The information obtained from the participants’ observation, informal conversations and interviews have allowed the researchers to understand the different “levels of care” that are used by the indigenous communities to address their health problems. The first level of care in this community is the use of traditional medicine, which can be homemade or provided by a specific healer. In the case of an unsuccessful treatment, participants search for the second level of care, which is provided by the health professionals of the official Peruvian healthcare system.
3.2.1. Traditional Medicine
As reported previously, the first level of care for the indigenous community is the use of traditional medicine. Indigenous persons tend to use plants as the first level treatment, but the types and amount of plants used can vary significantly according to the community studied. While some medicinal plants are used as crushed ointments or poultices (e.g., chupasangre against bumps or the leaf of tobacco for wound healing), other seeds are ingested, such as yahuar piri piri for the treatment of intestinal infections and bloody diarrhea. Another method of preparation is boiling in water, as in the case of oregano for heavy digestion or stomach pain. Some of them may even have different application options, such as sangre de grado: (I-12; indigenous, woman, secretary) “tears serve for all inflammations and healing. It is also taken for the gut, as antiseptics, for operations. You can apply directly or drink 2 or 3 drops in a glass of water, no more because it is very strong”.
In other cases, traditional medicine could also include animal remedies. This is the case of the gall of the majaz (large rat of the bush), whose use for a year provides contraceptive protection. Other animals are used as antidotes; for example, the river shrimp (camarón de rio) for scorpion stings or the termite comején for certain butterflies’ bites.
In addition to the physical effects of traditional medicine, participants have reported that there is a “spiritual component” in these plants that could enhance the treatment: (I-13; non-indigenous, man, priest) “there are plants that have a meaning that may seem strange, it’s what I call spiritual magic, but it really works. I have checked it and I have seen it with a man who was bitten by a poisonous viper”.
(I-2; indigenous, woman, community leader) “When we are worried or they say you have “mal aire (evil eye) [“Mal aire (evil eye)” is a metaphysical disease, whose terminology has been used since ancient times. The Indigenous population describe it as a phenomenon that occurs when a person sees someone walking at night and a light wind blows and this is accompanied by some spectrum. That ghostly appearance is considered an intrusion of evil since it enters the body of the subject who walks there and makes him sick. Sometimes it manifests itself in strange acute diseases, such as reddish and watery eyes and vomiting after encountering a spectral being or walking through places where there is bad energy], when you don’t have a job or you don’t feel good at job, you have mala vibra [bad vibes, bad energy]; when we are alone, we hear things, or imagine that someone is calling us, we take leaves, we boil them and we bathe. That’s how you feel well”.
(I-12; indigenous, woman, secretary) “My husband died and I saw him walking, but not in person like us, but his shadow. I started to vomit and if I didn’t take the piri piri I would have died. To stop seeing this shadow, I also put the crushed internal seeds in my eye (placed in a rag to make it wet)”.
In fact, although these spiritual issues are prevalent in this society, this is a universal truth found in every culture across time and geography and in no sense a unique observation among this ethnic group. Given these mystical issues, the indigenous population believes that the official health system is limited and does not offer them the services they consider appropriate for these spiritual problems, and, therefore, traditional medicine is considered as the only effective resource. As an example, the governmental health system has no treatment for “mal aire”, so indigenous people use their own treatments: (I-3; indigenous, woman, healer) “We use our resources [traditional medicine] in the case of mal aire (evil eye), scare or witchcraft, because they can do nothing or do not believe it [the official health system]”.
Self-Care at Home
The observations provide information on the important role of women in the healthcare of their children. Women are responsible for planting the medicinal plants, collecting information concerning the use of traditional medicine and treating the other members of the family: (I-15; indigenous, man, cocoa producer) “My mother [older woman] has planted there; she knows what are the healing herbs and to stop bleeding”. It is observed that women in the communities of Shonori and Bajo Capiri plant and take care of small orchards of medicinal plants next to their home. Each woman plants those herbs that can be used as a remedy more frequently, such is the case of piri piri for cuts. In the event that a woman does not have a certain plant, she usually receives it from another neighbor in her community.
Not only are women aware of the effects of natural remedies, but they also provide accurate information on use, dosage, duration of treatment or adverse events (Table 4
Traditional Specialized Care
When the homemade remedies do not work and the health problem persists or worsens, participants search for another type of treatment, considered a more specialized type of care which is provided by a traditional healer. Even when this specialized agent is not available in one community, it is sought in another community nearby. This was clearly observed by the principal researcher while investigating a residence with young girls. These girls refused to go to the hospital and demanded the presence of the head of an indigenous association along with a spiritualist healer.
The healers, also named shamans, are specialized indigenous persons who received at least one year of training. They are responsible for addressing the health problems of the indigenous population and use medicinal plants and spiritual rituals to treat patients. One of the best known rituals is the use of Ayahuasca, a tree from which the healer makes a drink to obtain spiritual and bodily healing: (I-14; indigenous, man, project technician) “If you want to know if someone wishes you evil, you can take the Ayahuasca. You start to see things, scenes, and with the indications of the healer you can know who is wrong”.
(I-1; indigenous, woman, university professor) “I was in poor health. I bathed, took pills and put on cream but nothing. On recommendation I went to a healer and did the Ayahuasca ritual. I saw how a house was built and crumbled, I built my boat and it also split. This was what happened in my life, that everything fell and nothing went well. Ants and a giant worm came out of my body. These bugs that represented evil began to leave my body with the healer’s song; I was being cured and since then everything improved”.
