The Kiss of Death

by Joseph William Bastien

  ladrón por su gusto, (thief for pleasure)

  médico por su deseo, (doctor for desire)

  [answer:] La Vinchuca.

  “A pointed analogy of musicians, clerics, thieves, and doctors for vinchucas with their needle-nosed proboscis, black-capped shell, thirst for blood, and blood-letting therapy” (Beltrán, interview 5/17/97).

  I spent several days traveling with José Beltrán in his pickup truck and visiting homes, neighborhoods, and communities.[63] José was born to share ideas. Along the road, he stopped a stranger and, using a flip chart, gave him a short lesson about Chagas’ disease. José later told me that he had missed this person on his previous visit. “You can’t miss anybody, you have to go house to house to talk with people.”

  “Now, I have to spend more time educating and motivating peasants,” José added, “because people have to invest more into improving their houses.” By 1997, Pro-Habitat no longer had funds to improve houses and had adopted a credit plan to loan people money to fix their houses. Loans vary from U.S. $100 to $500 at 12.5 percent interest per year. José believed this to be a superior plan: “Providing credit is more sustainable than giving them supplies, we don’t have the money to fix every house, and if we educate correctly and motivate them, then they will want to invest in their homes and keep them nice,” he said.

  Local experience gained from the Chuquisaca project as well as assistance from Vector Biology and Control Project (VBC), CDC, and SOH were used by SOH/CCH to implement similar pilot projects in the departments of Cochabamba and Tarija between 1992 and 1994. By 1994, approximately 3,100 houses in fifty-two communities had been improved in the three departments of Chuquisaca, Cochabamba, and Tarija (SOH/CCH 1994:54; Bryan et al. 1994). The average direct cost to the program in 1991 for each house improved was U.S. $251 in Cochabamba, $217 in Tarija, and $217 in Chuquisaca; but sums were reduced considerably for 1992 and 1993 (SOH/CCH 1994:17). A large percentage of project monies was spent for administrative offices, vehicles, consultants, and educational material—U.S. $4 million ($2.5 million from U.S. Public Law 480[64] and $1.5 million from CCH[65] (SOH/CCH 1994: 9)—which was about $1,300 per house.

  One general criticism of the SOH/CCH pilot projects is that to satisfy project goals for fast results and monies to be spent during an allotted time, houses were hastily built and little education about Chagas’ disease was provided. Some of these houses were not maintained; in others, the people moved their corrals alongside the houses and they became infested again. “Everybody wants a new house without much personal investment,” José added, “and some have moved back to their run-down houses, and they use the new houses to show off during fiestas.” He included Sensano’s project in his criticism.[66]

  I asked him, “How do you educate Tarijeños about house hygiene?” He replied:

  My pedagogy is participatory education, basically. Peasants who listen to me are not receptive subjects of what I teach them. But they participate in reflecting on the visual charts, so that they understand what I want to communicate. This presents excellent results, as you saw last night (Beltrán, interview 5/17/97).

  Well into midnight the night before, I had observed him teaching in Rancho Norte, a project community of about sixty families. The schoolroom was crowded, with the men standing back against the wall and women scattered around the room, seated on school benches. I sat with the women, exhausted from travel and interviews. José continually moved his body, raising his arms. He showed one elderly lady a picture, then pointed to a vinchuca illustration on the flip chart and asked her if she knew who “this fellow” was. She was confused. A few hands were raised, but José skated across the room to question someone about to doze off. “A vinchuca,” the person quickly answered.

  “And where do vinchucas live?” José continued.

  “In the cracks and ceilings of our houses,” someone answered.

  “Have we invited them to eat with us?”

  “No,” the old lady answered, “they are very ugly and shit on the walls.”

  “They bite us and take blood from us,” José added. “What happens if we see them full of blood and we squash them?” Everyone laughed at this, because they have squashed the bugs and seen blotches of blood.

