Social inequalities and health in rural Chiapas,
M exico: agricultural economy, nutrition,
and child health in La Fraylesca Region
De sig uald ad e s so c iale s y salud e n Chiap as, Mé xic o .
Ec o no mía ag ríc o la, nutric ió n y salud infantil
e n la re g ió n d e La Frayle sc a
1 Departam en to de Ep id em iología y Salu d Pú blica, División d e Población y Salu d , El Colegio d e La Fron tera Su r (Ecosu r). Carretera Pan am erican a y Periférico Su r s/no, C. P. 29290, San Cristóbal d e Las Casas, Ch iap as, M éx ico. h och [email protected] r.m x
Héctor Och oa-Díaz Lóp ez 1 Héctor Javier Sán ch ez -Pérez 1 M agd iel Ru íz -Flores 1 M ich ael Fu ller 1
Abst ract Th e objective of th is stu d y w as to in vestigate th e association betw een farm ers’ socioe-con om ic socioe-con d ition s an d th eir ch ild ren’s h ealth in La Fraylesca, Ch iap as. Data w ere collected u s-in g a cross-sect ion a l su rvey of 1046 h ou seh old s (5546 s-in d iv id u a ls) sa m p led from loca t ion s s-in tw o cou n ties situ ated in th e stu d y area. Th e su rvey in clu d ed an th rop om etric m easu rem en ts, a 24-h ou r d ietary recall, stool tests, an d ch ild h ood m ortality d ata. Ch ild ren of p rivate farm ers an d “w ealth y p easan ts” d isp layed better n u trition al statu s, h igh er qu ality d iet, low er p revalen ce of in testin al p arasites, an d a low er risk of d yin g th an th ose w h ose p aren ts w ere com m u n al farm ers, from e jid o s, or “p oor p easan ts”. Th e resu lts su ggest th at u sin g volu m e of m aiz e p rod u ction as a cla ssifica t ion m et h od p rov ed m ore v a lu a b le t h a n la n d t en u re t o id en t ify a gricu lt u ra l grou p s w it h d ifferen t h ea lt h st a t u s. It a p p ea rs t h a t t h e m a in d et erm in a n t s of h ea lt h d ifferen t ia ls a re stru ctu ral in equ ities in resou rce d istribu tion . Th u s, th e im p act of m ed ical in terven tion s on in -equ alities w ill be lim ited u n less th ey are accom p an ied by red istribu tion of resou rces.
Key words Social Con d ition s; Ch ild Health ; Ru ral Health ; Nu trition al Statu s; An th rop om etry
Resumen El objetivo d e este trabajo es in vestigar la relación en tre las con d icion es socioecon ó-m icas d e los p rod u ctores agrícolas y la salu d d e su s h ijos en La Fraylesca, Ch iap as, M éx ico. Los d atos se recop ilaron m ed ian te u n a en cu esta tran sversal d e u n a m u estra d e 1046 h ogares (5546 in d ivid u os) d e d os m u n icip ios d el área d e estu d io. La en cu esta in clu yó m ed icion es an trop om étricas, record atorio alim en tario d e 24 h oras, exám en es cop rológicos y d atos sobre m ortalid ad in -fan til. Los h ijos d e p rod u ctores p rivad os y cam p esin os “ricos”p resen taron m ejor estad o n u tricio, m ejor d ieta, p revalen cias m ás bajas d e p arásitos in testin ales y m en or riesgo d e m orir qu e los h i-jos d e ejid atarios/com u n eros o cam p esin os “p obres”. Estos resu ltad os su gieren qu e el volu m en d e p rod u cción d e m aíz es m ejor in d icad or qu e la ten en cia d e la tierra p ara an aliz ar d esigu ald ad es en salu d y n u trición . Los p rin cip ales d eterm in an tes d e d ich as d isp arid ad es p u ed en en con trarse en las in equ id ad es en la d istribu ción d e los recu rsos. De m od o qu e el im p acto d e in terven cion es m éd icas en las d esigu ald ad es será lim itad o, a m en os qu e se acom p añ en d e u n a red istribu ción d e recu rsos.
Introduction
Th e Zap atistareb ellio n b egin n in g o n th e first d a y o f Ja n u a r y 1994 a wa ke n e d Me xico to th e n eo-lib eral p olicies of glob alization of cap ital, th e weaken ed role of th e state, an d th e p rivati-zation an d con cen tration of in d u stries, form al-ly in itia te d th a t sa m e d a y u n d e r th e No rth Am e rica n Fre e Tra d e Agre e m e n t (Na fta ). Th e reb ellion b rou gh t in to sh arp relief th e extrem e p olarization an d social exclu sion of ru ral cam -pesin osan d in d igen ou s p eop les in Mexican so-ciety. It wa s n o a ccid en t th a t th e reb ellio n b e-ga n in th e Sta te of Ch ia p a s, wh ere p ea sa n ts in ru ral areas exh ib it th e sh arp est con trasts in liv-in g stan d ard s an d h ealth con d ition s (Sán ch ez-Pérez et al., 1995). For exam p le, Ch iap as h as th e h igh est m o rb id ity a n d m o rta lity ra tes in a ll o f Mexico for th e m ain in fectiou s diseases: in 1992, th e m a la ria ra te wa s e igh t tim e s h igh e r th a n o th e r m a la ria l a re a s o f Me xico, wh ile p re va -le n ce o f tu b e rcu lo sis wa s th re e tim e s h igh e r (SSA, 1993a); m ortality rates from d iarrh eal in -fe ctio n s fo r ch ild re n u n d e r five ye a rs o f a ge we re a lso th re e tim e s h igh e r (CAE, 1991; SSA, 1993b ). In 1991, n e a rly 50% o f h o u se h o ld s in Ch iap as lacked p ip ed d rin kin g water an d toilet facilities (In egi, 1990).
