Health-And-Quality-Of-Life-Of-Mexican-Woman.Pdf

Health and Quality of Life of Mexican women; a case study

ISBN 978-0-9917743-8-8

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ISBN 978-0-9917743-8-8

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Table of Contents

1 Preface …………………………………………………………………... 6

2 Introduction …………………………………………………………...... 9

3 Selection of communities and women to be interviewed ………….. 24

4 Overview of responses about each community ………………...... 30

5 Overview of each community for each age group …………………... 48

6 Overview for each community: opinions of medical personnel …… 57

7 Policy recommendations and concluding remarks ………………….. 65

Appendix I Draft protocol and questions ………………………...... 69

References ………………………………………………………………… 72

Biographies of authors ……………………………………………………. 75

Acknowledgements ………………………………………………………. 78

1 Preface

The focus of this project is on the health of women in 7 communities in Mexico. The communities are El Tuito, Higuera Blanca, Ixtapa, Las Palmas, Morelos, Sayulita and Tomatlán. We will seek clarification of the determinants of health for these women. We will focus on 4 groups of women in each community: old (50+), single (31-50), teenager (13-20), young mother (21-30). Rather than describing specific clinical details of the health or sickness for each woman we will focus on attitudes and perceptions of their health from their perspectives. Members of the medical professions in charge of the Public Clinics in each community will complement the data collected from the subjects, by offering comments and assessment of the health of women in the 7 communities. For comparative purposes, we will collect responses from 40 men in each community regarding health and the influence of tourism on health as they perceive it. The photograph on the cover is of four Mexican women: Rodrigo’s Mother, his wife and two daughters-each has a story about health and quality of life (QOL) as seen from their own experiences and situations. Using schematic diagrams (Figs 1, 2, 3, 4, 5 and 6) shown at the end of section 2 we summarise possible connections for each woman regarding attitudes toward health, sickness and wellbeing.

We must recognize that health, illness and disease are complex matters of science, perceptions and attitudes toward life. Disease may be considered as a pathological entity whereas illness is the effect of the disease on a person’s entire way of life. It may be tempting to suggest that health can be measured objectively and policies developed to alleviate pain, discomfort and suffering, and so enable individuals to live a full engaged life in their family, neighbourhood and community, and thus contribute to the overall welfare, success and stability of the state. Reality is much more complex. Health is defined by individual women in many ways: it defies a simple one- dimensional definition. Health as perceived and experienced by women may be connected in direct and in subtle indirect ways to happiness and quality of life as well as their inherited genetic characteristics and the social,

6 economic, environment and cultural milieu in which they live. Perspectives on health vary over time as information about medical matters and approaches to health care management are disseminated. Also over time a woman’s values and attitudes regarding health evolve and expectations are modified. One view of the ways that medical science impinges on health offered by Harari (2016) is that medicine helps to reduce premature death and ease pain. Whether such interventions reduce suffering as expressed by thoughts in the mind is debatable: the mind cannot exist without the body and much pain is felt somatically. The search for relief from pain and suffering often involves resorting to medical interventions, especially in modern western societies. However, the easing of suffering especially in societies that lack medical services often relies on support and the meaningful presence of family and friends, and a sense of belonging to a community and accepting the inevitabilities of life with a measure of equanimity rather than despair.

The communities we will study are selected from ones we have previously used as part of a long-term project on the impacts of tourism on QOL in Mexico. This new project complements earlier work (Massam et al. 2003, Massam et al. 2013, Massam and Sanchez 2012, Massam,Hracs and Sanchez 2012, Massam and Espinoza 2011, Massam et al. 2016, Massam, Hracs and Espinoza 2015, Everitt et al. 2008, Espinoza et al. 2014). Data derived from surveys using formal questionnaires, and interviews with members of the health care professions will be used to describe the perceived and actual health of women. Samples of women in four age categories in each community will be used. We offer interpretations of the status of health and connections with QOL as well as the impacts of tourism. Also, we will suggest approaches that may offer improvements for public policies, as well as behaviour by individuals, that may serve to improve the health of women in the communities. This case study can provide a framework for further work in other communities and so help in the overall object of our work; namely to understand and improve the human condition of all citizens in Mexico.

An overview of health in Mexico and the subject of the global burden of disease are provided on two web sites. http://www.healthdata.org/sites/default/files/files/country_profiles/Subnati onal/Mexico/CountryProfile_Subnational_Mexico_Mexico_2015.pdf http://www.economist.com/blogs/graphicdetail/2016/10/daily-chart-7

As individuals are living longer given improved medical interventions there are increasing numbers who suffer the consequences of severe chronic conditions. This raises complex ethical and economic issues that must be confronted by individuals and states in the coming years.

2 Introduction

It can be argued that most people live their lives locally and for the most part in the present time. How a person feels, acts, reacts, thinks and behaves is so often related to current circumstances and specific conditions around them. Of course, each person has memories of earlier times and may indeed envisage their future and how life may turn out for them and for others in the future. More reflective enquiry may engage a person to consider the long view of themselves as a unique sentient human being on the path of evolution of our species. The determinants of our current perceptions of health are embedded in our history as a species.

Currently most of us are concerned about caring for the sick and dealing with matters of heath as a reflection of personal concerns regarding happiness, wellbeing, relationships with others, fears, hopes and dreams of a meaningful satisfying life worth living and the legacy that is left when we die.

The ego and notions of the self as expressed by I, me and mine guide and control to a considerable degree, perhaps even dominate a person’s language and behaviour, the perceptions about ‘who I am’ and ‘what I want in life or do not want’, and also how a person relates to his or her body and mind, as well as their impressions and values about many aspects of the world. Matters concerning health, sickness and wellbeing are strongly influenced by perceptions and attitudes, and consequently thoughts, emotions and feelings of an individual, to say nothing about expectations and explanations which are embedded in the cultural context. We may assert and believe ‘I am sick because I have not placated the Gods, eaten the wrong food in the wrong way, and perhaps at the wrong time, not taken the right medications, caught a bug, bacteria or virus, not taken care of myself appropriately etc.’

The notion that we own our body and have control over it is pervasive in many western cultures, even as we observe the body changing following the immutable laws of physics, chemistry and biology. The somewhat misguided view of personal control leads us to suffer, and we often envisage

9 that if we can find the right diagnosis of the causes of our suffering we may be able to find a cure and treatment. This partial truth leaves many people anxious, distressed, and depressed as well as angry, annoyed and frustrated by what is perceived of as inadequacies of a health care system. We cry out for a better system and more expenditure or investments in health care to prolong our lives, and improve the quality of our lives and relieve us of pain and suffering. Implicit in this approach to health individuals tend to adopt the attitude that their happiness and wellbeing is closely connected to QOL and health. In a review of Harari’s (2014) fascinating book about human history Strawson notes ‘Harari draws on well-known research that shows that a person’s happiness from day to day has remarkably little to do with their material circumstances. Certainly, money can make a difference-but only if it lifts a person out of poverty. After that, money changes little or nothing … if we had an infallible ‘happyometer’, and toured Orange County and the streets of Kolkata, it’s not clear that we would get consistently higher readings in the first place than in the second.’ https://www.theguardian.com/books/2014/sep/11/sapiens-brief-history- humankind-yuval-noah-harari-review The renowned British author Penelope Lively (1997) observes in a story (In Olden Times) in her collection Beyond the Blue Mountain that the protagonist ‘Just occasionally, she was able to identify happiness. She saw it made manifest, and perceived what it was …it was Katie [her daughter] laughing in the bath … It could be quite other things, too, quite different things-a blue and green May morning, starlight, the sun on your face. You could identify it-with hindsight it always seemed. What you could not do was cost it, count it, add or subtract it. Catch and keep it. Interestingly, it seemed to have little to do with cars or washing machines or, indeed, houses.’

Most people pay limited attention or reflect on the broader historical development of the human species and the ways that health has emerged as a topic of major significance in the current world. It may be factually true that humans have existed for about 2.4 million years and homo sapiens ‘our egregious species of great apes’ (Strawson G. 2014 The Guardian, September

11) has only existed for about 150,000 years, and it was not until what Harari calls the ‘cognitive revolution’ stretching about 70,000 to 30,000 years ago, that comprised elements of intelligence, creativity and sensitivity we can recognize emerged in our brains and behaviour. Cognitive abilities of humans such as learning, remembering, communicating have evolved dramatically throughout the history of our species. Harari (2014) suggests that perhaps most dramatically we have developed intellectual skills to transmit information about things that do not exist at all, for example, legends, myths, Gods and religions all appeared with the cognitive revolution. Unlike animals that communicate specific things such as danger from a predator, humans communicate belief in abstract concepts like faith and significance of rituals and ways to conduct life as more or less meritorious based upon values which defy empirical verification, and typically are reinforced by power structures to control and implement sanctions of acceptance by a group or by exclusion and alienation

Evidence of burying the dead and caring for the sick emerged at the time of the Neanderthals in Europe and the Middle East. Perhaps such behavior was the initial step to reflect on matters of sickness and health. Homo sapiens who migrated from Africa successfully wiped out Neanderthals.

