Medicinal Plant Use Influenced by Health Care Service in Mestizo and Indigenous Villages in the Peruvian Amazon

Medicinal plants, as a type of non-timber forest products (NTFP), have been expected to support the livelihoods of people globally, especially in rural and forest areas in developing nations. As medicinal plants occupy a unique position, with direct repercussions for people’s health and as a potential income resource, it is necessary to take the interaction with, and influence of, modern medicine into account when they are considered as a NTFP. This study pursued the influence of the health care service on medicinal plant utilization in mestizo and indigenous villages near secondary population agglomerations in the Peruvian Amazon. The study found some influence of the health care services on medicinal plant use in the study site, indicating that 1) medicinal plants are not necessarily a highly dependable approach for health care, 2) there are insufficient conditions for the development of a commercial market for medicinal plants, and 3) mestizo and indigenous households have similar health care utilization behaviours, although indigenous households are more affected by modern medicine, especially health care insurance, than the mestizo households. The health care service is an important factor for medicinal plant use for both health and livelihood. Without considering this factor, the potential of medicinal plants as NTFP cannot be fully understood.


Introduction
Medicinal plants as a type of non-timber forest products (NTFP) have been expected to support the livelihoods of people, especially in rural and forest areas in developing nations.Medicinal plants hold a very unique position as they directly serve people's health and conversely represent a potentially large income resource if functional or medicinal properties are found in them.When medicinal plants are considered as a forest product, the interaction with, and influence of, modern medicine should not be overlooked.
In NTFP studies, whether NTFP support people's livelihoods is influenced by various factors including landscape, location, land use system (Wisersum, 1997;2004;Ros-Tonen & Wiersum, 2003;Chilalo & Wiersum, 2011) or the type of relationship between people and forest (Wisersum, 1997;Byron & Arnold, 1999).NTFP may support livelihood only as safety-nets (Shackleton & Shackleton, 2004) or increase inequity in communities (Kusters, et al., 2006).Lawrence, et al. (2005) report that whether NTFPs help livelihood is not yet known because the factors and levels of people's dependency on the forest are not fully determined.While these studies examined various factors for NTFPs relating to people's livelihood, none of them paid much attention on potential influencers to the market of the target NTFPs, such as competing products or demand and supply conditions.
Whether plants are extracted from the forest or cultivated is also one of the relevant issues.Cultivation is desired for plant and forest conservation (Schippmann et al., 2006;Wiersum et al., 2006;Aguilar-Stoen & Moe, 2007) and livelihood improvement (Ros-Tonen & Wiersum, 2003;Belcher et al, 2005).However, Aguilar--Støen and Moe (2007) report that 3.3% of medicinal plants found in studies in eight countries were cultivated species.Another aspect of NTFP studies is whether plants are used for household consumption or trade (Godoy et al., 2000;High & Shackleton, 2000;Shackleton et al., 2002;Twine et al., 2003;Shackleton & Shackleton 2004;Belcher, 2005).High and Schakleton (2000) show that more than 70% of plant products are consumed within households and the rest is traded in the case of a South African rural village.While these studies describe the use patterns of NTFP or medicinal plants, they hardly consider what influences such use pattern or demand.In the case of medicinal plant use, it is reasonable to ask whether the existence of modern medicine affects commercial potential as well as household consumption of medicinal plants.This may also impact whether the plants are cultivated or harvested from the forest.
For more than a quarter of a century, health care programs in developing countries based on modern medicine have been strengthened with concepts such as primary health care by the Alma Ata declaration in 1978 (World Health Organization, 1978) and universal health coverage in 2005 (World Health Organization, 2013).It is the case that folk and traditional medicine (hereafter, 'traditional medicine') has also been recognized as part of primary health care (Green, 1988;Kayne, 2010) to supplement the insufficient penetration of modern medicine, especially in remote or marginalized areas in developing countries.Medicinal plants, a part of the central method in most traditional medicines, have been also recognized as the essential in the primary health care (Akerele et al., 1991) and their conservation has been assured through the Chang Mai Declaration in 1988(van Seters, 1997;Kathe, 2006).Economic growth and international initiatives would highly influence the provision of modern medicine, which may change medicinal plant use.The possible ripple effects of such long-term international initiatives both to support modern and traditional medicine, and the possible influence of ever expanding global commercialization in the last decade beg the question as to what is the condition to use medicinal plants for people in the remote areas in developing countries today.
