Health Care Among the Culina, Western Amazonia
The Culina village of Moranaua sits on a ridge overlooking the upper Purus River in the state of Acre, western Brazil, near the Peruvian frontier. Relatively isolated, with only occasional outside contact from passing boats, the population at Maronaua enjoys wider access to game and horticultural land than do other Culina villages on the Purus or the Envira rivers. This relative isolation and the general adequacy of food resources allow these Culina to maintain a standard of health that appears to be significantly better than other communities in the region.
The Culina at Maronaua have the appearance of a generally healthy population. Adults, in particular, seem quite robust. Physically active, enjoying a varied and adequate diet, they suffer from virtually none of the problems associated with nutritional deficiencies or the chronic diseases of sedentary Western life. Adults still lack great resistance to infectious disease, however. Few adults survive into old age, and their illness-related deaths tend to be due to the complications of acute, short-term diseases, such as pneumonias.
Introduced infectious diseases historically have had a devastating impact on indigenous populations in the Purus-Jurua region. A measles epidemic killed many Indians on the Jurua River in 1877. Another measles epidemic in 1950 killed roughly half the Culina population then living in the village called Cupichaua, on the Purus; the survivors of that group form the core of the current population at Maronaua. In 1981 I found only four individuals at Maronaua in the 31-r0 age range - those who would have been young children during the 1950 epidemic.
A careful record of illness and other "medical" problems, maintained over a period of 160 days during both the dry and rainy seasons, includes a total of 546 cases among a resident population varying between 130 and 160 people, suggesting that the average individual at Maronaua would seek assistance for some kind of health problem roughly every 40 days. These 546 cases included 111 cases of colds and mild upper respiratory infections, and 101 cases of skin sores and ulcers among children, particularly in the rainy season, when the village grounds turn into a muddy soup in which dogs, chickens and pigs defecate and urinate. Diarrhea accounted for 95 cases (almost all among children), intestinal parasites for 64 cases and an epidemic eye infection for 33 cases. The remaining problems, with only a few exceptions, consisted of the stomachaches, headaches, coughs, fevers, cuts and contusions that plague any population. Because Culina normally ignore insect bites, they are not included in these figures. Maronaua is not located in a malarial area, and residents have none of the health problems associated with this parasite. Two individuals may have been suffering from tuberculosis, but did not request medical assistance and, indeed, declined an opportunity to be taken to Rio Branco, the capital of the state, for treatment. One probable case of gonorrhea was treated, but the patient was not a resident of the village, his wife was not available for treatment and it was unlikely that he had sexual contact with any Moranaua residents. There were good reasons to suspect that he had acquired gonorrhea from a Peruvian or Brazilian woman.
The health of adults is good, but the health of children is often compromised by nutritional deficiencies, in particular by protein deficiency. Culina at Maronaua enjoy an abundance of game animals in the forest surrounding the village. However, eating patterns allow adult men first access to meat; women normally have adequate leftover meal, but children often get little or none. The pattern is a classic one: nursing infants are healthy and well fed, but their older siblings struggle with diets consisting largely of manioc and plantains, which provide more bulk than nutrition. Extended bellies are common among children from age three to 10. Incidentally, this pattern of meat consumption does not reflect either a shortage of meat in the environment or any willful withholding of or competition for meat. Rather, Culina notions about human physiology and physical development make it appropriate and necessary for adults, and adult men in particular, to consume meat, and for children to eat more wild vegetable products.
The infant mortality rate among these Culina is difficult to determine. The meager evidence available suggests that been 40 and 60 percent of pregnancies result in stillbirths or infant deaths. However, the relatively large number of children currently in the village suggests that this rate may be declining. No records are kept of pregnancies and births. Moreover, parents experience a kind of cultural amnesia about infant deaths; every parent at Maronaua recalled that they had lost at least one infant, but no parent could remember in any detail infants who had died more than two or three years earlier - neither the number of deaths nor the sex of the infants. Infants are not yet "persons" for Culina; the period of infancy lasts up to about two and a half years, until the child can walk and talk with reasonable facility. During this period, particularly the period shortly after birth, unwanted or deformed infants will be killed or allowed to die of starvation or dehydration. For the Culina infant mortality is not simply a health issue, but a complex social issue. This point was illustrated by the case of Maronaua baby who, because of a harelip, could not nurse properly and slowly dying of malnutrition. The mother was encouraged by local missionaries to extrude milk from her breasts manually and feed it to her baby with a spoon. The mother, however, felt the bay should die, and declined to feed it. The missionaries then convinced the mother to accompany them to Rio Branco where the baby's deformity could be corrected surgically, but after a long and difficult trip they were told that the condition could not be treated after all. The baby's death was felt by the parent to be an appropriate if sad conclusion, but the missionaries' crisis journey to Rio Branco only generated bad feeling among village members. Culina are more likely to look forward to new children, and do not brood over those who do not survive infancy.
