CHANGING BIOCULTURAL PERSPECTIVES ON HEALTH

IN THE ANDES

THOMAS LEATHERMAN

Department of Anthropology, University of South Carolina, Columbia, SC 20298, U.S.A.

AbstractÐNew directions toward biocultural approaches to health and illness in Andean peoples haveemerged since the original Health in the Andes volume was published in 1981. The reformulation ofthese perspectives was stimulated in part by the growth of political-economic perspectives in Andeanethnography and by critiques of medical ecology by critical medical anthropologists. This paper pro-vides a brief history of changing biocultural perspectives on Andean health, and contrasts two projectsdealing with Andean biology and health carried out in the 1960s and 1980s in the District of NunÄ oa inSouthern Peru. The recent NunÄ oa research provides one example of a more critical bioculturalapproach that attempts to integrate perspectives from ecology and anthropological political economy.The utility of the approach is explored through the NunÄ oa case study, which focused on the reproduc-tion of illness and poverty in Andean households in contexts of social and economic change. Findingsof this research are compared with recent work in the Andes to illustrate how a more critical biocul-tural perspective can better articulate with the diversity of approaches in medical anthropology andAndean health studies. # 1998 Elsevier Science Ltd. All rights reserved

Key wordsÐAndean health, social relations, biocultural perspectives

INTRODUCTION

The American Anthropological Association mono-graph Health in the Andes, published in 1981

(Bastien and Donahue, 1981), brought together abroad sample of research on health and health sys-

tems in the Andes. The volume re¯ected prevailingapproaches in medical anthropology, including eth-

nomedicine, biomedicine, health ecology, andapplied health research. The themes of environment

and adaptation dominated most papers*, re¯ectingthe strength of ecological perspectives and commu-

nity studies in anthropology in the 1960s and 1970s(Ortner, 1984). The key factors shaping Andean en-

vironments were altitude and verticality, which

researchers viewed as both a stressor and a resourcefor biological, behavioral and cultural adaptations.

While ecology and adaptation dominated earlierperspectives on health, research in the 1980s and

1990s adopted a broader biocultural framework

that recognized the role of macro-political andeconomic factors in structuring local environments,and the importance of social relations shaping bi-

ology and health. This shift followed developmentsin Andean ethnography (Salmon, 1982; Starn,1994), biological studies (Thomas et al., 1988;

Goodman et al., 1988), and in critical medicalanthropology (Morsy, 1990; Singer, 1989). In thispaper{, I will brie¯y discuss the historical back-

ground to these changes, and discuss how shiftingbiocultural perspectives can lead to the examinationof new questions and relationships about Andeanhealth. The primary example comes from a com-

parison of research carried out in the 1960s and1980s in the District of NunÄ oa in the SouthernPeruvian highlands. The earlier research focused on

high altitude stress and adaptation (Baker andLittle, 1976), and the latter emphasized political-economic as well as ecological conditions structur-

ing household economy and health. The resultsfrom the more recent political-ecological researchare compared with other Andean health studies toillustrate the potential for integrative perspectives

on Andean health.

BACKGROUND

Starn (1991) has attacked ethnographic and bio-

cultural studies from the 1970s in the Andes as``missing the revolution'', the revolt of SenderoLuminoso (Shining Path) which came to dominatethe political landscape in Peru during the 1980s and

Soc. Sci. Med. Vol. 47, No. 8, pp. 1031±1041, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98 $19.00+0.00

PII: S0277-9536(98)00160-9

*It should be noted that papers by Bolton and Sue and byDonahue moved beyond the ecological and communityfocus. Bolton and Sue showed that variation in healthwas associated with economic di�erentiation within thecommunity, and Donahue focused on the intersectionof national health care policy and local political econ-omy as they shaped local health systems.

{This paper is based on an earlier version presented inthe symposium titled ``Landscapes of Health in theAndes: Toward a Synthesis of Theory and Method inMedical Anthropology'', organized for the 1993 meet-ings of the American Anthropological Association. Theauthor thanks Brooke Thomas and two anonymousreviewers for comments on earlier drafts.

1031

into the 1990s. He argued that the ecologically

oriented community studies in the 1970s tended toerect analytical boundaries around the populationsand cultures being researched to the neglect of

interregional and national processes. Andeanpeoples were seen to identify with tradition, notchange, and resisted by insulating themselves from

outsiders rather than seeking articulation with re-gional and national economic and political pro-

cesses. The prevailing picture of Andean societythen was one of stable adaptations underlain bypersistent cultural traditions.

The ``Andeanist'' orientation Starn identi®es andcritiques was not just an outgrowth of anthropolo-gical theory but the result of a longer historical

shift toward perspectives on Andean peoples.Andean ethnography in the 20th century worked to

overcome views of native Andeans as biologicallyinferior and socio-culturally backward. French andEnglish researchers studying the biology of high

altitude peoples in the Andes and Mexico in thelate 19th and early 20th centuries assumed thatAndean (and other highland) natives were physi-

cally inferior since normal physiological functioningwas not possible under hypoxic conditions (Cueto,

1989). Given the con¯ation of biology with racewhich dominated perspectives on human biologicaland social variation in the early twentieth century,

views on physical inferiority were often expressed interms of racial inferiority. Cueto (1989), forexample, notes that a `desperate call for European

immigration (by Peruvian intellectuals in the earlytwentieth century) was derived from a desire to``improve'' the Peruvian ``race'''.

