Health in the Andes wh246v86g

Table of contents :
Title Page
Copyright Page
Table of Contents
INTRODUCTION
PART 1: ANDEANETHNO MEDICINE
CHAPTER 1. SICKNESS AND DEATH IN PRECONQUEST ANDEAN COSMOLOGY: THE HUAROCHIRI ORAL TRADITION
CHAPTER 2. METAPHORICAL RELATIONS BETWEEN SICKNESS, SOCIETY, AND LAND IN A QOLLAHUAYA RITUAL
CHAPTER 3. AYMARA CURING PRACTICES IN THE CONTEXT OF A FAMILY HISTORY
CHAPTER 4. THE FOLK ILLNESS: ENTITY OR NONENTITY? AN ESSAY ON VICOS DISEASE IDEOLOGY
PART 2: ANDEAN ENVIRONMENT: ALTITUDE, NUTRITION, AND COCA
CHAPTER 5. STUDIES OF THE AYMARA OF HIGHLAND, INTERMONTANE, AND COASTAL CHILE
CHAPTER 6. AN ANALYSIS OF ADULT MORTALITY CAUSES AMONG MIGRANTS FROM ALTITUDE AND SEDENTES IN COASTAL SOUTHERN
CHAPTER 7. PREHISTORIC NUTRITION AND MEDICINE IN THE LAKE TITICACA BASIN
CHAPTER 8. MEDICINAL USES OF COCA IN BOLIVIA
PART 3: IMPROVING THE HEALTH OF ANDEANS
CHAPTER 9. IMPROVED HEALTH SERVICES AND INCREASING POPULATION PRESSURE IN AN ANDEAN COMMUNITY: SIMULATING A DILEMMA
CHAPTER 10. HEALTH DELIVERY IN RURAL BOLIVIA
CHAPTER 11. HEALTH AND WEALTH IN A PEASANT COMMUNITY
CONCLUSION
REFERENCES CITED
LIST OF CONTRIBUTORS
ACKNOWLEDGMENTS

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edited by JOSEPH W. BASTIEN and JOHN M. DONAHUE, Associate

| number 12

a special publication of the American Anthropological Association

Published by the American Anthropological Association 1703 New Hampshire Avenue, N.W. Washington, D.C. 20009

Production Editor David J. Puhlick

Copyright © 198] by the American Anthropological Association. All rights reserved. Copies of this publication are available from the publisher at $10.00 each for members of the American Anthropological Association and $15.00 each for non-members. Payment in full must accompany all orders.

CONTENTS 1 / Introduction Joseph W. Bastien Part 1: Andean Ethnomedicine

9 / Sickness and Death in Preconquest Andean Cosmology: The Haurochiri Oral Tradition George Urioste 19 / Metaphorical Relations between Sickness, Society, and Land in a Qollahuaya Ritual Joseph W. Bastien 38 / Aymara Curing Practices in the Context of a Family History

Hans C. Buechler ;

50 / The Folk Illness: Entity or Nonentity? An Essay on Vicos Disease Ideology William W. Stein

Part 2: Andean Environment: Altitude, Nutrition, and Coca 69 / Studies of the Aymara of Highland, Intermontane, and Coastal Chile William H. Mueller, William J. Schull, and Francisco Rothhammer 92 / An Analysis of Adult Mortality Causes Among Migrants from Altitude and Sedentes in Coastal Southern Peru James §. Dutt and Paul T. Baker 103 / Prehistoric Nutrition and Medicine in the Lake Titicaca Basin

David L. Browman |

119 / Medicinal Uses of Coca in Bolivia William E. Carter, José V. Morales, and Mauricio Mamani P.

Part 3: Improving the Health of Andeans

151 / Improved Health Services and Increasing Population Pressure in an Andean Community: Simulating a Dilemma James C. Blankenship and R. Brooke Thomas 173 / Health Delivery in Rural Bolivia John M. Donahue 196 / Health and Wealth in a Peasant Community Ralph Bolton and Michael Sue 224 / Conclusion John M. Donahue 231 / References Cited 249 / List of Contributors 251 / Acknowledgments

_ INTRODUCTION

7 JOSEPH W. BASTIEN This book contains research about the health and sickness of Andean people. It is the result of collaboration between Andean scholars who met at

the American Anthropological Association meetings in Los Angeles November 15-16, 1978, for three symposia on nutrition, medicine, and morbidity in the Andes. Eighteen scholars presented papers on environmental and biological factors, cultural and social factors, and applied aspects of

health and disease in the Andes. Discussants then commented on the

papers, and members of the audience added their expertise. When the third

symposia came to an end on Thursday afternoon, the speakers had presented a volume of carefully gathered data that provide some answers to complex questions about the health and sickness of Andean people. The central focus of this book is health maintenance in the Andes. Health is defined by WHO as a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or sickness. The authors of this book discuss the environmental, social, and physical condition of Andean people in an attempt to evaluate their well-being. There are three parts: Andean Ethnomedicine; Andean Environment: Altitude, Nutrition, and Coca; and Improving the Health of Andeans. First, the authors discuss how Andeans deal with sickness by myth and ritual. Second, the authors show how Andeans try to maintain their physical well-being by adaptation, physiologically and culturally, to an environment with dietary restrictions, a diurnal temperature climate, and high altitude. Finally, the authors provide ways to improve the health of Andeans.

. | ANDEAN ETHNOMEDICINE The purpose of part 1 1s to document ethnographically the compatibility or incompatibility between the Andeans’ traditional medical system and health maintenance: In what ways do their myths and rituals promote or demote the health of Andeans. On the one hand, George Urioste, Joseph Bastien, and Hans Buechler show how myths and rituals promote cultural, social, and mental well-being, and, on the other hand, Bill Stein shows how the physical well-being of the individual is harmed by certain folk beliefs. Andean people have their own concept of the causes of sicknesses which

,1

profoundly influences what they do individually and socially to advance | health. George Urioste, in chapter 1, analyzes sixteenth-century Huarochiri legends to understand Andeans’ conceptions of sickness and healing. For preconquest Andeans, illnesses resulted from a breach of custom, which could have been caused by a relative. This breach set forth a whole chain of

misfortunes detrimental to the health of the community: the agents of | sickness not only affected the individual’s physical body but also his household and subsistence activity. Finally, a diviner needed to reveal the breach of custom and to reverse its causality by ritual actions. According to

the Huarochiri legends, health maintenance for early Andeans centered more on dealing with cultural and social factors than on treating the physical symptoms. However, there is evidence that early Andeans were keen specialists in surgical practices and herbal medicine (Cobo 1895; Wassén 1972). Early Andeans, then, interrelated health to a combination of

physical, moral, and social factors: the physical well-being of the individual

was related to social and economic well-being. .

Presently, Andeans still regard sickness and healing as related to social ) and moral causes. In chapter 2, Joseph Bastien discusses contemporary .

rituals of the Qollahuaya Andeans of Kaata, Bolivia. Similar to Urioste’s conclusions, bodily illnesses of Qollahuayas are signs of disorders between man and his land or between his vertical Ayllu Kaata. The diviner’s role is to reveal this conflict and to redress it by ritual, which resolves the dispute and reorders the mountain. Qollahuaya diviners cure, not by isolating the individual in a hospital, away from his land, but rather by gathering the members of his social group in ritual, and together feeding all the parts of Ayllu Kaata. Symbolically, the diviners feed the ay//u (mountain), which they metaphorically conceptualize as a human body. By means of the body metaphor, diviners not only examine but also interrelate the complex networks of environmental factors and social structure with-physical distress.

This promotes health because action is taken to change social and environmental causes of the sickness. Moreover, ritual is an occasion for gathering resources from the ecological zones on Mount Kaata: this provides a balance of diet. Essentially, Andean ritualists try to bring about health by balancing the relationship of people with each other and with their environment. This reflects basic social and cultural realities of the Andes; namely, the efficient coordination of resources from a variety of levels and the balanced exchange of goods and people. Migration and urbanization cause stress-related illnesses for Andeans. Many Andeans migrate from the country to the city, where they live in crowded industrial settings. Health maintenance for these people is pro-

Paz. ,

vided by a mixture of religious practices that combine traditional and Western medicine. Hans C. Buechler, in chapter 3, shows the variety of Aymara curing practices employed to cure Lucia, a market woman from La

Lucia suffered from stress-related symptoms. Buechler presents her life history to illustrate that the various curing rituals are meaningful within the context of her family and rural-urban networks. He points out that magic is a nexus between people in the city and the country: it provides them with continuity. Buechler also shows how magic is a form of preventative medi-

- cine because it prevents susto, or fright.

, Andean rituals are also performative activities in which people circumscribe the dangers of sickness and limit their potency. Metaphysical premises of Andean culture are symbolized in ritual: this order reconfirms a

sense of ontological security threatened by sickness. Thus, these authors 2

show how medical anthropology is a valuable methodology for understanding Andean culture (Edwin Erikson, personal communication). Even though Andean folk medicine is effective in many ways, some think _ that it is inadequate for peasants who live between the pull of tradition and the pressure of change. With data from Vicos, Peru, William Stein shows in

‘chapter 4 that native disease categories may inhibit the cure of physical , ailments. Poverty and malnutrition cause diseases that folk medicine

~ ‘doesn’t address. Stein concludes that the chief enemy of scientific medicine

does not consist of ideas but consists rather of ignorance and poverty, sociocultural isolation, and exploitation. The first priority is not to change medical beliefs but to change underlying economic conditions. The authors in part 1 demonstrate the compatibility and uncover the tensions between Andean health maintenance and Western biomedical science so that future research may devise alternative strategies, which utilize findings from both systems.

| ANDEAN ENVIRONMENT | Historically, Andeans have tried to maintain their physical well-being by

adaptation to an environment with high altitude, severe temperature changes, and varied ecological zones. The purpose of part 2 is to present certain ways in which Andeans have adapted to the environmental factors by such devices as diet, coca chewing, herbs, and physiological change. These authors show that Andeans have been successful in adapting to their

environment. They point out the effects of physiological differences, specialization and utilization of resources from many levels, and the selection of certain resources (coca and herbs) that provide certain necessary chemicals to the body. Andeans maintain health by trying to keep a close relationship with their environment. This has become increasingly difficult

with industrialization. |

The vast majority of Andeans live at altitudes above 12,000 feet where the

oxygen is considerably less than at sea level. The effects of altitude on health and sickness have long been a research question in the Andes. Chapters 5 and 6 contain carefully gathered base-line data to answer these

- questions; they deal with the effects of migration of Andean populations to low altitudes and with the physiological characteristics of Andean populations. William Mueller, William Schull, and Francisco Rothhammer, in

chapter 5, assess the health status of Aymara Indians at sea level and at moderate (3,000 meters) and high (over 4,000 meters) altitudes in northern

Chile. They report on the physical growth, lung function, and blood pressure of 2,096 subjects of both sexes aged 2 to 80 years. In general, physical growth was retarded at high altitude, but lung function was augmented. The Aymara had broader anatomical measurements relative to

their stature as compared to those of European descent; otherwise, the changes in growth and physiological measurements were dependent on altitude of residence. Blood pressure changed little with altitude or ethnicity when body weight was held constant.

In regard to sickness, James Dutt and Paul Baker, in chapter 6, found 3

that high-altitude populations have lower cardiovascular and higher respiratory morbidity rates as judged from cause of death statistics ina ~ lowland region where 45% are immigrants. The findings of these studies show that physiological changes due to altitude present certain advantages and disadvantages for health maintenance. These biological factors influence significantly the type of health maintenance necessary in the Andes.

. Concerning nutrition, Andeans traditionally maximized their access to

many ecological zones by specialization and resource exchange. Verticality

is an underlying principle of Andean social, political, and economic organization (Murra 1972:429-468). In the Andes, altitude is the great ecological variable, and so it is an extremely important factor for control. _ Andean civilization arose through successful efforts to control as many vegetational zones as possible so as to furnish these people with necessary

nutrients. The mechanisms of vertical control include colonization, seasonal migration, resource exchange, and kinship relations (Bastien 1978:xxill). David Browman, in chapter 7, shows how llama caravans were important for transporting food throughout the Andes between 2,500 B.C.

and A.D. 1950. Caravans also carried important drugs, such as coca, quinine, and other herbs. During this period, Andeans maintained an adequate diet by utilization of many nutrients and resource exchange. After 1950, Andeans began replacing Andean foods with imported foods, which

are considerably lower in nutritional value. Browman illustrates that, although Andeans have adapted successfully in the past to their environment by verticality, outside influences (cash economy, imported ‘“‘prestige goods’’) disrupt this adaptation and lessen health maintenance of Andeans. Another outside influence affecting the health of Andeans is the attempt to eradicate coca in the Andes. A commission of the United Nations (UN) studied the issue in the 1950s and concluded that coca was harmful to the health of Andeans. From this data, now outdated, the UN and governments of the United States and South America have tried to abolish coca in the Andes since 1969. Presently, drug enforcement agencies believe that the solution to the illicit use of cocaine in the United States is to prohibit production in the Andes. The U.S. government has encouraged certain governments of South America to destroy coca fields and to punish Indians who chew it. Finally, they intend to abolish coca from the Andes by 1983. Policy makers believe they are improving the health of Andeans in the Andes.

A very pressing question is whether the chewing of coca leaves is beneficial or harmful to the health of Andeans. William Carter, Mauricio Mamani, and Jose V. Morales, in chapter 8, list the medicinal uses of coca, which are primarily for stomach and respiratory ailments. When used as a

medicine, coca is often combined with other herbal substances. These authors provide evidence that the use of coca is important to the health of Andeans. More research is needed to determine the physiological effects of coca on Andeans’ health, especially in regard to carbohydrate consumption

and hypoxia. ,

' Another way Andeans have utilized resources from a multiple of ecological zones is by the collection of medicinal plants and minerals. William Carter, in chapter 8, lists 45 sicknesses and their herbal cures. This

is part of the pharmacology of the Qollahuayas, who employ more than 4

1,000 medicinal plants in curing. Some of these herbs may be effective ~ substitutes for synthetic drugs. Subsequent research is needed to determine the effectiveness of medicinal plants for curing diseases in the Andes. In summary, part 2 deals with two basic characteristics of environmental health. Basic to Andean health is their ability to adapt physiologically to the - high altitude. More recently, this adaptation has resulted in certain health problems of respiratory illnesses. Another basic characteristic of Andean ~ medicine is the ingenuity to utilize the variety of resources found on different levels from the jungle to the mountaintop. Andeans score high in regard to environmental health. IMPROVING THE HEALTH OF ANDEANS

On the basis of our understanding of the effects of altitude on living style, nutrition, coca use, and ethnomedicine, what contributions can medical anthropology make to improve the health of Andéans? In part 3, the authors discuss applied aspects of improving the health of Andeans and ways in which public policy should be determined so as to provide the total well-

being of Andean people. These authors point out that health or positive well-being of Andeans can be improved by a balanced relationship between population size and land use, by more suitable locations of health facilities, and by a more equitable distribution of wealth. The authors show that at-

tempts to improve the health of Andeans must be multifaceted. Jim Blankenship and Brooke Thomas point out that controlling mortality without controlling fertility upsets the ratio and relationship of populations

to land. John Donahue shows how health planning and delivery efforts need to incorporate people at all community levels. Ralph Bolton shows that trying to improve health without improving the economic structure

- merely treats the symptoms, not the cause. |

First, the introduction of modern medical services alone in Andean communities could decrease mortality and stimulate population growth, thus upsetting stability of the population size. Using data from Nufioa, James Blankenship and Brooke Thomas, in chapter 9, devise a simulation model to explore some of the consequences of introducing modern medical ser~ vices. This model indicates that hardship, hunger, and even starvation could

result and that the well-being of the population would require not only

modern medical service but also reduced birth rates and improved technology necessary to increase food production. In a critique by Edwin Erikson, the peasants of Nufioa and other communities in the Andes live in broader economic, social, and political con-

texts, and their migratory history argues strongly that they know this.

an 5

George Kubler’s (1946) analysis of the demographics of the early years of the viceroyalty of Peru show that, in a consistent pattern of population loss

between the seventeenth and eighteenth centuries, certain jurisdictions

gained populations. These were urban mercantile centers and frontier , zones, mostly in the montafia, places where individuals could escape the exactions of mita, encomienda, and repartimiento. Since the turn of this century, large parties of campesinos travel from the highlands of central Peru

to coastal plantations for employment. There is a constant exchange of workers between communities on the a/tip/ano and in eastern Bolivia. Con- | sequently, projections predicted on local resources and production are incomplete for policy purposes because they simplify the view. The problem of overpopulation is one of national scope and probably longer term than the one depicted in Blankenship and Thomas’ model. A problem in medical anthropology, then, is studying the local community as though it were the only significant unit of analysis. Trying to avoid this, John Donahue studies the dynamic relationship between the political

structure of the community and the bureaucracy of national health programs. He shows how community-level factors influence the implementation of a low-cost rural health delivery system among highland migrant . homesteaders and lowland people in eastern Bolivia. Chapter 10 contains the procedures used to select pilot communities, organizational strategies employed to initiate the health program, and attempts to integrate community health personnel into the public health referral system. His prediction of those communities in which it would be successful was subsequently

born out. Spontaneous colonies and traditional villages more readily adopted the health program than organized colonies, probably because they are closer to major market and medical reference centers. This paper in conjunction with the simulation study of Blankenship and Thomas might well

become models for determining the effects of public health programs in communities and for selecting communities which will implement them. Ralph Bolton in chapter 11 points to another dimension in improving health, a more equitable distribution of wealth. Ralph Bolton shows that variations of wealth in a traditional peasant community influence the health status of individuals. Poor peasants suffer more illnesses than rich peasants,

probably because the poor have limited access to medical care, adequate diet, sanitation, and proper housing. As Bolton also points out, poor health can also lead to poverty because of the expenses of sickness and inability to. . work. There is a mutual interaction between health and wealth. Maintenance of health is a broad task for any society, especially if one defines health to include physical, mental, and social well-being. Yet, if you

read this book, you cannot help but be impressed by the many ways Andeans have used to stay healthy. Some of these methods have been very effective, but change has brought new problems for health. For example, this book evokes two major flows of Andean ethnohistory: Andeans’ efficient coordination and utilization of resources from many varied habitats and

foreigner’s efforts to destroy this variety with a tendency toward monopolizing for export and import. Too frequently, health programs

6|

follow the foreign flow of Andean history in that they tend to monopolize curing by restricting it to clinics and specialists. This makes the Andean dependent on ‘“‘imported’’ medical care, while his herbs are exported for their use as natural drugs by Western people. In other words, foreign intervention creates new health problems rather than solving existing ones. This is not because Western biomedical science is ineffective in the Andes and not needed, but rather that it has not been adjusted and fitted to Andean culture and society. This book shows how medical anthropology is a very useful device for

getting at broader cultural and social realities in the Andes. The chapters on

curing rituals provide abundant ethnographic information about Andean culture. Bastien approaches Andean cognitive patterns in his analysis of a curing ritual; he shows how Andeans understand their ay/lu-according to

the metaphor of a human body. Urioste delves deep into Andeans’ understanding of self from their explanations of disease. Buechler unfolds ‘the complexity of rural-urban networks by his life-history methodology. ~The chapters on altitude and demography by Dutt and Mueller contain Statistical data and analysis of physical characteristics of the Andes. Carter

provides us with the results of a very extensive survey of coca use. As Donahue notes in the Conclusion, these chapters provide the etic component to the more emic-oriented articles on Andean ethnomedicine. Conse- | quently, the reader is provided with a diversity of methodologies and aspects of Andean health. Although there is some diversity in the chapters, they are presented in one volume so that the reader will get a broad picture of Andean medical an-

, thropology. This is essential because Andeans do not fragment themselves into so many compartments; consequently, their health includes a complementarity between many components: the ancestors, land, lineages, levels, ritualists, rituals, herbs, as well as clinics, nurses, and doctors. The failure to deal with this diversity and complementarity has led scholars to isolate their research rather than to look for interdisciplinary dialogue. It has also led to some unnecessary mistakes by policy makers. This book is a

beginning toward a holistic approach to medical anthropology in the Andes. We hope this book reaches scholars and policy planners of public health in the Andes. Anthropologists should not only point out the validity

and coherence of ethnomedical practices, but they should also inform , policy makers concerning health care issues. As a result, perhaps, Andeans

may suffer less and prosper longer. re

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CS ee Fie tien “RE a a =? eeeet4 Se Se ‘ Be ee ee ee . ¥ cs Pas ee meee te Ee ee . ee 2s ——— es oo si 55.iE ee, Ree ies BE oS) ET ORS Sy, | eCa 2S , Rig 3 st°se =. bee iG6 sees e Se? £© oeBuff tame =o CSF aoe ee

ee yy Be eae ee | See a eeWeeae GS SB ee ee *« eea ae € Le Ae.SNeeOER. For studies concerning Qollahuaya herbalists see: La Barre 1948:217-220; Oblitas 1963,

1968, 1969; Otero 1951. . > Turner (1957:330) regards ritual as a mechanism of redress, postulating ‘‘that ritual mech-

anisms tend to come into play in situations of crisis where conflicts have arisen in and between villages as the result of structural contradictions.’’ * Rappaport (1967:17-30) studies how rituals affect New Guinea people’s relationship with

their land. The divination initiated by Carmen altered the power in Kaata by rallying the mystical forces of the dead ancestors against Martin (see Gluckman 1965:239, 264).