‘Its main argument is that Homo sapiens dominates the world because it is the only animal that can cooperate flexibly in large numbers. Besides, the author claims that prehistoric sapiens may have committed a massive genocide, leading other homo species such as the Neanderthals into extinction.’

http://www.livescience.com/28036-neanderthals-facts-about-our-extinct- human-relatives.html

The rise of universal political orders such as empires altered significantly the organization of our species; the first Empire was created about 4,500 years ago. This is the Akkadian Empire of Sargon, it may have given rise to collective desire for the benefit of all humans according to Harari (2014). The emergence of Buddhism for example about 2,500 years ago in India with its concern to offer and explore universal truths concerning the liberation of all

11 being from suffering, is an example of collective interpretations of shared values. Buddhist perspectives offer a worthy objective for contemplative inquiry without any supernatural forces guiding the arguments while accepting fully the natural laws of nature as defined by physics, chemistry and biology for example that exist on our universe. We are born and we die without the intervention of supernatural powers or a belief system or a faith. Such belief in supernatural system may of course ease our suffering by promises of redemption, relief or gratification of an unknown sort upon death. The tolerance of pains and ill health and sickness can be enhanced by the brain and thoughts engendered in faith and belief systems.

‘The book (Harari 2014) further argues that Homo sapiens can cooperate flexibly in large numbers, because it has a unique ability to believe in things existing purely in its own imagination, such as gods, nations, money and human rights. The author claims that all large scale human cooperation systems – including religions, political structures, trade networks and legal institutions – are ultimately based on fiction.

Other salient arguments of the book are that money is a system of mutual trust; that capitalism is a religion rather than only an economic theory; that agricultural revolution started as a promise of luxury but ended as a trap that made people’s life worse; that empire has been the most successful political system of the last 2,000 years; that money, empires and religions are the powers that are unifying the world; that the treatment of domesticated animals is among the worst crimes in history; that people today are not significantly happier than in past eras; and that humans are currently in the process of upgrading themselves into gods.’ http://www.livescience.com/28036-neanderthals-facts-about-our-extinct- human-relatives.html

‘In ancient cultures, religion and medicine were linked. The earliest documented institutions aiming to provide cures were ancient Egyptian temples. In ancient Greece, temples dedicated to the healer-god Asclepius, known as Asclepieia (Ancient Greek: Ἀσκληπιεῖα), functioned as centres of medical advice, prognosis, and healing. At these shrines, patients would enter a dream-like state of induced sleep known as enkoimesis (ἐγκοίμησις) not unlike anesthesia, in which they either

12 received guidance from the deity in a dream or were cured by surgery. Asclepeia provided carefully controlled spaces conducive to healing and fulfilled several of the requirements of institutions created for healing.’

(https://en.wikipedia.org/wiki/History_of_hospitals)

The very recent scientific revolution of about 500 years ago, followed by the industrial revolution of some 200 years ago, began the replacement of family and community by the state, and the market as the context for human existence within which matters of health are now situated.

The first hospital founded in the Americas was the Hospital San Nicolás de Bari [Calle Hostos] in Santo Domingo, Distrito Nacional Dominican Republic. Fray Nicolás de Ovando, Spanish governor and colonial administrator from 1502–1509, authorized its construction on December 29, 1503. This hospital apparently incorporated a church. The first phase of its construction was completed in 1519, and it was rebuilt in 1552. Abandoned in the mid-18th century, the hospital now lies in ruins near the Cathedral in Santo Domingo.

Conquistador Hernán Cortés founded the two earliest hospitals in North America: the Immaculate Conception Hospital and the Saint Lazarus Hospital. The oldest was the Immaculate Conception, now the Hospital de Jesús Nazareno in Mexico City, founded in 1524 to care for the poor.

‘Although it is commonly accepted that the basic concepts of ‘Health Promotion’ have been developed in the last two decades, they have their roots in ancient civilizations and in particular in Greek antiquity. As evident from medical and philosophical documents of the sixth to fourth centuries B.C., the ancient Greeks were the first to break with the supernatural conceptions of health and disease that had so far dominated human societies. The ancient Greeks developed the physiocratic school of thought, realizing that maintaining good health and fighting illness depend on natural causes and that health and disease cannot be dissociated from particular physical and social environments nor from human behavior. In this context, they defined health as a state of dynamic equilibrium between the internal and the

13 external environment, they took under consideration the physical and social determinants of health, they empowered individuals and communities through new democratic and participatory institutions, they gave emphasis in health education and skill development, they recognized the importance of supportive environments and of healthy public policy and they re-oriented medicine toward a more naturalistic and humanistic perspective. The aim of the present study is to highlight such core concepts from these early times that helped establishing the foundations for health promotion and education in the modern era according to the Ottawa Charter.’ http://heapro.oxfordjournals.org/content/24/2/185.full

The web site (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680297/) (Angus Deaton Journal Econ Perspect. 2008 Apr 1; 22(2): 53–72.) offers an excellent review of the relationships between income, health and wellbeing using data derived from Gallup World surveys.

‘The great promise of surveys in which people report their own level of life satisfaction is that such surveys might provide a straightforward and easily-collected measure of individual or national well-being that aggregates over the various components of wellbeing, such as economic status, health, family circumstances, and even human and political rights. Layard (2005) argues forcefully such measures do indeed achieve this end, providing measures of individual and aggregate happiness that should be the only gauges used to evaluate policy and progress. Such a position is in sharp contrast to the more widely accepted view, associated with Sen (1999), which is that human well-being depends on a range of functions and capabilities that enable people to lead a good life, each of which needs to be directly and objectively measured and which cannot, in general, be aggregated into a single summary measure.

‘In 2006, the Gallup Organization ran a World Poll using samples of people in each of 132 countries…The questionnaire covered many aspects of well-being, including an overall measure of life satisfaction, as well as several aspects of health and economic status .

Here I focus on the life satisfaction question about life at the present time, measured on an eleven-point scale from 0 (“the worst possible life”) to 10 (“the best possible life”), and the health satisfaction question (“are you satisfied or dissatisfied with your personal health?”) … “Life satisfaction” and “happiness” are not synonyms. Questions about life satisfaction ask respondents to make an overall evaluation of their lives. The results are often interpreted as measures of happiness, but happiness can also be thought of as relating to affect, and can be measured from experiential questions, for example, about smiling a lot, or feeling happy, or absence of depression, often during the day before the interview. The World Poll also includes such questions, and experiential happiness measures based upon them do not always line up with the evaluative measures from the life satisfaction question.

‘Without health, there is very little that people can do and, without income, health alone does little to enable people to lead a good life. Other factors, such as education, or the ability to participate in society, are important too, although income and health tend to get the primary attention in most evaluations of human wellbeing. For many reasons, elaborated by Sen and others, self-reports of satisfaction with life, with income, or health are given little weight. People may adapt to misery and hardship, and cease to see it for what it is. People do not necessarily perceive the constraints caused by their lack of freedom; the child who is potentially a great musician, but never has a chance to find out, will not express her lack of life satisfaction. Whole groups can be taught that their poor health, or their lack of political participation, are natural or even desirable aspects of a good world.

‘In spite of the positive relationship between life satisfaction and national income, and in spite of the plausibility of unhappiness and health dissatisfaction in the countries of Eastern Europe, neither life satisfaction nor health satisfaction can be taken as reliable indicators of population well-being, if only because neither adequately reflects objective conditions of health.’

An overview of the number of women in Mexico, their status and recent trends is given on the web site https://en.wikipedia.org/wiki/Women_in_Mexico

The status of women in Mexico has changed significantly over time. Until the twentieth century, Mexico was an overwhelmingly rural country, with rural women's status defined within the context of the family and local community. With urbanization beginning in the sixteenth century, following the Spanish conquest of the Aztec empire, cities have provided economic and social opportunities not possible within rural villages. Roman Catholicism in Mexico has shaped societal attitudes about women's social role, emphasizing the role of women as nurturers of the family, with the Virgin Mary as a model. Marianismo has been an ideal, with women's role as being within the family under the authority of men. In the twentieth century, Mexican women made great strides toward towards a more equal legal and social status. In 1953 women in Mexico were granted the vote in national elections.

Urban women in Mexico worked in factories, the earliest being the tobacco factories set up in major Mexican cities as part of the lucrative tobacco monopoly. Women ran a variety of enterprises in the colonial era, with the widows of elite businessmen continuing to run the family business. In the prehispanic and colonial periods, non- elite women were small-scale sellers in markets. In the late nineteenth century, as Mexico allowed foreign investment in industrial enterprises, women found increased opportunities for work outside the home. Women can now be seen working in factories, portable food carts, and owning their own business. In 1910, women made up 14% of the workforce, by 2008 they were 38%.

Mexican women face discrimination and at times harassment from the men exercising machismo against them. Although women in Mexico are making great advances they are faced with the traditional expectation of being the head of the household. Researcher Margarita Valdés noted that while there are few inequities imposed by law or policy in Mexico, gender inequalities perpetuated by social structures and Mexican cultural expectations limit the capabilities of Mexican women.[3]

As of 2014, Mexico has the 16th highest female homicide rate in the world.