Th e h e a lth d e live r y syste m is d ivid e d b e -tween th e p u b lic an d p rivate sectors. Be-tween a n d with in ea ch secto r th ere a re m a n y in co n -sisten cies in q u a lity: b etween u rb a n a n d ru ra l a rea s; by th e va riou s p u b lic clin ics a n d h osp i-tals organ ized for b lu e- an d wh ite-collar work-e rs, cam p esin os, a n d th e u n in su re d ; a n d b e -tween th e Mexico City m etrop olis an d th e rest of th e cou n try. As a resu lt, in 1995 Ch iap as h ad th e lowe st n u m b e r o f a va ila b le h o sp ita l b e d s a n d m ed ica l co n su lta tio n s in Mexico (by gen -eral p ractition ers an d sp ecialists), was th e sec-o n d lsec-owest in th e n u m b er sec-o f clin ica l tests a n d X-rays p er in h ab itan t, an d was th e th ird lowest in th e p e rce n ta ge o f a tte n d e d b irth s p e r 1000 fe rtile wo m e n (SSA, 1995), wh ile fe we r th a n 60% of th e p op u lation h ad access to basic m ed-ical services (SSA, 1992). In 1995 on e ou t of two Mexican s were covered by social secu rity b en e-fits, wh ile on ly on e ou t of five in h ab itan ts were covered in Ch iap as (SSA, 1995).
Th ere is stron g evid en ce to su ggest th at th e low stan d ard of livin g an d p oor h ealth an d n u -trition al statu s in Ch iap as, p articu larly am on gst th e p easan t p op u lation , are p artially d u e to th e fa ct th a t th is Sta te d id n o t p a rticip a te in th e a gra ria n re fo rm s in itia te d a fte r th e Me xica n Revolu tion . Th is h as p rolon ged an u n eq u al so-cia l stru ctu re fo cu se d o n th e la n d te n u re sys-tem (Ga rcía d e Leó n , 1996). La n d less la b o rers
an d p easan ts tillin g m argin al lan d su ffer overe xp lo it a t io n a n d a rovere overe xclu d overe d fro m t h overe b overe n -e fit s o f b a sic h -e a lt h s-e r vic -e s, a ll o f wh ic h is a ggra va te d b y a n u n sta b le e m p loym e n t m a r-ke t an d d isastrou s m igration flows (Esp in oza-Cortés, 1995). On Jan u ary 1, 1994, govern m en t a gra ria n p o licies were p roved a d ism a l fa ilu re b y t h e in d ige n o u s re b e llio n o f t h e Zap atista
Nation al Lib eration Arm y (EZLN).
Wh ile p reviou s h ealth stu d ies h ave con cen -tra te d p rim a rily o n th e co m p a riso n o f u rb a n a n d ru ra l a rea s, th is stu d y fo cu ses exclu sively on ru ral areas from a region in th e State of Ch iap as (La Fraylesca), wh ere we exam in e th e con -tra st in h ea lth a n d n u trition a l sta tu s a m o n gst ch ild re n o f va rio u s a gricu ltu ra l gro u p s u n d e r d ifferen t so cio eco n o m ic co n d itio n s. Id en tify-in g vu ln erab le ch ild ren at greater h ealth risk is p articu larly im p ortan t for th e d evelop m en t of a sou n d social an d h ealth p olicy (Hayes, 1991). Th e o b je ctive o f th is p a p e r is to e xa m in e th e a sso cia tio n b e twe e n fa rm e rs’ so cio e co -n om ic co-n d itio-n s a-n d th eir ch ild re-n’s h ealth i-n La Fraylesca, Ch iap as. Th is is exp ected to h igh -ligh t th e p u b lic p o licy im p lica tio n s o f th e a gra ria n la w re fo rm s p a sse d d u rin g th e la st Pre sid e n tia l Ad m in istra tio n o f Ca rlo s Sa lin a s d e Gortari (19881994). With in th e p resen t con -te xt, th e fin d in gs co u ld b e re le va n t fo r fu tu re p e a ce n e go tia tio n s b e twe e n th e fe d e ra l gov-ern m en t an d th e EZLN. Th e Ch iap as con flict is b a sica lly o n e o f in eq u a lity in a gricu ltu re, a n d th is p ap er p resen ts a p ractical ap p roach to th e p rob lem u sin g ep id em iologica l a n d socioeco-n o m ic cla ssifica to r y m e th o d s th a t ca socioeco-n p rove u sefu l for h ealth p lan n ers an d p olicy-m akers.
