Gender inequality also influences Chagas’ disease, in that there is greater malnourishment among girls than among boys, because Aymara girls often receive less food than boys. This makes girls more susceptible to acute attacks of the disease than boys. Also disadvantaged with less schooling and less Spanish instruction, girls learn less about Chagas’ disease.
One lesson observed from PBCM’s educational approach is that more efforts need to be made to educate women about Chagas’ disease and to address their increased responsibilities. This matter also needs to be discussed in group sessions with all community members.
House Improvement Committees
House Improvement Committees (HICs) were the functional units where plans and priorities for housing improvements were decided and where all participatory activities were coordinated. HICs consisted of a president and secretary who were responsible for organizing work groups of five to six villagers. HICs coordinated tasks with members of the community. These groups were assigned different tasks and were supervised by a master craftsman who taught members basic carpentry, about laying building foundations, tile making, and plastering. Local materials and personnel were used whenever possible. HICs and craftsmen supervised and coordinated the repair and/or construction of houses. They worked between the months of May and September, when agricultural work is least demanding and community members are most available. However, fiestas, popular during this time, delayed work for weeks at a time. Because of their success in Chuquisaca, HICs were adopted and modified as functional village units for other pilot projects in the departments of Cochabamba and Tarija (Ault et al. 1992:42, SOH/CCH 1994).[52]
Villagers worked to compensate for roughly half the cost of a house improvement ($75.00 per house) and provided supplies worth $18.75; and PBCM contributed supplies, fumigation, education, and supervision to the amount of $114.00. Each improved house cost $208.00, with villagers providing 45 percent and the project the remaining 55 percent.[53] Not counting free labor, the project improved a house for $114.00 and its total budget was $45,614 for 400 houses.[54]
As an evaluation, HIC failed to adapt to Andean labor and economic practices. Earlier, certain economic exchange principles of Andeans were discussed, such as ayni (labor debt), mita (community debt), and turqasiña (resource debt) that can be used to facilitate housing improvement. Ayni and turqasiña constitute a complicated system of exchange relationships that are socially embedded within familial and community relationships. Aynis are inherited and are considered more valuable than money, especially during harvest times and periods of hyperinflation. Thus, for example, if a roofer’s family was deeply indebted to other commoners who had taken care of his or her harvest, then the roofer got a chance to return the work obligation by doing roofing for the project. Although ayni implies exchanging like-work, HIC has been able to negotiate with both parties alternative work assignments. The president and secretary of the committee literally keep the books concerning ayni and employ it to accomplish necessary work.
Pilot project models need to fit the projects into the political and economic systems of the community in order to become replicated models. It is perhaps a misnomer to refer to them as pilot projects; a more appropriate title might be isolated projects.
House Improvement
House improvement consisted of putting in a solid concrete foundation that would not crack, plastering the inside and outside adobe walls to cover existing cracks, whitewashing the walls with lime, installing glass windows and metal screening, tiling the roof, and installing a ceiling to the interior. Bedrooms were first improved; later, dining and storage rooms. Depending on the condition of their houses, some families decided to demolish and reconstruct them, sometimes adding additional rooms, especially bedrooms. These improvements eliminated common nesting areas for triatomines. PBCM allotted supplies progressively in order to provide an incentive to complete each task and receive the next supply. Thus a temptation was removed to misallocate the materials. Households preferred to do the more favorable tasks first and neglected the less desirable, such as improving the surrounding area.
Figure 24a.
House before improvement. A family standing in front of the remains of their previous house that had been infested with vinchucas. (Photograph by Joseph W. Bastien)
Figure 24b.
A community health worker distributing building supplies. (Photograph by Joseph W. Bastien)
Figure 25a.
A neighbor helping mix plaster for walls. Exchange of labor is done through the concept of aynisiña. (Photograph by Joseph W. Bastien)
Figure 25b.
A man hammering stones between the adobe blocks of his house to prevent entry of bugs. (Photograph by Joseph W. Bastien)
One criticism of PBCM is that for the first 400 homes it did not improve peridomicile areas, and, when they were evaluated, vinchucas were found in these areas. By 1992, however, bug-proofing of peridomicile regions became part of the program. The strategy was then adopted of starting with the peridomicile; if this was improved, then material was supplied for the house. This way both corrals and houses were bug-proofed.
Traditional methods and available resources were used together with more innovative techniques, tools, and materials whenever possible. Sand, earth, and cow dung were collected locally to make wall plaster. Workers prepared the lime by heating locally collected limestone rocks in an open kiln for twenty-four hours and then pulverizing the residue with a hammer. After plastering, they applied a white paste of lime and water to the walls to improve the appearance.[55] Wall plastering substantially reduces vinchuca infestation; but to be successful it has to be done thoroughly, so as to seal all the cracks and crevices in the house walls. The use of slow-release insecticide paints is another preventative measure.[56]
PBCM also taught villagers to make ceramic tile roofs to replace thatched roofs, greatly reducing a popular infestation area for triatomines. One community mastered tile making and began marketing their tiles to neighboring villages, thus developing a small local industry. Low-cost roofing material is needed in developing countries to provide a substitute for corrugated galvanized iron roofing, which is very noisy when it rains and heats up when it is hot, both common conditions in the tropics.[57] Sheet roofing also is extremely dangerous in windy climates when it becomes stripped from the house and is sent hurtling through the air with its sharp edges.