Further details of the population in Mexico is given on the web site: https//en.wikipedia.org/wiki/Demographics_of_Mexico

The population of Mexico is increasing rapidly as is shown on the web site: http://worldpopulationreview.com/countries/mexico-population/

Mexico’s population is really growing in leaps and it’s touted to soon overtake the population of Japan. When this happens, Mexico will be among the ten most populous countries in the world today. As of July 2012, the population was estimated to be 114,975,406, putting Mexico as the 11th most populous nation in the world. Today, it retains that rank with an estimated 123.8 million people. Because of this, Mexico also has the highest population for a Spanish speaking nation. The country’s population is on a steady, positive growth rate as a result of better medication, medicine, and vaccines, which reduce the chances of death and increases the chances of successful births.

However, over the past two years, the annual population growth has dropped to less than 1%. The country has witnessed gradual increase in life expectancies. The life expectancy of women is higher than that of men by about 6 years. The fertility rate, noted as the number of children a woman has in her lifetime, has drastically dropped through the years to be at an all-time low for the country.

There are number of topics that relate to the health of women in Mexico which could be elaborated. We will not explore these in detail but offer summary remarks and references to specific sources of information.

The availability of advice at clinics for women regarding reproductive health is discussed on the web site:

https://www.cfhi.org/womens-reproductive-health-mexico

The Population Research Institute based in Virginia USA offers comments regarding policies in Mexico in recent years regarding birth rate controls and related matters of reproductive health: this is a topic of considerable controversy and one that touches social, political as well as religious matters. Some comments which can generate controversial discussions on population control and over-population are offered on the web site:

17 https://www.pop.org/content/what-women-of-mexico-want-hint-not-1884

The specific needs for information about reproductive matters for teenage women is discussed in a research report published by the Guttmacher Institute (www.guttmacher.org). The report is available at http://www.un.org/esa/population/meetings/egm-adolescents/juarez.pdf The broad field of feminism in Mexico as it has evolved and is changing in recent times is discussed with specific emphases on the rights and opportunities of women. ‘As of the most recent Gender Gap Index measurement of countries by the World Economic Forum in 2014, Mexico is ranked 80th on gender equality.’ Details are given on the web site: https://en.wikipedia.org/wiki/Feminism_in_Mexico

The topic of violence against women is one that is discussed by the International Coalition for the Responsibility to Protect and recent report about the situation in Mexico is given on the web site: http://www.responsibilitytoprotect.org/index.php/role-women-in-armed- conflict/409-in-mexico-womens-advocates-make-slow-but-steady-gains- against-violence

The relationship between the involvement of Mexico in the agency UN Women is a reflection of the emerging actions of women in Mexico and their concerns about health and the future of the society. ‘The Mexican commitment to the women’s agency reflects the strides that the country has made in promoting women’s rights in recent years, powered by government policies and its own vibrant nongovernmental organizations, often working in partnership with the United Nations.’ Details are given on the web site: http://passblue.com/2014/02/06/mexico- rising-advances-in-womens-health-and-rights/

The Economist in an article in 2010 draws attention to the distribution of access to health care for pregnant women especially in the poorer parts of the country: a topic of much significant to the central government and of course the women affected. ‘Maternal mortality in Mexico has fallen by 36%

18 since 1990, but it is still higher than in other Latin American countries. The problem is far worse among Indians and in the poorer south. Mothers in Chiapas, Oaxaca and Guerrero states die in childbirth 70% more often than the national average, and indigenous women are three times less likely to survive birth than non-indigenous women. Most of these deaths are preventable.’ The article is available at: http://www.economist.com/node/16439044

An overview of the status of the health of Mexican women in relation to heath care reforms in recent times is provided in recent paper by Frenk, Gómez-Dantés and Langer (2012). Details are given on the web site:

(http://bmcwomenshealth.biomedcentral.com/articles/10.1186/1472-6874- 12-42)

‘The most important message of this paper is that broad changes in health systems offer the opportunity to address women’s health needs through innovative approaches focused on promoting gender equality and empowering women as drivers of change.

‘The calculation of national health accounts in Mexico in the 1990s revealed that more than 50% of total health expenditure was out-of-pocket, due the fact that more than half of the population (around 50 million people) lacked health insurance. This type of expenditures exposed households to ruinous situations. In fact, further analyses demonstrated that close to 4 million households were paying catastrophic and/or impoverishing sums to meet the health needs of their family members.

The most important women and health challenges are far from over. There are still major threats that need to be addressed urgently. Salient among them are the further acceleration of the decline of maternal mortality to achieve MDG 5 and the attention to neglected emerging problems such as breast cancer and depression. Notwithstanding the importance of these problems, we should also recognize that several conceptual and empirical improvements in the field of women’s health have been recently achieved, with impacts both at the global and local levels. Salient among them are the global decline of maternal mortality figures, the innovative approaches to women’s health, and the successful implementation of comprehensive

19 policies to address the comprehensive women and health agenda at the national level, as exemplified by the Mexican health reform experience. Future initiatives in this field should take advantage of this progress and build on it.

The Mexican experience shows that broad reform efforts can be used to design and implement specific initiatives addressing priority needs. In this particular case, these were interventions to improve the reproductive and sexual rights of girls and women.

This reform experience, due to its novel nature, also offered the opportunity to move beyond traditional approaches to women’s health to build a comprehensive agenda, which also includes neglected and emerging challenges such as gender-based violence, breast cancer, and the introduction of the gender perspective in the design, implementation, and evaluation of health policies.

Finally, we should stress that the successful implementation of the women and health approach in Mexico resulted from the establishment of creative alliances between the government and various important actors of the women´s health field, including researchers, women’s groups, other NGOs and the media.

The women and health approach represents an essential contribution to the advancement of the unfinished women’s health agenda both from a human rights and a development perspective, at the national and global levels.

The first author (JF) was Minister of Health of Mexico during the period covered by this paper. The second author (OGD) was Director General for Performance Evaluation at the Ministry of Health of Mexico during the period covered by this paper. The third author (AL) was a frequent advisor to the Ministry of Health of Mexico on women’s health issues during the period covered by this paper.’

For illustrative purposes we have prepared a set of six schematic figures to show possible connections for a woman regarding determinants of health and components of health that will be addressed in this case study. The specific ways the components connect, and the nature and strength and intensity of the connections cannot be identified on such figures. Causative

20 relations are not inferred from the arrows on the figures. The general information on the figures will be incorporated into the formal questionnaires and interviews which we use to collect data. Details of the questionnaires and interview protocols will be presented in a later section. Figure 1

I never think much or often about health / sickness

Am I healthy / sick / well? I wonder if other people are healthy / sick / well?

I worry/do not worry about I try to do things to be healthy my health

Figure 2

Genetics/inherited from parents

Quality of environment, air,

water, pollution, land, Food vegetation, animals

Parasites/bacteria/viruses in Infections from others air / water / land

Figure 3

Clinics / nurses/ doctors / pharmacies

Natural health products Chemical medications

Life style –eating, working, exercise, hygiene, social interactions Vaccinations- compulsory/voluntary

Figure 4

HEALTH

What happens to my ideas/thoughts/actions/behavoiur about my health as I get older?

AGE

born die

Figure 5

In what ways is my health wellbeing and happiness important and

significant?

To me: feel good / happy, able to do all To my country: a helpful and able I want, work after myself, others member of society, to work and enjoy life

To my family: no burden To my neighbours / friends: able to help them

Who is concerned / worried about my health / happiness/ wellbeing?

Who am I concerned / worried about regarding health issues?

Figure 6

Relationship between my health and tourism / tourists

Positive: Negative:

Cleaner water Diseases from tourists

Sanitation pollution due to “development”

Neutral

3 Selection of communities and women to be interviewed

During the months of May and June 2016 Professor Espinoza visited several communities in the states of Jalisco and Narayit to identify suitable ones in which interviews could be conducted given the resources he had available in terms of accessibility and assistance. He identified 7 communities in which medical personnel were willing to be interviewed, and they provided help, with the assistance of community leaders, to select a set of 10 women in 4 age categories who agreed to be interviewed individually. A sample of 40 men in each community was also identified. The general interview protocol provided confidential surveys with the imperative not to breech any confidentialities. Draft interview questions were prepared and tested in June, and the empirical data collected by Professor Espinoza and his team in July, August, September and October 2016. The draft protocol and questions are shown in Appendix I. The location of the communities is shown on Fig 7.

Map with the seven communities in Jalisco and Nayarit, Mexico. FIG 7

An overview of each community is provided below.