, 37

CHAPTER 3 : , AYMARA CURING PRACTICES | IN THE CONTEXT OF A FAMILY HISTORY

HANS C. BUECHLER Similar to Bastien and Urioste, Hans Buechler goes beyond specific curing techniques and beyond the dyadic relationship between patients and specialized practitioners to studying illness within cognitive and social con- _~ texts. Buechler employs the life-history method to investigate the place of illness in the life of Lucia, an Aymara market woman and her relatives in La

Paz, Bolivia. His analysis reveals the degree of involvement of various members of the patient’s family in the cure, shows the manner in which dif-

ferent kinds of specialists are consulted as an illness progresses and illustrates the prophylactic effects of magic. For example, magicians prevent susto (soul loss) by ritual. In sum, Buechler presents a very interesting case study that shows how curing is embedded in wider processes. These processes are logical permutations of curing rituals. By now the reader is aware that there is no set of way of curing in the Andes. The manners of curing in the Andes are as varied as the levels of land. If one ritual fails to cure an individual, there is always another one to try. Nonetheless, all rituals are involved with ecological and social processes.

Moreover, practices in Andean ethnomedicine address themselves to both social-supernatural and empirical theories of disease causation. The following are a few examples of their biomedicine: Qollahuaya herbalists employ — more than 1,000 herbs for curing (Louis Girault, personal communication; Oblitas 1963, 1968, 1969, 1971). In the past, venesection (phlebotomy) was a pre-Columbian practice in Peru (Paradal 1937:49-50). According to Roy Moodie (1927:278), ancient Peruvians were far better surgeons than ‘‘any other primitive or ancient people’? (Ackerknecht 1978:168). Andeans practiced trepannation as early as A.D. 700 (Wassén 1972) and continued it until the turn of the twentieth century (Bandelier 1904:442). More than 50% of the people operated on recovered from the surgery, which is equal to Euro- . pean results in 1850 (Ackerknecht 1978:171; Shapiro 1927:266). Finally,

William Carter and Mauricio Mamani (chapter 8) provide more data on how Andeans skillfully and empirically treat illnesses. A wealth of alternative medical systems is often available in large cities

brought about by regional, interregional, and international migration, which adds new folk practices to the urban ones. In addition, officially recognized medical systems are usually based in cities. In fact, many of the services they provide may only be available there. Such complexity poses a number of interesting questions: How do individuals choose among alternate systems and how do they combine them? If more than one system is 38

employed by the same individual or family, how is access gained and how is a decision made in each illness? Finally, to what extent do medical practices constitute a separable domain and to what extent are they interlinked with other aspects of an individual’s general well-being? . , A useful method in answering such questions is the gathering and analysis

of family histories. Such an approach makes it possible to place medical , _ practices into the context of other developments in the life of a patient and - other members of his family. Furthermore, the investigator is less bound by the constraints of interviews on specific themes, leaving the informant more flexibility to define the topics of inquiry. They thus permit an examination of the manner in which medical practices are emically.related to the wider quest of individual and familial well-being in a variety of social settings. Such a method is also inherently dynamic, for it comprises time spans of at least two generations. Medical practices can thus be analyzed as a series of decisions, each made under a different personal and familial circumstance. In this paper I attempt to address the questions posed above by examining them in the context of the history of a family of. Aymara migrants to La Paz

who subsequently returned to the community of origin of one of its members. This study, undertaken with Judith-Maria Buechler, focused primarily on the life of Lucia, a 30-year-old market vendor, complemented by interviews with her mother and various other close relatives. The technique employed was inspired by network analysis. For each event described by our informants we sought to discover the identity of the principal protagonists, as well as the nature and the reason for their involvement. For instance, we asked who suggested each medical treatment and the circumstances that led to the suggestion. This enabled us to plot changes in the family’s social network as it moved to the city and returned to the country and helped us to discover the dynamics of decision making with respect to

health and related concerns. Oo

Lucia was born of Paceza and Miguel in a comunidad' on the shores of Lake Titicaca. Paceza had sought refuge in her grandmother’s house when her father was murdered for his land by close patrilineal kin. ‘Paceza migrated to La Paz after the birth of an illegitimate son. In La Paz she met her husband who was from a different part of the a/tiplano and

gave birth to another son and a daughter. After an apprenticeship she established herself as a candlemaker. Later, she was joined by her daughter, two daughters-in-law, and her husband, who was forced to retire from a job

as a railroad worker after suffering a crippling accident. Thanks to her business acumen, Paceza soon became wealthy enough to purchase her own house, a rambling compound surrounding a patio. There, various children,

grandchildren, kin, and neighbors from her natal community, as well as Pazefio tenants, have found temporary or permanent shelter over the years. In addition, she was able to purchase a bus. The bus became the source of a livelihood for her second son. The first-

born illegitimate son became a high-ranking militia officer under the M.N.R. regime, a truck owner and factory worker. Her daughter, Lucia,

Hs 39

was sent to a parochial school by her status-conscious brothers. There all teachers at first discriminated against her because her parents were mono-

lingual Aymara speakers, but soon she won their hearts. She became a

devout churchgoer and at one point played with the idea of becoming a nun.

In her spare time she helped her mother with the sale of candles. Soon, however, she sought greater economic independence. While still in school She began to sell vegetables in a street market on weekends, much to the dismay of her brothers, who saw the market as a low-status arena. Persons from her mother’s natal community, or paisanos, provided a steady supply of onions. However, Lucia did not intend to remain a market woman. She could have become a seamstress, because the nuns taught her how to sew. But she really hoped to become a nurse. This plan was interrupted by her mother’s decision to move the family back to her natal community, which became a new base for their marketing activities. Lucia now commutes between the new rural home and La Paz, engaging in complete transactions,~ which include the sale of onions, pork, and eggs. Her background gives Lucia an ambiguous position in the social hierarchies of La Paz and the rural community. She wears modern European dress but owns an expensive set of chola clothing worn by the wealthier market women. She thinks of switching to cho/a clothing entirely some day, but presently she wears it only at fiestas in her home community. She treats

the rural vendors whom she meets in the rural fairs and urban markets as equals, but they are well aware of her more cosmopolitan background. The onion vendors have made her their leader and she often counsels them. In addition, she is a friend and cook for the Pacefio schoolteachers who teach in her community and is a liaison for the Catholic church. Her social position thus accentuates the ambiguous status of her mother, who is an almost landless relative in her home community, but also the owner of the largest store there. At the same time she is an urban landlord. These divergent social spheres in which the family moves cannot always be reconciled. This was demonstrated in a housewarming fiesta (utachiri) it held in the rural community. Half of the guests, including the local school-

teachers, and kin and neighbors from La Paz drank in one room and ~~ danced to the tune of modern crio//o music. The rest, including community

elders and rural neighbors, sat moping in a smaller room because of the

family’s failure to observe local ritual forms. , This complex background is reflected in the variety of systems of prognosis, prophylaxis, diagnosis, and curing or redress the family employs in coping with illness and with other stressful situations. The family’s moves and the connections its members have established in La Paz and in the rural

community permit access to a wide range of practitioners and to other sources of medical practices and beliefs. In the rest of this paper I shall examine the multiplexity of both the prac-

tices and their sources and attempt to show how a migrant’s medical knowledge expands as his or her ties established in conjunction with other activities (e.g., education, marketing, and daily interaction with neighbors and members of one’s community of origin) are developed. I shall define the topic broadly. Lucia does not make any strict separation between practices and beliefs regarding health and those related to other aspects of her own and her family’s well-being: Curing and magical practices related to other concerns—particularly marketing—are often intertwined. Furthermore, those requiring specialized knowledge are often exercised by the same 40

practitioners. Therefore, rather than concentrate on medicine alone, I shall examine the entire realm of practices associated with the subjects’ wellbeing, letting the boundaries between different concerns become apparent

from the analysis itself. I shall organize our data according to the chronological unfolding of

disease and misfortune, which will permit me to compare Western classifications of stages in medical treatment with those employed by Lucia and the specialists consulted. I shall begin the exposition with the manner in which Lucia predicts future events of both a positive and negative nature. Dreams constitute Lucia’s principal technique of prognosis. She dreams regularly about success, theft, or loss and accidents while marketing as well

as about illnesses and death. She is assisted in the interpretation of these dreams by a magician in her rural community and by a sorcerer (brujo que tiene pacto con el diablo) in La Paz. They encourage her to dream and tell her that such dreams are a gift of God. After a rite to insure success in marketing, she was told that if she dreamt that she was climbing a hill she would be lucky. In this type of dream she often carries potatoes’ (an item which she does not normally sell). ‘“On the day following such a dream”’ she

says: ‘‘My clients come and seek me out, J don’t even have to hawk my wares.’’ In contrast, if she dreams about descending a slope or going to bed, this means misfortune. Bedwetting indicates the loss of all her money; falling or stepping into excrement may also signify loss or breakage of the eggs

she brings to market. |

Lucia also claims to have foretold illness and death in her family and in her neighborhood: ‘‘Once I dreamt that I met my sister-in-law dressed in fine clothes on the street. I asked her why she was angry at me and she derided me. So we had a fight and I tore out a big patch of her hair. The next morning I wondered what had happened to her. Sumptuous clothing means illness, and hair loss the loss of honor. My mother just laughed at me, but 2 weeks later I heard that my sister-in-law was in the hospital and had almost died of an abortion of an infant fathered by a lover.’’ A week before her father died, Lucia dreamt that she had lost her shoes. Then suddenly the sun appeared in her dream only to be darkened. ‘‘It was the fiesta of the patron saint of the community. I had no shoes to dance in and I cried because people would see me like that. I put some potatoes in my apron’ and went to the cemetery where I cried bitterly. I told my mother the next day and wondered why IJ had dreamt such things. A week later I went to the

cemetery to bury my father and cried just as I had done in my dream.’’. When someone Is going to die in the neighborhood, Lucia dreams of cars if the death is to be a woman or a child and of trucks or buses if it is to be a man. These vehicles represent coffins being taken away. Their size and color (dark for the elderly, bright and new for a young person) imply the height and age of the victim.

Lucia does not regard herself as entirely powerless in the face of her dreams. Her rural magician counsels her to tell the dream to her mother or to any other widow or widower as soon as she wakes up in the morning.

| Oo , 41

This may neutralize the prediction. Conversely, her La Paz sorcerer tells her to keep her dreams to herself if she wants them to come true.* Once, when she dreamt that she was waving good-bye to passengers in a long, new, sky-

blue bus, she went to her tenant who is a widower. Chewing coca rapidly, he waited for Lucia to recall her dream. ‘‘Who could it be?’’ she asked. ‘‘No one in our family is young and tall.’’ The tenant chewed more coca and spat

the liquid into a nightpot exclaiming: ‘‘May it be in vain. Let it not be.”’ Then, 2 months later the son of one of Lucia’s tenants fell asleep with a lit candle on a plastic plate beside him. The entire room caught fire and he was saved just in time. When Lucia told his mother about her dream, she was - _ exultant that her family had been spared worse misfortune. To celebrate,

She took the next day off to drink. |

Lucia’s use of dreams indicates that laypersons have the power to prognosticate as well as specialists. The specialist merely assists in the interpre- , tation. Foreseeing the future in one’s dreams is considered a gift that only «§ some individuals possess and that they can develop further. The belief

system surrounding dreams is not fatalistic: A dreamer can prevent a predicted event from occurring. Prevention of future harm can be resorted to in a more generalized manner by engaging specialists to make ritual offerings to supernatural powers. Every August and/or December Lucia asks her mother’s cousin (the magician in her local community) to prepare a dulce mesa, a spirit offering consisting of sweets, animal fat, and herbs (wira koa) on a bed of colored tufts of llama wool, to be sacrificed to the spirit of the hill behind the community. The mesa includes a number of dough squares with various designs in. relief. These serve to tell the future. For example, a truck signifies future truck ownership; the Virgin Mary, good health. The magician also divines by reading coca. The rituals appease the mountain spirits and are also de- _ signed to call the spirits (dnimos) of potential clients, including regular patrons of one’s competitors whose envy, thus engendered, must be guarded against as well.

The most important consultations, however, are those made when remedial action against misfortune becomes necessary. In marketing they ~ | become appropriate when sales drop due to competition rather than to a

general economic slump. Lucia attributes the former to witchcraft (brujeria). Usually this simply means that neighboring vendors are using effective magic to attract regular clients (caceras) away from all the others. In

this case, general countermeasures are sufficient. Lucia often consults Sefiora Blanca, a Pazefia who was trained by a Chilean woman. Sefiora Blanca reads cards and tells Lucia that her friends are stealing away her clients. She lights four cigarettes at once, the first representing Lucia; the second, her onions; the third, her marketing site; and the fourth, her clients. She lets the ashes drop into a container and counsels Lucia to sprinkle some of the powder on her merchandise. Sefiora Blanca, however, regards herself mainly as a diviner and refers Lucia to her family magician for further action. ‘‘Remember,’’ she told Lucia, ‘‘money is the domain of the tios.’’ The family magician gave Lucia a tiny bottle of alcohol to offer to the ¢fos for assistance. Unlike other Aymara, Lucia includes the pachamama (Mother Earth) in this category, and it is to her that she directs the libation in secret

early in the morning at the market before her competitors arrive.’ Lucia receives analogous counsel from a specialist in black magic in La Paz who has a pact with the Catholic devil whose power is mediated through the skull 42

of a famous magician. His rationale is the same as Sefiora Blanca’s. God is poor, and, therefore, it is useless to ask him for help in money matters. Sometimes Lucia feels that witchcraft is directed against her personally. She regards the witchcraft of her neighbors in the market as potentially the most harmful. Until recently Lucia felt that she was incapable of identifying the specific sources of the witchcraft which affected her vain. But her magi-

. cians told her that her dreams could serve this purpose, too. ‘‘When I wake

up in the morning after dreaming of chickens or guinea pigs, I tell my mother and she wonders who it could be. During subsequent nights I try to identify the culprit in my dreams. I may dream that my sister-in-law (herself a vendor) or the woman who sells next to me serves me a delicious dish.° If I eat the food, it means that the magic has already taken effect. If not, then it

has not yet succeeded. Once I quarrelled with my sister-in-law about a market site, and we didn’t speak to each other for 3 months. When she lost the fight, she shouted in parting: ‘I hope that your site will serve you well’ (presumably meaning just the opposite). At first I was selling normally, but then all of a sudden my luck failed me, my clients left, and I lost my capital.

I even ran into debt. I wondered what had happened. Then one night I dreamt that I went to visit my sister-in-law and we went to her neighbor’s house where I was served a sumptuous meal. Sefiora Blanca told me that my

sister-in-law had cast.a spell on me because she was angry at me. The neighbor who had served me in my dream must be the witch whom she had

employed for the purpose. | ‘*At first I didn’t believe her. But I always have friends who help me when

I am down. One of my friends asked me why I was so sad. I answered that I had no money and had even pawned my jewels to obtain working capital. She took me to the church of the Sefior de la Sentencia (where a number of soothsayers can be found on Fridays). I chose a tall de vestido woman (a woman wearing European-type clothing) and bought a peso’s worth of incense and another of copal (resin). Peering into the smoke, she told me that a relative of mine who lived in my compound had cast a spell on me because

of a dispute. She convinced me of her clairvoyance when she correctly divined that my foot was hurting and other facts about myself. She also told me that my father would be well again. This time I believed what I was told and consulted my mother’s cousin who prepared the usual mesa.”’ The sufferer is involved in diagnosis in the same way as he is in prediction. He or she is trained to push the skill of dreaming further. Eventually, an individual might be able to develop the skill far enough to become a professional, thereby completing the bridge between victim and practitioner. Lucia claims never to have employed witchcraft against anyone herself,

but she saw Sefiora Blanca invoke Santa Elena on behalf of one of her tenants to regain a lover who was living with another woman. The tech-

niques included the use of the victim’s hair (which the client had cut when

the lover was drunk just in case she might need it), the client’s and her child’s hair, a photograph of the victim, safety pins, thread, and ribbons.

a , 43

The object was to punish the victim and to make him quarrel with his new girl friend and renew the bond between him and the client, in such a way that he would be irresistibly attracted to her. Diagnosis of illness is in many ways similar to that of other misfortunes,

but in some ways it is simpler, since the symptoms are less ambiguous. A person who is ill feels ill, while a vendor whose sales have decreased may not perceive immediately that the personal misfortune may have been caused by her neighbors’ magic rather than merely by general market conditions. This difference may explain why Lucia does not mention diagnostic dreams in connection with illness. Rather, illnesses in Lucia’s family are diagnosed by her mother and by a wide range of practitioners. In the cases in which the

family consulted a practitioner, the diagnosis was little more than a more elaborate confirmation of their own perceptions of the cause and nature of ‘ the illness.

