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“I’m going to throw them into the fire,” said Amelia (pseudonym) referring to the multimicronutrients (MMN) that she was given at a public health center in Piura (Northern Peru) for the treatment of her son diagnosed with anemia. “I’ll give it [the MMN] to my dog,” said another woman from Huancavelica (Southern Peru), whose son has the same illness. Health workers confirm that other women across the country have had similar attitudes:

In Piura: “We found four MMN lying around on the road . . . surely she [a mother] received them from the health center and threw them out there.”

In Amazonas: “They are using MMN as poison for ants.”

In Huancavelica: “She, instead of giving it to her son, is giving it to her pig.”

Why do these mothers reject the medications that the Peruvian biomedical health system gives them? Some say this is due to its adverse effects, or speculation about its supposed effects. But a closer look at the matter shows this is a superficial aspect of a much larger and more complex problem of medical distrust.

A failed health initiative

In recent decades, anemia has become a top public health priority for the Peruvian government, in large part due to growing concern from the field of global health. Anemia, after all, disproportionately affects millions of Latin American children with severe and permanent consequences for their physiological and cognitive development; it also affects many women of reproductive age.

In 2017, after a slew of unsuccessful initiatives, Peru officially established a new national plan against anemia and chronic child malnutrition. The plan’s main goal was to reduce the rate of anemia from 43.6 percent (in 2016) to 19 percent (during 2017–2021) for children aged 6 to 36 months. Peru allocated billions of dollars to execute the Plan and received substantial resources and technical support from various global health agencies. Yet, by 2021, only minimal reductions had been achieved. The anemia rate barely dropped under 40 percent.

What went wrong in this effort? Many specialists, officials, and health workers blamed the population, framing the problem as one riddled by “cultural barriers,” “low educational level,” or “ignorance” of the people. I propose some alternative answers.  

Credit: Samuel King, 10 June 2013 (Healing Peru, humanitarian mission, Eglin Air Force Base, FL).
Many Peruvian mothers of children with anemia frequently complain about the very long waiting times they must spend in the health services, where they have to deal with intrincate paperwork and poor quality of care.

A Kafkaesque bureaucracy

The first and main reason for the failure of the Peruvian plan against anemia is to be found within the health system itself. Although it is rarely explicitly acknowledged in official sources, various analyses report great problems caused by a Kafkaesque health bureaucracy, characterized by its inefficiency, disorganization, and thoughtlessness (as shown in reports from the Ombudsman’s Office, the Ministry of Development and Social Inclusion, and civil organizations).

At the primary care level, many officials and health workers continually denounce the disorder and incompetence that they identify in high political-administrative areas, from where they are required to show results in anemia but without being given adequate or sufficient means to meet the plan’s goals. Logistical and supply problems, “lack of personnel,” “lack of budget,” poor training, and mistreatment from those higher levels are common complaints reported in health centers. There are also corruption allegations involving high-ranking health officials (Hongsheng Lu and colleagues write  of the “systemic corruption” in the Peruvian health sector), while at the end of 2018, almost two years after the start of the plan, a system for its monitoring and supervision had not yet been implemented.

This dysfunctional bureaucracy triggers the replication of small Kafkaesque orders within the primary care centers, where—in addition to the chronic shortage of resources and personnel—health workers and patients have to deal with intricate, overwhelming paperwork and bizarre situations of conflict between the health service areas and the administrative offices that process the admission of users. As a result, some patients are unable to access anemia care or do not receive the free medications and tests they need. There are health workers in charge of counseling mothers who do not have educational materials or appropriate offices for this activity. Others lack the resources to conduct demonstration sessions to teach mothers how to prepare iron-rich foods, or for home visits to mothers of children with anemia. 

In addition, mothers frequently complain about long waiting times in the anemia services. In one of these, a woman from Ucayali (in the Amazon region) recounted an experience suffered by many others throughout the country: “I go at 6:00 a.m., I wait there standing, sometimes without breakfast . . . sometimes we wait until 1:00 p.m.” Several of these women also report having experienced authoritarian mistreatment by health personnel (not unlike the disrespect and abuse found in other women’s health services).

Credit: Ovruni, 2 September 2021
In Peru, public health services are essentially services “for the poor”, where disorders and inefficiencies originating at higher political-administrative levels are replicated. As a result, many mothers of children with anemia abandon those services and seek help in their families and tradicional medicine (reference image).

Abandoning a health system

Given these situations, it is not difficult to understand why many mothers of children with anemia abandon these services and treatments to seek refuge in the help of their families and traditional medicine. That abandonment is more a consequence of a malfunctioning health system, rather than an expression of so-called cultural, educational, or communication barriers (which many public health studies insist). Considering the poor quality of public health services—which in Peru are, in essence, services for low-income citizens—and especially due to the mistreatment exerted by a despotic bureaucracy, the adverse effects of medications for anemia (real or perceived) are only one of the many elements that fuel the fire of Peruvians’ collective distrust of the State.

Quite explicit evidence of this distrust has been abundantly collected throughout Peru. For many mothers and families of children with anemia in Arequipa, Amazonas, Piura, Huancavelica, Ucayaly, Lima, and other regions (for example in reports of 2016, 2017, 2019, 2020a, and 2020b), the government gives them MMN “under tricks,” to “stupefy” the children (embrutecer), make them “foolish” (opas) or “useless” (inútiles, by “killing their neurons”), or “mad” and “aggressive”; or to “sterilize” them (as a method of population control, “because we are poor”), “poison them,” or “kill them” (“it is going to give us cancer”). Others say that the government distributes MMN to keep the country “backward” and the Peruvian population “controlled” and “submissive.” A man from Huancavelica said: “I gave it to my dog; now, he doesn’t bark or bite, he became dumb . . . he used to be fierce. The chispitas [MMN] have made him tame. That’s what the government sends us for . . . so that our children don’t rise up, don’t get ahead.” And there are even low-income people who prefer to buy medicines for anemia instead of receiving the free ones provided by the government.

It is necessary to examine the internal dysfunctions of the health system and to consider how these are a particular expression of other chronic and greater problems that affect the Peruvian State and its political system. For example, in the five years covered by the Plan against anemia, Peru has had five presidents and 11 ministers of health.

These realities should be taken more into account by international cooperation and global health agencies when providing support and resources to Peru and other countries or when evaluating the results of their actions. They would do well to try analyses that go beyond the strictly technical or health aspects of anemia and other diseases. Their political and administrative dimensions, for example, can be prefigured in an aphorism of Peruvian popular wisdom that says, “If Kafka had been born in Peru, he would have been a costumbrist writer.”

Melissa Salm is the outgoing section contributing editor for the Society for Medical Anthropology.


César R. Nureña

César R. Nureña is a Peruvian anthropologist and a doctor in social sciences candidate at the Universidad Nacional Mayor de San Marcos, Peru. He is also an international scholar of the NIH Fogarty International Clinical Research Scholars and Fellows Program and has conducted and published research on culture and politics, social exclusion, sexuality, and public health. This piece draws on ethnographic fieldwork on intercultural health since 2009, as well as a review of reports on anemia control in Peru.

Cite as

Nureña, César R.. 2023. “The Kafkaesque Control of Anemia in Peru.” Anthropology News website, November 28, 2023.