Health research: working with Indigenous People in Peru

Dear Editor,

We want to manifest our concern about a recent original article published in your journal that cited one of our articles. Gabriela Minaya and Joel Roque have included our work about indigenous people and sexually transmitted infections (STIs) in the Peruvian Amazon (Zavaleta et al. 2007a) in their discussion about “Ethical problems in health research with Indigenous or originary peoples in Peru”(Minaya and Roque 2015). We have detected a number of serious discrepancies between their affirmations regarding what we did vs. what we have published in 2007.

Minaya and Roque questioned if we provided education and treatment for our participants. In the introduction of the paper, we explain that the Ministry of Health (MoH) workers participated in this research and the MoH and Chayahuita community leaders approved of our study, which originally was motivated by the deep concern of a local Indigenous health promoter about an increasing number of fevers that were potentially STI associated. Once in the community, all procedures were realized in accordance with existing MoH guidelines, which included treatment for syphilis and individual pre- and post-test counselling for HIV. With the knowledge of the HIV positive results, as Peruvian health researchers and workers, we felt very concerned that highly active antiretroviral therapy was not available to this remote region, given the absence of appropriate facilities and staff for the frequent monitoring required. At that time, HAART was not being fully implemented in Peru, and it was only introduced around 2005, but only at tertiary hospitals with infectologists. Given that the local health personnel was aware of the lack of treatment availability for HIV, they prioritized preventive education for this ethnic group. Precisely because of this lack of treatment, the counselling process and a better understanding about the extension of the epidemics was critical as a public health strategy. Indeed, following our work, multiple initiatives have been undertaken to quantify the prevalence of STI, clarify their risk factors (Alva and Orellana 2012; Bartlett et al. 2008; Zavaleta et al. 2008; Ormaeche et al. 2012) and design an intercultural preventive strategy lead by the national Indigenous health authority (Zavaleta et al. 2007b). Although we agree that more work should be done to provide effective HIV treatment for remote Indigenous populations, our work has provided as much education and promoted access to health care.

Minaya and Roque also implied that our findings serve to stigmatize the population studied. We do not consider that the attribution of AIDS dissemination to “absence of use of condoms, homosexual behaviour, early initiation of sexual relations and polygamy”, as we mentioned in our paper, promotes stigmatization. On the contrary, we believe that the recognition, knowledge and respectful understanding of multiple cultures are key to initiate effective preventive measures on the ground. We believe that the increase of information about Indigenous culture including acceptable sexual practices and traditional social institutions such as polygamy, rather than serving to stigmatize these populations, is a way to increase the voice of underrepresented people to create more cultural adapted health policies in our Peruvian society.

Lastly, the authors wrote that our study results were generalized to the all Indigenous People of the region. We presented our results specifically for the community studied, although we made recommendations to take actions for preventing STIs among the Indigenous People living in the Amazon. We do not consider that extrapolating our preventive recommendations to more Indigenous People located in the Amazon was wrong. We felt that a strong call for attention was needed to mobilize the national and international public health community since the level of STIs was extremely high in a location with virtually absent health resources. Our work was instrumental in mobilizing local health authorities, international agencies and other groups to work towards stopping the spread of HIV among Chayahuita and other Amazon remote Indigenous People.

Instead of visualizing our publication as an ‘ethical problem’, the complete description of our work proves an example of how health researchers in Peru are doing investigations by prioritizing Indigenous health concerns, adapting western methods and ethical approaches to work in a respectful manner with Amazon Indigenous People and to contribute with culturally appropriate public health initiatives for historically excluded minorities. The publication was an initial report and did not include all of our subsequent work in Indigenous health. Perhaps, if the work had ended with the content of the original report, we would be in agreement with some of the criticism; nonetheless, we consider the interpretation of our work to be inaccurate and believe that the context is important to tell the full story of our investigation.

Compliance with ethical standards

Participants in the publication cited in this letter have signed a correspondent consent form.

Funding

We did not receive any special funding for writing this letter.

Conflict of interest

Carol Zavaleta declares that she is a Peruvian physician and an investigator who currently is doing a PhD at Canada. She has participated in several research studies involving Indigenous People in the Peruvian Amazon.

Eduardo Gotuzzo, Kelika Konda and Yadira Valderrama declare that they have no conflicts of interest.