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Chapter 2

THE APPROACHES

Striking a balance between the health of ecosystems and of the people who live in them calls for a new research framework -- a framework that includes not only scientists, but also community members, government representatives, and other stakeholders.

The new research framework proposed in this book and described in detail in this chapter is called the "ecosystem approach to human health" -- Ecohealth, for short. However, before describing this approach, it must be stressed that each Ecohealth activity or project inherently involves three groups of participants: researchers and other specialists; community members, including ordinary citizens, peasants, fisherfolk, miners, and city-dwellers; and decision-makers. This category includes everyone with decision-making power -- not only representatives of government or other key stakeholder groups but also those with informal influence based on their knowledge, experience, and reputation. The goal of each Ecohealth activity is to include this trio.

In addition to requiring the participation of these three groups, the Ecohealth approach is based on three methodological pillars: transdisciplinarity, participation, and equity.

• Transdisciplinarity implies an inclusive vision of ecosystem-related health problems. This requires the full participation of each of the three groups mentioned above and validates their complete inclusion.
• Participation aims to achieve consensus and cooperation, not only within the community, scientific, and decision-making groups but also among them.
• Equity involves analyzing the respective roles of men and women, and of various social groups. The gender dimension recognizes that men and women have different responsibilities and different degrees of influence on decisions: it is therefore important to take gender into account when dealing with access to resources. For their part, various castes, ethnic groups, and social classes often live in completely separate worlds: this isolation has its own repercussions on health and access to resources.

The following sections discuss each of these pillars and present examples of their application.

A transdisciplinary framework

When scientists from various disciplines involve both individuals and decision-makers from the communities they study, we can say that they are operating within a transdisciplinary framework. Scientists using a transdisciplinary approach send a clear signal that they will look at various aspects of a problem by closely involving the local population as well as decision-makers in their work.

When social problems are articulated in questions that can be addressed in a scientific process, communities are able to express what they expect from scientists and decision-makers. This, in turn, leads to "socially robust" solutions. These are just two of the many potential benefits of the transdisciplinary approach.

Transdisciplinarity therefore implies the participation not only of scientists but also of community representatives and other actors who, in addition to possessing particular knowledge of the problem at hand, have a role and a stake in its solution. Such "nonscientists" often belong to an NGO or government agency. The transdisciplinary approach gives them the right to be heard and thereby share their experiences, knowledge, and expectations.

The trandisciplinary approach differs from the unidisciplinary research that characterizes the experimental sciences, such as chemistry and physics, and the theoretical sciences, such as mathematics. It also differs from the interdisciplinary approach, which studies phenomena at the intersection of two disciplines that are usually close to each other, such as the overlap between biology and chemistry that has given rise to biochemistry. Nor is it equivalent to multidisciplinarity, in which researchers from different disciplines work side by side, thereby enriching their own understanding as a result of their colleagues' input, but where coordination does not necessarily lead to integrated actions.

The complexity of the interactions between the various economic, social, and environmental components of an ecosystem requires integrated research strategies that go beyond multidisciplinary frameworks (Figure 2).

A transdisciplinary approach enables researchers from different disciplines and key actors to develop a common vision, while preserving the richness and strength of their respective areas of knowledge. By adopting this approach at the outset the research team avoids carrying out parallel studies whose results are pooled only at the end. The integration of knowledge and the adoption of a common language take place while the problem is being defined -- that's the core of the transdisciplinary approach.

Figure 2. Human well-being in Yubdo-Lagabato, Ethiopia, is closely linked to the condition of agroecological system (adapted from ILRI 2001).

Defining a common language

The case of mercury pollution in the Amazon (see Box 9, p. 52) well illustrates transdisciplinarity's contribution. The initial research focused exclusively on the role of mining -- specifically, small-scale gold mining in which mercury was used to separate the gold from the ore. However, it was discovered that exposure to methyl mercury, a toxic derivative of mercury, did not diminish in proportion to the distance from the mine. Thanks to the input of a broad range of specialists in the fields of fisheries, aquatic ecology, toxicology, agriculture, human health, social sciences, and nutrition, as well as the participation of the communities concerned, it was finally discovered that local agricultural practices caused the problem.

In this particular case, a transdisciplinary framework was not established at the outset, but was introduced progressively. The research team's experiments in integrating the knowledge of specialists, local populations, and local actors gradually gave rise to a transdisciplinary approach.

