• The technical spoke concerns the connecting links of methods, tools, and materials that bring people together to help prevent and treat Chagas’ disease. Sometimes imported technologies separate personnel from community members; the standard guide is to use available technology, native resources, and personnel as much as possible in order to make community members less dependent upon outside sources. Bolivia has skilled laborers in the fields of construction, fumigation, and repair of houses. When household members themselves do such tasks they need to be instructed in proper techniques to make their houses vinchuca proof. Examples cited include the use of cow dung in plaster, improvement of the consistency of adobe, employment of insecticides in paint, and the formation of tile factories. Research is needed to discover drugs and insecticides from medicinal plants that can prevent or treat Chagas’ disease (see Bastien et al. 1996).
• The environmental spoke connects humans with biotic factors related to the parasitic cycle. Animals and plants are important in controlling the Chagas’ parasitic cycle. Its spread throughout the Americas is related to depletion of land, deforestation, and destruction of various species of plants and animals. Noted for their environmental practices, Aymara and Quechua cultures have adapted to mountainous environments in harmonious ways that other cultures can emulate. Lowland peasants of the departments of Santa Cruz and Tarija also understand their environment, and, once they are presented with information about the parasitic cycle of Chagas’ disease, they can assist in discovering ways to break this cycle. Andean concepts such as that of Kallawayas who feed earth shrines of their mountain so that the mountain will feed them are useful images to teach people about the relationship of humans to the land.
Reaching the center is done along all spokes, which intersect within the context of culture. A culture context is the central hub of the spokes. When housing improvement and hygiene are considered part of the culture context, people build these houses with their own resources and continue to maintain them while incorporating their aesthetic, social, and spiritual values. One reaches the center along another spoke when housing hygiene becomes second-nature to the majority of the community and ethnomedical practitioners have adapted features of biomedicine into their native practices and rituals. The CCT model will truly be a success when communities throughout Bolivia incorporate Chagas’ control measures into their communities.
The culture context model is a culturally sensitive and effective plan for the prevention of Chagas’ disease. It respects the culture of people, utilizes their cultural resources, and uses culture as a focal point and dynamic for innovative responses to the problem. Culture context can be seen as the “owner’s manual” of a community.
This model recognizes that a community may be a mix of ethnic classes and groups, such as Aymara and Quechua, with a mix of urban and rural features. Essentially, project personnel learn by participation and by observation about the culture context of the community where they intend to work. Moreover, they then should discuss matters with the people and let them help decide upon a course of action.
Future Hope
Several nongovernmental organizations have recently adopted a culture context model for projects other than Chagas’ disease, and directors of these projects helped me design the culture context model for Chagas’ disease. As already discussed, Oscar Velasco directs a health project in Potosi that includes biomedical and ethnomedical practitioners on an equal basis. They have incorporated biomedicine into the culture context of Andean ethnomedicine (see Bastien 1992). Antonio Prieto, also discussed, has developed an economic development project for peasants of Chuquisaca that focuses on the relationship of productivity to national and international economics within the culture context of the community; and Pablo Regalsky has renovated the culture context of the people of Raqaypampa, Department of Cochabamba, by reintroducing age-old practices of agroproduction that had been lost.
Evaristo Mayda has formed a strong organization of ethnomedical practitioners that serves the needs of the Quechua of Cochabamba. More than 130 community health workers of the Department of Oruro have separated from any institutional affiliation to form their own organization, with their own projects, within Aymara and Quechua culture contexts.
These Bolivians mentioned have recognized the failures and problems of vertically designed and biomedically oriented projects.[75] They are keenly aware of the pressures of global economics, privatization, and capitalization upon the production of peasants. They are actively involved in issues of peasant productivity, microcredit, and the formation of cooperatives. Many of these Bolivian leaders speak Andean languages, have studied anthropology, and have lived for years in peasant communities, appreciating the culture context of the community. Their projects fit the culture context of Bolivian communities; the programs’ success lies in the fact that they are generated by Bolivians with knowledge and sensitivity to the culture context.
For future projects, it is necessary that specialists from all relevant disciplines work together with members of the community and ethnomedical practitioners to reach solutions within the culture context of the community. Solutions should not be ready-made formulas.
International funding sources should seriously consider the following criteria before allocating funds for the prevention of Chagas’ disease. The institution should be knowledgeable about (and able to work within) the cultural, social, and economic systems of the community for which the project is planned. Project personnel should be able to speak the native language and communicate effectively with all members of the community while employing a balanced interdisciplinary approach.
The following pages will examine “cultural correctness” in development projects. One issue to be examined is the integrity of an institution’s objectives in carrying out a project within a culture context. Frequently, nongovernmental organizations (NGOs) use projects to advance their moral, political, or religious objectives. For example, the Roman Catholic relief organization Caritas distributes food donated by the U.S. government and has organized Clubes de Madres (mother’s clubs) in Bolivia while at the same time teaching these mothers the church’s position on family planning. Some medical institutions oppose ethnomedicine and ethnomedical practitioners in their endeavors to bring primary health care to the people. Fortunately, many NGOs in Bolivia now recognize the value of ethnomedicine and include it within their healthcare programs. Perhaps the biggest obstacle is the Western mentality that scientific biomedicine is the only answer to eliminating sickness and bringing about health. However, if one accepts the World Health Organization’s definition of health as not merely the absence of sickness but also the total well-being and happiness of the person, then culture needs to be considered in health programs.
