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Stories in the Time of Cholera

Racial Profiling during a Medical Nightmare

Charles L. Briggs (Author), Clara Mantini-Briggs (Contributor)


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Cholera, although it can kill an adult through dehydration in half a day, is easily treated. Yet in 1992-93, some five hundred people died from cholera in the Orinoco Delta of eastern Venezuela. In some communities, a third of the adults died in a single night, as anthropologist Charles Briggs and Clara Mantini-Briggs, a Venezuelan public health physician, reveal in their frontline report. Why, they ask in this moving and thought-provoking account, did so many die near the end of the twentieth century from a bacterial infection associated with the premodern past?

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.

List 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

Charles L. Briggs is the Alan Dundes Distinguished Professor and Professor and Professor of Anthropology at the University of California, Berkeley, and most recently coauthored Voices of Modernity (with Richard Bauman, 2003). Clara Mantini-Briggs, M.D. M.P.H., is an Associate Researcher in the Department of Demography and is affiliated with the PhD Program in Medical Anthropology at the University of California, Berkeley and the Director of Fundación para las Investigaciones Aplicadas Orinoco, which conducts research and initiates programs aimed at improving health conditions in Delta Amacuro, Venezuela.
“Charles and Clara (Mantini) Briggs powerfully unveil the complexity of the early 1990s cholera epidemic . . . [their book is] sophisticated and informative.”—Latin American Research Review
"Ten years ago, cholera ‘raced’ through part of eastern Venezuela, moving along social fault lines long in the making. This harrowing and beautifully written account chronicles a complex array of social responses to an epidemic and shows us what an engaged and responsible anthropology can offer those seeking to understand and prevent such plagues—and the injustices that foster them. Stories in the Time of Cholera is sure to have broad appeal within the social sciences and public health, and it should be required reading for public authorities and the press, whose prejudices clearly compounded the injuries meted out by the microbe itself. This is an exceedingly important book."—Paul Farmer, author of Infections and Inequalities

"Sometimes the historian can only envy the ethnographer's ability to observe and configure complex social and conceptual worlds. This study of cholera constitutes one of those occasions: I can only admire the authors' ability to unravel class, attitudinal, and institutional relationships, using social responses to cholera as their sampling device."—Charles E. Rosenberg, author of Explaining Epidemics

J. I. Staley Prize, School of American Research

2004 Bryce Wood Book Award, Latin American Studies Association

Death 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).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.2 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.3 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.4 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 19925

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.6 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. Which stories became part of official statements by regional, national, and international public health authorities? Which accounts of cholera made it into the regional and national press? How were explanations of cholera morbidity and mortality—who gets infected and who dies—retold in policy statements? And how were stories that provide alternative explanations kept from circulating or denied legitimacy? In examining the mechanisms through which stories were produced, transmitted, imbued with legitimacy, and challenged, we see that narratives had very real effects on how people live and die.7

Does it matter what sort of stories were told? Wasn't it more important to figure out why people were dying and what could be done to prevent additional deaths? The problem is that stories are just as real as germs and bottles of rehydration solution. Stories reported by the media were particularly powerful. Accounts in Caracas newspapers included what reporters saw and heard on the streets of Tucupita. Their stories put public health institutions on the line. They forced officials to act. Nevertheless, by constantly quoting public health officials and using their statements, journalists shaped the language that came to characterize the epidemic and inadvertently confirmed these officials' status as the sole authoritative source of information regarding the epidemic. Alternative stories, including those told by people living in the most deeply affected communities, became nearly invisible.

