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Understanding Peruvian Progress Fighting Maternal Mortality

Co-authored with Gustav Cappaert at Latin Correspondent.

Even though most maternal deaths are preventable, every day 800 women across the globe die due to complications during pregnancy and childbirth.

Peru is one of only two South American countries expected to hit its maternal mortality Millennium Development Goal, one of a set of UN-backed global poverty reduction targets that culminate in 2015. Peru today has a ratio of 67 maternal deaths per 100,000 live births, down from 265 in 1990.

The Andean nation remains behind industrialized countries like Japan (with a rate of six) but way ahead of the world’s least developed nations: in Sierra Leone, which has a maternal mortality rate of 1,100.

Help for expectant mothers

“The principal problem Peru has had is access to maternal health services,” said Mario Tavera, Health Specialist for UNICEF Peru. “Global evidence demonstrates that the reduction of maternal mortality is associated with medically-attended birth in health care centers,” he said.

Peru has made strides on this front, 80 percent of women now give birth at a medical facility, compared to just one quarter in the early 1990s. Over 90 percent attend prenatal care visits.

According to Tavera, Peru has more than doubled the number of state-run health facilities in operation, greatly increasing access to care. Some clinics operate associated casas maternas which allow women who live in remote areas to stay for up to a week as they wait to give birth.

But perhaps the most important change has taken place inside of clinics. “There’s a set of very distinct customs” in rural Peruvian communities, Tavera said. “The people were permitted to bring into the clinic customs from giving birth in their homes.” Family members were allowed into the birthing room for the first time; women were allowed to give birth sitting or on their knees; they could bring a rope to hold onto — another traditional custom.

There are wrinkles in this success story, though.

One-size-fits all?

Creating a one-size-fits-all policy is uniquely difficult in Peru. Its three major regions: coastal desert, mountainous center, and Amazon jungle each demand a different approach dictated by culture and geography.

On the traditionally wealthy coast, the average maternal mortality ratio was 56.4 between 2007 and 2011. In the poorer highland and jungle regions it was considerably higher, at 152 and 137 respectively.

“Peru is one of the most unequal countries in Latin America…Parts of Peru have European levels of mortality, other parts have African levels,” said Tavera.

In the mountains, a long history of discrimination against the majority indigenous population makes some women reluctant to visit government health posts. For one, health care providers rarely speak Quechua, the native language in most of highland Peru.

“Those that speak Spanish ignore us, those of us from the town, from the communities that come down. They humiliate us sometimes or don’t treat us well,” said Teresa Echame Vargas, a health promoter in the rural community of Huilloc.

Home births

Perhaps not surprisingly, home birth is more common in rural areas. Although official policy is to support traditional birthing methods and attend home births if possible – a practice supported by medical evidence – in reality it depends on the clinic. “We would like the health posts to attend at home, but they say they can’t,” said Vargas.

Fueling claims of discrimination is the illegal but common practice of imposing fines on women who chose to give birth at home.

Keri Baker, the executive director of the health promotion organization Ayni Wasi, recalled a patient who suffered complications during a home birth, “She hadn’t expelled her placenta all the way which can cause hemorrhaging. We saw her at that point, and she hadn’t sought medical care because of the fact that she had given birth in her home.”

A 2009 survey of women in the coastal community of Huaycan – the majority of whom had migrated from the highlands – found that 46.5 percent of women who elected home birth did so because they’d had a bad experience on a previous hospital visit or knew someone who had. A majority of women in a similar study in 2005 cited discrimination and a feeling of violation by health care providers as reasons to give birth at home.

In a jungle region like Madre de Dios, in Peru’s southeast, communities’ distance to health facilities makes professional attention a challenge. The Spanish-speaking population is transient – attracted by the lucrative business of illegal mining. Women that live in mining camps rarely make the river trip to attend prenatal visits, said Nelva Miraya, the government’s Coordinator for Community Strategy and Reproductive Health for the region.

Indigenous challenge

The area’s far-flung indigenous population of 60,000 is another challenge. Communities in Madre de Dios speak 12 different languages, and live in settlements up to three days away from the nearest hospital. The lack of government presence in these areas raises the possibility that deaths go unreported.

