Economic Anthropology 2019 DOI:10.1002/sea2.

12144

Water insecurity and mental health

in the Amazon: Economic and ecological
drivers of distress
Paula Skye Tallman

The Field Museum of Natural History in Chicago, Chicago, IL 60605, USA

Corresponding author: Paula Skye Tallman; e-mail: ptallman@fieldmuseum.org

Despite the abundance of water in the Amazon rainforest, people living in Awajún communities in northern Peru express concern over their water
security. In this article, I employ a critical biocultural approach to examine how shifts from subsistence to market-based livelihoods have created
threats to water security that can “get under the skin” to influence the mental health of Awajún community members. Specifically, I show how
highway construction, colonization, resource extraction, market integration, and overall transitions in settlement patterns have polluted rivers with
sewage, refuse, and hazardous waste. I connect this broader context to ethnographic data from Awajún communities documenting struggles with
water security in the form of contamination and accessibility. Finally, I quantitatively examine whether water insecurity scores are associated with
psychological distress. Data drawn from 225 Awajún men and women from four communities in the province of Amazonas, Peru, revealed that
higher water insecurity scores were associated with higher levels of perceived stress (β = 0.35, p < .01), depressive symptoms (OR = 1.32, p < .01),
and somatic symptoms (OR = 1.51, p < .01). This study adds a critical political–economic perspective to anthropological literature focused on water
insecurity and distress and advocates for future subdisciplinary collaborations to address growing concerns with the contamination and accessibility of
local water sources.

Keywords Critical Biocultural Approach; Mental Health; Water Insecurity; Amazon; Awajún

Anthropologists have long been interested in the idea that sociocultural transitions are linked to health outcomes,
with research on this topic utilizing key terms like globalization, acculturation, modernization, market integration,
and lifestyle change (see a review by McDade and Nyberg 2010). Recently, research on this broader topic has
narrowed in on how unequal access to resources, specifically food and water insecurity, is associated with distress
and poor health (Workman and Ureksoy 2017; Wutich and Brewis 2014).
While the relationship between food insecurity and psychobiological health has been fairly well explored within
and outside of anthropology (Hadley and Crooks 2012; Hadley and Wutich 2009; Klesges et al. 2001; Patil 2008; Maes
et al. 2009; Stuff et al. 2004; Vozoris and Tarasuk 2003; Weaver and Hadley 2009), understandings of the causes and
consequences of water insecurity are less well developed (Wutich and Brewis 2014). This is concerning because more
than one billion people live without access to adequate water supplies (World Health Organization 2004), and there
is an emerging body of literature showing that water insecurity is associated not only with diarrheal disease and
dehydration (Cifuentes and Rodriguez 2005; Rosinger 2018) but also with compromised mental health outcomes
(Eichelberger 2010; Ennis-McMillan 2001; Stevenson et al. 2012; Wutich and Ragsdale 2008).
In this article, I use a critical biocultural approach (Leatherman and Hoke 2016) to probe the economic drivers
of water insecurity and examine how water insecurity “gets under the skin” to influence both lived experience
and mental health. A critical biocultural approach is a perspective that combines theory and methods from the
anthropological subdisciplines of human biology and critical medical anthropology to study the interface between
biological and cultural factors affecting human health and well-being (Goodman and Leatherman 1998; Leatherman

© 2019 by the American Anthropological Association. All rights reserved 1

P. S. Tallman

and Goodman 2011). Leatherman and Hoke (2016, 283) contend that it is “the sort of anthropology that blurs
divisions among the subfields, that occupies hybrid spaces at the margins of normative approaches, that bleed into
and demand input from other perspectives within and outside of anthropology.”
The aim of this article is to further a critical biocultural approach by drawing on concepts from economic
anthropology to understand how water insecurity is connected to historical changes in modes of production,
exchange, and consumption (Wilk and Cliggett 2009). In the first section of this article, I take a historical perspective
examining how economically driven behaviors, such as resource extraction, highway construction, colonization,
market integration, and transitions in settlement patterns, have increased sewage, refuse, and hazardous waste
in the rivers surrounding Awajún communities. Then, I draw connections between this broader context and
ethnographic data from Awajún community members documenting their struggles with water security in the form
of contamination and accessibility. Finally, I quantitatively examine whether water insecurity scores are associated
with a number of measures of psychological distress.

