migrants per centro (mean = 0.1±0.2) Distance in hours to nearest medical center (mean = 2.9±3.2) River is source of drinking water (1 = yes (22%); 0 = no) No modern medical available locally (1 = yes (35%); 0 = no) Average household size (mean = 6.44±1.5) Average births per household in past year (mean = 0.39±0.3) Latrines available locally (1 = yes (61.4%); 0 = no) Centro has legal title (1 = yes (60.6%); 0 = no) Total observations (n) Adjusted R-squared Df

−0.10 0.30** 0.03*** 0.10* −0.08 0.06*** −0.21** −0.01 −0.10** 210 0.20*** 7.36

clean water and sanitation are urgently needed, and must be planned to anticipate significant growth in demand. Unexpected Migration Destinations In 2005, the Shuar Federation leadership expressed concern at the growing number of Shuar migrants, and expressed interest in gaining better data on the migration processes. Problems in the design of the Survey, however, limited its usefulness in this regard. Responses to questions that were included, however, revealed that just over 12% of all households reported at least one migrant, but only 2.6% reported that the migration took place during the previous year (Table 3). As expected, half of all migration occurred within the same canton (county), the average age of the migrants was early 20s, and a majority of the migrants were male (56.7%). Also as expected, a tiny but important minority of Shuar were living overseas. Spain was the preferred destination of the 26 documented emigrants who had reportedly migrated during the economic crisis of the late 1990s/ early 2000s (n=18) over the United States (n=7). This finding was somewhat unexpected because 60% of emigrants from Morona Santiago were reported to be in the United States (INEC 2001). Migration, Health, and Development: Surprising Links The Survey yielded evidence that Shuar households which included either domestic or international migrants (hereafter, “migrant households”) appeared materially wealthier than others—i.e., they were more likely to have a ‘colonist’ style house (with sawn timbers and a metal roof), to own land beyond the centro of residence, and to have more cattle. It is impossible to know if acquisition of these assets preceded or followed migration. But despite their relative wealth, migrant households pay a high health cost for having one or more members away: difference-of-means tests revealed

higher rates of reported sickness in households reporting at least one migrant; the relationship held in both the Upano Valley and Trans-Kutukú. Further, the higher the number of migrants per household, the higher the rates of reported sickness of remaining members. Households with no migrants averaged 0.65 reported illnesses in the previous two weeks; those with one migrant reported 1.21 illnesses; those with two migrants reported 1.32 illnesses, and those with three migrants reported 3.66 illnesses; these differences were significant (ANOVA). While this relationship may appear to simply be a function of the relative age of migrant households, the association held even when the age of the household was held constant. These findings were corroborated by evidence that sickness was more likely to be reported among households receiving remittances from absentee members, and this was particularly pronounced in the Upano Valley.12 Centro-level analyses corroborate the household-level signals regarding greater levels of reported sickness among migrant households (Table 2). Combined, these counter-intuitive findings are intriguing because other studies suggest that receipt of remittances tends to enhance the health of close non-migrant family members (Burazeri et al. 2007). For example, in Ecuador, LopezCevallos (2008) found that at the national level, international remittances had a direct, positive effect on health by increasing the purchase and use of anti-parasitic medicines. Our findings, in contrast, seem more in line with Pribilsky’s (2001) research from highland Ecuador, which found that numerous migrant households report children being afflicted with “nervios,” a folk description for an illness resembling depression and/or anxiety. The greater incidence of illness in Shuar homes of migrants suggests the need for better research on, and policy attention to, such households. 12

The Survey did not ask the quantity or frequency of remittances, simply if the household receives remittances and how the remittances are spent.

Author's personal copy Hum Ecol Table 3 Shuar migrants Total Total no. households reporting migrants Total no. of migrants reported Destination of migrants Intra-Provincial

Extra-Provincial

International

208 (10.8%) 254 131 Males: 56.1% Median age: 20 97 Males: 57.8% Median age: 19 26 Males: 84.6% Median age: 25