“(Until recently), in the entire region of La Salvación, there was only one obstetrician. She was the only one to intervene in native communities that are two, three, four days away by boat,” said a nurse in Madre de Dios’ capital of Puerto Maldonado.

Although recent progress on maternal mortality is encouraging, Mario Tavera of UNICEF warned about diminishing returns. “(Peru is) starting from a very high rate,” he said. “A country like Chile had 30 (maternal deaths per 100,000 live births). Getting to seven is more difficult.”

Which Countries Are Actually Sustainably Developed?

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Havana cityscape, 2010. The upside of not fixing crumbling buildings? Less carbon emissions.

This century, nine billion of us humans are going to have to try to figure out how to maintain the basic material comforts of modern life without totally wrecking the planet we live on.

There’s still a lot more economic growing to do, and one group of scientists has identified four key ways in which we are already undermining the planetary systems that sustain us: we are emitting too much carbon, driving too many species to extinction, causing too much nitrogen runoff, cutting down too many trees.

In the rich world, no country has figured out how to deliver prosperity while at the same time using the earth’s resources sustainably. We would need more than two Earths worth of resources even if we all consumed like Norway, among the greenest of European countries.

Lately I’ve been asking myself: which of the world’s nations has the highest sustainable quality of life? If we define sustainability in terms of hectares per capita biocapacity usage, what countries provide realistic examples of how humans can thrive within environmental limits? I used data from the Happy Planet Index and Global Footprint Network to try and find some contenders.

Not Costa Rica?

Like the forward-thinking European countries, Costa Rica has earned some deserved praise for its progress toward sustainability. Its bounty of hydropower even allowed Costa Rica to power its entire electric grid with renewable sources for three months this year. Costa Ricans also live long lives and are among the happiest people in the world.

But similar to countries like Norway, we tend to conflate Costa Rica’s relative enlightenment with actual environmental sustainability. Costa Ricans each need 2.5 hectares of land to neutralize their impact on the planet, well above the sustainable threshold of 1.8 hectares of biocapacity.

Vietnam, etc

The World Bank considers Vietnam a “lower middle income” country. Its residents each earn about $2,000 per year, and can expect to live to be 76. Vietnam’s citizens each use 1.4 hectares of biocapacity, well below the per capita sustainable share of about 1.8. Vietnam’s future is uncertain though, as the nation’s booming capitalist economy has meant a steadily increasing environmental footprint since the 1990s.

A number of countries have similar profiles—Albania, Syria, Sri Lanka, Tunisia, Armenia, Nicaragua, Colombia, Georgia, Jamaica, Guatemala. These countries are not quite as wealthy or as healthy as we in the West are, but deliver relatively comfortable lives to most of their citizens. In general, the greatest sustainability challenge these countries face is that their economies and populations are growing rapidly. In a few decades they are likely to enjoy much more of our affluent and unsustainable western lifestyles.

Cuba?

The United Nations considers Cuba a country with “very high human development,” due to health and education indicators that in many cases best those of the US. The UN Human Development Index suggests that Cubans enjoy a quality of life higher than any of the countries mentioned above, and they do it at least in the ballpark of sustainable limits at 1.9 hectares per capita biocapacity usage. Cuba’s uniquely sustainable development has been noticed by at least a few academics.

The downsides of life in Cuba are pretty well known, and are reflected in the data that suggest Cubans are less happy than many of the other countries listed in this post. But because of the nation’s success with the raw numbers, I’m planning on doing some more research on the implications Cuba has for sustainable development in the rest of the world.

3/30/2014 // Lithium Love // Salar de Uyuni, Bolivia

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Salar de Uyuni, the world’s largest salt desert, takes up hundreds of square miles in southwest Bolivia and is visible from space. Underneath it is by far the world’s largest lithium deposit, containing somewhere between 40 and 70 percent of the world’s total reserves. The mineral is used to power a wide variety of consumer electronics, and this GlobalPost report argues that the metal will become increasingly important as climate change drives the search for alternative forms of energy.

The Bolivian government sees the potential for windfall profits from the resource, and already has a lab on the Salar to experiment with various extraction methods. But as one Bolivian pointed out to me, widespread extraction would mean potentially scarring the view of one of the world’s most unique natural features. Big money for Bolivia maybe, but it would make the scene a little less romantic for the Argentinean couple off in the distance here.

