Peru: Breaking Down The Social and Cultural Structure

High in the mountains of old world Peru lives a tall, lanky fair-bearded man towering over the dark, short native Incans in a contrast as obvious as the differences in culture and health care from the United States. After interviewing Steve Solstrand about cultural differences in health care, these vastly different perspectives on health have aspects that seem to transcend culture. I had the opportunity to discuss several facets of his culture as they relate to health, including his personal points of view. Using the Purnell Model for Cultural Competence we discussed the 12 domains of culture including communication, behaviors, spirituality, and how they relate to healthcare practices (Purnell 2005). This model is organized to include and guide all members of an interdisciplinary team in understanding the culture of a client (Purnell 2005). Steve and I also discussed his personal views toward health and illness, current health status, and use of any traditional therapies and practitioners.

Cusco, the capital of the Incan empire, is high in the mountains sitting at about 12,000 feet above sea level with surrounding mountain tops reaching 20,000 feet above sea level (http://www.cusco-peru.info/index.html). Steve has reported that it is a city low on resources and money. Terraces are built into the steep terrain for potato farming primarily, and lamas and alpaca are herded on the mountain sides. Many residents still dress in traditional Incan apparel, as this city is less touched by outside influence as the larger cities like Lima are. Education has a very high value, but one must have the resources available to receive an education which is not often an option unless in a larger city. People emigrate from this area primarily for the opportunity of wealth, often through student or work visas to the United States.

Spanish is the primary language for communication and secondary is Quechua, the native language and the largest language spoken in the Americas, being the primary language for almost half of those who speak it (http://www.quechua.org.uk/). Steve notes that communication tones, volume (Purnell 2005) are very similar across all the America’s of Spanish and English speaking. Body language, touch, and gestures are quite similar across these connected continents. Content is quite open, most people in general are more than willing to share thoughts and feelings of all kinds that would compare to “too much information” in our culture. Comfortable social distances are much closer than my own culture. It is common to be within a foot or so when speaking, Steve reports “it’s something you would just have to get used to”. Greetings are also friendlier, always with soft handshakes between men and kisses on the cheeks among everyone else. Greetings can be casual, often using first names; however, people are given a first name, middle name, then paternal name, and last maternal name. One reason for this is to easily define the lineage of a person. The concept and importance of time is much different than my own culture where there is great concern for punctuality. They run on what is referred to as “the Peruvian hour.” It is normal to be late for nearly anything and everything, including weddings when a time is prearranged.

Family roles, Steve reflects, are very “chauvinistic,” or male dominated. The man is the head of the house hold and women are responsible for keeping the household and the childrearing. If a family has enough money then the children will get an education, otherwise are expected to work at home and on the farm for self sustainability. Steve also notes that that it is very rare if ever to see a woman driving a vehicle, especially in the more rural areas. Extended families live together and often include many generations. The concept of nursing homes and extended care facilities that are prevalent in my own culture, are nowhere to be seen in rural Peru. Families are expected to care for one another in the home.

The workforce in rural areas is very autonomic, as most families are mostly self-sustaining (http://www.avert.org/southamerica.htm). Working in the larger and more integrated cities, the diversity is greater and gender roles can overlap. Public hospitals and clinics are state funded and run by the ministry of health. They are not staffed as well, do supply most medical equipment or medications, where as the private hospitals are very similar to this culture, with highly educated professionals and more selective in accepting insurance companies. There are still very ethnic medicine men utilized but often in more rural areas or for serious health threats. Steve noted that when his wife’s parents built a new house, the medicine man came and assisted in burying a mummified baby lama (which can be purchased at a local market) under the foundation of the house to ward off bad spiritual elements. There is a blend of old and new seen in situations like this as they are devout Catholics, but still practice traditional ceremonies, like cleansing the home, as they were taught by previous generations.

Biocultural ecology, including ethnic and racial origins, heredity, and topography vary throughout Peru (Purnell 2005). In the more urban areas there is more Spanish influence in the blood lines of people. That makes them lighter in color than the natives and with slightly larger body frames. The higher you travel in elevation the darker people’s skin tones are. This can be genetic, or due to less influence from other races in native blood lines, and closer proximity to the sun. The people of this culture are also slighter in frame and size stature, and the more influence of Spanish heritage, the more full figured one might be. Steve also reported the susceptibility differences of small pox and typhoid fever. If a native from Peru were to get small pox they have a much higher mortality rate than I would. On the contrary, my mortality chances would be much higher if I contracted typhoid fever than a native would.

High risk behaviors include several things; substance abuse issues, reported by Steve, are primarily related to alcohol problems. They seem to take precedence over other substances. Though cocaine and marijuana are prevalent related to their cropping abilities, Steve says those drugs are more of a concern with outsiders and tourists than it is the local population. Another high risk concern is related to driving. Steve describes the streets as “real dangerous drivers, not like here where people follow most traffic laws and order.” It is fast and roads are dangerous, winding around mountains with stiff drops and no guard rails. People do use safely belts, particularly when in the front seat of a vehicle. As related to diet, weight, and exercise, it is a relatively healthy culture. Peruvians are generally more active and have very little obesity (http://www.unicef.org/infobycountry/perustatistics.html). Related to safe sex, they are a very Catholic culture and birth control is often not acceptable. There is an increase in condom usage and STI/HIV awareness is increasing (Young, Sean). Also unplanned pregnancies are being addressed by introducing condoms in some rural communities in the younger population (Stewart A).