Beginning in the 1920s, the indigenismo move-ment sought to address these biases, and assert

views of modern Andean peoples as direct descen-dants of the noble Inca (Cueto, 1989). On the bio-logical front, Carlos Monge Medrano ``engaged in

a scienti®c and cultural crusade for the redemptionof Andean people'' (Cueto, 1989, p. 640). MongeMedrano organized scienti®c expeditions to high

altitude regions to con®rm the successful adap-tations of native Andean populations to hypoxic

conditions. In Monge Medrano's work, Andeanpeoples became seen as possessing superior adaptivecapabilities as evidenced in physiological responses

to altitude which allowed them to function at alevel comparable to coastal populations even atextreme altitudes of 4000±5000 m (Cueto, 1989).

With funding from the Rockefeller Foundation andother American and Peruvian institutions, he was

instrumental in establishing the Institute of AndeanBiology (IBA: Instituto Biologia Andino) in 1931.He directed the institute from 1931 to 1956, and

was succeeded by his research director AlbertoHurtado. During this time the institute earned aninternational reputation as a center for research on

the biology of high altitude peoples. Political con-servatism in the late 1940s and early 1950s contrib-

uted to a decline in indigenismo, and the research

focus at the institute moved toward high altitudebiomedical studies, which also re¯ected the interestsof Hurtado in detailing physiological responses to

hypobaric hypoxia. Monge and Hurtado contrastedin style and in interpretation of dominant biologicalprocesses of altitude adaptation. Monge was con-

vinced of the genetic basis (and superiority) ofAndean populations, while Hurtado focused more

on non-genetic acclimatization responses.The work of these two pioneer researchers set the

stage for a new set of studies which had as one goal

unraveling the genetic vs non-genetic processesthrough which Andean populations adapted to highaltitude environments (Baker and Little, 1976).

Fueled by the space race and an industrial±militarycomplex concerned with the abilities of troops to

function in extreme environments such as high alti-tude, funding for high altitude research made itpossible for major multidisciplinary, multi-year pro-

jects to be implemented in high mountain regionsof North and South America, Africa and Asia. Oneof the most successful and signi®cant projects was

carried out in the District of NunÄ oa (Puno) in theSouthern Peruvian Andes under the direction of

Paul Baker in collaboration with Tulio Velasquesand Emilio Picon-Reategui of IBA. Results of theresearch were published in Man in the Andes (Baker

and Little, 1976), which re¯ected the researchers'dominant focus on high altitude population bi-ology, but also the breadth of an ecological orien-

tation illustrated in chapters on the physicalenvironment, social organization, demography, andenergy ¯ows in the District. Early expectations of

identifying genetic adaptations to hypobaric hy-poxia were not met, and their research ®ndings

suggested acclimatization and socio-behavioral re-sponses were the most important in coping with themultiple stress of a high altitude environment.

Studies of Andean culture and society concurrentwith the biological research in 1960s and 1970swere in¯uenced by the verticality concept especially

as established in John Murra's archipelago model(Murra, 1975) which stressed the integration of eco-

logically diverse regions through satellite colonies inorder to access the goods produced in each region.Murra was not a cultural ecologist, but his vertical-

ity concept and themes of resource complimentarityand social reciprocity provided a strong and attrac-tive organizing principle for ecologists interested in

micro-environmental use and technological adap-tation. Perhaps as in¯uential as his model, was his

dedication to understanding the essence of historicalAndean social formations and uncovering ``whatwas Andean'' about current Andean societies

(Murra, 1984). The characteristics that came todominate much of the perspective on Andeanpeoples, was their knowledge and use of micro-en-

vironments, an incredible range of technological in-novations, and formalized systems of labor

T. Leatherman1032

exchange (Alberti and Mayer, 1974). Even ideology

and culture was shaped in part by local landscapes(Isbell, 1977; Bastien, 1978).The legacy of this biological and cultural research

has been to reify the successful adaptation and resi-lience of Andean populations, and the continuity ofhistorical organizing principles over novel responses

to changing conditions. Thus, while it was alsoAndean to resist and revolt (McClintock, 1984;

Silverblatt, 1987; Stern, 1987; Smith, 1989), this ten-dency was downplayed in the ethnographic researchof the 1970s in part because adaptation theory has

never been well equipped to handle resistance andrevolution as adaptive behavior.In¯uenced by political-economic theoretical per-

spectives in cultural anthropology [2], Andean eth-nography in the 1970s and early 1980s (Orlove,

1977; Roseberry, 1983; Smith, 1989; Collins, 1991)increasingly emphasized the political unrest, exploi-tation, and poverty which was so much a part of

the Andean reality. They drew attention to the cen-turies of domination, the 150 yr of internationalwool trade, the market penetration and monetiza-

tion of rural economies, and to an agrarian reformwhich aided a few, yet further constrained access to

land for many (Caballero, 1984). Thus, Andean his-tory was marked not only by continuity, resilienceand adaptation, but also by four centuries of domi-

nation by outsiders seeking to gain control overresources and labor, and subsequently constrainingpeople's e�orts to meet basic needs.

