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SUMMARY REPORT
INITIAL HEALTH ASSESSMENT OF THE MINAS CONGA PROJECT AREA — PERU
Andrew Kestler MD
Sharry Erzinger Dr.PH
Jean Scandlyn PhD, MSN
Susan Niermeyer MD
Calvin Wilson MD
Javier Waksman MD
July 22, 2005
EXECUTIVE SUMMARY INITIAL HEALTH ASSESSMENT OF THE MINAS CONGA PROJECT AREA — PERU
Background
The University of Colorado School of Medicine was requested by Newmont
Mining Corporation in early 2005 to conduct community health assessments
in their concession areas of Ghana and Peru where Newmont mining activities
are currently under development, with the objective of identifying
specific areas of intervention that would result in improved community
health. The University of Colorado team was on-site in Peru from June
4 until June 18, 2005, spending the majority of its time in the communities
around Minas Conga, which is a project of the Newmont/Peruvian subsidiary,
Minera Yanacocha, SA, and is located in a mountainous agricultural
region to the northeast of the city of Cajamarca, in the northern Peruvian
Andes.
Methodology and Scope of Work
The University team consisted of 6 members with experience or specialization
in the following areas: Public Health, Medical Anthropology, Pediatrics/Neonatology,
Nursing, High-Altitude Medicine, Internal Medicine, Emergency Medicine,
Healthcare Management, Family Medicine, and Toxicology.
The team conducted interviews with community members in the 20 communities defined
as the Minas Conga area of influence, with an estimated population
of 6000 people. A rapid assessment method was used with a comprehensive
questionnaire addressing the health situation and infrastructure,
perceived health priorities, and community attitudes. Members of the
team visited the health care facilities available to the 20 communities,
including 11 health posts, 2 health centers, and 2 referral hospitals,
and interviewed health workers at each level. Interviews conducted
around Minas Conga, in Cajamarca, and in Lima also included Yanacocha/Minas
Conga officials, local government authorities, regional and national
health authorities, university faculty and administrators, and representatives
of active non-governmental organizations and religious groups.
| Recommendations and Rationale Based on the observations and findings of the assessment, the University team has proposed ten recommendations for both short and long-term activities that should improve the health status of the target communities. Some items will require further study to determine the specifics of implementation, and may need to be modified to adapt to changing economic or political realities. These recommendations and their rationale include the following: |
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| 1. | Establish a coordinating
body to design and implement a comprehensive strategy of social
investment in health and development for the Minas Conga area. The mission of this group would be to
work toward sustainable health status improvement based on a long-term,
integrated development strategy incorporating community needs and
community participation. This could be implemented by creating
an autonomous Board that represented the major stakeholders including
Newmont, with protected funding, and a staff charged with the responsibility
of developing and implementing a long-term strategic plan for community
development, with an emphasis on health improvement. Justification |
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Community interviews revealed that many projects in health, education, and economic development have been (or will be) supported by Minera Yanacocha, but that the strategic value of these projects may not be immediately apparent. Government officials and NGO representatives were at times wary of working directly with Minera Yanacocha, for fear of political fall-out, or negative impact on their reputation, but many expressed a willingness to collaborate with a Yanacocha-supported institution on health and development projects. | ||
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The successful, sustainable projects that were observed were characterized by partnership and resource sharing between various institutions, and responded to a long term strategic plan of development. | ||
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Many large corporations, both in the U.S. and multi-nationals, have successfully developed similar groups or foundations to respond to similar needs. Many models exist that could be used to guide development of such a group. | ||
| 2. | Commission a household
health study to establish a reliable health baseline in the target
communities, and repeat this survey every 2-4 years. The survey should be designed and
supervised by a joint team of investigators from the Ministry of
Health, the Universities of Colorado and Cajamarca, and experienced
local organizations such as CARE. It should investigate a variety
of parameters related to health, including household resources
and practices (water, sanitation, hygiene), selected common health
problems of each age group, targeted screening for anemia, parasites,
nutritional status, and environmental toxins such as lead and heavy
metals, and potentially include observations or monitoring of household
smoke and carbon monoxide levels. Justification |
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Review of documents from the health centers left the team with some misgivings about the quality and consistency of the data that were described, and some questions about the quality and reliability of the data arose on location in the communities. | ||
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Present indicators do not include the more invasive procedures such as exams of blood for anemia, feces for parasites, anthropometric measures of children, and toxicologic indicators that present a clearer picture of the health status of a community. | ||
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Indoor air pollution from burning organic fuels for cooking inside a closed house appears to be a major problem, which may contribute significantly to the extremely high incidence of respiratory ailments and other health problems in children and adults. | ||
| 3. | Assist selected communities
in attaining a safe and sufficient water supply and effective
sanitary facilities. This will require an engineering survey of the target communities
to determine the specific needs and available water resources of
each community, such as the feasibility of running pipes to each
home, or the need for a storage reservoir for the community, or
specific issues related to the placement of latrines. In most cases,
community committees, the local municipality or specific government
Ministries can contribute to the effort with labor and some funding.