UNICEF 2007

Strengths and Weaknesses of the Shuar Survey The Survey reviewed here was a meso-level demographic/ health instrument executed largely by and for an indigenous population in the eastern Ecuadorian Amazon. The scale of its coverage and the semi-autonomous nature of the Survey mean that it may have considerable potential as a model for indigenous groups to understand their own demographic and health issues and plan accordingly. We therefore review the Survey’s key strengths and weaknesses. Strengths 1. The Survey design was simple, questions were basic and straightforward, and misreporting was minimized by the fact that interviews were conducted in Shuar and Spanish by Shuar. It was highly successful in acquiring most of the information necessary to meet the stated data needs of personnel in the Shuar Federation, UNICEF, and the associated clinic and hospital. The Survey covered an impressive 11,000 individuals—a very robust sampling of the target population. 2. Notwithstanding some problems with data quality and data omission, straightforward statistical analysis of Survey data yielded surprising results, providing important and much-needed information for Shuar policymakers and their advocates. For example, the demonstrated links between community and individual health and sanitation infrastructure offers critical support for Shuar efforts to secure funding for improved water and sewage systems. 3. The endogenous nature of the Survey was a key strength. If census-taking is the mark of statecraft (Scott 1998), then the administration of a demographic/ health census by an indigenous federation appears to be

an important step towards collectively enacting the rights to self-determination enshrined in the new “UN Declaration on the Rights of Indigenous People” (Human Rights Council, 2007). Shuar are empowered when they begin the process of acquiring greater knowledge of their population dynamics and health status, and are better able to anticipate their future needs and composition. 4. Because the Survey focused on a self-defined indigenous population, thus getting beyond a crucial “disaggregation” problem that has challenged analysts of indigenous health using standard censal data (Banda 2004), it produced important findings that would likely not have been uncovered using alternative data sources, including the national census. The above examples show this focus allows analysts to use a large sample size to explore patterns and processes while being assured that ethnic ascription holds across the population, allowing for demographic/health issues to be understood within their specific cultural context.13 5. An important strength of the Survey was its recording of demographic and health information at multiple scales, each of which reflected locally meaningful levels of social and political organization (cf. Pereira et al. 2009). Our analytical ability to identify how community-level factors correlated with individuallyreported ill-health, for example, was predicated on our ability to collapse and merge data collected at the three scales generated by the Survey. This led to compelling evidence that the lack of clean water and adequate sewage facilities within Shuar centros are having measurable impacts on the well-being of portions of the population that are already epidemiologically vulnerable, including women in their child-bearing years. Such insights would be impossible using national census data, in which the lowest level of aggregation is the parish (parroquia), which has little meaning in Shuar social-political organization (a parish can include multiple centros and is distinct from a Shuar association), and obscures the sub-parroquia level processes essential to understanding health outcomes. 6. The Survey effectively combined health and demographic data. Although it may seem axiomatic that effective health interventions are those informed by good baseline data on a population’s age structure and vital rates, too often health concerns in developing areas are assessed separately from comprehensive population censuses (Belizán et al. 2005), making the information gathered in these 13

The Survey was designed to include only Shuar or Achuar; the number of mestizos represented in the Survey is likely trivial because the Survey was conducted in recognized rural Shuar centros, where the number of mestizo inhabitants is very small.


disparate endeavors very difficult to reconcile. Indeed, it is ironic that Shuar—like many rural minorities—have been surveyed numerous times; during interviews, respondents complained of survey fatigue.14 Further, data gathering exercises rarely match quantitative data with qualitative insights (UNESCO 2004). These disjointed processes lead to redundancies and poorly targeted health interventions, particularly in remote areas where the high cost of health provision makes careful targeting all the more imperative (Montenegro and Stephens 2006). The Survey’s integration of demographic and health issues therefore represents a model of conceptual and operational synergy between culturally sensitive public health programs and ethno-demographic research.15 To be sure, the design and execution could be much improved. But the results exemplify the sort of unexpected insights that can result even from such an imperfect study. For example, the exploration of combined migration and health dynamics moves beyond standard proximate understandings of health, to show that households and communities that send migrants carry a measurable health burden by doing so—even when they are receiving remittances. Given that migration among Shuar is likely to increase (see McSweeney and Jokisch 2007), health intervention efforts need be informed by data on how migration translates into health effects for those left behind. Weaknesses of the Survey The primary weaknesses of the Survey arise from issues of its design, training, sampling strategy, and its reliance on outsiders for funding, analysis, and dissemination. Indeed, if we hold the Shuar survey to the standard for data generation articulated by UNESCO (2004: 10) that Indigenous peoples should fully participate as equal partners, in all stages of [demographic and health] data collection, including planning, implementation, analysis and dissemination, access and return, with appropriate resourcing and capacity-building to do so. Data collection must respond to the priorities and aims of the indigenous communities themselves 14

