Mitig Adapt Strateg Glob Change (2013) 18:957–978

DOI 10.1007/s11027-012-9402-6

ORIGINAL ARTICLE

Community vulnerability to the health effects of climate

change among indigenous populations in the Peruvian
Amazon: a case study from Panaillo and Nuevo Progreso

I. Hofmeijer & J. D. Ford & L. Berrang-Ford &

C. Zavaleta & C. Carcamo & E. Llanos & C. Carhuaz &
V. Edge & S. Lwasa & D. Namanya

Received: 19 December 2011 / Accepted: 14 June 2012 / Published online: 26 July 2012
# Springer Science+Business Media B.V. 2012

Abstract This paper presents the results of an exploratory study working with two Amazonian
communities in Peru to identify key climate-related health risks from the perspective of local
residents, and characterize how these risks are experienced and managed. The work adopts a
vulnerability-based approach and utilizes participatory methodologies to document and examine
local perspectives on vulnerability and adaptive capacity. Thirty nine community members were
engaged in participatory photography (photovoice), and rapid rural appraisal workshops were
conducted with a total 40 participants. Contextual information was obtained from 34 semi-
structured interviews with key informants and participant observation during fieldwork. Three
climate-related health risks were identified by the communities as pressing issues (food insecu-
rity, water insecurity, and vector-borne disease), all of which are climate-dependent and reported
to be being affected by observed changes in climatic conditions. Sensitivity to these risks is high
due to social and economic disadvantages which force people to live in suboptimal conditions,
partake in dangerous activities, and engage in unhealthy behaviors. Traditional approaches to
health and strong social networks are important in moderating health risks, but are placed under
increasing stress in the context of local social and economic changes due to larger scale
influences, including resource development, deforestation, and changing social relations.

I. Hofmeijer : J. D. Ford (*) : L. Berrang-Ford

Department of Geography, McGill University, Montreal H3A 2K6, Canada
e-mail: james.ford@mcgill.ca

I. Hofmeijer : C. Zavaleta : C. Carcamo : E. Llanos : C. Carhuaz

Universidad Peruana Cayetano Heredia, Lima, Peru

V. Edge
Public Health Agency of Canada, Guelph, Canada

S. Lwasa
Department of Geography, Makerere University, Kampala, Uganda

D. Namanya
Ministry of Health, Kampala, Uganda
958 Mitig Adapt Strateg Glob Change (2013) 18:957–978

Keywords Climate change . Health . Indigenous peoples . Amazon . Peru . Shawi .

Shipibo . Food security . Water security . Vector-borne disease . Vulnerability . Adaptation

1 Introduction

A rapidly expanding body of scholarship has outlined the potential health implications of
climate change and indicates significant vulnerabilities (Costello et al. 2009; Haines et al.
2009; Myers and Patz 2009). Indigenous populations, particularly in the global south, are
expected to be amongst the most vulnerable, a function of dependence of livelihoods on the
environment, spiritual and cultural ties to land, political and economic marginalization, and
current indicators of health (Costello et al. 2009; Ford 2012; Green et al. 2009).
Simultaneously, their accumulated knowledge can help us understand how the climate is
changing, characterize impacts, and provide valuable lessons for adaptation. Despite the
value of this knowledge and it’s cultural significance, Indigenous populations have been
largely neglected in climate change and health research (Ford 2009a, b, 2012; Salick and
Byg 2007; Salick and Ross 2009; Berrang-Ford et al. 2011; Lesnikowski et al. 2011). Policy
discussions surrounding the United Nations Framework Convention on Climate Change
(UNFCCC) and within national level climate policy have similarly overlooked Indigenous
issues. For instance, of the 45/49 completed NAPAs, only 5 refer to Indigenous populations
and here only to note their heightened vulnerability, with none referring to health or
identifying specific adaptation needs (Ford 2012). This forms part of a broader deficit
in understanding the human dimensions of climate change (HDCC) for Indigenous
peoples (Ford 2009a, b, Ford 2012; Ford et al. 2012), with implications for adaptation
support targeted at highly vulnerable groups through the UNFCCC Green Climate
Fund.
This deficit in understanding is evident in the Peruvian Amazon, where a large
Indigenous population inhabits a region undergoing significant climate change. In the Alto
Mayo river basin region, for example, temperatures increased by 0.22–0.48 °C per decade
between the 1965 and 2005 (Díaz et al. 2009). Associated impacts include altered river
hydrology and flood regime, and a decrease in the coffee and cocoa harvest (MINAM 2010;
MJBDLF 2010). Future projections for the Peruvian Amazon indicate a mean temperature
rise of 0.5 °C–1.8 °C by 2020 (MJBDLF 2010), while precipitation is projected to decrease
by 10–20 % (MINAM 2010). The expected results of these projections are enhanced drought
conditions, loss of forest, and increased potential for flash flooding, and forest fires (Nepstad
2007; Oyama and Nobre 2003; UNEP and ACTO 2009).
Direct implications for health derive from the close correlations between water- and
vector-borne disease (e.g. malaria, dengue, leishmaniasis, yellow fever, and cholera) and
weather and climate patterns, particularly El Nino Southern Oscillation (ENSO) (Bravo and
Bravo 2001; Chamberlin et al. 2002; Checkley et al. 2000; Fraser 2009; Githeko and
Woodward 2003; Miranda et al. 2003). Indirect health impacts will likely stem from the
interaction of climate change with resource development (oil, gas, and minerals) and
deforestation, which are challenging access to and ownership of traditional lands, introduc-
ing new diseases, and creating conditions for the spread and re-emergence of existing
diseases, a number of which have a strong link to temperature and precipitation (Finer and
Orta-Martinez 2010; Foller 2001; Maheu-Giroux et al. 2010; Montenegro and Stephens
2006; Napolitano 2007). Despite the recognition of these potential risks, there is limited
knowledge about the impacts that climate change might have on the health of the Amazon’s
Indigenous populations. Of the 63 projects and initiatives on climate change vulnerability
Mitig Adapt Strateg Glob Change (2013) 18:957–978 959

and adaptation that took place in Peru between 1999 and 2009, none focus exclusively on
health issues in the Amazon; only one is targeted to Indigenous peoples focusing on the
Andean region (Gallardo 2008; MINAM 2010).
This paper is situated within the deficit in understanding the HDCC for Indigenous popula-
tions in general, and the Amazon in particular, reporting on an exploratory study conducted with
two remote Indigenous populations in the Peruvian Amazon. Using participatory methodologies,
the research documents local perspectives on climate-related health outcomes in order to identify
and characterize current vulnerability to the health effects of climate change. Specifically, we
identify health outcomes that are affected by climate, documenting locally observed changes
herein; characterize how climate-related health outcomes are experienced and managed, and;
identify factors that influence exposure and sensitivity and determine the efficacy, availability,
and success of adaptations. To our knowledge, this is one of the first assessments of Indigenous
health in a changing climate in the Peruvian Amazon, and indeed the Amazon more broadly. We
begin by outlining the conceptual and methodological approach guiding the work, before
describing the case study communities, outlining the key results, and finish by discussing
broader insights of the work for adaptation policy and outline future research directions.

