Oscar Velasco, M.D., coauthor

The following proposed culturally sensitive model attempts to lessen the gaps in cross‑cultural communication between project personnel and community members. Pilot projects in Chuquisaca, Cochabamba, and Tarija failed to become models for other projects because they lacked a model themselves.[68]These projects were rapidly designed, generously funded, and built several thousand houses. However, they provided little in the way of evaluation of ways to improve them, thus failing as pilot projects. Another fault was that Chagas’ prevention practices were barely integrated into the culture and economics of the community. Oscar Velasco and I have designed a program, called Culture Context Triangle (CCT), to be a model for Chagas’ control and other health projects.[69]

The CCT model provides educators and health workers with a framework for cross‑cultural communication and a guide for their activities. It recognizes that community members and ethnomedical practitioners are equal partners in Chagas’ control. It integrates the subjects’ ideas, values, and practices into the prevention and treatment of Chagas’ disease, whenever possible and feasible. It includes treatment of patients with Chagas’ disease; pilot projects in Tarija and Cochabamba detected cases of Chagas’ disease but never did anything to treat these patients (patients were treated in Chuquisaca). These projects made people aware of their sickness without providing measures for treatment.

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.