For example, the NGO CARE had recently completed a 1,500household survey of some portion of the study population; the Director of Health intermittently launched small surveys; the National Census had been carried out in 2001, and academics occasionally survey portions of the population. 15 We are aware that the narrow biomedical understanding of health (emphasized here) only represents a portion of how indigenous people approach their well-being (Izquierdo 2005). While the latter is beyond the scope of this study, we are aware of the ways in which alternative understandings of health could be better integrated into demographic/ health surveys generally.

then the Survey falls far short on several fronts. 1. Design and Training: The design phase was rushed. A generic health questionnaire was modified to accommodate some Shuar specifics, but the process was not particularly participatory or consultative. Also, there was only a one-day piloting of the Survey (UNICEF 2007). Had draft questionnaires been more broadly circulated among Shuar health personnel, and had the piloting been more extensive, then a few problems– including the Survey’s problematic and confusing articulation of illnesses in Spanish rather than in the Shuar language—might have been avoided. These lowcost modifications would have significantly improved an already quite adequate survey, lessening the potential for the survey to represent a “missed opportunity.” Although we were not privy to the process by which interviewers were trained, the uneven quality of the resultant data suggests that training might have been more rigorous. These were challenges faced by other indigenous surveys (see Azevedo 2003; Teixeira 2005). Improved training implies, of course, a high ‘sunk cost’ because of the difficulty of assembling, training, and dispatching 50+ individuals over a logistically challenging landscape. But had this training been ‘piggybacked’ onto other health-related training, rather than conducted as a one-off exercise, cost efficiencies and effectiveness might have been significantly enhanced. 2. Sampling strategy: Overall, the Survey’s sampling strategy was quite good; it reached an impressive number of Shuar individuals, households and centros (see above). However, the Survey was limited to rural Shuar and excluded urban Shuar living in Macas or Sucúa. This restriction was understandable given that the vast majority of Shuar live in rural centros, where they have extremely limited health care access, minimal sanitation, and hundreds of undervaccinated children. However, this decision resulted in a missed opportunity for documentation and scrutiny not only of urban Shuar, but of the complex urbanrural linkages that have a direct bearing on the wellbeing of all Shuar. Other indigenous surveys, in contrast, explicitly incorporated urban members of the target groups for these reasons (see Azevedo 2003; Teixeira 2005). The cost of incorporating urban residents could be offset from the gains accrued from a smaller rural sample. The variation among centros in Trans-Kutukú, for example, was small enough to justify a sampling strategy that would have included a smaller number of centros. 3. Reliance on outsiders: Ideally surveys like this one would be nearly autonomous and not rely on outsiders for the most critical components of the survey design,


implementation and analysis. In this case that would not have been realistic. Meso-scale surveys such as this inevitably require some partnering of indigenous organizations with external sources of funding and technical expertise. In this case, the Survey was “Shuarrun” only to the extent that it was planned and directed by the Shuar Director of Health, and executed by Shuar interviewers. Its funding, schedule, analysis, and dissemination relied on external parties—sympathetic ones, certainly, who were keen to support the Shuar Health Director’s vision for long-term health planning. But their priorities and perspectives nevertheless shaped the Survey in ways that may have unintentionally challenged Shuar authority over the process and its products. Presumably, a more deliberative planning process, a less turbulent political landscape, and a less constrained funding schedule could have gone far to minimize these outcomes. 4. Related to this point, we are particularly aware of the degree to which the analysis of the Survey and its dissemination relied on foreign social scientists (us). Most of the insights reported here and in the UNICEF 2007 publication required some basic statistical manipulation beyond the skills of Shuar and other members of the Survey team. This reliance on outsiders is not unusual; two other indigenous censuses were widely publicized precisely because non-indigenous academics and bureaucrats took a central role in analyzing the data and disseminating the results. Yet this reliance is a weakness because it places indigenous federations in a vulnerable position. While the collection of data on their own populations is a laudable achievement that does its own political work (see Scott 1998), the fact remains that the data must be manipulated by outsiders in order to be mobilized to serve indigenous projects. This is a process that, while perhaps unavoidable, must be very carefully shepherded by indigenous leaders so that indigenous data needs are prioritized throughout the analysis process (see, e.g., Gray et al. 2004). In this the case, the shift in Shuar leadership and our subsequent loss of sustained contact with the original survey stewards meant that our analysis lacked this guiding hand. While we tried to keep our analysis focused on the needs originally articulated by Shuar, we cannot know how much improved the results of a more inclusive analysis might have been.16