2 Conceptual and methodological framework

2.1 Vulnerability approach

The study was guided by the vulnerability framework of Ford and Smit (2004), refined in
an Indigenous health context by Ford et al. (2010b). A vulnerability approach is used since
it is consistent with the terminology and terms of reference in the UNFCCC, associated
international adaptation funds (Fankhauser and Burton 2011; Liverman and Billett 2010),
and the Intergovernmental Panel on Climate Change (IPCC) (Adger et al. 2007; Smit and
Pilifosova 2001). The approach has also been successfully implemented in climate change
studies with Indigenous populations (Ford 2009a, b; Ford and Beaumier 2011; Ford et al.
2010b) and more broadly in small marginalized communities (Keskitalo 2008; Pouliotte
2005b; Tschakert 2007b; Westerhoff and Smit 2009; Young et al. 2010), focusing on the
dynamic interaction between climate and society which produces vulnerable or resilient
populations.
Vulnerability is a measure of the susceptibility to harm in a system in response to a
stimulus or stimuli, and can essentially be thought of as the ‘capacity to be wounded,’ (Smit
and Wandel 2006). The work presented focuses on Indigenous health; the stimulus or stimuli
are health risks linked directly or indirectly to climate-related conditions. A general model of
vulnerability has emerged that conceptualizes vulnerability as a function of exposure and
sensitivity to climate change and adaptive capacity (Ebi et al. 2006; IPCC 2007; Smit and
Wandel 2006). In a health context, exposure refers to the nature of climate-related (direct or
indirect) health risks. Sensitivity concerns the organization and structure of health systems
and livelihoods relative to the climate-related risks and determines the pathways through
which exposure is manifested, specifically concerning who and what are at risk and why.
Adaptive capacity reflects the ability to address, plan for, or adapt to adverse climate-related
health risks and take advantage of new opportunities (Ebi and Burton 2008; Ebi et al. 2006;
Ebi and Semenza 2008; Ford and Smit 2004). The recognition of the role of adaptive
capacity and sensitivity is important for understanding the human health dimensions of
climate change, directing attention to the non-climatic factors that determine how climate
change will be experienced and responded to.
960 Mitig Adapt Strateg Glob Change (2013) 18:957–978

Application of this model to characterize vulnerability has typically followed a two-step

analytical framework, beginning with the identification of current vulnerabilities which
provides the basis for examining future vulnerability under conditions of projected climate
and socio-economic change (Burton and Lim 2005; Smit and Wandel 2006). Given time
constrains and the significant undertaking this entails, very few studies have assessed both
current and future vulnerability. This study is no different, reflecting an investigatory
examination of current vulnerabilities in two communities. In this way the work employs
a temporal analogue based approach, whereby past and present experience and response to
climatic variability, change and extremes are examined to uncover knowledge about vulner-
abilities and adaptive behaviours (Ford et al. 2010a, b, c; Glantz 1996; McLeman et al. 2008;
McLeman 2011). This enabled us to work closely with communities to examine recent
extremes and observed changes to: explore how community members experience and
manage climate-related risks; identify processes and conditions that determine the availabil-
ity, efficacy, and success of adaptations; develop a greater understanding of how social and
biophysical processes shape vulnerability; and, establish a range of possible societal
responses to future change. Some have argued that that there is no analogue for future
climate change given that projected changes are likely to exceed in magnitude and speed
anything previously experienced. Yet the strength of temporal analogues lies not in whether
past climate stresses are identical to those predicated by climate models, but in their ability to
empirically ground analysis of vulnerability to changing conditions based on an understand-
ing of how climate and society interact. Moreover, and particularly in an Indigenous context,
focusing on the present day and past is more tangible and consistent with socio-cultural
norms than focusing on projected future changes.

2.2 Case study location

The study focused on two remote Indigenous populations in the Peruvian Amazon: the
Shipibo of the Ucayali region and the Shawi of the Loreto region (Fig. 1). These groups were
selected upon consultation with the Interethnic Association for the Development of the
Peruvian Amazon (AIDESEP) and representatives from regional Indigenous federations.
Research was conducted in the Shipibo community of Panaillo and in the Shawi community
of Nuevo Progreso.

2.2.1 Panaillo

Panaillo is a Shipibo community (population 200) located on the banks of the Panaillo
tributary at the confluence with the Ucayali River. The village is organized as a ‘boulevard’
alongside the tributary, with each house having direct access to the river. Houses are built on
stilts since the area is exposed to seasonal flooding in the rainy season (December–June).
The village was forced to relocate 10 years ago when meandering of the Ucayali flooded the
original site. The community maintains strong traditions, with subsistence activities centred
on fishing and agriculture (Hern 2004). The village currently has a primary and a secondary
school, as well as a health post which was empty till mid-July 2010 when a technical nurse
was appointed by the Ministry of Health (MoH).
There is seasonal migration out of the village during the flood season when the working age
population seeks employment in the urban center of Pucallpa or seasonal harvesting work (e.g.
in palm oil plantations). The sale of agricultural produce and handicrafts and the adoption of a
market economy have expanded in recent years with the completion of a road in 2009 linking
the community to Pucallpa and facilitating access to the village in the dry season (July–
Mitig Adapt Strateg Glob Change (2013) 18:957–978 961

Fig. 1 Map of Peruvian Amazon study sites

November). Pucallpa, the regional and provincial capital, is approximately a 6-h boat ride or 2
to 4 h by road in the dry season. Connected to the rest of the Peru by the Trans-Andean highway,
the ease in accessibility to Pucallpa to the rest of Peru has made it an important regional trade
center, especially for the logging industry. The region has been identified as a ‘hotspot’ of
deforestation, estimated at 30,000 hectares a year (UNEP 2010). Other economic activities of
the region include petroleum exploration, fishing, cattle ranching, and agriculture.

2.2.2 Nuevo Progreso

Nuevo Progreso is a Shawi community (population 350) located on the Armanayacu River in
the sparsely populated and densely forested Loreto Region. Established ~100 years ago, village
residents maintain their traditional customs, subsisting from hunting, fishing, gathering, and
cultivation of yucca and banana. The central part of the village is alongside the river, with
homes organized around a communal playing field. Other homes are scattered deeper into the
jungle. The village has a primary school and the closest health post is in a neighbouring
community, an hour by foot. Until recently, Nuevo Progreso was highly isolated, accessible
by a 5 h boat ride in the rainy season (December to June) or a 7 h walk in the dry season (July to
November) from the regional centre, Yurimaguas. In May 2010 a new road was constructed
reducing access time to a 2 h drive. Yurimaguas is a rapidly growing port-town and commercial
trade center for both subsistence and market farmers in the region, and is the furthermost city in
the low-jungle of Loreto to be connected by road to the rest of Peru.
962 Mitig Adapt Strateg Glob Change (2013) 18:957–978

2.3 Methods

Preliminary trips were made to the case study regions and communities to discuss interest in the
project, solicit advice on research design from local people and representatives of Indigenous
organizations, and identify collaborators. This was followed at a later date by fieldwork, which
used qualitative methods including photovoice, rapid rural appraisal, and participant observa-
tion to document local perspective to: i) identify health outcomes that are affected (directly or
indirectly) by climate, and document locally observed changes herein ii) characterize how
climate-related health outcomes are experienced and managed, and iii) identify factors that
influence exposure and sensitivity and determine the efficacy, availability, and success of
adaptations. In order to facilitate participation of community members, local research collab-
orators were appointed by community leaders at each site before the research began.
The research began by conducting key informant interviews with representatives (n034)
from government, Indigenous organizations, and non-governmental organizations in or near
regional cities (Yurimaguas and Pucallpa) and in the national capital (Lima) to develop an
understanding of health issues affecting Indigenous peoples in the case study regions. A
semi-structured interview format was used, with key themes covering general health risks in
the region, climate-related health risks and potential impacts of climate change, Indigenous
health programs, and emerging disease risks.
Photovoice was then used to introduce the project to the communities and engage
community members in the identification of climate-related health risks and responses.
Participants were equipped with cameras and asked to take pictures over a 3-day period
that illustrated “How does the environment affect your health?” Recruitment was conducted
during fieldwork, with three unique groups of participants in both Panaillo and Nuevo
Progreso: community leaders (Panaillo n07, Nuevo Progreso n05), women (Panaillo n0
8, Nuevo Progreso n06), and men (Panaillo n07, Nuevo Progreso n06). These groupings
were chosen in collaboration with community members and designed to respect community
social organization and facilitate gender-sensitive discussions. The activity began with an
introductory workshop where research objectives were presented, and participants were
trained in the use of digital cameras and ethics of photographing human subjects. On the
last day of photography, each participant returned the camera to the researcher and chose key
pictures for group discussion at a results workshop the following day. At Panaillo, a total of
59 photographs were discussed and 51 in Nuevo Progresso.
While photovoice has not been widely used in vulnerability studies, it is recognized as
particularly suited to working with Indigenous populations where limits to standard interview-
based approaches have been noted (Lardeau et al. 2011; Healey et al. 2011), engaging
participants as researchers shaping data collection and analysis. By visually representing their
experiences, important issues can be effectively communicated to both researchers and the
community, and as such is a promising method for climate change research.
To expand insights from photovoice, rapid rural appraisal (RRA) techniques were used to
further incorporate local knowledge into the research process (Chambers 1994; Pouliotte
2005a; Tschakert 2007a; van Aalst et al. 2008). Transect walks of the community territory
were used to identify features, resources, uses, and problems of different zones, reveal
villagers perceptions of their natural resources, and gain understanding of the communities
surrounding environment (Chambers 1994; CIDA 2008; Mascarenhas 1991; van Aalst et al.
2008). The risk ranking exercise provided a forum to reveal community priorities, allowing
participants to physically rank risk items themselves (CIDA 2008; Tschakert 2007b). Risk
ranking workshops were used to identify key community risks in order to understand the
importance of climate and health stressors in comparison to other livelihood hazards. The
Mitig Adapt Strateg Glob Change (2013) 18:957–978 963

