- Catalyst

Chopter ,,
as being of importance.Foreignscholarsand seniorindigenamen ordinarily cast thesestoriesinto the dustbin.when choleraarrived in the delta,
howevel,r'en lost their controlof culturalmernory.The richly detaileclstories told by women continue to shapethe way that Mariusansremember
the epidemicand perceiveqr"restions
of life.and death,health and clisease.
None of the storiestold by Mariusansgot much chanceto influencehow
other peoplcpercei'edand r-eacted
to the epidernic.The questior.r
was not
simply one of "access
to the press":reportersinterviewedMariusansshortly
after they left the coast,and severalstoriesabor-rtthe^r appeareilin l{otidiorio.Nonetheless,
Mariusansand other indigencrs
*"r" ,-,n,portrayedin
ne\vsp a p c rar
s r dt c lc v is ions to ri e sa s p e rs o n sw h o w e reerp l or.i ngnarrati ve
and intellectualrnodelsthat would help them make sensenf .irh"' therr
srtuation or what was ttrkingplacein the region.Instead,they appearedas ignorant and helplessvictims whoseonly choicewas to acceptor relect
the
explanationsand resourcesofferedby more knowledgerrble
and powerful
public health officialsand politicians.
It is easyto dismissthe cholerirstoriesthat the Mariusanstold as beine
too poorly formed to count as narrativesor as reflc-ctingignora'ce of
thi
epidemic'sbiomedicalfoundation.To do so,however;is to ignore the pernicious influenceof rhe region's racialeconomy-the socialand political
practicesthat enforcedinequalityin pervasivelyracializecl
terms.Tie Bustamantesin Mariusaand the reporrers,politicians,arndofticialsin Tucupira
and Barrancasall ignored these factors,which deprivedMari'sans
of the
chanceto preparefor choier,rand compromisecl
their attemptsto sort thrngs
out when peoplestartedto get sick.
4 FightingDeath
in a RegionalClinic
CholeraArriaes in Pedernales
On z August ag94 Daniel Rodriguez,the regionalepidemiologist,
and I
(ClaraMantini-Briggs)were travelingalongthe PaseoManamo,one of the
larger streetsin Tucupita.The riveq,on our right, wils dottedwith small boats.
Sorneof the newervessels
weredestroyingthe small-townserenityby travelirrgat strbstantial
speed,
while ancientvessels
inchedalonglike water-borne
srrails.
C)nthe other sideof the streetstretcheda line of smallmercantilcestablishnrentsthat includedat leastfour liquor stores(photographro).
A messageon the portableradio in the jeep requestedthat Rodrfgr.rez
proceedto the RegionalHealth Office.Its coda,"cholerain Pedernales,"
prompteda torrent of angry and frustratedwords from Rodriguez."I kne.w
it! I said so to the doctor [MagdalenaBenavides,
directorof the Regional
Health Officel,but she never paid any attention to me!"1 As he spoke,his
frrcegrew pale.I couldn't discernwhether his fear sprangfrom his knowledgeof the disasterthat choleracould produceor from his concernabout
how peoplewould judge his work. "What can you do with this town? You
know what hasto be done,and you tell peoplewhat hasto be done,and yet
you lack the power;the authority to makeit happen.I haverepeatedlytold
thcrn in Caracasthat you just can't get things done herc-.I havehad meetings with the governor,the chief stateadnrinistratotthe directorsof state
agencies."He continuedby drawing on his prime example."You saw what
h,rppenedin the anti-choleracommittee.Everybodygoesto the meetings,
but not a thing happens;everybodymakesstittementsto the press,but they
don't do anything. It's a good thing that upstairs[in the national MSAS
offices]they know that it's nor my fauit, that I did everythi^g thcy told rne
to do.That' sw hat happenst o you. "
He then turned to me and,rsked,"How long haveyou beenhere?,,Answerin6;his own quesrion,he said,"You have tried to establishyour proBr
Sz
Chapt t ' r4
FightingDcatlt in a RcgionalClinic
tl3
.ro. The PaseoMrnarnoin front of the river in Tr-rcupita,
rvith one
Photograph
by Charles
L. Briggs.
of its liquorstoresandtheparishchurchvisible.Photograph
gram, the Programade Salud Carnpesinae Indigena[Peasantand Indigenous Healrh Program],lvith tremendousenthnsiasm,and the governing
party sent [to] you as workersworthlessmembersof the party's faithful,
who
peoplewho were chumso[ the doctoror onesshe had recommended,
do exactlyas they please."
Justthen we saw IsabelRomero,the directorof medicalcareat the Regional Health Office. She [laggedus down and imrnediatelyannounced,
s l c 6 l e ran o s e n tr6p or P edernal es].
" Ch o l e rab r ok ein on us at P e d e rn a l e[e
The nursesthere don't haveany rredicines,and the doctorsarc on leave.I
just sent them this morning with the medicinesthat we had on hand. But
we alreadyhave the first cleath,an indiganagirl elevenyearsold. And on
top of everything, the people from Barrancaskeep calling the Regional
Health Office,the governor'soffice,and the natior.raloffices,sayingthat they
havesonreof our ird{gutas who are cirusinghealth problemsthere."