The projects supported by IDRC's Ecohealth program have often started with multidisciplinary teams. This has been an important means of achieving transdisciplinarity. These projects have succeeded in broadening the horizons of several researchers used to concentrating on their own discipline while working in parallel with others. Despite this progress, however, widening areas of research does not always result in transdisciplinarity. Several projects began by producing essentially classic outcomes: a diagnosis of degradation of the environment or of human health, for instance, made without proposing concrete measures to improve health. Moreover, participating populations often became simple sources of information rather than full participants in the project.

Since 1997, IDRC has therefore systematically supported the organization of preproject workshops that give scientists, local authorities, and community members the opportunity to pool their knowledge and interests. This blending of information, ideas, and needs makes it possible to define research objectives that clearly reflect the community's real priorities. At the same time, the workshop specifies expectations, because it is just as important to state what the people will not receive. Once the community accepts that a hospital will not be built or that additional grants will be obtained, it becomes easier to reach consensus on what the community will actually get out of the project.

One such workshop, organized in the Mwea region north of Nairobi, Kenya, played a crucial role in a malaria-control project (see Box 6, p. 43). The initial workshop brought together 23 participants from 17 organizations representing government, local communities, rice producers, and various churches.

Several complex issues were involved and no single discipline was adequate to provide the knowledge needed to improve the environmental and health situation. Therefore, the scientific team assembled consisted of eight disciplines: a pathologist, a physician specialized in parasitology, a public health specialist, an agronomist, a veterinarian, an anthropologist, a sociologist, and a statistician. Once the issues were clearly defined, the team members integrated their knowledge and expertise into the research program. As mandated by the transdisciplinary approach, each specialist was required to work with representatives of other disciplines and to integrate the knowledge and concerns of nonscientific partners.

It is noteworthy that the composition of teams dealing with a problem like malaria can vary depending on location. Naturally, mosquitoes will always be a factor, but the local sociocultural and political context will rarely be the same. The composition of the research team will therefore vary according to the region's particular needs. That is why project planning -- a process that can take up to one or two years -- is so important.

To launch the process, the preproject workshops have proven their worth by bringing together scientists, community members, and political actors. One workshop consists of brainstorming between specialists and representatives of the groups most concerned. Together, they define a vision and common language that subsequently facilitates the conversion of research results into applicable, sustainable action programs. Anyone seeking a quick fix to social and environmental problems abstain: the substantial preliminary planning required for an Ecohealth project will test your patience.

The success of a preproject workshop can be measured by how easily the teams can get started. For example, a team working on the connections between malaria and farming practices in the Fayoum region of Egypt ran into major conceptual difficulties very early on in the project. Fortunately, the preproject workshop gave them the opportunity to integrate into their definition of the problem a wide range of social, anthropological, economic, behavioural, epidemiological, pedagogical, microbiological, hydrological, medical, and policy-related aspects. They were then able to rethink the project, go beyond a strictly agronomic and eco-toxicological framework, and adopt a more holistic view of the situation.

After consulting the local population, a project that initially focused on malaria was expanded to include two other equally important problems: the presence of gastrointestinal parasites and schistosomiasis. (Schistosomiasis, also known as bilharziasis, is a parasitic infection of the intestine, liver, blood vessels, or urinary organs.)

In addition, representatives of the country's health and agricultural ministries became keenly interested because their knowledge was taken into consideration when defining the project. What's more, a local NGO saw this project as an excellent opportunity to link social development -- the NGO's mission -- with the sustainable development of the local ecosystem. Representatives of this NGO quickly became the project's main driving force in the field.

In less than a year this transdisciplinary team has set in motion a research project involving almost 2 000 people, a fifth of the village population. These people make up a representative sample that is tested every six months for malaria, schistosomiasis, and gastrointestinal parasites. The team combines this information with its analyses of soil moisture content, soil erosion, and salinization. This data is also analyzed in terms of the socioeconomic and political characteristics of the various community groups.

The initial findings show that agricultural practices, which have traditionally been considered to be the cause of these diseases, are not the only factors responsible. For example, a direct link has been discovered between cases of schistosomiasis and gastroenteritis and the proximity of the many small sun- or oven-dried mud brick manufacturing operations in the region. The children who work in these factories show much higher levels of infection than others.

The scientists involved generally agree that the initial success of projects using an Ecohealth approach is partly due to the experience acquired in preproject workshops.

The challenges of transdisciplinarity

Even though, in theory, transdisciplinarity now enjoys high standing in the scientific community, it still remains a challenge for each Ecohealth project. Going beyond one's own discipline requires a great capability for synthesis as well as sensitivity to the strengths and limitations of others. Suceeding in a transdisciplinary initiative requires defining a research protocol (Box 1), finding ways of integrating the community in problem definition, and ascribing appropriate importance to the various ecosystem components.