ranking activity was split over two workshops, with the same participants in both (n015 in
Panaillo, n025 Nuevo Progreso). Participants were recruited via a public announcement. At
the first workshop, participants split into small groups in which they discussed and free-
listed community concerns. Subsequently, they were asked to classify concerns as a current
or future problem, and to mark those they considered to be climate-related. At the second
workshop, groups were asked to explain the reasoning behind each concern. Participants
then agreed on risk categories under which to group concerns. In small groups, participants
organized concerns into the categories and ranked each category from most pressing to least
pressing issue by giving each category a score from one to five. For the final ranking,
category ranking scores from each group were totalled, with the category scoring the least
being the most pressing (ranked first). The final ranking was presented and validated by
participants at the end of the workshop.
In addition to these formal methods, the research team engaged in daily life and social
relationships (i.e. participant observation). Researchers were hosted by a local family in
Panaillo and Nuevo Progreso during the main research visit. Experiencing and participating
in community routines and practices enabled the development of a better understanding and
contextualization of local perspectives of health and climate-related health risks as identified
in the RRA and photovoice, allowing questions to be asked in context, and allowing
community members to discuss their observations and opinions ‘on-site.’

2.4 Data analysis

Field notes and photographs from the interviews and other research methods were tran-
scribed and organized digitally according to participant and date. Risk ranking data were
used to determine priority health and climate risks to guide future research interventions.
Content analysis framed by the vulnerability framework was performed to identify themes
relating to health outcomes, exposures, sensitivity, and adaptive capacity. A number of
strategies were utilized to manage potential biases in data collection and ensure rigor. Key
findings from the RRA workshops, photovoice, and field notes summarized by the research-
er were reviewed with local assistants to assess accuracy and completeness. Cross referenc-
ing of narratives obtained in the workshops with photovoice, participant observation, and
key informant interviews enabled the information obtained to be checked to assess consis-
tency and credibility in the findings.

2.5 Ethics

The study followed standard ethical norms including obtaining university ethics approval
(McGill REB# 407-0410, Universidad Peruana Cayetano Heredia proyecto #56909), elicit-
ing informed consent from all study participants, and reviewing results with and presenting
results back to communities prior to publication. The research was guided by an ethical
framework determined in collaboration with the case study communities, and profiled in-
depth by Sherman et al. (in press).

3 Results

In this section the vulnerability framework is used to structure the identification and
characterization of climate-related health exposures, sensitivities, and adaptive capacity
based on key themes identified by participants (see Table 1 for summary).

Table 1 Summary of climate related health exposures, sensitivity and adaptive capacity ((↑) indicates observed change becoming more frequent, NP 0 Nueno Progreso only, P 0
Panaillo only)
Climate-related health risks Exposure
Water insecurity (access, • (↑) Heavy rainfall, high temps→water-borne
availability, quality of disease outbreaks (e.g. acute diarrheal diseases)
water) • (↑) Lower water levels in dry season→consumption • Boling not universally undertaken,
of stagnant water, water shortages, boat access
challenges
Food insecurity (access, • (↑) High temperatures, low precipitation→crop
availability, quality of failure, reduce yields, more pests, diminished
food) aquaje production (see Fig. 3)
• (↑) More pests→Diminished cassava root size
(NP) (Fig. 5)
• (↑) Flooding in wet season→decline in banana
size and yield (P) (Fig. 6)
Vector-borne disease • (↓) Malaria (NP)
• (↑) Stagnant pools of water→concern over
Leishmaniasis, dengue (Fig. 7) (NP)
Sensitivity
• No treated drinking water
particularly by elderly
• Dry season consumption of stagnant
water
• Road construction increasing
deforestation with implications for
water quality
• High poverty: households dependent
on extra cash from selling food at
market
• Dependence on subsistence harvests
• Seasonal migration to obtain cash income
• Wide reporting of mosquitoes net usage • Traditional remedies affected by
• Fewer people utilizing traditional
approaches to health and well-being
964
Adaptive capacity
• Rainwater collection
• Strong social networks: monitoring of
traditional lands for illegal activities
• Rice harvest 1 month earlier (but with
lower yield)
• Road construction increases access to
local markets and to health services;
can also introduce new diseases
through enhanced contact with outsiders
• Strong social networks: monitoring of
traditional lands for illegal activities
• Consumption of Pandisho when banana
crop declines
deforestation with new road access
• Fewer people utilizing traditional approaches
to health and well-being, but traditional
approaches still important
• Poor staffing at community of health post
(P); lack of health post (NP)
Mitig Adapt Strateg Glob Change (2013) 18:957–978
Mitig Adapt Strateg Glob Change (2013) 18:957–978 965

3.1 Exposure

Three climate-related health risks were identified as pressing issues facing the communities.
Firstly, concerns surrounding water insecurity–referring to access, availability and quality of
water–were regularly identified in both communities through photovoice (Fig. 2) and the
risk ranking exercise. In both communities there is no treated drinking water. Water for all
household uses is sourced directly from the river, exposing individuals to water-borne
pathogens. Exposure to water-borne diseases such as cholera and leptospirosis is high, with
heavy rainfall an important factor affecting outbreaks and pathogen transmission cycles
often temperature dependent (Confalonieri et al. 2007; Ganoza et al. 2006; Lau et al. 2010;
Mujica et al. 1994; Poulin 2006). Participants widely reported experiencing water-borne
associated illness, with temporal variability through the year, supported by district level
epidemiological data with acute diarrheal diseases (ADD) and leptospirosis reported as two
of the top ten most frequent diseases (DGE 2007, 2009).
In Panaillo, participants reported higher rates of diarrheal diseases across all ages during
the flood season, although for the elderly, the peak of the dry season brought about higher
self-reported rates of illness (Fig. 2) due to the dependence on a low river for their water.
This second observation is consistent with the Situational Analysis of Health of the Shipibo-
Konibo (OGE 2002) which recognizes the consumption of stagnant water as a leading cause
of diarrhoea. Participants in both communities also describe longer term trends with lower
water levels in rivers reported in recent years. This is perceived to be increasing the
concentration of waterborne pathogens; unfortunately there is no river monitoring or sam-