'And where'sthe doctor?"Rodriguezasked.
"You know that she'son leave,"repliedRomero.
Rodriguezcountered,"No, I know she'snot irround.The doctoris tteaer
aroundwhen anything happens."He turrredhis headto stareat a group of
weredanglingtheir feettrbove
drunkswho weresittingon the siclewalk.They
the opencanalthat servesas the town's sewersystem(photographrr). He
Photograph
r r. A mainstreetln thecenterof Tucrrprta,
w,ithan operlse\4,cr.
Photograph
by CharlesL. Briggs.
continued,rageand irustrationevidentin his voice.'And then the.ysaythat
I am a troublemake4as if we could think about diseasepreventionwhen
you can seethat we are in the capitalof the stateand the sewersare L-xposed.Sure, the governor'slived here ior years,and hc doesn'tcare.I've
told them time and time a5;ainthat they have to invest in health,but that
doesn'thelp lilgm get rich. And in any crrse,
they don't understand.They
don't have any foresightor rhe interestsof the peopleat hearr,much less
the Indians,who they would r-atherseedisap''pear.
The only thing that would
bother them is the ton of votesthey would lose."
Romero interrupted."Oh come on, Darriel,yorl rhink that they would
be sad about that? If the Indiansdisappear,
they won't have to spendthe
minuscule sums that they spend every five ycars to make a few rotten
schools,distributea little food and a few candiesto the comr'uniries,and,
most of all, get all the Indiansdrunk in order to makethem believethat this
84
I
Chapt er4
FightingDeath in tt RegionalClinic
c-
I
"
year their voteswill leadto an improvementin their condition.But, Daniel,
let's stop talking nonsense-if the doctorisn't around,who is going to be
i n c h a rg e ? "
D an i e lre p lied," Not m e! "
"Okay,I'll be," Romeroreturned."But rememberthat the only one who
can talk to the press,rboutcholerais you! And the physiciansare about to
arrive in Pedernales
without any ideaof what is waiting for thern,and the
nurses are sendingradio messagesbecausepatientsare arriving by the
We needto call a meetingof the anti-choleracommittee,
dozensin canoes.
becansenow they'll really be afraid.And officialsfrorn the nationaloffice
are coming,and we needto sendwc,rdto the doctor."
I chosethat moment to jump in. "Okay,let me suggest-don't you think
it would be better if I went to Pedernales
to begin the choleracontrol proc edu re?s "
The two doctorslookedat eachother and grantedapprovalwith a shrug
of their shoulders.
Reconstructing
this scenefrom memory was not difficuit,sinceI have relived it many times.Thesetwo individuals played essentialroles in siraping
institutionalresponses
to the choleraepidemic.Their wordspresaged
rntich
of what would be saitland donein the comingmonths.Rornero'srnetaphoricalcharacterization
of the beginningof the epidemic-"cholela brokein on
us at Pedernales"-is extremelytelling.The "us" is an institutionalplural
that equatesthe bordersof the regionand the institutionsthat adrninisterit
with the corporealspaceof the human body.It indicatesthat the most immediatethreatwasto institutionalwell-beingandto the reputarionsandjobs
of high officials.An irnportantdialecticof powerenlergesin Rodriguez'sresponse.An infuriating senseof impotence-his inability to take the sreps
that had l.'eenmandatedby national officials,public health practices,and rationality because
of ignclrance
and self-interect-is coupledwith a desireto
avoid rnakingdecisionsthat wiil be carefullyscrutinized.
Theseremarksalsoforeshadowthe complexway in which pulrlichealth
officialswould relateto politicians,the press,the public,andindigenasduring the courseoi the epidemic.Rodriguezblamespoliticiansfor the acute
inadequacyof sanitaryinfrirstructuresin Tuctrpitaand the inabiiity to improve public health in general.He had cornrnentede,rrlierthat the assignindividualsto the Peasantand
ment of unqualifiedand often trndisciplined
IndigenousHealth Programthat I directedon the basisof their virlueto the
PartidoAcci5nDemocrdticacameat the insistenceof Benavides,
herselfan
influentialparty rnember.Thesepointsof intersectionbetweenpoliticsand
public healthwould becomeparricularlycrucialdtiring the first electionof
stateand rnunicipalofficialsin Delta Amacuro,which had becomea statein
4991.
Rornero'sstatementto Rodriguezpoints to her foresightregardingthe
importanceof the role tl-represswas to play in the epide[ric.The national
epidemiologist-and,by extension,his regionalcounterparts-hird control
or,erthe releaseof information about choleraand the epidemicto other institutions ancl the press.Reguladng the representationsof cholera that
emergedin the pubiic sphere,particularlyin the press,was one of the RegionalHealth Office'smost importantjobs during the epidemic.An image
of publichealthofficialsaersusthe pressis too simplistic,however.Institutions often keep1 reporteron staff,and for theseindividualsgeneratingposirive imagesof publichealthofficialswas asviral as fendingoff hostilepubstrayedfrom the parameterssetup by pul''lic
licity.Indeed,the pressseldon-r
heolth authorities.