While in some developing countries medicinal plants are important in primary health care (Estomba et al., 2006;Kitula, 2007;Lozada et al., 2006;Milliken & Albert, 1997), reliance on modern medicine increases (Caniago & Siebert, 1998;Vandebroek & Balick, 2012) in other places.Choice between traditional and modern medicine depends on the users' social and cultural values with respect to each medicine (Janes, 1999;Wayland, 2004) or their knowledge of medicinal plants (Dahlber & Trygger, 2009).Use and knowledge of medicinal plants can be dependent on age, gender, occupation, education, or location of plant habitation (Case et al., 2005;Quinlan & Quinlan, 2007;Srithi et al. 2009;Meretika et al., 2010).Modernization and globalization are also considered to cause a loss of medicinal plant knowledge (Benz et al., 2000;Voeks & Leony, 2004;Case et al., 2005;Voeks, 2007;Quinlan & Quinlan, 2007;Srithi et al., 2009;Meretika et al., 2010).The presence of the health care service also affects the loss of knowledge about medicinal plants (Caniago & Siebert, 1998;Vandebroek & Balick, 2012).Meretika et al. (2010) show urbanization to be one of the important factors for the decrease in plant use and knowledge.All these studies show that the use and knowledge of medicinal plants varies depending on various factors, however, modernization and the presence of modern medicine appear as a key regarding the loss of knowledge, thus use of medicinal plants.
The Amazon basin including its Peruvian territory abounds with medicinal plants known through extensive ethnobotanical studies (Lacaze & Alexiades, 1995;Mejia & Rengifo, 1995;Communeros et al., 2007) and the use of the plants especially by indigenous people is well reported.While, in large cities in the Amazon basin, despite the easy access to modern medicine, active commercial activities relating to medicinal plants as much as overharvesting is concerned have also been reported (Galy et al., 2000;Shanely & Luz, 2003).Unlike the large cities, however, indigenous people near a secondary city in the Peruvian Amazon tend to rely on modern medicine on the one hand, yet, the presence of modern medicine does not necessarily lessen medicinal plant use on the other (Toda et al., 2016).These studies indicate that urbanization may not necessarily result in a uniform use pattern of medicinal plants.Padoch et al. (2008) found unique patterns of consumption and knowledge in a rural-urban migration process within Amazonia, whereby urban migrants increase the demand for forest-derived products in rural areas.These studies indicate that the level of urbanization affects the demand for medicinal plants.
The Ministry of Health of the Peruvian Government includes a division, the National Centre for Intercultural Health (Centro Nacional de Salud Intercultural), whose responsibility is to oversee and understand traditional medicine and its cultural syndrome, which is not within a scope of modern medicine, and to compile medicinal plant information.Conversely, although Cotlear (2006) reports that Peru has inadequately financed its health care systems, the government created the Comprehensive Health Insurance system in 2001 (Seguro Integral de Salud, SIS), which intends to provide health services by giving priority to the poorer sections of the population.The SIS subscribers do not need to pay for health services in appointed health facilities.Although disparities between rural and urban and poor and non-poor regarding health and health service provisions still exist, the SIS has expanded health coverage especially in rural and poor areas (Francke, 2013).Taking account of the rapid economic growth of the country in the last two decades and its potential effect on rural areas, the Peruvian Amazon would be an appropriate field in which to examine peoples' utilization of medicinal plants in relation to modern medicine.
We aim to elucidate the commercial and health care potential of medicinal plants as a NTFP under the influence of health care service provision through a case study in the central Peruvian Amazon.The interaction between traditional medicine, including medicinal plant use, and modern medicine has been of interest within the field of medical anthropology.However, it has not been the case for NTFP studies to the best of our knowledge.In order to determine the influence of health care service on the use of medicinal plants, we assume urbanization in the Peruvian Amazon increases accessibility to modern medicine, and in turn, decreases medicinal plant use.The objectives of the study were to 1) examine medicinal plant use for health (self-consumption) and commercial purposes, 2) determine the level of use of modern medicine, and 3) assess the influence of modern medicine on the use of medicinal plants and their interaction through comparing the utilization between mestizo and indigenous people in villages near the city.The study was conducted in the second strata of population agglomeration in Amazonian cities in Peru because, unlike larger cities, secondary cities seem to provide ambivalent conditions for choosing health care methods, reflecting the insufficient penetration of modern medicine as well as for the lower level of commercial development associated with remoteness, yet with the pervading influence of economic development in the country (Toda et al., 2016).

