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Due to limitations of space, the literature review can only be briefly sketched, within the confines of selected multidisciplinary works -- it is in no way inclusive. Only the most important anthropological, geographical and epidemiological works related to the research will be briefly discussed. In particular, the literature review was guided by research conducted in the Yaqui Valley in northwestern Mexico by Guillette (1998); the Yakima Valley Washington by Faustman, Fenske and Thompson (2002); the Aluoi Valley in Vietnam by Cau, Hung, and Dung (2000); in St. Lawrence Island, Alaska by Carpenter (2000); in Central America and Caribbean by Murray (1994) and Stonich (1993); and in Oaxaca, Mexico by Cartwright. These works are of particular value because they contain a concise review and discussion of the interactions between culture, health and environment – one of the conceptual components that this research draws upon for a theoretical basis. An important aspect of the literature review was the works of authors writing about local knowledge, beliefs and perceptions of environmental change and cultural interpretations and narratives regarding health, healing and illness.

Although the research problems and objectives are international in scope, there is nevertheless a great deal of emphasis placed upon the Dominican context. There are a number of reasons for this, none of which should be taken to imply that the issues addressed are peculiar to the Dominican Republic, or the findings of the research not applicable outside the Dominican Republic. The main reasons for selecting the Constanza Region were:

Location: The study area has well demarcated or defined geographical boundaries. The intermountain region allows for evaluating the influence of biogeophysical processes on pesticide drift and exposure.

Human Health Concerns: The region has a large rural population living in close proximity to pesticide sprayed fields. It has a large number of farm workers and children who are directly exposed to pesticides during work and school playground activities, respectively.

Environmental Quality Concerns: The region’s economy is based on pesticide-dependent agricultural production, and centered on non-traditional export crops. The existent economic and political structures regarding agricultural production favor pesticide use over environmentally-friendly and sustainable agricultural methods.

Non-existent Multidisciplinary Research: The literature review failed to find social, natural or environmental scientists, Dominican or otherwise, that treat the human-health-environment theme in a holistic and complementary manner.

Research Model: The region can serve as a research model for other intermountain regions in Latin America, Africa and Asia undergoing environmental and human health deterioration; influenced in part by human activities and behavior, political and economic decision-making, and biogeophysical processes.

Converging Disciplines

The broad spatial and temporal scales of human-environment interactions demand that models cross-disciplinary boundaries. As the dimensions of these interactions becomes broader, more disciplines may need to be incorporated. The research in general and the literature review, in particular, reflects the convergence of anthropology, geography and epidemiology for understanding human-environment interactions within the context of agrochemical exposure and human health. These complementary approaches allow for a more thorough understanding of the processes leading to adverse health events as a consequence of pesticide use; and more important, for discovering methods for improving environmental quality and community health. Human health, in and of itself, is a complex issue affected by a wide variety of sociocultural, political, economic and environmental processes and is treated throughout the literature review. Accordingly, the literature review is divided into three sections that reflect this diverse methodological approach: (1) Anthropology (Cultural Anthropology, Medical Anthropology, Environmental Anthropology); (2) Geography (Political Geography, Medical Geography, Biogeography, GIS); and (3) Epidemiology.

Anthropological Literature: Culture, Disease and Health

Cultural Anthropologist Elizabeth Guillete (1994) conducted her research on the effects of pesticides on preschool children in the Yaqui Valley in northwest Mexico. The comparative study used a sample population that shared similar genetic backgrounds, diets, cultural patterns, and social behaviors. The only major difference was their exposure to pesticides. Pesticides have been applied in the valley since the late 1940s. In 1990, high levels of multiple pesticides were found in the cord blood of newborns and in breast milk. Building on anthropological methods for evaluating environmental problems, a Rapid Assessment Tool for Preschool Children (RATPC) was developed to measure growth and development. (Environmental Health Perspectives 1998, 106: 347-353).

The children were divided into two groups. Thirty-three of these children lived in the valley, which is a farming area where pesticides are applied up to 45 times between planting and harvesting. These pesticides were mostly organophosphate and organochlorine mixtures, and pyrethroids. Seventeen other children lived in the foothills, which is a ranching area where there is minimal pesticide use. Both groups of children had minimal exposure to ambient contaminants. The authors found no differences in growth patterns, but they did find psychological and physiological differences in functional abilities. The RATPC measured varied aspects of physical growth and abilities to perform, or function in, normal childhood activities. Her findings show no differences in growth patterns of the children. However, functionally, the valley children demonstrated decreases in stamina, gross and fine eye-hand coordination, 30-minute memory, and the ability to draw a person (Environmental Health Perspectives 1998, 106: 347-353).