As the ®eld of anthropology experienced a shifttoward political-economic perspectives, medical

ecology began an internal reformulation of perspec-tive, looking to broaden contexts of research andrestructure key theoretical concepts such as adap-

tation. This was spurred on by numerous critiquesfrom critical medical anthropology (Singer, 1989),including: critiques of reductionist, static models

which ®t the status quo of cosmopolitan biomedi-cine and tended to ``naturalize social phenomena'';

critiques of adaptationism; and especially, a failureto address the social relations shaping health. In re-sponse to critiques, biocultural medical anthropolo-

gists have not abandoned ecology or adaptation,but have expanded their notion of ecological con-text, to bring political-economic, social and ideo-

logical factors to the foreground, and to rethinktheir notions of coping and adaptation (Armelagos

et al., 1992; Leatherman et al., 1993; Leatherman,1996). Armelagos and colleagues have called forbiocultural approaches to recognize biomedicine as

the ethnomedicine of ``Western cultures and empiri-cist scienti®c thought'' (Armelagos et al., 1992, p.40) which in comparison with local ethnomedical

systems may be more or less e�cacious and compa-tible with social relations of Andean communities(Bastien, 1982; Crandon, 1983; Ugalde, 1985).

Leatherman and colleagues (Leatherman et al.,1993; Leatherman, 1996) have called for a rethink-

ing of coping and adaptation that recognizes the

costs and contradictions embedded in responses toillness, and the way past coping actions shape pre-sent and future realities.

Relatively little published research on Andeanhealth was available up to the 1980s. An epidemio-logical study of four highland and lowland commu-

nities carried out by Buck et al. (1968), had abiomedical focus but was unusual in its multidisci-

plinary use of social and behavioral scientists.Bastien's Mountain of the Condor Bastien (1978)applied Andean cosmology and ritual, and the

theme of reciprocity, to medical beliefs and treat-ment of illness in an Andean ayllu in Bolivia. TheHealth in the Andes volume (Bastien and Donahue,

1981) was the ®rst collection of papers on Andeanhealth with a biocultural component, and as men-

tioned earlier, one dominated by a strong concernwith environment and adaptation.Recent biocultural approaches draw attention to

the social relations shaping health and patterns ofresort, and to how local interpretations of healthunderlie behavioral response (e.g., Leatherman et

al., 1986; Stoner, 1989; Carey, 1990; Oths, 1991;Larme, 1993; Luerssen, 1994). The work of

Crandon-Malamud (1991) bridged a number ofthese issues by addressing the pluralism of biomedi-cine and local ethnomedicine in speci®c local con-

texts infused with relations of class, gender andethnicity. She examined how these relations withina single community shaped the negotiation of ill-

ness, and how this negotiation was a window intobroader cultural, social, and political-economic pro-

cesses. She also provided insights into the cultureand power of biomedicine and how it con¯ictedwith local social relations. The legacy of Crandon-

Malamud's work was seen to one degree or anotherin most of the papers presented in the 1994 AAAsymposium titled ``Landscapes of Health in the

Andes: Toward a Synthesis of Theory and Methodin Medical Anthropology'', from which this collec-tion of papers emerged.

In the remainder of this paper I present resultsfrom research on the political ecology of health

among small-scale producers in the District ofNunÄ oa in the Southern Peruvian Andes. NunÄ oaprovides a useful case study since it was the site of

two distinct projects carried out two decades apartbut in the same communities within the district

(Baker et al., 1976; Thomas et al., 1988). The earlierresearch by Baker and colleagues examined popu-lation adaptations to high altitude environments.

The latter, directed by R. B. Thomas who partici-pated in the earlier project, focused on political-economic as well as ecological conditions structur-

ing Andean health and coping responses to illness.The goal is to provide an example of a critical bio-cultural approach and to illustrate how a shift in

perspective was associated with new questions andinterpretations on Andean biology and health. A

Biocultural perspectives on health in the Andes 1033

second goal is to illustrate how our ®ndings articu-

late with other recent research on Andean health,and the potential for further integrative understand-ings of health and health systems.

HEALTH AND HOUSEHOLD ECONOMY: A CASE STUDYFROM PERU

In 1983 we initiated a two-year ®eld study on theconsequences of illness to small scale farmers in theDistrict of NunÄ oa (Puno) in the Southern Peruvian

highlands (Thomas et al., 1988). The research builton the previous work by Baker and colleagues inthe 1960s (Baker and Little, 1976), that combined a``rigorous use of ecological systems theory and the

methods of ®eld biology'' (Salmon, 1982, p. 91) toexamine the capacity of Andean populations tophysiologically cope with the multiple stresses of a

high altitude environment. In addition to docu-menting ontogenetic and physiological responses tohypobaric hypoxia and cold, they sought to identify

adaptations to a highland environment throughpopulation demography, biological reproduction,growth and development, energy ¯ow, and general

socio-cultural characteristics. Like other ecologicalstudies, they tended to treat the local populationand ecosystem as a relatively closed, self-regulatingsystem attempting to maintain internal homeostasis

in the face of multiple stresses from primarily thephysical environment. This approach often im-plicitly assumes homogeneity in experience of stress

and adaptive response; that what is bene®cial toone individual is bene®cial to others in the popu-lation. Hence, less attention is given to broader,

interregional and international contexts, as well asto local variation in economy and class. Forexample, studies of growth in the 1960s selectivelyfocused on individuals who by virtue of surname,

dress, and economic status were considered indigen-ous. Individual variation in diet and health werelikely present, but was not addressed in a research