Site Selection and Descriptions
The city of Contamana was chosen because it is remote enough, not having road connections with the largest cities in the Peruvian Amazon that have rapidly developed in the last decade, yet, it is not separate from the influence of the country's economic development and global commercialization.Contamana is located in the central Peruvian Amazon along the Ucayali River, the major tributary of the Amazon River, and between the two largest Peruvian Amazon cities; Iquitos with a population of 440,000 and Pucallpa with a population of 200,000 (Figure 1).Having over 20,000 residents, Contamana is the capital of Ucayali province, the southern frontier of Loreto Department and adjacent to Ucayali Department.It can only be accessed by boat along the Ucayali River or by plane from Iquitos, the capital of Loreto Department, located 440 km (840 km by river) north, and Pucallpa, the capital of Ucayali Department, located 134 km (285 km by river) south.Common transportation consists of motorcycles and three wheelers, called moto-carro.The city is the regional commercial centre where people from not only surrounding but also remote villages travel five or six hours to come and sell agricultural and fishery products, their main livelihood.The Ucayali River is the sole means of transportation for many of the local people.
Two mestizo villages, named here m-1 and m-2, which adjacent to each other and an indigenous community of Shipibo, village S, were selected.They face the Ucayali River and are located in relatively close proximity, therefore the distance to the city is similar compared to other combinations of mestizo and indigenous villages.Mestizo are descendants of the Amerindian and Iberian peoples, and the Shipibo are the dominant indigenous ethnic group in the central Peruvian Amazon, dispersed mainly in Peru along the Ucayali River and partially living in Bolivian and Brazilian territories.Both mestizo and the Shipibo people around the study area generally practice slash-and-burn cultivation for living complemented by limited fishing and hunting.The Shipibo are well known as traditional users of a variety of medicinal plants (Enocaise et al., 2014).Village m-1, having 47 households, and Village m-2, having 34 households, are both located 13 km south of Contamana along the Ucayali River and it takes about 40 minutes by boat to get to the city.Both villages share the same port on the river, yet Village m-1 is located in upper land just above Village m-2.Village m-1 on the upper land has water distribution for several hours a day.People in Village m-2 use water from a communal well, a stream or the river.Village S had 39 households during the period of the field study and is located 18 km south of Contamana and a 5 minute walk inland from a port on the Ucayali River, at a tributary of the river.Village S also has water distribution, yet people often use water from the river.There is no health care facility in these villages.People have to go to either a medical clinic staffed by a nurse and a technician, located in a village 4 km from Villages m-1 and m-2 and 9 km from Village S or a hospital in the city for medical treatment (Table 1).If there is not enough stock of medicinal drugs in the village, they must go to those health care facilities or the city to purchase medicinal drugs.Motor boats are the sole means of access to the city and most of the nearby villages.Not everyone has a boat, yet there are regular boats running from and to the city a few times a day.jsd.ccsenet.

Data C
The data w permission explanatio the use an socio-econ interviewe Village minterviewe mestizo vi   e the ecies within their top five list was 156.The most frequently cited plant was Malva (Malachra alceifolia), a herb, with 23 counts, representing 14.7% overall; the second was Piñón Colorado (Jatropha gossypifolia), a shrub, with 20 counts, or 12.8%.These are mostly planted around the houses including the following three frequently used plants: Mucura (Petiveria alliacea), a herb; Ajo Sacha (Mansoa alliacea), a vine; and Coca (Erythroxylum coca), a shrub.The leaves of the plants were mainly used except for Piñón Colorado from which the resin is frequently used in addition to the leave.The top five represent 44.8%.Twenty-seven species out of 52 species were cited only once, representing 51.9% of the total count.In Village S, 39 species were cited, of which 21 species were cited only once, representing 53.8% of the total.The total count within their top five list was 147.The top cited plant was Piñón Colorado with 33 counts, representing 22.4%; the second was Malva with 28 counts (19.0%), followed by Sangre de Grado (Croton lechleri), a tree; Piripiri (Eleutherine bulbosa), a herb; and Piñón Blanco (Jatropha curcas), a shrub; the top five represents 57.8%.Sangre de Grado, of which only the resin is used, can be found in the forest, but is often planted.The other four species were mainly planted near the houses and their leafy parts were mainly used, except for the resin of Piñón Colorado and Piñón Blanco (Table 2).
Table 2. Top five most frequently used medicinal plants of villages M and S Note.Life form: H=herb, S=shrub, T=tree, V=vine.