Th e p ap er is organ ized as follows: we b egin b y p re se n tin g th e a gricu ltu ra l a n d so cio e co -n o m ic ch a ra cte ristics o f th e stu d y a re a i-n La Fraylesca an d th e d isp arities b etween th e vari-ou s m u n icip ios (d istrict or cou n ty ad m in istra-tive u n its) com p risin g th e region . Next, we p ro-vid e a d escrip tion of th e m eth od ology u sed for cla ssifyin g a gricu ltu ra l grou p s. Th e resu lts a re p resen ted in fou r section s: differen tials in ch ild -h o o d m o rta lity b e twe e n a gricu ltu ra l gro u p s, n u trition a l sta tu s for ch ild ren 0 to 4 yea rs old , d iet for ch ild ren aged 14 years, an d level of in -testin al p arasitic in fection am on gst ch ild ren 1 to 4 years old . Fin ally, th e p rin cip al fin d in gs are d iscu sse d in te rm s o f th e m e th o d s u se d a n d th eir im p lication s for h ealth p olicy.
The study area: the La Fraylesca region
low-la n d s (Figu re 1). It co m p rises fo u r m u n icip ios
with a to ta l p o p u la tio n o f 182,992 p e o p le, o f wh o m h a lf live in ru ra l a re a s. Ju st ove r fo rty-th ree p ercen t of rty-th e total are u n d er 15 years of age (In egi, 1990). Th e stu d y focu ses on two m u -n icip ios: An ge l Alb in o Co rzo (fo rm e rly Ja lte -n a -n go La Pa z) a -n d Villa flo re s. Fo r ye a rs, La Fraylesca h as b een called th e “b read b asket” of Ch ia p a s b e ca u se a gricu ltu re is th e m a in e co -n om ic activity. Th e regio-n is a-n im p orta-n t p
ro-d u ce r o f m a ize, b e a n s, ro-d a ir y p ro ro-d u cts, m e a t, vegeta b les, a n d fru its. Tota l m a ize p rod u ction is secon d on ly to th e h igh ly p rod u ctive Cen tral Va lley regio n . Villa flo res is th e wea lth iest m u -n icipioan d h as th e largest n u m b er of livestock in th e regio n . In La Fra ylesca a ca p ita list a gricu ltu ra l eco n o m y a n d a p ea sa n t eco n o m y co -e xist. Th -e a gricu ltu ra l s-e cto r o f La Fra yl-e sca fa irs b e tte r a n d is m o re m o d e rn th a n o th e r p overtystricken region s of th e State. For exam
-M exico
Chiapas La Fraylesca
Villa Co rzo Villaflo re s
Ang e l Alb ino Co rzo La Co nco rd ia
Fig ure 1
p le, La Fra yle sca h a s m o re fe rtile la n d , b e tte r irriga tio n syste m s, u se s m o re a gro ch e m ica ls, a n d h a s m o re a cce ss to fa rm cre d it a n d te ch -n o lo gica l su p p o r t t h a -n t h e h igh la -n d s re gio -n o f Ch ia p a s (Po h le n zCó rd ova , 1994). Th e so called “agricu ltu ral m od ern izin g m od el” as ap p lie d to La Fra yle sca h a s cre a te d a h e te ro ge n e o u s a gricu ltu ra l stru ctu re o f d isp a ra te in -com es an d social in equ alities. Sm all an d m ed i-u m la n d own e rs p re d o m in a n t, ra n gin g fro m su b siste n ce fa m ily p lo ts to sim p le fa rm s p a r-tia lly in te gra te d in to th e m a rke t e co n o m y. Farm ers h ave ad op ted d ifferen t su rvival strate-gie s, so m e e ve n tra ve lin g to o th e r re gio n s o f th e Sta te, re so rtin g to sa la rie d wo rk a s th e ir m ain sou rce of in com e (Ordoñ ez-Morales, 1983, 1984, 1989; Mo n toya , 1989; Villa fu erte-So lis & García-Agu ilar, 1995).
Th ere are strikin g d ifferen ces in livin g con -d itio n s b e twe e n th e va rio u s m u n icip ioso f La Fra yle sca . Fo r e xa m p le, in 1990 th e illite ra cy rate in Villaflores was 23%, wh ereas in An gel Al-bin o Corzo it was 36%. Th e p ercen tage of h ou se-h old s in Villaflores witse-h n o access to electricity wa s 11% a n d in Villa Co rzo it wa s 22%, wh ile la ck o f sewa ge d isp o sa l fa cilities wa s 33% a n d 47% resp ectively (Con a p o, 1990). Th e p op u la -tio n o f La Fra yle sca is p o o rly cove re d b y th e d iffe re n t p u b lic h e a lth se r vice s. In 1995 o n ly 55% of its p op u lation was covered . Of th e 55% covered , govern m en t h ealth services (Secretary o f Hea lth ) a cco u n ted fo r 32%, wh ile th e co m -b in ed social secu rity in stitu tion s (in clu d in g th e solid arity p rogram , a p overty-relief sch em e) to-ta le d 23%. Use o f p riva te se r vice s in clu d in g d o cto rs (th e h ea lth p ro fessio n a ls m o st wid ely co n su lte d ) a n d p h a rm a cie s is h igh a t 42% (Och oa-Díaz et al., 1995).