Golddigging AKA 500 Years Of Hoping There’s Nothing Shiny Beneath Your Feet

Another blog post that I wrote in January and never posted.

So I’ve been pretty captivated lately by the history of the Inca state of Vilcabamba, founded in 1539.

Just a decade earlier, the Incas had ruled a 770,000 square mile area ranging from modern-day Colombia to modern-day Argentina. Spanish invasion began in 1532, and by 1539 the Inca survivors controlled just a small patch of thick, remote Amazon jungle around the city of Vilcabamba.

For eight years, Vilcabamba was ruled by Titu Cusi, a politically savvy leader who kept Spanish invasion at bay through appeasement, acceptance of Spanish missionaries, and diplomatic stalling.

With one exception:

An innocent Spanish prospector called Romero appeared in Vilcabamba in 1570 and asked permission to search for gold. ‘The Inca gave him permission, and he discovered rich veins in his search for mines. In a few days he mined quantities of gold. Romero thought that the Inca would be delighted, and brought him the gold in the hope of negotiating a new licence for a period of months during which he could mine much. When the Inca saw the gold he thought it could arouse greed and attract thousands of Spaniards, so that he would lose his province. He therefore ordered them to kill the Spaniard Romero.’ Intercession by Diego Ortiz could not save Romero, who was beheaded and thrown into a river. This was the only Spaniard killed on Titu Cusi’s orders. The Inca rightly saw that the lure of mineral wealth was the one magnet that would certainly bring Spaniards swarming into Vilcabamba. –John Hemming

Vilcabamba was finally conquered in 1572 after the Spanish decided its example was a threat to their colonial project.

What’s crazy, though, is how much the dynamics sensed by Titu Cusi still operate today. If you’re a rural community trying to live on your ancestral territory, one of the most disastrous things that can happen is the discovery of natural wealth on your land.

I’m doing some work at the Potato Park, a project aimed at preserving Andean culture and potato biodiversity. One staffer recently argued to me that the project would be impossible if gold or copper existed in Potato Park territory.

To wit: Peru recently approved 18 new wells to drill for natural gas in the Amazon, despite studies arguing that the arrival of workers from far away could spread “fatal epidemics” in the Kugapakori-Nahua-Nanti Reserve for indigenous peoples. Ostensibly pro-indigenous Bolivian president Evo Morales is pushing a highway project through indigenous land despite widespread opposition, in order to facilitate natural gas extraction. In Honduras, conflicts over mines and dams have killed dozens in places like Río Blanco. It can literally mean the different between death and survival for a culture today: Illegal logging in Awá territory in Brazil has caused a ”genocide” of disease that whittled the Awá population to just 400 before the Brazilian government took action against loggers. It still remains to be seen whether the evictions came in time to save the group.

With Its Own Satellite, Bolivia Hopes To Put Rural Areas On The Grid

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Versión en español aquí. Written with Gustav Cappaert. Published at IPS. (Photo: El Palomar, an agricultural community in Bolivia, one of over a thousand rural communities to which the Bolivian government plans to expand internet access with national satellite Tupac Katari 1.

EL PALOMAR, Bolivia, Jun 23 2014 (IPS) – Maria Eugenia Calle, a local official in this Andean agricultural community, recently saw the Internet for the first time.

Her hometown of El Palomar will host one of about 1,500 telecommunications centres that the Bolivian government plans to open this year in rural areas. They will be served by Tupac Katari 1, a Bolivian satellite launched from China late last year.

Socialist President Evo Morales claims that the satellite will make Internet, cell phone service, distance education programmes and over 100 television channels available to everyone in this vast, sparsely populated country.

In El Palomar’s yet-to-be-opened telecom centre, Calle and a small group of onlookers watched as a reporter booted up a computer to test the signal.

“Go to the United States. Show us the White House. Search for Toyota. Search for Real Madrid,” they suggested.

Bolivia is the poorest country in South America, and also among the least connected. Only 7.4 percent of inhabitants have access to the Internet at home, by far the fewest on the continent. Because Bolivia is landlocked, undersea fibre optic cables do not reach the country, so Bolivians settle for some of the lowest speeds and most expensive connections in the world. Hopes for the satellite are high.