Maronaua is located some five days by motor upriver from the Culina village of Santo Amaro. Santo Amaro, which sits near the mouth of the Chandelles River, occupies a greatly restricted territory for which it competes with a number of local Brazilians, including a large Brazilian farm within sight of the village on the opposite bank of the Chandelles. Both the competition for agricultural and hunting land and the very frequent contact between Santo Amaro residents and Brazilians have had notable effects on the general health status of Santo Amaro residents. Meat is in extremely short supply, leaving fish as the principal source of available protein. Fishing, however, is not always productive. During the dry season, for example, when the river level is low, local Brazilians use long nets stretched across the river to catch large fish such as the giant catfish, leaving only small fish for the Culina. Moreover, the availability of manufacture goods leads many Santo Amaro residents to trade meat or larger fish for soap, salt, sugar, shotgun ammunition and other perceived "necessities."
The impact of this protein scarcity on the health of the Culina of Santo Amaro is profound. My own observations - even from a few days' visit - conform to missionary reports of fairly serious protein malnutrition among children and a relatively high infant mortality rate. Moreover, the greater contact between residents of Santo Amaro and local Brazilians produces more frequent epidemics of infectious diseases, colds, influenza and even mumps among the former. Although I do not have figures to document it, I would not be surprised to find relatively high mortality rates associated with complications of such diseases in Santo Amaro - higher than the more isolated and relatively well-fed population at Maronaua.
Indigenous Treatment of Illness
Culina ethnomedicine traditionally distinguishes witchcraft-related illness from other forms of illness. Culina witchcraft is consistent with the classic pattern: it emerges during times - and along lines - of social stress. In particular, witchcraft is suspected in the context of interhousehold tensions (for example, fighting between brothers-in-law). Illness due to witchcraft - dori - is described as being like a small stone that grows within the body until it kills the victim. This illness shares no particular symptoms; indeed, the important social referents of witchcraft make it unnecessary for an "illness" to exist in any narrow Western sense at all. Shamans treat dori by sucking out the dangerous substance during the nighttime curing ritual called tokorime. Culina at Maronaua rely heavily on shamans for treatment of dori, denying the efficacy of Brazilian (i.e., Westernized) medications for witchcraft illness.
A related illness, called epetuka'i, afflicts infants. This illness can be attributed to infants suffering from various gastrointestinal disorders including diarrhea, constipation or vomiting, but, like dori, it is defined less by a set of symptoms than by social relations. Epetuka'i is said to afflict a child when its parents eat the meat of a male animal - meat that parents are prohibited from eating, in the most conservative Culina estimate, throughout the first two and a half years of the child's infancy. This infant illness is also treated by shamans; though it can be fatal, it is said to be less serious and more easily cured than witchcraft illness. The social prerequisites of epetuka'i are suggested by the fact that parents pay little if any attention to this food taboo; though their infants are regularly troubled by gastrointestinal problems, they are rarely diagnosed as suffering from epetuka'i. Rather, the illness appears to be diagnosed only in the context of intrahousehold conflict, usually in the from of accusations of adultery.
Witchcraft and epetuka'i illnesses are said to occur only during the dry season, which lasts from April or May to September or October. During this period epetuka'i occurs only occasionally, but witchcraft illness is diagnosed often, and two or three curing rituals may be held every week. Because Maronaua had two loosely defined political factions and a third group that left in an angry dispute to relocate a short distance down river, the village experienced a fairly high level of social tension. During the worst phases, "preventive" curing rituals might be held even without "patients" at times when anxieties about witchcraft attacks reach critical levels.