design that was oriented towards population leveladaptations (Leatherman et al., 1995).A restudy of the NunÄ oa population provided the

opportunity for comparisons across two decades ofsigni®cant changes (e.g., agrarian reform, growth inmarkets and capitalism) and to expand the focus on

population biology to include variation in social,economic and biological characteristics of NunÄ oanhouseholds. The research questions and approachdi�ered substantially from the earlier NunÄ oa pro-

ject. We focused on problems of social origin Ð

poverty, illness and undernutritionÐ which we con-sidered the dominant stressors, as opposed to highaltitude hypoxia and cold. We worked under the

assumption that experience of stress and the ca-pacity to cope is variable within the local context,and sought variation in stress and adaptive response

among di�erent economic segments of the commu-nity. Ultimately, we were interested in examining

the relationships between illness, work, production,and household±economy relationships whichdemanded linking local realities to larger political-

economic processes.The approach we used combined perspectives

from ecology with political economy (Leatherman

et al., 1986; Thomas et al., 1988; Leatherman,1996). We expanded the traditional ecological

framework to explicitly assess local conditions as aproduct of the interaction with larger (global,national, regional) historical forces, following the

suggestion of Mckinley (1986) to ``focus upstream''toward the social relations which shape variationsin health. We emphasized human agency in local

production strategies and in coping with illness;stressing diversity over homogeneity in individuals

and households. Because individuals and house-holds are embedded in di�erent sets of social re-lations, their experiences, coping options, and

illness outcomes will vary widely. What is good forone individual, household and class may often bedetrimental to another. Thus, we were concerned

less with evaluating the net bene®t of a speci®c re-sponse, and rather with the ``coping process''through which responses are negotiated among

agents, the congruence and contradiction inherentin responses to competing constraints, and how the

consequences of responses serve to alter futurebehavior.A political-economic perspective brought obvious

insights to our study of illness among small-scalefarmers. The Andean environment now consideredas harsh, unproductive and generally marginal for

human populations provided rich and diverse pro-ductive options in the past (Murra, 1984). The pre-

sent marginality of Andean producers has more todo with changes in control over the means of pro-duction and the organization of the labor process

than the harsh environment they inhabit. Also, theadaptive capabilities of rural producers are largelydetermined by access to and control over pro-

ductive resources and labor. This locates coping re-sponses within local political economies. Thus,

political-economic conditions not only shape theunequal distribution of illness within the commu-nity, but they also shape its e�ects on household

economies by in¯uencing the coping process.While the research design called for an expanded

scope of data collection into the social and econ-

omic arena, we maintained the same rigorous use ofmethods from ®eld biology and collected much

Table 1. Comparison of household morbidity and work lost in tworural sites in NunÄ oa District

Health measureFarming ayllu

(n= 18)Cooperative(n= 18)

t-test (pvalue)

Morbidity (%symptoms)

21.5 (28.6) 13.1 (25.1) 0.001

Lost work (days) 1.8 (21.5) 0.6 (20.8) 0.007

T. Leatherman1034

comparable information on growth, nutrition, de-mography and other biobehavioral parameters to

facilitate comparisons with the earlier ®ndings andassess changes which had occurred over the ensuing15 yr. We gathered information on the economy,

demography, and activity patterns of householdsalong with measures of diet, nutrition and health*.Information on these domains was gathered season-

ally in three communities in the District, includinga farming ayllu, alpaca herding cooperative, and thesemi-urban capitol. An initial sample of 140 house-

holds in the ®rst survey were followed by sub-samples of 104 and 65 households in twosubsequent surveys. Information on health statusand perceptions of health included two-week and

longer recalls of illness events, symptomatology,and work days lost in illness. Household economicrelations were characterized by access to land and

articulation with the wage economy, as well as bymaterial conditions and possessions in the house-hold. Our analyses examined speci®c relationships

between illness, work, production, and householdeconomy, and elucidated how social relationsshaped patterns of health and resort, and the conse-

quences of illness on Andean households.

SOCIAL RELATIONS AND HEALTH

One consequence of shifting biocultural perspec-tives on the health of Andean populations is therecognition that socio-political and economic fac-tors shape human biology and health to a far

greater extent than altitude hypoxia or any othercomponent of the physical environment. The socialrelations through which households access land and

labor, articulate with the cash economy, and forminterpersonal networks, structure variation in nutri-tion and health status, responses to illness, and the

consequences of illness on household economy.Based on original studies by Frisancho and col-

leagues in NunÄ oa (Frisancho and Baker, 1970), a

pattern of high altitude growth emerged whichinterpreted a slow, prolonged growth process withdampened adolescent growth spurt and small adultstature as primarily due to the hypobaric hypoxia

associated with high altitude. Yet, researchers onthe 1980s NunÄ oa project found signi®cant economicvariation in diet, nutritional status, and growth pat-

terns (Leonard et al., 1990; Leatherman, 1994;Leatherman et al., 1995), and concluded that econ-omic variation was a greater contributor than alti-

tude to patterns of growth. Leatherman (1994)found signi®cant di�erences in dietary diversity inthree communities di�ering in economic base, and

among town households at di�erent economic

levels. Middle income households from the town

consumed twice the meat, dairy, and vegetable pro-ducts as low income families. Leonard and Thomas(1988) showed that dietary intake is seasonally con-

strained in NunÄ oa, and that these constraints arefelt by poorer but not wealthier households.Over one-half of the children (57%) in the