M ethods
Data were collected u sin g a cross-section al su r-vey of 1046 h ou seh old s (5549 in d ivid u als). Th e sam p le was d rawn from a th ree-stage stratified clu ster sa m p lin g sch em e. Ha lf o f th e h o u se-h old s sam p led were from town s an d villages in th e m u n icip ioo f An gel Alb in o Co rzo, a n d th e o th er h a lf were fro m Villa flo res. Th e sa m p lin g fra ctio n wa s a p p roxim a tely 6.0% o f th e to ta l p o p u la tio n o f th e two m u n icip ios. Th e m a in criterion for ch oosin g th ese two m u n icipioswas th a t th ey rep resen ted th e wo rst (An gel Alb in o Corzo) an d best (Villaflores) socioecon om ic con -d ition s in th e region . Th e su rvey of p resch ool ch ild ren in clu d ed an th rop om etric m easu res, a 24-h ou r d ietary recall, stool tests for in testin al p arasites, an d ch ild h ood m ortality d ata.
Nu trition al statu s was m easu red u sin g th ree in d ice s: h e igh t-fo r-a ge, we igh t-fo r-a ge, a n d weigh t-fo r-h eigh t. Preva len ce o f m a ln u tritio n wa s d efin ed a s th e p ro p o rtio n o f ch ild ren b e-low -2 sta n d a rd d evia tion s of th e WHO/ NCHS referen ce valu es ( WHO Workin g Grou p, 1986). Th e sa m p le fo r th e 24-h o u r d ieta ry reca ll su r-vey in clu d ed th e yo u n gest ch ild o f th e h o u seh o ld b e twe e n 14 ye a rs o f a ge. We u se d sta n -d ar-d ization p roce-d u res in th e collection of th e d ie ta r y d a ta : a sh o rt re ca ll p e rio d (24 h o u rs) a n d a n in ter view with th e ch ild ca re p rovid er. To m e a su re a m o u n ts o f fo o d we u se d sta n -d ar-d s su ch as p lates, glasses, cu p s, an -d sp oon s. Th e n u trien t con ten t of food was estim ated u s-in g fo o d co m p o sitio n ta b le s a d ju ste d fo r th e re gio n fro m Qu in tín -Ola sco a ga (1970) a n d Hern án d ez (1987).
Th e sam p le of ch ild ren for th e stool exam i-n atioi-n su rvey ii-n clu d ed all ch ild rei-n (1-14 years old ) from every fou rth h ou seh old (selected by system atic sam p lin g) from th e 1046 h ou seh old sam p le.
Mortality d ata were collected from wom en 15-49 ye a rs o f a ge wh o h a d h a d o n e o r m o re ch ild re n . Da ta in clu d e d in fo rm a tio n o n th e n u m b er of th eir ch ild ren wh o h ad d ied .
Classification of agricultural groups
Two m e th o d o lo gie s a re u se d in th is stu d y to d e fin e a gricu ltu ra l gro u p s: o n e is b a se d o n lan d ten u re, an d th e oth er relies on th e volu m e o f m a ize p ro d u ctio n p er yea r (fro m th e p revi-ou s yea r of th e su rvey). Th e first cla ssifica tion in clu d e s two b ro a d su b -gro u p s: ejid osa lo n g with co m m u n a l la n d p e a sa n ts, a n d p riva te farm ers. Th e ejidois sim ilar to com m u n al lan d excep t th a t it is d ivid ed in to sm a ller p lots a n d is tille d b y in d ivid u a ls. Ejid osa n d co m m u n a l la n d p e a sa n ts p ro d u ce low yie ld s a n d re ly a lm ost exclu sively on rain fall an d p rilm itive tech -n o lo gie s. Th e p riva te fa rm e rs, o -n th e o th e r h a n d , o b ta in h igh e r yie ld s d u e to th e ir m o re fertile lan d s an d th e im p lem en tation of b etter irrigation system s an d m od ern tech n ology.
key con cep ts: th e size of a p lot of lan d an d (by m e a su rin g m a ize p ro d u ctio n ) th e a m o u n t o f in ve stm e n t in p u ts in th e p ro d u ctio n p ro ce ss (cap ital an d lab or em p loyed ). Volu m e of m aize p ro d u ctio n d e p e n d s o n b o th th e size o f th e p lot an d th e am ou n t of lab or em p loyed an d th e u se of m ach in ery an d tech n ology.
Results
Childhood mortality
As m easu red by th e p rop ortion of m oth ers (15-49 ye a rs o f a ge ) wit h d e ce a se d ch ild re n , a n d a n a lyze d b y b o t h la n d t e n u re a n d vo lu m e o f m a ize p ro d u ct io n , ch ild re n o f h o u se h o ld s with p rivate farm s an d th ose of “rich p easan ts” sh owe d a lowe r r isk o f d yin g t h a n ch ild re n fro m h o u se h o ld s wit h ejid o/co m m u n a l la n d s a n d t h o se o f “p o o r p e a sa n t s”. Figu re 2 sh ows m a rke d d isp a r it ie s b e t we e n la n d t e n u re a n d socioecon om ic grou p s. For in stan ce, th e p reva-le n ce ra te o f m o th e rs with d e ce a se d ch ild re n fro m h o u se h o ld s o n ejid os a n d co m m u n a l farm s was m ore th an on e an d a h alf tim es h igh -er th an th at of p rivate farm s (p < 0.05). Diff-er- Differ-en ces b etweDiffer-en socioecon om ic grou p s are evDiffer-en m o re p ro n o u n ce d : fo r “p o o r p e a sa n ts” th e p revalen ce rate was alm ost th ree tim es th at of “rich p easan ts” (p < 0.01).