16

We do know, however, that our interactions with the Shuar Director of Health, while limited to brief discussions of survey design, calculation of basic demographic indicators, database development, and methods for presenting data (population pyramids, age specific fertility rate graphs, and the like)—informed his subsequent design of a similar survey among a separate population of Shuar.

Conclusion After weighing these strengths and weaknesses, we conclude that despite challenges, surveys such as the 2005 Shuar Survey are worthwhile for two primary reasons. First, the Survey results suggest immediate, pragmatic programmatic targets for the Shuar Federation. Second, it offers broader lessons about the potential for meso-scale studies to “open up” understanding of how and why indigenous populations face the demographic and health challenges that they do, and how these might be addressed. It therefore seems clear that indigenous-run surveys can offer information at a level of detail, representativeness, and cultural specificity that neither microdemographic studies nor large-scale samples such as national censuses or Demographic Health Surveys can. We are therefore convinced that they represent an important statistical complement to more conventional health and demographic approaches, and can demonstrate and build native peoples’ capacities for greater self-determination. Clearly, however, their effectiveness as either sources of sound, policy-relevant information or political empowerment rests on the quality of the survey process and results generated. With this in mind, we offer some recommendations for future indigenous surveys, including those planned in Ecuador and elsewhere. Regarding process, the three ‘indigenous-run’ surveys with which we are most familiar —all in Amazonia—relied to a large degree on external financing and outsider (mostly academic) support with data analysis and report-writing. Based on the experiences of First Nations people in Canada (see Gray et al. 2004), it seems likely that while completely independent indigenous censuses are neither feasible nor desirable, the type and degree of exogenous involvement can be incrementally rolled back. One way to accelerate this process—in Amazonia and elsewhere in Latin America—is for national indigenous organizations to be more closely involved from the outset. A national-level organization is, presumably, better positioned than individual indigenous federations to slowly assume the role held by outsiders, including some basic systematization of data-collection and analysis in order to reduce the redundancies, learning curves, and costs associated with one-off efforts such as the Shuar Survey. Further, national organizations can maximize the mobilization of resultant data in national and international policy forums to better support indigenous peoples’ selfdefined health projects at all levels. Outsiders can support this transfer of power by ensuring that all data related to the surveys with which they are involved—including reports summarizing the process, analysis, data storage protocols, and so on—be made available to all collaborators (see also UNESCO 2004). The institution most appropriate to take on this task would depend on the country. Clearly, it must have credibility among indigenous federations (and other organ-


izations) and have the personnel and funding to sustain the effort. A national effort likely will not provide a quick-fix to the numerous problems outlined above, but it may facilitate greater indigenous control and reduce missed opportunities. In the meantime, our experience suggests the need for immediate investments in demographic education within indigenous federations—in, for example: a) basic ‘demographic literacy’—i.e., a sound grasp of vital rates, sample techniques, etc.; b) survey design and administration; c) training in coding surveys and familiarity with database management; d) knowledge of standard statistical techniques; e) the conceptual tools to link demographic insights to health priorities; and f) finally, the need to build a systematic database documenting health outcomes over time. One way to build such capacity is to incorporate basic demographic training into processes that have already been relatively successful: in the case of Shuar, training of health promoters and auxiliary nurses. This would offer a relatively cost-effective way to have demographic inquiry “piggy-back” onto ongoing health initiatives. Since most of the indigenous surveys with which we are familiar already integrate health workers into data collection efforts, it seems natural that this group also include those trained in data analysis and mobilization, as well as having the long-term data management expertise to allow demographic information to be stored and accessed alongside, and in reference to, health records. Finally, the international community might profitably invest in “demographic-health” scholarships for indigenous health professionals towards meeting these goals. Whether meso-scale surveys become more popular or not, indigenous communities have a vested interest in generating, managing, and analyzing data about their own demographic and health processes. Acknowledgements We thank Steve Rubenstein for his advice and support throughout the research process. In Ecuador, we are most grateful to Washington Tiwi, Dr. José Pozo Mosquera, Rosana Posligua, Cecilia Dávila, Dr. Juan Chau, and the leadership and membership of the Shuar Federation (FICSH) for their guidance and willingness to incorporate us into the survey process. We are also grateful for fieldwork support from the National Geographic Society and a Lawrence A. Brown Faculty Fellowship at Ohio State. We thank the anonymous reviewers for their constructive comments.

