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 José Beltrán’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).
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 aynisiña (labor exchange) for house building, turqasiña (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 sayaña 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.
Physical aspects of the house touch upon cultural and social environments. Just as the parasitic cycle is dealt with in a total manner, so too housing changes need to be dealt with in a similar manner. This totality includes relationships of people to each other, to their animals and belongings, and to their shrines and household deities. For Andeans especially, the house is still revered as a place of the ancestors. Mummified ancestors were kept in houses well into the sixteenth century, until they were burned by missionaries. A few people still keep clothing of ancestors in their houses. Every house has a cabildo shrine for the male and another shrine for the female. The dead are said to return to the house at the celebratory Feast with the Dead.
• The spiritual spoke refers to the fact that many Bolivians include rituals and prayers in almost everything they do. If project personnel take a strictly secular and scientific approach to housing improvement, they will not be very motivational to peasants. However, project personnel should not use their religion as the spiritual axis. The spiritual axis appropriate to the community is the sum of that community’s religious beliefs and practices, including the cosmology, myths, and rituals of the community. Examples discussed were the use of a roof-thatching ceremony to improve houses, the inclusion of divination rituals before building a house, and the use of a dispelling ritual to get rid of vinchucas.
• The temporal spoke coordinates people by scheduling events and accounting for the intervals between events. Aymaras follow the path of the sun for their daily clock, and they follow the rainy and dry seasons for their agricultural cycle. Frequently, diviners throw coca leaves to determine when and where to plant. In general, peasants follow natural processes rather than the Western calendar. Project personnel continually complain that villagers don’t show up for agreed-upon tasks; however, the reason is that peasants have to take advantage of favorable natural conditions.
Peasants have very busy schedules with little free time to spend on outside projects. Women spin and weave, care for children, and listen to talks at the same time. Projects have to be woven into their schedule and according to their work load. Pilot projects had problems coordinating times with members of the community; often, either household members were absent when technicians were ready or materials weren’t available when the people had time.
As an alternative, Roberto Melogno[73] finds that providing credit to contract skilled laborers is more cost- and time-effective than enlisting volunteer work of community members, who have to be trained and freed from their other activities, only to then do inferior construction.[74]
• The corporeal spoke includes the health of the individual. Health is defined not only as the absence of disease but also as the total spiritual, material, and psychological well-being of the person. Projects need to include doctors and nurses to administer to patients with Chagas’ disease. They also need to include curanderos to deal with the cultural understanding of the symptoms of Chagas’ disease, such as empacho, cólico miserere, and mal de corazon. How peasants perceive of their bodies is important, because it provides the basis of therapy. If, for example, it is important to them to balance the wet and dry or hot and cold, then symptoms of Chagas’ disease need to be treated in a complementary manner.
• The ethnomedical spoke connects traditional practitioners to the project and creates a dialogue between biomedical and ethnomedical practitioners concerning the prevention and treatment of Chagas’ disease. Examples discussed in the book include the work of Jaime Zalles, misfortune rituals used to treat Juana, and Kallawaya mesas to feed the earth shrines.
Ethnological research of native ethnomedical practices is necessary to help incorporate them into prevention and therapy measures for Chagas’ disease. This includes surveys of medicinal plants and how they may be used to treat the symptoms of acute and chronic Chagas’ disease. It also includes an understanding of how Chagas’ symptoms are perceived as cultural illnesses and how they are treated by locals. Examples discussed were cólico miserere, empacho, muerto subito, and chullpa usu.
The CCT considers ethnomedical practitioners and project workers to be equal members of the elements composing the triangle, so they need
to be incorporated into the planning, prevention, and treatment of Chagas’ disease. If they are considered planners and players throughout the project, then they will more likely sustain it.
• The biomedical spoke is the scientific thread that relates biological facts to pathological, cultural, and social factors. The biological and medical sciences provide facts concerning the natural elements of Chagas’ disease, and this indispensable knowledge needs to be incorporated into Chagas’ control projects. Chagas’ disease is extremely complex and requires some knowledge of biology, parasitology, immunology, pathology, and entomology. It is helpful to have an interdisciplinary team of experts design vector-control projects. The biomedical spoke can be blocked by any one specialist overemphasizing his or her position; for example, entomologists insisting upon insecticides as the only proper response. Some issues are uncertain or are being revised, such as the concept of Chagas’ disease being an autoimmune disease.
Project personnel need scientific knowledge about Chagas’ disease. Many doctors are confused about its treatment, partial immunity, indeterminate phases, and therapy. Recently, the biomedical community in Bolivia has come to better recognize the prevalence of Chagas’ disease; nonetheless, however, many authorities believe that Chagas’ disease is not a major problem and that Chagas’ control projects have been overemphasized.
The biomedical spoke connects project personnel with people suffering from Chagas’ diseasedoctors and nurses treat patients. Pilot projects developed a protocol for treating the acute phase of Chagas’ disease in children younger than fourteen years; however, resources were not provided to treat them. A major concern is to treat the symptoms of heart disease and colonopathy.
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