Equally challenging is assembling a team and organizing the work of members from extremely different disciplines. In agricultural projects, for example, research teams are still mostly made up of medical specialists and agronomists. In general, these teams only have one social scientist, responsible simultaneously for the sociocultural aspects of the research, including gender and equity issues, and for implementing the participatory methodology.

Supervising a transdisciplinary project is all the more difficult when the original concept stems from a particular discipline and the researchers are not aware of the transdisciplinary nature of the problem. It is therefore only to be expected that the development of transdisciplinary projects is time-consuming. Funders of Ecohealth projects need to calculate the financial requirements accordingly. Make no bones about it, Ecohealth projects require large amounts of financial and human resources.

Box 1. A transdisciplinary research protocol

A. The groups or key players

• Scientists wanting to work directly for community well-being.
• A community ready to collaborate in a development process that uses research as a tool.
• Decision-makers who are able to devote time, knowledge, and expertise to a process of consensus-building

B. The steps

• Establish dialogue among the key players through informal meetings and exchange of letters and emails.
• Solicit the financial support required to fund problem definition in a pre-project workshop that brings together key players.
• Organize a preproject workshop to
  • Define the problem based on the views and knowledge of each group (focus group, maps, interaction, data)
  • Identify common areas of concern
  • Agree on common objectives
  • Specify the methodological approach of each group or actor
  • Define roles and responsibilities
  • Establish a schedule for team meetings.
• Iterate protocols on the basis of the results achieved.
• Translate research results into concrete action programs.
• Ensure the project's long-term sustainability and monitor progress.

A participatory approach

An extensive body of experience, including that acquired in IDRC projects, has shown that there can be no development without community involvement. This is a main feature of the ecosystem approach to human health. Participatory research gives equal weight to both local and scientific knowledge. Feasible solutions are identified by exchanging knowledge and jointly analyzing problems. Projects must take local knowledge, concerns, and needs into account. This requires involving the local population in the research conducted in their community. This type of research goes beyond the simple verification of hypotheses and leads to action.

The participatory approach targets community representatives and involves them directly in the research process. It takes the different social groups into account and facilitates negotiations.

Community members are no longer considered as simple guinea pigs or data sources. They actively participate in generating knowledge and developing solutions. They become protagonists and change agents. To do so, they must be integrated at all levels of the process -- from the initial problem identification, through research and assessment, to the final stage of concrete action. As Mukta Lama, of the Nepalese NGO Social Action for Grassroots Unity and Networking (SAGUN), explains. "We believe that involving people in reflecting on their own situation is the most effective way of raising awareness and internally understanding the need. Through these discussions, community members articulate action plans to address the problems. SAGUN helps them implement such plans and advocates community issues at broader levels."

The way a research project in Buyo, Côte d'Ivoire, was set up offers a good example of the complex negotiating dynamics in the participatory approach. A boom in agricultural production, especially coffee and cocoa, and the building of a hydroelectric dam on the Sassandra River attracted a large number of immigrants to the region. Since 1972, the population has increased from 7 500 to 100 000. The resulting economic, environmental, and social upheaval generated a host of problems, including an indiscriminate use of pesticides and inadequate sanitation.

An Ivorian team set about to improve the situation. From the first preproject workshop that brought together researchers, administrative officials, NGO representatives, village chiefs, men, women, and children, it quickly became clear that the community's concerns were very different from the research team's.

Of course, people wanted to improve the local infrastructure: electricity, roads, clinics, schools, wells, and so on. But what they wanted above all was housing. The construction of the dam had flooded their land and the villagers had been relocated to fibreglass structures. Over a 20-year period, these houses had rotted and were close to collapse. In this environment, it was pointless for the researchers to try to interest the people in the research project: the priority was to address the housing problem. The Ecohealth team therefore contacted local and national authorities. Even though the problem has not yet been completely resolved, the researchers enhanced their credibility by responding to the population's concerns.

Subsequently, the researchers were able to work with the population to address the problem of water contamination. As a result, slow sand filters were installed, which can eliminate 80­90 percent of microbiological contaminants and a large proportion of heavy metals. Their installation was endorsed by a physician from the local hospital, as well as by community members who attended the meetings. Encouraged by these initial successes on the gastroenteritis front, the community is now expected to move on to other environment-related health problems, such as vector-borne diseases and pesticide exposure.

