Cross-cultural communication between doctors and peasants in Bolivia

SOC. Sci. Med. Vol. 3. No. I?. pp. 1109-1118. Printed in Great Britain. All rights reserved

0277.953687 53.00+ 0.00 Copyright c 1987Pergamon Journals Ltd

1987

CROSS-CULTURAL COMMUNICATION BETWEEN DOCTORS AND PEASANTS IN BOLIVIA JOSEPH W. BASTIEN Department of Sociology, Anthropology and Social Work, The University of Texas at Arlington, Arlington, TX 76019, U.S.A. Abstract-Practitioners of modern medicine in Bolivia are often ignorant of traditional health practices among Andean peasants in the Department of Oruro. This ignorance makes them less effective agents for improving health. The author describes a method for teaching traditional concepts of health and disease to practitioners of modern medicine (doctors, nurses, and assistant nurses). He discusses workshops offered to these practitioners, where the participants were guided through a series of exercises which assisted them in deciding what aspects of the traditional system to change and what aspects to leave alone. He finally shows how Andean myths can be used as a method for teaching them how to cure disease. The objective is to educate modern medical practitioners in traditional beliefs and to use these beliefs for teaching peasants about modem medicine.

Key Words-Andes,

cross-cultural communication,

Throughout the world, modern health practitioners have endeavored to incorporate modern medicine with traditional practices. Jeanine Coreil writes that

in Haiti modern health workers promoted homemade hydrating solutions and teas as substitutes for oral rehydration therapy (ORT) in treating diarrhea [I]. She concluded that promotional strategies for Haitians should take advantage of popular beliefs regarding diarrhea as ‘hot’ disease and by associating ORT with the principle of a cooling remedy. She also suggested that modern practitioners encourage the addition of guava leaves or flavoring to the UNICEF package mix to promote more widespread acceptance by Haitians. This strategy illustrates the use of culturally conditioned tastes and concepts to promote one aspect of modern medicine. The Danfa Project in Ghana is an example of the training and integration of traditional birth attendants (TBA) into a comprehensive maternal health program [2]. The art and science of traditional midwifery was incorporated as a continuing part of the training program. For example, during the first training session the TBAs were asked to demonstrate how they practice midwifery in order to ascertain how the TBAs establish rapport with patient, how they perform an examination, how they interpret the findings and how they manage labor, delivery and its complications. Through these demonstrations, the trainers were able to improve their knowledge of these practices and increase rapport with the TBAs. The trainers were also able to dispel some misconceptions and utilize some positive features. These TBAs were unable to estimate the maturity of a pregnancy or determine the number of foetuses in the uterus. They believed that the foetus assumed a sitting position with the placenta acting as a cushion and only somersaults into a cephalic presentation during the seventh month. Through ‘massaging’ they believed they could turn the foetus to a cephalic presentation. They also believed that the bag of waters is an

change, oral rehydration therapy

obstruction during labor and efforts were made to rupture it if it does not do so naturally [3]. On the other hand, the TBAs’ traditional beliefs about the need for child spacing were compatible with modern ideas about family planning [2, p. 3471. IMoreover, their delivery techniques were basically salubrious and adaptable to modem health practices [3, pp. 197-2031. These examples show that to teach peasants about modem medicine it is important to understand their ideas and to use them for improving their health care.

BOLIVIAN DOCTORS AND NURSES AS CHANGE AGENTS

The first obstacle that Bolivian doctors and nurses have as change agents is their belief that western medicine should replace traditional medicine in the Andes. They are taught in medical school that western medicine is superior to traditional medicine. After they graduate, they dogmatically insist on western medicine, much to the disparagement of traditional medicine. One young doctor explained to me that what he had learned in medical school is the truth and what shamans teach are lies. This dogmatic and ethnocentric attitude decreases dialogue between modem and traditional practitioners. Medical schools little prepare doctors and nurses for work in rural areas. There is no training in Aymara and Quechua languages, which many peasants speak. Classes are aimed at training doctors for urban practices, where there are adequate support services to enable them to diagnose and treat illnesses. Rural doctors find themselves incapable of diagnosing diseases, whose symptoms are related in Andean concepts and terms. Moreover, medical students often aspire to be doctors to advance themselves economically and socially (a large percentage of Bolivian doctors have emigrated to the U.S.).