Background
The Awajún are an indigenous group of people living in the Peruvian Amazon, with more than fifty-five thousand
individuals living in the provinces of Amazonas, Cajamarca, Loreto, and San Martín (ODECOFROC 2010).
Traditionally, Awajún individuals lived in widely dispersed households organized around an extended family, where
they practiced small-scale subsistence farming, hunting, and fishing (Jernigan 2006). The importance of water in
Awajún livelihoods and culture cannot be overstated. Rivers have served as a source of food, water, and transport,
while Awajún cultural traditions were anchored in the practice of fasting at waterfalls or other sacred sites. At the
waterfall, young men would take a hallucinogenic vine with the aim of encountering an ancestral spirit. Making
contact with this spirit allowed the warrior to know his life purpose and gain power (Harner 1962). Thus sacred
water sources were an important backdrop for finding one’s identity and purpose, while rivers were the source of
fish for eating and water for drinking, bathing, and washing all household items.
Rivers and waterfalls continue to be important resources for the Awajún in the present day, but numerous
changes connected to the broader economic, political, and social arena have been threatening water quality.
Specifically, missionaries from the Church of Nazarene and the Summer Institute of Linguistics (SIL) (Stoll 1982;
Winans 1990) propagated a cultural model of success based on Western capitalism and paved the way for the
construction of a highway connecting the coast to the Amazonian interior. This highway opened Awajún territory
to colonization, market integration, and resource extraction (Tallman 2018). According to critical biocultural
anthropologist Alan Goodman (2013), scholars need to develop a richer historic and ethnographic context for
understanding and interpreting psychobiological results. Thus, in this article, I begin in the 1920s to take a closer
look at how the aforementioned transitions influenced Awajún lifestyles and relationships with water.

Historical political–economic context

In the 1920s, the Church of Nazarene sent Ester Carson and her husband, Roger Winans, to Awajún territory.
According to Cunningham (2003, 25–26), the Nazarenes were dedicated to “bringing a new social order into the
world” and believed that missions freed people from “the dungeon of economic and intellectual poverty.” Ester
supported these objectives in letters sent home, stating, “Especially we are striving to add an industrial feature to
the school and mission establishment” (Winans 1990, 95). She continued that this industrial feature of their work
“gives employment to many Indians, who when they are idle, are always restlessly making war on each other or
spending their time in vice and drunkenness” (95).
The Nazarene school became the source of a number of bilingual teachers who were later trained by educators
from the SIL, an institution with a dual identity. In foreign countries, the SIL operates as linguists, but in the United

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 Water Insecurity and Mental Health in the Amazon

States, for purposes of fund-raising and recruitment, the SIL was actually the Wycliffe Bible Translators. The Wycliffe
Bible Translators are one of the largest North American–based evangelical enterprises dedicated to translating
the New Testament.1 So “what the teachers actually taught was Western knowledge and the Scripture” (interview,
September 6, 2014, Shushug).
SIL educators promoted a transition from a subsistence livelihood to one based on a market economy by training
indigenous teachers to become paid workers who were able to buy goods with their earnings. The SIL also sent
economists to the region to promote economic development by training community members to buy and sell goods
(Olson 1995), promoting the commoditization of the environment and labor. Perhaps most significantly, SIL leaders
played a central role in facilitating the construction of a highway into Awajún territory that would catalyze further
lifestyle transitions.
The explicit relationships between the Peruvian government, Cameron Townsend (the founder of the SIL), and
R. G. LeTourneau (an American evangelist-millionaire) are laid bare by Dochuk (2012, 58):

In the early 1950s LeTourneau brokered a deal with Cameron Townsend, the founding director of Wycliffe Bible
Translators, and Peru president Manuel Odria to help complete the Trans-Andean Highway in exchange for a
million acres of uncultivated land. Odria hoped this project would give the Peruvian subsidiaries of Mobil Oil and
Gulf Oil access to the country’s petroleum reserves; Townsend hoped that it would facilitate expanded missionary
efforts into the Amazonian jungles. The plan suited LeTourneau too. He transformed the uncultivated land into
Tournavista, a community of natives and missionaries that carried out his plan for a “free” and self-sustaining
economy that might be used as a model of capitalism for “third world” societies. And so, in return for their
knowledge of undeveloped regions targeted for drilling, oil-friendly evangelicals of LeTourneau’s stature received
financial help (and government support) needed to build beacons of Christian democracy abroad.

