An ecosystem approach to human health assessment provides an inter-disciplinary, holistic view of the socio-economic and ecological factors affecting health. Research focuses on the relationships between the structure and function of stressed ecosystems and land use strategies, between natural resource use and nutritional status and between anthropogenic environmental changes and the transmission dynamics of disease. Capturing the complexity of these causal linkages and feedbacks demands I) multiple scales of investigation, II) interdisciplinarity and methodological pluralism and III) active local participation - the three key principles of an ecosystem approach
As evident in Table 1 and 2, the study variables exist at several scales, from the individual through to the landscape. Differences in nutrient intake of individuals versus families provide insight into issues of intra-household food allocation. Food security at the community versus the landscape level highlights the importance of surrounding ecological resources and biodiversity as food sources. The investigation of food and income sources at the farm, community and landscape level exposed the finding that the majority of families depend on an area much large than their farm for their livelihood. Despite issues of access, the rural population is constantly moving, synchronized to the rising and falling of rivers and lakes and the migratory paths of fish and animals. This continuous flow of people and resources sustains their livelihoods, as rarely can the area immediately surrounding them provide adequately for their needs. This extensive resource use system that dominates the region has important implications for land use options that attempt to intensify and concentrate resource use. Research and development activities confined to the farm or even the community, fail to capture the complete picture of the livelihood strategies in Ucayali and the link between activities at different scales.
In addition to spatial differences, multiple temporal scales are equally important in understanding ecosystem dynamics and its relationship to health. In the study each variable had a temporal dimension. Three time periods were selected to reflect seasonal changes, emphasising the patterns of change of these different variables over the year and the interactions among such changes. Therefore the nature of the links between the hydrological cycle, fluctuations in disease prevalence and changes in nutrient intake can provide insight into the determinants of health and the causal linkages between the components.
The ecosystem approach explicitly calls for a plurality of methods, drawing from several disciplines including both the “hard” and “soft” sciences. In the current study, they ranged from GIS (Geographic Information Systems) analysis and landscape epidemiology, to precise food recall techniques and participatory nutritional ethnography. Each method was selected based on how useful, appropriate and effective it was at answering a particular question. Upon implementation, the method was evaluated in terms of the accuracy and reliability of the information it provided. This iterative process of methodological evaluation and modification was critical to the design of the study and the success of the results.
In the selection of different methods, it is useful to consider the more subtle distinction between data and process approaches. As opposed to the familiar quantitative versus qualitative or social versus natural science distinction, data approaches focus of information extraction and process approaches demonstrate how the action of collecting information may initiate or change social processes within the community. Ideally, data and process approaches should be used simultaneously. Recognizing that data and process approaches tap different information sources and produce different outputs, the critical issue is how to combine them as complementary methods. That is, the challenge comes in not only collecting reliable and accurate data, but rather in seeing how the actual process of gathering information initiates other processes and changes existing processes within the community itself. For example, reliable information on morbidity and mortality failed to be captured by the individual surveys. Responses were simplified and restrained. However focus groups in a private place prompted active engagement in discussions. The recognition that others suffered similar illnesses was a catalyst that prompted further exploration of treatments and prevention measures. The leap from passive respondents to active participants, allowed women to not only identify their problems, but to analyze their etiology and link their health to other factors in their environment. At the outset, quantitative data was sought, however, in reality the situation demanded a process through which local understanding could be generated. What was lacking, besides exact figures on morbidity, was the creation of space or process through which women could better understand their problems and develop tools to do something about it.
Considering a plurality of methodologies, the sequence in which different methods are implemented affects one’s ability to compensate for weaknesses in individual techniques and to build on knowledge systematically. Different methods can be used to verify and crosscheck information. The more qualitative participatory methods in the study provided insight into those issues that the community perceived as important. The extensive survey then helped determine the extent to which these food security problems affect the whole community and which groups were most at risk. Moreover, once the community was involved in focus groups and felt that their needs were driving the project, they were more responsive and interested in the survey. They were better able to appreciate its value and therefore were more motivated to provide accurate answers.
