It was evident that the number of deaths resulted not only from inadequacies in medical services but also from the failure of public health officials to inform residents that cholera was likely to arrive. Less evident were the ways that scientists, officials, and politicians connected representations of infectious diseases with images of social inequality. In Venezuela, cholera was racialized as officials used anthropological notions of "culture" in deflecting blame away from their institutions and onto the victims themselves. The disease, the space of the Orinoco Delta, and the "indigenous ethnic group" who suffered cholera all came to seem somehow synonymous.
One of the major threats to people's health worldwide is this deadly cycle of passing the blame. Carefully documenting how stigma, stories, and statistics circulate across borders, this first-rate ethnography demonstrates that the process undermines all the efforts of physicians and public health officials and at the same time contributes catastrophically to epidemics not only of cholera but also of tuberculosis, malaria, AIDS, and other killers. The authors have harnessed their own outrage over what took place during the epidemic and its aftermath in order to make clear the political and human stakes involved in the circulation of narratives, resources, and germs.
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Stories in the Time of CholeraRacial Profiling during a Medical Nightmare
By Charles L. Briggs Clara Mantini-Briggs
University of CaliforniaCopyright © 2003 Regents of the University of California
All right reserved.
IntroductionDeath in the Delta
In 1992 and 1993 some five hundred persons died in the maze of rivers and thousands of large and small islands that form the delta region of the Orinoco River in eastern Venezuela (see map 1). The disease that killed so many so quickly was cholera. I (Charles Briggs) stumbled onto the epidemic in November 1992 during a two-week visit to Tucupita, a city of some forty thousand inhabitants and the capital of Delta Amacuro state. Many of my friends from the delta were living on the streets of Tucupita and nearby Barrancas del Orinoco, another small city on the edge of the delta, begging and performing odd jobs to survive, sleeping in shelters constructed of stray pieces of plastic and surplus lumber. Nine of my closest friends had died. The survivors were terrified.
Cholera is nearly unrivaled in terms of the speed with which it kills. Healthy adults can die in as little as twelve hours after exposure to the Vibrio cholerae bacteria. Humans absorb water, sodium, and chloride through the colon. The cholera toxin paralyzes the gut in such a way that all fluids pass right through the intestines, resulting in extremely rapid dehydration. Persons who are acutely symptomatic suddenly begin to expel an unbelievable volume of diarrhea and vomit-10 percent of a person's body weight can be lost in a matter of hours. The stench of diarrhea and vomit becomes overwhelming. The rapid dehydration leaves cholera patients weak and thirsty, their arms and legs grow cold and clammy, and powerful cramps seem to shrivel their limbs and tie them in knots. The tips of their tongues and their lips turn blue, their eyes sink back into their sockets, and their skin hangs limply on their bodies. A fifteen-year-old can be mistaken for a person of seventy.
Unless the lost fluid is replaced, consciousness fades rapidly. If not treated with rehydration therapy, as many as 70 percent of symptomatic patients can die. What is most appalling is that cholera is easy to prevent and treat. Uncontaminated food and water are all that is needed to keep the disease at bay. Most patients can be saved by drinking a commonly available solution containing sugar, salt, and electrolytes, and even severely dehydrated, nearly unconscious patients can be brought back to life through intravenous rehydration. The disease also responds readily to antibiotic treatment.
Two of my friends, Salomón Medina-known as "Comando"-and José Rivera, related the horrors that they experienced during the epidemic. Both are from the delta community of Mariusa. I had known Medina, a respected Mariusan elder, for many years. Previously a stocky, round-faced man of some sixty years of age with a distinguished and relaxed demeanor, he now looked thin and beleaguered, and his movements were uncertain and jerky. Rivera, a serious, hard-working young man in his twenties who possessed great warmth and a fine sense of humor, seemed to have aged at least two decades in the two years since I had seen him. Rivera had helped me learn Warao, the indigenous language that predominates in many delta communities. Now thin and pale, and red-eyed from lack of sleep, he bore the weight of several worlds on his shoulders. He was a favorite son of Santiago Rivera, who had been the kobenahoro (governor), the political leader of Mariusa, for about thirty years, as well as a great storyteller and a respected-even feared-healer. Lacking age, experience, and authority, José Rivera had been thrust into a leadership role by his father's death in some of the most precarious circumstances his community had ever faced.
