(Plan International and Pro-Habitat) and credit cooperatives (Pro-Mujer and ProHabitat), discussed in the next chapter.[50]
PBCM’s Chagas’ control programs were based upon the following conclusions derived from baseline studies (see Appendix 14): Many peasants live in unhealthy houses that should be bug-proofed; peasants often do not know the danger triatomines present in their houses and therefore are in need of health education; peasants need technical assistance in home-improvement projects and in spraying insecticides. The goal was basically preventativeto break the transmission chain by means of education, house improvement and improved hygiene, and by spraying for insects. Of some consideration, PBCM lacked a therapeutic outreach program for those with Chagas’ disease, even though its primary health care program assisted severe cases of heart disease and colonopathy.
Prevention breaks the transmission cycle of T. cruzi from triatomines to humans. In its most basic form, prevention against Chagas’ disease involves the following objectives: periodically spraying with insecticides to destroy triatomines, improvement of housing and corrals to eliminate nesting areas of triatomines, and better housing hygiene. However, each of these objectives involves achieving many changes within the household which are difficult to accomplish. Because the house is the base for peasants’ economy, where they eat, sleep, give birth, raise children, process food, store crops, and keep animals, Chagas’ control projects have difficulty changing some of these cultural and economic practices. Project personnel often overly concentrate on health issues rather than on issues of productivity and economics.
Infrastructure for Chagas’ Control
PBCM’s infrastructure for a primary health care program served as an effective base for Chagas’ control. Its infrastructure included three zones, each with a central hospital with three doctors (a director and two others to lead traveling teams), two health workers, and two social workers. These zones contained twenty-six puestos sanitarios (health posts) in the larger communities, each staffed with an auxiliary nurse and equipped with primary health care items (vaccines, antibiotics, bandages, and measuring instruments). Under Ruth Sensano’s leadership, auxiliary nurses within the three zones were provided with training, technical support, and monetary incentives. Peasants at the village level were responsible for their health and were invited to support a community health worker (CHW), already discussed. CHWs assisted auxiliary nurses and health teams and later became principal links between the village housing-improvement committees and project technicians. CHWs usually serve for two or three years without pay; and they consider this part of their community service, un cargo (a load).
The cargo system is deeply embedded in Andean and Latin American culture; it predicates that leadership is a burden (cargo) to be carried voluntarily without material gain, but this service accrues towards one becoming a complete adult (una persona muy completa) in the community (see Bastien 1978, Metraux 1967, Wolf 1955). Adolescents grow into adulthood in part by serving the community. Adulthood is achieved by assuming tasks for the community.
The maturity of the individual relates to the community; the health of the community brings health to the individual. Throughout Bolivia, the cargo system has been used effectively to elicit community support, with some individuals accepting the load of overseeing the community’s health as a community health worker (CHW).
Sensano had also trained traveling teams of technicians. Traveling teams from the hospitals educated and coordinated activities of the auxiliary nurses and CHWs and provided them with educational materials such as videos, slides, and posters. The traveling team consisted of a medical doctor, social worker, and health educator. Each hospital had two traveling health teams, so that one team was able to visit every village once a month while the other team worked at the hospital. Traveling teams initiated Chagas’ control measures, completed base studies and evaluation studies, and provided technical assistance for housing improvement projects.
Peasants’ Awareness of Chagas’ Disease
When Chagas’ disease control was begun in 1989, it presented additional challenges, which Sensano explains:
Adding Chagas’ disease control to PBCM was a challenge, because it involved changing houses and habits of peasants. Deeply rooted cultural patterns needed to be changed and housing behaviors needed to be modified. Fumigation and housing improvement requires cost-sharing. Eradication of triatomines is only one step that needs to be followed up with vigilance, refumigating, and housing hygiene (Sensano interview 6/16/91).
With such complexity in mind, Sensano, Rivas, and Martinez decided to initially limit their Chagas’ disease control efforts to four communities, which they selected according to the following criteria: high incidence of Chagas’ disease, semi-nucleated communities, similar socioeconomic levels, little possibility of outside asistance, accessibility, and a favorable response to first efforts at concientizacion, or consciousness-raising (Rivas et al. 1990:4). They chose the communities of Puente Sucre (Yotala zone), Tambo Acachila (Yotala zone), La Mendoza (Yamparaez zone), and Choromomo (Tarabuco zone). The activities of the project consisted in concientizacion, forming house-improvement committees, and actually improving houses.
Concientizacion: Education
Sensano educated peasants by trying to change their perceptions so that they felt that they could do something about their impoverished conditions. In Bolivia and elsewhere, peasants often have a fatalistic attitude that discourages them from trying to improve their conditions, which in most instances is borne out by a history of exploitation. In Chuquisaca, for example, some peasants refused to improve their houses for fear that the landowners would then charge them rent. They also thought that the supplies would be another form of debt peonage, with interest rates at 12 percent per month. Diseases, such as Chagas’ and tuberculosis, are facts of life for rural Bolivians; control over disease often is best initiated by means of rituals.
Concientizacion (consciousness-raising education, or CRE) was popular in Latin America during the 1980s. It implies that community members recognize the relationship of material conditions to behavioral, economic, social, and cultural factors by means of investigation and analysis of actual concerns.[51] Concientizacion attempts to help instill in poor people the hope of improving their situation. Concientizacion has premises in concepts of Christian social justice that relate the cause of the disease within the political and economic contradictions of Bolivian society. Therefore it is useful for looking at the connections between local causes of infestation and broader social concerns.
Even though Sensano proposed to look at the connection between broader concerns and causes of disease, she used an approach that scared peasants more than it made them reflect upon the political economy. As she describes it:
…concientizacion was, and still is, the key to our success. We used shock methods to make them realize that the bites of vinchuca cause bulbosos [welts] and heart problems. We traveled from house to house, showed them feces that the vinchucas left after they had sucked human blood, then became so full that they left traces of mierday sangre [feces and blood] on the walls. We pointed out their eggs,