El Tuito El Tuito is a community of 3,211 inhabitants that belongs to the municipality of Cabo Corrientes in the state of Jalisco. (http://www.coepo.jalisco.gob.mx). Cabo Corrientes is a municipality located in the Coast Sierra Occidental of Jalisco. This municipality has a border to the north with the Pacific Ocean and the municipality of Puerto Vallarta, to the east with the municipalities of Puerto Vallarta, Talpa de Allende and Tomatlán, and to the south with the municipality of Tomatlán and the Pacific Ocean, to the west with the Pacific Ocean. Its main communities are: El Tuito, Yelapa, Maito, Refugio de Suchitlan, Chacala, Las Juntas and Los Veranos, (H. Ayuntamiento de Cabo Corrientes, 2012- 2015). The population of Cabo Corrientes is 10, 029 inhabitants (5, 176 men and 4, 853 women). In the coastal zone the climate is semidry, with drought in winter and spring seasons. In the east zone it is humid, with drought in winter and spring so the annual average temperature is of 25.6°C with a maximum of 28.5 °C and minimum of 22.7°C. The main economic activities are agriculture, livestock of cattle raising, and more recently tourism has been developing. This municipality has a beautiful littoral with enchanting beaches that invites you to be a tourist for a while. The distance from Puerto Vallarta is 108 kms. and it is 468 kms. from Guadalajara, the capital of the state of Jalisco (Chavez, et. al., 2005; Andrade, et. al., 2007; INEGI, 2010; Andrade, et. al., 2011). Tourism activities are becoming important as part of the development of the coast of the municipality. El Tuito as head of this municipality has been trying to develop tourism because it has many tourist attractiveness both cultural and natural ones, but its efforts to grow significantly have been very slow, and the citizens wait to see tourism in the community contribute to solving some local economic problems (Chávez, R.M., Andrade, E., Espinoza, R. y González, L.F. 2005).

Higuera Blanca The community of Higuera Blanca is located in the municipality of Bahía de Banderas, in the state of Nayarit. The state of Nayarit is divided into various

26 regions for public administration. The municipality of Bahia de Banderas is in the South Coast Region of the state. To the north is the municipality of Compostela, to the South the State of Jalisco, to the east Compostela and the state of Jalisco, and to the west the Pacific Ocean. The municipality of Bahia de Banderas has a total of 157 localities or communities and the most important ones are: Bucerías, Corral del Risco, Sayulita, Nuevo Vallarta, Mezcales, Cruz de Huanacaxtle, Las Jarretaderas and Higuera Blanca, (SEDESOL, 2010; H. Ayuntamiento de Bahía de Banderas, 2011-2014). Higuera Blanca has 960 inhabitants (517 men and 443 women). Its climate is sub humid and warm with rain in the summer: the temperature oscillates between 23ºC and 28ºC. The main economic activities are: tourism, fishing, livestock and agriculture. The main products of this region are watermelon, pineapple, corn, mango, and banana; the livestock is mainly cattle. Higuera Blanca is located 53 kms. from Puerto Vallarta and around 200 hundred kilometers from Tepic the capital of the state of Nayarit (H. Ayuntamiento de Bahía de Banderas, 2011-2014).

Ixtapa The community of Ixtapa is located in the municipality of Puerto Vallarta which is part of the Coast and Sierra Occidental Region in the state of Jalisco. Its population is 23,977 inhabitants, 12,145 men and 11, 832 women (http://mexico.pueblosamerica.com/i/ixtapa-2/). Its main economic activity is agriculture and cattle ranching which it still practices by its ejidatarians, old people, but its close location to the international tourism destinations of Puerto Vallarta and Riviera Nayarit has resulted in many young people being integrated into the tourism sector, and now this community functions as a dormitory place (Espinoza, et. al., 2015). The rapid and recent development of tourism activities is very important for the community of Ixtapa.

Las Palmas The community of Las Palmas is located in the municipality of Puerto Vallarta, in the state of Jalisco. It has a population of 4,145 inhabitants (2, 073 men and 2,072 women). Its climate is semitropical and humid, with an

27 annual average of 25° C temperature, with a maximum of 31° C in summer, and a minimum of 19° C in winter. The main economic activities are agriculture, livestock, trade and tourism. The main crops are corn, beans, and watermelon with and without seed, chile poblano, tomatoes, forage sorghum and grain sorghum, plus vegetables such as cucumber, tomato, squash vegetable, cilantro and radishes. Las Palmas is located about 35 kms. from Puerto Vallarta city (Massam, et. al., 2003; Espinoza, et. al., 2014).

Morelos The community of Morelos is located at the municipality of Tomatlán. It has a population of 2, 970 inhabitants and this is composed by 1, 532 men and 1, 438 women. Its main activities are agriculture, cattle ranching and fishing. This community is in a poor economic situation. In the last five years the government and some social sectors have been working on some strategies to bring tourism development to its littoral which is very impressive and beautiful. The population of Morelos hopes that tourism can contribute some positive aspects to alleviate their poor economic and social conditions. Morelos community is around 115 kms. from the international tourism destination of Puerto Vallarta and around 120 kms. from the Rivera Nayarit. The development of alternative tourism is very important because it is considered that Chalacatpec Beach, where the government has planned to implement tourism development under the slogan “Vistas”, with thhe principles of economic and social sustainability (Lepe, V.M., 2014; Espinoza, et. al., 2015).

Sayulita The community of Sayulita is located in the municipality of Bahía de Banderas, in the state of Nayarit. The state of Nayarit is divided into various regions; the municipality of Bahia de Banderas is located in the South Coast Region of the state. It limits to the north is the municipality of Compostela, to the South the State of Jalisco, to the east Compostela and the state of Jalisco, and to the west the Pacific Ocean. The municipality of Bahia de Banderas has a total of 157 localities or communities and the most important ones are: Bucerías, Corral del Risco, Sayulita, Nuevo Vallarta, Mezcales,

Cruz de Huanacaxtle, Las Jarretaderas and Higuera Blanca, (SEDESOL, 2010; H. Ayuntamiento de Bahía de Banderas, 2011-2014). Its population is 2,262 inhabitants (INEGI, 2010). Sayulita is located inside the territory of La Riviera Nayarit International Tourism Destination. Its natural location gives the community a very important geographical position for the development of tourism activities. It is beside the littoral of the Pacific Ocean, and its main natural characteristic composition is a beautiful ocean creek that contributes to the tourism activities a very valuable asset. Sayulita was a fisherman village but currently the massive tourism practice is leaving behind the fishing industry as source of economic wealth. Its latest designation as a “Magic Town” is part of the promotion of this community and people wait for Sayulita to increase the amount of tourism development. The distance to the international tourism destination of Puerto Vallarta is 35 kms.

Tomatlán Tomatlán is a municipality in the South Coast Region of the state of Jalisco. It has a border to the north with the municipalities of Cabo Corrientes, Talpa de Allende and Atenguillo; to the east the municipalities of Atenguillo, Cuautla, Ayutla and Villa Purification; to the south the municipalities of Villa Purification, La Huerta and the Pacific Ocean; to the west the Pacific Ocean and the Municipality of Cabo Corrientes. It has a population of 35,050 inhabitants (17,822 men and 17,228 women). Its climate is semi-dry, in winter and the spring is dry and warm, the annual average temperature is 26.9° C, with a maximum of 34.1° C and minimum of 19.6° C. Its economy is supported by the following activities: agriculture, the main crops are corn; livestock, in the raising of cattle, pigs and poultry; logging, especially of precious woods such as barcino and parota; mining. Also it has a major salt mines in the state; fishery in species such as lobina, chacal or shrimp, tilapia etc. Currently tourism is minimal on its 68 kms. of beautiful coastline; trade and services are part of the economic dynamic of this municipality. The potential for the development of a vast tourist destination is being explored by number of public and private agencies for this region. The community of Tomatlán is located 100 kms. from Puerto Vallarta (Massam, et. al., 2003;

Massam y Espinoza, 2013; Espinoza, et. al., 2014; Chávez, et. al., 2005 and 2014, Espinoza, et. al., 2015).

For each community a medical person offered responses to a set of questions regarding the health of women in the community. For each sample of women for each community we used questions to solicit opinions and attitudes toward health, wellbeing and the impacts of tourism. We also collected information from a sample of 40 men in each community.

