This is a quick, very unofficial rundown on how
things are organized in Peru. This is not
the same thing as an explanation of how things really work.
First, Peru has a unified national government, not
a federal system such as exists in the United States, Canada, and some
other countries. The government is based in Lima, the nation's capital
city, over 600 miles (1,000 kilometers) across the Andes mountains from El
Fundo.
Peru's administration is conducted by agencies of
the national government, such as the ministries of health, education,
agriculture, energy, defense, foreign relations, and so forth. Each
ministry, including the Ministry of Health, has offices in various parts
of the country to carry out programs designed in Lima and paid for out of
the national budget. There local governments do not have independent legislative and tax collecting powers.
Peru is a bit different from most countries in
that there is a Ministry of the Presidency in Lima that reports directly
to the President, an elected civilian. The defense ministry, the armed
forces, and several other institutions are part of that presidential
agency, which spends over half the national budget. Since all ministries
have their head offices in Lima, most government employees are there, too.
A large part of the budget goes to pay government employees' salaries.
Peru's economy is small, so the government's revenues are very limited and
ministries are never able to provide as many services as they would like
to.
For administrative purposes, Peru is divided into
regions, which are further subdivided into smaller units. The largest
region is Amazonas, covering the whole northeastern part of the country.
This is not only the largest but the most sparsely populated area of Peru.
As one might expect, it lies in the Amazon River basin, east of the Andes.
Regions are divided into departments. The Department of Loreto is in the
eastern part of Amazonas. Departments are divided into provinces, of which
Maynas is the province around Iquitos, the only city of any size (about
275,000 people) in all of Amazonas.
To complicate this explanation a bit, Iquitos is
the administrative capital not only of Amazonas, but also of Loreto and
Maynas. (That doesn't interfere with daily life.) Iquitos have just one road
link to a close city called Nauta. If you want to get
to or from Iquitos, you travel by air (it has an international airport) or
by boat (oceangoing freighters dock there). Although Iquitos has streets
with cars and trucks, the few roads that lead out of town come to one
river or another within a few miles, and there they stop. No bridges cross
the rivers.
Provinces are divided into districts, and one
district of Maynas is Fernando Lores, a large area that lies about five hours upstream
(south) of Iquitos. The
administrative seat of Fernando Lores is Tamshiyacu, which you can find in
most atlases (southwest of Iquitos, on the southern left bank of the
Amazon River). El Fundo, APECA's base of operations, is within 15 minutes
walking distance of Tamshiyacu, if you care to use the footpath. Most
people prefer to use a boat, the basic transportation all over the region.
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There are 144 villages in the District of Fernando
Lores, home to about 18,000 people. That comes to an average of 125
inhabitants per village. Villages hug the river banks because the rivers
are the highways for people and goods. People use the rivers not only for
travel, but also for fishing, bathing, washing, toilet facilities, and
drinking water. One village may be across the river from another. Usually,
however, villages are separated by miles or, as distances are more
commonly expressed, several hours by hand-paddled canoe. Reaching more
than two or three villages in a day requires a boat with a powerful motor.
APECA wants to reach more than three villages a day.
The Peruvian Ministry of Health has a regional
office in Iquitos, responsible for two sizeable general hospitals in the
city as well as other facilities there, including a branch of the national
university's medical school. In Tamshiyacu there is a health center for
the District of Fernando Lores. The health center has a 10-person
professional staff. They provide services to about 2500 townspeople and to
as many villagers from outlying areas of Fernando Lores as can make it
there by boat.
However, there are also medical posts in 12
villages, each manned by a trained semiprofessional health worker. Each
health worker serves his own villagers and the inhabitants of several
villages in the vicinity. All employees in the Tamshiyacu health center
and the village medical posts are paid Ministry of Health employees.
Finally, in some lucky villages there is a "health promoter," a local,
unpaid volunteer who has had first aid training and therefore may be able
to help deal with minor injuries and mild or well-recognized illnesses.
At each level of this organizational hierarchy the
link with Lima becomes more attenuated, the professional skills less
developed, and the supply of medicines and medical supplies simpler,
smaller, and less reliably maintained. In many of the remote villages,
there are no medical services at all. In some, no one has ever been
vaccinated against diseases we consider banished
Why doesn't the Peruvian government do better? The
question itself reveals how we as foreigners, residents of powerful
countries with bountiful economies, take our wealth and privilege for
granted. Briefly put, the government never has enough money to provide
full services even to people in Lima. It provides what it can to Iquitos,
and tries to provide for Tamshiyacu and a handful of villages. The bald
fact is that people are spread too thinly across the District of Fernando
Lores for the government to reach them cost-effectively. The government
must help those whom it can reach using its modest resources. Ministry of
Health officials have the will and the skill, but not the wherewithal to
get out into the distant reaches of the rain forest.
But there is a |