Fig. 2 Concerns surrounding wa-

ter insecurity were regularly
identified in both communities
through photovoice
966 Mitig Adapt Strateg Glob Change (2013) 18:957–978

pling from which to further examine these observations. In Panaillo, more lakes around the
community were reported to be drying out earlier during the dry season. Additionally,
community members reported that many water bodies had reduced levels in both the dry
and rainy season. Participants in Nuevo Progreso complained that the water no longer
reached cool temperatures, and that community members regularly used warm water. Key
informants in the regional center, Yurimaguas, made similar observations, stating there had
been significantly less water in recent years, with a shortened rainy season and low river
levels. Informants stated that until the late 1990’s, fluvial transport was feasible for 6 months
a year, whereas boats can now navigate on the river at most 3 months a year. Health officials
noted that temperatures had risen and that rains had become sporadic rather than the custom
regular rains.
Secondly, food security–referring to the access, availability and quality of food–was a
widely reported health challenge linked to climatic conditions, reflected in multiple photo-
graphs of crops and fields, and risk ranking data. Regional nutritional health data mirrors this
food insecurity (see Table 2) due to significant percentage of chronically malnourished
children.
Climate directly affects subsistence agriculture, which is an important source of food and
livelihoods in both communities. A consistently reported observation concerned warming
temperature and its impacts on growing conditions. In Nuevo Progreso, diminishing rainfall
was also a concern in recent years. There is no published local weather station data to further
examine these observations. Crop failure has important implications for community health–
it directly affects availability of food, and also the ability to generate income and purchase
goods. In both locations, participants reported reduced yields, increased pests and weeds,
and increased risk of developing heat stress for agricultural workers. Knowledge on crop-
ping seasons is being challenged as villagers have to harvest crops before their normal due
point (Fig. 3).
The situation was described as particularly severe in Nuevo Progreso, where household
subsistence plantations were said to be producing fewer fruits. In addition, wild fruit food
alternatives of commercial value such as aguaje (Mauritia felxuosa) were described as being
less abundant. The aguaje tree grows in marshes and is highly water dependent. These
observations are consistent with the scarcity of aguaje in the market in 2006 when during the
first half of the year the plant did not give any fruit. The price per tonne of aguaje reached a
historical record of 100 Peruvian soles (35USD) in February 2006 and did not return to its
normal price till April (MJBDLF 2010). This was the first time that the fruit was scarce
during that time of year in Loreto and it is hypothesized locally that it was partly due to
climatic effects on plant phenology as a consequence of the Amazonian drought of 2005. In
Panaillo, diminishing crop harvests are affecting people’s income and ability to stock food
for the wet season. The 2010 rice harvest, in particular, took villagers by surprise (Fig. 3).
Changing climatic conditions might be also be influencing the crops growing season. In

Table 2 Key Regional Health Outcomes. % who attended health posts 2010 (CENAN–INS 2010)

Health outcome Ucayali Loreto Peru

Chronic malnutrition (<5 year) 18.3 21.4 18

Acute malnutrition (<5 year) 2.8 3.3 1.6
General malnutrition (<5 year) 11.8 14.6 8.4
Underweight (during pregnancy) 20.2 25.2 14.3
Mitig Adapt Strateg Glob Change (2013) 18:957–978 967

Fig. 3 Food insecurity was

a widely reported climate-related
health challenge

2010 for example, due to the rice already yellowing, the harvest was pushed forward to July,
a month earlier than usual, leading to a lower yield. In addition, a number of fields were
reported to have been lost to weeds which grew faster than the rice crop. Rice is the primary
source of income for most villagers, and stored for personal consumption during the wet
season, a time when food is scarce.
Both communities not only reported diminishing yield but also changes in the crop itself.
At Nuevo Progreso, the principal concern was about the diminished size of cassava roots,
and increased pest infestation in plantations (Figs. 4 and 5). At Panaillo, changing flood
968 Mitig Adapt Strateg Glob Change (2013) 18:957–978

Fig. 4 Increased pest infestations

were noted in Nuevo Porgreso

regimes were described to be decreasing banana yields and size (Fig. 6). The abundance and
frequency of pest infestation is projected to increase with climate change (Moore and Allard
2008; Reynolds 2010). Long hours of work in fields were also described as no longer being
possible, especially in Nuevo Progreso where villagers commented that more than 3 h of
outside work led to exhaustion due to more intense daytime heat.
Finally, vector borne diseases were identified as a concern, particularly in Nuevo
Progreso where photographs focused on exposure to mosquitoes. Local health sector key
informants confirmed the presence of malaria and leishmaniasis in the area but also
mentioned that entomological or epidemiological data on vector and disease prevalence
did not exist for the area. They also noted that malaria incidence had significantly dropped in
the region in general. This was primarily attributed to the PAMAFRO (www.orasconhu.org/
pamafro/presentacion), a global fund project providing malaria diagnostic and treatment
services in communities with limited access to health facilities. Whilst mosquitoes are also
found in Panaillo, this did not appear to be a health concern for the community and did not
emerge at any of the workshops. At Nuevo Progreso, participants extensively documented
stagnant water through photographs (Fig. 7), commenting that this is where mosquitoes
reproduce, which then affects villagers health. Stagnant waters were explained to be due to
two factors. First, ponds are due to natural actions such as the drying rivers. Second, water
has accumulated in new areas due to human actions, notably the recent road works.

Fig. 5 Dimished size of cassava

roots was reported in Nuevo
Progreso
Mitig Adapt Strateg Glob Change (2013) 18:957–978 969

Fig. 6 In Panaillo, changing flood

regimes were described to be
decreasing banana yields and size

3.2 Sensitivity

The exposures identified above capture the environmental pathways through which health is
being affected by changing climatic conditions, and may be affected by projections of future

Fig. 7 At Nuevo Progreso,

participants extensively docu-
mented stagnant water through
photographs
970 Mitig Adapt Strateg Glob Change (2013) 18:957–978

climate change. The nature of these exposures and who they affect, however, is determined
by social and economic conditions and health system characteristics which shape sensitivity.
Social and economic disadvantage in both communities was noted by participants, by key
informants and in the grey literature, and is evident in continuing and persistent high rates of
poverty and burden of ill-health, while access to education, housing and employment are
typically well below the norm for non-Indigenous populations (MINSA–DGE 2003; INEI
2009). These conditions increase sensitivity to climate-related health outcomes through a
number of pathways, including living in suboptimal conditions, engaging in dangerous
activities, and engaging in unhealthy behaviors.
Habitation in poor quality houses and associated living conditions were identified in both
communities as increasing sensitivity to climate-related health risks.
“Our traditional homes are uncomfortable (…) when it is cold we are completely
exposed and get ill.” (Panaillo, men group).
Traditional Shipibo homes are on stilts and open, with no walls. Consequently, residents are
directly exposed to the elements. There was a desire from a number of participants to wall-off
parts of their homes in order to be protected from extreme weather events. Equally, the raised
homes presented a level of protection from animals potentially hosting disease vectors and are
adapted to the annual flood cycle in the region. Mosquito net usage is common and well adopted
by both the Shawi and Shipibo communities, lowering their sensitivity to vector-borne diseases.
Inadequate water infrastructure increases the likelihood of outbreaks of temperature
related water-borne diseases including parasitic infections, with all water obtained from
untreated watercourses. While water is commonly boiled in Panaillo, this was not the case in
Nuevo Progreso. Generational differences emerged in Panaillo however, with elderly wom-
en commenting that they did not like the taste of ‘cooked water’ and preferred it ‘raw’.
Younger generations affirmed the benefits of boiling water, although many were observed to
drink water directly from the river without treatment during fieldwork.
“I know this water makes my baby sick, it’s yellow and smells like iron, but we have
no alternative.” (Panaillo, women group).
In both communities health systems are being affected by other stresses, including land use
change, degradation of ecosystem services, and social-economic trends associated with broader
globalizing forces. The recent construction of roads to regional center’s at both communities has
increased accessibility, bringing many positive implications for health, including increased
ability to trade, make a cash income and secure livelihoods, access goods which can have a
protective effect for health (e.g. sweaters and blankets for the cold, medicines), and reduced
travel time and cost to regional medical facilities. However, there is also the potential for the
introduction of new diseases and improved access for (often illegal) extractive industries.