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JOSEPH W. B.A.STIES

After medical school. doctors spend one year working in rural communities. This forced internment results in certain abuses because many see it as a waste of time and work at other jobs in the cities. One doctor was a cab driver. and another a teacher in La Paz during their years of provincial service. Others try to serve the peasants but become frustrated because of lack of communication and utilization of their services. They become discouraged when peasants refuse to accept vaccinations, therapy, and hygiene. Doctors interpret this as ignorance and resistance to change. Doctors are unaware that this resistance to change has structural and epistemological explanations which could be used to improve the health of peasants. Research on change agents has shown that information by itself is not sufficient to bring change. Frank Young illustrated this with the example of a nutritionist who diagnosed dietary deficiency and prescribed a supplement [-t]. Young pointed out that if the nutritionist and patient shared similar understandings of nutrition and dietics, then this information might work, but if the patient had another view of nutrition, such as balancing hot and cold, and wet and dry, then the prescription would not fit into the patient’s cognitive pattern. Items of information fit into structural-cognitive systems with underlying assumptions and premises: there is a basic logic to cultural and symbolic systems, as Levi-Strauss has pointed out in Su~~ge Mind. For the transference of information, then, there must be cross-over of knowledge from the structural-cognitive system of the change agent to that of the recipient. Information readily accepted and processed within the cognitive framework of one cultural system is often unable to be processed within the structures of another system. Transfer of information from doctors necessitates that the change item is comprehended and cognitively functional within thought patterns of peasants. Many doctors are capable of doing this because of their Andean ancestry, but they are unwilling because they have been taught to replace traditional medicine with modern medicine. Like noveau riche, these doctors think they have to turn their backs on their traditional heritage. Results are negation of deeper cognitive patterns and attitudes of superiority which generate resistance. Case of doctors and mid\cires The following case provides an example where doctors tried to change traditional practices of midwives without an adequate understanding of their tradition. In 1981 doctors in Oruro insisted that midwives have expectant mothers lie down for delivering babies instead of squatting as is customary throughout this region. Doctors feared that the newborn would eject too rapidly and injure its head on the concrete floor. These doctors were trying to change medical practices without adequately understanding Andean practices. Not one of them had seen a midwife deliver a baby, so we invited them to one such birth process. The midwife gave the mother a mute of anis, a commonly used oxytocic, when she was at the height of labor. The mother squatted close to the earth floor over a thick sheepskin rug, and as the baby protruded, the midwife received the head in

her palms. The umbilical cord was cut with scissors: short for girls, and long for boys (symbol of the penis). The infant was shielded from light. as the midwife explained latter, Xndeans believe that bright lights injure the baby’s eyes, so birthing rooms are kept dark except for candles. After the delivery. the husband brought his wife a bowl of sheep soup, believed to provide the exhausted mother with strength. After this participant observation, we discussed with the midwife items that should be changed and those that should be left alone. The doctors conceded that squatting is better than the supine position. Not only is there much scientific evidence to back this but also it is nearly impossible to change birth practices as it is to change dietary habits. The point was emphasized not to try to change customs which are not essential to improve health. The motto was ‘Go with the Andean System and Improve it.’ With this orientation, these Andean doctors began to think as peasants and devise ways to improve their health. The doctors noticed that the sheepskin rug was dirty, so they suggested that at the meetings of the Clubes de Madres (Clubs of Mothers), associations of mothers found in many Andean communities, expectant mothers be instructed to wash the sheepskin in soap and water and dry it in the sun (an excellent antiseptic) before the delivery. The doctors also questioned the midwife and learned that often the mother drinks mutes of oxytocics, such as anis, coca, and coffee, too early in labor and becomes too exhausted for the delivery. Because these vegetal oxytocics are not as controllable and powerful as synthetic drugs, midwives and mothers need to know exactly when to administer the mute, namely at the moment when the mother feels like she has to go to the toilet (in terms which they understand). On the other hand, the doctors learned that the bright lights and white colored walls of their delivery rooms were unpopular among Andean mothers. Also unpopular among Andeans was that doctors do not allow the family to bring sheep soup to the mother in the clinic after delivery. (Usually, the family smuggles it in anyway.) They also realised why they upset mothers when they cut the boy’s umbilical cord too short. These explanations and use of the supine position were possible factors why many Andeans refused to have babies delivered in clinics and hospitals. Although the doctors were not advocating clinics for normal deliveries (an estimate of 90% of babies are delivered by midwives in Bolivia), they instructed the midwives to recognize complicated carriages and refer the mothers to them. For new clinics, it was decided to decrease the lights in the delivery room, paint the walls in dark colors, and abolish the rule against bringing food. Characteristically, the doctors were very worried about germs so they suggested that midwives wash their hands, use sterilized gloves, and cut the umbilical cord with a disinfected razor blade. In subsequent meetings, midwives were instructed in this and presented with these materials in shiny aluminium cases, provided by UNICEF. After a year, the aluminum cases had to be replaced by cloth backpacks because the Indians had interpreted the metal cases as attracting lightning, a dreaded deity and lethal charge

