The Kiss of Death

by Joseph William Bastien

  Charismatic Leadership versus Bureaucratic Technicians

  I was encouraged to hear Ruth Sensano talk with such enthusiasm, which is not often the case with project directors and personnel. The bureaucracy of projects makes it difficult for technicians to become involved with peasants. Dr. Daniel Rivas, medical director, and Freddy Martinez, program development director, also shared Sensano’s motivation. They believed in the Bolivian people and were dedicated to improving their country. Selfless dedication, persistence, and motivation are as important as funding in making health projects work; however, these leadership qualities are often overlooked in the assessment of health projects.[46]

  Sensano’s charismatic style is matriarchal. She follows the teachings of the Catholic church, especially concerning ideas of the Blessed Mother. As a matriarchal leader, Sensano has adapted Catholic teaching to Andean culture, with its prayers and rituals to Pachamama. At every step of a project, she has sprinkled Mother Earth, thrown coca leaves to divine success, and prayed a rosary to the Blessed Mother. The peasants revere this Jacha Mama (Big Mother). When I asked her why she didn’t become a nun like Mother Teresa, she replied that she had to be “top dog” and could never answer to a superior.

  Religious motivation in health projects needs careful evaluation. Nongovernmental organizations (NGOs) currently administer health projects in Bolivia. Many projects receive funding from the United States government and other international sources. Some NGOs are religiously driven, so conversion strings are attached to the health care provided. This is one reason for the high rate of conversion to Protestantism among Aymaras of the Altiplano. Another problem with NGOs is their advocacy of other issues, such as family planning, pro-life positions, and biomedicine. These politically loaded agendas frequently divide the community; they can subvert the goals of Chagas’ prevention and misdirect the project.

  Sensano did not attempt to change the beliefs and practices of the peasants. She respected Andean beliefs and recognized the need for rituals. She invited shamans and yachajsto perform rituals at the beginning and end of the project. Her authoritarian style, however, made it difficult for PBCM to coordinate its efforts with other Chagas’ projects in the Department of Chuquisaca. She admits this. However, she finished everything as she had promised, when the estimated rate of unfinished and unsustained development projects is 90 percent. Sensano’s project was attuned to Chuquisaca peasants and was within their reach. This was partially because it fit into a working health program and also because she walked it through, step by step, developing and making it understood without any glitches.

  Model for Chagas’ Control in Bolivia

  At a national planning meeting for Chagas’ control in La Paz in November 1990, Sensano’s project gained acceptance as an effective model for chagasic control to be used by other nongovernmental organizations (NGOs) in Bolivia.[47] Its attractiveness lay in its efficiency, effectiveness, low cost, and use of culturally accepted techniques.[48]

  Primary health care is the primary objective of PBCM. Its goals, as ideally defined, are essential health care made universally accessible to individuals and families in the community, through their full participation and at a cost that the community and country can afford.[49]

  Sensano had incorporated Chagas’ control into PBCM’s primary health care mission in 1989 for the Department of Chuquisaca. It wasn’t until 1991 that Chagas’ disease was even considered to be a part of primary health care in other parts of Bolivia. The Department of Chuquisaca is heavily infested with triatomine bugs and has a high percentage of infected chagasic patients: 78.4 percent of the houses are infested with vinchucas, 39.1 percent of the intradomiciliary vinchucas carried T. cruzi, as did 25.3 percent of the peridomiciliary insects (SOH/CCH 1994:19). Some 78 percent of the population tested in endemic rural areas were seropositive to Chagas’ disease, and 26.6 percent were children from one to four years of age (SOH/CCH 1994:22). In Chuquisaca 9.4 percent of the inhabitants have latrines, 51 percent have potable water, and 2 percent have electricity.

  Earlier referred to as the Department of Sucre, Chuquisaca has a population of 451,722 (rural, 305,201; urban, 146,521) people, according to the 1992 census. It covers 51,524 square kilometers, with a density of 9.6 persons per square kilometer. The annual population growth rate in Chuquisaca is low, 1.47 percent, compared to other departments: La Paz (1.6 percent), Santa Cruz (4.10 percent), Tarija (2.81 percent), and Cochabamba (2.66 percent). This department consists of high plateaus and valleys gradually descending down the eastern slopes of the Cordillera Central of the Andes. These valleys range in altitude from 2,425 feet to 9,200 feet above sea level. The fertile lands produce cereals, fruits, and vegetables and traditionally supplied the miners of Potosi with food.

  Epidemiologists conducted studies in four communities where PBCM started Chagas’ control projects to assess the rate of infestation and infection with Chagas’ disease (see Appendix 14: Baseline Studies in Chuquisaca). Ninety percent of houses in the four communities were infested with vinchucas; 61 percent of these were transmitting the chagasic parasite (see Appendix 14, Table 5). Houses were classified as good, regular, and bad according to such factors as having straw and mud roofs; adobe walls partially plastered or without plaster; presence of cracks in walls, foundation, and roof; no ceiling; dirt floors; and poor hygiene (see Appendix 14, Table 6). The majority of the houses were found to be in poor condition and infested with vinchucas; a very high percentage of the population had Chagas’ disease. Unhealthy houses correlate closely with infestation rates, both being about 90 percent. This being the case, in endemic areas housing conditions alone could serve as indicators of infestation rates.

