From the Fat of Our Souls: Social Change, Political Process, and Medical Pluralism in Bolivia / Edition 1

by Libbet Crandon-Malamud

Overview

From the Fat of Our Souls offers a revealing new perspective on medicine, and the reasons for choosing or combining indigenous and cosmopolitan medical systems, in the Andean highlands. Closely observing the dialogue that surrounds medicine and medical care among Indians and Mestizos, Catholics and Protestants, peasants and professionals in the rural town of Kachitu, Libbet Crandon-Malamud finds that medical choice is based not on medical efficacy but on political concerns. Through the primary resource of medicine, people have access to secondary resources, the principal one being social mobility. This investigation of medical pluralism is also a history of class formation and the fluidity of both medical theory and social identity in highland Bolivia, and it is told through the often heartrending, often hilarious stories of the people who live there.

Product Details

ISBN-13:	9780520084308
Publisher:	University of California Press
Publication date:	12/17/1993
Series:	Comparative Studies of Health Systems and Medical Care , #26
Edition description:	First Edition
Pages:	308
Product dimensions:	6.00(w) x 9.00(h) x 0.80(d)

About the Author

Libbet Crandon-Malamud is Associate Professor of Anthropology at Columbia University and Director of Gender Studies, University of Arkansas, Little Rock.

Read an Excerpt

From the Fat of Our Souls

Social Change, Political Process, and Medical Pluralism in Bolivia

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By Libbet Crandon-Malamud

University of California Press

Copyright © 1993 Libbet Crandon-Malamud
All right reserved.
ISBN: 9780520084308

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Introduction
Locating a Theoretical Perspective, or How the Physician, the Preacher, the Peasant, and the Khan Achachi Came to Terms with One Another

Even the staid, imperturbable, American-educated Methodist pastor conceded that malignant spirits, or maybe enchanted incarnations, prowl in and around Chojña Kanata. The settlement of Chojña Kanata lies on the shore of Lake Titicaca on the Bolivian altiplano and is a half-hour walk, or about three miles, from the municipality of Kachitu. Kachitu qualifies as a social oasis on the vast, high, desert altiplano of Bolivia because, unlike Chojña Kanata, it is considered a veritable center of modern life: it can boast of a Catholic church with a full-time priest, a Methodist church, a hospital, a municipal building, a grammar school and high school designated by the national government as urban, a Sunday market, and a director of criminal investigation—called a DIC—who devoted himself wholeheartedly in 1977 to the fine art of inebriation. On the rare occasion that a crime occurs, one goes to the town seer, who acquired his clairvoyant powers in amalarial fever in the lowlands during the Chaco War. He is definitive evidence that the magic of medicine, disease, and illness plays a major role in the social and political life of Kachitu, in spite of its "cultural superiority" over Chojña Kanata.

In the late afternoon the walk from Kachitu to Chojña Kanata, past barren hills, the occasional mud-brick housing compound, and a few bleak stands of eucalyptus trees, is cold and brisk. The cold becomes bitter after the sun goes down over Illampu, an immense, glacier-covered peak of the Andean cordillera looming 10,000 feet above the expansive void of the altiplano. Frigid winds sweep down from the cordillera, cross the lake, and blast the emptiness of the plateau, silencing life in their wake. On this great plain two-and-a-half miles above sea level lives a phantom called the khan achachi who feeds on meat and alcohol and gifts it demands from the local people. If a man ignores the khan achachi, it feeds first, as a warning, on that man's crops, and then if that person does not respond, on his children, then on his wife, and finally on the man himself until the family hasbeen eliminated. Many people on the altiplano take the demands of the khan achachi very seriously.