“The cars are good though because they allow us to get to Pucallpa faster to sell our
products, especially in the dry season when the beach is so large that access to the river
is complicated (…) before if there was a medical emergency, it would take 7 h to get to
the hospital during the dry season, now it takes 2 h (..) But the road has also brought
problems (…) when a car drives by it lifts up a lot of dust (…) there has also been
more logging along the communal boundaries.” (Panaillo, men group).
“The road works ruined our river, dirt was constantly being dumped into the river and
the river banks were deforested (…) Now at night we can hear big trucks, it’s the
loggers taking out wood from neighboring communities.” (Nuevo Progreso, men
group).
Mitig Adapt Strateg Glob Change (2013) 18:957–978 971

Deforestation, due to outside demand for timber, in particular, was described as a major
concern, and is increasing the sensitivity of villagers to climate-related health problems
through a number of pathways. At Nuevo Progreso, participants complained that the lack of
big trees, preferentially harvested by loggers, no longer provided shade for work, thereby
exacerbating concerns over warmer temperatures and heat stress. The loss of trees is
affecting agricultural practices and traditional medicine, with implications for food security
and the traditional health system.
“(…) since the big trees are gone, the soil soaks up less water, all the fertilizer is swept
away” (Panaillo, men group).
“Illegal loggers steal our big trees from our territory (…) we are going to run out of
medicinal trees (…) our children won’t be able to recognize the different species, all
they see is xomi1” (Panaillo, women group).
This creates an additional layer of sensitivity to the health effects of climate change,
beyond physical wellness to encompass cultural and mental well-being. Traditional medi-
cine was described as the first line of health care in both communities, with a variety of local
plants employed for medical purposes. However, increased access to MoH services, limited
access to traditional medicinal plants, and limited transfer of ethno-botanical knowledge is
influencing the use of traditional medicine.
Both communities consider access to formal MoH services as a priority, but the degree to
which the formal services were consulted varied between communities. The risk ranking
exercise in Panaillo placed the lack of medical services as the second most important health
risk for the community, which at Nuevo Progreso was ranked fourth. This is probably due to
differences in exposure to biomedical health services. In Panaillo, before the village relo-
cated 10 years ago due to flooding, there was a permanent health post in the village. At the
new village site, a technical nurse has recently been appointed to the health post. In the
absence of medical attention at the village itself, Panaillo residents will customarily attend
the Tachsitea health post across the river, about a 30 min boat ride. At Nuevo Progreso, the
nearest health post is an hour walk away in the village of Nuevo Arica. Constraints to
accessing allopathic health care, however, were widely noted in both locations, as a function
of financial, geographic and cultural barriers. Consequently, traditional medicine is used as
the primary line of health care. Nevertheless, concerns were raised during the photovoice
and risk ranking exercises regarding the transfer of traditional knowledge to younger
generations.
“The big medicinal trees are far away, many days walk into the forest. Our children no
longer recognize or know the name these big trees; they only know xomi1 because it is
everywhere.” (Panaillo, women group)
“The children don’t know about our trees and their spirits, all they see in the
community is oje and that is the only tree they recognize (…) kids don’t know big
trees like lupuna. When I was a child, our grandfathers told us that only the juice of the
lupuna could be taken, cutting the tree would kill someone. (…) but the teachers don’t
know our stories and the kids don’t learn.” (Panaillo, leaders group)
“These are plants that our grandmothers used to use (…) some of us still prepare them,
but we have forgotten their names.” (Nuevo Progreso, women group).
The erosion of traditional knowledge systems has the potential to increase sensitivity, and
is a major challenge with the rapid cultural transitions that the communities are facing. A

1
Xomi (also known as Oje, latin name: Ficus insipida) is a medicinal tree with no commercial value
972 Mitig Adapt Strateg Glob Change (2013) 18:957–978

study among the Tsiname peoples of the Bolivian Amazon, for instance, showed that greater
access to the market economy led to a loss of knowledge of folk plant use (Reyes García et
al. 2005). A similar occurrence was described in both case study communities where there
has been increased access to regional urban centers. Greater access has facilitated the
adoption of western habits. For example, in Panaillo, a number of “bodegas” have emerged.
These small convenience stores sell an assortment of processed goods, from aspirin to sugar
and soft drinks. In Panaillo, the ease of access to western medicine by this means, and by
free distribution from the health post, creates a situation where traditional medicines, which
have a lengthy preparation process, are being replaced by pharmaceutical drugs which can
be taken instantly.
This process of acculturation leads to the abandonment of protective traditional habits.
Another study on the Tsiname looked to evaluate the impact of traditional knowledge on
child health. Results showed that maternal ethnobotanical knowledge and child health were
positively correlated, where increased maternal ethnobotanical knowledge led to a higher
likelihood of good child health (McDade et al. 2007), underlining the importance of
preserving Indigenous health care practices. Inter-generational loss of traditional knowledge
is an issue in case study communities where there are few formal mechanisms in place to
facilitate the transfer of knowledge to younger generations. The presence of a national
institutionalized education system limits the opportunities to expose children to traditional
practices, further aggravated by the decline in certain plant species. Alongside the facilitated
access to the formal health system, the successful integration of traditional approaches to
health into biomedical health systems was described as key to reducing sensitivity.

3.3 Adaptive capacity

A variety of conditions constrain the adaptive capacity of the case study communities to
manage climate-related health risks including access to economic resources, institutional
capacity, access to technology, and information deficit, and combine to create a high burden
of ill-health. Notwithstanding these challenges, community participants through photovoice,
demonstrated a number of adaptations being implemented to manage climate-related health
risks and changing conditions, and documented broader societal characteristics that acted as
sources of adaptive capacity. The diversity of the health system, in particular, was identified
as a source of strength. The first line of healthcare is treatment within the household using
commonly known medicinal plants. If this remedy fails to cure, advice from other commu-
nity member will be sought out, notably village elders in Panaillo and a shaman in Nuevo
Progreso. If both household and greater community treatment fails, patients will attend
formal biomedical health services which are freely available through the “seguro integral de
salud”, a free medical insurance distributed by the Peruvian Ministry of Health for groups
living in extreme poverty. While villagers expressed openness to accessing allopathic health
systems and valued the services offered, access constraints were noted, including lack of
resources available at the health post and money to buy medicines if prescribed. At Nuevo
Progreso, there was greater scepticism towards biomedical health services, with one of the
risks identified at the risk ranking workshop as “lack of acknowledgment of non-indigenous
knowledge on health.” Notwithstanding, the continued importance of traditional approaches
to health was commonly expressed and, as previously discussed, the lack of transfer of these
skills to the younger generations was a notable source of worry.
Both communities identified strong social networks within communities as a source of
adaptive capacity, including the role of informal local institutions which monitor and
manage resource access and which can respond to emerging threats. Thus in Panaillo, as
Mitig Adapt Strateg Glob Change (2013) 18:957–978 973