During the rainy season, when witchcraft is usually not a suspected cause of illness, the tokorime curing ritual is almost never held. The one exception during my research involved an elderly man who contracted a fatal pneumonia secondary to a viral infection; when it became apparent that his condition was serious, he became the subject of a series of curing rituals, lasting about a week, until he finally died. This extraordinary case, however, contrasts with that of another individual who suffered from chronic stomachaches and periodic gastrointestinal bleeding. During the dry season he was often treated by shamans in the context of a curing ritual, but during the rainy season he was never treated ritually, despite suffering considerable distress.
Aside from these "mystical" illness, Culina consider most other illnesses to be mild and non-threatening. In contrast to the "internal" mystical illnesses, other illnesses are generally felt to occur on the "outside" of the body, in particular on the skin in the form of sores, rashes, insect bites, stings and cuts. These benign illnesses can be diagnosed and treated by anyone, usually with various plant leaves that are chewed or boiled. The critical feature of medicinal plants is their smell: all plants with strong, "good" smells are assumed to have generalized curative properties, and little agreement exists on the specificity of particular types of plants for particular illnesses. I include snake-bite poisoning in this category of "external" illness: although snake bites are believed to be potentially fatal, they are treated with plant leaves. However, certain characteristics of snakes associate them with the spirit world and render snake poisoning an ambiguous, dangerous and quasi-mystical illness. The fact that Brazilians recommend sucking the venom out of a bite reinforces this vague similarity to illnesses that are treated by shamans.
The fact that the "good" smell of medicinal plants renders them curative is implicit in Culina views of the nature of the body and its functioning, but also suggests that these plants do not necessarily possess special pharmacological properties in a Western sense. The Culina believe that smells are transformative: good smells transform wild qualities into tame, sociable ones. For the Culina illness results, in one fundamental sense, from an improper penetration of "wildness" into the body, and the good smells of plants literally transform these irritating conditions into benign states. This view of illness and curative function has consequences for Culina views of Brazilian medications.
Brazilian Government Health Initiatives
The upper Purus is a remote, sparsely populated region; Maronaua in particular is near enough to the Peruvian frontier to have little contact with outsiders, including Brazilian government health workers. A FUNAI (Brazil's National Indian Foundation) post that is several days' trip downriver, in a Kashinaua village called Fronteira, offered no medical assistance to Maronaua during my stay in the village. Indeed, FUNAI essentially ignores the two large Culina villages on the Purus River, Santo Amaro and Maronaua, and instead relies on missionaries in each village to provide minimal services - missionaries who are officially illegal trespassers on indigenous lands, but who are passively tolerated by FUNAI.
The Brazilian government has made efforts to vaccinate children in indigenous groups in the area against several diseases, visiting villages every few years, but it has been relatively unsuccessful with the Culina. During the one government visit to Maronaua that I witnessed, two health workers who spoke no Culina gruffly ordered Culina who spoke no Portuguese to round up all children who had not been vaccinated in the past. Those children who did appear came more out of curiosity than compliance, and were roughly grabbed and jabbed with the hypodermic. Parents quickly shooed their children away to avoid this frightening, poorly understood procedure after only two or three terrified children were injected. During the remainder of their two-day stay in the village, the health workers treated several problems, never asking whether I was already treating these illnesses. Fortunately, the excess of treatment did no harm in these cases.
FUNAI is responsible for arranging medical treatment for Indians who make their way to Rio Branco, or, in emergencies, for those who can travel to the air strip, which is a trip of several days downriver from Maronaua. Nonetheless, the government has virtually no direct impact on the health of Culina in their villages. Even hospitalization is unwelcome. Culina know of at least two cases in which individuals who were taken to Rio Branco for medical treatment never returned to their villages. No one was afraid of dying in Rio Branco; the issue in these cases is the Culina's belief that FUNAI simply will not assist people in returning to their villages.
Missionary Participation in Health Care
Maronaua supported a missionary couple, agents of the Conselho Indigenista Missionário (CIMI), who served as the only regular source of Western medications for the village. Using the Brazilian version of the popular handbook, Where There Is No Doctor (The Hesperian Foundation, P.O. Box 1692, Palo Alto, CA), the missionaries went from house to house each morning treating the problems residents chose to present. Most Culina welcomed this service, and I believe the missionaries saw a majority of the obvious health problems in the village. This type of care was particularly valuable in treating bacterial and fungal infections, intestinal parasites and the inflamed and ulcerated feet children suffered during the rainy season. CIMI could also marshall resources to transport individuals to Rio Branco for hospitalization and treatment of to her more serious conditions, such as tuberculosis, and make special efforts to make sure that people were returned to their villages. CIMI also functioned as an advocate for Culina in dealings with FUNAI over medical issues, though FUNAI functionaries told me they expected CIMI to manage health issues without help, in return for which FUNAI functionaries told me they expected CIMI to mange health issues without help, in return for which FUNAI passively tolerated CIMI's presence in the region.
