the efforts of the Aguaruna and the. Huambisa Jungle Indian Council to integrate water supply, hygiene education and sanitation into their primary health care.
Water supply in primary health care: experiences of Amazon Indian communities By Jamie Bartram and Warren Johns
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Jamie Bartram and Warren Johns describe the efforts of the Aguaruna and the Huambisa Jungle Indian Council to integrate water supply, hygiene education and sanitation into their primary health care programme. THE AGUARUNA and Huambisa Jungle Indian Council has developed what is in many ways a model primary health care programme; yet over the course of 11 years it has failed to make any real change in the pattern and incidence of diseases suffered by the population. Recent improvements in the health programme revealed .the fundamental problem to be the lack of emphasis on preventive measures. As a result, an improvement strategy integrating water supply, hygiene education and sanitation is being developed.
Area, lifestyles and changes The 35,000 Aguaruna and Huambisa Indians living in Peru occupy an area of 22,000 square kilometres in the northern jungle. The area has always been isolated, protected by a combination of impassable rapids, mountains and dense jungle; only relatively recently have Western influences penetrated significantly. The main communication and transport routes are the rivers. The few roads, restricted to a small area in the south, are often impassable after rain. Telephone, telegram and mail
services are non-existent for most people. The soil of the area is poor so, paradoxicaIly, the luxuriant forest is a potential desert. It survives by an intense recycling of nutrients in a delicate ecological balancing act. Although to outsiders the upland rain forest often appears underused, a large amount of land is needed to maintain the traditional lifestyle. The forest-dwelIing Indians have evolved ways of life which respect this delicate equilibrium: their own survival depends on the rational management of the forest and its resources. The traditional way of life of the Aguaruna and Huambisa is largely subsistence, based on slash-andburn agriculture, hunting, fishing and the collection of jungle fruits. The tribes lived in semi-dispersed extended family groups, each maintaining a number of clearings cut by the men but maintained by the women for growing cassava and plantain, the food staples. The clearings were cropped for about seven years after which they were no
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The health programme The new, larger and more stable communities created greater competition for the limited resources available. Nearby cultivable land gradually became exhausted, the rivers depleted of fish and over-hunting demanded ever longer journeys to find game.
Table 1. Drinking-water quality by source type in communities affiliated to the Aguaruna and Huambisa Council Source type
Jamie Bartram is employed as a Research Officer at the Robens Institute of the University of Surrey. Since 1985 he has been working in Peru in a water supply surveillance and improvement programme co-funded by the Overseas Development Administration and the Peruvian Government. He can be written to at the Environmental Health Unit, Robens Institute, University of Surrey, Guildford, Surrey GU2 5XH, UK. Warren Johns is the Laboratory Technician Adviser to the Aguaruna and Huambisa Jungle Indian Council, CTIR, clo Embajada Britanica, Casilla Postal 854, Lima 100, Peru.
longer considered viable, and fresh clearings cut. Hunting was a male preserve, as was fishing except barbasco fishing, when a large number of people would work together to dam and poison a stretch of river and then coIlect the affected fish. Families would move on when suitable land was exhausted or local game depleted. During the 1950s and 1960s, however, the tribes were attracted by the schools and new trading opportunities and began to form larger, more fixed communities, migrating towards the banks of the five principal rivers. Other changes affected the lifestyle of the Aguaruna and Huambisa at this time. The jungle began to be viewed by outsiders as an under-exploited resource. There was a frontier war with Ecuador and reports of land seizures by outside colonists: these factors led many of the communities to form the Aguaruna and Huambisa Jungle Indian Council (CAH) in 1977. The CAH has over 100 affiliated communities and has developed five principal programmes - including one on health.
Pozo (shallow
A
B
C
D
(%l
(%)
(%)
(%)
36
17
27
20
57
28
o
14
spring)
Quebrada (shallow stream) River
100
Note: Water quality defined by faecal coliform count by membrane membrane lauryl sulphate broth at 44°C. A = O/100ml
B
=
1-1-/100ml
C
=
11-50/100ml
filtration and cultivation
D
=
on
>50/100ml
Source: Archive of the Health Programme, Aguaruna and Huambisa Council; quoted in Jamie Bartram, Saneamiento Ambiental en las Comunidades Afriliades al Consejo Aguaruna y Huambisa: Problematica, Prioridades y Objectivos, 1987. .