Communication between doctors and peasants in Bolivia in the highlands. Doctors then realized that the shiny, aluminum, and steel equipment in their clinics and hospitals probably had a similar effect on the peasants, providing another reason why there is such a low utilization of modem medical facilities by Andeans. Even though there has been a three-fold increase of clinics and medical personnel in rural areas within 30 years, the increment of use by peasants has increased minimally, about 13% [5]. The principal reason for underutilization of health services in Bolivia are lack of confidence of peasants in modem medicine because of financial, psychological, physical, and cultural barriers [5, 61. Watching the midwife vividly showed the doctors the importance of observing traditional practices and communicating with these practitioners. As another step in this direction, members of the Ministry of Rural Health in Oruro, Bolivia, and Gregory Rake of Project Concern initiated a series of workshops in which practitioners of modern medicine observed traditional practices and discussed health matters with these practitioners. Dr Oscar Velasco M.D., Angela Lutena R.N., and I directed 12 workshops, each three days, between 1981 and 1985. The participants were doctors, pharmacists, nurses, nursing assistants, technicians, community health workers (CHWs), shamans, herbalists, midwives, and nonprofessional people. The sessions were directed toward practitioners of modern medicine but from the point of view of traditional practitioners. For example, each session was directed toward a specific group, doctors, assistant nurses, or CHWs. Instruction included case studies where peasants first told their symptoms to a doctor and then to an herbalist or shaman, both of whom attempted to cure them. This was followed by discussion of understanding of symptoms. Most of the time, the doctors were unable to understand the symptoms because they could not speak Aymara or Quechua. Then we discussed the herbal and ritual activity of the herbalist or shaman. At first the doctors and nurses considered the vegetal and symbolic processes as ineffective and irrational, sort of a magic standing in the way of modem medicine. They needed an anthropological explanation of the cultural assumptions for these practices, or in more common terms, to see how these practices worked in Andean society. Using my ethnographic research among the Kallawayas, I discussed concepts of Kallawaya ethnophysiology with the participants. The participants were Aymara and Quechua Bolivians, who lived in the Altiplano district of the Kallawaya region. Although the groups are distinct, I assumed that major components were the same with minor variations, which the traditional practitioners of the region modified for the group. Part of the success in these sessions was the dynamic and processual exchange of information between both classes of practitioners. My role was a facilitator of dialogue between practitioners of both medicines. Oscar and I discussed the following assumptions of Andean medicine with the participants: (1) hot and cold consistencies of sicknesses and medicinal plants; (2) hydraulic concepts of the body (a&u, fat, blood, circulation, distillation, and elimination); (3) metaphoric relationship of the body to land (role of ritual

1111

in healing): (4) social relationship of the body to family and community (role of divination and other rituals, redressive of social conflicts in healing). We spent a morning or afternoon session of three hours on each topic. For homework, participants presented sociodramas where the lesson was applied to clinical practice. Sociodramas were an effective way of involving doctors in another cultural setting in that these exercises allowed them to enact the roles of sick people and traditional practitioners, thereby attempting to understand the situation from the Indian’s viewpoint. For instance, several doctors enacted a consultation where they greeted the sick peasant by exchanging coca leaves, sitting on the floor with him and his family, and discussing his ailments in a divination session with coca. Since then, one doctor has adopted this practice. The others are more understanding in their consultancy. Another doctor, a Canadian priest, strongly disapproved of traditional healing, especially rituals, at first, but after the workshop established a strong alliance with a prominent shaman in his parish. The shaman asked the doctor to cure his son of cancer. The son died from the operation. Nevertheless, the shaman invited the doctor/priest to the funeral and at the graveside, the shaman told the people that the doctor was a great medicine man and had done everything possible to heal his son [7]. Less successfully, some participants criticized the workshops as efforts to stop progress and return to the pharmacopoeia of the Incas. The most violent reaction was from a group of surgeons at the General Hospital in Oruro. One doctor stormed out of a session, slammed the door, and yelled, ‘*Cara@!” (Damn it!). The next day, a lady surgeon apologized for his behavior and explained that the angry doctor’s mother is the major distributor of herbal medicines and ritual paraphernalia for the people of Oruro. He illustrated the confiict that mestizo doctors face in having denied their ancestral medicine in accepting modern medicine. For them, both appeared at odds. Once these doctors realized that there were points of articulation between both medicines, they supported our efforts. In analysis, it was a problem of cognitive dissonance in which they had to separate themselves from their indigenous origins which were symbolized as backward in order to establish themselves with ‘modem’ medicine which is associated with knowledge and progress. As an anthropologist, I tried to show them the sophistication and function of traditional medicine to dispel their ideas of its primitive nature. I also pointed out that they could better practice modem medicine if they learned something about traditional medicine. The workshops also included modem medicine, emphasizing those parts comprehensible, salubrious, and appropriate to the rural populace. This ruled out complicated explications of diseases being caused by viruses and bacteria (peasants have been unconvincingly educated that bacillus Koch causes TB). Practitioners of public health had tried to convince peasants to dietary supplements by educating them about proteins, carbohydrates, minerals, and traces, when they could have used Andean concepts of exchange of resources between people living in herd-

JOSEPHW. BASTIEN

1112 Table Traditional Same

Wila

Curso.

Curso,

I.

Enquiry

format:

diarrhea

medicine

W#h’u.v.

oika.

Modem

ma1 de pro.

mon-

Diarrhea,

dysentery.

medicine

amoebic

dysente?.

charisqo. Symptoms

Causes

Fever.

colic,

dehydrauon.

sunken

eyes.

lack

frequent

bowel

stomach

disorder.

Fright, feeding,

Treatment

Mates wheat; llama

wind.

anger,

and

of bilyea,

wthout

getting

defecating

cold,

indigestlon.

thin, water

tears,

thirst,

green

feces.

or blood

stoppage

cinnamon, leather,

Restriction

Frequent

bowel

of breast

Germs,

bacteria.

disorders, chocolate,

peels; flour tula.

and

and coca; bread

of Canahua. carbon,

quinoa. sitting

of fluids.