Finally,the epidemicwas racializedfrom the outset.Cholerawas closeiy
identifiedwith "Indians." Although the term indigenawas generallyused
inditt ("Indtan" ) wirsmore cornmonin informal converin publicdiscourse,
Tht 'quest ionit nsi l ri on,p.trri cul arlywhen t he ir nplicat ionwas pejor at ive.
mediatelyaroseas to whether the epidemicwould signalthe long-expected
This questionhid a deepeasubversiveques"extinction" ctfIa itrtiLttDtlr(1o.
tion: Would the interestsof politiciansand government officialsbe best
servedby the "extinction" or by the "preservation"of this population?In
as indigenasaskedthemselves
the following months many peopleclassified
this question.
during the
Romero'srernarksconveythe chaosthat peopleexperienced
hadbeenmade,andmany
eirrlydaysof the epidemic.
Almost no preparations
clinicslackedphysiciansand medicine.The responseof public health and
other institutionsto the epidemicwas to attelnptto move from a situation
of ernergencvalarm,and crisisto one of orderand normalcy."Control" was
the masterstrategythat guidedthis effort.The officiallocusof attemptsto
control cholerawas to containthe diseasemedicaliy.The "choleracontrol
campaign"brought unprecedentednumbers of dedicatedindividuals,rncludingphysiciansand other medicalpersonnel,antibiotics,rehydrationsolutions,anclother medicaisupplies,and boats,gasoline,and food into delta
cornmunities.
Officialsalso sor.rghtto control the tremendousthreat to their institutionsandiobs.An explosionof cases
prepawould exposethe lackof adequate
rationsand the deplornblestateof public health in the delta.If this threat
I
86
FightingDeath in a RegionalClinic
Chapt er4
I
8l
the nursesthen quipped,"Of courseshe'sgoing! That's what they're like,
travelingaround the rivers following thoseIndians!"
Another nurse interruptedher to add,"That docto4,hmm! She'sgoing
to end up married to some Indian over there, you'll see!" Her comment
elicitedlaughterfrom the rest.
"This businessisn't a joke," interruptedRomero,using her usual macalled,saying
ternal tone of voice."The poor doctorsthere in Pedernales
that they need help, that the clinic is full of Indians,and that things are
photograph
MSAS,in Tucupita.
HealthService,
of the Regional
rz. Headquarters
L.
Briggs.
by
Charles
Photograph
couldbe adequatelycontrolled,it might evenprovideopportunitiesfor exwhile officialsin Tucupitaworpandingtheir agency'spower and resources.
ried about broad logisticaland institutional issues,medicalpersonnelin
did not havethe time to stockpileresourcesor
Nabasanukaand Pedernales
The problem in theseclinics
press
conferences.
and
meetings
hold endless
andvomit,andmany of them
diarrhea
wasbodies-lots of them,all emitting
showing signsof the advanceddehydrationthat could leadto rapid death.
R ACE A ND
DEATII
I N A M EDICAL
EM ERCENCY
of the RegionalHealth SerWhen I arrived ar the Tucupitaheadquarrers
after the officialarrival of
day
one
a992,
vice (photographrz) on 3 August
cholera,I found Ronero shouting instructionsto ernployeeswho were in
I asked
the medicalsuppliesstoreroompreparinga shipmentfor Pedernales.
patients
seventeen
that
replied
Romero
and
area,
in
that
about the patients
had beentransportedto the Luis RazettiHospitalin Tucupitadue to severe
dehydration.Only one still neededintravenousrehydration'
On our way from the storeroomto our offices,we stoppedat the office
where we exchangedgreetingswith the staff and acof nursing services,
cepteda hospitablecup of coffee.AnamariaTejeraaskedme if it was true
to which I respondedaffirmativeiy.One of
that I was going to Pedernales,
crazy."
One of the nursesbroke in. "Well, this choleramay overrun Tucupita."
Another staff member added,"Once this choleragetsstartedit won't stop.
staysin the populationfot minimum, ten years."
They saythat this disease
"Okay,
it starts over there in the delta. But when it
Tejeracommented,
gets here-over where I live we have problemswith the wate4 and this
choleracould make things really bad for us."
Trying to calm thesefears,TomasaGabald6n,chief of the nursing office,
said soothingly,"How is choleragoing to reachus here?The truth is that
well, we all know the conditionsin which thoseInit hit the deltabecause,
dians live-malnourished, tubercula4,with mange,malaria.And do you
know how they eat?On the floor,with mangy dogsright next to them, eating out of the sameplate.They don't even wash the plateswhen they are
going to eat.They're filthy and smelly.And on top of it all, they don't have
any supply of cleanwateq,becauseyou know that while they are eating
someoneis next to them shitting [cagando]."
Her statementeliciteda chorusof iaughterfrom her staff,who then intoned together,"What did you say,Mrs. Tomasa?"
"S-h-i-t-t-i-n-g," she spelledout with mock seriousness.
"Well, I think
that the bestthing that couldhappento them is that they couldall die off!"
This remark prompteda generalexclamationfrom severalpersonsand
an admonition-/Now really!"-from Romero.