As in marketing misfortunes, diagnosis and remedial action are intricate-

ly interlinked and must be dealt with in conjunction. To combat illness, : Lucia’s family has resorted to the entire range of divinatory and curative practices. These include techniques that require specialized knowledge and skills and others that are more generally known. Paceza handles minor illnesses with or without the assistance of the family magician. A good example was the time when Lucia was in bed with a bad limp, loss

of appetite, nausea, and a headache. Her brother’s father-in-law had brought an enormous bundle of onions for her to sell on the market and she had had a bad fall in the uneven street near her house. The fall had given her a bad shock (“‘me he astustado’’), but she had picked up her onions, asked a bystander to load the bundle on her back, and had sold the onions as usual. But that night she fell ill. Paceza diagnosed it as k’atjja,’ the equivalent of the criollo susto, or soul loss. It was unusual for Lucia to fall on that street and surely the pachamama (or earth goddess) had captured her soul. She

laid the blame on the relative who had brought the onions. Had he not come, the misfortune could have been prevented. Mother and daughter dif-

fer in their description of the cure (perhaps because they confused two separate occasions). According to the mother, she boiled alcohol, red __ ‘‘wine,’’ coca leaves and wira koa in a brand-new earthern pot and bathed Lucia’s entire body with this liquid. Then she spilled the remainder on the site where Lucia had fallen, ordering pachamama to release her daughter’s three souls: the dnimo, the coraje, and the ajayu.* Unfortunately, Lucia went out of the house the next day and became ill again, so the procedure had to be repeated. This time Lucia was kept inside for 3 days. Lucia’s version of the same story is that her mother called the Peruvian brujo she has employed for many years for marketing and general magic, who said that they would have to milluchar.’? Millu (alum) is a black earthlike substance. This the brujo put on her feet for almost an hour. Then he rubbed her body with it, ordering the illness to leave her. Finally, he put the remainder in a pot of hot urine and covered it with Lucia’s sweater. After a while, when he uncovered the pot, foam had formed on the surface, making a design which resembled the street where Lucia had fallen, complete with a mark indicating the spot where the mishap had occurred. Then the liquid was transferred into a brand-new pot, and the brujo poured it out on that

site. | }

For serious illness the family has invariably consulted Western physicians, albeit often in conjunction with other persons. This was the case when Lucia’s father, Miguel, was afflicted by acute paranoia. She at44

tributes his illness to his lengthy lawsuit to regain control over land usurped by his wife’s kin after they murdered her father. The family first noticed

that Miguel was not normal when he travelled to the rural community, ostensibly to supervise the manufacture of mud bricks for a house his wife was building to live in and to store her goods when she went on marketing trips. They found out that he went to some entirely different place. A crisis - developed when Miguel attempted to throttle Lucia, accusing her of hiding

the fact that her mother had given the title to their house to her brother (Miguel’s stepson). Lucia was able to escape and sought her mother, who

showed her father the document. Another time Miguel screamed that soldiers from the Chaco War were attacking him, and he picked up stones to defend himself. '° . Recognizing the gravity of the situation, Paceza first consulted a Western

doctor, who told her to commit her husband to a mental institution. She refused because she was ashamed and afraid of gossip. Then she went to practitioners of both black and white magic. She also took holy communion with her husband. At that time the priest sprinkled him with holy water and laid the Bible on him. Miguel sobbed like a child: ‘Why do you bring me

here? Have pity on me. It is good that you have whipped it.’’ He presumably meant the ‘‘devil’’ in him, which Lucia compares to devils in the film The Exorcist which she had seen recently. In addition, Paceza consulted her neighbors and acquaintances who recommended the blood of a black puppy which she mixed into her husband’s coffee surreptitiously and the brains of the same animal which they served him in the form of a pan-

cake. She also employed a tranquilizing herbal tea prescribed by a callawaya, a practitioner from the valley of Charazani. But on Tuesdays and Fridays Miguel continued to have attacks and so finally Paceza followed the counsel of a doctor and moved the family to her home community where their storehouse became their permanent home. There they enlisted

the help of a magician from the neighboring community, a specialist in countermagic (who later died at the hands of a k’arisiri, a supernatural who kills people by cutting away the fat from their liver). They also continued to

bring in the callawaya, accompanied by his assistant from La Paz. One treatment consisted of placing the entrails of a cat on Miguel’s head and _ rubbing his body with the animal. Accompanied by Abel, Miguel’s son, the magicians then took the cat and white llama wool spun counterclockwise

out into the lake as an offering to the lake spirit (chhua achila). Another treatment (which caused the patient considerable alarm) consisted of a visit

to the home of chullpas, or ancestors, in the hills behind the community where a live red cock and a red dog were placed in a cave in exchange for Miguel’s soul. It had been imprisoned there by the spirit of a mountain (tio) as a result of witchcraft. He also said that the lake spirit had captured the soul (é@nimo). The callawaya’s armadillo had found a buried sorcery bundle, which was evidence that Miguel had been the victim of witchcraft. The bundle contained a miniature coffin with three figures, presumably representing Miguel, Paceza, and one of their sons whose death was symbolized by the

coffin. One figure had a banknote wrapped around it so that its human counterpart would have no money; another held a miniature bottle and jigger, spelling drunkenness. The figure of the woman was wrapped in a tassel 45

taken from Paceza’s shawl, linking her as irremediably to the misfortune to be wrought as the hair of the lover in our example of love magic. With all this attention Miguel slowly regained his health and later showed few signs of his former illness. In the first example the interlinkage between diagnosis and cure can be

seen in the magician’s interpretation of the foam in the pot of urine. The - pattern which formed after the urine had reacted with the millu confirmed , the initial diagnosis. At the same time its conjunction with the real site of the accident was an integral part of the healing process. Similarly, in the sec-

ond example, Miguel’s reaction to the holy water can be considered both . diagnostic and curative. The holy water elicits aresponse from the spiritand

thereby reveals the cause of the illness. At the same time, the nature of — response indicates that the cure may be taking effect. The range of practitioners employed in Miguel’s cure probably is due to the involvement of different family members. The two examples show -in-

teresting contrasts in the conception of illness. According to Oblitas (1971:199) and Tschopik (1951:212-213) the ajayu detaches itself from the

body during sleep to take a tour of the outside world. Its impressions are recorded in the sleeper’s dreams. When a person suffers from k’atjja, the ajayu becomes similarly detached (if perhaps only partially) when the patient is awake, and it is captured by the spirit of the place where the untoward event occurred, e.g., by the pachamama or by a more specific place spirit (cf. La Barre 1948:220-221; Tschopik 1951:212-213; and Paredes 1963:257).'' In the case of k’atjja, the soul is the victim of an accidentally angered spirit; but, as Tschopik points out (1951:213), an evil spirit may also capture a victim’s soul on behest of a sorcerer. In both cases, the patient suffers a loss that must be recovered. In contrast, Lucia’s description of exorcism by the priest indicates intrusion of a malevolent spirit rather than loss. The practitioner’s task is to dislodge the intruder. Thus, depending on the specialist, the same case is diagnosed and treated as resulting from diametrically opposed causes.'” In order to complete the picture, I should add that lately Lucia resorted exclusively to Western physicians when she had a serious liver ailment and

that on another occasion she had a male friend take her ailing mother to consult a physician in a distant mining camp. In summary, the analysis of health care in the context of a family history of rural-urban migrants reveals that beliefs and practices about illness are intimately related to practices concerned with other forms of misfortune, in this case, stress in marketing. Both types of concern may be dealt with concurrently as in the annual propitiatory offerings, or one may ask for specific advice or countermeasures. But, even then, the consultation may provide information about other concerns. Life is not compartmentalized: a lawsuit may have witchcraft as a consequence resulting in illness just as easily as good luck in selling may cause envy, which in turn may lead to witchcraft, followed by a drop in sales or a loss of capital. The interlinkage of an individual’s worries is as clear to Aymara and mestizo curers and magicians as it is to the old-fashioned European country doctor. Their separation is an

46

artifact of recent Western overspecialization. |

In order to insure or restore their well-being, migrants to La Paz take ad-

vantage of an extremely wide range of practices, sometimes, but not always, aided by-practitioners ranging from herbal curers, magicians specialized in black or white magic to Western physicians and Catholic priests. Diviners and magicians include specialists trained afar in Chile and Peru and those such as the callawayas from Bolivian communities which specialize in curing. -This variety reflects the widening of the social network through extended

~ yural-urban contacts. As J-M Buechler (1972, 1976, n.d.) has shown, market women expand their social networks as they move from rural communities to the city. Before a permanent move to the city is made and during the initial period after the move, a market vendor relies heavily on ties in the home community as a source of produce, while slowly building up a faithful clientele of consumers and middlemen in the city. Later, contacts _ established in the city give vendors access to new sources of produce and to a wider clientele. However, rural ties are often retained and exploited in traditional as well as novel ways for many generations. The expansion of an individual’s network may take place over more than one generation. Vendors who return to their community of origin may retain the ties established in the city and use them to engage in new activities. Lucia can mobilize a wealth of connections as a result of such processes, and this in turn gives her access to a wide variety. of practitioners. In our examples, some of the practitioners were recruited through contacts in the rural community: thus, one of the family magicians is Paceza’s cousin; another magician came from a neighboring community where the family has kin links and where it has resided for some time. In the city, contacts established through commercial transactions, neighborhood interac-

tion, and schools lead to the recruitment of additional practitioners. Paceza’s family magician in La Paz was the. former owner of her house. Lucia was introduced to Sefiora Blanca by a neighbor’s adoptive daughter, a black girl whose natural mother lived in the yungas valleys and had consulted her in the past. The neighbor presented Lucia as a cousin. Further, a market neighbor suggested that she visit a diviner beside the church of the Sefior de la Sentencia, and the family took Miguel to a priest presumably because of Lucia’s intensive contact with the nuns in her school. Finally, complex combinations of ties with paisanos and urban-based ties may lead to a further expansion of the family’s medical horizon. Thus, the sorcerer Lucia consults for marketing magic and to foretell the family’s fortune was suggested by a paisana whose family had purchased a house from him and who subsequently established ritual ties with his brother. With the possible exception of the Western physicians and the priests, none of these traditions can be defined as either strictly urban or strictly rural. Urban-based practitioners may themselves be of rural origin. Furthermore, their careers appear to be subject to similar processes of network formation and concomitant modification of activities as those of the vendors (Bastien, personal communication). The city attracts individuals from

different parts of the country as well as from neighboring ones. Corre-

| . , , 47

spondingly, the practices favored by each family member show a shift from a greater reliance on purely Aymara practitioners (in the case of Paceza) to

Lucia’s eclectic use of practitioners representing a much wider range of

own. |

traditions. She reconciles the contradictions with syncretic constructs of her In conclusion, Lucia’s case shows that an individual can employ systems with conflicting underlying beliefs even in the course of the same illness. | These systems are related, in turn, to those employed in the prediction diagnosis and prevention of other kinds of misfortune. An individual’s access to them is dependent on the development of a varied network of con-

tacts in the city, and this network is correlated with length of urban residence. Continued links with the rural community and the rural origin of many urban practitioners renders a rural-urban dichotomy meaningless, ex-

cept in the sense that the city presents more choice and more opportunities |

for making new combinations. mS Viewed from a cognitive and communicative perspective, Lucia’s case exemplifies some of the same processes undergone by such explicitly communicative systems as fiestas. Elsewhere (H. Buechler 1970, 1975, 1976, and

1980), we have shown that change in fiestas is often due to the attempts made by migrants to find new frameworks in which to display markedly different networks. Similarly, Lucia’s consulting a priest, Seflora Blanca, and the black magician can be regarded as more than merely the outcome of her urban connections. It is also an attempt to justify and display these connections. When she attributes her father’s recovery principally to exorcism by a

priest, for instance, she is justifying her long-term involvement with Catholic schools and other Catholic institutions. In contrast, her mother credits the callawaya practitioners imported from Charazani with the cure. Cosmopolitans of rural extraction, they both represent and justify the way of life Paceza herself had chosen.’? I contend that an analysis of rural-urban linkages and their transforma-

tion over time is essential to understand the use of medical systems by

one way to achieve this goal.

migrants and the meanings they attach to them. The life-history method is.

. NOTES

' A community of free holders. > According to La Barre (1948:179) and Oblitas (1971:220), potatoes in dreams signify money. ; Perhaps this would be interpreted as her expenditures for the rite. “ According to Paredes (1963:33-35), bad dreams can be neutralized by telling them to a | dog, while positive ones should not be divulged right after one wakes up in order not to impair their efficacy. * Lucia is combining various beliefs, including the miners’ belief that minerals are the province of the tios (cf. Nash 1970) variously identified with the Aymara mountain spirits and the Christian devil and the Aymara belief that the pachamama is the source of fertility and the achachilas or tios are sources of potential destruction of crops and disease as well as potential protectors from such misfortunes. * A comparison with Paredes’ observations earlier in the century (1963:33-35) of the ‘‘clases populares’’ presumably of La Paz shows parallels in the symbolism. Thus, he too mentions guinea pigs as symbols of witchcraft. Cooking appears as an even stronger negative symbol: in this case it means death. For a detailed list of Callawaya dream symbolism, cf. Oblitas 1971:197-226.

48

’ Tschopik’s orthography derived from the verb k’atuna: ‘‘to catch’’ makes more sense than

Lucia’s own rendition: k’acjja. . * In contrast the literature on Aymara soul loss mentions only one soul as being susceptible

to susto. ° This brujo was creyente en Dios (believer in God), son of Saint James the Apostle. As a child, Lucia would see him come in the evening; beat everyone symbolically with a stick, and pull the boys’ ears, asking whether they had behaved well. Then he would read the coca leaves to ascertain the fortune of each member of the family. In the morning Lucia would wake up with wool tied around her to secure her dnimo. '° Interestingly, Oblitas (1971:224) lists the appearance of soldiers in dreams as an omen of illness. '' Oblitas’ (1971:133) explanation that the symptoms of illness experienced by the patient are

due to his body’s greater susceptibility to the penetration by a malevolent spirit when the soul has vacated its usual daytime residence does not correspond with that of other anthropologists.

'2 This does not seem to be a case of variance between Aymara beliefs and beliefs of Hispanic origin. Thus, susto is attributed to soul loss among Mexican Americans, too (Rubel 1960). There the belief is presumably of Spanish origin. '* Such symbolic statements do not, however, imply conflict. They simply arise from the fact that each member has a preference for those means which most closely represent her own position in the wider social system.

49

CHAPTER 4 |

THE FOLK ILLNESS: ENTITY OR NONENTITY? AN ESSAY ON VICOS DISEASE IDEOLOGY WILLIAM W. STEIN

According to Fabrega (1977:212), “‘disease causes organismic changes which reflect on how the individual comes to feel, judge himself, and orient to his social and physical environment. The individual interprets the altered

state of self associated with organismic changes in terms of the meanings ——

the final form of the illness.’’ | Unfortunately, these cultural understandings sometimes hinder the cur-

provided him by his culture. Such meanings play a role in and contribute to

ing process, as William Stein points out in this chapter. Stein describes a case from the Vicos medical clinic, which was established in 1953 by the Cornell-Peru Project. The patient, a little girl, is reported by her family to have shongo naney, “‘grief sickness, ’’ as a consequence of the deaths of her father and uncle. She is described as having a ‘‘leaking heart,’’ with much Dhysical pain in her abdomen. She had been given a number of treatments by folk practitioners, none of which had done her any good; and the condi-

tion had become progressively worse. After a lengthy discussion of the nature of the illness and its course by the mother with the anthropologist, the patient was examined by a physician in the clinic. He discovered worm infestation as the cause of the abdominal pains and discomfort. From this, Stein concludes that the confused and distorted understanding of this case

repertory of exotic diseases. _ of worms is due to ignorance and poverty rather than to some cultural

In critique, Arthur Rubel says that Stein avoids the real issue, which is to find the association between real diseases and diseases of the head. Anthropologists should study the associations between folk symptoms and physical

symptoms in the Andes, such as Rubel and O’Nell (1978:147-54) did in Oaxaca, Mexico. There, they found a high correlation between people with severe symptoms and asustado. Rubel and O’Nell (1978:150) concluded that

Dhysicians and other health staff should be sensitive to the language and manner in which patients present their complaints. This chapter provides a realistic balance to those of Bastien, Buechler, and Urioste, who emphasize the efficaciousness of Andean ethnomedicine. Anthropologists should study ways in which Andean folk medicine can be integrated with Western medicine, so that cognitively, culturally, and

socially both systems fit into Andean patterns and enhance health maintenance.

‘‘Disease is and always has been a socially created entity,’’ says Fabrega (1974:197) in his discussion of Disease and Social Behavior. It is a concept,

a social product that means different things in different contexts: as 50

‘*disease must be conquered,’’ ‘‘so-and-so has heart disease,’’ ‘‘that disease kills thousands,’’ ‘‘this is a diseased liver,’’ etc. Disease is thus ideological, an abstraction shaped by people, in contrast with an episode or occurrence of illness, which is a concrete and specific behavioral instance of disease (although the term i//ness is often used in the abstract sense, as in ‘‘folk ill-

ness entity’’). It will be useful to note also, that in this paper ‘‘disease’’ is

considered ideological in the sense that conceptions of it are “‘illusory representations of the real’’ (Godelier 1977:181) rather than real, in the sense of actual physical conditions. ' From either perspective, abstract or concrete, the processes of disease and illness involve both the biophysical and the psycho-socio-cultural ‘‘realms.’’

In medical practice, which is where these meet, they are not separable; rather, they constantly intrude on one another and affect each other, so that something we think of as a cause at one moment becomes an effect, caused by something which was an effect at another moment. Such a view is compatible with rapid change, and highly useful in the most developed part of the world where wealth and knowledge are concentrated and where scientific medicine is constantly being created and recreated by expanding theory and practice supported by growing wealth. In the underdeveloped world,

where the benefits of scientific medicine are mainly extended to the ‘‘modern’’ parts of societies, great masses of poor people are left with quite ineffective means of contending with medical problems. Indeed, as scientific medicine develops, the traditional, or ‘‘folk,’’ medical practices in this

other part of the world become even more sharply distinguished and set

apart from the modern. ; Nonscientific medical systems, in the sense of disease ideology and treatment procedures, are found everywhere, even in our highly urban and industrialized societies. Apparently, hope is better than despair, and some action is better than none. In this regard, Frake (1961:114) has the tollowing to say about the cultural universality of disease and its treatment: ‘*Am I sick?’’ ‘‘What kind of disease do I have?’’ ‘‘What are my chances?’’ ‘‘What caused this disease?’’ ‘‘Why did it happen to me (of all people)?’’ Illness evokes questions such as these among patients the world over. Every culture provides a set of significant questions, potential answers, and procedures for arriving at answers. The cultural answers to these questions are concepts of disease. . . . Because disease is not only suffered and treated, but also talked about, disease concepts are verbally labelled and readily communicable.

