The Kiss of Death

“Campesinos see a person working and then fall asleep and die with two or three drops of blood coming out of the nostril. They say she died ’asustado’ (frightened), or ’La Pachamama ha agarrado’ (Mother Earth snatched her!). In reality, la vinchuca got her, just as they got me!” (Sensano interview 6/17/91)

I noticed that her left eye had the carbuncular sore beneath the eyelid characteristic of acute Chagas’ disease, Romania’s sign, so I asked her if she had Chagas’ disease.

“I would be surprised if I wasn’t infected,” she replied, “seeing that I have slept in peasant huts many times. But that’s my job! More than likely, all my workers have Chagas’ disease. We are all in this together.”

Before I parted, an old Quechua lady came in with a face twisted from Bell’s Palsy. She was crying. Sensano hugged her, as a mother. Firmly, she advised the lady to take a taxi, providing her with the fare, to the Bolivian Supreme Court in Sucre.

^{Figure 22.}

^{Ruth Sensano assisting an Indian woman who had suffered Bell’s Palsy and had been released as a maid because of her facial deformity. Sensano served as arbitrator in the Bolivian courts over this matter. (Photograph by Joseph W. Bastien)}

“I’m also a social worker,” she explained to me. “This lady was fired as a maid after working thirty years for a wealthy family. They threw her out of the house because her disfigured face embarrassed them. They gave her no severance pay. Now, she is without a home and money.” Sensano is contesting this in court, and she hired a lawyer to defend the woman. The case was prolonged for six months. Ruth Sensano sighed, “So much suffering and so little justice in Bolivia.”

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