stresses from illegal deforestation have increased to the point of posing health risks, the
community has established a “woods and lakes committee” that patrols local territory to
catch illegal loggers and fishers exploiting the community’s resources. When loggers are
caught, the wood is confiscated. A community assembly is then called to decide what to do
with the confiscated wood. The wood is either sold and the revenue invested back into the
village or the wood is used to fix public infrastructure, such as schools. While the committee
has occasionally been successful in catching illegal loggers, it is challenging to patrol such a
large area. Moreover, it raises the potential for conflict, which could take on an interethnic
dimension with the majority of illegal loggers non-Indigenous. It is particularly difficult for
the committee to control the river and lakes because they do not have power boats and hence
cannot catch up to the illegal fishermen.
A number of adaptive mechanisms were described as helping to manage climate-related
food security challenges, with photographs from both communities recording Pandisho
(breadfruit, Artocarpus altilis) as a back-up wild food crop when other food sources are
unavailable. For example, in Panaillo, when the Ucayali flooded the original site of Panaillo,
villagers lost their banana plantations, a preferred source of food alongside fish. To replace
bananas, the community depended on breadfruit for an extended period of time until they
were able to re-establish the banana harvest. The high nutritional value of Pandisho makes it
an excellent wild-fruit alternative. If consumed with seed, 100 g of breadfruit has a
nutritional value of 135 kcal, 4.5 g of protein, 1.8 g of fats, and 29.0 g of carbohydrates
(CENAN 2009). The customary “platano ingiri” (boiled banana) only has 113 kcal, 1.2 g of
protein, 0.2 g of fats, and 10.5 g of carbohydrates (CENAN 2009).
At the time of fieldwork, the community at Nuevo Progreso was experiencing a food
shortage due to reduced harvest and lack of game animals. Consequently they opted for
eating Pandisho. In a response to the lack of food, both communities have also sought out
external food sources. At Panaillo, there are now a couple “convenience stores” selling
manufactured products from the city. If they have enough money, villagers will also go
across the river to Tacshitea to buy non-traditional foods such as chicken, tomatoes, and
onions. Seasonal migration is also commonly practiced among the working age population
in the wet season, providing an important source of income for the community to purchase
food when subsistence activities are constrained. At Nuevo Progreso, however, the difficulty
of relying on traditional livelihoods due to environmental changes has led a number of
villagers to permanently migrate to Yurimaguas.

4 Discussion

This study contributes to a small but growing body of scholarship examining the implica-
tions of climate change for Indigenous health (Berrang-Ford et al. 2012; Cunsolo Willox et
al. 2011; Ford et al. 2010a; Furgal and Seguin 2006; Green 2006; Green et al. 2009, 2010).
The majority of scholarship herein has been conducted in developed nations, and as such the
focus on small tropical forest communities is unique (Ford 2012). Using a vulnerability-
based approach, and focusing on past and present experience and response to climatic
variability, change and extremes, we outline the general processes and conditions affecting
how the two case study communities interact with climate-related health risks. The key
exposures identified by community participants included water borne diseases, food inse-
curity, and vector borne diseases, which are affected by temperature, precipitation, and
extremes (heat, flooding). Changing climatic conditions have already been observed by
community members, are affecting some of these exposures, and are occurring in the context
974 Mitig Adapt Strateg Glob Change (2013) 18:957–978

of other environmental changes mediated by deforestation and mineral extraction.

Regardless of whether these changes are indicative of longer term trends in climate change
or representations of climatic variability, examining interaction with communities provides
important insights on the determinants of vulnerability and adaptation to climate change.
Sensitivity and adaptive capacity to climate-related health risks and change are influenced
by socio-cultural-economic processes and conditions operating over multiple spatial-
temporal scales, and against a backdrop of marginalization and acculturative stress. Thus,
while traditional approaches to health remain important in the two communities and
underpin adaptability to changing conditions, there is widespread concern about the weak-
ening of these knowledge systems as communities try and benefit from increasingly
available western health services while maintaining traditional ways. This challenge faces
many Indigenous populations globally, and is of fundamental importance to shaping vul-
nerability. Increasing integration into regional and global economies is also affecting
vulnerability and adaptive capacity. New road developments for instance, both increase
access to health facilities and increase potential to earn a cash income and strengthen
livelihoods (reducing vulnerability), while also exacerbating deforestation and resource
development, increasing the potential for the emergence of new diseases, challenging legal
title and access to land, and undermining community dynamics (increasing vulnerability),
over which communities have limited control. These socio-economic-political factors will
play a major role in determining the pathways through which projected changing in climate
affect community health and well-being.
In discussing these results we also caution that the work is exploratory in nature. Future
studies will focus in-depth on specific determinants of vulnerability and adaptive capacity,
examine in greater detail specific extreme years (e.g. 2005 drought), formally examine the
implications of future climate projections using downscaled model output and in-light of
current vulnerability and socio-economic trends, conduct an epidemiological assessment of
key climate-related health risks to compliment local observations and knowledge, and
monitor over time how climatic-risks are experienced and managed. This will be undertaken
as part of the Indigenous Health Adaptation to Climate Change project (www.ihacc.ca), a 5-
year, trans-disciplinary, multi-country initiative led by the authors on this paper, and of
which the work presented here represents a first step. Moreover, by conducting further
community case studies in the two regions, we hope to develop an understanding of the
extent to which the processes and conditions affecting vulnerability in Nuevo Progresso and
Panaillo are generalizable.
Notwithstanding these caveats, the work can be used to stimulate discussion on the
integration of Indigenous issues into current debates on adaptation within the UNFCCC.
This is particularly salient given the development the Green Climate Fund and pledge by
annex-1 nations to provide $100bn per year by 2020 to help poorer nations respond to
climate change (Donner et al. 2011). To this end, identifying determinants of vulnerability
and sources of adaptive capacity is a key first step for developing an evidence base for
intervention. This preliminary work identifies broad level adaptation priorities herein for
communities in the study region, including efforts to strengthen traditional health systems
and enhance access to allopathic health care, focus on community-led development efforts to
address material conditions and behaviors associated with high levels of poverty, educational
and infrastructural investments to improve access to treated water, and protection of tradi-
tional lands from resource exploitation that does not have community consent. Many of
these are existing goals for communities and NGO/government-led development initiatives
in the region, with adaptation offering additional impetus to strengthen livelihoods and
culture, and re-establish decision making power and authority at a local level. Essential for
Mitig Adapt Strateg Glob Change (2013) 18:957–978 975

further work identifying, refining, and developing these adaptation entry points, is continued
partnership with communities and Indigenous organizations, integrating local/traditional
knowledge and science in planning for climate change.

Acknowledgments This work was carried out with the aid of a grant from the International Development
Research Centre (IDRC), the Canadian Institutes of Health Research (CIHR), the Natural Sciences and
Engineering Research Council of Canada (NSERC), and the Social Sciences and Humanities Research
Council of Canada (SSHRC), Ottawa, Canada. The researchers would like to acknowledge the hospitality
of the communities of Panaillo and Nuevo Progreso. In addition, Esderas Silvano, Connie Fernandez,
Segundo Pizango, and AIDESEP are especially thanked for their help in the early stages of fieldwork.

