The Kiss of Death

The pilot projects were exclusively concerned with spraying and housing improvement. They did not consider systemic relations between community health, agricultural production, economics, and the environment. Marco Antonio Prieto said that the pilot projects were puntales (isolated and unintegrated events), like an unsuitable but nice gift given to someone once or twice in a lifetime.[70] For a sustainable model of Chagas’ prevention, isolated actions are not adequate; it is necessary to look at systemic relations, not at causality. Bolivians don’t have enough money to solve all their problems; culturally sensitive community participation is necessary (Prieto, interview 5/25/97).

Another critic, Pablo Regalsky,[71] emphasizes the importance of understanding the native culture:

For any Chagas’ project, you need thirty years. You can’t do it in five years. You have to begin by forming community teams who understand the sickness and can work with the community, who can be understood by the community according to terms that the peasants understand. If they don’t understand how the disease functions, then it is impossible to be able to combat it. It is a long-term sickness and people will have to combat it for a long time. If a person becomes sick, what can he do? For example, Florencio, head of Sindicato, has been diagnosed with it. Florencio has to rest when he can, but he can’t rest. “I am the leader of the peasant syndicate,” he says, “and I have to travel, eating here and there, and not in my house.” This is the problem that is not solved by plastering a wall.

After forming a team, then you have to work for a long time in the community. We can’t say that I am going to fix up a house in a year but that we are going to plaster in ten or fifteen years. Little by little, you go from house to house, explaining (Regalsky, interview 5/30/97).

These criticisms and suggestions are not meant to discredit the efforts of project personnel; rather, they are steps leading to the proposed model, the cultural context triangle.

This model triangulates upward from three corners; project personnel and technical assistance, community members’ participation, and CHWs and ethnomedical practitioners form a pyramid whose apex is the prevention and treatment of Chagas’ disease.[72] The elements converge toward common goals, maintaining distinct identities but operating within a shared cultural context distinct to the particular community. The base of the triangle is the culture of the community.

^{Figure 29.}

^{Cultural Context Triangle Model. This culturally sensitive model attempts to reduce the gaps in cross-cultural communication in health projects between project personnel and community members. This model triangulates upward from three corners. Project personnel and technical assistance, community members and participation, and CHWs and ethnomedical practitioners form a pyramid whose apex is prevention and treatment of Chagas’ disease. The parts converge toward common goals, maintaining distinct identities, and operate within a shared cultural context distinct to the community.}

This structurally interrelated approach posits culture as the cohesive element binding together the project, the community, and the local health team. It is distinct from one-sided and vertically directed approaches that implant outside project goals. Elements of what might be called biomedical imperialism are usually present in health projects that assume that science knows what is best for the natives. This usually translates into project managers dictating what aid various people should get and how it should be given. Nor should the proposed model be confused with a culturally sensitive model that employs anthropological knowledge as a tool to translate the project’s goals into means acceptable to the community. In that type of project, goals take priority; in CCT, cultural context takes priority.

Developmental projects, programs to combat Chagas’s disease, and other health projects often have not been sustained because they failed to integrate the project into the culture of the community. Such projects have produced clinics, hospitals, and houses in Bolivia, but in many cases the dust of unsustainability now covers these structures, making them monuments to misspent endeavors at international charity. Some programs actually have been counter-cultural, with ethnocentric religious, political, and economic views subtly embedded into project methods and goals.

Spokes of Culture Context

Like spokes of a wheel, the cultural context triangle has a number of spokes that hold it together. Broadly, culture context refers to the configuration of beliefs, practices, and material objects passed along through generations and considered by community members as their guides through life. Culture context is a dynamic structural relationship that provides continuity as well as incorporating change for community members. Certain spokes interrelate project personnel, community members, and ethnomedical practitioners within a culture context that accommodates innovations necessary for Chagas’ control. These spokes connect the components and lead to the goal of culturally sustainable and workable solutions to Chagas’ disease.

• The communication spoke connects personnel, community members, and ethnomedical practitioners in a dialogue as equal partners. It implies that project personnel be able to speak native languages and converse with men, women, and children in meaningful ways. It implies that community members can discuss matters with project personnel. Openness implies the ability to accept the community’s point of view. It also implies integrity in stating one’s objectives.

• The economic spoke links the cost of the project to the productivity of the household and community; for example, it integrates house repairs into a local economy. Peasant economies are not as needful of gifts as they are of credit, fair wages, and increased productivity. Increased productivity enables peasants to improve their homes. Communal land ideals, shared labor practices, and community service are means that can assist project personnel to improve houses at reasonable costs. Basic Andean institutions provide suitable systems upon which cooperatives can be formed. Examples are aynisina (labor exchange) for house building, turqasina (resource exchange) for materials, mit’a (community service) for environmental projects, and communal land, used for cooperatives to provide peasants with collective producing power. Examples here include CEDEC’s assistance in agricultural and livestock productivity and Pro- Habitat and Plan International providing small loans for housing improvement (see Figure 30).

^{Figure 30.}

^{Martos Arredondo with family in front of his grease shop. Pro Habitat and Plan International provided him with small loans at reasonable credit to improve his house to make it vinchuca proof and to expand his oil-change business to include a truck wash. These loans average from $500 to $1,000 at 12 percent annual interest (compared to the usual 45 percent) and are guaranteed by neighbors who have similar enterprises. These micro-credit plans for house improvement provide a means to help eradicate Chagas’ disease in Bolivia. (Photograph by Joseph W. Bastien)}

• The house spoke connects the physical and cultural environment of the house to the parasitic cycle of Chagas’ disease. This involves removing material causes for infestation, but it also considers the values that household members place upon their homes. House uses include sleeping arrangements, gender relations, household activities, and celebrations. As an illustration, the house is considered as sayana for Aymaras of the Altiplano; it has thickly built walls, a thatched roof, and is small. It protects them against the wind and cold, yet it is one with the earth. The Guarani of Santa Cruz consider the house oca, open, centered around a courtyard that brings together diversity. Amazonian tribes live in raised thatched huts adjacent to the forests for seven years and then move to another locale when the insects become unbearable. Some bring their lifestyles to environments that don’t support them.

Chagas’ control projects have concentrated too exclusively on the material improvement of houses, and they frequently follow architectural styles suitable to mestizos. Personnel need to understand the house as a cultural institution and as a connecting and controlling metaphor that integrates all elements of the triangle.