Even though measures are taken to destroy vinchucas and purify blood banks, the congenital transmission of Chagas’ disease will still occur in Bolivia due to the large percentage (50 percent) of women who are infected with T. cruzi transmitting the parasite during pregnancy. The incidence of congenital transmission of Chagas’ disease is 10 percent in Bolivia, which is double that found in Argentina and Brazil, but this may be due to the fact that the latter two countries did not consider newborns in their counts. Preventative measures that relate to early detection of the infection and the subsequent treatment of newborns are required.
T. cruzi can travel in blood and organs to infect people in nonendemic regions. It travels with women as they migrate from rural to urban areas and from Bolivia to other countries of the world, and it is passed along to their children, usually for two generations. The transmission of T. cruzi is no longer limited to Latin America and the environments of its primary vectors, triatomines. It is becoming a worldwide problem. The silent traveler has arrived on distant shores.
CHAPTER FIVE
Cólico miserere: Enlarged Colon
Chagas’ disease is an elusive target for medical practitioners. It has a diffuse symptomology, if any, until the classic chronic stage, and its clinical symptoms could result from a number of other diseases and causes. It cannot be cured in its advanced stages. It is an autoimmune disease. Moreover, in Bolivia and most other places, Chagas’ disease is not well known and patients are rarely tested for it. Biomedical and ethnomedical practitioners treat its symptoms with a combination of home remedies, herbs, surgical practices, and rituals. Cultural and social interpretations of its symptoms sometimes delay medical treatment, but they help Bolivians understand in meaningful terms the suffering it causes. These interpretations can also be used to educate Bolivians about Chagas’ disease.
Juana
Juana is a Quechua-speaking peasant of the Calcha ethnic group in the north of Potosi. She and several other members of her family became sick with Chagas’ disease. Doctors Oscar Velasco and Francisco Delgadillo treated them and reported on how Juana experienced this disease and how she was treated. Velasco and Delgadillo are skilled in using ethnomedicine in conjunction with biomedicine. They do not subordinate one to the other, but respect each as distinct practices that converge towards a common goal of the patient’s health.
The Department of Potosí is situated in southwest Bolivia, between 18 and 23 degrees latitude and 65 and 69 degrees longitude. It is the fourth largest department in Bolivia and has 300,000 inhabitants living in a variety of ecological zones that range from 3,900 meters (13,000 feet) above sea level, where there is sparse vegetation, scarce rain, and permafrost, to valleys that range from 2,800 to 3,000 meters (9,200 to 9,850 feet) above sea level, where a moderate climate and fertile soil provide many agricultural products and where the majority of the population lives. The lower valleys constitute 38 percent of the territory; its natives speak Quechua and some Spanish. Other local ethnic groups are the Chichas, Chara, Calchas, and Yuras. Despite concerted European culture incursions, these groups have maintained traditional Andean cultures, especially the Calchas and Yuras, who are noted for their ethnocentrism.
Throughout her youth, Juana lived in this temperate valley climate, noted for its vast production of fruits and vegetables. Her parents worked as peasants for vast Spanish estates. During the colonial epoch, Spanish conquistadors and farmers entered these valleys to produce food and materials for the mines of Potosí, situated in a higher and drier zone. Spanish families and religious congregations divided the territory as they established adelantamietos (frontier posts), missions, and parishes. Farmers produced apples, apricots, figs, grapes, and vegetables, primarily to suit Spanish tastes.
Figure 18.
Bolivian doctors Oscar Velasco (pictured here) and Francisco Delgadillo work with a patient (Juana C.). Velasco and Delgadillo are skilled in using ethno-medicine with biomedicine as parallel sciences in treating Chagas’ disease. (Photograph by Joseph W. Bastien)
When Juana was fifteen, the Calchas elected her to be trained as a Responsable Popular de Salud (community health workerCHW) for their community (see Bastien 1990a for discussion of community health workers). Juana quickly learned how to provide basic medical treatment, give advice on health matters, refer cases to primary-health posts, and collect health data about the people in her community. She also educated Calchas about the care of infants, maternal care, family planning, and how to build a smokeless oven (horno loreno). Juana worked without wages for seven years as a CHW and was so successful that she received financial support to study as an Auxiliar de Enfermeria (auxiliary nurse) in Sucre.