In the 1960s, highway construction continued with the aim of colonizing “the forgotten Amazon through the
construction of a network of rural highways that would integrate Peru’s tropical territories into the national space”
(Greene 2009a, 137) and opening millions of acres of land for agriculture, colonization, and economic integration
(Horna 1976). This process was intensified by a petroleum pipeline project in Awajún territory (Greene 2009a),
which eventually connected the interior of the Amazon to the Pacific Coast (Brown 2014). With the influx of
colonists armed with land titles came a pressing need for the Awajún to stake their territorial claims over the
land. This was complicated by the 1969 Agrarian Reform Act, which stipulated that idle lands were made subject
to expropriation (Kay 1982). This meant that indigenous communities needed to form cooperatives and “use” the
land to receive land titles and government agricultural credit. Thus national laws pushed the Awajún to abandon
ecologically sustainable agricultural practices that left little mark on the forest for ones that made their impact, and
claims to the land, visible.
The main point is that highway construction, resource extraction, and colonization, which were politically and
economically motivated, shifted Awajún modes of production, with impacts on local water systems. Specifically,
highway construction in the Amazon left a pattern of deforestation (Gascon, Williamson, and da Fonseca 2000),
which is a known disruptor of hydrological cycles and atmospheric flows (Werth and Avissar 2002). This leads
to a greater risk for flooding in the wet season and drought in the dry season (Gloor et al. 2013), impacting the
cleanliness of the water, on one hand, and accessibility, on the other.
The aforementioned national migration and agricultural policies, in conjunction with pressures from evangelists
and educators to congregate around schools, churches, and trading posts, led the Awajún to shift to nucleated
communities. Nucleated settlements, in contrast to long-distance settlement patterns, create new pressures on
aquatic resources and challenges for the disposal of waste and sewage, as larger, condensed populations can lead
to the overharvesting of fish and the concentration of waste.

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Finally, mining and oil extraction pose major threats to water quality and human health, as these activities
produce a variety of toxins that have been associated with increases in the prevalence of a variety of cancers in
Amazonian communities located near extractive sites (Hurtig and San Sebastián 2002). In 2014, the Organización
de Desarrollo de las Comunidades Fronterizas del Cenepa released a short documentary called Yumi, Water Is Life:
The Fight of the Awajún that specifically focused on Awajún resistance to the impacts of extractive industries on
local rivers and health.
Next, I continue to follow the central tenets of a critical biocultural approach by connecting the aforementioned
global historical processes to local conditions (Leatherman and Hoke 2016). To do this, I use data from ethnographic
research conducted in four Awajún communities to move from this broader context to the on-the-ground concerns
that community members have regarding water security in the new millennium.

Lived experiences
For the ethnographic fieldwork that forms the basis of this research, I lived in the Awajún community of Shushug
for one year and spent extensive time in three nearby communities (Pagki, Mente, and Boca de Lobo). There are
a number of obvious and subtle differences among the four research communities. Shushug is five minutes away
from Highway 5 N and is home to the main schools in the area as well as a local health post. As such, it tends
to attract and retain community members with professional and market-oriented ambitions, and there are greater
visible disparities in wealth among households. Mente is east of Shushug and can only be reached by walking thirty
minutes from Shushug along a dirt path that becomes impassable after heavy rains. The community of Pagki is
southwest of Shushug. It is farther from Shushug than Mente but closer to the highway. The smallest and most
remote community is Boca de Lobo, which is an hour and a half by foot from the highway and attracts individuals
desiring a more remote lifestyle. Access to education, health care, technology, market foods, and other variables
of interest vary among the communities, although not in a straightforward manner.
I participated in community activities, visited households, and conducted semistructured interviews with key
informants in each of these communities (N = 30). I took written notes during all activities, and I voice-recorded
interviews with interviewees’ permission. Any interviews that directly or indirectly mentioned concepts of water
insecurity were flagged and transcribed using InqScribe. This qualitative research yielded narratives and quotes that
provide a window into the “lived experience” of water insecurity in these communities.
For example, I observed that the local river functioned as the source of water for drinking, bathing, and washing.
However, the population continues to expand without concurrent improvements in sewage facilities. Many pit
latrines dump into underground water supplies that connect to the river. Furthermore, people reported using the
river for garbage disposal and as a latrine. This led my neighbor to comment that the river was cochino, or dirty like
a pig. Additionally, I found that refuse from the local medical post was finding its way into the river, with children
squirting water at each other using medical syringes that were potentially contaminated with human blood or fecal
matter.
Finally, I noted that every few days, a helicopter flew above the community. I was told that the helicopters were
used to transport workers from the mining and oil operations that were in the interior of the region. Although oil
residue was not evident on the local rivers at the time of the study, community members expressed concern that
industrial contaminants were impacting children’s health. These concerns were warranted. In 2016, three oil spills
led to the release of more than three thousand barrels of crude oil into local rivers (Wolff and Floerke 2016).
Even before these egregious spills, community members clearly articulated the relation between social and
economic changes, the contamination of local water sources, and poor health outcomes. In 2013, one community
member stated,