While the universality and diversity of folk medical systems is not to be disputed, I am dissatisfied with the general approach because it contains a

hidden trap, that of cultural relativism, which would hold all medical systems to be equal—not, of course, in the sense of having equal paraphernalia, equal ideology, or equal effectiveness, but with the spurious notion of

a scientific equality which would permit their examination, one after another, as though they each had the same weight in human history. Such a position arises from anthropological ideology: the concept of culture. Like it, cultural relativism as Moore (1974:537) says of culture is to be rather ‘‘understood as part of a belief system than as a scientific discovery’’ and ‘‘makes more sense as ideology than as empirical science.’’ My own researches, as well as those of others, in rural Peru convince me that Peruvian 51

campesinos, rural dwellers, have great medical problems which their folk medicine does not address, that this folk medicine is quite inadequate for dealing with these problems, and that countless Peruvian citizens suffer and die because of it. If cultural relativism would accord the same dignity to human lives that it does to human cultures, it could not possibly consider all medical systems as equal; or, to paraphrase Lukacs (1971:48), if every medical system had attained an equal degree of perfection there would be no such thing as the history of medicine. This paper constitutes a second endeavor to report on ethnomedical matters in Vicos, a rural community in the Peruvian Andes.’ Although it deals with the same problems as those discussed in the prior essay (Stein 1975),* __ this one is supplementary and, it is hoped, complementary to the first in that the present effort extends further into Vicos disease ideology, expands © on the issue of the relationship between mental and material causation, discusses the correspondence between disease entities and physical conditions, and supports a less ideological and more scientific approach in ethno-

medicine. Like the first essay, this article relies on data collected by a research team associated with the Cornell-Peru Project in the medical phase of its activity at Vicos,* which with one exception (see Acknowledgments) have not been previously published or otherwise made available from the project’s archives.* At the time the data were collected, Vicos was operating in the style of a traditional hacienda in which colonos (payers of labor rent) worked for a patron (hacienda operator) 3 days a week, farming their own

tiny holdings and being available as casual day laborers for outside operators during the remainder of their time. Vicosinos, as Vicos people are called, were (and indeed still are) microproducers whose development has been limited for the most part by low-capital/high-labor investment with consequent poverty accompanied by political powerlessness, ignorance due

to monolingualism in Quechua, and poor health. Socioeconomic depriva- - . tion, together with linguistic isolation, has created and continually recreates a class of rural poor which is at the bottom of Peruvian society as a whole.°

The project was designed to break the pattern of rural social depression through agricultural development, education, liberation from the hacienda system (which involved both land reform and the institution of self-government), and the extension of medical services. It was found that the last type of intervention, the delivery of scientific medicine to Vicosinos by means of a clinic which was opened in 1954, was the most difficult and least successful of all the project’s developmental activities. Ideas about disease and its treatment seem to have been stubbormly resistant to change in Vicos. Montalvo (1967:123), who carried out studies of ‘‘health culture’’ there between 1956 and 1966, years of the greatest educational efforts, concluded that while people were more familiar with scientific medical services the health cultural system as a whole had not changed. Conceptually, Vicos and its region share with other Peruvian populations (Gillin 1945:115-142; Tschopik 1946:568-570; Simmons 1955; Valdivia

Ponce 1975), and also with other Latin American populations (Erasmus 1952; Foster 1953; Madsen 1964:68-79), several disease categories that include witchcraft sickness, fright sickness, penetration by ‘‘air’’ or ‘‘wind,’’ dirty stomach, anger sickness, grief sickness, and evil eye. Other categories 52

do not appear to share the wide distribution of these classic disease entities; these regional entities, which are likely to be found elsewhere in the Andes as well, include rainbow sickness, displaced stomach, displaced liver, earth sickness, and moonlight sickness, among others.’ These are all ‘“‘folk illnesses,’’ or ‘‘culture-specific syndromes’’ (Fabrega 1974:16), as compared

with other medical syndromes which could universally be translated as malaria, dysentery, or smallpox. Folk illnesses, or folk disease entities, are ~ not universal, but are linked to particular cultures. Rubel (1964:268) defines them as ‘‘syndromes from which members of a particular group claim to suffer and for which their culture provides an etiology, diagnosis, preventive measures, and regimens of healing. I apply the prefix ‘folk’ to those illnesses of which orthodox Western medicine professes neither understanding nor competence—a definition which, although somewhat cumbersome, has the value of subsuming a number of seemingly bizarre syndromes which are reported in anthropological, medical, and psychiatric literature from many

areas of the world.’’ . , 7

When we discuss folk disease entities we are dealing with ideological categories, beliefs or knowledge, which do not correspond with reality, that is, actual physical conditions, but which may have actual physical consequences, since ‘‘thought and language may function as. . . part of a society’s forces of production’’ (Godelier 1978:764). Thus ideological processes can have real effects, as in numerous cases of the deaths of despairing persons who are convinced they are the objects of sorcery and who suffer pro-

longed fear and shock along with little or no ingestion of food and fluid (Simmons and Wolff 1954:89-97). Here the indicated treatment would be to

let a patient understand that some kind of countersorcery is in effect. Similarly, the terror and panic inspired by pain can be reduced by furnishing a patient with a label, beliefs, an indicated treatment, and hope that he or she will get better. In faith healing, when hope is substituted for fear and reinfection or reinfestation does not take place or the condition is otherwise ‘‘curable,’’ improvement can take place. Mariategui Chiappe (1972:59) points out the tremendous persuasive force of folk rituals in Peru and their therapeutic impact for both the individual and the collectivity. It is not the magic that accomplishes a cure but the faith and hope with their consequent

physiological accompaniments.’ This brings us far from a narrowly - biomedical folk-healing concept, as Millones (1979:39), speaking of the diverse functions of the Andean shaman, suggests: (W)hen we speak of healing we are not referring to folk medicine, but to a group of special concepts regarding diseases and the nature of their remedies. In other words, apart from the real or imagined existence of organic diseases and the efficacy of one or another natural product, the virtue of the healer is rooted in the knowledge of the cultural world in which his clients dwell, and in the faith that they have in his capacity to cure their maladies, whether

| 53

_ they belong to this world or not. |

Analytical categories for the study of folk disease ideology, which are ap-

plicable to Vicos materials, are to be found in Erasmus’ (1952:412-413) study of Quito, Ecuador, in which he lists the following four: contagion, mechanical causes, psychological causes, and supernatural causes. Simmons (1955:60) outlines five major ‘‘patterns of etiology’’ in the ‘‘popular

medicine’’ of coastal Peru and Chile: ‘‘severe emotional upset, contamina- | tion by ritually unclean persons, obstruction of the gastrointestinal tract, undue exposure to heat or cold, or exposure to mal aire, ‘bad air.’ ’’ For Vicos, Montalvo (1967:79) begins with the distinction between ‘‘God-sent ills and evil-sent ills,’’ that is, between natural diseases and witchcraft sickness. He (1967:83-89) then distinguishes four Vicos disease theory models,

as follows: the calor-frio (‘‘hot-cold’’) balance model, derived from. perception of nature and ‘“‘sensorial thermal experience’’ but extending beyond this to classify natural objects as ‘‘hot’’ and ‘‘cold’’ or ‘‘cool’’

(fresco);? the imminent and transcendent power model, derived from the | conception of the “‘imminent power of the Earth which transcends thatof = | human beings,’’ as in patza, earth sickness, where one is gripped or eaten by the earth, mala hora, evil hour, a force with which one may collide, mountain sickness, rainbow sickness, ‘‘antimony’’ sickness, or force sent by the awkish, mountain spirits; the harmonic model, derived from the wish to maintain harmony between people and supernatural beings, in the case of saints by sponsoring festivals in their honor or otherwise pleasing them, and in the case of the spirits of the ancient people (ushnu), who live near archeological ruins, by offering them food, coca, cigarettes, alcohol, or some

other treat; and the good-evil model, derived from the values of human

desire, or fear. ,

relations, as in the wish to maintain harmony and avoid conflict and illness

which can result from emotional states like anger, grief, intense sexual In this paper I wish to leave witchcraft sickness, which could easily be the

subject of another report on Vicos, out of consideration and focus on the last category listed in the paragraph above, that is, the emotional entities; for not only do these diseases deserve separate consideration, but in Vicos they seem to be disease nexuses where thermal balance, the power of natural _

forces, and disharmony enter into diagnosis as well, most notably in the ~ association among fright (susto), patza, and soul loss, but present in other emotional diseases too. Moreover, as exotic disease entities (which seem not

to be amenable to scientific medical diagnosis, prognosis, and treatment),

they have already occupied some ethnomedical attention. The general category of psychological causation, first (as far as I have been able to trace it) described briefly by Erasmus (1952:413) as ‘‘illnesses that the folk ascribe to psychological causes,’’ was more firmly established in a key article by Foster (1953:216-217) as follows: (O)ne of the most striking characteristics of Spanish-American folk medicine is the prevalence of recognized and named illnesses or conditions which are not due to natural or supernatural causes or to witchcraft but to a series of emotional experiences which anyone can undergo and which can seriously incapacitate an individual. Anger, sorrow, sadness, shame,

embarrassment, disillusion, rejection, desire, fear—all are recognized as potentially dangerous—and as leading (depending on the country) to susto, espanto, colerina, pispelo, chucaque, tiricia, sipe, peche, caisa, pension, and so on. Many of these ‘‘illnesses’’ are but the formal expressions of several distinct psychological phenomena. In the first place it is undeniably true that emotional experiences may be the direct causes of physiological malfunctioning, in a purely clinical sense. In other cases, however, they are manifestations of cultural definition and culturally patterned behavior. The frightened individual realizes that his fright will probably lead to illness, and he will seize upon any general and slight symptoms of discomfort which he may have had for a long

54

time as evidence that he has indeed been frightened, and will build them up to a degree where

he and his family believe that medical treatment is necessary. The mere existence of a culturally recognized condition believed to result from fright produces patients who would never be produced in a culture without such definitions, and expected patterns of reactions. Finally, the functional value of emotionally defined illness as an escape mechanism is apparent. The individual who has been through an embarrassing experience, by taking refuge | in a culturally acceptable illness, receives the sympathy rather than the ridicule of his fellows. ~ Or the individual who has lost his temper may escape punishment or retribution by seeking immunity in an illness which his culture recognizes as a common result of his action.

Simmons (1955:61-62) documents the existence of the emotional entities further for mestizo communities of coastal Peru and Chile as follows: It is generally believed that severe emotional upset may directly cause organic disorders, most of which are potentially fatal. Susto ‘fright’ results from encountering an apparition, which always involves soul-loss, or from a sudden and unexpected experience such as being startled or attacked by an animal, falling, particularly falling into water, a loud noise or clap . on the back, perpetrated by a person whose presence was hitherto unsuspected, and so on, which may or may not involve soul-loss. Symptoms of fright include wasting away, fever, diarrhea, sleeplessness, loss of will, malaise, and general ‘‘nervousness.’’ There are no important differences in the syndromes identified with those cases where soul-loss does or does not occur. Embarrassment can result in chucaque, whose symptoms are severe aches in the head, stomach, and abdomen, vomiting, diarrhea, fever, and chills. A fit of anger can lead to colerina, characterized by severe stomach ache, diarrhea, vomiting, and fever. Celos ‘jealousy’ is an illness contracted by the youngest child when its mother becomes pregnant

and the child is jealous of the sibling to come... .

Of all the emotional entities discussed so far, susto has received the most

ethnological attention. It was first described in English by Gillin (1945:130-133) for the community of Moche, Peru. Gillin (1948) later compared it there with the somewhat different etiology and symptoms of susto

in Central America. Other accounts include descriptions for Mex-

ican-Americans of Hidalgo County, Texas, by Rubel (1960:803-809) and Madsen (1964:77-79), a general discussion of susto in Latin America by Rubel (1964), an analysis of sex differences in the incidence of the illness in two Zapotec communities in Oaxaca by O’Nell and Selby (1968), a discussion of susto as role playing in a non-Zapotec community in Oaxaca. by Uzzell (1974), a social psychological study of another Zapotec community by O’Nell (1975), and my own brief mention of the entity’s existence in Hualcan, Peru (Stein 1961:83-85, 309-310), which followed the tradition of psychocultural analysis and which I do not recommend to readers who are interested in understanding what susto is. What distinguishes all of this work is an emphasis on psychological and social psychological issues."' While Gillin (1945:131-132), basing his characterization of susto on medical

Opinions, notes that the disease is ‘‘a hysterical manifestation based on

general debility caused by malaria or tuberculosis’’ and says that ‘‘the | medical and psychiatric aspects of this condition should be more thoroughly studied,’’ he concludes that it ‘‘is somewhat similar to the ‘nervous breakdown’ among North Americans.’’ He suggests that therefore: Both phrases [i.e., susto and nervous breakdown] may cover, in their respective cultural contexts, a variety of psychopathic and physically pathological conditions, considered from the strictly diagnostic point of view. Both, however, are culturally defined escapes for the in-

55

dividual from the pressures and tensions of life. . . . Susto'also becomes a mechanism for . calling the group’s attention to the individual by his assumption of a culturally patterned configuration of ‘‘symptoms.’’ At all events it seems to represent at least a temporary collapse of the psychic organization of the individual and consequently of his ability to deal normally with his life problems.

Similar considerations lead Rubel (1964:280) to phrase a general hypothesis based on a social psychological conception of social relations, as

follows: |

In Hispanic-American societies, the susto syndrome will appear as a consequence of an episode in which an individual is unable to meet the expectations of his own society fora |. .

social role in which he or she has been socialized. . This style setter has led later investigators (O’Nell and Selby 1968;

Kearney 1969; Uzzell 1974; and O’Nell 1975) to emphasize role theory in discussing the disease and role incapacity or helplessness as strategic to the understanding of its etiology. Thus, an interesting situation comes about when a case of susto is ‘‘contaminated’’ (my word) by a physical condition: as when Uzzell (1974:370)—citing an unpublished paper by Charles I. Fitzsimmons on susto in Oaxaca where interviewing, psychological examina-

tion, and projective testing were supplemented by medical examination—says: ‘‘Unfortunately, the case ...is complicated by apparently severe amebic colitis and hepato amebiasis, which might account for the

symptoms of susto.’’ The circle is completed when a -psychiatrist, on digesting what anthropologists have produced—which is itself based apparently on some original psychiatric suggestion—takes the completed product at face value. This could be the case with Kiev’s (1972:69-70) definition of susto in his book on Transcultural Psychiatry, as follows: | Susto or espanto is an anxiety syndrome, believed to be caused by sudden fright, evil eye, bad air, black magic or witchcraft, all of which produce ‘‘soul loss.’’ It is characterized by irritability, asthenia, anorexia, insomnia, phobias, reduced libido, retardation, nightmares,

trembling, sweating, tachycardia, diarrhea, vomiting, other symptoms of anxiety and depression, and the belief that if the ‘‘fright’’ reaches the heart, death will occur. . . . Susto is found throughout the Latin-American world. It encompasses numerous clinical conditions and beliefs pertaining to various magical substances that enter into the body and alter its

natural balance. Despite these ‘‘superstitious’’ beliefs, the theory shares with modern theories of abnormal behavior the notion of environmental stress; of a patient’s vulnerability to illness or misfortune, which may be brought about by the patient’s own behavior in relation to cultural norms; and of illness as a reflection of the alteration of something vital within the individual.

In my earlier work on ethnomedical issues in Vicos (Stein 1975), which

need not be repeated here in any detail, as noted earlier in this paper, I presented some examples of folk illnesses that were also diagnosed medically: a case of witchcraft sickness that was diagnosed as an allergic reaction to sunshine, a case in which a patient who claimed he was being eaten by the ushnu that was diagnosed as tuberculosis, and a case in which folk diagnosis

had revealed that patient had been penetrated by hot and cold forces that was medically diagnosed as possible typhoid fever. This was a regular oc-

currence at Vicos during the time of the project’s intervention when 56

tegrated. '’ , ;

physical examinations and anthropological observations could be inLet us now turn to some general Peruvian materials pertaining to the

disease entity of susto. Excellent accounts of the clinical picture and traditional treatment of it have been provided by the late Federico Sal y Rosas (1958, 1962:274-278, 1972:250-252), a psychiatrist who spent his youth in - Huaraz, the capital of Ancash Department located 25 kilometers south of Vicos. Sal y Rosas was bilingual in Spanish and Quechua and knew the region’s folklore well. Beginning in 1935, with the cooperation of local physicians, he conducted a long-term study of susto, which is known as patza, or mantzakiy (‘‘fright’’), in Quechua. In his first article (1958:170-171)

the disease is described as follows:'? .

Susto appears in both sexes and at all ages, but it is more frequent among the young and ex-

ceptional with advanced age. The subject begins to become thin, is pale, sad, and without in- ' terest, neglects his or her appearance; is spiritless in work, without an appetite but very thirsty, is enervated all the time, ‘‘looks for the sun’’ and huddles up wrapped in a blanket here and there; however—except in late stages of the illness—does not stay in bed; the temperature is generally subfebrile, but later fever may be important, associated or not with

vomiting and diarrhea. .

Otherwise, the subject appears excessively fearful and timid, a condition which is particularly intense in children, while symptoms of asthenia and depression predominate in adults. During sleep the patient exhibits attacks, great shakings or convulsions of the body, which means that the earth is throwing him up or off . . . or there is a crisis of fear, day and

night: the patient sits up in bed or jumps from it, uttering cries of terror. .

With the disease’s progress the subject is yellower every day, more shrunken and prostrate; it is the state called michko, with which persons with knowledge [/.e., curers] associate

a dark and sad gaze under long and rigid eyelashes pointed downwards... . In sum, the susto of our popular medicine is characterized somatically by wasting and attenuation and psychically by fearful hyperexcitability and depression. It is an affection with subacute or chronic evolution and at times ends in death, but in general it lessens surprisingly

- with means of magical treatment... . a

Valdivia Ponce (1975:83-84) gives, folklorically, the popular etiology of

the disease, as follows: |

Susto... originates when a person’s soul ... . abandons the body due to a strong effect of fear. The body, abandoned by its soul, loses its homeostasis and equilibrium with its surroundings, which causes the disease. The soul can be stolen by a mountain, a canyon, a lonely place, a lake, a river, a storm, the night, a tomb, a goblin or other being, etc... . The withdrawal of the soul takes place, generally, in relation to an experience or serious accident which produces fear or fright, a situation which a being or the earth takes advantage of in order to steal the soul. The impression is given that the earth takes advantage of the state of being ‘‘outside oneself’’ . . . However, sometimes this withdrawal can take

place without the prior reaction of fright. | .

Sal y Rosas (1958:176-177), in his study of 176 patients examined in Huaraz, gives the following information on these cases: Almost two-thirds of them (112 cases) turned out to be affected by different organic diseases and 64 by psychiatric disorders, almost all of them presenting different neurotic manifestations with abundant functional organic symptomatology. Nine cases of these have been identified as susto proper, on presenting all the peculiar characters indicated by traditional medicine: psychogenic motivation for susto, characteristic somatic and mental symptoms,

57

complete cure by magical procedures reputed to be effective. The clinical notes of these nine __ cases reveal a predomination of anxiety symptoms and depression, premorbid personality, insecure or depressed in most cases except two which were hysterical in type; all are very timid, sensitive, and refractory to aggression, superimpressionable in unpleasant situations, and at the same time having strong hypochondriacal proclivities. ... Of the 55 other psychiatric cases, 24 are neurosis, classifiable as atypical susto, all presenting the conventional symptomatology of susto, but some of them lacking a clear motivation by fright, or the latter being associated with other psychogenetic causes with a secondary or

| equivocal role, while others appear to be resistant to the different systems of popular curing. The remaining 31 cases include 27 of neurosis and 4 of psychosis, with causes clearly apart from susto; their symptomatology only remotely approximates that of susto, in some by

paleness and wasting, in others by impressionability and nocturnal attacks... Among the 112 cases with organic etiology, there is in most still an appreciable psycho-_ genetic component, due to the general mechanism of the personality’s reaction to illness; ~ however, manifestations of the susto type are seen, no doubt through the suggestive influence of the native surroundings on the inhabitant, in the sense of attributing the state of malnutrition to susto, neurotic symptoms thus being secondarily created and added to those of the organic illness, giving it a primitive or predominantly psychiatric appearance. The principal causes in the cases where we have been able to establish diagnosis are chronic malaria, tuberculosis, dysentery and post-dysenteric colitis, latent septic foci, undereating, anemia, and Addison’s disease. In the children the principal causes are dystrophies from genetic damage (syphilis, tuberculosis, or the parent’s alcoholism), enteritis, premature

birth, etc. ...