Auxiliary nurses constitute the principal biomedical personnel throughout rural Bolivia. Doctors staff the hospitals in the municipalities and are required to do a year of practice in rural areas (año de provincia). Many do this grudgingly, making little effort to speak native languages and even less effort to understand Andean culture. Juana excelled in the six-month course and became the first native nurse among the Calchas, receiving a monthly salary of fifty dollars in 1985. She worked in a Posta Sanitaria (health post), where she vaccinated people, attended birth deliveries, and administered medicines and first aid. She educated Calchas in their native language about their health.
Juana became the pride of her family and community, having established herself as the local link between ethnomedicine and biomedicine. She was commended by the Secretaria Nacional de Salud for her work in rural Bolivia. She remained poor, as was her family, but they loved one another and were happy.
The ecology of these Bolivian valleys had changed drastically since the Conquest due to vast deforestation to provide timbers for the mines of Potosi and also to the erosive action of rivers, which during the rainy season carry topsoil from plantations and peasant farm plots to lower regions. Especially devastating, floods and droughts of the 1980s, followed by economic hyperinflation, increased impoverishment and migration among the Calchas and others within these valleys.
These factors also made these valleys endemic areas for Chagas’ disease, with vinchucas inhabiting every community and infecting more than half the population with T. cruzi. People became accustomed to vinchucas, which many say are harmless and don’t bite. Others believe that their bite is only a minor irritation. The fact that the bugs’ bite causes death is foreign to their natural view of more gentle balance and reciprocity. Juana and others have been unaware of the biomedical realities of Chagas’ disease.
As a nurse, Juana dealt with the following cultural illnesses in Calcha: las cámaras (diarrhea), la congestión (acute respiratory infections), las fiebres (fevers), las flegmasiasis (inflammation), orejo and susto (soul loss, depression), tabardillo (typhus), las tercianas (three-day fever), and cólico miserere (deadly colic). The Calchas attribute these illnesses to a combination of cultural and biomedical factors: las cámaras is due to imbalance of the hot and cold foods and unhygienic conditions; las tercianas to bad humors (malde aire, or malaria), susto to social concerns and the loss of fluids; la congestion to the concentration of fluids in the body and respiratory infections. As discussed in Chapter 3, Andean ethnophysiology adheres to a topographic-hydraulic model of the body combined with some aspects of a European humoral theory (balancing the hot and cold and the wet and dry) adapted from the teachings of Spanish missionaries (see Figure 11). Early missionaries taught humoral theory in medical schools throughout Latin America (see Foster 1978, 1987).
Cólico miserere approximates the megacolon symptom of Chagas’ disease but also refers to vólvulo (volvulus), which is the twisting of the bowel upon itself, and to ileus, which is blockage, both causing obstruction.[24] People of Potosí especially fear this cultural and symptom complex, which cannot be cured and causes death. Far from being caused by a parasite, cólico miserere is thought to be caused by the consumption of either very fresh or left-over foods that produce gas and swell the stomach. If the person cannot ventosear (b
reak wind) or zurrar (have a bowel movement) to dispel the cuezcos (cooked things), the stomach is thought to swell more and more until it shuts off the heart and the person dies. Potosiños say that “eating pork and drinking cold water brings cólico miserere, and if someone does this, don’t ask why they died.” Eating fresh foods without “hot” foods also causes cólico miserere; thus, eating cooked potatoes (a cold food because it grows in the ground) and not chewing coca leaves (a hot food) might cause cólico miserere. Rarely do Potosifios violate these dietary practices, which effectively serve as preventative medicine.
All classes of Potosifios and ethnic groups suffer from cólico miserere. Unusually fat people are prone to cólico miserere. Signs of the oncoming illness are choking, fainting, and indigestion. They are called “personas estreñidas” (constipated, up-tight, and niggardly people), having a stomach that holds things in rather than in a more open exchange with the outside environment.