This type of medical service presented some inevitable drawbacks. Missionary access to medical problems was incomplete, particularly when Culina felt that an illness was due to witchcraft and would not respond to Brazilian treatment. Unfortunately, these cases tended to be the more serious illnesses. Culina were also aware that Brazilians generally ridicule their traditional ethnomedical beliefs and practices, so they often simply concealed witchcraft illness from the missionaries. In addition, adults tended to present themselves for treatment more often than they presented their children, particularly young children. This represented, in part, a certain hesitance about Western medications, an aspect of a more general feeling that adults can interact with outsiders with relative impunity but that children can be harmed by such contacts.
The missionary medical system was also a source of political power for the village headman. Waki occupied this position only because his older brother Rimana, who was considered a more effective leader, had left the village with a group of follows to set up a smaller settlement about half an hour's journey downriver. Waki and the missionaries supported each other, but Rimana was opposed to the presence of the missionaries in the village. On frequent visits to Maronaua, Rimana harangued the villagers to force the missionaries to leave. Waki encountered this by citing the benefits of CIMI presence in the village, including access to Brazilian medications. Although I believe that most of the village members were not overly concerned one way or the other about the missionaries and their medicine, Waki had come to view them as an arm of this regime. This became clear the first day the missionaries were absent from the village; Waki came to me, frantic, demanding that I make the rounds through the village "looking for sickness." I suggested that there was no need for this exercise because he and I both knew there was no illness in the village that morning, but he was insistent. As headman, Waki had some obligation to oversee the health of his village members, buy he had largely abrogated this responsibility to the CIMI missionaries. My reluctance to make housecalls to healthy families left Waki appearing weak and ineffective, highlighting not only his failure to manage the health of the village, but also his inability to manage visitors.
The missionary couple assigned to Maronaua was relatively new to the village; even by the end of my research period they had learned little of traditional Culina views of health and illness, and remained relatively indifferent to these views. The irony, of course, lay in the fact that the disputes surrounding their presence in the village were the principal source of conflict, leading to witchcraft accusations and a rash of curing rituals. Indeed, there was a double irony here. It was clear that the missionaries assumed that the superiority of their Western system of diagnosis and treatment of illness would be evident to Culina; the missionaries could solidify their position within the village by creating a sense of reliance on their medical capabilities. Access to medical care was one of the primary reasons always given by the missionaries for their presence in the village. On the darker side, however, the missionaries hoped that Culina would come to rely on the medical service so that neither FUNAI nor Rimana could then expel them.
The missionaries' failure to understand Culina ideas about illness and its treatment had other effects, most notably in the willingness of village residents to take various forms of medication. For example, Culina felt strongly that injections provided the only means of placing medications directly into the "flesh," where they believe illness is located. Culina considered oral medications largely ineffective; things entering the body through the mouth simply passed through and were transformed into unpleasant substances. (A shipment of antibiotics donated by an Italian Catholic missionary organization, all in suppository form, was greeted with a combination of disgust and amusement.) Culina often declined to accept medications in oral form and would sometimes palm tablets instead of swallowing them; many important Brazilian medications, including aspirin, were accepted in indictable form. Culina suspicions of oral medications were also related to the view that all medications are essentially similar in any form in which it was administered. Most indictable medications were classed together as penisilina (penicillin); anything that was though not to be penicillin, or was not indictable, was met with suspicion.
The presence of numerous Brazilian medications in the village posed one serious problem: regulating access to potentially dangerous drugs. This problem had two dimensions. First, during the missionaries' frequent absences from the village, it was impossible to completely restrict Culina access to the medication storeroom. Adolescents, in particular, became adept at breaking into the locked room in search of gentian violet, which they used for facial painting. Once the room was open, adults would occasionally medicate themselves - a dangerous procedure, since many of the Brazilian government-produced medications were packaged in identical bottles, and Culina could not read the labels. Second, denying access to medications raised ethical questions about the obligations and responsibilities of the missionaries in the village. At best the system exemplified the kind of missionary paternalism that made Culina uncomfortable. Giving village members free access to medications clearly would have been hazardous, but Culina would have been more supportive of restricted access if they had been involved in making such decisions.