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Greater population density and increased community contact both within the tribes and with outsiders have also brought new diseases to a population previously isolated from them: there have been epidemics of measles and whooping cough and the transmission rate of the faecal-oral diseases has intensified. With the increasing scarcity of traditional nutritional sources and increasing competition for land to cultivate around the communities, malnutrition is a serious problem. At the same time diarrhoea is the most common disease and the parasite carrier rate is 54 per cent. Children are quickly drawn into the cycle of diarrhoea-malnutrition and the nutritional losses are difficult to regain; consequently 53 per cent of children under five are anaemic. The health programme obviously has an important role to play in helping these communities to reduce the incidence of disease. The health programme is based around a network of about 100 health promoters; communities select their own promoters and build a health post. Using a community fund to purchase medicine, promoters can obtain about 30 essential drugs from the central pharmacy. The health programme also has an impressive support network of five health centres, one on each of the principal rivers. Each river has its own elected supervisor while the promoters themselves attend yearly re-training courses; courses are also arranged for newly appointed promoters. The health programme has, based at the health centres, five laboratory technicians who carry out basic tests: haemoglobin, blood smears for malaria, stools for parasites, urine for infection and sputum for tuberculosis to help diagnosis and treatment. Health centre laboratories are traditionally viewed as small-scale hospital laboratories with a diagnostic role affecting treatment. The CAH's experience has shown that this alone is not viable; what is also needed is a 'community diagnostic', not just individual treatment but also the determination of fundamental community health problems which would allow long-term preventive planning including water monitoring. The laboratories now work at three levels: water monitoring, patient diagnosis and survey work. The latter includes examining haemoglobin to assess the general occurrence of anaemia and surveying parasite carriage to see what preventive and community treatment measures are needed. Both diagnostic and survey work are now carried out from portable laboratory kits, while water surveillance centres around sanitary inspection and a portable battery-powered water-testing kit.
SWN 81 joumal bearing
SWN 80
joumal bearing
SWN 81 ball bearing
SWN 80
ball bearing
SWN 80 pumphead for depths to 40 m
pumphead for depths to 100m
pumpstand can be modified • for use as pressure or suction pump with optional units built into pumpstand
thick-walled 1'h" (48/36 mm) high impact PVC _st88lrod
1 %" high impact ----. pvc socket
Table 2. Household hygiene in the communities Aguaruna and Huambisa Council Household
affiliated
Domestic animals kept within the dwelling Raw fruit and vegetables stored above ground level Cooked food stored under a lid Drinking-water container stored above ground level Drinking-water container kept under a lid Source: Archive Council; quoted
83 62 62 32 43
of the Health Programme, Aguaruna and Huambisa in Jamie Bartram, Saneamiento Ambiental en las
Comunidades Afriliades al Consejo Aguaruna y Huambisa; Problematica, Prioridades y Objectivos, 1987:.
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0.75 m 1.50 m 2.00 m
~
3.oom 4.oom
PVC casing and filter cylinder 1.0
~~ng
0.0
lilt••
2" 50 87 90/81 2'/, 83 83 110/101 3" 75 90 110/101 4" 100 115 1801147 .1••• in n:lm
2"
MADE IN 2W.
to the
%
practice
mm stainless
ri~r/rod elements in lengths of
Water surveillance and community diagnosis Carrying out water supply surveillance in the northern jungle required first a 'diagnosis' of the existing
o 10
."
