The Kiss of Death

used with biomedicine. Kallawayas employ about a thousand medicinal plants and are renowned throughout Argentina, Bolivia, Peru, and Chile as very skilled herbalists. This research resulted in Healers of the Andes: Kallawaya Herbalists and Their Medicinal Plants (Bastien 1987). I published an herbal manual in Spanish for peasants that was used for training community health workers in the Department of Oruro, Bolivia (Bastien 1983). I returned to Bolivia almost every year to do research.[1]

By 1980, I again felt the missionary’s impulse, not to evangelize but to argue for the inclusion of Andean traditional medicine, especially herbal medicines, rituals, and curanderos, into national and international health programs. I became an advisor to the National Secretariat of Health and the United States Agency of International Development on the integration of ethnomedicine and community health workers into primary health care programs.[2]

A more recent endeavor to integrate both types of medicine has been my collaborative research with chemists and pathologists in the testing of Kallawaya-Bolivian medicinal plants for curing AIDS, cancer, Chagas’ disease, and tuberculosis. The results are significant, with certain plants being protease inhibitors for AIDS, and others curing cancer and tuberculosis (Bastien et al. 1990, 1994, 1996). Kallawaya plant medicines also show promise as cures for Chagas’ disease. Scientists at the University of Antofagasta, Chile, are examining these plants.

Bolivian and international health personnel are beginning to integrate ethnomedicine and biomedicine in Bolivia, as I discuss in Drum and Stethoscope: Integrating Ethnomedicine and Biomedicine in Bolivia (Bastien 1992). Doctors, nurses, and project workers work with shamans, midwives, and community health workers in joint clinics. Associations of community health workers, midwives, and herbalists negotiate with doctors and nurses. The National Secretariat of Health coordinates both types of medicine, including providing staffed positions in ethnomedicine. State-run pharmacies stock and sell herbal medicines. This recognition and respect of Andean traditional medicine is encouraging; however, the current hegemony of biomedical medicine, propelled by pharmaceutical and insurance companies, medical associations, and privatization, essentially pits capitalist entrepreneurs against ethnic curanderos and shamans in what becomes for the latter a losing battle.

Kiss of Death’s call for activism is unusual in a scholarly text, but I feel it is appropriate if it helps lead to the creation of prevention programs. Western medical ethics has come to address the manner of distributing resources that affect the maintenance or restoration of health as a moral problem (see Lieban 1990:227). The pattern of allocating resources basic to health and survival raises serious ethical issues in light of the principle of distributive justice, defined as “the justified distribution of benefits and burdens in society” (Beauchamp and Childress 1983:184). Does distribution of resources for combatting Chagas’ disease involve a conflict between the perceived higher valuation of certain communities over others, males over females, adults over children, and wealthier countries over poorer countries?

Because Chagas’ control projects are expensive and involve only a small percentage of communities in Bolivia, an evaluation of their effectiveness as pilot projects is important. For this reason, I concentrate on two pilot projects in the Departments of Chuquisaca and Tarija. The Proyecto Britanico-Cardenal Mauer (PBCM) project in the Department of Chuquisaca was considered a successful Chagas’ control project in 1991 by the National Chagas’ Control Committee, which recommended it as a model for other projects throughout Bolivia. It provided a primary health care infrastructure into which Chagas’ control was included. Ruth Sensano organized this infrastructure. The Tarija project stands out for its education of the local populace about Chagas’ disease. Jose Beltran is the leading educator in this project. Sensano and Beltran are highlighted in these projects because they illustrate what individual Bolivians are doing. These projects serve to help create an improved model that reaches more people more economically and within the cultural context of the community.

I observed other projects, which were heavily funded, hastily done, and had limited effect on Chagas’ control. These projects concentrated on new houses and insecticides, measures that are not affordable and sustainable over time. Insecticides have become too expensive for most communities without government subsidies, which have been discontinued. The pilot nature of these projects failed because they never presented a model to follow. This book assesses the justice of the allocation of health resources in regard to Chagas’ disease. Moreover, it suggests alternative solutions to the problem of providing more people with the means to prevent Chagas’ disease.