Box 2. Ethiopian peasants articulate their problems

Yubdo Legabato, a village of some 5 000 inhabitants 80 km west of Addis Ababa in Ethiopia, was chosen as a test case for the Ecohealth approach because of iits extreme poverty, the poor health of its inhabitants, and the apparent intractability of its many problems.

The researchers sought to determine whether the people of Yubdo Legabato could articulate their health problems and formulate action plans to solve them within a transdisciplinary framework. The villagers were therefore asked what criteria they used to assess their own health, what factors caused their problems, and what actions they thought they could take to improve the situation.

Initially, the problem most frequently mentioned was a shortage of food. The farmers attributed their problems to dhabuu, which means "not having enough" in the Oromiya language. However, after the researchers encouraged the peasants to identify broader causes for their problems, they cited several other factors: lack of fodder, lack of water during the dry season, soil erosion, and a resurgence of malaria, measles, and gastroenteritis.

The Ecohealth team then helped the villagers make the connection between their farming practices, the use of natural resources, and their health. The results of this study show that agriculture, the environment, human health, and nutrition are closely interrelated. They highlight the need to adopt a holistic approach to the factors that are detrimental to human well-being. For example, the practice of sleeping on dirt floors with the animals during the cold season, when the average night temperature falls to 5°C, could explain many of the population's infections. But other reasons also underlie this habit, particularly the insecure land-tenure system. Why should people invest in constructing beds when they might be forced to clear out at a moment's notice, leaving everything behind?

The researchers encouraged the farmers to think of constructive changes they could make themselves, instead of waiting for outside help. As soon as the people realized that some of their practices were harmful to their health, they took matters into their own hands. Abiye Astatke, an agricultural engineer with the International Livestock Research Institute (ILRI), points out that since then "People built different houses for their livestock, people built a separate room for cooking their food, and also started building raised platforms for sleeping."

The researchers are convinced that the transdisciplinary lessons drawn from the Yubdo Legabato project have great significance for other mountainous regions in Ethiopia, western Africa, and even the world at large.

Increasing participation

Participation by communities in development projects plays out at several levels, ranging from a simple response to researchers' initiatives to taking charge of action programs.

About 95 percent of participatory projects remain at the level of passive participation whereby researchers just tell the people what they plan to do. People then simply provide information and respond to questionnaires. The ecosystem approach to human health, however, aims to achieve at least a level of participation in which people form groups that set concrete goals to improve their environment and health. While most of these groups tend to remain dependent on the outside project initiators, several succeed in becoming autonomous. Other types of participation are even more desirable. One is when communities and researchers jointly participate in an analysis of the problems that leads to action, strengthens existing institutions, and even creates new ones. Such community groups assume responsibility for local decisions. Another level of participation is when communities mobilize to bring about change in their own communities.

Several difficulties and constraints can undermine the implementation of a participatory approach. Levels of participation can vary from one group to the next and need to be negotiated with the partners in each particular context. Every group has its own concerns and interests, which are sometimes compatible with each other but are frequently not. Researchers must therefore demonstrate great care and extraordinary skill in motivating all concerned. An IDRC-supported project with Mapuche indigenous communities in Chile is an example of particularly fruitful community participation (see Box 3, p. 24).

Initially, the tension between the national government and the Mapuches, who were claiming land rights, prevented any collaboration. Considerable internal tension also existed among Mapuche representatives. The research project therefore took these factors into account by immediately working with the Mapuche Association and taking traditional Mapuche knowledge into account in project design.

The researchers and the Mapuche launched a series of workshops to examine the treaties between the Mapuche people and the Chilean government, study Mapuche-related legislation, and review traditional or nontraditional forms of negotiating with the government. Although relations with the Chilean government remain tense, some local Mapuche communities have rekindled a dialogue.

Challenges of the participatory approach

Unfortunately, at this time, very few projects involve communities in the definition of the research question. All too often, researchers continue to consult NGOs, government agencies, and local organizations, while discussions with the people directly concerned are used solely to validate the project.

Many obstacles impede the implementation of a participatory approach. Some communities have had bad experiences with researchers who failed to develop local capacity. A tradition of dependency can also foster the perception that development comes from the outside. Inequalities, power structures, and local elites who hijack the participatory process are other factors that can impede effective community participation.