District showed evidence of stunting, or low height-for-age, and 20% of the children were stunted

beyond any potential e�ects of altitude on growth(Leatherman, 1994). Both Carey (1990) andLeatherman (1994) have shown that within the

District of NunÄ oa, patterns of growth and stuntingwere signi®cantly associated with economic status.(z-scores of ÿ1.8 for moderate income households

vs ÿ2.5 for poor households; p < 0.02, t-test). Infact, stature is greatest and stunting is least among

individuals residing at the highest altitudes, becausethese herding households have experienced thegreatest gains in post-reform economy, while the

lowest altitude community experienced the greatestloss.Similar to ®ndings on diet and growth, measures

of household morbidity were associated with econ-omic status. Thirty-seven percent of the population

on average reported a health problem for each two-week recall period, with respiratory problems theleading category of illness (Leatherman, 1994).

About one-half of the households also had at leastone adult who was incapacitated from an illnessduring this same two-week period. In two rural

communities with economies dominated by agro-pastoral activities, an ayllu and a cooperative, mem-

bers of the ayllu reported signi®cantly more symp-toms, and days of work lost due to illness (Table 1).The ayllu had a limited land base for farming and

herding, and this was exacerbated by recent agrar-ian reforms. The ayllu received no new land in thereform, and the newly formed cooperatives did not

allow the exchanges of work for pasture to grazeanimals that had existed between ayllu householdsand haciendas. As a result, these households owned

only an average of 25 animals, mostly sheep. Incontrast, members of a newly formed alpaca herd-

ing cooperative, had access to ample land for farm-ing and pasturing private herds. In addition toreceiving a small monthly wage, cooperative house-

holds owned an average of 160 animals, mostlyalpacas. Given the high price of alpaca ®ber on theinternational market, many of these households

were doing relatively well ®nancially. Some ownedhouses in urban centers where their older children

attended school and even university. In the semi-urban town, access to land was more constrainedthan in either ayllu or cooperative. Twenty-two per-

cent of the town sample had no access to land forfarming or herding. Only 22% of town familiesconsidered agro-pastoral activities to provide the

major contribution to household economy, while60% considered some form of wage work to be a

*See earlier reports (Thomas et al., 1988; Carey, 1990;Leatherman, 1992, 1994; Leatherman et al., 1995) formore detailed discussions of the research design andmethodology.

Biocultural perspectives on health in the Andes 1035

major contributor. Only 31% of the sample owned

herd animals, and those with animals owned onlyan average of 50 animals. Health status amongtown households was associated with economic

level and especially access to a steady wage or com-mercial income. Middle income households reported

fewer illness symptoms than poor households,although slightly greater work lost. Neither di�er-ence is statistically signi®cant. Households with a

steady source of income reported signi®cantly fewerillness symptoms, and fewer days of work lost than

households with irregular incomes. Among moder-ate income households, no di�erences were foundbetween those with steady vs irregular incomes, and

among steady income families, no signi®cant di�er-ences were found by economic level. Thus, it

appears that either having a steady source ofincome or moderate wealth (e.g., from annual woolsales), placed one in a relatively lower risk category

for illness. However, being poor and without asteady source of income put households at a signi®-

cantly higher risk to illness. Low income familiesrelying on di�erent combinations of small-scalefarming, temporary wage work and small scale

commodity production for their income, reportedabout 8% more symptoms (p < 0.002) and over

twice the days of adult work lost per two-weekperiod (p< 0.03) (Tables 2 and 3).We found no signi®cant di�erences in illness

among poor farmers and non-farmers in contrast towork in the same town from 1987±1988 by

Luerssen (1994) who reported that poor farminghouseholds ate twice the value of local cultigensand meat as non-farming households, and lost only

one-third the work days over six month (8 vs 24 d)and one month (1 vs 3 d) recall periods. An attempt

in major land redistribution, known as Rimanakuy,occurred in 1986 as a response to the growth ofSendero Luminoso and general civil unrest, and

reallocated a portion of cooperative land to agrar-ian communities. In 1987±1988, three times more

households in the district had access to communal

lands than in 1981, and ten percent more townspeo-

ple had access to communal lands (Luerssen, 1994).Also, real wages had dropped as market goods were

undergoing triple-digit in¯ation. These factors mayhave accentuated the importance of farming in the

nutrition and health of poorer semi-urban house-holds.

As the information on days lost due to illness

suggests, illness causes a signi®cant amount of worklost to NunÄ oan households. Respiratory problems

contributed 57% of the illness cases associated withwork lost and 34% of the total days lost to adult

men and women. Skeletal-muscular (12% of cases,

15% of work lost) were the next major source ofdisruption, followed by reproductive problems (8%

of cases, 16% of work lost) and gastro-intestinalproblems (4% of cases, 2% of work lost). Heavy

work and cold and rainy conditions (or intense sun)in the ®elds were implicated both in respiratory and

skeletal-muscular complaints. NunÄ oans complainedof the aches and pains of strenuous work carrying

heavy loads and repetitive work of planting with

foot-plows, placing seeds, and harvesting. A fre-quent complaint was ``dolor de pulmones'' (pain in

the lungs). According to informants, the function ofthe pulmones was to was to help you breathe and

work, and their anatomical location was upperback and shoulders which often were sore after

strenuous work. A more serious respiratory pro-blem, pulmonia (often pneumonia) was also said to

be complicated by heavy work and inclement work-

ing conditions.As households are increasingly involved in the

capitalist economy and men in particular migrate

out of the community in search of work, womenincrease their work loads. Women reported 7%

more symptoms than men in all locations and sur-veys, and three times more work lost than men in

the town, twice the work lost in the cooperative,and about the same in the farming ayllu

