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C h a p t e r 6 Power and Participation Participation and active involvement in the determination of one’s own destiny is the essence of human dignity. —Mary Robinson, former UN High Commissioner for Human Rights Participation is a means of challenging forms of domination that restrict people’s agency and self-determination. —Magdalena Sepúlveda, former UN Special Rapporteur on Extreme Poverty and Human Rights In 2007, as director of research and investigations at Physicians for Human Rights, I led a field investigation into maternal mortality in Peru.1 I had lived in Peru for years before and knew the country well. As part of the follow-up to that investigation, I worked with CARE Peru to develop a program to strengthen the capacity of local health promoters in the subnational “department ” (state) of Puno, to accompany pregnant women to their antenatal checks and delivery care, and to ensure that their rights were respected. Among other things, the health promoters recorded such things as whether the women received respectful treatment from the health personnel, whether there were significant delays before they received care, whether they were spoken to in their own language and their customs were respected, and whether they were asked to pay for supplies or services that should have been provided free of charge. All of the women in the program were volunteers who had chosen to 158 Applying Human Rights Frameworks to Health participate on their own initiative, members of the indigenous communities spread over the Altiplano.2 Most of them had participated in another community-based reproductive health initiative in the past. The volunteer program gave them a formal opportunity to develop further knowledge and capacity with respect to human rights.3 We connected these local women volunteers with the Defensoría del Pueblo (the National Human Rights Ombuds Office), which is decentralized and has offices in each department of Peru. In this way, the women could channel any complaints to the Defensoría, who could then advocate on behalf of women in Puno. But they did not need to simply depend on the Defensor ía to speak for them; rather, these local health promoters were also invited to personally share their findings and recommendations with local government and in doing so, they had a personal voice and played a direct role in shaping and altering district-level policy and programming. They had real power to effect change. On one occasion, over breakfast with a group of these health promoters, Lupita—a destitute widow who spoke only broken Spanish—described to me her experiences of monitoring her local health center.4 An obviously hostile mestizo5 doctor, annoyed that this woman was interfering in his treatment of the patient, yelled at her, “Go home; this is my house. I don’t go to your house and tell you what to do; don’t try to come to mine and tell me what to do.” Lupita smiled a great toothless grin as she recounted how she had responded : “This is not your house; this is a public health center and you are a public servant. As long as this patient wants me here, I have a right to be here—as a citizen.” The doctor—undoubtedly taken aback—allowed her to stay. And, along with her colleagues, Lupita later presented her findings to the district-level health authority. To understand how significant it was for an illiterate, indigenous woman to stand up to a male, mestizo doctor, you need to know something about the deeply hierarchical Peruvian context, in which indigenous women sit at the bottom. For example, Peru’s Truth and Reconciliation Commission, which examined the brutal armed conflict with Shining Path (Sendero Luminoso ) between 1980 and 2000, underscored that a true national reconciliation would need to be based on “full citizenship for all Peruvians,” oriented toward overcoming the historical fragmentation and discrimination in Peruvian society.6 As health outcomes and the relationships between providers and patients at health facilities reflect that historical fragmentation and discrimination , it was extraordinary when Lupita and the other impoverished Power and Participation 159 and largely illiterate indigenous women could begin to change that dynamic to one of “entitlement and obligation.” In addition, this participation in the health system and the new way of relating to providers led to empowerment in the Peruvian health promoters ’ personal lives as well. These women had to negotiate with their husbands to care for their children while they were away from home accompanying...


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