Exchanging narratives was a means of dealing with anxiety for all parties, but the nature of the anxiety differed widely. For some, particularly for the relatives and neighbors of people who died, stories that explored "why we are dying" constituted means of trying out strategies for survival, attempting to obtain resources and medical assistance, and dealing with the widely expressed fear that "all of us are going to die!" Such illness narratives aid the search for order that takes place after sickness shatters our common-sense perspectives on daily life,8 much as the exchange of stories helps people deal collectively with disasters.9 For many public health officials, stories that explained "why they are dying," directed to politicians, colleagues, journalists, and the public, involved survival of a different sort: institutional survival. When pictures of dying indígenas appeared in national newspapers and television programs, officials in Caracas and politicians in Tucupita starting looking for scapegoats. Stories that attributed the epidemic to the geography of the delta and particularly to the culture of the indígena population transferred the blame onto the communities in which deaths abounded.

To be sure, cholera stories varied widely. Nevertheless, narrators tended to view the epidemic either in terms of its broad social, political, and historical factors or as a medical and epidemiological phenomenon. For those who adopted the first strategy, the epidemic thus took its place among stories of racism, labor exploitation, land expropriation, human rights violations, transnational commerce, environmental degradation, and international conflict. What people knew or learned about the Persian Gulf War, international commerce, and the environmental problems produced by transnational corporations deeply affected how they perceived and reacted to the disease. Cholera was cast in some of these narratives as the unintentional by-product of broad economic and social forces; in others it was a weapon of mass destruction used intentionally to finish a job begun five hundred years earlier: the extermination of indígenas. According to this perspective, the sharp increases in social inequality produced by the Venezuelan economic crisis of the 1980s had created expendable populations without access to health, economic well-being, or justice. According to this perspective, the fact that cholera was killing poor people of color should have surprised no one. These stories would suggest that cholera is a disease of modernity, globalization, and social inequality.

Other narratives treated cholera as a biomedical phenomenon that could be explained by the introduction and spread of Vibrio cholerae. These stories isolated the epidemic not only from the economic crisis but also from the way that racialization—a process of imbuing a broad range of phenomena (for example, bacteria) with racial meanings—structured access to health care, jobs, education, and other services.10 The disease became an "indigenous problem," closely aligned with an entire population, at the same time that it was individualized—that is, tied to the attitudes and behaviors of the specific people it infected. These narratives were created largely by public health officials and disseminated widely by the media. They came to play a key role in shaping the ideologies that guided institutional practices. At the heart of these narratives and their ideological effects lay the anthropological language of culture. Having identified indígenas or, more specifically, "the Warao," as responsible for transmission of the disease, the stories detailed how cultural beliefs and practices transformed individual bodies into natural bearers of disease. One of the major concerns of this book is the institutional use of cultural reasoning to blame poor populations for the devastating effects of racism and economic globalization, which is evident far beyond the rain forests of Delta Amacuro.

Cholera created a charged, high-stakes debate about the lives of the people it infected, and competing stories bore quite different policy implications. Some of these narratives cast people who suffered from the disease as modern subjects who demanded the political, economic, legal, and health rights they deserved. If you accept these stories, the solution would seem to lie in ending institutional racism and making fundamental changes in how power and resources are distributed. If you believe the individualizing, cultural narratives, then there is little that can be done, since culture cannot be changed through legislation or institutional policies. Cholera stories thus illustrate the dual significance of images of social inequality, serving both as representations of how poor people of color are placed within modernity and as a means of regulating access to jobs, education, legal protection, medical treatment, and capital. In other words, in purporting to describe the lives of the poor, such discourses play a key role in shaping them. Given the role in fostering social inequality played by globalization, its moral and political legitimacy hangs in the balance.

Because public health officials, reporters, and politicians believed that the blame ultimately lay in cultural difference, it was easier to adopt short-term policies aimed at ending the scandal than to move toward medical and social justice. Once the dust had settled, health conditions were worse in the delta, and persons classified as indígenas became the targets of more virulent racism. Pinned with the responsibility for branding Delta Amacuro as a backward, cholera-ridden region, they became even less welcome in the land they have occupied for centuries. Those who moved to the small cities near the fluvial area did so because they believed that they would never escape death in the delta. In these cities they lived in the most inhumane conditions. To this day, indígenas travel to Caracas to beg on the streets. Their lives are certainly no less "at risk" than they were during the epidemic—the nature of the risk has simply changed.

