Health Situation

rural areas (56.6%) and presents 10% points of difference in comparison with children in urban areas (46.6%) (INEI 2011:14).

In 2010, the prevalence of diarrhoea in children under 5 years was 14.9%, compared with 15.4%, in 2000 (INEI 2011a:222). The ENDES survey of 2010 revealed that at the national level two out of every ten children under three years of age (18.9%) have had diarrhoea, the proportion of which was greater in the urban area (19.3%) than in rural areas (18.3%) (INEI 2011:18). In 2010, 32.2% of children with diarrhoea received sales de rehidratación oral (oral rehydration therapy) in comparison with 21.9% in 2000 (INEI 2011a:225).

The infant mortality rate fell from 88.2 per 1,000 live births in 1987 to 45 per 1,000 during the period 1995-2000 (PAHO 2004). In 1998, diseases preventable by immunization, acute respiratory infections, intestinal diseases, meningitis, septicaemia, malaria, and nutritional deficiencies caused 42% of all deaths in children less than 5 years old (PAHO 2002). In 2004, the leading cause of death remained the acute respiratory infections, followed by ischaemic diseases of the heart and brain-vascular diseases. A peak was reached in 2007, with a mortality rate of 18.5 per 1,000 births (MINSA 2010a:13). According to the INEI, during the last eight years 26 children of 1,000 born were going to die before they could reach the age of 5 years (INEI 2010a:152). Mortality in adolescents is lower than in the general population, external causes being the leading cause of death. In the case of adults, external causes among males and cancer of the uteri and breast among females were the main causes of death for the rank of 20-59 year-olds. The estimation of maternal mortality, i.e. women who die due to complications of pregnancy, delivery or within forty-two days after childbearing was estimated to be 185 deaths per 100,000 live births by 2000. In 2010 there were still 93 maternal deaths per 100,000 births (INEI 2011:355), somewhat distant from the goal by 2015 of 66.3 deaths per 100,000 live births. Fertility among women aged 15-19 years decreased by 16% in 1986-2000. In 2000, 15% of them were already mothers or were bearing a child for the first time (PAHO 2002). There is a rising curve in the reduction of fertility rates, starting a change in the overall

participation of the child population and growth of average age groups in productive age, as the rapid increment in the population over 60 years (INEI 2008, 2009a).

For the general population mortality conditions remained constant between 2000 and 2009. The life expectancy of the Peruvian population has increased 14 years during the last three decades. Life expectancy at birth increased from 43.9 to 68.3 years by the year 2000; by 2009 Peruvians lived, in average, 73.5 years (70.9 years for men and 76.2 for women) (INEI 2009a:11). Nevertheless, a comparative analysis by regions shows that life expectancy reflects the persistence of inequalities in the country that are deeply rooted according to cultural and socioeconomic factors. The risk of dying was three times higher in Huancavelica (13.0 per 1000) than in El Callao (3.6 per 1,000), something reflected also in the 21-year difference regarding life expectancy at birth in the same cities, with 56.8 years in Huancavelica and 78.0 years in El Callao.

Additionally, it is estimated that nearly 50% of the deaths in Peru go unregistered (PAHO 2002). In his report on the Mission to Peru in 2004, Paul Hunt, UN Special Rapporteur on the Right to Health, placed a special emphasis on the enormous inequality access to services and health, indicating that many of the health problems in Peru are inextricably linked to problems of poverty and discrimination. He notes that both poverty and discrimination have perpetuated great disparities in the enjoyment of the right to health between rural and urban areas, between regions and among different population groups⁸³ (UN 2004:7).

Since the epidemic in 1992, there have been no reported deaths from measles; of the 5,256 suspected cases of measles-rubella reported through ESSALUD in 2000, only one measles case was confirmed (PAHO 2002). In the same year 10 cases of neonatal tetanus were reported, compared with 94 cases in 1995. Also, 41 suspected cases of jungle yellow fever (7 confirmed; 4 fatal) and 1,148 confirmed cases of hepatitis B were reported in 2000. Since 1990, vaccination coverage under the Expanded Program on Immunization (EPI) has maintained levels of over 90% (PAHO 2002; MINSA 2010a).