Gabald6ncontinued,"That just goesto show you-these Indiansdon't
get a break,not from God, not from the Devil, the Adecos,the Copeyanos,
or the Masistas.2
Eventhe priestsexploit thern.And now cholera-God must
surely have sentit!" With thesewords ringing in my earsI left the MSAS
building and walked down the streetto the dock,where a large blue boat
was moored,piled high with boxescarefullylabeled"Pedernales."
My first trip into the fluvial regionbegan.I watchedthe vegetationthat
floatson the river's surfaceglide pastlike a greencarpet.About four hours
later the boat arrivedin Pedernales.
Locatedin the northwestcornerof the
delta,Pedernales
is oricnredtoward the port of Giiiria (whichlies acrossthe
88
Chapt er4
Photograph
13. A streetin Pedernales,
with its usualvehiculartraffic.Photograph
by CharlesL. Briggs.
Gulf of Paria),Trinidad(tor which it servesasthe maior route into the delta;,
was discovered
by the modern
andTucupita(seernap1, pagez). Pedernales
on Capr-rre,
an adjacentisworld in r89o, when four oil wells were opene-d
land.StirndardOil of New Jerseyand its Venezuelan
affiliatesbegantheir oil
activitiesin the areasoonaftet and operationscontinuedthrough the midr96os.The companywasjoined at variouspointsby RichmondExploration
Barco,TexasPetroleumCclmpany,and Texaco.3
Companyof Venezuela,
is now a major administrativecenter.lt becamea municipalPedernales
ity with its own administrationand budgetwhen DeltaAmacuro,formerly
a federalterritory, becamea statein r99r. Accordingto the 199o census,
Pedernales's
populationof n7 is primarily "criollo." If it weren't for the
is an olrtpostin
ahsenceof cars,it would be hard to believethat Peclernales
town
on thL'mainthe middle of a small island in the delta rather than a
land. The main part oi the town consistsof well-constructedhouses,featuring tall doorsandwindows and indoor plumbing,that arelined up aiong
livpavedstreets(photographr3). The indigenapopulationis segregated,
paved
streets.
ing on the southernand easternfringesof town, beyondthe
of old piecesof metal roofing and
Their ramshacklehousesare constructecl
havethatchedroofsand walls.Waraoresidentsare not unwelcomeir-rPecler-
FightingDeath in n RegionalClinic
d9
nales,as they are in Tucupitaand Barrancas.
and many find decentjobs in
the fishing industry.Nevertheless,
they are second-class
cirizens,their status markednot only by their povertybut alsoby the jibes andjokes told by
criollo residentsand the assumptionthat criolloscandupe the indigenaswtth
ease,especiallyadolescent
girls.
The clinicis abouta blockfrom the "Warao sector"and aboutfour blocks
irom the municipal dock.As my boat arrived I saw a number of familiar
faces,particularlythoseof the nurseswho went eachmonth toTucupitain
scarchof medicinesand paychecks.
Other residentswaited alongsidewith
a wheelbarrow.After thesevolunteers helpedunload the cargo,the pilot of
the boat introducedme: "This is Dr. Clara,the assistantregionalepidemrologist." "How long will you be here?"askedthe man handlingthe wheelbarrow BeforeI could answerhe declared,"Things are bad here! you see
this wheelbarrow?This is the locirltransport.It's how we pick up thoseIndiansw]ren they arrive half-dead."By this tirne the wheelbarrorn'rvas
full
of boxes.Simulatingthe soundof an ambulance,
the man took off, pushing
his vehiclealong the srreets.
When I arrived at the clinic I greeredthe two residentphysicians,Marina Parraand Lilibeth Morillo, andwasimmediatelystruckby the vasthutran seathat filled the clinic.onc of the larger clinicsin the fluvial area,lt
is a squarestructuresomethirty-five meterson eachside,with wardsdistributedaroundan interior courtyard.Approximatelyfive hundredpersons
filied the entrance,hallways,waiting and examiningrooms,and courryard.
Their facesreflectedexhaustion,confusion,,rnda strongsenseof terror and
urlcertiiintyborn of the knowledgethat they might die from a diseasethat
none of thern had heardof the previousweek.clinic directorParrastudied
rny rcactionto the scenewhile rernainingthorotighly professionaland led
me through the tr"rmultof crying childrenand adultswho were hoping for
a sign that they would not die.The clarnorwas so loud that Parrawaspracti cal l yshouti ng.
The first room we camero held the sevenor eight patientsin the most
criticalcondition;all were suffering from seriousdehydration.In the nc-xt
room patienrsin lessseriousconditionlay not in standardmetal hospital
bedsbut on blue canvilscors,eachwith a large hole in the center.Eachcot
hild a rrash bag fitted inro this opening;th* hug hung down into a bucket
containingchlorineto kill the vibrio clrcIeraein the dinrrheathat cascaded
througlr the hole.Thesehtrmblebedswere a direct responseto guideli.es
generatedin Genevaby WHO and passedvia pAHO to MSAS and then to
thc RegionalHealth Sc-rvice
in Tucupita.
