APPENDIX 14
Baseline Studies in Chuquisaca
Baseline studies were completed in four communities of the Chuquisaca region where Proyecto Británico Cardenal Maurer was working. Project members surveyed seropositivity to Chagas’ disease, infestation rates and percentage of infected vinchucas, and types of housing. Meeting some resistance, doctors and nurses extracted blood samples from thirty-seven people in the community of Choromomo. Andeans frequently fear that blood lost will not be restored, based on beliefs that they have only a limited supply of blood. Blood and bugs were shipped by air to a laboratory in Cochabamba, where they were analyzed for T. cruzi. Results indicated that 61 percent (403) of the bugs (660) and 32 percent (12) of the blood samples (37) were positive for Chagas’ disease. Significantly, 27 percent (9) were from people between the ages of eight and twenty-six years (CRS-PROCOSI 1990:16).
Additional baseline studies in 1990 gave project workers some idea of infestation rates and conditions of housing for four characteristic communities (see Table 5).
Table 5
BASE STUDY OF TRIATOMINE INFESTATION IN CHUQUISACA
(CRS-PROCOSI 1990:8)
Community Houses Examined Triatoma Infected Houses Triatomas Captured Triatomas with T. cruzi
No. No. % No. No. %
Puente Sucre 21 18 86 73 32 44
Choromomo 32 32 100 120 104 87
La Mendoza 66 59 89 215 134 62
T. Ackachila 60 52 87 252 133 53
TOTAL 179 161 90 660 403 61
Ninety percent of houses in the four communities were infested with vinchucas, of which 61 percent were transmitting the chagasic parasite. Comparing the four communities, when infestation rates increase 10 percent, going from an average of 90 to 100 percent, the percentage of infected triatomines increases at a greater percentage, going from an average of 61 percent to 87 percent, as illustrated in Choromomo. Communities with 60 to 80 percent bug infestation rates also indicated similar infection rates. This suggests the hypothesis that at a nearly complete infestation rate, the parasite approximates this percentage.
Another study was completed to assess type of housing within the Department of Chuquisaca (see Table 6).
Table 6
CLASSIFICATION OF HOUSES IN FOUR COMMUNITIES OF SUCRE
(CRS-PROCOSI 1990:9)
COMMUNITY Type I (Good) Type II (Regular) Type III (Bad) TOTAL Closed Houses
Puente Sucre 0 2 20 22 1
Choromomo 0 4 28 32 2
La Mendoza 0 3 63 66 2
T. Ackachila 0 9 53 62 3
TOTAL 0 18 164 182 8
Dwellings were categorized into three types: Type 1good, Type 2regular, and Type 3bad. Houses were classified into types 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. This grouping was relatively easy to apply, because most houses fit into the bad category and none fit into the good category, with 18 regular and 164 (or 90 percent) bad (see Table 6). Unhealthy houses correlated closely with infestation rates, both being 90 percent. This being the case, in endemic areas, housing conditions alone could serve as indicators of infestation rates.
Baseline studies provided personnel with figures to evaluate progress and to what extent fumigation, house improvements, and housing hygiene lowered the infestation rates. After spraying and house improvements were completed, a new study of house infestation was done. Periodic surveys indicated that continued vigilance was essential to Chagas’ disease control. Since vinchucas kept colonizing homes if houses became run down, PBCM concluded that spraying was necessary every six months; however, this is costly.
Glossary
A
acute infection — Refers to initial infection with Trypanosoma cruzi, which may not be clinically apparent. If apparent, it is characterized by inflammation caused by the infiltration of mononuclear cells and may include fever, general malaise, swelling and soreness of the lymph nodes and spleen, and Romaña’s sign. Acute phase begins four to twelve days following the introduction of the organism and ends after approximately two months (sometimes up to four months). This phase can be deadly for infants, who do not have fully developed immune systems.
adenosine triphosphate (ATP) — An enzyme found in all cells. When this substance is split by enzyme action, energy is produced. Triatomines effectively acquire this through blood meals.
African trypanosomiasis — Another name for African sleeping sickness caused by trypanosome parasites that are salivaria (travel from the mouth of the insect).
Altiplano — A high plain or plateau (12,500 feet) between the eastern and western ranges of Bolivia and Peru. It is where Aymara- and Quechua-speaking Andeans live.
amastigote — A stage of trypanosoma found in the host that lack long flagella. Amastigotes are round and smaller than trypomastigotes. They are intracellular, forming cysts in muscle and neuron tissue. Within this stage, trypanosomes reproduce into more amastigotes and trypomastigotes.