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 Water Insecurity and Mental Health in the Amazon

Our ancestors did not have so much illness. They did not have so many problems. Although they suffered with
only so much food, our ancestors drank water without cooking it, because before, this did not produce illness
so easily. In contrast to now when the water quickly produces illness. And now the elders tell us that illness is
produced rapidly, because before, they did not sell gasoline . . . there were no cars. There was no petroleum or
smoke. (interview, October 5, 2013, Boca de Lobo)

Community members also expressed concern about the accessibility of water. Speaking about his chronic
experiences with pain and dizziness, an Awajún farmer stated, “How is it now that this illness has started? It is
because I do not have economy. No work. Not even a medicine. And I don’t eat well. Sometimes I live without
eating, without drinking” (interview, August 4, 2013, Pagki). This statement was confusing due to the abundance of
water sources in the area. However, I was later told that people suffered from thirst when they went to work in their
chacras (gardens where household and market agricultural products are grown), which could be anywhere from ten
minutes’ to two hours’ walk from the main river.
Because of the weight of water, people rarely carried it with them. This was particularly problematic for the
poorest people in the community for two reasons. First, I was told that the people from the wealthier and more
powerful families were able to secure lands closer to the communities, while those who were poorer or had less
entrenched familial connections in the communities had to go much farther to reach their gardens. Second, the
frequency of which individuals must travel to these gardens differed based on whether an individual was a farmer or
a “professional” (e.g., teacher). Teachers spend more time working in the schools near the rivers and make wages that
permit them to buy filtered water or sodas. Conversely, men who make their living through agriculture and women
who work extensively in their gardens to cultivate yucca and plantains for household consumption are more likely
to travel into the mountains and away from the main sources of water. Thus accessibility to water may be shaped by
gendered and socioeconomic hierarchies, creating additional stressors for already vulnerable individuals.
Finally, educational and economic resources influence who has the intention, or capability, to filter water from
the river for drinking. Some of the wealthiest households reported using chlorinated tablets to purify their drinking
water, while others boiled their water and others left it untreated. Boiling water is time and energy intensive,
leaving water tasting smoky. This creates obstacles to consistently purifying water for drinking or, even more rarely,
filtering the water for washing produce, potentially contributing to perceptions of water insecurity via concerns with
cleanliness.
To summarize, while there is an abundance of water in Awajún communities, issues with contamination,
accessibility, and usage (cleanliness) loom. As previously reviewed, water security has been associated with a range of
mental health outcomes in prior studies. In the next section, I use statistical analyses to examine whether quantitative
measures of water insecurity are associated with perceived stress, depressive symptoms, and somatic symptoms in
a sample of 225 Awajún adult men and women.

Water insecurity and mental health outcomes

A convenience sample of 118 Awajún men and 107 women, aged 18–65 years, participated in the quantitative phase
of this study. The survey was conducted in both Spanish and Awajún and included questions addressing water
insecurity and mental health.
At the time of survey development, I did not find an abundance of established methods for measuring water
insecurity and related concepts, and many questions that are applicable in one context are not applicable in
another. Thus I chose five yes–no questions from Stevenson et al.’s (2012) water insecurity measure that addressed
dimensions of the experience of water insecurity that were relevant to the Awajún context. Additionally, I added two
questions about boiling water, as participant observation in the first phase of the investigation indicated that this
practice varied among households. Water insecurity questions fell broadly into four categories: (a) perceived safety