Juana was frequently called to assist births in neighboring villages and could be away for days at a time. One time, on her return, her mother, Doñia Isica, complained that she was “muy esteñida” (very constipated) and had been unable to go to the toilet for four days. Juana gave her an herbal laxative that relieved her. A month later, Dofia Isica again became constipated, and her husband, Don Yupay, took her to a famous curandera of Chalca, Doña Fonseca, who was ninety years old. Yupay also brought along coca leaves and a large white guinea pig that belonged to Isica. Fonseca greeted them with coca leaves and soon began divining by means of coca leaves and the guinea pig. Fonseca marked the leaves with neat bite marks to designate wind, road, water, and ajayu (spirit). For more than an hour, Fonseca debated with Yupay and Isica the cause of the constipation. Fonseca then dug her fingers into the belly of the guinea pig, laying bare its intestines, which were bloated with grain. She whispered slowly that Isica was cold in the stomach, most certainly because she had eaten pork and that she had been taken by a mal viento (bad wind). Wayra is the wind deity that brings the rains and droughts, as well as good and evil.
Isica and Yupay feared Fonseca’s diagnosis of cólico miserere with its fatalistic implication, so they asked the curandera to pichar (sweep) the sajjra wayra (troublesome wind) away from her stomach by means of a picharada ritual. Fonseca mixed fat from a black hen with copal and hediondilla (Cestrum matthewsii Dun). She stroked Isica’s stomach in a dispelling motion, praying in Quechua, Sajjra Wayra, purijchej (“Be gone, troublesome wind!”). Fonseca left later that evening to deposit the ritual items with money attached at the crossroads so that someone else would find it and carry the evil to their house.
Isica improved, and the family resumed its daily activities. Towards the end of that year, Jovita, a thirteen-year-old sister of Juana, began complaining of chest pains and such fatigue that she felt like falling asleep even while herding goats. Juana examined her and found nothing abnormal. She gave her injections of vitamin B, saying that this would give her energy. Her grandmother said that Jovita was losing too much blood through menstruation and recommended that she drink fresh blood from a freshly sacrificed hen. These folk remedies were unsuccessful, however, and Jovita had to work sitting down. She complained that her legs were so weak that she couldn’t walk, and she lost her breath at the least exertion. She also still had pains in her chest.
Juana reported Jovita’s symptoms to the doctor at the regional hospital, who diagnosed the malady as nervousness and prescribed tranquilizers. He also said that she probably had some irritation in the liver or lungs that was causing the pain. He prescribed an injection of magnesium sulfate.
In September, a few months later, a child arrived at the house to inform Isica that Jovita had passed out while harvesting corn. Isica found the girl lying in the chacra (field). Jovita was trying to vomit and was gasping for breath. She felt very dizzy. Isica gave her chamomile and rose-hip tea, wrapped her in a blanket, and carried her home. After remaining in bed for two days, Jovita again felt “completo” (normal).
Around Carnival of the following year, Juana’s family celebrated the coming of Lent. They danced, drank, and ate for three days. A week later, Isica complained again that she had been unable to defecate for four days. Juana and Jovita rubbed her stomach with chicken fat and herbs, as the curandera had recommended. They gave her tea as a purgative.
Two nights later, Isica became very vexed. At first, it seemed like indigestion; she complained about a severe stomachache. Towards morning, Juana massaged her mother with a solution made from burro dung and boiled hediondilla. Isica got worse and her stomach enlarged. By sunrise, Isica suffered intense pain and could barely breathe. Her stomach was pushing against her heart.
Juana called a nurse from the neighboring health post, who diagnosed it as vólvulo. She prescribed an enema but they couldn’t insert it. In desperation, Juana and her father transported Isica in the back of a truck to the hospital in Potosi. The truck traveled for five hours along winding and bumpy roads that agitated the bloated stomach. Isica screamed in pain.