HOLLAND
0.3 It/stroke 0.5 It/stroke
1 .25 It/stroke 0.7 It/stroke
Van Reekum Matertu B.V. ~ P.O. Box 98 7300 AS APELDOORN. HOLLAND
Phone 55-213283 telex 36316 HAND OPERATED WATER SUPPLY EQUIPMENT
29
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problems, resulting in improved programmes, and continuing surveillance thereafter, where it was considered to be worthwhile. The first results from the diagnosis were surprising. It had always been assumed that the pozos (shallow springs) provided good water unless they were directly contaminated. When they were actually tested, however, they showed a variable, but high level of contamination, as did the principal rivers (Table 1). On the other hand, the quebradas (shallow streams) that ran through the communities, which had been assumed to be inferior sources, generally provided better water. In retrospect this should have been foreseen. The pozos are shallow depressions in the impermeable layer into which water slowly filters rather than fastflowing springs, and for convenience they are often dug near the dwellings. Although they were probably adequate when the tribes lived in small dispersed extended family units which moved regularly, as they grouped together and especially as they started to build latrines these springs became increasingly contaminated and contributed more and more to the exposure of community members to water-related diseases. The quebradas, however, are surface waters, so it should be assumed that they would carry higher levels of contamination, yet in practice their faecal contamination was generally lower. The reason for this was that
Table 3. Community
Health Diagnosis Results
Adults (%)
Age Group 6 to 11 (%)
o to 5 (%)
(%)
56
67
53
54
23
38
53
34
34
38
27
36
28
25
With intestinal parasites Anaemic (HB < 10g/dl) Hookworm carriers Healthy (non-anaemic with no intestinal parasites)
Total
Source: Informe do una encuesta de las frecuencia de anemia y parasitosis intestinal en 17 communidades nat/'vas del Alto Maranon relaizada por el Programa de Salud del Consejo Aguaruna y Huambisa. Asesores del Programa de Salud, CAH, 1988. communities are generally at the end of a quebrada where it joins the principal river; there is no tradition of keeping domestic animals except within the confines of the community itself, nor are there other communities above them on the same watercourse, so the water is relatively clean. Although quebradas may become contaminated as they pass through the community itself, any contamination introduced by stepping into the water or from dirty collection vessels is quickly carried away by the fast-moving current. The community diagnostic did not end with the water collection sites: the household storage of food and water and the use of latrines were also considered by the laboratory
workers (Table 2). Household water is generally stored in an open bucket or pot on the floor, making it open to contamination by both the children and animals. In contrast, the cassava beer is carefully tended in lidded pots, often raised off the ground. Whether this should be used as a model for household water storage, or whether drinking beer should replace water drinking was the subject of considerable discussion. At first, food storage appears to be a problem, since fruit and vegetables are stored at ground level, but whether there is a real health risk is not clear as most food is eaten hot and freshly cooked. Like many jungle groups, the Aguaruna and Huambisa Indians have scrupulous personal hygiene, but this may not always have direct health benefits. Hand-washing, for example, is invariably practised after eating, but rarely before. Although there are many latrines in the area, their contribution to health is doubtful as they are simple pit latrines, built close to the home and often inundated with water because of the high water-table. Their dampness gives them an unpleasant and unacceptable smell and also causes a fly nuisance near dwellings, with the accompanying health risks.
The future
Rain-water catchment guarantees a clean water source for some. 30
The persistently high level of intestinal parasites and anaemia as demonstrated by the laboratory survey has shown that over the years no fundamental improvement has occurred in real health status (Table WATERLINES
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3). The prestige of curative work has overshadowed the less glamorous work of greater long-term importance: that of prevention. Without approaching the fundamental cause - the hygiene habits that promote the diseases patterns will not change. So, after 11 years of developing a model primary health care programme, the CAH appears to have achieved little if simple health statistics are compared, although some successes can be seen, notably in the control of measles and chicken-pox by vaccination. But simple health statistics may not be an adequate measure. Forty years ago the communities of the Aguaruna and Huambisa tribes were scattered, lacked coordination and were under pressure from both the state and colonizers who they were in no position to resist, and who were likely to destroy their way of life along with much of the environment in which they lived. The CAH has provided a solid centre of activity for cohesion and autonomy, to which the health programme has contributed enormously. The work of these
Health promoters are a key part of the health care programme. years has built a solid infrastructure on which to build further, and disease prevention by vaccination has had some success. Individual treatment is under way and after a recent evaluation, new strategies for preventive medicine are being developed. Some communities have started to experiment with rainwater catchment; the latrine
problem is also seen as important, but the population has lost faith in traditional latrines, and Blair latrines are being considered as a more promising alternative. It seems that the achievement of good health in the developing world can only come by the actions of the people themselves - it will never come from outside. ~
WA TER TECHNICIANS BOTSWANA Senior Water Technicians are needed for five district councils to supervise the operation and maintenance of small to medium rural domestic water supplies which include borehole installations and diesel pumping stations. Some on-the-job training and administration involved.
Qualifications City and Guilds Certificate in Water Industry Parts I & II with 3 years' relevant experience including administration or recognised plumbing accreditation with substantial mechanical engineering and administration experience in water supply. Previous applicants are assured of consideration. IVS OVERSEAS provides a 2 year contract, salary based on local rates, flights, accommodation, NI contributions, medical cover and language training where necessary. Applicants
must have the right of permanent residence in U.K. or Ireland.
Regret no funding for dependants. Send C. V. to: Recruitment/Selection, IVS Overseas, 3 Belvoir Street, LEICESTER LE1 6SL. Please quote ref: WL/WAT/07/88.
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