83 At the time of the Hunt-Mission in June 2004, Peru was engaged in negotiations towards a bilateral trade agreement with the United States. The report expresses concerns that the agreement may result in

“WTO-plus” restrictions, i.e. including new patent and registration regulations that impede access to essential medicines, such as antiretrovirals for people living with HIV/AIDS (cf. Hunt 2006).

Cholera continued declining steadily from 42,000 suspected cases during the El Niño phenomenon to 934 in 2000⁸⁴. In analysing the social conditions of the population during the cholera and dengue epidemics in 1999 and 2005 respectively, Cueto speaks of a cultura de la sobrevivencia (surviving culture) to describe the principal characteristic of the PH muster in Peru. “The principal similarity (of both epidemics) is that the principal social cause was to find in the living conditions of the population with lower economic resources. They deteriorated even more after the neoliberal structural adjustment programmes and the economic politics first applied by the government of Alberto Fujimori” (Cueto 2009:253, t. sp.).

In 2000 11,310 cases of AIDS were reported (PAHO 2002). The incidence of HIV/AIDS in Peru has increased during the last year, and an estimated 78,000 people are currently living with HIV/AIDS (INEI 2011a). Malaria is also a widespread infectious illness, in particular in the forest. It is estimated that 2.5 million inhabitants live in areas at risk for malaria transmission. In the year 2000 the annual parasite index was 2.7 per 1,000 people (PAHO 2004). The population in areas of dengue transmission risk is estimated at 3.4 million. In 2000, all four serotypes of the dengue virus were isolated and the cumulative incidence was 21.7 cases per 100,000 among the population. In the first 26 weeks of 2001 a total of 23,454 cases of dengue were reported, including the country's first cases of hemorrhagic dengue (206 cases, 3 deaths). A total population of 600,000 is estimated to live in areas of Chagas' disease transmission. The Peruvian population is also vulnerable to other infectious diseases such as leishmaniasis –by year 2000 a total of 9,588 cutaneous and 863 mucocutaneous cases were reported. In 2011 the presence in the country of hanta virus was also confirmed⁸⁵.

The infecciones respiratorias agudas IRAS (acute respiratory infections), are a set of diseases that affect the tracks where the air passes in the human body and they are caused by both viruses and bacteria. This group of diseases are the main cause of

84 In 1991 more than 320,000 persons were affected by enfermedades diarreicas agudas EDA (acute diarrheic disease). The diagnosis of EDA was disputable, because it was impossible to verify if all cases

consultation in health services and causing more deaths, especially in children younger than 36 months and in people older than 60 years. The IRAs are more frequent when changes occur by swings in temperature and environments that are very contaminated.

The biggest percentage of IRAS is in children under 36 months (24.4%) in the forest, followed by the Coast (18.3%); the Andean region presents the lowest percentage or IRAS (15.6%) (INEI 2011:17-18).

Tuberculosis has been on the decline since 1992 to an incidence of 155 per 100,000 populations in 2000 (PAHO 2002). Nevertheless, Peru has still the highest incidence of pulmonary tuberculosis in Latin America, with 100 cases per 100,000 people compared with the regional average of 17 cases (UN 2004:7), as well as a high incidence of multi- drug-resistant tuberculosis.

An unresolved PH problem is the consequences of Peru’s conflicto armado, ocurred between 1980 and 1992, and caused ongoing psychosocial and psychosomatic health problems for the population that remain unattended by Peruvian health institutions (cf.