A stable concrete house foundation is necessary for each house to prevent water damage to the base of the walls and floor. Cement is expensive in terms of both price and transport costs, but a durable local substitute material was used in Chuquisaca. Soil stabilization was achieved by increasing the cohesion of the soil.[58] (This is one area where technical assistance is helpful.)
Figure 26.
A woman and her children standing in front of their house after its improvement. (Photograph by Joseph W. Bastien)
As an alternative, not utilized by PBCM, the mechanical compaction of adobe mix greatly increases its stability. An adobe press with a long handle used as a lever to compress the mud and clay in molds provides more leverage than the customary force of chest and arm muscles and results in a much harder adobe (Lunt 1980, Webb 1985, Webb and Lockwood 1987).[59]
Community Participation
Project success and sustainability are a function of community participation. As others have shown throughout Bolivia, community participation is more cost-effective than purely vertically structured programs (Bryan et al. 1994). Housing projects are more readily integrated into other programs if there is community participation. Community participation is active rather than passive involvement; it occurs when people make their own decisions and carry them out. Community participation refers to community members making decisions about, accepting, and complying with certain behavioral changes necessary in regard to combatting Chagas’ disease. These include plastering cracks in the walls, keeping animals outside, and storing objects in containers to keep vinchucas from infesting
the house.
Problems relating to community participation included the absence of skilled local labor for some tasks. There was some limited cooperation among households because of their distance from each other. Many peasants refused to cooperate because they didn’t own title to land and homes. Certain adults refused to work with other adults. Poor sanitary conditions persisted in many areas. Peasants also had other tasks they considered more necessary things to do, such as plant and harvest crops. These problems in part indicated a lack of understanding of sociocultural issues and limited skills in cross-cultural communication from project workers.
Cross-Cultural Community Participation
Technicians in Chagas’ control and other health projects sometimes confuse the idea of community participation when they imply that they have the solution to the problem. Technicians should endeavor to educate and activate peasants to participate in finding a solution. If technicians have already decided upon the solution, there is no room for alternative solutions. Cross-cultural community participation (CCCP) is a term that I have coined; it involves lengthy discussions with all members of the community (including women and children). CCCP does not have simple answers to prevent Chagas’ disease; it allows people to arrive at solutions after they have been presented with the facts in terms that are meaningful to them. It involves serious discussion as to why peasants behave as they do. Why, for example, do they keep animals in the house? If this is not seriously considered, they will continue to do so no matter how nice their new house is. This has been the experience of the housing project in Tarija. CCCP demands that technicians negotiate change only after considerable discussion takes place and understanding is achieved about values and why people do what they do. CCCP is a pedagogy based upon an epistemology of exchange: knowledge is mutually arrived at between interested parties. This is essential for Chagas’ disease, principally because of its social and cultural complexity that affords no unilineal or vertical approach.
Conclusion
The PBCM Chagas’ control project was built upon an existing health program and consequently it attacked Chagas’ prevention by focusing on the sickness.[60] Concientización, as practiced by PBCM, was exclusively about insect infestation and the sickness. The problem was not dealt with economically and socially: How are the people to take care of their cattle, pigs, and sheep? What can be done if someone abandons a house? What needs to be done to curtail migration? How can productivity be increased so as to lessen poverty?
When I last visited Ruth Sensano on June 13, 1997, I repeated the above criticism. She agreed with many of the points but added: “You have to begin somewhere and do something.” More than anything, development projects have to be within the reach of the people.
She looked tired and weary. I took her picture and asked her if she had any parting words. She replied: “Ama Kella (don’t be lazy), Ama Sua (don’t be a thief), Ama Lluya (don’t lie).” These are the words Mama Oqllo taught in ancient times to the women of the Incario.
CHAPTER NINE
Sharing Ideas
José Beltrán teaches children and adults about Chagas’ disease. He is a model teacher for Chagas’ prevention in the Department of Tarija and is the major educator for a number of communities that have improved over 1,350 houses by 1997. He succeeds because he communicates in culturally meaningful ways. José provided me with some examples:
I have good relations with the peasants because I am Tarijeño and speak their language, a dialect close to that of northern Argentina, chapaco style. Tarijeños share more and are much more open than Qollas (highland Andeans). Yesterday, for example, when I arrived late, they wanted to know why. It bothered them that they wasted time waiting for me. I always use simple language, “Poque se han hui?” “Why did you flee?” Or “Le wa sumba hu un piedrada,” “I am going to throw a stone.” Other Bolivians can’t understand Tarijeños because they speak a folk Spanish.[61]
I always use images. If I speak of parasites as something very small that you can’t see, they are not going to understand this. The microscope is putting many lenses to the eyes of your abuelita [grandmother] so as to increase the size so that she can see. Teachers are too scientific. You have to have the mentality of the peasant, which is related to earth and all organisms in it. This is the foundation upon which we must build, otherwise we will get nowhere.
