HIV patients are also unresponsive to mycobacterial antigens (Khoo et al. 1993). The progression from HIV seropositivity to AIDS is accompanied by a shift in T-helper (TH) cells from TH1 to TH2 and selective loss of the response to mycobacterial antigens. Significantly, chagasic patients are predisposed to the establishment of HIV infection and its rapid progression to AIDS (Botasso et al. 1994).
In conclusion, the rapid spread and progression of HIV infection in Latin America is related to the frequency of infection of Chagas’ disease. The rapid spread and progression of tuberculosis and other acute respiratory infections in Bolivia is also related to Chagas’ disease. Bolivian public policy makers often object to the fact that AIDS and tuberculosis take medical priority to Chagas’ disease, when the fact is that Chagas’ disease is also related to the epidemiology of other diseases by the nature of the autoimmune response to it that predisposes its victims to these diseases.
Reflections on the Epidemiology of the Immune System
The following reflections are intuitive considerations of the above findings. AIDS and Chagas’ disease have contributed greatly to our knowledge of the immune system and immunopathology. In Western allopathic medicine, diseases are caused by viruses, bacteria, and parasites; the cure is to rid oneself of the organism. The miracle drugs of the twentieth century have been the antibiotics, which are very successful for lysing bacterial infections but less so for viruses, and they are ineffective for parasites. Trypanicides were developed to lyse trypanosomes of T. cruzi, but they have met with less than satisfactory results.
By the turn of the millennium, super-bacteria, viruses, and parasites have emerged unscathed by antibiotics. Simple principles of natural selection explain this: antibiotics essentially select individuals of the species that are resistant to the drugs; when they reproduce, they pass on these selective features to their offspring. The unwarranted use of antibiotics in Western culture has led to their increasing ineffectiveness and to the evolution of superpathogens. This unwarranted use has also led to humans being less dependent upon their immune systems.
With Chagas’ disease and AIDS, researchers have learned much more about the human immune system and how this system is responsible for illnesses. We are also learning how to live with immune-driven diseasesdiabetes, rheumatism, AIDS, and Chagas’ diseaseand how to build up the immune system by alternative methods of therapy, including dieting, meditation, ritual, and use of herbal medicines. The paradigm of health is changing from that of allopathic medicine, where we lyse the causal agent, to one of immunopathic medicine.
Immunopathic medicine includes figuring out ways to build up our immune system and to help it deal with the realities of our bodies and the organisms within them. Health is learning how to live with what you have. This alternative way of health is not very attractive for those who want the technical quick cure of a drug or vaccine to destroy the pathogen; but, as we have seen, this does not work with Chagas’ disease, among others.
CHAPTER SEVEN
Culture and Political Economy of Homes
The condition of houses is a major factor in the spread of Chagas’ disease. Bolivian houses have become habitats for triatomine vectors of Trypanosoma cruzi (see Appendix 5: Housing Infestation in Bolivia). Thatched roofs, cracked walls, and scattered domestic belongings provide nesting sites and hiding places for vinchucas in Bolivian houses. Peasants do not place their clothes in closets but rather beneath beds, in bundles, and in corners. Triatomines nest within mattresses, newspapers, and behind objects hung on walls. Peasants also frequently store wood and crops inside their houses.
House Tour with an Entomologist
Juan Mamani lives with his wife and six children in an adobe house, roughly about the size of a single-car garage in the United States. The adobe walls are unplastered and cracked. Entering the wooden-framed doorway, one sees openings between the frame and the walls. The dirt floor is smoothly packed but covered with stacks of corn, potatoes, rice, and dried beans in one corner. A small earthen stove without a chimney is nestled in another corner with pots and pans surrounding it. The room smells of smoke and cooking. The ceiling is black from the soot of smoke. The building has a thatched roof, which forms the ceiling, and from crossbeams hang clothes, baskets, and several drums. Wooden beds with straw mattresses lie along each wall. Juan and his wife sleep in one bed, their children in the others. Beneath the beds lie shoes, clothes, boxes of valuables, and costumes for fiestas. A table with wooden chairs is in the center of the room. A small window provides a little light inside the cool, damp, and dark room. The house is basically a place to eat, sleep, and store things. Several guinea pigs scatter across the room, foraging on leftover food lying on the floor; others peek out from underneath the beds. A dog lies next to a bed, and one of four cats of the household sleeps on the window ledge. Eight humans and thirteen other mammals sleep in this room.
Along with the entomologists, we use a flashlight to search for vinchucas kissing bugs. On the wall are telltale signs—brownish streaks—indicating vinchucas have taken blood meals and defecated as they crawled up the wall. There also are several splotches of dried blood remaining where Juan swatted vinchucas. The inside of the house becomes more and more disgusting to us as we shine the flashlight into cracks and see hundreds of vinchuca eggs, like rice being stored inside the walls. After we lift up pictures on the wall, a large vinchuca sits paralyzed by the light. Kissing bugs lie hidden in the clothes hanging from the rafters and underneath the bed. Several bugs are hidden underneath the gunnysacks filled with food. Within half an hour, we find about twenty-five bugs. However, this cursory investigation exposes only the tip of the iceberga thorough investigation of the Mamani household would reveal hundreds of vinchucas.