(Leatherman, 1994). Reproductive problems werethe leading cause of work days lost to women (40%

of lost days) and likely re¯ects the multiple con-straints of heavy workload, inadequate diets, and

high fertility (7±8 births). The most commonly

reported reproductive problems were labeled as``sobre parto'' (due to birth), which were usually

chronic problems present many years after the lastbirth, and associated with a host of symptoms

including fatigue, weakness, headaches, aches andpains, inability to work, and malaise.

Table 2. Household morbidity and days lost in semi-urban households of di�erent econ-omic position

Health measure

A. Moderateincome(n = 17)

B. Lowincome(n= 25)

C. Steadyincome(n= 20)

D. Irregularincome(n = 23)

t-test Cvs D (pvalue)

Morbidity (%symptoms)

12.2 (29.0) 15.9 (26.8) 11.2 (24.6) 16.9 (26.4) 0.002

Work lost (days) 1.9 (22.1) 1.4 (21.5) 1.2 (21.2) 1.9 (22.1) N.S.

Table 3. Household morbidity and days lost in poor semi-urbanhouseholds with steady vs irregular incomes

Health measureLow steady

income (n = 20)Low irregular

income (n= 23)t-test (pvalue)

Morbidity (%symptoms)

18.3 (26.5) 10.7 (24.4) 0.003

Work lost (days) 1.8 (21.7) 0.7 (20.6) 0.03

T. Leatherman1036

Work activities of men and women in most ruralfarming households is less di�erentiated than in the

town, where it was more common for a man to beengaged in non-agricultural wage work, and womento be involved in petty commodity production and

mercantile activities, and solely in charge of house-hold work. In the labor market, women and mendid not have equal access to jobs, and women

received half the pay as men for identical jobs (evenlight agricultural labor). Consequently, womentended to work harder and receive less for their

e�orts. Thus, where the household's economic ac-tivity is more tied to the capitalist market and thedivision of labor is more di�erentiated, womenreport more work disruption.

If the ``double-day'' of women is responsible forgreater work lost seen in semi-urban women, weshould see the greatest disruption in single female-

headed households. More than 20% of the townhouseholds were single-female headed households,and these women reported losing 20% of their

work days to illness, as compared to 13% forwomen in dual-headed households. These di�er-ences are not due to greater morbidity which is ap-

proximately the same in both groups. Rather,similar levels of symptoms have greater e�ects onwork in these single-women whose work days aremost constrained.

Social networks and labor relations

In addition to relations of land and articulationwith the local monetized economy, interhouseholdrelations of support and labor exchange a�ected

health status and ability to cope with labor lost inillness. Carey (1990) studied the relationshipbetween health and social networks in NunÄ oa, andfound that household symptomatology was associ-

ated with the size and strength of networks in thetwo rural communities, but not in town households.Particularly in the small farming ayllu where pro-

ductive resources are constrained and cash wasscarce for hiring workers, households that receivedmultiple types of support from several supporting

households experienced less illness. A stronger senseof community and kin-based obligation was evidentin the extended lineage of the ayllu, and partici-pation in inter-household exchanges provided im-

portant economic and social supports. In thecooperative there was a positive association betweensize and strength of networks and reduced illness,

but the single most important network variable as-sociated with reduced levels of illness was theamount of support provided to other households. A

few powerful and relatively wealthy families, whichwere residents of the former haciendas at thislocale, occupied a central place in the social net-

work. They cemented their power base and accessto future assistance by in¯uencing the choice of newfamilies allowed into the cooperative, many ofwhich were related by marriage or other extended

kin tie. These older, more powerful households pro-

vided much support to the newer, younger, house-holds and this level of support was associated withlower levels of illness. In the town, where labor had

become more fully commoditized and where house-holds are more reliant on wage and market activi-ties, sources of social support and reciprocity have

diminished, and no associations were foundbetween health and support networks.

Social relations in access to labor were particu-larly critical in ways of coping with e�ects of illnesson work and household production. At the incep-

tion of the research, one key area in which weexpected to observe coping responses to illness wasin reciprocal labor exchanges because reciprocity

(ayni) was repeatedly described as a central featureof Andean society (Alberti and Mayer, 1974) and

health systems (Bastien, 1978, 1982). When askedhypothetically what they would do to maintain ade-quate labor in the face of illness, an overwhelming

number of families said they would seek reciprocalexchanges with friends and families. Yet, with thecommoditization of labor, reciprocal labor

exchanges were generally diminished throughout thedistrict, in favor of monetary payments (which at

times even occurred between siblings and fathersand sons). Similar observations have been made byErasmus (1956), Brown (1987), and Guillet (1981)

for other Andean communities.Guillet (1981) has argued that labor exchanges

for money or produce entail less social costs and

future obligations than reciprocal exchanges, andare preferred if cash is available. Where cash is

scarce and communal ideology stronger, reciprocallabor might be preferred. One would expect that incases of illness reciprocity might increase, especially