Appendix 1. Estimates of parity derived from the Shuar Survey (2005)

FERTILITY Total births in past year for all households (household data; BR EST 1) Birth rate (births/total population*1000) ESTIMATE 1

Total 750 62.89

Birth rate (births/total population*1000) ESTIMATE 2 Birth rate: ESTIMATE 3 Age-specific fertility rate (ASFR): 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Total Fertility Rate (TFR): Total women over 50 years All women >50 for whom we have fertility data Total no. births to women >50 for whom we have data Completed fertility rate (all children born to women over 50)

35.56 41.51 88.14 269.31 358.40 328.03 295.03 110.00 70.97 7.60 234 143 878 6.14

References Azevedo, M. M. (2003). Demografia dos povos indígenas do Alto Rio Negro/AM: um estudo de caso de nupcialidade e reprodução. Unpublished Doctoral dissertation, Universidade Estadual de Campinas (UNICAMP), Brazil. Banda, J. P. (2004). Data collection pertaining to indigenous peoples: issues and challenges, Workshop on Data Collection and Disaggregation for Indigenous Peoples. Department of Economic and Social Affairs, United Nations. (4 August, 2009). www.un.org. Belizán, J. M., Cafferata, M. L., Belizán, M., et al. (2005). Goals in Maternal and Perinatal Care in Latin America and the Caribbean. Birth 32(3): 210–218. Bilsborrow, R., Barbieri, A., and Pan, W. (2004). Changes in Population and Land Use Over Time in the Ecuadorian Amazon. Acta Amazonica [online] 34(4): 635–647. Bitrán, R., Giedion, U., Valenzuela, R., et al. (2005). Keeping healthy in an urban environment: public health challenges for the urban poor. In Fay, M. (ed.), The Urban Poor in Latin America. The World Bank, Washington D.C, pp. 179–194. Burazeri, G., Goda, A., Tavanxhi, N., et al. (2007). The Health Effects of Emigration on Those who Remain at Home. International Journal of Epidemiology 36: 1265–1272. Carr, D., Pan, W., and Bilsborrow, R. (2007). Declining Fertility on the Frontier: the Ecuadorian Amazon. Population and Environment 28: 17–39. CEPAR (2004). Situación de salud de los pueblos indígenas en el Ecuador. Encuesta Demografica y de Salud Materna e Infantil (ENDEMAIN). Quito, Ecuador: El Centro de Estudios de Población y Desarrollo Social (CEPAR). (January) cepar.org.ec/ endemain04/nuevo06/indice.htm Del Popolo, F. (2005). Pueblos indígenas y afrodescendientes de América Latin y el Caribe: relevancia y pertinencia de la información sociodemográfica para políticas y programas [Paper presented at: Seminario Internacional, Pueblos indígenas y afrodescendientes de América Latina y el Caribe]. CEPAL. (30 May, 2005). www.cepal.cl Del Popolo, F., Oyarce, A. M., Ribotta, B., et al. (2007). Indigenous Peoples and Urban Settlements: Spatial Distribution, Internal Migration, and Living Conditions. CELADE, Santiago de Chile. Dias Júnior, C. S. (2008). Fecundade das mulheres autodeclaradas indígenas residentes em Minas Gerais, Brasil: uma análise a