On May 18, 1977, the sunset over Illampu consisted of brilliant reds, oranges, and yellows. The mountain, a silent monument, lay shrouded in its own shadow. Though several hundred square miles were visible, I could see neither human nor animal, and the only sound was that of the wind in my ears. The sun set on a horizon of desolation. The wind swept down and blasted against my body as night descended, and on the road from Kachitu to Chojña Kanata, I figured there was a good possibility of my freezing to death before I reached the haven of Seferino Qaruru's home, in spite of my down parka, alpaca sweater, and long underwear. Seferino's mud-floored, thatch-roofed, windowless adobe hut was a dark mud cube in which the door must remain perpetually open to permit light and ventilation. Seferino's wife, barefoot and holding onto her shawl with one hand, led their cow and a few sheep to a small corral. She then joined her sister, her husband, and her mother-in-law, with whom she shared the one-room home, and the Methodist preacher and me.

We got on our knees on the mud floor. The preacher put his hands on the heads of Seferino and his wife and said, "Dear God, bless this couple and this household. Keep them from harm and illness. Make them, their fields, and their animals fertile. Help them stay in the path of righteousness. Give them the strength to believe in your almighty power, and to turn their backs in disbelief on the khan achachi."

Seferino had been sick for many months. His sickness followed the deaths of all three of his children. Their deaths followed the death of most of their livestock, which followed three years of crop failure. Although his neighbors warned Seferino that the cause of his misfortune was his refusal to feed the khan achachi, he turned to the physician for help.

The physician, Dr. Mauricio Sabas, first diagnosed pneumonia, then tuberculosis, and when Seferino did not respond to either treatment, Dr. Sabas, with Seferino's encouragement, turned to the preacher, the Reverend Angel. Reverend Angel advised that the answer to Seferino's problem resided in faith.

Seferino desperately wanted the doctor and the preacher, both authorities and employees of the Methodist church, to find the solutions to his problems, but he was not unheeding to the wisdom of his neighbors. Several days before my visit to Chojña Kanata, the neighbors' theories had gained a leading edge in Seferino's mind, yet he still refused to pay the khan achachi. Seferino desperately wanted to join the Methodist church. Such membership, however, would require that he renounce belief in the khan achachi and all supernatural beings except God. Fearing death, Seferino had returned once again to the Methodist clinic. Dr. Sabas, unable to identify any pathology except anemia, placed him under intensivecare—such as it was (and still is) in that tiny, understaffed, and poorly supplied hospital.

On the eve of his second night at the clinic, a neighbor came up with yet another possible solution: several sticks of dynamite. Seferino, with all the agility of an inspired man, abandoned his bedpan and intravenous solution. He ran to Chojña Kanata and to the altar for the khan achachi which his grandfather had built more than forty years before in order to feed the phantom and keep it at bay. Seferino blew up the altar, and with it, he hoped, his obligations to the khan achachi. In spite of the church's disapproval of any acknowledgment of the khan achachi, Pastor Angel persistently visited and observed prayer, and Seferino welcomed him, probably in part because he was not certain that the dynamite would be effective. He had never before heard of this particular innovation. But Seferino also appreciated the attention the pastor bestowed upon him. It made him feel important, and closer to membership in the Methodist church.

In this case of Seferino's illness, three very different people with different interests and from different social classes and cultural groups, with different goals and parameters informing and limiting their strategies and decisions pertaining to health care, accommodated each other in order to pursue some element of their interests which was embedded in Seferino's situation. Seferino's quest for a cure, and Sabas's and Angel's therapeutic administrations, were informed by political, economic, and social considerations which in turn defined their perceptions of medical efficacy. A closer look at Seferino's, Sabas's, and Angel's differential interests in the case, and their therapeutic actions, reveal conflicting dimensions of "the quest for therapy," and how the evaluation of what is medically effective is subordinate to the social context in which it is perceived.

Seferino, the Campesino

Seferino is a campesino ,1 or Aymara peasant, whose family has tilled land in Chojña Kanata for as many generations as he can remember. Before the Bolivian land reform of 1953, Chojña Kanata was a free Indian community. At that time, half of the population of the canton of Kachitu, and half of its land, fell under the domain of haciendas. Indians within that domain lived under the tutelage of the hacienda owners—hacendados or patrones —and the mestizo 2 managers they employed, and the Indians' legal rights were virtually limited to those of serfs.