Nutrition in this culture is driven largely by what is available, which is primarily potatoes, Steve reports 1200 different varieties of potatoes in South America. Rice is also consumed frequently, and meat and vegetables like tomatoes or cucumbers may be served on the side with a sauce. Some enzyme deficiencies, like iron, and dehydration are a threat, especially in more rural and poorer areas (Stewart A). Steve notes that breakfast is often a very small meal consisting of a beverage and maybe bread on the side. Lunch is the largest meat of the day. As Steve says, “it’s the only thing anyone is on time for; the city shuts down for it. Banks close, school is out, and even buses stop running so everyone can go home and eat.” The lunch meal is usually made up of at least two courses and started with soup. After lunch the city resumes to functioning, but takes at least an hour for people to eat their most important meal of the day. Dinner is reported to be more “take it or leave it,” by Steve. If it’s taken it is often a smaller one course meal, which he also notes could add to the better fitness seen in his culture than ours. Fast food is accessible in the larger cities, but does not seem to be abused the way it is here. Eating for health promotion and healing is recognized; salt is to be avoided if ill, and the consumption of celery and ginger is recommended for stomach health and artichokes for the liver. Greasy food is also to be avoided in general, as they eating relating to “healthy food is healthy living.” (Espinosa MC).

Pregnancy and childbearing practices vary throughout the regions and resource availability. There are some areas that believe a pregnant woman or a woman who is menstruating is impure and could be toxic to certain plants, crops, or animals (Espinosa MC). Steve noted that women are always the caretakers of the children and he recalls for Catholic practices than ethnic ones over all, but reports the wrapping of a baby in cloth and swinging the baby overhead for health and straight bones. Also babies are carried in a tight swaddle cloth and tied always to the backs of women, as this is a common carrying technique for many things in this culture. Birth control is generally taboo as they practice the Catholic faith that does not support the use of contraceptives.

Death rituals are relatively similar to those in American culture. Wearing black to a funeral is common, while crying or other expressions of emotions are normal practices of grieving, and are often seen during a funeral precession. Cremation is taboo and burial is not common due to the terrain of the mountain city, so tombs are most commonly used to lay a body to rest. Often before leaving the funeral, the guests are given, what Steve could best describe as “party favors.” These are little trinkets of sorts that are often placed on mantels in memory of departed.

Spirituality and religion are fairly intertwined in Steve’s home. It is strong Catholic culture, who also prays to “saints” that originally were native Gods who were converted to saint hood with the introduction of Catholicism by the Spanish. Steve noted that religious subtleties are always around. People may wear crosses on their necks or cross the holy trinity over the steering wheel before driving. Native medicine men are still utilized and the belief in bad spirits is respected. Some nearby areas believe very strongly in bad spirits that rest in places in nature. These people are very superstitious about traveling over these areas and that they lay in places that women cannot attend (Espinosa MC). One ethnic tradition that Steve reported was creating a small doll that was set above the door frame to the entrance of the home and things that were desired were tied or wrapped to it. If a new car was in need then a small toy car would be hung around the neck of the doll.

Health care practices in this culture focus on preventing illness and health restoration. Steve says to not drink unnecessary cold beverages when it’s cold outside or you risk becoming ill. There are several foods and herbs that can be used to enhance healing, like ginger for a bad stomach as mentioned earlier. Private hospitals are utilized in acute health situations when the monetary resources are available. State funded clinics are also frequented, especially in remote areas like this mountain city, Cusco. Seeing a physician is often the last thing to try after home remedies have been exhausted. Organ donation is not common due to lack of resources like donors or equipment, but it is not considered taboo or unacceptable. Mental health issues are also acknowledged and treated like any other medical condition. The cost of western prescription medications is far less expensive than in the United States.

This culture relies more on western medication and health practices than any traditional, ethnic, or magical ones. Practitioners are well educated and respected, at it is not uncommon to see women in these roles when they came from a family or background that had the financial ability to pay for college. The private hospitals are in stark contrast to the state funded ones. The private hospitals are similar to those in the states, with sanitary conditions, large healthcare teams, and acceptance of many insurance companies. The state funded clinics are found in more rural and remote areas, and it is not uncommon to see stray dogs running through the halls of the clinic. Patients are expected to their own medical supplies including syringes, bandages, and even gloves for the clinician. They are then sent to a medical supply stores and pharmacies for any follow up provisions needed.

When discussing with Steve, his views on health and illness, his first response was that health is the absence of sickness or injury. As we talked more about it, wondering how the rest of his family would answer the question, he modified his answer to be a more comprehensive. Steve still views health as before, but also that it is a balance of feeling well inclusive of the mind and emotions. Illness he feels is the opposite, could be physical sickness or injury, or any the disruption of the mind and body balance.

Steve is currently in excellent health and has received many vaccines and booster while in Peru. He also has suffered from salmonella on multiple occasions requiring the use of antibiotics until he built enough tolerance to it by frequent exposure. He has no underlying or chronic health issues that require follow up at any of the local clinics.

Steve and his family primarily use western medication and practitioners not traditional practitioners. They do use come traditionally cultural therapies at the start of an illness, like ginger for the stomach and avoiding salts, but they have the resources to take advantage of the more advanced health care options. Steve’s family is not overly wealthy, but they currently have enough resources for safe medical care, much like his wife’s nuclear family growing up who had enough income to give her an excellent education.

Several cultural competence models have been developed to assist in understanding health from a client’s viewpoint, as that is essential to provide the best care (Spector 2009). This is an absolute truth; Steve noted that within the last decade in Peru a western practicing physician was slaughtered after performing a gynecological assessment on a woman. Though assessments like that are a normal and expected part of a physical examination stateside, it was not understood by this particular culture where it is unacceptable for another man to touch a woman in such an intimate way. Perhaps it was a language barrier or poor explanation, but resulted in insufficient care that the physician paid for with his life. This is an extreme example; however, it fully illustrates the point that cultural awareness is essential in health and illness.