The Kiss of Death

Chagas’ disease, but they were not taking chemotherapy. I suggested the possibility of using Sangre de Drago, and I asked Jaime Zalles to provide them with the names of plants to treat heart problems and stomach disorders. Zalles provided them with an ample list.

In parting, Jose asked me to take a picture of the group. I was out of film on the only occasion I was asked to take a photograph. All embraced one another and we departed. Jose entertained us with Tarijeno couplets on the journey back.

Development of Teaching Aids

Jose Beltran collaborated with Irene Vance, director of Habitat, to produce educational material for Chagas’ control.[67] Initial production costs were U.S. $80,000. They used a classic methodology for material development that included the steps of conducting baseline studies for assessing cultural and economic conditions, an assessment of community resources and needs, the development of preliminary materials based on this information, field testing of potential materials, modification and production of materials, and evaluation of the effectiveness of the materials used. They produced beautifully illustrated posters, comic books, and flip charts to teach people about Chagas’ disease. They also produced slide shows and videos. By 1997, however, many of these teaching aids were no longer available in Tarija because the use and demand for them had been so great.

Although the success of these educational materials is unquestionable, critics have objected that this is an unsustainable resource which Bolivians cannot afford to continue. However, international funds are available for Chagas’ prevention and certainly effective and attractive educational material is needed to educate peasants as well as CHWs, technicians, nurses, and doctors. Also, although Bolivia is a poor country, televisions are common, and there is a potential for image-based education that should be developed.

One concern with the visual aids was that they lacked cultural sensitivity, primarily because they were designed by professionals in La Paz for all Bolivians. A principal argument of this book is the necessity to design projects relating to the many different ethnic and cultural contexts in Bolivia.

Nonetheless, teachers like Beltran are able to adapt teaching aids to the values of peasants, if they are creative and sensitive to the local culture. Because Bolivian educators normally follow strictly hierarchical models of teaching, they need to be encouraged to deviate from the formal texts and matter.

Jose Beltran has his own style. He composes songs, sociodramas, and role plays to illustrate T. cruzi, vinchucas, and the infirm. His classes are part theater and games. He uses puppets for children and adults and contracts Bolivia’s main puppeteer to do a show on vinchucas and parasites for the periodic health fair. Although it costs $100 to bring the puppeteer, the audience never forgets it. Jose spends several afternoons a week in the classroom, which he loves. “Children are curious about insects, creatures that are proportionate to their size,” he continues. “They are easier to teach than adults who relate more to larger creatures.”

Jose recognizes that cross-cultural communication is the major obstacle to health education. He stated:

We had the best coverage for vaccinations in Tarija, almost 100 percent. Why? Because I went to the barrios with my loudspeaker. We brought puppets, charts, and posters. Even a portable video. I put the needle into my arm a dozen times to show them that it didn’t hurt. They complained that when the Peace Corps was here, they used vaccinations to sterilize them. I don’t know if this is true. But we had to discuss these matters with them. We had to overcome many difficulties. Peasants are smart and they listen. They want to be healthy too. Today, doctors, nurses, and technicians do not have the same enthusiasm. If three children are not vaccinated, they don’t spend any time seeking them out. They look down upon peasants. They use a language that is sophisticated, abstract, and difficult for the peasants to understand. This is the most serious mistake. Why don’t they talk to the peasants as their cousins and friends? They go to the community, but they don’t communicate. I remember a nurse in Iskayachi who wanted to whip the children because they didn’t line up for vaccinations. There is what we say in Tarija, un desclacamiento, and they don’t want to identify with their people. They don’t want to return, and they think that they are in another status or class, and the peasants are burros (Beltran, interview 5/24/97).

Desclacamiento refers to the process of declassifying oneself from a lower class, but with the added notion of the nouveau riche, who look down upon the class from which they originated. Dr. Evaristo Mayda, director of Project Concern in Cochabamba, discussed this and added that the biggest obstacle in rural health improvement is the elitist attitudes of doctors, nurses, and technicians.

Jose Beltran continued in even stronger terms:

Peasants are considered burros because they haven’t had the opportunity to be educated as doctors have. Doctors do not want to see where they have come from. They think they are in another status and class. Doctors and technicians don’t want the peasants to have health because that deprives them of sales and control. They are not interested in educating people, they want to increase the demand in health. They are also afraid that if they educate the CHWs and nurses they will know more than them. Education is power, not to be shared. Or they are going to lose their business. Because before calling the doctor or nurse to treat a patient for Chagas’ disease, we instruct the CHW on how to do it, the doctor or nurse is going to lose the possibility of earning some money.

Once I brought a pregnant lady with a partial delivery (the placenta remained) twelve kilometers from a village to a hospital in Tarija. A woman doctor said to her, “Que esta cochina, como va a dar luz! (“What a sow, how is she going to birth? Why haven’t you bathed her!”). They were insulting her. She began to cry. They refused to take her, fearing she might contaminate the hospital. I had to take her to my house, put her in a bed, and call a doctor who treated her. No one had educated her on how to prepare for birth. This was a bitter experience. I criticize and censure this behavior.

Stratified Classes

Beltran highlights the problem of stratified classes to health projects. Chagas’ projects bring together people from different social classes who have to communicate with one another to combat Chagas’ disease. They often fail to achieve this goal because they perceive lower-class people as incompetent and inferior, thereby hindering community participation. The social dynamics of classes are important considerations for the success of any project.

Rural peasants generally are considered the lowest class. Since 1953 it has been against the law to refer to peasants as Indiansthe accepted word is campesino. Campesinos have equal voting rights with all other classes. Campesinos traditionally speak Andean languages, follow an agricultural calendar, and, as of 1994, have their own political organization. Vecinos, or residentes, are the people who live in the city. They include the salaried workers, and most of them are not much better off than the peasants. Already mentioned, only 2,000 salaried workers make over U.S. $10,000 annually (Presencia 1997). The upper class, sometimes called gente decente (civilized people), is composed of distinguished families and wealthy people. These are broad distinctions; there are many finer class strata in each of these groups, such as the cholo and mestizo classes, already discussed. Race, as defined by skin color, is not as important a marker in Bolivia as is social stratum, which is determined by one’s dress, behavior, family, and wealth. Consequently, such cultural markers as language, dress, and food habits are readily discarded to strip oneself from the lower peasant class. There is a tendency in peasants who have ascended to professional levels (doctors, nurses, and project personnel) to act out their perceived class superiority in dealing