The culture context triangle does not imply that everything within the culture is productive towards the absence of disease. Regarding Chagas’ disease, many types of behavior and values may have a negative impact. The CCT model, however, acknowledges that the culture context is dynamic and that it both can and should accept beneficial changes. Importantly, these changes need to fit into the systems of the culture (economic, social, political, and religious) in order to become permanent. The change must be a culturally acceptable negotiated agreement between project personnel, members of the community, and local ethnomedical practitioners.
CHAPTER ELEVEN
Solutions
The challenge of Chagas’ disease is not insurmountable. There are solutions, and this chapter contains some possibilities. Previous chapters addressed housing improvement and hygiene as ways to prevent the disease. I now consider solutions to socioeconomic and environmental issues that have helped precipitate this epidemic. The good news is that many Bolivians recognize these solutions and are applying them.
Interdisciplinary Approach
An interdisciplinary approach is necessary to deal with socioeconomic and environmental factors in the spread of Chagas’ disease. A major problem of the pilot projects was th
at Chagas’ disease was narrowly considered from a biomedical perspective, with little if any consideration of the cultural, economic, environmental, and social factors involved in this epidemic.[76] These pilot projects thus pointed to the importance of including the social and economic sciences in the effort to prevent Chagas’ disease. Narrowly focused approaches of particular disciplines are insufficient to deal with its complexity. If this book has shown anything, it is that Chagas’ disease is complicated by issues of biology, chemistry, parasitology, pathology, entomology, economics, ecology, sociology, and ethnology. Each of these studies is necessary to deal with Chagas’ control and disease. Detailed and varied perspectives need to be brought together within the culture context. The CCT model converges toward an apex of prevention and treatment of Chagas’ disease.
Anthropologists look at Chagas’ disease from a cultural perspective. Culture is seen as the major influence upon people’s behavior. Anthropologists examine the relationship of people’s values and behaviors with environmental factors related to vinchucas and T. cruzi. They study the etiology of Chagas’ disease and how people deal with its symptoms. They are able to explain the cultural dynamics of shamans, midwives, and curanderos. Anthropologists can be seen as the translators and negotiators between the technical-scientific world views of project personnel and the cultural practices of peasants.
The following anthropologists have contributed to the prevention of Chagas’ disease. Oscar Velasco integrates ethnomedicine and biomedicine in the treatment of Chagas’ disease. Alan Kolata and Charles Ortloff (1989) have shown that the raised-field technique in about A.D. 500 at Tiahuanaco, an archaeological site on the Altiplano, was a more productive farming technique than that used now by the Aymara, which was introduced by the Spaniards. Raised-field techniques also provided better nutrition. Applying this archaeological knowledge, Kolata is reintroducing raised-field techniques to Altiplano Aymaras.
Social anthropologist Xavier Albo has studied Aymara and Quechua political and economic systems to assist his public policy advocacy of their interests, and his studies greatly assist project personnel in these matters. Cultural anthropologist Pablo Regalsky leads an institute that promotes the ethnoscientific knowledge and traditional agricultural systems of peasants in the valleys of Cochabamba and Misqui. He has helped Quechua peasants of Ragaypampa restore traditional methods of crop rotation to enhance production and to maintain adaptive varieties of potatoes within the Misqui region. This has offset the trend for single-crop production of russet potatoes, caused by the demand for larger potatoes to make french fries in Cochabamba.
Sociologists deal with social stratification and ways to deal with divisions between peasants, city dwellers, cholos, and mestizos. Bolivian sociologists have been very helpful in the understanding of gender and age roles. There is a body of statistical information available that provides quantitative information about demographics, migration, income, and social stratification. Project sociologists are needed to assist in group dynamics, enlisting community participation, and providing leadership. Social psychologists are helpful in assessing motivational factors and social behavior.
Juan José Alva, for example, works in rural sectors of the city of Cochabamba on housing concerns and Chagas’ control. He is also a professor of sociology at the University of San Simon in Cochabamba. He teaches rural teachers and has been influential in getting them to use educational material that is adaptable to the people in these areas.
Roberto Bricefio-León and Silverio González analyze economic and social conditions leading to infestation of triatomines in villages of Venezuela. They introduced locus of control theory into the SOH/CCH pilot projects in Bolivia. Locus of control implies that an individual’s general expectations about his or her ability to control the future greatly influence that individual’s response to house improvement programs (González Tellez, interview 10/15/91). People’s notion of whether the future is controlled by themselves, the state, fate, or luck greatly influences their desire to act to prevent anything or improve houses. González helped project personnel deal with the fatalistic attitude of peasants. He also found that, after they improved their houses, many people gained a sense of empowerment.