  A lady with thin arms, face wrinkled and leathery, wearing a derby hat, asked him about vinchucas coloradas (red vinchucas). She was the lady who at first had been slow to answer, because it turned out that she was not sure which type of vinchuca was illustrated. José picked up her skills, “I’ll bet you $100, if the gringo loans it to me, that anyone can smash a vinchuca colorada and not find blood.” The lady adds that these vinchucas are different from the bad vinchucas, whose bodies are black with orange marks on the sides.

  José showed a slide picturing the harmful vinchucas, and then reminded them not to harm the good vinchucas, showing a keen sense of respect for beneficial insects. It was clear that peasants distinguished vinchucas as blood-eating, plant-eating, and insect-eating reduviids. Other educators have broadly declared war on all vinchucas, indiscriminately killing nectar and predator vinchucas. I wondered if insecticides also discriminated. José’s pedagogical method emphasized the necessity of listening to the peasants, discussing matters with them, and letting them arrive at the solution.

  To top off the evening in Rancho Norte, José showed the people a model of a house that they could build. They crowded around him, as he pulled off the roof to show them the floor plan. He began with simple questions:

  “How many walls do you need for two rooms?”

  “Four,” they answered.

  “No,” he replied. He asked a promotor (CHW) to count the walls.

  “Three,” he answered.

  “Counting the end wall,” José continued, “the middle wall separating the two room, and the end room which begins another room. See, you save a room with this design.”

  “Notice the porch that extends in front of the rooms. There is a roof over this so you can work outside and not get wet if it rains or, if the sun is shining, you don’t get hot,” José added. “You can work preparing food and crops here. Look how open it is to let the air circulate. Your present rooms are dark with small windows. See how the air can circulate through the house. This is healthy and helps prevent tuberculosis.”

  “When you cook, where do you have to bring your food from?” José asked.

  “We carry it across the patio to the eating room,” someone answered.

  “Yes,” José replied, “and if it is raining, you get more soup!” They laughed at this.

  Toward the end of the meeting, José asked me to say something, so we discussed Julio, who had recently died in Rancho Norte from Chagas’ disease. I asked if they were taking care of his children and widow, and people replied that they had plowed a plot of land for them. Then I asked how many thought they had Chagas’ disease. Six people out of thirty raised their hands. They had been diagnosed with Chagas’ disease, but they were not taking chemotherapy. I suggested the possibility of using Sangre de Drago, and I asked Jaime Zalles to provide them with the names of plants to treat heart problems and stomach disorders. Zalles provided them with an ample list.

  In parting, José asked me to take a picture of the group. I was out of film on the only occasion I was asked to take a photograph. All embraced one another and we departed. José entertained us with Tarijeño couplets on the journey back.

  Development of Teaching Aids

  José Beltrán collaborated with Irene Vance, director of Habitat, to produce educational material for Chagas’ control.[67] Initial production costs were U.S. $80,000. They used a classic methodology for material development that included the steps of conducting baseline studies for assessing cultural and economic conditions, an assessment of community resources and needs, the development of preliminary materials based on this information, field testing of potential materials, modification and production of materials, and evaluation of the effectiveness of the materials used. They produced beautif
ully illustrated posters, comic books, and flip charts to teach people about Chagas’ disease. They also produced slide shows and videos. By 1997, however, many of these teaching aids were no longer available in Tarija because the use and demand for them had been so great.

  Although the success of these educational materials is unquestionable, critics have objected that this is an unsustainable resource which Bolivians cannot afford to continue. However, international funds are available for Chagas’ prevention and certainly effective and attractive educational material is needed to educate peasants as well as CHWs, technicians, nurses, and doctors. Also, although Bolivia is a poor country, televisions are common, and there is a potential for image-based education that should be developed.

  One concern with the visual aids was that they lacked cultural sensitivity, primarily because they were designed by professionals in La Paz for all Bolivians. A principal argument of this book is the necessity to design projects relating to the many different ethnic and cultural contexts in Bolivia.