Author's personal copy Hum Ecol partir do Cénso Demográfico 2000. Cad. Saúde Públic 24(11): 2477–2486. Gray, J., Gideon, V., Tournier, C., and Schnarch, B. (2004). Our Voice, Our Survey, Our Future: The “Survey of Choice” by First Nations in Canada! Presentation to the Workshop on Data Collection and Disaggregation for Indigenous Peoples United Nations Permanent Forum on Indigenous Issues, New York (September) www.un.org/esa/socdev/unpfii Guerrero, F. (2006). Población indígena y afroecuatoriana en el Ecuador a partir de la información censal de 2001. Pueblos indígenas y afrodescendientes de América Latina y el Caribe: información sociodemográfica para políticas y programas. Santiago, Chile: Comisión Económica para América Latina y el Caribe (CEPAL), pp. 155–166. Hagen, E., and Clark Barrett, H. (2007). Perinatal Sadness Among Shuar Women. Medical Anthropology Quarterly 21(1): 22– 40. Hagen, E., Clark Barrett, H., and Price, M. (2006). Do Human Parents Face a Quantity-Quality Tradeoff?: Evidence from a Shuar Community. American Journal of Physical Anthropology 130: 405–418. Harner, M. (1972). Jívaro People of the Sacred Waterfalls. Doubleday/ Natural History Press, Garden City. Heaton, T. B., England, J. L., García Bencomo, M., et al. (2007). The Child Mortality Disadvantage Among Indigenous People in Mexico. Population Review 46(1): 1–11. Hendricks, J. W. (1988). Power and Knowledge: Discourse and Ideological Transformation Among the Shuar. American Ethnologist 15: 216–238. Human Rights Council (2007). United Nations Declaration on the Rights of Indigenous Peoples. United Nations, New York. INEC (National Institute of Statistics and Census) (1951). Censo de Población y Vivienda. Quito, Ecuador. INEC (National Institute of Statistics and Census) (2001). Censo de Población y Vivienda. Quito, Ecuador. Izquierdo, C. (2005). When “Health” is Not Enough: Societal, Individual and Biomedical Assessments of Well-Being Among the Matsigenka of the Peruvian Amazon. Social Science and Medicine 61: 767–783. Jívaro Indians of Ecuador. (ca. 1936), Washington D.C.: National Anthropological Archives and Human Studies Film Archives. Kennedy, D., and Perz, S. G. (2000). Who are Brazil’s Indígenas? Contributions of Census Data Analysis to Anthropological Demography of Indigenous Populations. Human Organization 59(3): 311–324. King, K., and Haboud, M. (2002). Language Planning and Policy in Ecuador, Current Issues in Language Planning 3(4):359–424. Kramer, K., Russell, L., and Greaves, G. (2007). Changing Patterns of Infant Mortality and Maternal Fertility Among Pumé Foragers and Horticulturalists. American Anthropologist 109 (4): 713–726. Larrea, C., and Montenegro Torres, F. (2006). Ecuador. In Hall, G., and Patrinos, H. A. (eds.), Indigenous Peoples, Poverty and Human Development in Latin America. Palgrave Macmillan, New York, pp. 67–105. Lopez-Cevallos, D. F. (2008). Understanding health care utilization: a theoretically-based analysis of the Ecuadorian health care system. Unpublished Dissertation, Oregon State University, Corvallis. Lu, F. E. (1999). Changes in subsistence patterns and resource use of the Huaorani Indians in the Ecuadorian Amazon. PhD dissertation, Department of Ecology, University of North Carolina, Chapel Hill. McKay, L., Macintyre, S. and Ellaway, A. (2003). Migration and Health: A Review of the International Literature, Medical Research Council Social and Public Health Sciences Unit, Occasional Paper No. 12 (January).