In contrast, the residents of free Indian communities enjoyed freedom from such masters: one's time and labor belonged to oneself and one's family. However, these communities were heavily taxed, and conditions inhibited, even prohibited, Indian participation in entrepreneurial activity. Hence, during the 450 years during which such laws pertained, from colonial times until the revolution and land reform, the men in free Indian communities like Chojña Kanata turned to the mines to earn cash to pay their taxes, and both men and women frequently traveled to lower altitudes to increase their resources through sale of their labor or trade. It is reasonable to assume that some of Seferino's ancestors lived in Chojña Kanata, working the mines and making seasonal treks to the lowlands, since at least the sixteenth century.

When Seferino and his wife married in 1973, they inherited the land they presently occupied in Chojña Kanata from Seferino's grandparents. The grandparents had, however, abandoned the land long before the land reform. Although it was rich and bordered the lake, the need for cash to pay heavy taxes forced Seferino's grandfather to leave the community annually after harvest to work in the mines and to trade in the lowlands, leaving Seferino's grandmother alone for months at a time.

During the 1970s, Seferino also left his wife alone at home while he went to La Paz, Bolivia's capital, and to the lowlands to trade his unskilled labor for cash, following the precedent that has at least 500 years of history in the rural highlands. At the Reverend Angel's request, Seferino explained to me the details of his grandparents' encounter with the khan achachi, their resultant misfortunes, and the source of the misfortunes of Seferino and his family, even though he simultaneously claimed not to believe in the khan achachi.

During one of his grandfather's absences, said Seferino his grandmother began to have dreams in which admiring men visited her. One admirer courted her for many months. In her dreams they had sexual relations. Eventually the grandmother discovered that she was, in very real fact, pregnant. In fear and shame she retired from social life and sequestered herself indoors, refusing even her own husband entry into the house, and forcing him to stay with his parents nearby. When the moment of her delivery arrived, she gave birth to a childless placenta. A red dog, said Seferino, came to the door, entered the house, ate the placenta, and left. No one knew the dog nor has seen it since. To prevent further disaster, the grandparents built an altar to the khan achachi and gave it gifts until they were able to abandon the land.

In 1973, Seferino's relatives and neighbors warned him of the obligations the khan achachi demands from anyone who lives on the property, and they urged him not to occupy it. He ignored this advice, he said, because he and his family had become involved with the Methodist church, and the church claims there is no such thing as a khan achachi. Seferino reasoned that if the Methodists were right, his own life would benefit. Almost all the Methodists in Chojña Kanata and in Kachitu are materially better off than their neighbors. The local Methodist church controls the clinic and the high school in Kachitu. Virtually all entrepreneurial activities in Kachitu are owned by present or past members of the Methodistchurch, and they have friends in La Paz and in the United States who are often useful.

More immediately, Seferino could not afford to buy other land. The land of his inheritnace was Seferino's only capital. Only fellow villagers in Chojña Kanata would have any interest in buying it and none of them would consider it because of its association with the khan achachi. The land also had its benefits. It had good soil and bordered the lake. Many of the neighboring villagers were Methodists and the church in Kachitu was only a half hour's walk away. Hence there were great advantages for Seferino if he could disbelieve in the khan achachi, particularly if, as a result, the khan achachi would actually go away. Therefore Seferino accepted his inheritance, burned the altar where his father's mother had paid the khan regularly after her peculiar delivery, and planted eucalyptus trees in its stead.

In 1974, while Seferino was absent on one of his periodic trips to La Paz, his wife "began to be visited in her dreams by admiring men. Over the next three years, the crops my wife and I planted failed. Most of our livestock died. We lost all three of our children before their first birthday. In 1977 I, too, fell ill." Upon finishing his story, Seferino buried his face in his hands and said to Pastor Angel, "Your Reverend, I am working very hard to not believe, but my wife, she is having more difficulty not believing."

"You must help her to not believe," replied Angel.

