The Kiss of Death

with peasants.

On the other hand, peasants have their own hierarchies, with certain members more distinguished than others; but this is based on completion of adult responsibilities within the community. Especially peasants from the Andean free communities (those that were not tied to haciendas) maintain a cooperative and communal spirit in their work. They help each other plow, seed, and harvest. If there is a fiesta, they all participate. If a project is to be completed, all members participate. When project personnel interact with such community members using class-stratified manners, they project upon the community political and social relationships that are offensive and counterproductive. Community participation in such groups is predicated on respect of differences and equality of participation; it is not based on paternalism, maternalism, classism, or racism.

Jose Beltran’s suggestions for better communication between doctors, nurses, technicians, and peasants include the fact that it is necessary that health professionals think in terms of cross-cultural communication and sharing of knowledge rather than having a superior form of knowledge. Doctors also have to internalize the reality of peasant culture and become motivated to work with these people as partners. This may necessitate spending several years in rural areas after medical school. It also involves learning native languages, colloquialisms, ethnomedicine, values, and economics.

At the conclusion of our last interview in 1997, Jose Beltran sang a song that he had taught children concerning Chagas’ disease. The tone is that of a cueca (popular dance of Chile), and the children dress like vinchucas and dance the cueca when they sing it.

Gracias a Dios que mi casa esta limpiay me curada.
Revocando las paredes combatimos las vinchucas.
Ordenaday revocada no hay mas bichos.

Thanks to God that my house is clean and I am healthy.
Plastering the walls we combat vinchucas.
Neat and plastered there are no bugs.

CHAPTER TEN Culture Context Model for Chagas’ Control Oscar Velasco, M.D., coauthor

The following proposed culturally sensitive model attempts to lessen the gaps in cross-cultural communication between project personnel and community members. Pilot projects in Chuquisaca, Cochabamba, and Tarija failed to become models for other projects because they lacked a model themselves.[68] These projects were rapidly designed, generously funded, and built several thousand houses. However, they provided little in the way of evaluation of ways to improve them, thus failing as pilot projects. Another fault was that Chagas’ prevention practices were barely integrated into the culture and economics of the community. Oscar Velasco and I have designed a program, called Culture Context Triangle (CCT), to be a model for Chagas’ control and other health projects.[69]

The CCT model provides educators and health workers with a framework for cross-cultural communication and a guide for their activities. It recognizes that community members and ethnomedical practitioners are equal partners in Chagas’ control. It integrates the subjects’ ideas, values, and practices into the prevention and treatment of Chagas’ disease, whenever possible and feasible. It includes treatment of patients with Chagas’ disease; pilot projects in Tarija and Cochabamba detected cases of Chagas’ disease but never did anything to treat these patients (patients were treated in Chuquisaca). These projects made people aware of their sickness without providing measures for treatment.

Successful cross-cultural communication strategies discussed in this book included the talks developed in Aymara and Quechua, the use of rituals to begin projects, educational material designed by Pro-Habitat, and Jose Beltran’s use of puppets and songs. Unproductive communication resulted from personnel who exhibited elitist and racist attitudes toward peasants, who didn’t speak Andean languages or use colloquialisms and other culturally appropriate forms, and who used overly scientific language.

In the previously mentioned projects, there were various shortcomings. To cut costs, project personnel studied and used available resources for building materials whenever possible. They failed to consider ways that natives control vinchucas with plants and other practices, however. Project personnel sometimes overlooked peasants’ work habits and calendar, ethnomedical beliefs and practices, economic exchange patterns, social and political systems, gender relationships, and role structures within the family. Omission of these cultural items jeopardizes project goals, because their inclusion makes it easier to implement projects and render them sustainable.

Community members failed to adopt Chagas’ control measures into their lifestyle for a number of reasons. The material goal to have a new house overshadowed the necessity of serious behavioral changes in isolating animals, maintaining the structure, and improving house hygiene. Project demands to follow the fiscal budget forced personnel to improve houses at a rate faster than the subjects could internalize the reasons for doing so. Failure to follow community values created class distinctions, with better houses for certain members of the community. (In Tarija, the project matched what each household provided; so, for example, if someone put in $3,000, the project had to put in an equal amount. This resulted in project monies being used to fix up the houses of wealthy people, who demanded equal access to the program as peasants.) The greatest failure was not to incorporate economic development into the projects to deal with impoverishment and migration, which ultimately cause neglect and abandonment of houses. Thus, this housing improvement was a “Band-aid approach” to the problem, which also did not deal directly with the sickness.

After they had improved their houses, some people developed symptoms of Chagas’ disease. Certain community members attributed this to the evil-eye; people envied those with new houses, so they gave them the eye. Other villagers refused to have their houses repaired because they didn’t want the evil-eye. Technicians often shrug this off to the ignorance of peasants but then illustrate their own ignorance in neglecting these feelings. The incorporation of shamans into the project would have helped villagers to believe they could avoid the evil-eye. Along these lines, Ruth Sensano had diviners perform summation rituals.

Project personnel project a scientific world view on the traditional mythological and cosmological world views of Bolivians. Project personnel assume that scientific technology such as spraying and house construction is the sole answer to vector control. However, this excludes the wisdom and practices of ethnomedical practitionersshamans, diviners, and midwives. Although curanderos do not follow scientific practices, their exclusion from health matters slights these respected community figures. It also makes them competitive, whereas their inclusion elicits their support. Because Bolivian communities have so many classes of curanderos (over thirty kinds of specialists), projects miss many opportunities to get support in what they are doing. For example, herbalists know certain plants that are insecticides and parasiticides. Curanderos often treat symptoms of Chagas’ disease and refer patients to doctors.

Diviners serve as agents against the possibility of mala suerte (bad luck), so feared by Bolivians when someone tries to change things. Midwives may be able to detect babies born with Chagas’ disease. Studies show that once ethnomedical practitioners are incorporated into biomedical projects they become an important asset (Bastien 1987a, 1992).