A defined system for disposal of contaminated medical waste from
Health Posts and Hospitals is also needed. Justification |
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A closed water system with piping to individual houses has been consistently shown in many studies around the world to significantly decrease the incidence of diarrhea, gastroenteritis, and skin infections (because of increased use of water for washing and bathing), and this improvement does not necessarily depend on the microbiological purity of the water. | ||
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Most of the communities visited do not have an adequate water system. In some communities, a spring has been closed and pipes run to some but not all homes in the community, while in others, the water system is in disrepair, leaking, and/or the water supply is inadequate during the dry season. Some communities continue to use streams or canals as their water source and have no closed water system at all. | ||
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Although the majority of the communities have some latrines in use, some have no latrines and simply used the open field. In those communities with latrines, many indicated that some were very old or non-useable, and needed to be replaced. | ||
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There is currently no observed standard for the collection and disposal of medical waste (contaminated dressings, syringes, needles, etc.) in the Health Posts. In most cases, this waste is either buried superficially or thrown into a nearby latrine. | ||
| 4. | Assist Health Centers
and communities to develop a sustainable communication infrastructure
that improves their healthcare, by facilitating the installation
of sufficient cell phone relays to cover the Minas Conga area
of influence. This should
focus initially on providing mobile service coverage for the Health
Posts and referral hospitals of the region (including the town
of Celendín), possibly using subsidized but restricted mobile
phones. It will require an engineering study to determine the ideal
placement of relay facilities, but it is anticipated that revenues
will rise rapidly as the service becomes available. Justification |
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Almost all healthcare providers and many community leaders interviewed indicated that the current communication system of shortwave radios linked to the assigned referral hospital was occasionally effective in emergency situations, but only if solar power was available for the radio (daylight hours) and health personnel were attending the receiving radio. Most of the communities visited had a single solar powered satellite telephone, but the phone was often some distance from the health center, and sometimes inaccessible. | ||
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Given the current essential work of the community health promoters in many of the smaller communities, it is essential that they also have good communication for consultation with the Health Center or Post of reference, and to the local referral hospital. | ||
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The benefits of expansion of the cell phone coverage go far beyond the immediate advantages of 24 hour, continuous contact among healthcare facilities for transport and referral. The anticipated healthcare benefits include the potential for immediate consultation in difficult or serious cases, better management of large-scale emergencies, and improved epidemiologic surveillance. The simple existence of infrastructure for mobile phone networks will encourage development of general communication systems between communities and outside markets, which could stimulate local economies. | ||
| 5. | Improve community access to healthcare: | ||
| 5-A. By assisting in the development of programs that
train, supervise, and support Health Promoters in the communities
of the Minas Conga area. This should begin with establishment of
a relationship with the Ministry of Health and other organizations
active in the support and training of Health Promoters, and development
of a joint plan for the training, support, equipping, and monitoring
of these individuals. Justification |
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Given the physical isolation of many of the communities in the Minas Conga region and the long distances individuals must travel on foot or by horse to reach their designated or closest health post, communities need a reliable source of first aid and basic preventive care, basic health care information, case finding, and referral on-site. | ||
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Although health promoters exist in many communities, various difficulties and barriers exist, such as poor support and monitoring of activities and the volunteer nature of their work. Where they are supported, health promoters are effective and valued members of the health care system, and are often leaders in the overall social and economic development of the community. | ||
| 5-B. By creating and testing