N utritional status of children (0 to 4 years old)
Th e p ro p o rtio n s o f m a ln o u rish e d ch ild re n a m o n g th e ove ra ll p o p u la tio n fo r h e igh t-fo r-age, weigh t-for-r-age, an d weigh t-for-h eigh t were 31.6%, 19.8%, an d 6.8%, resp ectively. Ch ild ren fro m h o u se h o ld s o n p riva te fa rm s o r o f “rich p ea sa n ts” d isp la yed b etter overa ll n u tritio n a l statu s (Figu res 3 an d 4). Prevalen ce of stu n tin g (low h e igh t-fo r-a ge ), a sso cia te d with ch ro n ic m aln u trition , was 1.3 tim es h igh er for ejidosor com m u n al farm s as com p ared to p rivate farm s (p = 0.07), wh ile fo r “p o o r p ea sa n ts” it wa s 1.7 tim es th a t o f “rich p ea sa n ts” (p = 0.05). Preva -len ce of u n d erweigh t ch ild ren (low weigh t-for-a ge ) fro m ejid oso r co m m u n a l fa rm s wa s 1.4 tim es th at of p rivate farm s (p = 0.07); for “p oor p easan ts” it was 4.3 tim es th at of “rich p easan ts” (p < 0.01). Pre va le n ce o f wa stin g (low we igh t-fo r-h e igh t), a sso cia te d with a cu te m a ln u tri-tio n , wa s 3.8 tim es h igh er fo r ejid osa n d co m -m u n a l fa r-m s th a n fo r p riva te fa r-m s (p < 0.01), wh ile for “p oor p easan ts” it was 2.3 tim es h igh -er th an for “rich p easan ts” (p = NS).
Fig ure 2
Mo the rs (15 to 49 ye ars o ld ) with o ne o r mo re d e c e ase d c hild re n b y land te nure and so c io e c o no mic g ro up s, La Frayle sc a, Chiap as, 1995.
0 5 10 15 20 25 30 35 40
land te nure g ro up s
so cio -e co no mic g ro up s
rich p e asants (n = 50) mid d le
p e asants (n = 174) p o o r
p e asants (n = 315) p rivate
farms (n = 162) e jido s and
co mmunal land s (n = 393)
p
re
v
a
le
n
c
e
r
a
te
p
e
r
1
0
0
< 0.05 < 0.01
p o o r vs rich mid d le vs rich
< 0.05
2.48 3.8
1.8
p = O R =
0.96-7.6 1.5-11.1
1.1-2.8
95% CI =
Fig ure 3
Pre vale nc e o f malnutritio n* amo ng c hild re n (0 to 4 ye ars o ld ) b y land te nure g ro up s, La Frayle sc a, Chiap as, 1995.
0 5 10 15 20 25 30 35 40
e jido s and co mmunal land s (n = 389)
p rivate farms (n = 164)
we ig ht-fo r-he ig ht we ig ht-fo r-ag e
he ig th-fo r-ag e
p
re
v
a
le
n
c
e
r
a
te
p
e
r
1
0
0
< 0.01 0.07
0.07
4.08 1.53
1.44
p = O R =
1.54-10.83 0.95-2.46
0.96-2.15
95% CI =
Dietary Survey (1 to 4 years old)
Th e resu lts sh ow th at in gen eral, ch ild ren’s in ta ke o f b o th e n e rgy a n d p ro te in wa s in a d e -q u a te (Figu re s 5 a n d 6). Mo st o f th e e n e rgy in th e ch ild ren’s d iet cam e from corn b ased d ish -e s a n d su ga r. B-e a n s a n d co rn w-e r-e th -e m a in sou rces of p rotein .
Th e two m o st fre q u e n tly co n su m e d fo o d grou p s (from th e p reviou s d ay of th e in terview) b y ch ild ren were su ga r (98%) a n d co rn d ish es (93%), wh ile e ggs (43%), fru its (43%), ve ge ta -b le s (44%), m e a t (45%), a n d m ilk (60%) we re less freq u en tly con su m ed . Of th e five selected food grou p s an alyzed (m aize, eggs, bean s, m ilk, an d m eat), strikin g d isp arities in con su m p tion were ob served am on g th e th ree p easan t grou p s a n d b e t we e n t h e la n d t e n u re ca t e go rie s (Fig-u res 5a an d 5b ). Th e ch ild ren of “p oor p easan t” h ou seh olds con su m ed m ore corn (p < 0.01) an d b ea n s (p < 0.05) th a n th ose in eith er th e “m id dle p easan t” or “rich p easan t” categories. Mean wh ile, th e “m id d le” a n d “rich p ea sa n ts” con -sum ed m ore m ilk (p < 0.01) and m eat (p < 0.0001). Th e sam e tren d was ob served wh en com p arin g
ejidos/ com m u n al lan d s an d p rivate farm s. Fo o d s o f a n im a l o rigin we re sca rce ly co n -su m ed by an y of th e agricu ltu ral grou p s, as refle cte d in th e low a ve ra ge a n im a l p ro te in in
-take of ch ild ren of all grou p s. Th ere were strik-in g d isp a ritie s strik-in th e a ve ra ge a n im a l p ro te strik-in in take between agricu ltu ral grou p s in both classification s u sed . For exam p le, m ean con su m p -tio n o f a n im a l p ro te in a m o n g ch ild re n fro m p riva te fa rm s wa s 1.7 tim e s th a t o f ch ild re n fro m ejid os a n d co m m u n a l fa rm s (p < 0.001), wh ile for ch ildren of “rich p easan ts” it was twice th a t o f ch ild ren o f “p o o r p ea sa n ts” (p < 0.001) (Figu re 6).