“It’s a dream, isn’t it?” said Calle, 40, El Palomar’s secretary of education. “I’m happy that my children are going to be able to communicate with the United States, other countries – or here in Bolivia, with La Paz, Cochabamba,” she said.

With a population of just 10 million and a modest national budget, Bolivia is a strange fit among the 45 nations with their own communications satellite, which are typically either wealthy, heavily populated, or both. However, an increasing number of developing nations are making the investment. In the next two years, Angola, Nicaragua, the Democratic Republic of the Congo, Turkmenistan and Sri Lanka will launch their own satellites.

Rural areas bring special challenges for Internet expansion. The cost of installing and maintaining equipment and training people to use new technology is higher farther from cities, said Francisco Proenza, an ICT scholar and visiting professor of Political Science at Pompeu Fabra University in Barcelona.

While the use of mobile phones has increased dramatically, the Internet has lagged behind. In rural Peru, for example, 62 percent of rural households own a mobile phone, while just 7 percent of those living in rural areas make use of the Internet

After a 2009 revision, Bolivia’s constitution guaranteed access to basic services including water, electricity, and telecommunications. In addition to the satellite, the Bolivian government has opened over 300 rural telecentres and offered incentives to telecommunications companies willing to build infrastructure in rural zones.

According to Ivan Zambrana, director of the Bolivian Space Agency, a national satellite is the most cost-effective way of providing access across Bolivia’s diverse rural terrain, which includes mountains, tropical rainforest and desert. It is also a means of protecting Bolivia’s communication infrastructure from political factors that could restrict access, like the United States’ embargo against ally Cuba.

Bolivia’s Ministry of Communications has marketed the satellite aggressively. The agency created a television advertisement, a Facebook and Twitter campaign, and an Android app to promote the project. In the months surrounding the satellite’s launch, billboards reading “Tupac Katari, Your Star” and “Communications Decolonized” were placed in major urban areas throughout the country.

“When we think of Bolivia, we don’t think of technology, we think of rural poverty, but Bolivia has changed,” said Robert Albro, an anthropologist at the American University in Washington who focuses on Bolivia.

Despite the fanfare, skeptics of the satellite argue that Bolivia’s priorities are misplaced, especially with alternatives available.

Many other countries, including neighbouring Peru, have extended access to rural areas by subsidising the use of existing satellites. Google and Facebook are each considering a fleet of low-flying drones that would provide worldwide Internet connectivity. Until now, Bolivia has spent 10 million dollars annually to lease satellite capacity from foreign providers.

To finance Tupac Katari, Bolivia took out a 300 million dollar loan from the Chinese Development Bank, which the government claims will be repaid by satellite revenues within 15 years.

“It puzzles me that countries like Bolivia are launching their own satellites,” said Heather Hudson, professor of public policy at the University of Alaska. According to Hudson, existing satellite coverage could meet rural Bolivia’s needs. “It’s like 20 or 25 years ago, when there was a wave among other countries, you had to have your own airline,” she said.

Meanwhile there are concerns about misplaced priorities. “Our priority is improving the conditions of nutrition, water and the environment,” said Isidro Paz Nina, national coordination secretary of the Movimiento Sin Miedo, a party looking to unseat President Morales in November elections. “The satellite isn’t bad, but we want people to not have to worry about suffering for lack of food.”

Delays and miscommunication have also brought frustration. “The government said that with the Tupac Katari satellite antenna, cell phones, television, the channels and all that would improve. Up until now, it hasn’t been seen,” said Victor Canabini Quispe, a 51-year-old in El Palomar. “I hope the government doesn’t deceive us,” he added.

Meanwhile, the public opening of the telecentre in El Palomar has been postponed due to delays in training a community member to run the centre and disputes over who will pay for the inauguration ceremony.

If the satellite project succeeds, it could have a big impact on life in rural Bolivia. The satellite will be a “window to the world” for children in rural areas, according to Zambrana, the Bolivian Space Agency chief. He said that many Bolivian children living in high altitude climates have never seen a tree in their lives, and will see one for the first time through satellite-delivered images.