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P. S. Tallman

and sufficiency (Have you drank water that you thought was not safe for your health? Have you collected water from
a dirty source?); (b) accessibility (In the last month, have there been times when you could not collect water because
it was too far away? In the last month, have there been times when you could not collect water because you were
too sick or weak?); (c) thirst (Have you gone to sleep thirsty because there was not clean water?); and (d) usage (Do
you boil all the water you drink? Do you boil the water you use to wash your food?). Scores for water insecurity
were summed and ranged from 0 to 7. A higher score indicated the experience of higher water insecurity for the
individual. Water insecurity scores served as the main predictors in the analyses.
The primary outcomes of interest, or dependent variables, included perceived stress, depressive symptoms, and
somatic symptoms. In terms of psychological stress responses, the most widely used measure of perceived stress is
the Cohen Perceived Stress Scale (PSS), which measures the level to which an individual considers his or her life
stressful by assessing how unpredictable or controllable a person feels his or her life is. To reduce participant burden,
I used the abridged four-item form of the PSS, which has been tested for reliability and validity (Cohen, Kamarck,
and Mermelstein 1983). The PSS is not a diagnostic instrument, so there are no established cutoffs, but in general,
higher scores indicate greater perceived stress experienced by individuals. In this study, scores ranged from 0 to 13
and were treated as a continuous variable in the statistical analyses.
Depression is a mood disorder that is related to feelings of sadness and disinterest (American Psychiatric
Association 2004). A range of scales have been created to measure depression, including the Hamilton Depression
Rating Scale, the Beck Depression Inventory, and the Patient Health Questionnaire (PHQ-9). The PHQ-9 was chosen
in this study because it has adequate test–retest reliability, internal consistency, item–total correlation, and factorial
structure (Güleç et al. 2012).
Somatic symptoms refer to a constellation of physical symptoms that are not associated with observable organic
pathology but are consistently associated with some form of stress (Kirmayer 2004), including headache, insomnia,
chronic pain, weakness, tiredness, blurred vision, and dizziness (Kleinman 1986). Again, a variety of scales are used
to measure somatic symptoms, but to keep the measures associated with mental health consistent, I elected to use
the Patient Health Questionnaire (PHQ-15) for somatic symptoms. Levels of depressive and somatic symptoms were
categorized by the summary score according to guidelines derived from the PHQ website.2 Levels ranged from 0
(none) to 3 (severe); thus these scores were treated as ordinal values.
The main hypothesis tested here is that higher water insecurity scores will be associated with higher perceived
stress, depressive symptom, and somatic symptom reporting. To test this hypothesis, multivariate linear and ordered
logistic regression analyses were conducted using the statistical program STATA 10, depending on whether the
dependent variable was continuous (linear) or ordered (ordered logistic). For the ordered logistic regressions,
the olog and odds ratio (OR) commands were used in STATA to report transformed ORs along with the 95%
confidence intervals. For linear regressions, the beta coefficient is reported along with the standard error. Relevant
covariates included age, community, and socioeconomic status, as they were expected to be associated with both
the independent and dependent variables. The community of Shushug serves as the reference community, as it was
the largest.

Results
A multivariate linear regression analysis was used to test the first hypothesis that higher water insecurity scores
will be associated with higher perceived stress. In the total sample, perceived stress scores ranged from 0 to 13
(Table 1).
In the fully adjusted model, water insecurity scores were significantly positively associated with perceived stress
scores, β (225) = −0.34, p < .01. Additionally, lower socioeconomic status and living in the community farthest

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Table 1 Descriptive Statistics for Independent, Dependent, and Control Variables among Awajún Men and Women

Total Samplec
a b
Men, M (SD) Women, M (SD) M (SD) Range
Independent variable
Water insecurity score 2.41 (1.66) 2.69 (1.60) 2.54 (1.63) 0.00–7.00
Dependent variables
Perceived stress score 7.51 (2.64) 7.56 (2.64) 7.53 (2.57) 0.00–13.00
Depressive symptom scores 4.23 (3.43) 6.35 (4.26) 5.24 (3.98) 0.00–22.00
Somatic symptom scores 4.84 (3.86) 7.74 (4.42) 6.22 (4.37) 0.00–20.00
Control variables
Socioeconomic status 1.38 (0.72) 0.98 (0.63) 1.19 (0.71) 0.17–3.50
Age (years) 34.12 (12.24) 32.57 (11.42) 33.38 (11.86) 18.00–65.00
Community (Shushug)d 71 69 140
Community (Pagki)d 24 17 41
Community (Mente)d 14 15 29
Community (Boca de Lobo)d 9 6 15
a
n = 118.
b
n = 107.
c
n = 225.
d
Number of people in each community.