  Chagas’ control projects are not easily incorporated into primary health care systems because of conflicting interests and inefficiency. A frequent conflict is that funding sources or advising institutions may be different: one organization may be responsible for primary health care, another funded for Chagas’ disease control. Programs have to work together. Other possible infrastructures for Chagas’ control include housing improvement projects (Plan International and Pro-Habitat) and credit cooperatives (Pro-Mujer and ProHabitat), discussed in the next chapter.[50]

  PBCM’s Chagas’ control programs were based upon the following conclusions derived from baseline studies (see Appendix 14): Many peasants live in unhealthy houses that should be bug-proofed; peasants often do not know the danger triatomines present in their houses and therefore are in need of health education; peasants need technical assistance in home-improvement projects and in spraying insecticides. The goal was basically preventativeto break the transmission chain by means of education, house improvement and improved hygiene, and by spraying for insects. Of some consideration, PBCM lacked a therapeutic outreach program for those with Chagas’ disease, even though its primary health care program assisted severe cases of heart disease and colonopathy.

  Prevention breaks the transmission cycle of T. cruzi from triatomines to humans. In its most basic form, prevention against Chagas’ disease involves the following objectives: periodically spraying with insecticides to destroy triatomines, improvement of housing and corrals to eliminate nesting areas of triatomines, and better housing hygiene. However, each of these objectives involves achieving many changes within the household which are difficult to accomplish. Because the house is the base for peasants’ economy, where they eat, sleep, give birth, raise children, process food, store crops, and keep animals, Chagas’ control projects have difficulty changing some of these cultural and economic practices. Project personnel often overly concentrate on health issues rather than on issues of productivity and economics.

  Infrastructure for Chagas’ Control

  PBCM’s infrastructure for a primary health care program served as an effective base for Chagas’ control. Its infrastructure included three zones, each with a central hospital with three doctors (a director and two others to lead traveling teams), two health workers, and two social workers.
These zones contained twenty-six puestos sanitarios (health posts) in the larger communities, each staffed with an auxiliary nurse and equipped with primary health care items (vaccines, antibiotics, bandages, and measuring instruments). Under Ruth Sensano’s leadership, auxiliary nurses within the three zones were provided with training, technical support, and monetary incentives. Peasants at the village level were responsible for their health and were invited to support a community health worker (CHW), already discussed. CHWs assisted auxiliary nurses and health teams and later became principal links between the village housing-improvement committees and project technicians. CHWs usually serve for two or three years without pay; and they consider this part of their community service, un cargo (a load).

  The cargo system is deeply embedded in Andean and Latin American culture; it predicates that leadership is a burden (cargo) to be carried voluntarily without material gain, but this service accrues towards one becoming a complete adult (una persona muy completa) in the community (see Bastien 1978, Metraux 1967, Wolf 1955). Adolescents grow into adulthood in part by serving the community. Adulthood is achieved by assuming tasks for the community.

  The maturity of the individual relates to the community; the health of the community brings health to the individual. Throughout Bolivia, the cargo system has been used effectively to elicit community support, with some individuals accepting the load of overseeing the community’s health as a community health worker (CHW).

  Sensano had also trained traveling teams of technicians. Traveling teams from the hospitals educated and coordinated activities of the auxiliary nurses and CHWs and provided them with educational materials such as videos, slides, and posters. The traveling team consisted of a medical doctor, social worker, and health educator. Each hospital had two traveling health teams, so that one team was able to visit every village once a month while the other team worked at the hospital. Traveling teams initiated Chagas’ control measures, completed base studies and evaluation studies, and provided technical assistance for housing improvement projects.

  Peasants’ Awareness of Chagas’ Disease

  When Chagas’ disease control was begun in 1989, it presented additional challenges, which Sensano explains:

  Adding Chagas’ disease control to PBCM was a challenge, because it involved changing houses and habits of peasants. Deeply rooted cultural patterns needed to be changed and housing behaviors needed to be modified. Fumigation and housing improvement requires cost-sharing. Eradication of triatomines is only one step that needs to be followed up with vigilance, refumigating, and housing hygiene (Sensano interview 6/16/91).

  With such complexity in mind, Sensano, Rivas, and Martinez decided to initially limit their Chagas’ disease control efforts to four communities, which they selected according to the following criteria: high incidence of Chagas’ disease, semi-nucleated communities, similar socioeconomic levels, little possibility of outside asistance, accessibility, and a favorable response to first efforts at concientización, or consciousness-raising (Rivas et al. 1990:4). They chose the communities of Puente Sucre (Yotala zone), Tambo Acachila (Yotala zone), La Mendoza (Yamparaez zone), and Choromomo (Tarabuco zone). The activities of the project consisted in concientización, forming house-improvement committees, and actually improving houses.