ing zones which produce meats, with those living in the potato, cereal, and vegetable zones. Hygiene was another example of inappropriate technology in that peasants didn’t have an adequate water supply to do the necessary washing. Another solution was to build latrines which gravitated the problem because chickens and sheep used them for corrals, thereby increasing the possibility of infection. Customarily, peasants urinate and defecate in places where the sun dries the feces. The point is not that these concepts are unimportant but that they are either conceptually foreign to Andeans or not appropriate to their needs at the moment [S]. After a number of workshops, Oscar and I devised a simple methodology for articulating traditional and modem medicine. Its objectives were to compare practices of modern with traditional medicine in regard to some disease, to analyze what is salubrious and deficient in each system’s practice, to select one essential and appropriate item to change, and finally to design a lesson plan for convincing peasants to make this change. The goal of the lesson plan was to communicate the message according to basic Andean cognitive patterns, such as the major components of their ethnophysiology. The methodology includes three steps, an inquiry, selection of focal point, and lesson plan. To illustrate these steps, I will discuss one workshop in which diarrhea was the topic. Diarrhea is a major cause of infant mortality in Bolivia which has an estimated infant mortality rate of 250 [9]. The workshop was held in Corque, Department of Oruro, Bolivia, on July 25-30, 1983. Participants were three doctors and 25 assistant nurses, who staffed small clinics (Postas Sunitarins) in peasant communities of the area. These auxiliary nurses knew a minimum of modern medicine, only having received a year’s training in a poorly staffed school in Oruro. Often, they were not supplied with medicines to take care of minor emergencies and give injections of antibiotics. They were poorly paid and received little support from the Ministry of Rural Health, yet were required to file many forms with their supervisors in Oruro. Consequently, much of their time was spent in bureaucratic paperwork. At this time in Bolivia, there was one physician for every 4000 people (mostly in cities), and one assistant nurse for every 1500 people (mostly in rural areas). Many assistant nurses were of peasant stock and spoke Aymara and Quechua. They were, and still are, important links between traditional and modem

on

mobcment

feces for dysentery.

High

wth fsicr

watep

substance.

and vomi:mg

Blood

m

for dysentery.

and

cwigos.

banana

ashes of dung.

crying

appetite,

movements,

change,

cheese or dried

of

wth

After

virus,

parasites.

change.

gastrointestinal

medxme

to treat causes.

bronco-pneumoma.

proper

and

Rehydration

hot

cooled:

add

to flavor.

diagnosis,

admimster

formulas:

Suero cu.wr~

? tbs. of sugar.

Administer

(I

I tps.of

3 or .I oz ever+

liter of boiled salt. and

lemon

water. juice

1 hr).

medicine. Unfortunately, many only had a superficial knowledge of both medicines. For the first days of the workshop. Oscar and I discussed major components of ethnophysiology with them. They became actively involved in sociodramas and rituals representing symbolic factors in healing. Several were also herbalists and shamans in practice, which they did not reveal to the group for fear of being fired by the Ministry. but their knowledge of traditional practices made it clear that they were more than casual observers. These experts aided the group in making lists of hot. cold. wet and dry diseases and plants. The participants were taught to use metaphors from animals and land to educate one another in health matters. They reveled in this exercise, each group trying to outwit the other group. They were much more comfortable using Andean symbols and traditional medicine than modern medicine. By Wednesday, the participants were ready for the methodology. ENQUIRY

Early Wednesday morning, Oscar and I drew a scheme with blanks to be filled in for the enquiry [IO] (see Table 1). They provided us with the information to fill in the spaces. For traditional medicine, they tried to reflect the thinking of peasants in their communities. In the blank for name. for example, they listed Aymara and Quechua words used to describe diarrhea: curso (flow). wijch’uy (expel rapidly, also used for vomiting), wifa curso (flow of blood), aika (diarrhea from change). mal de puto (duck disease), and mancharisqu (emotional diarrhea, often associated with susto). The participants became aware that Andeans distinguish different degrees of diarrhea. Aika is least important, often found in babies and travelers; it is caused by change of food, lodging, and climate. Wijch’u,~ describes temporary cases of diarrhea, whereas cnrso refers to persistent cases, and curso wila to perduring cases with blood in the stool (dysentery). This indicated that peasants classify diarrhea into categories translatable into modem pathology and that for this and other sicknesses medical personnel should begin by investigating the taxonomy of disease. One failure to do this resulted in the Bolivian Ministry of Health issuing posters in which they used the word uiku instead of nlifu curso to refer to the deadly disease of dysentery.