With reason, social scientists have described the Mamani household as a “sick house,” Casa Enferma, the title of Brisefio-León’s study of Chagas’ disease in Venezuela. Social scientists often use similar terms to describe unhygienic houses in cities. When urban renewals are promoted to improve housing, these houses often are classified as “run-down housing.” In Bolivia, political economists envision the country as developing through ecotourism and becoming a transportation link between neighboring countries; so many believe it is necessary to cover up certain places. For example, houses were painted along one street when the Pope visited Bolivia in 1987. Altruistic and political considerations frequently concentrate on the house as a focal point of disease rather than considering it as a family and cultural institution.
The House: A Vertical Entity
Gaston Bachelard writes in The Poetics of Space: “A house is imagined as a vertical being. It rises upward. It is a concentrated being. It appeals to our consciousness of centrality.” People never forget the house where they were born and raised. When they return to the hometown of their youth, they often visit this house, perhaps walking through it or at least driving by it. It is imbued with values which remain after the house is gone. The family home is a cherished image in society.
If within their home their fathers and mothers worked producing something, which in turn was stored in the basement of the house, the home also is remembered as a place of sustenance and supply. It evokes memories of banquets in the living room and parties in the yard. A certain room, for example, evokes scenes for me where my grandmother was laid out for burial. A home constitutes a body of images that give us proofs or illusions of stability.
The house is a familial and cultural institution that deserves understanding and respect from anyone attempting to improve it. Even though some houses are environments conducive to sickness, they are endowed with sacred, social, and economic meanings.
For Andean peasants, the house is the coming together of the vertical and the horizontal. Andeans frequently relate their homes to gender relationships and to land and body concepts. The Kallawayas of Bolivia understand their homes according to a mountain-body metaphor (see Bastien 1978). If they take care of the mountain and feed its earth shrines, c
orresponding geographically to parts of their body, then their homes, households, and bodies will be synchronized and they will be healthy. Health is the metaphorical synchronization of the house, household, and environment. These relationships are symbolically expressed in elaborate rituals which can also be used to explain the relationship of the vector, host, and parasites in Chagas’ disease.
The Aymaras of Qaqachaka, Bolivia, for example, think of their houses as the cosmos and cosmogony (Arnold 1992). Qaqachaka is located in valleys of the Altiplano, Department of Oruro. When a house is being constructed, the Aymaras sprinkle the foundation and walls with blood and sing about it as nido del cóndory el halcón (“nest of the condor and hawk”) and la madre nido (“mother nest”). The rooms of the house are symbolically associated with the woman and uxorlocal residence. The house is an entity within a system of parallel descent, and the feminine spirit of the house is what unites theoretically incompatible dualities, such as matrilineal and patrilineal descent, filiation and residence, and hypergamy and hypogamy, as Lévi-Strauss (1979) writes.
In Qaqachaka, the floor plan and arrangement of buildings within the patio are carefully arranged to synchronize with certain cosmological axes in order to connect the house with cosmic centers, such as those of the Incas, and ground the household firmly within cultural traditions. Each step of construction is preceded by a challa, a ritual sprinkling of blood, accompanied by prayers. “By analogy,” Arnold (1992:54) writes, “in the construction of the house, the sprinkling of animal blood provides power to the house as the mother nest to stand erect for generations and to maintain its honor.” The people of Qaqachaka say that the walls are made to stand with blood of the female. The roof is understood as the masculine zone and is related to the mountain.
These cultural practices and understandings indicate the sacredness of the house to Andeans. It is a shrine to the earth and their ancestors. Any endeavor to stereotype such houses as “sick” is not entirely different to someone referring to one’s religion as “sick.” This explains why Andeans accept vinchucas as part of their households, not because they enjoy being bitten or getting sick, but because they are there, attached to the household. Insects in themselves have neither a positive nor negative value; they simply are part of the universe. The discovery that vinchucas are killer bugs is easy for outsiders; but, for Aymaras, they are “kissing bugs.”
This adds an important consideration for anyone attempting to modify “sick” houses. Technicians in vector-control projects to improve housing have to respect these cultural values. Unfortunately, technicians of the pilot projects discussed in subsequent chapters paid little heed to the culture context of the house.
Conversely, cultural considerations can be assets in eliciting community members to participate to improve housing. These values can be used to help make houses vinchuca-proof. One culturally sensitive approach is to precede any construction with a ritual to the earth shrines of the home. In an even more practical vein, housing construction rituals, such as in laying the foundation, building walls, and thatching roofs can be used as occasions for instructing Andeans about preventing triatomine infestation.
Roof thatching is an important Andean institution, including a ceremony. Broadly, although there is much regional variation, this ritual as found among the Kallawayas, near Charazani, Bolivia, consists of a ritual to dispel the misfortunes of the surroundings, another to feed the earth shrines of the ayllu (communal land), the laying of the roof, and a festive banquet.