Other traps await researchers and specialists. Participation should not become a rigid, inflexible ideology: recognizing the value of sharing knowledge should not crystallize into a doctrinal attitude that the local population is always right. The search for new visions, ideas, and values must remain a constant concern. Research team members need to maintain a research-oriented attitude at all times. It is not enough to be the best in one's discipline; it is also necessary to show openness and a genuine desire for collaboration. The participatory approach succeeds when researchers socialize with the local people, stay out of local conflicts, foster the emergence of local leadership, respect all categories of people (including women, children, youth, and the poor), and accept constructive criticism.

However, some objections to this approach persist. For example, opinions differ as to the skill level of local community representatives. Scientists wonder whether local people have sufficient information to participate effectively in defining the research question. Some consider that the local people are not up to the job of describing their health problems in a comprehensible manner to the researchers. No matter: the primary goal is to encourage dialogue between researchers and communities so as to create a common understanding of health problems.

It is often argued as well that local populations do not have the resources to care for their health or to treat illness. Researchers must clearly explain that the goal is not necessarily to build a hospital or vaccinate children, but to help people identify their own solutions, based on modifications to the ecosystem and resource management. This element is crucial.

In a nutshell, investments in transdisciplinary action and community participation can become the foundations for ensuring that the solutions adopted are sustainable. The resultant improvements in the recipient community's health and environment should repay this investment several times over.

Box 3. Improving the Mapuches' quality of life

The Mapuche indigenous people, now spread out over about half of Argentina and Chile, suffer from serious problems of poverty, poor health, and ecosystem degradation. This deplorable situation is due to in large part to the implementation of policies by leaders who cared little about communicating with indigenous peoples. The goal of one IDRC-supported project in Chile is to find means of managing the ecosystem to provide safe drinking water for the Mapuche living in the Chol Chol valley, 400 km south of Santiago.

The government has converted the Mapuche's ancestral forestlands into large, company-owned farms. These changes have had many harmful consequences: degradation of soils, air, and water; pesticide contamination; loss of biodiversity; food insecurity; and disputes both within and between villages. As a result, the Mapuche have lost all trust in society at large.

Before attempting to change the Mapuche's situation, tensions had to be alleviated: this is what the participatory approach achieved. The Mapuche's views were included in the health program planning process. Several initiatives were launched: a more rational use of pesticides; reintroduction of traditional crops; reforestation with indigenous tree species; adoption of practices that reduce soil erosion; and the establishment of more representative community organizations.

A considerable amount of work still remains to be done to improve relations between municipalities. Survival issues also still loom large. Nonetheless, the people are now better equipped to face these challenges.

Gender and equity

Research does not take place in a vacuum. It is conducted in communities, with men and women whose life is determined by economic, social, and cultural factors. Understanding the qualitative and quantitative differences between the community's various social groups helps to reinforce development action programs.

Gender is one aspect of the Ecohealth approach that sheds light on the way in which male­female relations affect everyone's health. In any community, men and women do things differently. Beyond biology, the gender dimension covers cultural characteristics that define the social behaviour of men and women and the relationships between them. Each gender's particular tasks and responsibilities are constantly being renegotiated in households, workplaces, and communities. This sharing of responsibilities can affect human health, as in the case of communities in northern Côte d'Ivoire.

It is generally assumed that an increase in irrigated rice production results in more cases of malaria, since mosquitoes -- the vector of malaria -- breed more prolifically in wet environments. However, a comparison of two agroecosystems in northern Côte d'Ivoire, one with no irrigation and one rice harvest per year and the other with irrigation and two harvests per year, has invalidated this hypothesis while confirming the impact of rice culture on the incidence of malaria. There are certainly more mosquitoes and more cases of malaria among young children in the villages with irrigation, but the rate of malaria transmission (the number of infectious bites per year) is identical in both groups.

The IDRC-supported researchers studying this situation postulated that it was not only due to environmental factors, but that social, cultural, and economic factors were also involved. Their research shows that the increase in the number of mosquitoes as a result of irrigation does not necessarily cause an increase in the transmission of malaria because of the insects' shortened lifespan. Rather, the variation in the incidence of malaria between the villages is mainly due to changes in the socioeconomic status of women.

Traditionally in this region, when dry-crop cereals such as millet made up the people's staple diet, family heads were responsible for feeding their families. The moist valley lands were used almost exclusively by women, who would stock the rice and market-garden produce in their personal storehouses. When food was short, the women could use these reserves to help feed their families; they could also sell them to satisfy personal needs or respond to family emergencies (Table 1).