Communication

between

doctors

Another factor is that Andean women are shy in regard to diarrhea so if the doctor does not recognize the name, they are reluctant to explain it. If the doctor can question them using their taxonomy of disease, then these women can more adequately provide him with information. Names for diarrhea and other diseases vary throughout the Andes, so health workers need to learn the varying taxonomies in each community. The same holds true, perhaps more so, for symptoms. Not surprisingly, Andean peasants associated diarrhea with fever, colic, lack of appetite, weakness, thinness, and frequent bowel movements, which have water, blood, or a green liquid. Although some participants claimed that the peasants of their communities perceived that the symptoms included dehydration, most said that peasants did not associate diarrhea with thirst, sunken eyes, and crying without tears. This corresponded to the traditional belief that diarrhea is a wet disease with wet symptoms. It is not associated with dehydration, but often with a surplus of fluids. One conclusion from this section was that peasants recognized the symptoms of dysentery, regarded it as serious, and often referred the patient to clinic. However, they regarded other symptoms of diarrhea as not serious and dealt with these by home remedies. Consequently, educational programs needed to influence the families. Scrimshaw and Hurtado reported similar findings in Central America [IO]. They found that health posts, important parts of the intended distribution system for ORT, were referred to only for one kind of diarrhea, dysentery. The drugstore, home remedies, and folk curers were more frequently used for diarrhea. They concluded that educational programs should reach families with ‘milder’ forms of diarrhea to teach them about ORT and to prevent dysentery. Concerning its causes, Andean peasants attributed mancharisqa to a sudden fright which causes fluids to flow from the body, aika to imbalance of hot and cold brought about by a change of diet and climate, and orejudu, a form of susto to the sick child’s mother who looked at a dead dog while she was carrying the victim in her womb. Orejudu is a pathological syndrome that includes somatic, psychological, social, and symbolic dimensions. Herbalists skilled in medicinal plants and rituals, such as Nestor Llaves, can cure this. Peasants also believe that wind and cold cause diarrhea, called rvu~run curjuthu (caught by the wind) and thuyunpusjuthu (caught by the cold). For these types, it is important to restore the balance with warm remedies. They also attribute diarrhea to emotional states (bouts of anger, anxiety, and fear) and indigestion. In addition to these empirical factors, they often attribute diarrhea to custigo (punishment) by Puchumumu (Mother Earth) for failing to feed the earth shrines, participate properly in the community, and to care for the animals. Custigo is associated with other diseases as well. Because peasants perceive it as a cause, practitioners of modem medicine should refer their patients to shamans who can remove the cnstigo because perceptions of causes are related to expectations of recovery. Assurance that perceived causes have been addressed increases the potentiality of self-healing in the patient. The participants listed natural remedies for treat-

and peasants

in Boiibia

1113

ing diarrhea. These included mares of &/yea, cinnamon, chocolate. and coca; foods. such as bread with cheese, dried banana peels, fIours of kufiuhuu (Chenopodium pullidicuule Aelien), quinoa, and wheat; and ashes of burned leather, tulu (Lepidophylfum quadrangufure Benth.), and carbon. One interesting cure for diarrhea caused by the cold was to sit the sick child on heated sheep dung. The participants observed that the flour of cereal was used as treatment because peasants wanted to dry the person out. This and not associating dehydration as a symptom clearly indicated that many Andeans did not recognize the fact that diarrhea was a deadly disease. The participants slowly became aware that the problem lay in Andeans’ perception of diarrhea as a wet disease. This awareness was experientially brought home to them by the deductive enquiry into traditional medicine. Once the blanks for traditional medicine had been filled in, the participants proceeded to those for modern medicine. Although they ran through this, they demonstrated inaccuracies, such as not being able to prepare the rehydration formula (suer0 cusero) for diarrhea. Several participants thought that two tablespoons of salt, instead of sugar, should be added to the liter of water, which if administered would greatly aggravate the dehydration. Afterwards, two-thirds of the participants failed an exam concerning the preparation of suero cusero. This inexactitude shows that if modem medicine is to be effective, it must be done correctly. A serious problem for peasants is that many doctors and nurses do not practice modern medicine correctly. because of lack of education, instruments, and medicine. For instance, I witnessed cases in which unsterilized instruments were used for surgery and another where an eight year old boy was operated on for three hours without an anesthetic because the doctor had forgotten to get it from the Ministry of Health in Oruro. Sterility, skill, and instruments are needed to perform modem medicine because of its technical nature. Without these, it can do more harm than good. One conclusion is that nurses, assistant nurses, and doctors in rural areas need better and appropriate medical training to correctly practice modem medicine. Often their attack on traditional medicine is generated by an insecurity in modern medicine.

SELECTION

OF FOCAL

POINT

Selection of a focal point is the second step of this methodology. The importance of this phase is to train participants to select something which is pivotal to improving rural health and which the participants can accomplish. As already discussed, health workers often endeavor to educate peasants about inappropriate and unessential matters. They also try to eradicate traditional practices that are practical for Andeans, such as doctors trying to change the birthing positions or discouraging the use of vegetal drugs. This imprudence wastes time and effort. To lessen this, the workshop provided the participants with opportunities to make decisions and evaluate them according to practicality and sensitivity to Andean culture.

JOSEPH W. BU\STIEN

II 14

At this particular workshop, for example, the assistant nurses debated about the focal point. Many thought that they should deal with the causes of diarrhea, but others objected that diarrhea is a symptom of many diseases and has many causes. They discussed the various causes, lack of hygiene, improper diet, impure water, and change, but could not agree on one. They thought that too much instruction was needed to educate peasants concerning the classes of diarrhea and their causes. In regard to traditional etiology, the assistant nurses agreed that how peasants perceive causes of diarrhea is a topic too embedded in their culture to try to change. They realized that Andeans include environmental, social, and cultural causes which are important contributing factors to the disease. The assistant nurses were also aware that they should elicit the support of diviners and shamans to deal with these factors. Concerning traditional medicines, some wanted to have peasants change their native treatments of diarrhea, but others replied that certain plants and minerals were effective and that they should not change these unless the treatments were injurious to their health. They agreed that they should do laboratory studies of patients only if native treatments failed. Pharmaceutical and laboratory expenses are costly to peasants. Peasants often have to travel Far to be examined. The assistant nurses then realized that peasants do not consider diarrhea a serious ailment because it is common and has many household remedies. More significantly, peasants were unaware that diarrhea should be treated with rehydration formulas. After considerable discussion, the participants agreed upon the focal point; diarrhea is serious, can and often causes death, and should always be treated with a combination of native cures and a rehydration formula. The group had learned the objective of the second part of the methodology; namely, they had learned to utilize salubrious aspects of traditional medicine and to focus on practical and essential aspects of modern medicine. LESSON PLAN