Sustainable natural resource use is not a simple model or package to be imposed; it is more accurately described as a “process for learning” (Pretty, 1998). The shift to greater ecosystem sustainability and health involves not only the identification of appropriate resource uses, but learning those practices, facilitating that learning and creating institutional and policy frameworks that support such facilitation (Woodhill & Roling, 1998). This requires legitimate involvement of the local community, be they government agencies, women’s groups, non-governmental organizations (NGOs), or the community members themselves.
Active local participation is fundamental to the ecosystem approach. Without their involvement researchers cannot address the different conflicting goals whose interaction and trade-off affect overall sustainability and health of the ecosystem. In the study, a larger research team was created comprised of representatives from relevant organizations. In this larger group project objectives were refined and methods developed. More importantly, five of the twelve researchers involved in the field work were leaders or professionals from local governmental and non-governmental organizations. This ensured that knowledge in the methods as well as research findings fed back into local institutions and enhanced a sense of local ownership of the data and their implications.
The action component of PAR is equally important in the ecosystem approach. At the outset it was assumed that the process from analysis to action would be completed through once. First, with the participation of the local community the problem(s) would be diagnosed, then fieldwork implemented, community plans generated from the “answers’, new actions put into practice and lastly the results evaluated. In reality, there was not one path from participation to research to action; instead, countless smaller cycles of participatory reflection on action, learning about action and new informed action, all of which fed back on one another. After six months in the field several small-scale plans have been developed, simple actions carried out and these experiences used to focus and refine the understanding of what is really happening and what is really important to the community.
The key question is thus how much diagnosis and analysis is needed before action is taken. In contrast to the longer more conventional route of data collection and analysis, followed often years later with policy recommendations or development projects, in this study, researchers engaged in shorter cycles, whereby questions were raised, hypotheses tested, plans generated from the answers found and new actions/projects employed. This process was then immediately evaluated. If successful, it was expanded upon, if unsuccessful, hypotheses were re-visited, methods adapted and the necessary fieldwork carried out. This cycle occurs several times within the life of the project, each time re-focusing and expanding understanding of the problem and its appropriate solutions.
Application of this adaptive and iterative research cycle led to the discovery that there were in reality several cycles existing simultaneously, however moving at different speeds. It was evident that the more complex research questions required a longer cycle, where rigour in methods and analysis demanded years of work. For example, seasonality of nutritional status and disease periodicity required at least a year of research and similar data from communities located in different ecosystems.
However other questions that require smaller time intervals between analysis and action, were critical in involving the community early on in the study. Water quality, parasite loading and anaemia tests provided a good starting point, as these tests were conducted in the field and findings were readily available. The community was quickly able to grasp the significance of the results and incorporate them into their understanding of larger health issues. In several communities, stool and water testing initiated immediate action in cleaning and controlling defecation along stream banks and reducing contamination of wells. With time and the community’s growing understanding of their health problems, results from more complex issues such as the linkages between anthropogenic environmental change and disease transmission, become more accessible. In addition this early emphasis on action promoted greater interest and local ownership of the information, findings, and solutions. Ultimately, researchers are agents of change, recognizing and acknowledging their role as catalysts in the community.
Lastly, participatory research must address the fact that communities
are rarely homogenous in their composition and concerns. Differences
in interests and conflicts within the community shed light on power relations
and structures. Although gender is the obvious starting point, particularly
with respect to health, it is not the only difference, nor is it always
the main difference that affects people’s decisions and options.
Qualifying the category of women into smaller groups of older, poorer,
or minority, shows that in some settings, their identification as “women”
may be less important than their relative wealth, level of education, or
age (Cornwall, 1999). Differences between men and women are not fixed,
often they emerge and become significant in different ways and in different
contexts
| Photo: Chalk sell for new colons, Curimaná-Perú |