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)

ladrón por su gusto , (thief for pleasure)

médico por su deseo , (doctor for desire)

[answer:] La Vinchuca .

“A pointed analogy of musicians, clerics, thieves, and doctors for vinchucas with their needle‑nosed proboscis, black‑capped shell, thirst for blood, and blood‑letting therapy” (Beltrán, interview 5/17/97).

I spent several days traveling with José Beltrán in his pickup truck and visiting homes, neighborhoods, and communities.[63]José was born to share ideas. Along the road, he stopped a stranger and, using a flip chart, gave him a short lesson about Chagas’ disease. José later told me that he had missed this person on his previous visit. “You can’t miss anybody, you have to go house to house to talk with people.”

“Now, I have to spend more time educating and motivating peasants,” José added, “because people have to invest more into improving their houses.” By 1997, Pro‑Habitat no longer had funds to improve houses and had adopted a credit plan to loan people money to fix their houses. Loans vary from U.S. $100 to $500 at 12.5 percent interest per year. José believed this to be a superior plan: “Providing credit is more sustainable than giving them supplies, we don’t have the money to fix every house, and if we educate correctly and motivate them, then they will want to invest in their homes and keep them nice,” he said.

Local experience gained from the Chuquisaca project as well as assistance from Vector Biology and Control Project (VBC), CDC, and SOH were used by SOH/CCH to implement similar pilot projects in the departments of Cochabamba and Tarija between 1992 and 1994. By 1994, approximately 3,100 houses in fifty‑two communities had been improved in the three departments of Chuquisaca, Cochabamba, and Tarija (SOH/CCH 1994:54; Bryan et al. 1994). The average direct cost to the program in 1991 for each house improved was U.S. $251 in Cochabamba, $217 in Tarija, and $217 in Chuquisaca; but sums were reduced considerably for 1992 and 1993 (SOH/CCH 1994:17). A large percentage of project monies was spent for administrative offices, vehicles, consultants, and educational material–U.S. $4 million ($2.5 million from U.S. Public Law 480[64]and $1.5 million from CCH[65](SOH/CCH 1994: 9)–which was about $1,300 per house.

One general criticism of the SOH/CCH pilot projects is that to satisfy project goals for fast results and monies to be spent during an allotted time, houses were hastily built and little education about Chagas’ disease was provided. Some of these houses were not maintained; in others, the people moved their corrals alongside the houses and they became infested again. “Everybody wants a new house without much personal investment,” José added, “and some have moved back to their run‑down houses, and they use the new houses to show off during fiestas.” He included Sensano’s project in his criticism.[66]

I asked him, “How do you educate Tarijeños about house hygiene?” He replied:

My pedagogy is participatory education, basically. Peasants who listen to me are not receptive subjects of what I teach them. But they participate in reflecting on the visual charts, so that they understand what I want to communicate. This presents excellent results, as you saw last night (Beltrán, interview 5/17/97).

Well into midnight the night before, I had observed him teaching in Rancho Norte, a project community of about sixty families. The schoolroom was crowded, with the men standing back against the wall and women scattered around the room, seated on school benches. I sat with the women, exhausted from travel and interviews. José continually moved his body, raising his arms. He showed one elderly lady a picture, then pointed to a vinchuca illustration on the flip chart and asked her if she knew who “this fellow” was. She was confused. A few hands were raised, but José skated across the room to question someone about to doze off. “A vinchuca,” the person quickly answered.

“And where do vinchucas live?” José continued.

“In the cracks and ceilings of our houses,” someone answered.

“Have we invited them to eat with us?”

“No,” the old lady answered, “they are very ugly and shit on the walls.”

“They bite us and take blood from us,” José added. “What happens if we see them full of blood and we squash them?” Everyone laughed at this, because they have squashed the bugs and seen blotches of blood.

A lady with thin arms, face wrinkled and leathery, wearing a derby hat, asked him about vinchucas coloradas (red vinchucas). She was the lady who at first had been slow to answer, because it turned out that she was not sure which type of vinchuca was illustrated. José picked up her skills, “I’ll bet you $100, if the gringo loans it to me, that anyone can smash a vinchuca colorada and not find blood.” The lady adds that these vinchucas are different from the bad vinchucas, whose bodies are black with orange marks on the sides.

José showed a slide picturing the harmful vinchucas, and then reminded them not to harm the good vinchucas, showing a keen sense of respect for beneficial insects. It was clear that peasants distinguished vinchucas as blood‑eating, plant‑eating, and insect‑eating reduviids. Other educators have broadly declared war on all vinchucas, indiscriminately killing nectar and predator vinchucas. I wondered if insecticides also discriminated. José’s pedagogical method emphasized the necessity of listening to the peasants, discussing matters with them, and letting them arrive at the solution.

To top off the evening in Rancho Norte, José showed the people a model of a house that they could build. They crowded around him, as he pulled off the roof to show them the floor plan. He began with simple questions:

“How many walls do you need for two rooms?”

“Four,” they answered.

“No,” he replied. He asked a promotor (CHW) to count the walls.

“Three,” he answered.

“Counting the end wall,” José continued, “the middle wall separating the two room, and the end room which begins another room. See, you save a room with this design.”

“Notice the porch that extends in front of the rooms. There is a roof over this so you can work outside and not get wet if it rains or, if the sun is shining, you don’t get hot,” José added. “You can work preparing food and crops here. Look how open it is to let the air circulate. Your present rooms are dark with small windows. See how the air can circulate through the house. This is healthy and helps prevent tuberculosis.”

“When you cook, where do you have to bring your food from?” José asked.

“We carry it across the patio to the eating room,” someone answered.

“Yes,” José replied, “and if it is raining, you get more soup!” They laughed at this.

Toward the end of the meeting, José asked me to say something, so we discussed Julio, who had recently died in Rancho Norte from Chagas’ disease. I asked if they were taking care of his children and widow, and people replied that they had plowed a plot of land for them. Then I asked how many thought they had Chagas’ disease. Six people out of thirty raised their hands. They had been diagnosed with Chagas’ disease, but they were not taking chemotherapy. I suggested the possibility of using Sangre de Drago, and I asked Jaime Zalles to provide them with the names of plants to treat heart problems and stomach disorders. Zalles provided them with an ample list.

In parting, José asked me to take a picture of the group. I was out of film on the only occasion I was asked to take a photograph. All embraced one another and we departed. José entertained us with Tarijeño couplets on the journey back.