One who is familiar with Huaraz and the region can add that infectious hepatitis, typhoid infections, and both bacillary and amoebic dysentery are endemic. Whether one’s ill is diagnosed as physical or mental, one is likely _ -to be a ‘‘carrier’’ of one or all of these other diseases and to suffer their debilitating effects even if one does not manifest all their symptoms. The folk diagnostic situation in Vicos fits this picture: Many different clinical conditions can be attributed to susto, just as the same clinical condition can be attributed to one or another or a half dozen or more other folk illnesses.

In folk diagnosis the patient’s personal history is important; that is, in- . determining the nature of an illness, people seek causes in the patient’s life: where he or she has been and what was done, the person’s occupation, experiences, encounters, shocks, dreams, and so on. If there has been some accident in one’s past, susto may be suggested as the cause of the illness. '* This can be seen in Vicos data as, for example, in the following general account given to Abner Montalvo'’® by two Vicosinos: | Victor Quinto and his companion, whose name I did not get, tell me that treatments for susto can be given with different kinds of materials but that the course of the illness and treatment follow more or less this order: (1) Susto can be caused by accidents like falling from the horse which one is riding, falling from the branches of a tree, or falling from a high boulder, a ridge, a well, or a house, that is, from any height. (2) The accident victim suffers the loss of his dnimo [spirit or soul]. He becomes pale, weak; he does not eat; he has diarrhea. (3) The immediate treatment should be by shaking one’s hat around the same place as the fall; or, if there is a dog or another small animal, by shaking that about. (4) Performing a shoqma [rubbing] with dirt from the same place where the person had the accident. (Cornell-Peru Project Archives, hereafter referred to as CPP, January 24, 1955.)

In the next passage, there was apparently some disagreement among | curiosos (curers) as to whether a case was due to wawilu (postpartum sickness) or to susto, but it was finally resolved in favor of the latter, as follows: 58

I asked Juana Herrera how it was that she and her family believed that her pains were due to the wawllu she had, and why they are now saying that the pains are from the calor in her liver. She says that the latest curiosa is the one who discovered it and that nobody knew about it earlier. I asked how it is that she is suffering from calor when all the earlier circumstances had pointed to frio. She says that some time ago she suffered a great fright and the part of her that was the most frightened was exactly where she has suffered the greatest pains. One day, on her way home and carrying her infant son, now a big child, on her back she met up with a savage bull who came directly at her. This bull had a recently broken horn,

. with blood dripping from it, and it hooked at her, but the horn barely scraped her side because at that instant she jumped over a hollow at the side of the road. The family thought the illness must have been contagion from the bull’s blood. Then, too, she was surely frightened by her fall after she jumped, and at that moment the earth grabbed her. Her baby only took fright from the fall because at the time of the encounter with the bull he was sleeping and did not notice, but when she jumped and they fell he was frightened. She immediately took a handful of dirt where they fell, and some flowers from nearby, and gave him shoqma, leaving all those things in the same place. Later, she gave the child the

second treatment five times. This was by taking dirt from where a rooster had just bathed | itself, one that was just learning to crow, and then after the shoqma she brought the dirt to the place where they fell. She also gave him shoqma with flowers, which she brought at night also to place at the site of the accident, and also on the road in the form of a cross, calling out: ‘‘Now come back; now come back; here he is!’’ She only gave herself a light shoqma with the dirt and some flowers from the same place, but since she had been worried more about her child she was careless about herself, and so she got sicker. From then on, she kept feeling sick and had to get treated several times until she improved. (CPP: Abner Montalvo, February 17, 1955.)

My impression from examining the archival materials is that most cases

: of susto in Vicos involve abdominal cramps and diarrhea along with the other symptoms, but that practically any health problems can be diagnosed as susto if there is any indication of a frightening experience in the patient’s past history, as in the following case: Luciano Sanchez brought Pablo, his son, to the clinic to have him treated for a discharge from his ear. When I asked him if this ear condition had a name he told me it did not. Then he reported that Pablo once fell to the ground from a height and took fright. That was how the ear condition appeared; it came from the fright. The ground took hold of him and then: ‘‘Mantzakashmi.’’ (‘‘He has taken fright.’’) (CPP: Abner Montalvo, December 10, 1954.)

Other emotional disease entities are explained similarly, as in the case of anger sickness (cdl/era) which follows: Félix Colonia reports that his sister Fortunata has died in consequence of having been suffering from cdélera. He says that the reason why she got that disease was the fact that she had suffered when her son Manuel was put in jail for having landed a kick on a boy who died. Félix says that she felt helpless at her son’s misfortune and she began to have stomach pains which kept on increasing until the day she died. He says that her stomach pained her from grief, but that she was angry because the [Vicos Hacienda] managers sent her son to the authorities, and that from the anger her Dilis [bile] moved and this caused the pacha naney [stomach pain]. (CPP: Abner Montalvo, January 23, 1956.)

That some emotional ills can be passed from one person ‘to another is 1llustrated in the next case, as follows: About three days ago Rosa Gonzalez was angry about certain matters. On the next day her little boy woke up with vomiting and diarrhea. She thinks it is due to the milk he suckled

59

while she was angry. Now the child does not want to nurse and is very sick. She is thinking of | bringing him to the doctor. For the diarrhea and vomiting she gave the child pine syrup but he did not want to take it. She gave it to him because it does her good when her stomach is affected. What she gave to

| the child was some left over that she had taken earlier. :

When I asked her if the child still had diarrhea, she said yes and showed me by opening the

little one’s diaper. The child was covered all over with diarrhea. (CPP: Héctor Martinez,

February 25, 1956.) -

Strong desire is also believed to be the cause of illness. One kind of desire, which is accorded disease entity status, is that for a specified food as in the

following case of tushu (longing sickness): Victoria Tadeo says that tushu is an illness which appears in a person with a great desire to eat a certain thing when he or she has seen another person eating it and has not been offered any. She says, for example, it happens when somebody is eating some very pleasant thing, something which causes an intense desire in the one who has seen the other eating it. As a consequence of this desire, the person’s stomach begins to hurt and the pain keeps increasing all the time. In order to combat that pain, a person ought to eat those things that he wanted to eat when he saw them being eaten and was not offered any. If the person does not get to eat them death will come from the intense pains in the stomach. Victoria says that tushu has no remedy other than eating the desired things, but that nevertheless the relatives, sometimes hurried by concern because there is someone in the family who is suffering, give the person certain medicines to calm it but which really do not make it better. Tushu happens to any person, with no distinction as to sex or age. It is serious when pregnant women feel it, and if they do not get to combat it they can abort, as many cases will testify. Also, she says, pregnant women or those who are sick with any other disease are the

ones most likely to get tushu.... In Victoria’s case, when she was pregnant with one of her daughters she saw some Marcarinos [people from Marcara, a town 6 kilometers from Vicos] whom she did not know eating chicharrones [fried pork], and this brought about pains. When she got back to Vicos her husband had to return to Marcara to beg them to sell him a little, explaining that his wife

had tushu. ; ) a

In pregnant women, the desire to eat exists as much in the baby as in the patient, and so when the unborn baby gets the desire to try the food it comes to leave the maternal abdomen.

(CPP: Abner Montalvo, January 16, 1956.)

The last of the emotional disease entities to be discussed—and one which

will be more closely connected to the theme of this paper—is known in Vicos as shonqgo naney (literally, “‘heart pain’’) or grief sickness. Sal y Rosas (1972:253-254) translates this as mal de corazon (heart sickness) and describes it as a recurrent nervous malady, including epileptic seizures. It is associated ideologically with winds said to emanate from archeological sites or corpses. In the case to be presented here, which appears to be compli-

cated by susto, it is to be noted that the patient dreamed about deceased members of her family. Examination in the Vicos clinic revealed another condition which appears to be the source of much if not all of the patient’s } physical discomfort. It begins as follows: Rosa Lazaro, a widow who lives in the far upper part of Vicos, arrives in the Clinic carrying her daughter Catalina Coleto in her arms. It is 8:30 in the morning. Rosa goes to the bench in the waiting area to sit. When she came in, Rosa greeted Maria Sanchez, Margarita Evaristo, Eusebia Gonzales, and Bartolomé Candelaria who all were sitting on the floor near the place where she went to station herself. For a moment they were silent and then one of the women asked if the little girl were sick. The mother said yes that she was suffering from shonqo and

60

that people have told her that Catalina’s heart had leaked or spilled inside. The ones who were listening became alarmed and took on a doleful attitude toward the child. They were sympathetic, saying how she had already suffered with grief, being little. They came close and Maria Sanchez felt the heart area and said that she could still feel the heart. Rosa asked her if it was still strong so that she would live, and Maria answered yes that nothing was go- . ing to happen to her yet. They continued speaking sympathetically about the girl and the mother began to tell the following story. ... Since Catalina’s father died she has been suffering from grief. Those pains did not even let her eat when she had them. Then after some spell of pain it would go away and she would be comfortable. The grief had increased when her uncle, her father’s brother, died. The latter was very fond of her. However, what has aggravated the condition more is when her father’s living brother wanted to turn them out of the land which the deceased man left them. All these things made the girl suffer. She missed her father and her uncle and, like that, she recently began to dream about them. She saw them alive and they said to her: “‘We’d better leave quickly. I can carry you. Hurry!’’ Rosa thinks that these dreams will surely bring on - Catalina’s death because, according to her way of thinking, if they want to take her she is going to get worse.

| Rosa has been having her treated by curiosas who have given her shoqma with a cuy, with earth, with flowers, and so on, but she has not improved. They have given her all kinds of medicinal plants and these do not make her well. Always she is worse. Today, for example, they have given her shoqma with dirt from the ca/vario [a holy place] here in Vicos, with all her clothing off. The girl’s godmother performed it.

Rosa says that the girl has already suffered so much and for so long a time that their relatives have now being saying that it would be better to bring her to the doctor. Now that she is not getting well, she might die here but it might be that she will get well. That is why

Rosa has brought her. |

The women were very sympathetic and with doleful voices and words said that if she is dreaming about her uncle and father, who want to take her away, surely she is going to die. Eusebia says that maybe the reason why she got sick is because she eats all kinds of foods. Maria says that it must be from grief: ‘‘Grief is finishing her off. Poor little thing, just like that, now it’s going to put an end to her.’’ Then the mother says: ‘‘Even if she dies, I'll take her to the doctor. If she dies, let her die in his hands.’’ The little girl was listening to all this conversation without saying anything. She was completely unmoved from the time she came in. She did not become sad or mournful, and she did not cry, but she listened attentively to all of what was spoken aloud. After this talk, every one of the women began to speak of her own ills and the ways in which they were being

treated. ... At 9:15 they were called to be attended by the doctor... Only the little girl went in at first, and then the mother entered. The girl showed no fear. The doctor remarked that the girl’s face was dirty with soil and asked why she had not been washed. The’mother explained to him that it was because she had had shoqma given with earth from the calvario, because surely the girl was ‘‘gripped by patza.’’ The doctor listened _ and did not comment. Later the woman said that the girl had been spitting worms from her

mouth and anus, and that her stomach has been hurting her for a long time. The doctor asked her if she had had shoqma with a cuy given to the girl, and she said no but finally yes. The doctor asked why she believed that her daughter had patza and she said, ‘‘because in the shoqma we have seen in the cuy that it is whitish like cotton.’’ The curiosa said: ‘‘Shonqonmi utkuyeykan.’’ (‘‘Her heart is becoming like cotton.’’)

| The doctor told her that in order to cure the girl she would have to bring samples of feces. © He told her not to give the girl any treatment. They left at 9:30. (CPP: Abner Montalvo, |

March 11, 1955.) )

| It is not for me to show that little Catalina was not depressed—and the evidence is all to the contrary—but simply that much of her discomfort and

state of ill being was due to the worms, which are not to be expelled by

. 61

means of faith healing. Beyond this, a close examination of this case and the other cases, as different disease entities are reported by Vicosinos, reveals conflict between the names or labels of these disease entities and actual instances of illness. This would at the very least discourage the wider applica-

tion of Frake’s (1961:115) hypothesis, derived from his study of the | Subanun of Mindanao, that while ‘‘a single illness may successively or simultaneously require designation by several disease names’’ and ‘“‘not all illnesses can be diagnosed by a single disease name,’’ it is proposed that ‘“fevery disease name can diagnose a single illness.”’ In criticizing the as-

sumption that folk names are labels for objective categories, on the other |

hand, Rosaldo (1972:84) argues that: :

Labels encode discrete categories of experience only in certain limited cultural contexts, contexts in which it is necessary to make precise and stable discriminations between closely

‘related kinds of things. Elsewhere, the relation of words to referents may vary. Linguistic ~~ usage is constrained by our knowledge of objective reality, but the use and significance of labels depends on the context in which things are named. Naming is seen as a process which confers contextual significance on objective continuities and discontinuities in nature; anda properly contextual account of naming requires that we include ‘‘connotative’’ or ‘‘metaphorical’’ considerations in a description of the meaning of names.

Consideration of the social epidemiology of a disease, tuberculosis in this

instance, leads Fabrega (1974:48) to state that:

The notion that each disease has a precise biophysiologic identity that needs to be discovered

in order to be able to specify its equally precise cause is fallacious. Our search for the etiological factors or processes that contribute to impaired health and our attempts to understand them in a refined way are consequently hampered by the inappropriate use of a closed model and a descriptive nosological system that ties us to ‘‘disease entities’? that may in fact not exist as independent and biophysiologically self-contained units having a single cause.

What does this mean for ethnological studies of disease? It suggests that

the entities we have relied on may in fact be nonentities. In this regard, Fabrega and Silver (1973:124) are critical of earlier work in ethnomedicine, _ because the social scientists who have conducted such studies have lacked medical training and because of the difficulty of observing and recording

‘‘precise and reliable data about the components of illness episodes.’’ Fabrega (1974:30) points out that “‘regular absence of data regarding the behavior and symptoms of the person who is sick’’ is a deficiency of most ethnomedical research and (1974:66) that a need exists ‘‘for descriptions of illness that would allow investigators to draw inferences that have biological as well as social implications.’’ Fabrega and Silver (1973:8-9) note that consequently: In ethnomedical studies various exotic and unusual features or symptoms of illness that may or may not be intraculturally significant are very often given more attention by anthropologists than the rather basic question of what bodily and/or behavioral elements comprise the general model of illness in a culture. In other words, preoccupied with describing these so-called culture-bound syndromes or with rendering equivalent Western diagnoses of them, the ethnographer completely overlooks the cultural framework of illness referents that actually provides the basis for judgment-making in the group he is studying. Furthermore, the ethnographer interested in describing these syndromes and explaining their sources and mechanisms invariably reflects a psychiatric bias. That is, he assumes that since the unusual manifestations he sees are social and behavioral, they must be purely psychologic, and thereby he abandons his search for other bodily and physiological manifestations that might

be present. | 62

According to Fabrega (1974:97), investigations of folk illnesses have begun with prior assumptions regarding diseases and the universal applica-

bility of the principles of scientific medicine, that ‘“‘disease types (biomedically categorized) are universal or transcultural entities, which are

somehow being obscured by culturally specific categories, symbols, and , behavioral prescriptions.’’ He (1974:97) concludes: : This attempt to equate a biomedically specified disease with a folk illness involves a misuse and misinterpretation of both the relevance and significance of the cultural perspective. ... (N)ative explanations of illness do not, to any significant extent, involve notions of how the | body functions or whether the mind as opposed to an organ is affected. Thus, while adopting the cultural framework regarding the unit of analysis (that is, the folk illness), the investigator overlooks the native rationale for explaining the illness and substitutes his own, which involves different categories and premises. The result is a mixing of logical types.

The Vicos data support Fabrega’s (1974:180) conclusion that, since folk -jllnesses are based on folk treatment forms, they bear little or no resemblance to the investigator’s frame of reference: ‘‘Folk illness labels often seem to be applied in a random, haphazard manner, and public, observable

features of an illness occurrence seem unrelated to this labeling

process... .’’ To a Vicosino, to paraphrase Fabrega (1971:34), an illness means what it connotes in terms of ‘‘its severity and socio-moral implications.’’ From the scientific point of view, an illness is viewed as a configura-

tion of molecular, biochemical, and physiological processes; it will be classified according to cause, organ system involved, and pathology. Thus, ‘“it will be appreciated that an attempt to link the native system of medical knowledge with the scientific entails associating highly discrepant meaning systems.’’ As in the Zinacantan study by Fabrega (1970:312) and Fabrega and Silver (1973:98-104), folk concepts tend not to be specific; moreover,

they share meaning. Many symptoms associated with disease names are general: e.g., paleness, weakness, headache, and sadness are very broad and can be applied to a variety of illnesses; cramps, diarrhea, and vomiting sug- __

gest gastrointestinal localization; chills and fever indicate infectious/inflammatory processes. In Vicos illness is the focus of concern and confusion

more than it is of rational action. Before the coming of the clinic, most Vicosinos had no access to scientific medicine (except for a very few who had consulted outside Vicos) and could not be expected to share its concepts. Illness was (and still is) categorized according to traditional ideas, and treatment was given accordingly. Contemporary Vicos is little changed in this regard, except for the developed fringe of Spanish speakers who have been able to take advantage of the educational efforts of the past decades. For most people, in the absence of more effective responses to illness, traditional methods prevail. If a person’s illness episode is of such a nature that herbal remedies and faith healing will work, then, to be redundant about it in order to make the point, prognosis is favorable. What a particular illness is called for the most part depends on circumstances and not on some entity. Disease is, indeed, socially produced and rooted in real social conditions, whether we speak of biomedical processes, their accompanying emotional processes, or disease ideology, that is, processes which involve illusory ideas 63

and beliefs about disease. People, in producing, confronting, and acting on disease, change its nature as well as their own; this is medical development. As has been indicated, such development is almost absent in Vicos. The Vicos response to illness consists largely of magic and hope. While the second is indispensable, the first is not at all necessary. From a somewhat dif-

ferent point of view, in a discussion of pastoral intervention, Marzal , (1971:521) says the same in his plea for the campesino’s “‘liberation from magic,’’ as follows: (M)ost forms of magic respond to an inadequate knowledge of the world and are strongly

conditioned by the socio-economic situation .. . . Today the campesino is imprisoned by | | magical structures regarding death, the fear of being bewitched, the fear of contracting certain diseases, or of suffering losses in his farming and stock-breeding activities.

If we remove Vicos disease ideology from the folkloric context of anthro-

pological exotica (and I do not intend this statement as an attack on the study of folklore, which is a subject that deserves much careful attention by students who can discriminate between myth and reality, for oral literary

creations are worthy products of human endeavor, and nothing human should be alien to the anthropologist!'°), it is easier to see this belief system

as inadequate, confused, and distorted, a false awareness of reality that arises from real social conditions rather than from a cultural repertory of exotic folk disease entities, or nonentities, which explain the world with illusion and change the world in the imagination (see Godelier 1977:209).