The third step within the methodology is to communicate the focal point to Andean peasants so that they understand it according to their cognitive patterns and concepts of ethnophysiology. The main point must be taught within Andean concepts concerning disease and health. The lesson must also be motivational so that peasants change their behavior in regard to diarrhea. The assistant nurses prepared and presented a lesson plan concerning the focal point for diarrhea, namely that it is a deadly disease and should be treated with rehydration formulas. This presented a problem in that they had to deal with an Andean belief that diarrhea is a wet disease and should be treated with dry formulas. The objective was to override this concept with more basic Andean cognitive patterns. One especially creative person, Porfirio Alconze led the group. Porfnio Alconze is assistant nurse in Tortora, an Aymara village south of Oruro. Porfirio also practices as an herbalist and is very knowledgeable about Aymara thought. Porfirio recalled a

legend. well-known among the Aymaras living near the Bolivian and Chilean border. Originally. the legend concerned two mountains in love with a maiden mountain. who jilts both of them. The masculine mountains fight; one knocks the crest off the other causing it to look like a tooth, and the other sends gophers draining it of water. Originally, the legend explained why one volcano is pock marked and the other without a crest. Porfirio then restructured this legend for use as a teaching device about diarrhea and rehydration formula. The revised legend goes as follows: Near the CMean border are three mountains, Sajama, Sabaya. and Cariquina. In times past, Tuola Sajama and Tuara Sabaya were young men ( Wa.tmzkunn) who fell in love with Cariquina, a beautiful young maiden. They courted her with flowers grown on their loins and sent to her on the wings of eagles. When she became sick, the? sent her leaves of nencin (gentian) to soothe her ills. As time passed. Sajama and Sabaya became jealous of each others’ love for Cariquina. Each wanted to marry her. Their disputes resounded in lightning bolts and thunder. Their discussions caused icy winds. Skilled in the sling, Sajama whirled it around his head until it caused a tornado, and letting it go, he hurled a great rock at the uma pacha (head place) of Sabaya. The rock crashed into Sabaya’s crest, knocking it off. and causing it to tumble down the valley. Sabaya looked like a big tooth, instead of a mountain. Smoldering in revenge, Sabaya put a spell on Sajama with a mesa negra (misfortune table). The hex was that gophers drill holes all over Sajama. Rapidly, gophers appeared on Sajama. They multiplied and drilled more holes. Sajama began losing water through the gopher holes. Daily, Sajama became drier and drier as the water drained from his body. One day. Tiwula. the fox, ran up the side of Sajama’s back. Sajama beckoned to Tiwula, crying out. “Save me, all my water is flowing out to the river’s bottom!” “You must stop drinking!” the fox replied. “because this makes the water flow out!” Indeed, the fox didn’t want Sajama to get well so that he could continue to hunt and eat the gophers. The other animals became alarmed. They loved Turo Sajama as a father who had given them food and shelter, so they beckoned Condor. Condor flew immediately to Sajama. Sajama was dying and barely able to speak because his tongue and throat were dry. His eyes were sunken and he cried without tears. Barely conscious, he p!eaded: “I’m dying from lack of water, please save me!” “I’ll be right back with medicine!” Condor said. Then Condor flew to Mt Illimani who gave him a liter of crystalline-pure water: next to Ilillampu who gave him two soupspoons of sugar, then to Wyana Potosi who gave him one-fourth of a small spoon of salt; and finally to the Valley of Cochabamba where Mt Tunari gave him one-fourth of a small spoon of baking soda. Each time, Condor mixed these ingredients in the liter of pure water. After he returned to &It Sajama, Condor gave him a swallow of this medicine every five minutes. He did this slowly and carefully so that Sajama would not vomit. Because Sajama was a young man. Condor gave him two liters a day. Condor made many trips to the mountains for the cure. He also asked the eagles and hau-ks to hunt the gophers. Within a week. Sajama was cured and the gophers disappeared. Later that year, Sajama married Cariquina. Condors, eagles, and hawks attended the wedding. Sajama then told Condor to provide the herders of alpacas and llamas with the same cure, because many die each year in similar fashion!

Communication

between doctors and peasants in Bolivia

Portirio then explained the legend in terms of modern medicine. Sajama is comparable to people with diarrhea who are losing their fluids and dying. The gophers are like bacteria multiplying and causing holes in our bodies. The fox is like those who tell us that we should stop drinking when we have diarrhea. This does us more harm than good. The Condor is like the person who prepares suero cczsero for people with diarrhea. This is prepared with one liter of boiled water, two soupspoons of sugar, and onefourth of a small spoon each of salt and bicarbonate of soda. It is necessary to give this in small amounts, every 5 min. until the person is cured of diarrhea. The hawks and eagles are like the fathers and mothers who clean the house so that their children do not get diarrhea. This is followed by having the audience memorize the formula for ruero casero by repeating the parts of the legend where the Condor gathers the ingredients: one liter of boiled water from Illimani, two soupspoons of sugar from Wayna Potosi, etc. This way Andeans learn it by association with concrete references from nature and mythology (Figs I and 2). Following this workshop, Portirio, Oscar, and I edited a comic book with the above legend. Figures