  Nonetheless, teachers like Beltrán are able to adapt teaching aids to the values of peasants, if they are creative and sensitive to the local culture. Because Bolivian educators normally follow strictly hierarchical models of teaching, they need to be encouraged to deviate from the formal texts and matter.

  José Beltrán has his own style. He composes songs, sociodramas, and role plays to illustrate T. cruzi, vinchucas, and the infirm. His classes are part theater and games. He uses puppets for children and adults and contracts Bolivia’s main puppeteer to do a show on vinchucas and parasites for the periodic health fair. Although it costs $100 to bring the puppeteer, the audience never forgets it. José spends several afternoons a week in the classroom, which he loves. “Children are curious about insects, creatures that are proportionate to their size,” he continues. “They are easier to teach than adults who relate more to larger creatures.”

  José recognizes that cross-cultural communication is the major obstacle to health education. He stated:

  We had the best coverage for vaccinations in Tarija, almost 100 percent. Why? Because I went to the barrios with my loudspeaker. We brought puppets, charts, and posters. Even a portable video. I put the needle into my arm a dozen times to show them that it didn’t hurt. They complained that when the Peace Corps was here, they used vaccinations to sterilize them. I don’t know if this is true. But we had to discuss these matters with them. We had to overcome many difficulties. Peasants are smart and they listen. They want to be healthy too. Today, doctors, nurses, and technicians do not have the same enthusiasm. If three children are not vaccinated, they don’t spend any time seeking them out. They look down upon peasants. They use a language that is sophisticated, abstract, and difficult for the peasants to understand. This is the most serious mistake. Why don’t they talk to the peasants as their cousins and friends? They go to the community, but they don’t communicate. I remember a nurse in Iskayachi who wanted to whip the children because they didn’t line up for vaccinations. There is what we say in Tarija, un desclacamiento, and they don’t want to identify with their people. They don’t want to return, and they think that they are in another status or class, and the peasants are burros (Beltrán, interview 5/24/97).

  Desclacamiento refers to the process of declassifying oneself from a lower class, but with the added notion of the nouveau riche, who look down upon the class from which they originated. Dr. Evaristo Mayda, director of Project Concern in Cochabamba, discussed this and added that the biggest obstacle in rural health improvement is the elitist attitudes of doctors, nurses, and technicians.

  José Beltrán continued in even stronger terms:

  Peasants are considered burros because they haven’t had the opportunity to be educated as doctors have. Doctors do not want to see where they have come from. They think they are in another status and class. Doctors and technicians don’t want the peasants to have health because that deprives them of sales and control. They are not interested in educating people, they want to increase the demand in health. They are also afraid that if they educate the CHWs and nurses they will know more than them. Education is power, not to be shared. Or they are going to lose their business. Because before calling the doctor or nurse to treat a patient for Chagas’ disease, we instruct the CHW on how to do it, the doctor or nurse is going to lose the possibility of earning some money.

  Once I brought a pregnant lady with a partial delivery (the placenta remained) twelve kilometers from a village to a hospital in Tarija. A woman doctor said to her, “Que esta cochina, como va a dar luz! (“What a sow, how is she going to birth? Why haven’t you bathed her!”). They were insulting her. She began to cry. They refused to take her, fearing she might contaminate the hospital. I had to take her to my house, put her in a bed, and call a doctor who treated her. No one had educated her on how to prepare for birth. This was a bitter experience. I criticize and censure this behavior.

  Stratified Classes

  Beltrán highlights the problem of stratified classes to health projects. Chagas’ projects bring together people from different social classes who have to communicate with one another to combat Chagas’ disease. They often fail to achieve this goal because they perceive lower-class people as incompetent and inferior, thereby hindering community participation. The social dynamics of classes are important considerations for the success of any project.