The epidemic and the stories told about it point to the crucial importance of people's relationship to medicine, public health, and hygiene in determining the way they are treated by nation-states—in other words, in determining their status as citizens. Although the language of citizenship has been connected frequently with questions of inclusion and equality, scholars have recently argued that it has often provided a framework for excluding or subordinating particular communities; accordingly, "citizenship has entailed a discussion, and a struggle over, the meaning and the scope of membership of the community in which one lives."11 Scholars have suggested that citizenship involves civil and social as well as political elements.12 Arguing for a notion of cultural citizenship, a number of Latino researchers have suggested that the notion of a dominant culture can serve to exclude individuals and communities who are believed to embody a distinct culture.13

Sanitary citizenship is one of the key mechanisms for deciding who is accorded substantive access to the civil and social rights of citizenship. Public health officials, physicians, politicians, and the press depict some individuals and communities as possessing modern medical understandings of the body, health, and illness, practicing hygiene, and depending on doctors and nurses when they are sick. These people become sanitary citizens. People who are judged to be incapable of adopting this modern medical relationship to the body, hygiene, illness, and healing—or who refuse to do so—become unsanitary subjects. I explore how becoming infected with cholera became a key means of characterizing indígenas and other poor Venezuelans as unsanitary subjects.

Once a population was cast into the realm of the unsanitary subject, the characteristics of race, class, and gender that seem to exclude them from the ranks of sanitary citizens often led to differential treatment of individuals who bore such characteristics by clinicians and public health professionals. In analogy with the way drivers of color are often singled out in the United States for traffic stops and searches ("racial profiling"), we refer to differences in the distribution of medical services and the way individuals are treated based on their race, class, gender, or sexuality as medical profiling. Thus, assumptions made about "the Warao," delta residents classified as indígenas, affected who was warned about the possibility of an epidemic, how communities in which cholera cases were reported got treated by doctors, politicians, and the military, how they were characterized in the press, and what decisions were taken once the epidemic had ended. The implications of being relegated to the status of unsanitary subjects were profound, affecting people's access to the political, social, and civil dimensions of citizenship—and, ironically, to health care itself.


Author as Narrator

A reader's perception that a story "tells itself" is a powerful illusion created by the author, who extracts a story from the words of its narrator and the setting in which the story emerges. Retelling cholera narratives plays a crucial part in shaping their social and political impact. By resituating so many stories in these pages, we too become part of the politics of the epidemic and of social inequality. So it seems only fair to tell my own story of how I became a part of this narrative process.

Trained as an anthropologist, I conducted research in my home state of New Mexico for fourteen years, as both an activist and a scholar. There I concentrated principally on documenting ways that Spanish speakers, who often call themselves mexicanos, talk about the past. I attempted to discern the role that such talk plays in communities that are fighting for cultural and political-economic survival.

I first went to Delta Amacuro state in 1985, drawn by the advice of Venezuelan colleagues who suggested that research on social dimensions of the predominant language used in the delta, Warao, and how it interacts with Spanish might be useful in bolstering programs in bilingual education and health care. I lived in Delta Amacuro from August 1986 to July 1987, working primarily in two areas, Mariusa and Murako (see map 1). The people who live in Mariusa had not previously welcomed a researcher into their midst. Since very little Spanish was spoken there at the time, Mariusa proved to be an excellent place to improve my linguistic skills. In both areas I documented how social relations and power were shaped by the different ways that people used language in telling stories and in gossiping, giving speeches, mediating conflicts, teaching, asking for jobs and government services, and defending themselves against land expropriation, exploitation, and assaults on dignity and human rights. A key focus was the role of speech, song, and therapeutic touch in vernacular medical practices. I left in August 1987, but I have returned to these communities nearly every summer.