  Concientización: Education

  Sensano educated peasants by trying to change their perceptions so that they felt that they could do something about their impoverished conditions. In Bolivia and elsewhere, peasants often have a fatalistic attitude that discourages them from trying to improve their conditions, which in most instances is borne out by a history of exploitation. In Chuquisaca, for example, some peasants refused to improve their houses for fear that the landowners would then charge them rent. They also thought that the supplies would be another form of debt peonage, with interest rates at 12 percent per month. Diseases, such as Chagas’ and tuberculosis, are facts of life for rural Bolivians; control over disease often is best initiated by means of rituals.

  Concientización (consciousness-raising education, or CRE) was popular in Latin America during the 1980s. It implies that community members recognize the relationship of material conditions to behavioral, economic, social, and cultural factors by means of investigation and analysis of actual concerns.[51] Concientización attempts to help instill in poor people the hope of improving their situation. Concientización has premises in concepts of Christian social justice that relate the cause of the disease within the political and economic contradictions of Bolivian society. Therefore it is useful for looking at the connections between local causes of infestation and broader social concerns.

  Even though Sensano proposed to look at the connection between broader concerns and causes of disease, she used an approach that scared peasants more than it made them reflect upon the political economy. As she describes it:

  …concientización was, and still is, the key to our success. We used shock methods to make them realize that the bites of vinchuca cause bulbosos [welts] and heart problems. We traveled from house to house, showed them feces that the vinchucas left after they had sucked human blood, then became so full that they left traces of mierday sangre [feces and blood] on the walls. We pointed out their eggs, hundreds of them, tiny white beads inside walls, mattresses, and clothing. The earth and straw of their houses were filled with vinchucas. Inside their straw roofs we showed them nests of sleeping vinchucas.

  We showed them the damage vinchucas do. We made them afraid. If you don’t scare the campesino, he won’t do any work. We also showed them the parasites with microscopes and pictures of people with intestines stretched out. We made them hear the irregular heart beats of chagasic patients, 1231234121234, with a stethoscope. We showed them radiographs of a normal heart and some of a chagasic heart. We had a video made and showed them that. We told them that they have a responsibility to take care of their children and that it is their responsibility if children suffer from Chagas’ disease. Fathers and mothers cannot permit that their children die from vinchucas, it is just as necessary to get rid of vinchucas as it is to have their children learn to read and write. After educating and motivating them, they agreed to fix their houses (Sensano interview 6/17/91).

  Concientización was used by Sensano to frighten people and instill in them a hate of vinchucas. Peasants now had another object to fear; a bug they once thought was a sign of fertility was now seen as a harbinger of death. Bolivians realized the connection between vinchucas and some people with chronic heart disease, but life expectancy is not a major concern for peasants subsisting from day to day. Making peasants aware of disease-causing agents often is not enough to motivate them to do something. Disease and death are accepted facts of peasants’ lives; they have become long accustomed to the unhealthy environments of mines and factories and being subjected to revolutions, reprisals, and military repressions.

  Figure 23.

  Education of children about housing hygiene is important to prevent Chagas’ disease. Traditionally children regard vinchucas as “toys” to play with.

  Preventative health measures modify behavior to the degree that these measures produce some immediate and desirable effects. With Chagas’ disease, once community members realized how nice their houses would be if they did not suffer from insect bites there and that they thus would have increased prestige, they were motivated to improve their houses. When I brought up the objection that peasants might revert to unhygienic conditions after the house was built, Sensano replied that this was not the case, because the women take pride in their new homes. They sweep them and put things away every day. Prestige is more motivational than is either injustice or economics.

  Children and Women

  The education of schoolchildren about disease is important because children and adolescents constitute half of Bolivia’s increasing population, with a growth rate of 2.7 percent a year. Children share knowledge with their parents. Sometimes parents resist children advising them, but studies by Fry
er (1991) show that even though many parents showed initial resistance, they eventually began asking children about their lessons and learned with them. When fathers migrate to work and mothers tend the fields, older children often are left to take care of the smaller children and the households.

  An important factor for Chagas’ disease lessons for children is making them applicable to household tasks (housing hygiene) and assisting children in educating their parents, such as assigning shared tasks for children and parents while calming parents’ fears about their own inferiority in the face of their children’s knowledge.

  In Chuquisaca and elsewhere in Bolivia, inequality of women is increasing. Because of its social and cultural complexity, the division of labor among women, men, and children needs to be studied by anthropologists and sociologists so that education about housing improvement and maintenance and vector control can be carried out more effectively.

  Andean women have always worked alongside men; but, because men have migrated to find work, women have had to assume men’s traditional roles. Women often have become the sole agriculturalists, child raisers, and housekeepers of families. Some mothers work the fields carrying their babies; urban mothers take babies to their market stalls, where they are kept in cardboard boxes, being called “cardboard box babies.” Vinchucas can take advantage of these babies. Toddlers remain at home, being cared for by slightly older siblings, usually girls. Thus, girls especially can spend less time at school. Peasant girls average four to six years of education, boys six to eight years.