This rural Peruvian population is an ignorant, poor, and unhealthy one. However, that Vicosinos are too poor to afford scientific medical services,

other than what Peruvian public health agencies offer by way of the sporadic visits of mobile clinics, has little or nothing to do with their disease ideology. That is, they are not poor because of their culture, another entity —

that has no real existence, but because of real conditions. It is not merely that there exists an uneven distribution of medical knowledge in Peru, but that there exists an uneven distribution of everything. Rural people are underemployed'’ and overexploited in terms of the ‘‘historical tendency’’ for

agriculture to function as a net supplier of surplus to the rest of the economy’’ (Thorp and Bertram 1978:284). This decapitalization of the rural

sector by income transfers to the urban industrial sector is amply documented by Webb (1977). Moreover, Peruvian inequalities are growing: According to Cabieses and Otero (1978:71), between 1961 and 1972 the

: share of the two lowest quintiles of the population in national income decreased from 10 to 9%, while the highest quintile increased its share from 55.5 to 58.5%, the top 5% of the population from 26 to 33%, and the top 1% from 9.8 to 17.9%. My ‘‘pessimism’’ originates in the figures I have just presented, but it is reinforced every time I return to the Callej6n de Huaylas when I am sadly impressed by the number of friends and acquaintances who are dead or dying. I am also ‘‘pessimistic’’ in regard to the possibility of introducing scientific health concepts and techniques, that is, creating consumers of modern medicine, without changing radically social conditions as they presently ex-

ist. The chief enemy of scientific medicine does not consist of disease 64

ideology but of poverty, sociocultural isolation, ignorance, and the terms of

trade between the urban and rural sectors. Nevertheless, I become optimistic when IJ consider the possibilities for raising health levels if the flow

of wealth were to be reversed.'® In the latter case, not only would rural , development be possible, but many national problems could be resolved (e.g., the flood of rural migrants to urban areas, the need to use foreign exchange to import food, and nutritional problems), for rural life could then ,

be not only productive but healthy.

ACKNOWLEDGMENTS — The theme of this paper was first developed in a talk given to the Asociacion Psiquiatrica Peruana on April 29, 1977. I was able to secure additional data through the courtesy of the Department of Manuscripts and University Archives, Olin Library, Cornell University, and I am grateful to it for permission to use these materials, deposited there, from the project at Vicos. Without the hard work of Abner Montalvo Vidal, Héctor Martinez Arellano, and Mario C. Vazquez, whose field notes form such a vital part of the text of this paper, it could not have been written. Defects in the translations and interpretations are, of course, mine. Vicos was one of several field stations developed by the Department of Anthropology, Cornell University, in the 1950s with funding from the Carnegie Corporation. Without the inspiration of the late Professor Allan R. Holmberg, director of the Cornell-Peru Project, no research

would have been conducted there.

] have carried on research in Vicos and its region in 1951-1952, 1959, 1962, 1971, and 1977.

The last visit was made possible by a grant in aid from the Research Foundation of State University of New York and an award from the University Allocations Committee of State

University of New York at Buffalo. | |

The case of Catalina Coleto, the little girl with shongo naney and susto, has appeared

previously in Spanish in América Indigena (Stein 1977a:697-699)..

| NOTES ' Further, in the larger context, ideology ‘‘/egitimizes an existing social order, along with the relations of domination and oppression that it contains within it. One might even go so far as to say that the idea’s content, the fact that it is true or false, or more or less true, is irrelevant, and that any idea can become ideological the moment it enters the service of a dominant social group and presents this domination as a natural phenomenon. At the same time, though, surely an idea automatically becomes partly fa/se the moment it presents @ social order as the only possible, immutable, social order? An historic lie thus turns into a theoretical error’’ (Godelier 1978:766; emphasis in original). In Peru, the ‘‘ethnic’’ separation of the rural masses from the

rest of the country is emphasized and reinforced by the urban and middle-class consciousness . of their cultural distinctiveness. The existence of medical as well as other types of folklore is visible evidence of these ‘‘natural’’ differences which then not only serve to justify the social order but also become real forces in reproducing it (see also note 6). ? Vicos is situated at an altitude of around 3,000 meters on the eastern flank of the Callején de Huaylas, an intermontane valley drained by the Santa River. Its population is currently about 4,000, but at the time of the research reported here, 1948-1966, it grew from 1,700 to something over 2,200. The closest town is the district capital, Marcara (population circa 1,000) located in the main valley, 6 kilometers west of Vicos and connected to the latter by a truck road. The ethnography of Vicos is to be found in Vazquez (1952). > My first report on ethnomedical matters in Vicos dealt with diagnosis and curing in the context of the delivery of health care in the Peruvian nation. It has been published in a Spanish version, somewhat revised and expanded from the original (see Stein 1977a).

65 |

* Vicos was the site of this intensive research and development study between 1948 and 1966 when it terminated with the death of Professor Allan R. Holmberg, its principal investigator. This project was joined by many Peruvian and North American scholars and researchers. The Hacienda Vicos was rented by the project in 1952, jointly with the Peruvian Instituto Indigenista, at which time there were instituted agricultural experiments and other interventions involving the construction of a complete primary school and health clinic. For the most complete discussion of the project, see Dobyns, Doughty, and Lasswell (1971). For information on project personnel, see Dobyns and Vazquez (1964). The project’s activities in the field of medical development are discussed in Montalvo (1967) and Alers (1971). * The files, records, notes, and publications of the project have been deposited in Olin Library, Cornell University, Ithaca, New York, and are there available to interested scholars. * In Peru the rural poor are called ‘‘Indians.’’ However, there is no resemblance between the social conditions prevailing currently in the Peruvian hinterland and those of the aboriginalin- ~habitants of the region. Aside from folkloric survivals, some crops, domesticated animals, and some technological items, the Quechua language is the connecting link with the past. Although Peruvian people tend to become lighter with higher social class, and many individuals in the nation’s capital are quite European in appearance, there are no physical differences tobe discerned between the rural and the urban masses, the latter of whom are not called ‘‘Indians.”’ Since the word is an insult in Peru, why should people be so labeled if they do not wish it and when there are alternatives such as ‘‘person’’ and ‘‘Peruvian person’’? I deal with such issues

in the text.

at greater length elsewhere (see Stein 1977b). .

’ The English equivalents are presented in this passage. Most of these diseases are discussed

® See also the work by Frank (1961) in which a variety of persuasive techniques (ranging from ‘‘taboo death’’ to ‘‘thought reform’’) is discussed. * While such a classification into ‘‘hot’’ and ‘‘cold’’ aspects of nature might seem exotic, its origin is to be found in the Old World, in Hippocratic ‘‘humeral pathology.’’ See Foster and Rowe (1951), Foster (1953:291-207), and Foster (1960:14-15, 20). '° Fabrega (1974:39-40) calls attention to ‘‘the psychiatric bias of ethnomedical studies.’’ In another work, he (Fabrega 1970:306) notes how ‘“‘the preoccupation with the role of culture in relation to psychiatric syndromes is both a cause and a consequence of the investigator’s tendency to avoid dealing with bodily events and processes.’’ Thus, in his discussion of the ‘*hot-cold syndrome’’ as a ‘‘model of social relations’ in Mexican and Spanish-American folk medicine, Currier (1966:252) could make the statement that ‘‘. . . disease theory constitutes.a . symbolic system upon which social anxieties are projected, and it functions as a means of sym-

bolically manipulating social relationships which are too difficult and too dangerous to manipulate on a conscious level in the real social universe.’’ (!) '' I focus on ethnological works by North Americans here because some excellent Peruvian sources were, at the time of writing, inaccessible to me, for example, the important work by H. Valdizan and A. Maldonado, La Medicina Popular Peruana, published in Lima in 1922. I am aware of many other relevant works which could have helped shape this paper, listed in the bibliographies in Valdivia Ponce (1975) and Mariategui Chiappe (1972). '? Beginning in 1954, and in several succeeding years, a health team consisting of a physician, a public health nurse, two aides, and a social worker scheduled two weekly visits to Vicos. The team had to come from Huaraz, 25 kilometers south of Marcara, sometimes arrived late, and occasionally missed days. A physician was resident in Vicos in 1957 (see Montalvo 1967:98-99 and Stein 1977a:706-707). It was not possible to maintain these health services, especially after project activity at Vicos ceased. Currently, mobile clinics from Huaraz, now connected with Marcara by an asphalt road which has reduced a 2-hour trip to less than an hour, visit occasionally. In 1977, the clinic was still functioning as a drug dispensary with the same practical nurse in charge who began work there in 1966. He is a Vicosino trained in the Huaraz hospital. '? This and all other translations from the Spanish in this paper are mine. '* Chadbourn (1962:28-38) describes susto/patza in Vicos. 'S For brief discussions of the work of Abner Montalvo and that of Héctor Martinez, the other field-worker whose data are used in this paper, see Dobyns and Vazquez (1964). '€ Lukacs (1971:50) says: ‘‘(M)en perform their historical deeds themselves and . . . they do so consciously. But as Engels emphasises . . . this consciousness is false. However, the dialectical method does not permit us simply to proclaim the ‘falseness’ of this consciousness and to

66

persist in an inflexible confrontation of true and false. On the contrary, it requires us to investigate this ‘false consciousness’ concretely as an aspect of the historical totality and as a

stage in the historical process.’’ '7 “*(Jnderemployment’’ does not necessarily mean that people are not busy; while it can

mean ‘‘abnormally short work-weeks,’’ it can also refer to ‘‘abnormally low incomes’’ (Figueroa 1975:21-22). '§ However, it should be noted, such redistribution would necessarily take place at the expense of industrial growth (Thorp and Bertram 1978:299) and at the expense of the top quartile of national income earners, including professional persons and industrial workers as well as government administrators (Fitzgerald 1976:104), although as Webb (1975:98) points out, a

transfer of 5% of national income taken from the richest 1% and distributed to the poorest quartile would lower the incomes of the former by only 16% but would double those of the latter.

67

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Qollahuaya Andean of Charazani, Bolivia.

68

PART 2

ANDEAN ENVIRONMENT:

ALTITUDE, NUTRITION, AND COCA CHAPTER 5 STUDIES OF THE AYMARA OF HIGHLAND, INTERMONTANE, AND COASTAL CHILE | WILLIAM H. MUELLER, WILLIAM J. SCHULL, AND FRANCISCO ROTHHAMMER

This is a study of basic human physiology in relation to altitude of residence. For several years a multinational Andean genetic and health program has been carried out in Chile. Objectives included the evaluation of the effects of differences in oxygen tension on growth and development,

pulmonary function, and cardiovascular disease and the assessment of genetic contributions to anatomical, biochemical, and physiological responses of the Aymara; 2,096 individuals from three altitude zones who claimed to live all of their lives at the same altitude were studied. Extensive history, physical, physiological and laboratory studies were carried out.

Data were analyzed to separate effects of high altitude from ethnicity. Coastal people were mainly Spanish with few Aymara. The high-altitude people were all Aymara. The intermontane showed mixing. Physical exam-

ination showed mild retardation of growth at high altitude, especially of long bones, soft tissue, and body weight. This appeared to be mainly due to altitude and not related to ethnicity. They also found accelerated growth in pulmonary function and chest expansion. Aymara ancestry appeared to play a role as well as high altitude. High-altitude individuals tend to have a lower systolic blood pressure, apparently related to body leanness. The changes demonstrated were seen clearly in children. In adults the trends were in the same direction but not significantly different between

high-altitude and coastal people. ,

In relating these physiological findings with the pathological findings in

the paper by Dutt and Baker, it appears that high-altitude physiology and Aymara ethnicity do not cause significant enough changes to account for the differences in mortality rates, if such are real. Presumably the differences in illness incidence and mortality rates due to different causes relates to social-cultural factors, geographical isolation, access to medical care, nutrition, and other undetermined factors related to living at high altitudes rather than to physiological changes per se. , The adaptive capacity of high-altitude populations has long interested students of anthropology and human evolution. In 1870 David Forbes 69

observed the prominent chests of Bolivian Aymara and noted that this | feature diminished in lowland colonists. Although he only observed seven Aymaras, his detailed measurements render his ethnographic study a classic in physical anthropology. In 1932 Alberto Hurtado studied the physical growth and lung capacity of Peruvian Quechua children and concluded that Quechua children had more expansive chests, rounder chests, and larger

a lung capacities than North American children. These observations suggested a different pattern of growth and development in an hypoxic environment. It is unlikely that the differences in growth between Quechua

and North American children could be a function of factors other than hypoxia which differed between North and South America, for example; nutrition or disease. If such were the case, the North American children would be expected to exceed Quechua children in chest circumference and other measurements, whereas Hurtado demonstrated the opposite. It was still unclear, however, whether genetic differences between these popula-

tions could account for differences in chest size and lung capacity or whether these were a result of developmental responses to hypoxia over the

growing period. In other words, if the Quechua children had grown and developed at sea level, would their chests and lung capacities be comparable to those of the North American children? In order to answer this question,

Quechua controls at low altitude were needed. Although Hurtado did not have such controls, his emphasis on body and lung-function measurements of children whose ages spanned the growing period set the stage for other high-altitude studies which were to follow. While there’ were a number of Peruvian efforts to study altitude sickness (Monge 1960), other studies of child development in relation to altitude failed to appear until the middle 1960s with the proposals of the International Biological Programme (Baker and Weiner 1966). This program rallied resources to study the physical, bio-

chemical, and physiological characteristics of the world’s high-altitude — populations. Thus, we owe much of our present knowledge of human adaptation to hypoxia to the work of Paul Baker and his colleagues in the Andes

Mountains of southern Peru (Baker 1969), Ricardo Cruz-Coke and - coworkers in the Andes of northern Chile (Cruz—Coke 1968), G. Ainsworth Harrison and colleagues in the Simien Mountains of Ethiopia (Harrison et al. 1969), and to Ivan Pawson for his work in the Himalayan Mountains in Nepal (Pawson 1976). The rationale behind these investigations have been set forth by Baker (1966) and Harrison (1966). Like Hurtado’s (1932) earlier studies, these would be based on random samples of high-altitude popula-

tions (as opposed to selecting only a few individuals for physiological measurements in a laboratory situation). Thus, human variation was adequately sampled, and the observations might truly serve for generalizations _ about the genetic, anatomic, and physiological responses of high-altitude peoples. Also, the current studies are based on truly high-altitude groups, 1.e., populations living at or above 3,000 meters (11,000 feet) above sea

level. | As Newman (1961) and Clegg et al. (1970) have noted, other factors such as hypoxia also vary with altitude. These include temperature, wind, humidity, and exposure to ultraviolet radiation. Associated with this broad spectrum of environmental changes are biotic changes which limit the types 70

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of economies and lifestyles which can be practiced. The kinds of crops that | can be grown at the highest altitudes in the Andes are restricted to a few tubers and cereallike grains (Mazess 1968). Dietary diversity for highland Andeans depends on trade with other groups living in warmer regions at lower altitudes. Hence, the highland natives of the Andes Mountains may be a nutritionally stressed population. Some cultural practices, especially

those associated with coca chewing and maize preparation, may be behavioral adaptations to nutritional stress (Mazess and Baker 1964; Hanna 1970). Mountainous regions may be less economically developed due to their inaccessibility. This means fewer roads, sanitary facilities, and less

medical care. On the other hand, the cool air and rarefied atmosphere . makes mountainous regions unsuitable environments for malaria; and, in

the Andes, for Chagas disease. — Because the high-altitude environment includes a multiplicity of factors, | a multidisciplinary approach is logical to sort out the importance of each factor in human adaptability to this highly stressful environment. While the more recent high-altitude studies represent a step in the right direction, there remain some gaps in our knowledge. We know much about ‘‘Andean man’’ but little of Andean woman, since studies to date, especially those dealing with physiological capacity, have almost solely been of males. Moreover, it is not clear to what extent the latter comprise highly selected individuals rather than a random sample of Andean man. Not all previous studies of altitude adaptability have had controls at low altitude that are adequate in terms of sample size or appropriate ethnic and socioeconomic background. Studies to date have focused on two altitudes:

one high, one low. It would be advantageous to study populations at - various levels and indeed to inquire into differences which might obtain in any of the characteristics we may choose to measure among populations liv-

ing in the same altitudinal zone. Finally, most studies have had as their focus anatomic and physiological variables with no attention paid to possi-

ble genetic adaptation as revealed by biochemical markers, particularly those involved in the regulation of oxygen transport. In altitude studies researchers have asked these questions: To what extent _ is human adaptation physiological or acclimatizational, involving changes which take place in a short period of time after exposure to altitude, such as when a sea-level individual travels to mountainous areas? What characteristics result from years of exposure during growth and thus represent developmental adaptations? What characteristics of high-altitude dwellers are the result of natural selection over many generations and thus represent genetic adaptations? This is perhaps the most interesting question, but at the same time is the most difficult to answer. Proof of the adaptive value of observed changes of a character across altitudes would entail not only the demonstration that a variable changes systematically with changes in the selective force (oxygen tension), but that, in fact, a significant component of interindividual variation at any altitude stems from genetic variability. Further,

it is of interest to ask: What adaptations are cultural responses to the demands of altitude rather than genetic, developmental, or physiological ones? With these questions in mind, a multinational, multidisciplinary study in72

volving scientists from Chile, Bolivia, Peru, Ecuador, and the United States

was organized to evaluate the impact of altitude on the health of the Aymara inhabiting an altitudinal gradient in northern Chile (see Cruz—Coke et al. 1966 for the effects of altitude on fertility and mortality in this popu-

lation). The resultant series of investigations, termed the Multinational An- , dean Genetic and Health Program, has numerous objectives, including the ~-evaluation of the effects of differences in oxygen tension on growth and development, pulmonary function, cardiovascular disease, and the assessment of the genetic contribution to anatomical, biochemical and physiological responses of the Aymara. A full description of the objectives, scope,

and methods of this study has been given by Schull and Rothhammer (1977). Here, we present the changes which occur with age, altitude, and ethnicity in some of the continuously distributed variables of the study: an-

thropometrics, blood pressure, and lung function.’ MATERIALS AND METHODS

We saw 2,096 males and females from 2 months to 80 years of age who underwent the following examinations: medical history and physical examination, oral-dental, anthropometrics, pulmonary function, cardiovascular health including blood pressure and resting electrocardiogram, ophthalmoscopic, audiometry and tapping performance, reproductive and residential histories, and a venous blood specimen for biochemical genetic studies. The examinees were randomly selected from three altitudinal zones, the only criteria for inclusion in the study being a claim of Aymara ancestry. The

three zones comprise the following number of examination sites: two coastal locales (Azapa and Lluta) approximately 0-300 meters above sea level, six intermontane villages (Putre; Chapiquina, Tignamar, Socoroma, Murmuntani, and Belen) 2,500-3,500 meters elevation, and four altiplano hamlets (Visviri, Caquena, Parinacota, and Guallatire) 4,000-4,500 meters elevation. All of these villages lie within the Department of Arica, Chile and comprise a coast to altitude migrational gradient of the Aymara, known to exist for centuries (Cruz-Coke et al. 1966). The anthropometrics comprise 17 measurements of body size, head, and

chest. The manner in which these were taken as well as measurement changes with age and sex are described by Mueller et al. (1978a). There are four lung-function measurements. The vital capacity (FVC) is the maximum

volume of air expired forcefully from the lungs after a deep breath. The measurement is taken after the subject has expired continuously into the lung-function analyzer for 5 seconds. Even after a forced expiration, some air remains in the lungs. This is the residual volume which, however, we could not measure, since it requires a more complex apparatus. We mention it here because residual volume plus the vital capacity equals the total lung capacity. Most high-altitude studies have dealt only with the vital capacity and the other volumes described below, since these are easy to measure in

the field. Our lung-function analyzer (a portable Hewlett-Packard machine) also records three other measurements: the vital capacity at the end of 3 seconds (FEV3) and 1 second (FEV). These measures are related. 73

to air flow. Last, we have the peak-flow rate (PFR), or the maximum , volume of air expired over a standardized time interval. This is a measure of flow rate and bears little relation to the other three measurements, although

it is most correlated with FEV;. Lung-function measurements are often used to screen for various pulmonary diseases. For example, obstructive lung diseases will result in an unusually low peak-flow rate but will not af-

fect vital capacity. On the other hand, restrictive lung diseases will reduce the vital capacity but not the flow rate. In hypoxia studies, however, pulmonary function measurements represent the physiological fitness of individuals and probably reflect the size of the lungs as well. We tried to exclude all individuals who had respiratory diseases, which might have unduly — -

affected their pulmonary function. Also, smoking was not allowed an hour . before the test was given. A more detailed account of methods and age- and sex-related variation in these pulmonary function measurements is given in Mueller et al. (1978a). Four sets of measurements were taken, including a trial instructional run, and the average of the two highest readings for each

variable was taken as an individual’s measurement in the analysis as per recommendation of the National Heart and Lung Institute (1971). Diastolic and systolic blood pressures were recorded with a standard mercury sphygmomanometer and the subject seated (Makela et al. 1978). Three cuff sizes were used depending on the arm size. If an appropriate cuff size was not available, the individual’s blood pressure was not taken. In the present analysis, over half of the total sample were excluded for the following reasons: First, we include in the present phase only persons who have lived all of their lives at the altitude of ascertainment. These we will call permanent residents. Those who have migrated to an altitude different from the one in which they were born will be treated separately (Mueller et al. 1979). Second, blood pressure and lung-function tests could not be performed on very small children. Finally, certain pathological conditions were ~ | a basis for exclusion from some of the analyses which follow: respiratory

disease for the lung-function test and frank hypertension for the bloodpressure examination. Most were excluded for the lung-function and bloodpressures examinations (see Mueller et al. 1978a; Makela et al. 1978). The sample of the present paper consists of 1,047 permanent residents with an-

thropometric, 614 with lung-function, and 759 with blood-pressure _ measurements. These samples are more or less evenly divided between males

and females, children and adults, and the three altitudinal zones.