McKinley, M. (2003). Planning Other Families: Negotiating Population and Identity Politics in the Peruvian Amazon. Identities: Global Studies in Culture and Power 10: 31–58. McSweeney, K., and Arps, S. (2005a). “A Demographic Turnaround”: the Rapid Growth of Indigenous Populations in Lowland Latin America. Latin American Research Review 40(1): 3–29. McSweeney, K., and Arps, S. (2005b). Meta-analysis of demographic trends among indigenous populations in lowland Latin America. Unpublished paper presented in Tours, France: IUSSP XXV International Population Conference; 25pp. McSweeney, K., and Jokisch, B. (2007). Beyond Rainforests: Urbanisation and Emigration Among Lowland Indigenous Societies in Latin America. Bulletin of Latin American Research 26(2): 159–180. Mondini, L., Canó, E. N., Fagundes, U., et al. (2007). Condições de nutrição em crianças Kamaiurá–povo indígena do Alto Xingu, Brasil Central. Revista Brasileira Epidemiologica 10(1): 39–47. Montenegro, R. A., and Stephens, C. (2006). Indigenous Health in Latin America and the Caribbean. The Lancet 367(9525): 1859– 1869. PAHO. (2004a). Maternal and child mortality among the indigenous peoples of the Americas [On-line Newsletter for Indigenous People—Healing Our Spirit Worldwide]. Pan-American Health Organization. (September) www.paho.org/English/DD/PIN/ pr0407.htm PAHO. (2004b.) Health of the Indigenous Peoples Initiative: Data Collection and Disaggregation Workshop on Data Collection and Disaggregation for Indigenous Peoples, 19–21 Department of Economic and Social Affairs, United Nations. (4 August) www. un.org Peña, M., and Bacallao, J. (2000). Obesity Among the Poor: An Emerging Problem in Latin America and the Caribbean. In Peña, M., and Bacallao, J. (eds.), Obesity and Poverty. A New Public Health Challenge. Pan-American Health Association, Washington D. C., pp. 3–10. Pereira, N. O. M., Santos, R. V., Welch, J. R., Souza, L. G., and Coimbra Jr., C. E. A. (2009). Demography, Territory, and Identity of Indigenous Peoples in Brazil: the Xavante Indians and the 2000 Brazilian National Census. Human Organization 68(2): 166–180. Popoff, C., and Judson, D. H. (2004). Some methods of estimation for statistically underdeveloped areas. In Siegel, J. S., and Swanson, D. A. (eds.), The Methods and Materials of Demography, 2nd ed. Elsevier Academic, Amsterdam, pp. 603–641. Pozo, Dr. Juan Pozo Mosquera (2005). Personal Communication. Pribilsky, J. (2001). Nervios and ‘Modern Childhood:’ Migration and Shifting Contexts of Child Life in the Ecuadorian Andes. Childhood 8(2): 251–273. Puertas, B., and Schlesser, M. (2001). Assessing Community Health Among Indigenous Populations in Ecuador with a Participatory Approach: Implications for Health Reform. Journal of Community Health 26(2): 133–147. Riach, J. R. (2004). Ecosystem Approach to Rapid Health Assessments Among Indigenous Cultures in Degraded Tropical Rainforest Environments: Case Study of Unexplained Deaths Among the Secoya of Ecuador. EcoHealth 9(1): 86–100. Rubenstein, S. (2001). Colonialism, the Shuar Federation, and the Ecuadorian State. Environment and Planning D: Society and Space 19: 263–293. Rubenstein, S. (2002). Alejandro Tsakimp: A Shuar Healer in the Margins of History. University of Nebraska Press, Lincoln, Nebraska and London. Rubenstein, S. (2007). Circulation, Accumulation, and the Power of Shuar Shrunken Heads. Cultural Anthropology 22(3): 357–399. Scott, J. C. (1998). Seeing like a state: how certain schemes to improve the human condition have failed. Yale University Press, New Haven. Teixeira, P. (2005). Sateré-Mawé: Retrato de um povo indígena. UNICEF, Manaus, Brazil.

Author's personal copy Hum Ecol Uauy, R., Albala, C., and Kain, J. (2001). Obesity Trends in Latin America: Transiting from Under-to Overweight. Journal of Nutrition 131: 893S–899S. UNESCO. (2004). Report of the Workshop on Data Collection and Disaggregation for Indigenous Peoples United Nations Permanent Forum on Indigenous Issues, New York (September) www. un.org/esa/socdev/unpfii/news/news_workshop_doc.htm UNICEF. (2003). Ensuring the Rights of Indigenous Children Innocenti Digest No. 11, UNICEF Innocenti Research Centre, Florence.

UNICEF. (2005). UNICEF in Ecuador. Quito, Ecuador. ISBN-13: 97892-806-3947-6. UNICEF. (2007). Diagnóstico de Salud de las Nacionalidades Shuar y Achuar (Informe sobre los Resultados del Diagnóstico de la Situación de Salud de las Nacionalidades Shuar y Achuar de la Provincia de Morona Santiago, FICSH-FIPSE-NAE 2005). Report produced by Brad Jokisch and Kendra McSweeney. Quito, Ecuador: UNICEF (with the Ministry of Public Health and the Shuar Federation).