  Rural peasants generally are considered the lowest class. Since 1953 it has been against the law to refer to peasants as Indiansthe accepted word is campesino. Campesinos have equal voting rights with all other classes. Campesinos traditionally speak Andean languages, follow an agricultural calendar, and, as of 1994, have their own political organization. Vecinos, or residentes, are the people who live in the city. They include the salaried workers, and most of them are not much better off than the peasants. Already mentioned, only 2,000 salaried workers make over U.S. $10,000 annually (Presencia 1997). The upper class, sometimes called gente decente (civilized people), is composed of distinguished families and wealthy people. These are broad distinctions; there are many finer class strata in each of these groups, such as the cholo and mestizo classes, already discussed. Race, as defined by skin color, is not as important a marker in Bolivia as is social stratum, which is determined by one’s dress, behavior, family, and wealth. Consequently, such cultural markers as language, dress, and food habits are readily discarded to strip oneself from the lower peasant class. There is a tendency in peasants who have ascended to professional levels (doctors, nurses, and project personnel) to act out their perceived class superiority in dealing with peasants.

  On the other hand, peasants have their own hierarchies, with certain members more distinguished than others; but this is based on completion of adult responsibilities within the community. Especially peasants from the Andean free communities (those that were not tied to haciendas) maintain a cooperative and communal spirit in their work. They help each other plow, seed, and harvest. If there is a fiesta, they all participate. If a project is to be completed, all members participate. When project personnel interact with such community members using class-stratified manners, they project upon the community political and social relationships that are offensive and counterproductive. Community participation in such groups is predicated on respect of differences and equality of participation; it is not based on paternalism, maternalism, classism, or racism.

  José Beltrán’s suggestions for better communication between doctors, nurses, technicians, and peasants include the fact that it is necessary that health professionals think in terms of cross-cultural communication and sharing of knowledge rather than having a superior form of knowledge. Doctors also have to internalize the reality of peasant culture and become motivated to work with these people as partners. This may necessitate spending several years in rural areas after medical school. It also involves learning native languages, colloquialisms, ethnomedicine, values, and economics.

  At the conclusion of our last inter
view in 1997, José Beltrán sang a song that he had taught children concerning Chagas’ disease. The tone is that of a cueca (popular dance of Chile), and the children dress like vinchucas and dance the cueca when they sing it.

  Gracias a Dios que mi casa esta limpiay me curada.

  Revocando las paredes combatimos las vinchucas.

  Ordenaday revocada no hay mas bichos.

  Thanks to God that my house is clean and I am healthy.

  Plastering the walls we combat vinchucas.

  Neat and plastered there are no bugs.

  CHAPTER TEN

  Culture Context Model for Chagas’ Control

  Oscar Velasco, M.D., coauthor

  The following proposed culturally sensitive model attempts to lessen the gaps in cross-cultural communication between project personnel and community members. Pilot projects in Chuquisaca, Cochabamba, and Tarija failed to become models for other projects because they lacked a model themselves.[68] These projects were rapidly designed, generously funded, and built several thousand houses. However, they provided little in the way of evaluation of ways to improve them, thus failing as pilot projects. Another fault was that Chagas’ prevention practices were barely integrated into the culture and economics of the community. Oscar Velasco and I have designed a program, called Culture Context Triangle (CCT), to be a model for Chagas’ control and other health projects.[69]

  The CCT model provides educators and health workers with a framework for cross-cultural communication and a guide for their activities. It recognizes that community members and ethnomedical practitioners are equal partners in Chagas’ control. It integrates the subjects’ ideas, values, and practices into the prevention and treatment of Chagas’ disease, whenever possible and feasible. It includes treatment of patients with Chagas’ disease; pilot projects in Tarija and Cochabamba detected cases of Chagas’ disease but never did anything to treat these patients (patients were treated in Chuquisaca). These projects made people aware of their sickness without providing measures for treatment.