90
I
Chapt er4
on what Parrawassaying.My
At times I found it difficult to concentrate
stenchproducedby
penetrating
the
nostrils and lungs were assaultedby
the mixture of fecesand chlorine.The nursesand cleaningstaff fought valiantly to maintaina semblanceof hygienein that environment.In the middle of the patio a wortan wearinggloves,a surgicalmask,and an apronwas
hand-washingall of the linen usedin the clinic.Medical8owns,sheets,and
o t her i re mshad bc enplac edi n a l a rg etu b c o n ta i n i n ga S c nerousquanti ty
water drawn from the river by an elecof chlorine and chocolate-colored
tric pump.
All the criticallyill patientshad beenbrought backfrom their respective
Their bodieswere shrunken
Ievelsof dehydrationand were now stabilized.
and sweaty,and their voices,as they tried to respondto Parra'squestions,
were practicallyinaudible.She explainedto me that although the process
of rehydrationwas remarkablyrapid,it wasnecessaryto watchpatients carefully sincesomeinexplicablytook a suddendownturn. In the main examining room Morillo was examiningthe lessseverelydehydratedpatients,
and filling cupswith
of antibioticsfrom largecontainers,
extractingcapsules
oral rehydrationsolution from a largeplasticcooler.Shewas accompanied
beby a nursewho was providinga sputteringtranslationof the exchanges
tween doctorand patient.The ngrsebrought patientsforward accordingto
a list of patients.
rnadea dramaticentrance
At that moment a wheelbarrow-ambulance
through the main door of the clinic and into the examiningroom. As the
d r iv e r si mu lat edt he s oundo f a s i re n ," n y u trg u ," h i s c ri e stemporari l ysi lencedthe tumuit. The driver tilted his vehiclefirst to the left, then to the
right, avoidingphysicians,nurses,and the throng of patients'The wheelbarrow containedthe semi-nakedbody of a man,his armsandlegsdangling
Iooselytoward the floor.He resembleda rag doll ol perhaps,an anthropornorphicfigure of death.As parienrsrecoiled,giving the driver more room,
parra ordered,,,Puthim in with the other patientsin intensivecare."The
driver was aboutto say something,but the nurseinterruptedhim. "Follow
me," he instructed."I'il help you put him on the bed." The wheelbarrow
started down the hallway, and Parraand I beganto follow'
As we left the examiningroom the tumult reachedan evenSreaterlevel.
New patientsfrom the boat had enteredthe clinic.Morillo shouted,"will
the oneswho havejust arrived stay here!" Children criedand the anxiety
of ali the patientsrose.A woman grabbedMorillo's sleeveandimploreddisatida, m aukwatida! " (My daughtel,my daughter! )'
consolately," MotrkTL)
Women who had arrived the day beforetook her by the hand and led her
ro a cornerin the hallway.They beganto conversewith her in Waraowhile
FightingDeath h a RegionalClinic
I
9t
passingher cupsof oral rehydrationsolution.Morillo and two nursesbegan to add new namesto the list of patientsand to quickly provideantibioticsand oral rehydrationsolution for eachnew personwith diarrhea.He
alsoprovidedasymptomaticfamily memberswith dosesof antibiotics.
When Parraand I enteredintensivecare,the man who had beenin the
wheelbarrowwas stretchedout on one of the cots,and the ambulancedriver was exiting rapidly.He murmured in passing,"I'll be right backwith
somepatientswho are too weak to walk." The nursewas alreadycleaning
the patient.Sinceno verbalinformation canbe elicitedfrom semiconscious
have to rely on what we can observe.The stateof
patients,we ph,vsicians
and
color of the skin, and blood pressureand heart
the eyes,the turgidity
rate providegoodindicatorsof the degreeof dehydration.This patienthad
experienceda dangerousdrop in blood pressure,and we determinedthat four
IVs, one in each arm and ankle, would be necessaryto rehydrate him
sufficientlyto avoidpermanentdamageto his kidneysor other organs.His
bed was a spider'sweb of bottlesand tubes.
When we left the intensivecareunit we for,rndthat, remarkably,Morillo and the nurseshad providedtreatmentfor the patientsand their close
rclatives-who are termed '/contacts"-and restoredcalm.The crowdwas
sippingcupsof rehydrationsolutionand chattingas if they were attending
a cocktailparty.The physiciansslippedaway to the relativeprivacy of the
doctors'quarters.As we preparedand ateour dinner we mappedshifts,flipas asslsping a coin to decidethe order.I then assumedmy responsibilities
tant regionalepidemiologist,
shifting my focusfrom treatingindividualpatients to bringing choleraunder control in the lower westerndelta.After
Morillo and Parrahad providedme with information regardingthe iocation and approximatepopulationof areacommunities,we designedstrategies for ending local outbreaksand preventingnew cases.By the time we
had finishedeatingand Parrahad left to take the first shift, we had a plan
of actionand felt ready to put it into place.