In 1992 a letter from a bilingual schoolteacher reached me in New York, bearing the forbidden word cholera. Newspapers published in Caracas ran stories on the outbreak, and subsequently other friends conveyed the news to me in letters, the occasional telephone call, and even an e-mail message or two. Conversations with anthropologists and others who had worked with Warao communities for decades countered this information. First I was told, "It's not cholera, it's just the normal diarrhea that kills Warao this time of year." Given the high rate of death due to diarrheal disease, this was hardly good news. Later the story changed to "isolated cases of cholera." Having spent a week in the midst of a cholera epidemic in Ecuador in 1991, I was skeptical. Except in areas where cholera has become endemic or where chlorinated water and sewage treatment are widely available, the chances of there being only "isolated cases" are few. My response was typically gringo: "Can't we do something? I can raise money to help with treatment and relief efforts. Can't IVIC [the Instituto Venezolano de Investigaciones Científicas, the leading scientific university] send a medical team?" My colleagues repeated that there were only a few cases, that the situation was under control. I wasn't reassured. When María Eugenia Villalón, a fine Ph.D. student of mine, defended her dissertation at IVIC, I went to Caracas for the examination. I decided to go to Tucupita for a couple of days to see for myself just what "isolated cases of cholera" might entail.

What I found horrified me. I listened to story after story of cholera, how it had come, whom it had infected, how their bodies had been afflicted. And I decided that if I ever wanted to make what I had learned during my stay in the delta of any real value, now was the time to act. I made plans to return the following summer. In June and July 1993 I worked with leaders of the Mariusan community and government officials to enhance the community's ability to prevent cholera and other illnesses and to increase access to health care. I also recorded a wide range of accounts of the epidemic.

In June 1993 I met Dr. Clara Mantini, then director of the Rural and Indigenous Health Program for the Dirección Regional de Salud (Regional Health Office). Clara began her career working with a team of left-leaning activist physicians in Amazonas state (map 2). Amazonas, which lies on Venezuela's southern border, is also recognized as an "indígena state." It and neighboring states in Brazil are home to indígenas called Yanomami. Massacres by Brazilian gold miners and recent accusations that anthropologists promoted warfare and epidemics to enhance their own reputations have thrust these communities into the global media.14 Clara was the director and resident physician of a small clinic that served a population classified as belonging to the Piaroa and Guahibo étnias. (Étnias are defined as communities of indígenas living within a particular territory.)

Clara then accepted a post in Delta Amacuro. Although she expected to do extensive work with indígenas in the fluvial region, she was initially denied permission to travel into the delta. Budgetary limitations were cited. The ban ensured that she could not have much direct impact on health conditions there. When the first cholera cases were reported in Pedernales (map 2), however, administrators were only too happy to accept her offer to lead efforts to treat patients and to stop transmission of the disease. She accordingly gained a great deal of firsthand experience with the epidemic, both in communities in the fluvial region and in public health offices in Tucupita, where she worked as the assistant to the regional epidemiologist.

After meeting in 1993, Clara and I began to work together. We inaugurated a pilot project in Mariusa designed to demonstrate that it is possible to deliver community health services and to create a health education program that can change health outcomes even in an area where lack of access to health care is acute and health conditions are among the worst. We worked to establish collegial relations between vernacular healers and representatives of the public health sector. At the same time, since future cholera epidemics in the delta were extremely likely, we decided to collaborate in an intensive, systematic study that would be tied to a health education program aimed at preventing cholera and other infectious diseases. After undertaking preliminary work in 1993, we began fifteen months of intensive work in June 1994.

Clara and I visited every area of the delta. We were accompanied by Tirso Gómez, an intelligent, knowledgeable, and energetic resident of a community near Nabasanuka. We conducted interviews in most of the larger communities and a multitude of smaller settlements. We assessed the impact of the cholera epidemic on each community and probed the range of social, cultural, and political responses it engendered. Our goal was to document (1) how many individuals had been infected by cholera and how many had died, (2) how residents used vernacular and institutional medical systems, (3) how various actors conceived of cholera and its etiology, and (4) how the epidemic had affected the community in both the short and the long run. In the delta we interviewed fifty-three people in Warao, thirty-three in Spanish, three in English, and seven bilingually in Spanish and Warao.15 In the course of one encounter near the Guyanese border I interviewed three people simultaneously, one in English, one in Spanish, and one in Warao; I will never forget either the exchange or the roar of the waterfall in the background.