Though Dr. Sabas twice failed to cure him, first of pneumonia, then of tuberculosis, Seferino persisted in his belief in Sabas's medicine. Seferino also persisted in his trust in Reverend Angel and was grateful for his attention, particularly when everything seemed to be going wrong. Nevertheless, Seferino never failed to remain alert to the advice of his neighbors. While he was more or less successful in not "believing" in the khan, he "knew" the phantom to be effective. To "not believe" does not predude that the khan achachi exists. In his need for a pragmatic solution, Seferino reserved the right to allow that anything might be possible. Yet when he thought he was dying, Seferino chose medical care that had so far been totally ineffective, but that was defined by a philosophy, a social context, and a political position within the canton of Kachitu with which Seferino wished to associate himself. That is, there is no evidence in this case that Seferino returned to the clinic for medical reasons and much to argue that he returned for social ones.

The Doctor

Dr. Sabas was a mestizo from La Paz who had completed all the medical education available in Bolivia: six years of training after high school. There are no internship or residency programs in Bolivia. Hence, medical specialization is taken in the United States, Europe, Japan, or other countries in Latin America. Sabas chose anEastern European country where he studied internal medicine for three years. One component of that education which deeply impressed Sabas was its emphasis on social awareness. Sabas devoted a great deal of attention to studying the links between health and poverty. He returned to Bolivia with less enthusiasm for curing with the scanty diagnostic and therapeutic resources available in Kachitu, than inspiration to free its Indians from the bonds of poverty in the presence of which no amount of Western medical knowledge could resolve the health problems that plague Kachitu.

Dr. Sabas's foremost goal was to help the Indians. To his mind, working for the Methodist church was the most effective vehicle through which to accomplish this. It is one of the very few organizations that serve the Indians in the countryside.3 Since the 1970s this local church has been controlled by the campesinos themselves, rather than mestizos and foreigners, although it is subordinate to the mother church in La Paz. Furthermore the Methodist church's social and philosophical orientation is progressive, unlike the Evangelical movement throughout the rest of Latin America. In Kachitu the Methodists pay as much attention to Paulo Freire's Pedagogy of the Oppressed as they do to the Bible.

In a romantic fervor Sabas determined that Aymara was the first language in human evolutionary history. He referred frequently to a book that said so. He made effusive overtures to socialize with the campesinos, such as learning a few words of Aymara and tapping time to their music. In his more pragmatic but still inspired moods, he tried to organize an adult night school, a fisheries cooperative, and other ventures predicated on betterment through cooperative effort, but to no avail.

Much of Dr. Sabas's inability to help the Aymara might have been related to his inability to speak their language and his high standard of living relative to the campesinos. He resided in a house designed and built by the Methodist missionaries from the United States who first brought the church to Kachitu. It has two stories, wooden floors, indoor plumbing, a fairly modern kitchen, and an electrical generator; it could serve a middle-class family in Los Angeles. With a European wife and their two children, Sabas was not in a position to live like the indigenous population without heavy cost.

Sabas's material well-being did not reduce his desire to help the poor, but he gradually discovered that his ability to make a personal, substantial contribution to the Aymara on the altiplano was more limited than his aspirations. The only medical doctor in Kachitu, which had a population of 16,000, not including the province to the north which had no doctor at the time and also relied on Kachitu, Sabas was supplied with a closet full of drugs that had all surpassed their stipulated shelf life by at least five years and supported by a faulty generator to run his equipment and a truck that frequently broke down. Sabas discovered that he wasn't helping very much.