The complete set of empirical data is available on request from Professor Espinoza at the Universidad de Guadalajara. In this report we will select specific sets of responses to provide summary impressions and opinions which we will use to help in the search for ways that policy makers, community leaders and individuals might improve health services to relieve pain and suffering among women, and improve the overall QOL of all members of each community. The concept of QOL is reviewed by Massam 2002. 4 Overview of responses about each community

Using the empirical data, a series of Figures (8-18) have been prepared using the total set of responses from 40 women and 40 men in each of the 7 communities. As mentioned in the Preface we collected opinions from men in each community and we can compare responses for women and men. The focus of attention for Figures 8, and 9 is on the perceived detrimental or beneficial effects of tourism on health in a community. Overall about 60% of the responses for either men or women suggest that tourism is beneficial and contributes to improved health conditions in the community. However, with respect to the detrimental effects the response from the women are on average 24% whereas for the men the average response is 13%. There are considerable variations among the communities for both men and women. The variation for men is large: Las Palmas has a response of about 3% detrimental (men) and 17% (women). Las Palmas records a high no response rate of 37% and about 40% neutral effect. El Tuito records 10% neutral effects

30 from women and 3% from men. Beneficial numbers are 52% for women and 95% for men. It is clear that men and women perceive effects differently and this pattern deserves to be explored. Co-ordination of efforts among all the communities is suggested to explain the patterns. The respondents offered limited precise explanations as to the benefits but hinted at improved awareness of life styles regarding exercise, eating habits and use of regular medical checks as well as availability of modern medicines. On the detrimental side suggestions were made about the change in values due to the availability of contraband drugs, threats to personal security and violence, teen pregnancies as strong family values have changed and the reduced levels of reliance on family members for mutual support in times of health care needs due to the work trends as younger people leave the community to work in resort areas. Out of 280 women interviewed 172 suggested that tourism brought benefits whereas 70 suggested the effects are detrimental. The responses for men are more striking: 187 suggest there are benefits and only 38 suggest there are detrimental effects. In Las Palmas 14 out of 40 declined to answer. It might be useful to review these response rates over time as tourism changes, especially in Tomatlán and Sayulita which currently have somewhat limited amounts of tourist activities. There were very few (7) I do not know”” responses from women and none in this category from men.

The pairs of responses from women and men are shown on Figures 10 and 11, 12 and 13, 14 and 15. The figures summarize a large amount of empirical data derived from interviewing 40 women and 40 men in each community. We will not provide a detailed description and explanation of all the many patterns and trends captured by the data. However, we will select one aspect from each figure and offer comments on patterns and questions that are raised. These comments will serve as examples that the reader may wish to pursue by examining other aspects of attitudes toward health in each community as recorded by the response to the interviews. The three aspects about health we will comment on concern the overall assessment of the quality of the current healthcare facilities in each community drawing on data for question 9 regarding the acceptability of existing health care facilities shown on Figures 9/10. We summarize opinions concerning the use of traditional medicine compared to modern medicines using data in Figures 11/12 for question 11 on acceptability of traditional medicine. The overall impressions of perceived quality of health of interviewees in the communities using data in Figures 13/14 for question 3 will be described. We will compare responses from both women and men. We will not use detailed information for the 4 age groups of women in these comments. We offer comments on the opinions of women in the 4 age groups in section 5. For Figures 10/11 using responses to question 9 regarding health care facilities, women report on average 13 out of 40 for each community as being acceptable whereas 28/40 believe them to be unsatisfactory. A similar pattern emerges for men’s opinions with an average figure of 14/40 as satisfactory with 20/40 as unsatisfactory. Overall out of 564 valid responses there are 191 people who report satisfaction and 373 who are dissatisfied. Clearly there is much room for improvement in health care facilities in the communities. Regarding women’s opinions in El Tuito and Higuera Blanca 39 and 33 responses indicate dissatisfaction whereas in Morelos 39 report satisfaction. The reasons for these responses are worthy of further examination. For Figures 12/13 overall there is considerable support for the use of traditional medicines. An exception is for Las Palmas where only 7 men out

36 of 40 support the use of traditional medicine, and in this community 23 women out of 40 favour its use. Out of 536 valid responses there are 308 men and women who support the use of traditional medicine and 228 who do not. In El Tuito 30 out of 40 men do not support the use of traditional medicine where as 28 women in this do support its use. In Higuera Blanca 31 men support its use while only 1 man does not support its use. The underlying reasons for these patterns is a worthy topic for further exploration now that certain patterns have emerged from this project. For Figures 14/15 of the 280 women interviewed 231 report that they believe their health is very good/good or acceptable. Only in Las Palmas is there a very high level of poor or very poor health reported: 25 out of 40 report low quality of health. All other communities report low figures for poor health, for example, only 1 person in Ixtapa reports low quality of health and there are 2 cases in Morelos and 3 in Tomatlán. For men in Las Palmas all 40 men report very good/good or acceptable health yet in Higuera Blanca and Ixtapa 21 men report poor health. Further research is called for to unravel explanations for these patterns.

5 Overview of each community for each age group.

In this section we will provide set of four Figures that refer to a set of 7 questions, and the responses from each of the 4 groups of 10 women interviewed in each community. On Fig 16 responses to questions 3 and 4 are recorded. On Fig 17 we use responses to questions 7 and 8, and on Fig 18 we summarize responses to questions 9, 10 and 11. Comments on the patterns of responses will be offered. The results shown on Fig 16 clearly show that a majority perceive their health to be very good or excellent. The results indicate that 199 out of 280 women are in this category while only 15 rate their health as poor. This pattern is consistent across all the 4 groups. However, in the case of Las Palmas the figure for very good /excellent health is low at 15/40, but the rating of poor is also low at 3/40. El Tuito and Sayulita have figures that are low for very good/excellent health at 27/40 and 26/40. In the case of Las Palmas only 2 women in the elderly category rate their health as very good or excellent: this is the exception to the overall pattern and deserves investigation. There are only 2 single women in Morelos who rate their health as very good or excellent. Ixtapa is the place where 39/40 rate their health as very good or excellent. Perceptions of quality of health are subjective and so rating may reflect local attitudes rather than any objective assessment.

The women consistently rank good eating habits as the main reason for good health, followed by sport, rest, relaxation and regular checks.

On Figure 17 a summary of responses regarding responsibility for health of women in each community is presented. There is great similarity among the responses for the 4 groups of women in each community for question 7. Almost without exception all women argue that they are responsible. Only 30 responses among the total of 280 suggest doctors/parents/son/daughter or God are responsible. The assumption of personal responsibility is reflected in responses to question 8. But it is indicated that the government does have a degree of responsibility. For example, In Morelos 1 teenager and 1 young mother suggest a role for government. While all groups argue for mixed response 11/40 responses, with 27/40 indicate the individual is responsible. It seems appropriate to make women aware to greater degree the precise ways in which governments at various levels can and do contribute to the construction and staffing of facilities. Matters of accessibility, opening hours and services offered need to be distributed to all people in each community. School children could be shown the facilities as part of their education programme and after-school activities. Local newspapers have a role to play in advising citizens about health care facilities.

On Figure 18 responses for 3 questions are presented.

For question 9 regarding sufficiency of health care facilities out of 280 responses 215 indicate the facilities are insufficient. In Ixtapa the positive responses are only 26/40 with 6/10 suggesting the facilities are sufficient. In Las Palmas 14/40 suggest the facilities are sufficient but one 1 young mother supports this view.

With respect to traditional medicines there is strong support for their use. Out of 280 responses 171 support their usage. In Morelos 15/40 support the use and in Ixtapa 6 favour their use while 3 support the use of both scientific and traditional medicines. In Las Palmas 6/10 young mothers support the use of scientific medications with El Tuito, Higuera Blanca and Tomatlán almost half the young mothers opt for their use compared to traditional medicines. Perhaps because they use facilities quite often they are aware of the advantages of modern medications. Home remedies gain considerable support in all communities for all age groups. If there is clear evidence about the beneficial use of modern medicines, and evidence of the less effective use of traditional medicines and home remedies, then there is a need to make women aware of these facts.

6 Overview for each community: opinions of medical personnel

Unstructured interviews were conducted with medical personnel who are in charge of clinics in each community after first explaining to each person the overall purpose of the research project as outlined in Appendix I. At the end of each interview sincere thanks were offered to each respondent. Community of El Tuito.

The Director of the public health clinic of this community comments that the main problem in the region of Cabo Corrientes with respect to health is the personal insecurity, as this aspect brings with it the challenge that a clinic must treat a lot of people’s wounds from weapons every day, treating at least three bullet wounds, which is alarming because they don’t have the necessary technical equipment to treat these injuries. Also, they don’t have enough staff to treat all the demand for health matters. In relation to medicines, there is not enough to respond to the needs of the community.

She was also asked about if people trusted in scientific medicine to treat sickness or if they have more trust in traditional medicines to heal their diseases. She answered that almost all the population still try to heal their diseases with traditional remedies, and it is only when they don’t work that come to the clinic to get a medical treatment.

With specific respect to women we inquired about believe and faith in doctors and scientific medication. She answered that before coming to the clinic women try traditional home remedies, and if they do not work they go to a clinic, and that's when we take the opportunity to explain the health care programs that they have available in the clinic, and invite them to be involved in activities and check up programmes to prevent diseases. An important aspect she mentioned is that, in El Tuito, women have a "superhuman strength" and a strong character inherited from their ancestors. They are very attached to their customs and practices and belief in traditional remedies is strong, and the scientific approach to treat sickness is secondary and in the background.

She was asked about if doctors can heal diseases, she answered: “no, because doctors don’t heal, they only identify the problem, recommend a treatment and monitor its evolution”. She added that: “Health problems are generally related to the environment and social factors such as unemployment, low education levels, family problems, poverty and cultural aspects. To conclude she added “I wish that someday everyone could enjoy excellent health conditions, and women understand that they must take more care of themselves and their health conditions than about their husband, friends or neighbors.”

Community of Higuera Blanca.