Systematic irrigation of these lands has made it possible to produce two harvests per year, but it has also changed the division of labour. The increase in the quantity of rice grown by women in the valley bottoms has led to a reduction in dry-crop cereals, hitherto grown on the plateaus. Women have thus gradually become responsible for feeding the family. But since the amount of food they can produce is barely adequate to do so, they have little or no opportunity to sell their products in the market. Nor do they have time to participate in additional income-generating agricultural activities. This means they no longer have sufficient income to take quick action at the first signs of illness. Thus, in two-crop villages, women's new status no longer allows then to react as quickly as in villages with only one crop, although, with malaria, early treatment is needed to reduce the severity of an attack. In a nutshell, current levels of malaria are due to more than just biophysical changes in the agroecosystem.

This story well demonstrates the importance of studying all aspects of a problem, and not only its biomedical or environmental dimensions. In the Ecohealth approach, any response or action is useless if differences in gender roles and responsibilities are not taken into account.

Research that takes cultural and socioeconomic differences into account will naturally lead to consideration of the concept of equity. Division of labour is not only a matter of gender; it also varies by social group since people of lower status have access to fewer resources. Consideration of the equity dimension within a gender analysis framework also shows that "male" and "female" are not independent categories, but that the status of individual men and women also depends on their age, ethnic group, and social class. Male­male and female­female differences also exist.

Even though remarkable progress has been made, much still remains to be done to include women and other marginalized groups in the research agenda. For results to be truly convincing, the approach taken needs to be qualitative as well as quantitative, as the problem of battling plague in Tanzania well illustrates.

For almost 20 years, despite constant efforts, plague is still prevalent in the Lushoto region of Tanzania. In fact, it has become virtually endemic. In 1991, an IDRC-supported project called on an epidemiologist and an expert in quantitative social sciences. These two early researchers now work as part of a transdiciplinary team that includes a gender specialist and a specialist in community participation.

Even though the plague problem in Lushoto has not yet been resolved, certain behaviour patterns have been identified that shed new light on the issue. Rural development experts have observed, for instance, that, unlike other communities in eastern Africa, the residents of Lushoto store their grain stocks under the roofs of their homes, directly above the living quarters. The epidemiologists initially found that women and children were most susceptible to contracting the plague. Anthropologists and other social scientists then discovered the reason: the women and children usually fetch the corn for cooking. They are thus more likely than adult men to come into contact with the rats infested with plague-bearing fleas that look for food in the same place.

Another specific cultural pattern plays a role in this situation. In large families, nursing women and the men have priority for the household's beds, while children and the other women sleep on the ground where there is a much greater risk of coming into contact with rodents that move around the house at night.

Inclusion of the various social groups in the research agenda is not solely a question of equity; it is, in fact, a question of "good science" to ensure that the research findings are valid. It has even been observed that in social systems subject to a high degree of stress, conflict can often be transformed into cooperation through a strategy that emphasizes women. However, it should also be realized that the increased involvement of women in various committees is itself an additional stressor because of the time and energy they must invest in these tasks.

With its three pillars of transdisciplinarity, participation, and equity, the Ecohealth approach has now proven itself. Communities have changed the ways they manage their environment and have improved their overall health.

Box 4. Healthier farmers in Ecuador

Carchi province in northern Ecuador is one of the country's main potato producing areas. Here, close to 8 000 farmers grow 40 percent of the national crop.

The use of pesticides and fungicides, which started in the late 1940s, has enabled the people to move from subsistence to cash-crop farming, with a concomitant large increase in family income. However, the rate of pesticide-related deaths in Carchi is one of the highest in the world: 4 people out of 10 000 each year. In the rural areas, 4 percent of the population also suffer from nonlethal poisoning, but do not report their condition to the authorities.

A team of researchers studied three villages using ecosystem approaches to human health: La Libertad, Santa Martha de Cuba, and San Pedro de Piartal. Their transdisciplinary approach included gender-specific parameters. According to an Ecuadorian researcher, the late Veronica Mera-Orcés, the difference between male and female attitudes toward pesticides lies in the fact that "it is widely believed that pesticides cannot harm a strong man." Research has shown, however, that men and women are equally vulnerable: the men are mainly exposed while working in the fields while women and children are in contact with dangerous products either in the houses where the products are stored or when the women wash the men's contaminated clothing.

With the adoption of new, integrated pest-control techniques and better targeted spraying methods, pesticides are now being applied much more efficiently. The result has been a drop of 40­75 percent in the use of certain fungicides and insecticides. Production costs have dropped in tandem, thereby increasing people's income. Now, women are no longer reluctant to tell the men to take care and the men themselves are starting to realize that they should be more careful when handling pesticides.

Document(s) 4 of 7