American trypanosomiasis — Another name for Chagas’ disease, caused by trypanosome parasites that are sterecoria (travel from the intestines and fecal matter).
antibody — A protein produced in the immune system that responds to a foreign substance or antigen. See Immunoglobin.
auxiliary nurses — Medical personnel who manage health posts in rural areas of Bolivia. They receive six months training in primary health care and emergency medicine.
ayllu — Distinguishable groups in the Andes whose solidarity is formed by religious and territorial ties (llahta ayllu), by permanent claim to land and lineage (jatun ayllu), by affinal ties (masi ayllu), and by work (mitmaj ayllu). Kallawayas understand ayllu as the vertical triangular land masses divided into high, center, and low ecological zones where communities live. They also perform healing rituals to the earth shrines of the ayllu.
Aymaras — A civilization and ethnic group of Andean peoples who speak the Aymara language and live in the highlands of Chile, Bolivia, and Peru.
aynisiña (ayni) — A basic Andean institution wherein peasants set up a system of compensation regarding work tasks. An ayni would be an amount of work, such as thatching a roof, that someone owes another because he or she has done the same or an equivalent task for that person.
B
barbeiro — A popular Brazilian name for vinchucas, or triatomine vectors of Chagas’ disease.
baseline study (survey) — A collection of initial epidemiological, entomological, and social data concerning incidence of disease, infestation of insects, and condition of housing that is used as a basis to determine the effectiveness of Chagas’ control projects.
Benznidazole (synonyms are R07-1051, Radanil, and Rochagan) — A drug used to treat Chagas’ disease. It is a 2-nitroimidazole derivative with antiprotozoal activity.
Bolivian agrarian reform — It marks the end of feudalism in Bolivia and began after the April 1952 revolution. It divided the haciendas, distributed land to the peasants, and abolished the tribute system. It restored to indigenous communities the lands which had been usurped from them, and it cooperated in the modernization of agriculture. After the Agrarian Reform law was signed, 90 percent of the landlords abandoned their estates and the countryside essentially belonged to the Indians.
C
campesinos (peasants) — A word used to refer to traditional Andeans and the vast majority of Aymara and Quechua farmers and herders throughout the Andes. They speak native languages and generally dress in traditional clothes.
capitalization — Influx of investment funds for capital development.
cargo system — A deeply embedded Andean political institution in which leadership is seen as a burden (cargo) to be carried voluntarily without material gain but which accrues toward becoming a complete adult (una persona muy completa) in the community. It entails a number of leadership responsibilities for each person: leading the village, taking care of
fiestas, being a secretary, and, lately, being involved in community health work.
carrier (also carrier host) — One who harbors disease organisms in his body without manifesting symptoms-thus acting as a carrier or distributor of infection. Many Bolivians do not suffer from Chagas’ disease but are infected with Chagas’ disease and thus are carriers from which uninfected bugs can contract the parasite.
chagoma — A carbuncle sore or painful node covered by tight reddened skin that often, but not always, appears at the site where T. cruzi enters the skin. The most characteristic of these is Romaña’s sign, which appears around the eye.
chapaco — A popular name given to people of the Department of Tarija, Bolivia.
cholos — Aymara and Quechua people who have adopted some Western ways but who continue to hold on to many Andean traditions. Many speak Spanish, and the men wear Western clothing, whereas many women continue to wear stove-pipe and derby hats and pullera (traditional skirts). In a hierarchical, class-stratified society, cholos are higher than campesinos (peasants) and lower than mestizos. The cholo class has become a dominant merchant class in Bolivia, excelling as truckers, traders, market vendors, merchants, and politicians. See campesinos and mestizos.
chronic phase (also called Tertiary Chagas’ disease, classic chronic) — A result of gradual tissue destruction, usually of the colon, esophagus, and heart. Some patients remain relatively asymptomatic until this phase when organ damage appears. Other patients who have suffered severe acute infections pass immediately into the chronic phase because of initial organ damage. The chronic phase is considered incurable, with only its symptoms being treated.
chuyma usu (“sick heart”) — A phrase used by Andeans to express heart disease, which often indicates T. cruzi infection.
cólico miserere (“miserable colic”) — Refers to enlarged colon, often caused by obstruction or entangled intestines (volvulus) or denervation of intestinal tissue from T. cruzi infection.
colostomy — The opening of some portion of the colon onto the surface of the abdomen to release feces. This is performed when it is impossible for the feces to pass through the colon and out the anus due to damage caused by T. cruzi or other pathological conditions.