Sabas's only guaranteed strategy for being in any way effective lay in his gaining the campesinos' confidence. Their confidence was predicated on his respect for the Aymara. His need to demonstrate his respect impelled him to acknowledge the legitimacy of their medical world view, most of which differed radically from his biomedical training. Seferino was one possible convert to Sabas's economic schemes to revolutionize the countryside. Seferino was a seed in Chojña Kanata where, given the high percentage of Methodist church members, Sabas as staff at the Methodist clinic, might finally get a sympathetic audience. However, it became clear that Sabas was not going to gain Seferino's confidence by dispensing medical care. Consequently, when Seferino did not respond to his treatment, Sabas acknowledged that perhaps there was something beyond his biomedical powers, something inherent in this Aymara world, which he couldn't touch and which must be respected. To pursue Seferino's case he turned to religion. Being born a Catholic mestizo in La Paz, he confused Aymara medical belief with Catholic cosmology. Unaware that the khan achachi is not the Christian devil, he requested Pastor Angel to perform an exorcism, overlooking the fact that Methodists do not believe in the devil4 and do not perform exorcisms.

The Preacher

The Reverend Angel was delighted to oblige. He also was born a Catholic mestizo from La Paz and saw in the Methodist church the possibility of social change in Bolivia: national development through the betterment of the campesinos through education, health care, and economic organization. Being the pastor, married to a mestiza from the city, and with several children, he also lived in a two-floored, wooden home provided by the North American missionaries for the preacher in residence. He at least spoke Aymara. Nevertheless, he was having a difficult time being accepted by the local Aymara. They refused his authority. Since he was neither campesino nor from Kachitu, they disputed his ability to speak for them. They resented the mother church in La Paz sending outsiders to assume authority that they felt should be in the hands of their own local members. Instead of improving the lot of the Indians as he had intended, Angel frequently found himself defending himself and his ideas. When the doctor called upon him to help Seferino, he was grateful to respond. The immediate need as he saw it was to maintain Seferino's confidence in him and in the church while he maintained his own integrity to church doctrine, even though no explanation or resource presented itself to help Seferino that was more effective than the belief system surrounding the khan achachi. On one hand, if the pastor had adamantly denied the khan achachi, he might have made Seferino feel foolish and resentful, and have lost a potential ally. On the other hand, if he could somehow encourage Seferino's suspicions about thekhan achachi without himself acknowledging the phantom, he could relieve himself and Dr. Sabas of responsibility for alleviating Seferino's problems without alienating Seferino from their advances. Angel told me:

Many years ago, when Christ first came to earth, the air was filled with evil spirits. Christ had two means with which to rid the world of these spirits. First he did not believe and tried through the strength of his belief to rid the world of the evil spirits. But the people continued to believe, and the evil spirits did not go away. So Christ tried a second way: he did believe, and in his belief he performed ceremonies against the evil, and in this way was able to begin to rid the world of evil spirits. Likewise I must say that I can only help if I accept what you believe. This is how I approach my people here in Kachitu.

He did not stop there, however, but continued mixing scientific, Christian, and magical Aymara images. The emphases are mine:

Once there was a girl somewhere around here, living all alone during the Chaco War. A soldier was passing through and stopped by to visit with her, and she became pregnant. During her pregnancy her behavior changed. She began to act NEUROTIC. She didn't want to see anybody. When she delivered, the midwives came to help her. And they tell that the girl gave birth to a ball of fire. The Khan Achachi came, put out the fire, and left. IT COULD HAVE BEEN THE DEVIL OR SOME MANIFESTATION SENT BY THE DEVIL. It has several bodily forms it can take: sometimes it has a donkey's head with huge eyes; inside its head is fire so that its huge eyes glow like coals. It floats in the air
and has a comet with a long tail and it visits where it will. IF IT VISITS YOUR LAND YOU MUST FEED IT; burn mesas and comida, a llama fetus, pigs, potatoes, oca, guinea pigs, and other foods, and make challa with alcohol and wine. When it visits these places, if people do not feed it, it makes the family sick. It destroys their crops and kills their animals. One can tell when the Khan Achachi kills an animal because it dies with a green spot on its skin. THE ILLNESS THE FAMILY GETS VARIES AND DISAPPEARS IF THEY BEGIN TO FEED THE Khan Achachi.

After struggling in Kachitu for several years, Angel himself was having difficulty "not believing."