Table 2 Linear and Logistic Regression Analyses of Perceived Stress Scale Scores, Depressive Symptom Scores, and Somatic Symptom
Scores on Water Insecurity Scores for the Total Sample

Perceived Stress Score Somatic Symptom Score Depressive Symptom Score

𝛃 (SE ) p-Value OR (95% CI) p-Value OR (95% CI) p-Value
Independent variable
Water insecurity score 0.34 (0.09) 0.001** 1.50 [1.27, 1.77] 0.00*** 1.34 [1.13, 1.58] 0.000***
Socioeconomic status −0.81 (0.25) 0.002** 0.81 [0.53, 1.23] 0.33 0.81 [0.53, 1.24] 0.33
Age (years) −0.00 (0.01) 0.78 1.01 [0.99, 1.03] 0.23 1.01 [0.98, 1.03] 0.23
Sex 0.30 (0.34) 0.38 0.28 [0.15, 0.50] 0.00*** 0.28 [0.22, 0.69] 0.00***
Ref. community (Shushug)
Pagki −0.34 (0.50) 0.49 0.43 [0.19, 0.96] 0.04* 0.43 [0.16, 0.90] 0.04*
Mente 0.53 (0.45) 0.24 0.47 [0.22, 0.98] 0.05* 0.47 [0.24, 1.12] 0.05*
Boca de Lobo 2.10 (0.68) 0.003** 0.50 [0.15, 1.67] 0.27 0.50 [0.09, 1.22] 0.27
Adjusted R2 0.1282 0.1186 0.0844
Note: n = 225.
*
p < .05.
**
p < .01.
***
p < .001.

from the highway, Boca de Lobo, was associated with higher perceived stress scores, β (225) = −0.81, p = .002, and
β (6) = 2.10, p = .003, respectively (Table 2).
Next, multivariate-ordered logistic regression analyses were used to test the second and third hypotheses that
higher water insecurity scores will be associated with higher levels of reported depressive and somatic symptoms.
In the fully adjusted model, water insecurity scores were significantly positively associated with somatic symptom
scores, OR (225) = 1.50 p < .01. Being male was associated with lower odds of reporting somatic symptoms, OR
(225) = 0.28 p < .00, as well as living in the two communities, which were at an intermediate distance from the
highway: Pagki, OR (225) = 0.43, p = .04; Mente, OR (225) = 0.50, p = .05 (Table 2).

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P. S. Tallman

Water insecurity scores were also significantly positively associated with depressive symptom scores, OR
(225) = 1.34, p < .01. Being male was associated with lower odds of reporting depressive symptoms, OR (225) = 0.28,
p < .00, as was living in Pagki, OR (225) = 0.43, p = .04, and Mente, OR (225) = 0.50, p = .05 (Table 2).
To summarize, higher water insecurity scores were associated with higher levels of depressive symptoms,
somatic symptoms, and perceived stress in the total sample. Significant relationships also emerged between these
outcomes and gender and community.

Discussion
In this article, I used a critical biocultural approach to show how economically driven changes, such as highway
construction, resource extraction, and transitions in settlement patterns, have impacted water insecurity in Awajún
communities. These changes have created increased levels of trash, sewage, and environmental pollutants in local
rivers, leading to concerns over contamination, accessibility, and cleanliness of water. This has implications for men-
tal health, as higher water insecurity scores are associated with increases in perceived stress, depressive symptoms,
and somatic symptoms among Awajún men and women. In the following discussion, I address the potential mech-
anisms connecting water insecurity to mental health, the limitations of this research, and theoretical and method-
ological directions for future investigations of this topic.
One of the goals of a critical biocultural approach in anthropology is to understand how “external” forces are
“internalized” via the local construction and shaping of power relations (Roseberry 1998). According to Wolf (1982),
power results from the control of social labor, making economic anthropology an apt subdiscipline from which to
approach a “critical” analysis of the causes of water insecurity. In this article, I traced how American missionaries
trained a new generation of indigenous, bilingual teachers, creating a new “professional” class. These actors, in
conjunction with national agrarian reforms, encouraged the Awajún to move from widely dispersed households to
communities centered around a school, church, and trading post that perpetuated a system of knowledge based on
economic evaluation that has implications for water insecurity and mental health.
Indeed, I find that in this sample, water insecurity is associated with increased levels of perceived stress, somatic
symptoms, and depressive symptoms, which are well-known correlates of psychological distress (Brown, Craig, and
Harris 1985; Kleinman 1986). Gender and community were also associated with these outcomes. A consideration
of the potential mechanisms underlying the relationships between these variables can be found in Tallman (2015,
2018). In regard to water insecurity, Wutich and Brewis (2014) propose that multiple pathways may explain the
relationship between water insecurity and distress, including (a) uncertainty and unpredictability, (b) social stigma
and shame, and/or (c) perceptions of unfairness or injustice. Each of these mechanisms may be at play in Awajún
communities.
Beginning with uncertainty and unpredictability, many Awajún community members complained that flooding
in the river made bathing and the procurement of water unpleasant. As mentioned, highway construction leads to
deforestation, which influences global climate and atmospheric flows, such that flooding and droughts are increasing
in intensity and frequency (Gloor et al. 2013). Research in Peru and Bolivia shows that flooding in Amazonian
communities increases dimensions of water and food insecurity, elevating the risk for the spread of vector-borne
disease and human displacement (Hofmeijer et al. 2013; Rosinger 2018; Sherman et al. 2016). In this analysis,
uncertainty connected to flooding may have been captured by questions included in the PSS asking participants
about whether they felt unable to control the important things in their lives. Considering that Awajún community
members spend a significant portion of their daily lives using the rivers for transport, washing, bathing, and
drinking, any variables that complicate this access could create distress through a feeling of unpredictability.
Perceived stress scores, as well as depressive symptoms, such as “feeling hopeless,” may also be connected to
perceptions of unfairness in terms of the contamination of local water sources with pollutants from upstream

