martes, febrero 10, 2009

Cueto (2003). Stigma and Blame during an Epidemic. Cholera in Peru, 1991.

Cueto, Marcos. 2003. Stigma and Blame during an Epidemic. Cholera in Peru, 1991. In Diego Armus (ed.) Disease in the History of Modern Latin America. Durham: Duke University Press.

Looking at epidemics in specific societies can lead to understand social production of inequalities or can lead to reinforce them through strategic uses of blaming-the-sick rhetoric. Something like this happened with the Cholera in Peru in 1991 when “inner forces” (Sendero Luminoso) and “outer forces” (World Bank, IMF) put Peru under major sets of “crisis”: economic, political violence, collapse of public services, reduction of the state under neo-liberal policies, etc. One thing that underscores this article is the political manipulation and masking of the key role of (poor or inexistent) water and sewage systems that made possible the epidemics of Cholera (and the individualization of the problem), the fight that health workers made to the disease, and the general and governmental perceptions and images that emerged during and after the epidemic and the after effects in the general public health.

When Cholera started to spread in some parts of the country, the first reaction was to develop radical measures that would control the Cholera (ban of fish, veggies, fruits, raw, and canned food, then quarantines of Peruvian passengers in international airports, etc.). In the first months Cholera had a different impact in the urban, rural, highlands or Amazon areas according to the distinct access (or not) to (un)contaminated water (safe drinking water was unequally accessible: in rural areas only 22%, in cities 67%, and in shantytowns 24% of the population). Although diarrheal diseases was always present, and even though Peru had the 3rd highest rate of infant mortality mainly caused by these types of diseases, the extension of the Cholera epidemic was immense. And it came in the “worst moment”, when hyperinflation, political violence and terrorism (both military and guerrilla were terrorists killing and disappearing thousands of people) were devastating the country (although one would be inclined to think that Cholera came because of the social conditions).

At this juncture Dr. Vidal, the Peruvian minister of Health at that time, started a campaign to change the behavior and perceptions of common people, he follow WHO indications and implemented oral rehydration therapy and wide use of antibiotics to help patients in the overcrowded public hospital of Peru. During the epidemics Peruvian researchers found out that the literature in relation to treatment to severe cases of Cholera was wrong and they developed low-cost effective treatments using saline solutions. Another thing that happened was that people went massively to the public and free hospitals in contrast with the 1980s when a movement of de-centralization of public health, with the influence of primary health care movement, was de-hospitalizing public health. But much criticism arose to Dr. Vidal’s policies and he eventually quitted his job. Fujimori denied that eating raw fish could lead to Cholera and the government changed its campaign focusing on the individual behavior, especially poor individual behavior, for the government and media the equation was clear filthiness + poor areas (slums) = Cholera. This, indeed, masked the deeper? real? causes of the problem, that unequal access to water & sewage & health services = Cholera. It became a self-fulfilling prophecy, because the majority of the people that died from Cholera came from the slums and the lower classes of the urban spectrum, this should lead to conclude that it is their fault, and they are the causes of Cholera. In fact, as Naomi Klein suggests with her “shock doctrine”, Cholera reinforced the neoliberal trend, and Charles Briggs also implies that Cholera stigmatization was instrumental in further marginalizing of the poorest inhabitants of the cities. The final note to highlight is that after the epidemics many Peruvians “realized that taking care of the sick was an individual and family responsibility and expected less from the state” (285), and if this is true it means that the neoliberal policies and the idolaters of the shrinking of the state have won.

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