among poorer households where reciprocity wasalready practiced. Yet, reciprocal labor exchangeswere diminished among households with sick

workers, in part because there was little predictabil-ity if and when the labor would be returned.Reciprocal exchanges did occur even in illness

among close kin in small communities where socialexpectations and sanctions led healthy kin and

friends to help out ``because it is their obligation tohelp kin''. For the most part, however, householdlabor power and especially wealth, were the critical

factors shaping a household's ability to cope withillness and maintain production activities. Thistended to work against poorer households that

lacked the resources for hiring outside help, sincemost older adolescents in these households had

migrated outside the community in search of work.In sum, poorer households often had fewer social

as well as material resources with which to cope

with illness. Unable to meet labor needs in farmingproduction, they planted half as many ®elds and ata lower level of productivity (Leatherman, 1992).

Reduced production and earnings serve to repro-duce the poverty, poor nutrition and health in

Biocultural perspectives on health in the Andes 1037

NunÄ oan households, and over time this can lead tothe inability to maintain access to means of pro-

duction, what Deere (1990) has called householddisintegration. This, in turn, may lead to loweredexpectations of basic needs and health

(Leatherman, 1992). For example, when Luerssen(1994) asked heads of households in NunÄ oa whatthe probable outcome of a serious illness might be,

eighty-nine percent of poor non-farming householdsand 64% of poor farmers said the individual wouldprobably die. All moderate-income households

thought that they would be able to get adequatetreatment for the sick individual, and none expectedthat death might be the outcome of the illness. Inthis context, personal social networks are often the

only source of aid one can muster, and even expec-tations of receiving aid from friends or family werediminished in town households. As one local school

teacher said, ``the last place you look for help whenyou are sick is from your relatives''.

DISCUSSION

In the 15 yr between the pioneering work of

Baker and colleagues in the mid-1960s and ourresearch in the early 1980s, the number of landlessin NunÄ oa grew, relative poverty increased, and for

many, levels of nutrition and health were the sameor worse than before. This was the case despite thebetter transportation networks, bigger markets,

more schools and health clinics Ðfactors assumedto improve economy and health. Poor nutrition andhealth are symptoms of poverty, but they also con-

strain household production and reproduction. Thissynergistic relationship threatens the viability ofsmall-scale farming households. Increased monetiza-tion of rural Andean economies may have exacer-

bated the impacts of health on farming householdsby altering the social relations through which farm-ing households obtain their livelihood, and cope

with illness. By the mid-1980s in NunÄ oa, it was im-possible to miss the revolution which had begun inAyacucho. Malnutrition and illness were certainly

not the direct catalysts of resistance and revolt, butthey did play a role in reproducing the conditionsof poverty and poor health at the local level whichwere an important part of a broader context in

which the Shining Path movement grew(McClintock, 1984).For better or worse, these results and interpret-

ations are di�erent from the sorts of conclusionsdrawn from earlier biocultural research on Andeanbiology and health. There is not a body of similar

critical biocultural research from which to extrap-olate across di�erent Andean contexts, and thusargue for a major shift in perspective in biocultural

health research in the Andes. An important contri-bution of shifting biocultural perspectives is in thepotential for better articulation with the breadth ofhealth research in the Andes re¯ecting perspectives

from ecological, biocultural, critical, and interpre-

tive medical anthropologies. In the following discus-sion I draw attention to some of this researchparticularly where it o�ers clear comparison with

the results from NunÄ oa.In a review of Andean growth studies, Greksa

(1986) noted that the NunÄ oan population was

among the smallest of all highland growth samples.It is evident from our results that the small stature

in NunÄ oa is largely a result of poverty. Othergrowth studies in the Andes by Stinson (1982) andGreksa et al. (1985) have also demonstrated that

while hypoxic conditions may a�ect growth pro-cesses, nutritional status as a product of economicconditions also had a major e�ect on high altitude

growth. Leonard (1995) recently concluded that acomparison between highland and lowland

Ecuadorian populations illustrates that nutritionand disease status and not altitude is the determin-ing factor responsible for shorter stature among

highland groups. The recent results from NunÄ oaand these other ®ndings are important because formore than two decades a picture of high altitude

growth has been dominated by the original descrip-tion from NunÄ oa that emphasized the role of hypo-

baric hypoxia over social and economic context.These associations between poverty and growth arenot surprising and likely prevailed during earlier

NunÄ oa research in the 1960s. Yet, the focus onpopulation level adaptation in (assumed) homo-geneous native Andean communities, meant that

economic variation in growth was not addressed(Leatherman et al., 1995).