We selected interviewees in such a way as to obtain maximum geographic coverage, since experiences even in neighboring communities were often quite different, and a cross-section in terms of age, gender, social position, occupation, and degree of bilingualism. We attempted to speak with all medical personnel who had had close contact with cholera patients. Although we did not use written protocols, we tried to get the same baseline information for each area while leaving plenty of room for people to tell their stories with as few interruptions as possible. We interviewed a wide range of persons, including patients, relatives of individuals who had died from cholera, lay and institutional medical practitioners, community leaders and government officials, missionaries, entrepreneurs, fishermen, and other residents. With the help of community leaders and vernacular healers, we conducted nineteen focus groups aimed at sparking collective discussions of the epidemic and its aftermath.

In addition, Clara assessed health conditions in the communities we visited. Equipped with supplies provided by the Dirección Regional de Salud, she provided free medical attention. In communities with very limited access to health care she sometimes treated fifty patients a day. When a nurse was not available I assumed that role, even though I doubt that I was a credit to the profession. In each area we inaugurated a health education program that centered on preventing future outbreaks of cholera and diminishing the incidence of other diseases.

The recordings made in the delta were supplemented by extensive interviews in Tucupita and surrounding cities. We spoke with physicians, nurses, and other medical workers who had treated cholera patients, as well as with politicians, missionaries, merchants, taxi drivers, journalists, and officials in a wide range of government agencies. In addition to documenting the epidemic, we studied political, economic, and legal dimensions of contemporaneous events. In Caracas and other cities we interviewed officials in the Ministerio de Sanidad y Asistencia Social (MSAS, the Ministry of Health and Public Assistance) and other institutions, members of Congress, officials in the U.S. embassy, and representatives of other agencies. In Tucupita, Caracas, and other parts of Venezuela (excluding the fluvial area), we interviewed fifty-three people in Spanish, twenty-six people in Warao, one person in Spanish and Warao, and one person in English. We also participated in three focus groups each in Warao and Spanish. At the same time that we attempted to maintain a good cross-section in terms of age, gender, social position, and occupation, we focused on eliciting as broad a range of types of experience as possible and on interviewing important players in the epidemic, including the governor, the directors of the regional health service and the regional epidemiologist, the director of the regional office of indigenous affairs, indígena activists, opposition politicians, journalists, and others.

Visits to New York (UNICEF and other agencies), Atlanta (the Centers for Disease Control, or CDC), Washington (PAHO), Geneva (WHO), and Bangladesh (International Centre for Diarrhoeal Disease Research) provided us with firsthand information on how cholera research is conducted and how clinical and policy-oriented formulations are generated at the international level. We conducted eleven interviews in Spanish and eleven in English in these sites, and we also attended meetings and conferences at which cholera was discussed. Whenever possible, interview materials were supplemented by documentary evidence, including regional and national newspapers, official reports and publications, manuals, flyers, correspondence, and photographs.

Nearly all of the interviews were tape-recorded; the only exceptions were in places (such as the U.S. embassy in Caracas) where recording was not allowed. Recordings in Warao were transcribed and translated into Spanish by Rosalino Fernández of San Francisco de Guayo, who was assisted for several months by Elizabeth Gómez. Estrella Mantini transcribed all the recordings in Spanish. Several individuals, including the author, transcribed the interviews in English. Given this tremendous volume of material, I had to be very selective in deciding which interviews to use in this book. I tried to include a variety of experiences while highlighting narrators who particularly illuminated what took place. Since respondents often commented on a number of aspects of the epidemic, it was often necessary to draw material from different parts of the interview. Ellipses indicate where these breaks occur or where shorter segments have been edited out to eliminate repetitions, asides, and the like. The transcriptions are verbatim, except when I edited out my own exclamations or other responses that did not seem to significantly shape what was said.