Cultural interpretations of health and illness are important components of the study. However, very often the medical anthropology literature (Walker, 1972; Fabrega and Silver 1973; Kinzie, et al. 1976; Gould 1977; Landy 1977; Kleinman 1976, 1978; Bauwens et al. 1978; Foster and Anderson 1978; Altman and Chemers 1980; Singer 1989; Seedhouse 1989; Farmer 1998; Rapport 1992; Finkler 1993, 1998; Foster 1998; Helman 2000; Hunter 1996, 1991; Laurier 1998; Levi-Strauss 1998; Rubel 1998; Trotter 1998; Strathern and Stewart 1999; Adler 1999, 1995, 1994, 1991; Shorter 1992, 1994, 1997, 2000; O’Connor and Hufford 2001; Adler, and Shelley, 2001; Owen Jones and Polk 2001; Bury 2002) focuses only on the cultural dimensions of health and healing practices, cultural beliefs and perceptions, to the exclusion of other, equally important, health issues, such as environmental quality and community health. On the other hand, the epidemiological literature (Guo, Lai, Ju, Chen, Hsu 1993; Guillette 1994; Auger, Kunstmann, Czyglik and Jouannet 1995; Guillette, Crain, Rooney, Pickford 1995; 2000; Carpenter 2000; Faustman 2002) is more thorough in treating the interconnections between health and environment, but the culture component is absent.

Numerous anthropologists have written on the importance of the traditional or folk healer-patient relationship including: Fabrega and Silver 1973; Clark 1973; Kinzie 1976; Gould 1977; Landy 1977; Peters 1978; Foster and Anderson 1978; Kleinman 1980; Dobkin de Rios 1981; and Finkler 1998. Finkler (1998) offers a comparison of the theory and practice of healing for two medical systems - spiritualism and biomedicine in Mexico and asks: Do epistemological differences affect the quality of the interaction between healers and their patients? According to Finkler (1998), the epistemologies (the ways of knowing and explaining things) of the two medical systems are different, and “medical pluralism” exists between the two. Patients readily accept both medical systems and are not concerned about the differences between the two. For Finkler, patients are pragmatic, when they want relief from pain or illness they will seek healing where answers and solutions are offered. The author argues that many people, who become spiritualists, do so after suffering a health crisis and being cured. Empowered with their “healing gift”, spiritualists narrate their own illness and healing to the patient seeking treatment.

Following the same precepts (Bauwens, 1978:83) states that: “within a cultural context, the concept of health must be viewed in terms of beliefs and practices that contribute to the maintenance of a sense of well being, and beliefs and practices that give a sense of mastery in times of stress…” Stafford (1978:12) stresses the importance of “distinguishing disease from illness. Disease is a term used to describe a process in the patient that is open to objective description and definition…illness is a term that denotes the patient’s perception of a health problem and is therefore more subjective. These terms are used interchangeably when there is agreement between provider and patient as to the nature of the problem. When views diverge, however, it is important to perceive the nature of the illness through the eyes of the patient in addition to defining the disease process. It is the patient’s perception of the illness that governs his or her behavior" (1978:12).

Thus, health may be seen as that which enables people to achieve their maximum personal potential and the ability to adapt to new or changing circumstances. This capacity is seen as a fundamental human trait, part of which is human ability and willingness to alter the environment in ways that adversely impact human health. Stafford continues: “knowledge and beliefs about health and illness are frequently agreed upon by individual members of a cultural group. These beliefs influence the patient’s recognition of illness, the selection of a health care provider, the expectations of the provider patient encounter, and the attitudes toward professional institutions and social agencies in which medical care is invested. In addition to cultural factors, the choice of medical care is influenced by economic factors and by the availability and accessibility of health care (1978:12).”

Geographical Literature: Human Behavior and Activities in Time and Space

A significant amount of evidence, theoretical and empirical, has gradually been acquired which indicates that biogeophysical processes matter in maintaining healthy environmental systems. In view of that, an abundant literature on geographical indicators, frameworks and related topics are discussed in this section. There are some noteworthy authors/documents listed below that can provide the interested reader with a substantial foundation in the theory and practice of geographical approaches in the area of human-environment interactions.