The chagas parasite is like us. It looks for different places. We want places that please us, and we remain in places that we like, that give us food and where the harvest is good. So too the parasite inhabits our organs to get food, develop, and multiply. It colonizes our body (Beltrán, interview 5/16/97).
José Beltrán has been a health educator for Tarija Chagas’ projects for six years. Previously, he worked in health education for the Bolivian Ministry of Health for fifteen years. Tarija projects are noteworthy for their education about Chagas’ disease and serve as examples for other programs.[62] The Department of Tarija has the same percentage—78 percent—of houses infested with vinchucas as does Chuquisaca. Percentages of vinchucas with T. cruzi are lower in Tarija with 20 percent, compared to 23 percent in Chuquisaca (SOH/CCH 1994). Tarija has 61 percent of its people infected with Chagas’ disease, compared to 78 percent in Chuquisaca and 46 percent in Cochabamba. Tarija projects constructed 750 houses in five communities between 1992 and 1994, and 600 more in six other communities between 1994 and 1997. Chagas’ control projects were placed in the Department of Tarija for both health and political reasons. Tarija has produced two presidents in recent years, Victor Paz Estenssoro (1985-1989) and Jaime Paz Zamora (1989-1993), both of whom made great efforts to address social concerns of their people.
Figure 27.
Chagas’ control project worker checking a guinea pig house for vinchucas. (Photograph by Joseph W. Bastien)
Tarija’s warm and temperate climate helps explain its high incidence of Chagas’ disease. The Department of Tarija borders on Argentina to the south, Paraguay to the east, the Department of Chuquisaca to the north, and the Department of Potosi to the west. Its geography consists of lower valleys, plains, and a dry boreal forest (Gran Chaco), the scene of a disastrous war between Bolivians and Paraguayans from 1932 to 1935. The region is noted for its wheat, cattle, and grapes, which are pressed, fermented, and distilled to make wine, singani, and pisco. The climate is moderate, with altitudes of 1,000 to 3,000 feet, making it a vacation spot for tourists from within Bolivia and from neighboring countries.
Factors in the increase of Chagas’ disease in the Department of Tarija have included the increase of population within urban areas. According to the 1976 census, the total population was 187,204 inhabitants, with 72,740 people (39 percent) living in urban areas and 114,464 people (61 percent) living in rural areas. The surface area of the department is 15,052 square miles, with a population density of 12.4 people per square mile (Muñoz 1977). According to the 1992 census, the total population was 290,851, with 159,841 inhabitants (55 percent) living in urban areas and 131,010 inhabitants (45 percent) living in rural areas (Censo Nacional 1992). This reflects a national trend in Boliviaa marked decrease in the percentage of inhabitants living in rural areas. Between the years of 1976 and 1992, Tarija had a population growth rate of 2.81 percent, above the Bolivian national average of 2.03 percent. This movement of population from rural to urban areas and subsequent crowding in communities has spread vinchuca bugs to the cities, causing a marked increase in Chagas’ disease.
Another factor in the spread of Chagas’ disease has been the regular migration of Tarijefios to Argentina and Chile for farm work. Decreased agricultural production and loss of land has forced many Tarijefios to look for seasonal work elsewhere. They travel in large numbers to harvest sugar cane in the Department of Santa Cruz, Bolivia. Of ethnic concern, nomadic Guarani peoples have been displaced by dams and flooding of their land. Some of them now have infection rates of 100 percent, seriously endangering the survival of the last of these hunters and gatherers.
The Department of Tarija is culturally and ethnically rich. Colonial Spanish culture similar to that of Argentina predominates in Tarija. It is referred to as chapaco and has a wealth of proverbial sayings, songs, couplets, and a distinct Spanish dialect. Cowboys and Guarani Indians roam throughout the plains and forests. Local natives consider themselves descendants of Chiriguanos, a long-extinct ethnic group associated with lowland tribes of the Department of Santa Cruz. Aymaras and Quechuas consider themselves superior to lowland peoples. Aymaras and Quechuas further distinguish Tarijeños from Cambas, although both groups are lowlanders. People from La Paz and Cochabamba find Tarijeños amusing, slow-mannered, and not terribly listo (sharp). They often make them the butt of jokes, such as “Tarijefios are so lazy that their dogs bark lying down.”
Figure 28.
José Beltrán teaching children and adults about Chagas’ disease. (Photograph by Joseph W. Bastien)
“Tarijefios have a sense of humor and a relationship with vinchucas,” José Beltrán said, “best expressed in the following riddle”:
Quien es? (Who is?)
Un capitán flautero (A capital flute player)
saco de clérigo, (cassock of priest)
The Kiss of Death Page 18