Complex data sets such as the one under discussion in which many variables are involved are difficult to plumb. Graphical presentation of the data often, however, can facilitate insight and serve to guide analysis. We have therefore chosen to introduce our data through a series of figures that

set forth the averages of the various measurements at different ages by altitude and sex. We are searching for systematic differences between altitudes and whether such differences which obtain in children also are reflected in adults of the sample. Since all have lived 100 percent of their lives at the respective altitudes—coast, sierra, or altiplano—such differences that obtain could represent developmental adaptations or changes in growth in response to the environmental changes which occur moving from sea level to high altitude. 74

At some point we must test the significance of these differences judged against some standard of random variation, the error variance. We have chosen to do this by the technique of multiple regression. In this method the dependent variable represents the measurement in question: any of the 17 body, 4 lung-function, or 2 blood-pressure measurements. The independent variables are as follows: age, the square of age (to test for nonlinear changes _. in the measurements as a function of age), altitude of residence (0 = coast,

3 = sierra, 4 = altiplano), and ethnicity (—1 = Spanish, 0 = mestizo, 1 = Aymara). The association of a dependent variable with the independent variables is tested. If there is a significant association the dependent variable

is adjusted for the effects of the independent before testing for effects of other independents. For example, we know before starting that age will have a real influence on all of these measurements: older children will be larger than younger ones. Thus, a child’s measurements must be expressed in relation to the average expected for his or her particular age. After age adjustments are made in this manner, we test for the effects of altitude and ethnicity. A word must be said about ethnicity. Because of the possible settlement of different ethnic groups at different altitudes, every effort was made to include in the study only individuals who claimed Aymara ancestry. Never-

theless, after almost 500 years of Spanish domination, one can expect to find individuals in the sample who are clearly Aymara, others of mixed ancestry (mestizo), and still others who are more European. Aymara surnames are recognizably different from Spanish surnames, and these formed the basis of a classification of individuals into either one of three categories: Aymara (+ 1), mestizo (0), or Spanish (— 1), shown with the values assigned each category (see Schull and Rothhammer 1977). The assignment was con-

servative in the sense that more Aymara are likely to be misclassified as mestizo, than mestizo and Spanish are likely to be misclassified as Aymara. Genetic and other biological markers support this assertion (Goldsmith et

al. 1977). We also attempted to account for those surnames that, while ostensibly Spanish, are simply translations of Aymara surnames, since some acculturated individuals would adopt hispanicized names. | Last, it must be noted that height and weight are included as independent variables in some of the analyses which follow, as for example it 1s usual to express an individual’s lung function, blood pressure, or chest size in relation to a body size specific value.

In Figures 5.1 through 5.6 we present the averages of selected measurements by age group, sex, and altitude. In all of these figures, altitude is represented by three symbols: circles = coastal means, small triangles = sierra averages, and large triangles = altiplano means. We also tested means of the various villages within a given altitude to see if these were similar. They were found to be so, so data from the various villages at each altitude were combined as presented in these figures. Figure 5.1 shows that coastal children and adults are slightly taller and heavier than their counterparts in the sierra or altiplano, and at most ages sierra children are intermediate in size to coastal and altiplano residents. Body-size differences between altitudes are small during the growing period amounting to 2 to 3 centimeters in height and 2 to 3 kilograms body weight 75

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FIGURE 5.1. Weight and height for age at three altitudes in Chile. as averages. Body-weight differences among altitudes are greater in adults (age 18+). These may reflect changes in lifestyle: more calories and less physical activity in coastal adults as compared to mountain residents of the intermontane or altiplano areas. 76

In Figure 5.2 other dimensions are shown: knee height is a measure of linear growth and wrist breadth, one of bone breadth or robusticity. The length of long bones changes more rapidly than other body segments or features such as bony breadths during early and middle childhood, hence linear measurements may be more susceptible to environmental stress, par- , ticularly nutritional stress. For this reason we compare the response of these - two measurements to altitude. Differences are apparent among altitudes for knee height, coastal residents being larger, while wrist breadth is virtually the same at all altitudes. Moreover, the knee height difference appears to

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FIGURE 5.2. Knee height and wrist breadth for age at three altitudes in Chile. 77

persist in adults, suggesting that the pattern is a developmental response to differences in environmental factors among altitudes. It has been suggested that nutritional stress would be reflected most in rapidly growing dimen-

sions such as long bone length (Hunt 1958). Indeed, the fact that knee height seems most affected suggests that nutritional differences among altitudes could be playing a role in the pattern we see in Figure 5.2. Unfor-

, tunately, we know very little how hypoxia per se affects bony proportions. Nonhuman animal models are lacking in this important area. Most experimental animal studies have dealt with changes in organ or overall size in

response to hypoxia. Another factor which varies with altitude is temperature. Peoples in colder climates tend to have foreshortened append-ages which would increase the mass to surface area ratio, a feature which would conserve heat. This could also account for the relatively greater decrease in long bone length with altitude. Illustrated here are the problems

of interpretation that arise in studies of adaptation of peoples in mountainous zones (Stinson and Frisancho 1978). Chest measurements have long been standard in high-altitude studies for obvious reasons. Two such dimensions are shown in Figure 5.3: transverse chest, taken across the chest at the level of the union of the third and fourth

sternebrae, and antero-posterior (A-P) or chest depth taken at the same level. Again, differences between the altitude groups appear to be very small. However, as the regression analyses which follow show, the differences in transverse chest are Statistically significant, coastal children hav-

ing the widest chests. Differences between altitudes in the chest depth are not significant. We also measured chest circumference before and after a deep breath. Both chest circumferences were smaller at high altitude also. It should be remembered that chest measurements include information on fat and muscle as well as the rib cage size. Hence, part of the seeming reduction

coastal controls.

in chest measurements with altitude may reflect the same changes we saw earlier in body weight, those at altitude being relatively leaner than the We may combine transverse and antero-posterior chest in an index of

chest shape (TR/A-P). Early investigators noted the barrel-shaped chests of Andean dwellers (Hurtado 1932), although it was not clear what the functional significance of such anatomical features were (Mazess 1970). This index is shown in Figure 5.4, and there are clear altitude differences: chests are rounder at high altitude with sierra values intermediate to altiplano and coast. This pattern is expected for a feature dependent on hypoxia as lifestyle differences between sierra and altiplano are probably minimal. We have shown elsewhere that roundness of the chest is associated with higher peak-flow rates in children, but not adults (Mueller et al. 1978a). Hence this feature may have some adaptive significance. Now we turn to two of the lung-function measurements in Figure 5.5, the volume of air expired after 1 second (FEV) and the vital capacity (FVC). We saw that for most body measurements, except possibly antero-posterior

chest and wrist breadth, high-altitude children and adults had smaller

78 .

dimensions than coastal dwellers and that most differences contrasted coast with the mountain populations together (sierra and altiplano). In contrast in Figure 5.5, altiplano residents tend to have the larger FVCs and FEV s, and

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used in one of only five ways: (1) as an infusion or mate; (2) in simple acullico or chewing a quid; (3) as a plaster composed of moistened leaves; (4) as a poultice made from a coca quid; and (5) in combination with other herbs, usually in the form of an infusion. Of these five, mate de coca is the simplest and most common. It is prepared by putting a pinch of coca leaves

in boiling water and allowing them to seep, covered, for 5 minutes. Remedies may also be prepared by mixing coca with other herbs, alcohol, and urine. Usually such mixtures are prepared only by trained curers. The following listing, though lengthy, includes only those maladies for which coca is employed as a ‘‘medicine,’’ or as magical food for the spirits. In the seven communities in which case studies were carried out coca enters into the direct treatment of some 45 pathological states. And to the listing must be added native veterinary medicine. Although coca use for animals is fairly rare, when it does occur it tends to be modeled after human use: ‘‘In order to cure sick animals, such as cattle and horses, one prepares coca in 4 or 5 liters of water and gives the infusion to the animals through the nose.

The effects can be noticed immediately. I have saved my animals from death in this manner a number of times. Coca is medicine for people as well.’”?

| COMMON DISEASES AND CURES The following diseases and treatments reveal an important internal distinction (Table 8.9). Maladies that are diagnosed as purely physical in nature tend to be identified with the concepts and terminology of Western medicine, and the treatment is physical, coca being used for its real or presumed chemical properties. More diffuse maladies seem to be regarded as psychosomatic in nature. Their etiology is seen as supernatural, and treatment is made accordingly, coca being handled here as magical substance

: with curative powers totally dependent on faith in the ritual act.

These diseases and their treatment indicate that there is not so much a

contrast between traditional ideology and modern science as there is a clear recognition of the physiological nature of certain pathological states and the psychosomatic nature of others. How the diagnostician determines what his client is suffering from is still not entirely clear. We do know, however, that in addition to consulting his coca leaves or his deck of cards (naipes), the yatiri carefully studies his client’s physical and mental condition, at times taking his pulse, touching his temple, studying his eyes, examining his urine, and asking a series of questions about his symptoms. It is these procedures that undoubtedly give him guidance. For coca divination is basically an exercise in imitative magic. A leaf bent at the tip will indicate illness or injury to the head, and one with a hole through its midsection will indicate gastrointestinal maladies. In traditional medicine, coca is used then as both a drug and a symbol. Although much of its effectiveness depends solely on its psychological impact, a good part of it would appear to derive from the real properties of its chemistry. For traditional Andean man, good health depends on maintaining proper structural imbalance between an individual and his environment.

. 137

In maintaining such balance and redressing occasional imbalance, the symbolic power of the coca leaf holds full sway. But many diseases are today

defined in purely materialistic terms. And for these use of the coca leaf is

physical and direct.

In our questionnaire, we asked about coca use for a whole series of common illnesses; 13 of these could be classified as psychosomatic in nature, and 17 as physiological. The percentages of respondents who used coca for one or the other varied significantly, not only in terms of the malady itself,

but also in terms of our basic sociocultural variables (Table 8.10). Of the psychosomatic illnesses for which coca was used and which were included in our questionnaire, earth disease (tierra) and soul loss (susto) were those for which the incidence of use appears to have been the highest. _

Limpu was the lowest. There was little variation between the sexes, but there was a gradual rise in use corresponding with age, the largest jump being that between the 15- to 24- and the 25- to 34- year age sets (Table 8.11). An analysis of the relationship between language or ethnic affiliation-and

the use of coca to treat traditional types of illness suggests that Quechua speakers are by far the most conservative of those interviewed (Table 8.12). Some 58% reported using coca for these purposes, as opposed to only 46%

of Aymara speakers and 18% of Spanish speakers. This would appear to refute much that has been written in the popular media about the progressive Quechua and the backward Aymara. In terms of conceptualization of disease, it would appear that it is the Quechua who most fervently retain the Andean tradition, a fact that is totally consistent with their greater use

ofAs would coca for all purposes. be expected, the two variables that most affect use of coca for

treating this sort of disease would appear to be level of education and religion. Neither persons with secondary education nor Protestants seem to turn to coca very frequently for this purpose, as can be appreciated from

Tables 8.13 and 8.14. So

The four physiologically defined maladies for which coca would appear to be most frequently used are stomach ailments, sprains, edema‘or swelling, and colds (Table 8.15). The fact that 87% of our survey respondents reported using coca for stomach ailments forced us to conclude that only 13% were totally nonusers. The differences between the sexes were small. Although, in general, women are considered more conservative than men, with regard to the medicinal use of coca, they tended to generate a slightly — lower percentage of affirmative responses. At first glance this would appear

to be contradictory to the distribution of mention of medicinal use in response to the open-ended question, ‘‘For what do you use coca?’’ contained in our first survey instrument. There, 87% of females and only 76% of males mentioned use for medicinal purposes. Again, however, we must point out that, with an open-ended question of that type, one can explore the gamit of use, but not specify its precise distribution. Many men who were ‘‘chewers’’ may have spoken of their use of coca for work and to cope with cold and hunger and simply not thought, at the moment, of their occasional use to quell stomach pangs or treat a sprain. Women, among whom the percentage of ‘‘chewers’’ is nearly always lower, would have been more likely to have thought of other uses. Thus we find that in terms of female 138

use of coca for medicinal purposes the 86.2% generated by the second survey is entirely compatible with the 87.7% generated by the previous one, particularly when the addition of the lowland department of Santa Cruz is

taken into consideration. , | In terms of linguistic and ethnic groupings, we find a reverse pattern to that generated. for the psychosomatic cluster of diseases (Table 8.16).

Whereas Quechua speakers appear to use coca more frequently for psychosomatic diseases, Aymara speakers do so for physiological ones.

surveys. a.

Again, this would suggest a higher degree of conservatism on the part of the

Quechua, an interpretation entirely in keeping with other findings of the When we look at the matter of religion, we find that more Protestants ap-

pear to turn to coca for physiological maladies than for those of a purely psychosomatic nature (Table 8.17). This is to be expected, since those diseases that are defined according to traditional Andean (i.e., Amerindian)

| concepts are part of a total cultural fabric that interweaves folk catholicism with indigenous animism. One of the basic thrusts of Protestant leaders, whether missionaries or nationals, has been to combat both. As to coca use in treating stomach ailments, relatively few differences emerged with regard to age and level of education, the single exception being that of individuals who had been exposed to higher education (Tables 8.18 and 8.19). For all other cells, as presented in Tables 8.18 and 8.19, affirmative responses exceeded 80%, a finding entirely in keeping with those

TABLE 8.10. Use of Coca for Psychosomatic Illness by Sex.

Male Female xX

Iliness (N = 1,889) ~ (N = 1,614) (N = 3,500)

Wind (sajra waira) 49.2% 45.0% 47.3%

Evil spirits 44.1 — 40.5 42.4 Earth (allp’a Kajta, Pachamama) - 58.1 55.8 57.0 Manantial (pujyu, uma,

~ jalsu juturi) ) 46.9 42.7 44.9

rayu aire) 43.547.7 39.6 41.7 Evil spell (laigaska) 45.6 Fright (susto, manchariska, : 46.8 Lightning (rayu onkoy,

ajayu) 56.2 55.5 55.8 Curse (maldicién) 49.1 44.7 47.1

Prenatal malnutrition |

(urija, larpha) 33.7 29.2 31.6

Osteomyelitis (chullpa) 37.9 32.3 35.3

Arrebato 43.2 39.4 41.5 Envy 35.1 32.1 33.7

Limpu 24.9 20.5 22.9

, Os — 139

4 Ten did not respond.

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142

TABLE 8.14. Use of Coca for Psychosomatic Diseases by Religion.

Catholic Protestant None OX Wind (sajra waira) 51.3% 10.7% 21.4% 47.2%

(N = 3,141) (N = 345) (N = I4) (N = 3,500)4

Evil spirits 46.1 9.0 57.1 42.5: Earth (jallp’a, Pachamama) . 61.9 -12.2 71.4 57.1 Manantial (pujyu, uma, jalsu juturi) 48.8 9.0 :64.3 45.0 Lightning (rayu on_ koy, onkoy aire) 45.2 10.8 50.0 41.8

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chariska, ajayu) 60.6 . 12.8 64.3 55.9

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tion (urija, larpha) 34.3 7.0 42.9 31.6 Osteomyelitis , 42.9 35.3 (chullpa) 38.4 7.3 Arrebato 44.435.6 14.88.135.7 41.5 Envy (envidia) 28.6 33.7 Limpu 24.8 6.1 14.3 22.9 @ Thirteen did not respond.

of the previous year’s survey. But, by specifying individual maladies, we do discover that both age and level of education seem to be heavily influencing use for medicinal ends. This was not evident in the results of the open-ended

question. contained in the previous survey. Thus, in terms of means, the range by age set is 27.1 to 51.6%, and by level of education it is 14.8 to 45.0%. While one could argue that those respondents in the youngest age set had not yet learned the full patterns of coca use and that they would in subsequent years (as suggested by the ascending percentages that accompany advancing years), it would be hard to argue that those with higher levels of education would, over the years, move more toward traditional medicine. More than half probably will continue to use coca for gastrointestinal maladies, but this will be the principal reason they turn to the leaf. In the previous year’s survey, 100% of those who had studied in normal

school or the university reported that they used coca for medicinal purposes. But these were only 10 individuals, 8 of whom had attended normal school and 2 of whom had been to the university. The second survey, for which we lumped both types of schooling into a single higher education category, polled 28 such individuals, nearly three times as many. Neither population is large enough to warrant any final conclusions, but the larger one has probably given us more statistical validity. That individuals with

oe | 143

higher levels of education would use coca more than would illiterates,

regardless of the purpose, flies in the face of everything we know regarding

TABLE 8.15. Coca Use for Physiological Maladies by Sex.

Male Female xX

_ Illness (N = 1,889) (N = 1,614) (N. = 3,500)4

Stomachache 88.1% 86.7% 87.5%

Swelling 66.061.5 60.064.4 63.2 Sprains ; 66.8 — Fractures 37.4 30.5 34.2 Toothaches 26.3.33.6 21.6 35.0 24.1 Headache 36.2 Colds 64.7 61.0 63.0

Sore muscles 50.4 42.9 47.5 Sores 36.6 29.9 33.3 Lung trouble 31.8 26.1 29.2 Rheumatism (tullu thajay) 43.2 34.7 39.3 |

Fever (onkoy mallku)19.8 20.813.8 15.1 17.0 18.1 Malaria (chujchu)

quebrazon) 29.3 24.4 27.0

Hernia (pakiska,

(madre) 30.6 29.8 30.2 Influenza 26.0 21.6 24.0

Uterus inflammation

Internal injury (chojre) 39.4 33.5 36.7

4 Ten did not respond. 7

the general role of coca in Bolivian society. The figures we present in Tables

8.18 and 8.19 are totally consistent with that role. The study of the medicinal use of coca as practiced in the rural areasand small towns of Bolivia opens to us a world alien to the thought of most in- | ternational planners. Just as it is easy for someone sitting in an office in Washington, Geneva, or Paris to conclude that the most efficient way to

deal with the growing illegal market in cocaine is to eliminate the raw material from which it is extracted, so is it difficult for these individuals to conceive that, within the Western world, there continue to be traditions as non-Western as those we have described in this paper. The temptation is to attribute such customs and ways of thinking to mere backwardness and to | assert not only that they will disappear but that, indeed, they are rapidly disappearing. Many government officials, even in Bolivia itself, suffer from such delusions. Yet what we have reported here belies them. If coca use ever does disappear in Bolivia, the last variant to go will probably be the use of the leaf for curing. A higher percentage of all population segments of the country employ it for this than for any other purpose. Even

Spanish speakers in overwhelming numbers use it to treat stomach maladies. Yet the debate continues as to the efficacy of such use. No one fully understands how, aside from purely psychosomatic considerations, the leaf could accomplish all or a small portion of what it is said to do. It is generally conceded that the leaf has analgesic qualities, and this could help explain its use for gastrointestinal problems. It is also generally accepted 144

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. . 145

TABLE 8.17. Coca Use for Physiological Maladies by Religion.