Medina and José Rivera were on the Mariusa River at the point where it reaches the Caribbean when they first witnessed the effects of cholera. This area is deemed to be one of the most "remote" parts of the vast matrix of forested, often swampy islands that make up the 40,000-square-kilometer Delta Amacuro. There were no clinics, missions, schools, government offices, or stores there when the epidemic hit. Physicians were not available to treat patients or explain what was taking place. Vernacular healers attempted to cope with a disease that baffled them. Santiago Rivera was one of the most respected practitioners of hoarotu medicine, which incorporates therapeutic touch in addition to chanting and the ingestion of tobacco. Cholera rewarded his unsuccessful efforts to heal a patient by killing him. A colleague who specialized in wisidatu medicine also died from cholera in the early days of the epidemic. The Mariusan community could only speculate that some sort of sorcery was to blame for these sudden, violent, and inexplicable events.
Medina and José Rivera described the moment at which the unknown disease thrust them into a nightmarish world of terror and dislocation. "We don't know what that disease is. We don't know-it appeared so quickly," said Medina. "Look, we were eating well." "We were just fine," affirmed Rivera. Medina continued the story.
Salomón Medina, Tucupita, November 1992
We were eating well, eating well, eating well, and then all of a sudden we starting shitting all the time.... We were living as we always had, we were just fine-look, we were happy. And even though we were just fine, he [Santiago Rivera] starting shitting in the middle of the night. He shitted, shitted, he shitted four times. He was getting really sick, he was getting really sick. "I'm getting really weak, I'm getting really weak"-[he] spoke his very last words. When he grew silent after saying these words, he died.
Since we didn't know what was going on, we didn't know why he died. Because we didn't know what was going on, the people, they said, "Damn! That Warao who knows criollo sorcery has put a spell on him with a cross, he died from a spell." We didn't know what was going on then, we thought the guy had killed him. We thought that he had killed him with witchcraft. Since we didn't know anything about the illness, that's why, that's how [we thought] he died. Then the next day another person started shitting just the same. We started shitting early in the morning, and the other guy died a little later.
We were shitting, the guy was shitting, shitting, shitting, shitting, and when he shitted again he passed out. "I'm going"-those were his last words. Look, then horrible cramps would shake our bodies, and people would die right away, people would die right away, that's how they died. Another, another, and another died, and when dawn came another died, another was shitting, another was shitting just the same way, shitting, shitting, shitting, vomiting. And when people starting vomiting, they'd say "I'm going"-those would be their last words.
When this unknown disease killed two of their most respected leaders and seven others within a few days, the Mariusans became even more frightened, believing that all would die. They boarded their canoes in search of the medicine practiced by criollos. Many headed for Tucupita and Barrancas (see map 1). It was only the beginning of a series of horrible experiences that revealed the true nature and meaning of social inequality.
Cholera had been absent from Latin America for nearly a century. It returned to Latin America nine years before the date targeted in the "Health for All by the Year 2000" campaign that was thrust into prominence by the World Health Organization (WHO). Just as a new revolution was supposedly bringing CNN, Coca-Cola, and democracy (or at least the democratic right to consume) to all parts of the globe, the presence of one of the world's most extensive cholera epidemics suggested that "progress" and "modernity" had left many people behind. The growing gap between the haves and the have-nots was, and is, fostered by economic globalization and the trade and labor policies imposed by the World Bank, the International Monetary Fund, the governments of wealthy countries, and transnational corporations, factors that promote competition and free markets and discourage the social "safety nets" designed to help poor populations. The cholera stories that we heard and have recorded here offer sobering testimony about the fate of poor populations, especially people of color, in today's world.
Racism was a crucial factor that placed people in Delta Amacuro state "at risk" from cholera. Venezuelans who live in the delta region are classified as either indígenas or criollos-as either indigenous or non-indigenous persons. Most of those who died from the disease in the region were indígenas, classified as members of the "Warao ethnic group." Both indígenas and criollos are Venezuelan citizens, but a person's racial classification shapes nearly every aspect of day-to-day life in the region. These people died, by and large, because racism affected the distribution of vital government services such as health care and water and waste treatment facilities, as well as economic and other resources, and affected how individuals who received them were treated. When germs and race mix, however inadvertently, the result is often fatal.
The devastating effects of the epidemic continued to be felt long after it was officially declared to have ended in mid-1993. Faith in vernacular healing was undermined, and institutional physicians and their medicines, particularly antibiotics, came to be seen by many delta residents as possessing magical powers. After the cholera scandal had passed and the reporters had returned to Caracas, the impressive infusion of physicians, medicines, boats, and gasoline disappeared. The cholera epidemic and the subsequent exodus of Mariusans and their neighbors to major cities had discomfited the state government, threatened its legitimacy, and further stigmatized Delta Amacuro as being a bastion of backwardness and ignorance, a premodern cancer on a modernizing country. "The Warao" were seen not simply as an embarrassment and an obstacle to exploitation of the delta's resources, but as a political liability. Therefore, the few clinics established in this vast area were often without even aspirin on their shelves. When patients were turned away by disillusioned physicians and nurses, institutional medicine was also delegitimated. "When they wanted to save our lives, they did," noted one delta resident. "Now they want us to die."