References

Adger WN, Agrawala S, Mirza MMQ, Conde C, O’Brien K, Pulhin J, Pulwarty R, Smit B, Takahashi K
(2007) Assessment of adaptation practices, options, constraints and capacity. In: Parry ML, Canziani OF,
Palutikof JP, van der Linden PJ, Hanson CE (eds) Climate change 2007: impacts, adaptation and
vulnerability. Contribution of working group II to the fourth assessment report of the intergovernmental
panel on climate change. Cambridge University Press, Cambridge, pp 717–743
Berrang-Ford L, Ford JD, Patterson J (2011) Are we adapting to climate change? Glob Environ Chang 21:25–33
Berrang-Ford L, Dingle K, Ford JD, Lee C, Lwasa S, Namanya DB, Henderson J, Llanos A, Carcano C,
Edge V (2012) Vulnerability of indigenous health to climate change: a case study of Uganda’s Batwa
Pygmies. Soc Sci Med. doi:10.1016/j.socscimed.2012.04.016
Bravo W, Bravo F (2001) El efecto del fenómeno de El Niño en las enfermedades dermatológicas. Folia
Dermatol Peru 12:29–36
Burton I, Lim B (2005) Adaptation policy framework for climate change. Cambridge University Press, Cambridge
CENAN (2009) Tablas Peruanas de Composición de Alimentos. In: Centro Nacional de Alimentación y
Nutrición–Instituto Nacional de Salud (ed), Lima
CENAN–INS (2010) Estado nutricional en niños menores de 5 años y gestantes que acuden a los estableci-
mientos de salud. In: Salud CNdAyN-INd (ed), Lima
Chamberlin J, Laughlin L, Romero S, Solórzano N, Gordon S, Andre R, Pachas P, Friedman H, Ponce C,
Watts D (2002) Epidemiology of endemic Bartonella bacilliformis: a prospective cohort study in a
Peruvian mountain valley community. J Infect Dis 186:983–990
Chambers R (1994) The origins and practice of participatory rural appraisal. World Dev 22:953–969
Checkley W, Epstein LD, Gilman RH, Figueroa D, Cama RI, Patz JA, Black RE (2000) Effects of EI Niño and
ambient temperature on hospital admissions for diarrhoeal diseases in Peruvian children. Lancet 355:442–450
CIDA (2008) Additional resources–participatory appraisal techniques. http://www.acdi-cida.gc.ca/acdi-cida/
acdi-cida.nsf/eng/EMA-218123623-NP9
Confalonieri U, Menne B, Akhatar R, Ebi KL, Hauengue M, Kovats RS, Revich B, Woodward A (2007) Human
health. In: Parry ML, Canziani OF, Palutikof JP, van der Linden PJ, Hanson CE (eds) Climate change 2007:
impacts, adaptation and vulnerability. Contribution of working group II to the fourth assessment report of the
intergovernmental panel on climate change. Cambridge University Press, Cambridge, pp 391–431
Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S, Groce N, Johnson A, Kett M, Lee M, Levy
C, Maslin M, McCoy D, McGuire B, Montgomery H, Napier D, Pagel C, Patel J, Puppim de Oliveria JA,
Redclift N, Rees H, Rogger D, Scott J, Stephenson J, Twigg J, Wolff J, Patterson C (2009) Managing the
health effects of climate change. Lancet 373:1693–1733
Cunsolo Willox A, Harper S, Landman K, Houle K, Ford J, Rigolet Inuit Community Government (2011)
‘The land enriches our soul’: on environmental change, affect, and emotional health and well-being in
Nunatsiavut, Canada. Emot Space Soc
DGE (2007) Análisis de la Situación de Salud de Loreto–2007. In: Dirección Ejecutive del Centro de
Prevencion y Control de Enfermedades (ed), Iquitos, Loreto, Perú
DGE (2009) Análisis de Situación de Salud de Ucayali 2008. In: Dirrección de Salud Ucayali (ed), Pucallpa,
Ucayali, Perú
Díaz A, Rosas G, Avalos G, Oria C, Acuña D, Llacza A, Miguel R (2009) Escenarios Climáticos en la cuenca
del rio Mayo para el año 2030. In: SENAMHI (ed), Lima, Perú
976 Mitig Adapt Strateg Glob Change (2013) 18:957–978

Donner SD, Kandlikar M, Zerriffi H (2011) Preparing to manage climate change financing. Science 334:908–909
Ebi KL, Burton I (2008) Identifying practical adaptation options: an approach to address climate change-
related health risks. Environ Sci Pol 11:359–369
Ebi KL, Semenza JC (2008) Community-based adaptation to the health impacts of climate change. Am J Prev
Med 35:501–507
Ebi KL, Kovats SR, Menne B (2006) An approach for assessing human health vulnerability and public health
interventions to adapt to climate change. Environ Heal Perspect 114:1930–1934
Fankhauser S, Burton I (2011) Spending adaptation money wisely. Clim Pol 11(3):1037–1049
Finer M, Orta-Martinez M (2010) A second hydrocarbon boom threatens the Peruvian Amazon: trends,
projections, and policy implications. Environ Res Lett 5(1):014012
Foller M-L (2001) Interactions between global processes and local health problems. A human ecology
approach to health among indigenous groups in the Amazon. Cad Saude Publica 17:115–126
Ford JD (2009a) Dangerous climate change and the importance of adaptation for the Arctic’s Inuit population.
Environ Res Lett 4(2):024066
Ford JD (2009b) Vulnerability of Inuit food systems to food insecurity as a consequence of climate change: a
case study from Igloolik, Nunavut. Reg Environ Chang 9(2):83–100
Ford JD (2012) Indigenous health and climate change. Am J Public Health 102(7):1260–1266
Ford JD, Beaumier M (2011) Feeding the family during times of stress: experience and determinants of food
insecurity in an Inuit community. Geogr J 177(1):44–61
Ford JD, Smit B (2004) A framework for assessing the vulnerability of communities in the Canadian Arctic to
risks associated with climate change. Arctic 57:389
Ford JD, Berrang-Ford L, King M, Furgal C (2010a) Vulnerability of aboriginal health systems in Canada to
climate change. Glob Environ Chang 20:668–680
Ford JD, Keskitalo ECH, Smith T, Pearce T, Berrang-Ford L, Duerden F, Smit B (2010b) Case study and
analogue methodologies in climate change vulnerability research. WIREs Clim Chang 1(3):374–392
Ford JD, Berrang-Ford L, King M, Furgal C (2010c) Vulnerability of aboriginal health systems in Canada to
climate change. Glob Environ Chang Hum Policy Dimens 20:668–680
Ford JD, Vanderbilt W, Berrang-Ford L (2012) Authorship in IPCC AR5 and its implications for content:
climate change and indigenous populations in WGII. Clim Chang 113(2):201–213
Fraser BJ (2009) The Andes’ triple bottom line: climate change is hitting South America with a triple whammy:
More water stress, more migration, more disease. The Daily Climate, 11 May 2009
Furgal C, Seguin J (2006) Climate change, health, and vulnerability in Canadian Northern Aboriginal
communities. Environ Heal Perspect 114:1964
Gallardo M (2008) Directorio nacional. Cambio climático en el Perú: instituciones, investigadores, políticas,
progrmas, proyectos y recopiación bibliográfrica. In: Primera aproximación. Soluciones Práctica-ITDG
Ganoza CA, Matthias MA, Collins-Richards D, Brouwer KC, Cunningham CB, Segura ER, Gilman RH,
Gotuzzo E, Vinetz JM (2006) Determining risk for severe leptospirosis by molecular analysis of
environmental surface waters for pathogenic Leptospira. PLoS Med 3:e308
Githeko AK, Woodward A (2003) International consensus on the science of climate and health: the IPCC
Third Assessment Report. In: McMichael A, Haines A, Slooff R, Kovats S, Franco E (eds) Climate
change and human health. WHO, Geneva, pp 43–57
Glantz M (1996) Forecasting by analogy: local responses to global climate change. In: Smith JB (ed) Adapting
to climate change. Springer, New York, pp 407–426
Green D (2006) Climate change and health: impact on remote indigenous communities in Northern Australia.
Commonwealth Scientific and Industrial Research Organisation, Victoria, Australia
Green D, King U, Morrison J (2009) Disproportionate burdens: the multidimensional impacts of climate
change on the health of indigenous Australians. Med J Aust 190:4–5
Green D, Alexander L, McLnnes K, Church J, Nicholls N, White N (2010) An assessment of climate change
impacts and adaptation for the Torres Strait Islands, Australia. Clim Chang 102:405–433
Haines A, Wilkinson P, Tonne C, Roberts I (2009) Aligning climate change and public health policies. Lancet
374:2035–2038
Healey GK, Magner KM, Ritter R, Kamookak R, Aningmiuq A, Issaluk B, Mackenzie K, Allardyce L,
Stockdale A, Moffit P (2011) Community perspectives on the impact of climate change on health in
Nunavut Canada. Arctic 64(1):89–97
Hern WM (2004) Shipibo. In: Ember CR, Ember M (eds) Encyclopedia of medical anthropology. Springer,
US, pp 947–956
INEI (2009) II Censo de Comunidades Indigenas de la Amazonía Peruana. In: Informatica INdEe (ed), Lima, Peru
IPCC (2007) Climate change 2007: impacts, adaptation and vulnerability. Contribution of working group II to
the third assessment report of the Intergovernmental Panel on Climate Change (IPCC). Cambridge
University Press, Cambridge
Mitig Adapt Strateg Glob Change (2013) 18:957–978 977