Economists devise ways that projects can be financed by community members. They also help to increase productivity in rural areas. Many factors in vector infestation are related to economic problems. Migration and inadequate housing are caused in part by low productivity, unemployment, debt peonage, and impoverishment. Chagas’ disease has increased because poverty in Bolivia and other countries of Latin America has increased, especially in cities.
Innovative economists are forming microcredit institutions and cooperatives to assist community members to develop free trade. As an example, Marco Antonio Prieto analyzes problems within the rural communities of Chuquisaca and devises economic measures such as microcredit and cooperatives to deal with these problems. Ronald Gutiérrez, an economist for Plan International, studies how the political economy affects migration and housing development in the Department of Tarija. Plan International and Pro-Habitat provide credit for housing improvement in the barrios of Tarija. Ruth Sensano has introduced the production of tile roofing to certain communities. It serves not only to prevent vinchucas but also as an additional source of income to the community. The parish in San Lorenzo, Territory of Lomerío, has a housing cooperative that provides credit to Chiquitano Indians to build houses and a tile-and-brick cooperative to provide them with building materials.
Agriculturalists study land to increase productivity, decrease depletion, and improve farming and herding. They have introduced rotational planting. Livestock suffer similar symptoms of Chagas’ disease, and its toll on sheep, cattle, goats, horses, alpacas, llamas, and guinea pigs is very great. Percentages of livestock infection are proportional to percentages of human infection wherever animals are kept near dormitories, which is almost always the case among peasants. Chagas’ disease’s toll on animal productivity is a concern that Bolivians generally haven’t even begun to consider. At the present, the major concern is that domiciliary animals attract vinchucas and are carriers of T. cruzi, adding yet another infected blood source for uninfected vinchucas. Agriculturalists deal with ways that livestock can be kept so that they do not serve as reservoir hosts for parasites. Bolivian agriculturalists also practice veterinary medicine and are necessary to treat infected and ill livestock.
Linda Gregg, an expert in animal husbandry, studies goat and cattle herding among the Quechuas of Misqui, Bolivia, an area where Chagas’ disease is 70 percent endemic. She provides medical care for sick animals and has found that imported cattle brought hoof-and-mouth disease to cattle in the region. She is introducing ways to increase herds, produce healthier animals, and improve herding techniques to minimize erosion caused by goats. She also is assessing the loss of productivity in livestock as caused by T. cruzi.
Community health workers have been trained in agriculture and animal husbandry in the Department of Oruro. They have introduced carpas solares (solar gardens) to hundreds of communities of the Altiplano, where previously because of the cold nights and altitude of 12,500 feet the growing of tomatoes, cabbages, onions, and carrots was not feasible. Now these communities have vegetables to help balance their diet of potatoes. Workers also have introduced new types of seeds and rabbits.
Naturalist Jaime Zalles studies the economical uses of wild plants throughout Bolivia. He and ethnologist Manuel de Luca have published popular books on the medicinal and nutritional uses of plants. Written in the Aymara, Quechua, and Guarani languages, these books are well-illustrated and helpful guides to members of the community, CHWs, and ethnomedical practitioners. Zalles gives presentations to peasants about Chagas’ disease and informs them about native plants that can be used to treat its symptoms or as insecticides. He cultivates medicinal plants for export and is involved with scientists trying to find herbal cures for Chagas’ disease, AIDS, and cancer.
Thes
e specialists, many of whom are Bolivians, may provide innovative and unique solutions to Chagas’ disease, and many could be employed for less than the cost of one consultant from the United States. They constitute an interdisciplinary team for dealing with Chagas’ disease. Bolivians should be able to provide a more integrated interdisciplinary and culturally sensitive approach to the prevention of Chagas’ disease than could international agencies or nongovernmental organizations. However, they too must avoid Bolivia’s inherent class and race stratification. They too need to be trained in the culture context triangle. Their endeavors do bear out the premise of the culture context model: that people within a community know best how to solve their own problems once they are educated about them. The role of project workers is to meaningfully educate them.
Decreased Productivity
Economic and social costs of Chagas’ disease are huge for Bolivians and other peoples of Latin America. Chagas’ disease helps creates a downward spiral of productivity; it is a debilitating disease at all stages. At its early stages parasites sap vital nutrients and dispel toxic waste products; at its later stages diseased organs totally disable workers. Most notably, peasants suffer fatigue, especially those working at higher altitudes, where they often must stop farming their plots or leave the work to relatives and children. The inability to work results in decreased crops, which causes malnourishment that leads to increased susceptibility to Chagas’ disease.
Even more costly, many adult victims die during their most productive years. Children are left without mentors and families without breadwinners. Remaining members of the community then must assume responsibility for the survivors. For this reason, Chagas’ disease is a major obstacle to development in Latin America. The World Bank considers it the fourth most serious health problem in Latin America (after respiratory and diarrheal illnesses and HIV infection), as measured by years of life lost adjusted for disability (see Figure 31). From a cost-benefit analysis, it is cheaper to build a house for every Bolivian family than to cover the cost of Chagas’ disease to the economy from loss of production (not including the loss of animals).
The Kiss of Death Page 21