The Outcome of Seferino's Case

As a result of Seferino's case, Sabas made changes in hospital policy that permitted greater interaction and collaboration between indigenous medical healers, called yatiris, and the clinic personnel. These changes were reversed by one of Sabas's successors, an Aymara in the process of turning Bolivian elite, who had his own strategies and problems, which are analyzed in chapter 7. They were later reinstituted when the hospital administration came under the control of the local Aymara Methodists in 1983, after an argument over the issue with a North American missionary physician and several mestizos. The argument was resolved in the Aymaras' favor when they tried to burn the North American physician's house down, stole his jeep, and threatened his life.

Acknowledgment of the value of indigenous medicine at the hospital under Sabas and his successors reinforced the legitimacy of the yatiris' abilities and gave them greater influence—social, political, and economic as well as medical—within the social world of Kachitu. As is demonstrated in several of the case studies in this book, yatiris are able to translate their medical legitimacy, obtained in this post-colonial, twentieth-century town in a Third World country trying to develop, into local political power. Political power is defined here and will be demonstrated throughout this book as the ability to modify the behavior of others and enforce, through either social or supernatural sanction, a monopoly of opinion. Sanction distinguishes political power from influence. Sabas's shift in ideology and change in hospital policy had broad and long-term implicatons in Kachitu. It positively affected the political power of yatiris and moderately increased his own influence among the Aymara (but not among all mestizos) in Kachitu.

The Reverend Angel incorporated more and more Aymara belief into Methodist doctrine and encouraged indigenous leadership at his own expense. The local church, including the administration of the clinic and controlling influence on the board of the high school, was securely in the hands of the local Aymara Methodists by 1979, the year that Seferino joined the Methodist church. Unlike the earlier missionaries from the United States, the local Aymara Methodists see indigenous beliefs, such as the one about the khan achachi, not as medical heresy but as cultural heritage that should be preserved. The Reverend Angel's endorsement of those beliefs, therefore, had implications for the content of the cultural identity of the Aymara Methodists. This element of their cultural identity has political ramifications because it is used to differentiate these Methodists as Aymara from the mestizo population as evidenced when the Methodist Aymara hospital administration insisted upon institutionalizing the use of Aymara medicine in the hospital.

When I left in 1978, Seferino's wife was pregnant again. But in 1983 and 1984, drought destroyed more than 90 percent of the altiplano crop. In 1985, massive flooding raised the lake and eliminated hundreds of thousands of acres of agricultural land, including Seferino's. The lake is expected to recede to its pre-1984 level no earlier than 1990. Meanwhile, economic and political disasters related to the sudden rise of the cocaine economy in 1980, the closure of the mines in 1987, massive unemployment, and unprecedented inflation made starvation chronic for the first time in Bolivia's history. As a member of the Methodist church, Seferino would no longer have had to concern himself with conflicting beliefs, had his economic and political aspirations not been destroyed by these disasters. By the time of my return to Kachitu in 1987, however, Seferino and his wife had disappeared into the slums of La Paz.

The Significance of Seferino's Case

The almost inevitable student response to the recapitulation of Seferino's case is to ask if the dynamite worked, and what was really the cause of Seferino's misfortunes. "Hey," they say, "what REALLY happened?" or "What did he really suffer from?"