Intestinal Parasitic Infections (children 1 to 4 years old)
In testin a l p a ra sites a re co m m o n in p resch o o l ch ild ren , as m easu red by stool tests. Th e m ain p a ra site s id e n tifie d we re p ro tozo a n s, su ch a s
En tam oeba h istolyticaan d Giardia lam blia, an d ro u n d wo rm s, su ch a s Ascaris lu m bricoid es. In gen eral, ch ild ren of “h ead s of h ou seh old s” wh o were ejidoor com m u n al farm ers or were in th e “p o o r p e a sa n ts” ca te go r y h a d a h igh e r p re va -len ce of m u ltip le in testin al p arasites (Figu re 7). To illu strate, ch ild ren of “p oor p easan ts” h ad a p revalen ce rate of m u ltip le in testin al p arasites alm ost th ree tim es th at of ch ildren of “rich p easa n ts”. Pre veasa le n ce reasa te s fo r th e e n tire p o p u leasa -tion (agricu ltu ral an d n on -agricu ltu ral grou p s) fo r s p e c ific p a r a s it e s s u c h a s E. h ist olyt ica
a re q u ite h igh a t a ro u n d 40 p e rce n t. Wh ile a ll groups are affected, children of households from
ejid oso r co m m u n a l fa rm s o r “p o o r p ea sa n ts” are at an even greater d isad van tage: th eir rates were th ree a n d fo u r tim es, resp ectively, th o se of p rivate farm s or “rich p easan ts” (Figu re 8).
Discussion
Th e resu lts of th is stu d y p rovid e evid en ce of in -eq u a lities in th e h ea lth a n d n u tritio n a l sta tu s of p resch ool ch ild ren from d ifferen t agricu ltu r-a l gro u p s livin g in th e two m u n icip iosu n d e r stu d y in th e ru ra l a re a s o f La Fra yle sca , Ch ia p a s. Co m p a riso n s o f ch ild h o o d m o rta lity, n u -tritio n , d ie t, a n d p a ra sitic in fe ctio n s fo r ch il-d re n o f h o u se h o lil-d s fro m ejid os/ co m m u n a l fa rm s a n d p riva te fa rm s sh ow a n a sso cia tio n b etween lan d ten u re an d h ealth an d n u trition -al statu s. Categories b ased on volu m e of m aize p rod u ction are also associated with h ealth an d n u tritio n a l sta tu s, a n d to a gre a te r d e gre e. Th ese fin d in gs are rem arkab ly con sisten t with th o se o f p re vio u s stu d ie s ca rrie d o u t a t o th e r sites in Mexico an d elsewh ere in Latin Am erica (Lau rell & Blan co-Gil, 1977; Victora & Vau gh an , 1985). A cla ssifica tio n sch e m e b a se d o n vo l-u m e of m aize p rod l-u ction (as com p ared to lan d
Fig ure 4
Pre vale nc e o f malnutritio n* amo ng c hild re n (0 to 4 ye ars o ld ) b y so c io e c o no mic g ro up s, La Frayle sc a, Chiap as, 1995.
0 5 10 15 20 25 30 35 40
p o o r p e asants (n = 239)
mid d le p e asants (n = 224)
rich p e asants (n = 50)
we ig ht fo r he ig ht we ig ht fo r ag e
he ig ht fo r ag e
p
re
v
a
le
n
c
e
r
a
te
p
e
r
1
0
0
NS < 0.01
p o o r vs rich
0.05
2.43 5.37
2.03
p = O R =
0.58-10.26 1.80-16.00
1.00-4.13
95% CI =
ten u re) h as allowed u s to m ore p recisely ch ar-acterize th e m aterial circu m stan ces of th e d if-feren t grou p s of p easan ts livin g in th e region .
As with th e typ o lo gy p ro p o se d b y th e
Com isión Econ óm ica p ara la Am érica Latin a
(Cep a l, 1986) to d ifferen tia te b etween gro u p s with in th e agricu ltu ral sector, ou rs is also b ased on th e id ea of th e cap acity of a p rod u ctive u n it to regen erate its p rod u ction over a sp ecific p e-rio d o f tim e. Howe ve r, wh ile Ce p a l’s typ o lo gy
b a ses its m ea su res o f regen era tive p ro d u ctive cap acity on th e size of a p lot of lan d , ou r typ ol-o gy is b a se d ol-o n th e vol-o lu m e ol-o f m a ize p rol-o d u c-tio n a n d , co n seq u en tly, o n in vestm en t in p u ts (a d irect social an d econ om ic in d icator, rath er th a n a n in d irecto n e ). In so m e a sp e cts th is is sim ila r to Ce p a l’s ca te go rie s. Acco rd in gly th e “p oor p easan ts” category corresp on ds to its “in -fra-su b sisten ce” category, “m id d le p easan ts” to “su b sisten ce” an d “station ary” categories, an d 0
20 40 60 80 100 120 140 160 180
e jido/ co mmunal (n = 228)
p rivate (n = 100)
me at fo o d g ro up s milk
e g g s b e ans
co rn
a
v
e
ra
g
e
c
o
n
s
u
m
p
ti
o
n
(
g
ra
m
s
)
< 0.005 < 0.001
NS NS
< 0.01
p * =
Fig ure 5a
Ave rag e intake p e r fo o d g ro up amo ng c hild re n (1 to 4 ye ars) b y land te nure g ro up s, La Frayle sc a 1995.