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extractive industries. In 2009, the passing of trade policies to facilitate expanded oil and gold extraction prompted
several thousand Awajún and Huambisa community members to block the main local highway. The protests
provoked a sense of injustice, as some community members were unjustly incarcerated and others were killed by
the police (Greene 2009b). More recently, Awajún community members have vehemently protested multiple oil
spills and the proposed construction of a series of dams on their rivers. The very real threat of compromised water
quality due to oil extraction, mining, and dam construction is truly an injustice; as Awajún community members
have articulated, “without water, there is no life.”3
Finally, in terms of shame, in the second part of this article, we heard from an Awajún farmer who attributed
his chronic illness to lacking water, among other concerns, drawing attention to the possibility that accessibility to
water was shaped by socioeconomic hierarchies. He continued his narrative, saying,

How did this illness begin? And when will I get better? I always think of this, especially when I am alone in my
garden. How can I go back to the way I was before? Without sickness so that I could leave for work without any
doubts. Because of this I am not happy. I am not happy with my family because of this illness. I don’t want to talk
about this illness, because it always makes me feel bad or embarrassed [siempre me da pena].
I say, how can I live eating well? Like the others eat? The others eat well because they earn well. Because of this,
they eat whatever they desire. But instead I, I who do not have anything, what am I going to buy? This is why
sometimes I do not eat in a day. How am I going to get enough money? My garden does not always give all good
fruit. It gives a little by little. This is why I don’t have money. How can I have money to cure myself? I always say
this and will always be saying it. (interview, October, 28, 2013, Mente)

In the rest of the quote, we see evidence for shame as an operating mechanism; the role of economy as a driver
of concerns; the synergistic effects of multiple stressors; and the circular nature of worry, poor health, and isolation.
Specifically, it is possible that extended efforts to obtain water create distress, and distress contributes to a depressed
mental outlook, reducing motivation to obtain or filter water and creating the conditions for dehydration and disease
that can hinder future efforts to secure clean water. Such reciprocal relationships tap into Leatherman’s (2005)
concept of a “space of vulnerability” and Paola Rattu’s (as cited in Wutich and Brewis 2014) suggestion that future
work on water insecurity should consider the circular relationships between water insecurity and distress.
In addition to examining circular spaces of vulnerability, future research on this topic should consider advances
in survey methods, in the detection of local expressions of distress, in biomarker technology, and in models that
may serve as unifying frameworks connecting the economic, social, psychological, biological, and applied aspects
of water insecurity and health. In the final paragraphs of this article, I address the limitations of the present study
and consider the aforementioned methodological and theoretical advances for future research.
First, the measure of water insecurity applied in this study was a modified version of Stevenson et al.’s (2012)
survey questions. Such modifications reduce the power of comparisons among studies. Jepson et al. (2017b) suggest
that future efforts should focus on developing scales and other methods suitable for cross-cultural and cross-site
comparisons, and significant efforts are under way by Young and colleagues to create a cross-culturally valid
household water insecurity scale (HWISE 2018).
Second, while this study included three measures of mental health, addressing local expressions of distress in
relation to water insecurity could reveal more nuanced dynamics. For example, Wutich and Ragsdale (2008) found
that expressions of fear, worry, and anger were stated in relation to social inequities in water distribution, providing
insights into the economic and political drivers of water insecurity. As well, local idioms of distress can serve as an
entry point to the cultural meanings of water that are not easily captured by standardized metrics (Jepson et al.
2017b) and may provide a window into the biological correlates of stress. Pike and Williams (2006) found that
idioms of distress were more highly correlated with salivary cortisol than standardized measures of perceived stress
in their work in Turkana.