The study uses geographical methods and tools to uncover important and distinct interactions and address the complexity of spatial-temporal dimensions of anthropogenic activities (Ward, Nuckols, Weigel, Maxwell, Cantor, and Miller, 2000). Further, since human-environmental interactions are usually influenced by biogeophysical and biogeochemical processes, we must include these processes in the discussion. The literature review on the interaction of human health, biogeophysical and biogeochemical processes within the dimensions of space and time is extensive (Betts, 1999; Brovkin et al., 1999; Chase, 2000; Claussen and Gayler, 1997; DeFries et al., 1999; Kleidon et al., 2000; Kutzbach et al., 1996; Pitman and Zhao, 2000; Wang, Takle, and Shen, 2001).

There is also an extensive literature that incorporates concepts from complex system theory, such as the notions of feedbacks and hierarchies to facilitate biogeochemical and biogeophysical understanding. Noss and Cooperrider (1994) combine systems theory to first develop the concept of ecosystem integrity and then proceed to determine potential indicators of integrity and disintegrity (or threat) for natural and modified landscapes. They argue that an important factor influencing healthy environmental systems is the extent to which landuse and landcover change occurs. Changes in both landuse and landcover have a direct impact on biogeophysical and biogeochemical processes via the feedback loops between vegetation and atmosphere. For example, changes in biomass will directly modify near-surface energy, moisture, and momentum via changes in albedo, roughness, leaf area, and by changes in atmospheric CO2 concentration.

Space, place and time are intrinsically intertwined with the research, and geographical approaches are used that allow for a thorough exploration of the various ways in which our perceptions and awareness of the environment is constructed. Closely related to space and place, is power. According to Massey (1999:324), power in its various guises and disguises serves a divisive purpose: identifying them and us and drawing boundaries that maintain the core inside and periphery outside. For Massey, these “relations are conceived through their fixed and fluid geographies” (1999:324). Edward Said, looks at these fixed and fluid geographies through the “geographical distinctions such as the terrains of ‘ours’ and ‘theirs’, the dividing line of inside and outside, and relations of proximity more generally” (Massey 1999:325). Fluid geographical betokens a shift in analytical emphasis from reiterating fixed surfaces to tracing points of connection and lines of flow (Law and Mol 1994 in Massey 1999:31).

Massey (1999) argues, “ that thinking geographically can alter the way in which we understand events, and issues”, and in part, it is this that my research has sought to demonstrate. In particular, that pesticide exposure and the consequent adverse health outcomes are produced through: (1) spatial activities and behaviors; (2) geographical proximity to a source of contamination; and (3) social, economic and political systems (internal and external), which allows for the production and frequent use of toxic agrochemicals, that can have harmful effects on environmental quality and community health.

The notion of “uncertainty” is used in the study to understand not only the dynamics of environmental change, but how it is described and perceived by others. . According to Golledge and Stimson uncertainty is “a description of the precision and accuracy with which something is known or predicted from knowledge. It is not an abstract hypothetical construct used to help define formal models, but rather a natural fact of living in an environment that is complex enough and large enough to prevent the instantaneous dissemination of all knowledge” (1997:207).

Massey (1996) further argues that the reproduction of geographical knowledge by others is also situated in their particular interpretations of their particular circumstances: “actors actively draw upon localities as a basis for interpretation, thus, certain understandings of place is important to specific notions of health. Although Massey sees place as “articulated moments in networks of social relations and understanding, she fails to explain the relationship between both. The author (1994) looks at the notion of spatial division of labor to examine the geography of the social relations within a “the economic”. She focuses on the social relations of production and reproduction, insisting that the economic is also the social, and that gender as well as class must be central to analysis.

Epidemiological and Pesticide Exposure Literature

The conventional epidemiological approach to health has been the “eradication of disease”, in which disease is seen as an abnormality in a part of the body. This approach is the basis for most toxicological research on adverse health events caused by pesticide exposure. This concept can be used, under certain circumstances, to identify pesticide exposed and non-exposed groups based on the absence of symptoms associated with pesticide exposure. However, presence or absence of symptoms is not a strong indicator of illness or disease, as the research demonstrates. Even in the absence of disease, some individuals may experience symptoms that may be associated with other “health stressors”. For example, in pesticide-exposed communities, the perception of risk related to exposure to pesticides is often a cause of anxiety and distress, which may lead to ill health and disease. The appropriate question to be asked is: what caused the illness or disease? Was it caused by the anxiety and stress of living in a perceived contaminated environment; or did a real and not imagined agent cause the illness?