Marginal economic conditions are also re¯ectedin health and nutrition status among NunÄ oanhouseholds. Stoner (1989) reports an almost identi-

cal prevalence of illness in Yanque, a poor farming-herding community in the Colca valley of SouthernPeru (36% of individuals reporting an illness over a

two-week recall period vs 37% in NunÄ oa). In con-trast, Oths (1991, and this volume) reports betterhealth and nutritional status from the Northern

Peruvian community of Chugurpampa, where shenotes that many common health problems such as

infectious disease, infant diarrhea, and malnutritionhave been alleviated. She found much lower infantmortality rates (31 deaths per 1000 live births vs

129 in NunÄ oa (Carey, 1990)), only one-®fth asmany days of work lost to illness, and superior dietand nutritional status in Chugurpampa. This can

probably be attributed to better economic con-ditions, including more fertile soils and greater agri-

cultural productivity, and more hygienic conditionsof water quality and sanitation. These comparisonshighlight the importance of inter-regional variation

in assessments of health across the Andes, a themeOths explores in greater detail in this collection.Similar to our ®ndings in NunÄ oa, Larme (1993)

and Stoner (1989) working in Southern Peru, Oths(1991) in Northern Peru, and Finerman (1983) in

T. Leatherman1038

Ecuador found that associations between work and

health were evident in reported morbidity and localetiologies of illness. In the communities they stu-died, respiratory illness and skeletal muscular com-

plaints were leading categories of reported illness,and local etiologies stressed that strenuous workand exposure to inclement conditions were respon-

sible for both. Larme (1993) for example, gatheredan extensive list of work related causes of illness

symptoms reported by members of two ayllus in theDistrict of Cuyo Cuyo in Southern Peru. Heavywork of carrying loads, strenuous farming tasks,

and hot±cold interactions related to work placeconditions were perceived to be major contributorsto illness. Work and travel also takes individuals

into contact with di�erent environmental zones andfeatures, many of which may be associated with ill-ness. Farming households in Cuyo Cuyo were

involved seasonally in gold mining in lowland en-vironments, and the work of mining and exposure

to tropical conditions were considered to be keyfactors a�ecting health in men.The relationship between women's economic pos-

ition, high work loads and fertility, and health hasbeen a focus of increased attention in the Andes.

Oths (1991) found that women report symptoms ofchronic malaise such as we found in NunÄ oa underthe category of ``debilidad'' which she related to

reproductive stress. Finerman (1983) working withAndean women in Ecuador, related the prevalenceof nervios Ða folk illness with symptoms related to

chronic weakness and nervous feelingsÐ to highfertility levels. Larme (1993) found that other thanthe hot±cold environmental properties, reproductive

problems were reported by women in Cuyo Cuyoas the leading cause of illness. Like in NunÄ oa, she

found that sobreparto was an encompassing labelfor a variety of reproductive illness, and that mostsobrepartos were associated with similar chronic

symptoms of weakness and malaise. One woman inCuyo Cuyo explained this by saying `` After givingbirth, a woman's body is completely malogrado

(ruined), just like after a truck accident'' (Larme,1993). These illness reports highlight the real and

metaphorical stress which women feel comes withrepeated childbirth in contexts of heavy work loadsand marginal living conditions.

At the outset of our research, we expected thatsocial and economic reciprocity might be a centralfeature of coping with illness since reciprocity was a

central theme in descriptions of Andean social or-ganization (Alberti and Mayer, 1974) and health

systems (Bastien, 1982). Greenway (1987) forexample notes that ties of reciprocity to nature, so-ciety and cosmos are critical to healing rituals

which restore balance to body and soul. Bastien(1982) notes that ``reciprocal obligations provideAndean ethnomedicine with a perpetuating struc-

ture of prestation and counterprestation betweenthe person cured and the specialist'' that is central

to the healing process. In NunÄ oa, the ideology ofreciprocity was indeed central to most individuals'

descriptions of ideal coping strategies in illness, andlabor reciprocity provided important material andsocial support for some households, especially in

smaller rural communities. Yet, social networks andreciprocal labor relations were diminished in con-texts of monetization and labor markets, and this

left many individuals and households withoutresources to cope with illness. These ®ndings echoedother research on the disappearance of reciprocity

with the increase of monetization in the Andes, dueto factors of prestige, time, cash availability and atendency towards ``individualization'' of households(Erasmus, 1956; Aramburu and Ponce Alegre, 1983;

Brown, 1987). While other Andean studies have notspeci®cally addressed labor reciprocity in illness, orits decline, there is a general theme of individual

containment of health problems (Oths, 1991) andthe reluctance when ill to seek outside help fromothers (Stoner, 1989; Larme, 1993).

SUMMARY

Since the publication of Health in the Andes in1981, research on Andean health has expanded inscope beyond ecological frameworks toward critical,

interpretive, and more integrated (biocultural, pol-itical-ecological, critical, interpretive) perspectives.Relations of power seen through class, gender and

ethnicity are common themes in this work and pro-vide room for future collaboration across the gapwhich has separated biocultural and ecological

approaches and those from critical medical anthro-pology (McElroy, 1990). One example of researchbased on a more integrated biocultural approach,combining perspectives from ecology and political-

economy, was presented in this paper, with theobjective of illustrating how such an approach cangenerate new questions and interpretations on

Andean biology and health, and can better articu-late with the larger corpus of socio-cultural healthresearch in the Andes. This approach can provide

valuable insights into the changing nature of pov-erty and poor health by locating biocultural adjust-ments in the context of the social and politicalrealities that structure both environmental exposure

and response opportunities. A more complete bio-cultural framework might also include a strongercognitive or interpretive perspective within political-

ecological contexts as seen in the work of Larmeand Greenway in this collection. While the wealthof diverse approaches to health in medical anthro-

pology is welcome and enriches the discipline, syn-thetic approaches are important to mine thecomplimentary knowledge this diversity provides.

The Andes provides an excellent context for devel-oping more synthetic biocultural approaches andcross-disciplinary strengths in medical anthropol-ogy.

Biocultural perspectives on health in the Andes 1039

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