Many narratives retold here poignantly portray a situation of profound human suffering. The way that people talked about cholera exerted very real effects on who lived and who died in Delta Amacuro. Although the racialization of cholera centered its fatal effects on people classified as indígenas, we are all affected by the larger process of globalization and the invocation of a logic based on strategies that attempt to rationalize social inequality in order to justify institutional shortcomings. Failing to take adequate measures aimed at preventing cholera epidemics among the poor and then asserting that their deaths provide evidence of their inferiority were crucial by-products of attempts by individuals, populations, and nations to claim the mantle of the modern. Cholera narratives suggest just how powerful these imaginings of modernity continue to be and, at the same time, reveal the magical sleight of hand that sustains them. Preventing such unconscionable and unnecessary deaths demands a concerted and collective effort to challenge denigrating imaginings of modernity, race, and inequality and the practices they justify. In the case of infectious diseases, this project must cross lines of race, class, and nation. Once undertaken, it will enhance the chances of survival and the level of well-being for all of us.

Witnessing this human catastrophe in Delta Amacuro and being involved in attempts to prevent more needless suffering and death left me with a deep sense of responsibility. I feel it is particularly important to convey this information to as wide an audience as possible because much of it has been actively suppressed, thereby precluding more visible and substantive responses on the part of national and international audiences and organizations. At a time when "new" and "re-emerging" infectious diseases threaten populations in both the so-called Third and First worlds, reflecting on the outbreak of cholera in Venezuela and on the regional, national, and transnational forces that made it so deadly raises crucial questions about globalization's nature and effects. We need to recognize why these diseases are creating critical social and political as well as medical problems worldwide as we begin the twenty-first century. I hope to increase awareness of the fact that people in industrialized countries play active roles in creating these problems, not simply in extending acts of charity aimed at lessening their brutal impact. This book attempts to disrupt the circulation of stories and practices that kill, foster critical awareness of the politics of health and inequality, and support global cooperation and justice.



1 Population data are from Oficina Central de Estadística e Informática, Censo Indígena de Venezuela, 1992, 2 vols. (Caracas: Oficina Central de Estadística e Informática, 1993). When referring to the political jurisdiction that includes Tucupita, the capital, I use the expression Delta Amacuro or Delta Amacuro state. I use the term delta to refer to the fluvial area, which includes parts of neighboring Monagas and Sucre states. Although Tucupita actually lies on an island connected to the mainland by a bridge across the Manamo River, my use of the term delta does not include Tucupita, nor does it include another city on the edge of the fluvial area in Monagas state, Barrancas.

2 For studies of this epidemic, see P.D. Rodríguez Rivero, Epidemias y sanidad en Venezuela (Caracas: Tip. Mercantil, 1924); and Germán Yépez Colmenares, "La epidemia de cólera morbus o asiático de 1854 a 1857 y sus efectos sobre la sociedad venezolana," Anuario del Instituto de Estudios Hispanoamericanos de la Facultad de Humanidades y Educación 1, no. 1 (1989): 151-180.

3 See G.H. Rabbani and William B. Greenough III, "Pathophysiology and Clinical Aspects of Cholera," in Cholera, ed. Dhiman Barua and William B. Greenough III (New York: Plenum Medical, 1992), 209-228. However, many persons infected with Vibrio cholerae are asymptomatic, and many cases are mild.

4 This figure is for Delta Amacuro state; see Oficina Central de Estadística e Informática, Censo, 3: 13. It thus includes the high ground south of the Orinoco River and excludes parts of the fluvial area that lie in Monagas state.

5 Each excerpt from an interview is identified by the place and date on which it was recorded. When providing additional material from the same interview in the same chapter, however, we do not repeat this identifying information unless the two portions of the transcript are widely separated.