patient evacuation plans for each community. This should be done in each community in collaboration
with the municipal authorities and community organizations such
as the Ronda (Vigilance committee), parent's groups, and ECO groups
(Communal health and transport committee). It could also include
establishment of several central transportation hubs with available
vehicles and drivers, and upgrading of the Cajamarca airport to
allow for emergency night flights. Justification |
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In almost every community without a health post, transportation to the closest health post was cited as a limitation on efforts to improve the health status of people in the region, and various examples of unnecessary deaths were evident. The primary causes cited were distance, poor roads, lack of vehicles or drivers, and lack of reliable communication with higher centers of care. | ||
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Evacuation of patients with life-threatening conditions requiring specialty care, e.g., strokes or premature labor, to Lima is limited by the lack of air transportation at night. | ||
| 6. | Help communities train
and retain local healthcare personnel. This could be done by development of scholarships for
local students who want to establish a career in healthcare, and
by supporting selected students already in medical or nursing training
who need additional assistance. In addition, a program of continuing
education for practicing physicians, nurses, and midwives should
be established in collaboration with the Ministry of Health and
partner universities, such as the University of Colorado and of
Cajamarca. Justification |
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In any rural community, the healthcare personnel most likely to provide long-term care to the community are those whose roots are in that area. Although many of the health workers in the target area came from other areas of Peru, those who had the longest tenure were most likely to have come from Cajamarca or northern Peru. | ||
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One of the more consistent findings in the survey of health workers was that almost none had any recent continuing education in their discipline. Many indicated that they would very much appreciate and benefit from any form of continuing education, but that it had to be within their budget, and preferably offered in a location close to their workplace. | ||
| 7. | Support education and health education in communities…: | ||
| 7 - A. by encouraging female
literacy and education. This
could be done by developing scholarships for selected students
who need assistance in completing their secondary schooling, by
focusing on the hiring of female employees, and by encouraging
the further training of female employees of the mine. Justification |
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In several communities, women said that they wanted to limit the number of children they had because it was expensive to provide them with education. The correlation between increasing levels of formal education, particularly of females, and decreasing fertility has been documented in many societies. | ||
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Findings from numerous studies of infant and child mortality conducted in developing countries over the last decade show a nearly universal, positive association between maternal education and child survival, and in Peru, at least one study has demonstrated that women with more education are more likely to use maternal health care services during pregnancy, labor and delivery, and in the post-partum period. | ||
| 7 - B. by supporting the training
and retention of teachers and by using teachers as resources
for health education. The planned
community literacy program should include the identification of
individuals with interest and aptitude for careers in teaching,
and scholarships could be established to support these students
in going on to become teachers. In addition, a continuing education
program to support existing teachers could be established through
the Ministry of Education. Justification |
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Teachers observe their students daily over long periods of time and can observe their general level of health and nutrition as well as patterns of absences, and they are in a position to provide messages related to health and hygiene. Programs that support the retention of teachers in communities enhance their ability to refer students for health care when needed and to work with personnel at the health posts and health promoters in the community to enhance health education. | ||
| 7 - C. Through radio broadcasts. Although Minas Conga currently
broadcasts some information on the local radio stations, a regular
program that combines news and mining information with nutrition
and other health-related messages could be useful. Justification |
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We observed that throughout the region, even in the most rural and remote communities, men carry transistor radios with them. There are several local radio stations and community members told us that the radio was an important means of communicating information about community events, discussing issues, and providing education. | ||