Personal Awareness of Chagas’ Disease

Chagas’ disease first became a major health concern in Bolivia in 1991. Until then, it had been a “silent killer” of millions of Bolivians. After twenty years of fieldwork, I first learned about the disease in 1984 when a doctor/epidemiologist and I were visiting Cocapata, a Quechua community, located between snow-crested mountains to the west and the Amazon to the east. We lodged in a peasant’s hut of adobe and thatch and slept on llama skins covering the dirt floor. Even though insects bit me, I slept through the night. As the sun came through the tiny window, I arose and asked my companion how he slept.

“I didn’t sleep at all,” he replied. When I asked why, he continued. “I refused to sleep. I chased vinchucas from my body. I didn’t want them to bite me!” When I asked what vinchucas were, he told me that they cause Chagas’ disease. He was not afraid of malaria and syphilis, but he dreaded Chagas’ disease. He explained what this disease was, and, for the first time in my life, I questioned the potential price of a good night’s sleep. Having lived years in peasants’ huts, I realized that I had long been at risk and wondered why no one had advised me about Chagas’ disease. Even today, Chagas’ disease remains unknown to many educated people and doctors throughout the world. Tropical diseases in impoverished countries receive little recognition and research, primarily because biomedical technology and pharmaceutical companies concentrate on wealthier clientele in temperate zones of industrial countries. The doctor’s final comments were, “Chagas’ disease is a poverty-driven disease.”

Once I began looking for Chagas’ disease, I found it throughout Bolivia. When I was researching Kallawaya herbalists outside of Charazani, Bolivia, they reported increased mal de corazon (heart problems) and muerto subito (sudden death) among their peasants, which seemed strange to them. Andeans living at high altitudes are noted for their strong hearts as well as increased lung capacity. Acute respiratory diseases are major diseases in higher altitudes. Peasants complained of fatigue, somewhat unusual for people accustomed to working above 9,750 feet (3,000 m.). I suspected that Kallawayas were dying of Chagas’ disease, and, not surprisingly, as I later learned, the Kallawaya region is an endemic area of Chagas’ disease.

When I interviewed Kallawaya herbalists about local diseases and plant uses, I found no direct references to Chagas’ disease. This is not unusual, however, because the symptoms of Chagas’ disease are varied and diffuse. I suspected that they were treating the disease’s symptoms, such as fevers, intestinal disorders, and heart problems. One local herbalist, Florentino Alvarez, taught me herbal curing (see Bastien 1987a:9-10). When I met him in 1979 he was paralyzed from a stroke and hardly able to walk and talk. I massaged his legs, gave him vitamins, and helped him along with crutches. As he slowly recovered, he showed me some plants and explained how they were used. Florentino Alvarez died in 1981, of unknown causes, perhaps from Chagas’ disease.

The full impact of Chagas’ disease struck me in November 1990 when I attended a planning session for Chagas’ control in Bolivia. Earlier that year, Paul Hartenberger of the United States Agency for International Development (USAID) and Joel Kuritsky of the Centers for Disease Control (CDC) asked Robert Gelbard, U.S. ambassador to Bolivia, to request monies from President George Bush for prevention of Chagas’ disease in Bolivia. Although the Ministry of Health in Bolivia had been granted $20 million for a child survival program from 1989 to 1994, no monies had been allocated for Chagas’ control. Gelbard asked the newly inaugurated president of Bolivia, Jaime Paz Zamora, to request monies from President Bush when he visited the White House later that year. Bush granted one million dollars to immediately begin a Chagas’ campaign in Bolivia. Later, several million more dollars were added to fund the SOH/CCH Chagas’ control pilot projects.

Kuritsky convened world experts on Chagas’ disease to meet in La Paz, Bolivia, in November 1990 to design a Chagas’ program. He invited me to assist in regard to cultural and social aspects of Chagas’ disease and prevention. After five days of participation in these meetings, I learned about the disease’s epidemic proportions,