In 1992 and 1993 some five hundred people 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. The disease that killed so many so quickly was cholera. One of us, Charles, stumbled onto the epidemic in November 1992 during a two-week visit to Tucupita, a city of some 40 thousand inhabitants and the capital of Delta Amacuro state. Clara was working for the regional office of the Ministry of Health and Public Assistance, and she helped to coordinate efforts to prevent the spread of the epidemic. Many 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. 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 12 hours after exposure to the Vibrio cholerae bacteria. The cholera toxin paralyzes the gut in such a way that all fluids pass right through the intestines, resulting in extremely rapid dehydration. Unless the lost fluid is replaced, consciousness fades rapidly. If not treated with rehydration therapy, as many as 70% of symptomatic patients can die. What is most appalling is that cholera is easy to prevent and treat. Uncontaminated food and water are all that is needed to keep the disease at bay. Most patients can be saved by drinking a commonly available solution containing sugar, salt, and electrolytes, and even severely dehydrated, nearly unconscious patients can be brought back to life through intravenous rehydration. The disease also responds readily to antibiotic treatment.
Two of my friends, Salomón Medina*––known as "Comando"––and José Rivera, related the horrors that they experienced during the epidemic. Both are from the delta community of Mariusa. Medina and José Rivera were on the Mariusa River at the point 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-thousand-square-kilometer Delta Amacuro. There were no clinics, missions, schools, government offices or stores there when the epidemic hit. Physicians were not available to treat patients or explain what was taking place. Vernacular ["folk"] healers attempted to cope with a disease that baffled them. Santiago Rivera, José’s father, was one of the most respected practitioners of hoarotu medicine, which incorporates therapeutic touch in addition to chanting and the ingestion of tobacco smoke. 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.
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. It was only the beginning of a series of horrible experiences, experiences that revealed the 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 many people had been left behind by "progress" and "modernity." The growing gap between the haves and the have-nots was, and is, a product of 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 offered sobering testimony about the fate of poor populations, especially people of color, in today’s world. Cholera is a disease of modernity, globalization, and social inequality.
In a word, racism was a crucial factor that placed people in Delta Amacuro state "at risk" from cholera. Venezuelans who live in the delta region are classified as either indígenas or criollos—as either indigenous or non-indigenous persons. Most of the people 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 policies for the distribution of vital government services such as health care and water and waste treatment facilities, as well as economic and other resources. When germs and race mix inadvertently, however, the result is often fatal.
The devastating effects of the epidemic continued to be felt long after it was officially declared over in the middle of 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, the impressive emergency 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. 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 concems about the population expansion of people of color. Race and class clearly lie at the core of these fears.
The story of the cholera epidemic in Delta Amacuro is not a simple tale of Machiavellian conspiracies or evil powermongers 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 in which 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 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.
Exchanging narratives, stories related to the disease, 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 of daily life, much as the exchange of stories helps people deal collectively with disasters.
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. Cholera was cast in some of these narratives as the unintentional byproduct of broad economic and social forces; in others it was a weapon of mass destruction used intentionally to finish a job begun 500 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.
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. The disease became an "indigenous problem," closely aligned with an entire population, at the same time that 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 they were 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.
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. 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 refuse to do so—become unsanitary subjects. Becoming infected with cholera became a key means of characterizing indígenas and other poor Venezuelans as unsanitary subjects. The implications of being relegated to this status were profound, affecting people’s access to the political, social, and civil dimensions of citizenship—and, ironically, to healthcare itself.
Peruvian public health officials formally notified their Venezuelan counterparts of the cholera epidemic in January 1991. The announcement generated immediate anxiety within the Ministry of Health and Social Assistance (MSAS), the national agency responsible for Venezuela’s public health infrastructure. Although cholera was not officially reported in Venezuela for ten months, the disease became the primary focus of attention. MSAS became, to borrow Michael Taussig’s pun, a nervous system. Cholera began to dominate the relationship between MSAS and the press. The publication of stories about cholera involved a daily dance between officials and reporters. Starting in early February 1991, articles about cholera appeared almost daily in Venezuelan newspapers.
Defining the epidemic in terms of its location within and capacity to "spread" beyond national borders provided a narrative structure that appeared over and over. Just as cholera was characterized as having been "born in India," Peru became the point of origin for the disease and its permanent home in the Americas. A standard line in articles began "The epidemic, which first appeared in Peru…." The focus of cholera stories progressed through a number of stages: A neighboring country was "threatened" by cholera; the beginning of the "invasion" was signaled by the first few cases, which were usually portrayed as "imported" from another nation-state; a rising morbidity and mortality count was adumbrated; and then cholera moved toward a new national border. Thus, through a slow cyclical process, cholera, like the unseen specter in a ghost story that comes closer and closer to the protagonists, remained newsworthy for months, generating new events that demanded the attention of reporters and readers.