Usage
The purpose of medicinal plants was assessed through the top five most frequently used medicinal plants.
Generally, medicinal plants are used for multiple purposes and some plants are mixed for a specific purpose.
Although the usage list does not quantitatively, precisely represent these purposes, it shows the tendency of the villagers medicinal plant use.The households use a variety of the 52 species of medicinal plants in Village M and 39 in Village S. In Village M, among 35 different usages or symptoms, frequently mentioned were fever, cold, headache, the abdominal area including stomach, joints, and wounds, followed by fresh drink, cough, bronchitis, and diarrhea.In Village S, among the 31 usages or symptoms, frequently mentioned were fever, headache, wound, diarrhea, and cough, followed by cold, vomit, and abdominal area problems including stomach.

Commercial Medicinal Plant Products
People also purchase or sell medicinal plants, mainly in the form of remedies (tinctures).In Village M, 21 or 45.7%, of the total respondents purchased medicinal plant remedies in Contamana in the last one year.Among them, only 4 respondents purchased once a month or more and the rest purchased only a few times a year.They all purchased remedies in the city.As for the sales of medicinal plants, only three people sold medicinal plants and the sales represented 16% or less of their total livelihood income.In Village S, 9, or 23.1%, of the total respondents purchased them and three respondents purchased three times a year and were the most frequent purchasers.Only two households sold medicinal plants, and the sales represented 50% or more of their livelihood.One of the sellers was ordered to make specific remedies for indigenous ceremonies for tourists by an outsider.visits and medicinal drug purchases were significantly correlated in both villages.This indicates a possible uniform behaviour towards modern medicine.The frequency of use including visits and purchases alone may not fully explain the influence of modern medicine on the use of medicinal plants.
On the other hand, health insurance subscription clearly influences health care seeking behaviour in both village M and S and it does more so in indigenous households, increasing health care facility visits and decreasing medicinal plant use.The results indicate that the health insurance system effectively works and promotes the use of more health care services.Therefore, as previous studies (Caniago & Siebert, 1998;Vandebroek & Balick, 2012) have found, it is safe to say that the health care service contributes to the decrease in medicinal plant use and knowledge, although not directly.What this study found is that indigenous people seemed to be more influenced by the health care service than the mestizo population, in turn, knowledge loss would be a concern, and too much knowledge may have already been lost.

Perception of Medicinal Plants and Modern Medicine
The results indicate that at least half of the target population tends to rely on modern medicine in both villages, yet indigenous people are more influenced by health care service provision.Even though more than half of the households in both villages believe that medicinal plants are more efficacious than medicinal drugs, in Village S, a higher percentage of households than in Village M also believe in the efficacy of modern medicine.In terms of willingness to learn about medicinal plants, Village S has a higher score than Village M.Moreover, among those who think losing medicinal plants is a problem there was no significant difference between the two villages, with more households associating the reasons with insurance holdings or health care service provisions in Village S than Village M. As a study by Compos and Ehringhaus (2003) suggests that part of the indigenous knowledge was acquired through the interaction with local people, today, the use and knowledge of medicinal plants may have been mixed between the two types of communities.Although culture is one of the factors in health care seeking behaviour (MacKian et al., 2004;Shaikh & Hatcher, 2005;Grundy & Annear, 2010), it is possible that culture has been transforming the knowledge of medicinal plants.The present study did not determine the reason why indigenous households were influenced more by health care services.This question is left to further investigation.

Concluding Remarks
This study suggests that the potential importance of considering the extensive background of a NTFP, such as conditions of competitive products and other influencers including urbanization and geographical location to the demand of the target NTFP, when the value of a NTFP for livelihood is concerned.The influencers on the demand also affect the utilization of resources from the forest.In the case of medicinal plants, the influencers affect health care behaviours of people.This result was based on a case study, yet suggests a direction for further study. ( Figure Figure 7. F