Early the next morning I met with community leaders.Theseincluded
the judge,the policechief,the commanderof the local GuardiaNacional,
thc friar in chargeof the Capuchinmission,teachers,
ownersof the fishing
enterprises,
presidentsof neighborhoodorganizations,
and medicalpersonnel. After taking an inventory of the boats,gasoline,chlorine,medicrnes,
and other suppliesthat we could use,we decidedto launch a door-to-door
informational program and to inauguratea clean-upeffort aimed at the
public dump and the river shore.The level of fear in the community was
suchthat supportwas forthcomingfrom evcry sector.I then turned to my
next task:exhuming thc body of the first personto die from choleraand
92
Clt npt t : r4
placinglime and chlorinein all of the corpse'sorifices,asdictatedby MSAS
guidelines.
arrivedlater that day.He helped
the regionalepiderniologist,
Roclrfguez,
and
helpedlaunch the health edudecidewhich communitiesto visit first
The arrivalof publichealthphysicianRoberto
cationprogramin Pedernales.
Guzm6n and nurse RicardoSim5n provicledus with much-neededhelp for
the cholera control efforts. Guzm6n is tall and relatively thin, with a
roundish facethat frequentlybearsa friencllysmile.He is a conscientious
physicianwho was quite concernedwith the well-beingof communitiesin
the fluvial area.Sim6n was the only personclassifiedas indigenaand one
of only a handful of nursesin the deltawho had receiveda university destandard,the coursein simplified
greein nursinp;(ratherthan the regionarl
The
medicine,which combineslimited courseworkand practicalexperience).
institutional racismthat deems indigenttsincapableof adequatelymasterand practices-and that guardsagainstthe posing modernepistemologies
,,a Warao" might supervisethe work of criollos-had denied
sibility that
sim6n a positionof responsibility,keepinghim at the levelof a "nursing assistant, (enfermcro auxiliarl A member of a politicallyimportant family of
a
the MacareoRiver area,Sim6n is short,stocky,and strong'He possesses
communities
delta
of
knowledge
goodsenseoi humor.He has an extensive
Guzm6nand Sirn6nassumed
and a desireto improvethe lot of its residents.
responsibilityfor the Manamo River area.
My team included Al{redo Guacara,a nurse frorn Tucupita assignedto
office.Guacarahad learneda Sreatdealabout
the regionalepidemiologist's
publichealth by working with Rodriguezand his staff and through particTall, dark, and athletic,Guacarawas reipation in vaccilation campaigns.
to racialhierarchiesand had a strong desireto
Iuctantto make coucessions
in
improve health conditions the lluvitrl region.Thesequalities,cor.nbined
with his great enthusiasmand seerninglyinexhaustibleenergy,were invaluablein the days ro corle. Neither Guacaranor I spokeWarao,but the
driver of our boathad a rudimentary knowledgeof the language.FIewas a
srrong fellow of about thirty-five with deepblack,expressiveeyes,a boyknowledgeof the area'srivers
ish grin, a calmingmanne(,and an impeccable
River
and communities.Our teamassumedresponsibilityfor the Pedernales
sector.
Eachteam iollowedthe sameroutine in eachcommunity.Eachboat was
chlorinesolution,.lnd other supwith a largeamount of rr-retlicine's,
stockecl
plies,sufficientto treat patients,reequipsmall clinics,use in heirltheducaand supply iocaloral rehydrationcenters.Personswith
tion presentations,
cholerasvmptomswererreatedwherethey lay.In eachhouseholdwe trained
FightingDeath in a RegionalClinic
93
r4. Walirnoko.
by Charles
L. Briggs.
Photograph
Photograph
solutionthat wasusedto treat
oneindividualto preparethe oral rehydratior.r
all casesof diarrhea.We alsoobservedthe preparationand consurnptionof
food.AII presentreceivedinstructionregardingcholerasymptomsand how
We worked nonstopuntil nightfall, then
to prevent and treat the disease.
we returned to the Pedernales
clinic,where we helpeduntil we were overcomeby exhaustion.
On one rainy Ar"rgust
morning our route took us to Waranoko(seenrapr
on pagez and photograph14),wherewe found about threehundredpeople
crowdedinto the housesof this small comrnunity.We soon learnedthat
this suddenpopulationincreasewasdue to irn influx of residentsfrom nearby communitieswho had grabbedtheir belongingsand fled their homes
when peoplebeganto die.The community's clinic (type I) was locatedin
the home of CasimiroSilva, who receiveda small salary from MSAS for
this service.As we approachedthe site Silva calledto us and appealedfor
help.Fatiguehad transformedthe soft featuresof his young faceinto a mask.
Hc relatedthat for dayshis househad beenfull of patients,that he had run
out of medicine,that he was in despairbecause"the canoeskeepcoming in
all tl'retime with more and more people.
" As he motionedus insidehis house
we could seeten of the more seriouslydehydratedpatientsand l.tottlesof
rehydration solution dangling from the bcamsof the thatchedrooi ,rbove
their hammocks.
94
/
Chapt er4
The two nursesand I worked all morning, checkingthe conditionof patients,providing antibioticsto thosewho had been exp.se.lto the disease
and who might be asyrnpromaricccrriers,and showing a member of each
householdhow to prepareoral rehydrations.lution. we enlistedthe assistance of the principal local healer to teirch residentsabout ch.lera, the
benefitsof oral rehydrations.lution, and the importanceof using it to treat
any type of diarrheaand to impressupon everyonethe importanceof hygiene.The csmisayis-1helocalgovernrlentalrepresentative-helpedthe
vernacularhealerreportingnew casesand keepingtrack of groupsseeking
treatmentthat arrivedfrorn other communities.