In these stories, Venezuela was depicted metaphorically as a corporeal or social body that was about to be invaded by the disease. El Nacional characterized the nation as a house that was being secured against the threat of an intruder: "Cholera has two doors by which to enter Venezuela: Zulia, where it is already looking in, and Bolívar state, due to the riverine port and the movement of Brazilian miners and indígenas who are closely associated with Colombia." Another article, titled "The Assassin at the Door," stated that "like one of the horsemen of the Apocalypse, the infectious agent Vibrio cholerae gained speed as it rode toward the borders of Latin American countries." Cholera became a threat to the health of not just individuals but also the nation-state.
Such metaphors created a sense of impending doom while generating the reassuring feeling that public health authorities were protecting the body politic by securing the country’s borders. Military metaphors were used in regard to neighboring Colombia—"declaration of war on the Colombian-Venezuelan border"—a rhetoric that was ironically often juxtaposed with statements regarding binational cooperation. Since Colombia acknowledged cholera cases in mid-March 1991 and the first official cases were not reported in Venezuela until early December, this militaristic lexicon had a long time to coalesce. The metaphor of a Colombian invasion fit a familiar national rhetoric: Venezuela regularly blamed its neighbor for a host of economic and political problems. The power of spatial and nationalistic language was remarkable. Cholera was clearly an international phenomenon, in terms of not only its "pandemic" reach across continents but also the effects that economic globalization had on public health infrastructures and health care systems and the rapid circulation of capital, people, goods, information and germs. Nevertheless, these reports seemed to make the nation-state and its geopolitical boundaries more real, confirming them as the natural units for understanding something as important as the threat of widespread death and disruption.
Great pressure was placed on MSAS "to intensify its efforts to prevent the cholera virus from entering the country." Cholera, a bacterial disease, was often characterized as a virus, perhaps owing to concern over HIV, Ebola, Hanta, and other "killer" viruses or to the persistent presence of dengue. In mid-February MSAS reported that it had established a "cordon sanitaire" on its border with Colombia. This measure apparently consisted of subjecting persons arriving from countries in which cholera cases had been reported to rigorous inspection and, in some cases, continuing to keep track of these individuals for several days. In February it was reported that closing the border was being considered as an "emergency health measure." "Cholera controls" greeted airplanes and ships arriving in Venezuela from "infected countries." When cholera cases were reported in Colombia, public health and other government institutions in Venezuela were placed on "maximum alert." All these measures involved close collaboration between military and public health personnel.
That this nationalistic discourse had at least some effect on popular perceptions of the disease is evident in polls taken on the streets of Caracas in late April. El Nacional reported that 91% of Venezuelans believed that their country’s borders should be closed to prevent a cholera epidemic. To be sure, talk of defending Venezuela’s borders against Peruvians, Ecuadorians, and Colombians and the image of foreign carriers of cholera entering the country, perhaps illegally, linked cholera to anti-immigrant discourses that blamed citizens of these countries for economic and social problems.
The "geography of blame," to use Paul Farmer’s powerful phrase, that linked cholera and poverty remapped Venezuela itself. In an address delivered at a conference titled "Cholera is Everyone’s Problem" and reported in El Mundo, Dr. Fermín González asserted that "cholera is an infection that typically and almost exclusively affects very poor people." The term González used, gente miserable, is also commonly used to designate individuals who are villainous. Discussions of poverty and cholera in the press focused on the cerros ("hills," referring to hillside communities) or barrios marginales of Caracas and other urban centers. In this context, "marginal" conveyed a sense of people who stand outside democratic politics, the formal economy, the law, and morality. In the bourgeois imagination, barrios marginales are places in which promiscuity, violence, criminality, and psychopathology are pervasive and natural. Discourses of poverty decontextualize and depoliticize images. The link between hillside barrios, the poor, and cholera helped to reimagine popular protest as a timeless product of poverty rather than a strategy for dealing with the differentially distributed effects of a particular political-economic crisis.
The residents of these communities figured prominently in the popular protests in 1989 over President Carlos Andrés Pérez’s attempt to impose neoliberal economic policies at the beginning of his term. This group continued to be the focus of resistance, middle-class anxiety and political repression in the early 1990s. The bourgeoisie referred to the 1989 action as cuando bajaron los cerros, "when they came down from the hills." Reporter Asdrubal Barrios’ reference to "the daily descent of tons of fecal material from the hills" that was converting Caracas into a cholera "time bomb" juxtaposed fears of cholera and those associated with popular insurrection.