In five years, Bolivia “will be more modern, better connected, with more educated citizens. We’re going to be a little richer – or a little less poor,” he commented.

The message is one that is resonating in at least one remote part of Bolivia – San Juan de Rosario, a small community in Bolivia’s arid southwest, and a planned telecentre site.

Gregoria Oxa Cayo owns a hotel here for tours visiting Salar de Uyuni, the world’s largest salt flats, but by necessity she lives four hours away in the larger town of Uyuni. She grew up in San Juan and her parents still live here, but she needs Internet access to run her hotel and travel agency, and there is none in the isolated desert town.

“If there was Internet here, I would live here,” she said.

Some Kind Of Personal Quest To Find The Meaning Of Happiness

Diagram

So back at the farm I drew the above, uh, “diagram” in my notebook. Showed it to my travel-mate Sean.

He said: “It looks like an acid trip. ‘Everything is connected, man!’”

I responded: “Nah man, it’s not that. Whenever we go to a new place—like Chala today—I always find myself trying to figure out how well people there are living, but don’t really know where to begin looking. So I’m trying to organize my thoughts a little.”

Sean: “Well, people need three things. A place to eat, a place to sleep, and a place to poop.”

Me: “That’s enough to keep you from dying, but life is more than that.”

S: “Are you on some kind of personal quest to find the meaning of happiness?”

C: “That’s not why I made this, but yeah, basically.”

S: “Well, I’ve probably told you my philosophy a bunch of times.”

C: “I’m not sure you have.”

S: “It’s all about empathy and appreciation. The more empathy you have, the more you will appreciate the world we live in.”

There was some elaboration of this idea. I asked: “But why is that the true purpose of human existence?” Some talk that I can’t remember about neurons, and then Sean explained that his goal in life is “textured consciousness.”

S: “It feels good to learn new things, and that adds layers that your brain uses to appreciate things more. That’s why I want to travel a lot and do lots of different things. It’s a human tendency to form patterns and habits in your thinking, so I want to make an effort to break those patterns. Then I’ll have a more textured consciousness. For instance, since arriving to the farm I have gained more appreciation for cumbia music and for motorcycles, and I’ll use that to deepen my appreciation of other things.”

C: “But implicit in that is an entire philosophy about what the purpose of humanity is, and how we should spend our lives. I have some things I could say about that, but for me I guess it’s still an open question.”

A pause.

S: “Well, for me it’s textured consciousness.”

 

Lima, City of Possibilities

Lima highway

Any city of 10 million is bound to be hectic but Lima moves with a unique fervor, at least among places I’ve visited. In recent decades, Peruvians have flocked to the city to escape an economically neglected and war-torn countryside. Lima had half a million residents in 1940, 3.5 million in 1981 and has 10 million today, faster growth than any government could ever hope to order or control.

As such, life in Lima is frenetic and spontaneous. Bus drivers race from stop to stop, literally competing with each other for riders. Many neighborhoods were originally built by squatters in what 30 years ago was desert. Residents who can’t find work make their own; vendors peddle everything from candy to self-help tapes to UV lights that identify counterfeit money. Everywhere is crowded: sidewalks, parks, stores, vehicles, and especially roads. In one taxi ride our driver, caught in a traffic jam, blasted onto a 100-yard stretch of empty pedestrian promenade to bypass the stopped vehicles and then veered back into the road at the front of the pack. “It’s Lima, everything is possible,” he said.

Perhaps all the raw energy results from everyone trying to get a leg up at the same time. Peru’s economy is growing steadily but the nation’s export-led, laissez-faire economic development model doesn’t organize how the wealth is distributed, so Peruvians are left to carve out their own spot.

For better or worse, the entire world is urbanizing at a similar rate. In Lima, call it a work in progress. Entire swaths of the capital lack plumbing, clean water, or trash removal, and the city’s streets have the most crashes of any in South America. The organized chaos also boasts results, though. Peru has cut its poverty rate in half, from 54.4 percent in 1991 to 25.8 percent last year. But questions remain: can the same economic policies uplift that last quarter? How long will it take? Are there other development strategies that would work better, or is the messy Peruvian way the only way?