Just as we were finally wrapping up orlr work, a profound silencesuddenly descendedupon the commurrity.Mute children,women, and men
staredfixedly at a canoerhat was moving painfully slowly aiong the river
toward Silva'shouse-clinic.
As the boarcarneto shore,menjumped our inro
the water and draggedit up to the-dock.Peopleon rhe bank,I alnongthem,
movedevery which way to get a goodview of the occ'pantsof the craft.we
salvabout fifteenpeoplepackedinto the boat'ssmall quarrers.They stared
fixedly at the horizon,soakedbv rain and u.done by terror and dehydration.No oneon shoreseemedcapable
of utteri.g a singleword,perhapsholdi'g their breathto seeif tireseemaciatedbodieswould emit any sign of life.
The faceof a wornanwho sat at the far end of the canoew.s the mosr arrestirlg.The sadnessand desolationit expressedwere strikir-rg.Her skin
seemeddesiccarted
despitehaving beenmoistencdby the rain, her eyeshad
sunk into their sockets,
and her body was so thin that her boneswere visible beneaththe skin o. her face.Her hendbowed,she staredat an infant
who was wrappedin the fold of her bright floral skirt.
The rninutesof silencethat elapsedas the canoewas pulled to thc dock
and securedfinally endedasour piiot askedthe passengers
wherethey lived.
He receivedno reply,but his initiative spurredthe onlookersto help the
peopleclimb out of the canoe.The order in which the passengers
were
brought into the clinic-housewas determinedbv their locationin the canoe
rather than the apparentseverity of their condition.I had gone with the
nurseto find a new sitewithin the residence
that couldbe claimedfor medical cirrewhen I heardthe pilot shout abovethe clamor,"Call the doctorthere are four deadbodiesherel" I shoutedbackfrom the other sideof the
house-,"Leave the deadin the canoefor now Let's treat the livine first!"
The fires were stokedwith wood in order to boil water irnd pr"p..",r,,..
rehydrationsoh-rtion.
we beganto distributervhatrvasleft fronr the rnorning's brew among the newcomers.I hookedrrp IVs to rhe more seriouslyill
and tlieci to kec'pthesenew patients,many of whom rveresoakedin diar-
Figl:tirtgDeath in tr RegionalClinic
I
yS
rhea, frorn reinfecti.g the people who were being treated.our efforts to
chc'ckthe conditio. of padentswere impededby the mazeof hamrnockropes,
the IVs, and the relariveswho were seatednearby.we strainedto seethrolrgl.l
clouclsof srnol<e
ge.erateclby burning greenor wet logs.silva, fully bilingual,communicatedwith patientsand relativesalike,instructingthe latter
on how to wash their handswith soapafter goi'g to the bathrounrand b"fore eating.The latter instruction was uninrentionally ironic, given that
there was alreadyvery little to eat in rhe community and thut ther" *ere
now many additionalpeopleto ieed.
I was working with the healer and comisariowhen Guacaracalledme
over to the dock.I felt resentfulthat I had beeninterrr,rpted
until I saw that
he and severalmen were attemptto move the woman in the backof the canoe,who was desperatelyembracingher child. ,,Bring her to me,,,I cried.
whe'r someonenearby advisedme quietly, "Ir's rhat she doesn'twirnt to
let go of the chlld," I added.',Bring them both at the sametime.,,But the
men simply lookedat me.
The pilot cameover and whispered,"Look, docto4,
what hashappenedis
thi rt.ne of the co'psesin r he cr noeis her hushancJ,
ond t he childsf iehasr n
her arms is dead,too." I tried to repressmy own fear and ang'ish, inspirccl
n.t so much by the thought that this wo'an had lost her child and hr.rsba'd as by the sight of her snrroundedby corpsesand, most of ail, by trre
crpressi onon her f acc.
To providethe woinan wirh a se.rblanceof privacy and dignity, people
turrled away as several
gently helpedher; still clurchinghe'. ghostly
'ren
child,ascendo.to the d.ck.wornen graspedtheir own children,instinctively
tryi.g to protccrthem, and a pr.found silencefell onceagainover the entire communiry.Everyonehad stoppedwhat they were doing anri seemed
to be reflectingon what this shatteredwomirn must be feellng.supported
by two men, shetook severalpainful stepsin the directionof tir" hum,-,-rock
that had beenpreparedfor her.As shesatdown,her hair still shroudi.g her
child,I couldbarelyheara murm'r emanatingfrorn her lips.In a voice
weakened by dehydrarion,she repearedover and over,like a secret,
constanr
prayet " Mnukwatidn, m'ukutatida,,, attemptLng
to intone .a sons.She lay
down in the hamrnock,holding the child'sbody to her chestwith
wrinkled
hands.Her eyes seemedfocusedon another worlcl,and
she repeatedher
prayerful words.She could barely hold on to her infant.
shc *as seriousry
dehydrated.D i arrheapour edint o t he buckc-beneat
t
ht he ham m . ck, and
her p' l se w as barcly audible.she was near ly unconscions.
wc gcnt r y r ernovedthe child,and the r'vvonursesand I h'oked up
rhe IVs
gnr,. h",
^,.,J
antibiotics.