The head of the health public clinic of Higuera Blanca comments that the general population come to the clinic to treat their symptoms, but even so, sometimes patients assume that their sicknesses are the product of witchcraft. He also said that the Higuera Blanca population is very healthy compared with others communities which experience close contact with tourism. He added that in the community there are few problems such as drug addiction, prostitution or insecurity. These are common problems in a community where most of the people work in the tourism sector or in urbanized communities. He also added that they only work from Monday to Friday so what happens on weekends is unknown to him.

He was questioned if the general population, and specifically women believe and have faith in the medical vision and doctors to provide health care, he immediately answered: “Of course they do believe in medicine and in doctors, I say this because every Monday we treat a lot of people with symptoms that occurred on Saturday or Sunday. I would like to add that, we treat mostly women in the clinic, and if it weren’t for them most of men wouldn’t come; women are also very active in health programs to prevent diseases. About the common diseases that the population presents we keep a record about how we diagnose and treat them, this information can be

58 consult in the Municipal head (Valle de Banderas) in the Municipal Health Services Coordination”.

He was asked if women from Higuera Blanca fully trust in doctors and the clinic to treat their sickness, and if they prefer to use modern medicines to heal instead of traditional remedies, he answered: “I cannot say that they come to the clinic solely for modern medications, but also they still use traditional remedies as a first option to treat their diseases and when they don’t work they come to us in search of medicines. I would also like to add that women from Higuera Blanca are strong, and due to their traditional rural education do not complain about their health condition, and only care about their children and try to involve them in every programme related to health.”

Community of Ixtapa.

The Director for the public health clinic of this community comments that women from Ixtapa come to the clinic for medical consultations and checks when they get sick, but there’s a problem related to the scientific point of view due to a pervasive view of the population of the community who believe in psychosomatic causes and suggest that diseases can be caused by witchcraft. However, in the community there’s a general problem related to prostitution and drug addiction. However, there are no major outbreaks of diseases among the population.

Regarding the acceptance of people to go to the clinic to treat their health problems, he comments that people come regularly for medical consultations when they feel sick. But nowadays, a disease is occurring, not in the community, but among those in charge of healthcare, such as doctors, who are developing chronic cases of diabetes; this is contradictory, because we, as doctors, are the ones who diagnose health problems and recommend treatments, but also we’re the ones who are sick, this is a very important matter to address.

When he was asked about if he was sure that doctors can heal diseases with scientific methods, he answered: “Doctors don’t heal sickness, what we do, as I said before, it’s identify the health problem, recommend a treatment and monitor its evolution”. In addition, he reported that people from this community still use traditional remedies to try to heal themselves, for example, they make use of herbs like chamomile or lemon tea to treat stomach pains, or garlic to treat a scorpion string. “However, we can say that in general the population does believe in doctors because they come to the clinic when the remedies don’t work.”

He was also directly questioned if social indicators influence in the community health, he answered: “I´m in totally agreement, health conditions of people are directly related to daily aspects that everyone live in the community, since being satisfied with what you do influences your mood, this is important, because most diseases are caused by stress, which is a major cause of silent diseases”. To conclude he added: “I think that it’s important that the community start to believe more in science and in medical visions, I also consider that we need to preach with the example, which we’re not doing as doctors of the community of Ixtapa”. Community of Las Palmas.

According to the information provided by the Director of the Public Clinic, the population of Las Palmas still uses traditional medicine to care for their health. When a remedy is trendy the whole population wants to use it, as is the case today of the “Moringa”; a plant that they consider cures everything, as well as the use of peppermint for the stomach and migraine pains. This means that their traditions and customs are still alive. A relevant aspect about their customs is that is old people are the ones who encourage their descendants to make decisions about health care and are handing over trust in scientific methods to treat sickness. Regarding the perception of tourism and health, he affirmed that the tourism that occurs in Puerto Vallarta and not that of the community, influences the health of the population since the majority of the population work in the

60 hotels and restaurants in Puerto Vallarta. This exposure changes their vision regarding health, making it an important factor since in their workplace they have social insurance and the benefits of laws and health regulations.

The doctor added that the use of technologies such as computer tablets and smartphones has significantly affected public health because the younger generations do fewer physical activities, and spend more and more time surfing the internet. On the other hand, she says that the health sector has been promoting sports programmes in primary and secondary schools that promote recreation and physical activity. She also mentions that one of the main health problems presented by the population of Las Palmas is that scorpion stings are frequent, and people often use traditional remedies such as chlorine, milk and mud to combat the poison, and it is not until they realize that the remedy does not work that they attend the clinic in search of medication. From the doctor's point of view, diseases are not cured by medication, but are products of the social environment in which an individual develops, and factors such as safety, work, family, friends, recreation and tranquility strongly influence public health; she also adds that doctors do not cure sick people, they identify the problem, recommend a treatment and monitor their evolution. They emphasize that public health is a matter directly related to the social environment, something that is not controlled by clinics, but by the population. In conclusion, she mentioned that it is important that the University promote research and practical health care programmes for the community. Community of Morelos.

The Director responsible for the public health clinic of Morelos says that a big problem of health among the young population, namely drug addiction, reaching even young children with the sale of drugs in primary schools. The low level of public security exacerbates the drug situation. The doctor was asked if women come to the clinic, she answered that there’s a very rare cultural pattern in the community, because women are the only

61 one interested in bringing all her relatives to see the medical personnel. Men are generally not interested in such places but when they get sick, no matter if it's a child, a young man or an old man, it is a woman who takes them to the doctor. However, this has caused men of any age to become dependent on their mother, wife or grandmother to take them to get medical attention. She also said that women are very active in the activities of health promotion performed by the clinic. In terms of common diseases in women and the general population, the doctor commented that the main problem comes in the rainy season, with increased scorpion stings, since there’s not enough medication or technology to respond the necessities of the community, and if we add to this that, almost all use home remedies before they attend the clinic, the problem gets worse. Then, she was also asked that if she considers that if the doctors are the ones who heal the diseases of the population in general, she answered: “no, because as doctors we identify the problem, recommend a treatment, and monitor its evolution”. Also, the doctor says that, what makes people healthy are their daily practices, which is a big problem that hasn’t been solved in this community because the population does not like exercise and the education level is low. To conclude she added that if it weren’t for the maternal figure, men from this community would do nothing, they would be obese because they do not care about exercising, but women have influence on the idea of exercise and the notion that they don’t need to do anything because they will inherit land and livestock from their parents. Community of Sayulita.

The head of the public health clinic in the community of Sayulita commented that the health problems of the population are the same as the rest of the rural communities in the region. She does not perceive any important cultural pattern that makes a difference about the problems of coastal communities like Sayulita. She added that the clinic mainly deals with cases

62 of dehydration, scorpion stings and drug poisonings. She assures us that the latter was because of the high rate of personal insecurity in the community, as well as the sale of drugs and the increase of the transient/floating population that is increasing day by day.

She was questioned about the clinic’s programs that focus on diseases prevention, she said: “Of course, we work with kids from kindergarten and primary school, there’s also a lot of volunteer work related to cultural, educational and recreational activities provided by non-governmental organizations. These activities support and promote health care.”

She was directly asked if the general population, and specifically women believe in the medical vision for health care to treat diseases that they suffer from. She answered that people come to the clinic when they get sick, however in this community there’s still the custom of treating diseases with traditional remedies inherited and passed from generation to generation. Concerning the female sector, she comments “women from this community are strong and they still believe that they can heal themselves with remedies and only when they don’t work they come to the clinic to seek medication, but in general I can say that they do believe that doctors can heal their sickness with scientific medicines”.

Then she was questioned if the population in general perceive that the health sector, that she represents, as something which can solve the health problems of Sayulita, she answered: “This information is not within my reach, we would have to consult the municipal head to get it”. To conclude she adds “In general women from Sayulita are strong and even though they treat their diseases with traditional remedies they believe in doctors and a medical vision, and come to the clinic in emergency cases and to undergo medical consultations about sexuality or drug addiction”.

Community of Tomatlán.

The Sub-director of the public health clinic of Tomatlán comments that the biggest health problem for women in the community concerns pregnancies among 13 to 15 years old girls. This is largely due to the culture of the community, since this is a specific characteristic of the Mexican indigenous communities, pregnant women come sporadically to monthly check ups. Added to this there’s a tradition of seeking help from healers called “midwives”, and sometimes this aggravates or makes worse the situation even causing the death of the mother or the child. Fortunately, this habit has decreased in recent years, but being an embedded cultural aspect of the community, sometimes this cultural attitude prohibits male doctors from treating women, because according to local believes, women shouldn’t show their “noble” parts to a man.

On the other hand, the Sub-director was asked if the community believes in the scientific medical vision to treat diseases, or if women of this community trust more in home remedies to take care of their health. In response he said that as Tomatlán is still largely an indigenous community the tradition of treating diseases and sickness with traditional remedies is very common, for example, if someone is stung by a scorpion, which is very frequent in the region, instead of come immediately to the clinic to get the treatment the victim chooses to use remedies such as: drinking chlorine, garlic, milk, mud, water, “chacales”, etc. which aggravates the situation because these remedies are not very effective and when they do not work, they come to the clinic with more severe symptoms requiring more medication. This is a big problem because sometimes the medication is not enough to respond to the needs of the community.