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1 and 2 contain several sketches from this comic book. We gave these books to 46 CHWs for instructing members of their communities. CHWs claim that these books have contributed to the declining rate of deaths from diarrhea in the Department of Oruro. The effectiveness of this methology has been documented by Oscar Velasco (1985) who employed it for gathering information and educating assistant nurses between 1983 and 1984 (111. Most notable effects were the delineation and comparison of four cultural sicknesses (Cutjbtha, chullpa, lari lari, and liquichado) to the modern pathology of hysteria, osteomyelitis, septicemia, and tuberculosis (anorexia nervosa) respectively. Another result of the methodology has been to enable health workers to create, revise, and reject lesson plants. Articulation between both medicines implies a dynamic exchange of information (not dogma dictated from one system to another). ANALYSIS

OF METHODOLOGY

For analysis, I will explain how the above illustrations articulate modem medicine with Andean ethnophysiology. In another article, I indicate that Kal-

Sajama is dying because gophers have dug holes and water is draining out of him. The Condor flies to neighboring mountains to save him.

Condor receives a llter of crystaillne water from Illlmanl, two soupspoons of sugar from Ilillampu, one-fourth of a small spoon of salt from Wayna Potosl, and one-fourth of a small spoon of baking soda from Tunarl.

Fig. I

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JOSEPH

W. BASTES

Condor gives Sajama a swallow of this every five minutes throughout the day and week until he notices that Sajama no longer is thirsty.

Sajama is well and asks Condor about the healing formula. Condor says that it is called B. Sajama then teaches all the peasants about this great cure for diarrhea.

Fig. 2 Figs I and 2. Sketches from comic book on diarrhea.

lawayas and probably other Andeans understand their bodies as hydraulic systems which circulate, distill, and disperse fluids according to centripetal and centrifugal forces [12]. In synopsis, Kallawayas look to their uylfu, a mountain with three ecological levels, and its waterways for understanding their physiology. Analogously, Kallawayas understand the body as a vertically layered axis with a system of ducts through which air, blood, fat, and water flow to and from the sonco (heart). Blood and fat, principles of life and energy, come together at the heart and flow to the members of the body in a hydraulic cycle of centripetal and centrifugal motion. Basic to this model is an enantiomorphic understanding that the structure of their bodies reflect the structure of their land. Andeans look to their bodies for understanding of land, and they look to the land for understanding of their bodies. The analogies are never one to one but involve basic premises of

concentration and circulation of fluids, vertical levels with a center, and nutritional and waste fluids. Significantly, the structures of land and body interact with each other. This can be conceptualized as two objects whose external appearances are different but exist because they represent and share similar dynamics, which differentiate them and constitute them. Within these philosophical concepts, Andeans perceive vital properties in their bodies as reflecting (formal causality) and generating (efficient causality) similar properties in animals, plants, and land. The methodology trained assistant nurses to use the metaphorical process to instruct Xndeans in health matters. First, they selected key symbols from plants, animals, and land, then they associated these symbols with practical and essential features of modern medicine. They did not try to disprove the metaphorical process by inculcating the paradigm of modem medicine. Rather, they respected and utilized

Communication

between

doctors

Andean legends, rituals, and geographical features to instruct them. Andeans have flexibility in their cognitive style of metaphorical knowledge which can be used to improve their health by vaccinations, hygiene, and nutrition. Basic to this approach is the assumption that this cognitive style of metaphorical knowledge has enabled Andeans to adapt and survive in the Andes for thousands of years. The premise that land and bodies reflect each other contributes to a close relationship of Andeans with their environment. Terrain of Andean highlands is steep and often barren, yet they regard it as symbolic of their bodies and feed it as a mother. In similar fashion, health workers can use metaphors of animals and land to teach them about modern medicine. In the revised legend, metaphor and Andean ethnophysiology were used to communicate ideas about contagion and dehydration to Andean peasants. Hydraulic physiology was utilized in the legend about Sajama. Sajama was dying because of loss of water caused by gophers; the analogy was then applied to diarrhea, where a person was dying from loss of water. The point was made that diarrhea is serious, and people die from it. Sajama was saved by a rehydration formula; this is similar to concentration of fluids in the body within the sonco according to centripetal motion. The practical application is that they should treat all diarrhea as serious and give suero casero. According to their concepts, people die when too much liquid flows from them, and they are saved when fluids return to them. Health is the continual exchange of fluids within the body and the environments; any stoppage (accumulation or dispersal) of the centripetal and centrifugal forces results in death. These are the hidden premises or cognitive structures with which Andeans interpret the stories about typhoid fever and diarrhea. One problem of modem medicine is that it is communicated in terms that common people do not comprehend. Doctors’ decisions are decisive factors because they have the scientific knowledge. This does not encourage education and communication between doctors and patients. Traditional practitioners, such as Kallawaya herbalists, also have a tendency toward authoritarian, practitioner-dominated communications with their clients. Even though they share these characteristics with doctors and nurses, Kallawayas use culturally meaningful explanations and are more sensitive than doctors to the client’s perceptions of health and disease [13]. This article contains a methodology for improving communication between practitioners. REFERENCES

Coreil J. Community acceptance of oral rehydration therapy in Haiti. Paper presented at the American Anthropological Association Meetings, pp. 6-9, December 5, 1985. Nicholas D., Ampofo D., Ofosu-Amaah S., Asante R. and Neumann A. Attitudes and practices of traditional birth attendants in rural Ghana: implications for training in Africa. Wld Hlth Org. Bull. -9, 343-346, 1976. Ampofo D., Nicholas D., Amonoo-Acquah M., OfosuAmaah M. and Neumann A. The training of traditional birth attendants in Ghana: experience of the Danfa

4

5

6.