96
I
Chapt er4
FightingDeath in a RegionalClinic
I
gl
He left
Guacaraand I then returnedto the canoeto dealwith the corpses.
canoes
small
into
the
carved
with severalmen to fell trees that would be
that often serveascoffins.Meanwhile,a nurseassistedme in impregnating
were ready
all orificesof eachcorpsewith chlorine.When the canoe-coffins
them
dusted
and
corpses
the
laid
out
then
lime,
with
we dustedthe interiors
a
distant
into
canoes
five
the
with rnore lime. A funeral processioncarried
and swampypart of the forest.Eachwas coveredwith mud and huge palm
leavesand suspendedin forks formed abovethe ground by felling two trees
"Then why didn't you come and take the medicationwhen they called
you?" The woman simply lookedaway,becomingeven more ashamed.
At that moment, a community leadersteppedforward and angrily addressedme. "Look, madam," he said,raising his hand in a gestureof au"what happenedis that thesepeoplearrived last
thority and exasperation,
night tired and sufferingfrom diarrheaafter paddlingfor hours.And then
it turns out that you haveto have a name here to get a pill."
Sim6n interrupted,"So who cameup with the name-the woman her-
and lashingthem togetherto form an X.
Beforedeparting,we directedthe implementationof a preventionproand all the medicineand
gram, leaving bottles of chlorine,eyedroppers,
of oral rehydration saltswe could spare.We then checkedthe
"nu.lop.,
patientsone more time, promisedto return as soonas possible,and left for
During the return trip we encounteredtwo largecanoestrying
Pedernales.
died.
to reachthe clinicbeforea number of severeiydehydratedpassengers
with us,we reachedPedBringing the most seriouslyill of thesepassengers
of someforty more paarrival
the
for
prepare
Morillo
ernalesand helped
physicallyand emomost
the
of
It had beenone
tients beforewe collapsed.
self or sorneoneelse?"
The leadercontinued,"That's what I'm telling you. Lastnight the nurse
and the doctorgavethem thesenames,and she has forgottenhers."
I asked,"You mean that Warao peopledon't have names?"
The leaderanswered,"Well, somedo havenamesin Spanish,but others
tionally trying daysof my stay in Pedernales.
Beforeleavingthe clinic the following morning, Guzmdn and I stopped
nurseswere callingout the
to observethe routine.Two Spanish-speaking
be briefly examinedand
could
each
namesof ambulatorypatientsso that
giv cn th e i r anr ibiot ict r c c t m c n ts .I c o u l ds e eth a t th e n u rs esw ert' havi ng
difficulty surnrnoningthe patientsby name.One nurseannounced,for example,"JuanaAloy." When no one responded,he repeated,"JuanaAloy"
severaltimes more.After hearingthe nurseshout, "JuanaAloy | " a few more
that the patientwas "retimes,I steppedin. My rnedicaltraining suggested
sistant"or "noncornpliant"-that is,wasrefusingto takethe requiredmedication.I askeda couplewho was standingin front of rne what was going
on. They merely shooktheir headsand said,"I don't know'" I calledSim6n
and a ske dh i m t o inv c s r ig, a tc .
that the bearer
He discovered
By that time the nursehadmet with success.
,,JuanaAloy" was seatedlessthan a meter away frorn him. As
of the name
shecameup to takeher medicine,the nursesaid,"You seehow stupidthese
Warao are.They don,t even know their own names!" Making pejorative
commentsaboutindigenrts,a commonpracticein Delta Amacuro,is meant
themselvescriollos.Sim6n askedthe woman
to amusethosewho c<tnsider
"What happened'sister?
embarrassed,
deepiy
in Warao,who was obviously
H ad yo u fa l l enas lec P ?"
"No," she rcsponded,"I was right over there."
don' 1."
Sim6n added,"The oneswho go to schooland are raisedin the mission
do, but not everyone."At this point, the nurse resumedreadingnamesoff
the list, shouting,"Jos6P6.reztJos6P6tezl"
emergedfrom a group sitting near
an adolescent
After somediscussion,
was alsosubmittedto
us,and someonesaid,"This is him." The adolescent
the gauntlet of iaughter and raunts.Trying to justify a practicethat he
seemedto find demeaningfor everyone,Guzmdn muttered ambivalently,
"We have to keepa registerof patients,"and we left the clinic.
Our effortsbore epiNearly a month went by beforewe left Pedernales.
demiologicaifruit within aboutthree weeksof intensivework: the number
of choleracasesin thesecommunitiesfell by some 90 percent.The health
educationprogramwaswell received,which greatly pleasedme. Nevertheless,the constantflow of insults directedat indigenapatientsby the residents of Pedernalesand government officials,including those employed by
publichealth institutions,wore me down to the point that I requestedpermissionto return temporarily to Tucupita.