He was also questioned about the programmes in the clinic that focus on involving the population in disease prevention and health care. He said that there’s a programme focusing on sexual education, and that women are involved because nowadays, with the use of Technologies on the

Information and Communication (TOCS’S), discussing sexual behaviour is no longer a taboo subject. What is still taboo being the fact that women shouldn’t remain single after the age of 18 years, because they’re considered maids or a “periquita”, this strengthens men and determines the role of the woman.

Another question that was asked about the scientific vision regarding health, and if doctors are the ones that cure sickness and he answered: “No, the only thing that doctors do is identify the problem, recommend a treatment and monitor its evolution…” he also added “… health in the community is related to customs and social aspects, as concerns and stress are typically generated by insecurity, poverty, unemployment and family breakdown, for example.”

7 Policy recommendations and concluding remarks

In this section we will offer summary remarks concerning the project, the analysis and results. Detailed results and observations about patterns of health care are given in earlier sections and will not be repeated here. The opinion data collected from the women and men support the general observations presented by the medical officials in each community. However, while most of the women and women interviewed self identify as having acceptable, good or very good health the medical persons in the clinics did identify some health problems that deserve attention. Further, the observations we draw from the empirical data complement and amplify the comments and remarks presented in a variety of documents as summarised in section 2, in which the health of women in Mexico is reviewed and found to be in need of improvements. These reports consistently recognize that health is largely a subjective notion but that scientific medicine has a key role to play in promoting good health and curing and alleviating pain. The determinants of health as outlined in Appendix I and presented on the web site http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php are consistently identified as the appropriate ones to explain health status.

Attitudes toward health care are evolving in Mexico and more needs to be done to promote good habits and turn away from the reliance on traditional and home remedies. Exercise programme should be promoted and efforts made to confront matters of drug abuse, teenage pregnancies, violence and the ways that men perceive health treatment. There is pervasive view among many that QOL as a surrogate for happiness is a direct result or consequence of certain causes and conditions. A well- paid job, good quality housing, and good health care for example, can yield a high QOL and much happiness and contentment. Poor health can cause a person to experience pain and suffering: happiness is denied to them. While lived experiences generally support these arguments we should also note that happiness is indeed a state of mind that involves awareness of reality, acceptance of reality and the nature of individual aspirations, as well as a sense of identity, belonging, being needed, wanted, appreciated, accepted, attended to and the like. These attributes of the good life are essentially intangible, and beyond the scope of public policies and government intervention, and medicine per se or the market place and consumerism. In material terms and in terms of availability of high quality medical care and facilities many who live in the 7 communities may be described as somewhat deprived by modern western standards in advanced industrial societies like Scandinavia and Western Europe, and the New World. Yet, overall those interviewed recognize that their lives are for the most part enjoyable and their health is rarely defined as poor or very poor. Some express the view that more and better health care would be beneficial, yet they do not see this as a direct and immediate route to happiness. The rise of consumerism and new attitudes regarding perceptions of the body, combined with a decline in strong extended family values and structures yield challenges that are expressed by frustration, distress, envy and increased desire for new ways of living. Depression and emotional disorders can be observed. Access to social media exposed individuals to choices and options others may promote yet are unavailable to those in the communities we studied. Matters relating to access to illegal drugs is a serious challenge to seek explanations and realistic programmes to reduce the drug trade and its ill

66 effects on wellbeing. It is suggested that violence and prostitution are serious problems and some of these problems may be connected to proximity to tourist resorts. The health, wellbeing and the QOL of Mexicans we interviewed, and the overall happiness and contentment of Mexicans, must be viewed in the context of a complex web of relationships between family members, friends, neighbours, community and health care providers as well as the cultural setting of norms, and traditional values and attitudes toward life and attitudes toward the present and future. A sense of belonging and identity, and personal emotional security express themselves in a variety of ways: eating habits, ways of treating sickness, expectations about aging, motherhood, child rearing, also attitudes toward agencies of the state that provide help and support to a community I terms of health care. Public policies to improve and create more health care facilities can contribute positively, and raising awareness about causes and conditions and outcomes of health are very important. Personal hygiene and sanitary conditions, good living habits and sound education have critical roles to play in promoting health care. Health is a complex notion that can be defined objectively but is largely subjectively. Clinical tests can identify conditions like high blood pressure, respiratory diseases and diabetes for example, and regular checks are important Much can be said about the role of attitudes concerning health and the treatment of sickness. Early education in schools reinforced by family values and community support can bring about changes to make life better and less stressful. This is a long-term project to engage full citizen participation with the support of social agencies and institutions such as the church. The identification of successful health care programmes and best practices can be a useful planning approach to offer less successful communities specific examples they can emulate.

A recent report from the UN described on the web site http://www.who.int/ageing/events/world-report-2015-launch/en/ makes it clear that aging and health demand a clear focus of attention in many countries.

Comprehensive public health action on population ageing is urgently needed. This will require fundamental shifts, not just in the things we do, but in how we think about ageing itself. The World report on ageing and health outlines a framework for action to foster Healthy Ageing built around the new concept of functional ability. Making these investments will have valuable social and economic returns, both in terms of health and wellbeing of older people and in enabling their on-going participation in society.

Finally, we suggest that the framework and approaches used in this study can provide a frame of reference as the baseline for further studies in other communities, and long-term studies to examine trends over time as new public policies designed to improve the health of Mexican are implemented.

Appendix I Draft protocol and questions

The Universities of Guadalajara and York University (Canada) are conducting collaborative research to learn about the health situation of women in 7 communities in the states of Jalisco and Nayarit: we will seek information on the perceptions of health and impacts of tourism. We also interview a sample of men. There is a growing body of evidence about what makes people healthy. It is suggested that there are 12 basic factors that may determine the state of health. It is also argued that health is a subjective notion influenced by the attitude of the person. The 12 key factors for health are: income and social status; social support networks; education and literacy; employment/ working conditions; social environments; physical environments; personal health practices and coping skills; healthy child development; biology and genetic endowment; health services; gender; and culture. There is mounting evidence that the contribution of medicine and health care is quite limited, and that spending more on health care will not always necessarily result in significant further improvements in population health. There are strong and growing indications that factors such as living and working conditions are crucially important for a healthy population. We ask each person some questions about their health situation in their own community. We explain that it is suggested that 12 basic factors that determine or influence health, and we explain that health is a subjective notion determined to some degree by the attitude of the individual.

Details of the determinants are given on the web site: http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php

ASK EACH PERSON TO SELECT THE MOST IMORTANT FACTORS THAT THEY THINK APPLY TO THEM AND THE EAST IMPORTANT ONES FOR THEM

Emphasize the responses are confidential and there are no RIGHT or WRONG responses. Questionnaire about determinants of health of women in seven rural communities of Mexico

Interviewer:______File Number:______DATE

Occupation:______

Age:______status …single/married/separated/divorced

Old women/teenage women/young mothers/ single women

1. Were you born here? Yes______NO______Where______2. Do you think health is important compared to employment or friendships or family relationships or religión for example? Yes:______No:______ADD COMMENTS 3. How healthy do you think you are? a) A lot_____ b) A Little______c) Little______d) Not healthy______e) So so______use 5 point scale >>>EXCELLENT ….SATISFACTORY >>>>VERY POOR HEALTH 4. What do you do to keep healthy or to improve your health? 5. What are the most important 3 or 4 factors do you pay attention to in order to improve your health? 6. Why do you think you are healthy or not healthy? 7. Who do you think is basically responsible for your health? 8. Do you think the government is responsible for your health or is it your own responsability? 9. Do you think the community of……has the necesary health equipment and facilities to face the health problems and challenges of its population now and in the next 5 years? Yes______No______why?

10. How did you deal with the diseases (sicknesses) before doctors and clinics came into the community? 11. Do you think traditional medicine helps to solve or manage health problems better than scientific methods and medication from doctors? Yes______No______Why______

Tourism and health: some questions for each person

1 Does your community experience tourism?

2 Is tourism increasing or decreasing in your community?

3 Is tourism beneficial or detrimental to health in your community?

Give examples: cleaner water/polluted air/more expensive housing and food costs/drugs/awareness of medical advances etc

4 Has tourism brought you personally some benefits to your health eg more money from work to buy food/medications/better housing etc

5 Has tourism caused more health problems to you personally for example less time for exercises and social life due to work commitments?

6 Overall is tourism rather neutral in terms of benefits or problems: do you agree or disagree/strongly or weakly

7 Do you have any general or specific comments about the impacts of tourism on your health and the health of your community NOW or into the next 5 years?

Discussions with selected medical personal in each community will involve a review of background material used for the interviews with men and women. The comments and opinions of medical personnel will be presented as statements rather than as numerical data.