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P. S. Tallman

Beyond measures of salivary cortisol, progress in biomarkers has had relevance for understanding the biological
correlates of water insecurity. For example, Rosinger (2018) used urine-specific gravity to investigate dehydration
in relation to floods in the Bolivian Amazon. As well, Hoke et al. (2018) recently validated a measure of EndoCAb
in dried blood spots (DBS). EndoCAb is a measure of endotoxin core antibodies, which gauge subclinical intestinal
damage caused by frequent oral–fecal contamination that could occur by drinking dirty water. These measures
could be paired with DBS measures of immunoglobulin E, which reflects repeated macroparasitic infection, and
quantitative measures of water quality detecting the presence of Salmonella, Citrobacter, and other pathogens that
can cause gastrointestinal disease (Rosinger 2018).
Beyond methodological advances in both survey and biomarker technology, theoretical understandings of
water insecurity have expanded to consider how entitlements, capabilities, and a relational approach (Jepson 2017a;
Nussbaum and Sen 1993) can shift our view to the institutional drivers of resource insecurity and potentially to the
policy changes that could intervene in the cycles of vulnerability created by economic and extractive processes.
Particularly, there may be room for deeper integration of these concepts into a critical biocultural approach
(Goodman and Leatherman 1998).
For example, Leatherman and Hoke (2016, 286) contend that we can use a critical biocultural approach to
“understand the multiple dimensions of poverty that emerge from different historical forces and how these underlay
unequal exposure to problems, access to resources, and the biological and social responses to a range of conditions.”
If we bring in a perspective that considers human entitlements, capabilities, and fairness (Wutich et al. 2013), this
call to research expands the anthropological vision to also ask how people “can live their lives as they choose, achieve
freedoms in line with their own vision, and achieve their fullest potential” (Jepson et al. 2017a, 48). It encourages
us to consider not only water but also food, energy, and air in an anthropology of resource insecurity (Wutich and
Brewis 2014) that includes considerations of freedom from need and the freedom to live with dignity (Zografos,
Goulden, and Kallis 2014). This perspective aligns with indigenous claims to environmental justice (Jepson et al.
2017a) that question the sustainability of capitalist models of development that unequally extract resources and
labor from the Global South.
In conclusion, future research on water insecurity would greatly benefit from increased collaboration among
the anthropological subdisciplines. Economic anthropologists can shed light on the processes of production and
exchange that form the basis of exploitative models of economic development that lead to water insecurity (Li
2013), while cultural anthropologists can position these discussions within a broader understanding of global
and transnational processes (Aiyer 2007; Raffles 1999; Sam and Armstrong 2013). Environmental anthropologists
could contribute to understandings of the ecological impacts of economic and extractive practices, while medical
anthropologists and human biologists could attend to the lived experiences and biological and psychological
correlates of marginalization and vulnerability.
Twenty years ago, Thomas (1998, 67–68) stated that “the urgency of synthesis is underwritten by the types
of problems we face that require solutions that integrate environmental quality, human health and social justice.”
This urgency is more salient than ever as our climate continues to warm and clean water sources dwindle. It is
my hope that new subdisciplinary collaborations among anthropologists will use the most cutting-edge theory
and technologies to question whether our current pathways to “development” are fueling cycles of vulnerability
and to contemplate new choices that can better support human freedom, capabilities, and, ultimately, flourishing
(Nussbaum and Sen 1993; Sen 1999).

Acknowledgments
This research was funded by a Wenner–Gren Foundation Dissertation Fieldwork Grant (P0023308-60033657). Special thanks go to the
participating communities; the Peruvian Ministry of the Environment; the Organización Regional de los Pueblos de las Comunidades

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 Water Insecurity and Mental Health in the Amazon

Indıgenas de la Amazonıa Peruana Norte (ORPIAN); Giuliana Sanchez, who aided in the collection of the data; and Edilberto Kinin, who
made the fieldwork possible.

Notes
1 See http://www.wycliffe.org/.
2 See http://www.phqscreeners.com/instructions/instructions.pdf.
3 See https://www.youtube.com/watch?v=Jwqu0FCbd-c&t=1215s.

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