The epidemiological literature is replete with works on the effects of pesticides on humans and wildlife. These works examine the potential human health effects of pesticides outside the laboratory setting. This is important because epidemiological studies can provide information that cannot be predicted from testing on nonhuman species. Studying the effects of testing on nonhuman species adds to the toxicological evidence derived from laboratory studies. Conversely, the literature reports putative links between self-reporting symptoms associated with pesticide exposure and increased development of chronic illness such as liver, respiratory, brain diseases (Pimentel and Pimentel, 1978; Wedin, Pennente, and Sachdev, 1984; Minton 1988; Jeyaratnam 1985, 1990; Abebe 1991; Pimentel 1991; Dinham 1993; Jeyaratnam and Chia, 1994; Pimentel 1993; Garcia-Rodriguez 1996; Habib 1996; Guillette 1996; Kavlock 1996; Daniels 1997; Bekkers 1997; Repetto and Baliga 1996, 1997; Weiss 1997; Gupta 1998; Ecobichon 1999; Fenske 1999; Harris 2000; Teske, Ice, and Thistle, 2000; Lu 2000; Agate 2001; Bell 2001; Cabello 2001; Karalliedde 2001; Arcury 2001; Teske, Bird, Esterly, Curbishley, Ray, and Perry, 2002; Teske, and Ice, 2002; Faustman 2002).

Faustman, Fenske and Thompson (2002) conducted research in the Yakima Valley in Washington to evaluate the contribution of several environmental exposure pathways affecting children's health. This study quantifies spatial and temporal variability in pesticide residues in and around residences of children that live in close proximity to fields where agrochemicals are used. It also characterizes child behavior and activities during periods of pesticide application and when children have access to pesticide-treated areas. Faustman’s (2002) study evaluates the contribution of several pathways to children's pesticide exposure. This study quantifies spatial and temporal variability in pesticide residues in and around residences of farm worker children. It also examines child activities during periods of residential pesticide contamination and during periods when children have access to recently pesticide-treated areas. The significance of Faustman’s study is the development of a source attribution model for the major pesticide exposure pathways. More importantly, the study offers specific recommendations for rapid intervention for protecting the health of rural residents, in particular children.

In farming communities, the potential for exposure to pesticides is greater than for the general population (Shalat et al., 2002). Numerous studies have shown that children are exposed to environmental chemicals, particularly pesticides, through different mechanisms and often in greater quantities than adults (Fenske et al., 1990, 2000; Simcox et al., 1995; Bradman et al., 1997; Loewenherz et al., 1997; Lu and Fenske, 1999; Lu et al., 2000). Several studies have examined pesticide exposure in children who live in close proximity to agricultural fields (Loewenherz et al., 1997; Fenske et al., 2000; Lu et al., 2000; O'Rourke et al., 2000; Sumner and Langley, 2000; McCauley et al., 2001). Results from these studies show that children who live in agricultural communities had five times higher pesticide metabolites in their urine than children who resided in nonagricultural communities (Lu et al., 2000). These studies found that children who resided near orchards had statistically significantly higher urinary levels of pesticides. When compared to EPA chronic dietary reference doses, 56% of those whose parents worked in agricultural settings exceeded these levels (Fenske et al., 2000).

Cau, Hung, and Dung (2000) conducted their study in the A Luoi Valley in central Vietnam. They examine herbicides and defoliation used to destroy the forest of South Vietnam by the U.S. Army between 1961 and 1971. According to the authors, the levels of application of these toxins for the military operation known as Ranch Hand Operation, was 20 to 40 times greater than for normal agricultural usage. The A Luoi Valley had been one of the most heavily sprayed areas in Vietnam because it was located along the Ho Chi Minh trail. Their research on the effects of toxic war chemicals and present pesticide use has been on going since 1993. Preliminary results show that the surrounding area of the valley’s (Vietnam War era) airfield has a very high level of dioxin concentration in soil. Their findings also show ratios of reproductive abnormalities and congenital deformities that are two or three times higher as compared to the pre-war ratios. Results also indicate that dioxin concentration in poultry and fish are significant and could be a sign of the presence of dioxin in the food chain.