Community Health Workers (CHWs, promotores) — Members of an outreach program in which community members become involved in their own health delivery and elect some resident to be trained in providing primary health care. Many rural communities in Bolivia have CHWs, who play an integral part in the prevention of Chagas’ disease.
community participation — Involvement of community members in decision making involving acceptance of and compliance with certain social and behavioral changes in regard to Chagas’ disease.
concientización — (consciousness-raising education, CRE)A pedagogy of development that helps community members recognize the relationship of material conditions to behavioral, economic, social, and cultural factors by means of phenomenological investigation and analysis of concerns.
congenital transmission — Vertical transmission of T. cruzi from an infected mother to her infant, through the birth canal, blood, or maternal milk.
contamination — The deposit of T. cruzi in the fecal matter of triatomine bugs on the skin where the parasite enters through an abrasion or by scratching. This mode of infection is distinct from that of malaria parasites directly injected into the skin by mosquitos. Hygiene thus is an important factor when contamination is the primary route for infection.
cross-cultural communication — The ability of people from different cultures to be able to effectively express their concepts with terms that each side will understand and be able to fit into their culture.
cross-cultural community participation (CCCP) — Active involvement of technicians and community members from different cultures (such as Western biomedicine and Andean ethnomedicine) to discuss differences and be able to arrive at acceptable solutions to both.
cultural epidemiology — The study of cultural factors affecting the transmission, distribution, prevalence, and incidence of disease, which attempts to explain values, behaviors, and ethnomedical practices as they relate to the spread and curtailment of a disease. (Cultural epidemiology is a study initiated by the author, and it is the methodology employed in this book.)
culture — The sum total of artifacts, behaviors, beliefs, practices, technology, material objects, and values that societies hold and pass from one generation to the next. Cultures can be compared to “owner’s manuals” that one receives at birth from other members of the society, although cultures are dynamic and continually changing.
culture context — Configurations, patterns, or structural relationships characteristic of any culture that provide members with themes, values, and functional arrangements perceived as very important to them.
culture context model — A development model that considers culture context as the primary basis for adopting change, such as Chagas’ prevention.
culture context triangle — A model of development based on equal participation of 1) ethnomedical practitioners and community health workers, 2) community members, and 3) technical personnel within the cultural context of a community.
curandero — A generalized term used throughout Latin America to refer to traditional healers.
D
Darwin’s disease — Sometimes used to refer to Chagas’ disease on the assumption that Charles Darwin suffered and died from Chagas’ disease; discussed in Chapter 1.
defecation time — The length of time after the triatomine bug feeds until it defecates. An important index, because certain triatomine species, such as Triatoma infestans, are much more infective than others like Panstrongylus megistus, because the former defecates sooner, thereby depositing infected fecal matter near the bite site.
disease burden — Refers to productive years that a worker loses because of a certain disease or disability; also known as disability-adjusted life years (DALYs). Chagas’ disease is very high in this regard, because many workers die young from it; moreover, children are left without parents.
E
electrocardiogram — A record of the electrical activity of the heart that provides important information concerning the spread of excitation to different parts of the heart. It is valuable for Chagas’ disease treatment in that it detects abnormal cardiac rhythm and myocardial damage.
empacho (constipation) — A culturally defined condition that includes the inability to defecate, which may be a sign of megacolonitis caused by Chagas’ disease.
endemic — The continuous presence of a disease in a region for long periods of time. Chagas’ disease is endemic in most of Bolivia.
entomologist — One who studies insects; medical entomologists study insects and their relationship to human diseases.
epidemic — An infectious disease that attacks many people at the same time in the same geographical area.
epidemiology — The study of the various factors relating to the transmission, distribution, prevalence, and incidence of disease. This study attempts to explain or anticipate an outbreak of disease. See cultural epidemiology.
epimastigotes — A transformative stage of T. cruzi found within an insect that follows the ingested trypomastigote stage and leads eventually to the metacyclic trypomastigote stage. Epimastigotes are distinguishable from trypomastigotes because in epimastigotes the flagellum begins near the center of the parasite between the nucleus and kinetoplast, extends along the anterior undulating membrane, and protrudes from the prow.
F
flagellate protozoa — Protozoa having a flagellum, such as T cruzi.
flagellum — A whiplike extension attached to the parasite’s membrane that propels the organism by undulating along its side and at certain life stages extending forward from its prow, making parasites agile swimmers and intruders into cells. The flagellum may also be used to attach to the insect’s gut wall or salivary glands.
G
gentian violet — A dye us
ed to destroy trypomastigotes in blood supplies.
H
hematophagous insects — Insects that live off blood.
host — The organism from which a parasite obtains its nourishment. Hosts in Chagas’ disease include mammals, some other animals, and humans. Hosts refer to organisms where the parasite is infective and primarily reproduces. See vector.
house improvement committees (HICs) — The functional units at the community level in the PBCM project where plans and priorities for house improvements were decided and where all participatory activities were coordinated.
house infestation — Refers to the number of triatomine insects found in a house.
hypoxia — High-altitude stress from decreased oxygen.
I
ileostomy — Excision of the ileum.
immune system — The defensive protective reaction of the body to substances that are foreign or are interpreted as being foreign.
immunization — The process of rendering a patient immune to, or protecting individuals from developing, certain diseases.
immunocompetence — Being capable of developing an antigenic response to stimulation by an antigen.
immunodeficiency — The decreased or compromised ability to respond to antigenic stimuli, which may be caused by malnutrition and diseases such as AIDS.
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