Keskitalo E (2008) Vulnerability and adaptive capacity in forestry in Northern Europe: a Swedish case study.
Clim Chang 87:219–234
Lardeau M-P, Healey G, Ford JD (2011) The use of Photovoice to document and characterize the food security
of users of community food programs in Iqaluit, Nunavut. Rural Remote Health 11:1680
Lau CL, Smythe LD, Craig SB, Weinstein P (2010) Climate change, flooding, urbanisation and leptospirosis:
fuelling the fire? Trans R Soc Trop Med Hyg 104:631–638
Lesnikowski A, Ford J, Berrang-Ford L, Berrara M, Heymann J (2011) Adaptation to health impacts of
climate change: a systematic study of UNFCCC Annex I countries. Environ Res Lett
Liverman D, Billett S (2010) Copenhagen and the Governance of Adaptation. Environment 52:28–36
Maheu-Giroux M, Casapia M, Soto-Calle VE, Ford LB, Buckeridge DL, Coomes OT, Gyorkos TW (2010)
Risk of malaria transmission from fish ponds in the Peruvian Amazon. Acta Trop 115(1–2):112–118
Mascarenhas J (1991) Participatory rural appraisal: proceedings of the February 1991 Bangalore PRA Trainers
Workshop, RRA Notes, IIED, London. MYRADA, Bangalore
McDade T, Reyes-Garcia V, Blackinton P, Tanner S, Huanca T, Leonard W (2007) Ethnobotanical knowledge
is associated with indices of child health in the Bolivian Amazon. Proc Natl Acad Sci 104:6134
McLeman RA (2011) Settlement abandonment in the context of global environmental change. Glob Environ
Chang Hum Policy Dimens 21:S108–S120
McLeman R, Mayo D, Strebeck E, Smit B (2008) Drought adaptation in rural eastern Oklahoma in the 1930s:
lessons for climate change adaptation research. Mitig Adapt Strateg Glob Chang 13:379–400
MINAM (2010) Segunda Comunicación Nacional del Perú al la Convención Marco de las Naciones Unidas
sobre Cambio Climático Lima, Peru
MINSA–DGE (2003) Análisis de la Situación de los Pueblos Indígenas de la Amzonia Peruana. In:
Epidemiología MdS-OGd (ed), Lima, Perú
Miranda J, Cabezas C, Maguiña C, Valdivia J (2003) Hipertermia durante el fenómeno de El Niño, 1997–
1998. Rev Peru Med Exp Salud Pública 20:200–205
Mjbdlf F (2010) Cambio climáticon en el Perú–Amazonía. Apus Graph Ediciones, Lima
Montenegro RA, Stephens C (2006) Indigenous health 2–indigenous health in Latin America and the
Caribbean. Lancet 367:1859–1869
Moore BA, Allard GB (2008) Climate change impacts on forest health. Forest Health & Biosecurity Working
Papers. FAO, Food and Agriculture Organization, Rome
Mujica O, Quick R, Palacio A, Beingolea L, Vargas R, Moreno D, Barrett T, Bean N, Seminario L, Tauxe R
(1994) Epidemic cholera in the Amazon: the role of produce in disease risk and prevention. J Infect Dis
169:1381–1384
Myers SS, Patz JA (2009) Emerging threats to human health from global environmental change. Annu Rev
Environ Resour 34:223–252
Napolitano DA (2007) Towards understanding the health vulnerability of Indigenous peoples living in
voluntary isolation in the Amazon rainforest: experiences from the Kugapakori Nahua Reserve, Peru.
EcoHealth 4:515–531
Nepstad DC (2007) Sequía y fuego en el invernadero: Puntos ecológicos y climáticos críticos del bosque húmedo
tropical más grande del mundo y medidas prácticas de prevención. Los círculos viciosos de la Amazonía. WWF
OGE (2002) Analisis de la Situacion de la Salud del Pueblo Shipibo–Konibo. In: Epidemiologia OGd (ed)
Oyama M, Nobre C (2003) A new climate-vegetation equilibrium state for tropical South America. Geophys
Res Lett 30:2199
Poulin R (2006) Global warming and temperature-mediated increases in cercarial emergence in trematode
parasites. Parasitology 132:143–151
Pouliotte J (2005a) Climate livelihoods, changing vulnerability. Adapting to climate change in Subarnabad
Village, Bangladesh. Department of Geography, University of Guelph, MA Thesis
Pouliotte J (2005b) Climate livelihoods, changing vulnerability. Adapting to climate change in Submabad
Village, Bangladesh University of Guelph
Reyes García V, Vadez V, Byron E, Apaza L, Leonard William R, Perez E, Wilkie D (2005) Market economy
and the loss of folk knowledge of plant uses: estimates from the Tsimane’ of the Bolivian Amazon. Curr
Anthropol 46:651–656
Reynolds MP (2010) Climate change and crop production. CABI Publishing, Oxfordshire
Salick J, Byg A (2007) Indigenous peoples and climate change. A Tyndall Centre Publication. Tyndall Centre
for Climate Change Research, Oxford, p 32
Salick J, Ross N (2009) Traditional peoples and climate change introduction. Glob Environ Chang Hum
Policy Dimens 19:137–139
Sherman M, Berang-Ford L, Ford JD, Sherman M, Berrang-Ford L, Ford J, Lardeau M, Hofmeijer I, Zavaleta
C (in press) Balancing indigenous principles and institutional research guidelines for informed consent: a
case study from the Peruvian Amazon. Am J Bioeth: Prim Res
978 Mitig Adapt Strateg Glob Change (2013) 18:957–978

Smit B, Pilifosova O (2001) Adaptation to climate change in the context of sustainable development and
equity. In: McCarthy J, Canziani OF, Leary NA, Dokken DJ, White KS (eds) Climate change 2001:
impacts, adaptation, vulnerability (Chapter 18). Cambridge University Press, Cambridge, pp 876–912
Smit B, Wandel J (2006) Adaptation, adaptive capacity and vulnerability. Glob Environ Chang Hum Policy
Dimens 16:282–292
Tschakert P (2007a) Views from the vulnerable: understanding climatic and other stressors in the Sahel. Glob
Environ Chang Hum Policy Dimens 17:381–396
Tschakert P (2007b) Views from the vulnerable: understanding climatic and other stressors in the Sahel. Glob
Environ Chang 17:381–396
UNEP (2009) Environmental outlook in Amazonia – GEO Amazonia. Panama City, Panama and Brasilia,
Brazil: United Nations Enviornment Programme and the amazon cooperation Treaty Organization in
collaboration with the Research Center of the Universidad del Pacifico
UNEP (2010) Latin America and the Caribbean Atlas of our changing environment. In: UNEP (ed)
van Aalst MK, Cannon T, Burton I (2008) Community level adaptation to climate change: the potential role of
participatory community risk assessment. Glob Environ Chang 18:165–179
Westerhoff L, Smit B (2009) The rains are disappointing us: dynamic vulnerability and adaptation to multiple
stressors in the Afram Plains, Ghana. Mitig Adapt Strateg Glob Chang 14:317–337
Young G, Zaval H, Wandel J, Smit B, Salas S, Jimenez E, Fiebig M, Espinoza R, Diaz H, Cepeda J (2010)
Vulnerability and adaptation in a dryland community of the Elqui Valley, Chile. Clim Chang 98:245–276