Neurotoxicologist David Carpenter’s work in Southeast Asia examines the specific environmental conditions existing in the Western Pacific Basin countries that are affecting children's health. As Carpenter notes, “environmental quality has important direct and indirect determinants of children's health in Asia and elsewhere in the world. Poor children and especially poor children in the poorest countries are most at risk from environmental quality problems. Poor children are the most vulnerable and disenfranchised segment of any society, and environmental hazards in conjunction with social stress and malnutrition often pose almost insurmountable barriers to a child's normal development. It is the health of children under 5 years of age that is most damaged by poor environmental quality. The lack of safe drinking water and uncontaminated food is of particular importance, causing morbidity and mortality through diarrhea and other infections, both because of exposure to infectious organisms and contaminant-induced suppression of the immune system" (2000). Carpenter describes several problems related to pesticide exposure of children in Asia: lack of education, proper pesticide handling and use enforcement, and understanding of exposure risks He reports that farm workers “believe that it is their fate to be exposed, and therefore they accept these exposures.” As reported by Carpenter (2000) in Southeast Asia, child labor is also wide spread. Children live in close proximity to the father's employment, resulting in additional exposure. There is often inadequate or no labeling of pesticides.

The literature is consistent that there are many possible mechanisms of chemical action on the human organism. One of the most common mechanisms may be the ability of many chemicals to act as an antagonist of the natural hormones, and binding their receptors. For example, some organophosphates can act as estrogens or anti-estrogens, depending on the level of exposure.

An on-going study conducted by Guillette (1994), focuses on the ability of environmental contaminants to mimic chemical messengers (hormones) and alter functioning of the reproductive and endocrine systems. Although considered rare until a decade ago, evidence that many types of chemicals, such as some pesticides, industrial chemicals and detergent products, alter the signaling systems in our bodies and those of wildlife species is common. These chemicals have been widely reported as "Environmental Estrogens" but have numerous actions beyond mimicry of estrogenic hormones.

As Guillette points out, by mimicking our hormones and acting upon their receptor cell sites they trigger unwanted activities and block other crucial biological events from taking place. Sexual identity, reproduction and brain development are among the many functions that hormones are responsible for in humans and other animals. In humans, attention deficit, problems with reading and memory, and difficulty in coping with stress may all be linked to hormone-disrupting toxins in our environment. While there is strong evidence of reproductive health effects associated with endocrine disruptors from a number of epidemiological studies, most of the direct evidence has come primarily from wildlife studies, as those conducted by Guillette. While data have led to a biologically plausible model of effects on human reproductive development even at low exposure levels, the significance of the findings for humans has yet to be established.

Bell (et al. 2001) presents the results of a case-control study on pesticides and fetal death due to congenital anomalies. This study shows a consistent pattern with respect to the timing of exposure. The greatest risks for exposure through pesticide applications were from exposure during the 3rd-8th week of pregnancy. When the exposure period was extended to the first trimester of pregnancy, and further to the time before 20 weeks of gestation, the effect estimates decreased. Using data from two population-based case-control studies, Croen (et al. 1997) investigated whether maternal residential proximity to hazardous waste sites increased the risk for selected congenital malformations in California.

Bracken (1997) suggests that studies of specific chemical exposure in occupational settings are likely to be more informative than are studies of waste sites. The association between birth defects and pesticides, however, has been studied in occupational settings applying careful industrial hygienic exposure assessment, but without the ability to estimate total environmental pesticide exposure. As was the case for Blatter (et al. 1996), the researchers of earlier studies were unable to link the observed excess of birth defects in agricultural work conclusively with pesticides. Blatter pointed out that environmental pollution with pesticides, on and around the farm, has been studied in occupational settings applying careful industrial hygienic exposure assessment, but without the ability to estimate total environmental pesticide exposure (1996). Schaum (1990) conducted a study on routes of various chemical exposures (air, water, dermal, and food) and their relative contribution to total human exposure. Pimentel (1991, 1993) presents the results of a study that examines the ethical, economic, environmental and health issues related to pesticides and, more broadly, related to pest management. Pimentel offers recommendations and methods for implementing environmentally sound pest management practices in agriculture.

Conclusion

This literature review provided an insightful and careful exploration of all the mechanisms at work that contribute to the environmental and community health problems. Although an extensive literature exists on culture, health and environment, there has not yet been a truly multidisciplinary and holistic treatment of the relationship between these components, in the Constanza Region or any other region in the Caribbean. The literature review failed to find social, natural and environmental scientists, Dominican or otherwise, that treat this relationship in the context of culture, environmental quality, community health and pesticides. In short, in the Caribbean, and the Dominican Republic in particular, there is much fertile ground left to till, particularly by an anthropologist with multidisciplinary tools.

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