Reporters and public health authorities often refined the notion that cholera is the disease of poverty by linking the disease explicitly to filth, thereby helping to exclude the first way of connecting cholera and poverty. A reporter suggested that "filth [suciedad] is the preferred habitat of this character [cholera] in order to multiply its fatal action. And the best place that it has encountered to propagate is the marginal areas." Suggesting that the streets of Caracas "smell of cholera," Barrios referred to suciedad as the parent of cholera and "its best ally." Barbara García, chief of the Food Control Division of INH, stated that "in the places in which poverty reigns, people are often not educated to be able to perceive cleanliness as a healthy way to live." The phrase she used, falta la educación, can refer either to a lack of health education or, more idiomatically, to a lack of sophistication and manners. Whichever way you read the statement, it reflects the common conviction that barrio residents were ignorant of and failed to practice hygienic norms. By creating filthy environments "they" marked themselves as the likely targets of cholera. The equation became firmly established: barrio = poor dirty = cholera.
Poverty was not the only characteristic that accorded communities the dubious honor of being "at high risk" for cholera: Indígenas took their place alongside the poor and "residents of hillside barrios" as potential bearers of the disease. Zulia state contains the largest population of persons in Venezuela who are classified as indígenas. They are generally referred to as "the Waayú" (also spelled Guayú). Even before the first cases were reported in Venezuela, Senator María Pérez linked "the Waayú" to cholera.
"With the entrance of cholera in Zulia state," Pérez said, "there is a serious risk of an epidemic of considerable proportions among the members of the Waayú etnia, since the great majority of those who live in Sinamaica and Paraguaipo don’t have the most elementary sanitary services in the region, in addition to which they drink water from springs [jagueyes], where the animals drink, they don’t have latrines, and their hygienic habits are primitive."
The two rhetorics of poverty intersect here, drawing attention simultaneously to the paucity of public services in the Sinamaica and Paraguaipo areas and to the "hygienic habits" of "the Waayú" which, according to the senator’s statement, seem to predestine them to become bearers of cholera. The image of the jaguey evokes an old stereotype that equates indígenas with animals.
Those persons whose habits and mental dispositions seem to place them beyond cholera’s grasp were construed as sanitary citizens. They became complex subjects who possessed a full set of normative economic, cultural, familial, legal, educational, sexual and medical characteristics.
Sanitary citizens were identified by their status as Venezuelan, rather than being marked specifically in terms of a single dimension, such as social class. The state assumed the obligation of protecting them from Vibrio cholerae after suggesting that they were in any case unlikely to be infected. Persons whose "ignorance," place of residence, occupation, poverty, race and unhygenic habits placed them at risk for cholera became unsanitary subjects. Unsanitary subjects lacked the broader set of characteristics that would have enabled them to adequately fit the model of the modern citizen, and thus they could be denied access to jobs, legal protections and human dignity. They seemed to be intrinsically linked to a particular package of premodern or "marginal" characteristics—poverty, criminality, ignorance, illiteracy, promiscuity, filth, and a lack of the relations and feelings that define the nuclear family. Because the bodies and minds of unsanitary subjects seemed to be inseparable from their despicable environments, the state had to protect them from their own natures and desires—in short, from themselves. At the same time, the state isolated its unsanitary subjects because its sanitary citizens had to be protected.
Assertions regarding cultural difference—the idea that poor people and individuals representing marginalized communities think and act differently and cannot embrace modern hygiene and medicine—increasingly shape institutional practices that permit or even multiply unnecessary and unconscionable deaths from disease. Specifics may place this narrative in Venezuela in 1992 and 1993, but the general problem has a great deal to say about tuberculosis in Peru or Harlem, or about AIDS in Zimbabwe, Haiti or San Francisco. This is, in the end, a story about all of us, about the ways that we are implicated in the resurgence of "old diseases" as well as the emergence of new plagues. It is, in the end, a story about finding ways to deal with disease and inequality that avoid blaming others, a paralyzing defensive reaction that precludes a deeper search for answers that could avert a dumbfounding return to disease patterns that resemble those of the nineteenth century.
*All names in this article, except that of Venezuela’s President, have been changed.
ABOUT THE AUTHORS:
Charles L. Briggs is professor of ethnic studies and director of the Center for Iberian and Latin American Studies, University of California, San Diego. Clara Mantini-Briggs, MD MPH is a Venezuelan physician who currently serves as the medical advisor of the National Congress of the Venezuelan Indian (CONIVE). This article is adapted from their book Stories in the Time of Cholera: Racial Profiling during a Medical Nightmare, forthcoming from the University of California Press. (c) 2002 The Regents of the University of California. Published by arrangement with the University of California Press.