9.

IO.

and peasants

in Bolivia

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rural health project. Trap. Geogr. Med. 29, 197-203, 1977. Young F. Intervention versus explication in applied science. J. Home Econ. 60, 262-267, 1968. See also Young R. A structural approach to development. J. &vi Areas 2, 363-376, 1968; and Young F. Reactive subsystems. A. Sot. R. 35, 297-307, 1970, for more information about structural theories of change. Evaluacidn Integral del Sector de Salud en Bolivia. USAID, La Paz, Bolivia, p. 6 1. SeeBastien J. Exchange between Andean and Western medicine. Sot. Sci. Me>. 16, 795-803. 1982, for more ethnomaohic information on modem and traditional practytioners in Bolivia. Evaluacibn, p. 61, 1978. See also Kroeger A. South American Indians between traditional and modem health serivces in rural Ecuador. Proc. Am. Hlth Org. Bull. 16, 242-254, 1982. Kroeger found similar conditions in rural Ecuador. Major reasons given for not using modem health facilities were their lack of cultural, geographic, and financial accessibility. He concludes that modern services must be cultural and ecologically adapted to local conditions. This priest-doctor is supervisor of the Hospital at Huayllamarca. He gave the shaman an illustrated medical book and explained to him about cancer of the stomach which his son was inflicted with. There has been insurgence of cancer within this region in the last 20 years. This doctor and Doctor Velasco attribute it to eating excesses of refined sugar, which these peasants began eating since 1950. They have conducted no scientific studies to validate this. This is not to imply that Andean peasants are too unsophisticated to understand biomedical explanations of disease, which is slowly being taught to Bolivian children in schools. The problem is not the teaching and understanding of these concepts but rather their application to culturally meaningful contexts of health and sicknesses. Epistemologically, Andeans perceive sicknesses with many causes, which are related synergetically with each other. The body is more than a biophysical entity, separated from the environment, universe, and society. Their perceptions of the body include immediate biochemical components, which need to be correctly understood according to modern science, as well as holistic components, such as causal relationships with animal, land, and relatives, which are culturally relative and need to be considered and utilized for applied health measures. The purpose of this article is not to indoctrinate Andeans into modem medicine with a deceptive technique but rather to extend biomedicine, as we know it, beyond the exclusive individual approach to a more holistic or structural view that includes culture, social-psychology, and philosophy. The infant mortality rate varies greatly in Bolivia from region to region, for example the figure for Sucre is 59.4 and that of Trinidad is 241 .I. The official estimate is 154, but this is low because these figures are derived from urban areas. In rural areas, the rate will be higher because the deaths of children are infrequently registered. See also [5. p. 1671. Scrimshaw S. and Hurtado E. Anthropologist’s involvement in Central American diarrhea control project. Paper presented at the American Anthropological Association IUeetings, December 5, 1985. Schrimshaw and Hurtado improvised a similar enquiry among health workers in Central America. In this exercise, the staff were asked to till in a taxonomy of diarrhea according to vertical categories of cause, symp toms. and treatment cross listed with horizontal categories of mother, food, tooth eruption, fallen stomach, evil eye, cold, and dysentery. In another exercise, the staff listed home and folk cures, divided into drinks, mechanical, enemas, and baths, on one side and phar-

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JOSEPH W. BASTIES

maceutical cures on the other side. The authors reported that these exercises were quick, simple strategies for gathering information and informing staff of traditional practices. These authors and I agree that the challenge is not only to investigate traditional practices but also to find ways to make them useful in a rapid, clear, and meaningful way for such diverse audiences as clinicians, basic researchers, health educators, and program directors. The thrust must be to select significant points, improvise effective pedagogies, and convince peasants. 11. Velasco 0. El estado de consciencia y las enfermedades en la cultura aymara-quechua. Paper presented at International Congress of Americanists. Bogota, 1985. 12. Bastien J. Qollahuaya-Andean body concepts: a topographical-hydraulic model of physiology. Am.

Anthrop. 87, 595-61 I. 1985. See also Bastien J. Healers of the Andes: Kallarrpaya Herbalists and their Medicinal Plants. University of Utah Press, 1987. 13. See Kleinman J. Patients and Healers in the Context of Culture. Univeristy of California Press, Berkeley. Calif.. 1980, for a discussion of the therapeutic value of communication between practitioners and clients in Taiwan. He writes, “What sets indigenous communication off from that of Western medical practice is not the tendency toward authoritarian, practitionerdominated communication, which both share. but the sensitivity to client EMS and the use of psychosocially meaningful explanations.” This is also true of modern and traditional practitioners in Bolivia. I ‘with mod’.