In late afternoon Isica arrived at the public hospital. A doctor said that he needed to operate and wasn’t sure what might happen. Juana said that they didn’t want an operation, only some medication to relieve the pain. The doctor then told them to leave and asked the orderly to remove them from the hospital. His parting comments were: “These peasants wait until the last moment to bring their relatives to the hospital,… they expect miracles,… if the patient dies, they blame the doctor!” His remarks hurt Juana, who understood Spanish and had served the medical profession freely for five years.[25]
Feeling ashamed and rejected, Juana and Yupay transported Isica to a private clinic. An attending nurse explained that Isica’s lower intestines had become so knotted that she could not pass gas and other matter. She needed to be operated upon to remove the knot or she would die. Juanas father agreed and paid the U.S. equivalent of $200 to have the doctor proceed.
When the surgeon had finished, he said that he had removed part of the lower colon, which was damaged. He showed them a small hole on Isica’s left side, a temporary anus (colostomy) to be used until the intestine healed. In several months, he would tie the separated intestines together and Isica could defecate normally.
They were horrified. Yupay told the surgeon that he had said nothing about making such a hole. They argued, but it was too late; the situation could not be remedied. When Isica realized she had a colostomy, matters became worse. A foul odor came from the bandages, and she asked what caused this. Juana explained what happened. Isica said that they should have let her die. Isica refused to cooperate with the nurses when they tried to help her. They tried to instruct her to use a plastic bag to collect the excrement, but she refused.
Juana returned to her community several days later to plant the crops and take care of the cows and chickens. Villagers were coming in and out of her house, and a neighbor told her in tears that her sister Jovita had died that morning. The night before her sister had complained that the pain had returned to her chest. They had found her dead in her chacra, the field she owned and worked and in which she had her earth shrine. “At least,” as Isica said, “she died with Pachamama.”
After burying her sister, Juana visited her mother in the clinic and told her about the death of her youngest daughter. Isica remained silent for a long while and then screamed, “Why do we have to suffer so much?” The doctor arrived to comfort them. He then told Juana that Jovita likely had died from Chagas’ disease and that Isica was also suffering from it. He suggested that all members of the family be tested for it.
Some time after, Juana, Isica, Yupay, and Ramon, the youngest son, were tested for Chagas’ disease. Juana, Isica, and Yupay were found to be infected; Ramon was not infected. Juana has a damaged heart muscle and a slightly enlarged lower intestine. Yupay has severely dilated intestines that are developing into cólico miserere. The doctor prescribed nifurtimox for Juana and Yupay to curtail their infection. However, they discontinued chemothera
py because they were unable to pay the necessary $200 a month, roughly equivalent to half a year’s earnings, for nifurtimox.
Dr. Oscar Velasco recently spoke with Juana at a conference for auxiliary nurses in Potosí. She still does not believe that vinchucas contributed to the death of her sister and to other illnesses. She said that peasants had always lived in houses with vinchucas and that they never got sick from their bites; and it is true that in the past vinchucas were not infected with T. cruzi to the extent that they are today. When Dr. Velasco asked her if she had ever seen vinchucas suck blood from humans, she said that vinchucas suck blood from animals but not from humans. Certain nongovernmental agencies have participated in housing-improvement projects to combat vinchucas in Calcha, but she admits that no one in her community pays much attention to their advice.
Of major concern to doctors in Bolivia is that peasants see little connection between severe constipation and possible T. cruzi infection. Constipation is associated with the eating of improper and unbalanced foods, and people with megacolon are said to have died from “dolor de barriga” (stomachache), “se ha hinchado la barriga” (swollen stomach), or “me ha dolido mucho y no he podido hacer qaqa” (severe stomachache accompanied by the inability to defecate). These frequently reported symptoms all can be attributable to T. cruzi parasites, although many Bolivians think they are caused by failing to maintain a balance of the hot and cold and wet and dry principles they associate with natural foods and other objects.
As mentioned before (see Figure 11), a native Andean understands his/her body as the center of a distillation process that takes in fluids (air, water, food) and processes them into useful fluids (milk, semen, blood, and fat) and toxic fluids (feces, urine, and sweat) that need to be eliminated. The circulation of fluids is believed to be a process of centripetal (fluids concentrating in distillation) and centrifugal (fluids going to the peripheral) motions. Volvulus, empacho, is understood as the stopping of the centripetal movement. This has cultural significance in that Andeans thus suffering are unable to connect with the blood and fat outside their bodiesthe energy and life forces of nature.
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