References

Andrade, E. Chávez, R. M. y Espinoza, R. (2011). Turismo desarrollo y región: estudio de caso. Primera edición: Universidad de Guadalajara: México. Andrade, R. Chávez, R. M. Espinoza, R. y Villnueva, R. (2007). Tomatlán: patrimonio natural y cultural. Primera edición; Universidad de Guadalajara: México. Chavez, R. M. Andrade, R. Espinoza, R. y González, L. F, (2005). Cabo Corrientes: patrimonio natural y cultural. Primera edición; Universidad de Guadalajara: México. Chávez, R.M. Espinoza, R. Andrade, E. Sánchez, Y. y Martínez, V.E. (2014). Turismo rural y desarrollo local endógeno en la comunidad indígena de Tomatlán, Jalisco. Caso presa Cajón de Peñas. Ponencia presentada en el 8vo. Congreso Internacional sobre: Turismo y Desarrollo en Málaga España. Eumed.net. Chávez, R.M. Andrade, E. Espinoza, R. y González, L.F. (2005). Cabo Corrientes: patrimonio natural y cultural. Universidad de Guadalajara. México. Espinoza, R. Chávez, R.M. Andrade, E. Cornejo, J.L. y Plantilla, Y. (2014). Una década de colaboración académica para el desarrollo entre México y Canadá. Primera edición; Universidad de Guadalajara: México. Espinoza, R., Téllez, J. Chávez, R.M. Andrade, E. y Cornejo, J.L. (2015). Tomatlán a futuro: edificando el porvenir 2012-2040. Universidad de Guadalajara. México. Everitt, J. Massam, B. H. et al. 2008 The Imprints of Tourism in Puerto Vallarta, Jalisco, Mexico, The Canadian Geographer, Vol. 52, No 1 pp. 83-104. H. Ayuntamiento de Bahía de Banderas, (2011-2014). Consultado el 05 de septiembre del 2014 en http://www.bahiadebanderas.gob.mx/. H. Ayuntamiento de Cabo Corrientes, (2012-2015). Consultado el 05 de septiembre del 2014 en http://www.cabocorrientes.gob.mx/. Instituto Nacional de Estadistica y Geografia, INEGI, (2010). Información nacional, por entidad federativa y municipios. Consultado el 05 de septiembre del 2014 en http://www3.inegi.org.mx/sistemas/mexicocifras/default.aspx.

H. Ayuntamiento de Puerto Vallarta, (2012-2015). Consultado el 05 de septiembre del 2014 en http://www.puertovallarta.gob.mx/. Harari, Y. N. (2016). Homo Deus: a brief history of tomorrow London: Harvill Secker Harari, Y. N. (2014). Sapiens: a brief history of humankind London: Harvill Secker Layard, R. (2005). Happiness: lessons from a new science London: Penguin Press Lepe, V.M. (2014). Percepción de los impactos socioeconómicos del turismo en el desarrollo local endógeno. Caso “Nuevo Cancún” en el ejido de José María Morelos del municipio de Tomatlán, Jalisco. Tesis de grado de licenciatura. Universidad de Guadalajara. México. Lively, P. (1997). Beyond the Blue Mountain London: Penguin Massam, B. H. Andrade, E. Cortés, M. C. Espinoza, R. Quevedo, R. Navarro, M. C., Everitt, J. Cupul, A. González, L. F. Hernandez, L. G. y Raymundo, A. R. (2003). Quality of life in the Puerto Vallarta Region of Jalisco state, México. Working Paper #2003-01. August 25th. Brandon University. Canada. Massam, B. H. y Espinoza, R. (2013). Tourism in México: cui bono, autem cui malo. Primera edición; Swn y Mor Press: México. Massam, B. H. and Sánchez, R. E. (2012). Memories of-Memorias de Puerto Vallarta Toronto: Swn y Mor Massam, B. H. Hracs, B. Sanchez, R. and Ko, C. (2016). A significant Minority: Mexican seniors in tourist resorts, Universidad de Guadalajara, Mexico Massam, B. H. Hracs, B. and Sanchez, R. (2015). Tourism in Mexico: many faces, Martin Institute of Prosperity-University of Toronto, Toronto Massam, B. H. Hracs, B. and Sanchez R. (2012). Lived Experiences, Martin Institute of Prosperity, University of Toronto, Toronto Massam, B. H. and Espinoza, R. S. (2011). Presentacion, in Romo, E. Agostino, R. and Sanchez, R.E. (eds) (2011). Turismo, Desarrollo y Region: estudio de casos, Universidad de Guadalajara Press, Mexico, pages 5-10

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Biographies of authors

Bryan H. Massam is a University Professor Emeritus and Senior Scholar at York University, Toronto, Canada. He is the author of academic books, scholarly articles and reports on planning, environmental assessment, quality of life, the public good, economic/social/cultural rights, multi-criteria decision analysis, civil society and policy making. He also writes and publishes fiction.

As a consultant and lecturer, he has worked in many parts of the world. From 1969 until 1977 Dr Massam was a Professor at McGill University in Montreal where he taught in the School of Urban Planning. He has been a visiting professor at several universities including the London School of Economics, the Singapore National University, the University of Hong Kong, Simon Fraser University-British Columbia, the University of Calgary- Alberta, Bar Illan University Jerusalem, and the Hebrew University Jerusalem, the University of Umea in Sweden and the Universidad de Guadalajara, Centro Universitario de la Costa, Campus Puerto Vallarta, Mexico. In 1995 he was elected as a Fellow of the Royal Society of Canada (FRSC) and he served as President of the Canadian Association of Geographers for the period 1996-8. He was the Dean of Research at York University, Toronto, Canada from 1980-86. Mountains and beaches attract him; swimming, Taoist Tai Chi, meditation in the Buddhist tradition, hiking, writing fiction and painting fill some of his time. ([email protected])

Rodrigo Espinoza He was born in Michoacan State, and grew up on the coast of Jalisco State. He studied at primary school in his native state and he completed secondary and high school in Jalisco. After finishing high school, he went to Colima City to study at the university in Business Administration. He completed a master degree at the University of Guadalajara, in the Centro Universitario de la Costa. In October 2010 he was awarded a PhD in Education from the University of Tijuana.

Rodrigo has undertaken research on the Quality of Life in the Puerto Vallarta region of Jalisco in collaboration with colleagues from Brandon and York Universities in Canada. Also, he has undertaken collaborative research on sustainable development with colleagues from the University of Oviedo, Spain. He has published various books, chapters in books, papers, and reports of his research projects and as a member of research teams. He is a member of the consolidated academic group of Analysis Regional and Tourism (ART) with clue: UDG-CA-443, where he works on research about: A) Quality of Life and Well Being, b) Rural Tourism and Sustainable Development, C) Communities and Practices in Tourism. He belongs as a member of some research networks concerning Tourism and Development: a) National Net of Academic Groups (RECADyT), b) Intra-University Net about Patrimonial Goods and Development (REPADER), c) Latin American Research Net on Tourism and Development (RELIDESTUR), d) Ibero - American Research Net Global-Local. He is a member of the Mexican Academy of Research in Tourism (AMIT) and the Countryside Mexican Academy (ACAMPA). Also he is a member of the editorial committee of TURyDES scientific magazine in the University of Malaga, Spain. He is affiliated to the Administrative and Accounting Department in the Centro Universitario de la Costa. His e-mail: [email protected]; and [email protected].

Connie Ko is the GIS / Remote Sensing Technician for the Department of Geography, York University, Canada. Connie received her Ph.D. in Department of Earth and Space and Engineering from York University in 2014 and during her doctoral research programme, she developed an interdisciplinary research project that incorporates geo-informatics, remote sensing, machine learning and spatial analysis as the key aspect of geographical work. Her research involves the development of 3D geometric attributes derived from LiDAR (Light Detection and Ranging) point clouds for the classification of tree genera. She improved the classification accuracy results by designing an ensemble classification scheme using meta-trend within the field of machine learning. The application of this technology allows for better vegetation management along hydro-electricity corridor rights of way such that power outages due to fallen trees on lines can be proactively eliminated. Connie has also participated in a variety of geographical projects on social planning, quality of life and planning. She has participated in a project studying the integrative multiplicity through suburban realities, particularly in exploring the diversity through public spaces in Scarborough, Toronto, Canada. Currently she is involved in a project comparing the experience of displaced migrants in three cities, Toronto, Kolkata and Havana. ([email protected])

Acknowledgements

The willing participation of 40 women and 40 men in 7 communities who agreed to provide us with their opinions about health care was a vital component of this project. We are most grateful for their participation. We are grateful for the information provided by medical personnel in each community about the health status of women, and the assistance of community leaders who helped in the selection of interviewees. Also, we want to thank all the students of DELFIN Net who helped to collect the information in the communities. Financial support for the project was provided by the Universidad de Guadalajara, Centro Universitario de la Costa, UDG-CA-443 and the International Collaborative PRODEP NET: Tourism, Development and Impacts for this we are most grateful. Editorial assistance was provided by Dr Brian Hracs (http://brian- hracs.squarespace.com/) this is much appreciated.