Fig ure 5b
Ave rag e intake p e r fo o d g ro up amo ng c hild re n (1 to 4 ye ars) b y so c io e c o no mic g ro up s, La Frayle sc a 1995.
0 20 40 60 80 100 120 140 160 180
p o o r p e asants (n = 154)
mid d le p e asants (n = 128)
rich p e asants (n = 31)
me at milk
e g g s b e ans
co rn fo o d g ro up s
a
v
e
ra
g
e
c
o
n
s
u
m
p
ti
o
n
(
g
ra
m
s
)
< 0.0001 < 0.005
NS < 0.05
< 0.005
p * =
th e “rich p easan ts” to th e “exceed in g” category. Howe ve r, u sin g p lo t size a s a n in d ica to r m a y n o t a ccu ra te ly re p re se n t th e so cio e co n o m ic co n d itio n s o f h o u se h o ld s. Fo r e xa m p le, h igh yields are p ossible on sm all p lots of lan d if th ere a re su b sta n tia l ca p ita l a n d la b o r in p u ts, a n d vice ve rsa , low yie ld s a re p o ssib le fro m la rge p lots of lan d with a low in vestm en t in in p u ts.
Co m p a rin g th e two cla ssifica tio n sch em es u se d in th is stu d y (la n d te n u re a n d m a ize yields), th e two follow th e sam e p attern as m ea-su re s o f so cio e co n o m ic we ll-b e in g ( Ta b le 1). Th e ejido/com m u n al farm ers h ave sm aller p lots of la n d a n d em p loy lower n u m b ers of sa la ried workers th an p rivate farm ers. Com p arin g “p oor p easan ts” to “m iddle” an d “rich p easan ts” sh ows th e sa m e tre n d , b u t to a gre a te r d e gre e. Th e sam e typ e of correlation can b e seen for lack of ed u cation , p oor h ou sin g con d ition s, an d in low m eat con su m p tion . In all cases of com p arison b e twe e n th e two cla ssifica tio n sch e m e s, th e on e b ased on m aize p rod u ction (as op p osed to lan d ten u re) h as p roven m ore valu ab le in illu s-tra tin g d isp a ritie s in h e a lth a n d n u tritio n , wh ile still reflectin g th e gen era l tren d s of la n d ten u re an d Cep al’s classification sch em e.
Th e resu lts of th is stu d y h a ve two im p lica -tion s for h ealth p olicy. Th e first is related to th e id en tification of grou p s in th e ru ral p op u lation a t h igh er risk (wh ich is releva n t fo r a m o re effe ctive a n d e q u ita b le h e a lth p o licy a n d p la n n in g based on h ealth n eeds). Th e secon d is con -cern ed with th e typ e of in terven tion op tion s.
First, to obtain th e greatest im p act, ch ildren o f im p ove rish e d cam p esin osa n d fro m ejid os/
com m u n al farm s cou ld b e id en tified as p riori-ty ta rgets fo r sp ecia l d ep loym en t o f reso u rces with in th e ru ra l p o p u la tio n , re d u cin g h e a lth in e q u a litie s th ro u gh th e p rin cip le o f p o sitive d iscrim in a tio n . Th e a b ility to id e n tify th e se grou p s at greater risk cou ld p rovid e an op p or-tu n ity to a ch ieve sign ifica n t im p rovem en ts in th eir low h ealth statu s. However, th is ap p roach h as som e lim itation s. Wh ile im p roved accessi-b ility to h ealth services an d im p lem en tation of sp e cific h e a lth ca re m e a su re s (th e so -ca lle d “b asic h ealth p ackage”) cou ld h ave a m ajor ef-fe ct in th e sh o rt te rm b y re d u cin g in ef-fe ctio u s d ise a se s a n d m o r t a lit y in r u ra l so cie t ie s like th e on e u n d er stu d y, th ere are m an y exam p les wh e re h e a lth d iffe re n tia ls p e rsist d e sp ite th e availab ility of h ealth services an d m ed ical tech -n ologies (Rifki-n & Walt, 1986). That is, delivery of h ealth services alon e is n ot su fficien t to im p rove the health of socially excluded groups. Moreover, socioecon om ic b arriers m ay p reven t cam p esi-n oan d in d igen ou s p op u lation s from receivin g th e lim ited b en efits of m ed ical in terven tion s.
Fig ure 6
Ave rag e animal p ro te in intake o f c hild re n (1 to 4 ye ars o ld ) in the p re c e d ing 24 ho urs b y land te nure and so c io e c o no mic g ro up s, La Frayle sc a, Chiap as 1995.