3.2.2. Official Health System
Use of the Official Health System
The fact that the indigenous population is recognized in Peru as a group in poverty, living in a vulnerable situation, the government confers the use of SIS (basic medical insurance) to this group. However, the official health system, as mentioned previously, is a resource that the indigenous population tend to use only when the traditional medicine is not enough to solve the problem: (I-5; indigenous, woman, traditional midwife) “When I see that it cannot be done at home or there will be problems [referring to childbirth], I say to the woman: I can’t see you, go to the doctor”. Nevertheless, even while using the official health system, traditional therapies are still used by the indigenous persons as a combined therapy. Thus, although medications such as monthly injectable contraceptives, antipyretics, anti-inflammatories and analgesics are used to treat acute medical conditions, these drugs are discontinued when the symptoms disappear: (I-7; non-indigenous, woman, doctor) “They usually come after 2 or 3 months, because they want to follow their customs and heal with their herbs. That is why they do not usually follow medical controls”.
On the other hand, they do not trust the use of official health services due to uncertainty about the true fate of blood taken in analytics, the beliefs that vaccines will make them sick (I-11; indigenous, woman, community health agent), and the perception of rejection by health professionals: (I-9; indigenous, woman, coordinator of a residence for students) “The herbs that women take in childbirth are strong and for them (health personnel) they stink”; (I-20; indigenous, woman, JASS member) “Although they [doctors] know that we take plants, after the surgery, they don’t say to use them to heal you”.
Strategies to Enhance Healthcare
To allow better access to certain health services and to reduce the economic costs to indigenous persons, the health facilities use medical specialists to perform more specialized care when needed: (I-10; non-indigenous, woman, doctor) “Sometimes we get some doctors from Lima to come; in October, ophthalmologists will come to operate cataracts using lasers in adults and the elderly”.
(I-7; non-indigenous, woman, doctor) “When we detect that several patients require psychological service, we ask for support from “Mazamari”. We will have the next psychological attention within 10 days”.
Another important strategy to minimize these cultural differences between the official health system and the indigenous communities is the use of CHAs. CHAs are important and influential people within their own community that work in a multidisciplinary team performing advisory functions, family assessments, child health monitoring, and health education. The principal investigator was able to observe the work of CHA in the community, including educational workshops on correct hand washing or proper incorporation of local foods to achieve an optimal nutritional balance in children. The indigenous Asháninka people spoke with greater confidence with these agents, they allowed them to enter their houses and this allowed them to alert the doctor to vital emergency situations, one of which even saved the life of a baby.
(I-11; indigenous, woman, community health agent) “We are seven CHA working with 60 moms. We usually walk from an hour to an hour and a half doing home visits. We record how mothers are taking care of their children and assess the conditions of their homes. We can enter their lives because we are people closest to them”.
Another strategy to improve healthcare is a system of financial compensation for mothers, which meets the minimum requirements for their children. The government program is named “Chispitas” and aims to monitor the nutritional status of children (I-10; non-indigenous, woman, doctor). There is also the social support program named “Juntos” [Together], in which every child receives routine health check-ups, receives the correct doses of vaccination and has their school attendance verified (I-6; indigenous, man, agricultural technician).
Weaknesses/Barriers to Healthcare
The most common barriers pointed out by participants were the difficult access to healthcare and the low coverage of the health system. Complex medical conditions are treated only in central areas such as Huancayo (7 h away from Satipo) or the capital of the country, Lima (12 h away from Satipo). This distance implies in the temporary abandonment of work activity and unexpected economic costs that Asháninka families usually cannot afford: (I-4; indigenous, woman, JASS member) “I have to go to Huancayo and would have to pay the ticket, the paperwork for the ticket, and also the stay and the operation. We will die because we have no money”.
Although medical facilities near the indigenous communities offer basic healthcare services, several deficiencies were noted by the principal investigator. It was observed that the facilities were old and the material was damaged and incomplete. During the visit, one of the medical facilities was running out of water for a week: (I-17; indigenous, woman, community health agent) “We have the support of the municipality, but there is no stretcher, nor equipped briefcases”. It was also common to hear health workers saying that some products (e.g., hand soap) were bought by themselves or by non-governmental organizations.
The lack of health personnel was another problem in the provision of care to these patients. As a result, professionals had to perform jobs even without having the proper competence to do so, such as cleaning, administrative tasks and treating health conditions outside their area of expertise: (I-7; non-indigenous, woman doctor) “If I’m not there, the nurse technician will attend the patient. I know it’s wrong, but there is no other doctor. The day I rest there is no doctor, and the same happens with the dentist for example”. Another problem is that the working conditions do not favor the continuity of care. Although in-training physicians are obliged to complete rural service during their studies, all of them leave the job after one year and new doctors have to be selected.
The fact that there is a conflict between medical personnel and indigenous persons due to cultural issues creates further difficulties. The health professionals interviewed recognized that the traditional medicine of the Asháninka population deserves respect, but they have no knowledge about these remedies: (I-7; non-indigenous, woman doctor) “I can’t lie to you, I don’t have much notion of herbs and their properties. They have so much diversity that I know them when they come and they tell me”. However, when the healthcare staff know their properties, they try to include these elements in the treatment options. An example the doctor from Huantashiri, who included sacha inchi as a treatment against a patient’s hypertriglyceridemia: (I-10; non-indigenous, woman, doctor) “it helps them to increase their level of good fats such as HDL. As a start, I do not suggest western drugs, but their products, which are healthy and available”.
It is this lack of knowledge about popular ways of addressing health problems that makes the connection between the traditional and official health system difficult: (I-16; indigenous, man, community leader) “There is a native local midwife, but the health staff does not have much contact with her. Sometimes it is not known that a woman is pregnant or has given birth. Nobody alerts health professionals”.