6 Some terminological notes are in order. The racialization of much of the population in Delta Amacuro state played a key role in shaping the cholera epidemic and how it was represented. The opposition between indígena (indigenous person) and criollo (Creole, or nonindigenous person) thus lies at the center of my analysis. By retaining the Spanish terms indígena and criollo, we hope to constantly draw the reader's attention to the status of these terms as powerful constructions. We similarly employ the term Warao to refer to the indígena population of the Orinoco delta. It is a term of pride for many delta residents. Nevertheless, it is also used in enforcing a strict separation of criollos and indígenas and in discriminating against people who fall into the latter category. We place the term in quotation marks occasionally as a means of reminding readers of its role in this racializing and stigmatizing process. The population figure is drawn from the 1990 census, as reported in Oficina Central de Estadística e Informática, Censo, 1:19.

7 Ana Tsing recently warned us about the power of metaphors such as "flow" and "circulate" to make problematic developments (such as globalization) seem like natural processes that have positive overtones; see "The Global Situation," Cultural Anthropology 15, no. 3 (2000): 327-360. In this book, we use the term circulation to describe how narratives, manuals, epidemiological bulletins, technologies, and statistics travel between institutional sites. The last impression that we would want to create is that this process is as unproblematic, benign, and benevolent as, for example, the circulation of blood in the body. We have, however, been unable to find a term that would draw attention to this process without creating other metaphorical problems. We accordingly ask our readers to keep in mind that the "circulation" we describe is not a free flow but rather follows institutional structures and is shaped by global relations of power that channel and constrain what moves, prevent other narratives and perspectives from traveling, and configure the rights of particular parties to control this process.

8 See Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988).

9 See Kai Erikson, Everything in Its Path: The Destruction of Community in the Buffalo Creek Flood (New York: Simon and Schuster, 1977); and Anthony Oliver-Smith, The Martyred City: Death and Rebirth in the Andes (Albuquerque: University of New Mexico Press, 1986).

10 On the process of racialization, see Michael Omi and Howard Winant, Racial Formation in the United States: From the 1960s to the 1990s (New York: Routledge, 1994). Our thinking about race and racism has also been shaped by critical race theory and by the largely European Critical Discourse Analysis (CDA), which brings a range of linguistic approaches to bear on the study of racism. For overviews of CDA, see Norman Fairclough, Discourse and Social Change (Cambridge: Polity, 1992); Teun van Dijk, Elite Discourse and Racism (Newbury Park, Calif.: Sage, 1993); R. Wodak and M. Reisgl, "Discourse and Racism: European Perspectives," Annual Review of Anthropology 28 (1999): 175-199; and Jan Blommaert and Chris Bulcaen, "Critical Discourse Analysis," Annual Review of Anthropology 29 (2000): 447-466.

11 See Stuart Hall and David Held, "Citizens and Citizenship," in New Times: The Changing Face of Politics in the 1990s, ed. Stuart Hall and Martin Jacques (London: Verso, 1990), 175.

12 This is T.H. Marshall's classic division, as presented in his essay "Citizenship and Social Class," in Class, Citizenship, and Social Development, ed. Seymour Martin Lipset (Westport, Conn.: Greenwood Press, 1964), 65-122. For Marshall, the civil element refers to "liberty of the person, freedom of speech, thought, and faith, the right to own property and to conclude valid contracts, and the right to justice" (71). The social element ranges from questions of "economic welfare and security to the right to share to the full in the social heritage and to live the life of a civilized being according to the standards prevailing in the society," and he suggests that this element is tied most closely to educational and social service institutions (72).

13 See William V. Flores and Rina Benmayor, eds., Latino Cultural Citizenship: Claiming Identity, Space, and Rights (Boston: Beacon, 1997), especially the introduction; and Renato Rosaldo, "Cultural Citizenship, Inequality, and Multiculturalism," in Flores and Benmayor, eds., Latino Cultural Citizenship, 27-38.

14 We comment on this debate in chapter 13.

15 Some individuals were interviewed more than once.

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