0 1 2 3 4 5 6 7 8 9 10 land te nure g ro up s
so cio -e co no mic g ro up s
rich p e asants (n = 31) mid d le
p e asants (n = 128) p o o r
p e asants (n = 154) p rivate
farms (n = 100) e jido s and
co mmunal land s (n = 228)
a v e ra g e i n ta k k e ( g ra m s )
< 0.001 < 0.001
p * =
* No n-p arame tric ANO VA Kruskal-Wallis te st.
Fig ure 7
Multip le * inte stinal p arasite s amo ng c hild re n (1 to 4 ye ars o ld ) b y land te nure and so c io e c o no mic g ro up s, La Frayle sc a, Chiap as, 1995.
0 5 10 15 20 25 30 land te nure g ro up s
so cio -e co no mic g ro up s
rich p e asants (n = 11) mid d le
p e asants (n = 38) p o o r
p e asants (n = 51) p rivate
farms (n = 39) e jido s and
co mmunal land s (n = 70)
p re v a le n c e r a te p e r 1 0 0 NS NS
p o o r vs rich mid d le vs rich
0.08
2.53
p = O R =
0.88-7.30
95% CI =
Se co n d , wh e n co n sid e r in g t h e ra n ge o f h ealth p olicy op tion s resu ltin g from th is stu dy’s fin din gs we m u st in evitably con sider th e socioe-con om ic d eterm in an ts of in equ alities in h ealth statu s. Th e fin din gs su ggest th at h ealth differen -tials su ch as th ese call for p rofou n d ch an ges in th e u n eq u al d istrib u tion of lan d an d resou rces in ru ral Ch iap as. Wh ile in terven tion strategies a im ed a t im p rovin g th e p reca riou s h ea lth sta -tu s o f th e cam p esin oa n d in d ige n o u s p o p u la -tion are n ecessary to p reven t th e situ a-tion from gettin g worse, su ch strategies will rem ain in ef-fective in th e lo n g term u n less th e u n d erlyin g cau ses of existin g social in eq u alities an d wid e-sp read p overty in ru ral Ch iap as are ad d ressed .
Conclusions
Ou r resu lts su ggest th at th e two classification s u se d in th is stu d y, b a se d o n la n d te n u re a n d vo lu m e o f m a ize p ro d u ctio n , p roved u sefu l in detectin g sign ifican t differen tials in ch ild h ealth a n d n u tritio n a l sta tu s in th e a gricu ltu ra l se c-to r. Cla ssifica tio n s b a sed o n vo lu m e o f m a ize p rod u ction sh ow greater d ifferen tials b etween categories for m ost n u trition al an d h ealth vari-a b le s. In ge n e rvari-a l, sm vari-a ll p lo ts o f lvari-a n d vari-a n d low cro p yie ld in th e a gricu ltu ra l se cto r id e n tify h igh risk grou p s an d sign al seriou s h ealth an d n u trition al p rob lem s for ch ild ren . In ad d ition , wo rkin g a n d livin g co n d itio n s p la y a n im p o rtan t role in exp lain in g th e p oor h ealth an d n u -tritio n a l sta tu s o f ch ild re n in ru ra l Ch ia p a s. Med ica l in terven tio n s m a y h a ve so m e im p a ct in p reven tin g in fectiou s d iseases an d red u cin g in fa n t m o rta lity. Howe ve r, th e re is m u ch e vi-d en ce to sh ow th at social ch an ges are m ore
ef-Tab le 1
Main stud y g ro up s b y se le c te d so c io e c o no mic and ag ric ultural c harac te ristic s, La Frayle sc a, Chiap as, 1995.
Indicator “Ejidos” and Private land Poor peasants M iddle peasants Rich peasants Communal land
% o f ho use ho ld s with p o o r 50.2 31.3 57.7 34.1 12.0 ho using c o nd itio ns
% o f he ad o f ho use ho ld s with o ve r 5.6 17.5 4.4 12.5 20.0 7 ye ars o f sc ho o ling
% o f ho use ho ld s c o nsuming me at 47 39 61.1 42.1 22 o nc e a mo nth o r le ss
% o f p lo ts o f land with mo re than 15.4 24.5 6.3 22.7 56 12 he c tare s
% o f ho use ho ld s e mp lo ying lab o re rs 5.7 13 1.5 8.4 29 fo r mo re than 250 p aid wo rking d ays
Fig ure 8
Pre vale nc e o f E. histo lytic aamo ng c hild re n (1 to 4 ye ars o ld ) b y land te nure and so c io -e c o no mic g ro up s, La Frayle sc a, Chiap as, 1995.
0 5 10 15 20 25 30 35 40 45
land te nure g ro up s
so cio -e co no mic g ro up s
rich p e asants (n = 11) mid d le
p e asants (n = 38) p o o r
p e asants (n = 51) p rivate
farms (n = 39) e jido s and
co mmunal land s (n = 70)
p
re
v
a
le
n
c
e
r
a
te
p
e
r
1
0
0
NS 0.07*
p o o r vs rich mid d le vs rich
< 0.01
5.88 4.27
p = O R =
0.85-40.83 1.56-11.72
95% CI =
* Fishe r’s Exac t Te st (Rig ht).
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