| 8. | Support and link nutrition
and economic development projects. Projects that improve the productivity of crops, grazing
land, and domesticated animals would result in improved nutrition
for the family, and in economic benefits such as increased yields,
greater return from the sale of agricultural products, and increased
reserves for local consumption. Justification |
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Agricultural activities are the primary occupation of most inhabitants in the Minas Conga area of influence. Care of the land and its animals are closely linked to the self-worth and identity of the population in the region. | ||
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Malnutrition is identified by health professionals and teachers as a major contributor to the high rates of respiratory and diarrheal illness among children. | ||
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In most communities visited, meat is consumed less frequently than once per week and milk is made available to children primarily through specific subsidy programs (Vaso de Leche). Milk, butter, cheese, and eggs are routinely sold or traded for essential commodities such as sugar and salt and manufactured goods. | ||
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Improved consumption of high-quality protein (Andean cereals, meat, milk, eggs) and essential micronutrients (iron, zinc) improves overall nutritional status and disease resistance. | ||
| 9. | Improve healthcare facilities
and equipment, especially referral hospital centers (Celendín and Cajamarca hospitals). The Health Posts and Hospitals should be upgraded on a case-by-case
basis, primarily in terms of needed equipment and furniture, in
collaboration with the Regional Directorate of Health in Cajamarca,
and with input from the local health network director in Celendín
and the acting director of each Health Post. Justification |
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Although most of the Health Centers and Health Posts visited had the minimum necessary infrastructure and equipment to deal with the common primary care and preventive issues of the community, in many cases the Health Posts lacked adequate sinks or were not connected to a local water system, and some lacked even nearby latrines. The capabilities and effectiveness of the community healthcare workers could be greatly enhanced with selected equipment, such as an otoscope/ophthalmoscope, oxygen tanks and masks, minor surgical instruments, etc. | ||
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The Regional Hospital of Cajamarca is planning a large addition (with support from Minera Yanacocha), but has several immediate needs, such as 2-3 new X-ray units to replace non-repairable units, specific neonatal equipment, and emergency monitoring equipment. The Hospital of Celendín should be considered for a major upgrading, with major equipment needs such as a lead-lined X-ray room, ultrasound, laboratory, emergency and surgical equipment. | ||
| 10. | Support applied research
into the unresolved health problems of the area. The first recommended investigation would
focus on the issue of household smoke pollution, with a study that
would monitor indoor pollutants before and after the placement
of a low-cost, fuel-efficient cooking stove to replace the traditional
open fireplace. The end-points to be monitored would include acceptance
of the improved stove, levels of pollutants such as smoke particles
and carbon monoxide, and especially the incidence of acute respiratory
infections, ear infections, asthma, and other pollutant-related
illnesses. Justification |
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Very high levels of smoke have been noted inside most households, and it is suspected that indoor carbon monoxide levels are also elevated. It has been hypothesized, and some preliminary studies in other countries have shown, that this indoor pollution may be a significant factor in the high incidence of respiratory infections and problems. | ||
Stakeholders and Potential Partners
Almost all of the recommendations made will require the planning assistance
and
support of the Regional Directorate and Network administrators of the
Ministry
of Health in Cajamarca and Celendín. Other partners that may be included
in selected activities include the staff of the Health Centers and
Posts, community health promoters, local municipal authorities, the University
of Cajamarca, and the University of Cayetano Heredia (Lima). Organizations
that could contribute significant expertise and assistance include CARE,
the Adventist development organization ADRA, the Catholic Church and its
organization for health promoters (APROMSAC), and various organizations sponsored
by government Ministries. The Colorado-based organization Project Cure could
be an important partner in equipping the health facilities. Finally, the
University of Colorado is well positioned to participate with and assist
these local partners.