Unfortunately these questions place us squarely within a conceptual construct that leads to decision-making and explanatory models such as those that have been used by Cosminsky and Scrimshaw (1980), DeWalt (1977), Kleinman (1980), and James Young (1981). They seek to solve the problem of Seferino's medical symptoms and confine us to the assumption that when we know the medical answer, we will resolve Seferino's problem. The implication that there is a single correct answer assumes that the answer will affirm which is the most effective medical system. Allan Young (1982) has argued5 that such questions and such decision-making and explanatory models do not address the political and economic contexts in which medical decisions are made. Furthermore, they construct patient and healer as Rational Man in the classical economic sense, looking for medical efficacy as understood in positivist, or scientific, terms. Indeed, Seferino's problem wasn't solely medical, nor did he see it as such. Furthermore, a number of contexts besides the purely medical affected the thinking of Sabas, Angel, and Seferino. Such questions and conceptual constructs also do not address the total outcome of Seferino's, Sabas's, and Angel's medical decisions, which affected many people besides Seferino. If the anthropological and medical significance of the case is greater than Seferino's medical symptoms, we need to ask questions and employ a conceptual model appropriate to the nature and scope of the larger issues, which appear to be the nature of medical pluralism and the use of ideologies. The broader and thus more accurate question to ask, then, is how Seferino's choices of action were informed, and what the consequences of them were, not only for him, but for all parties involved in the case. Contrary to the assumption behind the question "Did the dynamite work?" Seferino entertained at least two conflicting etiological theories about his own illness simultaneously. By 1977, the physician and the preacher had also shifted their own medical beliefs, though this was not because empirical evidence demonstrated the superior efficacy of Aymara medical practice to exorcise the khan achachi.

Part of the significance of Seferino's case is that Seferino, Sabas, and Angel shifted their medical beliefs because by doing so, they could obtain desired resources. These resources were not only medical, but economic, social, and political as well. Sabas was able to change hospital policy and thereby gain greater influence over the local population. Seferino's medical strategies brought him closer to Angel and hence to the Methodist church and to the economic benefits he surmised could accrue from membership in it. Yatiris were able to appropriate political power through changes in hospital policy pertaining to the dispensation of therapy. Indeed, all parties involved in the case reaped the rewards of resources obtained through medicine, with varying degrees of success. Seferino's case thus illustrates how we, the anthropological observers, can conceptualize medicine as a "primary resource" through which one can gain access to other "secondary resources," a conceptual model first suggested by Paul Unschuld (1975). Primary resources are, like capital, fungible. They can be used to acquire something else or transformed into something else. Secondary resources are those things acquired or created through primary resources. This model is predicated not only on the assumption that ideologies are conditioned by material conditions and class relations, but that individuals select from them and use them to accomplish their own ends. Thus, the use of medical ideology in the analysis of Seferino's case, and throughout this book, is not Parsonian, Marxist, or Harrisian, but conceives of the individual as a conscious actor who often maintains what we as outsiders might consider conflicting ideologies.

Employing this model, we can understand the total outcome of Seferino's case—the effect of all medical decisions made in it—by tracing why Seferino entertained several medical models simultaneously, why Sabas and Angel shifted their own medical beliefs, and what were the consequences of this seemingly irrational use of ideologies. By asking why people entertain various medical beliefs and why they choose different medical resources, we can understand medical behavior and medical pluralism.

Of further significance is that the outcome of Seferino's, Sabas's, and Angel's involvement was a change in social relations that significantly affected the whole community of Kachitu. Most of the literature in medical anthropology which addresses social relations demonstrates how medicine reconstructs6 within the medical context those social relations that pertain outside the medical context (e.g., Frankenberg 1981). They argue that the hierarchy of medical care reproduces the social hierarchies found in society at large in order to render dispensation of such care more efficient. The case of Seferino demonstrates, and this book will discuss, how, within a medically plural environment, medicine restructures (Comaroff 1980; Taussig 1980; Crandon 1987) social relations outside the medical context.

In the Seferino case, all three parties shifted their beliefs in order to accommodate each other within a particular sociopolitical and historical context, in which all three parties had specific goals and limitations. As a result, by May 18, 1977, at least three social relationships, as well as the boundaries between cosmopolitanand indigenous medicine in Kachitu, had changed because of Seferino's illness in Chojña Kanata. By examining not only the case but the context in which the parties operated, and the anatomy of their strategies which extends beyond their medical interests, we are able to trace and understand the shifts in the medical or medically related beliefs entertained by the actors involved in the case. These shifts were not limited to the case itself. They ultimately affected medical ideology and social life in Kachitu, in Chojña Kanata, in the other surrounding communities (comunidades ), and throughout the entire canton that the municipality of Kachitu serves.

Continues...

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