Catholic Protestant None xX Stomachaches 90.3% 61.0% 85.7% 87.5%

Illness (N = 3,141) (N = 345) (N = 14) (N = 3,500)%

Swelling 66.3 36.8 57.1 63.3 | Sprains 67.0 ~ 38.9 46.2 64.4. . Fractures 35.6 23.2 21.4 34.3 Toothaches (25.4 12.8 14.3 24.1 Headaches 36.3 24.1 42.9 35.1 . Colds 66.2 35.1 71.4 63.2 Sore 50.421.4 23.2 33.4 35.7 47.6 Soresmuscles 35.4 15.4

Rheumatism (tullu thajay) 42.0 15.4 © 21.4 33.4 Fever (onKoy : , mallku) 19.5 18.4 5.8 4.7 21.4 18.2 Malaria (chujchu) 21.4 17.1 Hernia (p’akiska, | quebrazon) 28.9 10.4 21.4 27.1

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Uterus inflammation

4 Thirteen did not respond.

that absorption of its alkaloids can lead to vasoconstriction, and this could .explain in part its use to cauterize open wounds. How effective it could be when only a few leaves are used in infusion, and this in combination with other herbs, continues to be open, however, to speculation. We have no knowledge about the interaction among its 14 alkaloids, much less as to how these alkaloids might interact with water of varying acidity and with

the alkaloids deriving from other plant materials. , While some insight into the validity of claims made for the curative

qualities of coca may come through research on the acute and chronic effects of ‘‘chewing,’’ such insight will be limited. The conclusions, for example, of Buck, Sasaki, Hewitt, and Macrae (1968)—that chronic coca chewing is correlated with a poorer nutritional state, increased frequency and

severity of hookworm anemia, inferior personal hygiene, and a higher number of person days of incapacitating illness—may be suggestive of lines of possible inquiry, but in the end may turn out to be irrelevant. The same

could be said for Fuchs’ reinterpretation (Fuchs 1978) of the Buck et al. data, a reinterpretation in which he argues that the lower hematocrit levels reported by Buck et al. for chronic chewers would be adaptive for high-

altitude settings. , The unanswered questions regarding the medicinal use of coca clamor for

146

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FIGURE 10.2 Map of Rural Health Delivery System—

Montero, Santa Cruz, Bolivia. |

of sugar and cotton production and cattle raising, as well as petrochemical

installations. By contrast, the area north, east, and west of Montero is largely inhabited by small landholders and sharecroppers. Besides the native

lowland mestizo population (Cambas), the past 15 years have witnessed a major immigration of highland peoples (Qollas). These migrants come principally from the departments of Cochabamba and Potosi, are Quechua

speakers, and represent recent attempts of land-poor highlanders to homestead in the tropical lowlands. Some are drawn to the area for the seasonal cotton and sugar cane harvests. Others have settled in the small communities to the north, east, and west of Montero along the Santa FeMontero-Okinawa Road. In addition to the Quechua highlanders, various other ethnic groups have settled in the district of Montero. They include two

colonies of Japanese east of Montero and several groups of Mennonites. The east-west road Santa Fe-Montero-Okinawa represents, then, the

boundary north of which live increasingly large numbers of migrant laborers and small homesteaders. In addition to their agricultural pursuits, they provide a readily available labor supply for the agroindustrial enterprises to the south between Montero and Santa Cruz. The first task of the health project was to define a representative group of communities in which

to begin the program on a pilot basis.

CRITERIA FOR SELECTING THE PILOT COMMUNITIES

In January 1976 I was invited to help design a series of criteria with which

to select the pilot communities. The suggested criteria included represen177

tativeness, historical factors, sociocultural, geographical, and timing criteria.

There are four major types of communities in the rural Montero area.

They are the traditional Camba communities (TCCs), traditional mixed | communities of Cambas and Qollas (TMCs), the more recent (since 1954) government-organized colonies (OCs), and spontaneous colonies (SCs). The suggestion was made that the health program be piloted in at least one community of each type. The objective was to later compare the dif-

ferential responses of each type of community and to refine the methodology further for working in other areas of the country. 7 The second criteria, historical factors, suggested that the health planners avoid those communities that might already have access to health facilities

or have already been part of a health promotion effort. Although the ad- | vantages of building on a successful program were noted, there was a : distinct possibility that “‘the Project would inherit any problems either organizational or motivational which the community might have encountered upon entering the Health Sector. Since the roots of such problems would antedate the Project, they might be by that time difficult to correct’’ (Donahue 1976:2).

A third criteria recommended that communities with severe social divisions not be chosen for the pilot program. For example, in the nuclear community of San Julian (OC), there was a split between the Qollas from Potosi and Sucre such that the local agricultural cooperative had failed. Similarly,

program. ; .

I observed that the same rivalry between the several religious sects in Puesto

Fernandez (SC) would impede a united community response to the health Fourth, I predicted that geographical accessibility would figure in the suc-

cess or failure of the program and should be a criteria in the selection of pilot communities. On the one hand, communities with ready access by all weather roads to nearby health facilities would feel less of a need for their own health programs. On the other hand, the referral and supervising com- _ _ ponents of the program assumed minimal accessibility to the communities. Communities accessible only by foot or horse would be less likely to receive the necessary support from the programs’ supervisory and referral systems for them to function effectively. Nor under such conditions would the community members find it practical to seek secondary and tertiary medical assistance at the UBS or subdistrict levels. Since referral was to be a major

part of the delivery system, it was recommended that only those com- _ munities be chosen where access into and out of the community made referral and supervision feasible in a systematic way at least.

Fifth, I noted that time itself should figure as a criteria in the selection process. The APD project was originally to run for 18 months, a short period of time in which to achieve the organization, implementation, and evaluation of the RHDS. The number and location of the pilot communities had to conform to time constraints, both programmatic and seasonal. For example, during the rainy season (November to March) access to the rural communities 1s at best problematic and often impossible, thus cutting back on the time available to organize and maintain consistent contact with the dispersed settlements. 178

Finally, the criteria were not meant to suggest that the pilot program should avoid all ‘“‘problem’’ communities, but that, given the design of the

system, only those communities should be chosen in which there was a likelihood of success. Comments on the design of the health delivery system

itself are made in the section entitled Prospects for the Future.

- IMPLEMENTATION OF THE PROGRAM The final selection of communities was not made until a year after the criteria were suggested. The final selection included two communities, Puesto Fernandez and Aroma, whose choice had not been recommended. The justification given for the final selection was that the program needed to attempt an interface with the established health infrastructure. A further modification of the original criteria included the expansion of the program into 8 nuclear communities (UBS) and 31 satellites (UCs), twice as many as had been recommended, considering the seasonal and programmatic time constraints. It was decided that, for the program to be more cost effective, an increase in the size of the service area was necessary. The first year of the program’s existence (1976) was dedicated to training the auxiliary nurses I who would supervise the health promoters and health communities. Three 6-month courses were held during 1976 and 68 auxiliary nurses I graduated (Ministerio de Prevision Social y Salud Publica

1977c:30). :

The year’s delay in final program implementation at the community level seems to have been due also to an early focus of the program on infrastruc-

tural and institutional reorganization within the pilot program and the

and national levels. a However, a proportional amount of time was not put into the equally

counterpart offices of the Ministry of Public Health at the district, regional,

necessary task of creating community awareness and motivation to action. The final selection of communities, the community survey, and program implementation were effected within a short span of 5 months (March to August 1977). Pilot community surveys and program implementation were carried out in the final four communities in August and September 1977 along with data collection in the 37 control communities. Program implementation included six 2-day meetings of professors, auxiliary nurses, and the project outreach staff and five 2-day meetings between members of the health committees and the project outreach staff in the eight nuclear

communities (UBS) (Ministerio de Prevision Social y Salud Publica 1977e:25).

Once the communities were contacted and health committees formed, health promoters were chosen and sent to Montero for a 7-week course. The first group of promoters came from the communities of San Ignacio (six), Antofogasta (seven), and Puesto Fernandez (four). The majority were mar-

ried adults. They had been selected during the agricultural off-season, began their training course in July 1977, and were back in their communities in late August. The second group was selected in October 1977 during the planting season. Consequently, the candidates were mostly young unmar179

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180

ried men and women without major agricultural responsibilities. Older married men were not available to the program at that time. In January 1978 several communities had not paid their health promoters (Bravo, personal communication). The situation was most critical in those communities that had an older, married health promoter. They, unlike the young, unmarried

promoters, could not afford to work without remuneration. The younger promoters, however, were more likely to be supported by their parents when the communities failed to remunerate them for their services. _ By January 1978 the RHPM had reached 8 basic health units (UBSs) and 31 catchment areas (UCs) (Table 10.1). CHARACTERISTICS OF THE PILOT AND CONTROL COMMUNITIES

A community survey instrument was designed to collect base-line data from the 39 pilot communities and 35 communities selected as a control group for subsequent evaluation of the impact of the health intervention in _ the one group as compared with the other.* A comparison of the two sets of communities as to population size, mobility, ethnicity, community structure, and accessibility to major medical and market centers will reveal how those variables have affected the implementation of the health program. Pilot and control communities manifest similar population parameters. The 37 pilot communities have a population of 15,115, as compared to 14,586 in the control group. Median community size of the pilot communities is 333, within a range from 93 to 2,233. The median control community size is 290, within a range of 58 to 1,600 (Table 10.2). Each group has nearly equal proportions of communities with populations less than 300 (pilot, 49%; control, 51%) or more than 300 (pilot, 54%; control, 46%). No statistically significant differences were found in the place of origin of the residents of the pilot and control communities (Table 10.3) *

Those communities whose residents come principally from the departments of Cochabamba, Potosi, and Tarija represent the recent migrations of Quechua- and Aymara-speaking highlanders into the Santa Cruz region beginning in the middle 1960s. Both pilot and control groups had proportional representations of migrant to native-born communities (Table 10.4). The highland-lowland origin of the residents of both pilot and control communities is reflected in residence patterns. The populations of native-

born lowlanders (Traditional Camba Community) or mixed

lowlander/ highlander (traditional mixed community) tend to be more stable than the communities made up principally of migrants from the highlands. Most of the latter are found in colonization projects organized by the Bolivlan government (Organized Colonies) or in communities of homesteaders which have sprung up in the area (Spontaneous Colonies). Both types of

colonies are dispersed settlements with plots of land 20 to 50 hectares marked out along a road. Fresh land is cleared by the slash-and-burn technique, and peasants engage principally in monocrop agriculture. Of the 21 organized colonies in the total sample, 14 (67%) are made up, in their majority, of migrants. The 36 spontaneous colonies are equally divided between natives and migrants. The residents of the traditional villages are prin181

TABLE 10.2. Population Characteristics of the Pilot and Control Communities.

Type of Total Median Range

community population Number size Lower Upper

Pilot 93582,233 Control15,115 14,586 |37 — 333 35 290 1,600 Totals 29,701 72 — — —_—

mostly migrant (Table 10.5). A comparison of the proportions of each of the four types of comcipally Cambas, while the residents of the three ranch communities are

munities in the control/pilot samples reveals a selection bias in the control group against organized colonies and traditional communities (Table 10.6). The bias may be due to the fact that control communities seem to have been selected for their proximity to the city of Montero. In such a case, the more distant organized colonies would have been negatively selected. The same bias that favored the selection of control communities from among those more readily accessible from Montero is reflected in the mode

of transportation to markets and medical centers. For example, control communities have much more ready access by bus or truck to medical centers than the more isolated pilot communities (x2 = 11.07,df=2,p < 0.003).°

This greater lack of accessibility to major centers -of medical and economic activity may explain why the pilot communities tend to be more organized into social, religious, or civic groups than residents in the control

communities (x2 = 8.25, df = 1, p< 0.004). So too, it is not surprising that the less-isolated control group had 43% fewer organized health committees than the pilot communities and more places where residents could -

purchase medicines (x2 = 4.35, df = 1, p < 0.03). Population size, mobility and ethnicity, community structure, and acTABLE 10.3. Place of Origin of the Residents of the Pilot and Control Communities.

Place of Pilot Control origin communities communities

(N = 37) (N = 34) Total

Montero Santa Cruz16% 27%32% 24% 24% 26%

Cochabamba | 27% 29% 28% Potosi 27% 9% 18% Tarija 3% 6% 4%

Total 100% 100% 100%

Note: X” not significant at p < 0.05. |

182

TABLE 10.4 Immigrant and Native-born Communities in the Pilot and Control Groups.

Pilot | Control

Migrant status communities communities

(N = 37) (N = 34) Total

Immigrant 57% 44% 51% Native born? 43% 56% 49% Total 100% ' 100% 100% Note: x~ not significant at p < 0.05. -

4 Communities whose residents come principally from the departments of Cochabamba, Potosi,. or Tarija. b Communities in which the majority of residents are from Montero or from the department of Santa Cruz.

cessibility to major medical and market centers have appeared as important descriptors of similarities and differences between pilot and control communities. The preceding discussion has set the stage for an analysis of how these same factors have affected the implementation of the health program in the 37 pilot communities. PROGRAM EVALUATION WITHIN THE PILOT COMMUNITIES

Each pilot community was scored as to the success or lack of success of the rural health program in that community as of June 1978.° In Table 10.7 the eight major health units are ranked according to the percentage of communities that had satisfactorily functioning programs. There follows a breakdown by community type and success. The first observation that merits comment is the fact that the overall success rate of the program at the community level is a little less than 50%. No Statistically significant differences could be found between the rate of success and the type of community possibly due to the small number of cases

| TABLE 10.5. Migrant Status of Combined Pilot and Control Populations by Community Type. ,

Type of |

community Migrants Nonmigrants Total Organized colony (OC) 14 ( 67%) 7 ( 33%) 21 (100%) Spontaneous colony (SC) 19 ( 53%) 17 ( 47%) 36 (100%) Traditional village (TC) 0( 0%) 11 (100%) 11 (100%)

Ranch 3 (100%) 0 ( 0%) 3 (100%) Total 36 ( 51%) 35 ( 49%) - 71 (100%) 4

4 One missing case. ,

| ; , 183

Note: x2 = 16.43, df = 3, p < 0.001.

TABLE 10.6. Pilot and Control Communities by Type of Community.

Type of Pilot Control

community communities communities Total Organized colony (OC) 12 ( 32%) 9 ( 26%) 21 ( 29%)

Spontaneous colony (SC) 16 ( 43%) 19 ( 54%) 35 ( 48%)

Traditional village (TC ) 9 ( 24%) 3( 9%) 12 ( 17%)

Ranch 0( 0%) 4 ( 11%) 4( 6%) Total 37 (100%) 35 (100%) 72 (100%)

Note: x* = 7.63, df = 3,p < 0.05. | . and the four missing observations. Yet the data suggest that the program has been more successful in the traditional villages and the spontaneous col- onies than in the organized colonies. Further analysis will show that the differential impact of the program at the community level can be traced to the interplay of the same variables that were observed to be operating between

the pilot and control groups, namely, community structure, population size, mobility, ethnicity, and accessibility to major market and medical centers.

A fundamental problem in the RHDP-Montero is the shifting social boundaries of many of the communities in the Santa Cruz area. Traditional definitions of community based on common name, legal status, and other geopolitical descriptors are less useful community differentiators in areas of intense immigration. Table 10.8 suggests that by several such criteria the ‘‘communities’’ of the pilot and control groups can be defined in the tradi-

tional manner. Nevertheless, the co/onos of the organized and spontaneous colonies | alternate living in the colonies and the nearby towns or communities of origin. Thus, the so-called satellite communities (UCs) of organized and spontaneous colonies are not permanent settlements. Kraljevic (1978) reports that the more successful colonos move into nearby towns and return only to supervise the less well-off colonos who are hired to work their land.

Those colonos who do not do well can either hire out to the more successful ones, move farther into the forest to repeat the process, or become landless laborers for the larger agroindustrial enterprises in the areas. The mobility of the population diffuses allegiance to any one place of residence.

This pattern is especially evident in the organized colonies. Crankshaw (1977) reported that the Community 22 Transversal (Antofogasta) had decreased from 150 families in 1968 to 54 families in 1977. The outmigration and continuing high mobility in the organized colonies seems to be tied to fluctuations in the rice market. When rice prices are down, colonos are forced to supplement their incomes with employment outside the colony. The instability of the population of the organized colonies may explain in great part the lack of success of the health program among them when compared to the spontaneous colonies and traditional communities. The arena of medical behavior in the highly mobile populations further

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sample are hardly well-off materially. The maximum score on the livestock value index was 46, the equivalent of 2 cows, 20 sheep, and 6 pigs.

Self-Perception of Health , One of the questions included in the questionnaire but not incorporated in any of the health indexes was as follows: ‘‘Would you say that your health is: (a) very good, (b) regular, (c) somewhat poor, (d) very poor?”’ Responses to this question are shown in Table 11.3. Comparing those with a

basically positive assessment of their own health with those having a negative assessment (‘‘very good’’ or ‘‘regular’’ versus ‘‘somewhat poor’’ or ‘‘very poor’’), we find a tendency for the wealthier informants to consider themselves healthy and the poorer informants to consider themselves

unhealthy. However, the results do not achieve an adequate level of statistical significance:

x2 = 2.00, p < 0.10, one-tailed, N = 52. When we compare the rich and the poor, though, the results are clear cut in favor of the hypothesis: the rich do perceive themselves to be healthier than

the poor do:

p < 0.05, one-tailed, N = 26, Fisher Exact Test. Health Questionnaire: The Long Index The results of tabulations of responses on the 42 questions included in the Long Index are shown in Tables 11.4 and 11.5. An item-by-item analysis of

responses on these questions produced the following significant differences _ or tendencies. The poorer informants were more likely than the wealthier

informants to acknowledge these problems: S| 1. Staying awake during the daytime (vp < 0.08). | 2. Having suffered from nosebleeding as a child (p < 0.07). | 3. Experiencing nausea as an accompaniment of headaches (p < 0.06).

TABLE 11.3 Self-Perception of Health Status.

Informants .

of health status N Percent *“Very good”’ 6 11.54 Self-perception

**Regular’”’ 251148.08 *‘Somewhat poor’”’ 21.15 ““Very poor’ 10 19.23

Total 52 | 100.00 , 205

TABLE 11.4. A Comparison of Responses by Wealthier and Poorer Informants to Symptoms and Illnesses Listed on the Health Questionnaire.

Wealthier Poorer

Percent informants informants

Symptom/illness | W