This scene may seem far removed from the experience of residents of Europe and North America. Cholera is, after all, not a major concern in wealthy countries of "the North." Or is it? Government officials worry that epidemics of Third World diseases, whether spread accidentally or disseminated deliberately by terrorists, could produce widespread death. Agencies such as the U.S. Department of Defense and the Centers for Disease Control have created units to plan for the threat of bioterrorism, which security analysts in the United States commonly cite as the new clear and present national danger. Films such as Contagious and Outbreak and books such as Laurie Garrett's bestseller The Coming Plague: Newly Emerging Diseases in a World out of Balance have contributed to the public's growing fear of killer "bugs." As anthrax circulated through the U.S. Postal Service and killed five persons in the fall of 2001, these fears came to life as people opened the daily mail and watched the evening news. Emerging and "re-emerging" diseases are tied to anxieties that deadly germs are passing from Asian, African, and Latin American bodies and environments into white bodies, anxieties that are exacerbated by talk of immigration and population increase. Race and class clearly lie at the core of these fears.
The Importance of Narrative
The story of the cholera epidemic in Delta Amacuro is not a simple tale of Machiavellian conspiracies or evil power mongers who gleefully marked others for death. It is, rather, a story of well-trained professionals who, in general, took their obligation to protect the health of the public quite seriously. It is not a tale of a backward, Third World country where callous officials were ignorant of or unconcerned with modernizing health care. The citizens of oil-rich Venezuela have long prided themselves on being a shining example of democracy and modernity in Latin America. Moreover, the denigrating images and timeworn stereotypes attached to the indígenas and the poor in the epidemic were not invented in Venezuela alone. Medicines, techniques of diagnosis and treatment, technologies, manuals, statistics, reports, and interpretations are transnational, moving rapidly among public health institutions around the world.
Images of Latin America cholera patients began to circle the globe in reports issued by WHO and the Pan American Health Organization (PAHO) as soon as the first cases were reported in Peru in January 1991, and they found their way into government agencies and newspaper articles and television reports. Descriptions of cholera patients were circulating in Venezuela ten months before Vibrio cholerae crossed the border, affecting how Venezuelans perceived the disease and the people it infected. Ideologies and practices of social inequality-particularly ways of perceiving and relating to persons in terms of their ability to internalize modern hygiene and biomedical conceptions of health and disease-were disseminated at the same time.
Clara and I listened for years to the ways that individuals in a host of settings talked about the cholera epidemic in Delta Amacuro, Venezuela, and Latin America. Each story created a dramatis personae, a series of events, and a set of causal inferences. Each depicted some parties as heroes who acted wisely and courageously, others as villains who promoted death for their own gain or glory, and still others who were pathetic bystanders not smart enough to get out of the way. Cholera stories circulated among employees in the public health sector, from the state director to physicians and nurses in small rural clinics, and they were also told by people who survived the illness and relatives and neighbors of those who did not. Vernacular healers, politicians, officials in government agencies, political activists, entrepreneurs, soldiers, journalists, and the people in the street also told cholera narratives. Stories circulated throughout the region with incredible rapidity. Governors, public health officials, taxi drivers, and patients frequently told the same narratives, albeit in different ways.
It is, of course, not simply the content of cholera narratives that rendered them potent. Until stories are retold, they have little impact. It is crucial to ask how stories circulate.
Excerpted from Stories in the Time of Cholera by Charles L. Briggs Clara Mantini-Briggs Copyright © 2003 by Regents of the University of California. Excerpted by permission.
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Table of ContentsList of Illustrations
Introduction: Death in the Delta
1. Preparing for a Bacterial Invasion: Cholera Control in Venezuela
2. Courtship of an Epidemic: Preparing for Cholera in Delta Amacuro
3. Stories of an Epidemic Foretold: Cholera Reaches Mariusa
4. Fighting Death in a Regional Clinic: Cholera Arrives in Pedernales
5. Turning Chaos into Control: Initial Responses by Regional Institutions
6. Containing an Indigenous Invasion: Quarantine in Barrancas
7. Exile and Internment: The Mariusans on La Tortuga
8. Medicine, Magic, and Military Might: Cholera Control on La Tortuga
9. Culture Equals Cholera: Official Explanations for the Epidemic
10. Challenging the Logic of Culture: Resistant Explanations for the Epidemic
11. Local Numbers and Global Power: The Role of Statistics
12. Sanitation and Global Citizenship: International Institutions and the Latin American Epidemic
13. Virulent Aftermath: The Consequences of the Epidemic