On the other hand, the CIMI approach, despite its drawbacks, appeared to have benefits over the system established by the Summer Institute of Linguistics (SIL) at the Culina village of San Bernardo in Peru, on the Purus upriver from Maronaua. Although I was not able to visit this village, a number of Culina visitors from San Bernardo gave what I believe is a reasonably accurate picture of the SIL health care system. The SIL has trained a Culina man to serve as a "nurse," or sanitário, to the village. This individual impressed me as well intentioned, but largely inadequate as a health care provider. For example, he was known to give penicillin for any and all illnesses; indeed, he gave penicillin to the man with gastrointestinal bleeding, mentioned earlier, who had come to Maronaua to find some effective treatment. The Sanitário's training had filed to acquaint him with the Western principles of illness and its treatment, and he consequently appeared to practice in an odd combination of Western (or Peruvian) and Culina styles.
Most surprising, however, was the fact that the SIL infirmary required village members to pay for their treatment. The Protestant missionary interest in establishing a capitalist ethic is not unknown, but the notion of paying for illness treatment is so counter to fundamental Culina ideas about sociability that I could scarcely believe that San Bernardo residents complied with the system. The SIL missionaries also reportedly have tried to prohibit shamanistic treatment of witchcraft illness. This information is consistent with notes on file at the SIL headquarters in Brasilia in which missionaries associate Culina shamanism and shamans' spirits with Satan. In view of the extremely important functions of shamanism in the social life of Culina villages, it seemed unlikely that the SIL had succeeded in halting curing rituals; indeed, I was told that the tokorime curing rituals are regularly held in secret, just as other forms of traditional curing operate parallel to the SIL infirmary. And, in at least two serious cases in which curing rituals could not be conducted in secret, San Bernardo residents made the trip downriver to Maronaua for treatment. From the information given me by residents of that village, it appeared that the major health care benefit of the SIL is its ability to fly people to Pulcalpa for hospital treatment.
The Culina on the Purus river might well have survived the worst effects of contact with Brazilian and Peruvian rubber tappers at the turn of the century by fleeing to this inhospitable river where, as Chandless wrote in the 1850s, between the biting flies during the day and the mosquitoes at night, no humans can live. Despite epidemics of infectious disease and difficulties of restricted access to protein, they maintain a separate, largely independent life, satisfying their need for Western-manufactured products through only occasional contact with Brazilian merchants. Most strikingly, those several groups of Culina who formerly worked for Brazilian rubber tappers now enjoy improved diets and lower infant mortality rates.
The overall health of Culina villages appears to be closely related to the extent of their contact with Brazilians and their access to land for horticulture and hunting. Maronaua, with extensive available lands, has a relatively well-fed and healthy population. However, Santo Amaro, where hunting is rarely productive and even fishing is often profitless, has more serious health problems resulting form both nutritional deficiencies and easier introduction of communicable diseases.
The impact of Brazilian government health initiatives on Culina has been negligible, but missionaries have produced varying results. Brazilian Catholic missionaries provide services that are useful, if unnecessary, particularly in treating milk bacterial infections and intestinal parasites. Ultimately, however, missionaries apply medical care in a typically Western "reactive" model in which one individual treats another; broader scale public health measure would probably have a great impact on the overall health of indigenous villages. Culina evaluate introduced concepts of illness and treatment within their own cultural framework, assimilating new diseases and medications to existing categories; the need to understand these indigenous ideas cannot be overemphasized. Unfortunately, missionary agendas rarely leave room for indigenous views. Among the Culina, missionaries either use medical care as a model for a market economy, or as a valuable commodity that only they can provide.
The Culina have been described for some 30 years as secretive about their traditional beliefs and practices; through this secrecy they have maintained much of their traditional culture, in the face of rubber tappers, traders, and FUNAI and CIMI. Indigenous concepts of illness and treatment have been particularly resistant to change. Condensing complex notions of social order and personhood as well as "physiology" and cosmology, illness beliefs express precisely those central values and views that are most powerful and consequently most secret. The simultaneous operation of two parallel systems of illness treatment within Culina villages, one Western and the other indigenous, suggest that each is addressing distinct sets of issues. Clearly, sensitivity to both will be necessary to ensure the survival and well-being of such groups.
Article copyright Cultural Survival, Inc.