CVR 2003, 2003a). The Partido Comunista del Perú Sendero Luminoso PCP-SL (Communist Party of Peru Shining Path) resulted from a long sectarian, dogmatic and, violent adaptation of the harder lines of Marxism. SL defines itself as a “Marxist- Leninist-Maoist” organisation. From Lenin it took the thesis of the construction of a match based on exclusive and secret squares or teams, a sophisticated organisation (el partido tiene mil ojos y mil oídos) prepared to impose the “dictatorship of the proletariat”, with weapons. From Stalin, a minor figure among SL, it adopted the simplified version of Marxism as dialectical and historical materialism. In addition, the thesis of the single party and the cult of the leader’s personality was inspired by Mao Zedong, for whom the conquest of power would take place in so-called semifeudal countries by means of a “popular prolonged war from the countryside to the city” (CVR 2003b:13-15). These issues make up the history of the PCP-SL and the enthronement of Abimael Guzmán as the “fourth sword of Marxism” (after Marx, Lenin, and Mao) and the incarnation of so-called “thinking Gonzalo” conducting war’s ideology.

The Comisión de la Verdad y la Reconciliación, CVR (Truth and Reconciliation Commission) estimates that the subversive war in Peru produced at least 69,280 deaths, of which 75% were Quechua-speaking people, more than half were peasants, and almost 80% lived in the following five departments: Ayacucho, Junín, Huanuco, Huancavelica, and Apurímac (CVR 2003a:13-25). Except for the department of Junin, these four departments have the highest poverty ratio in Peru (PNUD 2002:45-48).

According to the CVR’s report, the peasant population was the principal victim of this violence, a situation that was combined with socioeconomic gaps, which highlighted the seriousness of ethno-cultural inequalities that still prevail in the country (CVR 2003:43- 48). Some national and international senderólogos –experts on SL– have identified SL and its followers as one of the most violent, bloodthirsty, and cruel terrorist movements of the whole world history (cf. Roncagliolo 2007). For Degregori, SL could arise precisely as a result of the irreconcilable distance between the capital and the provinces, between the city and the countryside, between the Andeans and the criollos, and represented the authoritarian and defensive reaction of a narrow strip located at the pole more beaten and broken up by this antithetical specific development (Degregori 1988:8).

Based on almost 17,000 private and public testimonies in the early post-conflict period, the CVR devoted an entire chapter to the destabilizing and destructive psychosocial effects of Peru’s war that challenged and exceeded the capacity of psychological defenses (Laplante and Rivera 2006:140). The CVR emphasised a host of psychosomatic problems that the conflict-weary population were experiencing, including feelings of insecurity, helplessness, impotence, loss of confidence in oneself and others, generalized anxiousness, fears and phobias, impulsiveness, and aggressiveness (CVR 2003c:167-179). The CVR also confirmed that political violence had left an indelible mark on the well-being of the communities in which these suffering individuals resided, affecting social functioning and limiting the possibilities of a dignified life (CVR 2003c:167). Laplante and Rivera (2006) reported that the unique nature of Peru’s conflict had created an intense climate of fear and distrust, ruptured social bonds and solidarity due to community conflict and interpersonal violence. The

executions, disappearances, arbitrary detentions, rape) had caused a sharp sense of vulnerability within the population (CVR 2004:355). This terror imposed an atmosphere that made speaking out too dangerous, resulting in anxiety that created the perception of imprecise, but always imminent, risk that disturbed daily life⁸⁶ (CVR 2003c:169, t. sp.).

Several subsequent studies on the psychosocial consequences of the political violence in Peru among indigenous population have shown specific post-war syndromes and cultural forms of affliction (idioms of distress) such as llakis (painful memories), pinsamientuwan (recurring concerns/tribulations) and manchay (fear, fright) (Pedersen et al. 2010). Also iquyay (weakness), alcansu (damage), llaki nuño (scared teat), and ñakari (cf. Malvaceda 2010), are extensively present in victims’ tribulations. The CVR puts public policies on mental health in Peru’s national agenda⁸⁷ by calling to special attention the devastating pychosocial damage caused by the war. In their recommended Integral Plan of Reparations (PIR), a mental health component is included, in which a communitarian approach that moved beyond an individualized clinical- and medical- based model was proposed. To the present, this plan has not been throughout implemented.