The first part is a symbolic sweeping of the house to dispel misfortunes (such as triatomine insects). A diviner arrives on a Friday night, throws coca leaves to discern what misfortunes are found within the house, and then goes throughout the house symbolically sweeping with ritual symbols and breaking string. As an adaptive strategy, the community health worker could participate in the coca seance to volunteer information about vinchucas and how this misfortune carries another tiny misfortune (T. cruzi) that injures the chuyma (heart and other central organs) and can cause muerto subito (sudden death) and empacho (constipation). The worker would instruct the inhabitants that this remedy requires continual vigilance, housing hygiene, and use of insecticides. After the shaman has ritually swept the household, the health worker could spray the house (see Bastien 1981, 1992). When the participants take the kintos (bundles of sacred items that attract the misfortunes) to the river, they could also take clothes to wash in efforts to dispel the evil. This ritual behavior could be used in this context to explain the importance of keeping the house clean.
The second part of the ritual consists of misa sumaj suertepah wasi (“Good Luck Table for the House”), where a yachaj (diviner) and the family prepare symbolic products corresponding to the head, trunk, and legs of the three major ecological levels of the ayllu: llama fat and fetus for the head, highlands, and herder; guinea-pig blood for the heart, central levels, and potato and oca fields; and coca leaves and chicha (corn beer) for the legs, lowlands, and cereal farmers (see Bastien 1978).
Implications for health workers include the fact that Andean peasants closely identify body and house concepts with community and environmental concepts. Health workers can assist at the sumaj suerte ritual to discuss erosion, deforestation, and animal depletion, and the relationship of these factors to migration, urbanization, impoverishment, and Chagas’ disease. More readily than most Americans, Andeans thoroughly accept the relationship of bodily health to environmental well-being.
The House: An Economy of Exchange
Bolivians have a sacred economy centered around the house. They celebrate fiestas to the saints within their patios. They continually ch’allar (sprinkle) the courtyard, giving the initial drink to Pachamama (Mother Earth). Before they leave the house, they bless themselves and deposit an offering of coca leaves to the cabildo (shrine of the household). Good-luck tables featuring candies, coca, llama fat, qoa, tinfoil, and a llama fetus periodically are presented to the household shrines. The overriding concept is that, if they offer symbolic foods to the earth shrines, Pachamama, and earth, then the earth will bestow upon them an abundant harvest. Some would call this an imitation magic of reciprocity, but it can be seen as an economics of reciprocal exchange between beings who live on vertically distinct ecological levels, each with its unique products and resources. For rural Bolivians, a “sick” house is one that has turned in upon itself in selfish interest or that has been abandoned. It is sick like a body because it is not in centrifugal and centripetal motion with everything around it.
The economics of exchange fits into this in the following way: peasants throughout Bolivia pass through the countryside and observe that certain houses are chullpa wasikuna (tomb houses) and that certain communities are chullpa llahta (tomb communities). They refer to the fact that these places are without inhabitants, much like their ancient shrines (chullpas) to their ancestors, commonly found throughout Bolivia. They believe that anyone digging near a chullpa will die from chullpa usu (polio, or osteomyelitis). Chullpa wasi is the peasants’ term for a “sick house.” It is sick, not because of some intrinsic evil but because it is no longer an exchange unit between the people who inhabit it and the surrounding fields. It is a tomb of what was.
In contrast, sayaña is the Aymara word for house, and it refers to the bedrooms, kitchen, and storage rooms. It includes family members, alpacas, llamas, sheep, pigs, guinea pigs, and chickens. It contains the surrounding gardens and plots in the qhapanas (large fields). It includes the above sacred connotations and is considered a shrine. Pablo Regalsky graphically described this concept among the Quechua of Raqaypampa. After the harvest, the house is completely covered with corn so that it is symbolically no longer a building but a pile of corn. The Andean house is continually transformed by the cycle of activities surrounding it.
Sayaña is also founded on ayni and turqasiña, which are expressed in the ritual/work of thatching houses. These important Andean economic structures of the sayaña could be incorporated into hous
ing-improvement projects to lower costs, increase community participation, and ensure continuity. Community members participate in a system of work exchange, aynisiña, and resource exchange, turqasiña.
Aynisiña is a basic Andean institution wherein peasants set up a system of mutual aid regarding work tasks. For example, someone helps another person thatch his roof; the recipient or his children now owe the helper an ayni for roof thatching or an equivalent task, due at some future time. A local health worker may donate a week at a training course or spray insecticides for a week. In exchange, members of the community owe the health worker an equivalency of work, such as herding the health worker’s sheep or plowing a field.
Community health workers used ayni during the drought in Bolivia between 1982 and 1984 when they encouraged labor exchanges and cooperation in the communities of the Altiplano to prevent the hoarding of water as well as other conflicts (Bastien 1992). They coordinated the activities of digging wells, routing water, and building irrigation canals. One creative way they used ayni was to have the family of a treated sick person do some public-health service, such as building a latrine or digging a sewage ditch, in return for treatment provided by the local health worker.
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